BACKGROUND:There is limited international agreement on defining care quality for the millions of people hospitalized with heart failure worldwide. Our objective was to compare and measure agreement across existing internationally published quality indicators (QIs) for the care of adults hospitalized for heart failure. METHODS:Systematic review and evidence gap map of internationally published articles reporting on QIs for adults hospitalized for heart failure, using PubMed, MEDLINE, EMBASE, and TRIP from inception to July 18, 2022. Narrative synthesis and descriptive statistics characterized included articles and QIs using the Donabedian Framework of Structural, Process, and Outcomes. The methodological quality of QI sets was assessed using the Appraisal of Indicators through Research and Evaluation instrument. Agreement about QIs was defined as having at least 3 different cardiovascular societies recommend its use. An evidence gap map displayed each QI according to its clinically relevant category, methodological quality, and reporting articles. RESULTS:Fourteen articles from 11 societies reported 75 unique QIs; 53 QIs were process, 16 were structural, and 7 were outcome measures. There was limited agreement on individual QIs across sets as a minority were recommended by ≥3 societies (12%; 9/75 QIs). The most common QIs included postdischarge follow-up (73%, 8/11 societies), specific pharmacotherapy (64%, 7/11 societies), patient education (45%, 5/11 societies), assessment of left ventricular ejection fraction (45%, 5/11 societies), 30-day readmission rate (45%, 5/11 societies), cardiac rehabilitation (36%, 4/11 societies), and multidisciplinary management (27%, 3/11 societies). CONCLUSIONS:There was little agreement on defining high-quality care and limited agreement on measures including postdischarge follow-up, specific pharmacotherapies, patient education, assessment of left ventricular ejection fraction, 30-day readmission, cardiac rehabilitation, and multidisciplinary management. These measures may define high-quality care and highlight opportunities to improve the quality of care for adults hospitalized for heart failure.

© Author(s) (or their employer(s)) 2023. No commercial reuse. See rights and permissions. Published by BMJ. Too often, seemingly simple interventions are implemented without fully considering how the intervention might achieve the desired results, whether it can cause harm, or whether a different intervention should be considered. The tendency to favour rapid cycle implementation over analysis and measurement represents a common pitfall in quality and safety studies. Quality improvement and patient safety (QIPS) studies often omit the critical details underlying the success (or lack thereof) of the intervention, in part due to the perception that simple interventions do not require rigorous measurement. 4 Consequently, reported measures often solely focus on the outcomes rather than the mechanisms and processes that led to the outcomes. For instance, suppose you are doing rounds at your healthcare setting. You notice a blue flower next to your patient’s name on the electronic whiteboard, but you are unsure what it means. Your colleague tells you that the blue flower is part of a dementia care quality improvement programme. You wonder how exactly the blue flower is supposed to make dementia care better. In this issue of BMJ Quality & Safety, Sutton and colleagues identify the mechanisms by which visual identifiers for patients with dementia can generate positive or negative consequences. The qualitative study consisted of indepth case reviews and interviews with 21 dementia leads and healthcare professionals, 19 carers and 2 people with dementia (PwD) in four acute care hospitals. The authors identified four mechanisms through which visual identifiers can potentially enhance care for PwD: (1) acting as quick reference cue for staff, (2) signalling eligibility for dementiaspecific interventions, (3) informing prioritisation of resources on wards and (4) enabling coordination of care at organisational level. The authors also identify factors that can undermine the effectiveness of the intervention or result in unintended effects such as stigma associated with a dementia diagnosis. The findings highlight the importance of knowing why and how an intervention might achieve the desired effects. One surprising observation is that this study was done after several national improvement projects had been undertaken, without apparent knowledge of how such an intervention might work, what other elements of the intervention might be needed and what unintended downsides might be incurred. A prior systematic review of dementia identifiers focused only on whether such identifiers were acceptable. A study like that of Sutton and colleagues would have been a very helpful first step prior to a costly widespread implementation of a potentially ineffective intervention. Without an understanding of why and how an intervention might be successful, even apparently simple interventions may prove difficult to implement and ineffective at improving patient care. Compared with clinical trials which use rigorous measurement with dedicated funding and clear protocols for data collection, quality and safety studies have fewer measurement standards and less funding. 4 8 A recent Delphi panel suggested 61 measurement considerations to guide projects from initial conception through to scaled sustainable implementation. We propose five golden rules for measurement that should help improvement projects get started in the right direction.

