Multidisciplinary Care Coordination Research Articles

Multidisciplinary care for patients with gastroesophageal cancers (GEC): A quality improvement initiative in community cancer clinics.

e16096 Background: Evidence-based guidelines for GEC management recommend multimodal care, which involves close coordination between medical, surgical, and radiation oncologists, together with specialists to manage symptoms and treatment-related adverse events (AEs). Optimizing the high level of multidisciplinary care required for effective GEC management poses substantial challenges for community oncology care teams. Methods: In August-October 2023, 57 healthcare providers (HCPs) from 4 US community oncology clinics completed surveys on challenges, barriers, and improvements needed in the multimodal care of patients with GEC. Based on findings from the baseline data, 70 HCPs participated in audit/feedback (AF) sessions to review site-specific gaps and challenges and develop action plans to address identified gaps. Follow-up surveys will evaluate the impact of changes in practice following action plan implementation. Results: Providers identified their 3 top challenges to providing care for patients with GEC: interdisciplinary care coordination, providing patient-centered supportive care, and managing AEs. They reported that care coordination was hampered by low frequency and poor-quality communication between medical oncology and surgical teams, by misalignment on methods of communication, and by a lack of relationship between the specialties. About one-third of HCPs reported recognizing and managing AEs as the most challenging aspect of caring for patients with GEC, including AEs that were immune-related (26%), dermatologic (19%), gastrointestinal (19%), neurologic (14%), immunosuppression-related (10%), and respiratory (5%). After the AF sessions, HCPs reported improving communication and coordination among care team members as an important means of improving and individualizing patient care plans and integrating new therapies into clinical workflows. Action plans included streamlining communication with surgical teams, increased use of patient navigation, and ensuring that every patient is reviewed through the multidisciplinary tumor board. With regard to AE management, action plans included improving patient education on AE identification, and better communication within the team on nutritional support. HCPs who participated showed improved confidence, knowledge, and competence in appropriately sequencing systemic therapy and surgical interventions. Conclusions: GEC care teams from community cancer clinics reported dissatisfaction with multidisciplinary care coordination, including poor communication between specialists involved in multimodal care of patients with GEC. Integration of sustainable changes in clinical workflows driven by this initiative improved oversight of multimodal care, improved workflows, and improved AE management.

Perianal disease: Updates and controversies in closing the gaps

Perianal complications are common and morbid in children with Crohn’s disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes – both medical and patient-centered.

The TSANZ and Lung Foundation Australia 2023 landscape survey of lung cancer care across Australia and Aotearoa New Zealand.

Unwarranted variations in lung cancer care have been well described in both Australia and Aotearoa New Zealand, with shortfalls in hospital-based workforce and infrastructure previously demonstrated. A survey of lung cancer clinicians was performed to gain an updated understanding of current workforce and infrastructure. An online Qualtrics survey included questions on institutional demographics, estimated lung cancer case load, multidisciplinary team (MDT) characteristics including workforce and local infrastructure. We sought to obtain one response from every institution treating lung cancer in Australia and Aotearoa New Zealand. Responses were received from 89 institutions, estimated to include 85% centres treating lung cancer in Australia and 100% of public hospitals in Aotearoa New Zealand. Lung cancer nurse specialist and Nuclear Medicine are poorly represented in multidisciplinary teams (MDTs) with just 34/88 (38%) institutions fulfilling recommended core workforce for MDT meetings. Case presentation is low with 32/88 (36%) regularly discussing all lung cancer patients at MDT. Metropolitan institutions appear to have a more comprehensive range of services on site, compared to non-metropolitan institutions. Few (4/88) institutions have embedded smoking cessation services. Compared to the previous 2021 Landscape Survey, thoracic surgery representation and core MDT workforce have improved, with modest change in specialist nurse numbers. This wide-reaching survey has identified persistent deficiencies and variations in lung cancer workforce and gaps in infrastructure. Multidisciplinary collaboration and care coordination are needed to ensure all patients can access timely and equitable lung cancer care.

