Implementing an osteoarthritis management program to deliver guideline-driven care for knee and hip osteoarthritis in a U.S. academic health system

Objective

Assess implementation feasibility and outcomes for an Osteoarthritis Management Program (OAMP) at an academic center.

Design

This open study assessed an OAMP designed to deliver care in 1-5 individual or group visits across ≤12 months. Eligibility included adults with knee or hip osteoarthritis with ≥1 visit from 7/1/2017-1/15/2021. A multidisciplinary care team provided: education on osteoarthritis, self-management, exercise, weight loss; pharmacologic management; assessments of mood, sleep, quality of life, and diet. Clinic utilization and growth are reported through 2022. Patient outcomes of body mass index (BMI), pain, and function were analyzed using multivariable general linear models. OAMP outcomes were feasibility and sustainability.

Results

Most patients were locally referred by primary care. 953 patients attended 2531 visits (average visits 2.16, treatment duration 187.9 days). Most were female (72.6%), older (62.1), white (91.1%), and had medical insurance (95.4%). Obesity was prevalent (84.7% BMI ≥30, average BMI 40.9), mean Charlson Comorbidity Index was 1.89, and functional testing was below average. Longitudinal modeling revealed statistically but not clinically significant pain reduction (4.4-3.9 on 0-10 scale, p ​= ​0.002). BMI did not significantly change (p ​= ​0.87). Higher baseline pain and BMI correlated with greater reductions in each posttreatment. Uninsured patients had shorter treatment duration. Increasing clinic hours (4-24 ​h weekly) and serving 953 patients over four years demonstrated OAMP sustainability.

Conclusions

OAMP implementation was feasible and sustainable. Patients with high baseline pain and BMI were more likely to improve. Noninsurance was a barrier. These results contribute to understanding OAMP outcomes in U.S. healthcare.

Imaging of pancreatic ductal adenocarcinoma - An update for all stages of patient management

Background

Pancreatic ductal adenocarcinoma (PDAC) is a common and lethal cancer. From diagnosis to disease staging, response to neoadjuvant therapy assessment and patient surveillance after resection, imaging plays a central role, guiding the multidisciplinary team in decision-planning.

Review aims and findings

This review discusses the most up-to-date imaging recommendations, typical and atypical findings, and issues related to each step of patient management. Example cases for each relevant condition are presented, and a structured report for disease staging is suggested.

Conclusion

Despite current issues in PDAC imaging at different stages of patient management, the radiologist is essential in the multidisciplinary team, as the conveyor of relevant imaging findings crucial for patient care.

[Fragility Fractures: Preoperative assessment and optimisation]

Fragility fractures are associated with high morbidity and mortality. An interdisciplinary collaboration and an individualized, patient-centered approach are essential to ensure an optimized preoperative period and to improve perioperative safety. Preoperative responsibilities of trauma surgery include in the first step the identification of fragility fractures and the necessity for geriatric involvement. Orthogeriatric co-management (OCM) focuses on the identification of the medical, functional and social needs of the patient. In the preoperative period attention is focussed on acute diseases in need of treatment that have a negative impact on the course of further treatment and the prevention of delirium.

Rehabilitation of patients with inflammatory rheumatic diseases and comorbidities: unmet needs

Comorbidities may contribute to inadequate response to therapy and accelerate disability in various rheumatic diseases such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and psoriatic arthritis (PsA). Cardiovascular, oncological, and infectious comorbidities are common in rheumatic patients. The rehabilitation of patients with inflammatory rheumatic diseases (IRDs) with comorbidities requires a multidisciplinary approach to improving patients' functional mobility, slowing down the disease progression and minimizing the risks of complications. The evidence suggests that cardiac rehabilitation can be implemented in daily practice in patients with IRDs to reduce mortality for those with established risk factors. Physical exercises reduce the severity, improve the clinical course, and reduce hospitalization rates in patients with rheumatic diseases. A rehabilitation program with focused physical therapy can lead to functional improvements and reduction of disease activity in patients with lowered quality of life (QoL). Health professionals should provide evidence-based recommendations for patients with rheumatic diseases and comorbidities to initiate the self-management of their diseases and prevent complications.

Multidisciplinary team for patients with neurocutaneous syndromes: The little discussed importance of dentistry

Neurocutaneous syndromes comprise a heterogeneous group of congenital or hereditary conditions that are known to be associated with the risk of different disorders and complications. Two of the most common neurocutaneous syndromes are Neurofibromatosis type 1 (NF1) and Tuberous Sclerosis Complex (TSC). Although there appears to be a general consensus on the importance of a multidisciplinary approach in managing these cases, there is still very little emphasis in discussions addressed in the literature on the role of dentistry in accordance with the perspective of comprehensive care. Evidence-based propositions, together with a broad discussion of new insights in this regard, should have the ability to strongly impact related future perspectives, aiming for greater advances and better outcomes for these patients. In this review article, the authors discuss updated general aspects of NF1 and TSC, and the potential additional roles of dentistry, in addition to addressing suggestions for actions in dentistry at related levels of care, as well as priorities for future research.

Language and communication rehabilitation in patients with schizophrenia: A narrative review

Language impairments often appear in patients with schizophrenia and are potential targets for rehabilitation. Clinical practice and research should be intimately connected. The aim was to perform a narrative review of the assessment and intervention tools that have been used for the rehabilitation of schizophrenia patients with language and communication impairments. Two types of tools, general and specific, were developed for both purposes. General tools include the Positive and Negative Syndrome Scale for assessment, and the Integrated Psychological Therapy for intervention. The specific tools used to evaluate language and communication impairments include the Scale for the Assessment of Thought, Language and Communication, the Formal Thought Disorder scales (for caregivers and patients), and the Thought and Language Disorder scale. The most recent language-specific intervention tools include the Cognitive Pragmatic Treatment, Conecta-2, Let's talk! Multimodal Speech-Gesture training, Speech Therapy Intervention Group, and PragmaCom. These tools primarily involve psychopathology/psychiatry, psychology, linguistics, speech and language therapy, and nursing. In conclusion, a wide range of assessment and intervention tools are available for the rehabilitation of language and communication impairments associated with schizophrenia. An integrative and interdisciplinary approach should always be considered for rehabilitation of language and communication in patients with schizophrenia throughout their lifetime.

Impact of the health policy for interdisciplinary collaborative rehabilitation practices in intensive care units: A difference-in-differences analysis in Japan

BACKGROUND

Early rehabilitation in intensive care units (ICUs) may be beneficial but is not routinely performed for adults with critical illness. In April 2018, the Japanese government introduced a health policy to provide financial incentives to hospitals that met the requirements of interdisciplinary collaboration and had teams specialized in ICU rehabilitation practices.

OBJECTIVES

The present study aimed to investigate whether the health policy is associated with improved clinical practices of ICU rehabilitation.

METHODS

Using a nationwide administrative inpatient database and hospital statistics data from Japan, we identified hospitals that admitted adult patients to the ICU within two days of hospital admission from April 2016 to March 2019. Using hospital-level propensity score matching, we created matched cohorts of 101,203 patients from 108 intervention hospitals that introduced the health policy, and 106,703 patients from 108 control hospitals that did not. We then conducted patient-level difference-in-differences analyses to examine changes in the percentage of patients from the intervention and control hospitals, who underwent early ICU rehabilitation within two days of ICU admission before and after the implementation of the health policy.

RESULTS

In the intervention group, patients undergoing early ICU rehabilitation increased from 10% and 36% after the policy implementation. In the control group, it increased from 11% to 13%. The difference-in-difference in the percentage of patients who underwent early ICU rehabilitation between the two groups was 24% (95% confidence interval, 19%-29%).

CONCLUSIONS

Early ICU rehabilitation can be facilitated by financial incentives for hospitals that engage in interdisciplinary collaboration with specialist teams.

IMPLICATIONS FOR CLINICAL PRACTICE

Our Findings are relevant for hospital administrators, professional organizations, and policymakers in other nations considering strategies to support the additional deployment burdens of early ICU rehabilitation. Future studies need to explore the long-term effects and sustainability of the observed improvements in ICU rehabilitation practices.

Oral health and healthy ageing: a scoping review

BACKGROUND

Good oral health is an important part of healthy ageing, yet there is limited understanding regarding the status of oral health care for older people globally. This study reviewed evidence (policies, programs, and interventions) regarding oral health care for older people.

METHODS

A systematic search of six databases for published and grey literature in the English language by the end of April 2022 was undertaken utilising Arksey and O'Malley's scoping review framework.

