Complex Care Pathways Research Articles

Mind the gap: exploring stakeholder perspectives on police-led pathways to crisis mental health care for young people in Ireland

ABSTRACT Over the past few decades, the level of police involvement at a community level in matters of mental health has increased significantly. Police are often the only agency immediately available day or night to respond to such emergencies and are often left to deal with mental illness and associated social crises with very limited support. Whilst recent years have witnessed an upsurge in governmental policy intended to safeguard vulnerable groups, such as young people and people with mental illness, there is a dearth of research regarding the proficiency and operability of these directives in practice. Even less is known about how these policies are practically applied to young people in crisis. The study examines the police-led care pathways of Irish youth experiencing a crisis mental health event from the commencement of police involvement through to the initiation of psychiatric care. Qualitative interviews were conducted with police and a group of stakeholders comprised of medical professionals and a social worker. Results indicate a complex care pathway beset with ambiguous policy and legislation, deficits in specialist training, and chronic under-resourcing of services. In the face of these shortcomings, police innovate informal practices that sometimes help and at other times pose a risk to young people in crisis. Furthermore, uncertainties surrounding formal procedure was a source of significant psychological burden for police and potential disciplinary action. These findings are discussed in the context of existing theory and research, and recommendations for policy and practice are offered.

Digitalizing Access to Care: How Self-Check-In Kiosks Shape Access to Care and Efficiency of Hospital Services

Responding to labor shortages and rising healthcare expenses, hospitals increasingly turn to self-check-in kiosks to streamline service delivery and improve patients’ experiences. The purpose of this study was to reflect on the implementation of these self-check-in kiosks in a Dutch university hospital, particularly in relation to access to care for more vulnerable patients and intended efficiency goals. We followed a technology-in-practice approach to better understand how new technologies shape care practices in relation to in/exclusion and carried out an ethnographic action study involving desk research, participatory observations, semi-structured interviews, and reflection sessions with developers and hospital staff. Data were analyzed through ethnographic content analysis. Our results show that although self-check-in kiosks work well for some patients, many people experience practical and psychosocial difficulties, especially those who go through a complex care pathway, are low-literate, experience a distance the online world, or have sensory, motor, or cognitive impairments. Kiosks are not yet attuned to these patients and typically leave little flexibility and room for negotiation and personal support in what is, for many, a foreign environment. Therefore, patients frequently seek confirmation and assistance from already downsized or busy staff. In conclusion, we find that digitalization under the banner of efficiency within a healthcare system already under pressure carries risks, as it can unintentionally generate extra (invisible) work for patients and care professionals and threaten access to and quality of care for patients most in need. A more concentrated effort on refining the digitalization of healthcare processes using an inclusive-technology-in-practice approach has the potential to contribute to fairer and more efficient care for all patients.

A Canadian Simulation Model for Major Depressive Disorder: Study Protocol.

