Care Approach For Patients Research Articles

Examining the Role of Single versus Dual Decision-Making Approach for Patient Care

Decisions related to patient treatment during their hospital stay are done by two key decision-makers: The attending physician (AP) and the operating physician (OP). Under the single decision-making approach (S-DMA), the AP and OP are the same, whereas, under the dual decision-making approach (D-DMA), the AP and OP are different. In recent years, hospitals have seen an increasing trend towards D-DMA over S-DMA approach to accommodate physician schedules. While research outside healthcare operations management has argued for benefits from both S-DMA and D-DMA approaches, very little knowledge exists on what is effective during healthcare delivery. In this study, we address this gap by investigating the DMA within a hospital through physicians effectively improves patient care outcomes. Using detailed data from the state of Florida on cardiology patients over three years, we find that a S-DMA is associated with reduced patient length of stay, treatment cost, and mortality. This runs counter to some of the trends observed in practice. Further, we find that the effect is more significant for patients with greater disease complexity. A follow-up post-hoc analyses also reveal interesting insights: (1) S-DMA is more beneficial for community hospitals than teaching and academic hospitals (2) S-DMA is more critical than physician specialization. Our results are robust to alternate explanations and demonstrate the role that physicians can play in effective care treatment during a hospital stay.

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study

BackgroundLumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS.MethodsThis is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation.DiscussionThis study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Interprofessional collaboration to support patients with social problems in general practice—a qualitative focus group study

BackgroundSocial problems of patients such as family or work-related conflicts as well as financial difficulties affect the individual health situation and the treatment of diseases in general practice. General practitioners (GPs) would like to have direct access to professionals in social care services. In Germany, there are many different social care facilities for people with a wide range of social problems. As the social and health care systems hardly interact collaborations between social professionals (SPs) and GPs are rare exceptions.This study explored perspectives of GPs regarding their patients with social problems in combination with the perspectives of SPs. Aim of this study was to explore how a systematic interprofessional collaboration between GPs and SPs could be realised.MethodsWe carried out a participatory sequential qualitative study design consisting of two focus groups with GPs, two with SPs and two mixed-professional focus groups with GPs and SPs. The focus groups were conducted with semi-structured moderating guidelines and analysed with a qualitative content analysis approach using inductive and deductive categories.ResultsGPs view themselves as the first point of contact for their patients' social problems. For persistent social problems, they expressed a desire for support and SPs were willing to provide this. We developed a stepped care implementation model for a systematic cooperation consisting of nine collaboration strategies. These strategies included: index or website of social care services, referrals to the social care system, using flyers and posters of social care services, direct contact/hotline to local social care services, participation in meetings of social care facilities, involving physician assistants, external social care advice service in GP rooms, implementation in education and training and access to volunteers.ConclusionsOur stepped care implementation model for a systematic cooperation of GPs and SPs could be a feasible need- and resource-oriented approach for the collaborative care of patients with social problems to improve their medical treatment in most western healthcare systems. GPs and SPs are ready to generate the necessary evidence for policy makers in high quality RCTs.

Factors Associated With Patient-Centered Medical Home Teams' Use of Resources for Identifying and Approaches for Managing Patients With Complex Needs.

Using data from a Veterans Health Administration national primary care survey, this study identified the most highly rated tools and care approaches for patients with complex needs and how preferences varied by professional role, staffing, and training. Nurses were significantly more likely to rate most tools as very important as compared with primary care providers. Having a fully staffed team was also significantly associated with a very important rating on all tools. Nurses and fully staffed teams reported a greater likeliness to use most care approaches, and those with perceived need for training reporting a lower likeliness to use.

Upholding Work Ethics: A Key To Elevating Health Service Quality

In the dynamic landscape of healthcare, the role of work ethics stands paramount in determining the quality of health services. Rooted in trust, the healthcare sector relies heavily on the ethical standards set and practiced by its professionals. This article dives into the intricacies of how work ethics, ranging from professional competence to patient-centered care, directly influence the reliability and efficiency of healthcare delivery. Emphasizing the importance of teamwork and communication, the piece further explores how ethics shape team dynamics, fostering a more coordinated patient care approach. It also delves into the challenges posed by ethical dilemmas, emphasizing the need for clear frameworks to navigate these complex scenarios. Finally, the article underscores the societal implications of healthcare ethics, suggesting that an ethical healthcare system promotes overall societal trust and cohesion. In conclusion, the correlation between robust work ethics and quality healthcare is undeniable, urging professionals to maintain a strong ethical foundation for the betterment of both individual patients and society at large

Multipronged Programmatic Strategy for Preventing Secondary Fracture and Facilitating Functional Recovery in Older Patients after Hip Fractures: Our Experience in Taipei Municipal Wanfang Hospital.

