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Coeckelberghs E, Vanhaecht K, Akiki A, Castillón P, Cox B, Attal RE, Foss NB, Frihagen F, Gerich TG, Kanakaris NK, Kristensen MT, Mohaddes M, Panella M, Pape HC, Sermon A, Seys D, Nijs S. Variation in care and outcome for fragile hip fracture patients: a European multicentre study benchmarking fulfilment of established quality indicators. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02549-0. [PMID: 38819678 DOI: 10.1007/s00068-024-02549-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 05/08/2024] [Indexed: 06/01/2024]
Abstract
PURPOSE Despite the availability of clinical guidelines for hip fracture patients, adherence to these guidelines is challenging, potentially resulting in suboptimal patient care. The goal of this study was (1) to evaluate and benchmark the adherence to recently established quality indicators (QIs), and (2) to study clinical outcomes, in fragile hip fracture patients from different European countries. METHODS This observational, cross-sectional multicenter study was performed in 10 hospitals from 9 European countries including data of 298 consecutive patients. RESULTS A large variation both within and between hospitals were seen regarding adherence to the individual QIs. QIs with the lowest overall adherence rates were the administration of systemic steroids (5.4%) and tranexamic acid (20.1%). Indicators with the highest adherence rates (above 95%) were pre-operative (99.3%) and post-operative haemoglobin level assessment (100%). The overall median time to surgery was 22.6 h (range 15.7-42.5 h). The median LOS was 9.0 days (range 5.0-19.0 days). The most common complications were delirium (23.2%) and postsurgical constipation (25.2%). CONCLUSION The present study shows large variation in the care for fragile patients with hip fractures indicating room for improvement. Therefore, hospitals should invest in benchmarking and knowledge-sharing. Large quality improvement initiatives with longitudinal follow up of both process and outcome indicators should be initiated.
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Affiliation(s)
- E Coeckelberghs
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium.
- European Pathway Association, Leuven, Belgium.
| | - K Vanhaecht
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
- European Pathway Association, Leuven, Belgium
- Department of Quality, University Hospitals Leuven, Leuven, Belgium
| | - A Akiki
- Hôpital Riviera Chablais, Rennaz, Switzerland
| | - P Castillón
- Servei de Cirurgia Ortopèdica i Traumatologia, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, España
- Universitat Autònoma de Barcelona (UAB), Bellaterra, Barcelona, España
| | - B Cox
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | - R El Attal
- Klinik für Orthopädie und Unfallchirurgie, Sporttraumatologie, Landeskrankenhaus Feldkirch, Feldkirch, Austria
| | - N B Foss
- Departments of Anaesthesia and Intensive Care, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
- Denmark Institute for clinical medicine, University of Copenhagen, Copenhagen, Denmark
| | - F Frihagen
- Orthopedic Department, Østfold Hospital Trust, Grålum, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - T G Gerich
- Head of orthopaedic trauma, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - N K Kanakaris
- Leeds Major Trauma Centre, Leeds Teaching Hospitals NHS Trust, Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
| | - M T Kristensen
- Departments of Physiotherapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - M Mohaddes
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Orthopedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - M Panella
- European Pathway Association, Leuven, Belgium
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - H C Pape
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Zurich, Switzerland
| | - A Sermon
- Traumatology Department at University Hospitals Leuven, Leuven, Belgium
| | - D Seys
- Leuven Institute for Healthcare Policy, Leuven, KU, Belgium
| | - S Nijs
- Traumatology Department at University Hospitals Leuven, Leuven, Belgium
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Thompson JA, Hersch D, Kasozi RN, Miner MH, Adam P. Disparities in Offering Enrollment in Remote Patient Monitoring for COVID-19. Telemed J E Health 2024; 30:715-721. [PMID: 37707989 PMCID: PMC10924046 DOI: 10.1089/tmj.2023.0150] [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] [Indexed: 09/16/2023] Open
Abstract
Introduction: Remote patient monitoring (RPM) programs are increasingly common. There is a risk that inequitable use of RPM will perpetuate existing health care disparities. We conducted a study to determine if enrollment in a COVID-19 RPM program was offered differentially across demographic groups. Methods: From March through September 2020, patients with COVID-19 were evaluated within a large academic health system with a standardized care pathway that directed providers to refer the patients for RPM. We conducted a retrospective cohort study to evaluate the effects of social vulnerability and urbanicity of residence on the odds of referral. We estimated vulnerability using the CDC social vulnerability index (SVI) and used logistic regression to determine odds ratios (ORs) for referral based on SVI and urbanicity. Results: Of 16,739 patients who had a qualifying health care encounter, 2,946 (17.6%) were referred for RPM. Patients in census tracts with higher social vulnerability were less likely to be referred than those in tracts with lower vulnerability (OR 0.73, 95% confidence interval 0.63-0.84). Patients living in Micropolitan/Large Rural Cities or Small Towns/Small Rural Towns were more likely to be referred than those in Metropolitan/Urban areas. In the full regression model, including both SVI and urbanicity, urbanicity was the strongest predictor of referral, and patients living in Metropolitan/Urban areas were the most likely to be referred. Conclusions: We found disparities in who is offered access to remote monitoring despite the use of standardized care pathways. Health systems need to evaluate how they implement RPM programs and care pathways to ensure equitable care delivery.
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Affiliation(s)
- Joshua A Thompson
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Derek Hersch
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Ramla N Kasozi
- Department of Family Medicine, Mayo Clinic College of Medicine and Sciences, Jacksonville, Florida, USA
| | - Michael H Miner
- Eli Coleman Institute for Sexual and Gender Health, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Patricia Adam
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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García-Lorenzo B, Gorostiza A, Alayo I, Castelo Zas S, Cobos Baena P, Gallego Camiña I, Izaguirre Narbaiza B, Mallabiabarrena G, Ustarroz-Aguirre I, Rigabert A, Balzi W, Maltoni R, Massa I, Álvarez López I, Arévalo Lobera S, Esteban M, Fernández Calleja M, Gómez Mediavilla J, Fernández M, del Oro Hitar M, Ortega Torres MDC, Sanz Ferrandez MC, Manso Sánchez L, Serrano Balazote P, Varela Rodríguez C, Campone M, Le Lann S, Vercauter P, Tournoy K, Borges M, Oliveira AS, Soares M, Fullaondo A. European value-based healthcare benchmarking: moving from theory to practice. Eur J Public Health 2024; 34:44-51. [PMID: 37875008 PMCID: PMC10843953 DOI: 10.1093/eurpub/ckad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Value-based healthcare (VBHC) is a conceptual framework to improve the value of healthcare by health, care-process and economic outcomes. Benchmarking should provide useful information to identify best practices and therefore a good instrument to improve quality across healthcare organizations. This paper aims to provide a proof-of-concept of the feasibility of an international VBHC benchmarking in breast cancer, with the ultimate aim of being used to share best practices with a data-driven approach among healthcare organizations from different health systems. METHODS In the VOICE community-a European healthcare centre cluster intending to address VBHC from theory to practice-information on patient-reported, clinical-related, care-process-related and economic-related outcomes were collected. Patient archetypes were identified using clustering techniques and an indicator set following a modified Delphi was defined. Benchmarking was performed using regression models controlling for patient archetypes and socio-demographic characteristics. RESULTS Six hundred and ninety patients from six healthcare centres were included. A set of 50 health, care-process and economic indicators was distilled for benchmarking. Statistically significant differences across sites have been found in most health outcomes, half of the care-process indicators, and all economic indicators, allowing for identifying the best and worst performers. CONCLUSIONS To the best of our knowledge, this is the first international experience providing evidence to be used with VBHC benchmarking intention. Differences in indicators across healthcare centres should be used to identify best practices and improve healthcare quality following further research. Applied methods might help to move forward with VBHC benchmarking in other medical conditions.
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Affiliation(s)
- Borja García-Lorenzo
- Biosistemak Institute for Health Systems Research, Torre del Bilbao Exhibition Centre, Barakaldo, Spain
| | - Ania Gorostiza
- Biosistemak Institute for Health Systems Research, Torre del Bilbao Exhibition Centre, Barakaldo, Spain
| | - Itxaso Alayo
- Biosistemak Institute for Health Systems Research, Torre del Bilbao Exhibition Centre, Barakaldo, Spain
| | - Susana Castelo Zas
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Innovation and Quality Assistant Service, Barakaldo-Bizkaia, Spain
| | - Patricia Cobos Baena
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Mammary Pathology Service, Barakaldo-Bizkaia, Spain
| | - Inés Gallego Camiña
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Innovation and Quality Assistant Service, Barakaldo-Bizkaia, Spain
| | - Begoña Izaguirre Narbaiza
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Analytical Accounting, Economic and Financial Directorate, Barakaldo, Spain
| | - Gaizka Mallabiabarrena
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Mammary Pathology Service, Barakaldo-Bizkaia, Spain
| | - Iker Ustarroz-Aguirre
- Osakidetza Basque Health Service, Ezkerraldea Enkarterri Cruces Integrated Health Organisation, Economic Evaluation Unit, Economic and Financial Directorate, Barakaldo, Spain
| | - Alina Rigabert
- Fundación Andaluza Beturia para la Investigación en Salud (FABIS), Huelva, Spain
| | - William Balzi
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Roberta Maltoni
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Ilaria Massa
- IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Isabel Álvarez López
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Medical Oncology, Donostia, Spain
- Biodonostia, Donostia, Gipuzkoa, Spain
| | - Sara Arévalo Lobera
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Medical Oncology, Donostia, Spain
- Biodonostia, Donostia, Gipuzkoa, Spain
| | - Mónica Esteban
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Economic Resource Service, Donostia, Gipuzkoa, Spain
| | - Marta Fernández Calleja
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Mamary Pathology Service, Donostia, Gipuzkoa, Spain
| | - Jenifer Gómez Mediavilla
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Medical Oncology, Donostia, Spain
| | - Manuela Fernández
- Osakidetza Basque Health Service, Donostialdea Integrated Health Organisation, Economic Resource Service, Donostia, Gipuzkoa, Spain
| | - Manuel del Oro Hitar
- Gynecology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - María del Carmen Ortega Torres
- Gynecology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Luís Manso Sánchez
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Biomédica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pablo Serrano Balazote
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Biomédica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carolina Varela Rodríguez
- Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación Biomédica del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mario Campone
- Institut de Cancérologie de l’Ouest, Angers-Nantes, France
| | - Sophie Le Lann
- Institut de Cancérologie de l’Ouest, Angers-Nantes, France
| | - Piet Vercauter
- Department of Pulmonary Medicine, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
| | - Kurt Tournoy
- Department of Pulmonary Medicine, Onze-Lieve-Vrouw Hospital, Aalst, Belgium
- Faculty of Medicine and Life Sciences, Ghent University, Ghent, Belgium
| | | | | | - Marta Soares
- Instituto Português de Oncologia do Porto, Portugal
| | - Ane Fullaondo
- Biosistemak Institute for Health Systems Research, Torre del Bilbao Exhibition Centre, Barakaldo, Spain
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Wilkins-Caruana A, Bandara M, Musial K, Catchpoole D, Kennedy PJ. Inferring actual treatment pathways from patient records. J Biomed Inform 2023; 148:104554. [PMID: 38000767 DOI: 10.1016/j.jbi.2023.104554] [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: 09/01/2023] [Revised: 10/23/2023] [Accepted: 11/21/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE Treatment pathways are step-by-step plans outlining the recommended medical care for specific diseases; they get revised when different treatments are found to improve patient outcomes. Examining health records is an important part of this revision process, but inferring patients' actual treatments from health data is challenging due to complex event-coding schemes and the absence of pathway-related annotations. The objective of this study is to develop a method for inferring actual treatment steps for a particular patient group from administrative health records - a common form of tabular healthcare data - and address several technique- and methodology-based gaps in treatment pathway-inference research. METHODS We introduce Defrag, a method for examining health records to infer the real-world treatment steps for a particular patient group. Defrag learns the semantic and temporal meaning of healthcare event sequences, allowing it to reliably infer treatment steps from complex healthcare data. To our knowledge, Defrag is the first pathway-inference method to utilise a neural network (NN), an approach made possible by a novel, self-supervised learning objective. We also developed a testing and validation framework for pathway inference, which we use to characterise and evaluate Defrag's pathway inference ability, establish benchmarks, and compare against baselines. RESULTS We demonstrate Defrag's effectiveness by identifying best-practice pathway fragments for breast cancer, lung cancer, and melanoma in public healthcare records. Additionally, we use synthetic data experiments to demonstrate the characteristics of the Defrag inference method, and to compare Defrag to several baselines, where it significantly outperforms non-NN-based methods. CONCLUSIONS Defrag offers an innovative and effective approach for inferring treatment pathways from complex health data. Defrag significantly outperforms several existing pathway-inference methods, but computationally-derived treatment pathways are still difficult to compare against clinical guidelines. Furthermore, the open-source code for Defrag and the testing framework are provided to encourage further research in this area.
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Affiliation(s)
- Adrian Wilkins-Caruana
- Australian Artificial Intelligence Institute, Faculty of Engineering and IT, University of Technology Sydney, Australia.
| | - Madhushi Bandara
- Australian Artificial Intelligence Institute, Faculty of Engineering and IT, University of Technology Sydney, Australia
| | - Katarzyna Musial
- Complex Adaptive Systems Lab, Data Science Institute, Faculty of Engineering and IT, University of Technology Sydney, Australia
| | - Daniel Catchpoole
- Australian Artificial Intelligence Institute, Faculty of Engineering and IT, University of Technology Sydney, Australia; Biospecimen Research Services, The Children's Cancer Research Unit, The Children's Hospital at Westmead, Australia
| | - Paul J Kennedy
- Australian Artificial Intelligence Institute, Faculty of Engineering and IT, University of Technology Sydney, Australia; Joint Research Centre in AI for Health and Wellness, University of Technology Sydney, Australia and Ontario Tech University, Canada
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Gartner JB, Côté A. Optimization of Care Pathways Through Technological, Clinical, Organizational and Social Innovations: A Qualitative Study. Health Serv Insights 2023; 16:11786329231211096. [PMID: 37953914 PMCID: PMC10637140 DOI: 10.1177/11786329231211096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/12/2023] [Indexed: 11/14/2023] Open
Abstract
Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action.