Major depressive disorder (MDD) is a common, often recurrent condition and a significant driver of healthcare costs. People with MDD often receive pharmacological therapy as the first-line treatment, but the majority of people require more than one medication trial to find one that relieves symptoms without causing intolerable side effects. There is an acute need for more effective interventions to improve patients' remission and quality of life and reduce the condition's economic burden on the healthcare system. Pharmacogenomic (PGx) testing could deliver these objectives, using genomic information to guide prescribing decisions. With an already complex and multifaceted care pathway for MDD, future evaluations of new treatment options require a flexible analytic infrastructure encompassing the entire care pathway. Individual-level simulation models are ideally suited for this purpose. We sought to develop an economic simulation model to assess the effectiveness and cost effectiveness of PGx testing for individuals with major depression. Additionally, the model serves as an analytic infrastructure, simulating the entire patient pathway for those with MDD. Key stakeholders, including patient partners, clinical experts, researchers, and modelers, designed and developed a discrete-time microsimulation model of the clinical pathways of adults with MDD in British Columbia (BC), including all publicly-funded treatment options and multiple treatment steps. The Simulation Model of Major Depression (SiMMDep) was coded with a modular approach to enhance flexibility. The model was populated using multiple original data analyses conducted with BC administrative data, a systematic review, and an expert panel. The model accommodates newly diagnosed and prevalent adult patients with MDD in BC, with and without PGx-guided treatment. SiMMDep comprises over 1500 parameters in eight modules: entry cohort, demographics, disease progression, treatment, adverse events, hospitalization, costs and quality-adjusted life-years (payoff), and mortality. The model predicts health outcomes and estimates costs from a health system perspective. In addition, the model can incorporate interactive decision nodes to address different implementation strategies for PGx testing (or other interventions) along the clinical pathway. We conducted various forms of model validation (face, internal, and cross-validity) to ensure the correct functioning and expected results of SiMMDep. SiMMDep is Canada's first medication-specific, discrete-time microsimulation model for the treatment of MDD. With patientpartner collaboration guiding its development, it incorporates realistic care journeys. SiMMDep synthesizes existing information and incorporates provincially-specific data to predict the benefits and costs associated with PGx testing. These predictions estimate the effectiveness, cost-effectiveness, resource utilization, and health gains of PGx testing compared with the current standard of care. However, the flexible analytic infrastructure can be adapted to support other policy questions and facilitate the rapid synthesis of new data for a broader search for efficiency improvements in the clinical field of depression.

Impact of coordinated care on adherence to antihypertensive medicines among adults experiencing polypharmacy in Australia.

Adherence to antihypertensives is key for blood pressure control. Most people with hypertension have several comorbidities and require multiple medicines, leading to complex care pathways. Strategies for coordinating medicine use can improve adherence, but cumulative benefits of multiple strategies are unknown. Using dispensing claims for a 10% sample of eligible Australians, we identified adult users of antihypertensives during July 2018-June 2019 who experienced polypharmacy (≥5 unique medicines). We measured medicine use reflecting coordinated medicine management in 3 months before and including first observed dispensing, including: use of simple regimens for each cardiovascular medicine; prescriber continuity; and coordination of dispensings at the pharmacy. We measured adherence (proportion of days covered) to antihypertensive medicines in the following 12 months, and used logistic regression to assess independent associations and interactions of adherence with these measures of care. We identified 202 708 people, of which two-thirds (66.6%) had simple cardiovascular medicine regimens (one tablet per day for each medicine), two-thirds (63.3%) were prescribed >75% of medicines from the same prescriber, and two-thirds (65.5%) filled >50% of their medicine on the same day. One-third (28.4%) of people experienced all three measures of coordinated care. Although all measures were significantly associated with higher adherence, adherence was greatest among people experiencing all three measures (odds ratio = 1.63; 95% confidence interval: 1.55-1.72). This interaction was driven primarily by effects of prescriber continuity and dispensing coordination. Coordinating both prescribing and dispensing of medicines can improve adherence to antihypertensives, which supports strategies consolidating both prescribing and supply of patients' medicines.

Care pathways in older patients seen in a multidisciplinary same day emergency care (SDEC) unit.

Same day emergency care (SDEC) services are being advocated in the UK for frail, older patients in whom hospitalisation may be associated with harm but there are few data on the 'ambulatory pathway'. We therefore determined the patient pathways pre- and post-first assessment in a SDEC unit focussed on older people. In consecutive patients, we prospectively recorded follow-up SDEC service reviews (face-to-face, telephone, Hospital-at-Home domiciliary visits), outpatient referrals (e.g. to specialist clinics, imaging, and community/voluntary/social services), and hospital admissions <30days. In the first 67 patients, we also recorded healthcare interactions (except GP attendances) in the 180days pre- and post-first assessment. Among 533 patients (mean/SD age = 75.0/17.5years, 246, 46% deemed frail) assessed in an SDEC unit, 210 were admitted within 30days (152 immediately). In the 381(71%) remaining initially ambulatory, there were 587 SDEC follow-up reviews and 747 other outpatient referrals (mean = 3.5 per patient) with only 34 (9%) patients being discharged with no further follow-up. In the subset (n = 67), the number of 'healthcare days' was greater in the 180days post- versus pre-SDEC assessment (mean/SD = 26/27 versus 13/22days, P= 0.003) even after excluding hospital admission days, with greater healthcare days in frail versus non-frail patients. SDEC assessment in older, frail patients was associated with a 2-fold increase in frequency of healthcare interactions with complex care pathways involving multiple services. Our findings have implications for the development of admission-avoidance models including cost-effectiveness and optimal delivery of the multi-dimensional aspects of acute geriatric care in the ambulatory setting.

