Consumers' and health providers' views and perceptions of partnering to improve health services design, delivery and evaluation: a co-produced qualitative evidence synthesis

BACKGROUND

Partnering with consumers in the planning, delivery and evaluation of health services is an essential component of person-centred care. There are many ways to partner with consumers to improve health services, including formal group partnerships (such as committees, boards or steering groups). However, consumers' and health providers' views and experiences of formal group partnerships remain unclear. In this qualitative evidence synthesis (QES), we focus specifically on formal group partnerships where health providers and consumers share decision-making about planning, delivering and/or evaluating health services. Formal group partnerships were selected because they are widely used throughout the world to improve person-centred care. For the purposes of this QES, the term 'consumer' refers to a person who is a patient, carer or community member who brings their perspective to health service partnerships. 'Health provider' refers to a person with a health policy, management, administrative or clinical role who participates in formal partnerships in an advisory or representative capacity. This QES was co-produced with a Stakeholder Panel of consumers and health providers. The QES was undertaken concurrently with a Cochrane intervention review entitled Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation.

OBJECTIVES

1. To synthesise the views and experiences of consumers and health providers of formal partnership approaches that aimed to improve planning, delivery or evaluation of health services. 2. To identify best practice principles for formal partnership approaches in health services by understanding consumers' and health providers' views and experiences.

SEARCH METHODS

We searched MEDLINE, Embase, PsycINFO and CINAHL for studies published between January 2000 and October 2018. We also searched grey literature sources including websites of relevant research and policy organisations involved in promoting person-centred care.

SELECTION CRITERIA

We included qualitative studies that explored consumers' and health providers' perceptions and experiences of partnering in formal group formats to improve the planning, delivery or evaluation of health services.

DATA COLLECTION AND ANALYSIS

Following completion of abstract and full-text screening, we used purposive sampling to select a sample of eligible studies that covered a range of pre-defined criteria, including rich data, range of countries and country income level, settings, participants, and types of partnership activities. A Framework Synthesis approach was used to synthesise the findings of the sample. We appraised the quality of each study using the CASP (Critical Appraisal Skill Program) tool. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. The Stakeholder Panel was involved in each stage of the review from development of the protocol to development of the best practice principles.

MAIN RESULTS

We found 182 studies that were eligible for inclusion. From this group, we selected 33 studies to include in the final synthesis. These studies came from a wide range of countries including 28 from high-income countries and five from low- or middle-income countries (LMICs). Each of the studies included the experiences and views of consumers and/or health providers of partnering in formal group formats. The results were divided into the following categories. Contextual factors influencing partnerships: government policy, policy implementation processes and funding, as well as the organisational context of the health service, could facilitate or impede partnering (moderate level of confidence). Consumer recruitment: consumer recruitment occurred in different ways and consumers managed the recruitment process in a minority of studies only (high level of confidence). Recruiting a range of consumers who were reflective of the clinic's demographic population was considered desirable, particularly by health providers (high level of confidence). Some health providers perceived that individual consumers' experiences were not generalisable to the broader population whereas consumers perceived it could be problematic to aim to represent a broad range of community views (high level of confidence). Partnership dynamics and processes: positive interpersonal dynamics between health providers and consumers facilitated partnerships (high level of confidence). However, formal meeting formats and lack of clarity about the consumer role could constrain consumers' involvement (high level of confidence). Health providers' professional status, technical knowledge and use of jargon were intimidating for some consumers (high level of confidence) and consumers could feel their experiential knowledge was not valued (moderate level of confidence). Consumers could also become frustrated when health providers dominated the meeting agenda (moderate level of confidence) and when they experienced token involvement, such as a lack of decision-making power (high level of confidence) Perceived impacts on partnership participants: partnering could affect health provider and consumer participants in both positive and negative ways (high level of confidence). Perceived impacts on health service planning, delivery and evaluation: partnering was perceived to improve the person-centredness of health service culture (high level of confidence), improve the built environment of the health service (high level of confidence), improve health service design and delivery e.g. facilitate 'out of hours' services or treatment closer to home (high level of confidence), enhance community ownership of health services, particularly in LMICs (moderate level of confidence), and improve consumer involvement in strategic decision-making, under certain conditions (moderate level of confidence). There was limited evidence suggesting partnering may improve health service evaluation (very low level of confidence). Best practice principles for formal partnering to promote person-centred care were developed from these findings. The principles were developed collaboratively with the Stakeholder Panel and included leadership and health service culture; diversity; equity; mutual respect; shared vision and regular communication; shared agendas and decision-making; influence and sustainability.

