1
|
Selle JM, Hanson KT, Habermann EB, Gebhart JB, Trabuco EC, Occhino JA, Young AD, Linder BJ. The Impact of an Overactive Bladder Care Pathway on Longitudinal Patient Management. UROGYNECOLOGY (PHILADELPHIA, PA.) 2024; 30:330-336. [PMID: 38484250 DOI: 10.1097/spv.0000000000001479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
IMPORTANCE Implementation of an overactive bladder (OAB) care pathway may affect treatment patterns and progression. OBJECTIVES This study aimed to assess the effect of OAB care pathway implementation on treatment patterns for women with OAB. STUDY DESIGN This retrospective cohort study evaluated women with OAB, before (January 1, 2015-December 31, 2017) and after (January 1, 2019-December 31, 2021) care pathway initiation. Care pathway use included standardized counseling, early introduction of therapy, and close follow-up. Primary outcomes included OAB medication use, follow-up visits, third-line therapy, and time to third-line therapy. RESULTS A total of 1,349 women were included: 1,194 before care pathway implementation and 155 after. Patients after implementation were more likely to have diabetes mellitus (P = 0.04) and less likely to smoke (P = 0.01). Those managed via a care pathway were more likely to use any medication or third-line therapy within 1 year after consultation (61.3% vs 25.0%; P < 0.001). This included higher proportions receiving a medication (50.3% [95% confidence interval (CI), 41.8%-57.6%] vs 23.3% [95% CI, 20.9%-25.7%]; P < 0.001) and progressing to third-line therapy (22.6% [95% CI, 15.7%-28.9%] vs 2.9% [95% CI, 2%-3.9%]; P < 0.001). Among those who underwent third-line treatment, care pathway use was associated with shorter time to third-line therapy (median, 10 days [interquartile range, 1-56 days] vs 29 days [interquartile range, 7-191 days]; P = 0.013). Those managed via a care pathway were less likely to have additional clinic visits for OAB within 1 year after initial consultation (12.3% vs 23.9%; P < 0.001). CONCLUSIONS Use of an OAB care pathway was associated with higher rates of oral medication and third-line therapy yet decreased follow-up office visits. Use of an OAB care pathway may promote consistent and efficient care for women with OAB.
Collapse
Affiliation(s)
| | - Kristine T Hanson
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | | | | | | | | | | |
Collapse
|
2
|
Emerson MR, Huber M, Mathews TL, Kupzyk K, Walsh M, Walker J. Improving Integrated Mental Health Care Through an Advanced Practice Registered Nurse-Led Program: Challenges and Successes. Public Health Rep 2023; 138:22S-28S. [PMID: 37226950 PMCID: PMC10226067 DOI: 10.1177/00333549221143094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023] Open
Abstract
Integrated and collaborative care delivery models have demonstrated efficacy for the management of psychiatric conditions in the primary care environment, yet organizations struggle with implementation of integrated efforts in clinical practice. Delivering care with a population focus versus face-to-face encounters with individual patients requires financial investment and adjustment in care delivery. We discuss the early implementation process of an advanced practice registered nurse (APRN)-led integrated behavioral health care program, including the challenges, barriers, and successes in the first 9 months of the program (January-September 2021), for an academic institution in the Midwest. A total of 161 Patient Health Questionnaire 9 (PHQ-9) and 162 Generalized Anxiety Disorder (GAD-7) rating scales were completed on 86 patients. The mean PHQ-9 score at the initial visit was 11.3 (moderate depression); after 5 visits, it decreased significantly to 8.6 (mild depression) (P < .001). The mean GAD-7 score at the initial visit was 10.9 (moderate anxiety); after 5 visits, it decreased significantly to 7.6 (mild anxiety) (P < .001). A survey completed by 14 primary care physicians 9 months after program launch revealed improvements in satisfaction with collaboration but, most notably, in perception of access to and overall satisfaction with behavioral health consultation/patient care services. Program challenges included adapting the environment to enhance leadership roles for the program and adjusting to virtual availability of psychiatric support. A case example highlights the value of integrated care along with improved depression and anxiety-related outcomes. Next steps should include efforts that capitalize on nursing leadership strengths while also promoting equity among integrated populations.
Collapse
Affiliation(s)
- Margaret R Emerson
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Melanie Huber
- Department of Internal Medicine, The Nebraska Medical Center, Omaha, NE, USA
| | - Therese L Mathews
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kevin Kupzyk
- College of Nursing, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michael Walsh
- Department of Internal Medicine, The Nebraska Medical Center, Omaha, NE, USA
| | - Jerry Walker
- Department of Neurological Sciences, The Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
3
|
Li L, Kruger M, Kim N, Ong S, Riley S, Cameron K, Koslosky K, Rhodes D. A Novel Approach to Delivering Evidence-based, High-quality Care in Psychiatry Through an Electronic Integrated Care Pathway (eICP) Pilot. Psychiatr Q 2023:10.1007/s11126-023-10016-z. [PMID: 36840898 PMCID: PMC9959944 DOI: 10.1007/s11126-023-10016-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 02/26/2023]
Abstract
Integrated care pathways (ICPs) are evidence-based decision support tools intended to reduce variation and improve quality of care. Historically, adoption of ICPs has been difficult to measure, as the pathways were outside of the electronic health record (EHR), where care delivery documentation and orders were completed. This Technology Column describes the innovative development and implementation of a diagnosis specific electronic ICP that directly embeds pathway steps into an EHR to facilitate order sets, clinical decision-making, and usage tracking. The pathway was implemented at a seven-hospital academic medical center, and details the technology, team structure, early adoption results, and future directions. As such, the importance of investing and organizing resources to create an eICP (e.g., time, technology, and specialized teams) to provide a user-friendly experience to support early adoption is underscored. Preliminary findings show that the eICP had consistent use in the first year of implementation. This manuscript is intended to serve as a practical guide to build eICPs within behavioral health service areas across institutions.
Collapse
Affiliation(s)
- Luming Li
- Yale School of Medicine, New Haven, CT, USA.
- Baylor School of Medicine, Houston, TX, USA.
- University of Texas McGovern School of Medicine, Houston, TX, USA.
- The Harris Center for Mental Health and IDD, Houston, TX, USA.
| | | | - Nancy Kim
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | - Shawn Ong
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | - Sarah Riley
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| | | | | | - Deborah Rhodes
- Yale School of Medicine, New Haven, CT, USA
- Yale New Haven Health System, New Haven, CT, USA
| |
Collapse
|
4
|
Kim HK, Banik S, Husain MI, Tang V, Levitan R, Daskalakis ZJ, Kloiber S. Systematic review of structured care pathways in major depressive disorder and bipolar disorder. BMC Psychiatry 2023; 23:85. [PMID: 36732746 PMCID: PMC9893602 DOI: 10.1186/s12888-022-04379-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 11/08/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Structured care pathways (SCPs) consist of treatment algorithms that patients advance through with the goal of achieving remission or response. These SCPs facilitate the application of current evidence and adequate treatment, which potentially benefit patients with mood disorders. The aim of this systematic review was to provide an updated synthesis of SCPs for the treatment of depressive disorders and bipolar disorder (BD). METHOD PubMed, PsycINFO, and Embase were searched through June 2022 for peer-reviewed studies examining outcomes of SCPs. Eligibility criteria included being published in a peer-reviewed journal in the English language, reporting of intervention used in the SCP, and having quantitative outcomes. Studies Cochrane risk of bias tool was used to assess quality of RCTs. RESULTS Thirty-six studies including 15,032 patients were identified for qualitative synthesis. Six studies included patients with BD. The studies were highly heterogeneous in design, outcome measures, and algorithms. More than half of the studies reported superiority of SCPs over treatment as usual, suggesting that the standardized structure and consistent monitoring inherent in SCPs may be contributing to their effectiveness. We also found accumulating evidence supporting feasibility of SCPs in different settings, although dropout rates were generally higher in SCPs. The studies included were limited to being published in peer-reviewed journals in English language. The heterogeneity of studies did not allow quantitative evaluation. CONCLUSIONS The findings of our study suggest that SCPs are equally or more effective than treatment as usual in depression and BD. Further studies are required to ascertain their effectiveness, particularly for BD, and to identify factors that influence their feasibility and success.
Collapse
Affiliation(s)
- Helena Kyunghee Kim
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Suman Banik
- grid.440972.c0000 0004 0415 1244Yorkville University, Fredericton, NB Canada
| | - Muhammad Ishrat Husain
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada ,grid.155956.b0000 0000 8793 5925Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 100 Stokes Street, Toronto, ON M6H 1J4 Canada
| | - Victor Tang
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada
| | - Robert Levitan
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada ,grid.155956.b0000 0000 8793 5925Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 100 Stokes Street, Toronto, ON M6H 1J4 Canada
| | - Zafiris J. Daskalakis
- grid.17063.330000 0001 2157 2938Department of Psychiatry, University of Toronto, Toronto, ON Canada ,grid.155956.b0000 0000 8793 5925Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 100 Stokes Street, Toronto, ON M6H 1J4 Canada ,grid.266100.30000 0001 2107 4242Department of Psychiatry, University of California San Diego, San Diego, USA
| | - Stefan Kloiber
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada. .,Centre for Addiction and Mental Health, Campbell Family Mental Health Research Institute, 100 Stokes Street, Toronto, ON, M6H 1J4, Canada.
| |
Collapse
|
5
|
George RE, Brown MEL. Understanding integrated care through patient journeys. CLINICAL TEACHER 2023:e13561. [PMID: 36717203 DOI: 10.1111/tct.13561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/06/2023] [Indexed: 02/01/2023]
Affiliation(s)
- Riya E George
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Megan E L Brown
- University of Buckingham & Research Fellow at Medical Education Innovation and Research Centre, Imperial College London, London, UK
| |
Collapse
|
6
|
Håland E, Melby L. Coding for quality? Accountability work in standardised cancer patient pathways (CPPs). Health (London) 2023; 27:129-146. [PMID: 33926302 PMCID: PMC9743077 DOI: 10.1177/13634593211013882] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A vital part of standardised care pathways is the possibility to measure performance through different indicators - for example, codes. In this article, based on interviews with health personnel in a project evaluating the introduction of standardised cancer patient pathways (CPPs) in Norway, we explore the specific types of work involved when health personnel produce codes as (intended) signifiers of quality. All the types of work are dimensions of what we define as accountability work - work health personnel do to make the codes signifiers of quality of care in the CPP.Codes and coding practices raise questions of what quality of care represents and how it could and should be measured. Informants in our study advocate for coding as important work for the patient more than for 'the system'. This shows how organising for quality becomes a crucial part of professional work, expanding what it means to perform high quality care.
Collapse
Affiliation(s)
- Erna Håland
- Erna Håland, Department of Education and Lifelong Learning, Norwegian University of Science and Technology (NTNU), Trondheim 7491, Norway.
| | | |
Collapse
|
7
|
Nursing Care Coordination in Primary Healthcare for Patients with Complex Needs: A Comparative Case Study. Int J Integr Care 2023; 23:5. [PMID: 36819614 PMCID: PMC9912854 DOI: 10.5334/ijic.6729] [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: 04/06/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Despite nurses' substantial role in care coordination, few education programs exist to better support them in this role. Identification of a set of core care coordination activities across heterogeneous care coordination programs would facilitate the development of a standard of practice. We sought to examine care coordination activities across two care coordination programs in Family Medicine Groups in Quebec, and their relationship to the program design. Methods We performed a comparative case study of two care coordination programs in primary care targeting frequent users of healthcare services and people with Alzheimer's disease and related disorders. Data collection included documents and semi-structured interviews with key informants. Results Several activities were common to both programs, such as patient identification; assessment, development of an individualized service plan; and linking patients and caregivers with professionals and services. However, their components were different due to the impact of the integrated care program design, policy environment, and the target patient populations' complex needs. Discussion The homogeneity or heterogeneity of patients' complex needs shapes their care trajectory and the intensity of their care coordination needs. As the complexity of these needs grows, so does the necessity to build the care coordinators' capacity for integrated care.
