The Impact of Health Equity-Informed Eligibility Criteria to Increase the Delivery of Pharmacist-Delivered Comprehensive Medication Management Services for Patients with High Blood Pressure

OBJECTIVE

Evaluate a cardiovascular care intervention intended to increase access to comprehensive medication management (CMM) pharmacy care and improve vascular health goals among socially disadvantaged patients.

DESIGN

Retrospective electronic health records-based evaluation.

SETTING

Thirteen health care clinics serving socially vulnerable neighborhoods within a large health system.

PARTICIPANTS

Hypertensive and hyperlipidemic adult patients.

INTERVENTION

CMM pharmacists increased recruitment among patients who met clinical criteria in clinics serving more diverse and socially vulnerable communities. CMM pharmacists partnered with patients to work toward meeting health goals through medication management and lifestyle modification.

MAIN OUTCOME MEASURES

Changes in the engagement of socially disadvantaged patients between preintervention and intervention time periods; vascular health goals (ie, controlled blood pressure, appropriate statin and aspirin therapies, and tobacco nonuse); and the use of health system resources by CMM care group.

RESULTS

The intervention indicated an overall shift in sociodemographics among patients receiving CMM care (fewer non-Hispanic Whites: N = 1988, 55.81% vs N = 2264, 59.97%, P < .001; greater place-based social vulnerability: N = 1354, 38.01% vs N = 1309, 34.68%, P = .03; more patients requiring interpreters: N = 776, 21.79% vs N = 698, 18.49%, P < .001) compared to the preintervention period. Among patients meeting intervention criteria, those who partnered with CMM pharmacists (N = 439) were more likely to connect with system resources (social work: N = 47, 10.71% vs 163, 3.74%, P < .001; medical specialists: N = 249, 56.72% vs N = 1989, 45.66%; P < .001) compared to those without CMM care (N = 4356). Intervention patients who partnered with CMM pharmacists were also more likely to meet blood pressure (N = 357, 81.32% vs N = 3317, 76.15%, P < .001) and statin goals (N = 397, 90.43% vs N = 3509, 80.56%, P < .001) compared to non-CMM patients.

CONCLUSIONS

The demographics of patients receiving CMM became more diverse with the intervention, indicating improved access to CMM pharmacists. Cultivating relationships among patients with greater social disadvantage and cardiovascular disease and CMM pharmacists may improve health outcomes and connect patients to essential resources, thus potentially improving long-term cardiovascular outcomes.

Feelings expressed by professionals caring for children and teenagers victims of sexual violence

OBJECTIVE

to describe the feelings expressed by health professionals when caring for child and adolescent victims of sexual violence from the theoretical perspective of Symbolic Interactionism.

METHOD

qualitative research carried out with 30 female health professionals. An instrument was used consisting of closed questions for sociodemographic data and a script with open questions for interviews. The data was organized and analyzed using Nvivo software version 12, according to Bardin's proposal, from the perspective of Symbolic Interactionism in the work of Charles Morris. The project was approved by the Research Ethics Committee.

RESULTS

five thematic categories emerged, revealing feelings of empathy, fear, indignation, suffering, and consternation. These feelings remained in the interviewees' memories, making caring for child and adolescent victims of sexual violence a moving and difficult experience that deeply marks the life of the health professional.

CONCLUSION

there is a need to adopt strategies to support the mental health of professionals who work in services that provide general care to children and adolescents, considering that there is a possibility that they will provide care to child and adolescent victims of sexual violence in compliance with pre-existing public policies.

HIGHLIGHTS

(1) Feelings stem from individual impressions in line with social interaction. (2) Caring for child and adolescent victims has a negative impact on professionals' emotions. (3) Service managers need to pay attention to the health of professionals who assist victims.