AUTHORS' CONCLUSIONS

Successful formal group partnerships with consumers require health providers to continually reflect and address power imbalances that may constrain consumers' participation. Such imbalances may be particularly acute in recruitment procedures, meeting structure and content and decision-making processes. Formal group partnerships were perceived to improve the physical environment of health services, the person-centredness of health service culture and health service design and delivery. Implementing the best practice principles may help to address power imbalances, strengthen formal partnering, improve the experiences of consumers and health providers and positively affect partnership outcomes.

Preliminary results regarding automated identification of patients with a limited six-month survival prognosis using nursing assessment in uro-oncology patients

INTRODUCTION

Contrary to current recommendations, palliative co-management of tumor patients often occurs late in daily clinical practice. Palliative care specialist (PCS) co-management should be considered at the latest after a 6-month prognosis has been presumed. Therefore, identifying patients with a limited prognosis is a reasonable measure.

METHODS

Patients were identified using a screening tool for limited prognosis, which combined their tumor stage and data from the nursing anamnesis. In this retrospective study, a monocentric cohort of patients with urological malignancies-UICC (Union for International Cancer Control) stages III and IV - were enrolled from March to December 2019, with a 6-month follow-up period ending in May 2020.

RESULTS

Most patients were male and suffered from prostate cancer. Patients with uro-oncological tumors dying within 6 months correlated significantly with the presence of repeated hospitalizations within three months, pain on admission, malnutrition, impaired breathing and reduced mobility (P < 0.001). The test was fair in quality (AUC 0.727) at a cut-point of five; a sensitivity of 97% and a specificity of 25% were obtained. The PPV was 0.64 and NPV was 0.82.

DISCUSSION/CONCLUSION

We specifically identified the predictors of limited prognosis in urological cancer patients across several entities using an automated scoring system based on tumor stage and data from the nursing anamnesis. Therefore, we recognized hospitalization as an important transition point and determined nurses to be valuable partners in identifying unmet palliative care needs without additional technical, personnel or financial effort.

Sexual and gender minority identity in undergraduate medical education: Impact on experience and career trajectory

INTRODUCTION

The wellbeing of sexual and gender minority (SGM) medical students and the impact of their experiences on career trajectory remain poorly understood. The present study aimed to characterize the incidence of mistreatment in SGM trainees as well as general perspectives on the acceptance of SGM individuals across medical and surgical specialties.

METHODS

This was a cross sectional survey study of all actively enrolled medical students within the six University of California campuses conducted in March 2021. An online, survey tool captured incidence of bullying, discrimination, and suicidal ideation as well as perceived acceptance of SGM identities across specialties measured by slider scale. Differences between SGM and non-SGM respondents were assessed with two-tailed and chi-square tests. Qualitative responses were evaluated utilizing a multi-stage, cutting-and-sorting technique.

RESULTS

Of approximately 3,205 students eligible for participation, 383 submitted completed surveys, representing a response rate of 12.0%. Of these respondents, 26.9% (n = 103) identified as a sexual or gender minority. Overall, SGM trainees reported higher slider scale scores when asked about being bullied by other students (20.0 vs. 13.9, P = 0.012) and contemplating suicide (14.8 vs. 8.8, P = 0.005). Compared to all other specialties, general surgery and surgical subspecialties had the lowest mean slider scale score (52.8) in perceived acceptance of SGM identities (All P < 0.001). In qualitative responses, students frequently cited lack of diversity as contributing to this perception. Additionally, 67.0% of SGM students had concerns that disclosure of identity would affect their future career with 18.5% planning to not disclose during the residency application process.