Collapse
|
8
|
Lesaine E, Francis-Oliviero F, Domecq S, Bijon M, Cetran L, Coste P, Lhuaire Q, Miganeh-Hadi S, Pradeau C, Rouanet F, Sevin F, Sibon I, Saillour-Glenisson F. Effects of healthcare system transformations spurred by the COVID-19 pandemic on management of stroke and STEMI: a registry-based cohort study in France. BMJ Open 2022; 12:e061025. [PMID: 36130741 PMCID: PMC9494013 DOI: 10.1136/bmjopen-2022-061025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the impact of changes in use of care and implementation of hospital reorganisations spurred by the COVID-19 pandemic (first wave) on the acute management times of patients who had a stroke and ST-segment elevation myocardial infarction (STEMI). DESIGN Two cohorts of patients who had an STEMI and stroke in the Aquitaine Cardio-Neuro-Vascular (CNV) registry. SETTING 6 emergency medical services, 30 emergency units (EUs), 14 hospitalisation units and 11 cathlabs in the Aquitaine region. PARTICIPANTS This study involved 9218 patients (6436 patients who had a stroke and 2782 patients who had an STEMI) in the CNV Registry from January 2019 to August 2020. METHOD Hospital reorganisations, retrieved in a scoping review, were collected from heads of hospital departments. Other data were from the CNV Registry. Associations between reorganisations, use of care and care management times were analysed using multivariate linear regression mixed models. Interaction terms between use-of-care variables and period (pre-wave, per-wave and post-wave) were introduced. MAIN OUTCOME MEASURES STEMI cohort, first medical contact-to-procedure time; stroke cohort, EU admission-to-imaging time. RESULTS Per-wave period management times deteriorated for stroke but were maintained for STEMI. Per-wave changes in use of care did not affect STEMI management. No association was found between reorganisations and stroke management times. In the STEMI cohort, the implementation of systematic testing at admission was associated with a 41% increase in care management time (exp=1.409, 95% CI 1.075 to 1.848, p=0.013). Implementation of plan blanc, which concentrated resources in emergency activities, was associated with a 19% decrease in management time (exp=0.801, 95% CI 0.639 to 1.023, p=0.077). CONCLUSIONS The pandemic did not markedly alter the functioning of the emergency network. Although stroke patient management deteriorated, the resilience of the STEMI pathway was linked to its stronger structuring. Transversal reorganisations, aiming at concentrating resources on emergency care, contributed to maintenance of the quality of care. TRIAL REGISTRATION NUMBER NCT04979208.
Collapse
Affiliation(s)
- Emilie Lesaine
- CIC-EC 14-01, CHU de Bordeaux, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
| | - Florence Francis-Oliviero
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
- Pôle de santé publique, Service d'Information Médicale, CHU de Bordeaux, Bordeaux, France
| | - Sandrine Domecq
- CIC-EC 14-01, CHU de Bordeaux, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
| | - Marine Bijon
- Pôle de santé publique, Service d'Information Médicale, CHU de Bordeaux, Bordeaux, France
| | - Laura Cetran
- Coronary Care Unit, CHU de Bordeaux Hôpital Cardiologique, Pessac, France
| | - Pierre Coste
- Coronary Care Unit, CHU de Bordeaux Hôpital Cardiologique, Pessac, France
- University of Bordeaux, Talence, France
| | - Quentin Lhuaire
- Pôle de santé publique, Service d'Information Médicale, CHU de Bordeaux, Bordeaux, France
| | - Sahal Miganeh-Hadi
- CIC-EC 14-01, CHU de Bordeaux, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
| | | | | | - Floriane Sevin
- CIC-EC 14-01, CHU de Bordeaux, Bordeaux, France
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
| | - Igor Sibon
- Neurology, Stroke Unit, CHU de Bordeaux, Bordeaux, France
- INCIA CNRS UMR 5287, University of Bordeaux, Talence, France
| | - Florence Saillour-Glenisson
- University of Bordeaux, ISPED, Centre INSERM U1219, Bordeaux Population Health, Bordeaux, France
- Pôle de santé publique, Service d'Information Médicale, CHU de Bordeaux, Bordeaux, France
| |
Collapse
|
9
|
Courtney DB, Cheung A, Henderson J, Bennett K, Wang W, Chen S, Battaglia M, Strauss J, Mitchell R, Wang K, Relihan J, Prebeg M, Darnay K, Szatmari P. CARIBOU-1: A pilot controlled trial of an Integrated Care Pathway for the treatment of depression in adolescents. JCPP ADVANCES 2022; 2:e12083. [PMID: 37431464 PMCID: PMC10242836 DOI: 10.1002/jcv2.12083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/04/2022] [Indexed: 11/11/2022] Open
Abstract
Background To co-ordinate a multidisciplinary team in the delivery of guideline recommendations using a measurement-based care framework, our group previously developed a care pathway for the treatment of depression in adolescents. Core components of the pathway were: assessment, education, cognitive-behavioural therapy, a caregiver intervention group, a medication algorithm, and monthly measurement-based care "team reviews" with the adolescent present. The aim of this study was to test the feasibility of conducting a controlled clinical trial of the pathway. Method We conducted a 20-week pilot controlled clinical trial of the care pathway relative to treatment as usual. Participants were adolescents (age 14-18) with a primary diagnosis of Major Depressive Disorder recruited from one of two outpatient psychiatric clinics at academic hospitals. Site of presentation was the method of allocation. Thirty-five youth were allocated to the pathway and 31 were allocated to treatment as usual. As this is a pilot study, trial feasibility outcomes were of primary interest, including clinician fidelity to the care pathway. Results Our target sample size was recruited over a 15-month time interval. Clinician fidelity and adolescent engagement in the care pathway components on a priori checklists were high (95% and 80%, respectively). We collected baseline and 20-week endpoint data for our primary outcome of the Children's Depression Rating Scale - Revised (CDRS-R) for 83% of the sample. On linear mixed effects modelling, we observed a linear decrease in CDRS-R across 4-week intervals up to the 20-week endpoint in both groups (β = -2.07; 95% CI -3.14 to -1.01). Conclusion A controlled clinical trial of a complex, multi-component intervention for the treatment of depression in adolescents is feasible. Given the need to find optimal strategies to deliver effective care for adolescents with depression, a definitive randomized controlled trial of the pathway is warranted.Trial is registered at Clinicaltrials.gov: NCT03428555.
Collapse
Affiliation(s)
| | - Amy Cheung
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Joanna Henderson
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Kathryn Bennett
- Department of Clinical Epidemology & BiostatisticsMcMaster UniversityHamiltonOntarioCanada
| | - Wei Wang
- Centre for Addiction and Mental HealthTorontoOntarioCanada
| | - Sheng Chen
- Centre for Addiction and Mental HealthTorontoOntarioCanada
| | - Marco Battaglia
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | | | - Rachel Mitchell
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Karen Wang
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Jacqueline Relihan
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental HealthTorontoOntarioCanada
| | - Matthew Prebeg
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental HealthTorontoOntarioCanada
| | | | - Peter Szatmari
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
10
|
Kassim SA, Gartner JB, Labbé L, Landa P, Paquet C, Bergeron F, Lemaire C, Côté A. Benefits and limitations of business process model notation in modelling patient healthcare trajectory: a scoping review protocol. BMJ Open 2022; 12:e060357. [PMID: 35636803 PMCID: PMC9152926 DOI: 10.1136/bmjopen-2021-060357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The adoption of business process model notation (BPMN) in modelling healthcare trajectory can enhance the efficiency and efficacy of healthcare organisations, improve patient outcomes while restraining costs. Existing systematic reviews have been inconclusive regarding the effectiveness of BPMN in modelling healthcare trajectory. The aims of this scoping review are to map and aggregate existing evidence on the benefits and limitations associated with BPMN in healthcare trajectory, highlighting areas of improvement on BPMN and its extensions in healthcare. We will assess BPMN's ability to model key dimensions or concepts of the healthcare process and to meet the needs of stakeholders. The review will highlight the advantages of this approach to support clinical activities and decision-making processes associated with the healthcare trajectory, proposing a conceptual framework for improving the use of BPMN in healthcare. METHODS AND ANALYSIS This study will be performed in accordance with the methodological framework suggested by Arksey and O'Malley. A wide range of electronic databases and grey literature sources will be systematically searched using predefined keywords. The review will include any study design focusing on the application of the BPMN approach for optimising healthcare trajectories, published in either English or French from 1 January 2004 to 9 December 2021. Two reviewers will independently screen titles, abstracts and full-text articles and select articles meeting the inclusion criteria. A customised data extraction form will be used to extract data. The results will be presented using descriptive statistics and thematic analysis on qualitative data. ETHICS AND DISSEMINATION Research ethics approval is not required. Review findings will be used to advance understanding about BPMN, its extensions and application in healthcare trajectory optimisation. The review will develop recommendations on tailoring BPMN strategies for optimising care pathways and decision-making processes. Findings will be disseminated in peer-reviewed journals, conferences and discussions with relevant organisations and stakeholders.
Collapse
Affiliation(s)
- Said Abasse Kassim
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
| | - Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, CISSS de Chaudière-Appalaches, Québec, QC, Canada
| | - Laurence Labbé
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
| | - Paolo Landa
- Département d'opérations et systèmes de décision, Faculté des sciences de l'administration, Université Laval, Québec, QC, Canada
- Centre de Recherche CHU de Québec, Université Laval, Québec, QC, Canada
| | - Catherine Paquet
- Centre de Recherche CHU de Québec, Université Laval, Québec, QC, Canada
- Département de Marketing, Faculté des sciences de l'administration, Université Laval, Québec, QC, Canada
- Centre Nutrition, santé et société (NUTRISS), INAF, Université Laval, Québec, QC, Canada
| | - Frédéric Bergeron
- Bibliothèque, Direction des services-conseils, Université Laval, Québec, QC, Canada
| | - Célia Lemaire
- Laboratoire Humanis, EM Strasbourg-Business School, Université de Strasbourg, Strasbourg, France
| | - André Côté
- Département de management, Faculté des sciences de l'administration, Universite Laval, Quebec, QC, Canada
- Centre de recherche en gestion des services de santé, Université Laval, Quebec, QC, Canada
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- VITAM Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
- Centre de recherche du CISSS de Chaudière-Appalaches, CISSS de Chaudière-Appalaches, Québec, QC, Canada
| |
Collapse
|
11
|
Gartner JB, Abasse KS, Bergeron F, Landa P, Lemaire C, Côté A. Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review. BMC Health Serv Res 2022; 22:558. [PMID: 35473632 PMCID: PMC9040248 DOI: 10.1186/s12913-022-07960-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/13/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Confusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework. METHODS An innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed. RESULTS Forty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management. CONCLUSIONS This study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.