RESULTS

The findings from oral health policy documents (n = 17) indicated a lack of priorities in national health policies regarding oral health care for older people. The most common oral health interventions reported in the published studies (n = 62) included educational sessions and practical demonstrations on oral care for older adults, nurses, and care providers. Other interventions included exercises of facial muscles and the tongue, massage of salivary glands, and application of chemical agents, such as topical fluoride.

CONCLUSION

There is currently a gap in information and research around effective oral health care treatments and programs in geriatric dental care. Efforts must be invested in developing guidelines to assist both dental and medical healthcare professionals in integrating good oral health as part of healthy ageing. Further research is warranted in assessing the effectiveness of interventions in improving the oral health status of the elderly and informing approaches to assist the integration of oral health into geriatric care.

Multidisciplinary Panel Consensus for the Management of Patients with Type 2 Diabetes: A Delphi Study

AIM

To reach a multidisciplinary consensus on managing patients with type 2 diabetes among specialists in family medicine, cardiology, endocrinology, internal medicine, and nephrology.

METHODS

A two-round Delphi study was conducted using a questionnaire with 68 positive/negative statements distributed in four thematic blocks on diabetes management: early diagnosis and prediabetes, referral criteria, treatment and comorbidities, and clinical management. The expert panel was composed of 105 physicians from different specialties (family medicine, cardiology, endocrinology, internal medicine, and nephrology) with experience in managing patients with diabetes and who were members of a diabetes-related society.

RESULTS

Response rates for the first and second rounds were 86.7 and 75.2%, respectively. After both rounds, a consensus was reached on 52 (76.5%) items. The recommendations with the highest degree of consensus (median = 10, IQR = 0.00) were related to anti-smoking education, cardiovascular risk factor target control, and diabetic kidney disease. There were significant differences between family physicians and other specialties for some items.

CONCLUSIONS

This study provides a set of recommendations for diabetes management agreed upon by specialists from different healthcare settings.

Goals of the Morbidity and Mortality meeting in acute care: A scoping review

OBJECTIVE

The objective of this study was to describe what is known about understandings of the goals of the Morbidity and Mortality meeting.

REVIEW METHODS USED

The study utilised scoping review methodology.

DATA SOURCES

Papers in English presenting empirical data published in academic journals with Morbidity and Mortality meetings as the central concept of study. Included papers presented data about the perception of stakeholders about goals of the Morbidity and Mortality meeting. Medline, Embase, and CINAHL databases were search conducted from earliest record - October 20th 2021. A manual search of the reference lists of all included papers identified further eligible papers.

REVIEW METHODS

Data about the location, participant type, and methods/ methodology were extracted and entered onto a database. Content analysis of the results and discussion sections of qualitative papers yielded broad categories of meeting goal. This provided a framework for the organisation of the quantitative findings, which were subsequently extracted and charted under these categories.

RESULTS

Twenty-five papers were included in the review, and six main categories were identified in the qualitative synthesis of findings. These included meeting goals related to quality and safety, education, legal and reputational risk management, professional culture, family/caregivers, and peer support.

CONCLUSIONS

There are heterogeneous understandings of key terminologies used to describe Morbidity and Mortality meeting goals, particularly evident within understandings of educational and quality and safety meeting goals. This paper defines and unravels this complexity in a way that researchers and clinicians can define, compare and evaluate their own department's meeting goals.

An established abdominal wall multidisciplinary team improves patient care and aids surgical decision making with complex ventral hernia patients

INTRODUCTION

Abdominal wall reconstruction (AWR) is an emerging subspecialty within general surgery. The practice of multidisciplinary team (MDT) meetings to aid decision making and improve patient care has been demonstrated, with widespread acceptance. This study presents our initial experience of over 150 cases of complex hernia patients discussed in a newly established MDT setting.

METHODS

From February 2020 to July 2022 (30-month period), abdominal wall MDTs were held bimonthly. Key stakeholders included upper and lower gastrointestinal surgeons, a gastrointestinal specialist radiologist, a plastic surgeon, a high-risk anaesthetist and two junior doctors integrated into the AWR clinical team. Meetings were held online, where patient history, past medical and surgical history, hernia characteristics and up-to-date computed tomography scans were discussed.

RESULTS

Some 156 patients were discussed over 18 meetings within the above period. Ninety-five (61%) patients were recommended for surgery, and 61 (39%) patients were recommended for conservative management or referred elsewhere. Seventy-eight (82%) patients were directly waitlisted, whereas seventeen (18%) required preoperative optimisation: three (18%) for smoking cessation, eleven (65%) for weight-loss management and three (18%) for specialist diabetic assessment and management. In total, 92 (59%) patients (including operative and nonoperative management) have been discharged to primary care.

DISCUSSION

A multidisciplinary forum for complex abdominal wall patients is a safe process that facilitates decision making, promotes education and improves patient care. As the AWR subspecialty evolves, our view is that the "complex hernia MDT" will become commonplace. We present our experience and share advice for others planning to establish an AWR centre.

A service blueprint approach to prioritize operational improvements in a new outpatient clinic

As a US-based health care system, Mayo Clinic faced considerable challenges opening a new affiliated outpatient facility in the UK at the beginning of the COVID-19 pandemic, which severely affected patient volumes and staffing. As COVID-19 restrictions were eased, the clinic had to prioritize gradual improvements to reestablish service while using resources responsibly. To assist in understanding the current state and to isolate challenges, we elected to develop a service blueprint. We describe how we did this during the COVID-19 pandemic with the use of both face-to-face and virtual services. In many industries, service blueprints are used to help with the design, delivery, and management of new and established services. Although they share some features with value stream mapping, service blueprints often focus on human tasks and the customer's service experience, while value stream maps emphasize information or product flows and capabilities. Several themes for prioritized improvement efforts were identified for future work. In addition, the service blueprint workshops led to a much better understanding of how each person's work affected the other team members and the patient experience. We learned that service blueprints are an efficient way to identify and anticipate critical operational interdependencies and team dynamics that will affect the patient experience when building new clinical services.

Comparative Analysis of Palliative Care Needs Identified in Inpatient Rehabilitation and Skilled Nursing Facilities by Multidisciplinary Team Members

OBJECTIVE

Assess access to, need for, and beliefs surrounding specialized palliative care (PC).

DESIGN

Observational, comparative analysis needs assessment survey.

SETTING

Four inpatient rehabilitation facilities (IRFs) or skilled nursing facilities with long-term care (SNFs/LTC) that provide subacute rehabilitation within 1 tertiary care system.

PARTICIPANTS

Allied health professionals, physicians, nursing, case managers, social workers, spiritual care (n=198).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Frequency of patient needs, attitudes about current systems, individual beliefs, and barriers to PC. Confidence in management, communicating, and navigating primary PC competencies among clinical pathway employees.

RESULTS

Of 198 respondents, 37% said PC was available at their facility. Those in IRF reported higher frequencies of grief/unmet spiritual needs of patients compared with SNF/LTC (P≤.001). Conversely, SNF/LTC reported higher frequencies of agitation, poor appetite, and end-of-life care (P≤.003). Respondents in SNF/LTC felt more confident managing end-of-life care, explaining what hospice and PC are and appropriateness for referral to each, discussing advance directives, determining appropriate decision-makers, and navigating ethical decisions than in IRFs (P≤.007). SNF/LTC participants reported higher effectiveness of their current system involving PC and ease of hospice transition compared with IRFs (P≤.008). A majority agreed that PC does not take away patient hope, could prevent recurrent hospitalizations, improve symptom management, communication, and patient and family satisfaction. The most common reported barriers to PC consultation were (1) attitudes and beliefs of staff or patients and families, (2) system issues with access, cost, or prognosis communication, and (3) lack of understanding of PC role.

CONCLUSIONS

A gap exists in PC access in IRF and SNF/LTC despite patient needs and staff beliefs. Future studies should focus on identifying which patients should be referred to PC in the post-acute setting and what outcomes can be used as a guide to meet the needs of this growing area of practice.

Nonalcoholic Fatty Liver Disease as a Systemic Disease and the Need for Multidisciplinary Care

Nonalcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease, and there has been a rapid increase in cases worldwide. NAFLD is rapidly becoming the leading cause of hepatocellular carcinoma and is also associated with an increased risk of cardiovascular disease or exacerbation of other organ diseases, thus posing a significant health problem from both a medical and a socioeconomic perspective. NAFLD is a systemic disease and requires the involvement of numerous medical professionals. Multidisciplinary collaboration, in which different professionals within different specialties come together and work together toward a common goal, supports better patient care by integrating perspectives of multiple experts and facilitating the exchange of opinions. Due to the large number of potential patients, gastroenterologists and hepatologists cannot manage the patients alone, and collaboration between specialists in various fields, including family doctors, dentists, nutritionists, and pharmacists is required for treatment of NAFLD. This review will discuss NAFLD from the perspective of various specialties and introduce multidisciplinary collaboration.