DOP04 Screening and management of fistula cancers in patients with perianal fistulising Crohn’s Disease: an expert consensus

Abstract Background Fistula cancer is a rare and often devastating diagnosis in patients with perianal fistulising Crohn’s disease (CD). Fistula cancer management is a complex process requiring multi-disciplinary effort. However, given the low incidence and subsequent lack of data and clinical trials in the field, there is little to no guidance on screening and management of fistula cancer. To inform clinical practice, we developed consensus guidelines on fistula cancer in perianal fistulising Crohn’s disease by multidisciplinary experts from the international TOpCLASS consortium. Methods We performed a systematic review of the literature by standard methodology, using the Newcastle-Ottawa quality assessment tool. Data were retrieved from articles according to these domains: epidemiology and risk factors, clinical presentation, diagnostics, staging, and treatment. We developed consensus statements using a Delphi consensus approach. Participants included gastroenterologists, surgeons, radiologists, and pathologists. We performed two rounds of voting: (1) online survey followed by statement edits and (2) hybrid meeting with discussion until over 80% consensus was achieved for each statement. Results Of 550 articles identified, 99 were eligible, and 80 articles were included. The overall quality of evidence was low. Seven statements were accepted in the final consensus (Table 1). Patients with longstanding (>10 years) perianal fistulising CD should be considered at small but increased risk of developing fistula cancer, including anal squamous cell cancer (SCC) and anorectal carcinoma. Risk factors for anal SCC, including human papilloma virus (HPV), should be considered. Clinical signs and symptoms of fistula cancers are non-specific, and several case reports included asymptomatic patients. New or refractory/progressive perianal symptoms should prompt evaluation for fistula cancer. There was no consensus on timing or frequency of screening in patients with asymptomatic perianal fistula. Regarding diagnostics, multiple modalities may be required, including repeated exam under anesthesia with biopsy. Multidisciplinary team efforts were deemed central for the management of fistula cancers. Conclusion Clinicians managing patients with perianal fistulising CD should be aware of the risk of fistula cancers, including anal SCC and anorectal carcinoma. Our expert consensus recommends consideration of patient factors including duration of fistulas, HPV status, and perianal symptoms, and gives guidance on diagnostic modalities and treatment considerations. Multidisciplinary coordination of care is paramount, and more studies in the field are needed.

Role of primary care for individuals with childhood-onset neurologic conditions

BackgroundIndividuals with childhood-onset neurologic conditions often face challenges in the pediatric-to-adult health care transition (HCT). Furthermore, the importance of implementing primary care is unrecognized. We investigated the situation of adults with childhood-onset neurologic conditions from the perspective of health care professionals (HCPs) in community- and hospital-based primary care practice. Design and methodsOverall, 1334 HCPs in medical facilities across Tokyo (mainly in Kita, Nerima, and Itabashi Cities) were surveyed regarding their experience caring for adults with childhood-onset neurologic conditions. Snowball sampling was also deployed to enhance the input from various health professions. The questionnaire included quick response codes linked to web-based questionnaires identical to paper-based ones, enabling additional HCPs to answer the questionnaire. The survey included questions about the care provided by HCPs, the perceived challenges and worthwhileness of the care, and their views on HCT. ResultsWe collected 276 responses (response rate, 20.7%): 224 by mail and 52 online. In total, 94 HCPs of the respondents (75 doctors, 11 nurses, 5 therapists, 2 care workers, and 1 medical social worker) involved in caring for this population were analyzed. Doctors and nurses managed medical devices, educated patients, and provided consultation and care. Doctors cited the management of comorbidities outside of their expertise and difficulties securing hospitalization during emergencies as barriers to care. HCPs found the valuable opportunities to enrich their clinical experience and long-term relationships with patients worthwhile. HCPs expressed the need for systems that guarantee patient hospitalization and multidisciplinary conferences between HCPs and specialists. ConclusionWe described the roles of HCPs in community- and hospital-based primary care, which are vital components of HCT for adults with childhood-onset neurologic conditions. Their practice includes multidisciplinary involvement, patient education, and care coordination. For better HCT in this population, efforts are required to enhance HCPs’ capability to respond to patients with disabilities, patients’ multiple comorbidities, and families’ needs. Practice implicationsFurther efforts to deepen community-based care are desired to improve HCT for people with childhood-onset neurologic conditions.

