Current Care Pathways Research Articles

Digital healthcare in COPD management: a narrative review on the advantages, pitfalls, and need for further research.

Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality despite current treatment strategies which focus on smoking cessation, pulmonary rehabilitation, and symptomatic relief. A focus of COPD care is to encourage self-management, particularly during COVID-19, where much face-to-face care has been reduced or ceased. Digital health solutions may offer affordable and scalable solutions to support COPD patient education and self-management, such solutions could improve clinical outcomes and expand service reach for limited additional cost. However, optimal ways to deliver digital medicine are still in development, and there are a number of important considerations for clinicians, commissioners, and patients to ensure successful implementation of digitally augmented care. In this narrative review, we discuss advantages, pitfalls, and future prospects of digital healthcare, which offer a variety of tools including self-management plans, education videos, inhaler training videos, feedback to patients and healthcare professionals (HCPs), exacerbation monitoring, and pulmonary rehabilitation. We discuss the key issues with sustaining patient and HCP engagement and limiting attrition of use, interoperability with devices, integration into healthcare systems, and ensuring inclusivity and accessibility. We explore the essential areas of research beyond determining safety and efficacy to understand the acceptability of digital healthcare solutions to patients, clinicians, and healthcare systems, and hence ways to improve this and sustain engagement. Finally, we explore the regulatory challenges to ensure quality and engagement and effective integration into current healthcare systems and care pathways, while maintaining patients’ autonomy and privacy. Understanding and addressing these issues and successful incorporation of an acceptable, simple, scalable, affordable, and future-proof digital solution into healthcare systems could help remodel global chronic disease management and fractured healthcare systems to provide best patient care and optimisation of healthcare resources to meet the global burden and unmet clinical need of COPD.

Individual Components of Post-Hepatectomy Care Pathways Have Differential Impacts on Length of Stay

Introduction: Optimization of perioperative factors contributing to post-hepatectomy length of stay (LOS) is an aim of current care pathways. However, individual variable contributions to LOS are difficult to separate. Method: Using a prospectively-maintained quality improvement database, hepatectomy patients (1/1/2017-7/1/2020) were included in Poisson regression and marginal effects analysis for LOS. Kawaguchi-Gayet (K-G) complexity classifications were used for comparing expected LOS among pathways (minimally-invasive=MIS; low-intermediate=K-G I/II; high=K-G III; combination operations). Prolonged LOS was >25% median LOS by pathways. “Diet tolerance” was defined as 24 hours of eating. Results: Among 978 consecutive patients, median LOS was 2, 4, 5, and 5 days for MIS, K-G I/II, K-G III and combination operations, respectively. Multivariable Poisson regression identified age, intraoperative fluids, delayed diet tolerance, and combination cases associated with increased LOS (all p<0.01). MIS pathway was associated with shorter LOS (p<0.001, Table 1). Marginal effects analysis demonstrated on average, each additional year of age contributed 0.03x increased LOS; each 250mL of intraoperative IV fluids contributed 0.06x; each additional operative hour contributed 0.2x; each additional day to diet tolerance contributed 0.4x, while MIS approach had 1.2x increased probability of shorter LOS. Combination operations contributed 0.7x increased probably of longer LOS (Figure 1). Conclusions: Modifiable components of post-hepatectomy care pathways to potentially impact LOS include restricting intraoperative fluids, optimizing operative time, introducing a diet on postoperative day 1, and favoring MIS approaches when feasible. Intentionally highlighting these individual pathway components may maximize the overall effects of the comprehensive care bundle.Tabled 1Table 1: Multivariable Model for Length of Stay after Hepatectomy According to Level of Operative ComplexityVariableIRRp-value*95% CIAge (in years)1.006<0.0011.003-1.009Male sex1.0060.8710.94-1.08Intraoperative IV fluids (per 250 mL)1.0140.0111.003-1.02Total operative time (per 60 min)1.037<0.0011.17-1.06Estimated blood loss (in mL)1.000.6470.99-1.00Tolerated regular diet for 24 hours (in days)1.09<0.0011.07-1.10PathwayK-G I/IIK-G IIIMISCombination casesRef1.080.731.15Ref0.129<0.0010.004Ref0.98-1.190.64-0.821.04-1.26IRR: Incidence Rate Ratio; IV: intravenous; CI: confidence interval; MIS: minimally invasive surgery; K-G: Kawaguchi-Gayet*p-value set at alpha of 0.05 Open table in a new tab IRR: Incidence Rate Ratio; IV: intravenous; CI: confidence interval; MIS: minimally invasive surgery; K-G: Kawaguchi-Gayet *p-value set at alpha of 0.05

Care pathway for Covid-19 patients in a hospital in Luxembourg

The current care pathway for COVID-19 patients was set up at the Centre Hospitalier de Luxembourg following the experiences of the first wave. The role of the nurse in this pathway is fundamental: she coordinates care and themultidisciplinary team as well as the families, in addition to monitoring and treating the patients. Her tool is clinical reasoning, which is the guarantee of care adapted to the needs and expectations of the patients.