Effectiveness of call system implementation for postpartum hemorrhage in a tertiary emergency medical center: a retrospective cohort study

BACKGROUND

Postpartum hemorrhage is the leading cause of maternal death and severe maternal morbidity worldwide. Previous studies have reported the importance of multidisciplinary treatment approaches for postpartum hemorrhage; however, only a few studies have shown a clear improvement in maternal outcomes. Therefore, this study aimed to investigate the efficacy of a call system for postpartum hemorrhage in a tertiary emergency facility for rapid multidisciplinary treatment and its effect on maternal outcomes.

METHODS

This single-center retrospective cohort study included patients transferred to our hospital due to postpartum hemorrhage between April 1, 2013, and March 31, 2019. The primary outcome was mortality, and the secondary outcomes were morbidity (duration of hospital stay, duration of intensive care unit stay, admission to the intensive care unit, respirator use, duration of ventilator support, acute kidney injury, transfusion-associated circulatory overload/transfusion-related acute lung injury, hysterectomy, composite adverse events, blood transfusion initiation time, blood transfusion volume, and treatment for postpartum hemorrhage). An in-hospital call system implementation commenced on April 1, 2016. The study outcomes were compared 3 years before and after implementing the call system.

RESULTS

The blood transfusion initiation time and duration of hospital stay were significantly shortened after implementing the call system for postpartum hemorrhage. No maternal deaths were observed after implementing the system.

CONCLUSIONS

Implementing call systems specialized for postpartum hemorrhage in tertiary emergency facilities may improve maternal outcomes.

Effect of the addition of a mental health specialist for evaluation of undiagnosed patients in centres for rare diseases (ZSE-DUO): a prospective, controlled trial with a two-phase cohort design

Background

People with complex symptomatology but unclear diagnosis presenting to a centre for rare diseases (CRD) may present with mental (co-)morbidity. We hypothesised that combining an expert in somatic medicine with a mental health specialist working in tandem will improve the diagnostic outcome.

Methods

Patients aged 12 years and older who presented to one of the 11 participating German CRDs with an unknown diagnosis were recruited into this prospective cohort trial with a two-phase cohort design. From October 1, 2018 to September 30, 2019, participants were allocated to standard care (SC, N = 684), and from October 1, 2019 to January 31, 2021 to innovative care (IC, N = 695). The cohorts consisted mainly of adult participants with only a minority of children included (N = 67). IC included the involvement of a mental health specialist in all aspects of care (e.g., assessing medical records, clinic visits, telehealth care, and case conferences). Clinicaltrials.gov identifier: NCT03563677.

Findings

The proportion of patients with diagnoses established within 12 months after the first visit to the CRD explaining the entire symptomatology (primary outcome) was 19% (N = 131 of 672) in the SC and 42% (N = 286 of 686) in the IC cohort (OR adjusted for centre effects 3.45 [95% CrI: 1.99-5.65]). The difference was mainly due to a higher prevalence of mental disorders and non-rare somatic diseases in the IC cohort. The median time to explaining diagnoses was one month shorter with IC (95% CrI: 1-2), and significantly more patients could be referred to local regular care in the IC (27.5%; N = 181 of 659) compared to the SC (12.3%; N = 81 of 658) cohort (OR adjusted for centre effects 2.70 [95% CrI: 2.02-3.60]). At 12-month follow-up, patient satisfaction with care was significantly higher in the IC compared to the SC cohort, while quality of life was not different between cohorts.

Interpretation

Our findings suggested that including a mental health specialist in the entire evaluation process of CRDs for undiagnosed adolescents and adults should become an integral part of the assessment of individuals with a suspected rare disease.

Funding

The study was funded by the Global Innovation Fund from the Joint Federal Committee in Germany (Innovationsfonds des Gemeinsamen Bundesausschusses), grant number 01NVF17031.

Initial evaluation of a multidisciplinary pediatric aerodigestive program in a Brazilian hospital: challenges and mitigation strategies

OBJECTIVE

To identify clinical and epidemiological characteristics of children evaluated by the pediatric aerodigestive program at the beginning of its activity, describe challenges in follow-up, and suggest mitigation strategies.

METHODS

A case series was conducted describing the first 25 patients discussed by the aerodigestive team from a Brazilian quaternary public university hospital between April 2019 and October 2020. The median follow-up was 37 months.

RESULTS

During the study period 25 children were seen by the group and the median age at first assessment was 45.7 months old. Eight children had a primary airway abnormality, five had a tracheostomy. Nine children had genetic disorders and one had esophageal atresia. Dysphagia was present in 80% of the patients, 68% had a history of chronic or recurrent lung disease, 64% had a gastroenterological diagnosis and 56% had neurological impairment. Moderate to severe dysphagia was identified in 12 children and 7 of these had an exclusive oral diet at the time. The majority of children (72%) had 3 or more comorbidities. Following team discussion, a change in feeding strategy was suggested in 56% of the children. The most frequently ordered exam was pHmetry (44%) and gastrostomy was the surgical procedure with the longest waiting list.

CONCLUSIONS

Dysphagia was the most frequent issue encountered in this initial group of aerodigestive patients. Pediatricians caring for these children must be involved in aerodigestive team discussions and hospital policies must be revised to facilitate access to exams and procedures needed for this population.

Clinicians' use and perceptions of the pre-medical emergency team tier of one rapid response system: A mixed-methods study

BACKGROUND

The pre-medical emergency team (pre-MET) tier of rapid response systems facilitates early recognition and treatment of deteriorating ward patients using ward-based clinicians before a MET review is needed. However, there is growing concern that the pre-MET tier is inconsistently used.

OBJECTIVE

This study aimed to explore clinicians' use of the pre-MET tier.

METHODS

A sequential mixed-methods design was used. Participants were clinicians (nurses, allied health, doctors) caring for patients on two wards of one Australian hospital. Observations and medical record audits were conducted to identify pre-MET events and examine clinicians' use of the pre-MET tier as per hospital policy. Clinician interviews expanded on understandings gained from observation data. Descriptive and thematic analyses were performed.

RESULTS

Observations identified 27 pre-MET events for 24 patients that involved 37 clinicians (nurses = 24, speech pathologist = 1, doctors = 12). Nurses initiated assessments or interventions for 92.6% (n = 25/27) of pre-MET events; however, only 51.9% (n = 14/27) of pre-MET events were escalated to doctors. Doctors attended pre-MET reviews for 64.3% (n = 9/14) of escalated pre-MET events. Median time between escalation of care and in-person pre-MET review was 30 min (interquartile range: 8-36). Policy-specified clinical documentation was partially completed for 35.7% (n = 5/14) of escalated pre-MET events. Thirty-two interviews with 29 clinicians (nurses = 18, physiotherapists = 4, doctors = 7) culminated in three themes: Early Deterioration on a Spectrum, A Safety Net, and Demands Versus Resources.

CONCLUSIONS

There were multiple gaps between pre-MET policy and clinicians' use of the pre-MET tier. To optimise use of the pre-MET tier, pre-MET policy must be critically reviewed and system-based barriers to recognising and responding to pre-MET deterioration addressed.

Multidisciplinary Team Meeting in the Core of Nasopharyngeal Cancer Management Improved Quality of Care and Survival of Patients

Nasopharyngeal cancer (NPC) cases are often diagnosed in advanced stages. The complexity of clinical management for advanced-stage NPC requires thorough communication and shared decisions between medical professionals and allied teams. Incorporating a multidisciplinary team meeting (MDTM) for newly diagnosed NPC patients was chosen to facilitate collaboration and communication between physicians. This retrospective study aimed to compare the quality of care, clinical responses and survival between NPC patients treated with and without MDTM. Data on clinical responses, assessment visits, date of progression and death with progression-free survival (PFS), overall survival (OS), and hazard ratio (HR) were collected and analyzed with 95% confidence interval (CI) and significance set as P < .05. There were 87 of 178 NPC patients treated with MDTM. Revisions of diagnosis and stage occurred in 5.7% and 52.9% of cases during the MDTM. More clinical responses were achieved by patients treated with MDTM (69.0%vs 32.0%, P < .00). NPC patients who received MDTM treatment recommendation had a lower risk for progression (median PFS 59.89 months vs 12.68 months; HR 0.267, 95% CI: 0.17-0.40, P < .00) and mortality (median OS was not reached vs 13.44 months; HR 0.134, 95% CI: 0.08-0.24, P < .00) compared to patients without MDTM. Incorporating the MDTM approach into NPC management improves patients' clinical responses and survival.