Closing the Gap: Multidisciplinary Coordination of a Care Plan for Patients with Multimorbidity

Introduction: Multidisciplinary communication and collaboration are of utmost importance in order to transition from fragmented and disease-centered care to patient-centered care for people with multimorbidity. Interdisciplinary coordination of a care plan is a vital part of this collaboration, yet can take many different forms. Our primary aim is to uncover the existing pathways of multidisciplinary communication and collaboration to reach an integrated treatment plan. Our secondary aim is to identify potential limitations and strengths of these pathways, in order to propose ways to improve interdisciplinary coordination, and ultimately improve outcomes of care for patients with multimorbidity in the hospital.
 Methods: Seven focus groups were organized, in both secondary and tertiary hospitals in the Netherlands. Each focus group was centered around a recent, local case study regarding a patient with multimorbidity. All involved health care professionals related to this specific patient were invited to participate in the focus group. Focus groups followed a discussion guide and were transcribed verbatim. Text was fragmented, coded and thematized using the principles of grounded theory. Member checking was performed by experts in the field.
 Results: 20 medical professionals were interviewed from three secondary, and four tertiary hospitals. None of the focus groups included all invited professionals due to their conflicting schedules. Analysis showed that the process of interdisciplinary coordination could be divided into the ‘reason’, ‘timing’, ‘modality’ and ‘outcome’. The ‘reason’ to seek interdisciplinary coordination could be medical complexity, a signal from a patient that indicates uncoordinated care, need for division of care roles, or to explore if care plans are aligned with the patient as a whole. Care providers could opt for different modalities to collaborate, such as: a phone call, referral to a colleague, or organizing a multidisciplinary team meeting. Possible outcomes could be integrating patient goals into the care plan, reduction in care consumption, and/or higher patient satisfaction. Factors of influence were identified for all main elements of this process: e.g. level of experience of the health care professional and available financial structures for different modalities of collaboration.
 Implications: We introduce a process model describing the current pathways in multidisciplinary coordination of care for patients with multimorbidity. This model shows that depending on the reason to collaborate, and with the desirable outcome in mind, different modalities of collaboration and communication are possible. Using case studies, we illustrate how and where current pathways can fall short and new innovative ways of providing care can be developed. For the Netherlands, we are developing a new mode of seeking coordination based on this model which ensures better multidisciplinary collaboration and inclusion of the patient perspective: a structured multidisciplinary patient review (MPR) for patients with multimorbidity. We hope to inspire the international community to adapt this innovative model to their own context of care.
 

Caring for Long Covid patients in Belgian primary care.

Background: The Covid-19 pandemic affected primary health care in various ways and general practitioners (GPs) take a key position in caring for patients with persistent Covid-19-related symptoms, also referred to as Long Covid. In this study, GPs’ knowledge, experiences and opinions on Long Covid, as well as the definition being used by GPs is investigated to provide more insight in the care for Long Covid patients in primary care.
 Methods: An online questionnaire, validated by experts, was distributed to all Belgian GPs through established national GP networks (SGP network, Domus Medica and SSMG) during spring 2022. The survey has 16 (ordinal, open-ended or multiple choice) questions on Long Covid. To characterize GPs, practice and demographic characteristics were collected. A case definition for Long Covid was not included, as there was no widely accepted definition available in general practice at the timing of the study. Descriptive and analytic statistics were performed.
 Results: A total of 105 GPs responded to the survey. GPs were well distributed across all Belgian regions and practice type. Female GPs represented 58.1% and mean age was 51 years (IQR: 38-63).
 Most of GPs reported that they did not have sufficient scientific knowledge on Long Covid, they reported lack of availability of reliable information on Long Covid diagnosis and treatment, and felt that accessibility to educational material on Long Covid was limited.
 For the diagnoses of Long Covid, 60.0% reported that a positive Covid-19 test result is a minimum requirement when speaking about Long Covid complaints. The commonest criteria utilized by GPs for diagnosing Long Covid was the duration of symptoms (from 4 weeks to 5 months) and on the basis of diagnostic criteria by the GP. 58.1% of GPs stated that Long Covid should be considered a chronic disease.
 The majority (75.2%) of participating GPs reported to have cared for Long Covid patients (independently of practice type, GP’s gender or age). These patients suffered mainly from fatigue (94.9%), concentration/memory problems (74.7%), breathing difficulties (68.0%), impairment in daily functioning (66.7%) and brain fog (46.2%).
 Most GPs (93.4%) believed that caring for Long Covid patients should follow multidisciplinary approach. Half of them (51.9%) reported to have been following up these patients by themselves or by GP colleagues and 32.9% by multidisciplinary cooperation. Other healthcare professionals involved include pneumologists, physiotherapists, specialists in physical medicine/rehabilitation and neurologists. GPs were consulted biweekly (17.9%), monthly (47.8%) or every few months (19.4%) by these Long Covid patients. 
 Conclusion: In Belgian general practice, similar definitions and diagnostic criteria are used by GPs to identify Long Covid patients. A majority of GPs frequently provide care to Long Covid patients and GPs take a key role in the (multidisciplinary) coordination of care for these patients. However, multidisciplinary care for Long Covid patients is less organized than preferred by GPs at the timing of the study (spring 2022). With the establishment of the ‘care trajectory post-Covid-19’ for Long Covid patients in primary care since July 2022, collaboration between care givers may be stimulated in Belgian primary health care.