Patients Unmet Needs in Chronic Rhinosinusitis With Nasal Polyps Care: A Patient Advisory Board Statement of EUFOREA

Background: European patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have had only limited occasions to unite to have their voices heard, hence missing the opportunity to contribute to the improvement of CRSwNP care.Aims: To identify unmet needs in CRSwNP from the perspective of CRSwNP patients from the Patient Advisory Board (PAB) of the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA).Methodology: Semi-structured interviews were conducted individually with 15 European patients with CRSwNP and with a disease history of more than 2 years. Patients shared their burden of the disease and frustrations related to CRSwNP care, experiences with key pillars of current treatment options, shortcomings of the current care pathways and recommendations for improvement of care. A panel of 30 members of the Patient Advisory Board reviewed the interview report and provided further input during 2 virtual meetings.Results: CRSwNP patients indicated the need for greater awareness from society and physicians of the disease burden with impact on social function and well-being. Along with a loss of ability to smell and the continuous presence of secretions in the nose, most patients reported poor sleep quality and psychological impact as the most bothersome symptoms. Patients' frustrations relate primarily to the underestimation of the disease burden, the lack of coordination of care and the limited treatment options available to them. Treatment options with oral corticosteroids and/or sinus surgery both have positive and negative aspects, including the lack of long-lasting efficacy. Better coordination of care, more patient-centered care, greater public awareness, increases in research on the disease mechanisms and better therapeutic options would be warmly welcomed by CRSwNP patients.Conclusions: This statement of the EUFOREA Patient Advisory Board on CRSwNP provides novel insights on the underestimation of the burden of CRSwNP and shortcomings of current care. Multiple recommendations made by the patients can underpin action plans for implementation of better care for CRSwNP among all physicians treating patients with this disabling disease.

Implementation of biopsychosocial supported self-management for chronic primary oro-facial pain including temporomandibular disorders: A theory, person and evidence-based approach.

Aims of the study were to: Implement supported self-management for chronic primary oro-facial pain in a clinical setting. Evaluate its impact on consultation rates, pain severity, interference with life and patient experience. Sixty-six patients with chronic primary oro-facial pain received the intervention at a facial pain clinic at Leeds Dental Institute, UK. Brief Pain Inventory (BPI) scores measured pain severity and interference with life before and after the intervention. Process mining outlined patient care pathways. Monthly consultation rates measured 12months before and after the intervention were used to evaluate burden on healthcare services and economic impact. Patient feedback was assessed via Patient and Public involvement discussion groups. Mean BPI scores significantly improved after intervention-from 5.70 (SD 1.89) to 3.78 (SD 2.34) (p<.001); mean pain interference score reduced from 19.95 (SD 9.41) to 12.05 (SD 9.64) (p<.001). Average monthly consultations significantly (p=.001) reduced from 0.42/month before the intervention to 0.16/month after the intervention. Economic assessment showed cost savings of £293 per patient per year. Process mining showed high rates of service usage with 31 patients also attending 51 other specialist services between them. Patient and Public Involvement discussion groups with 5 patients identified that the intervention was a 'constant companion' and should be implemented at the outset in the care pathway. Supported self-management for chronic primary oro-facial pain has a positive impact on health outcomes (physical functioning, pain intensity and patient experience), as well as service usage and healthcare costs when implemented in a secondary care clinical setting. Reconfiguring current care pathways to upscale early implementation of such interventions should be a priority for future testing.

Effectiveness of a coordinated support system linking public hospitals to a health coaching service compared with usual care at discharge for patients with chronic low back pain: protocol for a randomised controlled trial

