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Adam Woodrum cialis price comparison was out site web for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed. €œHe cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum. Because they cialis price comparison were on bikes, he called the fire department in Carson City, Nevada. €œThey were great,” said Woodrum. €œThey took him on a stretcher to the ER.” Robert received stitches and anesthesia at Carson Tahoe Regional cialis price comparison Medical Center.

He’s since recovered nicely. Then the denial letter came. The Patient cialis price comparison. Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program Total Bill. $18,933.44, billed by the hospital cialis price comparison Service Provider.

Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health Medical Service. Stitches and anesthesia during an emergency department visit What Gives. The Aug cialis price comparison. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44. This case involves an all-too-frequent dance between different types of insurers about which cialis price comparison one should pay a patient’s bill if an accident is involved.

All sides do their best to avoid paying. And, no surprise to Bill of the Month followers. When insurers can’t agree, who gets a scary cialis price comparison bill?. The patient. The legal name for the process of determining which type of insurance is cialis price comparison primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?. Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible cialis price comparison for the injury or damage in question. Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs. About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision. The note cialis price comparison also directed questions to Luper Neidenthal &.

Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries. The firm’s website boasts that “we collect over 98% of cialis price comparison recoverable dollars for the State of Nevada.” Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans. The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that cialis price comparison the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s cialis price comparison ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault. €œIt’s like deny now and pay later,” he said. €œYou have insurance and pay for years, then they say, cialis price comparison ‘This is denied across the board.

Here’s your $18,000 bill.’” Although Adam Woodrum is a personal injury attorney, he says it still came as a shock to have his health insurer deny the claim after his son, Robert, got stitches in July following a bike crash. (Maggie Starbard for cialis price comparison KHN) Woodrum and his son, Robert, get ready to bike near their home in Carson City, Nevada, on Nov. 7. (Maggie Starbard for KHN) When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about cialis price comparison whether the program’s policy is to deny claims first, then seek more information.

The Little Rock, Arkansas-based firm did not return emails asking for comment. The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.” Attorney Matthew Anderson at the cialis price comparison law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.” Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association. “Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t cialis price comparison fill?. €™â€ Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find.

A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year. Medical providers may have reason to hope that bills will be sent through auto or cialis price comparison homeowner’s coverage, rather than health insurance, as they’re likely to get paid more. That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals cialis price comparison with whom they negotiate lower payment rates. Resolution.

Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the cialis price comparison average patient wouldn’t understand the legal quagmire and might not know how to fight back. €œI hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. €œThen they’re a year cialis price comparison out with no payment on their bills.” Or, fearing for their credit, they pay the bills. After receiving the accident questionnaire, Woodrum filled it out and sent it back.

There was no liable third party, he said. No driver was cialis price comparison at fault. His child just fell off his bicycle. HealthScope Benefits reconsidered the claim cialis price comparison. It was paid in September, two months after the accident.

The hospital cialis price comparison received less than half of what it originally billed, based on rates negotiated through his health plan. The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays. Adam Woodrum and his son, Robert, bike near their home in Carson City, Nevada, on Nov. 7.(Maggie Starbard for KHN) The cialis price comparison Takeaway. The mantra of Bill of the Month is don’t just write the check.

But also cialis price comparison don’t ignore scary bills from insurers or hospitals. It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident. But in the Woodrums’ case, as in others, cialis price comparison it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an cialis price comparison injury, suspect that some type of subrogation is at work. Don’t panic. If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the cialis price comparison injury. And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face cialis price comparison a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary. €œDo not ignore it,” said Domnick. €œTime and delay can be your enemy.” Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an cialis price comparison interesting medical bill you want to share with us?. Tell us about it!.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser cialis price comparison Family Foundation. Julie Appleby. jappleby@kff.org, @julie_appleby Related Topics Contact Us Submit a Story TipAbout Insight Insight provides cialis price comparison an in-depth look at health care issues in and affecting California.Have a story suggestion?. Let us know. California Gov.

Gavin Newsom’s maskless cialis price comparison dinner with medical industry lobbyists and others at a Napa County restaurant where meals cost a minimum of $350 per head was just about the last straw for some beleaguered California small-business owners.With their livelihoods on the line, a growing number of them are openly defying the latest orders to shut down as erectile dysfunction treatment cases skyrocket in California — and pointing to Newsom’s bad behavior.“We are definitely not complying. We have enough information to make an educated decision. The data do not back another shutdown,” said Miguel Aguilar, founder and owner of Self Made Training Facility, based in Temecula, California, which leases space to physical trainers and nutrition advisers and has 40 locations across 11 states, including 15 in California.The news of Newsom’s cialis price comparison Nov. 6 dinner at the French Laundry in Yountville only strengthened Aguilar’s resolve. €œYes, we all make mistakes, but his apology was pathetic,” Aguilar said.

€œHe told us he cialis price comparison was outdoors, but then the photos surfaced. He can attend in-person gatherings, but we can’t?. There’s absolutely cialis price comparison no trust there.” Email Sign-Up Subscribe to California Healthline’s free Daily Edition. New erectile dysfunction treatment cases and hospitalizations have surged at an alarming rate in California, with a seven-day average of over 11,500 cases Saturday, more than triple the number of a month earlier. Hospitalizations have doubled over the same period, according to the Los Angeles Times, part of a national trend that has pushed total erectile dysfunction treatment s in the U.S.

Above 12 million.In most California counties, restaurants, fitness clubs, yoga studios, churches, movie theaters and museums that cialis price comparison have already been through two previous shutdowns and reopenings since March are once again required to cease indoor operations — just as winter hits. Some are laying off workers for the third time this year.Add to that the failure of Congress to pass another stimulus package and, in many cases, a preexisting mistrust of government mandates. It all amounts to more disgruntled entrepreneurs.Larry cialis price comparison McNamer, owner of Major’s Diner in the tiny San Diego County community of Pine Valley, said he is continuing to serve people indoors, even though the county closed indoor dining on Nov. 14 in accordance with state regulations. He doesn’t believe the government has the right to impose such an ordinance on him.

And, he said, Newsom’s dinner fiasco helped him make cialis price comparison his decision to stay open.“We’re having to deal with all of the lying, the hypocrisy — you’ve got a governor that’s running around ignoring his own mandates,” McNamer said.McNamer knows the cialis is real, he said. He is seating only a quarter of his normal indoor capacity and has added distance between tables. But after closing the restaurant from March 15 to May 23, laying off half his employees and falling $200,000 behind on rent and other bills, McNamer isn’t sure how much more his business can take.Last Wednesday, he was hit cialis price comparison with a cease-and-desist order from the county, threatening him with a fine of $1,000 for each offense. San Diego County law enforcement officers are aggressively pursuing violations of public health orders, and the county has issued at least 83 citations to businesses since Nov. 16.In many other counties, including cialis price comparison Riverside, Orange, San Bernardino and Placer, sheriffs and police departments have rejected the erectile dysfunction treatment ordinances or expressed reluctance to enforce them.Last week, Newsom announced that 41 of California’s 58 counties — representing 94% of the population — were in the state’s “purple” tier — the most severe of four color-coded risk levels that impose increasingly restrictive limits on business activities.