The Effectiveness of Collaborative Care Interventions for the Management of Patients With Multimorbidity: Protocol for a Systematic Review, Meta-Analysis, and Meta-Regression Analysis

BACKGROUND

Collaborative care interventions have been proposed as a promising strategy to support patients with multimorbidity. Despite this, the effectiveness of collaborative care interventions requires further evaluation. Existing systematic reviews describing the effectiveness of collaborative care interventions in multimorbidity management tend to focus on specific interventions, patient subgroups, and settings. This necessitates a comprehensive review that will provide an overview of the effectiveness of collaborative care interventions for adult patients with multimorbidity.

OBJECTIVE

This systematic review aims to systematically assess the effectiveness of collaborative care interventions in comparison to usual care concerning health-related quality of life (HRQoL), mental health, and mortality among adult patients with multimorbidity.

METHODS

Randomized controlled trials evaluating collaborative care interventions designed for adult patients (18 years and older) with multimorbidity compared with usual care will be considered for inclusion in this review. HRQoL will be the primary outcome. Mortality and mental health outcomes such as rating scales for anxiety and depression will serve as secondary outcomes. The systematic search will be conducted in the CENTRAL, PubMed, CINAHL, and Embase databases. Additional reference and citation searches will be performed in Google Scholar, Web of Science, and Scopus. Data extraction will be comprehensive and include information about participant characteristics, study design, intervention details, and main outcomes. Included studies will be assessed for limitations according to the Cochrane Risk of Bias tool. Meta-analysis will be conducted to estimate the pooled effect size. Meta-regression or subgroup analysis will be undertaken to explore if certain factors can explain the variation in effect between studies, if feasible. The certainty of evidence will be evaluated using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach.

RESULTS

The preliminary literature search was performed on February 16, 2024, and yielded 5255 unique records. A follow-up search will be performed across all databases before submission. The findings will be presented in forest plots, a summary of findings table, and in narrative format. This systematic review is expected to be completed by late 2024.

CONCLUSIONS

This review will provide an overview of pooled estimates of treatment effects across HRQoL, mental health, and mortality from randomized controlled trials evaluating collaborative care interventions for adults with multimorbidity. Furthermore, the intention is to clarify the participant, intervention, or study characteristics that may influence the effect of the interventions. This review is expected to provide valuable insights for researchers, clinicians, and other decision-makers about the effectiveness of collaborative care interventions targeting adult patients with multimorbidity.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO) CRD42024512554; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=512554.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/58296.

Renal Denervation for the Treatment of Hypertension: A Scientific Statement From the American Heart Association

Hypertension is a leading risk factor for cardiovascular morbidity and mortality. Despite the widespread availability of both pharmacological and lifestyle therapeutic options, blood pressure control rates across the globe are worsening. In fact, only 23% of individuals with high blood pressure in the United States achieve treatment goals. In 2023, the US Food and Drug Administration approved renal denervation, a catheter-based procedure that ablates the renal sympathetic nerves, as an adjunctive treatment for patients in whom lifestyle modifications and antihypertensive medications do not adequately control blood pressure. This approval followed the publication of multiple randomized clinical studies using rigorous trial designs, all incorporating renal angiogram as the sham control. Most but not all of the new generation of trials reached their primary end point, demonstrating modest efficacy of renal denervation in lowering blood pressure across a spectrum of hypertension, from mild to truly resistant. Individual patient responses vary, and further research is needed to identify those who may benefit most. The initial safety profile appears favorable, and multiple ongoing studies are assessing longer-term efficacy and safety. Multidisciplinary teams that include hypertension specialists and adequately trained proceduralists are crucial to ensure that referrals are made appropriately with full consideration of the potential risks and benefits. Incorporating patient preferences and engaging in shared decision-making conversations will help patients make the best decisions given their individual circumstances. Although further research is clearly needed, renal denervation presents a novel treatment strategy for patients with uncontrolled blood pressure.

Risk evaluation and mitigation strategy compliance for pulmonary hypertension medications after policy implementation with computerized provider order entry support

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Treatment for pulmonary hypertension includes medications with risk evaluation and mitigation strategy (REMS) programs. Health-system inpatient pharmacies dispensing these agents must comply with inpatient REMS dispensing criteria. Implementing a health-system policy with computerized provider order entry (CPOE) decision support may improve REMS compliance.