BackgroundAlthough many people with chronic low back pain (LBP) improve following conservative treatment, one in five will experience worsening symptoms after discharge from treatment and seek health care again. The current LBP clinical care pathway in many health services lacks a well-integrated, systematic approach to support patients to remain physically active and self-manage their symptoms following discharge from treatment. Health coaching can support people to improve physical activity levels and may potentially reduce health care utilisation for LBP. The primary aim of this study is to evaluate the effect of introducing a coordinated support system (linking hospital outpatient physiotherapy services to a public health coaching service) at discharge from LBP treatment, on the future use of hospital, medical, and health services for LBP, compared with usual care provided at discharge.MethodsThree hundred and seventy-four adults with chronic non-specific LBP will be recruited from the outpatient physiotherapy departments of public hospitals in New South Wales, Australia. Participants will be individually randomised to a support system (n = 187) or usual care group (n = 187). All participants will receive usual care provided at discharge from treatment. Participants allocated to the support system will also receive up to 10 telephone-based health coaching sessions, delivered by the Get Healthy Service®, over a 6-month period. Health coaches will monitor and support participants to improve physical activity levels and achieve personal health-related goals. The primary outcome is the total number of encounters with hospital, medical, and health services for LBP, at 12 months from baseline. A within-trial economic evaluation will quantify the incremental costs and benefits of the support system from a health system perspective, to support reimbursement decision making.DiscussionThis study will establish the effect of a coordinated support system, introduced at discharge from treatment, on the future use of hospital, medical, and health services for LBP and various health outcomes.ConclusionInnovative community-driven solutions to support people with chronic LBP after discharge from treatment are urgently needed. Study findings will help inform health care policy and clinical practice in Australia.Trial RegistrationProspectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12620000889954) on 10/09/2020.

Multimodal imaging interpreted by graders to detect re-activation of diabetic eye disease in previously treated patients: the EMERALD diagnostic accuracy study.

Owing to the increasing prevalence of diabetes, the workload related to diabetic macular oedema and proliferative diabetic retinopathy is rising, making it difficult for hospital eye services to meet demands. The objective was to evaluate the diagnostic performance, cost-effectiveness and acceptability of a new pathway using multimodal imaging interpreted by ophthalmic graders to detect reactivation of diabetic macular oedema/proliferative diabetic retinopathy in previously treated patients. This was a prospective, case-referent, cross-sectional diagnostic study. The setting was ophthalmic clinics in 13 NHS hospitals. Adults with type 1 or type 2 diabetes with previously successfully treated diabetic macular oedema/proliferative diabetic retinopathy in one/both eyes in whom, at the time of enrolment, diabetic macular oedema/proliferative diabetic retinopathy could be active or inactive. For the ophthalmic grader pathway, review of the spectral domain optical coherence tomography scans to detect diabetic macular oedema, and seven-field Early Treatment Diabetic Retinopathy Study/ultra-wide field fundus images to detect proliferative diabetic retinopathy, by trained ophthalmic graders. For the current standard care pathway (reference standard), ophthalmologists examined patients face to face by slit-lamp biomicroscopy for proliferative diabetic retinopathy and, in addition, spectral domain optical coherence tomography imaging for diabetic macular oedema. The primary outcome measure was sensitivity of the ophthalmic grader pathway to detect active diabetic macular oedema/proliferative diabetic retinopathy. The secondary outcomes were specificity, agreement between pathways, cost-consequences, acceptability and the proportion of patients requiring subsequent ophthalmologist assessment, unable to undergo imaging and with inadequate quality images/indeterminate findings. It was assumed for the main analysis that all patients in whom graders diagnosed active disease or were 'unsure' or images were 'ungradable' required examination by an ophthalmologist. Eligible participants with active and inactive diabetic macular oedema (152 and 120 participants, respectively) and active and inactive proliferative diabetic retinopathy (111 and 170 participants, respectively) were recruited. Under the main analysis, graders had a sensitivity of 97% (142/147) (95% confidence interval 92% to 99%) and specificity of 31% (35/113) (95% confidence interval 23% to 40%) to detect diabetic macular oedema. For proliferative diabetic retinopathy, graders had a similar sensitivity and specificity using seven-field Early Treatment Diabetic Retinopathy Study [sensitivity 85% (87/102), 95% confidence interval 77% to 91%; specificity 48% (77/160), 95% confidence interval 41% to 56%] or ultra-wide field imaging [sensitivity 83% (87/105), 95% confidence interval 75% to 89%; specificity 54% (86/160), 95% confidence interval 46% to 61%]. Participants attending focus groups expressed preference for face-to-face evaluations by ophthalmologists. In the ophthalmologists' absence, patients voiced the need for immediate feedback following grader's assessments, maintaining periodic evaluations by ophthalmologists. Graders and ophthalmologists were supportive of the new pathway. When compared with the reference standard (current standard pathway), the new grader pathway could save £1390 per 100 patients in the review of people with diabetic macular oedema and, depending on the imaging modality used, between £461 and £1189 per 100 patients in the review of people with proliferative diabetic retinopathy. For people with diabetic macular oedema, the ophthalmic grader pathway appears safe and cost saving. The sensitivity of the new pathway to detect active proliferative diabetic retinopathy was lower, but may still be considered acceptable for patients with proliferative diabetic retinopathy previously treated with laser. Suggestions from focus group discussions should be taken into consideration if the new pathway is introduced to ensure its acceptability to users. Lack of fundus fluorescein angiography to confirm diagnosis of active proliferative diabetic retinopathy. Could refinement of the new pathway increase its sensitivity to detect proliferative diabetic retinopathy? Could artificial intelligence be used for automated reading of images in this previously treated population? Current Controlled Trials ISRCTN10856638 and ClinicalTrials.gov NCT03490318. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology AssessmentVol. 25, No. 32. See the NIHR Journals Library website for further project information.