CONCLUSIONS

Overall, SGM respondents reported higher incidences of bullying and suicidal ideation as well as increased self-censorship stemming from concerns regarding career advancement, most prominently in surgery. To address such barriers, institutions must actively promote diversity in sexual preference and gender identity regardless of specialty.

Palliative care use among bladder cancer patients treated with radical cystectomy

INTRODUCTION

Practice guidelines recommend early consideration for palliative care for patients with advanced malignancies, and there has been limited research regarding the use of palliative care for patients with advanced bladder cancer. Our aim is to describe the rate and determinants of the use of palliative care consultation for patients treated with radical cystectomy at our institution.

METHODS

A retrospective review was performed to identify patients who underwent cystectomy for bladder cancer between September 2014 and June 2019 at our institution. Our primary outcome was receipt of palliative care, defined as receiving a palliative care consult. We tested for associations between factors and our outcome of interest, and then estimated the impact on various determinants of palliative care use by fitting a multivariable logistic regression model.

RESULTS

Over the study period, 294 patients underwent radical cystectomy. Of those patients, 29 (9.9%) received palliative care. Mean time from surgery to palliative care consult was 11.4 months. Palliative care consults were initiated by urologists in 32.1% of cases. On multivariable analysis, patients were more likely to receive palliative care if they had pT3+ disease (P < 0.001), were readmitted after surgery (P = 0.028), or had any major complication after surgery (P = 0.025).

CONCLUSION

Rates of palliative care consults in patients with advanced bladder cancer at our institution are higher than other population-based estimates nationally. The majority of palliative care consults were requested by medical oncologists, highlighting an opportunity for educational initiatives for urologic oncologists to promote earlier consideration of palliative care referrals.

The Growth of Integrated Care Models in Urology

With heightened awareness of health care outcomes and efficiencies and reimbursement-based metrics, it is ever more important that urologists consider the effects of integrated care models on physicians/staff/clinics fulfillment and patient outcomes, and whether and how to optimally implement these models within their unique practice settings. Despite growing evidence that integrating care improves outcomes, uncertainty persists regarding which approach is most efficient and achievable in terms of specialty considerations and financial resources. In this article, we discuss strategies for integrating urologic care and its impact on current and future health care delivery.

High-intensity end-of-life care among Medicare beneficiaries with bladder cancer

OBJECTIVES

To quantify the proportion of patients receiving high-intensity end-of-life care, identify associated risk factors, and assess how receipt of palliative care impact end-of-life care; as the delivery of such care, and how it relates to palliative care, has not been reported in bladder cancer SUBJECTS AND METHODS: We conducted a retrospective cohort study of patients with bladder cancer who died within 1 year of diagnosis using Surveillance, Epidemiology, and End Results linked Medicare data. The primary outcome was a composite measure of high-intensity end-of-life care (>1 hospital admission, >1 ED visit, or ≥1 ICU admission within the last month of life; receipt of chemotherapy within the last 2 weeks of life; or acute care in-hospital death). Secondary outcomes included the use of such care over time and any association with the use of palliative care. A generalized linear mixed model assessed for independent determinants.

RESULTS

Overall, 45% of patients received high-intensity end-of-life care. This proportion decreased over time. Patients receiving high-intensity care had higher rates of comorbidities, advanced bladder cancer, and nonbladder cancer cause of death. These patients more often received palliative care but, compared to those not receiving high-intensity care, this occurred farther removed from bladder cancer diagnosis and closer to death.

CONCLUSIONS

Nearly half of Medicare beneficiaries with bladder cancer who die within 1 year of diagnosis receive high-intensity care at the end of life. Palliative care was seldom used and only very near the time of death.

Incorporating palliative care principles to improve patient care and quality of life in urologic oncology

Palliative care - specialized healthcare focused on improving quality of life for patients with serious illnesses - can help urologists to care for patients with unmet symptom, coping and communication needs. Society guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network recommend incorporating palliative care into standard oncological care, based on multiple randomized trials demonstrating that it significantly improves physical well-being, patient satisfaction and goal concordant care. Misconceptions regarding the objective and ideal timing of palliative care are common; a key concept is that palliative care and treatments seeking to cure or prolong life are not mutually exclusive. Urologists are well positioned to champion the integration of palliative care into surgical urologic oncology and should be aware of palliative care guidelines, indications for palliative care use and how the field of urologic oncology can adopt best practices.