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Affiliation(s)
- Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l’administration, Université Laval, Québec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche de l’Institut Universitaire de Cardio-Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | - André Côté
- Département de management, Faculté des sciences de l’administration, Université Laval, Québec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Québec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, Québec, QC, Canada
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche de l’Institut Universitaire de Cardio-Pneumologie de Québec, Université Laval, Québec, QC, Canada
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Green CA, Johnson JD, McKenzie C, Stuebe AM. Standardized Order Sets Do Not Eliminate Racial or Ethnic Inequities in Postpartum Pain Management. Health Equity 2023; 7:685-691. [PMID: 37908404 PMCID: PMC10615045 DOI: 10.1089/heq.2022.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2023] [Indexed: 11/02/2023] Open
Abstract
Objective To quantify the extent to which a standardized pain management order set reduced racial and ethnic inequities in post-cesarean pain evaluation and management. Methods We conducted a retrospective cohort study to quantify racial and ethnic differences in pain evaluation and management before (July 2014-June 2016) and after implementation of a standardized post-cesarean order set (March 2017-February 2018). Electronic medical records were queried for pain scores >7/10, number of pain assessments, and opioid, nonsteroidal anti-inflammatory drug (NSAID), and acetaminophen doses. Outcomes were grouped into 0 to <24 and 24-48 h postpartum, and stratified by race/ethnicity (Hispanic, non-Hispanic Black [NHB], non-Hispanic White [NHW], Asian, and other), as documented in the electronic health record. Analyses included logistic regression for the categorical outcome of pain score >7 (severe pain), and linear regression, with propensity score adjustment. Main effect and interaction terms were used to calculate the difference-in-difference in pain process and outcome measures between the baseline and follow-up periods. Results After order set implementation (N=888), severe pain remained more common among NHB patients (% pain scores >7 NHW vs. NHB 0 to <24 h: 22% vs. 33%, p=0.003; 24-48 h: 26% vs. 40%, p<0.001). Among all patients, pain management processes changed after implementation of the order set, with overall fewer assessments, less Opioids, and more nonopioid analgesics. However, racial and ethnic inequities in a number of assessments and in treatment were unchanged (all p for interaction >0.05), with the exception of a modest increase in NSAID doses 24-48 h postpartum for Hispanic patients. Conclusion A standardized pain management order set reduced overall postpartum opioid use, but did not reduce racial and ethnic disparities in pain evaluation and management. Future work should investigate racial equity-focused education and interventions designed to eliminate disparities in pain management.
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Affiliation(s)
- Celeste A. Green
- Department of Obstetrics and Gynecology, University of Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jasmine D. Johnson
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana, USA
| | - Christine McKenzie
- Department of Anesthesiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Alison M. Stuebe
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
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Wendel SK, Bookman K, Holmes M, Wiler JL. Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic. Qual Manag Health Care 2023; 32:205-210. [PMID: 36913774 PMCID: PMC10289068 DOI: 10.1097/qmh.0000000000000408] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. METHODS On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. RESULTS Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. CONCLUSIONS Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.
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Affiliation(s)
- Sarah K. Wendel
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Kelly Bookman
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Molly Holmes
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Jennifer L. Wiler
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
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8
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McGuier EA, Aarons GA, Wright JD, Fortney JC, Powell BJ, Rothenberger SD, Weingart LR, Miller E, Kolko DJ. Team-focused implementation strategies to improve implementation of mental health screening and referral in rural Children's Advocacy Centers: study protocol for a pilot cluster randomized hybrid type 2 trial. Implement Sci Commun 2023; 4:58. [PMID: 37237302 PMCID: PMC10214641 DOI: 10.1186/s43058-023-00437-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/08/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Children's Advocacy Centers (CACs) use multidisciplinary teams to investigate and respond to maltreatment allegations. CACs play a critical role in connecting children with mental health needs to evidence-based mental health treatment, especially in low-resourced rural areas. Standardized mental health screening and referral protocols can improve CACs' capacity to identify children with mental health needs and encourage treatment engagement. In the team-based context of CACs, teamwork quality is likely to influence implementation processes and outcomes. Implementation strategies that target teams and apply the science of team effectiveness may enhance implementation outcomes in team-based settings. METHODS We will use Implementation Mapping to develop team-focused implementation strategies to support the implementation of the Care Process Model for Pediatric Traumatic Stress (CPM-PTS), a standardized screening and referral protocol. Team-focused strategies will integrate activities from effective team development interventions. We will pilot team-focused implementation in a cluster-randomized hybrid type 2 effectiveness-implementation trial. Four rural CACs will implement the CPM-PTS after being randomized to either team-focused implementation (n = 2 CACs) or standard implementation (n = 2 CACs). We will assess the feasibility of team-focused implementation and explore between-group differences in hypothesized team-level mechanisms of change and implementation outcomes (implementation aim). We will use a within-group pre-post design to test the effectiveness of the CPM-PTS in increasing caregivers' understanding of their child's mental health needs and caregivers' intentions to initiate mental health services (effectiveness aim). CONCLUSIONS Targeting multidisciplinary teams is an innovative approach to improving implementation outcomes. This study will be one of the first to test team-focused implementation strategies that integrate effective team development interventions. Results will inform efforts to implement evidence-based practices in team-based service settings. TRIAL REGISTRATION Clinicaltrials.gov, NCT05679154 . Registered on January 10, 2023.
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Affiliation(s)
- Elizabeth A McGuier
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA.
| | - Gregory A Aarons
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
- UC San Diego ACTRI Dissemination and Implementation Science Center, La Jolla, CA, USA
- Child and Adolescent Services Research Center, San Diego, CA, USA
| | - Jaely D Wright
- Western Psychiatric Hospital, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - John C Fortney
- Division of Population Health, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
- Department of Veterans Affairs, HSR&D Center of Innovation for Veteran-Centered and Value Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Byron J Powell
- Center for Mental Health Services Research, Brown School, Washington University in St. Louis, St. Louis, MO, USA
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
- Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis, St. Louis, USA
| | - Scott D Rothenberger
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Laurie R Weingart
- Tepper School of Business, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David J Kolko
- Department of Psychiatry, School of Medicine, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA, 15213, USA
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9
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Butow P, Faris MM, Shaw J, Kelly P, He S, Harris M, Cuddy J, Masya L, Geerligs L, Kelly B, Girgis A, Rankin N, Beale P, Hack TF, Kirsten L, Dhillon H, Grimison P, Viney R, Clayton JM, Schlub T, Shepherd HL. Effect of core versus enhanced implementation strategies on adherence to a clinical pathway for managing anxiety and depression in cancer patients in routine care: a cluster randomised controlled trial. Implement Sci 2023; 18:18. [PMID: 37217928 DOI: 10.1186/s13012-023-01269-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/03/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Optimal strategies to facilitate implementation of evidence-based clinical pathways are unclear. We evaluated two implementation strategies (Core versus Enhanced) to facilitate implementation of a clinical pathway for the management of anxiety and depression in cancer patients (the ADAPT CP). METHODS Twelve cancer services in NSW Australia were cluster randomised, stratified by service size, to the Core versus Enhanced implementation strategy. Each strategy was in place for 12 months, facilitating uptake of the ADAPT CP (the intervention being implemented). The Core strategy included a lead team with champions, staff training and awareness campaigns prior to implementation, plus access to feedback reports and telephone or online support during implementation. The Enhanced strategy included all Core supports plus monthly lead team meetings, and proactive, ongoing advice on managing barriers, staff training and awareness campaigns throughout implementation. All patients at participating sites were offered the ADAPT CP as part of routine care, and if agreeable, completed screening measures. They were allocated a severity step for anxiety/depression from one (minimal) to five (severe) and recommended management appropriate to their severity step. Multi-level mixed-effect regression analyses examined the effect of Core versus Enhanced implementation strategy on adherence to the ADAPT CP (binary primary outcome: adherent ≥ 70% of key ADAPT CP components achieved versus non-adherent < 70%), with continuous adherence as a secondary outcome. Interaction between study arm and anxiety/depression severity step was also explored. RESULTS Of 1280 registered patients, 696 (54%) completed at least one screening. As patients were encouraged to re-screen, there were in total 1323 screening events (883 in Core and 440 in Enhanced services). The main effect of implementation strategy on adherence was non-significant in both binary and continuous analyses. Anxiety/depression step was significant, with adherence being higher for step 1 than for other steps (p = 0.001, OR = 0.05, 95% CI 0.02-0.10). The interaction between study arm and anxiety/depression step was significant (p = 0.02) in the continuous adherence analysis only: adherence was significantly higher (by 7.6% points (95% CI 0.08-15.1%) for step 3 in the Enhanced arm (p = .048) and trending to significance for step 4. DISCUSSION These results support ongoing implementation effort for the first year of implementation to ensure successful uptake of new clinical pathways in over-burdened clinical services. TRIAL REGISTRATION ANZCTR Registration: ACTRN12617000411347 (Trial registered 22/03/2017; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372486&isReview=true ).
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Affiliation(s)
- Phyllis Butow
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia.
| | - Mona M Faris
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Joanne Shaw
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Patrick Kelly
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sharon He
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Marnie Harris
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Jessica Cuddy
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Lindy Masya
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Liesbeth Geerligs
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Brian Kelly
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Afaf Girgis
- South West Sydney Clinical Campuses, UNSW Medicine & Health, University of New South Wales, Kensington, Australia
| | - Nicole Rankin
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Philip Beale
- Department of Medical Oncology, Concord Hospital, NSW, Concord, Australia
| | - Thomas F Hack
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Laura Kirsten
- Nepean Hospital, Nepean Cancer Care Centre, Kingswood, NSW, Australia
| | - Haryana Dhillon
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
| | - Peter Grimison
- Chris O'Brien LifehouseCamperdown, Sydney, NSW, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW, Australia
| | - Josephine M Clayton
- HammondCare, The Palliative Centre, Greenwich Hospital, Greenwich, NSW, Australia
- Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Timothy Schlub
- School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Heather L Shepherd
- School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), The University of Sydney, 31 Ellalong Rd North Turramurra 2074, Sydney, NSW, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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10
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Blanco Saiz I, Anda Apiñániz E, Pineda Arribas J, Caudepón Moreno F, Fernández Iglesias A, Huarte Jiménez M, de Miguel Muñoz AI, Irigoyen Aristorena MI, Goñi Gironés E. Clinical pathway of metabolic therapy with 131I in differentiated thyroid cancer. Rev Esp Med Nucl Imagen Mol 2023; 42:178-187. [PMID: 36906068 DOI: 10.1016/j.remnie.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 03/11/2023]
Abstract
Clinical Pathways are care plans that are applied to clinical processes with a predictable course, with the intention of protocolizing these processes and reducing the variability in their management. Our objective was to develop a clinical pathway for 131I metabolic therapy in its application to differentiated thyroid cancer. A work team was organized consisting of doctors (Endocrinology and Nuclear Medicine), nursing staff (Hospitalization Unit and Nuclear Medicine), Radiophysics and the Clinical Management and Continuity of Care Support Service. For the design of the clinical pathway, several team meetings were held, in which the literature reviews were pooled and the design and development of the clinical pathway was undertaken in accordance with current clinical guidelines. This team achieved consensus on the development of the care plan, establishing its key points and drafting the different documents that make up the Clinical Pathway: Timeframe-based schedule, Clinical Pathway Variation Record Document, Patient Information Documents, Patient Satisfaction Survey, Pictogram Brochure, Quality Assessment Indicators. Finally, the clinical pathway was presented to all the clinical departments involved and to the Medical Director of the Hospital and is now being implemented in clinical practice.
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Affiliation(s)
- I Blanco Saiz
- Servicio de Medicina Nuclear, Hospital Universitario de Navarra, Pamplona, Spain.
| | - E Anda Apiñániz
- Servicio de Endocrinología, Hospital Universitario de Navarra, Pamplona, Spain
| | - J Pineda Arribas
- Servicio de Endocrinología, Hospital Universitario de Navarra, Pamplona, Spain
| | - F Caudepón Moreno
- Servicio de Radiofísica y Protección Radiológica, Hospital Universitario de Navarra, Pamplona, Spain
| | - A Fernández Iglesias
- Servicio de Radiofísica y Protección Radiológica, Hospital Universitario de Navarra, Pamplona, Spain
| | - M Huarte Jiménez
- Unidad de Enfermería, Hospitalización Endocrinología, Hospital Universitario de Navarra, Pamplona, Spain
| | - A I de Miguel Muñoz
- Unidad de Enfermería de Radiodiagnóstico I y II, Hospital Universitario de Navarra, Pamplona, Spain
| | - M I Irigoyen Aristorena
- Servicio de Apoyo a la Gestión Clínica y Continuidad Asistencial, Hospital Universitario de Navarra, Pamplona, Spain
| | - E Goñi Gironés
- Servicio de Medicina Nuclear, Hospital Universitario de Navarra, Pamplona, Spain
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11
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Burisch J, Zhao M, Odes S, De Cruz P, Vermeire S, Bernstein CN, Kaplan GG, Duricova D, Greenberg D, Melberg HO, Watanabe M, Ahn HS, Targownik L, Pittet VEH, Annese V, Park KT, Katsanos KH, Høivik ML, Krznaric Z, Chaparro M, Loftus EV, Lakatos PL, Gisbert JP, Bemelman W, Moum B, Gearry RB, Kappelman MD, Hart A, Pierik MJ, Andrews JM, Ng SC, D'Inca R, Munkholm P. The cost of inflammatory bowel disease in high-income settings: a Lancet Gastroenterology & Hepatology Commission. Lancet Gastroenterol Hepatol 2023; 8:458-492. [PMID: 36871566 DOI: 10.1016/s2468-1253(23)00003-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/06/2023]
Abstract
The cost of caring for patients with inflammatory bowel disease (IBD) continues to increase worldwide. The cause is not only a steady increase in the prevalence of Crohn's disease and ulcerative colitis in both developed and newly industrialised countries, but also the chronic nature of the diseases, the need for long-term, often expensive treatments, the use of more intensive disease monitoring strategies, and the effect of the diseases on economic productivity. This Commission draws together a wide range of expertise to discuss the current costs of IBD care, the drivers of increasing costs, and how to deliver affordable care for IBD in the future. The key conclusions are that (1) increases in health-care costs must be evaluated against improved disease management and reductions in indirect costs, and (2) that overarching systems for data interoperability, registries, and big data approaches must be established for continuous assessment of effectiveness, costs, and the cost-effectiveness of care. International collaborations should be sought out to evaluate novel models of care (eg, value-based health care, including integrated health care, and participatory health-care models), as well as to improve the education and training of clinicians, patients, and policy makers.