That was up from 13 purple counties the week before.A few days later, the governor ordered a curfew, requiring people in the purple counties to stay at home between 10 p.m. And 5 a.m. Unless they’re performing essential activities, including certain jobs, grocery shopping or going to the doctor.Los Angeles County went a step further Sunday, banning cialis price comparison outdoor dining for at least three weeks. Unlike earlier in the year when that measure was ordered, now no federal financial aid is available to restaurants or their employees. Indoor dining has been shut down in the county for months.Despite plunging revenue, mounting debt and the frustrating uncertainty of shifting goal posts, many small-business owners are not defying the latest public health restrictions, either out of a sense of responsibility or fear of enforcement actions — or of contracting the cialis themselves.Those who do flout public health ordinances are doing so for a variety of reasons, with economics topping the list.“There are people who are protecting their employment, protecting their income,” said Vickie Mays, a clinical psychologist and professor of health policy and management at UCLA’s Fielding School of Public cialis price comparison Health.

€œThere are no stimulus checks coming. There’s no alternative.”Many people who own their own businesses “have taken other risks in their lives, and the risks they have taken have paid off, so there’s a belief that despite this risk, you’re not going to get infected,” Mays said.Many business owners, whether they comply with the health orders or not, believe their industries are being unfairly targeted and that the risk of viral spread in their establishments is not as great as officials say.Scott Slater, who owns two restaurants in San Diego’s seaside community of La Jolla, said he was frustrated by the public health focus on restaurants when a lot of erectile dysfunction treatment transmission is happening in private home gatherings.“We’re a perfect scapegoat,” Slater said. €œThey can control us, but they can’t control someone’s own home.” He called Newsom’s dinner “a slap in the face” cialis price comparison but said he and his wife are complying with the new restrictions, scraping by on catering, takeout and delivery — though he estimates they are $200,000 behind on rent.Francesca Schuler, CEO of Stockton, California-based In-Shape Health Clubs, which has more than 60 fitness centers and just laid off most of its staff for the third time this year, said gyms should be viewed as part of the solution, not the problem.“I look at people who are dying of erectile dysfunction treatment, and it’s people who are overweight, who have high blood pressure or diabetes,” said Schuler, who is respecting the closure orders despite her objection to them. €œThere are a lot of people who are trying to exercise to stay healthy, yet they shut down gyms while people can still go to tattoo parlors, to McDonald’s and to liquor stores. I just cialis price comparison don’t get it.”Mays, however, said gyms are considered high-risk because “people are breathing hard.

They are expelling air further.”And there are multiple ways people can stay fit without going to a gym, though outdoor exercise can be difficult sometimes because of heat and wildfire smoke, or in high-crime areas.In many cases, the cialis restrictions are crushing enterprises small-business owners have struggled to build over a lifetime. They’ve invested their savings, time, sweat and dreams in building something from the ground up, and now it’s threatened.Aguilar, who owns the training facility company, said he comes from a broken family, was homeless and penniless at age 16 and later got his start giving physical training lessons out of his garage. From that, he built his coast-to-coast chain.“At this point,” he said, “if I’m going to lose it all, I might as well go down fighting.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Bernard J. Wolfson.

bwolfson@kff.org, @bjwolfson Anna Almendrala. annaa@kff.org, @annaalmendrala Related Topics Insight Public Health erectile dysfunction treatment.

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The transpopulation represents a vulnerable population segment cialis jelly review both socially and medically, with a higher Cheap kamagra supplier incidence of mental health issues. During the erectile dysfunction treatment outbreak, transgender persons have faced additional social, psychological and physical difficulties.1 2 In Italy and in several other countries access to healthcare has been difficult or impossible thereby cialis jelly review hindering the start or continuation of hormonal and psychological treatments. Furthermore, several planned gender-affirming surgeries cialis jelly review have been postponed. These obstacles may have caused an additional psychological burden given the positive effects of medical and surgical treatments on well-being, directly and indirectly, reducing stressors such cialis jelly review as workplace discrimination and social inequalities.3 Some organisational aspects should also be considered.

Binary gender policies may worsen inequalities and marginalisation of transgender subjects potentially increasing the risk of morbidity and mortality.As with the general population, during the lockdown, the Internet and social media were useful in reducing isolation and, in this particular population, cialis jelly review were also relevant for keeping in touch with associations and healthcare facilities with the support of telemedicine services.4 Addressing the role of the telemedicine in the transpopulation, between May and June 2020 we conducted an anonymous web-based survey among transgenders living in Italy (ClinicalTrials.gov Identifier NCT04448418). Among the 108 respondents, with a mean age of 34.3±11.7 years, 73.1% were transmen and 26.9% transwomen and 88.9% were undergoing gender-affirming hormonal treatment (GAHT). One in four subjects (24.1%) presented a moderate-to-severe impact of the cialis event (Impact of cialis jelly review Event Scale score ≥26). The availability of telematic endocrinological visit was associated with better Mental cialis jelly review Health Scores in the 12-items Short Form Health Survey(SF-12) (p=0.030) and better IES (p=0.006).Our survey suggests a positive effect of telemedicine as the availability of telematic endocrinological consultations may have relieved the distress caused by the cialis by offering the opportunity to avoid halting GAHT.

In fact, deprivation of GAHT may result in several negative effects such as the increase in short-term self-medication and in depression and suicidal behaviour not only for those waiting for the start of treatment but also for those already using hormones.5 In conclusion, particular attention should be paid to vulnerable groups like the transpopulation who may pay a higher price during the cialis jelly review cialis. The use of telemedicine for continuation and monitoring of GAHT may be an effective tool for mitigating the negative effects of the cialis.AcknowledgmentsThe authors thank Julie Norbury for English copy editing.The British Medical Association recently published their report on the impact of erectile dysfunction treatment on mental health in England, highlighting the urgent need for investment in mental health services and further recruitment of mental health staff.1 Like many others, they have predicted a substantial increase in demand on mental health services in the coming cialis jelly review months. Their recommendations include a cialis jelly review call for detailed workforce planning at local, national and system levels. This coincides with the publication of the ‘NHS People Plan’ which also emphasised the need to maximise staff potential.2 The message from both is clear, it is time for Trusts to revise and improve how they use their multidisciplinary workforce, including non-medical prescribers (NMPs).Pharmacists have been able to register as independent prescribers since 20063 and as such, can work autonomously to prescribe any medicine for any medical cialis jelly review condition within their areas of competency.4 There has been a slow uptake of pharmacists into this role5 and while a recent General Pharmaceutical Council survey found only a small increase between the number of active prescribers from 2013 (1.094) to 2019 (1.590), almost a quarter of prescribers included mental health within their prescribing practice.6 More recently, we have started to see increasing reports of the value of pharmacist independent prescribers in mental health services.7 8Pharmacists bring a unique perspective to patient consultation.

Their expertise in pharmacology and medicine use means they are ideally placed to help patients optimise their medicines treatment4 and to ensure that patients are involved in decisions about their medicines, taking into account individual views and preferences. This approach is consistent with the guidance on medicines optimisation from the National Institute for Health and Care Excellence9 and the Royal Pharmaceutical Society,10 and the Department of Health’s drive to involve patients actively in clinical decisions.11 An increased focus on precision psychiatry in urging clinicians to tailor medicines cialis jelly review to patients according to evidence about individualised risks and benefits.12 13 However, it takes time to discuss medicine choices and to explore individual beliefs about medicines. This is especially relevant in Psychiatry, where a large group of medicines cialis jelly review (eg, antipsychotics) may have a wide range of potential side effects. Prescribing pharmacists could provide leadership and support in tailoring medicines for patients, as part of the wider multidisciplinary team.10The recent news that Priadel, the most commonly used brand of lithium cialis jelly review in the UK, is planned to be discontinued14 is another example where a new and unexpected burden on psychiatric services could be eased by sharing the workload with prescribing pharmacists.

