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Spending by the National Health Service continues to rise. To continue to offer safe and effective health care, we need to find ways to improve efficiency and reduce costs. Children make up one-fifth of the UK population and 10% of the general practice workload. If we can find ways to improve efficiency in paediatric care, everyone could benefit, most of all children and their parents.
EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy
Food allergy can have significant effects on morbidity and quality of life and can be costly in terms of medical visits and treatments. There is therefore considerable interest in generating efficient approaches that may reduce the risk of developing food allergy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Prevention and is part of the EAACI Guidelines for Food Allergy and Anaphylaxis. It aims to provide evidence-based recommendations for primary prevention of food allergy. A wide range of antenatal, perinatal, neonatal, and childhood strategies were identified and their effectiveness assessed and synthesized in a systematic review. Based on this evidence, families can be provided with evidence-based advice about preventing food allergy, particularly for infants at high risk for development of allergic disease. The advice for all mothers includes a normal diet without restrictions during pregnancy and lactation. For all infants, exclusive breastfeeding is recommended for at least first 4-6 months of life. If breastfeeding is insufficient or not possible, infants at high-risk can be recommended a hypoallergenic formula with a documented preventive effect for the first 4 months. There is no need to avoid introducing complementary foods beyond 4 months, and currently, the evidence does not justify recommendations about either withholding or encouraging exposure to potentially allergenic foods after 4 months once weaning has commenced, irrespective of atopic heredity. There is no evidence to support the use of prebiotics or probiotics for food allergy prevention. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Primary prevention of food allergy in children and adults: Systematic review
Background: Food allergies can have serious physical, social, and financial consequences. This systematic review examined ways to prevent the development of food allergy in children and adults. Methods: Seven bibliographic databases were searched from their inception to September 30, 2012, for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-and-after studies, interrupted time series studies, and prospective cohort studies. Experts were consulted for additional studies. There were no language or geographic restrictions. Two reviewers appraised the studies using appropriate tools. Data were not suitable for meta-analysis due to heterogeneity, so were narratively synthesized. Results Seventy-four studies were included, one-third of which were of high quality. There was no good evidence to recommend that pregnant or breastfeeding women should change their diet or take supplements to prevent allergies in infants at high or normal risk. There were mixed findings about the preventive benefits of breastfeeding for infants at high or normal risk, but there was evidence to recommend avoiding cow's milk and substituting with extensively or partially hydrolyzed whey or casein formulas for infants at high risk for the first 4 months. Soy milk and delaying the introduction of solid foods beyond 4 months did not have preventive benefits in those at high or normal risk. There was very little evidence about strategies for preventing food allergy in older children or adults. Conclusions: There is much to learn about preventing food allergy, and this is a priority given the high societal and healthcare costs involved. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Anaphylaxis: Guidelines from the European Academy of Allergy and Clinical Immunology
Anaphylaxis is a clinical emergency, and all healthcare professionals should be familiar with its recognition and acute and ongoing management. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals. The development of these guidelines has been underpinned by two systematic reviews of the literature, both on the epidemiology and on clinical management of anaphylaxis. Anaphylaxis is a potentially life-threatening condition whose clinical diagnosis is based on recognition of a constellation of presenting features. First-line treatment for anaphylaxis is intramuscular adrenaline. Useful second-line interventions may include removing the trigger where possible, calling for help, correct positioning of the patient, high-flow oxygen, intravenous fluids, inhaled short-acting bronchodilators, and nebulized adrenaline. Discharge arrangements should involve an assessment of the risk of further reactions, a management plan with an anaphylaxis emergency action plan, and, where appropriate, prescribing an adrenaline auto-injector. If an adrenaline auto-injector is prescribed, education on when and how to use the device should be provided. Specialist follow-up is essential to investigate possible triggers, to perform a comprehensive risk assessment, and to prevent future episodes by developing personalized risk reduction strategies including, where possible, commencing allergen immunotherapy. Training for the patient and all caregivers is essential. There are still many gaps in the evidence base for anaphylaxis. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
EAACI Food Allergy and Anaphylaxis Guidelines: Diagnosis and management of food allergy
Food allergy can result in considerable morbidity, impact negatively on quality of life, and prove costly in terms of medical care. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Guidelines for Food Allergy and Anaphylaxis Group, building on previous EAACI position papers on adverse reaction to foods and three recent systematic reviews on the epidemiology, diagnosis, and management of food allergy, and provide evidence-based recommendations for the diagnosis and management of food allergy. While the primary audience is allergists, this document is relevant for all other healthcare professionals, including primary care physicians, and pediatric and adult specialists, dieticians, pharmacists and paramedics. Our current understanding of the manifestations of food allergy, the role of diagnostic tests, and the effective management of patients of all ages with food allergy is presented. The acute management of non-life-threatening reactions is covered in these guidelines, but for guidance on the emergency management of anaphylaxis, readers are referred to the related EAACI Anaphylaxis Guidelines. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
Evaluation of medium-term consequences of implementing commercial computerized physician order entry and clinical decision support prescribing systems in two 'early adopter' hospitals.