Operationalising generalism in medical education: a narrative review of international policy and mission documents

ABSTRACT Introduction Despite moves across medical education to increase learning of generalist principles, a lack of clarity about what generalism means and how we should train doctors as ‘generalists’, has remained. This study explores how international, undergraduate and postgraduate, policy and educational mission documents characterise the practice and learning of generalism and how this can inform physician training. Methods A narrative literature review was conducted based on policy and mission documents identified through grey literature searches and a wider systematic review looking at empirical texts. Texts published between 1999 and present and related to ‘generalism’ were eligible for inclusion. Texts were coded and codes were reviewed and grouped into key themes. Results Thirty-four documents were included. Definitions vary: some described generalism as a basic skill, whilst others emphasised expertise. Factors which support learning generalism include: favourable financial outcomes; ageing populations; coordination of multidisciplinary care; demand for doctors with transferable skills; and patient expectations. Barriers to learning about generalism include: preference for specialisation; structure of undergraduate teaching and assessment; and the hidden curriculum. Solutions may include re-imagining generalists and specialists as being on a continuum as well as increasing exposure throughout medical education. Discussion Whilst generalism is consistently positioned as valuable, less clarity exists about how best to operationalise this in medical education. Fundamental ideological and structural changes within teaching curricula and assessment, are necessary to improve generalist learning and to promote sustainable practice. Medical education needs careful, considered planning to ensure workforce expertise is meeting population needs.

Advancing Care of Patients with Sickle Cell Disease through a Transformative Quality Improvement Initiative

Background Managing sickle cell disease (SCD) and its associated complications requires specialized knowledge often limited in primary and emergency care settings. Despite the availability of guideline recommendations and an expanding therapeutic landscape, hematologists experience challenges in managing sickle cell pain and implementing multidisciplinary care coordination that improves morbidity, overall disease management, and quality of life. To improve SCD care, we conducted a quality improvement (QI) study, bringing together healthcare professionals (HCPs) from established SCD centers to assess current practice patterns and develop strategies to overcome barriers to acute pain management and transitions of care for patients with SCD. Methods This QI initiative is comprised of baseline surveys (n = 115), pre- and post-surveys (n = 71) from the small-group, team-based audit-feedback (AF) sessions (Table 1), and 90-day follow-up surveys of HCPs from the four enrolled centers. Survey questions were designed to assess knowledge, confidence, and experiences managing acute pain, transitioning care, and keeping up with the latest clinical evidence and guideline recommendations for SCD. Care teams from each clinic, along with a nationally renowned expert SCD physician, participated in audit and feedback sessions to (a) assess system-specific practice gaps identified via the provider surveys, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Results Baseline surveys results revealed providers' top challenge encountered in managing patients with SCD as managing acute complications (40%) (Figure 1). Gaps were observed in clinicians reporting high/very high confidence in their ability to adequately manage SCD patients' acute pain episodes (51%), align clinical practices with evidence-based SCD guidelines (44%), and coordinate transitions of care (33%). Furthermore, baseline surveys showed only 19% of providers reported they are very/extremely satisfied with their current process for transitioning patients, noting top challenges in patient's difficulty navigating the adult healthcare system (47%) and deficiency of providers caring for patients with SCD near me (26%). Following participation in the AF sessions, clinicians indicated gains in high/very high confidence in their ability to adequately manage an acute pain episode for a patient with SCD (52% to 69%) and ability to coordinate transitions of care for patients with SCD (44% to 56%). During the AF sessions, Care teams set goals to improve provider education, appropriate acute care management of SCD and patient engagement. Action plans to achieve these goals include sharing the action plan with additional clinical team members (47%), collaborating among clinical teams to improve pain management plans for patients with SCD (39%) and improving patient education about SCD (31%). In 90-day follow up surveys, 75% of clinics reported improvements in acute pain management and transitions of care for patients with SCD. Furthermore, the top 3 areas of most improvement at the time of follow-up were enhancing sickle cell education provided to patients (75%), supporting teenage and young adult patients in independently managing their own care (50%), and coordinating meetings with local adult sickle cell providers and teenage/young adult patients and families (50%). Conclusions Through this QI initiative, clinical teams identified barriers to optimal SCD care, creating and implementing specific action plans to increasing knowledge of SCD and evidence-based therapies, optimizing transitions of care and improving acute pain management. While meaningful confidence and action plan gains were demonstrated, these data underscore clinical practice gaps to address in future initiatives to support safe, effective, and evidence-based processes for managing SCD to prevent complications and optimize outcomes and quality of life. Study Sponsor Statement The study reported in this abstract was funded by educational grants from Vertex Pharmaceuticals Incorporated and Agios Pharmaceuticals, Inc. The grantors had no role in the study design, execution, analysis, or reporting.