Background and Objectives: The study assessed the effectiveness of a fracture liaison service (FLS) after 1 year of implementation in improving the outcomes of hip fracture surgery in older adult patients at Taipei Municipal Wanfang Hospital. Materials and Methods: The Wanfang hospital’s FLS program was implemented using a multipronged programmatic strategy. The aims were to encourage the screening and treatment of osteoporosis and sarcopenia, to take a stratified care approach for patients with a high risk of poor postoperative outcomes, and to offer home visits for the assessment of environmental hazards of falling, and to improve the patient’s adherence to osteoporosis treatment. The clinical data of 117 and 110 patients before and after FLS commencement, respectively, were collected from a local hip fracture registry; the data were analyzed to determine the outcomes 1 year after hip fracture surgery in terms of refracture, mortality, and activities of daily living. Results: The implementation of our FLS significantly increased the osteoporosis treatment rate after hip fracture surgery from 22.8% to 72.3%, significantly decreased the 1-year refracture rate from 11.8% to 4.9%, non-significantly decreased 1-year mortality from 17.9% to 11.8%, and improved functional outcomes 1 year after hip fracture surgery. Conclusions: Implementation of our FLS using the multipronged programmatic strategy effectively improved the outcomes and care quality after hip fracture surgery in the older adult population, offering a successful example as a valuable reference for establishing FLS to improve the outcomes in vulnerable older adults.

P-007 Unraveling the genetic basis of Idiopathic Azoospermia: Α transcriptome profiling analyses in a Greek Population

Abstract Study question Are there differentially expressed genes (DEGs), in the testicular tissue of azoospermic males which could uncover tissue specific gene expression signatures, associated with idiopathic azoospermia? Summary answer The current findings link for the first time the pathophysiology of idiopathic azoospermia to the immune system and open a new era for further investigation What is known already Azoospermia is the most severe form of male infertility and affects 10% of the infertile men and 1% of the general male population which equals to several million men all over the world. A causal genetic factor is established in only 25% of the cases while in the remaining 75% there is no diagnosis and is termed idiopathic. Published data demonstrate that in idiopathic azoospermia heterogeneous genetic factors are the underlying cause. Clarifying the genetic basis of azoospermia will immensely improve our current clinical and treatment approaches for patient care at the levels of diagnosis, therapy, treatment, and safety Study design, size, duration During June 2020 and June 2021 testicular samples from 26 consented IVF patients were included in this study. The samples were divided in 7 pools based on the presence of testicular spermatozoa found. In particular, Pools 1-3 included testicular samples with high, average and very low presence of spermatozoa, Pools 4 & 5 samples with no spermatozoa found, and Pools 6-7 included only CF carriers. Pools 6 &7 were used as controls. Participants/materials, setting, methods Total RNA was isolated using the RΝeasy plus universal mini kit (Qiagen) and quantified using a photometer. Next, RNA sequencing was performed by Novogene, using the Illumina NovaSeq platform and the DEGs that were identified were processed using Gene Ontology (GO) functional enrichment analysis, pathway enrichment analysis and protein-protein interaction (PPI) network reconstruction using the Gene Ontology Resource, the KEGG database and the STRING database respectively. Main results and the role of chance In total RNA from up to 39.664 genes was detected and significant differences in gene expression (DEGs, log2fold change≥2, p-value < 0.05) were identified in the 7 pools analyzed. The top 10% of the protein coding DEGs from each comparison was further analyzed. Up to 1.900 protein coding genes were found to be common in at least two comparisons and exhibit consistent expression profiles. In particular, 920 genes were overexpressed in the “good quality” testicular samples (high & average presence of spermatozoa) while 940 genes were overexpressed in the “low quality” testicular samples (rare or no spermatozoa found). GO analysis revealed that the sexual reproduction, male gamete generation spermatogenesis, cilium movement and fertilization biological processes were enriched in the “good quality” testicular pools while the biological processes response to stimulus, response to stress, response to cytokine and defense response were overrepresented in the “low quality” testicular samples. The PPI network of the DEGs was reconstructed and hub proteins with a putative key role in the pathogenesis of azoospermia were identified. Limitations, reasons for caution While transcriptomics analysis is becoming a powerful analysis tool there are still technical limitations which may impact the accurate representation of the DEGs profiles found. The data obtained in this study represent the whole testicular tissue samples analyzed and they are not cell-type specific Wider implications of the findings The findings of this study demonstrate that in the “low quality” testicular samples, there is a significant under-expression of testis-specific genes directly involved in spermatogenesis and fertilization processes, an over-expression of the genes involved in the body’s immune defense system and advance our understanding in the pathophysiology of idiopathic azoospermia. Trial registration number Τ1EDK-02787