To understand the medium-term consequences of implementing commercially procured computerized physician order entry (CPOE) and clinical decision support (CDS) systems in 'early adopter' hospitals. In-depth, qualitative case study in two hospitals using a CPOE or a CDS system for at least 2 years. Both hospitals had implemented commercially available systems. Hospital A had implemented a CPOE system (with basic decision support), whereas hospital B invested additional resources in a CDS system that facilitated order entry but which was integrated with electronic health records and offered more advanced CDS. We used a combination of documentary analysis of the implementation plans, audiorecorded semistructured interviews with system users, and observations of strategic meetings and systems usage. We collected 11 documents, conducted 43 interviews, and conducted a total of 21.5 h of observations. We identified three major themes: (1) impacts on individual users, including greater legibility of prescriptions, but also some accounts of increased workloads; (2) the introduction of perceived new safety risks related to accessibility and usability of hardware and software, with users expressing concerns that some problems such as duplicate prescribing were more likely to occur; and (3) realizing organizational benefits through secondary uses of data. We identified little difference in the medium-term consequences of a CPOE and a CDS system. It is important that future studies investigate the medium- and longer-term consequences of CPOE and CDS systems in a wider range of hospitals. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Investigating the cost-effectiveness of health information technologies: A systematic review protocol
Introduction: There is a need to develop new, more cost-effective models of healthcare and in this vein there is a considerable international interest in exploiting the potential offered by major developments in health information technologies (HITs). Very substantial investments are, as a result, now being made globally, but these still probably only represent a fraction of the investments needed if healthcare is to make the transition from the paper to the digital era. Investing greater resources is, however, inherently challenging and unpopular at a time of financial austerity and this is furthermore complicated by the thus far variable evidence of health benefits and demonstrable short-term to medium-term returns associated with investments in HITs. Objectives: Building on our related systematic overviews investigating the impact of HITs, we now seek to estimate the cost-effectiveness of HITs and as a secondary aim to identify potentially transferable lessons in relation to how to realise returns on investments in these technologies. Methods: We will conduct a systematic review to identify the empirical evidence base surrounding the return on investments from implementing HITs. Two reviewers will independently search major international databases for published, unpublished and on-going experimental and quasi-experimental studies of interest published during the period 1990-2013. These searches of bibliographic databases will be supplemented by contacting an international panel of experts. There will be no restriction on the language of publication of studies. Studies will be critically appraised using the Critical Appraisal Skills Programme (CASP) Economic Evaluations checklist. In view of the anticipated heterogeneity in intervention investigated, study design and health system contexts, we will undertake a descriptive, narrative and interpretative synthesis of data. Ethics and dissemination: Ethical approval is not required. Results: These will be presented in one manuscript. The protocol is registered with the International Prospective Register for Systematic Reviews (PROSPERO) CRD42013005294.
The orthopaedic error index: Development and application of a novel national indicator for assessing the relative safety of hospital care using a cross-sectional approach
Objective: The Orthopaedic Error Index for hospitals aims to provide the first national assessment of the relative safety of provision of orthopaedic surgery. Design: Cross-sectional study (retrospective analysis of records in a database). Setting: The National Reporting and Learning System is the largest national repository of patient-safety incidents in the world with over eight million error reports. It offers a unique opportunity to develop novel approaches to enhancing patient safety, including investigating the relative safety of different healthcare providers and specialties. Participants: We extracted all orthopaedic error reports from the system over 1 year (2009-2010). Outcome measures: The Orthopaedic Error Index was calculated as a sum of the error propensity and severity. All relevant hospitals offering orthopaedic surgery in England were then ranked by this metric to identify possible outliers that warrant further attention. Results: 155 hospitals reported 48 971 orthopaedic-related patient-safety incidents. The mean Orthopaedic Error Index was 7.09/year (SD 2.72); five hospitals were identified as outliers. Three of these units were specialist tertiary hospitals carrying out complex surgery; the remaining two outlier hospitals had unusually high Orthopaedic Error Indexes: mean 14.46 (SD 0.29) and 15.29 (SD 0.51), respectively. Conclusions: The Orthopaedic Error Index has enabled identification of hospitals that may be putting patients at disproportionate risk of orthopaedic-related iatrogenic harm and which therefore warrant further investigation. It provides the prototype of a summary index of harm to enable surveillance of unsafe care over time across institutions. Further validation and scrutiny of the method will be required to assess its potential to be extended to other hospital specialties in the UK and also internationally to other health systems that have comparable national databases of patient-safety incidents.
