A qualitative research on co-creating care pathways for Sarcoma and GIST by stimulating reflection

This study was conducted to prioritize the competencies for the operational manager regarding the management of care pathways. In the Schouten & Nelissen Competence Model (SNCM), the operational manager works according to the management style ‘task-centred leader/producer’. A measurement instrument was developed to conduct a Delphi study. The competencies on which complete consensus has been reached were presented to a focus group in the second phase of the study. The Delphi was carried out with five experts in three rounds. Complete consensus on 30 competencies was reached. The focus group consisted of three participants and produced 10 core competencies. These belong to the level of operational management and the management style ‘task-centred leader/producer’ in the SNCM. The number of experts in both the Delphi study and focus group was limited, which may have influenced the outcome. There is hardly any literature on competencies operational managers' need for managing care pathways. This study has produced 10 competencies that the operational manager needs for coordinating care pathways. These core competencies can be used to specify or complete the competence profile of operational managers working with care pathways.

Within the Belgian-Dutch Clinical Pathway Network, there is a need for research concerning the management of care pathways in care processes. The purpose of this research is to develop a list of required competencies for operational managers regarding the process management of care pathways by means of a literature review. A search in Pubmed/Medline, Embase and Cinahl was carried out between 2001 and 2006. Twenty-three articles were found and 10 of them were included. The study describes experiences of professionals, in relation to tasks and skills. These descriptions are compared and connected to the competencies according to the Schouten & Nelissen Competence Model. The results are combined in order to create competencies for the operational manager to manage care pathways. These factors can be influenced by managers if they have the appropriate competencies.

Aim Integrated care pathways (ICP) are management technologies which formalise multidisciplinary team-working and enable professionals to examine their roles and responsibilities. ICPs are now being implemented across international healthcare arena, but evidence to support their use is equivocal. The aim of this study was to identify the circumstances in which ICPs are effective, for whom and in what contexts. Methods A systematic review of high-quality randomised controlled trials published between 1980 and 2008 (March) evaluating ICP use in child and adult populations in the full range of healthcare settings. 1 For relatively predictable trajectories of care ICPs can be effective in supporting proactive care management and ensuring that patients receive relevant clinical interventions and/or assessments in a timely manner. This can lead to improvements in service quality and service efficiency without adverse consequences for patients. 2 ICPs are an effective mechanism for promoting adherence to guidelines or treatment protocols thereby reducing variation in practice. 3 ICPs can be effective in improving documentation of treatment goals, documentation of communication with patients, carers and health professionals. 4 ICPs can be effective in improving physician agreement about treatment options. 5 ICPs can be effective in supporting decision-making when they incorporate a decision-aide. 6 The evidence considered in this review indicates that ICPs may be particularly effective in changing professional behaviours in the desired direction, where there is scope for improvement or where roles are new. 7 Even in contexts in which health professionals are already experienced with a particular pathway, ICP use brings additional beneficial effects in directing professional practice in the desired direction. 8 ICPs may be less effective in bringing about service quality and efficiency gains in variable patient trajectories. 9 ICPs may be less effective in bringing about quality improvements in circumstances in which services are already based on best evidence and multidisciplinary working is well established. 10 Depending on their purpose, the benefits of ICPs may be greater for certain patient subgroups than others. 11 We do not know whether the costs of ICP development and implementation are justified by any of their reported benefits. 12 ICPs may need supporting mechanisms to underpin their implementation and ensure their adoption in practice, particularly in circumstances in which ICP use is a significant change in organisational culture. 13 ICP documentation can introduce scope for new kinds of error. Conclusions ICPs are most effective in contexts where patient care trajectories are predictable. Their value in settings in which recovery pathways are more variable is less clear. ICPs are most effective in bringing about behavioural changes where there are identified deficiencies in services; their value in contexts where inter-professional working is well established is less certain. None of the studies reviewed included an economic evaluation and thus it is not known whether their benefits justify the costs of their implementation.

Situation of study (SoS) has been reported as an excellent strategy to promote students’ significant learning. This work intended to demonstrate how a SoS on health education (“Knowing cancer: a way to life”) can be implemented within the co-creation (CoC) framework. The study was carried out in a middle school, with the participation of five groups: students (14-15 years old), teachers, future teachers, university teacher trainers and health professionals. The 10 activities were carried out in school and outdoors for five months, undergoing a process of self-reflexive cycle: “reflecting and planning”, “acting and observing”, and “analyzing and reflecting”. Transcripts of debates and of students’ and teachers’ texts were subject to content analysis. This study on a topic of health education demonstrated that the Situation of Study implemented in a co-creation process was very efficient for students to develop significant learning.