Creating and developing a comprehensive pediatric physical medicine program: A 10-year experience.

A multi-institutional and multidisciplinary pediatric physical medicine rehabilitation healthcare system was developed to meet regional patient needs. A ten-year experience meeting regional patient care needs in northeast Florida and southern Georgia is described. A collaborative effort of multiple institutions resulted in the recruitment of a pediatric physical medicine and rehabilitation physician in June 2009, followed by planning stages that included initiation, development, and structuring of the program. selection of clinic spaces, training of existing staff, creating specialized programs. recruitment of an additional physician and dedicated advanced practice registered nurse, hospital nursing and radiology personnel training, development of protocols for specific disease entities, formulating a team approach for patient care, development of dedicated clinics for disease processes. Phase III: incorporating care into existing multidisciplinary clinics, education of existing physical, occupational, and speech therapists in dedicated remote clinics on early detection and management of specialty issues. Phase IV: ongoing education provided by rehabilitation faculty. Quality improvement aspects included outcome studies, coordinating with the Cerebral Palsy Research Network databank, and others. All phases overlapped in time and are ongoing, adapting to new needs. A collaborative program can be created to provide comprehensive pediatric physical medicine and rehabilitation in regions lacking such a system.

Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study.

BackgroundThe HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home‐based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home.Methods and ResultsWe conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi‐structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on‐going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours).ConclusionsOur results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.

Metabolic (dysfunction)-associated fatty liver disease in individuals of normal weight.

Metabolic (dysfunction)-associated fatty liver disease (MAFLD) affects up to a third of the global population; its burden has grown in parallel with rising rates of type 2 diabetes mellitus and obesity. MAFLD increases the risk of end-stage liver disease, hepatocellular carcinoma, death and liver transplantation and has extrahepatic consequences, including cardiometabolic disease and cancers. Although typically associated with obesity, there is accumulating evidence that not all people with overweight or obesity develop fatty liver disease. On the other hand, a considerable proportion of patients with MAFLD are of normal weight, indicating the importance of metabolic health in the pathogenesis of the disease regardless of body mass index. The clinical profile, natural history and pathophysiology of patients with so-called lean MAFLD are not well characterized. In this Review, we provide epidemiological data on this group of patients and consider overall metabolic health and metabolic adaptation as a framework to best explain the pathogenesis of MAFLD and its heterogeneity in individuals of normal weight and in those who are above normal weight. This framework provides a conceptual schema for interrogating the MAFLD phenotype in individuals of normal weight that can translate to novel approaches for diagnosis and patient care.

P.088 Family identified barriers to accessing services for children with attention deficits and neurodevelopmental disorders

Background: Obtaining early intervention services is crucial for improving outcomes in children with neurodevelopmental disorders (NDDs) such as Autism or Attention Deficit/Hyperactivity Disorder. Identifying barriers in accessing services in the healthcare system is necessary to optimize the Patient and Family-Centered Care approach. Methods: Parents of children with an NDD co-occurring with attention deficits were recruited from the Neurodevelopmental Attention Clinic at the Alberta Children’s Hospital. Parents completed a semi-structured interview and the Barriers to Accessing Services (BAS) questionnaire. Results: Nine families participated representing 10 children. Interviews were evenly spread between biological mothers and fathers. All children had attention deficits; 4 children were also diagnosed with Autism and 5 with “other” neurologic conditions. The two barriers most identified by families (67%) through the BAS questionnaire were “Didn’t know where to find help” and “Steps to seek help are too overwhelming”, consistent with information obtained in the interview. Conclusions: Children with an NDD and attention deficits often have complex medical needs. Parents have identified challenges initiating, and navigating the many steps involved to secure services. We will collect information from more families to determine how services for children with complex medical needs can become more accessible.