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Affiliation(s)
- Johan Burisch
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark.
| | - Mirabella Zhao
- Gastro Unit, Medical Division, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark; Copenhagen Center for Inflammatory Bowel Disease in Children, Adolescents and Adults, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Selwyn Odes
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Melbourne, VIC, Australia; Department of Medicine, Austin Academic Centre, The University of Melbourne, Melbourne, VIC, Australia
| | - Severine Vermeire
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium; Faculty of Medicine, KU Leuven University, Leuven, Belgium
| | - Charles N Bernstein
- IBD Clinical and Research Centre, University of Manitoba, Winnipeg, MB, Canada; Department of Internal Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Gilaad G Kaplan
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Dana Duricova
- IBD Clinical and Research Centre for IBD, ISCARE, Prague, Czech Republic; Department of Pharmacology, Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans O Melberg
- Department of Community Medicine, University of Tromsø-The Arctic University of Norway, Tromsø, Norway; Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Mamoru Watanabe
- Advanced Research Institute, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hyeong Sik Ahn
- Department of Preventive Medicine, College of Medicine, Korea University, Seoul, South Korea
| | - Laura Targownik
- Division of Gastroenterology and Hepatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Valérie E H Pittet
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health, University of Lausanne, Lausanne, Switzerland
| | - Vito Annese
- Division of Gastroenterology, Department of Internal Medicine, Fakeeh University Hospital, Dubai, United Arab Emirates
| | - K T Park
- Stanford Health Care, Packard Health Alliance, Alameda, CA, USA; Genentech (Roche Group), South San Francisco, CA, USA
| | - Konstantinos H Katsanos
- Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, University of Ioannina School of Health Sciences, Ioannina, Greece
| | - Marte L Høivik
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zeljko Krznaric
- Department of Gastroenterology, Hepatology and Nutrition, University Hospital Zagreb, Zagreb, Croatia
| | - María Chaparro
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Peter L Lakatos
- Division of Gastroenterology, McGill University Montreal, QC, Canada; Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| | - Javier P Gisbert
- Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Willem Bemelman
- Department of Surgery, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bjorn Moum
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Richard B Gearry
- Department of Medicine, University of Otago, Christchurch, New Zealand
| | - Michael D Kappelman
- Division of Pediatric Gastroenterology, Department of Pediatrics and Center for Gastrointestinal Biology and Disease, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ailsa Hart
- IBD Unit, St Mark's Hospital, Middlesex, UK
| | - Marieke J Pierik
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Jane M Andrews
- IBD Service, Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Siew C Ng
- Department of Medicine and Therapeutics, Li Ka Shing Institute of Health Sciences, State Key Laboratory of Digestive Disease, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Renata D'Inca
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Pia Munkholm
- Department of Gastroenterology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
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12
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Sather EW, Iversen VC, Svindseth MF, Crawford P, Vasset F. Exploring sustainable care pathways - a scoping review. BMC Health Serv Res 2022; 22:1595. [PMID: 36585672 PMCID: PMC9801530 DOI: 10.1186/s12913-022-08863-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 11/21/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with mental health problems experience numerous transitions into and out of hospital. AIM The review studies assessing clinical care pathways between psychiatric hospitalization and community health services. METHODS We used publications between 2009-2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community. RESULTS Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care. RESOURCES Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need. ETHICAL ISSUES Respectful communication and patient-centred, non-humiliating care. CONCLUSIONS System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication.
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Affiliation(s)
- Eva Walderhaug Sather
- grid.5947.f0000 0001 1516 2393Faculty of Medicine and Health Sciences, Department of Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Valentina Cabral Iversen
- grid.5947.f0000 0001 1516 2393Faculty of Medicine and Health Sciences, Department of Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Marit Folsvik Svindseth
- grid.5947.f0000 0001 1516 2393Faculty of Medicine and Health Sciences, Department of Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Paul Crawford
- grid.5947.f0000 0001 1516 2393Faculty of Medicine and Health Sciences, Department of Health Sciences, The Norwegian University of Science and Technology (NTNU), Trondheim, Norway ,grid.4563.40000 0004 1936 8868Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Frøydis Vasset
- grid.411834.b0000 0004 0434 9525Department for Health and Social Sciences, University College in Molde, Molde, Norway
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13
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Meier ME, Hagelstein-Rotman M, van de Ven AC, Van der Geest ICM, Donker O, Pichardo SEC, Hissink Muller PCE, van der Meeren SW, Dorleijn DMJ, Winter EM, van de Sande MAJ, Appelman-Dijkstra NM. A multidisciplinary care pathway improves quality of life and reduces pain in patients with fibrous dysplasia/McCune-Albright syndrome: a multicenter prospective observational study. Orphanet J Rare Dis 2022; 17:439. [PMID: 36528764 PMCID: PMC9758844 DOI: 10.1186/s13023-022-02588-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 11/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Fibrous dysplasia/McCune-Albright syndrome (FD/MAS) may cause pain, impaired ambulation and decreased quality of life (QoL). International guidelines advocate management of FD/MAS in a tertiary multidisciplinary care pathway, but no longitudinal data are available to support this recommendation. This multicenter prospective observational study aimed to evaluate effects of 1 year of treatment in the FD/MAS care pathway in 2 tertiary clinics on QoL and pain, assessed by change in Short Form 36 and Brief Pain Inventory between baseline and follow-up. Patients completing baseline questionnaires < 1 year after intake were classified as new referrals, others as under chronic care. RESULTS 92 patients were included, 61 females (66%). 22 patients (24%) had monostotic disease, 16 (17%) isolated craniofacial FD, 27 (40%) polyostotic FD and 17 (19%) MAS. 26 were new referrals (28%) and 66 chronic patients (72%). Median age at baseline was 47 years (Q1-Q3 36-56). Skeletal burden correlated with baseline Physical Function (rs = - 0.281, p = 0.007). QoL was in all domains lower compared to the general population. New referrals reported clinically important differences (CID) over time in domains Physical Function (mean 67 ± SD24 to 74 ± 21, effect size (ES) 0.31, p = 0.020), Role Physical (39 ± 41 to 53 ± 43, ES 0.35, p = 0.066), Social Functioning (64 ± 24 to 76 ± 23, ES 0.49, p = 0.054), and Health Change (39 ± 19 to 53 ± 24, ES 0.76, p = 0.016), chronic patients in Physical Function (52 ± 46 to 66 ± 43, ES 0.31, p = 0.023) and Emotional Wellbeing (54 ± 27 to 70 ± 15, ES 0.59, p < 0.001). New referrals reported a CID of 1 point in maximum pain, average pain and pain interference, chronic patients reported stable scores. Change in pain interference and Role Physical were correlated (rs = - 0.472, p < 0.001). Patients with limited disease extent improved more than patients with severe disease. Patients receiving FD-related therapy had lower baseline scores than patients not receiving therapy and reported improvements in QoL after 1 year. Yet also patients without FD-related therapy improved in Physical Function. CONCLUSIONS All FD-subtypes may induce pain and reduced QoL. A multidisciplinary care pathway for FD/MAS may improve pain and QoL, mainly in new referrals without MAS comorbidities with low baseline scores. Therefore, we recommend referral of patients with all subtypes of FD/MAS to specialized academic centers.
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Affiliation(s)
- Maartje E. Meier
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Marlous Hagelstein-Rotman
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Annenienke C. van de Ven
- grid.10417.330000 0004 0444 9382Department of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ingrid C. M. Van der Geest
- grid.10417.330000 0004 0444 9382Department of Orthopaedic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Olav Donker
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarina E. C. Pichardo
- grid.10419.3d0000000089452978Department of Oral and Maxillofacial Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Petra C. E. Hissink Muller
- grid.508552.fDepartment of Paediatric Rheumatology, Willem Alexander Children’s Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Stijn W. van der Meeren
- grid.10419.3d0000000089452978Department of Ophthalmology, Leiden University Medical Center, Leiden, The Netherlands
| | - Desirée M. J. Dorleijn
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M. Winter
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
| | - Michiel A. J. van de Sande
- grid.10419.3d0000000089452978Center for Bone Quality, Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Natasha M. Appelman-Dijkstra
- grid.10419.3d0000000089452978Division of Endocrinology, Department of Internal Medicine, Center for Bone Quality, Leiden University Medical Center, Leiden, The Netherlands
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14
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James CA, Lewis PS, Moore MB, Wong K, Rader EK, Roberson PK, Ghaleb NA, Jensen HK, Pezeshkmehr AH, Stroud MH, Ashton DJ. Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion. Pediatr Radiol 2022; 52:2413-2420. [PMID: 35451632 PMCID: PMC9023697 DOI: 10.1007/s00247-022-05365-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/15/2021] [Accepted: 03/21/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND While chest tube placement with pleural fibrinolytic medication is the established treatment of pediatric empyema, treatment failure is reported in up to 20% of these children. OBJECTIVE Standardizing fibrinolytic administration among interventional radiology (IR) physicians to improve patient outcomes in pediatric parapneumonic effusion. MATERIALS AND METHODS We introduced a hospital-wide clinical pathway for parapneumonic effusion (1-2 mg tissue plasminogen activator [tPA] twice daily based on pleural US grade); we then collected prospective data for IR treatment May 2017 through February 2020. These data included demographics, co-morbidities, pediatric intensive care unit (PICU) admission, pleural US grade, culture results, daily tPA dose average, twice-daily dose days, skipped dose days, pleural therapy days, need for chest CT/a second IR procedure/surgical drainage, and length of stay. We compared the prospective data to historical controls with IR treatment from January 2013 to April 2017. RESULTS Sixty-three children and young adults were treated after clinical pathway implementation. IR referrals increased (P = 0.02) and included higher co-morbidities (P = 0.005) and more PICU patients (P = 0.05). Mean doses per day increased from 1.5 to 1.9 (P < 0.001), twice-daily dose days increased from 38% to 79% (P < 0.001) and median pleural therapy days decreased from 3.5 days to 2.5 days (P = 0.001). No IR patients needed surgical intervention. No statistical differences were observed for gender/age/weight, US grade, need for a second IR procedure or length of stay. US grade correlated with greater positive cultures, need for chest CT/second IR procedure, and pleural therapy days. CONCLUSION Interventional radiology physician standardization improved on a clinical pathway for fibrinolysis of parapneumonic effusion. Despite higher patient complexity, pleural therapy duration decreased. There were no chest tube failures needing surgical drainage.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA.
| | - P Spencer Lewis
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Kevin Wong
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Emily K Rader
- Quality, Risk, and Safety Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nancy A Ghaleb
- Anesthesia Department, Detroit Medical Center and Wayne State University, Detroit, MI, USA
| | - Hanna K Jensen
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Michael H Stroud
- Pediatrics Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daniel J Ashton
- Radiology Department, Arkansas Children's Hospital and University of Arkansas for Medical Sciences, Slot 105, 1 Children's Way, Little Rock, AR, 72202, USA
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15
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Montejo M, Paniagua N, Pijoan JI, Saiz-Hernando C, Castelo S, Martin V, Sánchez A, Benito J. Reducing Unnecessary Treatment of Bronchiolitis Across a Large Regional Health Service in Spain. Pediatrics 2022; 150:189721. [PMID: 36222087 DOI: 10.1542/peds.2021-053888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season. METHODS We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018-March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates. RESULTS We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P < .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P < .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P < .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures. CONCLUSIONS The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.
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Affiliation(s)
| | | | | | | | | | | | - Alvaro Sánchez
- Primary Care Research Department, Biocruces Bizkaia Health Research Institute, Biscay, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital
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16
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Luijten J, Westerman M, Nieuwenhuijzen G, Walraven J, Sosef M, Beerepoot L, van Hillegersberg R, Muller K, Hoekstra R, Bergman J, Siersema P, van Laarhoven H, Rosman C, Brom L, Vissers P, Verhoeven R. Team dynamics and clinician’s experience influence decision-making during Upper-GI multidisciplinary team meetings: A multiple case study. Front Oncol 2022; 12:1003506. [DOI: 10.3389/fonc.2022.1003506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/02/2022] [Indexed: 12/24/2022] Open
Abstract
BackgroundThe probability of undergoing treatment with curative intent for esophagogastric cancer has been shown to vary considerately between hospitals of diagnosis. Little is known about the factors that attribute to this variation. Since clinical decision making (CDM) partially takes place during an MDTM, the aim of this qualitative study was to assess clinician’s perspectives regarding facilitators and barriers associated with CDM during MDTM, and second, to identify factors associated with CDM during an MDTM that may potentially explain differences in hospital practice.MethodsA multiple case study design was conducted. The thematic content analysis of this qualitative study, focused on 16 MDTM observations, 30 semi-structured interviews with clinicians and seven focus groups with clinicians to complement the collected data. Interviews were transcribed ad verbatim and coded.ResultsFactors regarding team dynamics that were raised as aspects attributing to CDM were clinician’s personal characteristics such as ambition and the intention to be innovative. Clinician’s convictions regarding a certain treatment and its outcomes and previous experiences with treatment outcomes, and team dynamics within the MDTM influenced CDM. In addition, a continuum was illustrated. At one end of the continuum, teams tended to be more conservative, following the guidelines more strictly, versus the opposite in which hospitals tended towards a more invasive approach maximizing the probability of curation.ConclusionThis study contributes to the awareness that variation in team dynamics influences CDM during an MDTM.
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17
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Chan TCY, Forster K, Habbous S, Holloway C, Ieraci L, Shalaby Y, Yousefi N. Inverse optimization on hierarchical networks: an application to breast cancer clinical pathways. Health Care Manag Sci 2022; 25:590-622. [PMID: 35802305 DOI: 10.1007/s10729-022-09599-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 05/12/2022] [Indexed: 11/30/2022]
Abstract
Clinical pathways are standardized processes that outline the steps required for managing a specific disease. However, patient pathways often deviate from clinical pathways. Measuring the concordance of patient pathways to clinical pathways is important for health system monitoring and informing quality improvement initiatives. In this paper, we develop an inverse optimization-based approach to measuring pathway concordance in breast cancer, a complex disease. We capture this complexity in a hierarchical network that models the patient's journey through the health system. A novel inverse shortest path model is formulated and solved on this hierarchical network to estimate arc costs, which are used to form a concordance metric to measure the distance between patient pathways and shortest paths (i.e., clinical pathways). Using real breast cancer patient data from Ontario, Canada, we demonstrate that our concordance metric has a statistically significant association with survival for all breast cancer patient subgroups. We also use it to quantify the extent of patient pathway discordances across all subgroups, finding that patients undertaking additional clinical activities constitute the primary driver of discordance in the population.
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Affiliation(s)
- Timothy C Y Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | | | - Steven Habbous
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Claire Holloway
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Luciano Ieraci
- Ontario Health (Cancer Care Ontario), Toronto, Ontario, Canada
| | - Yusuf Shalaby
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Nasrin Yousefi
- Smith School of Business, Queen's University, Kingston, Ontario, Canada.