Background: Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors. Methods: We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more. Results: We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%–13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit. Interpretation: Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

Donald A Redelmeier , Edward E Etchells and Umberin Najeeb Department of Medicine, University of Toronto, Toronto, ON, M5S 3H2, Canada Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, ON M4N 3M5, Canada Institute for Clinical Evaluative Sciences in Ontario, Toronto, ON M4N 3M5, Canada Division of General Internal Medicine, Sunnybrook Health Science Centre, Toronto ON M4Y 3M5, Canada Centre for Quality Improvement and Patient Safety, University of Toronto, Toronto, ON, M5T 3M6, Canada Division of General Internal Medicine, Women’s College Hospital, Toronto, ON M5S 1B2, Canada Corresponding author: Donald A Redelmeier. Email: dar@ices.on.ca

[Voir la version anglaise de l’article ici : www.cmaj.ca/lookup/doi/10.1503/cmaj.220302][1] Vishma est née à Toronto de parents immigrés originaires de Trinité-et-Tobago. Elle a eu une enfance heureuse, faite de moments agréables, passés en famille et entre amis. À 19 ans, Vishma a eu une

The authors declare no conflicts of interest.

Vishma was born in Toronto to parents who had immigrated from Trinidad and Tobago. Her childhood was filled with family, friends and fun. When she was 19 years old, she had a daughter and graduated from high school. She subsequently got her undergraduate degree and began her career in sales and

ABSTRACT Objectives Emergency department (ED) patients with unexplained syncope are at risk of experiencing an adverse event within 30 days. Our objective was to systematically review the accuracy of multivariate risk stratification scores for identifying adult syncope patients at high and low risk of an adverse event over the next 30 days. Methods We conducted a systematic review of electronic databases (MEDLINE, Cochrane, Embase, and CINAHL) from database creation until May 2020. We sought studies evaluating prediction scores of adults presenting to an ED with syncope. We included studies that followed patients for up to 30 days to identify adverse events such as death, myocardial infarction, stroke, or cardiac surgery. We only included studies with a blinded comparison between baseline clinical features and adverse events. We calculated likelihood ratios and confidence intervals (CIs). Results We screened 13,788 abstracts. We included 17 studies evaluating nine risk stratification scores on 24,234 patient visits, where 7.5% (95% CI = 5.3% to 10%) experienced an adverse event. A Canadian Syncope Risk Score (CSRS) of 4 or more was associated with a high likelihood of an adverse event (LR score≥4 = 11, 95% CI = 8.9 to 14). A CSRS of 0 or less (LR score≤0 = 0.10, 95% CI = 0.07 to 0.20) was associated with a low likelihood of an adverse event. Other risk scores were not validated on an independent sample, had low positive likelihood ratios for identifying patients at high risk, or had high negative likelihood ratios for identifying patients at low risk. Conclusion Many risk stratification scores are not validated or not sufficiently accurate for clinical use. The CSRS is an accurate validated prediction score for ED patients with unexplained syncope. Its impact on clinical decision making, admission rates, cost, or outcomes of care is not known.

