Clinical Pathway For Management Research Articles

Defining the Process of a Cardiovascular Risk Assessment Program: Lessons Learned From Cardiac Assessment of Elite Soccer Players in the United Kingdom.

Retrospectively analyze the cardiac assessment process for elite soccer players, and provide team physicians with a systematic guide to managing longitudinal cardiac risk. Descriptive Epidemiology Study. Cardiac assessments incorporating clinical examination, 12-lead ECG, echocardiography, and health questionnaire. Soccer players at 5 professional clubs in England, the United Kingdom. Data was retrospectively collected, inspected, and analyzed to determine their clinical management and subsequent follow-up. Over 2 years, 265 soccer players, aged 13 to 37 years with 66% of white European ethnicity, were included in the cohort. Eleven percent had "not-normal" assessments, of these assessments, 83% were considered gray screens, falling into three broad categories: structural cardiac features (including valvular abnormalities), functional cardiac features, and electrocardiogram changes. After cardiology consultation, all assessments were grouped into low, enhanced and high-risk categories for ongoing longitudinal risk management. Overall clear-cut pathology was identified in 2%. Cardiovascular assessment is a vital tool in identifying athletes at risk of sudden cardiac death to mitigate their risk through surveillance, intervention, or participation restriction. The decision whether a player is fit to play or not requires a robust risk assessment followed by input from a multidisciplinary team that includes both the team physician and cardiologist. This educational article proposes a clinical management pathway to aid clinicians with this process. Sudden cardiac death is the important medical cause of death during exercise. The team physician should assume responsibility for the management of the longitudinal risk of their players' cardiac assessments in conjunction with sports cardiologist.

The Elusive Search for Success: Defining and Measuring Implementation Outcomes in a Real-World Hospital Trial.

Objective and Study Setting: Research efforts to identify factors that influence successful implementation are growing. This paper describes methods of defining and measuring outcomes of implementation success, using a cluster randomized controlled trial with 12 cancer services in Australia comparing the effectiveness of implementation strategies to support adherence to the Australian Clinical Pathway for the Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients (ADAPT CP).Study Design and Methods: Using the StaRI guidelines, a process evaluation was planned to explore participant experience of the ADAPT CP, resources and implementation strategies according to the Implementation Outcomes Framework. This study focused on identifying measurable outcome criteria, prior to data collection for the trial, which is currently in progress.Principal Findings: We translated each implementation outcome into clearly defined and measurable criteria, noting whether each addressed the ADAPT CP, resources or implementation strategies, or a combination of the three. A consensus process defined measures for the primary outcome (adherence) and secondary (implementation) outcomes; this process included literature review, discussion and clear measurement parameters. Based on our experience, we present an approach that could be used as a guide for other researchers and clinicians seeking to define success in their work.Conclusions: Defining and operationalizing success in real-world implementation yields a range of methodological challenges and complexities that may be overcome by iterative review and engagement with end users. A clear understanding of how outcomes are defined and measured, based on a strong theoretical framework, is crucial to meaningful measurement and outcomes. The conceptual approach described in this article could be generalized for use in other studies.Trial Registration: The ADAPT Program to support the management of anxiety and depression in adult cancer patients: a cluster randomized trial to evaluate different implementation strategies of the Clinical Pathway for Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients was prospectively registered with the Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12617000411347.

