Care Pathway For Patients Research Articles

The Pendulum: The Need to Develop a Safe, Effective, and Equitable Management Strategy for Opioids in Cancer Patients.

The opioid epidemic has caused major morbidity and mortality to Americans. Although there are multiple sources of this staggering issue, one inciting factor has been the use of opioids to manage pain. Although recent efforts have changed care pathways for patients with chronic pain, the first-line management of cancer pain remains opioids. Despite this, there is very little evidence and no guidelines/regulations to assist in the management of these patients. Although the literature suggests a number of current barriers to identifying and managing the challenges (such as the preferred management of patients with opioid use disorder (OUD), the optimal approach to taperering, or approaches to disparities), there are no concrete strategies for providers to manage these circumstances. Investing in further research utilizing the national opioid settlement funding, exploring the equity gaps using community based participatory research and community health worker models, and increasing provider education pathways are all potential approaches to improving this issue. These solutions could help identify and address some of the gaps that affect cancer patients taking opioids for pain.

Periprocedural Anticoagulation Management of Patients Undergoing Colonoscopy with Polypectomy.

Introduction/Objective Colonoscopy with polypectomy is an integral component of colorectal cancer screening. There are limited data and consensus on periprocedural anticoagulation management, especially regarding bleeding risk with uninterrupted anticoagulation and thromboembolic risk with interruption. Our aim was to determine the incidence of bleeding and thromboembolic complications among colon screening participants undergoing colonoscopy following implementation of a novel patient care pathway for standardized periprocedural anticoagulation management. Methods We conducted a retrospective study including all participants (age 50-74) on an oral anticoagulant (e.g., vitamin K antagonists, direct oral anticoagulants) referred to the British Columbia Colon Screening Program for colonoscopy following abnormal fecal immunochemical test in a 6-month period (March-August 2022). Data relating to their specific periprocedural anticoagulant management and colonoscopy results including method of polypectomy were obtained. Primary outcomes were major bleeding and arterial or venous thromboembolic events from time of oral anticoagulant interruption until 14 days of postcolonoscopy. Secondary outcomes included nonmajor and minor bleeding, acute coronary syndrome, emergency room visit, hospital admission, and death due to any cause. Results Over the 6-month period, 162 participants completed standardized periprocedural anticoagulation management, colonoscopy ± polypectomy, and 14-day follow-up. One (0.6%) had a major bleeding event and one (0.6%) had an arterial thromboembolic event. Conclusions A novel patient care pathway for standardized periprocedural anticoagulation management with a multidisciplinary team is associated with low rates of major bleeding and thrombotic complications after colonoscopy with polypectomy.

Deinstitutionalization in Georgia-why it is so slow

IntroductionMental health reform represents one of the most transformative changes in the field of healthcare, as it not only changes the forms of services but also the nature of services offered. While many countries have successfully implemented such reforms, others, including Georgia, have struggled with a protracted and inconsistent process. Despite decades of advocacy by professionals for deinstitutionalization and the development of community-based services, psychiatric hospital treatment continues to dominate in Georgia.ObjectivesThe purpose of the review is to explore the concept of deinstitutionalization within the mental health landscape and assess its status in the context of Georgia. It aims to study the lessons learned from successful deinstitutionalization and illuminate achievements and challenges surrounding deinstitutionalization in Georgia’s reality.MethodsA qualitative analysis including desk review, in-depth interviews and focus group discussions was conducted. Proceeding from the research objectives we analyzed the existing legislation, strategic documents and clinical practices concerning individuals with mental disorders; Interviews were also conducted with key informants on the shortcomings and problems in deinstitutionalization practicesResultsThe review findings reveal, that despite recent progress such as the development of community mobile teams and increased funding allocated for community services within mental health budget, several issues persist: there is no agreement among stakeholders on how to restructure existing hospital beds and financial provisions remain unresolved. The field of mental health in Georgia suffers from a lack of human resources. Attracting new personnel, ensuring regional distribution, and enhancing qualifications are necessary components of deinstitutionalization that require the involvement of all stakeholders, coordinated and time-planned action. The current mental healthcare system in Georgia is characterized by a lack of coordination and collaboration among its various components. Establishing patient care pathways with clear referral criteria is crucial for improving the efficiency of mental health services. This research highlights that successful deinstitutionalization requires additional funds, time, and trained people. Institutions should have a long-term (3-5) year development plan, detailing the source of funding, activities to be implemented, and expected outcomes. In the absence of such a plan, progress remains sporadic, intermittent, uncoordinated, and less effective.ConclusionsIn conclusion, the protracted nature of deinstitutionalization in Georgia requires a multifaceted approach involving various stakeholders. By addressing identified challenges and promoting coordination among mental health components, Georgia can guide a more effective course toward a community-based, patient-centered mental healthcare system.Disclosure of InterestNone Declared