Background Patients with heart failure (HF) are at the highest risk for hospital readmissions during the first few weeks after discharge when patients are transitioning from hospital to home. Telemonitoring (TM) for HF management has been found to reduce mortality risk and hospital readmissions if implemented appropriately; however, the impact of TM targeted for patients recently discharged from hospital, for whom TM might have the biggest benefit, is still unknown. Medly, a mobile phone–based TM system that is currently being used as a standard of care for HF at a large Canadian hospital, may be an effective tool for the management of HF in patients recently discharged from hospital. Objective The objective of the Medly-After an Incidence of acute Decompensation (Medly-AID) trial is to determine the effect of Medly on the self-care and quality of life of patients with HF who have been recently discharged from hospital after an HF-related decompensation. Methods A multisite multimethod randomized controlled trial (RCT) will be conducted at 2 academic hospitals and at least one community hospital to evaluate the impact of Medly-enabled HF management on the outcomes of patients with HF who had been hospitalized for HF-related decompensation and discharged during the 2 weeks before recruitment. The trial will include 144 participants with HF (74 in each control and intervention groups). Control patients will receive standard of care, whereas patients in the intervention group will receive standard of care and Medly. Specifically, patients in the intervention group will record daily weight, blood pressure, and heart rate and answer symptom-related questions via the Medly app. Medly will generate automated patient self-care messages such as to adjust diuretic medications, based on the rules-based algorithm personalized to the individual patient, and send real-time alerts to their health care providers as necessary. All patients will be followed for 3 months. Primary outcome measures are self-care and quality of life as measured through the validated questionnaires Self-Care of Heart Failure Index, EQ-5D-5L, and the Kansas City Cardiomyopathy Questionnaire-12. Secondary outcome measures for this study include cost of health care services used and health outcomes. Results Patient recruitment began in November 2018 at the Sunnybrook Health Sciences Centre, with a total of 35 participants recruited by July 30, 2019 (17 in the intervention group and 18 in the control group). The final analysis is expected to occur in the fall of 2020. Conclusions This RCT will be the first to assess the effectiveness of the Medly TM system for use following discharge from hospital after a HF-related decompensation. Trial Registration ClinicalTrials.gov NCT03358303; https://clinicaltrials.gov/ct2/show/NCT03358303 International Registered Report Identifier (IRRID) DERR1-10.2196/15753

As the global population ages and the prevalence of dementia rises, telemedicine has garnered attention as a means of delivering care to a frail cognitively-impaired population through a virtual interface. The benefits of telemedicine-based in person patient-physician encounters include increased access to healthcare irrespective of distance, as well as reduction in travel costs and carbon emissions. While Telemedicine has proven feasible and effective in other areas of medicine, its use in a cognitively-impaired population is less well studied and poses unique challenges. The current literature review aims to compare and contrast the use of televisits across neurodegenerative disease, with a particular focus on dementia care. We performed a systematic review of the literature published between January 2000 and January 2020. Databases OVID Medline and PubMed were searched using keywords “Telemedicine”, “Neurodegenerative disease”, “Dementia” and their respective synonyms. Eligible articles were selected after screening the titles and abstracts. Studies were included if they examined the use of virtual healthcare visits (i.e. televisits) in the management of patients with neurodegenerative diseases. The search yielded 503 potentially eligible articles. After further screening, a total of 35 articles met inclusion criteria. Positive benefits of televisits across neurodegenerative diseases included high rates of patient satisfaction, feasibility and validity. A particular challenge that emerged as unique in dementia care is a lack of interpersonal engagement. While telemedicine has clear potential benefits for neurodegenerative disease management, further research is required to assess long-term clinical and quality of life outcomes in patients with dementia.