Integrating the business of oncology during oncology fellowship: An ASCO State of Cancer Care in America (SOCCA) study of professional preparedness and practice expectations among medical oncology fellow physicians in training between 2013 and 2023.

48 Background: The current healthcare climate calls for a deep understanding among physicians on the business side of medicine. Oncology fellows entering clinical practice face key issues related to the business of cancer care, prompting us to explore the preparation from fellowship training for those financial competencies that factor into day-to-day practice. Methods: All fellows taking the 2023 ASCO Medical Oncology In-Training Exam (ITE) were invited to participate in a post-exam survey which included items on perception of preparedness for future practice and expected practice setting. Respondents answering one or more survey items are included in this analysis. Practice setting expectations were compared to findings from the 2013 post-ITE survey (n=1536). Descriptive statistics and Chi-squared tests comparing responses by fellowship year and exam years are presented. Results: Overall, 2184 (97%) of 2231 fellows taking the 2023 ITE participated in this post-ITE survey study, including 704 in their first, 807 in their second, and 673 in their third year of fellowship. Overall, in areas of communication, most felt adequately prepared by their program: communicating with patients about treatment options (98%), multidisciplinary care coordination (97%), electronic records or other healthcare tech use (95%), staying up to date on changes in oncology (95%), and practicing cultural humility (92%). However, in areas on business of oncology, a greater proportion felt under- or unprepared; specifically, 30% of fellows felt unprepared or unsure about discussing the cost of medical care with patients, 35% on obtaining prior authorization, and 45% on participating in alternative payment models. Compared to 2013, the expected practice setting of the 2023 fellows remained unchanged with subsets anticipating an academic practice (62% in 2023 vs 61% in 2013), non-academic practice (hospital/health system or physician/independently owned; 32% in 2023 vs 34% in 2013), government/regulatory (2%), industry (<1%), or other setting (3%). Conclusions: While nearly all oncology fellows reported high levels of preparedness for certain essential components of patient-centered multidisciplinary practice, over a third felt unprepared or underprepared to navigate domains under the business of oncology. These findings highlight the opportunity to augment oncology fellowship training to include financial competencies of clinical practice and care, which collectively form the foundation of cancer care.

Salvage and Reconstruction of the Mangled Hand: A Case Study Utilizing a Multi-Composite Tissue Product Reconstructive Approach