Revised European guidelines for the accreditation of sleep medicine centres.

The accreditation of sleep centres aims to ensure high-quality diagnosis and management of sleep centres. European accreditation standards were introduced in 2006, and were aimed at centres offering inpatient polysomnography and vigilance tests (Mean Sleep Latency Test and Maintenance of Wakefulness Test). Since then, the practice of sleep medicine has evolved, with greater use of ambulatory polysomnography and polygraphy. As a result, in many sleep centres, actual clinical practice, although of a high standard, is no longer in accordance with the published guidelines. The current criteria have been revised with the introduction of level-based criteria. Level 1 and 2 centres offer full diagnostic testing in a laboratory-based setting. Level 1 practices will usually be university affiliated, and have a full teaching and active research role. Level 3 and 4 practices may offer both inpatient and ambulatory testing. Level 3 practices perform polysomnography, while level 4 practices (usually monodisciplinary and focussed on sleep apnea) perform polygraphy only. The role of the medical and paramedical team, training, appropriate equipment, patient care pathways and patient management according to national/European recommendations is underlined for accreditation at each level. It is anticipated that the guidelines will be reviewed and if necessary revised after 4 years.

Multimorbidity healthcare expenditure in Belgium: a 4-year analysis (COMORB study)

BackgroundThe complex management of health needs in multimorbid patients, alongside limited cost data, presents challenges in developing cost-effective patient-care pathways. We estimated the costs of managing 171 dyads and 969 triads in Belgium, taking into account the influence of morbidity interactions on costs.MethodsWe followed a retrospective longitudinal study design, using the linked Belgian Health Interview Survey 2018 and the administrative claim database 2017–2020 hosted by the Intermutualistic Agency. We included people aged 15 and older, who had complete profiles (N = 9753). Applying a system costing perspective, the average annual direct cost per person per dyad/triad was presented in 2022 Euro and comprised mainly direct medical costs. We developed mixed models to analyse the impact of single chronic conditions, dyads and triads on healthcare costs, considering two-/three-way interactions within dyads/triads, key cost determinants and clustering at the household level.ResultsPeople with multimorbidity constituted nearly half of the study population and their total healthcare cost constituted around three quarters of the healthcare cost of the study population. The most common dyad, arthropathies + dorsopathies, with a 14% prevalence rate, accounted for 11% of the total national health expenditure. The most frequent triad, arthropathies + dorsopathies + hypertension, with a 5% prevalence rate, contributed 5%. The average annual direct costs per person with dyad and triad were €3515 (95% CI 3093–3937) and €4592 (95% CI 3920–5264), respectively. Dyads and triads associated with cancer, diabetes, chronic fatigue, and genitourinary problems incurred the highest costs. In most cases, the cost associated with multimorbidity was lower or not substantially different from the combined cost of the same conditions observed in separate patients.ConclusionPrevalent morbidity combinations, rather than high-cost ones, made a greater contribution to total national health expenditure. Our study contributes to the sparse evidence on this topic globally and in Europe, with the aim of improving cost-effective care for patients with diverse needs.