On track on the care pathway: Care coordination, information, and communication needs among Norwegian cancer patients.

Background: Cancer patients may have long-lasting and complex care pathways. These typically involve a wide range of care providers who must coordinate their actions, so that treatment and follow up is experienced as seamless and integrated. Good communication with patients and providing them with the 'right amount' of information is crucial to ensure that patients feel engaged and empowered along the pathway. &#x0D; The study: This paper reports from an ongoing research study ('Pathway') on the management of patient pathways in Norway, exemplified with cancer pathways. The project aims to give detailed descriptions of the unfolding of pathways, with an emphasis on patients' experiences and needs. These form the basis for the development of a theoretical pathway model and a visual multi-layered modeling language. This paper addresses the research question: What are cancer patients' information- and communication needs from care providers during their patient pathway?&#x0D; Methods: We conducted three workshops with cancer patients and next of kin (n=35), supplemented with individual interviews (n=6) in June 2022. Participants had various cancer diagnoses. Data collection was conducted on a digital platform. Study participants were asked i.e., about communication with the services, their information needs, and how they keep overview of their appointments and contacts with the services, as well as how they would like to stay informed and engaged. &#x0D; Results: A 'regular' cancer pathway was described to involve a wide range of providers, like regional and local public hospitals, private medical imaging centers, general practitioners, municipal care providers (i.e., physiotherapy, home care services), as well as the labour and welfare office. For the most complex cancers, and for multimorbid patients, the pathways could be even more complex. Study participants unanimously agreed that knowing as much as possible about the disease, its treatment, and follow up is critical to feel in control. Even though the participants mostly were satisfied with the cancer pathway, they all had experienced breakdowns in care coordination, missing and contradictory information, and providers lacking overview of their situation. Most participants had experience with taking on the task of collecting and aligning information and taking responsibility for coordinating their own follow up and care. Specifically, this was true when patients were discharged from hospital and from the standardized cancer patient pathway (CPP). The participants had invented various creative ways of keeping track of all the information they were given, and they frequently acted as messengers between providers. &#x0D; Learning and next steps: The study underscores the challenge of ensuring integrated care for patients. Cancer is among the diseases that has evidence-based treatment protocols, and in Norway diagnostics and treatment is organized in standardized care pathways. Nevertheless, also these patients struggled with keeping track of their 'simple' pathways. Such findings remind us about the need to keep on working for improving integration across disease specific pathways, and that good communication and access to information for all the involved actors are means for achieving this. The next step in our study is to map patients' touchpoints with the services over time, in detail.

Clinical and Scientific Challenges to Effectiveness Studies Under Coverage with Evidence Development in Alzheimer's Disease.

The Centers for Medicare and Medicaid Services (CMS) has recently issued a national coverage determination for US Food and Drug Administration (FDA)-approved anti-amyloid monoclonal antibodies (mAbs) for the treatment of Alzheimer's disease (AD) under coverage with evidence development (CED). CED schemes are complex, costly, and challenging, and often fail to achieve intended objectives because of administrative and implementation issues. AD is a heterogeneous, progressive neurodegenerative disorder with complex care pathway that additionally presents scientific challenges related to the choice of study design and methods used in evaluating CED schemes. These challenges are herein discussed. Clinical findings from the US Veterans Affairs healthcare system help inform our discussion of specific challenges to CED-required effectiveness studies in AD.