A qualitative analysis of educational, professional and socio-cultural issues affecting interprofessional collaboration in oncology palliative care

ObjectivesOncology palliative care (PC) services seek to improve quality of life in patients with cancer. PC providers face significant systemic obstacles, stemming from insufficient collaboration between healthcare providers. This study explores these obstacles and strategies to help facilitate successful collaboration amongst healthcare providers at a systemic level. MethodsA multicenter qualitative study was conducted via interviews and focus groups. Fifty employees in Italian-speaking Switzerland were interviewed, along with ten relatives of oncology patients. Framework analysis was used to identify and categorize the most prominent themes. ResultsThree main themes were identified: knowledge of and connection to other healthcare approaches; beliefs, attitudes and behavior regarding collaboration; and values, attitudes and beliefs towards life, end-of-life and optimal care approaches for oncology patients. ConclusionsStrategies that promote interprofessional collaboration and oncology PC services should foster a cultural shift towards perceiving these services as a medical specialty, thereby contributing to quality patient care. ImplicationsAn overview of potential limitations is provided, in addition to a timeline of interprofessional collaboration which would help to optimize oncology PC services.

Innovative virtual care delivery in a Canadian paediatric tertiary-care centre.

Health care systems and providers have rapidly adapted to virtual care delivery during this unprecedented time. Clinical programs initiated a variety of virtual care delivery models to maintain access to care, preserve personal protective equipment, and minimize infectious disease spread. Herein, we first describe the context within paediatric health delivery during the COVID-19 pandemic in Canada that fueled the rise of virtual care delivery. We then summarize the development, implementation, and beneficial impact of the innovative virtual care delivery programs currently in use at Children's Hospital of Eastern Ontario (CHEO) for both inpatient and outpatient care, specifically in our ambulatory clinics, emergency department, and mental health program. We highlight the transferable unique ways CHEO has integrated virtual care delivery through our governance structure, stakeholder engagement including patient, caregivers and health care providers and staff, development, and use of eHealth tools and novel approaches for patient care requiring physical assessment. We conclude with our vision for the future of virtual care, one component of paediatric care delivery in the post-COVID-19 era, which requires a common framework for virtual care evaluation. Importantly, rapid implementation of a primarily virtual care model at CHEO sustained high volume quality paediatric care. We believe many of these programs should and will remain in the post-pandemic era. A comprehensive, unified approach to evaluation is essential to yield meaningful results that inform sustainable care delivery models that integrate virtual care, and ultimately help ensure the best health outcomes for our patients.

Cognitive Performance and Health-Related Quality of Life in Patients with Neuromyelitis Optica Spectrum Disorder.

Background: The frequency of cognitive impairment (CI) reported in neuromyelitis optica spectrum disorder (NMOSD) is highly variable, and its relationship with demographic and clinical characteristics is poorly understood. We aimed to describe the cognitive profile of NMOSD patients, and to analyse the cognitive differences according to their serostatus; furthermore, we aimed to assess the relationship between cognition, demographic and clinical characteristics, and other aspects linked to health-related quality of life (HRQoL). Methods: This cross-sectional study included 41 patients (median age, 44 years; 85% women) from 13 Spanish centres. Demographic and clinical characteristics were collected along with a cognitive z-score (Rao’s Battery) and HRQoL patient-centred measures, and their relationship was explored using linear regression. We used the Akaike information criterion to model which characteristics were associated with cognition. Results: Fourteen patients (34%) had CI, and the most affected cognitive domain was visual memory. Cognition was similar in AQP4-IgG-positive and -negative patients. Gender, mood, fatigue, satisfaction with life, and perception of stigma were associated with cognitive performance (adjusted R2 = 0.396, p < 0.001). Conclusions: The results highlight the presence of CI and its impact on HRQoL in NMOSD patients. Cognitive and psychological assessments may be crucial to achieve a holistic approach in patient care.