Differences in the Patterns of Care Between Emergency Department Visits with and Without a Physician

BACKGROUND

A variety of clinicians practice in emergency departments (EDs). Although most ED patients prefer seeing physicians, a subset sees no physician.

OBJECTIVES

We sought to determine the factors that predict when an ED patient is seen by at least one physician and compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

METHODS

We used 11 years of cross-sectional data from the National Hospital Ambulatory Medical Care Survey and focused on the sample of ED patient visits seen by at least one physician and those seen by no physician. We used bivariate statistics to compare characteristics between samples and used multivariate logistic regression analysis to identify the factors that predicted being seen by a physician. Finally, we compared the practice patterns of patient visits seen by at least one physician compared with those seen by no physician.

RESULTS

Approximately 10% of the sample was not seen by any physician. Patients seen by at least one physician had, on average, 0.8 more diagnostic services ordered/provided and 0.1 more procedures provided compared with patients who were not seen by any physician. Patients seen by at least one physician had longer visits by 29.4 min, on average, and had increased odds of being hospitalized (adjusted odds ratio 3.9, 95% confidence interval 2.9-5.2).

CONCLUSIONS

A variety of patient and hospital characteristics influenced whether ED patients were seen by physicians. Diagnostic services, procedures, visit length, and hospital admission differed by physician presence. Findings have implications for ED practice and future research.

Patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury: A pilot qualitative interview study

OBJECTIVE

To explore patients' experiences with goal setting during initial rehabilitation after newly acquired spinal cord injury/disorder (SCI/D).

DESIGN

Qualitative design with semi-structured interviews and purposively sampled participants. Interviews were transcribed verbatim. Transcripts were analyzed for qualitative content analysis using the Mayring method.

SETTING

Specialized acute care and rehabilitation center for SCI/D-patients.

PARTICIPANTS

Patients in initial rehabilitation after a newly acquired SCI/D.

INTERVENTIONS

n.a.

OUTCOME MEASURES

n.a.

RESULTS

Ten participants were interviewed in the post-acute phase after a newly acquired SCI/D. Participants described individual patient characteristics as well as organizational elements influencing their experience with goal setting. Organizational elements comprised structural elements (e.g. ward rounds, rehabilitation meetings, etc.) and interaction with and among the interprofessional teams. Perspectives from various health care professionals (HCPs) were perceived as increasing adequate goal setting and motivation. Furthermore, the participants described their own involvement and motivation as crucial for goal achievement. The main point of the critique was the standardization of the goal setting process. Interviewees would have preferred individualized goal setting embedded in a clearly foreseeable rehabilitation plan.

CONCLUSION

Organization and collaboration with and among the HCPs should be geared towards identifying specific patient needs during the course of rehabilitation and deriving individually tailored goals from them. Communication plays an important role in the individual goal setting.

Differences of Sex Development: Current Issues and Controversies

Differences of sex development (DSD) encompass a broad range of conditions in which the development of chromosomal, gonadal, or anatomic sex is not typically male or female. Terms used to describe DSD are controversial, and continuously evolving. An individualized, multidisciplinary approach is key to both the diagnosis and management of DSD. Recent advances in DSD care include expanded genetic testing options, a more nuanced approach to gonadal management, and an emphasis on shared decision-making, particularly related to external genital surgical procedures. The timing of DSD surgery is currently being questioned and debated in both medical and advocacy/activism spheres.

Establishment and implementation of a nurse-led interdisciplinary management strategy for central line maintenance: A single-center experience

Objectives

This study aimed to establish and implement an interdisciplinary management strategy led by senior nurses via a vascular access specialist team (VAST) at a teaching hospital.

Methods

In 2021, the hospital established and implemented a nurse-led VAST management strategy to improve the quality of clinical central line maintenance. The VAST comprised senior nurses specialized in intravenous therapy, ultrasound/radiology technologists, medical doctors with central venous catheterization certificates, central line maintenance nurses, and administrative coordinators. The management strategy mainly included systemic on-the-job training for VAST members, the establishment of an interdisciplinary central line emergency "green channel," the formation of a VAST-based, nurse-led standardized clinical rounding system, and the standardization of central line self-care instructions for patients. During the pre- (July 2020 to April 2021) and post- (May 2021 to May 2022) of the implementation the interdisciplinary management strategy, overall patients' self-care ability, the success rate of catheterization at first time, central line management compliance rate, and patients' satisfaction with catheter maintenance were investigated and compared.

Results

The results showed the score self-care ability was increased from 74.75 ± 18.4 (pre-VAST) to 99.10 ± 23.65 (post- VAST); the success rate for catheterization at first time was improved to 100% (225/225), compared to 92.9% (209/225) at pre-VAST; the central line management compliance rate was also increased to 99.6% (224/225) at post-VAST from 93.3% (210/225) at pre-VAST. A patient satisfaction survey on catheter maintenance showed improvements in all five indicators were compared to the pre- VAST (P < 0.05).

Conclusions

The nurse-led VAST interdisciplinary strategy can effectively improve the quality of clinical central line management and should be used to reinforce clinical catheterization and maintenance of central lines.

Understanding pediatric palliative care within interdisciplinary palliative programs: a qualitative study

PURPOSE

To describe the process of delivery of pediatric palliative care from the perspective of a pediatric interdisciplinary team and the children's parents.

METHODS

A qualitative descriptive case study was conducted. Purposeful sampling took place within a specialized pediatric palliative care Unit in Madrid (Spain), located at the Niño Jesus Hospital. The study participants included a specialized pediatric palliative care team from Madrid's pediatric palliative care program, other professional teams involved in interdisciplinary care and parents of children under pediatric palliative care. Data were collected via semi-structured interviews, focus groups and researchers' field notes. A thematic analysis was performed.

RESULTS

This study included 28 participants (20 women, 8 men), of whom 18 were professionals who belonged to the pediatric palliative care interdisciplinary team, 4 professionals were from other units that collaborated with the pediatric palliative care, and 6 were parents (5 women, 1 man). The mean age of the pediatric palliative care members was 38.2 years (SD ± 7.9), that of the collaborating professionals was 40.5 (SD ± 6.8), and that of the parents was 44.2 (SD ± 5.4). Two main themes emerged: a) Pediatric palliative care has a distinct identity, associated with life. It represents the provision of special care in highly complex children, in the context of the home, far from the hospital environment; b) The team is key: its interdisciplinary organization provides a more comprehensive view of the child and their family, fosters communication among professionals, and improves coordination with other services involved in the care of children. The mindset shift experienced by ID-PPC professionals towards a palliative approach makes them more sensitive to the needs of their patients and leads them to develop specific skills in areas such as communication, decision-making, and adaptability that were identified as differentiating aspects of pediatric palliative care.

CONCLUSIONS

Describing pediatric palliative care from the professional and parental perspective helps to establish realistic and comprehensive goals for the care of children and their parents. The findings of this study may help with the establishment of a pediatric palliative care team, as a necessary organizational change in a health care system that cares for children with complex and life-threatening conditions. Promoting training in pediatric palliative care, prioritizing more horizontal organizations, providing tools and spaces for coordination and communication between professionals from different services, together with the creation of a position of case coordinator in the care process of children could enhance the understanding of pediatric palliative care services.

Living with Type 2 Diabetes: Podcast of a Patient-Physician Discussion

For patients with type 2 diabetes (T2D), the journey to diagnosis may not be straightforward. Patients can present with one of many diabetic complications before a diagnosis of T2D is made. These include heart disease and chronic kidney disease, in addition to cerebrovascular disease, peripheral vascular disease, retinopathy, and neuropathies, all of which can be asymptomatic in the early stages. In their clinical guidelines on standards of care in diabetes, the American Diabetes Association recommends regular screening for conditions such as kidney disease in patients with T2D. Furthermore, the frequent coexistence of diabetes and cardiorenal and/or metabolic conditions often requires a holistic approach to patient management, with specialists from multiple disciplines, including cardiologists, nephrologists, endocrinologists, and primary care physicians, working together. In addition to the use of pharmacological therapies, which can improve prognosis, the management of T2D should include attention to patient self-care, including appropriate dietary changes, consideration of continuous glucose monitoring, and advice on physical exercise. In this podcast, a patient and a clinician discuss a lived experience of the diagnosis of T2D, and the importance of patient education for understanding and managing T2D and its complications. The discussion highlights the central role of the Certified Diabetes Care and Education Specialist, and the role of ongoing emotional support in managing life with T2D, including patient education through reputable online resources and peer support groups. Podcast video with Pamela Kushner (PK) and Anne Dalin (AD) (MP4 92088 KB).