Mobile Photoplethysmographic Technology to Detect Atrial Fibrillation

BackgroundLow detection and nonadherence are major problems in current management approaches for patients with suspected atrial fibrillation (AF). Mobile health devices may enable earlier AF detection and improved AF management. ObjectivesThis study sought to investigate the effectiveness of AF screening in a large population-based cohort using smart device–based photoplethysmography (PPG) technology, combined with a clinical care AF management pathway using a mobile health approach. MethodsAF screening was performed with smart devices using PPG technology, which were made available for the population ≥18 years of age across China. Monitoring for at least 14 days with a wristband (Honor Band 4) or wristwatch (Huawei Watch GT, Honor Watch, Huawei Technologies Co., Ltd., Shenzhen, China) was allowed. The patients with “possible AF” episodes using the PPG algorithm were further confirmed by health providers among the MAFA (mobile AF app) Telecare center and network hospitals, with clinical evaluation, electrocardiogram, or 24-h Holter monitoring. ResultsThere were 246,541 individuals who downloaded the PPG screening app, and 187,912 individuals used smart devices to monitor their pulse rhythm between October 26, 2018, and May 20, 2019. Among those with PPG monitoring (mean age 35 years, 86.7% male), 424 (of 187,912, 0.23%) (mean age 54 years, 87.0% male) received a “suspected AF” notification. Of those effectively followed up, 227 individuals (of 262, 87.0%) were confirmed as having AF, with the positive predictive value of PPG signals being 91.6% (95% confidential interval [CI]: 91.5% to 91.8%). Both suspected AF and identified AF markedly increased with age (p for trend <0.001), and individuals in Northeast China had the highest proportion of detected AF of 0.28% (95% CI: 0.20% to 0.39%). Of the individuals with identified AF, 216 (of 227, 95.1%) subsequently entered a program of integrated AF management using a mobile AF application; approximately 80% of high-risk patients were successfully anticoagulated. ConclusionsBased on the present study, continuous home monitoring with smart device–based PPG technology could be a feasible approach for AF screening. This would help efforts at screening and detection of AF, as well as early interventions to reduce stroke and other AF-related complications. (Mobile Health [mHealth] Technology for Improved Screening, Patient Involvement and Optimizing Integrated Care in Atrial Fibrillation [MAFA II]; ChiCTR-OOC-17014138)

Development and implementation of a quality improvement toolkit, iron deficiency in pregnancy with maternal iron optimization (IRON MOM): A before-and-after study.

BackgroundIron deficiency (ID) in pregnancy is a common problem that can compromise both maternal and fetal health. Although daily iron supplementation is a simple and effective means of treating ID in pregnancy, ID and ID anemia (IDA) often go unrecognized and untreated due to lack of knowledge of their implications and competing clinical priorities.Methods and findingsIn order to enhance screening and management of ID and IDA in pregnancy, we developed a novel quality-improvement toolkit: ID in pregnancy with maternal iron optimization (IRON MOM), implemented at St. Michael’s Hospital in Toronto, Canada. It included clinical pathways for diagnosis and management, educational resources for clinicians and patients, templated laboratory requisitions, and standardized oral iron prescriptions. To assess the impact of IRON MOM, we retrospectively extracted laboratory data of all women seen in both the obstetrics clinic and the inpatient delivery ward settings from the electronic patient record (EPR) to compare measures pre- and post-implementation of the toolkit: a process measure of the rates of ferritin testing, and outcome measures of the proportion of women with an antenatal (predelivery) hemoglobin value below 100 g/L (anemia), the proportion of women who received a red blood cell (RBC) transfusion during pregnancy, and the proportion of women who received an RBC transfusion immediately following delivery or in the 8-week postpartum period. The pre-intervention period was from January 2012 to December 2016, and the post-intervention period was from January 2017 to December 2017. From the EPR, 1,292 and 2,400 ferritin tests and 16,603 and 3,282 antenatal hemoglobin results were extracted pre- and post-intervention, respectively. One year after implementation of IRON MOM, we found a 10-fold increase in the rate of ferritin testing in the obstetric clinics at our hospital and a lower risk of antenatal hemoglobin values below 100 g/L (pre-intervention 13.5% [95% confidence interval (CI) 13.0%–14.11%]; post-intervention 10.6% [95% CI 9.6%–11.7%], p < 0.0001). In addition, a significantly lower proportion of women received an RBC transfusion during their pregnancy (1.2% pre-intervention versus 0.8% post-intervention, p = 0.0499) or immediately following delivery and in the 8 weeks following (2.3% pre-intervention versus 1.6% post-intervention, p = 0.0214). Limitations of this study include the use of aggregate data extracted from the EPR, and lack of a control group.ConclusionsThe introduction of a standardized toolkit including diagnostic and management pathways as well as other aids increased ferritin testing and decreased the incidence of anemia among women presenting for delivery at our site. This strategy also resulted in reduced proportions of women receiving RBC transfusion during pregnancy and in the first 8 weeks postpartum. The IRON MOM toolkit is a low-tech strategy that could be easily scaled to other settings.