Case Discussions in Advanced Care Planning

BACKGROUND

Advanced care planning (ACP) provides an opportunity for individuals to explore and document their values concerning medical care decisions prior to an acute event. This manuscript explores the value of ACP and compares and contrasts 2 ACP models currently in practice.

METHODS

This hypothetical case describes an elderly, frail patient with end-stage chronic obstructive pulmonary disease who is also a high user of health care resources. A new palliative care-led outpatient ACP clinic model is described using this example.

RESULTS

Using the ACP clinic model in this case reveals how different a patient's end of life experience may be when proper, proactive planning measures are in place. With proper education and discussion around this patient and family's wishes pertaining to the end of his life, this man was able to change his plan of care from aggressive resuscitation treatment in hospital to a peaceful palliative experience at home.

CONCLUSIONS

In this case description, the valuable role of ACP in preserving quality of life for patients, increasing satisfaction with care, and decreasing distress among family members during a medical event is demonstrated.

Outcomes of an Integrated Urology-Palliative Care Clinic for Patients With Advanced Urological Cancers: Maintenance of Quality of Life and Satisfaction and High Rate of Hospice Utilization Through End of Life

INTRODUCTION

Systematic integration of palliative care in a surgical setting is important, but has yet to be achieved. Despite evidence of early palliative care improving patients' quality of life, hospice utilization remains low. Through an integrated palliative care-urology clinic, we aim to assess the effect of early outpatient palliative care on hospice utilization, health-related quality of life (HRQOL) and satisfaction in patients with advanced urological cancers.

METHODS

Participants were recruited from 2012 through 2016 in the Greater Los Angeles Veterans Affairs Hospital. We partnered with palliative care clinicians to develop an integrated urology-palliative care clinic, where participants were seen by the palliative care team on the same day as their urological visit. The 12-item Short-Form Survey, Patient Satisfaction Questionnaire Short-Form, Patient Health Questionnaire, and Brief Pain Inventory were administered at initial and subsequent visits. Follow-up questionnaire results were compared between baseline and the 2 follow-up visits, and hospice utilization rates were assessed.

RESULTS

Fifty-three participants completed baseline questionnaires. Of those 22 (42%) patients completed at least one follow-up assessment. The median time for the first and second follow-up visits was 2.9 and 7.8 months, respectively. There were no significant differences in HRQOL and satisfaction between baseline and subsequent follow-up visits. A total of 36 (68%) of 53 participants who were enrolled at the start of the study were deceased. Of those, 29 (81%) expired within a home or inpatient hospice.

CONCLUSIONS

Rates of hospice use were high in an integrated palliative care-urology model. Health-related quality of life and satisfaction did not worsen over time.

Opportunities to maximize value with integrated palliative care

Palliative care involves aggressively addressing and treating psychosocial, spiritual, religious, and family concerns, as well as considering the overall psychosocial structures supporting a patient. The concept of integrated palliative care removes the either/or decision a patient needs to make: they need not decide if they want either aggressive chemotherapy from their oncologist or symptom-guided palliative care but rather they can be comanaged by several clinicians, including a palliative care clinician, to maximize the benefit to them. One common misconception about palliative care, and supportive care in general, is that it amounts to “doing nothing” or “giving up” on aggressive treatments for patients. Rather, palliative care involves very aggressive care, targeted at patient symptoms, quality-of-life, psychosocial needs, family needs, and others. Integrating palliative care into the care plan for individuals with advanced diseases does not necessarily imply that a patient must forego other treatment options, including those aimed at a cure, prolonging of life, or palliation. Implementing interventions to understand patient preferences and to ensure those preferences are addressed, including preferences related to palliative and supportive care, is vital in improving the patient-centeredness and value of surgical care. Given our aging population and the disproportionate cost of end-of-life care, this holds great hope in bending the cost curve of health care spending, ensuring patient-centeredness, and improving quality and value of care. Level 1 evidence supports this model, and it has been achieved in several settings; the next necessary step is to disseminate such models more broadly.