Objective: To evaluate the efficacy of a novel reconstructive approach utilizing Multiple Composite Tissue Products (MCTPs) in severe hand injuries with risk of amputation. Methods: A comprehensive, single MCTP operation was performed at a single institution involving three tissue products to salvage the nerves, tendons, bone, and skin. This patient case study exemplifies the successful reconstruction of a mangled hand. Results: The application of three tissue products resulted in securing the integrity of the mangled hand’s structures and preservation of basic hand and wrist function, obviating the need for amputation. The patient regained significant restoration substantiating the safety and efficacy of this approach for structural, functional, and cosmetic outcomes. Discussion: Preoperative assessment and multi-disciplinary coordination of care was imperative in optimizing the successful outcomes. The patient’s medical history was complicated by diabetes mellitus, neuropathy, and osteonecrosis. Intensive postoperative rehabilitation, including Passive and Active Range of Motion (PROM, AROM), contributed to recovery and outcomes. Significance: The MCTP reconstructive approach is a promising avenue for optimizing tissue viability to recover from mangled hand injuries. The amelioration of adhesion formation directs proper tissue recovery which conserves tissue that might otherwise necessitate further excision, and possibly amputation. Per patient centered outcomes, this strategy mitigated extensive pain and minimized scarring, which enhanced the cosmetic appeal of reconstructing the mangled hand. These findings underscore the reconstructive potential of a MCTP approach in complex hand salvage, contributing to the recovery of function and cosmetic appeal. Future research should aim to validate similar findings of this case study strategy in a larger cohort.

Sex trafficking survivors' experiences with the healthcare system during exploitation: A qualitative study.

While most individuals who have experienced sex trafficking will seek medical attention during their exploitation, very few will be identified by healthcare professionals (HCP). It constitutes a lost opportunity to provide appropriate support, resources, and services. In this study, we examined the experiences of accessing care of sex trafficking survivors in the Greater Montreal area and their interactions with HCPs to inform trafficking education programs for HCPs and allied health professionals regarding the needs of this patient population. We conducted seven semi-structured in-depth interviews with purposively selected sex trafficking survivors participating in "Les Survivantes," a program of the SPVM (Service de Police de la Ville de Montréal), designed to support trafficked individuals' exit journey. We used interpretive description to understand the lived experiences of trafficked individuals with direct applications to clinical education and care. Our results revealed that trafficked individuals accessing care present with a fragile trust in HCPs and how HCPs have many opportunities to conduct comprehensive examinations and query trafficking. Trafficked individuals' initial trust in HCPs can be strengthened by non-judgemental approaches or damaged by stigmatizing conduct, serving to isolate further and alienate this patient population. Health professionals' attitudes combined with healthcare settings' cultures of care (i.e., community vs emergency) and exposure to marginalized groups were key influencers of survivors' perception of healthcare interactions. The findings also emphasized the importance of routinely querying trafficking through sensitive psychosocial questioning based on observation of trafficking cues. Survivors reported a list of trafficking cues to recognize and emphasized the importance of trust as a condition of disclosure. Finally, survivors identified the need for exit planning to be centered around trafficked individuals' agency and holistic needs, and for streamlined community-based multidisciplinary collaboration to better serve this population. Our results highlight that most challenges experienced by trafficking survivors in accessing care and resources are modifiable through HCP education and training. Our study also provides new insights and concrete advice to improve care and support throughout the exiting process. We argue that healthcare services for this population be modeled harm reduction approaches that focus on victims' agency and needs, independent of their desire to exit trafficking. We emphasize the urgent need for proper case management and intersectoral and multidisciplinary care coordination in community-based settings as well as facilitated access to mental health support.

The holistic management of malignant bowel obstruction in women with advanced ovarian cancer at end of life.

Bowel obstruction is commonly a pre-terminal event in women with advanced ovarian cancer. Management of symptoms will often be the focus rather than surgical intervention. Determining the patient's end-of-life wishes is paramount - because the prognosis for these patients can be short, advanced care planning is key. This case study will explore the management of nausea and vomiting associated with malignant bowel obstruction and demonstrate how a patient's psychological and social wellbeing is as important as managing the physical symptoms. It will discuss how skilled and effective communication is vital early in the disease trajectory in ensuring the patient's needs are met. Additionally, by undertaking a thorough holistic needs assessment, all aspects of end-of-life care can be discussed with the patient and family, which may enable the achievement of a preferred place of care and a peaceful, dignified death. Multidisciplinary working and co-ordination of care may allow for quick interventions, meeting individual needs and symptoms being managed more effectively.

