Providers and Patients Caught Between Standardization and Individualization: Individualized Standardization as a Solution Comment on "(Re) Making the Procrustean Bed? Standardization and Customization as Competing Logics in Healthcare"

Treatment confidence and patient participation in multidisciplinary tumor conferences: A structural equation modeling approach

OBJECTIVE

Multidisciplinary tumor conference (MTC) is a key instrument in multidisciplinary cancer care. In recent years, if and how patient participation in MTC can contribute to a more patient-centered care have been scientifically discussed. This study aimed to identify determinants of treatment confidence in the context of patient participation in MTC. Therefore, the association among health literacy-sensitive communication, trust in health-care providers (HCP), and treatment confidence is examined.

METHODS

This study used data from the multicenter, observational study "PINTU" on patient participation in MTC. Data were collected from November 2018 to February 2020. Validated scales for treatment confidence, health literacy-sensitive communication, and trust in providers were included in the structural equation modeling (SEM) analysis.

RESULTS

A total of 95 patients participated in MTC. The sample compromised n = 80 completed datasets. The SEM fit measures indicated good fit of the proposed model. The analysis showed a positive association between health literacy-sensitive communication and treatment confidence when adding the mediating effect of trust in providers.

CONCLUSION

Patient-centered communication during MTC in combination with a trustful relationship between participating patients and health-care providers is positively associated with treatment confidence. The results indicated the relevance of a trustful doctor-patient communication and relationship. Trainings for physicians targeting patient-centered communication could be a promising approach to strengthen patient participation.

Synthesis of 'joint class' curricula at high volume joint replacement centres and a preliminary model for development and evaluation

RATIONALE

Preoperative patient education through 'joint class' has potential to improve quality of care for total joint replacement (TJR). However, no formal guidance exists regarding curriculum content, potentially resulting in inter-institutional variation.

OBJECTIVE

We aimed to (a) synthesize curriculum components of 'joint classes' across high-volume institutions and (b) develop a preliminary theory of change model for development and evaluation guided by the existing curricula and related literature.

METHODS

We reviewed 'joint class' curricula from the websites of the 10 highest-volume TJR centres (by average annual 2017-2019 volume) that publicly disclosed this information. Two reviewers qualitatively compared available content and noted common categories, which were synthesized into key domains across institutions. We then reviewed the PubMed database for literature on pre-TJR patient education and education needs in the past 10 years. Drawing on our curriculum synthesis and related literature, we proposed a theory of change model: hypothesized mechanisms through which 'joint class' confers benefits to patients and health systems.

RESULTS

We identified 30 categories in our review of existing class content, which we synthesized into seven key domains: (I) Practical Elements, (II) Logistics, (III) Medical Information, (IV) Modifiable Risk Factors, (V) Expected Outcomes, (VI) Patient Role in Recovery and (VII) Enhanced Education. Variation across institutions was noted. Our preliminary model based on the curriculum synthesis and related literature on the impact of 'joint class' includes three levels: (1) Practical Elements ('joint class' accessibility and information quality), (2) Class Goals (increased health literacy, increased adherence, risk mitigation, realistic expectations, and reduced anxiety) and (3) Target Outcomes (improved clinical outcomes, positive patient experience and increased patient satisfaction).

CONCLUSION

Our synthesis identified core common topics included in pre-TJR education but also highlighted variation across institutions, supporting opportunities for standardization. Clinicians and researchers can use our preliminary model to systematically develop and evaluate 'joint classes,' with the goal of establishing a standard of care for TJR preoperative education.

Curricular and pedagogical approaches for physical activity prescription training: a mixed-methods study of the "Exercise is Medicine" workshops in Colombia

BACKGROUND

The physical activity (PA) prescription workshop for physicians, through the global health initiative "Exercise is Medicine" (EIM), has trained more than 4000 health care professionals (HCPs) in Latin America. It has shown to be effective in increasing PA prescription knowledge and awareness among HCPs. The purpose of this paper is to evaluate the curricular and pedagogical approach used by EIM Colombia at the PA prescription workshops implemented between 2014 and 2015.