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18
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Taylor IK, Burlile JF, O'Brien K, Schaeffer EK, Mulpuri K, Shea KG. Developmental Dysplasia of the Hip: An Examination of Care Practices of Pediatricians. J Pediatr 2022; 246:179-183.e2. [PMID: 35231491 DOI: 10.1016/j.jpeds.2022.02.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/04/2022] [Accepted: 02/23/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the decision making processes of pediatricians regarding diagnosis and management of developmental dysplasia of the hip (DDH) by conducting a survey of pediatricians in the United States. STUDY DESIGN An electronic survey was sent to multiple American Academy of Pediatrics state chapters and academic pediatrics groups, and responses were received from pediatricians in 10 states. The survey included demographics, guideline use, clinical scenarios, and referrals/imaging practices. The number of responses to each survey question and their relative frequencies were calculated. RESULTS We received 139 responses and included 126 in our analyses. Only 50% of the responding pediatricians (63 of 126) practiced in an institution that endorses a care pathway for DDH. Only 5.6% of the pediatricians (7 of 125) have referred patients at 12-18 months between diagnosis and management to a specialist for suspected DDH, and 9.5% (12 of 125) have referred patients between 6 and 9 months. Almost one-quarter of the pediatricians (23%; 29 of 126) cited "hip click" as an abnormality that would prompt them to refer a patient to a specialist, and 72.2% (91 of 126) indicated that family history of DDH warrants an ultrasound regardless of the physical examination findings. Moreover, 10.3% of the surveyed pediatricians (13 of 126) reported being only "somewhat" or "moderately" familiar with the Barlow and Ortolani maneuvers. CONCLUSIONS The results of this study indicate that there is an opportunity to better distribute and implement DDH guidelines. The large number of pediatrician respondents who would not refer patients to a specialist or order imaging studies appropriately represents an opportunity for education. The implementation of a care map with standard referral and imaging practices could improve the care of patients with DDH.
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Affiliation(s)
| | | | - Karlie O'Brien
- University of Utah School of Medicine, Salt Lake City, UT
| | - Emily K Schaeffer
- Department of Orthopaedics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kishore Mulpuri
- Department of Orthopaedics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kevin G Shea
- Department of Orthopedic Surgery, Stanford University School of Medicine, Stanford, CA
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19
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Luijten JCHBM, Vissers PAJ, Brom L, de Bièvre M, Buijsen J, Rozema T, Mohammad NH, van Duijvendijk P, Kouwenhoven EA, Eshuis WJ, Rosman C, Siersema PD, van Laarhoven HWM, Verhoeven RHA, Nieuwenhuijzen GAP, Westerman MJ. Clinical variation in the organization of clinical pathways in esophagogastric cancer, a mixed method multiple case study. BMC Health Serv Res 2022; 22:527. [PMID: 35449018 PMCID: PMC9022421 DOI: 10.1186/s12913-022-07845-2] [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: 11/01/2021] [Accepted: 03/17/2022] [Indexed: 12/24/2022] Open
Abstract
Background Among esophagogastric cancer patients, the probability of having undergone treatment with curative intent has been shown to vary, depending on the hospital of diagnosis. However, little is known about the factors that contribute to this variation. In this study, we sought to understand the organization of clinical pathways and their association with variation in practice. Methods A mixed-method study using quantitative and qualitative data was conducted. Quantitative data were obtained from the Netherlands Cancer Registry (e.g., outpatient clinic consultations and diagnostic procedures). For qualitative data, thematic content analysis was performed using semi-structured interviews (n = 30), observations of outpatient clinic consultations (n = 26), and multidisciplinary team meetings (MDTM, n = 16) in eight hospitals, to assess clinicians’ perspectives regarding the clinical pathways. Results Quantitative analyses showed that patients more often underwent surgical consultation prior to the MDTM in hospitals associated with a high probability of receiving treatment with curative intent, but more often consulted with a geriatrician in hospitals associated with a low probability of such treatment. The organization of clinical pathways was analyzed quantitatively at three levels: regional, local, and patient levels. At a regional level, hospitals differed in terms of the number of patients discussed during the MDTM. At the local level, the revision of radiological images and restaging after neoadjuvant treatment varied. At the patient level, some hospitals routinely conduct fitness tests, whereas others estimated the patient’s physical fitness during an outpatient clinic consultation. Few clinicians performed a standard geriatric consultation in older patients to assess their mental fitness and frailty. Conclusion Surgical consultation prior to MDTM was more often conducted in hospitals associated with a high probability of receiving treatment with curative intent, whereas a geriatrician was consulted more often in hospitals associated with a low probability of receiving such treatment. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07845-2.
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Affiliation(s)
- J C H B M Luijten
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511, DT, Utrecht, The Netherlands.
| | - P A J Vissers
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511, DT, Utrecht, The Netherlands.,Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - L Brom
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511, DT, Utrecht, The Netherlands
| | - M de Bièvre
- Department of Gastroenterology, Viecuri Medical Center, Venlo, The Netherlands
| | - J Buijsen
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - T Rozema
- Department of Radiation Oncology, Verbeten Insitute, Tilburg, The Netherlands
| | - N Haj Mohammad
- Department of Medical Oncology, Utrecht UMC, Utrecht University, Utrecht, The Netherlands
| | | | | | - W J Eshuis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - C Rosman
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - P D Siersema
- Department of Gastroenterology, Radboudumc, Nijmegen, The Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - R H A Verhoeven
- Department of Research & Development, Netherlands Comprehensive Cancer Organization (IKNL), Godebaldkwartier 419, 3511, DT, Utrecht, The Netherlands. .,Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | | | - M J Westerman
- Department of Epidemiology and Datascience, Amsterdam UMC, Amsterdam, The Netherlands
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20
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Balhorn J, Su'a B, Jin J, Peng S, Weston M, Israel L, Connolly A, Hill AG, Taneja A. Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic. ANZ J Surg 2022; 92:1394-1400. [PMID: 35429226 PMCID: PMC9324913 DOI: 10.1111/ans.17676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Abstract
Introduction Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an ‘as required’ basis in contrast to the traditional physician‐initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments. Method The purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed ‐ ‘Painful PR bleeding’ and ‘Painless PR bleeding’. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments. Results There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups. Conclusion Initiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.
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Affiliation(s)
- Joshua Balhorn
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Bruce Su'a
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - James Jin
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Sze‐Lin Peng
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Maree Weston
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Lincoln Israel
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Andrew Connolly
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Andrew G. Hill
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Ashish Taneja
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
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21
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Mizrahi D, Goldstein D, Kiernan MC, Robinson L, Pitiyarachchi O, McCullough S, Mendoza-Jones P, Grimison P, Boyle F, Park SB. Development and consensus process for a clinical pathway for the assessment and management of chemotherapy-induced peripheral neuropathy. Support Care Cancer 2022; 30:5965-5974. [PMID: 35394563 PMCID: PMC9135801 DOI: 10.1007/s00520-022-07024-3] [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: 01/11/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cancer patients treated with neurotoxic chemotherapy are at risk of developing neurological symptoms that can impact functional capacity and quality of life. However, there are no standardised pathways to assess and manage chemotherapy-induced peripheral neurotoxicity (CIPN). This study aimed to determine consensus on statements regarding a CIPN assessment and management clinical pathway. METHODS A CIPN clinical pathway (CIPN-path) was developed and reviewed by an expert multi-disciplinary panel and consumers. Agreement with 18 statements regarding four content themes (pretreatment review, screening and assessment, management and referral, and CIPN-path feasibility) were assessed by 70 Australian respondents (68 health professionals, 2 consumers), using a 2-stage Delphi survey process to reach consensus. Respondents rated statements using a 5-point Likert scale to determine the level of agreement, with consensus defined as ≥ 80% of respondents agreeing with each statement. RESULTS The consensus was reached for 14 of 18 items after stage 1 and all items after stage 2. Feedback was obtained for all items to refine the CIPN-path. There was an agreement on important characteristics of the CIPN-path, including pretreatment screening, regular patient-reported assessment, and a stepped-care approach to investigating and managing symptom burden. There was a lack of agreement on who should oversee CIPN assessment, which may differ according to the structure and resources of each site. CONCLUSIONS There was an overall agreement concerning the CIPN-path to assess and manage CIPN, which may be adapted accordingly to the resources of each clinic. The CIPN-path may assist teams across different health services in identifying CIPN symptoms, aiding decision-making, and reducing morbidity from CIPN.
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Affiliation(s)
- David Mizrahi
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, Australia.,Faculty of Medicine and Health, Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia
| | - David Goldstein
- Faculty of Medicine and Health, Prince of Wales Clinical School, UNSW Sydney, Sydney, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, The University of Sydney, Sydney, Australia.,Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Louisa Robinson
- Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia
| | | | - Susan McCullough
- Translational Cancer Research Network Consumer Advisory Panel, Sydney, Australia
| | - Phil Mendoza-Jones
- Translational Cancer Research Network Consumer Advisory Panel, Sydney, Australia
| | - Peter Grimison
- Chris O'Brien Lifehouse, Sydney, Australia.,Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Frances Boyle
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.,Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital, North Sydney, Australia
| | - Susanna B Park
- Brain and Mind Centre, The University of Sydney, Sydney, Australia.
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22
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Bauer J, Kösel E, Henkel AG, Spinner CD, Kolisch R. [Integrated care concepts and multidisciplinary process chains in a radiological context]. Radiologe 2022; 62:331-342. [PMID: 35201396 DOI: 10.1007/s00117-022-00976-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
Modern patient-centered and cost-efficient care concepts in hospitals require the mapping of multidisciplinary process chains into clinical pathways. Clinical decision support systems and operations research methods use algorithms to classify patients into homogeneous groups and to model a complete clinical pathway for scheduling individual procedures. An improvement of the economic situation of the care facility can be achieved through improved resource utilization, reduced patient waiting times and a shortening of the length of stay. The interdisciplinary use of centrally stored interoperable information and comprehensive care management via information technology (IT) services lay the foundation for the dissolution of traditional IT system architectures in medicine and the development of flexibly integrable modern system platforms. New IT approaches such as the semantically standardized definition of procedures and resource properties, the use of clinical decision support systems and the use of service-oriented system architectures form the basis for the deep integration of radiology services into comprehensive interdisciplinary care concepts.
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Affiliation(s)
- J Bauer
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - E Kösel
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - A G Henkel
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - C D Spinner
- Abteilung Informationstechnologie, Klinikum rechts der Isar, Fakultät für Medizin, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland
| | - R Kolisch
- Lehrstuhl für Operations Management, Fakultät für Wirtschaftswissenschaften, Technische Universität München, München, Deutschland
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23
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Butow P, Shepherd HL, Cuddy J, Rankin N, Harris M, He S, Grimison P, Girgis A, Faris M, Shaw J. Staff perspectives on the feasibility of a clinical pathway for anxiety and depression in cancer care, and mid-implementation adaptations. BMC Health Serv Res 2022; 22:192. [PMID: 35164772 PMCID: PMC8842573 DOI: 10.1186/s12913-022-07532-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 12/14/2021] [Indexed: 08/30/2023] Open
Abstract
Background Clinical pathways (CPs) are intended to standardise and improve care but do not always produce positive outcomes, possibly because they were not adapted to suit the specific context in which they were enacted. This qualitative study aimed to explore staff perspectives of implementation of a CP for routine screening, assessment, referral and management of anxiety and depression (the ADAPT CP) for patients with cancer, focussing on perceived feasibility of the CP and negotiated adaptations made during the implementation phase. Methods The ADAPT CP was implemented in 12 urban and regional oncology services in Australia. Services were randomised to receive core versus enhanced implementation strategies. Core sites received support until implementation commencement and could access progress reports. Enhanced sites received proactive, ongoing support during the 12-month implementation. Purposively selected staff were interviewed prior to implementation (n = 88) and 6 months later, half-way through the implementation period (n = 89). Monthly meetings with lead multi-disciplinary teams at the eight enhanced sites were recorded. Data were thematically analysed. Results Six overarching themes were identified: ADAPT is of high value; timing for introducing the CP and screening is difficult; online screening is challenging; a burden too much; no-one to refer patients to; and micro-logistics are key. While early screening was deemed desirable, diverse barriers meant this was complex, with adaptations made to time and screening location. Online screening prompted by email, seen as time-saving and efficient, also proved unsuccessful in some services, with adaptations made to in-clinic or phone screening, or repeated email reminders. Staff negative attitudes to ADAPT, time constraints, and perceived poor fit of ADAPT to work roles and flows, all impacted implementation, with key tasks often devolving to a few key individuals. Nevertheless, services remained committed to the ADAPT CP, and worked hard to create, review and adapt strategies to address challenges to optimise success. Conclusions This study demonstrates the interactive nature of health service change, with staff actively engaging with, forming views on, and problem-solving adaptations of the ADAPT CP to overcome barriers. Obtaining staff feedback is critical to ensure health service change is sustainable, meaningful and achieves its promise of improving patient outcomes. Trial registration The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07532-2.
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Affiliation(s)
- Phyllis Butow
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
| | - Heather L Shepherd
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia.
| | - Jessica Cuddy
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
| | - Nicole Rankin
- The University of Sydney, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Marnie Harris
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
| | - Sharon He
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
| | | | - Afaf Girgis
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, Australia
| | - Mona Faris
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
| | | | - Joanne Shaw
- The University of Sydney, School of Psychology, Psycho-Oncology Co-operative Research Group (PoCoG), Sydney, NSW, 2006, Australia
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24
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Yamashita T, Wakata Y, Nakaguma H, Nohara Y, Hato S, Kawamura S, Muraoka S, Sugita M, Okada M, Nakashima N, Soejima H. Machine learning for classification of postoperative patient status using standardized medical data. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 214:106583. [PMID: 34959156 DOI: 10.1016/j.cmpb.2021.106583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 09/06/2021] [Accepted: 12/07/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Real-world evidence is defined as clinical evidence regarding the use and potential benefits or risks of a medical product derived from real-world data analyses. Standardization and structuring of data are necessary to analyze medical real-world data collected from different medical institutions. An electronic message and repository have been developed to link electronic medical records in this research project, which has simplified the data integration. Therefore, this paper proposes an analysis method and learning health systems to determine the priority of clinical intervention by clustering and visualizing time-series and prioritizing patient outcomes and status during hospitalization. METHODS Common data items for reimbursement (Diagnosis Procedure Combination [DPC]) and clinical pathway data were examined in this project at each participating institution that runs the verification test. Long-term hospitalization data were analyzed using the data stored in the cloud platform of the institutions' repositories using multiple machine learning methods for classification, visualization, and interpretation. RESULTS The ePath platform contributed to integrate the standardized data from multiple institutions. The distribution of DPC items or variances could be confirmed by clustering, temporal tendency through the directed graph, and extracting variables that contributed to the prediction and evaluation of SHapley Additive Explanation effects. Constipation was determined to be the risk factor most strongly related to long-term hospitalization. Drainage management was identified as a factor that can improve long-term hospitalization. These analyses effectively extracted patient status to provide feedback to the learning health system. CONCLUSIONS We successfully generated evidence of medical processes by gathering patient status, medical purposes, and patient outcomes with high data quality from multiple institutions, which were difficult with conventional electronic medical records. Regarding the significant analysis results, the learning health system will be used on this project to provide feedback to each institution, operate it for a certain period, and analyze and re-evaluate it.