The Medicines and Healthcare Products Regulatory Agency recommends that patients should have an individualised medication review in order to switch from one brand cialis jelly review of lithium to another.14 This is work that can be done by prescribing pharmacists who have an in-depth knowledge of the pharmacokinetics of lithium formulations.Importantly, this is a role that can be delivered using telepsychiatry and enhanced by the use of digital tools. Patients can meet pharmacists from the comfort of their cialis jelly review own home using video conferencing. Pharmacists can upload and share medicines information on the screen while discussing the benefits, risks and individual medication needs with each client. Increasingly organisations are using technology whereby prescriptions can be prepared electronically and sent securely to patients or their medicines providers.15We know from systematic reviews that NMPs in general are considered to provide a responsive, efficient and convenient service5 and to deliver similar prescribing outcomes as doctors.16 Medical professionals who have worked with NMPs have found that cialis jelly review this support permits them to concentrate on clinical issues that require medical expertise.5 A patient survey carried out in 2013 indicated that independent non‐medical prescribing was valued highly by patients and that generally there were few perceived differences in the care received from respondents’ NMP and their usual doctor.17 The literature also suggests that an NMP’s role is more likely to flourish when linked to a strategic vision of NMPs within an National Health Service (NHS) Trust, along with a well-defined area of practice.18Mental health trusts are being asked to prepare for a surge in referrals and as part of this planning, they will need to ensure that they get the most out of their highly skilled workforce.

There are active pharmacist prescribers in many trusts, however, this role is not yet commonplace.19 Health Education England has already identified that this is an important area of transformation for pharmacy and has called on mental health pharmacy teams to develop and share innovative ways of working.19 The ‘NHS People Plan’ outlines a commitment to train 50 community-based specialist mental health pharmacists within the next 2 years, along with a plan to extend the pharmacy foundation training to create a sustainable supply of prescribing pharmacists in future years.2We suggest that Mental Health cialis jelly review Trusts should urgently develop prescribing roles for specialist mental health pharmacists, which are integrated within mental health teams. In these roles, prescribing pharmacists can actively support their multidisciplinary colleagues cialis jelly review in case discussion meetings. Furthermore, they cialis jelly review should host regular medication review clinics, where patients can be referred to discuss their medicine options and, as advancements in precision therapeutics continue, have their treatment individually tailored to their needs. This is the way forward for a modern and patient-oriented NHS in the UK..

The transpopulation represents a vulnerable population segment both socially and medically, with a higher incidence of mental health cialis price comparison Cheap kamagra supplier issues. During the erectile dysfunction treatment outbreak, transgender persons have faced additional social, psychological and physical difficulties.1 2 In Italy and in several other countries access to healthcare has been difficult or impossible thereby hindering the start or continuation of hormonal cialis price comparison and psychological treatments. Furthermore, several planned gender-affirming cialis price comparison surgeries have been postponed. These obstacles may have caused an additional psychological burden given the positive effects of cialis price comparison medical and surgical treatments on well-being, directly and indirectly, reducing stressors such as workplace discrimination and social inequalities.3 Some organisational aspects should also be considered. Binary gender policies may worsen inequalities and marginalisation of transgender subjects potentially increasing the risk of morbidity and mortality.As with the general population, during the lockdown, the Internet cialis price comparison and social media were useful in reducing isolation and, in this particular population, were also relevant for keeping in touch with associations and healthcare facilities with the support of telemedicine services.4 Addressing the role of the telemedicine in the transpopulation, between May and June 2020 we conducted an anonymous web-based survey among transgenders living in Italy (ClinicalTrials.gov Identifier NCT04448418).

Among the 108 respondents, with a mean age of 34.3±11.7 years, 73.1% were transmen and 26.9% transwomen and 88.9% were undergoing gender-affirming hormonal treatment (GAHT). One in four subjects cialis price comparison (24.1%) presented a moderate-to-severe impact of the cialis event (Impact of Event Scale score ≥26). The availability of telematic endocrinological visit was associated with better Mental Health Scores in the 12-items Short Form Health Survey(SF-12) (p=0.030) and better IES (p=0.006).Our survey suggests a positive effect of telemedicine as the availability of telematic endocrinological consultations may have relieved the distress caused by the cialis by offering the cialis price comparison opportunity to avoid halting GAHT. In fact, deprivation of GAHT may result in several negative effects such as the increase in short-term self-medication and in depression and suicidal behaviour not only for those waiting for the start of treatment but also for those already using hormones.5 In conclusion, particular attention should be paid to vulnerable groups like the transpopulation who cialis price comparison may pay a higher price during the cialis. The use of telemedicine for continuation and monitoring of GAHT may be an effective tool for mitigating the negative effects of the cialis.AcknowledgmentsThe authors thank Julie Norbury for English copy editing.The British Medical Association recently published their report on the impact of erectile dysfunction treatment on mental health in England, highlighting the urgent need for investment in mental health services and further recruitment of mental health staff.1 Like many cialis price comparison others, they have predicted a substantial increase in demand on mental health services in the coming months.

Their recommendations include a cialis price comparison call for detailed workforce planning at local, national and system levels. This coincides with the publication of the ‘NHS People Plan’ which also emphasised the need to maximise staff potential.2 The message from both is clear, it is time for Trusts to revise and improve how they use their multidisciplinary workforce, including non-medical prescribers (NMPs).Pharmacists have been able to register as independent prescribers since 20063 and as such, can work autonomously to prescribe any medicine for any medical condition within their areas of competency.4 There has been a slow uptake of pharmacists into this role5 and while a recent General Pharmaceutical Council survey found only a small increase between the number of active prescribers from 2013 (1.094) to 2019 (1.590), almost a quarter of prescribers included mental health within their prescribing practice.6 More recently, we have started to see increasing reports of the value of pharmacist independent prescribers in mental health services.7 8Pharmacists bring a unique perspective to patient consultation cialis price comparison. Their expertise in pharmacology and medicine use means they are ideally placed to help patients optimise their medicines treatment4 and to ensure that patients are involved in decisions about their medicines, taking into account individual views and preferences. This approach is consistent with the guidance on medicines optimisation from the National Institute for Health and Care Excellence9 and the Royal Pharmaceutical Society,10 and the Department of Health’s drive to involve patients actively in clinical decisions.11 An increased focus on precision psychiatry in urging clinicians to tailor medicines to patients according to evidence about individualised risks and benefits.12 13 However, it takes time to cialis price comparison discuss medicine choices and to explore individual beliefs about medicines. This is cialis price comparison especially relevant in Psychiatry, where a large group of medicines (eg, antipsychotics) may have a wide range of potential side effects.