Improving the Management and Treatment of Diabetic Foot Infection: Challenges and Research Opportunities.

Diabetic foot infection (DFI) management requires complex multidisciplinary care pathways with off-loading, debridement and targeted antibiotic treatment central to positive clinical outcomes. Local administration of topical treatments and advanced wound dressings are often used for more superficial infections, and in combination with systemic antibiotics for more advanced infections. In practice, the choice of such topical approaches, whether alone or as adjuncts, is rarely evidence-based, and there does not appear to be a single market leader. There are several reasons for this, including a lack of clear evidence-based guidelines on their efficacy and a paucity of robust clinical trials. Nonetheless, with a growing number of people living with diabetes, preventing the progression of chronic foot infections to amputation is critical. Topical agents may increasingly play a role, especially as they have potential to limit the use of systemic antibiotics in an environment of increasing antibiotic resistance. While a number of advanced dressings are currently marketed for DFI, here we review the literature describing promising future-focused approaches for topical treatment of DFI that may overcome some of the current hurdles. Specifically, we focus on antibiotic-impregnated biomaterials, novel antimicrobial peptides and photodynamic therapy.

Photobiomodulation in the management of oral mucositis for adult head and neck cancer patients receiving irradiation: the LiTEFORM RCT.

Oral mucositis is a debilitating and painful complication of head and neck cancer irradiation that is characterised by inflammation of the mucous membranes, erythema and ulceration. Oral mucositis affects 6000 head and neck cancer patients per year in England and Wales. Current treatments have not proven to be effective. International studies suggest that low-level laser therapy may be an effective treatment. To assess the clinical effectiveness and cost-effectiveness of low-level laser therapy in the management of oral mucositis in head and neck cancer irradiation. To identify barriers to and facilitators of implementing low-level laser therapy in routine care. Placebo-controlled, individually randomised, multicentre Phase III superiority trial, with an internal pilot and health economic and qualitative process evaluations. The participants, outcome assessors and therapists were blinded. Nine NHS head and neck cancer sites in England and Wales. A total of 87 out of 380 participants were recruited who were aged ≥ 18 years and were undergoing head and neck cancer irradiation with ≥ 60 Gy. Random allocation (1 : 1 ratio) to either low-level laser therapy or sham low-level laser therapy three times per week for the duration of irradiation. The diode laser had the following specifications: wavelength 660 nm, power output 75 mW, beam area 1.5 cm2, irradiance 50 mW/cm2, exposure time 60 seconds and fluence 3 J/cm2. There were 20-30 spots per session. Sham low-level laser therapy was delivered in an identical manner. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks following the start of irradiation. Higher scores indicate a worse outcome. A total of 231 patients were screened and, of these, 87 were randomised (low-level laser therapy arm, n = 44; sham arm, n = 43). The mean age was 59.4 years (standard deviation 8.8 years) and 69 participants (79%) were male. The mean Oral Mucositis Weekly Questionnaire-Head and Neck Cancer score at 6 weeks was 33.2 (standard deviation 10) in the low-level laser therapy arm and 27.4 (standard deviation 13.8) in the sham arm. The trial lacked statistical power because it did not meet the recruitment target. Staff and patients willingly participated in the trial and worked hard to make the LiTEFORM trial succeed. However, the task of introducing, embedding and sustaining new low-level laser therapy services into a complex care pathway proved challenging. Sites could deliver low-level laser therapy to only a small number of patients at a time. The administration of low-level laser therapy was viewed as straightforward, but also time-consuming and sometimes uncomfortable for both patients and staff, particularly those staff who were not used to working in a patient's mouth. This trial had a robust design but lacked power to be definitive. Low-level laser therapy is relatively inexpensive. In contrast with previous trials, some patients found low-level laser therapy sessions to be difficult. The duration of low-level laser therapy sessions is, therefore, an important consideration. Clinicians experienced in oral cavity work most readily adapt to delivering low-level laser therapy, although other allied health professionals can be trained. Blinding the clinicians delivering low-level laser therapy is feasible. There are important human resource, real estate and logistical considerations for those setting up low-level laser therapy services. Further well-designed randomised controlled trials investigating low-level laser therapy in head and neck cancer irradiation are needed, with similar powered recruitment targets but addressing the recruitment challenges and logistical findings from this research. This trial is registered as ISRCTN14224600. This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 46. See the NIHR Journals Library website for further project information.