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Affiliation(s)
| | - Yoshifumi Wakata
- Medical IT Center, Tokushima University Hospital, Tokushima Japan
| | | | - Yasunobu Nohara
- Faculty of Advanced Science and Technology, Kumamoto University, Kumamoto Japan
| | - Shinji Hato
- National Hospital Organization, Shikoku Cancer Center, Ehime Japan
| | - Susumu Kawamura
- National Hospital Organization, Shikoku Cancer Center, Ehime Japan
| | | | | | - Mihoko Okada
- Institute of Health Data Infrastructure for all, Tokyo Japan
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Fukuoka Japan
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van Linschoten RCA, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, de Jonge V, Hazelzet JA, van der Woude CJ, West RL, van Noord D. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. BMJ Open 2022; 12:e050539. [PMID: 35022169 PMCID: PMC8756277 DOI: 10.1136/bmjopen-2021-050539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Biologics are effective for the treatment of inflammatory bowel disease (IBD). However, unwarranted variation in processes and outcomes has been reported in the treatment of IBD. A care pathway for the treatment of IBD has the potential to reduce practice variation and improve outcomes. This study aims to compare the effect of a uniform care pathway for the treatment of patients with IBD with biologics to the current situation. METHODS AND ANALYSIS IBD Value is a longitudinal multicentre non-randomised parallel cluster trial with a baseline period. The study takes place in eight centres in the Netherlands. The baseline period will run for 12 months, after which the care pathway will be implemented in 6 of the 8 participating hospitals during the implementation phase of 3 months. Hereafter, the effect of the care pathway will be assessed for 12 months. Total study period is 27 months. The primary outcome is the effect of the care pathway on disease control (IBD-Control questionnaire). Secondary outcomes are the effect of the care pathway on the other outcomes of the International Consortium of Health Outcomes Measurement IBD standard set, health-related generic quality of life, patient experiences and degree of variation; cost effectiveness of the care pathway; and the variation between hospitals in the aforementioned outcomes in the baseline period. Outcomes will be measured every 6 months. The study started on 1 December 2020 and a minimum of 200 patients will be included. ETHICS AND DISSEMINATION The study was deemed not to be subject to Dutch law (WMO; Medical Research Involving Human Subjects Act) by the Medical Ethics Committee of the Erasmus MC, the Netherlands (registration number: MEC-2020-075) and a waiver was provided. Results will be disseminated through peer-reviewed journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER NL8276.
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Affiliation(s)
- Reinier Cornelis Anthonius van Linschoten
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Nikki van Leeuwen
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Erwin Birnie
- Department of Statistics and Education, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
- Department of Genetics, University of Groningen, Groningen, The Netherlands
| | | | - Karen Evelyne Verweij
- Department of Gastroenterology and Hepatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Vincent de Jonge
- Department of Gastroenterology and Hepatology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - C Janneke van der Woude
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Rachel Louise West
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Desirée van Noord
- Department of Gastroenterology and Hepatology, Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
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26
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Butow P, Shepherd HL, Cuddy J, Harris M, He S, Masya L, Faris M, Rankin NM, Beale P, Girgis A, Kelly B, Grimison P, Shaw J. Acceptability and appropriateness of a clinical pathway for managing anxiety and depression in cancer patients: a mixed methods study of staff perspectives. BMC Health Serv Res 2021; 21:1243. [PMID: 34789239 PMCID: PMC8600707 DOI: 10.1186/s12913-021-07252-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
Background Clinical pathways (CPs) can improve health outcomes, but to be sustainable, must be deemed acceptable and appropriate by staff. A CP for screening and management of anxiety and depression in cancer patients (the ADAPT CP) was implemented in 12 Australian oncology services for 12 months, within a cluster randomised controlled trial of core versus enhanced implementation strategies. This paper compares staff-perceived acceptability and appropriateness of the ADAPT CP across study arms. Methods Multi-disciplinary lead teams at each service tailored, planned, championed and implemented the CP. Staff at participating services, purposively selected for diversity, completed a survey and participated in an interview prior to implementation (T0), and at midpoint (6 months: T1) and end (12 months: T2) of implementation. Interviews were recorded, transcribed and thematically analysed. Results Seven metropolitan and 5 regional services participated. Questionnaires were completed by 106, 58 and 57 staff at T0, T1 and T2 respectively. Eighty-eight staff consented to be interviewed at T0, with 89 and 76 at T1 and T2 (response rates 70%, 66% and 57%, respectively). Acceptability/appropriateness, on the quantitative measure, was high at T0 (mean of 31/35) and remained at that level throughout the study, with no differences between staff from core versus enhanced services. Perceived burden was relatively low (mean of 11/20) with no change over time. Lowest scores and greatest variability pertained to perceived impact on workload, time and cost. Four major themes were identified: 1) Mental health is an important issue which ADAPT addresses; 2) ADAPT helps staff deliver best care, and reduces staff stress; 3) ADAPT is fit for purpose, for both cancer care services and patients; 4) ADAPT: a catalyst for change. Opposing viewpoints are outlined. Conclusions This study demonstrated high staff-perceived acceptability and appropriateness of the ADAPT CP with regards to its focus, evidence-base, utility to staff and patients, and ability to create change. However, concerns remained regarding burden on staff and time commitment. Strategies from a policy and managerial level will likely be required to overcome the latter issues. Trial registration The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347. https://www.anzctr.org.au/. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07252-z.
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Affiliation(s)
- Phyllis Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Heather L Shepherd
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia. .,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.
| | - Jessica Cuddy
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Marnie Harris
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Sharon He
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Lindy Masya
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Mona Faris
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - Nicole M Rankin
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Philip Beale
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Cancer Services for the Sydney Local Health District, Incorporating Royal Prince Alfred, Concord and Canterbury Hospitals, Campsie, NSW, Australia
| | - Afaf Girgis
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
| | - Brian Kelly
- School of Medicine & Public Health, University of Newcastle, Callaghan, NSW, Australia
| | | | | | - Joanne Shaw
- Psycho-Oncology Co-operative Research Group (PoCoG), School of Psychology, The University of Sydney, Sydney, NSW, Australia
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Wong TLW, Husain S, Ismail A, Zahedi FD, Aljunid SM, Nur AM. Evaluation of previous management against a developed clinical pathway for chronic rhinosinusitis with nasal polyposis in Universiti Kebangsaan Malaysia Medical Center. Medicine (Baltimore) 2021; 100:e27675. [PMID: 34871247 PMCID: PMC8568441 DOI: 10.1097/md.0000000000027675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/16/2021] [Indexed: 11/26/2022] Open
Abstract
The study aims to evaluate previous management of CRSwNP patients in Universiti Kebangsaan Malaysia Medical Center (UKMMC) against a developed CP.Chronic rhinosinusitis with nasal polyposis (CRSwNP) has high economic burden and impacts patient's quality of life. Implementation of clinical pathway (CP) can standardize care while optimizing resources.Analytical cross-sectionalThis study utilized medical records of 103 CRSwNP patients at UKMMC otorhinolaryngology clinic from 2010 to 2015. Patients were divided into groups who underwent or did not undergo surgery. Information was obtained regarding sociodemographic, follow-ups, pharmaceutical regimes, and treatment cost. Cost analysis was done using top-down analysis and activity-based costing and CP was formulated. Cost was calculated using year 2020 rates to adjust for inflation. (United States Dollars [USD]1 = Ringgit Malaysia [RM] 4.2015)Study showed non-CP patients were undertreated compared to CP. This affects clinical outcomes as optimal treatment demanded by CP was not achieved. Total cost for non-CP, non-surgery patients were lower (USD660) compared to CP (USD780) due to under treatment and shorter follow-ups. Meanwhile, total cost for non-CP surgery patients were higher (USD3600) compared to CP (USD2706) due to longer visit durations and hospital stays. Non-CP surgery group underwent lengthy follow-up duration (20.7 months) prior to operation compared to 12 months expected in CP.Study showed non-CP patients were undertreated compared to CP. We identified aspects which resulted in resource wastage and unnecessary burden to our healthcare system. This study enables development of a written CP by fine-tuning various aspects of CP which could be applied to our future practice.
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Affiliation(s)
- Timothy LW Wong
- Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
- Surgical Based Department, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Salina Husain
- Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Aniza Ismail
- Department of Community Health, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Farah Dayana Zahedi
- Department of Otorhinolaryngology-Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia
| | - Syed Mohamed Aljunid
- International Center for Casemix and Clinical Coding, Faculty of Medicine, Universiti Kebangsaan Malaysia
- Department of Health Policy and Management, Faculty of Public Health, Kuwait University, Kuwait
| | - Amrizal Muhammad Nur
- Department of Health Policy and Management, Faculty of Public Health, Kuwait University, Kuwait
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Seys D, Coeckelberghs E, Sermeus W, Van Zelm R, Panella M, Babu Payedimarri A, Vanhaecht K. Overview on the target population and methods used in care pathway projects: A narrative review. Int J Clin Pract 2021; 75:e14565. [PMID: 34165865 DOI: 10.1111/ijcp.14565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND There is evidence that the efficiency and effectiveness of care processes can be improved in all countries. Care pathways (CPs) are proposed as a method to improve the quality of care by reducing variation. During the last decades, CPs have been intensively used in practice. The objective of this study is to examine the study designs for investigating CPs, for which pathologies CPs are used and what the reported indicators to measure the impact of CPs are. METHODS A narrative review of the literature published from 2015 to 2019 was performed. RESULTS We identified 286 studies, of which 207 evaluated the impact of CPs, 33 were review articles, 29 studies described the development of a CP, 12 were study protocols and 5 opinion papers. The most frequently reported study design for studying the impact of a CP is pre-posttest (n = 82), followed by cross-sectional studies (n = 50). Oncology, cardiovascular disease and abdominal surgery are the domains with the highest numbers of studies evaluating the impact of CPs. Financial (n = 86), process (n = 76) and clinical indicators (n = 74) are the most frequently reported indicators while service (n = 12) and team indicators (n = 6) are less reported. CONCLUSIONS Based on the relative low number of identified studies compared with the number of CP projects in organisations, we conclude that the CP knowledge is not only found in the literature. We, therefore, argue that (inter)national scientific societies should not only focus on searching and spreading evidence on the content of care but also enhance their knowledge sharing initiatives on the organisation of care processes.
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Affiliation(s)
- Deborah Seys
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ellen Coeckelberghs
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Walter Sermeus
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Ruben Van Zelm
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Massimiliano Panella
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Anil Babu Payedimarri
- Department of Translational Medicine, University of Eastern Piedmont Amedeo Avogadro, Novara, Italy
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
- Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
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29
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Riquelme-Galindo J, Lillo-Crespo M. Designing Dementia Care Pathways to Transform Non Dementia-Friendly Hospitals: Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179296. [PMID: 34501886 PMCID: PMC8431306 DOI: 10.3390/ijerph18179296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 11/16/2022]
Abstract
People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients’ routes and processes considering the increasing demographic changes of people with cognitive impairment.
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Affiliation(s)
- Jorge Riquelme-Galindo
- Faculty of Health Sciences, University of Alicante, 03690 Alicante, Spain;
- HLA Vistahermosa Hospital, 03015 Alicante, Spain
- Correspondence:
| | - Manuel Lillo-Crespo
- Faculty of Health Sciences, University of Alicante, 03690 Alicante, Spain;
- HLA Vistahermosa Hospital, 03015 Alicante, Spain
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Sugihara T, Kanehira T, Suzuki M, Araki K. Behavioral signs of an unintended error in nursing information sharing with electronic clinical pathways: a mixed research approach. Inform Health Soc Care 2021; 47:159-174. [PMID: 34428108 DOI: 10.1080/17538157.2021.1966015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Electronic clinical pathways (ECPs) strongly encourage the standardization of medical treatment and the sharing of information among medical staff. The goal of this study was to determine the influence of ECPs on information sharing among nurses in a university hospital. Four experienced nurses, selected based on ECP composing and operation experience, were recruited from the department with the most frequent users in the first-round interview, 132 nurses' questionnaire answers were analyzed, and eight nurses participated in the second-round interview. This study conducted a mixed-method (interview-questionnaire-interview) investigation to extract the behavioral signs of unintended errors in information sharing after the ethical approval was obtained. On the basis of ANOVA and t-test for the questionnaire and constant comparison for interview, this study found that the greater extent of user dependency on convenient ECPs in the frequent-use group led to mistakes under hectic conditions. This study also found evidence of poor management of ECPs when problems occurred. The immature design of ECPs provoked inappropriate behaviors among nurses even though they brought about some benefits such as mitigation of the burden of daily recording tasks. The findings empirically showed the ECP user's behavioral changes regarding the technology-induced error.
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Affiliation(s)
- Taro Sugihara
- Department of Innovation Science, School of Environment and Society, Tokyo Institute of Technology, Tokyo, Japan
| | - Tadashi Kanehira
- Division of Medical Bioengineering, Graduate School of Natural Science and Technology, Okayama University, Okayama, Japan
| | - Muneou Suzuki
- Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kenji Araki
- Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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31
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Keikes L, Kos M, Verbeek XAAM, Van Vegchel T, Nagtegaal ID, Lahaye MJ, Méndez Romero A, De Bruijn S, Verheul HMW, Rütten H, Punt CJA, Tanis PJ, Van Oijen MGH. Conversion of a colorectal cancer guideline into clinical decision trees with assessment of validity. Int J Qual Health Care 2021; 33:6184988. [PMID: 33760073 PMCID: PMC8023581 DOI: 10.1093/intqhc/mzab051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/11/2021] [Accepted: 03/23/2021] [Indexed: 12/14/2022] Open
Abstract
Objective The interpretation and clinical application of guidelines can be challenging and time-consuming, which may result in noncompliance to guidelines. The aim of this study was to convert the Dutch guideline for colorectal cancer (CRC) into decision trees and subsequently implement decision trees in an online decision support environment to facilitate guideline application. Methods The recommendations of the Dutch CRC guidelines (published in 2014) were translated into decision trees consisting of decision nodes, branches and leaves that represent data items, data item values and recommendations, respectively. Decision trees were discussed with experts in the field and published as interactive open access decision support software (available at www.oncoguide.nl). Decision tree validation and a concordance analysis were performed using consecutive reports (January 2016–January 2017) from CRC multidisciplinary tumour boards (MTBs) at Amsterdam University Medical Centers, location AMC. Results In total, we developed 34 decision trees driven by 101 decision nodes based on the guideline recommendations. Decision trees represented recommendations for diagnostics (n = 1), staging (n = 10), primary treatment (colon: n = 1, rectum: n = 5, colorectal: n = 9), pathology (n = 4) and follow-up (n = 3) and included one overview decision tree for optimal navigation. We identified several guideline information gaps and areas of inconclusive evidence. A total of 158 patients’ MTB reports were eligible for decision tree validation and resulted in treatment recommendations in 80% of cases. The concordance rate between decision tree treatment recommendations and MTB advices was 81%. Decision trees reported in 22 out of 24 non-concordant cases (92%) that no guideline recommendation was available. Conclusions We successfully converted the Dutch CRC guideline into decision trees and identified several information gaps and areas of inconclusive evidence, the latter being the main cause of the observed disagreement between decision tree recommendations and MTB advices. Decision trees may contribute to future strategies to optimize quality of care for CRC patients.