Barriers to Adoption of a Secure Text Messaging System: a Qualitative Study of Practicing Clinicians

BACKGROUND

Secure text messaging systems (STMS) offer HIPAA-compliant text messaging and mobile phone call functionalities that are more efficient than traditional paging. Although some studies associate improved provider satisfaction and healthcare delivery with STMS use, healthcare organizations continue to struggle with achieving widespread and sustained STMS adoption.

OBJECTIVE

To understand the barriers to adoption of an STMS among physicians and advanced practice providers (APPs).

DESIGN

We qualitatively analyzed free-text comments that clinicians (physicians and APPs) across a large healthcare organization offered on a survey about STMS perceptions.

PARTICIPANTS

A total of 1110 clinicians who provided a free-text comment in response to one of four open-ended survey questions.

APPROACH

Data were analyzed using a grounded theory approach and constant comparative method to characterize responses and identify themes.

KEY RESULTS

The overall survey response rate was 20.5% (n = 1254). Clinicians familiar with the STMS frequently believed the STMS was unnecessary (existing tools worked well enough) and would overburden them with more communications. They were frustrated that the STMS app had to be downloaded onto their personal mobile device and that it drained their battery. Ambiguity regarding who was reachable in the app led to missed messages and drove distrust of the STMS. Clinicians saw the exclusion of other care team members (e.g., nurses) from the STMS as problematic; however, some clinicians at hospitals with expanded STMS access complained of excessive messages. Secondhand reports of several of these barriers prevented new users from downloading the app and contributed to ongoing low use.

CONCLUSIONS

Clinicians are reluctant to adopt an STMS that does not offer a clear and trustworthy communication benefit to offset its potential burden and intrusiveness. Our findings can be incorporated into STMS implementation strategies that maximize active users by targeting and mitigating barriers to adoption.

Facilitators and Barriers to the Implementation of BETTER WISE, a Chronic Disease and Prevention Intervention in Canada: A Qualitative Study

The aim of the BETTER WISE intervention is to address cancer and chronic disease prevention and screening (CCDPS) and lifestyle risks in patients aged 40-65. The purpose of this qualitative study is to better understand facilitators and barriers to the implementation of the intervention. Patients were invited for a 1-h visit with a prevention practitioner (PP), a member of a primary care team, with specific skills in prevention, screening, and cancer survivorship. We collected and analyzed data from 48 key informant interviews and 17 focus groups conducted with 132 primary care providers and from 585 patient feedback forms. We analyzed all qualitative data using a constant comparative method informed by grounded theory and then employed the Consolidated Framework for Implementation Research (CFIR) in a second round of coding. The following key elements were identified: (1) Intervention characteristics-relative advantage and adaptability; (2) Outer setting-PPs compensating for increased patient needs and decreased resources; (3) Characteristics of individuals-PPs (patients and physicians described PPs as compassionate, knowledgeable, and helpful); (4) Inner setting-network and communication (collaboration and support in teams or lack thereof); and (5) Process-executing the implementation (pandemic-related issues hindered execution, but PPs adapted to challenges). This study identified key elements that facilitated or hindered the implementation of BETTER WISE. Despite the interruption caused by the COVID-19 pandemic, the BETTER WISE intervention continued, driven by the PPs and their strong relationships with their patients, other primary care providers, and the BETTER WISE team.

Immune Checkpoint Inhibitors in Breast Cancer: A Narrative Review

Breast cancer is the most frequently diagnosed malignancy in patients worldwide and the main cause of cancer-related death. Though still incurable, metastatic breast cancer's prognosis has been considerably improved in the past 10 years due to the introduction of new targeted agents, such as immune checkpoint inhibitors (ICI). However, these medications are associated with unique side effects known as immune-mediated adverse events (irAE). In this paper, we review the clinical evidence for the use of ICIs in breast cancer, in both the metastatic as well as neoadjuvant/adjuvant setting, followed by a review of irAE most commonly seen, and the medications used to treat them. Our opinion is that any cancer specialist treating patients with breast cancer should be aware of these side effects for early detection and management, and oncologists should be the leaders of the multidisciplinary team that will take care of them.

Improving care for older patients visiting emergency departments. Are they receiving falls prevention guideline care?

BACKGROUND

The primary objective was to examine whether the Emergency Department (ED) treatment of older adults who fall in Australia is concordant with falls prevention and management clinical guideline care recommendations.

METHODS

A retrospective medical records audit was completed for patients 65years and older, who attended the ED with a fall and were discharged home. An audit tool was developed from local, national, and international falls clinical guidelines.

RESULTS

One thousand and twenty-seven patients presented following a fall throughout 2020. One hundred and seven patient medical records were audited. Assessment of cognition (94%), medication review (76%) and use of a falls risk screen (76%) were commonly completed. Under half of the patients had a documented gait evaluation (40%) and review of vision (18%). Concordance with guideline care was more likely for older patients (p = 0.042), with higher levels of comorbidity (p = 0.013), who required care assistance (p = 0.008) and received treatment from a multidisciplinary team (p < 0.001) in an observation ward (p < 0.001).

CONCLUSIONS

Older patients with increased comorbidities and higher care needs had more falls guideline care recommendations documented. This was likely to occur when patients were moved to the observation ward where more comprehensive care by a multidisciplinary team could occur.

The Effects of Post-Acute Care in Patients with Heart Failure in Taiwan: A Single Center Experience

Background

The National Health Insurance Administration in Taiwan has promoted the heart failure post-acute care (HF-PAC) program as a means to provide proactive integrated care within the optimal treatment timeframe to enhance functional recovery after acute decompensated heart failure (HF).

Objectives

The aim of this program was to reduce HF readmission rates, improved medication prescription rates, and improve the quality of life in HF patients.

Methods

Patients who had a reduced left ventricular ejection fraction (LVEF) of ≤ 40% were included and followed up for 6 months after discharge. They underwent cardiac rehabilitation and physiological, and nutritional status evaluations. The main clinical outcomes of the HF-PAC program were guideline-directed medical therapy prescription rate and 6-month readmission rate.

Results

A total of 122 patients were recruited from June 2018 to December 2020 at a medical center in southern Taiwan. The patients' activities of daily living, nutritional status, quality of life and LVEF were significantly improved during the HF-PAC program. More than 95% of the patients received guideline-directed medical prescriptions at the end of the HF-PAC program. The cardiovascular-related 6-month re-admission rate after the HF-PAC program ended was 27.7%, and it could be predicted by the New York Health Association functional class [hazard ratio (HR) 95% confidence interval (95% CI) = 4.12 (1.36-12.46)], value of the Mini Nutritional Assessment - Short Form [HR (95% CI) = 0.46 (0.31-0.68)] and LVEF [HR (95% CI) = 0.95 (0.91-0.99)].

Conclusions

By incorporating multidisciplinary healthcare teams, the HF-PAC program improves the guideline- directed medical therapy prescription rate, thus improving patients' cardiac function, physical activity recovery, the quality of life, and also reduces their readmission rate.

[Interdisciplinary extremity board in the treatment of complex injuries]

BACKGROUND

Interdisciplinary case conferences are well-established in the field of oncology in order to provide the best possible treatment for patients with complex disease patterns which overlap several disciplines.

METHODS

After studying the available literature the aims, indications, frequency, patient enrolment and documentation modalities, disciplines necessary to create the reconstruction plan and evaluation parameters of the board, were agreed in an interdisciplinary discussion among colleagues. The utilization of the extremity board and demographic features of the cases presented in the extremity board within the first 6 months were subsequently descriptively analyzed.

RESULTS

The agreed primary aim of an extremity board is the timely and transparent preparation of a high-quality holistic reconstruction plan for optimized treatment of a challenging patient collective with complex injuries of the extremities. Decisive interfaces of an extremity board are the participation of interdisciplinary disciplines, established enrolment and documentation modalities and a longitudinal analysis of parameters of the acute medical treatment, the long-term function and quality of life of those affected. The patient collective so far mostly includes men under 40 years old with traumatic soft tissue defects and combined injuries. On average, reconstruction plans for 1-2 patients were approved in an interdisciplinary team per session.

