Treatment goal setting for complex patients: protocol for a scoping review

Self-Management Analysis in Chronic Conditions (SMACC) checklist: an international consensus-based tool to develop, compare and evaluate self-management support programmes

OBJECTIVES

The Self-Management Analysis in Chronic Conditions (SMACC) checklist was developed as a guidance tool to support the development, comparison and evaluation of self-management support programmes for persons with a chronic condition. The checklist was based on a previously performed concept analysis of self-management. The aim of this study was to validate its content using an international Delphi study and to deliver a final version.

DESIGN

A two-round Delphi study was conducted between October 2022 and January 2023. Using the researchers' networks, professionals with research or clinical expertise in self-management support and chronic conditions were recruited via online purposive snowball sampling. Participants were asked to score each item of the checklist (16 items total) on 3 content validity indicators: (1) clarity and comprehensibility, (2) relevance and importance and (3) degree of alignment with the overall goal of the checklist to promote adequate and comprehensive self-management support programmes. A consensus threshold of 75% agreement was used. The participants were also asked general questions about the checklist as a whole and were asked to provide feedback considering its refinement.

RESULTS

Fifty-four professionals with an average 14.5 years of experience participated in round 1, 48 with an average 12.5 years of experience participated in round 2. The majority of professionals were from Western Europe. For the majority of items consensus was reached after round 1. In round 2, 3 of the 4 remaining items reached consensus, 1 last item was retained based on highly recurring feedback.

CONCLUSIONS

The SMACC checklist was considered a valid and comprehensive tool to aid the development, evaluation and comparison of self-management support programmes. It was acknowledged as a useful instrument to supplement existing frameworks and was seen as feasible to implement in both research and clinical settings. Further validation in the field, with input from patients and peer experts, will be valuable.

Cirugía bariátrica en pediatría, ¿qué impacto tiene? Revisión de la literatura

Introducción. La obesidad en la población pediátrica ha ido aumentando de manera progresiva y el manejo médico de la obesidad mórbida en esta población se ha mostrado insuficiente. El objetivo de este artículo fue describir el estado actual de la literatura científica publicada hasta abril 15 de 2021 sobre el impacto de la cirugía bariátrica en la población pediátrica. Métodos. Se realizó una revisión de la literatura que evaluó dos bases de datos, donde se incluyeron revisiones sistemáticas, reportes de casos, series de casos y ensayos clínicos, publicados desde el 1 de enero de 2010 hasta el 15 de abril de 2021, en español, inglés y francés. Resultados. Se incluyeron 56 documentos y 18 estudios clínicos, en los que se encontró que la cirugía bariátrica (bypass gástrico por Y de Roux, gastrectomía en manga, plicatura gástrica y banda gástrica) alcanzó una pérdida de peso significativa en el primer año, con un adecuado sostenimiento de dicha pérdida al quinto año, además de una resolución completa de las comorbilidades metabólicas y cardiovasculares en la mayoría de los pacientes. Conclusión. La cirugía bariátrica se presenta como una alternativa eficaz en el manejo de la obesidad mórbida y sus complicaciones en el paciente pediátrico

Definition of patient complexity in adults: A narrative review

Background

Better identification of complex patients could help to improve their care. However, the definition of patient complexity itself is far from obvious. We conducted a narrative review to identify, describe, and synthesize the definitions of patient complexity used in the last 25 years.

Methods

We searched PubMed for articles published in English between January 1995 and September 2020, defining patient complexity. We extended the search to the references of the included articles. We assessed the domains presented in the definitions, and classified the definitions as based on (1) medical aspects (e.g., number of conditions) or (2) medical and/or non-medical aspects (e.g., socio-economic status). We assessed whether the definition was based on a tool (e.g., index) or conceptual model.

Results

Among 83 articles, there was marked heterogeneity in the patient complexity definitions. Domains contributing to complexity included health, demographics, behavior, socio-economic factors, healthcare system, medical decision-making, and environment. Patient complexity was defined according to medical aspects in 30 (36.1%) articles, and to medical and/or non-medical aspects in 53 (63.9%) articles. A tool was used in 36 (43.4%) articles, and a conceptual model in seven (8.4%) articles.