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Affiliation(s)
- Lotte Keikes
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Noord-Holland 1105 AZ, Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, Utrecht 3511 DT, Netherlands
| | - Milan Kos
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Noord-Holland 1105 AZ, Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, Utrecht 3511 DT, Netherlands
| | - Xander A A M Verbeek
- Department of Research, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, Utrecht 3511 DT, Netherlands
| | - Thijs Van Vegchel
- Department of Research, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, Utrecht 3511 DT, Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, Gelderland 6525 GA, Netherlands
| | - Max J Lahaye
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, Amsterdam, Noord-Holland 1066 CX, Netherlands
| | - Alejandra Méndez Romero
- Department of Radiation Oncology, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam, Zuid-Holland 3015 GD, Netherlands
| | - Sandra De Bruijn
- Department of Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, Delft, Zuid-Holland, 2625 AD, Netherlands
| | - Henk M W Verheul
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, Gelderland 6525 GA, Netherlands
| | - Heidi Rütten
- Department of Radiation Oncology, Radboud University Medical Center, Geert Grooteplein Zuid 10, Nijmegen, Gelderland 6525 GA, Netherlands
| | - Cornelis J A Punt
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Noord-Holland 1105 AZ, Netherlands
| | - Martijn G H Van Oijen
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Noord-Holland 1105 AZ, Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation, Godebaldkwartier 419, Utrecht 3511 DT, Netherlands
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32
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de Belvis AG, Pellegrino R, Castagna C, Morsella A, Pastorino R, Boccia S. Success Factors and Barriers in Combining Personalized Medicine and Patient Centered Care in Breast Cancer. Results from a Systematic Review and Proposal of Conceptual Framework. J Pers Med 2021; 11:654. [PMID: 34357121 PMCID: PMC8306768 DOI: 10.3390/jpm11070654] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 02/06/2023] Open
Abstract
Breast Cancer (BC) is the leading cause of death due to cancer in women. Ensuring equitable, quality-assured and effective care has increased the complexity of BC management. This systematic review reports on the state-of-the art of available literature investigating the enactment of personalized treatment and patient-centered care models in BC clinical practice, building a framework for the delivery of personalized BC care within a Patient-Centered model. Databases were searched for articles (from the inception to December 2020) reporting on Patient-Centered or Personalized Medicine BC management models, assessing success factors or limits. Out of 1885 records, 25 studies were included in our analysis. The main success factors include clearly defined roles and responsibilities within a multi-professional collaboration, appropriate training programs and adequate communication strategies and adopting a universal genomic language to improve patients' involvement in the decision-making process. Among detected barriers, delays in the use of genetic testing were linked to the lack of public reimbursement schemes and of clear indications in timing and appropriateness. Overall, both care approaches are complementary and necessary to effectively improve BC patient management. Our framework attempts to bridge the gap in assigning a central role played by shared decision-making, still scarcely investigated in literature.
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Affiliation(s)
- Antonio Giulio de Belvis
- Department of Life Sciences and Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; (A.G.d.B.); (A.M.); (R.P.); (S.B.)
- Clinical Pathways and Outcome Evaluation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via della Pineta Sacchetti 217, 00168 Rome, Italy
| | - Rossella Pellegrino
- Clinical Pathways and Outcome Evaluation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via della Pineta Sacchetti 217, 00168 Rome, Italy
| | - Carolina Castagna
- Department of Life Sciences and Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; (A.G.d.B.); (A.M.); (R.P.); (S.B.)
| | - Alisha Morsella
- Department of Life Sciences and Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; (A.G.d.B.); (A.M.); (R.P.); (S.B.)
- Clinical Pathways and Outcome Evaluation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via della Pineta Sacchetti 217, 00168 Rome, Italy
| | - Roberta Pastorino
- Department of Life Sciences and Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; (A.G.d.B.); (A.M.); (R.P.); (S.B.)
| | - Stefania Boccia
- Department of Life Sciences and Public Health, Section of Hygiene, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy; (A.G.d.B.); (A.M.); (R.P.); (S.B.)
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Montejo M, Paniagua N, Saiz-Hernando C, Martínez-Indart L, Pijoan JI, Castelo S, Martín V, Benito J. Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway. Pediatrics 2021; 147:peds.2019-4021. [PMID: 33958438 DOI: 10.1542/peds.2019-4021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. METHODS We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. RESULTS We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) (P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) (P <.001), respectively. No significant variations were noted in control measures. CONCLUSIONS An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.
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Affiliation(s)
| | | | | | | | | | - Susana Castelo
- Innovation and Quality of Care, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Biscay, Basque Country, Spain
| | - Vanesa Martín
- Innovation and Quality of Care, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Biscay, Basque Country, Spain
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Lin D, Zhang C, Shi H. Effects of Clinical Pathways on Cesarean Sections in China: Length of Stay and Direct Hospitalization Cost Based on Meta-Analysis of Randomized Controlled Trials and Controlled Clinical Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115918. [PMID: 34072956 PMCID: PMC8198843 DOI: 10.3390/ijerph18115918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 11/16/2022]
Abstract
The cesarean section (CS) on maternal request increased sharply in China, bringing pressure to medical resources and national insurance. We assessed the use of clinical pathways (CPWs) for CS compared with conventional medical care by outcomes of length of stay (LOS) in hospital and direct hospitalization cost (DHC). Four Chinese electronic databases, including China National Knowledge Infrastructure (CNKI), Wanfang, CQVIP, and SinoMed, were explored to December 2020 for the full-text papers published in Chinese. Literature that quantitatively assessed the effects of CPW on LOS or DHC were eligible for inclusion. The weighted mean differences (WMDs) were pooled. Twenty-five articles were included in our analysis, with a total sample of 7761 women. These studies were performed from 2004 to 2017 and reported from 2005 to 2018. The synthesized results showed a shorter LOS (in days) (WMD = −1.37, 95% CI: −1.48 to −1.26) and a less DHC (CNY¥) (WMD = −520.46, 95% CI: −554.06 to −503.63) in the CPW group, comparing with that of conventional care. With the need for CS on the rise, the introduction of CPW could effectively reduce LOS and DHC, thereby releasing the medical resources and insurance pressure.
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Affiliation(s)
- Dan Lin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai 200032, China;
| | - Chunyang Zhang
- Fujian Center for Disease Control and Prevention, Fuzhou 350001, China;
| | - Huijing Shi
- Department of Maternal, Child and Adolescent Health, School of Public Health, Fudan University, Shanghai 200032, China;
- Correspondence:
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Antonacci G, Lennox L, Barlow J, Evans L, Reed J. Process mapping in healthcare: a systematic review. BMC Health Serv Res 2021; 21:342. [PMID: 33853610 PMCID: PMC8048073 DOI: 10.1186/s12913-021-06254-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Process mapping (PM) supports better understanding of complex systems and adaptation of improvement interventions to their local context. However, there is little research on its use in healthcare. This study (i) proposes a conceptual framework outlining quality criteria to guide the effective implementation, evaluation and reporting of PM in healthcare; (ii) reviews published PM cases to identify context and quality of PM application, and the reported benefits of using PM in healthcare. METHODS We developed the conceptual framework by reviewing methodological guidance on PM and empirical literature on its use in healthcare improvement interventions. We conducted a systematic review of empirical literature using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology. Inclusion criteria were: full text empirical study; describing the process through which PM has been applied in a healthcare setting; published in English. Databases searched are: Medline, Embase, HMIC-Health Management Information Consortium, CINAHL-Cumulative Index to Nursing and Allied Health Literature, Scopus. Two independent reviewers extracted and analysed data. Each manuscript underwent line by line coding. The conceptual framework was used to evaluate adherence of empirical studies to the identified PM quality criteria. Context in which PM is used and benefits of using PM were coded using an inductive thematic analysis approach. RESULTS The framework outlines quality criteria for each PM phase: (i) preparation, planning and process identification, (ii) data and information gathering, (iii) process map generation, (iv) analysis, (v) taking it forward. PM is used in a variety of settings and approaches to improvement. None of the reviewed studies (N = 105) met all ten quality criteria; 7% were compliant with 8/10 or 9/10 criteria. 45% of studies reported that PM was generated through multi-professional meetings and 15% reported patient involvement. Studies highlighted the value of PM in navigating the complexity characterising healthcare improvement interventions. CONCLUSION The full potential of PM is inhibited by variance in reporting and poor adherence to underpinning principles. Greater rigour in the application of the method is required. We encourage the use and further development of the proposed framework to support training, application and reporting of PM. TRIAL REGISTRATION Prospero ID: CRD42017082140.
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Affiliation(s)
- Grazia Antonacci
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Laura Lennox
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Applied Research Collaboration (ARC) Northwest London, London, UK
| | - James Barlow
- Business School, Centre for Health Economics and Policy Innovation (CHEPI), Imperial College London, London, UK
| | - Liz Evans
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
| | - Julie Reed
- Department of Primary Care and Public Health, Imperial College London, National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, London, UK
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Matsumoto K, Nohara Y, Wakata Y, Yamashita T, Kozuma Y, Sugeta R, Yamakawa M, Yamauchi F, Miyashita E, Takezaki T, Yamashiro S, Nishi T, Machida J, Soejima H, Kamouchi M, Nakashima N. Impact of a learning health system on acute care and medical complications after intracerebral hemorrhage. Learn Health Syst 2021; 5:e10223. [PMID: 33889732 PMCID: PMC8051343 DOI: 10.1002/lrh2.10223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/10/2020] [Accepted: 02/02/2020] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Patients with stroke often experience pneumonia during the acute stage after stroke onset. Oral care may be effective in reducing the risk of stroke-associated pneumonia (SAP). We aimed to determine the changes in oral care, as well as the incidence of SAP, in patients with intracerebral hemorrhage, following implementation of a learning health system in our hospital. METHODS We retrospectively analyzed the data of 1716 patients with intracerebral hemorrhage who were hospitalized at a single stroke center in Japan between January 2012 and December 2018. Data were stratified on the basis of three periods of evolving oral care: period A, during which conventional, empirically driven oral care was provided (n = 725); period B, during which standardized oral care was introduced, with SAP prophylaxis based on known risk factors (n = 469); and period C, during which oral care was risk-appropriate based on learning health system data (n = 522). Logistic regression analysis was performed to evaluate associations between each of the three treatment approaches and the risk of SAP. RESULTS Among the included patients, the mean age was 71.3 ± 13.6 years; 52.6% of patients were men. During the course of each period, the frequency of oral care within 24 hours of admission increased (P < .001), as did the adherence rate to oral care ≥3 times per day (P < .001). After adjustment for confounding factors, a change in the risk of SAP was not observed in period B; however, the risk significantly decreased in period C (odds ratio 0.61; 95% confidence interval 0.43-0.87) compared with period A. These associations were maintained for SAP diagnosed using strict clinical criteria or after exclusion of 174 patients who underwent neurosurgical treatment. CONCLUSIONS Risk-appropriate care informed by the use of learning health system data could improve care and potentially reduce the risk of SAP in patients with intracerebral hemorrhage in the acute stage.
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Affiliation(s)
- Koutarou Matsumoto
- Department of Medical SupportSaiseikai Kumamoto HospitalKumamotoJapan
- Department of Health Care Administration and Management, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Yasunobu Nohara
- Medical Information CenterKyushu University HospitalFukuokaJapan
| | | | | | - Yukio Kozuma
- Department of Medical InformationSaiseikai Kumamoto HospitalKumamotoJapan
| | - Rui Sugeta
- Department of Medical InformationSaiseikai Kumamoto HospitalKumamotoJapan
| | - Miki Yamakawa
- Department of NursingSaiseikai Kumamoto HospitalKumamotoJapan
| | - Fumiko Yamauchi
- Department of NursingSaiseikai Kumamoto HospitalKumamotoJapan
| | - Eri Miyashita
- Department of NursingSaiseikai Kumamoto HospitalKumamotoJapan
| | - Tatsuya Takezaki
- Department of NeurosurgeryKumamoto University HospitalKumamotoJapan
| | - Shigeo Yamashiro
- Division of NeurosurgerySaiseikai Kumamoto HospitalKumamotoJapan
| | - Toru Nishi
- Department of NeurosurgerySakura Jyuji HospitalKumamotoJapan
| | - Jiro Machida
- Department of Medical InformationSaiseikai Kumamoto HospitalKumamotoJapan
| | - Hidehisa Soejima
- Department of InspectionSaiseikai Kumamoto HospitalKumamotoJapan
| | - Masahiro Kamouchi
- Department of Health Care Administration and Management, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
- Center for Cohort Studies, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Naoki Nakashima
- Medical Information CenterKyushu University HospitalFukuokaJapan
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Logan AM, Landera MA. Clinical Practices in Head and Neck Cancer: A Speech-Language Pathologist Practice Pattern Survey. Ann Otol Rhinol Laryngol 2021; 130:1254-1262. [PMID: 33733876 DOI: 10.1177/00034894211001065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Clinical practices of speech-language pathologists (SLP) treating head and neck cancer (HNC) patients range widely despite literature trending toward best practices. This survey study was designed to identify current patterns and assess for gaps in clinical implementation of research evidence. METHOD A web-based survey was distributed to SLPs via listserv and social media outlets. Descriptive statistics and group calculations were completed to identify trends and associations in responses. RESULTS Of 152 received surveys, the majority of respondents were hospital-based (86%) and had greater than 5 years of experience (65%). There was group consensus for the use of prophylactic exercise programs (95%), recommendations for SLP intervention during HNC treatment (75%), and use of maintenance programs post-treatment (97%). Conversely, no group consensus was observed for use of pre-treatment swallow evaluations, frequency of service provision, and content of therapy sessions. Variation in clinical decision making was noted in use of prophylactic feeding tubes and number of patients taking nothing by mouth during treatment. No associations were found between years of experience and decision-making practices, nor were any associations found between practice setting and clinical decision making. CONCLUSION Despite the growing body of literature outlining evidence-based treatment practices for HNC patients, clinical practice patterns among SLPs continue to vary widely resulting in inconsistent patient care across practice settings. As compared to prior similar data, increased alignment with best practices was observed relative to early referrals, implementation of prophylactic intervention programs, and intervention with the SLP during the period of HNC treatment.