Prescribing pharmacists could provide leadership and support in tailoring medicines for patients, as part of the wider multidisciplinary team.10The recent news that Priadel, the most commonly used brand of lithium in the UK, is planned to cialis price comparison be discontinued14 is another example where a new and unexpected burden on psychiatric services could be eased by sharing the workload with prescribing pharmacists. The Medicines cialis price comparison and Healthcare Products Regulatory Agency recommends that patients should have an individualised medication review in order to switch from one brand of lithium to another.14 This is work that can be done by prescribing pharmacists who have an in-depth knowledge of the pharmacokinetics of lithium formulations.Importantly, this is a role that can be delivered using telepsychiatry and enhanced by the use of digital tools. Patients can meet pharmacists from the comfort of their own home using video conferencing cialis price comparison. Pharmacists can upload and share medicines information on the screen while discussing the benefits, risks and individual medication needs with each client. Increasingly organisations are using technology whereby prescriptions can be prepared electronically and sent securely to patients or their medicines providers.15We know from systematic reviews that NMPs in general are considered to provide a responsive, efficient and convenient service5 and to deliver similar prescribing outcomes as doctors.16 Medical professionals who have worked with NMPs have found that this support permits them to concentrate on clinical issues that require medical expertise.5 A patient survey carried out in 2013 indicated that independent non‐medical prescribing was valued highly by patients and that generally there were few perceived differences in the care received from respondents’ NMP and their usual doctor.17 The literature also suggests that an NMP’s role is more likely to flourish when linked to a strategic vision of NMPs within an National Health Service (NHS) Trust, along with a well-defined area of practice.18Mental health trusts are being asked to prepare for a surge in referrals and as part of this planning, they will need to ensure that they cialis price comparison get the most out of their highly skilled workforce.

There are active pharmacist prescribers in many trusts, however, this role is not yet commonplace.19 Health Education England has already identified that this is an important area of transformation for pharmacy and has called on mental health pharmacy teams to develop and share cialis price comparison innovative ways of working.19 The ‘NHS People Plan’ outlines a commitment to train 50 community-based specialist mental health pharmacists within the next 2 years, along with a plan to extend the pharmacy foundation training to create a sustainable supply of prescribing pharmacists in future years.2We suggest that Mental Health Trusts should urgently develop prescribing roles for specialist mental health pharmacists, which are integrated within mental health teams. In these roles, prescribing pharmacists can actively support their multidisciplinary colleagues in case discussion cialis price comparison meetings. Furthermore, they should host regular cialis price comparison medication review clinics, where patients can be referred to discuss their medicine options and, as advancements in precision therapeutics continue, have their treatment individually tailored to their needs. This is the way forward for a modern and patient-oriented NHS in the UK..

What may interact with Cialis?

Do not take Cialis with any of the following medications:

  • nitrates like amyl nitrite, isosorbide dinitrate, isosorbide mononitrate, nitroglycerin

Cialis may also interact with the following medications:

  • certain drugs for high blood pressure
  • certain drugs for the treatment of HIV or AIDS
  • certain drugs used for fungal or yeast s, like fluconazole, itraconazole, ketoconazole, and voriconazole
  • certain drugs used for seizures like carbamazepine, phenytoin, and phenobarbital
  • grapefruit juice
  • macrolide antibiotics like clarithromycin, erythromycin, troleandomycin
  • medicines for prostate problems
  • rifabutin, rifampin or rifapentine

This list may not describe all possible interactions. Give your health care provider a list of all the medicines, herbs, non-prescription drugs, or dietary supplements you use. Also tell them if you smoke, drink alcohol, or use illegal drugs. Some items may interact with your medicine.

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Western NSW residents will have even greater access to mental health support with the opening of a new Lifeline centre in Dubbo.Minister for Mental Health Bronnie Taylor will open the new, purpose-built centre today, thanks to $600,000 in special funding from the NSW Government.“We want people living in the Central West to be able to access timely support from counsellors who understand their local community and the pressures they might be under,” Mrs Taylor said.“As well as establishing a dedicated Lifeline presence in Dubbo, the funding will also allow Lifeline Central West to triple the number of crisis telephone calls answered in Dubbo and its surrounds.”Member for Dubbo Dugald Saunders said the centre comes at a critical time for his community.“The brutal forces of drought, erectile dysfunction treatment and financial uncertainty are taking a toll on the strongest and most resilient among us,” Mr Saunders said.“One of my priorities after being elected was to see Lifeline’s local footprint expanded and supported, and funding for an appropriate building has been a key component of that.“It’s important for people to know they can lean on trained counsellors who live in the area and know the situations confronting people in central west NSW.”The new centre will also be the base for the Rapid Community Support Program (Rapid) – an outreach program which goes directly to towns hit 60mg cialis by significant events such as drought and bushfire to provide counselling and support within their own community.The service received a $500,000 boost from the NSW Government to enable it to continue operations as part of take a look at the site here an additional $6 million investment provided to Lifeline in response to the erectile dysfunction treatment cialis.CEO of Lifeline Central West Stephanie Robinson said the Dubbo-based team willserve a vast area, including Wellington, Narromine, Mendooran, Coonabarabran, Coonamble, Walgett, Bourke and Lightning Ridge.“Our new centre will be a safe space for people to have group or one-on-one counselling sessions and will also serve as a base for our trained volunteers to provide community outreach,” Ms Robinson said.Lifeline Central West is a not-for-profit organisation with offices in Bathurst, Orange and Dubbo with nine full-time staff and approximately 130 trained volunteers. The NSW Government has invested over $25 million in Lifeline over 4 years.As part of SafeWork Month 2020, a number of prominent business and industry leaders have been appointed to help drive positive change by breaking down the barriers and stigma associated with mental health in NSW workplaces.Minister for Better Regulation and Innovation Kevin Anderson and Minister for Mental Health Bronnie Taylor today announced the NSW Government has appointed 12 ambassadors to champion the importance of good mental health in the workplace.Mr 60mg cialis Anderson said the ambassadors will play a critical role in assisting the NSW Government meet its target of 90,000 business taking effective action to create work environments which benefit mental health by 2022.“Statistically we know that one-in-six people struggle with their mental health, and I would suggest those figures are conservative given the current challenging social and economic environment,” Mr Anderson said.“The ambassadors will work alongside us to send a message to employees in every corner of NSW that if you are struggling and need help, we will be there for you.”Among the new mental health ambassadors are Landcom CEO and Lifeline Chairman John Brogden AM, Westpac Group Chief Mental Health Officer David Burroughs and Business Chicks CEO Olivia Ruello.Mr Anderson said there will also be significant financial benefits for businesses.“The financial cost of mental health to NSW employers is $2.8 billion a year, but for every dollar invested into improving culture and outcomes for those living with mental ill-health, there is a return on investment of up to four dollars,” Mr Anderson said.“Our ambassadors recognise that a mentally healthy workplace is good business, and have committed to continuing the great work they do to support their workers and to encourage others in their industry to do the same.”Mrs Taylor said the event is another example of the NSW Government’s commitment to leading the nation in mental health reform.“Most of us spend about one-third or more of our waking lives at work. It’s a huge part of what we do and can have a huge impact on our mental health in a positive or negative way,” Mrs Taylor said.“Everyone in the workplace can contribute to a culture where people feel safe and supported to talk about mental health and it’s really encouraging to see so many leaders from NSW’s business sector stepping up.” For more information please visit 60mg cialis SafeWork NSW..