Results of a multinational survey of diagnostic and management practices of thromboembolic pulmonary embolism in children

IntroductionThe incidence of thromboembolic (TE)-pediatric pulmonary embolism (PPE) is increasing. We sought to evaluate current practice patterns and gaps in the management of TE-PPE. Materials and methodsAfter Institutional Review Board approval, SurveyMonkey® questions were sent to members of the Pediatric/Neonatal Thrombosis and Hemostasis Subcommittee, of the International Society on Thrombosis and Haemostasis and the Hemostasis and Thrombosis Research Society. ResultsOf 442 members of the two groups, 134 (30%) responded, and 125 (28%) complete responses were analyzed. Eighty percent practiced at a pediatric facility, 88% at academic centers, and 59% in the USA. Computed tomography pulmonary angiography (CTPA) was the preferred diagnostic modality (89%). D-dimer testing was variably used; 22% used clinical diagnostic prediction models and 8% had specific clinical care pathways for TE-PPE management. Prognostic stratification models were used to guide therapy by 4%. Indications for thrombolytic therapy varied considerably; 40% had a standardized protocol for thrombolysis, employing various modalities (45% systemic, 25% catheter-directed, 19% pharmaco-mechanical) and tissue plasminogen activator dose intensities. Duration of anticoagulation was variable with 58% prescribing anticoagulation for duration of >3 months–6 months; 61% followed for long-term adverse outcomes. ConclusionThis multinational survey of thrombosis/hemostasis specialists mainly based at pediatric academic centers demonstrates that antithrombotic management of TE-PPE (including duration of anticoagulation and use/non-use of thrombolysis) varies considerably. Furthermore, standardized care pathways to facilitate acute evaluation and management decisions are in place in a minority of centers. These findings help to inform the design of future clinical trials in TE-PPE.

Outcomes and Safety Among Patients With Obstructive Sleep Apnea Undergoing Cancer Surgery Procedures in a Freestanding Ambulatory Surgical Facility.

Patients with obstructive sleep apnea (OSA) may be at increased risk for serious perioperative complications. The suitability of ambulatory surgery for patients with OSA remains controversial, and several national guidelines call for more evidence that assesses clinically significant outcomes. In this study, we investigate the association between OSA status (STOP-BANG risk, or previously diagnosed) and short-term outcomes and safety for patients undergoing cancer surgery at a freestanding ambulatory surgery facility. We conducted a retrospective analysis of all patients having surgery at the Josie Robertson Surgery Center, a freestanding ambulatory surgery facility of the Memorial Sloan Kettering Cancer Center. Surgeries included more complex ambulatory extended recovery procedures for which patients typically stay overnight, such as mastectomy, thyroidectomy, and minimally invasive hysterectomy, prostatectomy, and nephrectomy, as well as typical outpatient surgeries. Both univariate and multivariable analyses were used to assess the association between OSA risk and transfer to the main hospital, urgent care center visit, and hospital readmission within 30 days postoperatively (primary outcomes) and length of stay and discharge time (secondary outcomes). Multivariable models were adjusted for age, American Society of Anesthesiologists score, robotic surgery, and type of anesthesia (general or monitored anesthesia care) and also adjusted for surgery start time for length of stay and discharge time outcomes. χ tests were used to assess the association between OSA risk and respiratory events and device use. Of the 5721 patients included in the analysis, 526 (9.2%) were diagnosed or at moderate or high risk for OSA. We found no evidence of a difference in length of stay when comparing high-risk or diagnosed patients with OSA to low- or moderate-risk patients whether they underwent outpatient (P = .2) or ambulatory extended recovery procedures (P = .3). Though a greater frequency of postoperative respiratory events were reported in high-risk or diagnosed patients with OSA compared to moderate risk (P = .004), the rate of hospital transfer was not significantly different between the groups (risk difference, 0.78%; 95% CI, -0.43% to 2%; P = .2). On multivariable analysis, there was no evidence of increased rate of urgent care center visits (adjusted risk difference, 1.4%; 95% CI, -0.68% to 3.4%; P = .15) or readmissions within 30 days (adjusted risk difference, 1.2%; 95% CI, -0.40% to 2.8%; P = .077) when comparing high-risk or diagnosed OSA to low- or moderate-risk patients. Based on the upper bounds of the CIs, a clinically relevant increase in transfers, readmissions, and urgent care center visits is unlikely. Our results contribute to the body of evidence supporting that patients with moderate-risk, high-risk, or diagnosed OSA can safely undergo outpatient and advanced ambulatory oncology surgery without increased health care burden of extended stay or hospital admission and avoiding adverse postoperative outcomes. Our results support the adoption of several national OSA guidelines focusing on preoperative identification of patients with OSA and clinical pathways for perioperative management and postoperative monitoring.