CONCLUSION

The extremity board serves as a platform for coordinated planning of treatment for patients with complex injuries. The limited personnel and time resources represent the greatest challenge for the successful implementation. The extremity board enables a high degree of interdisciplinary networking. The digital registration and documentation modality within the internal hospital documentation system is of utmost relevance. The preparation of the reconstruction plan is of decisive importance for the qualitative success of treatment and the restoration of function. The longitudinal analysis of appropriate parameters is imperative to measure the quality of treatment.

Collaborative dietetic and psychological care in Interprofessional Enhanced Cognitive Behaviour Therapy for adults with Anorexia Nervosa: a novel treatment approach

Clinical practice guidelines for anorexia nervosa (AN) and atypical anorexia nervosa recommend treatment from a team including a mental health professional and a dietitian. To date, however, AN treatment models such as Enhanced Cognitive Behaviour Therapy (CBT-E) seldom include dietitians and have low to moderate treatment efficacy. Given interprofessional approaches to healthcare have been shown to improve treatment outcomes and enhance patient and clinician satisfaction, formalising collaborative dietetic and psychological treatment may be a feasible strategy to improve treatment outcomes and the patient and clinician experience of treatment. Moreover, malnutrition is a serious consequence of AN, and dietitians are considered experts in its diagnosis and treatment. This paper proposes a novel treatment approach, Interprofessional Enhanced Cognitive Behaviour Therapy (CBT-IE), an adaptation of CBT-E where dietitians deliver content related to malnutrition and dietary restraint and mental health professionals deliver content related to cognitive and behavioural change. The rationale for developing CBT-IE, treatment structure, and future research directions is discussed.

Prevention and screening during the COVID-19 pandemic: qualitative findings from the BETTER WISE project

BACKGROUND

The COVID-19 pandemic challenged healthcare systems worldwide and disrupted primary care, particularly prevention, screening, and lifestyle counselling. BETTER WISE is a comprehensive and structured approach that proactively addresses cancer and chronic disease prevention and screening (CCDPS), including cancer survivorship and screening for poverty and lifestyle risks for patients aged 40 to 65. Patients from 13 primary care clinics (urban, rural, and remote) in Alberta, Ontario, and Newfoundland & Labrador, Canada were invited for a 1-hour visit with a prevention practitioner (PP), a member of the primary care team with specialized training in CCDPS to provide patients an overview of eligible screening and assist with lifestyle counselling. This qualitative sub-study describes how the COVID-19 pandemic impacted BETTER WISE in a constantly changing medical landscape.

METHODS

We conducted 17 focus groups and 48 key informant interviews with a total of 132 primary care providers (PPs, physicians, allied health professionals, and clinic staff) over three different time points to better understand their perspectives on the BETTER WISE project. We also received 585 patient feedback forms of the 1005 patients who agreed to participate in the study. We also collected field notes and memos and employed thematic analysis using a constant comparative method focused on the impact of the pandemic on BETTER WISE.

RESULTS

We identified four themes related to how the COVID-19 pandemic impacted the BETTER WISE study: 1) Switch of in-person visits to visits over the phone; 2) Lack of access to preventive care and delays of screening tests; 3) Changes in primary care providers' availability and priorities; 4) Mental health impacts of the pandemic on patients and primary care providers.

CONCLUSIONS

The COVID-19 pandemic had and, at the time of writing, continues to have an impact on primary care, particularly on prevention, screening, and lifestyle counselling. Despite structural, procedural, and personal challenges throughout different waves of the pandemic, the primary care clinics participating in BETTER WISE were able to complete the study. Our results underscore the importance of the role of primary care providers in adapting to changing circumstances and support of patients in these challenging times.

TRIAL REGISTRATION

This qualitative study is a sub-component of the BETTER WISE pragmatic, cRCT, trial registration ISRCTN21333761 (date of registration 19/12/2016).

Pragmatic cluster randomized trial to evaluate effectiveness and implementation of EHR-facilitated collaborative symptom control in cancer (E2C2): addendum

We previously described the hypotheses, outcomes, design, and analysis for E2C2, a pragmatic stepped-wedge trial to assess an intervention to improve symptom control in patients with cancer. Subsequent consideration of the design and cohort led to the addition of a second primary hypothesis. This article describes and presents the rationale for this second hypothesis. This addendum also details a revised analytic approach, necessitated by inconsistencies in the original analytic plan. The design, outcomes, and other aspects of the protocol remain unchanged.

Radiologic-pathologic correlation of lesions in resected liver specimens with an ex vivo MRI-compatible localization device

OBJECTIVE

Liver lesion characterization is limited by the lack of an established gold standard for precise correlation of radiologic characteristics with their histologic features. The objective of this study was to demonstrate the feasibility of using an ex vivo MRI-compatible sectioning device for radiologic-pathologic co-localization of lesions in resected liver specimens.

METHODS

In this prospective feasibility study, adults undergoing curative partial hepatectomy from February 2018 to January 2019 were enrolled. Gadoxetic acid was administered intraoperatively prior to hepatic vascular inflow ligation. Liver specimens were stabilized in an MRI-compatible acrylic lesion localization device (27 × 14 × 14 cm3) featuring slicing channels and a silicone gel 3D matrix. High-resolution 3D T1-weighted fast spoiled gradient echo and 3D T2-weighted fast-spin-echo images were acquired using a single channel quadrature head coil. Radiologic lesion coordinates guided pathologic sectioning. A final histopathologic diagnosis was prepared for all lesions. The proportion of successfully co-localized lesions was determined.

RESULTS

A total of 57 lesions were identified radiologically and sectioned in liver specimens from 10 participants with liver metastases (n = 8), primary biliary mucinous cystic neoplasm (n = 1), and hepatic adenomatosis (n = 1). Of these, 38 lesions (67%) were < 1 cm. Overall, 52/57 (91%) of radiologically identified lesions were identified pathologically using the device. Of these, 5 lesions (10%) were not initially identified on gross examination but were confirmed histologically using MRI-guided localization. One lesion was identified grossly but not on MRI.

CONCLUSIONS

We successfully demonstrated the feasibility of a clinical method for image-guided co-localization and histological characterization of liver lesions using an ex vivo MRI-compatible sectioning device.

KEY POINTS

• The ex vivo MRI-compatible sectioning device provides a reliable method for radiologic-pathologic correlation of small (< 1 cm) liver lesions in human liver specimens. • The sectioning method can be feasibly implemented within a clinical practice setting and used in future efforts to study liver lesion characterization. • Intraoperative administration of gadoxetic acid results in enhancement in ex vivo MRI images of liver specimens hours later with excellent image quality.

Design, methods, and recruitment outcomes of the Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study

The Veterans' Pain Care Organizational Improvement Comparative Effectiveness (VOICE) study is a 12-month pragmatic randomized comparative effectiveness trial conducted at ten United States Veterans Affairs (VA) health care sites. The overall goal was to test interventions to improve pain while reducing opioid use among VA patients with moderate-severe chronic pain despite treatment with long-term opioid therapy (LTOT). Aims were 1) to compare lower-intensity telecare collaborative pain management (TCM) versus higher-intensity integrated pain team management (IPT), and 2) to test the option of switching to buprenorphine (versus no option) in a high-dose subgroup. Recruitment challenges included secular trends in opioid prescribing and the COVID-19 pandemic. Participants were recruited over 3.5 years. Of 6966 potentially eligible patients, 4731 (67.9%) were contacted for telephone eligibility interview; of those contacted, 3398 (71.8%) declined participation, 359 (7.6%) were ineligible, 821 (24.2%) enrolled, and 820 (24.1%) were randomized. The most common reason for declining was satisfaction with pain care (n = 731). The most common reason for ineligibility was not having moderate-severe chronic pain (n = 110). Compared with the potentially eligible population, randomized participants were slightly younger, more often female, had similar prescribed opioids, and had similar or higher rates of pain and mental health diagnoses. The enrolled patient number was lower than the original target, but sufficient to power planned analyses. In conclusion, the VOICE trial enrolled a diverse sample similar to the population of VA patients receiving LTOT. Results will add substantially to limited existing evidence for interventions to improve pain while reducing opioid use. ClinicalTrials.gov identifier: NCT03026790.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis

BACKGROUND

Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA_1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes.

METHODS

PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA_1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ² and I² test statistics. Overall effects were evaluated using Z statistic.

RESULTS

A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA_1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA_1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI.