METHODS

This was a retrospective, quasi-experimental study comparing REMS compliance before and after development of a policy with CPOE decision support that was implemented in August 2019. Patients 18 years of age or older with a diagnosis of pulmonary hypertension were included if they received at least one dose of an endothelin receptor antagonist or riociguat while hospitalized. Patients were included in the preintervention group if they were hospitalized between August 1, 2017, and August 31, 2019, and in the postintervention group if they were hospitalized between September 1, 2019, and August 31, 2021. The primary outcome was the REMS compliance rate. Secondary endpoints included the time to REMS compliance and independent factors associated with failed or delayed REMS compliance.

RESULTS

A total of 150 patients were included, with 75 patients in both the pre- and postintervention groups. Compliance increased significantly from the preintervention (50%) to postintervention (92%) group (P < 0.001). Time to compliance was also significantly reduced from 770 minutes in the preintervention group to 140 minutes in the postintervention group (P = 0.031). Factors independently associated with REMS compliance were being in the postintervention group (odds ratio, 16.9; 95% confidence interval, 5.8-49.2) and being admitted to a pulmonary hypertension center for comprehensive care. (odds ratio, 7.8; 95% confidence interval, 2.9-21.2).

CONCLUSION

A health-system policy with CPOE decision support improved both the rate of and time to compliance with inpatient REMS dispensing procedures.

An Integrative Review of Interprofessional Teamwork and Required Competence in Specialized Palliative Care

To deliver quality care, social and healthcare professionals should be competent both in their own professional work and interprofessionally. The aim of this integrative review was to describe interprofessional teamwork and the required competencies for teamwork in specialized palliative care. Totally 14 studies published between 2003 and 2020 were included in the review. Interprofessional teamwork was described from the patients and professionals' perspective. The required interprofessional competencies were described as teamwork knowledge, skills, attitudes, and values. Interprofessional teamwork is one of the essential factors in providing holistic and ethically sustainable care to palliative patients. The way how professionals confront death and dying effects the whole team; this suggests that support practices are important in palliative care settings. Ascertaining the interprofessional competence in palliative care will produce better collaborative practices and increase the care outcomes. The findings can be used as a framework when developing interventions to promote clinical and educational practices.

Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis

BACKGROUND

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs.

OBJECTIVE

The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs.

DESIGN

Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score.

PARTICIPANTS

Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit.

INTERVENTION

PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services.

MAIN OUTCOMES AND MEASURES

Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date.

KEY RESULTS

Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM.

CONCLUSIONS AND RELEVANCE

VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes.

TRIAL REGISTRATION

PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Role of social media in the presentation of disorders of gut-brain interaction: Review and recommendations

As clinicians involved in the care of patients with disorders of gut-brain interaction (DGBIs), we-and many colleagues-have the impression that social media are adversely shaping the nature, presentation, and ability to manage these disorders, especially at the severe end of the DGBI clinical spectrum. We turned to the research literature to see if these clinical impressions were corroborated but found it virtually nonexistent. Social media have rapidly become a ubiquitous, pervasive part of the lives of most people on the planet. Although they bring many benefits, they are also replete with health misinformation, reinforcement of abnormal sick-role behavior, and undermining of the legitimacy of psychological care. We first set out four reasons for concern about social media and DGBIs, particularly severe DGBIs. These reasons stem from phenomena described in medical fields outside DGBIs, but there is no reason to think DGBIs should be exempt from such phenomena. We then present the results of a literature search, which yielded only eight disparate recent empirical studies. We review these studies, which, although not uninformative, reveal a field in its infancy. We set out implications, most urgently multidisciplinary research directly addressing the role of social media and evaluation of interventions to mitigate its ill effects. Gastroenterological clinicians involved in DGBI care and research need to collaborate with experts in social media research, which is a very rapidly evolving, specialized field. Although knowledge is at an early stage, there are implications for specialist practice, education and training, and DGBI service delivery.

Using quality improvement frameworks to develop, implement, and evaluate a novel ambulatory oncology pharmacy practice model: A descriptive example

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

To describe the application of the Plan-Do-Study-Act quality improvement framework in the development, implementation, and evaluation of a novel pharmacy practice model in ambulatory oncology.