METHODS

A mixed methods study, with a sequential explanatory design was implemented among a convenience sample of HCPs attending twenty-six PA prescription workshops. HCPs health status, PA personal habits, and medical practices were collected using a questionnaire at baseline among 795 participants (pre-test measurement), and subsequently quantitatively analyzed. A workshop satisfaction survey was administered after the completion of the workshop among 602 HCPs. The curricular and pedagogical approach of the workshop, the designers' and students' contextual factors, and perceptions about the workshop were measured using qualitative methods (analysis of the procedures manual, two workshop observations, three semi-structured interviews, and one focus group including 8 HCPs).

RESULTS

The workshop is student-centered and guided by an expert with an academic and clinical background. Learning was achieved with theoretical and practical components using authentic performance and collaborative learning. An active teaching and learning approach was used with strategies such as interactive lectures, hands-on elements, and role-playing (patient-counselor). The workshop emphasized an individual approach when prescribing PA integrating in clinical practice not only health benefits but also patient´s beliefs, motivations, needs, and barriers.

CONCLUSIONS

Evidence-based practices and authentic performance were the most salient pedagogical elements used by EIM Colombia at the PA prescription workshop. A knowledge assessment that includes the practical aspect is suggested for future workshops. The curricular and pedagogical approach of the PA prescription workshop implemented in Colombia is well received by the medical community and a useful continuing medical education intervention with a potential contribution to current, and future health promotion needs.

Precision cancer medicine and the doctor-patient relationship: a systematic review and narrative synthesis

BACKGROUND

The implementation of precision medicine is likely to have a huge impact on clinical cancer care, while the doctor-patient relationship is a crucial aspect of cancer care that needs to be preserved. This systematic review aimed to map out perceptions and concerns regarding how the implementation of precision medicine will impact the doctor-patient relationship in cancer care so that threats against the doctor-patient relationship can be addressed.

METHODS

Electronic databases (Pubmed, Scopus, Web of Science, Social Science Premium Collection) were searched for articles published from January 2010 to December 2021, including qualitative, quantitative, and theoretical methods. Two reviewers completed title and abstract screening, full-text screening, and data extraction. Findings were summarized and explained using narrative synthesis.

RESULTS

Four themes were generated from the included articles (n = 35). Providing information addresses issues of information transmission and needs, and of complex concepts such as genetics and uncertainty. Making decisions in a trustful relationship addresses opacity issues, the role of trust, and and physicians' attitude towards the role of precision medicine tools in decision-making. Managing negative reactions of non-eligible patients addresses patients' unmet expectations of precision medicine. Conflicting roles in the blurry line between clinic and research addresses issues stemming from physicians' double role as doctors and researchers.

CONCLUSIONS

Many findings have previously been addressed in doctor-patient communication and clinical genetics. However, precision medicine adds complexity to these fields and further emphasizes the importance of clear communication on specific themes like the distinction between genomic and gene expression and patients' expectations about access, eligibility, effectiveness, and side effects of targeted therapies.

Facilitators and barriers of implementation of routine postnatal care guidelines for women: A systematic scoping review using critical interpretive synthesis

Background

Postnatal care (PNC) has the potential to prevent a substantial burden of maternal and newborn morbidity and mortality. This scoping review aimed to identify and synthesise themes related to facilitators and barriers of implementation of guidelines on routine PNC for women (postpartum care) in all settings.

Methods

This is a scoping review guided by the standard principles of Arksey & O'Malley's framework. We used the critical interpretive synthesis method to synthesise the whole body of evidence. We searched four databases (Medline, Embase, Global Health, CINAHL Plus) using a combination of search terms comprising four key concepts: postnatal care, routine care, guidelines and implementation. No restrictions on country or language of publication were applied. We excluded studies not presenting findings about PNC for women. We thematically charted the themes of studies included based on title and abstract screening. All studies included after full text screening were described and their results synthesised using the socio-ecological model framework. We did not conduct a risk of bias analysis or quality assessment of included studies.