Clinical care pathways of patients with biliary tract cancer: A French nationwide longitudinal cohort study

BackgroundAlthough the incidence of BTC is raising, national healthcare strategies to improve care lack. We aimed to explore patient clinical care pathways and strategies to improve biliary tract cancer (BTC) care. MethodsWe analysed the French National Healthcare database of all BTC inpatients between January 1, 2017 and December 31, 2021. Multinomial logistic regression adjusted odds ratios (aOR) were used to identify healthcare organisation factors that influenced access to curative care both overall and in a longitudinal sensibility analysis using optimal matching and hierarchical ascending classification to detect a subgroup of curative-care patients with a high survival over a two-year period. ResultsA total of 19,825 new BTC patients and three clinical care pathways (CCP) were identified: ‘Palliative care’ (PC-CCP), ‘Non-curative Care’ (NCC-CCP) and ‘Curative Care’ (CC-CCP) involving 7669 (38.7%), 7721 (38.9%) and 4435 (22.4%) patients respectively. Out of 1200 centers involved in BTC treatment, 84%, 11% and 5% were of low- (<15 patients/year), medium- (15–30 patients/year) and high-volume (>30 patients/year) respectively. Among patient, tumor and hospital factors, BTC management in academic (aOR: 2.32; 95%CI: 1.98–2.71), private (2.51; 2.22–2.83), semi-private (2.25; 1.91–2.65) and in high- (2.09; 1.81–2.42) or medium-volume (1.49; 1.33–1.68) centers increased probability to CC-CCP. These results were maintained in a longitudinal cluster of 2363 (53%) CC-CCP patients presenting a higher two-year survival compared with the rest [96.4% (95.1; 97.6) vs. 38.8% (36.3; 41.4), log-rank p < 0.001]. ConclusionsAmong factors subject to healthcare policy improvement, the volume and type of centers managing BTC strongly influenced access to curative care.

Nationwide Audit of Postoperative Mortality and Complications After Digestive Cancer Surgery: Will New Legal Thresholds be Sufficient?

French policymakers recently chose to regulate high-risk digestive cancer surgery (DCS). A minimum of five cases per year should be performed for each of the following types of curative cancer surgery: esophagus/esogastric junction (ECS), stomach (GCS), liver (LCS, metastasis included), pancreas (PCS), and rectum (RCS). This study aimed to evaluate the hypothetical beneficial effects of the new legal minimal volume thresholds on the rates of 90-day postoperative mortality (90POM) for each high-risk DCS. This nationwide observational population-based cohort study used data extracted from the French National Health Insurance Database from 1 January 2015-31 December 2017. Mixed-effects logistic regression models were performed to estimate the independent effect of hospital volume. During the study period, 61,169 patients (57.1 % male, age 69.7 ±12.2 years) underwent high-risk DCS including ECS (n = 4060), GCS (n = 5572), PCS (n = 8598), LCS (n = 10,988), and RCS (n = 31,951), with 90POM of 6.6 %, 6.9 %, 6.0 %, 5.2 %, and 2.9 %, respectively. For hospitals fulfilling the new criteria, 90POM was lower after adjustment only for LCS (odds ratio [OR],15.2; 95 % confidence interval [CI], 9.5-23.2) vs OR, 7.6; 95 % CI, 5.2-11.0; p < 0.0001) and PCS (OR, 3.6; 95 % CI, 1.7-7.6 vs OR, 2.1; 95 % CI, 1.0-4.4; p<0.0001). With higher thresholds, all DCSs showed a lower adjusted risk of 90POM (e.g., OR, 0.38; 95 % CI, 0.28-0.51) for PCS of 40 or higher. Based on retrospective data, thresholds higher than those promulgated would better improve the safety of high-risk DCS. New policies aiming to further centralize high-risk DCS should be considered, associated with a clear clinical pathway of care for patients to improve accessibility to complex health care in France.