Persistent Orofacial Pain Attendances at General Medical Practitioners

Patients with persistent orofacial pain (POFP) can go through complex care pathways to receive a diagnosis and management, which can negatively affect their pain. This study aimed to describe 44-y trends in attendances at Welsh medical practices for POFP and establish the number of attendances per patient and referrals associated with orofacial pain and factors that may predict whether a patient is referred. A retrospective observational study was completed using the nationwide Secure Anonymised Information Linkage Databank of visits to general medical practices in Wales (UK). Data were extracted using diagnostic codes (“Read codes”). Orofacial and migraine Read codes were extracted between 1974 and 2017. Data were analyzed using descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 468,827 POFP and migraine diagnostic codes, accounting for 468,137 patient attendances, or 301,832 patients. The overall attendance rate was 4.22 attendances per 1,000 patient-years (95% confidence interval [CI], 4.21–4.23). The attendance rate increased over the study period. Almost one-third of patients (n = 92,192, 30.54%) attended more than once over the study period, and 15.83% attended more than once within a 12-mo period. There were 20,103 referral codes that were associated with 8,183 patients, with over half these patients being referred more than once. Odds of receiving a referral were highest in females (odds ratio [OR], 1.23; 95% CI, 1.17–1.29), in those living in rural locations (OR, 1.17; 95% CI, 1.12–1.22), and in the least deprived quintile (OR, 1.39; 95% CI, 1.29–1.48). Odds also increased with increasing age (OR, 1.03; 95% CI, 1.03–1.03). The increasing attendance may be explained by the increasing incidence of POFP within the population. These patients can attend on a repeated basis, and very few are referred, but when they are, this may occur multiple times; therefore, current care pathways could be improved.

Optimising the balance of acute and intermediate care capacity for the complex discharge pathway: Computer modelling study during COVID-19 recovery in England.

ObjectivesWhile there has been significant research on the pressures facing acute hospitals during the COVID-19 pandemic, there has been less interest in downstream community services which have also been challenged in meeting demand. This study aimed to estimate the theoretical cost-optimal capacity requirement for ‘step down’ intermediate care services within a major healthcare system in England, at a time when considerable uncertainty remained regarding vaccination uptake and the easing of societal restrictions.MethodsDemand for intermediate care was projected using an epidemiological model (for COVID-19 demand) and regressing upon public mobility (for non-COVID-19 demand). These were inputted to a computer simulation model of patient flow from acute discharge readiness to bedded and home-based Discharge to Assess (D2A) intermediate care services. Cost-optimal capacity was defined as that which yielded the lowest total cost of intermediate care provision and corresponding acute discharge delays.ResultsIncreased intermediate care capacity is likely to bring about lower system-level costs, with the additional D2A investment more than offset by substantial reductions in costly acute discharge delays (leading also to improved patient outcome and experience). Results suggest that completely eliminating acute ‘bed blocking’ is unlikely economical (requiring large amounts of downstream capacity), and that health systems should instead target an appropriate tolerance based upon the specific characteristics of the pathway.ConclusionsComputer modelling can be a valuable asset for determining optimal capacity allocation along the complex care pathway. With results supporting a Business Case for increased downstream capacity, this study demonstrates how modelling can be applied in practice and provides a blueprint for use alongside the freely-available model code.