Collapse
Affiliation(s)
- Jean-Baptiste Gartner
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, 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.
| | - Kassim Said Abasse
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, 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
- VITAM, Centre de recherche en santé durable, Université Laval, Québec, QC, Canada
| | - Frédéric Bergeron
- Bibliothèque-Direction des services-conseils, Université Laval, Québec, QC, Canada
| | - Paolo Landa
- Centre de recherche du CHU de Québec, Université Laval, Québec, QC, Canada
- Département d'opérations et systèmes de décision, Université Laval, Québec, QC, Canada
| | - Célia Lemaire
- Université de Strasbourg, EM Strasbourg-Business School, HuManiS, Strasbourg, France
| | - André Côté
- Département de management, Faculté des sciences de l'administration, Université Laval, 2325 rue de la Terrasse, Québec, QC, G1V 0A6, 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
| |
Collapse
|
12
|
Analysis of Rapid Rehabilitation Effect of Children with Severe Viral Encephalitis Based on Continuous Nursing of Omaha System. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:6481697. [PMID: 35494511 PMCID: PMC9050245 DOI: 10.1155/2022/6481697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/05/2022] [Indexed: 11/17/2022]
Abstract
Objective. To establish the Omaha System-based intensive care of children with viral encephalitis, compared with the conventional nursing applied in children with severe viral encephalitis for children with clinical symptoms, motor function, the incidence of complications, and the influence of quality of life, to intensive care of children with viral encephalitis way provide certain scientific basis. Methods. 62 cases of severe viral encephalitis diagnosed and treated in our hospital from X month 20XX to X month 20XX were randomly divided into 31 cases of intervention group and 31 cases of control group. The control group received routine nursing, and the intervention group added Omaha system on the basis of the control group. The recovery time of clinical symptoms and signs, FMA score, disability rate, quality of life, and satisfaction of family members were compared between the two groups. Results. The recovery time of clinical signs in the intervention group was shorter than that in the control group. Motor function was improved in both groups, but the improvement effect in intervention group was higher than that in control group. The quality of life in both groups was improved 1–3 months after discharge, but the improvement effect in the intervention group was higher than that in the control group. The incidence of physical dysfunction and behavioral abnormalities was low in the pregroup, and the difference between the two groups was statistically significant (
), but the difference between language impairment and intellectual impairment was not statistically significant (
). Conclusion. Omaha system nursing can significantly reduce the recovery time of clinical signs, improve FMA score, reduce disability rate, and improve the quality of life and family satisfaction of children with severe viral encephalitis.
Collapse
|
13
|
Erjavec K. Team Members and Patients’ Views on Cost-effectiveness of (Integrated) Clinical Pathway. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Integrated clinical pathways (ICPs), which have particularly enhanced existing clinical pathways (CPs) through the work of multifunctional teams, have become an important tool to enable informed decision-making and provide more efficient, cost-effective, and value-based care.
AIM: In the absence of studies on the cost-effectiveness of ICPs, the aim of this study was to determine the opinion of team members treating patients with total hip arthroplasty and their patients on the practice of cost-effectiveness of the existing CP and ICP that might be introduced in the future.
METHODS: A mixed descriptive quantitative and qualitative approach was used. A survey of 61 team members of CP for total hip arthroplasty was conducted, as well as in-depth interviews (n = 12) and focus groups (n = 11). In addition, in-depth interviews were performed with 20 patients who had undergone total hip arthroplasty at CP in a typical Slovenian general hospital.
RESULTS: The results showed that participants occasionally prioritized cost-effectiveness over quality of health care. They frequently used CP to reduce the cost and time of patient care. Nurses with secondary education were statistically significantly more likely to prioritize cost-effectiveness of health care over quality of health care than nurses with higher education, physicians, and others. Team members and patients evaluated positively the cost-effectiveness of ICP for total hip arthroplasty, but patients also pointed out that staff, especially nurse had too little contact with patients.
CONCLUSION: Both team members treating patients with total hip arthroplasty and their patients have a positive attitude toward the cost-effectiveness of ICP. The nursing staff has too little contact with the patients due to staff shortages.
Collapse
|
14
|
Provider and Manager Perspectives on the Use of an Integrated Clinical Pathway for Community-Dwelling Older Adults: A Qualitative Case Study. Int J Integr Care 2022; 22:1. [PMID: 35087350 PMCID: PMC8782094 DOI: 10.5334/ijic.5965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 01/06/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Integrated care pathways (ICPs) could improve the organisation and delivery of care for community dwelling older adults. An ICP was developed and implemented in Québec to support home care processes. This study explores the perspectives of home care staff on the use of an ICP to support the organisation and delivery of health and social care to community-dwelling older adults with complex needs. Theory and Methods: A case study based on eleven semi-structured interviews and analysis of documents was carried out in an urban home care unit. The Normalization Process Theory was used for mixed thematic analysis. Results: While its capacity to store data and enhance interprofessional information exchange was appreciated by home care staff, the broad scope, and automated features of the ICP tool were often problematic. Concerns about increased provider workloads, disruption to provider-client relationships during clinical encounters, and difficulties engaging clients in decision-making were main obstacles in the use of the ICP. Conclusion: Given the importance of ICPs in advancing clinical integration, it is critical to continuously adjust their design to align with providers’ realities in order to optimize their potential in real life contexts.
Collapse
|
15
|
Thomas K, Dannapfel P. Organizational readiness to implement a care model in primary care for frail older adults living at home in Sweden. FRONTIERS IN HEALTH SERVICES 2022; 2:958659. [PMID: 36925790 PMCID: PMC10012617 DOI: 10.3389/frhs.2022.958659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/27/2022] [Indexed: 11/25/2022]
Abstract
Background The demographic change of an aging population constitutes a challenge for primary care organizations worldwide. The systematic implementation of preventative and proactive care models is needed to cope with increased care demands. Objective To investigate the organizational readiness in primary care to implement a new care model to prevent hospitalization among frail older adults. Method Individual qualitative interviews with health care staff investigated organizational readiness at seven primary care units in Sweden. A semi-structured interview guide was used during the interviews and included broad questions on individual and collective readiness to change. Directed content analysis and organizational readiness to change theory were used in data analysis. Results Positive beliefs among staff such as perceived benefits and compatibility with existing values contributed to a strong commitment to implement the new care model. However, perceptions such as unclear task demands, limited resources and concerns about new collaborative structures challenged implementation. Conclusions The findings emphasize implementation as an inter-organizational phenomenon, especially for holistic practices that span across multiple health care providers and disciplines. Furthermore, implementing care models in healthcare may require a change of culture as much as a change of practice.
Collapse
Affiliation(s)
- Kristin Thomas
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden
| | - Petra Dannapfel
- Division of Society and Health, Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health, Linköping University, Linköping, Sweden.,Region Östergötland, Linköping, Sweden
| |
Collapse
|
16
|
Mind the Differences: How Diagnoses and Hospital Characteristics Influence Coordination in Cancer Patient Pathways. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168818. [PMID: 34444567 PMCID: PMC8394059 DOI: 10.3390/ijerph18168818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/12/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022]
Abstract
Integrated care pathway (ICP) is a prevailing concept in health care management including cancer care. Though substantial research has been conducted on ICPs knowledge is still deficient explaining how characteristics of diagnose, applied procedures, patient group and organizational context influence specific practicing of ICPs. We studied how coordination takes place in three cancer pathways in four Norwegian hospitals. We identified how core contextual variables of cancer pathways affect complexity and predictability of the performance of each pathway. Thus, we also point at differences in core preconditions for accomplishing coordination of the cancer pathways. In addition, the findings show that three different types of coordination dynamics are present in all three pathways to a divergent degree: programmed chains, consultative hubs and problem-solving webs. Pathway coordination also depends on hierarchical interaction. Lack of corresponding roles in the medical–professional and the administrative–institutional logics presents a challenge for coordination, both within and between hospitals. We recommend that further improvement of specific ICPs by paying attention to what should be standardized and what should be kept flexible, aligning semi-formal and formal structures to pathway processes and identify the professional cancer related background and management style required by the key-roles in pathway management.
Collapse
|
17
|
Lee KS, Yordanov S, Stubbs D, Edlmann E, Joannides A, Davies B. Integrated care pathways in neurosurgery: A systematic review. PLoS One 2021; 16:e0255628. [PMID: 34339465 PMCID: PMC8328336 DOI: 10.1371/journal.pone.0255628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 07/20/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Integrated care pathways (ICPs) are a pre-defined framework of evidence based, multidisciplinary practice for specific patients. They have the potential to enhance continuity of care, patient safety, patient satisfaction, efficiency gains, teamwork and staff education. In order to inform the development of neurosurgical ICPs in the future, we performed a systematic review to aggregate examples of neurosurgical ICP, to consider their impact and design features that may be associated with their success. Methods Electronic databases MEDLINE, EMBASE, and CENTRAL were searched for relevant literature published from date of inception to July 2020. Primary studies reporting details of neurosurgical ICPs, across all pathologies and age groups were eligible for inclusion. Patient outcomes in each case were also recorded. Results Twenty-four studies were included in our final dataset, from the United States, United Kingdom, Italy, China, Korea, France, Netherlands and Switzerland, and a number of sub-specialties. 3 for cerebrospinal fluid diversion, 1 functional, 2 neurovascular, 1 neuro-oncology, 2 paediatric, 2 skull base, 10 spine, 1 for trauma, 2 miscellaneous (other craniotomies). All were single centre studies with no regional or national examples. Thirteen were cohort studies while 11 were case series which lacked a control group. Effectiveness was typically evaluated using hospital or professional performance metrics, such as length of stay (n = 11, 45.8%) or adverse events (n = 17, 70.8%) including readmission, surgical complications and mortality. Patient reported outcomes, including satisfaction, were evaluated infrequently (n = 3, 12.5%). All studies reported a positive impact. No study reported how the design of the ICP was informed by published literature or other methods Conclusions ICPs have been successfully developed across numerous neurosurgical sub-specialities. However, there is often a lack of clarity over their design and weaknesses in their evaluation, including an underrepresentation of the patient’s perspective.
Collapse
Affiliation(s)
- Keng Siang Lee
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- * E-mail: (KSL); (BD)
| | - Stefan Yordanov
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Daniel Stubbs
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ellie Edlmann
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Alexis Joannides
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Benjamin Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- * E-mail: (KSL); (BD)
| |
Collapse
|
18
|
Goodmaker CJG, Kopczynska M, Meskell R, Slade D. Paving the road to recovery: the colorectal surgery ERAS pathway during the COVID-19 pandemic. Br J Surg 2021; 108:e322-e323. [PMID: 34227658 PMCID: PMC8406880 DOI: 10.1093/bjs/znab208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/08/2021] [Indexed: 12/02/2022]
Affiliation(s)
- C J G Goodmaker
- Department of Colorectal Surgery, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| | - M Kopczynska
- Department of Colorectal Surgery, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| | - R Meskell
- Department of Colorectal Surgery, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| | - D Slade
- Department of Colorectal Surgery, Salford Royal Hospital, Stott Lane, Salford, M6 8HD, UK
| |
Collapse
|
19
|
Implementing a Care Pathway for Complex Chronic Patients from a Nursing Perspective: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126324. [PMID: 34207974 PMCID: PMC8296156 DOI: 10.3390/ijerph18126324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 05/31/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022]
Abstract
A care pathway constitutes a complex care strategy for decision-making and the organization of processes in the care of complex chronic patients, avoiding the fragmentation of care. Health professionals play a decisive role in the implementation, development, and evaluation of care pathways. This study sought to explore nurses’ opinions on the care pathway for complex chronic patients three years after its implementation. The study participants were thirteen nurses with different roles who were involved in the care pathway. Thematic content analysis of the semi-structured interviews resulted in four major themes: (a) the strengths of the route; (b) the impact of the route on caregivers; (c) the weaknesses of the route; and (d) the future of the route. Overall, the pathway was positively valued for the benefits it provides to patients, the caregiver, and the administration of professional health care. Participants voiced their concerns regarding: communication and coordination difficulties among professionals across the different levels of care, the need for improved teamwork and consensus among professionals at the same center, and human and material resources. The ongoing evaluation and monitoring of facilitators and barriers is necessary throughout the implementation process, to ensure continuity and quality of care in the health system.