Comorbidity identification and referral in atopic dermatitis: a consensus document

Background Atopic dermatitis (AD) is associated with different comorbidities. Objective To develop evidence-based and practical recommendations for comorbidity detection in patients with AD in daily practice. Methods We employed a modified RAND/UCLA methodology, including a systematic literature review (SLR). A group of six experts on AD was established. We conducted a comprehensive search strategy on Medline, Embase, and Cochrane Library up to June 2020. The selection criteria included studies with AD patients with any comorbidity reporting data on comorbidity prevalence, burden, and management. The included studies quality was assessed. The SLR results were discussed in a nominal group meeting, and several recommendations were generated. The recommendation agreement grade was tested on additional experts through a Delphi process. Results The recommendations cover the following issues: (1) Which comorbidities should be investigated at the first and subsequent visits; (2) how and when should comorbidities be investigated (screening); (3) how should patients with specific comorbidities be referred to confirm their diagnosis and initiate management; (4) specific recommendations to ensure an integral care approach for AD patients with any comorbidity. Conclusions These recommendations seek to guide dermatologists, patients, and other stakeholders in regard to early comorbidity identification and AD patient referral to improve decision-making.

Population Pharmacokinetics of Valproic Acid in Pediatric and Adult Caucasian Patients.

(1) Background: The aim of this study was to explore the valproic acid (VPA) pharmacokinetic characteristics in a large population of pediatric and adult Caucasian patients and to establish a robust population pharmacokinetic (PopPK) model. (2) Methods: A total of 2527 serum VPA samples collected from 1204 patients included in a therapeutic drug monitoring program were retrospectively analyzed. Patients were randomly assigned to either a model development group or an external evaluation group. PopPK analysis was performed on 1751 samples from 776 patients with NONMEM using a nonlinear mixed-effect modelling approach. The influence of demographic, anthropometric, treatment and comedication variables on the apparent clearance (CL/F) of VPA was studied. The bootstrap method was used to evaluate the final model internally. External evaluation was carried out using 776 VPA serum samples from 368 patients. (3) Results: A one-compartment model with first-order absorption and elimination successfully described the data. The final model included total body weight, age and comedication with phenytoin, phenobarbital and carbamazepine with a significant impact on VPA elimination. Internal and external evaluations demonstrated the good predictability of the model. (4) Conclusions: A PopPK model of VPA in Caucasian patients was successfully established, which will be helpful for model-informed precision dosing approaches in clinical patient care.

Reflections at the Time of Covid-19: The Doctor Becomes the Patient.

As a family physician, we are trained to practice a biopsychosocial-spiritual approach for a holistic patient care. But a doctor gains deeper appreciation for the importance of addressing a patient’s spirituality once he becomes a patient himself. My spirituality played a role in my recovery as a patient. This experience led me to appreciate the unique role a patient’s spirituality can play in one’s recovery. It has given me a different experience with God.

Neoantigen Cancer Vaccines: Generation, Optimization, and Therapeutic Targeting Strategies.

Alternatives to conventional cancer treatments are highly sought after for high-risk malignancies that have a poor response to established treatment modalities. With research advancing rapidly in the past decade, neoantigen-based immunotherapeutic approaches represent an effective and highly tolerable therapeutic option. Neoantigens are tumor-specific antigens that are not expressed in normal cells and possess significant immunogenic potential. Several recent studies have described the conceptual framework and methodologies to generate neoantigen-based vaccines as well as the formulation of appropriate clinical trials to advance this approach for patient care. This review aims to describe some of the key studies in the recent literature in this rapidly evolving field and summarize the current advances in neoantigen identification and selection, vaccine generation and delivery, and the optimization of neoantigen-based therapeutic strategies, including the early data from pivotal clinical studies.

Recognising, assessing and managing chest pain

Chest pain is a common medical symptom that paramedics attend to in the out-of-hospital environment. The causes of chest pain and the signs and symptoms are explained in this article, alongside tools that could be useful in diagnosis, such as clinical risk scores and troponin testing. Finally, pain management strategies that use a balanced approach for optimal patient care are referred to, with some specificity for cardiac chest pain explained.

Outcomes of a Dedicated Low Fluoroscopy Ablation for Supraventricular Arrhythmia Program

Ablation of supraventricular arrhythmias can be a highly successful approach for optimal patient care. Risks may exist with radiation exposure for both patients and staff. We examined outcomes of a single site, single operator program to reduce fluoroscopy during ablation.