Management of overweight and obesity in primary care-A systematic overview of international evidence-based guidelines.

SummaryOverweight and obesity are increasing worldwide. In general practice, different approaches exist to treat people with weight problems. To provide the foundation for the development of a structured clinical pathway for overweight and obesity management in primary care, we performed a systematic overview of international evidence‐based guidelines. We searched in PubMed and major guideline databases for all guidelines published in World Health Organization (WHO) “Stratum A” nations that dealt with adults with overweight or obesity. Nineteen guidelines including 711 relevant recommendations were identified. Most of them concluded that a multidisciplinary team should treat overweight and obesity as a chronic disease. Body mass index (BMI) should be used as a routine measure for diagnosis, and weight‐related complications should be taken into account. A multifactorial, comprehensive lifestyle programme that includes reduced calorie intake, increased physical activity, and measures to support behavioural change for at least 6 to 12 months is recommended. After weight reduction, long‐term measures for weight maintenance are necessary. Bariatric surgery can be offered to people with a BMI greater than or equal to 35 kg/m2 when all non‐surgical interventions have failed. In conclusion, there was considerable agreement in international, evidence‐based guidelines on how multidisciplinary management of overweight and obesity in primary care should be performed.

Proactive Management of Iron Deficiency and Anemia in Pediatric Inflammatory Bowel Disease—Development of a New Care Pathway

Anemia is a common complication of inflammatory bowel disease (IBD), with studies reporting an even greater prevalence among children (49-70%) than adults (20-39%) at any given time during disease course. In the majority of cases, anemia is a result of iron deficiency (ID), chronic inflammation, or a combination of both. Both anemia and ID itself have been associated with high rates of IBD-related complications, resource utilization, and impaired quality of life. However, ID and anemia remain under-recognized and undertreated. To align clinical practice with guideline recommendations, we developed a clinical care pathway for screening, management, and follow-up of ID and anemia among pediatric patients with IBD. In the absence of specific pediatric guidance, these recommendations are based on international adult clinical guidelines and evidence-based pediatric publications. We aim to achieve a 70% screening and intervention rate by June 2019. This QI initiative was started at the CHOP IBD Center in November 2017. PDSA cycles included review of our current performance with all IBD providers (11/2017), educational sessions given in the inpatient and outpatient setting (01/2018), modification of the divisional IV iron therapy order set (02/2018), development of a new clinical pathway for active screening and management of iron deficiency and anemia (1st version available 2/2018 and open access online 11/2018), and creation of individualized monthly reports for all of our GI providers identifying patients with anemia (12/2018). In parallel, ferric carboxymaltose was made available for outpatient management of iron deficiency as of November 2017. Baseline data from July 2016 was compared to data after initiation of the QI initiative. Prior to this QI initiative, review of our performance at CHOP, revealed that 35.7% of our active outpatient IBD population was anemic, however only a minority of these patients were being screened for iron deficiency (20%) and appropriately treated with supplementation (18.4%). Following the implementation of this QI project, improvement was observed with screening and treatment rate increasing to 54.6% and 36.9% respectively by February 2019 (Figures 1 and 2). Iron deficiency and anemia is commonly underdiagnosed and undertreated in children with IBD. An evidence and expert based pathway may help increase screening and intervention. We expect to show continued improvement once this pathway is fully incorporated into clinical practice.

An in-hospital clinical care pathway with integrated decision support for cancer pain management reduced pain intensity and needs for hospital stay.

A clinical care pathway for pain management in a palliative care unit was studied with outcomes related to patients, physicians, and health care service. Mandatory use of patient-reported outcome measures (PROMs) and physician-directed decision support (DS) were integrated parts of the pathway. Adult cancer patients with pain intensity (PI) ≥ 5 (NRS 0-10) at admission were eligible. The patients reported average and worst PI at admission, day four, and discharge. The physicians completed the DS at admission and day four. The DS presented potential needs for treatment changes based on pain severity and pathophysiology. The physicians reported treatment changes due to input from the DS system. The two primary outcomes were average and worst PI changes from admission to discharge. Hospital length of stay (LOS) was registered. Of 52 included patients, 41 were discharged alive. For those, the mean average PI at admission and at discharge was 5.8 and 2.4, respectively, a reduction of 3.4 points (CI 95% 2.7-4.1). The corresponding worst pain intensities were 7.9 and 3.8, a reduction of 4.1 points (CI 95% 3.4-4.8). The physicians completed DS forms for all patients. Fifty-five percent (CI 95% 41-69) of the patients had pain intervention changes based on the DS. A significant reduction in LOS (4.4days, CI 95% 0.5-8.3) was observed during the study period. The interventions were implemented according to the intentions and PI was reduced as hypothesized. For evaluation of generalizability, the interventions should be studied in other settings and with a controlled design.