Results

We identified a total of 8692 unique records and included 43 studies which identified facilitators and barriers to implementing routine guidelines in provision of PNC to women. Three quarters of studies pertained to PNC provision in high-income countries. Specific facilitators and barriers were identified and thematically presented based on whether they affect the provision of PNC or the intersection between provision of PNC and its use by women and families. We applied a critical global health lens to synthesise three constructs in the literature: finding a balance between standardisation and individualisation of PNC, the fragmented PNC provision landscape complicating the experiences of women with intersecting vulnerabilities, and the heavy reliance on the short postpartum period as an opportunity to educate and retain women and newborns in the health system.

Conclusions

This interpretive synthesis of evidence shows that the fragmented and narrow nature of PNC provision presents specific challenges to developing, adapting and implementing routine PNC guidelines. This results in a lack of linkages to social support and services, fails to address intersecting vulnerabilities and inequities among women, and negatively influences care seeking. There is a lack of evidence on how processes of individualising PNC provision can be applied in practice to support health workers in providing woman-centered PNC in various global settings.

Registration

https://www.protocols.io/private/C99DA688881F11EBB4690A58A9FEAC02.

Physicians' experiences and actions in making complex level-of-care decisions during acute situations within older patients' homes: a critical incident study

BACKGROUND

Complex level-of-care decisions involve uncertainty in which decisions are beneficial for older patients. Knowledge of physicians' decision-making during acute situations in older patients' homes is limited. Therefore, this study aimed to describe physicians' experiences and actions in making complex level-of-care decisions during the assessment of older patients in acute situations within their own homes.

METHODS

Individual interviews and analyses were performed according to the critical incident technique (CIT). In total, 14 physicians from Sweden were included.

RESULTS

In making complex level-of-care decisions, physicians experienced collaborating with and including older patients, significant others and health care professionals to be essential for making individualized decisions regarding the patients' and their significant others' needs. During decision-making, physicians experienced difficulties when doubt or collaborative obstructions occurred. Physicians' actions involved searching for an understanding of older patients' and their significant others' wishes and needs, considering their unique conditions, guiding them, and adjusting care according to their wishes. Actions further involved promoting collaboration and reaching a consensus with all persons involved.

CONCLUSION

Physicians strive to individualize complex level-of-care decisions based on older patients' and their significant others' wishes and needs. Furthermore, individualized decisions depend on successful collaboration and consensus among older patients, their significant others and other health care professionals. Therefore, to facilitate individualized level-of-care decisions, the health care organizations need to support physicians when they are making individualized decisions, provide sufficient resources and promote 24 - 7 collaboration between organizations and health care professionals.

Shared-Decision-Making Experiences in Breast Cancer Care with and without Patient Participation in Multidisciplinary Tumor Conferences: A Mixed-Methods-Study

Purpose

This study aimed (1) to analyze patients' perceived shared decision-making (SDM) experiences over 4 weeks between patients participating or not in multidisciplinary tumor conferences (MTCs) and (2) to analyze the association of patients' active participation in and organizational variables of MTCs with patients' perceived SDM experience directly after MTC.

Patients and Methods

From the N=317 patients, this observational study included patient surveys, observations, and audio transcripts from MTCs with (N=82) and without (N=145) patient participation in six breast and gynecologic cancer centers. We performed t tests for within- and between-group comparisons and linear regression with "patients' perceived SDM experiences in MTC" as the dependent variable.

Results

Patients' perceived SDM experiences increased at 4 weeks after MTC (p<0.001) with lower perceived SDM experiences for participating versus nonparticipating patients (p<0.001). Linear regression showed that the organizational variable "round table seating arrangement" was significantly associated with higher perceived SDM experiences compared with a theater or U-shape arrangement (beta=-0.38, p=0.043; beta=-0.69, p=0.010) directly after MTC.

Conclusion

Results provide first insights into patients' perceived SDM experiences in MTCs. SDM in MTCs is associated with organizational variables of MTCs. A round table seating arrangement in MTCs with patient participation seems important for patients' perceived SDM experiences. The relatively low perceived SDM experiences of participating patients directly after MTC indicates room for improvement, eg concerning patient-centered communication.