There is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of 'care maps' - a patient-identified social network map of their care community - for health professionals in providing person-centred care. We piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes. Health professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients' support networks, synthesising what is known and unknown. Health professionals understood patients' perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice. Care maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had 'social function' for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients' lifeworlds.

Families are involved in decision-making regarding end-of-life (EOL) care in Japan. However, how support from medical professionals toward families' decision-making affects families' satisfaction with EOL care has not been adequately studied. We aimed to examine the impact of support from medical professionals considering the care recipients' preferences on families' overall satisfaction with EOL care and the mediating effect of fulfilling care recipients' preferences.We administered self-report questionnaires through home-nursing providers to bereaved families (n=753), who lost loved ones between April 2015 and March 2016. Analyses were conducted with 237 of these bereaved families whose loved ones had been ≥65 years old, and had no missing values in key variables. We asked whether the families had received any support from medical professionals in determining the care recipients' EOL preferences, in discussing how to honor the care recipients' own interests, and in supporting the families' decision-making. We also collected data measuring the overall satisfaction with EOL care, families' perceptions that the care recipients' preferences were honored during EOL care, and demographic characteristics of care recipients and caregivers.Data from 58 male and 179 female family members were analyzed. The average age was 65.8 (standard deviation [SD]=11.9) years. Care recipients were 113 men and 124 women, and their average age was 83.0 (SD=9.1) years old at the time of death. A path analysis revealed that support for families from medical professionals was related to families' satisfaction with EOL care through the mediating factor of fulfilling care recipients' preferences.Support from medical professionals considering care recipients' preferences will help families' involvement in EOL decision-making.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract. Their main features are the expression of CD117 (KIT) and mutations of KIT or PDGFRA in 85 % of patients. however, 10–15 % of adult GIST and 85 % of pediatric GIST do not have KIT/PDGFRA mutations (KIT/PDGFRA WT GIST or “wild-type” GIST). The prognosis and clinical course of these tumors and GIST with KIT/PDGFRA mutations differ. “Wild-type” GIST are quite heterogeneous group of tumors in terms of clinical phenotype, genetic etiology, and molecular pathways. Gastrointestinal stromal tumors are divided into SDH-deficient and SDH-competent based on the succinate dehydrogenase (SDH) complex. SDH-deficient GIST occur predominantly in children and young patients with Carney–Stratakis syndrome and Carney triad; there are also sporadic tumors. More than half of SDH-deficient GIST contain mutations in SDHA, SDHB, SDHD or SDHC, while the rest are caused by hypermethylation of the SDHC promoter. SDH-competent “wild-type” GIST include tumors with BRAF, RAS, or NF1 mutations that activate the RAS-RAF-MAPK pathway and KIT/PDGFRA/SDH/RAS-P WT GIST subtype or “quadruple wild type” GIST. The genomic profiles of these tumors and GIST with KIT/PDGFRA mutation or SDH deficiency differ significantly. One of the features of “quadruple wild type” GIST is activation of the FGFR (fibroblast growth factor receptors) signaling pathway due to chimeric FGFR, FGFR mutations, or overexpression of FGF (fibroblast growth factor). Another feature is chimeric genes containing fragments of NTRK, BRAF, FGFR and other genes that behave as oncogene drivers. In “quadruple wild-type” GIST the somatic mutations in TP53, MAX, MEN1, CTNND2, CHD4, ARIDIA and other genes were revealed as well as in the cell cycle genes RB1, CDK4, CDKN1B. There is no specific treatment for patients with “wild-type” GIST; the choice of drug is determined by the genetic disorder. There is a need to improve our understanding of the molecular mechanisms underlying the different GIST subtypes to develop more effective therapeutic approaches.