Personalized, interdisciplinary patient pathway for cross-sector care of multimorbid patients (eliPfad trial): study protocol for a randomized controlled trial

BackgroundMultimorbid and frail elderly patients often carry a high burden of treatment. Hospitalization due to the onset of an acute illness can disrupt the fragile balance, resulting in further readmissions after hospital discharge. Current models of care in Germany do not meet the needs of this patient group. Rather lack of coordination and integration of care combined with a lack of interdisciplinary approaches result in fragmented and inadequate care and increase the burden of treatment even more.MethodseliPfad is a randomized controlled trial conducted in 6 hospitals in Germany. Multimorbid elderly patients aged 55 or older are randomly assigned to the intervention or control group. Patients in the intervention group receive the eliPfad intervention additional to standard care. The core components of eliPfad are:Early assessment of patients’ individual treatment burden and support through a specially trained case managerInvolvement of the patient’s general practitioner (GP) right from the beginning of the hospital stayPreparation of an individual, cross-sectoral treatment plan through the interdisciplinary hospital team with the involvement of the patient’s GPEstablishment of a cross-sectoral electronic patient record (e-ePA) for documentation and cross-sectoral exchangeSupport/Promote patient adherenceTailored early rehabilitation during the hospital stay, which is continued at homeClose-tele-monitoring of medically meaningful vital parameters through the use of tablets, digital devices, and personal contacts in the home environmentThe intervention period begins in the hospital and continues 6 weeks after discharge. Patients in the control group will be treated according to standard clinical care and discharged according to current discharge management. The primary aim is the prevention/reduction of readmissions in the first 6 months after discharge. In addition, the impact on health-related quality of life, the burden of treatment, survival, self-management, medication prescription, health literacy, patient-centered care, cost-effectiveness, and process evaluation will be examined. Nine hundred forty-eight patients will be randomized 1:1 to intervention and control group.DiscussionIf eliPfad leads to fewer readmissions, proves (cost-)effective, and lowers the treatment burden, it should be introduced as a new standard of care in the German healthcare system.Trial registrationThe trial was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 08/14/2023 under the ID DRKS00031500.

Patient-reported outcome measures in value-based healthcare: A multiple methods study to assess patient-centredness

ObjectivesValue-based healthcare (VBHC) involves the use of standardised outcome measures, including patient-reported outcome measures (PROMs). This study aimed to assess to what extent discussion of PROMs is associated with patient- and person-centredness. MethodsThis study used a separate sample pre-/post-test design and multiple methods (observations, questionnaires, and interviews) in a VBHC care pathway for patients with a vestibular schwannoma, to assess to what extent the implementation of PROMs is associated with a difference in patient- and person-centredness. ResultsA total of 139 patients with a vestibular schwannoma and their four treating physicians were included in the study. No significant differences were found in observed patient-centredness (Mpre=6.71 ± 2.42 vs. Mpost=6.93 ± 2.01; P = 0.60) or patient-reported patient-centredness (Mpre=1.73 vs. Mpost=1.68; P = 0.63) and person-centredness after PROM implementation (Mpre=11.81 vs. Mpost=13.42; P = 0.34). We observed more discussion of patient-reported outcomes. However, a majority of patients did not expect PRO discussion in consultations. ConclusionsThe implementation of standardised PROMs in a VBHC care pathway was associated with more discussion on patient-reported outcomes in clinical consultations. Overall, the implementation of PROMs was not observed or perceived as leading to more patient-centred consultations. Practice implicationsPhysicians should assess whether the discussion of PROMs add value collaboratively with patients.

Descriptive study of general practitioner's practices and knowledge about Parkinson's disease in the north of France

BackgroundParkinson's disease (PD), the second most frequent neurodegenerative disease, constitutes a major public health challenge. A guide published by the French National Authority for Health in 2012 and revised in 2016 put forward recommendations for general practitioners (GP) planning care pathways for parkinsonian patients. It is well known that PD can be difficult to diagnose, and that when patients consult their GP, symptoms are often still limited and embedded in clinical uncertainty. This means the pathway to confirmed diagnosis of PD can be lengthy and uncertain. Consequently, it is important to identify the difficulties GPs encounter when caring for PD patients in order to help them better close the gaps in care strategies. MethodsWe conducted a descriptive cross-sectional survey in northern France to evaluate GP practices and knowledge about PD and their accordance with care pathway recommendations. The survey was conducted using a 30-item questionnaire sent to a sample of GPs. ResultsThere were 164 GPs who responded to the study questionnaire. The responding GPs generally followed current care pathway recommendations. In presence of a parkinsonian syndrome, 93.3% of the GPs reported systematically looking for an iatrogenic cause; 57.4% did not announce the diagnosis without the advice of a neurologist; 97.6% referred patients to a neurologist when they suspected PD; and 80.5% asked the neurologist to modify treatments. Our findings also revealed some difficult aspects of GP practices: only 2.5% had had additional training in neurology; only 53.6% felt comfortable with the diagnosis of PD; 63.6% prescribed additional exams for the diagnosis; most of the GPs were unaware of second-line treatments and their indications, and finally existence of PD expert centers was unknown for 85.2%. ConclusionsThese findings could be useful to guide implementation of new measures supporting more holistic care for PD patients; PD expert centers in France could provide complementary information and training for GPs.