Using blended learning to improve education on clinical pathways for breast cancer management in Nigeria: Preliminary results.

10539 Background: Most Nigerian clinicians lack adequate skills and resources in screening, diagnosis, and managing women with breast cancer. The absence of locally-sensitive clinical pathways in hospitals in Abia State impact patient outcomes and clinicians job satisfaction. Blended learning (BL), a combination of online and face-to-face teaching methods, has been used in other settings to improve the competencies of clinicians. Research seeks to develop and evaluate a BL course that will train clinicians in Abia State on using NCCN breast cancer management guidelines, and to develop and implement locally-sensitive clinical pathways. Methods: The course is divided into four online modules delivered via Google Classroom and a workshop module to be delivered in 3 cities. Course evaluation involves an objective-focused method, following a mixed-methods design. Data collection includes pre-and-post-tests, course evaluation and focus group discussions. Data analysis involved descriptive statistics and t-test. Comments deductively analyzed to identify common themes. A sample size of 107 individuals is required to identify a moderate effect size for the BL course. Results: Forty-three participants (physicians=15, Nurses=28) have been recruited for cohort 1, with average age of 44 (±9.9) years. Most participants have never taken an online class (65%) but use mobile phones (60%) to access the course. With a maximum of 20 points in each test, there is a pattern of improvement in the post-tests performance compared with the pre-tests. Table shows mean scores. Most participants have expressed satisfaction with the course. Conclusions: Results show improvement in learning. More participants are being recruited. The workshops will hold at after the online modules.[Table: see text]

A retrospective, real-world population-based analysis of treatment patterns and outcomes in adult patients with relapsed/refractory acute myeloid leukemia in Alberta, Canada.

e18505 Background: In order to describe the impact of future targeted therapies on treatment outcomes of patients (pts) with relapsed and/or refractory (RR) acute myeloid leukemia (AML), a better understanding of the clinical management pathway in these pts is needed. We therefore evaluated the treatment patterns and associated outcomes in a real-world cohort of pts with RR-AML using a population-based cancer registry and patient medical records. Methods: Pts newly diagnosed wih AML between January 2013 and December 2016, aged ≥ 18 years were identified from the provincial-wide Alberta Cancer Registry (ACR). Data for pts who met the criteria for RR-AML were assessed by hematologists and were extracted from medical records. RR-AML pts were then categorized as: receiving intensive therapy (IT); receiving non-intensive therapy (NIT); or treated with best-supportive care (BSC) following a diagnosis of RR-AML. Results: 572 AML pts were identified from the ACR, of which 199 met criteria for RR-AML and were included in the analysis (124 males, 75 females; median age at diagnosis of RR-AML 66.8 years; median follow-up 4.7 months). In this RR-AML cohort, 26 (13%) pts received ≥ 2 lines of prior therapy. Unadjusted median overall survival (mOS) was 5.3 months, with a 12-month overall survival rate of 29.6% (95% CI 29.0–30.3%) from the time of RR. Following RR, 46 (23%) pts received IT, 65 (33%) pts were treated with NIT, and 88 (44%) pts received BSC, with unadjusted mOS of 13.8, 9.4, and 2.1 months, respectively ( P &lt; 0.001). When stratified by European LeukemiaNet risk classification at diagnosis, unadjusted mOS was 12.4, 4.7, and 4.0 months for favorable risk, intermediate risk, and adverse risk groups, respectively ( P &lt; 0.01). Conclusions: This retrospective, real-world study in Alberta Canada confirms the poor prognosis reported to date in the RR-AML population. Notably, a large proportion of pts received BSC which was associated with dismal survival outcomes. These data also highlight that effective and tolerable alternatives to current treatment options are urgently needed.

