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Parkin S, Neale J, Strang J. Conceptualising retention in treatment with long-acting injectable buprenorphine (for opioid use disorder) as a journey: Findings from a longitudinal qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104221. [PMID: 37865052 DOI: 10.1016/j.drugpo.2023.104221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Conceptualisations of the 'patient journey' are popular within health service research. Patient journeys provide a person-centred approach to health care that typically prioritise subjective patient experience with the aim of improving relevant forms of intervention. This article explores the conceptualisation of retention in treatment for opioid use disorder (OUD) using long-acting injectable buprenorphine (LAIB) as a journey. METHODS Data derive from a longitudinal qualitative study, involving semi-structured interviews (held at six time-points), with participants who each initiated LAIB for the first time. Data analysis for this article focuses exclusively upon the experiences of those who had continued with LAIB treatment throughout one year (11 participants). Framework and thematic narrative analyses of 64 interviews with 11 participants sought to identify 'retention-narratives' that would indicate a 'retention journey' associated with LAIB treatment. FINDINGS Shared treatment experiences consisted of three distinct phases (Withdrawal and Separation, Transformation, and Engagement) that progressed in a linear and intersecting manner through time. Each phase had features that defined treatment experiences at a given time but changed as treatment progressed. All 11 participants experienced multiple features within each of the three treatment phases and all participants reported separation from their respective service provider throughout the first 12 months of treatment. Although some valued the latter separation, most were dissatisfied by reduced levels of contact. CONCLUSION Retention in treatment for OUD with LAIB, for at least 12-months, can be conceptualised as a journey. This conceptualisation emphasises the benefits (and challenges) clinicians and patients may expect to encounter during the first year of a LAIB treatment programme. An added implication of conceptualising LAIB treatment in this manner is that optimal benefits of the medication (as observed by participants) began to emerge during 'months 7-12' of the retention journey.
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Affiliation(s)
- Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK.
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; Centre for Social Research in Health, University of New South Wales, NSW 2052, Australia
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, SE5 8BB, UK; South London & Maudsley (SLaM) NHS Foundation Trust, London SE5 8AZ, UK
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Schlencker A, Messer L, Ardizzone M, Blaison G, Hinschberger O, Dahan E, Sordet C, Walther J, Dory A, Gonzalez M, Kleinlogel S, Bramont-Nachman A, Barrand L, Payen-Revol I, Sibilia J, Martin T, Arnaud L. Improving patient pathways for systemic lupus erythematosus: a multistakeholder pathway optimisation study. Lupus Sci Med 2022; 9:9/1/e000700. [PMID: 35568439 PMCID: PMC9109107 DOI: 10.1136/lupus-2022-000700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/28/2022] [Indexed: 11/29/2022]
Abstract
Objective Among the most significant challenges in SLE are the excessive diagnosis delay and the lack of coordinated care. The aim of the study was to investigate patient pathways in SLE in order to improve clinical and organisational challenges in the management of those with suspected and confirmed SLE. Methods We conducted a cross-sectional study of patients with SLE, healthcare providers and other representative stakeholders. Focus groups were conducted, and based on the collected data the most impactful disruption points in SLE patient pathways were identified. A novel framework to improve individual patient pathways in SLE was developed, discussed and validated during a consensus meeting with representative stakeholders. Results Six thematic clusters regarding disruption in optimal patient pathways in SLE were identified: appropriate and timely referral strategy for SLE diagnosis; the need for a dedicated consultation during which the diagnosis of SLE would be announced, and following which clarifications and psychological support offered; individualised patient pathways with coordinated care based on organ involvement, disease severity and patient preference; improved therapeutic patient education; prevention of complications such as infections, osteoporosis and cancer; and additional patient support. During the consensus meeting, the broader panel of stakeholders achieved consensus on these attributes and a framework for optimising SLE patient pathways was developed. Conclusions We have identified significant disruption points and developed a novel conceptual framework to improve individual patient pathways in SLE. These data may be of valuable interest to patients with SLE, their physicians, health organisations as well as policy makers.