SUMMARY

Four iterations of the Plan-Do-Study-Act framework were completed to develop a patient-facing, pharmacist-led ambulatory oncology clinic program. The clinic provided care to patients with prostate cancer on oral anticancer therapy. Metrics were collected throughout all stages of development to inform target processes for improvement. The pharmacist saw 136 patients between July 2019 and January 2023, resulting in 464 total encounters. The pharmacist provided clinical interventions and counseling to patients newly starting on oral anticancer therapy and those established on therapy using a longitudinal model of care.

CONCLUSION

Application of the Plan-Do-Study-Act quality improvement framework to a novel pharmacy practice model supported the development, evaluation, and sustainability of a pharmacist-led ambulatory oncology clinic providing care to patients with prostate cancer on oral anticancer therapy.

Spontaneous Papillary Muscle Rupture: An Uncommon Presentation in the Absence of Myocardial Infarction

BACKGROUND Papillary muscle rupture (PMR) is a rare complication of myocardial infarction (MI); experiencing PMR without MI makes it even more uncommon, thereby complicating its diagnosis. Therefore, we report a case of spontaneous PMR to raise awareness of this entity. CASE REPORT A 48-year-old man with type 2 diabetes presented to the Emergency Department (ED) after experiencing sudden shortness of breath that began the day before. He had no history of chest trauma, fever, chills, or ischemic chest pain. His vital signs showed stable blood pressure and mild tachycardia. The patient had hypoxemia that did not respond to use of a non-rebreather mask (oxygen saturation 70%). Upon examination, he had increased respiratory rate, altered sensorium, no lower-limb edema, and his chest auscultation revealed bilateral crackles. Chest radiography showed pulmonary edema. Two electrocardiograms (ECG) showed no signs of ST elevation myocardial infarction (STEMI) or RV strain. The patient was intubated but remained hypoxic despite maximum ventilation settings. Transthoracic echocardiography (TTE) performed immediately thereafter revealed acute severe mitral regurgitation with evidence of PMR. A multidisciplinary team approach was adopted early in this case, which resulted in a positive outcome. Eventually, mitral valve replacement was performed, and the patient was discharged home after 17 days, with a favorable neurological outcome. CONCLUSIONS We report a very rare case of spontaneous PMR in a middle-aged man with no evidence of MI, infective endocarditis, or preceding chest trauma. It shows the importance of adopting an early multidisciplinary team approach and showcases the abilities of emergency medicine physicians in early recognition.

Opportunities and challenges of lupus care in Latin America, the Middle East, and Asia-Pacific: A call to action

Lupus remains a disease with a low prioritisation in the national agendas of many countries in Latin America, the Middle East, and Asia-Pacific, where there is a dearth of rheumatologists and limited access to new or even standard lupus treatments. There is thus an important need for education, advocacy, and outreach to prioritise lupus in these regions to ensure that patients receive the care they need. This article reviews some of the specific challenges facing the care and management of people with lupus in these regions and suggests strategies for improving patient outcomes. Specifically, we review and discuss (with a focus on the aforementioned regions) the epidemiology of lupus; economic costs, disease burden, and effects on quality of life; barriers to care related to disease assessment; barriers to effective treatment, including limitations of standard treatments, high glucocorticoid use, inadequate access to new treatments, and low adherence to medications; and strategies to improve lupus management and patient outcomes. We hope that this represents a call to action to come together and act now for the lupus community, policymakers, health authorities, and healthcare professionals to improve lupus management and patient outcomes in Latin America, the Middle East, and Asia-Pacific.

Capturing Home Care Information Management and Communication Processes Among Caregivers of Older Adults: Qualitative Study to Inform Technology Design

BACKGROUND

The demand for complex home care is increasing with the growing aging population and the ongoing COVID-19 pandemic. Family and hired caregivers play a critical role in providing care for individuals with complex home care needs. However, there are significant gaps in research informing the design of complex home care technologies that consider the experiences of family and hired caregivers collectively.