Collapse
|
20
|
Melby L, Håland E. When time matters: a qualitative study on hospital staff's strategies for meeting the target times in cancer patient pathways. BMC Health Serv Res 2021; 21:210. [PMID: 33750379 PMCID: PMC7941937 DOI: 10.1186/s12913-021-06224-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/28/2021] [Indexed: 12/22/2022] Open
Abstract
Background Cancer patient pathways (CPPs) were introduced in Norway in 2015. CPPs are time-bound standardised care pathways that describe the organisation of and responsibilities for diagnostics and treatment, as well as communication with the patient and next of kin. The aim is to ensure that cancer patients experience a well-organised, coherent and predictable pathway without any delays in assessment and diagnostics caused by non-medical reasons. Preventing delays in diagnostics by meeting specific target times is central to the successful implementation of CPPs. The aim of this paper is to describe how hospital staff cope with the increased focus on meeting CPP target times and the measures and strategies implemented by hospitals and their staff. Methods Data for this paper were collected in a larger study on implementation and experiences with CPPs among hospital staff, general practitioners, and patients in Norway (2017–2020). The study had a qualitative cross-sectional design, and data were collected through interviews. This article is based on semi-structured interviews with hospital staff (N = 60) in five hospitals. Results Hospital staff are highly aware of the target times, and try to comply with them, in the interest of both the patients and the hospitals. The implementation of CPPs was not accompanied by the allocation of additional resources; therefore, hospitals could not simply increase capacity to meet the target times. Instead, they had to develop other strategies. Four categories of strategies were identified: (i) introducing new roles and more staff, (ii) reorganising the workflow, (iii) gaming the system and (iv) outsourcing services. Conclusions Hospital staff are torn between meeting the target times and a lack of resources and capacity. This is not unusual in the current healthcare context, where staff face organisational reforms and increasing demands on a regular basis. It is important to recognise frontline workers’ efforts towards realising new organisational changes. Therefore, carefully weighing the benefits against the costs and undertaking the necessary planning are important in the design and implementation of future care and treatment pathways for patients.
Collapse
Affiliation(s)
- Line Melby
- Department of Health Research, SINTEF, P.O. Box 4760, Torgarden, 7465, Trondheim, Norway.
| | - Erna Håland
- Norwegian University of Science and Technology, 7491, Trondheim, Norway
| |
Collapse
|
21
|
Manns BJ. Evidence-Based Decision Making 5: Knowledge Translation and the Knowledge to Action Cycle. Methods Mol Biol 2021; 2249:467-482. [PMID: 33871859 DOI: 10.1007/978-1-0716-1138-8_25] [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: 06/12/2023]
Abstract
There is a significant gap between what is known and what is implemented by key stakeholders in practice (the evidence to practice gap). The primary purpose of knowledge translation is to address this gap, bridging evidence to clinical practice. The knowledge to action cycle is one framework for knowledge translation that integrates policy makers throughout the research cycle. The knowledge to action cycle begins with the identification of a problem (usually a gap in care provision). After identification of the problem, knowledge creation is undertaken, depicted at the center of the cycle as a funnel. Knowledge inquiry is at the wide end of the funnel, and moving down the funnel, the primary data is synthesized into knowledge products in the form of educational materials, guidelines, decision aids, or clinical pathways. The remaining components of the knowledge to action cycle refer to the action of applying the knowledge that has been created. This includes adapting knowledge to local context, assessing barriers to knowledge use, selecting, tailoring implementing interventions, monitoring knowledge use, evaluating outcomes, and sustaining knowledge use. Each of these steps is connected by bidirectional arrows and ideally involves health-care decision makers and key stakeholders at each transition.
Collapse
Affiliation(s)
- Braden J Manns
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| |
Collapse
|
22
|
Olsson O. Are cancer care pathways associated with longer waiting times. Analysing crowding out effects in radiology, pathology, and surgery. INTERNATIONAL JOURNAL OF CARE COORDINATION 2020. [DOI: 10.1177/2053434520978173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction In 2015, Sweden initiated the implementation of standardised cancer care pathways (CCPs). With short, nationally imposed target times from diagnosis to first treatment, the issue of crowding out effects has been debated. This study investigate whether the implementation of CCPs is associated with longer waiting times for surgery, radiology scans and pathology analyses for other patient groups. Methods Data from the internal computer systems used in radiology, pathology and surgery to plan and follow the production at a county hospital in Sweden during 2014–2017 were analysed. By utilising the different priority categories used in these specialties, changes in waiting times before and after the implementation of CCPs could be analysed. Results The results are consistent with an association between the implementation of CCPs and longer waiting times for the priority category prioritised immediately after the CCP category in all specialties. In addition, none of the lowest priority categories within each subspecialty have experienced increased waiting times after CCP implementation. Discussion These results are consistent with a change in prioritisation where CCP patients are receiving shorter waiting times after CCP implementation at the expense of other patient groups. Crowding out effects related to CCP implementation have not been previously researched. This study therefore fills a gap in present literature. With an increased awareness of these challenges, and a more holistic perspective in the implementation process, actions can be put in place to identify and counteract crowding out effects.
Collapse
|
23
|
Mæhle PM, Small Hanto IK, Smeland S. Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E9199. [PMID: 33317088 PMCID: PMC7764546 DOI: 10.3390/ijerph17249199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.
Collapse
Affiliation(s)
- Per Magnus Mæhle
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0314 Oslo, Norway
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Ingrid Kristine Small Hanto
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Sigbjørn Smeland
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
| |
Collapse
|
24
|
Du C, Berg WT, Siegal AR, Huang Z, Nguyen A, Cheung A, Mehraban-Far S, Anderson R, Jacob S, Kim J. A retrospective longitudinal evaluation of new overactive bladder patients in an FPMRS urologist practice: Are patients following up and utilizing third-line therapies? Neurourol Urodyn 2020; 40:391-396. [PMID: 33197059 DOI: 10.1002/nau.24573] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/17/2020] [Accepted: 10/29/2020] [Indexed: 11/11/2022]
Abstract
AIMS Third-line therapies are efficacious in improving overactive bladder (OAB) symptoms; however, OAB patients have poor follow-up and rarely progress to these therapies. Clinical care pathways (CCP) may improve OAB follow-up rates and third-line therapy use. We sought to determine how new OAB patients follow up and utilize third-line therapies with the implementation of an OAB CCP in a fellowship Female Pelvic Medicine and Reconstructive Surgery (FPMRS) trained urologist's academic practice. METHODS We identified new OAB patients using ICD-9 and 10 codes. They were placed into two groups: pre- and post-CCP use. Basic demographic data were collected. Patients were evaluated in a retrospective longitudinal fashion over 12 months to determine follow-up and third-line therapy utilization. RESULTS A total of 769 new OAB patients (261 pre-CCP and 508 post-CCP) were identified. The mean number of follow-up visits increased significantly at 6 months (0.94 vs. 1.64 visits, p = .001) and 12 months (1.26 vs. 2.46 visits, p < .003). Follow-up rates increased significantly at 3 months (38.7% vs. 50.2%, p = .002). Mean time to third-line therapy decreased significantly (280 days vs. 160 days, p = .016). Third-line therapy utilization therapy rates increased at 6 months (7.7% vs. 13.4%, p = .018) and at 12 months (11.1% vs. 16.5%, p = .044). CONCLUSIONS New OAB patients follow-up and progress to third-line therapies faster and more frequently with the use of a CCP in an FPMRS-trained urologist practice. However, many OAB patients still fail to follow up and overall utilization of third-line therapies remains low. Future studies are warranted to identify factors to why overall OAB compliance remains low.
Collapse
Affiliation(s)
- Chris Du
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - William T Berg
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Alexandra R Siegal
- Renaissaince School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Zhenyue Huang
- Department of Urology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Anh Nguyen
- Division of Urology, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Cheung
- Division of Urology, Albany Medical College, Albany, New York, USA
| | - Sina Mehraban-Far
- Renaissaince School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Rebecca Anderson
- Renaissaince School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Sophia Jacob
- Renaissaince School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - Jason Kim
- Department of Urology, Stony Brook University Hospital, Stony Brook, New York, USA
| |
Collapse
|
25
|
Yuliyanti S, Utarini A, Trisnantoro L. A protocol study of participatory action research: integrated care pathway for pregnant women with heart disease in Indonesia. BMC Health Serv Res 2020; 20:932. [PMID: 33036607 PMCID: PMC7547524 DOI: 10.1186/s12913-020-05769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/28/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Heart diseases are increasingly identified as an important indirect cause of maternal mortality in several cities in Indonesia. The management of pregnancy with heart diseases requires a multidisciplinary approach, and interprofessional collaboration practice (IPCP) is critical to improving the quality of patient care. To enable the effective implementation of IPCP, integrated care pathways (ICPs) are needed to define the roles and responsibilities of the health professionals involved. This study aims to examine the obstacles and enabling factors of IPCP, to develop and use ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. METHODS A participatory action study consisting of four stages (diagnostic, planning, implementation, and evaluation) will take approximately 2 years after consensus of ICPs are made. The primary data collection process will employ consensus, observations, focus group discussions, and in-depth interviews throughout the four stages, while secondary data from referral documents and medical records will be collected mainly during the diagnostic and evaluation stages. The findings are being analysed and will then be used to develop an ICPs through consensus building at the planning stage to be applied in the implementation stage. Finally, the implementation outcome, including acceptability, adoption, appropriateness, and feasibility of IPCP, will be assessed in the evaluation stage. All qualitative data will be analysed thematically by two coders using NVIVO 12 software. DISCUSSION This research aims to assess the needs of IPCP, develop and use the ICPs in the implementation of IPCP in health care services for pregnant women with heart diseases. Findings from this study will be used for health service planning and policy making to strengthen practice of IPCP during the referral process. As a result, pregnant women with heart disease will have better access to high-quality services at every health care facility to reduce maternal mortality. TRIAL REGISTRATION Retrospectively registered in the ISRCTN registry with study ID ISRCTN82300061 on Feb 6, 2019.