Healthcare utilization and clinical characteristics of genetic epilepsy in electronic health records.

Understanding the clinical characteristics and medical treatment of individuals affected by genetic epilepsies is instrumental in guiding selection for genetic testing, defining the phenotype range of these rare disorders, optimizing patient care pathways and pinpointing unaddressed medical need by quantifying healthcare resource utilization. To date, a matched longitudinal cohort study encompassing the entire spectrum of clinical characteristics and medical treatment from childhood through adolescence has not been performed. We identified individuals with genetic and non-genetic epilepsies and onset at ages 0-5 years by linkage across the Cleveland Clinic Health System. We used natural language processing to extract medical terms and procedures from longitudinal electronic health records and tested for cross-sectional and temporal associations with genetic epilepsy. We implemented a two-stage design: in the discovery cohort, individuals were stratified as being 'likely genetic' or 'non-genetic' by a natural language processing algorithm, and controls did not receive genetic testing. The validation cohort consisted of cases with genetic epilepsy confirmed by manual chart review and an independent set of controls who received negative genetic testing. The discovery and validation cohorts consisted of 503 and 344 individuals with genetic epilepsy and matched controls, respectively. The median age at the first encounter was 0.1 years and 7.9 years at the last encounter, and the mean duration of follow-up was 8.2 years. We extracted 188,295 Unified Medical Language System annotations for statistical analysis across 9659 encounters. Individuals with genetic epilepsy received an earlier epilepsy diagnosis and had more frequent and complex encounters with the healthcare system. Notably, the highest enrichment of encounters compared with the non-genetic groups was found during the transition from paediatric to adult care. Our computational approach could validate established comorbidities of genetic epilepsies, such as behavioural abnormality and intellectual disability. We also revealed novel associations for genitourinary abnormalities (odds ratio 1.91, 95% confidence interval: 1.66-2.20, P = 6.16 × 10-19) linked to a spectrum of underrecognized epilepsy-associated genetic disorders. This case-control study leveraged real-world data to identify novel features associated with the likelihood of a genetic aetiology and quantified the healthcare utilization of genetic epilepsies compared with matched controls. Our results strongly recommend early genetic testing to stratify individuals into specialized care paths, thus improving the clinical management of people with genetic epilepsies.

Scoping review on the role of the family doctor in the prevention and care of patients with foetal alcohol spectrum disorder

BackgroundFoetal alcohol spectrum disorder (FASD) is the leading preventable cause of nongenetic mental disability. Given the patient care pathway, the General Practitioner (GP) is in the front line of prevention and identification of FASD. Acknowledging the importance of the prevalence of FASD, general practitioners are in the front line both for the detection and diagnosis of FASD and for the message of prevention to women of childbearing age as well as for the follow-up.ObjectivesThe main objective of the scoping review was to propose a reference for interventions that can be implemented by a GP with women of childbearing age, their partners and patients with FASD. The final aim of this review is to contribute to the improvement of knowledge and quality of care of patients with FASD.MethodsA scoping review was performed using databases of peer-reviewed articles following PRISMA guidelines. The search strategy was based on the selection and consultation of articles on five digital resources. The advanced search of these publications was established using the keywords for different variations of FASD: "fetal alcohol syndrome," "fetal alcohol spectrum disorder," "general medicine," "primary care," "primary care"; searched in French and English.ResultsTwenty-three articles meeting the search criteria were selected. The interventions of GPs in the management of patients with FASD are multiple: prevention, identification, diagnosis, follow-up, education, and the role of coordinator for patients, their families, and pregnant women and their partners. FASD seems still underdiagnosed.ConclusionThe interventions of GPs in the management of patients with FASD are comprehensive: prevention, identification, diagnosis, follow-up, education, and the role of coordinator for patients, their families, and pregnant women and their partners.Prevention interventions would decrease the incidence of FASD, thereby reducing the incidence of mental retardation, developmental delays, and social, educational and legal issues.A further study with a cluster randomized trial with a group of primary care practitioners trained in screening for alcohol use during pregnancy would be useful to measure the impact of training on the alcohol use of women of childbearing age and on the clinical status of their children.