LO87: Impact of an evidence-based clinical pathway for suspected renal colic in low-risk patients with previous nephrolithiasis on CT utilization and emergency department throughput

Background: Choosing Wisely (CW) recommends patients under age 50 with uncomplicated, recurrent renal colic do not require CT scans. Despite this, CT use has risen dramatically in the past two decades, resulting in unnecessary radiation, cost and prolonged length of stay (LOS). Additionally, a common alternative – formal ultrasound (US) – is not always available. Returning for US can add 10 hours to LOS. We introduced a clinical management pathway (CMP) for low-risk patients with renal colic utilizing point-of-care ultrasound (POCUS) and evaluated its impact on emergency department (ED) CT rates and LOS. Aim Statement: By April 2019, we aim to reduce CT utilization by 50% and time from physician initial assessment (PIA) to discharge by 1 hour for patients under age 50 presenting to Sunnybrook ED with uncomplicated, recurrent renal colic. Measures &amp;amp; Design: The primary intervention was a CMP developed collaboratively with local urologists. The CMP uses POCUS to assess for hydronephrosis (HN) as a marker of nephrolithiasis. Patients with HN receive follow-up in urology clinic without confirmatory imaging. Patients without HN proceed to usual care. An Ishikawa diagram helped identify barriers to success. Subsequent PDSA cycles included the introduction of reference cards, POCUS workshops and online modules. Outcome measures were ED CT utilization and PIA to discharge times. Process measures were referrals to urology clinic and proportion of patients receiving XR, US and no imaging. Balancing measures were urology CT utilization, alternate diagnoses and return ED visits. Data was plotted on a run chart. Evaluation/Results: Data collection is ongoing and will conclude by April 2019. Interim data shows patients enrolled in the CMP have a reduction in mean PIA-to-discharge time of 173 minutes. Fidelity – specifically, the willingness of ED physicians to use POCUS compared to the ease of ordering CTs – is the biggest challenge to success. Discussion/Impact: This study addresses the feasibility of CW recommendations and utilizes POCUS as a tool for recurrent renal colic. Collaboration with Urology will provide insight into the CMP's sustainability and downstream impact. Reduction of unnecessary CTs will lead to improved patient safety and reduced costs. Decreased PIA-to-discharge times will reduce overcrowding, shorten wait times and improve access to imaging for other patients. Finally, this project may encourage use of POCUS for low-risk patients with renal colic.

AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations.

AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations.

A Novel Pathway for Somatic Symptoms: Strategies for Successful Pathway Implementation

In this month’s Hospital Pediatrics , Ibeziako et al1 present a clinical pathway for hospital-based management of somatic symptoms and related disorders (SSRDs). SSRDs include psychiatric diagnoses outlined in the Diagnostic and Statistical Manual, Fifth Revision , such as conversion disorder, factitious disorders, and illness anxiety disorder, as well as other medical conditions, such as functional gastrointestinal disorders, amplified pain syndromes, and “psychogenic” conditions such as nonepileptiform seizures and syncope. This new pathway outlines principles of managing SSRDs in hospitalized patients and provides resources to aid hospital teams in effective management. Although mental health conditions are among the most common reasons for pediatric hospitalization2 and are a common comorbidity in medical and surgical hospitalizations,3 few clinical pathways exist to guide hospital management of mental health concerns. The SSRD pathway breaks new ground by providing standards to guide the care of a complex group of disorders requiring collaboration across medical and psychosocial disciplines. Given the complexities of managing SSRDs, hospital teams will likely experience challenges implementing the guidelines provided in the SSRD pathway. We have drawn from our own experiences caring for patients with SSRDs to outline likely difficulties and suggest strategies that might help address each one. How the SSRD pathway is implemented will vary depending on hospital setting and resources. Determining which clinicians have familiarity in treating …

Hepatobiliary and pancreatic surgery in a low budget country: experience from Ayder Referral Hospital, Northern Ethiopia.