Collapse
Affiliation(s)
- Suryani Yuliyanti
- Public Health Department, Faculty of Medicine, Universitas Islam Sultan Agung, Jl. Kaligawe Raya km 4, Semarang, 50122 Indonesia
- Doctoral Study Programme, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
| | - Adi Utarini
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
| | - Laksono Trisnantoro
- Department of Health Policy and Management, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Jl. Farmako Sekip Utara, Yogyakarta, Sinduadi, Mlati, Special Region of Yogyakarta 55281 Indonesia
| |
Collapse
|
26
|
van Loon YT, Clermonts SHEM, Belt R, Nagle D, Wasowicz DK, Zimmerman DDE. Implementation of an easy in-hospital educational stoma pathway results in decrease of home nursing care services after discharge. Colorectal Dis 2020; 22:1175-1183. [PMID: 32180331 DOI: 10.1111/codi.15034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 02/20/2020] [Indexed: 02/08/2023]
Abstract
AIM New stoma patients often rely heavily on the assistance of the ward nursing staff during the hospital stay and on the availability of home nursing care services (HNCS) after discharge. An easily executable 4-day in-hospital educational stoma pathway was developed and implemented. The aim was to increase their level of independence (LOI) in order to reduce the need for HNCS after discharge. METHOD All new stoma patients on the gastrointestinal surgery ward, physically and psychologically capable of performing independent stoma care (SC), were enrolled in this pathway. They were compared to a retrospective control group of new stoma patients before the onset of the stoma pathway. The primary outcome is the need and frequency of HNCS for SC at the moment of discharge. Secondary outcome is the LOI in SC at discharge. RESULTS A total of 145 patients [m:f = 102:43, median age 67 (range 27-90) years] were included in the present study. Patients requiring daily HNCS for SC decreased from 80% to 50%, P < 0.001; patients discharged without HNCS for SC increased from 5% to 27%. Patients' independence in SC at discharge increased from 8% to 68%, P < 0.001. CONCLUSION This study shows that a clinical 4-day in-hospital educational stoma pathway is feasible and effective in increasing the LOI in SC of new stoma patients and significantly reducing their need for HNCS. Cost-benefit analysis and applicability of this pathway in multicentre settings are currently being investigated.
Collapse
Affiliation(s)
- Y T van Loon
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - S H E M Clermonts
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - R Belt
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D Nagle
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - D K Wasowicz
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - D D E Zimmerman
- Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| |
Collapse
|
27
|
Daghash H, Lim Abdullah K, Ismail MD. The effect of acute coronary syndrome care pathways on in-hospital patients: A systematic review. J Eval Clin Pract 2020; 26:1280-1291. [PMID: 31489762 DOI: 10.1111/jep.13280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/31/2019] [Accepted: 08/21/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Health care institutions need to construct management strategies for patients diagnosed with acute coronary syndrome (ACS) that focus on evidence-based treatments, adherence to treatment guidelines, and organized care. These help to reduce variations as well as the mortality and morbidity rates, which indicates the critical need for standardized care and adherence to evidence-based practices for patients hospitalized with ACS. The care pathways translate research and guidelines into clinical practice to close the gap between the guidelines and the clinical practices. OBJECTIVES This review focuses on identifying the indicators used to evaluate ACS care pathways and their effect on the care process and clinical outcomes. METHODS This review follows the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The systematic research was conducted using five research databases. Two groups were created by dividing the studies according to their year of publication. The first group included those studies published from 1997 to 2007 ("Group 1"), while the second included those published from 2008 to 2018 ("Group 2"). Selected studies were screened using the Effective Public Health Practice Project (EPHPP) quality assessment tool. RESULTS Seventeen studies were included in this review. One study was a randomized controlled trial, 14 were predesigns and postdesigns, and two were longitudinal observational designs. The Group 1 studies demonstrated that ACS care pathways had a positive effect on reducing the length of the hospital stay and the door-to-balloon times. Similar effects were observed for the Group 2 studies. CONCLUSION Implementing ACS care pathway helps to organize care processes and decrease treatment delays as well as improve the patient outcomes without adverse consequences for patients or additional resources and costs. While the current level of evidence is inadequate to warrant a formal recommendation, there is a need for more studies with an emphasis on well-designed randomization to measure patient outcomes.
Collapse
Affiliation(s)
- Hanan Daghash
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Khatijah Lim Abdullah
- Department of Nursing Science, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Muhammad Dzafir Ismail
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
28
|
Wankah P, Guillette M, Lemaitre T, Belzile L, Couturier Y. Challenges in measuring integrated care models: International knowledge and the case of Québec. INTERNATIONAL JOURNAL OF CARE COORDINATION 2020. [DOI: 10.1177/2053434520945087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction The implementation of integrated care models requires significant efforts, especially due to institutional and organisational inertial forces that characterize health and social care systems of developed countries. It is therefore crucial to deploy strategies that promote continuous adjustment to these barriers so as to improve the benefits of integrating care. Measuring the implementation and effects of integrated care models are key component of these strategies. However, measuring integrated care also faces major challenges. This study aims to identify and characterise integrated care measurement challenges. Methods A review of reviews on the measurement of integrated care identified 12 papers. A thematic analysis was conducted to identify and categorize measurement challenges. Document analysis was done on the measurement of an integrated care model for older adults in Québec. Results Eight categories of measurement challenges were identified. These challenges include difficulties in measuring structures, processes, and effects of models; conceptual ambiguity and heterogeneity of organisational forms; involving multiple actors in the measurement strategy; and including multiple data sources, amongst others. These challenges revealed and explained potential gaps in the measurement of integrated care for older adults in Québec. For instance, the Québec measurement strategy did not include effects indicators. Conclusion Although the measurement of integrated care is a complex endeavour, there is a need for adequate measurement strategies that allow to appreciate important elements of integrate care. The findings of this study could be used as a reflexive tool in advancing research and practice of measuring integrated care.
Collapse
|
29
|
Busnel C, Ludwig C, Da Rocha Rodrigues MG. [Complexity in nursing practice : Toward a new conceptual framework in nursing care]. Rech Soins Infirm 2020; 140:7-16. [PMID: 32524804 DOI: 10.3917/rsi.140.0007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
While complexity theory has gradually influenced the field of health and social sciences, it has also had an impact on nursing care by introducing a wealth of terminology into the field. The terms “complex patient,” “complex case,” “complex care,” “complex practice,” and “complex needs” have been proposed to describe different aspects of complexity in nursing care. As these qualifiers reflect, nurses become actors in multidefined care and must integrate complexity into their reflective practice. By way of a narrative literature review, this article aims to offer a new perspective on nursing by explaining the different terms used in the discipline, using a multi-level approach. At the end of this review, the authors propose a new integrative conceptual framework for complexity in nursing practice.
Collapse
|
30
|
Design and Execution of Integrated Clinical Pathway: A Simplified Meta-Model and Associated Methodology. INFORMATION 2020. [DOI: 10.3390/info11070362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Integrated clinical pathways (ICPs) are task-oriented care plans detailing the essential steps of the therapeutic pathway referring to a specific clinical problem with a patient’s expected clinical course. ICPs represent an effective tool for resource management in the public and private health domains. To be automatically executed, the ICP process has to be described by means of complex general purpose description language (GPDL) formalisms. However, GPDLs make the process model difficult to grasp by a human. On the other hand, the adoption of a reduced set of graphical constructs prevents a fully automated process execution due to the lack of information required by a machine. Unfortunately, it is difficult to find a balance between modelling language expressiveness and the automated execution of the modelled processes. In this paper, we present a meta-model based on a GPDL to organize the ICP process knowledge. This meta-model allows the management of ICP information in a way that is independent from the graphic representation of the adopted modelling standard. We also propose a general framework and a methodology that aim to guarantee a high degree of automation in process execution. In particular, the corresponding execution engine is implemented as a chatbot (integrated with social media), which plays a two-fold role: during the actual execution of the entire ICP, it acts as a virtual assistant and gathers the patient’s health data. Tests performed on a real ICP showed that, thanks to the proposed solution, the chatbot engine is able to engage in a dialogue with the patient. We provide discussion about how the system could be extended and how it could be seen as an alternative to Artificial Intelligence (AI) and Natural Language Processing (NLP)-based approaches.
Collapse
|
31
|
[Problem-oriented mangement in modern orthopaedic trauma]. Unfallchirurg 2020; 123:505-506. [PMID: 32638061 DOI: 10.1007/s00113-020-00821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
32
|
Volkmer A, Spector A. Speech and language therapy for primary progressive aphasia: Referral patterns and barriers to service provision across the UK. DEMENTIA 2020; 19:1349-1363. [PMID: 30180763 PMCID: PMC7309358 DOI: 10.1177/1471301218797240] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To assess the extent of UK speech and language therapy engagement in assessment and management of primary progressive aphasia, determine the factors contributing to any shortfall and explore a gap in the research literature on current speech and language therapy practices with people with primary progressive aphasia. METHODS A 37-item, pilot-tested survey was distributed electronically via clinical networks and through the Royal College of Speech and Language Therapists. Survey items included questions on intervention approaches, referral numbers and demographics, referral sources and access to services. RESULTS One hundred and five speech and language therapists completed the survey. Over the previous 24 months, respondents reported seeing a total of 353 people with primary progressive aphasia (an average of 3.27 per speech and language therapist). Neurologists were the most commonly reported referrers to speech and language therapy (22.5%). Seventy-eight percent of respondents reported that people with primary progressive aphasia experienced barriers to accessing speech and language therapy. Key barriers were a lack of referrer awareness of a speech and language therapist's role, and restrictive eligibility criteria for services. CONCLUSIONS This study highlighted inequities in access to speech and language therapy for people with primary progressive aphasia. The medical and speech and language therapy professions need to develop appropriate care pathways for people with primary progressive aphasia. Speech and language therapists have a duty to develop a relevant evidence base for speech and language interventions for people with primary progressive aphasia.
Collapse
Affiliation(s)
- Anna Volkmer
- Division of Psychology and Language Sciences, University College, London, UK
| | - Aimee Spector
- Division of Psychology and Language Sciences, University College, London, UK
| |
Collapse
|
33
|
HUGHES GEMMA, SHAW SARAE, GREENHALGH TRISHA. Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts. Milbank Q 2020; 98:446-492. [PMID: 32436330 PMCID: PMC7296432 DOI: 10.1111/1468-0009.12459] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced. CONTEXT Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts. METHODS We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care. FINDINGS We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other. CONCLUSIONS Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.
Collapse
Affiliation(s)
- GEMMA HUGHES
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
| | - SARA E. SHAW
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
| | - TRISHA GREENHALGH
- Nuffield Department of Primary Care Health SciencesUniversity of Oxford
| |
Collapse
|
34
|
van der Kolk BM, van den Boogaard M, van der Hoeven JG, Noyez L, Pickkers P. Sustainability of clinical pathway guided care in cardiac surgery ICU patients; 9-years experience in over 7500 patients. Int J Qual Health Care 2020; 31:456-463. [PMID: 30184204 DOI: 10.1093/intqhc/mzy190] [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: 03/24/2018] [Revised: 07/14/2018] [Accepted: 08/23/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine trends over time regarding inclusion of post-operative cardiac surgery intensive care unit (ICU) patients in a clinical pathway (CP), and the association with clinical outcome. DESIGN Retrospective cohort study. SETTING ICU of an academic hospital. PARTICIPANTS All cardiac surgery patients operated between 2007 and 2015. MEASURES AND RESULTS A total of 7553 patients were operated. Three patient groups were identified: patients treated according to CP (n = 6567), patients excluded from the CP within the first 48 h (n = 633) and patients never included in CP (n = 353). Patients treated according to CP increased significantly over time from 74% to 95% and the median Log EuroSCORE (predicted mortality score) in this group increased significantly over time (P = 0.016). In-hospital length of stay (LOS) decreased in all groups, but significantly in CP group (P < 0.001). Overall, the in-hospital, and 1-year mortality decreased from 1.5 to 1.1% and 3.7 to 2.9%, respectively (both P < 0.05). Patients with a Log EuroSCORE >10 were more likely excluded from CP (P < 0.001), but, if included in CP, these patients had a significantly shorter Intensive Care stay and in-hospital stay compared to excluded patients with a Log EuroSCORE >10 (both P < 0.001). CONCLUSIONS The use of a CP for all post-operative cardiac surgery patients in the ICU is sustainable. While more complex patients were treated according to the CP, clinical outcome improved in the CP group.