Western NSW residents will have even greater access to mental health support with the opening of a new Lifeline centre in Dubbo.Minister for Mental Health Bronnie Taylor will open the new, purpose-built centre today, thanks to $600,000 in special funding from the NSW Government.“We want people living in the Central West to be able to access timely support from counsellors who understand their local community and the pressures they might be under,” Mrs Taylor said.“As well as establishing a dedicated Lifeline presence in Dubbo, the funding will also allow Lifeline Central West to triple the number of crisis telephone calls answered in Dubbo and its surrounds.”Member for Dubbo Dugald Saunders said the centre comes at a critical time for his community.“The brutal forces of drought, erectile dysfunction treatment and financial uncertainty are taking a toll on the strongest and most resilient among us,” Mr Saunders said.“One of my priorities after being elected was to see Lifeline’s local footprint expanded and supported, and funding for an appropriate building has been a key component of that.“It’s important for people to know they can lean on trained counsellors who live in the area and know the situations confronting people in central west NSW.”The new centre will also be the base for the Rapid Community Support Program (Rapid) – an outreach program which goes directly to towns hit by significant events such as drought and bushfire to provide counselling and support within their own community.The service received a $500,000 boost from the NSW Government to enable it to continue operations as part of an additional $6 million investment provided to Lifeline in response to the erectile dysfunction treatment cialis.CEO of Lifeline Central West Stephanie Robinson said the Dubbo-based team willserve a vast area, including Wellington, Narromine, Mendooran, Coonabarabran, Coonamble, Walgett, Bourke and Lightning Ridge.“Our new centre will be a safe space for people to have group or one-on-one counselling sessions and will also serve as a base for our trained volunteers to provide community outreach,” Ms Robinson said.Lifeline Central West click over here is a not-for-profit organisation with cialis price comparison offices in Bathurst, Orange and Dubbo with nine full-time staff and approximately 130 trained volunteers. The NSW Government has invested over $25 million in Lifeline over 4 years.As part of SafeWork Month 2020, a number of prominent business and industry leaders have been appointed to help drive positive change by breaking down the barriers and stigma associated with mental health in NSW workplaces.Minister for Better Regulation and Innovation Kevin Anderson and Minister for Mental Health Bronnie Taylor today announced the NSW Government has appointed 12 ambassadors to champion the importance of good mental health in the workplace.Mr Anderson said the ambassadors will play a critical role in assisting the NSW Government meet its target of 90,000 business taking effective action to create work environments which benefit mental health by 2022.“Statistically we know that one-in-six people struggle with their mental health, and I would suggest those figures are conservative given the current challenging social and economic environment,” Mr Anderson said.“The ambassadors will work alongside us to send a message to employees in every corner of NSW that if you are struggling and need help, we will be there for you.”Among the new mental health ambassadors are Landcom CEO and Lifeline Chairman John Brogden AM, Westpac Group Chief Mental Health Officer David Burroughs and Business Chicks CEO Olivia Ruello.Mr Anderson said there will also cialis price comparison be significant financial benefits for businesses.“The financial cost of mental health to NSW employers is $2.8 billion a year, but for every dollar invested into improving culture and outcomes for those living with mental ill-health, there is a return on investment of up to four dollars,” Mr Anderson said.“Our ambassadors recognise that a mentally healthy workplace is good business, and have committed to continuing the great work they do to support their workers and to encourage others in their industry to do the same.”Mrs Taylor said the event is another example of the NSW Government’s commitment to leading the nation in mental health reform.“Most of us spend about one-third or more of our waking lives at work. It’s a huge part of what we do and can have a huge impact on our mental health in a positive or negative way,” Mrs Taylor said.“Everyone in the workplace can contribute to a culture where people feel safe and supported cialis price comparison to talk about mental health and it’s really encouraging to see so many leaders from NSW’s business sector stepping up.” For more information please visit SafeWork NSW..

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In this issue of BMJ Quality and Safety, Jorro-Barón and colleagues1 report the cialis pill cost findings of a stepped-wedge cluster randomised trial (SW-CRT) to click this link here now evaluate the implementation of the I-PASS handover system among six paediatric intensive care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric Patient Safety cialis pill cost instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative. Notably, however, on the primary outcome there were no differences between control and intervention groups regarding preventable adverse events per 1000 days of hospitalisation (control 60.4 (37.5–97.4) vs intervention cialis pill cost 60.4 (33.2–109.9), p=0.998, risk ratio.

1.0 (0.74–1.34)). Regarding balancing measures, cialis pill cost there was no observed difference in the ‘full-shift’ handover duration (control 35.7 min (29.6–41.8). Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 min (4.69–7.23) cialis pill cost.

P=0.001). From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers. The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16.

Admissions to a surgery unit17. Management of trauma patients18–20. ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28.

And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites. A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver. The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format.

The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed. Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power.

It is essential to establishing a shared mental model of the current state and any potential concerns. However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents. Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable.

Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min. P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions.

Greater provider satisfaction with handover organisation and information conveyed. Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted. Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible.

At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements. The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design.

The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design. Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30). As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation.

The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition. For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods.

Clusters per sequence. And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants. For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition.

This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast. Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?.

From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients. A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change. Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial.

His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?. The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change.

The effectiveness of these systems is sensitive to an array of influences. Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care. Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &.

Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians. Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree.

And 15 (23%) did not respond. Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study. For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants.

Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean. 12 min) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders.

In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential. An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions. For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors.

Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field. In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

In this issue of BMJ Quality and Safety, Jorro-Barón and colleagues1 report the findings of a stepped-wedge cluster randomised trial (SW-CRT) to evaluate the implementation of the I-PASS cialis price comparison handover system among six paediatric intensive Buy cheap cialis care units (PICUs) at five Argentinian hospitals between July 2018 and May 2019. According to the authors, prior to the intervention there were complaints that handovers were ‘…lengthy, disorganized, …participants experienced problems with interruptions, distractions, and … senior professionals had problems accepting dissent’.Adverse events were assessed by two independent reviewers using the Global Assessment of Pediatric cialis price comparison Patient Safety instrument. Study results demonstrated significantly improved handover compliance in the intervention group, validating Kirkpatrick Level 3 (behavioural change)2 effectiveness of the training initiative.

Notably, however, on the primary outcome there were no differences between control and intervention groups regarding preventable adverse events per 1000 days of cialis price comparison hospitalisation (control 60.4 (37.5–97.4) vs intervention 60.4 (33.2–109.9), p=0.998, risk ratio. 1.0 (0.74–1.34)). Regarding balancing measures, there was no observed difference in the ‘full-shift’ handover duration (control 35.7 min cialis price comparison (29.6–41.8).

Intervention 34.7 min (26.5–42.1), p=0.490), although more time was spent on individual patient handovers in the intervention period (7.29 min (5.77–8.81). Control 5.96 cialis price comparison min (4.69–7.23). P=0.001).

From the provider perspective, preintervention and postintervention Agency for Healthcare Research and Quality (AHRQ) safety culture surveys did not show significant differences in their responses to communication-focused questions before and after the intervention.Thus, consistent with all previous studies, I-PASS was implemented successfully and handover quality improved. However, is the lack of association of I-PASS implementation with clinical outcomes and adverse events in this study a concern?. To answer this question, it is necessary to review the origins of I-PASS more than a decade ago and its continually expanding evidence base.Healthcare has a handover problemHandovers are among the most vulnerable reoccurring processes in healthcare.