Background: Ayder Referral Hospital is located in Northern Ethiopia, rendering service to a population of over 8 million people. Up to 2013 HBP surgery in Ethiopia was restricted mainly to Addis Abbeba, located 800 km from Ayder. Methods: Starting in 2012 a team of German doctors regularly visited Ayder and established a HBP surgery training program. In addition, they provided equipment for the operating rooms and the intensive care unit. HPB training commenced in 2013 with external support by one experienced HBP surgeon (MWH). It was the aim to establish a self-sustaining HBP surgical program. Results: HBP training included lectures, hands-on surgical training as well as clinical pathways for HBP procedures and complication management. One surgeon (RE) received additional training in Germany and India to advance HBP surgical skills. To date 3 liver resections and 11 pancreatic head resections (10 without external support) were performed with one patient death from PTE two months postoperatively. Conclusion: A training program and clinical knowledge transfer have successfully been established at Ayder hospital. Complex HBP procedures are now being performed independently by a local team of surgeons. Further efforts strive to increase patient numbers, as well as to improve postoperative patient care in the intensive care unit and after discharge from the hospital. Our experience demonstrates that advanced HPB procedures can safely be performed after training “on the spot”.

Hepatobiliary and pancreatic surgery in a low budget country: experience from Ayder Referral Hospital, Northern Ethiopia

Background: Ayder Referral Hospital is located in Northern Ethiopia, rendering service to a population of over 8 million people. Up to 2013 HBP surgery in Ethiopia was restricted mainly to Addis Abbeba, located 800 km from Ayder. Methods: Starting in 2012 a team of German doctors regularly visited Ayder and established a HBP surgery training program. In addition, they provided equipment for the operating rooms and the intensive care unit. HPB training commenced in 2013 with external support by one experienced HBP surgeon (MWH). It was the aim to establish a self-sustaining HBP surgical program. Results: HBP training included lectures, hands-on surgical training as well as clinical pathways for HBP procedures and complication management. One surgeon (RE) received additional training in Germany and India to advance HBP surgical skills. To date 3 liver resections and 11 pancreatic head resections (10 without external support) were performed with one patient death from PTE two months postoperatively. Conclusion: A training program and clinical knowledge transfer have successfully been established at Ayder hospital. Complex HBP procedures are now being performed independently by a local team of surgeons. Further efforts strive to increase patient numbers, as well as to improve postoperative patient care in the intensive care unit and after discharge from the hospital. Our experience demonstrates that advanced HPB procedures can safely be performed after training “on the spot”.

Comparison of implementation strategies to influence adherence to the clinical pathway for screening, assessment and management of anxiety and depression in adult cancer patients (ADAPT CP): study protocol of a cluster randomised controlled trial

BackgroundHealth service change is difficult to achieve. One strategy to facilitate such change is the clinical pathway, a guide for clinicians containing a defined set of evidence-based interventions for a specific condition. However, optimal strategies for implementing clinical pathways are not well understood. Building on a strong evidence-base, the Psycho-Oncology Co-operative Research Group (PoCoG) in Australia developed an evidence and consensus-based clinical pathway for screening, assessing and managing cancer-related anxiety and depression (ADAPT CP) and web-based resources to support it - staff training, patient education, cognitive-behavioural therapy and a management system (ADAPT Portal). The ADAPT Portal manages patient screening and prompts staff to follow the recommendations of the ADAPT CP. This study compares the clinical and cost effectiveness of two implementation strategies (varying in resource intensiveness), designed to encourage adherence to the ADAPT CP over a 12-month period.MethodsThis cluster randomised controlled trial will recruit 12 cancer service sites, stratified by size (large versus small), and randomised at site level to a standard (Core) versus supported (Enhanced) implementation strategy. After a 3-month period of site engagement, staff training and site tailoring of the ADAPT CP and Portal, each site will “Go-live”, implementing the ADAPT CP for 12 months. During the implementation phase, all eligible patients will be introduced to the ADAPT CP as routine care. Patient participants will be registered on the ADAPT Portal to complete screening for anxiety and depression. Staff will be responsible for responding to prompts to follow the ADAPT CP. The primary outcome will be adherence to the ADAPT CP. Secondary outcomes include staff attitudes to and experiences of following the ADAPT CP, using the ADAPT Portal and being exposed to ADAPT implementation strategies, collected using quantitative and qualitative methods. Data will be collected at T0 (baseline, after site engagement), T1 (6 months post Go-live) and T2 (12 months post Go-live).DiscussionThis will be the first cluster randomised trial to establish optimal levels of implementation effort and associated costs to achieve successful uptake of a clinical pathway within cancer care.Trial registrationThe study was registered prospectively with the ANZCTR on 22/3/2017. Trial ID ACTRN12617000411347

Post-Hospitalization Short-Term Oxygen Therapy: Use of a Clinical Management Pathway and Long-Term Follow-Up.