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Affiliation(s)
- Ashley M Logan
- Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, FL, USA.,Department of Otolaryngology-Head and Neck Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Mario A Landera
- Dr. Pallavi Patel College of Health Care Sciences, Nova Southeastern University, Fort Lauderdale, FL, USA.,Department of Otolaryngology, University of Miami School of Medicine, Miami, FL, USA
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Wells MB, Delilovic S, Gunnarsson M, Dervish J, von Knorring M, Hasson H. Primary care physicians' views of standardised care pathways in cancer care: A Swedish qualitative study on implementation experiences. Eur J Cancer Care (Engl) 2021; 30:e13426. [PMID: 33559330 DOI: 10.1111/ecc.13426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/16/2020] [Accepted: 01/11/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVE Primary care physicians (PCPs) recently started using standardised care pathways (PCPs) to refer patients to specialists for diagnostics in Sweden. The aim of the current study is therefore to examine PCPs views of implementing standardised care pathways (SCPs) in cancer care. METHOD In total, 27 semi-structured interviews (17 individual and 10 group interviews) were conducted within 24 primary care units, including 61 physicians representing the public and private sectors. Interviews were conducted during 2017 and 2018. Data were analysed using a thematic analysis approach. RESULTS Eight themes, including both perceived opportunities and challenges with the SCPs, were identified in the analysis. Most PCPs valued the SCPs, citing that they expedited the referral system and decreased patient waiting time. However, the guidelines were not completely clear leaving PCPs to wonder what constituted an SCP referral, who should initiate the referral, and how PCPs should communicate and collaborate with specialists. CONCLUSION SCPs were a welcomed organisational change by PCPs, where PCPs thought that the SCPs could help in providing better patient care to potential cancer patients. However, updated guidelines and clarifications within the SCPs are warranted to have increased services for both the patients and medical personnel.
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Affiliation(s)
- Michael B Wells
- Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Sara Delilovic
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Malin Gunnarsson
- Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Jessica Dervish
- Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
| | - Mia von Knorring
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.,Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
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Vogus TJ, McClelland LE, Lee YS, McFadden KL, Hu X. Creating a compassion system to achieve efficiency and quality in health care delivery. JOURNAL OF SERVICE MANAGEMENT 2021. [DOI: 10.1108/josm-05-2019-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PurposeHealth care delivery is experiencing a multi-faceted epidemic of suffering among patients and care providers. Compassion is defined as noticing, feeling and responding to suffering. However, compassion is typically seen as an individual rather than a more systemic response to suffering and cannot match the scale of the problem as a result. The authors develop a model of a compassion system and details its antecedents (leader behaviors and a compassionate human resource (HR) bundle), its climate or the extent that the organization values, supports and rewards expression of compassion and the behaviors and practices through which it is enacted (standardization and customization) and its effects on efficiently reducing suffering and delivering high quality care.Design/methodology/approachThis paper uses a conceptual approach that synthesizes the literature in health services, HR management, organizational behavior and service operations to develop a new conceptual model.FindingsThe paper makes three key contributions. First, the authors theorize the central importance of compassion and a collective commitment to compassion (compassion system) to reducing pervasive patient and care provider suffering in health care. Second, the authors develop a model of an organizational compassion system that details its antecedents of leader behaviors and values as well as a compassionate HR bundle. Third, the authors theorize how compassion climate enhances collective employee well-being and increases standardization and customization behaviors that reduce suffering through more efficient and higher quality care, respectively.Originality/valueThis paper develops a novel model of how health care organizations can simultaneously achieve efficiency and quality through a compassion system. Specific leader behaviors and practices that enable compassion climate and the processes through which it achieves efficiency and quality are detailed. Future directions for how other service organizations can replicate a compassion system are discussed.
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Nathan K, Uzosike M, Sanchez U, Karius A, Leyden J, Segovia N, Eppler S, Hastings KG, Kamal R, Frick S. Deciding without data: clinical decision-making in pediatric orthopedic surgery. Int J Qual Health Care 2020; 32:658-662. [PMID: 32986101 DOI: 10.1093/intqhc/mzaa119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/05/2020] [Accepted: 09/24/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Identifying when and how often decisions are made based on high-quality evidence can inform the development of evidence-based treatment plans and care pathways, which have been shown to improve quality of care and patient safety. Evidence to guide decision-making, national guidelines and clinical pathways for many conditions in pediatric orthopedic surgery are limited. This study investigated decision-making rationale and quantified the evidence supporting decisions made by pediatric orthopedic surgeons in an outpatient clinic. DESIGN/SETTING/PARTICIPANTS/INTERVENTION(S)/MAIN OUTCOME MEASURE(S) We recorded decisions made by eight pediatric orthopedic surgeons in an outpatient clinic and the surgeon's reported rationale behind the decisions. Surgeons categorized the rationale for each decision as one or a combination of 12 possibilities (e.g. 'Experience/anecdote,' 'First principles,' 'Trained to do it,' 'Arbitrary/instinct,' 'General study,' 'Specific study'). RESULTS Out of 1150 total decisions, the most frequent decisions were follow-up scheduling, followed by bracing prescription/removal. The most common decision rationales were 'First principles' (n = 310, 27.0%) and 'Experience/anecdote' (n = 253, 22.0%). Only 17.8% of decisions were attributed to scientific studies, with 7.3% based on studies specific to the decision. As high as 34.6% of surgical intervention decisions were based on scientific studies, while only 10.4% of follow-up scheduling decisions were made with studies in mind. Decision category was significantly associated with a basis in scientific studies: surgical intervention and medication prescription decisions were more likely to be based on scientific studies than all other decisions. CONCLUSIONS With increasing emphasis on high value, evidence-based care, understanding the rationale behind physician decision-making can educate physicians, identify common decisions without supporting evidence and help create clinical care pathways in pediatric orthopedic surgery. Decisions based on evidence or consensus between surgeons can inform pathways and national guidelines that minimize unwarranted variation in care and waste. Decision support tools and aids could also be implemented to guide these decisions.
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Affiliation(s)
- Karthik Nathan
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Maechi Uzosike
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Uriel Sanchez
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Alexander Karius
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Jacinta Leyden
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Nicole Segovia
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Sara Eppler
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Katherine G Hastings
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Robin Kamal
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
| | - Steven Frick
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards R105, Stanford, CA 94304-1426, USA
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Latina R, Salomone K, D’Angelo D, Coclite D, Castellini G, Gianola S, Fauci A, Napoletano A, Iacorossi L, Iannone P. Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228634. [PMID: 33233824 PMCID: PMC7699889 DOI: 10.3390/ijerph17228634] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 11/16/2020] [Accepted: 11/18/2020] [Indexed: 12/14/2022]
Abstract
Clinical or care pathways are developed by a multidisciplinary team of healthcare practitioners, based on clinical evidence, and standardized processes. The evaluation of their framework/content quality is unclear. The aim of this study was to describe which tools and domains are able to critically evaluate the quality of clinical/care pathways. An overview of systematic reviews was conducted, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using Medline, Embase, Science Citation Index, PsychInfo, CINAHL, and Cochrane Library, from 2015 to 2020, and with snowballing methods. The quality of the reviews was assessed with Assessment the Methodology of Systematic Review (AMSTAR-2) and categorized with The Leuven Clinical Pathway Compass for the definition of the five domains: processes, service, clinical, team, and financial. We found nine reviews. Three achieved a high level of quality with AMSTAR-2. The areas classified according to The Leuven Clinical Pathway Compass were: 9.7% team multidisciplinary involvement, 13.2% clinical (morbidity/mortality), 44.3% process (continuity-clinical integration, transitional), 5.6% financial (length of stay), and 27.0% service (patient-/family-centered care). Overall, none of the 300 instruments retrieved could be considered a gold standard mainly because they did not cover all the critical pathway domains outlined by Leuven and Health Technology Assessment. This overview shows important insights for the definition of a multiprinciple framework of core domains for assessing the quality of pathways. The core domains should consider general critical aspects common to all pathways, but it is necessary to define specific domains for specific diseases, fast pathways, and adapting the tool to the cultural and organizational characteristics of the health system of each country.
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Affiliation(s)
- Roberto Latina
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Katia Salomone
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Daniela D’Angelo
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Daniela Coclite
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Greta Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (G.C.); (S.G.)
| | - Alice Fauci
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Antonello Napoletano
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
| | - Laura Iacorossi
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
- Correspondence:
| | - Primiano Iannone
- National Center for Clinical Excellence, Healthcare Quality and Safety, Istituto Superiore di Sanità, 00162 Rome, Italy; (R.L.); (K.S.); (D.D.); (D.C.); (A.F.); (A.N.); (P.I.)
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MedPath: A process-based modeling language for designing care pathways. Int J Med Inform 2020; 146:104328. [PMID: 33281069 DOI: 10.1016/j.ijmedinf.2020.104328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 07/10/2020] [Accepted: 11/01/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Medical professionals and hospitals promote solutions like care pathways and Health Information Systems (HIS) to support medical conduct and improve the quality of medical care. PURPOSE This study proposes MedPath: a Domain Specific Language (DSL) for modeling care pathways based on the paradigms of Model-Based Engineering (MBE) that can be integrated into software solutions. PROCEDURES We have developed MedPath's abstract syntax with the Eclipse Modeling Framework by employing Ecore technology and concrete syntax with the Eclipse Sirius. FINDINGS We have modeled over 85 care pathways that are in use in 45 hospitals in Brazil. MedPath-originated pathways have been used over 3.2 million times since October 2017. We conducted a survey among the professionals who used MedPath to evaluate user satisfaction. CONCLUSIONS We believe MedPath can translate any care pathway into an action flow with its current abstractions. MedPath makes care pathways more easily integrated into HIS and electronic patient records, as it enables programmatic modeling and generates consumable artifacts.
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Lee XJ, Blythe R, Choudhury AAK, Simmons T, Graves N, Kularatna S. Review of methods and study designs of evaluations related to clinical pathways. AUST HEALTH REV 2020; 43:448-456. [PMID: 30089529 DOI: 10.1071/ah17276] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/19/2018] [Indexed: 11/23/2022]
Abstract
Objective The HealthPathways program is an online information portal that helps clinicians provide consistent and integrated patient care within a local health system through localised pathways for diagnosis, treatment and management of various health conditions. These pathways are consistent with the definition of clinical pathways. Evaluations of HealthPathways programs have thus far focused primarily on website utilisation and clinical users' experience and satisfaction, with limited evidence on changes to patient outcomes. This lack motivated a literature review of the effects of clinical pathways on patient and economic outcomes to inform a subsequent HealthPathways evaluation. Methods A systematic review was performed to summarise the analytical methods, study designs and results of studies evaluating clinical pathways with an economic outcome component published between 1 January 2000 and 31 August 2017 in four academic literature databases. Results Fifty-five relevant articles were identified for inclusion in this review. The practical pre-post study design with retrospective baseline data extraction and prospective intervention data collection was most commonly used in the evaluations identified. Straightforward statistical methods for comparing outcomes, such as the t-test or χ2 test, were frequently used. Only four of the 55 articles performed a cost-effectiveness analysis. Clinical pathways were generally associated with improved patient outcomes and positive economic outcomes in hospital settings. Conclusions Clinical pathways evaluations commonly use pragmatic study designs, straightforward statistical tests and cost-consequence analyses. More HealthPathways program evaluations focused on patient and economic outcomes, clinical pathway evaluations in a primary care setting and cost-effectiveness analyses of clinical pathways are needed. What is known about the topic? HealthPathways is a web-based program that originated from Canterbury, New Zealand, and has seen uptake elsewhere in New Zealand, Australia and the UK. The HealthPathways program aims to assist the provision of consistent and integrated health services through dedicated, localised pathways for various health conditions specific to the health region. Evaluations of HealthPathways program focused on patient and economic outcomes have been limited. What does this paper add? This review synthesises the academic literature of clinical pathways evaluations in order to inform a subsequent HealthPathways evaluation. The focus of the synthesis was on the analytical methods and study designs used in the previous evaluations. The previous clinical pathway evaluations have been pragmatic in nature with relatively straightforward study designs and analysis. What are the implications for practitioners? There is a need for more economic and patient outcome evaluations for HealthPathways programs. More sophisticated statistical analyses and economic evaluations could add value to these evaluations, where appropriate and taking into consideration the data limitations.
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Affiliation(s)
- Xing Ju Lee
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Robin Blythe
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Adnan Ali Khan Choudhury
- Northern Queensland Primary Health Network, James Cook University, Building 500, 1 James Cook Drive, Douglas, Qld 4811, Australia. Email
| | - Toni Simmons
- Mackay Hospital and Health Service, Mackay, 475 Bridge Road, Mackay, Qld 4740, Australia. Email
| | - Nicholas Graves
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
| | - Sanjeewa Kularatna
- Institute of Health and Biomedical Innovations, School of Public Health and Social Work, Queensland University of Technology, Brisbane, 60 Musk Avenue, Kelvin Grove, Qld 4059, Australia.
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Baker E, Woolley A, Xyrichis A, Norton C, Hopkins P, Lee G. How does the implementation of a patient pathway-based intervention in the acute care of blunt thoracic injury impact on patient outcomes? A systematic review of the literature. Injury 2020; 51:1733-1743. [PMID: 32576379 PMCID: PMC7399576 DOI: 10.1016/j.injury.2020.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Blunt thoracic injury is present in around 15% of all major trauma presentations. To ensure a standardised approach to the management of physical injury, patient pathway-based interventions have been established in many healthcare settings. It currently remains unclear how these complex interventions are implemented and evaluated in the literature. This systematic review aims to identify pathway effectiveness literature and implementation studies in relation to patient pathway-based interventions in blunt thoracic injury care. METHODS The databases Medline, Embase, Web of Science, CINAHL, WHO Clinical Trials Register and both the GreyLit & OpenGrey databases were searched without restrictions on date or study type. A search strategy was developed including keywords and MeSH terms relating to blunt thoracic injury, patient pathway-based interventions, evaluation and implementation. Due to heterogeneity of intervention pathways, meta-analysis was not possible; analysis was undertaken using an iterative narrative approach. RESULTS A total of 16 studies met the inclusion criteria and were included in analysis. Pathways were identified covering analgesic management, respiratory care, surgical decision making and reducing risk of complications. Studies evaluating pathways are generally limited by their observational and retrospective design, but results highlight the potential benefits of pathway driven care provision in blunt thoracic injury. CONCLUSIONS The results demonstrate the complexity of evaluating patient pathway-based interventions in blunt thoracic injury management. It is important that pathways undergo rigorous evaluation, refinement and validation to ensure quality and patient safety. Strong recommendations are precluded as the quality of the pathway evaluation studies are low.