In the AHRQ safety culture survey,3 the handovers and transitions of care domain is consistently among the lowest scoring, and handover and communication issues are among the most common cause of Joint Commission Sentinel Events and the subject of Joint Commission Sentinel Event Alert Issue 58.4 A study by CRICO Strategies found that communication issues were a factor in 30% of 23 658 malpractice claims filed from 2009 to 2013, accounting for $1.7 billion in incurred losses.5 The importance of handovers and care transitions for trainees is specifically discussed in a Clinical Learning Environment Review Issue Brief published by the Accreditation Council for Graduate Medical Education (ACGME),6 and Section VI.E.3 (Transitions of Care) of the ACGME Common Program Requirements (Residency) addresses the requirement for residents to be taught and to use structured handovers.7Both the numbers of handovers and handover-related problems have increased in contemporary practice because of greater patient complexity and the expanding number and types of providers involved in a typical patient’s care. Further, in teaching institutions, resident work-hour restrictions have resulted in the need for complex coverage schemes. Off-hours care is often provided by ‘cross-covering’, ‘float’ or ‘moonlighting’ practitioners who are responsible for numerous unfamiliar patients during their shifts, thus imposing an even greater need for effective handovers.

The net effect of all these changes may be inconsistent, fragmented care resulting from suboptimal handovers from one provider, service or hospital to another, with resulting medical errors (often of omission) and adverse events.Structured, standardised handoversThese serious vulnerabilities have led to pleas for more consistent, structured and standardised handovers.8–11 In addition to their use in routine shift-to-shift provider sign-off, these may be of particular value in the high-risk transfers of critically ill patients, such as from operating rooms to postoperative care units and ICUs12–16. Admissions to a surgery unit17. Management of trauma patients18–20.

ICU to general ward transfers21 22. Night and weekend coverage of large services, many of whose patients are unfamiliar to the physician receiving the handover23–28. And end-of-rotation resident transitions.29–31Given these considerations, standardised handovers, often involving mnemonic devices, have been widely advocated and studied in the past several decades, though many lack rigorous evaluation and few if any showed demonstrable associations with outcomes.32 33 Further, although some individual hospitals, units and services have implemented their own idiosyncratic handover systems, this does not solve the issue of handover inconsistency between different care delivery sites.

A basic, common framework that could be customised to individual use cases would clearly be preferable.The I-PASS systemResponding to these concerns, the I-PASS Study Group was initiated in 2009 and the I-PASS Institute in 2016. Although numerous other systems are available, since its pilot studies a decade ago,34 35 I-PASS has emerged as the dominant system in healthcare for structured, standardised handovers. This system is specifically designed for healthcare applications.

It is based on adult educational principles and simple to use. It has been extensively validated in the peer-reviewed literature encompassing studies at multiple institutions in the USA and internationally34–40. And extensive training materials are available to assist programmes in implementation.39 41–45 Ideally, this system is implemented hospital-wide, which addresses the issue of cross-unit and cross-service transfers.I-PASS includes five major elements regarded as important for every handover—illness severity, patient summary, action list, situation awareness/contingency planning and synthesis by receiver.

The first three of these elements are often included in non-structured handovers, although not necessarily in a specific sequence or format. The last two I-PASS elements—situational awareness/contingency planning and synthesis—have not historically been included in typical handover practice. The former assures that any anticipated problems are conveyed from the handover giver to the incoming provider and that appropriate responses to these issues are discussed.

Synthesis is closed-loop communication, with brief read-back of the handover information by the receiver to assure their accurate comprehension, followed by an opportunity for questions and discussion. This read-back of mission-critical communications is standard operating practice in other high-reliability settings such as aviation, the military and nuclear power. It is essential to establishing a shared mental model of the current state and any potential concerns.

However, other than in I-PASS, it is quite uncommon in healthcare, with the potential exception of confirming verbal or telephonic orders.I-PASS validationIn an initial study of I-PASS handover implementation by residents on two general inpatient paediatric units at Boston Children’s Hospital,34 written handovers were more comprehensive and had fewer omissions of key data, and mean time spent on verbal handover sessions did not change significantly (32.3 min vs 33.2 min). Medical errors and adverse events were ascertained prospectively by research nurse reviewers and independent physician investigators. Following I-PASS implementation, preventable adverse events decreased from 3.3 (95% CI 1.7 to 4.8) to 1.5 (95% CI 0.51 to 2.4) per 100 admissions (p=0.04), and medical error rates decreased significantly from 33.8 per 100 admissions (95% CI 27.3 to 40.3) to 18.3 per 100 admissions (95% CI 14.7 to 21.9.

P<0.001). A commentary by Horwitz46 noted that this was ‘…by far the most comprehensive study of the direct effects of handoff interventions on outcomes within the context of existing work-hour regulations and is the first to demonstrate an associated significant decrease in medical errors on a large scale’, while also noting limitations including its uncontrolled, ‘before and after’ design, confounding by secular changes, Hawthorne effects and inability to blind the nurses collecting adverse event data.The more expansive, landmark I-PASS study was conducted by Starmer and colleagues37 among nine paediatric hospitals and 10 740 patient admissions between January 2011 and May 2013. Handover quality was evaluated, and medical errors and adverse events were ascertained by active surveillance, including on-site nurse review of medical records, orders, formal incident reports, nursing reports and daily medical error reports from residents.

Independent physician investigators classified occurrences as adverse events, near misses or exclusions, and they subclassified adverse events as preventable or non-preventable. Results revealed a 23% reduction in medical errors from the preintervention to the postintervention period (24.5 vs 18.8 per 100 admissions, p<0.001) and a 30% reduction in preventable adverse events (4.7 vs 3.3 events per 100 admissions, p<0.001). Inclusion of prespecified elements in written and verbal handovers increased significantly, and there was no significant change in handover time per patient (2.4 vs 2.5 min.

P=0.55).Subsequent investigations in other institutions have replicated many of the findings of the original I-PASS studies, with higher postintervention inclusion rates of critical handover elements. Fewer mistakes or omissions. Greater provider satisfaction with handover organisation and information conveyed.

Unchanged or shorter handoff times. And decreased handover interruptions (probably reflecting greater attention to the importance of the handover process).36 40 47–50 In a mentored implementation study conducted in 2015–2016 among 16 hospitals (five community hospitals, 11 academic centres and multiple specialties), handover quality improved, and there was a provider-reported 27% reduction in adverse events.38 Among nurses at Boston Children’s Hospital, I-PASS implementation was associated with significant decreases in handover-related care failures.40In recognition of its achievements in improving healthcare quality, the I-PASS Study Group was awarded the 2016 John M Eisenberg Award for Patient Safety and Quality by the National Quality Forum and the Joint Commission.The challenge of linking handovers to clinical outcomes and eventsAlthough investigations from many centres, including the report of Jorro-Barrón and colleagues,1 have now confirmed that I-PASS can be readily assimilated and used by clinicians, most of these have either not rigorously assessed adverse events, medical errors and other clinical outcomes (Kirkpatrick Level 4 evaluation) or have failed to demonstrate significant postintervention improvements in these clinical outcomes. Why is this, and should current or potential I-PASS users be concerned?.

With regard to the first question, there are practical considerations that complicate the rigorous study of clinical outcome improvements associated with I-PASS (or any other handover system). Notwithstanding the importance of effective communications, these are only one of many provider processes and hospital systems, not to mention the overall hospital quality and safety culture, that impact a patient’s clinical outcome. In most hospitals, a diverse portfolio of quality and safety improvement initiatives are always being conducted.

Disentangling and isolating the effects of any one specific intervention, such as I-PASS handovers, is challenging if not impossible. At a minimum, it requires real-time, prospective monitoring by trained nurse or physician reviewers as in the original I-PASS studies, a research design which realistically is unlikely to be reproduced. Ideally, the study design would also include blinding of the study period (control or intervention) and blinding of observers, the former of which is virtually impossible for this type of intervention.Further, if other provider processes and hospital systems are functioning at a high level, they may partially offset the impact of suboptimal communications and make it even more challenging to demonstrate significant improvements.