Twenty four-hour helpline access to expert management advice for food-allergy-triggered anaphylaxis in infants, children and young people: A pragmatic, randomized controlled trial
Background Anaphylaxis is a life-threatening emergency. If promptly administered, adrenaline is potentially life-saving. Many food-allergic- children/carers are unsure when to use their adrenaline autoinjectors, contributing to a low quality of life and worse outcomes in the setting of an acute allergic reaction. Objectives The aim of this study was to assess the effectiveness of 24-hour telephone access to specialist clinical advice on disease-specific quality of life. Methods A pragmatic two-arm, parallel-group randomized control trial was conducted. Children/carers (<16 years) with food allergy, trained in adrenaline auto-injector use, were recruited from a hospital-based paediatric allergy clinic. Baseline disease-specific quality of life was ascertained using the validated Food-Allergy-Related Quality-of-Life Questionnaire (FAQLQ), either Parent Form, Child Form or Teenager Form depending on child's age. Participants were then centrally randomized for a 6-month period to 24-hour telephone specialist support line or to usual care. The primary outcome measure was a change in FAQL scores, at one and 6 months postrandomization, compared with baseline. The minimum clinically important difference (MCID) in score is 0.5. Results Fifty two children/carers were recruited. FAQL scores remained static in the control group across the three time points. Scores gradually improved in the intervention group, with a significant difference seen at 6 months (T1-T3 Mean difference = -1.5, (CI 0.87-2.25) P < 0.005] Follow-up questionnaires, 6 months after the intervention was removed, T4, showed sustained significant difference between the groups (control M = 3.0; intervention M = 1.1[t = -4.113, P < 0.05]). Conclusion The 24-hour helpline improved food-allergy-specific quality of life in children. Six-month intervention support resulted in sustained benefits for at least a further 6 months. © 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.
The quality of reporting of randomised controlled trials in asthma: A systematic review
Background: There are concerns about the reporting quality of asthma trials. Aims: To describe the reporting of contemporary asthma trials and to identify factors associated with better reporting quality. Methods: Two reviewers independently searched MEDLINE for randomised controlled trials (RCTs) of asthma published between January 2010 and July 2012 in leading generalist and specialist journals. We calculated the proportion of trials that adequately reported each Consolidated Standards of Reporting Trials (CONSORT) checklist item and an overall quality score for each trial. Factors associated with better reporting quality were investigated. Results: Thirty-five RCTs satisfied our eligibility criteria. Four trials adequately reported <50% of the items, 15 adequately reported 50-60% of items, and 16 adequately reported >60% of items. Seventeen of the 38 CONSORT items were consistently well reported in more than two-thirds of the articles. In contrast, nine items were poorly reported in more than half the trials - namely, identification as a randomised trial in the title (40.0%), an adequate structured summary/abstract (48.6%), details of eligibility criteria (34.3%), recruitment (48.6%), randomisation procedures (22.9%), intervention (38.5%), harms (34.3%), the funding source (45.7%), and access to the full trial protocol (17.1%). Studies led by teams in high-income country settings were associated with better quality of reporting (relative risk=1.33, 95% CI 1.09 to 1.64). Conclusions: The quality of reporting in contemporary asthma literature remains suboptimal. We have identified important areas in which reporting quality needs to be improved. © 2013 Primary Care Respiratory Society UK. All rights reserved.
Behavior change interventions to improve the health of racial and ethnic minority populations: A tool kit of adaptation approaches
Context Adapting behavior change interventions to meet the needs of racial and ethnic minority populations has the potential to enhance their effectiveness in the target populations. But because there is little guidance on how best to undertake these adaptations, work in this field has proceeded without any firm foundations. In this article, we present our Tool Kit of Adaptation Approaches as a framework for policymakers, practitioners, and researchers interested in delivering behavior change interventions to ethnically diverse, underserved populations in the United Kingdom. Methods We undertook a mixed-method program of research on interventions for smoking cessation, increasing physical activity, and promoting healthy eating that had been adapted to improve salience and acceptability for African-, Chinese-, and South Asian-origin minority populations. This program included a systematic review (reported using PRISMA criteria), qualitative interviews, and a realist synthesis of data. Findings We compiled a richly informative data set of 161 publications and twenty-six interviews detailing the adaptation of behavior change interventions and the contexts in which they were undertaken. On the basis of these data, we developed our Tool Kit of Adaptation Approaches, which contains (1) a forty-six-item Typology of Adaptation Approaches; (2) a Pathway to Adaptation, which shows how to use the Typology to create a generic behavior change intervention; and (3) RESET, a decision tool that provides practical guidance on which adaptations to use in different contexts. Conclusions Our Tool Kit of Adaptation Approaches provides the first evidence-derived suite of materials to support the development, design, implementation, and reporting of health behavior change interventions for minority groups. The Tool Kit now needs prospective, empirical evaluation in a range of intervention and population settings. © 2013 Milbank Memorial Fund.