OBJECTIVE

The objective of this study was to explore the health documentation and communication experiences of family and hired caregivers to inform the design and adoption of new technologies for complex home care.

METHODS

The research involved semistructured interviews with 15 caregivers, including family and hired caregivers, each of whom was caring for an older adult with complex medical needs in their home in Ontario, Canada. Due to COVID-19-related protection measures, the interviews were conducted via Teams (Microsoft Corp). The interview guide was informed by the cognitive work analysis framework, and the interview was conducted using storytelling principles of narrative medicine to enhance knowledge. Inductive thematic analysis was used to code the data and develop themes.

RESULTS

Three main themes were developed. The first theme described how participants were continually updating the caregiver team, which captured how health information, including their communication motivations and intentions, was shared among family and hired caregiver participants. The subthemes included binder-based health documentation, digital health documentation, and communication practices beyond the binder. The second theme described how participants were learning to improve care and decision-making, which captured how they acted on information from various sources to provide care. The subthemes included developing expertise as a family caregiver and tailoring expertise as a hired caregiver. The third theme described how participants experienced conflicts within caregiver teams, which captured the different struggles arising from, and the causes of, breakdowns in communication and coordination between family and hired caregiver participants. The subthemes included 2-way communication and trusting the caregiver team.

CONCLUSIONS

This study highlights the health information communication and coordination challenges and experiences that family and hired caregivers face in complex home care settings for older adults. Given the challenges of this work domain, there is an opportunity for appropriate digital technology design to improve complex home care. When designing complex home care technologies, it will be critical to include the overlapping and disparate perspectives of family and hired caregivers collectively providing home care for older adults with complex needs to support all caregivers in their vital roles.

Team climate and patients' perception of primary healthcare attributes in Brazil: a cross-sectional study

Team climate and attributes of primary healthcare (PHC) are key elements for collaborative practice. Few researchers have explored the relationship between team climate and patients' perceptions of PHC. This study aimed to assess the association between team climate and patients' perceptions of primary healthcare attributes. A quantitative approach was adopted. In Stage 1, Team climate was assessed using Team Climate Inventory in 118 Family Health Strategy (FHS) teams at a PHC setting. In Stage 2, Patients' perceptions of PHC attributes were assessed using the Primary Care Assessment Tool (PCATool) in a sample of 844 patients enrolled in teams studied in Stage 1. Cluster analysis was used to identify team climate groups. The analysis used multilevel linear regression models. Patients assigned to teams with the highest team climate scores had the highest PHC attributes scores. Patients who reported affiliation at the team level had the highest PCATool scores overall. They also scored higher on the attributes of comprehensiveness and coordinated care compared to patients with affiliation to the health unit. In conclusion, patients under the care of FHS teams exhibiting a more favorable team climate had more positive patient perceptions of PHC attributes.

Palliative Care for Pediatric Urology

Palliative care in the field of urology has largely been limited to adult oncologic conditions. Although there is a plethora of established literature suggesting the advantageous impact of palliative care, there is limited integration of palliative care in adult urology. This underutilization is further exacerbated in pediatric urology, and palliative care in pediatric urology remains an underexplored area despite the prevalence of several life-limiting conditions in this patient population. This paper highlights the potential need for palliative care intervention in a variety of urologic conditions in the pediatric population, including congenital lower urinary tract obstruction, neurogenic bladder dysfunction, exstrophy-epispadias complex, and congenital bilateral renal agenesis. Each condition poses unique challenges that can be addressed with the inclusion of a palliative care team, including decision-making spanning prenatal-neonatal-pediatric periods, acute and chronic symptom management, family relations, body image issues, risk of recurrent hospitalizations and surgeries, and potentially fatal complications. Alongside standard urologic interventions, palliative care can serve as an additional means of addressing physical and psychosocial symptoms experienced by pediatric urology patients to enhance the quality of life of patients and their families.