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Affiliation(s)
- Edward Baker
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK; Emergency Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Alison Woolley
- Department of Cardio-thoracic Surgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Andreas Xyrichis
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Philip Hopkins
- Department of Intensive Care Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Geraldine Lee
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK.
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Geerligs L, Shepherd HL, Rankin NM, Masya L, Shaw JM, Price MA, Dhillon H, Dolan C, Prest G, Butow P. The value of real-world testing: a qualitative feasibility study to explore staff and organisational barriers and strategies to support implementation of a clinical pathway for the management of anxiety and depression in adult cancer patients. Pilot Feasibility Stud 2020; 6:109. [PMID: 32742718 PMCID: PMC7388211 DOI: 10.1186/s40814-020-00648-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 07/07/2020] [Indexed: 01/17/2023] Open
Abstract
Background Effective translation of evidence-based research into clinical practice requires assessment of the many factors that can impact implementation success. Research methods that draw on recognised implementation frameworks, such as the Promoting Action Research in Health Services (PARiHS) framework, and that test feasibility to gain information prior to full-scale roll-out, can support a more structured approach to implementation. Objective This paper presents qualitative findings from a feasibility study in one cancer service of an online portal to operationalise a clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients. The aim of this study was to explore staff perspectives on the feasibility and acceptance of a range of strategies to support implementation in order to inform the full-scale roll-out. Methods Semi-structured interviews were conducted with fifteen hospital staff holding a range of clinical, administrative and managerial roles, and with differing levels of exposure to the pathway. Qualitative data were analysed thematically, and themes were subsequently organised within the constructs of the PARiHS framework. Results Barriers and facilitators that affected the feasibility of the online portal and implementation strategies were organised across eight key themes: staff perceptions, culture, external influences, attitudes to psychosocial care, intervention fit, familiarity, burden and engagement. These themes mapped to the PARiHS framework's three domains of evidence, context and facilitation. Conclusions Implementation success may be threatened by a range of factors related to the real-world context, perceptions of the intervention (evidence) and the process by which it is introduced (facilitation). Feasibility testing of implementation strategies can provide unique insights into issues likely to influence full-scale implementation, allowing for early tailoring and more effective facilitation which may save time, money and effort in the long-term. Use of a determinant implementation framework can assist researchers to synthesise and effectively respond to barriers as they arise. While the current feasibility study related to a specific implementation, strategies such as regular engagement with local stakeholders, and discussion of barriers arising in real-time during early testing is likely to be of benefit to all researchers and clinicians seeking to maximise the likelihood of long-term implementation success.
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Affiliation(s)
- Liesbeth Geerligs
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia
| | - Heather L Shepherd
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Nicole M Rankin
- Faculty of Health Sciences, The University of Sydney, Sydney, NSW Australia
| | - Lindy Masya
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia
| | - Joanne M Shaw
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Melanie A Price
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | - Haryana Dhillon
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
| | | | | | | | - Phyllis Butow
- Psycho-oncology Co-operative Research Group (PoCoG), The University of Sydney, Sydney, NSW Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), The University of Sydney, Sydney, NSW Australia
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Hendriks MP, Verbeek XAAM, van Manen JG, van der Heijden SE, Go SHL, Gooiker GA, van Vegchel T, Siesling S, Jager A. Clinical decision trees support systematic evaluation of multidisciplinary team recommendations. Breast Cancer Res Treat 2020; 183:355-363. [PMID: 32627108 PMCID: PMC7383031 DOI: 10.1007/s10549-020-05769-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/17/2020] [Indexed: 12/16/2022]
Abstract
Purpose EUSOMA’s recommendation that “each patient has to be fully informed about each step in the diagnostic and therapeutic pathway” could be supported by guideline-based clinical decision trees (CDTs). The Dutch breast cancer guideline has been modeled into CDTs (www.oncoguide.nl). Prerequisites for adequate CDT usage are availability of necessary patient data at the time of decision-making and to consider all possible treatment alternatives provided in the CDT. Methods This retrospective single-center study evaluated 394 randomly selected female patients with non-metastatic breast cancer between 2012 and 2015. Four pivotal CDTs were selected. Two researchers analyzed patient records to determine to which degree patient data required per CDT were available at the time of multidisciplinary team (MDT) meeting and how often multiple alternatives were actually reported. Results The four selected CDTs were indication for magnetic resonance imaging (MRI) scan, preoperative and adjuvant systemic treatment, and immediate breast reconstruction. For 70%, 13%, 97% and 13% of patients, respectively, all necessary data were available. The two most frequent underreported data-items were “clinical M-stage” (87%) and “assessable mammography” (28%). Treatment alternatives were reported by MDTs in 32% of patients regarding primary treatment and in 28% regarding breast reconstruction. Conclusion Both the availability of data in patient records essential for guideline-based recommendations and the reporting of possible treatment alternatives of the investigated CDTs were low. To meet EUSOMA’s requirements, information that is supposed to be implicitly known must be explicated by MDTs. Moreover, MDTs have to adhere to clear definitions of data-items in their reporting.
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Affiliation(s)
- Mathijs P Hendriks
- Department of Medical Oncology, Northwest Clinics, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands.
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands.
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Xander A A M Verbeek
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Jeannette G van Manen
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Sannah E van der Heijden
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Shirley H L Go
- Department of Radiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Gea A Gooiker
- Department of Surgery, Northwest Clinics, Alkmaar, The Netherlands
| | - Thijs van Vegchel
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research and Development, Netherlands Comprehensive Cancer Organization, Utrecht, The Netherlands
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Agnes Jager
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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Numico G, Viale M, Bellini R, Ippoliti R, Rossi M, Maan T, Carobene A, Pizzini A, Mistrangelo M, Bertetto O. Toward uniform and controlled clinical pathways in cancer care: a qualitative description. Int J Qual Health Care 2020; 31:781-786. [PMID: 30809643 DOI: 10.1093/intqhc/mzz015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 01/05/2019] [Accepted: 02/05/2019] [Indexed: 11/13/2022] Open
Abstract
QUALITY ISSUE The definition of clinical pathways (CPs) and their application are heterogeneous. Each center is used to choose whether to adopt this instrument or not and to variably conceive its features We consider CPs as the necessary description of the cancer patient journey and we emphasize their role as the user view of clinical processes rather than a local translation of guidelines. CHOICE OF SOLUTION We proposed a unique CPs model for all the centers of our regional network, with the aim of making CPs accountable and comparable. We also established a central quality evaluation. IMPLEMENTATION Through a multi-step process, the model was proposed to the 22 Regional centers. Landmark characteristics of the project were: the involvement of hospital administrations; reference to a unique set of guidelines; a peer-review and open evaluation. EVALUATION Of the 374 expected CPs, 253 (68%) were received and evaluated. A median number of 131 items were the object of evaluation in each hub center and 77 in each spoke center. About 79.5% items were considered well described, 15.5% were absent and 5.0% partially described. The median percentage of fulfilled indicators was 85.6% in hub CPs and 82.2% in spoke CPs. Although, not all diseases were equally covered through the territory a high degree of homogeneity and a good quality of compilation were achieved. LESSONS LEARNED The project was shown to be feasible and achieved its goal. We suggest this process as a functional way for building uniform cancer CPs.
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Affiliation(s)
- Gianmauro Numico
- Medical Oncology. SS Antonio e Biagio e C Arrigo Hospital; Via Venezia 16, Alessandria, Italy
| | - Monica Viale
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | - Roberta Bellini
- Quality and Management Control Unit, SS Antonio e Biagio e C Arrigo Hospital, Via Venezia 16, Alessandria, Italy
| | - Roberto Ippoliti
- Department of Business, Administration and Economics, University of Bielefeld, Bielefeld, Deutschland, Germany
| | - Maura Rossi
- Medical Oncology. SS Antonio e Biagio e C Arrigo Hospital; Via Venezia 16, Alessandria, Italy
| | - Tatiana Maan
- Quality and Management Control Unit, SS Antonio e Biagio e C Arrigo Hospital, Via Venezia 16, Alessandria, Italy
| | - Angelica Carobene
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | | | - Marinella Mistrangelo
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
| | - Oscar Bertetto
- Rete Oncologica del Piemonte e della Valle d'Aosta, Città della Salute e della Scienza, Torino, Italy
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Applying normalization process theory and process mapping to understand implementation of a co-management program for older hip fracture patients in China: a qualitative study. Arch Osteoporos 2020; 15:92. [PMID: 32562001 DOI: 10.1007/s11657-020-00760-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED This qualitative study identified the barriers to the implementation of a multidisciplinary co-management program for older hip fracture patients and provided evidence for future intervention improvement and scale-up. INTRODUCTION Multidisciplinary co-management has been recommended as an effective intervention for hip fracture management in older people. This study is a process evaluation of a multidisciplinary co-management program in an orthopaedic hospital in Beijing, China, to better understand the barriers to implementation. METHODS Data collection involved semi-structured interviews with key implementers of the co-management intervention (surgeon, geriatrician, physician, nurse, physiotherapist and anaesthetist) and observations of patients' journey to map the care processes were conducted in Beijing Jishuitan Hospital. Data were transcribed, qualitatively coded and analysed using normalization process theory to understand the intervention process from four constructs: coherence, cognitive participation, collective action and reflexive monitoring. RESULTS Ten stakeholder interviews were conducted. Despite multidisciplinary co-management intervention was meaningful and valued by participants, barriers to its implementation were identified. These included unmatched investment and benefit (cognitive participation), challenges of facing increased workload (collective action), deficient training and supervision system (collective action), limited accommodating capacity of hospital (collective action) and difficulties in accessing information about the effect of the intervention (reflexive monitoring). CONCLUSIONS Multiple barriers to the effective implementation of the multidisciplinary co-management program in China were identified. The process evaluation highlights key aspects in less willingness to fully invest in the program, inappropriate workload allocation and lack of training and supervision which need to be addressed before scaling up.
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Soria-Aledo VÍC, Flores-Pastor B, Fe Candel-Arenas M, Carrillo-Alcaraz A, Campillo-Soto ÁL, Miguel-PerellÓ J, Carrasco Prats M, Aguayo-Albasini JL. Evaluation and Monitoring of the Clinical Pathway for Thyroidectomy. Am Surg 2020. [DOI: 10.1177/000313480807400107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study is to present the evaluation and monitoring of a clinical pathway for thyroidectomy 1 year after its implementation and after 4 years’ follow up. We compare the results of an evaluation and monitoring indicators series before and after the establishment of the clinical pathway for thyroidectomy in the Surgery Department of Morales Meseguer Hospital, a general university hospital in Murcia, Spain. Implementation of the clinical pathway led to a reduction in length of hospital stay for all the surgery patients (4.8 ± 2.1 and 3.6 ± 1.9 days before and after pathway implementation, respectively; P < 0.001). Implementation of the clinical pathway led to a reduction in cost in all the operated patients (3357 ± 966 and 2695 ± 970 US$ before and after implementing the clinical pathway, respectively; P < 0.001). Evolution of the mean hospital cost according to year of study shows a reduction from 2000 (3400 ± 1056 US$) to 2004 (2404 ± 666 US$) with a slight increase during 2005 (2721 ± 1335 US$) (P < 0.001). Implementation of the clinical pathway for thyroidectomy has successfully reduced clinical variation and therefore the length of hospital stay and mean cost of the process. In subsequent years, no such major improvements have been made with regard to hospital stay, although they are still clearly better than those before pathway implementation.
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Affiliation(s)
- VÍCtor Soria-Aledo
- Investigation Unit, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
- Department of General Surgery, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
| | - Benito Flores-Pastor
- Department of General Surgery, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
| | - Mari Fe Candel-Arenas
- Department of General Surgery, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
| | | | - ÁLvaro Campillo-Soto
- Department of General Surgery, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
| | - Joana Miguel-PerellÓ
- Department of General Surgery, “J.M. Morales Meseguer” University Hospital, Murcia, Spain
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Hendriks MP, Verbeek XAAM, van Vegchel T, van der Sangen MJC, Strobbe LJA, Merkus JWS, Zonderland HM, Smorenburg CH, Jager A, Siesling S. Transformation of the National Breast Cancer Guideline Into Data-Driven Clinical Decision Trees. JCO Clin Cancer Inform 2020; 3:1-14. [PMID: 31141422 DOI: 10.1200/cci.18.00150] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The essence of guideline recommendations often is intertwined in large texts. This impedes clinical implementation and evaluation and delays timely modular revisions needed to deal with an ever-growing amount of knowledge and application of personalized medicine. The aim of this project was to model guideline recommendations as data-driven clinical decision trees (CDTs) that are clinically interpretable and suitable for implementation in decision support systems. METHODS All recommendations of the Dutch national breast cancer guideline for nonmetastatic breast cancer were translated into CDTs. CDTs were constructed by nodes, branches, and leaves that represent data items (patient and tumor characteristics [eg, T stage]), data item values (eg, T2 or less), and recommendations (eg, chemotherapy), respectively. For all data items, source of origin was identified (eg, pathology), and where applicable, data item values were defined on the basis of existing classification and coding systems (eg, TNM, Breast Imaging Reporting and Data System, Systematized Nomenclature of Medicine). All unique routes through all CDTs were counted to measure the degree of data-based personalization of recommendations. RESULTS In total, 60 CDTs were necessary to cover the whole guideline and were driven by 114 data items. Data items originated from pathology (49%), radiology (27%), clinical (12%), and multidisciplinary team (12%) reports. Of all data items, 101 (89%) could be classified by existing classification and coding systems. All 60 CDTs could be integrated in an interactive decision support app that contained 376 unique patient subpopulations. CONCLUSION By defining data items unambiguously and unequivocally and coding them to an international coding system, it was possible to present a complex guideline as systematically constructed modular data-driven CDTs that are clinically interpretable and accessible in a decision support app.
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Affiliation(s)
| | | | - Thijs van Vegchel
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands
| | | | | | | | | | | | - Agnes Jager
- Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Sabine Siesling
- Netherlands Comprehensive Cancer Organization, Utrecht, the Netherlands.,University of Twente, Enschede, the Netherlands
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