Collapse
Affiliation(s)
- B M van der Kolk
- Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands.,Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - M van den Boogaard
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - L Noyez
- Department of Cardiothoracic Surgery, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| | - P Pickkers
- Department of Intensive Care Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, HB Nijmegen, The Netherlands
| |
Collapse
|
35
|
Santaeugènia SJ, Mas MA, Tarazona-Santabalbina FJ, García-Lázaro M, Alventosa AM, Gutiérrez-Benito A, Monterde A, Cunill J. Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways. Geriatr Gerontol Int 2020; 20:366-372. [PMID: 32072727 DOI: 10.1111/ggi.13877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 12/30/2019] [Accepted: 01/12/2020] [Indexed: 01/24/2023]
Abstract
AIM The aim of this study was to compare the clinical impact of two intermediate care pathways. METHODS A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge. RESULTS Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain. CONCLUSIONS The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.
Collapse
Affiliation(s)
- Sebastià J Santaeugènia
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,Chronic Care Program, Ministry of Health, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), Universitat de Vic - University of Vic-Central University of Catalonia (UVIC-UCC), Vic, Spain
| | - Miquel A Mas
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain.,RE-FiT bcn Research Group, Vall d'Hebrón Institute of Research (VHIR), Barcelona, Spain
| | - Francisco J Tarazona-Santabalbina
- Department of Geriatric Medicine, Hospital Universitario de la Ribera, Valencia, Spain.,Valencia Catholic University Saint Vincent Martyr, Valencia, Spain
| | - Manuela García-Lázaro
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Ana Maria Alventosa
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Alícia Gutiérrez-Benito
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Albert Monterde
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| | - Joan Cunill
- Department of Geriatric Medicine and Palliative Care, Badalona Serveis Assistencials, Badalona, Catalonia, Spain
| |
Collapse
|
36
|
Bjønness S, Viksveen P, Johannessen JO, Storm M. User participation and shared decision-making in adolescent mental healthcare: a qualitative study of healthcare professionals' perspectives. Child Adolesc Psychiatry Ment Health 2020; 14:2. [PMID: 31988656 PMCID: PMC6969458 DOI: 10.1186/s13034-020-0310-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Most mental health problems occur in adolescence. There is increasing recognition of user participation and shared decision-making in adolescents' mental healthcare. However, research in this field of clinical practice is still sparse. The objective of this study was to explore healthcare professionals' perspectives on user participation, and opportunities for shared decision-making in Child and Adolescent Mental Health Service (CAMHS) inpatient units. METHODS Healthcare professionals at CAMHS inpatient units participated in three focus group interviews. Fifteen participants with experience with user participation and shared decision-making were recruited from five hospitals in Norway. RESULTS Five themes emerged: (1) involvement before admission; (2) sufficient time to feel safe; (3) individualized therapy; (4) access to meetings where decisions are made; and (5) changing professionals' attitudes and practices. CONCLUSION User participation and shared decision-making require changes in workplace culture, and routines that allow for individualized mental health services that are adapted to adolescents' needs. This calls for a flexible approach that challenges clinical pathways and short-stay hospital policies. The results of this study may inform further work on strengthening user participation and the implementation of shared decision-making.Trial registration Norwegian Regional Committees for Medical and Health Research Ethics, reference number 2017/1195.
Collapse
Affiliation(s)
- Stig Bjønness
- Centre for Resilience in Healthcare (SHARE), Department for Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
| | - Petter Viksveen
- Centre for Resilience in Healthcare (SHARE), Department for Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Olav Johannessen
- Department of Psychiatry, Stavanger University Hospital, Stavanger, Norway
- Department for Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Marianne Storm
- Department for Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| |
Collapse
|
37
|
Shepherd HL, Geerligs L, Butow P, Masya L, Shaw J, Price M, Dhillon HM, Hack TF, Girgis A, Luckett T, Lovell M, Kelly B, Beale P, Grimison P, Shaw T, Viney R, Rankin NM. The Elusive Search for Success: Defining and Measuring Implementation Outcomes in a Real-World Hospital Trial. Front Public Health 2019; 7:293. [PMID: 31681724 PMCID: PMC6813570 DOI: 10.3389/fpubh.2019.00293] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 09/27/2019] [Indexed: 11/13/2022] Open
Abstract
Objective and Study Setting: Research efforts to identify factors that influence successful implementation are growing. This paper describes methods of defining and measuring outcomes of implementation success, using a cluster randomized controlled trial with 12 cancer services in Australia comparing the effectiveness of implementation strategies to support adherence to the Australian Clinical Pathway for the Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients (ADAPT CP). Study Design and Methods: Using the StaRI guidelines, a process evaluation was planned to explore participant experience of the ADAPT CP, resources and implementation strategies according to the Implementation Outcomes Framework. This study focused on identifying measurable outcome criteria, prior to data collection for the trial, which is currently in progress. Principal Findings: We translated each implementation outcome into clearly defined and measurable criteria, noting whether each addressed the ADAPT CP, resources or implementation strategies, or a combination of the three. A consensus process defined measures for the primary outcome (adherence) and secondary (implementation) outcomes; this process included literature review, discussion and clear measurement parameters. Based on our experience, we present an approach that could be used as a guide for other researchers and clinicians seeking to define success in their work. Conclusions: Defining and operationalizing success in real-world implementation yields a range of methodological challenges and complexities that may be overcome by iterative review and engagement with end users. A clear understanding of how outcomes are defined and measured, based on a strong theoretical framework, is crucial to meaningful measurement and outcomes. The conceptual approach described in this article could be generalized for use in other studies. Trial Registration: The ADAPT Program to support the management of anxiety and depression in adult cancer patients: a cluster randomized trial to evaluate different implementation strategies of the Clinical Pathway for Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients was prospectively registered with the Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12617000411347.
Collapse
Affiliation(s)
- Heather L Shepherd
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Liesbeth Geerligs
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia
| | - Phyllis Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Lindy Masya
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia
| | - Joanne Shaw
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia
| | - Melanie Price
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia
| | - Haryana M Dhillon
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, Australia.,Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Thomas F Hack
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, MB, Canada.,Psychosocial Oncology & Cancer Nursing Research, St. Boniface Hospital Research Centre, Winnipeg, MB, Canada
| | - Afaf Girgis
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Melanie Lovell
- HammondCare Northern Sydney, Greenwich, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Brian Kelly
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Philip Beale
- Cancer Services for the Sydney Local Health District (Incorporating Royal Prince Alfred, Concord and Canterbury Hospitals), Sydney, NSW, Australia
| | - Peter Grimison
- Chris O'Brien Lifehouse, Camperdown, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Charles Perkins Centre, Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, UTS Business School, University of Technology Sydney, Sydney, NSW, Australia
| | - Nicole M Rankin
- Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| |
Collapse
|
38
|
Kobayashi ST, Campolina AG, Diz MDPE, de Soárez PC. Integrated care pathway for rectal cancer treatment: cross-sectional post-implementation study using a logic model framework. SAO PAULO MED J 2019; 137:438-445. [PMID: 31939569 PMCID: PMC9745824 DOI: 10.1590/1516-3180.2018.0364160919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Management of rectal cancer has become more complex with multimodality therapy (neoadjuvant chemoradiotherapy and surgery) and this has led to the need to organize multidisciplinary teams. The aim of this study was to report on the planning, implementation and evaluation of an integrated care pathway for neoadjuvant treatment of middle and lower rectal cancer. DESIGN AND SETTING This was a cross-sectional post-implementation study that was carried out at a public university cancer center. METHODS The Framework for Program Evaluation in Public Health of the Centers for Disease Control and Prevention (CDC) was used to identify resources and activities; link results from activities and outcomes with expected goals; and originate indicators and outcome measurements. RESULTS The logic model identified four activities: stakeholders' engagement, clinical pathway development, information technology improvements and training programs; and three categories of outcomes: access to care, effectiveness and organizational outcomes. The measurements involved 218 patients, among whom 66.3% had their first consultation within 15 days after admission; 75.2% underwent surgery < 14 weeks after the end of neoadjuvant treatment and 72.7% completed the treatment in < 189 days. There was 100% adherence to the protocol for the regimen of 5-fluorouracil and leucovorin. CONCLUSIONS The logic model was useful for evaluating the implementation of the integrated care pathways and for identifying measurements to be made in future outcome studies.
Collapse
Affiliation(s)
- Silvia Takanohashi Kobayashi
- MD, MSc. Ophthalmologist, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR.
| | - Alessandro Gonçalves Campolina
- MD, MSc, PhD. Scientific Researcher, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina FMUSP, Universidade de Sao Paulo (FMUSP), Sao Paulo, SP, BR.
| | - Maria del Pilar Estevez Diz
- MD, PhD. Attending Physician, Centro de Investigação Translacional em Oncologia, Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR.
| | - Patrícia Coelho de Soárez
- MPH, PhD. Associate Professor, Department of Preventive Medicine, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR.
| |
Collapse
|
39
|
Forrester A, Hopkin G. Mental health in the criminal justice system: A pathways approach to service and research design. CRIMINAL BEHAVIOUR AND MENTAL HEALTH : CBMH 2019; 29:207-217. [PMID: 31478274 DOI: 10.1002/cbm.2128] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Care pathway approaches were introduced into health care in the 1980s and have become standard international practice. They are now being introduced more specifically for health care in the criminal justice system. Care pathway delivery has the theoretical advantage of encouraging a whole-systems approach for health and social care within the criminal justice system, but how well is it supported by empirical evidence? AIMS The aim of this study is to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000. METHOD We used an exploratory narrative method to review the nature and extent of evidence streams supporting health care delivery within interagency pathway developments since 2000. The available literature was reviewed using a keyword search approach with three databases: PubMed, Medline, and Google Scholar. FINDINGS Research in this field has covered police custody, courts, prisons, and the wider community, but there is little that follows the entire career through all these elements of offender placement. Main themes in the research to date, regardless of where the research was conducted, have been counting the disorder or the need, development and evaluation of screening tools, and evaluation of clinical intervention styles. Most evidence to date is simply observational, although the possibility of conducting randomised controlled trials of interventions within parts of the criminal justice system, especially prisons, is now well established. CONCLUSIONS Access to health care while passing through the criminal justice system is essential because of the disproportionately high rates of mental disorder among offenders, and the concept of structured pathways to ensure this theoretically satisfying, but as yet empirically unsupported. Further, substantial cuts in services, generally following government economies, are largely unresearched. Considerable investment in new possibilities, driven by both pressure groups and government, tend to be informed by good will and theory rather than hard evidence and are often not evaluated even after introduction. This must change.