User perspectives on systematic data collection regarding back pain managed in general practice - a qualitative study

Background

Back pain is a main driver of disability and the most prevalent reason why people in Demark visit a general practitioner (GP). However, little is known about back pain management in primary care. For new strategies to be sustainable and to accommodate the recommendations for evidence-based practice, patients’ perspectives are paramount to complement clinical expertise and research evidence.

This study aimed to identify recommendations for systematic data collection in a nationwide cohort regarding the management of back pain in general practice from the perspectives of GPs and patients.

Method

We applied an adapted exploratory sequential design using focus groups and individual interviews. Seven GPs and ten patients with back pain participated, and four focus groups and seventeen individual interviews were conducted. Data were analyzed using abductive reasoning.

Results

Both GPs and patients with back pain found that 1) recruitment to a cohort should take place through the GPs, 2) the heterogeneity of patients with back pain and their need for individualized treatment and care should be considered, and 3) data from the cohort should feed into a flowchart or guideline to illustrate a generic patient pathway and visually assist both the patient and GP to obtain an overview and, thus, structure the patient pathway.

Conclusion

GPs and patients with back pain both considered the nationwide cohort with the overall aim to investigate back pain management as being extremely relevant in relation to improve t the patient pathway. User perspectives should be explored and integrated into health care interventions.

Balancing standardisation and individualisation in transitional care pathways: a meta-ethnography of the perspectives of older patients, informal caregivers and healthcare professionals

BACKGROUND

Transitional care implies the transfer of patients within or across care settings in a seamless and safe way. For frail, older patients with complex health issues, high-quality transitions are especially important as these patients typically move more frequently within healthcare settings, requiring treatment from different providers. As transitions of care for frail people are considered risky, securing the quality and safety of these transitions is of great international interest. Nevertheless, despite efforts to improve quality in transitional care, research indicates that there is a lack of clear guidance to deal with practical challenges that may arise. The aim of this article is to synthesise older patients, informal caregivers and healthcare professionals' experiences of challenges to achieving high-quality transitional care.

METHODS

We used the seven-step method for meta-ethnography originally developed by Noblit and Hare. In four different but connected qualitative projects, the authors investigated the challenges to transitional care for older people in the Norwegian healthcare system from the perspectives of older patients, informal caregivers and healthcare professionals. In this paper, we highlight and discuss the cruciality of these challenging issues by synthesising the results from twelve articles.

RESULTS

The analysis resulted in four themes: i) balancing person-centred versus efficient care, ii) balancing everyday patient life versus the treatment of illness, iii) balancing user choice versus "What Matters to You", and iv) balancing relational versus practical care. These expressed challenges represent tensions at the system, organisation and individual levels based on partial competing assumptions on person-centred-care-inspired individualisation endeavours and standardisation requirements in transitional care.

CONCLUSIONS

There is an urgent need for a clearer understanding of the tension between standardisation and individualisation in transitional care pathways for older patients to ensure better healthcare quality for patients and more realistic working environments for healthcare professionals. Incorporating a certain professional flexibility within the wider boundary of standardisation may give healthcare professionals room for negotiation to meet patients' individual needs, while at the same time ensuring patient flow, equity and evidence-based practice.

Patient engagement in the design of an intervention to prevent muscle loss in individuals with knee osteoarthritis and a body mass index (BMI) ≥ 35

OBJECTIVE

Interventions for knee osteoarthritis (OA) in adults with a large body size (defined as a body mass index [BMI] ≥ 35 kg/m² ) often prioritise weight-loss, which may overshadow specific benefits for physical function, metabolic health, and body composition. As part of the development of a future clinical study, we gathered perspectives from individuals living with knee OA and a large body size to inform the proposed intervention design and delivery.

METHODS

Purposive and voluntary sampling was used to engage individuals ≥40 years of age with self-reported knee OA and a BMI ≥ 35 kg/m² . An anonymous electronic survey was distributed on social media between April 2020 and June 2020. Open-ended questions addressed a proposed 12-week multimodal intervention (involving targeted nutrition, resistance exercises, and self-management support). An optional semi-structured interview was offered upon completion, with interviews recorded and transcribed verbatim. Reflexive thematic analysis and interpretation guided by an acceptability framework was used to identify recommendations for the intervention design and delivery.