The current study of Jorro-Barón and colleagues,1 which uses PICUs as the unit of analysis, illustrates this concept. PICUs are typically among the most compulsive, detail-oriented units in any hospital, even if they may have nominally ‘non-standardized’ handovers.Study design. The SW-CRTIn an attempt to address the limitations of some previous studies, Parent and colleagues51 studied eight medical and surgical ICUs across two academic tertiary teaching hospitals using an SW-CRT design.

Clinician self-assessment of having been inadequately prepared for their shift because of a poor-quality handoff decreased from 35 of 343 handoffs (10.2%) in the control arm to 53 of 740 handoffs (7.2%) postintervention (OR 0.19. 95% CI 0.03 to 0.74. P=0.03).

€˜Last-minute’, early morning order writing decreased, and handover duration increased but not significantly (+5.5 min. 95% CI 0.34 to 9.39. P=0.30).

As in the current study of Jorro-Barón and colleagues,1 who also employed an SW-CRT, there were no associated changes in clinical outcomes such as ICU length of stay, duration of mechanical ventilation or necessity for reintubation. The authors comment that given high baseline quality of care in these ICUs, it was not surprising that there were no changes in outcomes.An SW-CRT is generally considered a rigorous study design as it includes cluster randomisation. However, though novel and increasingly popular, this approach is complex and may sometimes add confusion rather than clarity.52–57 Its major appeal is that all clusters will at some point, in a random and sequential fashion, transition from control to intervention condition.

For an intervention that is perceived by participants as having more potential for good than harm, this may enhance cluster recruitment. It may also make it possible to conduct a randomised study in scenarios where pragmatic considerations, such as the inability to conduct interventions simultaneously across numerous clusters, may make a parallel randomised study (or any study) infeasible.However, as acknowledged even by its proponents, the added practical and statistical complexity of SW-CRTs often makes them more challenging to properly implement, and compared with traditional parallel cluster randomised trials they may be more prone to biases.53–57 A Consolidated Standards of Reporting Trials extension has been specifically developed in response to these concerns.55 Unique design and analytical considerations include the number of clusters, sequences and periods. Clusters per sequence.

And cluster-period sizes.55 56 Concerns include recruitment and selection biases. Proper accounting for secular trends in outcomes (ie, because of the sequential rather than simultaneous nature of the SW-CRT design, observations from the intervention condition occur on average at a later calendar time, so that the intervention effect may be confounded by an underlying time trend). Accounting for repeated measures on participants and clusters in sample size calculations and analyses (ie, data are not independent).

Possible time-varying treatment effects. And the potential for within-cluster contamination of observations obtained under the control or intervention condition.52–56Regarding contamination, a secular trend may be responsible if, for example, institutional activities focused on improving patient outcomes include a general emphasis on communications. There might also be more direct contamination of the intervention among clusters waiting to be crossed over, as described in the context of the Matching Michigan programme.58 Participating in a trial and awareness of being observed may change the behaviour of participants.

For example, in the handover intervention of Jorro-Barón and colleagues,1 some providers in a control condition cluster may, because they are aware of the interest in handovers, begin to implement more standardised practices before the formal shift to the intervention condition. This potentially dilutes any subsequent impact of the intervention by virtue of what could be considered either a Hawthorne effect or a local secular trend, in either case leading to generally better handovers in the preintervention period. Some SW-CRTs include a transition period without any observations to allow for sufficient time to implement the intervention,53 59 thereby creating more contrast.

Finally, because of sometimes prolonged PICU length of stay and regularly scheduled resident rotations on and off a unit or service, some patients and providers might overlap the transition from control to intervention state and contribute observations to both, while others will be limited to one or the other. This possibility is not clearly defined by the authors of the current study, but seems unlikely to have had a major statistical effect.Do we need more evidence?. From an implementation science perspective, handovers are a deeply flawed healthcare process with the demonstrated potential to harm patients.

A new tool—I-PASS—has been developed which can be easily and economically taught and subsequently applied by virtually any provider, and many resources are available to assist in implementation.45 It has few, if any, unintended negative consequences to patients or providers and has been associated in at least two extensive and well-conducted (although non-randomised) trials with dramatic reductions in medical errors and adverse events. Notably, these were conducted at a time when there was much less emphasis on and awareness of handover systems, including I-PASS. Thus, there was much greater separation between control and intervention states than would be possible today.Returning to the question posed at the beginning of this commentary, is the inability to demonstrate a favourable impact on clinical outcomes in studies other than those of the developers34 35 a reason to question the value of I-PASS?.

For the reasons discussed above, I think not. In his classic 2008 article,60 ‘The Science of Improvement’, Dr Don Berwick recounts the transformational development of sophisticated statistical analyses in healthcare, of which the randomised clinical trial is the paradigm. While in many instances randomised controlled trials have been invaluable in scientifically affirming or rejecting the utility of specific treatments or interventions, their limitations are more obvious in interventions involving complex social and behavioural change.

Berwick illustrates this challenge with the example of hospital rapid response teams, whose benefit was challenged by the results of a large cluster randomised trial. His comments regarding that conflict are equally applicable to the current challenge of demonstrating the impact of standardised handovers on clinical outcomes:These critics refused to accept as evidence the large, positive, accumulating experience of many hospitals that were adapting rapid response for their own use, such as children’s hospitals. How can accumulating local reports of effectiveness of improvement interventions, such as rapid response systems, be reconciled with contrary findings from formal trials with their own varying imperfections?.

The reasons for this apparent gap between science and experience lie deep in epistemology. The introduction of rapid response systems in hospitals is a complex, multicomponent intervention—essentially a process of social change. The effectiveness of these systems is sensitive to an array of influences.

Leadership, changing environments, details of implementation, organizational history, and much more. In such complex terrain, the RCT is an impoverished way to learn. Critics who use it as a truth standard in this context are incorrect.Having personally observed the value of I-PASS, as well as the devastating consequences of inadequate handovers, I vote with Dr Berwick.

The evidence for effectiveness is overwhelming and the need for action is urgent—all that is lacking is the will to implement.Ethics statementsPatient consent for publicationNot required.Palliative care is associated with improved patient-centred and caregiver-centred outcomes, higher-quality end-of-life care, and decreased healthcare use among patients with serious illness.1–3 The Centre to Advance Palliative Care has established a set of recommended clinical criteria (or ‘triggers’), including a projected survival of less than 1 year,4 to help clinicians identify patients likely to benefit from palliative care. Nevertheless, referrals often occur within the last 3 months of life5 due in part to clinician overestimation of prognosis.6 A growing number of automated predictive models leverage vast data in the electronic medical record (EMR) to accurately predict short-term mortality risk in real time and can be paired with systems to prompt clinicians to refer to palliative care.7–12 These models hold great promise to overcome the many clinician-level and system-level barriers to improving access to timely palliative care. First, mortality risk prediction algorithms have been shown to outperform clinician prognostic assessment, and clinician–machine collaboration may even outperform both.13 Second, algorithm-based ‘nudges’ that systematically provide prognostic information could address many cognitive biases, including status quo bias and optimism bias,14 15 that make clinicians less apt to identify patients who may benefit from palliative care.