IMPORTANCE Syncope can result from a reduction in cardiac output from serious cardiac conditions, such as arrhythmias or structural heart disease (cardiac syncope), or other causes, such as vasovagal syncope or orthostatic hypotension. OBJECTIVE To perform a systematic review of studies of the accuracy of the clinical examination for identifying patients with cardiac syncope. STUDY SELECTION Studies of adults presenting to primary care, emergency departments, or referred to specialty clinics. DATA EXTRACTION AND SYNTHESIS Relevant data were abstracted from articles in databases through April 9, 2019, and methodologic quality was assessed. Included studies had an independent comparison to a reference standard. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, and likelihood ratios (LRs). RESULTS Eleven studies of cardiac syncope (N = 4317) were included. Age at first syncope of at least 35 years was associated with greater likelihood of cardiac syncope (n = 323; sensitivity, 91%[95% CI, 85%-97%]; specificity, 72%[95% CI, 66%-78%]; LR, 3.3 [95% CI, 2.6-4.1]), while age younger than 35 years was associated with a lower likelihood (LR, 0.13 [95% CI, 0.06-0.25]). A history of atrial fibrillation or flutter (n = 323; sensitivity, 13%[95% CI, 6%-20%]; specificity, 98%[95% CI, 96%-100%]; LR, 7.3 [95% CI, 2.4-22]), or known severe structural heart disease (n = 222; range of sensitivity, 35%-51%, range of specificity, 84%-93%; range of LR, 3.3-4.8; 2 studies) were associated with greater likelihood of cardiac syncope. Symptoms prior to syncope that were associated with lower likelihood of cardiac syncope were mood change or prodromal preoccupation with details (n = 323; sensitivity, 2% [95% CI, 0%-5%]; specificity, 76%[95% CI, 71%-81%]; LR, 0.09 [95% CI, 0.02-0.38]), feeling cold (n = 412; sensitivity, 2%[95% CI, 0%-5%]; specificity, 89%[95% CI, 85%-93%]; LR, 0.16 [95% CI, 0.06-0.64]), or headache (n = 323; sensitivity, 3%[95% CI, 0%-7%]; specificity, 80% [95% CI, 75%-85%]; LR, 0.17 [95% CI, 0.06-0.55]). Cyanosis witnessed during the episode was associated with higher likelihood of cardiac syncope (n = 323; sensitivity, 8%[95% CI, 2%-14%]; specificity, 99%[95% CI, 98%-100%]; LR, 6.2 [95% CI, 1.6-24]). Mood changes after syncope (n = 323; sensitivity, 3%[95% CI, 0%-7%]; specificity, 83%[95% CI, 78%-88%]; LR, 0.21 [95% CI, 0.06-0.65]) and inability to remember behavior prior to syncope (n = 323; sensitivity, 5%[95% CI, 0%-9%]; specificity, 82%[95% CI, 77%-87%]; LR, 0.25, [95% CI, 0.09-0.69]) were associated with lower likelihood of cardiac syncope. Two studies prospectively validated the accuracy of the multivariable Evaluation of Guidelines in Syncope Study (EGSYS) score, which is based on 6 clinical variables. An EGSYS score of less than 3 was associated with lower likelihood of cardiac syncope (n = 456; range of sensitivity, 89%-91%, range of specificity, 69%-73%; range of LR, 0.12-0.17; 2 studies). Cardiac biomarkers show promising diagnostic accuracy for cardiac syncope, but diagnostic thresholds require validation. CONCLUSIONS AND RELEVANCE The clinical examination, including the electrocardiogram as part of multivariable scores, can accurately identify patients with and without cardiac syncope.

The implementation of health information technology (HIT) is complex. A method for mitigating complexity is incrementalism. Incrementalism forms the foundation of both incremental software development models, like agile, and the Plan-Do-Study-Act cycles (PDSAs) of quality improvement (QI), yet we often fail to be incremental at the union of the disciplines. We propose a new model for HIT implementation that explicitly links incremental software development cycles with PDSAs, the QI-HIT Figure 8 (QIHIT-F8). We then detail a subsequent local HIT implementation where we demonstrated its use. The QIHIT-F8 requires a reprioritization of project management activities around tests of change, strong QI principles to detect these changes, and the presence of both baseline and prospective data about the chosen indicators. These conditions are most likely to be present when applied to indicators of high strategic importance to an organization.