État des lieux des modalités de poursuite en ville des préparations pharmaceutiques à usage pédiatrique initiées au sein de l’Assistance publique des Hôpitaux de Marseille

Hospital internal-use pharmacies are required to make pharmaceutical preparations in order to obtain a medication in a dosage and/or Galenic form (FG) suitable for pediatric use. The aim of this study is to assess the procedures for continuing pharmaceutical preparations initiated within the Assistance Publique des Hôpitaux de Marseille in an outpatient setting. Hospital discharge prescriptions and/or consultation prescriptions involving paediatric magistral preparations and issued by our Hospital Centre were collected from two pharmacies with significant preparation activity at national level. An analysis of regulatory compliance was carried out, as well as a comparison of the formulation of preparations made in the outpatient setting and in the hospital. Au total, 45 prescriptions were collected, representing 52 preparation lines. The regulatory analysis revealed that all the prescriptions contained at least one non-conformity, 60.8% of which related to drug treatments. The prepared FG differed in the outpatient setting compared to the hospital in 46.2% of cases, and in 56% of cases, the vehicle and concentration of the active ingredient used differed when the FG was a liquid oral form. The lack of clear and complete hospital prescriptions makes it difficult to carry out treatment initiated in hospital in the outpatient setting. The multiplicity of information systems between hospitals and outpatient settings are obstacles to the interoperability needed to coordinate patient treatment, particularly in paediatrics. The quality of discharge prescriptions needs to be improved to optimise the patient care pathway.

Immediate and long-term management practices of acute symptomatic seizures and epileptiform abnormalities: A cross-sectional international survey.

Acute symptomatic seizures (ASyS) and epileptiform abnormalities (EAs) on electroencephalography (EEG) are commonly encountered following acute brain injury. Their immediate and long-term management remains poorly investigated. We conducted an international survey to understand their current management. The cross-sectional web-based survey of 21 fixed-response questions was based on a common clinical encounter: convulsive or suspected ASyS following an acute brain injury. Respondents selected the option that best matched their real-world practice. Respondents completing the survey were compared with those who accessed but did not complete it. A total of 783 individuals (44 countries) accessed the survey; 502 completed it. Almost everyone used anti-seizure medications (ASMs) for secondary prophylaxis after convulsive or electrographic ASyS (95.4% and 97.2%, respectively). ASM dose escalation after convulsive ASyS depends on continuous EEG (cEEG) findings: most often increased after electrographic seizures (78% of respondents), followed by lateralized periodic discharges (LPDs; 41%) and sporadic epileptiform discharges (sEDs; 17.5%). If cEEG is unrevealing, one in five respondents discontinue ASMs after a week. In the absence of convulsive and electrographic ASyS, a large proportion of respondents start ASMs due to LPD (66.7%) and sED (44%) on cEEG. At hospital discharge, most respondents (85%) continue ASM without dose change. The recommended duration of outpatient ASM use is as follows: 1-3 months (36%), 3-6 months (30%), 6-12 months (13%), >12 months (11%). Nearly one-third of respondents utilized ancillary testing before outpatient ASM taper, most commonly (79%) a <2 h EEG. Approximately half of respondents had driving restrictions recommended for 6 months after discharge. ASM use for secondary prophylaxis after convulsive and electrographic ASyS is a universal practice and is continued upon discharge. Outpatient care, particularly the ASM duration, varies significantly. Wide practice heterogeneity in managing acute EAs reflects uncertainty about their significance and management. These results highlight the need for a structured outpatient follow-up and optimized care pathway for patients with ASyS.