Life-Saving Multidisciplinary Management of Self-Inflicted Tracheal Transection: A Case Report

Self-inflicted cut-throat injuries, often associated with severe psychiatric disorders and exacerbated by socioeconomic factors, present significant medical complexities. Here, we present the case of a 45-year-old male with major depressive disorder who attempted suicide with a sword, resulting in complete tracheal transection. Upon admission, he presented with severe respiratory distress and hemorrhage, necessitating immediate fluid resuscitation and immediate airway securing with pediatric fiberoptic bronchoscopy, which successfully stabilized his airway. The surgical intervention included end-to-end tracheal anastomosis and T-tube placement without immediate complications. Postoperatively, the patient required intensive care with ventilator support and psychiatric intervention. Successful management of severe self-inflicted neck injuries relies on prompt airway control, precise surgical techniques, and comprehensive postoperative care to mitigate complications such as sepsis and tracheal stenosis.

Exploring the implementation of multidisciplinary collaboration at nursing homes in Jakarta, Indonesia: A descriptive phenomenological study

Background

A well-functioning multidisciplinary team optimizes resource utilization and reduces care redundancy, fragmentation, and wastage. Collaborative efforts yield a clearer understanding of older people's needs and desires, significantly reducing hospitalization days. Despite limited studies, particularly in Indonesia, investigating professionals' experiences in implementing multidisciplinary collaboration in government nursing homes, nursing care quality remains a concern.

Objective

This study aimed to explore the implementation of multidisciplinary collaboration in nursing homes from the perspectives of various disciplines.

Methods

A descriptive phenomenological study was used with semi-structured interviews and focus group discussions with multidisciplinary care providers, including nurses, doctors, social workers, physiotherapists, psychologists, occupational and recreational activity instructors, and clergy in nursing homes owned by the Jakarta provincial government. A total of 64 participants were involved, and data were collected from September 2022 to July 2023. Data were analyzed using content-based analysis.

Results

Three main themes emerged: 1) context of multiple collaborations, 2) barriers to implementing multiple collaborations, and 3) impacts of non-optimal multidisciplinary collaborations. Nursing home management's multidisciplinary teams predominantly implement professional-centered care with limited support systems. While providers generally perceive collaboration positively, shared responsibility and joint work among professionals are lacking.

Conclusion

This study highlights the need to improve multidisciplinary collaboration in nursing homes to enhance care quality for older individuals. While providers view collaboration positively, barriers like a lack of shared responsibility and joint work persist. Enhancing teamwork cohesion through improved communication and integrated case reporting systems is crucial. Addressing human resource and systemic barriers is also vital. By overcoming these challenges, nursing homes can optimize resource use, reduce care redundancy, and better meet the diverse needs of older residents.

Goals of Morbidity and Mortality meetings in paediatric acute care. A qualitative case study

Morbidity and Mortality meetings are conducted in varied clinical contexts including paediatrics. Widely cited as an educational or quality improvement tool, the reality is more complex. In this qualitative study, the aim was to explore the perceived goals of the paediatric acute care Morbidity and Morbidity meeting. This study used semi-structured interviews and observation within a qualitative case study methodology. Data were collected in a large paediatric quaternary hospital. Analysis generated themes related to meeting observations and the participant's interpretation of meeting goals. A total of 44 interviews were conducted with 14 nurses, 29 doctors, and 1 allied health professional. Thirty-two meetings in six clinical departments were observed. Two themes were developed: complex and nuanced goals; and tensions and contest between and within goals. Meeting goals to evaluate care, learn, support, adhere, and change and respond were sometimes in competition and had varied interpretations. Morbidity and Mortality meetings in this setting are valued and occupy a complex role which reaches beyond identification of measurable patient safety interventions. Understanding goals more fully can lead to optimised conduct and meaningful measurement of efficacy. The strength in these meetings may be the way they promote an embedded safety culture, and an informed and skilled workforce.

The perceptions of nurses and physicians in primary care of rehabilitation for frail older adults

OBJECTIVES

To investigate the perceptions of primary care nurses and physicians of the potential contributions of physiotherapists (PTs) and occupational therapists (OTs) in the treatment of frail older persons, as well as the obstacles to, and opportunities for, collaboration.