Collapse
Affiliation(s)
- Andrew Forrester
- Edenfield Centre, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
- Offender Health Research Network, University of Manchester, Manchester, UK
| | - Gareth Hopkin
- Department of Health Policy, London School of Economics and Political Science, London, UK
| |
Collapse
|
40
|
McKeown A, Cliffe C, Arora A, Griffin A. Ethical challenges of integration across primary and secondary care: a qualitative and normative analysis. BMC Med Ethics 2019; 20:42. [PMID: 31269930 PMCID: PMC6610833 DOI: 10.1186/s12910-019-0386-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/26/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND This paper explores ethical concerns arising in healthcare integration. We argue that integration is necessary imperative for meeting contemporary and future healthcare challenges, a far stronger evidence base for the conditions of its effectiveness is required. In particular, given the increasing emphasis at the policy level for the entire healthcare infrastructure to become better integrated, our analysis of the ethical challenges that follow from the logic of integration itself is timely and important and has hitherto received insufficient attention. METHODS We evaluated an educational intervention which aims to improve child health outcomes by making transitions between primary to secondary care more efficient, ensuring children and parents are better supported throughout. The programme provided skills for trainee paediatricians and general practitioners (GPs) in co-designing integrated clinical services. RESULTS The key ethical challenges of integrated care that arose from a clinical perspective are: professional identity and autonomy in an integrated working environment; the concomitant extent of professional responsibility in such an environment; and the urgent need for more evidence to be produced on which strategies for integrating at scale can be based. CONCLUSIONS From our analysis we suggest a tentative way forward, viewed from a normative position broadly situated at the intersection of deontology and care ethics. We adopt this position because the primary clinical ethical issues in the context of integrated care concern: how to ensure that all duties of care to individual patients are met in a newly orientated working environment where clinical responsibility may be ambiguous; and the need to orientate care around the patient by foregrounding their autonomous preferences and ensuring good patient clinician relationships in clinical decision-making.
Collapse
Affiliation(s)
- Alex McKeown
- Department of Psychiatry, University of Oxford, Warneford Lane, Oxford, OX3 7JX, England
| | - Charlotte Cliffe
- University College London Medical School, 74 Huntley Street, London, WC1E 6AU, England
| | - Arun Arora
- University of Manchester Medical School, Oxford Road, Manchester, M13 9PL, UK
| | - Ann Griffin
- Research Department for Medical Education, University College London Medical School, 74 Huntley Street, London, WC1E 6AU, England.
| |
Collapse
|
41
|
Parry W, Wolters AT, Brine RJ, Steventon A. Effect of an integrated care pathway on use of primary and secondary healthcare by patients at high risk of emergency inpatient admission: a matched control cohort study in Tower Hamlets. BMJ Open 2019; 9:e026470. [PMID: 31189676 PMCID: PMC6575714 DOI: 10.1136/bmjopen-2018-026470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To assess the effects of an integrated care pathway on the use of primary and secondary healthcare by patients at high risk of emergency inpatient admission. DESIGN Observational study of a real-life deployment of integrated care, using patient-level administrative data. Regression analysis was used to compare integrated care patients with matched controls. SETTING A deprived, inner city London borough (Tower Hamlets). PARTICIPANTS 1720 patients aged 50+ years registered with a general practitioner in Tower Hamlets and at high risk of emergency inpatient admission enrolled onto integrated care during 2014. These patients were matched to control patients, also selected from Tower Hamlets, with respect to demographics, diagnoses of health conditions, previous hospital use and risk score. INTERVENTIONS Enrolled patients were eligible for a range of interventions, such as case management, support with self-care and enhanced care coordination. Control patients received usual care. PRIMARY AND SECONDARY ENDPOINTS Number of emergency inpatient admissions in the year after enrolment onto integrated care. Secondary endpoints included numbers of elective inpatient admissions, inpatient bed days, accident and emergency attendances, outpatient attendances and general practitioner contacts in the year after enrolment. RESULTS There was no evidence that the integrated care pathway reduced patients' healthcare utilisation in the first year post-enrolment. Matched controls and integrated care patients were similar at baseline. Following enrolment, integrated care patients were more likely than matched controls to experience elective inpatient admissions (adjusted incidence rate ratio (IRR)=1.27, 95% CI 1.08 to 1.49, p=0.004). They were also more likely to experience general practitioner contacts (adjusted IRR=1.11, 95% CI 1.06 to 1.16, p<0.001), but other endpoints were not significantly different between the groups. CONCLUSIONS The integrated care pathway was not associated with a reduction in healthcare utilisation in the first year, but appeared to have increased elective inpatient admissions and general practitioner workload.
Collapse
|
42
|
Dorner TE, Wilfinger J, Hoffman K, Lackinger C. Association between physical activity and the utilization of general practitioners in different age groups. Wien Klin Wochenschr 2019; 131:278-287. [PMID: 31076889 PMCID: PMC6570780 DOI: 10.1007/s00508-019-1503-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Physical activity (PA) is an important tool in health promotion, prevention, curation, and rehabilitation and should be part of general practitioners (GP) consultations. For tailoring GP's service it is important to know the PA habits of the clients. METHODS Data from the Austrian Health Interview Survey 2014 with 15,770 subjects were analyzed. The association between PA, measured with the Physical Activity Questionnaire of the European Health Intervies Survey (EHIS-PAQ) and having visited a GP within the last 4 weeks was examined in different age groups (15-29, 30-64, and 65+ years). In multivariate analyses we adjusted for sociodemographic and health-related variables (body mass index, 17 chronic diseases, and the use of medication). RESULTS In subjects aged 15-29 years and 30-64 years fulfilling aerobic PA recommendations was significantly associated with a lower chance of having consulted the GP with unadjusted OR (95% CI) 0.82 (0.70-0.96) and 0.90 (0.82-0.99), respectively, whereas work-related PA was associated with a higher chance, with OR 1.21 (1.03-1.42) and 1.10 (1.00-1.20), respectively. Adjusting for sociodemographic and health-related factors led to loss of significance. In subjects aged 30-64 years, muscle strengthening PA was associated with a higher chance for GP consultation with OR 1.12 (1.00-1.24) in the fully adjusted model. In subjects aged 65+ years, PA was associated with a lower chance of having visited the GP with OR 0.74 (0.64-0.86) and 0.83 (0.71-0.97) for work related PA and total PA, respectively, in the fully adjusted model. CONCLUSION The association of PA and GP consultation is dependent on age and type of PA, and partly mediated by sociodemographic and health-related factors.
Collapse
Affiliation(s)
- Thomas E Dorner
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria.
| | - Julia Wilfinger
- Department for Health Promotion and Prevention, SPORTUNION Austria, Falkestraße 1, 1010, Vienna, Austria
| | - Kathryn Hoffman
- Department of General Practice and Family Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/I, 1090, Vienna, Austria
| | - Christian Lackinger
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Kinderspitalgasse 15/1, 1090, Vienna, Austria.,Department for Health Promotion and Prevention, SPORTUNION Austria, Falkestraße 1, 1010, Vienna, Austria
| |
Collapse
|
43
|
Osmundsen TC, Dahl U, Kulseng B. Enhancing knowledge and coordination in obesity treatment: a case study of an innovative educational program. BMC Health Serv Res 2019; 19:278. [PMID: 31046766 PMCID: PMC6498688 DOI: 10.1186/s12913-019-4119-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 04/24/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Currently, there is a lack of knowledge, organisation and structure in modern health care systems to counter the global trend of obesity, which has become a major risk factor for noncommunicable diseases. Obesity increases the risk of diabetes, cardiovascular diseases, musculoskeletal disorders and cancer. There is a need to strengthen integrated care between primary and secondary health care and to enhance care delivery suited for patients with complex, long-term problems such as obesity. This study aimed to explore how an educational program for General Practitioners (GPs) can contribute to increased knowledge and improved coordination between primary and secondary care in obesity treatment, and reports on these impacts as perceived by the informants. METHODS In 2010, an educational program for the specialist training of GPs was launched at three hospitals in Central Norway opting for improved care delivery for patients with obesity. In contrast to the usual programs, this educational program was tailored to the needs of GPs by offering practice and training with a large number of patients with obesity and type 2 diabetes for an extended period of time. In order to investigate the outcomes of the program, a qualitative design was applied involving interviews with 13 GPs, head physicians and staff at the hospitals and in one municipality. RESULTS Through the program, participants strengthened care delivery by building knowledge and competence. They developed relations between primary and secondary care providers and established shared understanding and practices. The program also demonstrated improvement opportunities, especially concerning the involvement of municipalities. CONCLUSIONS The educational program promoted integrated care between primary and secondary care by establishing formal and informal relations, by improving service delivery through increased competence and by fostering shared understanding and practices between care levels. The educational program illustrates the combination of advanced high-quality training with the development of integrated care.
Collapse
Affiliation(s)
| | - Unni Dahl
- Norwegian Hospital Construction Agency, Klæbuveien 118, 7031 Trondheim, Norway
| | - Bård Kulseng
- Centre for Obesity Research (ObeCe), Clinic of Surgery, St. Olavs University Hospital, 7006 Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway
| |
Collapse
|
44
|
Wheatley A, Bamford C, Shaw C, Boyles M, Fox C, Allan L. Service organisation for people with dementia after an injurious fall: challenges and opportunities. Age Ageing 2019; 48:454-458. [PMID: 30921459 PMCID: PMC6503936 DOI: 10.1093/ageing/afz010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 12/19/2018] [Accepted: 01/29/2019] [Indexed: 11/21/2022] Open
Abstract
Introduction people with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explored current service provision to help inform the development of a new intervention. Methods qualitative approaches were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. These data were analysed using a thematic, iterative analysis. Findings while a wide range of services potentially relevant to people with dementia was identified, there were no dedicated services for people with dementia with fall-related injuries in our three geographical areas. Factors influencing service uptake included a lack of knowledge of local provision amongst professionals and underdeveloped information sharing systems. Some aspects of current service organisation were incompatible with the needs of people with dementia. These include an emphasis on time-limited interventions; lack of longer-term follow-up; and service delivery in environments that could be challenging for people with dementia. Conclusions care pathways for people with dementia who fall are fragmented and unclear. This is likely to preclude people with dementia from receiving all appropriate support and contribute to poor recovery following a fall. The findings highlight the need for new approaches to service organisation and delivery which address the specific needs of people with dementia who fall.
Collapse
Affiliation(s)
- Alison Wheatley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Caroline Shaw
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Miriam Boyles
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Fox
- Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Louise Allan
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- Institute of Health Research, University of Exeter, Exeter, UK
| |
Collapse
|
45
|
Abstract
PURPOSE Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help. DESIGN/METHODOLOGY/APPROACH Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches. FINDINGS A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement. RESEARCH LIMITATIONS/IMPLICATIONS The authors provide a conceptual framework that requires empirically testing. PRACTICAL IMPLICATIONS This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery. ORIGINALITY/VALUE For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.