This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review. To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles. We conducted the original search in September 2009, and the updated search in June 2013. All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Two review authors assessed the results of the searches against the predetermined criteria for inclusion. The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update. With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review. To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015. All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane. We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study. There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

Effect of support programme to reduce stress in spouses whose partners ‘fall off’ clinical pathways post cardiac surgery

Quality of life is recognized as an important outcome of health care for people with all abilities. There has been a marked increase in interest and the number of oral health-related quality of life (OHRQoL) instruments. In the absence of adequate care, resulting oral diseases like dental caries and periodontal problems can have not only physical and functional but also social, psychological and economic impacts.1 However, there is no such study on people with disabilities for whom it is difficult to assess the quality of life, especially those with limited or no communication skills, who are unable to express pain and discomfort. They depend greatly on their carers for their daily activities including oral care and for seeking appropriate dental treatment that could have an impact on their quality of life. Carers play the ‘gate keeper role’ as a contact person of the care recipient making decisions on their behalf and the ‘supportive role’, assisting with oral care and making visits to the dentist.2 The most widely reported reason for dental visits is when a carer suspects that the care recipient might be experiencing pain by noting changes in behaviour particularly at mealtimes, followed by secondary reasons including halitosis, drooling and aspiration of food and/or liquids.3 It is the carer who is best placed to note small changes in behaviour and detect any problem. It is the carer’s perceived impact of conditions that will drive them to take their care recipient for treatment. Therefore, the overall aim was to assess oral health-related quality of life (OHRQoL) among adults with disabilities, from the carer's perspective. The specific aims were to: (1) compare reported negative impacts with indicators like oral health problems and treatment need; and (2) determine factors that are associated with reports of one or more negative impacts on OHRQoL. The study was a cross-sectional survey of carers of 18–44 year olds with physical and intellectual disabilities living in South Australia in three settings: family home, community housing and institutions. Ethical clearance was obtained from The University of Adelaide Human Research Ethics Committee in July 2004. In August 2004, 21 organizations were approached to seek their assistance in contacting carers of 18–44 year old care recipients with physical and intellectual disabilities registered with them. From the information received, the target sample was carers of 1448 disabled adults. However, after removing people who were deceased or out-of-scope due to age, and after reconciling duplicate responses, the adjusted target was 1280 care recipients. In February 2005, 12 participating organizations sent an information package to the primary carer of each registered care recipient in their database which included an information sheet on the study for the carer and the care recipient, a questionnaire for the carer and a reply-paid envelope. A reminder card was posted to all carers two weeks later and a final follow-up letter to all non-responders four weeks later. A mail questionnaire was completed by carers between February and June 2005. Questions included carer characteristics, care recipient characteristics, questions from oral health impact profile (OHIP),4 oral hygiene practices, oral health problems and perceived treatment need. From Locker's model of oral health,1 four conceptual dimensions of impact were explored – psychological disability, physical pain, physical disability and social disability – using four questions from OHIP. Questions from OHIP were: How often during the last year has your main care recipient … had trouble sleeping (psychological disability); had pain and discomfort (physical pain); had unsatisfactory diet (physical disability); been irritable (social disability)…because of a dental problem? These four questions were selected from the 49-item OHIP questionnaire4 with the assumption by the authors that observable domains like function (problem eating) or social issues (irritability) are more likely to be validly assessed. Studies show that proxies appear to provide better answers about more objective rather than subjective information, with validity of the information increasing with the closer personal relationship to the proxy.5 Responses were made on a Likert scale ranging from ‘never’ (code = 1), ‘rarely’(code = 2), ‘sometimes’ (code = 3), ‘fairly often’ (code = 4), and ‘very often’ (code = 5). The last three responses were coded as negative impact on quality of life. As a significant proportion of carers responded ‘don't know’, it was treated as an additional response (code = 6). Responses were received for 485 adults with disabilities (37.9%). The data were weighted to represent the South Australian population of adults with disabilities.6 Unweighted data were used to describe characteristics of carers and care recipients. Subsequent analyses were undertaken using weighted data. The characteristics of the carers are described in Table 1. Approximately one-third of carers were over the age of 55 and 82.3% were females. Carers comprised of family carers (51.9%) and non-family carers (48.1%) in institutions and community housing. Characteristics of the care recipients are described in Table 2. There were slightly more males than females (61.9% male, 38.1% female), with 47.4% of them living with family, 31.4% in the community and 21.2% in institutions. The main disabling conditions were intellectual disability (38.5%), autism (31.7%), cerebral palsy (19.5%) and others (spina bifida, quadriplegia, head injury) (10.4%). While 21.3% communicated non-verbally, almost a third (30.3%) of their care recipients had little or no effective communication. Non-verbal means of communications included sign language, use of picture cards/boards, writing, typed/computer messages. Other (Spina bifida, quadriplegia, head injury) Prevalence of negative impact from a dental problem on individual items like diet, sleep, behaviour, and pain and discomfort was low. About 9.2% reported a negative impact for pain and discomfort, 7.7% for irritable behaviour, 6.1% for trouble sleeping, and 3.0% related to unsatisfactory diet. However, more than one in 10 care recipients (13.5%) reportedly experienced one or more negative impacts (Impact 1+) during the last year. The proportion of ‘don't know’ for each question was higher (Table 3). A much higher proportion of carers thought their care recipient currently had both an oral health problem and dental treatment need (Table 4). Some 11.8% of carers reported not knowing whether their care recipient had an oral health problem and a slightly higher 14.7% responded ‘don't know’ for perceived treatment need. The most frequent oral health problem reported was bad breath followed by decay