Conclusion

A consensus concerning the definition of patient complexity was lacking. Most definitions incorporated non-medical factors in the definition, underlining the importance of accounting not only for medical but also for non-medical aspects, as well as for their interrelationship.

Contextually appropriate school entry hearing screening protocol for low- and middle-income countries: A scoping review

BACKGROUND

In low- and middle-income countries (LMICs), where universal newborn hearing screening programmes are often not available, school entry hearing screening programmes serve as a safeguard for early detection and intervention for hearing loss in school learners.

OBJECTIVE

To determine a contextually appropriate school entry hearing screening protocol for LMICs.

METHODS

A scoping review was utilised to comprehensively search for relevant publications in the following electronic databases: Africa-Wide Information, CINAHL, Health Source: Nursing/Academic Edition, Cochrane Library, Pubmed, Scopus, and Web of Science. Studies included those that investigated school-based hearing screening protocols or programmes for LMICs among learners aged five to twelve years. The review was conducted and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews checklist.

RESULTS

The search yielded 1863 studies, and after removing duplicates and ineligible studies, 19 studies were selected for data extraction. Pure tone audiometry screening was the most frequently used age-appropriate hearing screening test in the reviewed studies (n = 17). Conducting pure tone audiometry screening using 1, 2, and 4 kHz frequency combination resulted in referral rates ranging from 3.2% to 21%. In studies that included 0.5 kHz to the screening frequencies, referral rates ranged from 5.8% to 56%. Screening at 25 dB HL intensity level yielded referral rates ranging from 3.2% to 10.3%. Immediate rescreening reduced overall referral rates for learners referred for audiological diagnostic testing by up to 57%. Ambient noise levels were controlled by conducting screening in quiet rooms (n = 14) and utilising screening equipment that allows for monitoring and reducing environmental noise (n = 3).

CONCLUSION

An ideal school entry hearing screening protocol in LMIC contexts could potentially utilise pure tone audiometry screening at 1, 2, and 4 kHz, using 25 dB HL screening intensity level with an immediate rescreen for learners with a refer result. School entry hearing screening should be conducted in a quiet room, preferably using hearing screening equipment capable of monitoring ambient noise levels to reduce false positive referrals.

Barriers and facilitators related to undertaking physical activities among men with prostate cancer: a scoping review

BACKGROUND

Prostate cancer (PC) and its treatments lead to significant acute, chronic, or latent adverse effects that result in declines in patients' physical functions, quality of life and reduced sense of masculinities. Robust evidence shows that physical activity (PA) can improve many health outcomes in men with PC; however, less is known about the facilitators, preferences, and barriers to PA engagement in this population. The purpose of this scoping review is to document the nature and extent of literature related to these aspects of PA participation among men with PC.

METHODS

We conducted a scoping review of PA among men with PC. Databases searched included Medline, CINAHL, Embase, Rehabilitation & Sports Medicine Source, and SportDiscus from inception to June 30, 2020. Multiple reviewers were used in all screening and data abstractions.

RESULTS

The search yielded 2788 individual citations after duplicates were removed. Following title and abstract screening, 129 underwent full-text review, and 46 articles were included. Quantitative data related to our research question showed that structured group exercise was the most commonly reported facilitator/preference among men with PC, whereas treatment-related effects and lack of time are the most common barriers. In terms of qualitative data, the most prominent theme noted related to masculinities and gender-specific needs within the context of having PC.

CONCLUSION

Men with PC have unique facilitators and barriers concerning PA. More work is needed from the research and clinical practice perspectives to enable this population to engage and remain in regular PA.

Chloroquine and its derivatives in the management of COVID-19: A scoping review

Introducción.

Recientemente, investigadores chinos y franceses reportaron la eficacia de la cloroquina y la hidroxicloroquina para inhibir la replicación in vitro del virus SARS-CoV-2. La diseminación oportuna de la información científica es clave en tiempos de pandemia. Es urgente contar con una revisión sistemática sobre el efecto y la seguridad de estos medicamentos en la COVID-19.

Objetivo.

Describir el estado actual de la literatura científica publicada hasta el 25 de marzo de 2020 sobre el uso de la cloroquina o sus derivados en el manejo de pacientes con COVID-19.

Materiales y métodos.