SWK-01. Partnership between caregivers, patients and healthcare professionals: promoting collaboration in a complex care pathway in pediatric neuro-oncology

Children with a brain tumor and their families encounter, from the moment of diagnosis, a complex, multidisciplinary and multisite journey. Oscar's Angels (OA) is an association of trained patient advocate volunteers within a hospital structure who provide daily support to pediatric neuro-oncology patients and their families in complex care pathways. The association promotes collaboration in healthcare by facilitating a strong link between the daily reality of patients and their families and that of the hospital. OA volunteers are active and fully accepted members of the hospital multi-disciplinary team and collaborate on a very high level in the care of pediatric patients. Such a collaborative setting is possible because the work of OA is structured around three principles: Innovative, practical and theoretical initial and ongoing training and quality assessment of volunteers Patient and family support from Oscar’s Angels volunteers throughout the care pathway Government certification, institutional representation and active collaboration in educating healthcare professionals about the importance of patient advocacy and patients’ needs Operating in France since 2001 and in Italy since 2017 (with more than 600 and 200 families respectively supported last year), the OA volunteering program is specifically tailored to the needs and demands of hospitals and families. It can therefore be successfully reproduced in many settings. OA’s services come at no cost to hospitals. This is particularly important for implementing the program in developing countries where healthcare resources are extremely limited. But it is also relevant in developed countries as well where healthcare budgets are under strain. In 2020 an informal internal OA survey highlighted that the patient/family/volunteer/healthcare professional interface provides added value for all of these stakeholders. A formal survey will be conducted in 2022 to corroborate these results.

Definition and conceptualization of the patient-centered care pathway, a proposed integrative framework for consensus: a Concept analysis and systematic review

BackgroundConfusion exists over the definition of the care pathway concept and existing conceptual frameworks contain various inadequacies which have led to implementation difficulties. In the current global context of rapidly changing health care systems, there is great need for a standardized definition and integrative framework that can guide implementation. This study aims to propose an accurate and up-to-date definition of care pathway and an integrative conceptual framework.MethodsAn innovative hybrid method combining systematic review, concept analysis and bibliometric analysis was undertaken to summarize qualitative, quantitative, and mixed-method studies. Databases searched were PubMed, Embase and ABI/Inform. Methodological quality of included studies was then assessed.ResultsForty-four studies met the inclusion criteria. Using concept analysis, we developed a fine-grained understanding, an integrative conceptual framework, and an up-to-date definition of patient-centered care pathway by proposing 28 subcategories grouped into seven attributes. This conceptual framework considers both operational and social realities and supports the improvement and sustainable transformation of clinical, administrative, and organizational practices for the benefit of patients and caregivers, while considering professional experience, organizational constraints, and social dynamics. The proposed attributes of a fluid and effective pathway are (i) the centricity of patients and caregivers, (ii) the positioning of professional actors involved in the care pathway, (iii) the operation management through the care delivery process, (iv) the particularities of coordination structures, (v) the structural context of the system and organizations, (vi) the role of the information system and data management and (vii) the advent of the learning system. Antecedents are presented as key success factors of pathway implementation. By using the consequences and empirical referents, such as outcomes and evidence of care pathway interventions, we went beyond the single theoretical aim, proposing the application of the conceptual framework to healthcare management.ConclusionsThis study has developed an up-to-date definition of patient-centered care pathway and an integrative conceptual framework. Our framework encompasses 28 subcategories grouped into seven attributes that should be considered in complex care pathway intervention. The formulation of these attributes, antecedents as success factors and consequences as potential outcomes, allows the operationalization of this model for any pathway in any context.

A disparate and complex care pathway: assessments and impact on the quality of life of endometriosis patients

A disparate and complex care pathway: assessments and impact on the quality of life of endometriosis patients

Care transitions in the first 6 months following traumatic brain injury

Background: No large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI). Objectives: To characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors. Methods: This was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE). Results: In total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2–3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09–1.18; P = 0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as “common pathways”. Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months. Conclusions: A high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of “common data elements for TBI care pathways” for future studies. Study registration: ClinicalTrials.gov NCT02210221.

Healthcare resource use and costs for people with type 2 diabetes mellitus with and without severe mental illness in England: longitudinal matched-cohort study using the Clinical Practice Research Datalink.