and bleeding gums (Table 5). Other problems included ulcers, infection, tartar build-up, tooth wear and wisdom teeth. Accordingly, the most frequent perceived treatment need reported was scaling (89.6%), followed by filling (21.2%) (Table 6). Other perceived treatment needs included general check-up and capping of worn teeth. Table 7 summarizes perceived negative impacts as reported by carers from family, community and institutional settings. About 13.5% of care recipients reportedly experienced one or more negative impacts (Impact 1+), with family carers reporting more negative impacts compared to carers from other settings (p < 0.05). Reported negative impacts were more among those who could communicate verbally than for those with little or no communication (Table 8). For all other associations, ‘don't know’ response was treated as ‘missing’. Binary logistic regression modelling testing bivariate associations was carried out to examine which care recipient and carer factors were associated with reporting of one or more negative impacts (Impact 1+). Family carers and one-on-one carers reported greater odds of their care recipient having one or more negative impacts compared to care recipients cared for by non-family carers and care recipients with 5+ carers respectively (Table 9). Family carers had just over two times the odds of reporting negative impacts (OR = 2.1, [0.97, 4.6]) than non-family carers. The odds of negative impacts reported for those receiving one-on-one care was almost five times more than for those cared for by five or more carers (OR = 4.8, [1.8, 12.9]). The younger age group, those with autism and those who communicate verbally were reported to have experienced more negative impacts than their older counterparts, those with other disabling conditions and those who lacked verbal means of communication respectively. Once a day toothbrushing, those with oral health problems and perceived treatment need were associated with higher odds of negative impact than twice a day toothbrushing, and those without oral health problems and no perceived treatment need. After adjusting for carer- and care recipient-characteristics, multivariate analysis showed that there were more reports of negative impacts for those who could communicate verbally, than for those with non-verbal and little or no effective communication. Also, those reported to have perceived dental treatment need had about six times the odds of reporting of one or more negative impacts (Table 10). Age, disabling condition, toothbrushing frequency, carer type, number of carers providing care and oral health problems were not statistically significant (p > 0.05). The low response rate seems to reflect the time constraints faced by carers of people with disabilities. There were several other reasons or comments for non-response to the questionnaires. Some returned blank questionnaires or with short comments like ‘thanks but no thanks’ and ‘happy with private practice’. Some called to say they were not willing to participate, giving reasons like they were sick of surveys that did not help them and that research is done only to get a degree. There was a 75-year-old female who called to say she was unable to complete the questionnaire and there was no one else to help her, highlighting yet another problem of ageing carers. One was too sick to participate and another had died. Over 30% of carers were over the age of 55 years, highlighting another problem in the near future when these ageing carers (especially parents) themselves become functionally dependent. The high prevalence of non-verbal and little or no effective communication in this population challenges both carers and health professionals in providing care. Carers, who are expected to best know their care recipients, were unable to report OHRQoL for a significant proportion (18%) of those with little or no effective communication skills. When they did, negative impacts reported were much lower than reported oral health problems and perceived treatment need, suggesting carers may be underestimating pain and suffering experienced by their care recipients. Furthermore, a retrospective study of 103 special needs patients in France has shown that dental needs of special care patients are severely underestimated by both their carers and the dental profession.3 It can be argued that the more frequently reported oral health problems like gum problems and bad breath may not be assessed as having a negative impact on the OHIP questions used in this survey. At the same time, it must also be noted that the gum problems in this population may be more on the extreme end of the scale compared to the general population and could be causing pain and discomfort. Bad breath could be putting off the carers from cleaning their care recipient's teeth and the problem could worsen with time and have additional negative impacts on social life. From the responses from this survey, perhaps more appropriate additional questions asked could have been: How often during the last year, has your main care recipient … had stale breath (functional limitation), had painful gums (physical pain) because of a dental problem? Family carers and one-on-one carers reported more negative impacts than other carers, suggesting that they may be more observant. Alternatively, those being cared for by family carers and one-on-one carers may in fact be having more oral health problems, perceived dental treatment need and therefore more reported negative impacts. More of the younger care recipients live at home and are cared for by parents and therefore the association between younger age group and higher reporting of negative impacts. Those with autism and other disabling conditions where care recipients are able to communicate verbally were more likely to report negative impacts. After adjusting for carer- and care recipient-characteristics, multivariate analysis showed that those who could communicate verbally and reported perceived dental treatment need had higher odds of reporting negative impacts than those who communicated non-verbally or had little or no effective communication skills, and did not report reported perceived dental treatment need. Carer's view of the oral health of their care recipients may differ from an oral health assessment obtained from a clinical examination. However, the objective was to assess OHRQoL among adults with disabilities from the carer's perspective and also understand negative impacts of oral health problems on their care recipents. Those who could communicate verbally had higher odds of reporting negative impacts than those who communicated non-verbally or had little or no effective communication skills. Those reported to have one or more negative impacts were more likely to be reporting perceived dental treatment need. Yet the prevalence of reported negative impacts was lower than the prevalence of oral health problems and dental treatment need. Carers were unable to report OHRQoL for a significant proportion of those with little or no effective communication skills. Therefore, carers need to be made aware of negative impacts of oral problems and trained to identify them by observing behavioural changes at an early stage to reduce the suffering caused by advanced disease and to improve OHRQoL. This report was supported by a Faculty of Health Sciences Divisional Scholarship, The University of Adelaide and the Australian Dental Research Foundation. The authors are grateful to the participating organizations and the South Australian Dental Service for their assistance. This article was prepared by Dr Archana Pradhan.