Lived experiences of genetic diagnosis for rare disease patients: a qualitative interview study

BackgroundGenetic diagnosis is often understood as a single event within the care pathway of rare disease patients. Legal, policy and ethical scholarship focusing on rare diseases and genetic information discusses questions of how to best deal with the process of genetic diagnosis and the communication of genetic information within a given health system. We co-created a research design with rare disease patients and their families in Austria to explore in-depth the experiences of genetic diagnosis for people affected by rare diseases. Our objective was to trace the whole pathway of genetic testing and understand how rare disease patients experience genetic diagnosis as part of their care pathway in the healthcare system.ResultsData was collected through in-depth semi-structured qualitative interviews with 14 patients with a suspected or diagnosed rare disease or their parents, focusing on their perception of the pathway of genetic diagnosis in Austria. This pathway included the initial triggering of genetic diagnosis, the process of testing and its immediate (communication of results, counselling) and long-term, wider aftermath. Patients missed a clear link to already established forms of care such as their primary care/treating physicians. They also advocate for an integrated and interdisciplinary care pathway.ConclusionsOur study underscores the importance of a continuous care and communication pathway spanning from the initial genetic diagnosis process to post-test phases. It further shows the importance of exploring patients’ perspectives through qualitative research methods to understand the intricate workings of public health policies and tools. Integrating genetic diagnosis into a broader care trajectory is crucial for a holistic approach to care for rare disease patients who often rely on regular interactions with the healthcare system. Achieving this holistic approach requires collaboration between experts in specific rare disease areas, primary care physicians, and support networks.

Strategic flexibility in healthcare: an exploration of real options

PurposeThis survey explores the application of real options theory to the field of health economics. The integration of options theory offers a valuable framework to address these challenges, providing insights into healthcare investments, policy analysis and patient care pathways.Design/methodology/approachThis research employs the real options theory, a financial concept, to delve into health economics challenges. Through a systematic approach, three distinct models rooted in this theory are crafted and analyzed. Firstly, the study examines the value of investing in emerging health technology, factoring in future advantages, associated costs and unpredictability. The second model is patient-centric, evaluating the choice between immediate treatment switch and waiting for more clarity, while also weighing the associated risks. Lastly, the research assesses pandemic-related government policies, emphasizing the importance of delaying decisions in the face of uncertainties, thereby promoting data-driven policymaking.FindingsThree different real options models are presented in this study to illustrate their applicability and value in aiding decision-makers. (1) The first evaluates investments in new technology, analyzing future benefits, discount rates and benefit volatility to determine investment value. (2) In the second model, a patient has the option of switching treatments now or waiting for more information before optimally switching treatments. However, waiting has its risks, such as disease progression. By modeling the potential benefits and risks of both options, and factoring in the time value, this model aids doctors and patients in making informed decisions based on a quantified assessment of potential outcomes. (3) The third model concerns pandemic policy: governments can end or prolong lockdowns. While awaiting more data on the virus might lead to economic and societal strain, the model emphasizes the economic value of deferring decisions under uncertainty.Practical implicationsThis research provides a quantified perspective on various decisions in healthcare, from investments in new technology to treatment choices for patients to government decisions regarding pandemics. By applying real options theory, stakeholders can make more evidence-driven decisions.Social implicationsDecisions about patient care pathways and pandemic policies have direct societal implications. For instance, choices regarding the prolongation or ending of lockdowns can lead to economic and societal strain.Originality/valueThe originality of this study lies in its application of real options theory, a concept from finance, to the realm of health economics, offering novel insights and analytical tools for decision-makers in the healthcare sector.

Facilitators and barriers to the implementation of prehabilitation for frail patients into routine health care: a realist review

BackgroundDespite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why.MethodsFollowing Pawson’s realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated.ResultsFrom 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients’ needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision.ConclusionsImplementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention’s goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients.Trial registrationPROSPERO (CRD42022335282).