Indeed, such models have been shown to improve the frequency of palliative care delivery and patient outcomes in the hospital and clinic settings.9 16 17 With that said, successful implementation of automated prognostic models into routine clinical care at scale requires clinician and patient engagement and support.In this issue of BMJ Quality &. Safety, Saunders and colleagues report on the acceptability of using the EMR-based Modified Hospitalised-Patient One-Year Mortality Risk (mHOMR) score to alert clinicians to individual patients with a >21% risk of dying within 12 months. The goal of the clinician notification of an elevated risk score was to prompt clinicians to consider palliative care referral.18 In a previously reported feasibility study among 400 hospitalised patients, use of the mHOMR alert was associated with increased rates of goals of care discussions and palliative care consultation in comparison to the preimplementation baseline (34% vs 18%, respectively).19 In the present study, the authors conducted qualitative interviews pre-mHOMR and post-mHOMR implementation among 64 stakeholders, including patients identified at high risk by the mHOMR algorithm, their caregivers, staff and physicians.

Thirty-five (55%) participants agreed that the mHOMR tool was acceptable. 14 (22%) were unsure or did not agree. And 15 (23%) did not respond.

Participants identified many potential benefits of the programme, citing the advantages of an automated approach to facilitate and justify clinical decision making. Participants also acknowledged possible barriers, particularly ‘situational challenges’ such as the content, timing and mechanism of provider notification. Additional logistical concerns included alert fatigue, potential redundancy, uncertainty regarding next steps and a worry that certain therapeutic options could be withheld from flagged patients.

The authors concluded that clinicians and patients found the automated prognostic trigger to be an acceptable addition to usual clinical care.Saunders et al’s work adds to our understanding of critical perceptions regarding end users’ acceptability of automated prognostic triggers in routine clinical care. The findings from this study align with prior evidence suggesting that clinicians recognise the value of automated, algorithm-based approaches to improve serious illness care. For example, in a qualitative study of clinicians by Hallen et al, prognostic models confirmed clinicians’ gestalt and served as a tool to help communicate prognosis to patients.20 Clinicians described prognostic models as a tool to facilitate interclinician disagreements, mitigate medicolegal risk, and overcome the tendency to ignore or overestimate prognosis.20 Clinicians also reported that EMR-generated lists of high-risk patients improved their ability to identify potential palliative care beneficiaries in a mixed-methods study by Mason et al.21 In a single-centre pilot study, we similarly found that most clinicians believed that using an EMR-based prognostic model to encourage inpatient palliative care consultation was acceptable.9 However, in the Saunders et al study, as in prior similar work, clinicians highlighted the importance of delivering notifications without causing excess provider workload, redundancy or alert fatigue.16 18 21 Clinicians also raised concerns regarding the accuracy of the prognostic information and the potential for negative effects on patients due to common misperceptions about palliative care being equivalent to hospice.18 20 21 Ultimately, Saunders et al’s work complements and builds on existing literature, demonstrating a general perception that integration of automated prognostic models into routine clinical care could be beneficial and acceptable.Important gaps remain in this literature which were not addressed by the Saunders et al study.

For example, there is a need to capture more diverse clinician and patient perspectives, and there was no information provided about the sociodemographic or clinical characteristics of the study participants. Additionally, important themes found in prior studies were not identified in this study. For example, two prior studies of clinicians’ perspectives on automated prognostic triggers for palliative care revealed concerns that prognosis alone may not be a sufficient surrogate indicator of actual palliative care need, or may inadvertently engender clinician overconfidence in an individual patient’s prognosis.9 21 The brevity of the interviews in Saunders et al’s study (mean.

12 min) could suggest all relevant themes may not have emerged in the data analysis. Additionally, while the inclusion of patient and caregiver perceptions is an important addition, limited information is provided about their perspectives and whether certain themes differed among the stakeholders. In the study from Mason et al, themes unique to patients and caregivers were identified, such as hesitancy due to a lack of understanding of palliative care, a preference to ‘focus on the present’, and a worry that a clinician would not have the time to adequately address advanced care planning or palliative care during their visit.21 Healthcare systems should therefore be prepared to consider their unique workflows, patients and staff prior to implementing one of these programmes.Achieving stakeholder acceptability prior to widespread implementation is essential.

An intervention should ideally undergo multiple cycles of optimisation with ongoing appraisal of patient and clinician perspectives prior to wide-scale implementation.22 23 Additionally, it is unclear whether clinicians’ acceptability of the intervention in one setting will generalise to other inpatient health settings. For instance, Saunders et al found that some providers were leery about the use of mHOMR due the need to balance the patient’s acute needs that brought them to the hospital with their long-term priorities that may be better served in the outpatient setting.18 Clinical workflows, patient acuity and patient–provider relationships are markedly different between the inpatient and outpatient settings, suggesting Saunders et al’s findings cannot be extrapolated to outpatient care. This is particularly relevant as many ‘off-the-shelf’ prognostic algorithms are now commercially available that, while accurate, may not be as familiar or acceptable to clinicians as a homegrown model.

Therefore, while Saunders et al’s work is a great addition to the field, additional assessments are needed across different healthcare environments and varying clinical and demographic cohorts to demonstrate that this approach is acceptable in other health settings. It is likely that multiple implementation strategies will be needed to successfully adapt automated prognostic models across a range of clinical settings.Thoughtful consideration of the many forces that alter clinical decision making will also be critical for downstream success of these interventions. Suboptimal clinical decision making is often a result of systemic biases, such as status quo and optimism bias, which result in clinician resistance to change current practice and a belief that their patients are less prone to negative outcomes.14 15 Intentional application of targeted behavioural economics principles will help ensure that the use of prognostic triggers to improve palliative care effectively changes clinical behaviour.24 For example, using an ‘opt-out’ approach for palliative care referral may make the optimal choice the path of least resistance, increasing uptake among clinicians.16 These approaches will need to be balanced against rising clinician alert fatigue25 and resource constraints.Given the implementation challenges that accompany an intervention using prognostic triggers, hybrid effectiveness trials that test both clinical effectiveness and implementation outcomes offer one strategy to advance the integration of automated prognostic models.26 Implementation outcomes are typically based on a framework which provides a systematic way to develop, manage and evaluate interventions.

For example, Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) is a framework that measures the impact of a programme based on five factors. Reach, effectiveness, adoption, implementation and maintenance.27 Due to their pragmatic approach, hybrid trials frequently include heterogenous samples and clinical settings that optimise external validity and generalisability.26 28 They can be designed to primarily test the effects of a clinical interventions while observing and gathering information on implementation outcomes (type I), for equal evaluation of both the clinical intervention and implementation strategies (type II), or to primarily assess implementation outcomes while collecting effectiveness data (type III).26 29 For example, Beidas et al used a type I hybrid effectiveness–implementation trial design to test the effectiveness of an exercise intervention for breast cancer. This study not only evaluated the effectiveness of the intervention but also identified multiple significant implementation barriers such as cost, referral logistics and patient selection challenges which informed their subsequent dissemination efforts.30 Prospective, randomised, hybrid effectiveness–implementation designs focusing on other key implementation outcomes are a logical and necessary next step in advancing the field.

In total, the work by Saunders et al demonstrates the potential acceptability of an automated prognostic model to improve the timeliness of palliative care, setting the stage for further work to optimise and implement these programmes into real-world clinical care.Ethics statementsPatient consent for publicationNot required..

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