BackgroundImplementing public health interventions in schools requires active involvement of multiple stakeholders and adaptation of interventions to fit local contexts, to account for successful design, implementation, and consequently effectiveness of these interventions. Active collaboration, preferably in a co-creation process, with school staff is needed to enhance the implementation of school-based public health interventions. However, involving them in research through a co-creation process is challenging due to competing demands on their time. Hence, there is a need for insights into the factors facilitating or impeding co-creation processes involving school staff.MethodsTo gain in-depth knowledge of school staff’s experiences a scoping review and thematic synthesis have been conducted. Peer reviewed articles written in English and published between January 2012 and November 2023 were retrieved from ERIC, Education Database, Medline (PubMed interface), Embase, Web of Science, Scopus, and Health CASCADE Co-creation Database. Considering the high amount of search results the title and abstract screening was performed using ASReview. A thematic synthesis was conducted on the included articles.ResultsTen scientific peer reviewed articles were included and thematically synthesised. Six descriptive themes described factors influencing the co-creation process, including competing work roles and responsibilities of school staff, multistakeholder collaboration, benefits of participation in the co-creation process, power imbalances between different stakeholders, and school staff’s lived experiences. Additionally, four analytical themes emerged indicating that demands of the co-creation process outweigh its benefits. To tackle excessive demands school staff preferred a guided process in which high-level participation was less important. School staff joined the co-creation process to serve students and emphasised the importance of being heard and taken seriously.ConclusionsSchool staff indicated that excessive demands outweigh the benefits experienced during the co-creation process. Therefore, school staff preferred less time-intensive processes. Improving students outcomes was school staff’s motivation to be involved, which asks for processes with student-related goals and observable student benefits. Moreover, school staff needs to be acknowledged as an expert and valued for their involvement. These results should be considered to make co-creation processes involving school staff more feasible and satisfactory.