DESIGN

A qualitative study.

PARTICIPANTS AND SETTING

Nurses (n = 9) and physicians (n = 8) in primary care in the county council [14 women (82%)] with experience working with older people.

METHOD

Interview study conducted with a semi-structured interview guide. Analyses were carried out with content analysis with an inductive approach.

RESULTS

The analysis resulted in six categories: knowledge of physiotherapy and occupational therapy interventions; what triggers the need for physiotherapy and occupational therapy?; the availability of rehabilitation interventions; teamwork opportunities and difficulties; motivating the patient; the site of the rehabilitation.

CONCLUSIONS

Close and clear collaboration between nurses and physicians and PTs and OTs is an important factor in ensuring that rehabilitation interventions provide the greatest possible benefit to the patient. Improving communication between different healthcare providers and clarifying the contact routes is a prerequisite for patients to be able to get the rehabilitation they need. More research is needed to determine the best approach to achieving this goal.

Well-Being and Leadership Within the Emergency Department

Description This article looks at well-being and the role of leadership from the perspective of emergency medicine. The importance of leadership within the emergency department (ED), emergency medicine writing at large, and the prevention of burnout and compassion fatigue cannot be overstated. This article looks at the need for more research and measured interventions within the ED. It also highlights some measures that could be taken to help improve well-being from a leadership perspective to improve patient safety and outcomes within the ED.

Effects of a collaborative health management model on people with congestive heart failure: A systematic review and meta-analysis

AIM

To determine the effects of collaborative health management of congestive heart failure through the rigorous evaluation and extraction of evidence.

BACKGROUND

Over the past two decades, cardiovascular disease has been the leading cause of death worldwide. Multidisciplinary team intervention for congestive heart failure has increased with population ageing and congestive heart failure incidence rate as well as cost of care. However, the effectiveness and feasibility of collaborative health management need to be explored.

DESIGN

Systematic review and meta-analysis.

METHODS

We conducted systematic literature searches in the Cochrane Library, PubMed, CINAHL and Medline for articles published between 2002 and 2022. After screening based on the inclusion and exclusion criteria, 13 articles were included in a rigorous review and evidence extraction process, evaluated methodological quality using the Jadad Quality Scale. Statistical heterogeneity was evaluated using Review Manager (RevMan Version 5.4) for the meta-analysis.

RESULTS

In this study, a systematic review and meta-analysis were performed on 13 studies regarding the collaborative health management of people with congestive heart failure. The common result is that the collaborative health management model enables the enhancement of self-care and monitoring abilities, the strengthening of cardiac function, the alleviation of physiological and psychological symptoms and the improvement of readmission rates, mortality rate and quality of life.

CONCLUSION

The congestive heart failure collaborative health management model could decrease the hospitalization rate related to congestive heart failure, all-cause mortality rate, and all-cause hospitalization rate, and improve the quality of life.

IMPLICATIONS FOR PRACTICE

The collaborative health management model could effectively coordinate interdisciplinary team cooperation and provide information, which decreases hospitalization and mortality risks and improves their quality of life.

NO PATIENT OR PUBLIC CONTRIBUTION

Our paper is a systematic review and meta-analysis, and such details do not apply to our work. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: The Collaborative Health Management Model provides in-depth insights, aiding in the design tailored to the specific circumstances of each country. Highlighting its critical role in the context of a global shortage of nursing staff, the model emphasizes the integration of multidisciplinary professional roles and the strengthening of collaboration as essential elements in addressing challenges posed by workforce shortages. Implementation of the Collaborative Health Management Model not only enhances patient care outcomes but also relieves pressure on healthcare systems, lowers medical costs, and addresses challenges arising from the shortage of nursing staff. Consequently, this model not only contributes to individual patient care improvement but also holds broader implications for enhancing the efficiency and sustainability of global healthcare systems.

TRIAL AND PROTOCOL REGISTRATION

The detailed study protocol can be found on the PROSPERO website.