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Affiliation(s)
- Aurelien Schlencker
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Laurent Messer
- Service de Rhumatologie, Hôpitaux Civils de Colmar, Colmar, France
| | - Marc Ardizzone
- Service de Rhumatologie, GHR Mulhouse Sud-Alsace, Mulhouse, France
| | - Gilles Blaison
- Service de médecine interne, Centre de compétence Maladies auto-immunes rares, Hôpitaux Civils de Colmar, Colmar, France
| | - Olivier Hinschberger
- Service de médecine interne, Centre de compétence Maladies auto-immunes rares, Hôpitaux Civils de Colmar, Colmar, France
| | - Etienne Dahan
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France
| | - Christelle Sordet
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Julia Walther
- Service de pharmacie stérilisation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Anne Dory
- Service de pharmacie stérilisation, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Maria Gonzalez
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Stéphanie Kleinlogel
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Aurélia Bramont-Nachman
- Service de Pathologie Professionnelle et de Médecine du Travail, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Jean Sibilia
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France.,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
| | - Thierry Martin
- Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France.,Service d'immunologie clinique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux universitaires de Strasbourg, Strasbourg, France .,Centre National de Références des Maladies Auto-immunes Rares (CRMR RESO), Strasbourg, France
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Gage-Bouchard EA. Social support, flexible resources, and health care navigation. Soc Sci Med 2017; 190:111-118. [PMID: 28858696 PMCID: PMC5607112 DOI: 10.1016/j.socscimed.2017.08.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 11/24/2022]
Abstract
Recent research has focused attention on the role of patients' and clinicians' cultural skills and values in generating inequalities in health care experiences. Yet, examination of how social structural factors shape people's abilities to build, refine, and leverage strategies for navigating the health care system have received less attention. In this paper I place focus on one such social structural factor, social support, and examine how social support operates as a flexible resource that helps people navigate the health care system. Using the case of families navigating pediatric cancer care this study combines in-depth interviews with parents of pediatric cancer patients (N = 80), direct observation of clinical interactions between families and physicians (N = 73), and in-depth interviews with pediatric oncologists (N = 8). Findings show that physicians assess parental visibility in the hospital, medical vigilance, and adherence to their child's treatment and use these judgments to shape clinical decision-making. Parents who had help from their personal networks had more agility in balancing competing demands, and this allowed parents to more effectively meet institutional expectations for appropriate parental involvement in the child's health care. In this way, social support served as a flexible resource for some families that allowed parents to more quickly adapt to the demands of caring for a child with cancer, foster productive interpersonal relationships with health care providers, and play a more active role in their child's health care.
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Affiliation(s)
- Elizabeth A Gage-Bouchard
- Roswell Park Cancer Institute, Department of Cancer Prevention and Control, Elm & Carlton Streets, Buffalo, NY 14263, United States.
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Buchbinder M. Keeping out and getting in: reframing emergency department gatekeeping as structural competence. SOCIOLOGY OF HEALTH & ILLNESS 2017; 39:1166-1179. [PMID: 28422296 PMCID: PMC5600633 DOI: 10.1111/1467-9566.12566] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sociologists have tended to frame medical gatekeeping as an exclusionary social practice, delineating how practitioners and clerical staff police the moral boundaries of medicine by keeping out patients who are categorised as 'bad', 'deviant', or otherwise problematic. Yet medical gatekeeping, understood more broadly, can include not only keeping patients out of particular clinical settings, but also redirecting them to alternative sources of care. In this article, I draw on qualitative analysis of audio-recorded patient-provider interactions in a United States emergency department (ED) to illustrate medical gatekeeping as a two-step process of, first, categorising certain patient complaints as unsuitable for treatment within a particular setting, and second, diverting patients to alternative sites for care. I refer to these as the restrictive and facilitative components of medical gatekeeping to denote how each relates to patients' access to care, recognising that both components of medical gatekeeping are part of a coordinated organisational strategy for managing resource scarcity. By illustrating how ED providers reveal intimate knowledge of structural vulnerabilities in diverting socioeconomically disadvantaged patients with chronic back pain to clinical sites that are better equipped to provide care, I suggest that we rethink the emphasis on restrictive practices in sociological accounts of medical gatekeeping.
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Affiliation(s)
- Mara Buchbinder
- Department of Social Medicine, Center for Bioethics, University of North Carolina, Chapel Hill, USA
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Perlman DC, Jordan AE. Considerations for the Development of a Substance-Related Care and Prevention Continuum Model. Front Public Health 2017; 5:180. [PMID: 28770195 PMCID: PMC5513894 DOI: 10.3389/fpubh.2017.00180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 07/04/2017] [Indexed: 12/19/2022] Open
Abstract
There are significant gaps in the identification and engagement in care and prevention services of people who use illicit substances. Care continuum models have proven to be useful tools in the evaluation of care for HIV and other conditions; numerous issues in substance-related care and prevention resemble those identified in other continua models. Systems of care for substance misuse and substance use disorders (SUDs) can be viewed as consisting of a prevention and care continuum, reflecting incidence and prevalence of substance misuse and SUDs, screening and identification, medical and psychosocial evaluation for treatment, engagement in evidence-based treatment, treatment retention, relapse prevention, timeliness of step completion, and measures of overall and substance use-related specific morbidity and mortality. Care and prevention continuum models could potentially be applied at program, local, regional, state, and national levels. We discuss important lessons that can be drawn from applications of continuum models in other fields. The development and use of a substance-related care and prevention continuum may yield significant patient care, program evaluation and improvement, and population-level benefits.
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Affiliation(s)
- David C. Perlman
- Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, United States
- Center for Drug Use and HIV Research, New York, NY, United States
| | - Ashly E. Jordan
- Center for Drug Use and HIV Research, New York, NY, United States
- Department of Epidemiology, School of Public Health, City University of New York, New York, NY, United States
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Gage-Bouchard EA. Culture, Styles of Institutional Interactions, and Inequalities in Healthcare Experiences. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2017; 58:147-165. [PMID: 28661778 DOI: 10.1177/0022146517693051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In this study, I examine how parents' cultural knowledge shapes experiences navigating the healthcare system after a child is diagnosed with cancer and the extent to which differential styles of health-related advocacy contribute to inequalities in healthcare experiences. I combine data from parents' perspectives, physicians' perspectives, and direct observation of clinical interactions and find three overarching styles of health-related advocacy. Findings show that cultural dispositions and competencies shape parents' abilities to effectively navigate the healthcare system, and physicians differentially reward each style of health-related advocacy. Parents' styles of advocacy shape relationships with clinicians, physicians' perceptions of families, and physicians' strategies for interacting with families. These findings refine understanding of the mechanisms through which social class manifests in clinical interactions, shapes patient-physician relationships, and contributes to unequal healthcare experiences.