(373) Economic Benefits of Patient Care for Prostate Cancer Survivors with Stress Urinary Incontinence and/or Erectile Dysfunction: A Physician Reimbursement Analysis

Abstract Introduction Reconstructive urological procedures play a vital role in enhancing the satisfaction and quality of life of patients with prostate cancer (PCa) following radical prostatectomy (RP). Providing comprehensive postoperative care for common side effects of post-RP, including stress urinary incontinence (SUI) and erectile dysfunction (ED), may result in a greater number of patients with PCa receiving needed consultations and therapies. This analysis sought to explore the potential economic benefits of offering men’s health consultations and reconstructive care for PCa survivors. Objective This study quantified the relative value units (RVUs) generated from providing patient care to PCa survivors covered by Medicare Fee-for-Service who may experience SUI and/or ED due to RP. Methods This physician reimbursement analysis was based on typical patient care pathway scenarios for patients at risk of developing SUI or ED post-RP. Current Procedural Terminology (CPT) codes were utilized to identify and describe the care provided to patients in each scenario, leading to an artificial urinary sphincter (AUS) or male sling for SUI and/or an inflatable penile prosthesis (IPP) for ED. The 2023 CMS Physician and Clinical Laboratory Fee Schedule and Medicare reimbursement rates were used to obtain the most recent RVUs and reimbursement for each CPT. RVUs represent the value assigned to a service or procedure performed by a physician and are used to capture the relative cost values associated with patient care. For each scenario, we reported the total RVUs, which include work, non-facility or facility, and malpractice RVUs, and the total physician reimbursement. The 2023 Physician Conversion Factor was used to calculate the Medicare physician reimbursement. The Medicare physician reimbursement was used as a conservative estimate. Results The four clinical pathway scenarios were patients who did not experience recurrent SUI or ED (no recurrent SUI/ED), patients who only experienced SUI (only SUI), patients who only experienced ED (only ED), and patients who experienced both SUI and ED (SUI + ED). For the no SUI/ED scenario, the total RVUs from providing patient care were 5.26 RVUs, resulting in $205 in physician reimbursement. For the only SUI scenario, the total RVUs were 56.20 RVUs with an average of $1,996 in physician reimbursement for those receiving AUS and 55.54 RVUs with an average of $1,974 in physician reimbursement for those receiving male sling. For the only ED scenario, the total RVUs were 42.51 RVUs, resulting in $1,550 in physician reimbursement. For the SUI + ED scenario, the total RVUs were 98.71 RVUs with an average of $3,547 in physician reimbursement for those receiving AUS and 98.05 RVUs with an average of $3,524 in physician reimbursement for those receiving male sling. Conclusions This study justified the economic benefits of expanding patient care to men who underwent RP for PCa and provided urology practice insight into the potential physician reimbursement when PCa survivors were seen by reconstructive urologists. Disclosure Yes, this is sponsored by industry/sponsor: Boston Scientific. Clarification: Industry initiated, executed and funded study. Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

Surgical Complexity and Physician Workload in Craniofacial Surgery: Do RVUs Need to be Adjusted?

RVU valuations need to be revisited regularly as procedure complexity and patient care pathways continue to evolve. The NSQIP-P database was queried for craniofacial procedures performed in North America between 2012 and 2019. Multivariate regression was performed to determine correlation coefficients of perioperative variables deemed to reflect procedure severity, including procedure duration, blood transfusion, length of stay, serious adverse events, related readmission, and related reoperation. CPT 21159 Le Fort III with forehead advancement remains the craniofacial procedure with the highest RVUs using our model at 33.93 units. The most underestimated procedure is CPT 42235 Repair of anterior palate, including vomer flap, with a suggested change of +8.27 units, which is a 194% increase from current compensation. Adjusted RVUs based on quantitative and nationally representative perioperative variables that reflect procedure severity might be a better alternative for procedure valuation over current survey methods to determine appropriate insurance compensation.

What is the quantity, quality and type of systematic review evidence available to inform the optimal prescribing of statins and antihypertensives? A systematic umbrella review and evidence and gap map

ObjectivesWe aimed to map the systematic review evidence available to inform the optimal prescribing of statins and antihypertensive medication.DesignSystematic umbrella review and evidence and gap map (EGM).Data sourcesEight bibliographic databases...