Background/context Unnecessary laboratory testing leads to considerable healthcare costs. Aspartate aminotransferase (AST), commonly ordered with alanine aminotransferase (ALT) and blood urea nitrogen (BUN), commonly ordered with creatinine (Cr), often add little value to patient management at significant cost. We undertook a choosing wisely based quality improvement initiative to reduce the frequency of testing. Objectives To reduce the ratio of AST/ALT and BUN/Cr to less than 5% for all inpatient and outpatient test orders. Measures Absolute number and ratio of AST/ALT and BUN/Cr; AST, ALT, BUN and Cr tests per 100 hospital days; projected annualised cost savings and monthly acute inpatient bed days. Improvements We created guidelines for appropriate indications of AST and BUN testing, provided education with audit and feedback and removed AST and BUN from institutional order sets. Impact/results The ratios of AST/ALT and BUN/Cr decreased significantly over the study period (0.37 to 0.14, 0.57 to 0.14, respectively), although the goal of 0.05 was not achieved due to a delay in adopting the choosing wisely strategies during the study time period by some inpatient units. The number of tests per 100 hospital days decreased from 20 to 7 AST (95% CI 19 to 20.5, 5.6 to 8.7, p<0.001) and from 72 to 17 BUN (95% CI 70 to 73.4, 16.6 to 22.9, p<0.001). The initiative resulted in a projected annualised cost savings of C$221 749. Discussion A significant decrease in the AST/ALT and BUN/Cr ratios can be achieved with a multimodal approach and will result in substantial healthcare savings.

See article on page 972–980, in this issue

A 60-year-old woman presented with intractable nausea and vomiting, which had progressively intensified over the past 2 weeks. Her past medical history was remarkable for mild thrombocytopenia and mildly elevated liver enzymes. Her vomiting was triggered by oral intake, nonbloody and nonbilious, and associated with nonresolving epigastric pain, dysphagia, anorexia, and weight loss. She had no remarkable exposures or ill contacts. Examination revealed an ill-looking patient with sinus tachycardia and clinical volume depletion. Epigastric palpation reproduced her pain and triggered vomiting. There were no other localizing abdominal findings. An incidental note was made of a diffusely enlarged, nontender thyroid, with no lymphadenopathy.

A 54-year-old woman presented to the emergency department with increasing shortness of breath over four days. She reported an increased cough over the previous two months and that her daughter recently had an upper respiratory tract infection. The patient had metastatic breast cancer (estrogen-

In this issue of BMJ Quality & Safety , Schnipper et al evaluate the implementation of a multifaceted medication reconciliation intervention at six hospitals using the MARQUIS medication reconciliation implementation toolkit.1 The planned intervention included the following elements: hiring or reallocating new staff to obtain medication histories, performing both admission and discharge medication reconciliation, improving access to preadmission medication sources, introducing policy, training staff on obtaining medication histories and patient counselling, implementing a gold standard medication reconciliation process including targeting of high-risk patients, improving healthcare information technology and utilising social marketing and community engagement. The study had many methodological strengths, including independent observers for outcome verification, clinical assessment of medication discrepancies, pragmatic implementation in both community and teaching hospitals, mentored implementation and a large randomly selected patient sample with controls and temporal trending. The main result was that potentially harmful discrepancies did not decrease over time beyond baseline temporal trends (adjusted incidence rate ratio 0.97 per month (0.86 to 1.08), p=0.53). One potential explanation for the main result of Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) is that multifaceted medication reconciliation interventions are ineffective. We think this is unlikely. While the overall quality of the literature remains mixed,2 several well-designed studies demonstrate that medication reconciliation programmes can successfully reduce potentially harmful medication discrepancies, and some studies show downstream benefits on healthcare utilisation.3–5 To optimise patient impact, effective medication reconciliation should be embedded in a multifaceted medication management interventional bundle, …