Se hizo una revisión sistemática exploratoria en PubMed, Embase, Lilacs y 15 bases de datos de la Plataforma de Registros Internacionales de Ensayos Clínicos de la Organización Mundial de la Salud (OMS). Se incluyeron publicaciones empíricas y teóricas en inglés, español, italiano, francés o portugués, y se hizo una síntesis narrativa de los resultados.

Resultados.

Se incluyeron 19 documentos y 24 registros de ensayos clínicos (n=43) de 18.059 pacientes. El 66 % (16/24) de los ensayos están registrados en China. Nueve ensayos evalúan la cloroquina exclusivamente y ocho, la hidroxicloroquina. Los documentos son comentarios (n=9), estudios in vitro (n=3), revisiones narrativas (n=2), guías de práctica clínica (n=2), así como una revisión sistemática, un consenso de expertos y un ensayo controlado.

Conclusiones.

Un ensayo clínico pequeño (n=26), no aleatorizado y defectuoso, respalda el uso de la hidroxicloroquina en pacientes con COVID-19. Se requiere de manera urgente tener acceso a los resultados de otros ensayos clínicos para determinar la efectividad y la seguridad de la cloroquina y sus derivados en pacientes con COVID-19.

Eficacia y seguridad de la medicina tradicional china en COVID-19: una revisión exploratoria

Introducción

Ante la ausencia de una vacuna o tratamiento específico para controlar la actual pandemia, es necesario seguir investigando potenciales agentes terapéuticos contra la COVID-19. La medicina tradicional china (MTC) se ha usado en el tratamiento de pacientes con SARS (síndrome respiratorio agudo grave) y MERS (síndrome respiratorio de Oriente Medio), y podría tener un rol en la prevención, tratamiento o rehabilitación de pacientes con COVID-19.

Objetivo

Describir el estado actual de la literatura científica publicada hasta el 17 de mayo de 2020, sobre la eficacia y seguridad de la MTC en pacientes con COVID-19.

Material y métodos

Revisión sistemática exploratoria que incluyó PubMed, Embase, Scopus y 18 bases de datos de la Plataforma de Registros Internacionales de Ensayos Clínicos de la Organización Mundial de la Salud. Se incluyeron publicaciones empíricas y teóricas en inglés y español.

Resultados

Se incluyeron 35 documentos y 93 registros de ensayos clínicos (n = 128); 46 ensayos clínicos evalúan decocciones, cápsulas, gránulos, inyecciones y soluciones orales a base de agentes herbarios. Los documentos son revisiones narrativas (n = 9), cartas al editor (n = 6), revisiones sistemáticas (n = 4), estudios in silico (n = 4), editoriales (n = 3), comentarios (n = 2), serie de casos (n = 2), recomendaciones de práctica clínica (n = 2), guías de práctica clínica (n = 1), estudios in vitro (n = 1) y artículo de opinión (n = 1).

Conclusiones

Solo 2 estudios de series de casos en las que se emplean fórmulas a base de agentes herbarios reportaron beneficios en pacientes con neumonía leve y grave por SARS-CoV-2. Hay 78 ensayos controlados aleatorizados en curso que pronto arrojarán evidencia sobre la eficacia y seguridad de la MTC en pacientes con COVID-19.

Inconsistent descriptions of lumbar multifidus morphology: A scoping review

Background

Lumbar multifidus (LM) is regarded as the major stabilizing muscle of the spine. The effects of exercise therapy in low back pain (LBP) are attributed to this muscle. A current literature review is warranted, however, given the complexity of LM morphology and the inconsistency of anatomical descriptions in the literature.

Methods

Scoping review of studies on LM morphology including major anatomy atlases. All relevant studies were searched in PubMed (Medline) and EMBASE until June 2019. Anatomy atlases were retrieved from multiple university libraries and online. All studies and atlases were screened for the following LM parameters: location, imaging methods, spine levels, muscle trajectory, muscle thickness, cross-sectional area, and diameter. The quality of the studies and atlases was also assessed using a five-item evaluation system.