RESULTS

Twenty individuals living across Canada completed the survey (100% female; 18 aged <65 years and 2 ≥ 65 years). Ten individuals completed the interview. From aggregate survey and interview data, three recommendations were generated: (1) the effectiveness of the intervention for health improvement (specifically mobility and pain) must be emphasised to avoid perceived weight-loss expectations; (2) extend support beyond 12-weeks and consider terminology free from weight-bias to enhance acceptance; (3) include optional customisation of intervention delivery to reduce acceptability-related burden.

CONCLUSION

These female patient-derived recommendations may improve perceived intervention acceptability, and thereby may enhance participant enrolment and retention in clinical trials.

A Pragmatic Benchmarking Study of an Evidence-Based Personalised Approach in 1938 Adolescents with High-Risk Idiopathic Scoliosis

Combining evidence-based medicine and shared decision making, current guidelines support an evidence-based personalised approach (EBPA) for idiopathic scoliosis in adolescents (AIS). EBPA is considered important for adolescents' compliance, which is particularly difficult in AIS. Benchmarking to existing Randomised Controlled Trials (RCTs) as paradigms of single treatments, we aimed to check the effectiveness and burden of care of an EBPA in high-risk AIS. This study's design features a retrospective observation of a prospective database including 25,361 spinal deformity patients < 18 years of age. Participants consisted of 1938 AIS, 11-45° Cobb, Risser stage 0-2, who were studied until the end of growth. EBPA included therapies classified for burdensomeness according to current guidelines. Using the same inclusion criteria of the RCTs on exercises, plastic, and elastic bracing, out of the 1938 included, we benchmarked 590, 687, and 884 participants, respectively. We checked clinically significant results and burden of care, calculating Relative Risk of success (RR) and Number Needed to Treat (NNT) for efficacy (EA) and intent-to-treat analyses. At the end of growth, 19% of EBPA participants progressed, while 33% improved. EBPA showed 2.0 (1.7-2.5) and 2.9 (1.7-4.9) RR of success versus Weinstein and Coillard's studies control groups, respectively. Benchmarked to plastic or elastic bracing, EBPA had 1.4 (1.2-1.5) and 1.7 (1.2-2.5) RR of success, respectively. The EBPA treatment burden was greater than RCTs in 48% of patients, and reduced for 24% and 42% versus plastic and elastic bracing, respectively. EBPA showed to be from 40% to 70% more effective than benchmarked individual treatments, with low NNT. The burden of treatment was frequently reduced, but it had to be increased even more frequently.

Value configurations for balancing standardization and customization in chronic care: a qualitative study

BACKGROUND

Demands for both customization and standardization are increasing in healthcare. At the same time, resources are scarce, and healthcare managers are urged to improve efficiency. A framework of three value configurations - shop, chain, and network - has been proposed for how healthcare operations can be designed and organized for efficient value creation. In this paper, use of value configurations for balancing of standardization and customization is explored in the context of care for chronic mental conditions.

METHODS

A typical case is presented to illustrate the manifestations of conflicting demands between customization and standardization, and the potential usefulness of the value configurations framework. Qualitative data were collected from managers and care developers in two focus groups and six semi-structured interviews, completed by a national document describing a care pathway. Data were coded and analysed using an insider-outsider approach.

RESULTS

Operationalization of the balance between standardization and customization were found to be highly delegated and ad hoc. Also, the conflict between the two demands was often seen as aggravated by scarce resources. Value configurations can be fruitful as a means of discussing and redesigning care operations if applied at a suitable level of abstraction. Applied adequately, all three value configurations were recognized in the care operations for the patient group, with shop as the overarching configuration. Some opportunities for improved efficiency were identified, yet all configurations were seen as vital in the chronic care process.

CONCLUSIONS

The study challenges the earlier proposed organizational separation of care corresponding to different value configurations. Instead, as dual demand for customization and standardization permeates healthcare, parallel but explicated value configurations may be a path to improved quality and efficiency. Combined and intermediate configurations should also be further investigated.