Collapse
Affiliation(s)
- Sharon Williams
- College of Human and Health Sciences, Swansea University , Swansea, UK
| | | |
Collapse
|
46
|
Schang L, Sundmacher L, Grill E. [New Forms of Cooperation Between The Outpatient and Inpatient Sectors: An Innovative Funding Concept]. DAS GESUNDHEITSWESEN 2019; 82:514-519. [PMID: 30716776 PMCID: PMC7723519 DOI: 10.1055/a-0829-6465] [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] [Indexed: 11/07/2022]
Abstract
Ziel der Studie
Die Kontinuität der Versorgungs- und
Informationskette an der Schnittstelle zwischen stationärem und
ambulantem Sektor ist nicht immer gewährleistet. Um
Übergänge zwischen den Sektoren wie Aufnahme und Entlassung
aus der stationären Einrichtung zu verbessern und dem
Koordinationsbedarf von Patienten mit komplexen Erkrankungen oder multiplen
Risikofaktoren gerecht zu werden, wurden Eckpunkte für ein
Förderkonzept entwickelt.
Methodik
Im Rahmen der Bayerischen Landesarbeitsgemeinschaft
Gesundheitsversorgungsforschung (LAGeV) wurden konzeptionelle Grundlagen
für die Förderung von sektorenübergreifenden
Kooperationen entwickelt.
Ergebnisse
Das Konzept für neue Formen der Zusammenarbeit im
ambulanten und stationären Sektor umfasst die Förderung von
Strukturen intersektoraler Versorgungsnetzwerke und den modularen Ausbau
durch innovative Konzepte, die der patientenzentrierten Verbesserung der
Kommunikation und Koordination der Versorgung dienen. Dazu zählt
auch der Aufbau eines Case Managements zur Unterstützung der
Koordination an sektoralen Schnittstellen. Folgende Module werden vertiefend
erläutert: sektorenübergreifende, integrierte
Behandlungspfade; Entlassmanagement; intersektorale Qualitätszirkel;
strukturierte Pharmakotherapie; Einbindung von Akteuren aus der Pflege und
der Rehabilitation; und Gesundheitsförderung und Prävention.
Abschließend wird die Bedeutung einer systematischen und
vergleichenden Evaluation der Netzwerke erörtert.
Schlussfolgerung
Damit wirksame Impulse für die Verbesserung
der sektorübergreifenden Kooperation gesetzt werden, sollten
zielgerichtete Module zur Verbesserung der patientenzentrierten Versorgung
an zentralen Schnittstelle zwischen stationärem und ambulantem
Sektor gefördert werden. Die verpflichtende Evaluation sollte
netzwerkübergreifend anhand validierter Qualitätsindikatoren
zur Prozess- und Ergebnisqualität als auch entlang
netzwerkspezifischen Zielen erfolgen.
Collapse
Affiliation(s)
- Laura Schang
- Fachbereich Health Services Management, Ludwig-Maximilians-Universität München, München
| | - Leonie Sundmacher
- Fachbereich Health Services Management, Ludwig-Maximilians-Universität München, München
| | - Eva Grill
- Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München
| |
Collapse
|
47
|
Griffin A, Knight L, McKeown A, Cliffe C, Arora A, Crampton P. A postgraduate curriculum for integrated care: a qualitative exploration of trainee paediatricians and general practitioners' experiences. BMC MEDICAL EDUCATION 2019; 19:8. [PMID: 30612565 PMCID: PMC6322273 DOI: 10.1186/s12909-018-1420-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 12/05/2018] [Indexed: 05/09/2023]
Abstract
BACKGROUND Integrated care unites funding, administrative, organisational, service delivery and clinical levels to create connectivity, alignment and collaboration within and between care delivery and prevention sectors. It aims to improve efficiency by avoiding unnecessary duplication of resources. Consequently, implementing integrated care is increasingly important; however, there are many barriers and how we teach healthcare practitioners to work across systems is under-researched. This paper explores an innovative educational curriculum, the Programme for Integrated Child Health (PICH). METHODS The PICH involved an experiential learning approach supported by taught sessions on specific issues relevant to integrated care. A qualitative study was conducted by interviewing 23 participants using semi-structured one-to-one interviews. Participants included trainees (general practice, paediatrics) and programme mentors. Data was thematically analysed. RESULTS Results are coded under three main themes: integrated care curriculum components, perceptions of a curriculum addressing integrated care and organisational change, and personal and professional learning. The data highlights the importance of real-world projects, utilising healthcare data, and considering patient perspectives to understand and develop integrated practices. Trainees received guidance from mentors but, more crucially learnt from, with, and about one another. They learnt about the context in which GPs and paediatricians work and developed a deeper understanding through which integrated services could be meaningfully developed. CONCLUSIONS This study explored participants' experiences and can be taken forward by educationalists to design curricula to better prepare healthcare practitioners to work collaboratively. The emergence of integrated care brings about challenges for traditional pedagogical approaches as learners have to re-align their discipline-specific approaches with evolving healthcare structures. PICH demonstrated that trainees acquired knowledge through real-word projects and experiential learning; and that this facilitated integration, empowering doctors to become leaders of organisational change. However, there are also many challenges of implementing integrated curricula which need to be addressed, including breaking down professional silos and integrating resourceful healthcare. This study begins to demonstrate the ability of an integrated curriculum to support trainees to work collaboratively, but further work is needed to develop the wider efficacy of the programme incorporating other professional groups, and to assess its longer term impact.
Collapse
Affiliation(s)
- Ann Griffin
- Research Department of Medical Education, UCL Medical School, The Directorate, 74 Huntley Street, London, WC1E 6AU UK
| | - Laura Knight
- Research Department of Medical Education, UCL Medical School, Royal Free Hospital, Room GF/664, London, NW3 2PF UK
| | - Alex McKeown
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX UK
| | - Charlotte Cliffe
- Research Department of Medical Education, UCL Medical School, Royal Free Hospital, Room GF/664, London, NW3 2PF UK
| | - Arun Arora
- Manchester University, Oxford Rd, Manchester, M13 9PL UK
| | - Paul Crampton
- Research Department of Medical Education, UCL Medical School, Royal Free Hospital, Room GF/664, London, NW3 2PF UK
| |
Collapse
|
48
|
Identifying and classifying indicators affected by performing clinical pathways in hospitals: a scoping review. INT J EVID-BASED HEA 2018; 16:3-24. [PMID: 29176429 DOI: 10.1097/xeb.0000000000000126] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIM To analyse the evidence regarding indicators affected by clinical pathways (CPW) in hospitals and offer suggestions for conducting comprehensive systematic reviews. METHODS We conducted a systematic scoping review and searched the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, OVID, Science Direct, ProQuest, EMBASE and PubMed. We also reviewed the reference lists of included studies. The criteria for inclusion of studies included experimental and quasi-experimental studies, implementing CPW in secondary and tertiary hospitals and investigating at least one indicator. Quality of included studies was assessed by two authors independently using the Critical Appraisal Skills Program for clinical trials and cohort studies and the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental Studies. RESULTS Forty-seven out of 2191 studies met the eligibility and inclusion criteria. The majority of included studies had pretest-posttest quasi-experimental design and had been done in developed countries, especially the United States. The investigation of evidence resulted in identifying 62 indicators which were classified into three categories: input indicators, process and output indicators and outcome indicators. Outcome indicators were more frequent than other indicators. Complication rate, hospital costs and length of hospital stay were dominant in their own category. Indicators such as quality of life and adherence to guidelines have been considered in studies that were done in recent years. CONCLUSION Implementing CPW can affect different types of indicators such as input, process, output and outcome indicators, although outcome indicators capture more attention than other indicators. Patient-related indicators were dominant outcome indicators, whereas professional indicators and organizational factors were considered less extensively. WHAT IS KNOWN ABOUT THE TOPIC?: WHAT DOES THIS ARTICLE ADD?
Collapse
|
49
|
Cavazzana L, Fornili M, Filocamo G, Agostoni C, Auxilia F, Castaldi S. Hospital clinical pathways for children affected by juvenile idiopathic arthritis. Ital J Pediatr 2018; 44:139. [PMID: 30458837 PMCID: PMC6245695 DOI: 10.1186/s13052-018-0576-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 10/29/2018] [Indexed: 11/17/2022] Open
Abstract
Background Juvenile idiopathic arthritis (JIA) is the most common pediatric chronic rheumatic disease, which requires constant follow-up over the years, due to relapses during its progression. To maintain a good quality of life, it is important to limit admissions as far as possible. With the development of a Diagnostic Therapeutic Assistance Pathway (DTAP), we aim to select patients with suitable clinical conditions to be moved from routine hospital management to day care or outpatient treatment, evaluating the number of patients to whom this would apply. Methods Monocentric study regarding admissions for JIA between 2014 and 2016 in a Pediatric Unit of a university hospital in Milan. Through an analysis of the medical records, relevant information was extracted and collected in a Microsoft™ Excel database; starting from the data collected during the first year, a DTAP was prepared for patients with active arthritis and appropriate clinical conditions. Results The study includes data from 223 JIA hospitalization cases involving 127 patients. Applying DTAP criteria, 32% patients would have avoided admissions and 23% would have been admitted less frequently. The data concerning the activities of the Unit for JIA patients showed a relevant drop in the number of hospitalizations since 2015, from 89 in 2014 to 66 and 68 in 2015 and 2016 respectively. Conclusion The opportunity offered by DTAP, has suggested feasible changes in hospitalization management and it’s use would promote the possibility of treating the children without hospitalization, or minimizing it. In conclusion DTAP application is a priority for the continuous improvement of clinical practice and quality of life for patients and their families.
Collapse
Affiliation(s)
- L Cavazzana
- Post Graduate School of Public Health, University of Milan, Milan, Italy.
| | - M Fornili
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Filocamo
- Intermediate Pediatric Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - C Agostoni
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Intermediate Pediatric Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F Auxilia
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - S Castaldi
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.,Quality Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
50
|
Butow P, Shaw J, Shepherd HL, Price M, Masya L, Kelly B, Rankin NM, Girgis A, Hack TF, Beale P, Viney R, Dhillon HM, Coll J, Kelly P, Lovell M, Grimison P, Shaw T, Luckett T, Cuddy J, White F. Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): study protocol of a cluster randomised controlled trial. BMC Cancer 2018. [PMID: 30404619 DOI: 10.1186/s12885‐018‐4962‐9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Health service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period. METHODS This cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will "Go-live", implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live). DISCUSSION This will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care. TRIAL REGISTRATION The study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347.
Collapse
Affiliation(s)
- Phyllis Butow
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.
| | - Joanne Shaw
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Heather L Shepherd
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Melanie Price
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Lindy Masya
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Brian Kelly
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
| | - Nicole M Rankin
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Cancer Council NSW, Woolloomooloo, NSW, Australia
| | - Afaf Girgis
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Kensington, Australia
| | - Thomas F Hack
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,CancerCare Manitoba Research Institute, Winnipeg, Canada
| | - Philip Beale
- Cancer Services for the Sydney Local Health District (Incorporating Royal Prince Alfred, Concord and Canterbury Hospitals, Campsie, NSW, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW, Australia
| | - Haryana M Dhillon
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia.,Centre for Medical Psychology and Evidence-based Decision-making (CeMPED), University of Sydney, Sydney, NSW, Australia
| | - Joseph Coll
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Patrick Kelly
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Melanie Lovell
- HammondCare Northern Sydney, Sydney, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Peter Grimison
- Chris O'Brien Lifehouse, Camperdown, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Tim Shaw
- Charles Perkins Centre Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
| | - Tim Luckett
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Ultimo, NSW, Australia
| | - Jessica Cuddy
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | - Fiona White
- Psycho-Oncology Co-operative Research Group (PoCoG), University of Sydney, Sydney, NSW, 2006, Australia
| | | |
Collapse
|