Results

In all, 303 studies and 19 anatomy atlases were included in this review. In most studies, LM morphology was determined by MRI, ultrasound imaging, or drawings – particularly for levels L4–S1. In 153 studies, LM is described as a superficial muscle only, in 72 studies as a deep muscle only, and in 35 studies as both superficial and deep. Anatomy atlases predominantly depict LM as a deep muscle covered by the erector spinae and thoracolumbar fascia. About 42% of the studies had high quality scores, with 39% having moderate scores and 19% having low scores. The quality of figures in anatomy atlases was ranked as high in one atlas, moderate in 15 atlases, and low in 3 atlases.

Discussion

Anatomical studies of LM exhibit inconsistent findings, describing its location as superficial (50%), deep (25%), or both (12%). This is in sharp contrast to anatomy atlases, which depict LM predominantly as deep muscle. Within the limitations of the self-developed quality-assessment tool, high-quality scores were identified in a majority of studies (42%), but in only one anatomy atlas.

Conclusions

We identified a lack of standardization in the depiction and description of LM morphology. This could affect the precise understanding of its role in background and therapy in LBP patients. Standardization of research methodology on LM morphology is recommended. Anatomy atlases should be updated on LM morphology.

Game-Based Learning Interventions to Foster Cross-Cultural Care Training: A Scoping Review

Objective: Differences in cultural background between health providers and patients can reduce effective access to health services in multicultural settings. Health sciences educators have recently suggested that game-based learning may be effective for cross-cultural care training. This scoping review maps published knowledge on educational games intended to foster cross-cultural care training and highlights the research gaps for future research. Materials and Methods: A scoping review searched PubMed, Eric, Embase, Lilacs, PsycINFO, and Google Scholar for theoretical and empirical research, using terms relevant to cross-cultural care and game-based learning. A participatory research framework engaged senior medical students and participatory research experts in conducting and evaluating the review. Results: Forty-one documents met the inclusion criteria, all from developed countries. The most common source of publication was nursing and medicine (39%; 16/41) and used the cultural competence approach (44%; 18/41). Around one-half of the publications (51%; 21/41) were theoretical and 39% (16/41) were empirical. Empirical studies most commonly used mixed methods (44%; 7/16), followed by strictly quantitative (31%; 5/16) or qualitative (25%; 4/16) approaches. There were no randomized controlled trials and only one study engaged end-users in the design. Empirical studies most frequently assessed role-play-related games (44%; 7/16) and used game evaluation-related outcomes or learning-related outcomes. None used patient-oriented outcomes. Findings suggest that educational games are an effective and engaging educational intervention for cross-cultural care training. Conclusions: The paucity of studies on educational games and cross-cultural care training precludes a systematic review. Future empirical studies should focus on randomized counterfactual designs and patient-related outcomes. We encourage involving end-users in developing content for educational games.

Mental health services in the Northwest Territories: a scoping review

The impacts of colonization have had significant impacts on the mental health and community wellness Indigenous peoples in the Northwest Territories (NWT). It is important that all communities in the NWT have access to key services in a culturally relevant way in achieving mental and community wellness. A scoping review was conducted to identify mental health services available in the NWT. To guide the understanding of the landscape of mental health services in the NWT, the information on health services gathered was organized using the First Nations Mental Wellness Continuum (FNMWC) Model’s Continuum of Essential Services. Documents accessed included grey literature, consisting of government documents, practice guidelines, education materials, community wellness reports, internet searches and expert consult interviews to collect data on mental health and wellness services in the NWT. 68 mental health services were included in this review, from 23 different sources. Results were summarized and described the Continuum of Essential Services from the FNMWC Model. This guided approach was found to be useful for mapping mental health services for communities in the NWT. The findings highlight and catagorize existing mental health services and gaps in relation to a First Nation’s perspective using the FNMWC Model. Specific areas examined included the Continuum of Essential Services, Key Partners, Culture as a Foundation, and Indigenous Social Determinants of Health. Findings can guide communities and health authorities in planning, implementing and coordinating a full range of optimized mental health services in the NWT.

Goal-Based Shared Decision-Making: Developing an Integrated Model

Objective:

Definitions of shared decision-making (SDM) have largely neglected to consider goal setting as an explicit component. Applying SDM to people with multiple long-term conditions requires attention to goal setting. We propose an integrated model, which shows how goal setting, at 3 levels, can be integrated into the 3-talk SDM model.