The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

BACKGROUND

First-level leadership is uniquely positioned to support evidence-based practice (EBP) implementation for behavioral health due to first-level leaders' access to and relationship with service providers. First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others. However, first-level leadership is underrepresented in existing reviews of the impact of leadership on EBP implementation. This review describes the relationship between first-level leadership and implementation determinants and outcomes.

METHODS

A scoping review was performed to synthesize the literature on the relationship between first-level leadership and inner-context and implementation outcomes. A literature search was conducted in PubMed, Eric, PsycINFO, CINAHL, Scopus, and Web of Science. To be eligible, studies had to examine first-level leadership, be conducted in settings providing behavioral health services, and examine the relationship between first-level leadership and an implementation or inner-context outcome. Data extraction and synthesis were performed to describe study characteristics, leader-outcome relationships, and overlap in leadership frameworks.

RESULTS

Twenty-one records met our inclusion criteria. Studies primarily relied on observational designs and were often cross-sectional. Studies more often examined general leadership rather than leadership strategically focused on EBP implementation (i.e., strategic implementation leadership). Our findings suggest that several forms of first-level leadership are inconsistently related to a broad set of implementation determinants, with infrequent examination of specific implementation outcomes. The broad set of implementation determinants studied, limited number of replications, and inconsistent findings have resulted in sparse evidence for any specific leadership-outcome relationship. The greatest accumulation of evidence exists for general leadership's positive relationship with providers' EBP attitudes, most notably in the form of transformational leadership. This was followed by evidence for strategic implementation leadership facilitating general implementation. Our synthesis revealed moderate conceptual overlap of strategic implementation leadership behaviors described in the theory of implementation leadership and theory of middle managers' role in implementation.

CONCLUSIONS

Our findings suggest that first-level leadership may play an important role in shaping implementation determinants and outcomes, but consistent empirical support is sparse and confidence dampened by methodological issues. To advance the field, we need studies that adopt stronger methodological rigor, address the conceptual overlap in leadership frameworks, examine a broader set of implementation outcomes, and examine conditions under which leadership impacts implementation.

TRIAL REGISTRATION

This review was not registered.

Immunological Evaluation for Personalized Interventions in Children with Tuberculosis: Should It Be Routinely Performed?

Childhood tuberculosis (TB) is a significant public health problem and the ninth leading cause of death worldwide. Progression of Mycobacterium tuberculosis infection to active disease depends on mycobacterial virulence, environmental diversity, and host susceptibility and immune response. In children, malnutrition and immaturity of the immune system contribute to an inadequate immune response. Coinfections, though rarely described in TB, might be associated with host immune deficiencies. Here, we describe the immunological evaluation of eight pediatric patients infected with a member of the M. tuberculosis complex, most of them with concomitant pulmonary infections (bacteria, viruses, or fungi). We assessed the functionality of several innate immunity receptors, IL-12 receptor, and IFN-γ receptor, as well as the antioxidant levels (glutathione), which are essential mechanisms for fighting intracellular pathogens such as M. tuberculosis. This study is aimed at developing a thorough immunological evaluation of patients with TB and a coinfection.

Patients' perspectives of facilitators and barriers to patient-centred care: insights from qualitative patient interviews

OBJECTIVES

Previous studies on patient-centred care (PCC) and its facilitators and barriers usually considered specific patient groups, healthcare settings and aspects of PCC or focused on expert perspectives. The objective of this study was to analyse patients' perspectives of facilitators and barriers towards implementing PCC.

DESIGN

We conducted semistructured individual interviews with chronically ill patients. The interviewees were encouraged to share positive and negative experiences of care and the related facilitators and barriers in all settings including preventive, acute and chronic health issues. Interview data were analysed based on the concept of content analysis.

SETTING

Interviews took place at the University Hospital Cologne, nursing homes, at participants' homes or by telephone.

PARTICIPANTS

Any person with at least one chronic illness living in the region of Cologne was eligible for participation. 25 persons with an average age of 60 years participated in the interviews. The participants suffered from various chronic conditions including mental health problems, oncological, metabolic, neurological diseases, but also shared experiences related to acute health issues.