Smoking cessation interventions for ethnic minority groups - A systematic review of adapted interventions
Objective: Existing smoking cessation interventions tend to be under utilized by ethnic minority groups. We sought to identify smoking cessation interventions that have been adapted to meet the needs of African-, Chinese- and South Asian-origin populations, to increase understanding of the approaches used to promote behavior change, to assess their acceptability to the target populations, and to evaluate their effectiveness. Methods: Two reviewers independently searched for, identified, critically appraised and extracted data from studies identified from 11 databases (January 1950-April 2013). Study quality was assessed using validated instruments (EPHPP and STROBE). Adaptations were independently coded using an established typology, and findings descriptively summarized and thematically synthesized. Results: 23 studies described interventions adapted for African-Americans, and five for Chinese-origin populations. No intervention adapted for South-Asian populations was identified. Six studies directly compared a culturally adapted versus a non-adapted intervention. Adapted interventions were more acceptable to ethnic minority groups, but this did not translate into improvements in smoking cessation outcomes. Conclusions: Given the evidence of greater acceptability of adapted interventions, it may be ethically preferable to use these. There is, however, no clear evidence of the effectiveness of adapted interventions in promoting smoking cessation in ethnic minority groups. © 2013 Elsevier Inc.
Exploring telemonitoring and self-management by patients with chronic obstructive pulmonary disease: A qualitative study embedded in a randomized controlled trial
Objective: To explore patient and professional views on self-management in the context of telemonitoring in chronic obstructive pulmonary disease (COPD). Methods: Semi-structured interviews with patients with COPD and healthcare professionals participating in a randomized controlled trial of telemonitoring in Lothian, Scotland, explored experiences of using telemonitoring, and dynamics in patient-practitioner relationships. Transcribed data were analyzed using the Framework approach. Results: 38 patients (mean age 67.5 years) and 32 professionals provided 70 interviews. Patients considered that telemonitoring empowered self-management by enhancing their understanding of COPD and providing additional justification for their decisions to adjust treatment or seek professional advice. Professionals discussed telemonitoring as promoting compliance with medical advice and encouraged patients to exercise personal responsibility within clinical parameters, but expressed concerns about promoting the sick role and creating dependence on telemonitoring. Conclusion: Telemonitoring assisted many patients to embrace greater responsibility for their health but the model of service provision remained clinician-centered. A medical model of 'compliant self-management' may paradoxically have promoted dependence on professionals. Practice implications: Patients and professionals shared responsibility for meeting the central objective of prompt management of exacerbations of COPD. Care is needed, however, to minimize the risk in some patients, of telemonitoring increasing dependence on practitioner support. © 2013 Elsevier Ireland Ltd.
Integrating telehealth care-generated data with the family practice electronic medical record: qualitative exploration of the views of primary care staff.
BACKGROUND: Telehealth care is increasingly being employed in the management of long-term illness. Current systems are largely managed via "stand-alone" websites, which require additional log-ons for clinicians to view their patients' symptom records and physiological measurements leading to frustrating delays and sometimes failure to engage with the record. However, there are challenges to the full integration of patient-acquired data into family physicians' electronic medical records (EMR) in terms of reliability, how such data can best be summarized and presented to avoid overload to the clinicians, and how clarity of responsibility is managed when multiple agencies are involved. OBJECTIVE: We aimed to explore the views of primary care clinicians on the acceptability, clinical utility, and, in particular, the benefits and risks of integrating patient-generated telehealth care data into the family practice EMR and to explore how these data should be summarized and presented in order to facilitate use in routine care. METHODS: In our qualitative study, we carried out semi-structured interviews with clinicians with experience of and naïve to telehealth care following demonstration of pilot software, which illustrated various methods by which data could be incorporated into the EMR. RESULTS: We interviewed 20 clinicians and found 2 overarching themes of "workload" and "safety". Although clinicians were largely positive about integrating telehealth care data into the EMR, they were concerned about the potential increased workload and safety issues, particularly in respect to error due to data overload. They suggested these issues could be mitigated by good system design that summarized and presented data such that they facilitated seamless integration with clinicians' current routine processes for managing data flows, and ensured clear lines of communication and responsibility between multiple professionals involved in patients' care. CONCLUSIONS: Family physicians and their teams are likely to be receptive to and see the benefits of integrating telehealth-generated data into the EMR. Our study identified some of the key challenges that must be overcome to facilitate integration of telehealth care data. This work particularly underlines the importance of actively engaging with clinicians to ensure that systems are designed that align well with existing practice data-flow management systems and facilitate safe multiprofessional patient care.