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Perlman DC, Jordan AE, Nash D. Conceptualizing Care Continua: Lessons from HIV, Hepatitis C Virus, Tuberculosis and Implications for the Development of Improved Care and Prevention Continua. Front Public Health 2017; 4:296. [PMID: 28119910 PMCID: PMC5222805 DOI: 10.3389/fpubh.2016.00296] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/23/2016] [Indexed: 01/04/2023] Open
Abstract
Background To examine the application of continuum models to tuberculosis, HIV, and other conditions; to theorize the concept of continua; and to learn lessons that could inform the development of improved care and prevention continua as public health metrics. Methods An analytic review of literature drawn from several fields of health care. Results The continuum construct is now part of public health evaluation systems for HIV, and is increasingly used in public health and the medical literature. Issues with the comparability and optimal design of care continuum models have been raised, and their methodologic and theoretic underpinnings and scope of focus have been under-addressed. Review of relevant publications suggests that a key limitation of current models is their lack of measures reflecting incidence and mortality. Issues relating to continua data being longitudinal or cross-sectional, definition of numerators and denominators for each step, data sources, measures of timeliness of step completion, theoretic models to facilitate inferences of causes of care continuum gaps, how measures of prevention efforts, reinfection/relapses, and interactions of continua for co-occurring comorbidities should be reflected, and how analyses of differences in retention over time, across geographic regions, and in response to interventions should be conducted are critical to the development of sound care and prevention continuum models. Conclusion Lessons learned from the application of continuum models to HIV and other conditions suggest that the application of well-formulated constructs of care and prevention continua, that depict, in well defined, standardized steps, incidence and mortality, along with degrees of and time to screening, engagement in care and prevention, treatment and treatment outcomes, including relapse or reinfection, may be vital tools in evaluating intervention and program outcomes, and in improving population health and population health metrics for a wide range conditions.
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Affiliation(s)
- David C Perlman
- Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Ashly E Jordan
- Department of Epidemiology, School of Public Health, City University of New York, New York, NY, USA; Center for Drug Use and HIV Research, New York, NY, USA
| | - Denis Nash
- Department of Epidemiology, School of Public Health, City University of New York , New York, NY , USA
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Bodolica V, Spraggon M, Tofan G. A structuration framework for bridging the macro-micro divide in health-care governance. Health Expect 2015; 19:790-804. [PMID: 26072929 DOI: 10.1111/hex.12375] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Extant studies demonstrate that macro (hierarchical) and micro (relational) governance initiatives in health-care settings continue to be developed in isolation rather than interactively. Government-driven hierarchical governance endeavours that guide health-care reforms and medical practice are disconnected from micro-level physician-patient interactions being unable to account for patient preferences in the macro-level policymaking. METHOD/OBJECTIVE We undertake a review of the recent literature to couch our argument for a unified governance framework for bridging the macro-micro divide in medical contexts. Adopting an interdisciplinary approach to health-care delivery, we maintain that the (strong) structuration theory provides a fruitful opportunity for narrowing the gap between hierarchical and relational governance. DISCUSSION Emphasizing the coexistence of institutional structures and human agency, the (strong) structuration theory elucidates how macro and micro governance devices shape each other's structure via mutually reinforcing cycles of influence. Micro-level encounters between patients and physicians give rise to social structures that constitute the constraining and enabling forces through which macro-level health-care infrastructures are altered and reproduced over time. Permitting to illustrate how patients' agency can effectively emerge from complex networks of clinical trajectories, the advanced structuration framework for macro-micro governance integration avoids the extremes of paternalism and autonomy through a balanced consideration of professional judgement and patient preferences. CONCLUSION/IMPLICATIONS The macro-micro integration of governance efforts is a critical issue in both high-income states, where medical institutions attempt to deploy substantial realignment efforts, and developing nations, which are lagging behind due to leadership weaknesses and lower levels of governmental investment. A key priority for regulators is the identification of relevant systems to support this holistic governance by providing clinicians with needed resources for focusing on patient advocacy and installing enabling mechanisms for incorporating patients' inputs in health-care reforms and policymaking.
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Affiliation(s)
- Virginia Bodolica
- School of Business Administration, American University of Sharjah, P.O. Box 26666, Sharjah, United Arab Emirates
| | - Martin Spraggon
- School of Business Administration, American University of Sharjah, P.O. Box 26666, Sharjah, United Arab Emirates
| | - Gabriela Tofan
- National Health Insurance Company, MD 2005 Chisinau, Republic of Moldova
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