Method:

The model was developed by integrating 2 published models.

Results:

An integrated, goal-based SDM model is proposed and applied to a patient with multiple, complex, long-term clinical conditions to illustrate the use of a visualization tool called a Goal Board. A Goal Board prioritizes collaborative goals and aligns goals with interventional options.

Conclusion:

The model provides an approach to achieve person-centered decision-making by not only eliciting and prioritizing goals but also by aligning prioritized goals and interventions.

Practice Implications:

Further research is required to evaluate the utility of the proposed model.

Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis

BACKGROUND

Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity.

METHODS

Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component.

RESULTS

Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences (n = 16), Doctor knowledge and recommendations (n = 19) and Make or explicitly defer a decision (n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes.

CONCLUSIONS

Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients.

The ART of conversation: feasibility and acceptability of a pilot peer intervention to help transition complex HIV-positive people from hospital to community

OBJECTIVES

To pilot a peer-based intervention for people living with HIV who used substances, had challenges with antiretroviral adherence and would be discharged from hospital to community.

STUDY DESIGN

A community-based, quasi-experimental pilot intervention study designed to assess feasibility, acceptability and connection to a community-based HIV organisation.

SETTING

This study was conducted in Toronto, Canada, at Casey House (CH; hospital for people living with HIV) in collaboration with the AIDS Committee of Toronto (ACT; community-based HIV organisation).

PARTICIPANTS

People living with HIV who were CH inpatient between 1 April 2017 and 31 March 2018, struggled with antiretroviral adherence, actively used substances and would be discharged to community were eligible. Forty people met criteria, 19 were approached by an inpatient nurse and 17 consented. Average age was 48.8 years (SD=11.4), 58.8% were male and participants averaged 7.8 physical and mental health comorbidities (SD=3.1).

INTERVENTION

Titled 'The ART of Conversation', the three-pronged personalised intervention was developed through input from CH clients and ACT volunteers, all living with HIV. Intervention components were (a) predischarge goal-setting (adherence, substance use and self-identified goal) with the study nurse; (b) predischarge meeting with an HIV+ peer volunteer (PV) and (c) nine postdischarge phone calls between PV and participant, once per day for 3 days, then once per week for 6 weeks.

PRIMARY OUTCOMES

Feasibility was measured through proportion of eligible participants recruited and PV availability. Acceptability was assessed through participant interviews at three times (preintervention, post-intervention and 6 weeks follow-up) and through PV call logs. Client records determined connection to ACT within the study timeframe.

RESULTS

Twelve participants completed the intervention and nine connected with ACT. Predischarge goal-setting and PV meeting were both feasible and acceptable. Postdischarge phone calls were a challenge as half of completers missed at least one call.

CONCLUSIONS

Although predischarge goal-setting and PV meeting were feasible, methods to maintain connection following discharge require further investigation.

A three-goal model for patients with multimorbidity: A qualitative approach

Background

To meet the challenge of multimorbidity in decision making, a switch from a disease‐oriented to a goal‐oriented approach could be beneficial for patients and clinicians. More insight about the concept and the implementation of this approach in clinical practice is needed.

Objective

This study aimed to develop conceptual descriptions of goal‐oriented care by examining the perspectives of general practitioners (GPs) and clinical geriatricians (CGs), and how the concept relates to collaborative communication and shared decision making with elderly patients with multimorbidity.

Method

Qualitative interviews with GPs and CGs were conducted and analyzed using thematic analysis.

Results

Clinicians distinguished disease‐ or symptom‐specific goals, functional goals and a new type of goals, which we labelled as fundamental goals. “Fundamental goals” are goals specifying patient's priorities in life, related to their values and core relationships. These fundamental goals can be considered implicitly or explicitly in decision making or can be ignored. Reasons to explicate goals are the potential mismatch between medical standards and patient preferences and the need to know individual patient values in case of multimorbidity, including the management in acute situations.

Conclusion

Based on the perspectives of clinicians, we expanded the concept of goal‐oriented care by identifying a three‐level goal hierarchy. This model could facilitate collaborative goal‐setting for patients with multiple long‐term conditions in clinical practice. Future research is needed to refine and validate this model and to provide specific guidance for medical training and practice.