Grasping the meaning of perinatal palliative care for the multiprofessional team

OBJECTIVE

To grasp the meaning of perinatal palliative care for the multidisciplinary team.

METHODS

This is a qualitative study guided by content analysis. The study included 56 health professionals working in maternal and child units of a public university hospital. A semi-structured interview was conducted, which was recorded and subsequently fully transcribed. The collection took place from June 2018 to May 2019. Data were entered and exported to Atlas ti: The Qualitative Date Analysis & Research Software, version 23.1.1.0.

RESULTS

Four thematic categories emerged from the data analysis: palliative care and eligible public in the view of professionals; communication between family and team in decision-making; assistance in palliative care; humanized care.

CONCLUSIONS

The professionals think of palliative care in Perinatology in a similar way and perceive the difficulties of communication with the family and decision-making. They agree that it is necessary to provide greater support to the family, and to provide comfort measures, either for the non-viable fetus or for the baby eligible for palliative care.

A road less traveled in critical care: A call for improved acceptance and implementation of palliative and supportive care

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Patients' experiences of and roles in interprofessional collaborative practice in primary care: a constructivist grounded theory study

AIM

This constructivist grounded theory study aimed to (1) explore patients' experiences of and roles in interprofessional collaborative practice for chronic conditions in primary care and (2) consider the relevance and alignment of an existing theoretical framework on patients' roles and based on the experiences of patient advocates.

BACKGROUND

High-quality management of chronic conditions requires an interprofessional collaborative practice model of care considering an individual's mental, physical, and social health situation. Patients' experiences of this model in the primary care setting are relatively unknown.

METHODS

A constructivist grounded theory approach was taken. Interview data were collected from primary care patients with chronic conditions across Australia in August 2020 - February 2022. Interviews were recorded, transcribed verbatim, and thematically analysed by (1) initial line-by-line coding, (2) focused coding, (3) memo writing, (4) categorisation, and (5) theme and sub-theme development. Themes and sub-themes were mapped against an existing theoretical framework to expand and confirm the results from a previous study with a similar research aim.

FINDINGS

Twenty adults with chronic conditions spanning physical disability, diabetes, heart disease, cancer, autoimmune, and mental health conditions participated. Two themes were developed: (1) Adapting to Change with two sub-themes describing how patients adapt to interprofessional team care and (2) Shifting across the spectrum of roles, with five sub-themes outlining the roles patients enact while receiving care. The findings suggest that patients' roles are highly variable and fluid in interprofessional collaborative practice, and further work is recommended to develop a resource to support greater patient engagement in interprofessional collaborative practice.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams

PURPOSE

Despite increased clinician awareness of systemic racism, lack of substantial action toward antiracism exists within health care. Clinical staff perspectives, particularly those of racial-ethnic minorities/persons of color (POC) who disproportionately occupy support staff roles with less power on the team, can yield insights into barriers to progress and can inform future efforts to advance diversity, equity, and inclusion (DEI, also referred to as EDI) within health care settings. This qualitative study explored the perspectives of staff members on race and role power dynamics within community health clinic teams.

METHODS

We conducted semistructured 45-minute interviews with staff members working in community health clinics in a large urban health care system from May to July 2021. We implemented purposeful recruitment to oversample POC and support staff and to achieve equal representation from the 13 community health clinics in the system. Interviews were audio recorded, transcribed, and analyzed over 6 months using a critical-ideological paradigm. Themes reflecting experiences related to race and role power dynamics were identified.

RESULTS

Our cohort had 60 participants: 42 (70%) were support staff (medical assistants, front desk clerks, care navigators, nurses) and 18 (30%) were clinicians and clinic leaders. The large majority of participants were aged 26 to 40 years (60%), were female (83%), and were POC (68%). Five themes emerged: (1) POC face hidden challenges, (2) racial discrimination persists, (3) power dynamics perpetuate inaction, (4) interpersonal actions foster safety and equity, and (5) system-level change is needed for cultural shift.

CONCLUSIONS

Understanding the race and role power dynamics within care teams, including experiences of staff members with less power, is critical to advancing DEI in health care.