1030-P: Large-Scale Implementation of a Digital Solution to Support Management of Gestational Diabetes

Introduction: Gestational Diabetes Mellitus (GDM) is one of the most common medical conditions of pregnancy and its incidence is rising. The MoTHer system, an App and web-based portal, was developed to support GDM management. It enables multidisciplinary care co-ordination by providing shared access to healthcare professionals involved in GDM care. Methods: MoTHer was developed through co-design with users at an urban Australian hospital and tested in a feasibility study (n=40) in 2017-18. An implementation trial commenced in June 2020 and is currently underway in 5 Australian hospitals of varying sizes. Results: More than 5000 women have utilised the MoTHer app. Care models differ at participating hospitals, some offering MoTHer as business as usual to all women with GDM, others providing MoTHer as an alternative to the traditional paper-based blood glucose diary, and one hospital only offering MoTHer to GDM patients on insulin. Each site has different implementation requirements and experiences, yet feedback from surveys administered (>300 responders) is positive, suggesting long-term adoption. Initial economic evaluation indicates a modest saving to health services. However, cost savings for the woman are estimated to be considerable (≈US$400 per patient) after accounting for lost wages, childcare, and travel expenses avoided. Comparing pre- and post-implementation groups, maternal (onset, mode of birth) and neonatal (birthweight, nursery admission) outcomes suggest MoTHer is clinically equivalent to traditional care. Discussion: The MoTHer system has been created to see greater efficiencies for both healthcare providers and for expectant mothers. This multi-site study highlights the adaptability of a digital solution to different GDM health services. Moreover, re-imagining GDM patient care by introducing a digital based model of care is promising substantial positive cost implications for patients without compromising their clinical outcomes. Disclosure M.Varnfield: None. K.Butten: None.

Multidisciplinary coordination of care for children with esophageal atresia and tracheoesophageal fistula.

Esophageal Atresia/Tracheoesophageal Atresia (EA/TEF) is a multisystem congenital anomaly. Historically, children with EA/TEF lack coordinated care. A multidisciplinary clinic was established in 2005 to provide coordinated care and improve access to outpatient care. This single-center retrospective cohort study was conducted to describe our cohort of patients with EA/TEF born between March 2005 and March 2011, assess coordination of care, and to compare outcomes of children in the multidisciplinary clinic to the previous cohort without a multi-disciplinary clinic. A chart review identified demographics, hospitalizations, emergency visits, clinic visits, and coordination of outpatient care. Twenty-seven patients were included; 75.9% had a C-type EA/TEF. Clinics provided multidisciplinary care and compliance with the visit schedule was high with a median of 100% (IQR 50). Compared to the earlier cohort, the new cohort (N = 27) had fewer hospital admissions and LOS was reduced significantly in the first 2years of life. Multidisciplinary care clinics for medically complex children can improve coordination of visits with multiple health care providers and may contribute to reduced use of acute care services.

Utility of the Healthy Aging Brain Care Monitor as a Patient-Reported Symptom Monitoring Tool in Older Injury Survivors

IntroductionThe objective of this study was to evaluate the performance of the Healthy Aging Brain Care Monitor (HABC-M) as a patient-reported outcome tool to measure cognitive, functional, and psychological symptoms among older adults who sustained non-neurologic injuries requiring hospital admission. MethodsWe used data from a multicenter randomized controlled trial to evaluate the utility of the HABC-M Self-Report version in older patients recovering from traumatic injuries. A total of 143 patients without cognitive impairment were included in the analysis. Cronbach's alpha was used to measure the internal consistency, and Spearman's rank correlation test was used to evaluate the relationship of the HABC-M with standard measures of cognitive, functional, and psychological outcomes. ResultsThe HABC-M subscales and the total scale showed satisfactory internal consistency (Cronbach's alpha = 0.64 to 0.77). The HABC-M cognitive subscale did not correlate with the Mini-Mental State Examination. The HABC-M functional and psychological subscales correlated with corresponding standard reference measures (|rs| = 0.24-0.59). ConclusionsThe HABC-M Self-Report version is a practical alternative to administering multiple surveys to monitor functional and psychological sequelae in older patients recovering from recent non-neurologic injuries. Its clinical application may facilitate personalized, multidisciplinary care coordination among older trauma survivors without cognitive impairment.

Clinical and financial outcomes of transplant recipients following emergency general surgery operations

IntroductionDue to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS. MethodsThe 2010–2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences. ResultsOf 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54–0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types. ConclusionThe incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.

Cause-specific mortality among patients with renal cell carcinoma in the United States from 2000 to 2018.