RESULTS

Participants described facilitators and barriers of PCC on the microlevel (eg, patient-provider interaction), mesolevel (eg, health and social care organisation, HSCO) and macrolevel (eg, laws, financing). In addition to previous concepts, interviewees illustrated the importance of being an active patient by taking individual responsibility for health. Interviewees considered functioning teams and healthy staff members a facilitator of PCC as this can compensate stressful situations or lack of staff to some degree. A lack of transparency in financing and reimbursement was identified as barrier to PCC.

CONCLUSION

Individual providers and HSCOs can address many facilitators and barriers of PCC as perceived by patients. Large-scale changes such as reduction of administrative barriers, the expansion of care networks or higher mandatory nurse to patient ratios require political action and incentives.

TRIAL REGISTRATION NUMBER

DRKS00011925.

Exploring healthcare professionals' knowledge, attitudes and experiences of shared decision making in rheumatology

OBJECTIVES

To explore physicians' and nurses' knowledge, attitudes and experiences of shared decision making (SDM) in rheumatology, to identify barriers and facilitators to SDM, and to examine whether physicians' and nurses' perspectives of SDM differ.

METHODS

A cross-sectional, exploratory, online survey was used. Besides demographic characteristics, healthcare professionals' knowledge, attitudes and experiences of SDM in rheumatology were assessed. Barriers and facilitators to SDM were identified from healthcare professionals' answers. Descriptive statistics were computed and differences between physicians' and nurses' perspectives of SDM were examined with a t-test or Fisher's exact test, as appropriate.

RESULTS

Between April and June 2019, 77 physicians and 70 nurses completed the survey. Although most healthcare professionals lacked a full conceptual understanding of SDM, almost all physicians (92%) and all nurses had a (very) positive attitude toward SDM, which was most frequently motivated by the belief that SDM improves patients' treatment adherence. The majority (>50%) of healthcare professionals experienced problems with the application of SDM in clinical practice, mostly related to time constraints. Other important barriers were the incompatibility of SDM with clinical practice guidelines and beliefs that patients do not prefer to be involved in decision making or are not able to take an active role. Modest differences between physicians' and nurses' perspectives of SDM were found.

CONCLUSIONS

There is a clear need for education and training that equips and empowers healthcare professionals to apply SDM. Furthermore, the commitment of time, resources and financial support for national, regional and organisational initiatives is needed to make SDM in rheumatology a practical reality.

Implementation of patient-centred care: which organisational determinants matter from decision maker's perspective? Results from a qualitative interview study across various health and social care organisations

OBJECTIVES

Health and social care systems, organisations and providers are under pressure to organise care around patients' needs with constrained resources. To implement patient-centred care (PCC) successfully, barriers must be addressed. Up to now, there has been a lack of comprehensive investigations on possible determinants of PCC across various health and social care organisations (HSCOs). Our qualitative study examines determinants of PCC implementation from decision makers' perspectives across diverse HSCOs.

DESIGN

Qualitative study of n=24 participants in n=20 semistructured face-to-face interviews conducted from August 2017 to May 2018.

SETTING AND PARTICIPANTS

Decision makers were recruited from multiple HSCOs in the region of the city of Cologne, Germany, based on a maximum variation sampling strategy varying by HSCOs types.

OUTCOMES

The qualitative interviews were analysed using an inductive and deductive approach according to qualitative content analysis. The Consolidated Framework for Implementation Research was used to conceptualise determinants of PCC.

RESULTS

Decision makers identified similar determinants facilitating or obstructing the implementation of PCC in their organisational contexts. Several determinants at the HSCO's inner setting and the individual level (eg, communication among staff and well-being of employees) were identified as crucial to overcome constrained financial, human and material resources in order to deliver PCC.

CONCLUSIONS

The results can help to foster the implementation of PCC in various HSCOs contexts. We identified possible starting points for initiating the tailoring of interventions and implementation strategies and the redesign of HSCOs towards more patient-centredness.