CONCLUSIONS

CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA_1c is ≥8% and with interventions containing four or more CCM elements.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO  CRD42021273959.

Characterizing intensive care unit rounding teams using meta-data from the electronic health record

PURPOSE

Teamwork is an important determinant of outcomes in the intensive care unit (ICU), yet the nature of individual ICU teams remains poorly understood. We examined whether meta-data in the form of digital signatures in the electronic health record (EHR) could be used to identify and characterize ICU teams.

METHODS

We analyzed EHR data from 27 ICUs over one year. We linked intensivist physicians, nurses, and respiratory therapists to individual patients based on selected EHR meta-data. We then characterized ICU teams by their members' overall past experience and shared past experience; and used network analysis to characterize ICUs by their network's density and centralization.

RESULTS

We identified 2327 unique providers and 30,892 unique care teams. Teams varied based on their average team member experience (median and total range: 262.2 shifts, 9.0-706.3) and average shared experience (median and total range: 13.2 shared shifts, 1.0-99.3). ICUs varied based on their network's density (median and total range: 0.12, 0.07-0.23), degree centralization (0.50, 0.35-0.65) and closeness centralization (0.45, 0.11-0.60). In a regression analysis, this variation was only partially explained by readily observable ICU characteristics.

CONCLUSIONS

EHR meta-data can assist in the characterization of ICU teams, potentially providing novel insight into strategies to measure and improve team function in critical care.

Identifying Situational Awareness Behaviors in Trauma Teams; a Nominal Group Technique Study

Introduction

Situational awareness (SA), as a nontechnical human factor, is critical to the success of a trauma team. This study aimed to identify representatives of behaviors supporting (desirable) and diminishing (undesirable) SA for trauma teams while performing the initial assessment of multi-trauma patients.

Methods

This Nominal Group Technique Study was conducted on twenty attending physicians from various specialties affiliated with Tehran University of Medical Sciences, who were invited to a nominal group technique meeting in 2020. Participants were asked to write down their proposed behaviors in silence. Subsequently, each participant shared their list with the group in a round-robin format, and clarifications were made through discussion. After categorizing the ideas, we asked participants to rate each behavior's importance on a five-point Likert scale. The consensus was defined as ≥70% agreement on a rating of 4 and 5.

Results

The final SA behaviors for the trauma team consisted of 29 (22 desirable and 7 undesirable) behaviors arranged in seven dimensions: resource allocation, anticipate and plan, avoid fixation errors, call for help if needed, prioritize attention, reassess patient, and shared mental model. The most important desirable and undesirable behaviors were identified in resource allocation (n=8) and avoid fixation errors (n=7) dimensions, respectively. Resource allocation behaviors consist of 'checking necessary equipment', 'allocating an alternative person(s) to do the required task if needed', 'assigning tasks to the right person(s)', and 'Addressing each team member with a requested task'. Avoid fixation errors behaviors were 'insisting on performing the procedure', 'making decisions without considering all available information', and 'emphasizing others' expertise in the diagnostic process'.

Conclusion

The proposed team SA behaviors may be used in assessing the trauma team performance and training program to promote trauma team SA.

Efficacy of geriatric multidisciplinary oncology clinic in the surgical treatment decision-making process for frail elderly patients with colorectal cancer

Purpose

Multidisciplinary care has become a cornerstone of colorectal cancer management. To evaluate the clinical efficacy of a geriatric multidisciplinary oncology clinic (GMOC), we analyzed the surgical treatment decision-making process and outcomes.

Methods

This retrospective single-center study reviewed the data of patients aged ≥65 years who participated in the GMOC at a tertiary referral hospital between 2015 and 2021. The clinical adherence rate, comprehensive geriatric assessment, and a multidimensional frailty score (MFS) were obtained. The groups that were recommended and not recommended for surgery were compared, analyzing the factors impacting the decision and 1-year survival outcomes. Furthermore, the postoperative complications of patients who underwent surgery were evaluated.

Results

A total of 165 patients visited the GMOC, and 74 had colorectal cancer (mean age, 85.5 years [range, 81.2–89.0 years]). Among patients with systemic disease (n = 31), 7 were recommended for surgery, and 5 underwent surgery. Among patients with locoregional disease (n = 43), 18 were recommended for surgery, and 12 underwent surgery. Patients recommended and not recommended for surgery had significantly different activities of daily living (ADL) (P = 0.024), instrumental ADL (P = 0.001), Mini-Mental State Examination (P = 0.014), delirium risk (P = 0.039), and MFS (P = 0.001). There was no difference in the 1-year overall survival between the 2 groups (P = 0.980). Of the 17 patients who underwent surgery, the median (interquartile range) of operation time was 165.0 minutes (120.0–270.0 minutes); hospital stay, 7.0 days (6.0–8.0 days); and 3 patients had wound complications.

Conclusion

Proper counseling of patients through the GMOC could lead to appropriate management and favorable outcomes.

Engaging with ethnic minority consumers to improve safety in cancer services: A national stakeholder analysis

OBJECTIVE

Ethnic minority populations are often exposed to healthcare-associated harm. There is little evidence about whether current patient engagement interventions are relevant. We conducted a national analysis of existing approaches amongst stakeholders in cancer care.

METHODS

Five online focus groups were conducted with 24 participants from consumer and health organisations across the Australian cancer system. Case studies depicting common methods of healthcare engagement to improve patient safety were developed and used to explore the suitability of current methods. Data were analysed thematically using the framework method.

RESULTS

Three themes were identified: 1) sociocultural foundations of consumer engagement; 2) principles for adaptation; and 3) integration and implementation into cancer services. Sociocultural beliefs about cancer were considered to influence suitability. Adaptation may include multichannel methods, visual modalities and culturally specific content. Health system capacity, cultural competence of health service providers and consumer-led co-development were identified as critical to successful implementation.

CONCLUSIONS

Existing engagement strategies are not completely suitable for ethnic minority populations nor feasible for implementation within cancer services.

PRACTICE IMPLICATIONS

Healthcare services must work with ethnic minority populations to understand if and how underpinning beliefs influence engagement with cancer services. A range of tangible techniques may enhance the suitability of existing interventions.

A framework to support the progressive implementation of integrated team-based care for the management of COPD: a collective case study

Background

In Canada, there is widespread agreement about the need for integrated models of team-based care. However, there is less agreement on how to support the scale-up and spread of successful models, and there is limited empirical evidence to support this process in chronic disease management. We studied the supporting and mitigating factors required to successfully implement and scale-up an integrated model of team-based care in primary care.

Methods

We conducted a collective case study using multiple methods of data collection including interviews, document analysis, living documents, and a focus group. Our study explored a team-based model of care for chronic obstructive pulmonary disease (COPD) known as Best Care COPD (BCC) that has been implemented in primary care settings across Southwestern Ontario. BCC is a quality improvement initiative that was developed to enhance the quality of care for patients with COPD. Participants included healthcare providers involved in the delivery of the BCC program.

Results

We identified several mechanisms influencing the scale-up and spread of BCC and categorized them as Foundational (e.g., evidence-based program, readiness to implement, peer-led implementation team), Transformative (adaptive process, empowerment and collaboration, embedded evaluation), and Enabling Mechanisms (provider training, administrative support, role clarity, patient outcomes). Based on these results, we developed a framework to inform the progressive implementation of integrated, team-based care for chronic disease management. Our framework builds off our empirical work and is framed by local contextual factors.

Conclusions

This study explores the implementation and spread of integrated team-based care in a primary care setting. Despite the study’s focus on COPD, we believe the findings can be applied in other chronic disease contexts. We provide a framework to support the progressive implementation of integrated team-based care for chronic disease management.

Association of care by a non-medical intensive care unit provider team with outcomes of medically critically ill patients

OBJECTIVE

To determine the association of boarding of critically ill medical patients on non-medical intensive care unit (ICU) provider teams with outcomes.

DESIGN

A retrospective cohort study.

SETTING

ICUs in a tertiary academic medical center.