Approximately 60 000 people in England have coexisting type 2 diabetes mellitus (T2DM) and severe mental illness (SMI). They are more likely to have poorer health outcomes and require more complex care pathways compared with those with T2DM alone. Despite increasing prevalence, little is known about the healthcare resource use and costs for people with both conditions. To assess the impact of SMI on healthcare resource use and service costs for adults with T2DM, and explore the predictors of healthcare costs and lifetime costs for people with both conditions. This was a matched-cohort study using data from the Clinical Practice Research Datalink linked to Hospital Episode Statistics for 1620 people with comorbid SMI and T2DM and 4763 people with T2DM alone. Generalised linear models and the Bang and Tsiatis method were used to explore cost predictors and mean lifetime costs respectively. There were higher average annual costs for people with T2DM and SMI (£1930 higher) than people with T2DM alone, driven primarily by mental health and non-mental health-related hospital admissions. Key predictors of higher total costs were older age, comorbid hypertension, use of antidepressants, use of first-generation antipsychotics, and increased duration of living with both conditions. Expected lifetime costs were approximately £35 000 per person with both SMI and T2DM. Extrapolating nationally, this would generate total annual costs to the National Health Service of around £250 m per year. Our estimates of resource use and costs for people with both T2DM and SMI will aid policymakers and commissioners in service planning and resource allocation.

Conflicts of interest: an invisible force shaping health systems and policies

Conflicts of interest: an invisible force shaping health systems and policies

Care transitions in the first 6months following traumatic brain injury: Lessons from the CENTER-TBI study.

No large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI). To characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors. This was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE). In total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2-3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09-1.18; P=0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as "common pathways". Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months. A high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of "common data elements for TBI care pathways" for future studies. ClinicalTrials.gov NCT02210221.

Survival of Dental Implants in Oncology Patients versus Non-Oncology Patients: A 5-Year Retrospective Study.

Patients with a history of cancer are increasingly common in the dental office. Treating cancer patients requires a multidisciplinary team, which should include the dentist, in order to control the complications that occur in the oral cavity and also to recover the patient undergoing treatment in any of its types: surgical, medical, radiotherapeutic, or its possible combinations. Dental implants can be a safe and predictable treatment option for prosthetic rehabilitation. The aim of this paper is to describe in retrospect the success rate of osseointegrated implants in oncology and non-oncology patients placed by the Master of Dentistry in Oncology and Immunocompromised Patients, as well as the Master of Medicine, Surgery and Oral Implantology of the University of Barcelona Dental Hospital, between July 2011 and March 2016. 466 patients were reviewed, with a total of 1405 implants placed, considering the oncological history of the patients and the implant success rate. The total success rate in the concerned period was 96.65%. When comparing cancer patients with healthy ones, the success rate has been 93.02% in the first case, and 97.16% in the latter. According to the literature review, our results encourage implant placement in cancer patients, it is important to recognize that this is an analysis of a complex care pathway with a large number of confounding variables. However, the findings should not be considered as generalizable.

Complex care pathways for children with multiple referrals demonstrated in a retrospective population-based study.

To identify children with complex medical needs by examining their patterns of hospital care. We conducted a retrospective population-based study on 18577 patients aged 6-12years from the Haukeland University Hospital register over a 3-year period (from 2013 to 2015). Data were structured to examine the temporal patterns and sequences of referrals, care episodes and diagnoses, including flowacross medical specialties. Over a third of patients had repeated referrals, and 14.9% of all had three or more. Furthermore, 9.3% of patients were referred to both somatic and mental healthcare services. Patients with such combined referrals had a higher number of referrals as well as a higher number of different diagnoses. Overall, there was a high frequency of non-specific diagnoses, and 34.8% of patients still had a non-specific main diagnosis at the end of their hospital contact. This study demonstrates an increased risk for complex care pathways in children with multiple referrals. Interdisciplinary patterns of referrals were relatively common, particularly for patients in mental health care. These findings highlight the importance of developing interdisciplinary-based approaches for patients with complex complaints.