Background Integrated Care Pathways (ICPs) are management technologies which formalise multi-disciplinary team-working and enable professionals to examine and address how they articulate their respective roles, responsibilities and activities. They map out a patient’s journey and aim to have: ‘the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome’. Initially introduced into the health care context in the 1980s in the US, enthusiasm for ICPs now extends across the world. They have been promoted as a means to realise: evidence based practice, clinical governance, continuity of care, patient empowerment, efficiency gains, service re-engineering, role realignment and staff education. While ICPs are now being developed and implemented across international health care arena, evidence to support their use is equivocal and understanding of their ‘active ingredients’ is poor. Reviews of evidence of ICP effectiveness have focused on their use in specific patient populations. However, ICPs are ‘complex interventions’ and are increasingly being implemented for a variety of purposes in a range of organisational contexts. Identification of the circumstances in which ICPs are effective is the first step towards developing hypotheses about their active ingredients and the generative mechanisms by which they have their effects. This review was designed to address a slightly different set of questions to those that typify systematic reviews of ICP effectiveness. Rather than simply asking: ‘Are ICPs effective?’, our concern was to identify the circumstances in which ICPs are effective, for whom and in what contexts. In addition to identifying evidence of ICP effectiveness, the review therefore required attention to the contexts in which ICPs are utilised, the purposes to which they are put and the factors critical to their success. In framing the review in this way we are drawing on the insights afforded by Pawson and Tilley’s realistic evaluation methodology. The underlying rationale for this approach is that if we know and understand how different interventions produce varying effects in different circumstances, we are better able to decide what policies/services to implement in what conditions. Objectives To identify the purposes for which ICPs are effective, for whom and in what contexts; To identify the purposes for which ICPs are not effective, for whom and in what contexts; To produce recommendations on how ICPs should be used in the full range of health care settings. Inclusion Criteria Types of participants The review focused on adults and children that accessed health care settings in which ICPs are used. Types of intervention(s)/phenomena of interest For the purposes of the review, the ICP had to meet the defining characteristics set by the European Pathway Association (EPA): An explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations; Facilitation of communication, coordination of roles, and sequencing of activities of the multidisciplinary care team, patients and their relatives; The documentation, monitoring, and evaluation of variances and outcomes; The identification of the appropriate resources. Here multidisciplinary is taken to refer to the involvement of two or more disciplines. Types of outcomes Outcome measures were determined by the purposes of the studies selected for review and the type of study participant. Specific clinical outcomes were determined by the group of patients for which the ICP was developed. Types of studies To address the aims of the review it was necessary to examine evidence of ICP effectiveness across the full spectrum of contexts in which they are in use. In order to keep the study to a manageable scale we limited its scope to randomised controlled trials (RCTs). All RCTs reported TRUNCATED AT 600 WORDS.

Due to the emergence of oral anticancer therapies, existing care processes in oncology - that are mainly focused on in-hospital treatments - must be rethought. The development of a care pathway is a well-known methodology to reorganise and standardise care for a specific patient group. However, care pathway development might be complex and burdensome for healthcare teams, requiring a well-thought-out methodology that provides guidance to the teams. In 10 Belgian oncology departments, multidisciplinary teams developed a tailored care pathway, aimed to offer high-quality patient-centred care. Each department followed a cocreation methodology, consisting of a current practice assessment, a priority setting, and the actual development of the care pathway. The aim of this study was to investigate how and to which extent underperformed evidence-based key elements (KEs), identified in the current practice assessment, guided the development of the care pathway, and how compliant the final care pathways are with the list of evidence-based KEs. A qualitative content analysis was conducted to describe and compare the results of each phase of the cocreation methodology. This study shows that much of the evidence and feedback on current practice that was used as a starting point, got lost throughout the cocreation process. Only a limited proportion of the (seriously) underperformed KEs were prioritised by the multidisciplinary teams. Furthermore, several prioritised KEs could not be retrieved in the care pathway documents. Also, the final care pathways were not fully compliant with existing evidence. Based on the findings, a more rigorous cocreation methodology seems needed, offering very concrete support for multidisciplinary teams to integrate the prioritised KEs in the care process (e.g., by using a model care pathway). Next to the selfreported performance data from healthcare professionals and patients, more objective data (e.g., walkthrough, medical records) and more extensive patient involvement should be considered in the priority setting.

Clinical pathways have been implemented in many healthcare settings as a link between evidence and practice. Most published research concludes that when clinical pathways are implemented and used by health professionals, there is a positive impact on health outcomes. However, some research also suggests that utilization of clinical pathways by health professionals is low and that implementation strategies for linking evidence with clinical practice often prove to be weak or ineffective. This paper describes a before and after study to determine whether an interdisciplinary, genuinely collaborative, and evidence-based process of clinical pathway implementation resulted in increased documented use of an acute myocardial infarction (AMI) clinical pathway by health professionals in a regional Australian hospital. Underpinning the design and implementation process was the belief that true team involvement would lead to ownership, acceptance, and, ultimately, to increased usage of the pathway. Documented clinical pathway usage was measured in two ways: (1) the presence of the AMI clinical pathway in the medical records of patients diagnosed with an AMI and (2) the proportion of the AMI clinical pathway completed when it was present in the medical record. A total of 195 medical records of those diagnosed with an AMI were audited before (n = 124) and after (n = 71) the implementation process. The interdisciplinary, truly collaborative, and evidence-based implementation process resulted in a statistically significant increase in documented usage of the AMI pathway (22.6% vs. 57.7%; p <.000). Results indicate that involvement of key users in the design and implementation of a clinical pathway significantly increases staff utilization of the document.