There has been little focus on the non-cancer causes of death in patients with renal cell carcinoma (RCC). Therefore, we aimed to assess the frequency and risk of different causes of death, stratified by tumor stage, and demographics, after a diagnosis of RCC in the United States. Data on eligible patients with RCC from January 1, 2000, to December 31, 2018, in the United States were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Standardized mortality ratios for causes of death were calculated using the SEER*Stat software 8.3.9.2 for the overall population and stratified subgroups. A total of 165,969 patients with RCC were included and 60,290 (36.3%) died during follow-up. The majority of deaths were due to kidney cancer (51.3%) but a significant proportion was non-cancer causes (37.6%). The proportion of deaths attributed to RCC decreased with increasing follow-up with non-cancer causes becoming dominant after the fifth year following RCC diagnosis. Overall, cardiovascular diseases and cerebrovascular diseases were the most common non-RCC-related causes of death. AJCC stage I and localized RCC had the most deaths attributed to non-cancerous causes (66.2% and 61.2%, respectively) while AJCC stage IV and distant RCC had the most deaths due to RCC (86.2% and 86.5%, respectively). A large proportion of RCC patients die of non-cancerous causes especially early-stage patients and advanced-stage patients who survive >5 years. Coordination of multidisciplinary care with relevant specialists depending on the stage of the disease is needed to better prevent death overtime from non-cancer causes.

Healthcare experiences of people with advanced colorectal cancer: A qualitative study.

Qualitative research examining healthcare experiences and needs of people with advanced (metastatic or recurrent) colorectal cancer CRC-A is limited. This study aimed to fill this gap in CRC-A survivors treated with surgical or palliative chemotherapy, through a qualitative study. Australian adults treated for CRC-A were recruited 0.5-2 years post-surgery or post-diagnosis of CRC-A (for palliative chemotherapy groups). Semi-structured telephone interviews, analysed via framework analysis, explored healthcare experiences. Demographic, clinical, and quality of life data characterised the sample and informed framework analyses. Data was compared against the Institute of Medicine's framework for quality healthcare. Interviews from 38 participants (22 female) of median age 59 years (range 27-84) revealed six overarching themes relating to the safety, effectiveness, timeliness, patient-centredness, efficiency, and equity of CRC-A care: 1) Early experiences influence later perceptions; 2) Trusting the system, trusting the professionals; 3) The benefits of multidisciplinary care co-ordination; 4) Feeling lost in follow-up; 5) Whose role is it anyway? Gaps in responsibility for survivorship care; and 6) Useful or useless? Perceptions of psychosocial support. Healthcare systems for CRC-A can be improved through delivery of repeated information, upskilling general practitioners and/or implementing written survivorship care plans or survivorship clinics, to ensure quality healthcare.

Procedural and Surgical Interventions for Esophageal Stricture Secondary to Caustic Ingestion in Children

BackgroundEsophageal injury after caustic ingestion can vary in severity and may result in significant long-term morbidity due to stricture development. The optimal management remains unknown. We aim to determine the incidence of esophageal stricture due to caustic ingestion and quantify current procedural and operative management strategies. MethodsThe Pediatric Health Information System (PHIS) was utilized to identify patients 0–18 years old who experienced caustic ingestion from January 2007–September 2015 and developed subsequent esophageal stricture until December 2021. Post-injury procedural and operative management was identified utilizing ICD-9/10 procedure codes for esophagogastroduodenoscopy (EGD), esophageal dilation, gastrostomy tube placement, fundoplication, tracheostomy, and major esophageal surgery. Results1,588 patients from 40 hospitals experienced caustic ingestion of which 56.6% were male, 32.5% non-Hispanic White, and the median age at time of injury was 2.2 years (IQR: 1.4,4.8). Median length of initial admission was 1.0 day (IQR: 1.0, 3.0). 171/1,588 (10.8%) developed esophageal stricture. Among those who developed stricture, 144 (84.2%) underwent at least 1 additional EGD, 138 (80.7%) underwent dilation, 70 (40.9%) underwent gastrostomy tube, 6 (3.5%) underwent fundoplication, 10 (5.8%) underwent tracheostomy, and 40 (23.4%) underwent major esophageal surgery. Patients underwent a median of 9 dilations (IQR 3, 20). Major surgery was performed at a median of 208 (IQR: 74, 480) days after caustic ingestion. ConclusionMany patients with esophageal stricture after caustic ingestion will require multiple procedural interventions and potentially major surgery. These patients may benefit from early multi-disciplinary care coordination and the development of a best-practice treatment algorithm. Level of evidenceIII.