PATIENTS

Patients with medical critical illness.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

We compared outcomes for critically ill medical patients admitted to a non-medical specialty ICU team (April 1 - August 30, 2020) with those admitted to the medical ICU team (January 1, 2018 - March 31, 2020). The primary outcome was hospital mortality; secondary outcomes were hospital length of stay (LOS) and hospital disposition for survivors. Our cohort consisted of 1241 patients admitted to the medical ICU team and 230 admitted to non-medical ICU teams. Unadjusted hospital mortality (medical ICU, 38.8% vs non-medical ICU, 42.2%, p = 0.33) and hospital LOS (7.4 vs 7.4 days, p = 0.96) were similar between teams. Among survivors, more non-medical ICU team patients were discharged home (72.6% vs 82.0%, p = 0.024). After multivariable adjustment, we found no difference in mortality, LOS, or home discharge between teams. However, among hospital survivors, admission to a non-medical ICU team was associated with a longer LOS (regression coefficient [95% CI] for log-transformed hospital LOS: 0.23 [0.05,0.40], p = 0.022). Certain subgroups-patients aged 50-64 years (odds-ratio [95% CI]: 4.22 [1.84,9.65], p = 0.001), with ≤10 comorbidities (0-5: 2.78 (1.11,6.95], p = 0.029; 6-10: 6.61 [1.38,31.71], p = 0.018), without acute respiratory failure (1.97 [1.20,3.23], p = 0.008)-had higher mortality when admitted to non-medical ICU teams.

CONCLUSIONS

We found no association between admission to non-medical ICU team and mortality for medically critically ill patients. However, survivors experienced longer hospital LOS when admitted to non-medical ICU teams. Middle-aged patients, those with low comorbidity burden, and those without respiratory failure had higher mortality when admitted to non-medical ICU teams.

Plasma exchange in the intensive care unit: a narrative review

In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.

Semi-intensive and Intensive Interdisciplinary Treatments Have Similar Effects on Metabolic Syndrome and Selected Inflammatory Markers in Adolescents with Obesity

Background

The purpose of the present study was to compare the impact of semi-intensive and intensive interdisciplinary weight-loss therapies on the treatment of metabolic syndrome (MS) and selected inflammatory markers in adolescents with obesity.

Methods

The study included 166 adolescents enrolled in two groups for 22 weeks: the intensive group (in-person aerobic and resistance exercise three times a week, and psychological and nutritional counselling once a week), or the semi-intensive group (six in-person exercise orientation meetings and six in-person psychological support sessions with an online nutritional and exercise program). Anthropometric parameters, blood pressure, fasting glucose, insulin, lipid profile, triglycerides (TG), leptin and adiponectin were assessed before and after the interventions.

Results

Body weight and waist circumference decreased in both groups (P<0.001) and large effect sizes (η²= 0.586 and η²=0.465, respectively) were noted. Significant time and group interactions were found (P=0.001) with medium effect sizes (η²=0.095 and η²=0.105, respectively). The prevalence of MS decreased from 27.9% to 13.1% (P=0.012) and 29.4% to 5.9% (P=0.004) in the semi-intensive and intensive groups, respectively. All MS risk factors decreased significantly over time (P<0.001) and a significant time*group interaction was observed (P<0.05), except for fasting TG (P=0.832) and glucose (P=0.128, η²=0.021).

Conclusion

The results suggested that both approaches promoted significant clinical improvement in the condition of adolescents with MS and reduced associated risk factors. Studies that consider the cost effectiveness of both treatments are still needed to determine whether semi-intensive care, with its lower financial costs, may be a suitable option to treat obesity and MS in adolescents with obesity.

Identifying the Needs Based on the Patients' Performance Status for Palliative Care Team: An Observational Study

Objectives:

The study aim was to determine the association between patient performance status (PS) and the contents of a palliative care team (PCT) intervention. Identifying intervention requirements for differing PS may help to provide appropriate palliative care in under-resourced facilities.

Materials and Methods:

We collected data from medical records of inpatients (n = 496) admitted to PCT services at a centre for palliative care at Kindai University Hospital, Japan, from April 2017 to March 2019. We analysed the content of PCT activities according to each PS using Pearson’s Chi-square test.

Results:

The following PCT activities were provided in full regardless of PS: Gastrointestinal symptoms, depression, medical staff support, food and nutrition support and oral care. The following PCT responses were associated with PS: Pain, respiratory symptoms, fatigue, insomnia, anxiety, delirium, decision-making support, family support and rehabilitation. PS3 patients tended to receive those PCT interventions associated with PS, except for anxiety and fatigue. PS4 patients received PCT interventions for respiratory symptoms, delirium and family support. Patients with good PS (0–1) tended to receive PCT interventions for anxiety.

Conclusion:

This study demonstrated that there were different needs for different PS. The results may allow for efficient interventions even in facilities with limited resources.

Results from a PI-RADS-based MRI-directed diagnostic pathway for biopsy-naive patients in a non-university hospital

Purpose

To assess the safety and performance of a MRI-directed diagnostic pathway for patients with first-time suspicion of prostate cancer in a non-university hospital.

Methods

Between May 2017 and December 2018 all biopsy-naive patients examined in our hospital followed a MRI-directed diagnostic work-up algorithm based on PI-RADS score. In short, PI-RADS 1–2 was generally not biopsied and PI-RADS 3–5 was reviewed by a multidisciplinary team. Patients with PI-RADS 4-5 were all referred to biopsy, either transrectal ultrasound-guided biopsy or MRI in-bore biopsy for small tumors and for sites difficult to access. PI-RADS scores were compared to the histopathology from biopsies and surgical specimens for patients who had prostatectomy. Non-biopsied patients were referred to a safety net monitoring regimen.

Results

Two hundred and ninety-eight men were enrolled. 97 (33%) had PI-RADS 1–2, 44 (15%) had PI-RADS 3, and 157 (53%) had PI-RADS 4–5. 116 (39%) of the patients avoided biopsy. None of these were diagnosed with significant cancer within 2–3.5 years of safety net monitoring. Almost all high ISUP grade groups (≥ 3) were in the PI-RADS 4–5 category (98%). Prostatectomy specimens and systematic biopsies from MRI-negative areas indicated that very few clinically significant cancers were missed by the MRI-directed diagnostic pathway.

Conclusion

Our findings add to evidence that a MRI-directed diagnostic pathway can be safely established in a non-university hospital. The pathway reduced the number of biopsies and reliably detected the site of the most aggressive cancers.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03249-8.

The development and implementation of a "B-Team" (buprenorphine team) to treat hospitalized patients with opioid use disorder

IMPLEMENTATION INSIGHTS.

Teamwork competencies for interprofessional cancer care in multiteam systems: A narrative synthesis

Numerous teamwork competency frameworks are designed for co-located, procedure-driven teams delivering care in acute settings. Little is known about their applicability or evaluation among larger teams-of-teams, known as multiteam systems (MTS), involved in delivering care for complex chronic conditions like cancer. In this review we aimed to identify studies examining teamwork competencies or teamwork competency frameworks developed or tested in healthcare teams, identify the extent to which they have been applied or evaluated in cancer care, and understand their applicability to larger MTSs involved in coordinating cancer care. We identified 107 relevant original articles, consensus statements, and prior systematic reviews published from 2013-2019. Most original papers (n = 96) were intervention studies of inpatient acute care teams (52, 54%). Fifty-eight articles (60%) used existing frameworks to define competency domains. Four original articles and two consensus statements addressed teamwork competencies for cancer care. Few frameworks or interprofessional education (IPE) curricula specifically addressed teamwork among larger, distributed teams or examined competencies necessary to overcome care coordination challenges in cancer care MTSs. Research guiding the development of frameworks and IPE that consider challenges to effective coordination among larger MTSs and studies of their impact on patient and clinical outcomes is essential to optimal, high-quality care.

Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents

Background

An existing hospital avoidance program, the Aged Care Rapid Response Team (ARRT), rapidly delivers geriatric outreach services to acutely unwell or older people with declining health at risk of hospitalisation. The aim of the current study was to explore health professionals’ perspectives on the factors impacting ARRT utilisation in the care of acutely unwell residential aged care facility residents.

Methods

Semi-structured interviews were conducted with two Geriatricians, two ARRT Clinical Nurse Consultants, an ED-based Clinical Nurse Specialist, and an Extended Care Paramedic. Interview questions elicited views on key factors regarding care decisions and care transitions for acutely unwell residential aged care facility residents. Thematic analysis was undertaken to identify themes and sub-themes from interviews.

Results

Analysis of interviews identified five overarching themes affecting ARRT utilisation in the care of acutely unwell residents: (1) resident care needs; (2) family factors; (3) enabling factors; (4) barriers; and (5) adaptability and responsiveness to the COVID-19 pandemic.

Conclusion

Various factors impact on hospital avoidance program utilisation in the care of acutely unwell older aged care facility residents. This information provides additional context to existing quantitative evaluations of hospital avoidance programs, as well as informing the design of future hospital avoidance programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06575-1.