Home oxygen therapy is commonly prescribed for patients who remain hypoxemic at hospital discharge, although evidence supporting this practice is lacking. This study aimed to evaluate oxygen prescription and follow-up for patients who were prescribed post-discharge short-term oxygen therapy (STOT) and to assess their long-term outcome. A retrospective audit was undertaken of subjects prescribed STOT following hospitalization at a single site in Melbourne, Australia, between January 2011 and December 2015. During the study period, a designated clinical pathway for STOT prescription and follow-up after hospital discharge was in place. Chart review was performed to collect subject demographics and comorbidities, results of oxygen assessment (arterial blood gas and 6-min walk tests) and prescription, and results at follow-up re-assessment and mortality. Over five 5 years, 205 subjects were prescribed STOT upon hospital discharge. Common indications for oxygen treatment were chronic lung disease (54%) and dyspnea palliation (26%). Of the 152 subjects who were discharged with non-palliative oxygen therapy, 28% did not fulfil the recommended prescribing criteria or did not have recommended assessments. Among the 118 subjects who returned for re-assessment 4 weeks after initial oxygen provision, 47 (40%) did not fulfill criteria for long-term oxygen therapy. The 1-y cumulative survival rate for the study population was 56%. A significant proportion of subjects who were prescribed post-discharge STOT did not fulfill the recommended prescribing criteria. The long-term prognosis for subjects who were prescribed post-discharge STOT was poor.

Disorders of Sex Development/Intersex: Gaps in Psychosocial Care for Children.

* Abbreviation: DSD — : disorder and/or difference of sex development Access to psychosocial care is currently inadequate for patients and families affected by a disorder of sex development (DSD; some individuals prefer the terms “intersex” or “differences of sex development,” and some do not identify with any of the labels). In 1 recent study of parents of infants with a DSD, only half of those parents who identified a need for emotional support received what they perceived to be adequate psychological care.1 This is troubling in that a case can be made that the primary challenges faced by parents of children newly diagnosed with a DSD are informational and psychosocial, not medical or surgical. Even in the case of life-threatening congenital adrenal hyperplasia, the most common cause of a 46,XX DSD, clinical management pathways are well established and driven by clinical practice guidelines not dissimilar from, for example, type 1 diabetes. In a DSD, however, families grapple with a variety of challenges beyond understanding complex medical and/or genetic information, including stigma-related concerns, coping with anatomical differences (whether or not surgery has occurred), surgical complications, lack of clarity regarding gonadal tumor risk, uncertainty about the stability of the child’s gender identity, fertility potential, and the disruptions and burdens associated with repeated medical visits. Detection of a DSD at birth is commonly a time of particularly acute distress; parents report high levels of emotional upheaval and cognitive confusion that often occurs concomitant with medical and surgical decision-making. There are close to 80 single-gene etiologies for isolated or syndromic DSDs.2 Major categories include genes affecting sex determination (eg, … Address correspondence to Michelle M. Ernst, PhD, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: michelle.ernst{at}cchmc.org

Colon cancer screening with CT colonography: logistics, cost-effectiveness, efficiency and progress.

Colorectal cancer (CRC) incidence and mortality can be significantly reduced by population screening. Several different screening methods are currently in use, and this review focuses specifically on the imaging technique computed tomographic colonography (CTC). The challenges and logistics of CTC screening, as well as the importance of test accuracy, uptake, quality assurance and cost-effectiveness will be discussed. With comparable advanced adenoma detection rates to colonoscopy (the most commonly used whole-colon investigation), CTC is a less-invasive alternative, requiring less laxative, and with the potential benefit that it permits assessment of extracolonic structures. Three large-scale European trials have contributed valuable evidence supporting the use of CTC in population screening, and highlight the importance of selecting appropriate clinical management pathways based on initial CTC findings. Future research into CTC-screening will likely focus on radiologist training and CTC quality assurance, with identification of evidence-based key performance indicators that are associated with clinically-relevant outcomes such as the incidence of post-test interval cancers (CRC occurring after a presumed negative CTC). In comparison to other CRC screening techniques, CTC offers a safe and accurate option that is particularly useful when colonoscopy is contraindicated. Forthcoming cost-effectiveness analyses which evaluate referral thresholds, the impact of extra-colonic findings and real-world uptake will provide useful information regarding the feasibility of future CTC population screening.