04. MAMMA (Mastitis and Mammary abscess Management Audit): Phase 1 interim results

Introduction: Mastitis is a common benign breast condition. The aim of Phase 1 MAMMA study is to understand the current care pathway in the management of mastitis and breast abscess in the UK and Ireland.

Characteristics of hospital encounters and associated economic burden of patients with major depressive disorder and acute suicidal ideation or behavior

ABSTRACT Objectives Relatively little is known about the hospital experience among patients with major depressive disorder (MDD) and acute suicidal ideation or behavior (MDSI). The objectives of this study were to examine hospital encounter characteristics, including the associated economic burden and risk of subsequent hospital encounters of patients with MDSI in the US. Methods In this retrospective analysis, patients ≥18 years of age with a hospital encounter (emergency department [ED] visit or inpatient admission) were selected from the de-identified Premier Hospital database between 1 January 2017 and 30 September 2018. Patients were required to have MDD as the primary and acute suicidal ideation or behavior as a secondary discharge diagnosis or vice versa. Patient demographics and characteristics of hospital encounters were examined. Rates and costs of subsequent all-cause and MDD-related hospital encounters 6 months following initial discharge were also evaluated. Results The study population consisted of 123,179 patients with a hospital encounter for MDSI (mean age: 38 years, 50.9% female, 74.6% White); 50.2% were treated in the ED only (mean ± standard deviation cost: $693±$630), while 49.8% were admitted as inpatients ($6,478±$7,001). Among those with ED visits, very few (7.0%) received an antidepressant (AD). Among those with an inpatient admission, 87.2% received ≥1 AD and 39.0% received AD augmentation. Overall rates and costs of subsequent all-cause and MDD-related hospital encounters were 22.3% ($5,136±$11,791) and 12.0% ($3,722±$9,621), respectively; nearly half of subsequent encounters (41.3% and 44.3%, respectively) occurred in the first month following initial discharge. Conclusions This analysis of patients with MDSI presenting to US hospitals shows heterogeneity in treatment and a concentration of costly subsequent hospital encounters within 1-month post discharge, suggesting that healthcare systems may benefit from examination of current care pathways for this vulnerable patient population.

New drugs and PDTA. Financing methodology for care pathways and overcoming of silos.

The Research and Health Foundation led a preliminary analysis to understand how drugs are cited and what their weight is within the current diagnostic-therapeutic care pathways (PDTA) referring to chronic diseases. The results highlight the need to provide for the specification of which drugs to use and the related methods of use. The issue is also important due to the connection between specific decisions of the Italian Medicines Agency concerning the access and reimbursement of the drug and their use.

Modelling Prenatal Care Pathways at a Central Hospital in Zimbabwe.

Background:Maternal mortality remains a problem in low-income countries (LICs). In Zimbabwe, there has been an unprecedented increase in maternal mortality in the last 2.5 decades. Effective prenatal care delivery, particularly early visits, appropriate number of visits, and receiving recommended care is viewed as key to reducing fatal care outcomes.Aims:This study sought to model and identify gaps requiring service and care delivery improvement in prenatal care pathways for pregnant women visiting Mpilo Central Hospital in Bulawayo, Zimbabwe.Methods:This was a case study of the services offered by an antenatal care department at Mpilo Central Hospital in Bulawayo, Zimbabwe. Evidence from literature in low-income countries was used to develop prenatal care pathway guidelines as a tool to guide care delivery and identify gaps in care and service delivery. One hundred cases of prenatal care records were reviewed to determine the prenatal care pathway and care delivered to pregnant women. This data was complemented by interviews with 20 maternity care clinicians.Results:In 100 maternity case records studied, 53% booked for prenatal care. Of the 53% (n = 53) pregnant women who booked, their first visit on their pregnancy was late at an average gestational age of 27.1 weeks with extremes of 30 to 40 weeks in 38% (n = 20) cases. Missing scheduled prenatal care appointments was prevalent, with only 11% (n = 6) having attended all the expected 5 visits, whilst 60% (n = 32) missed 3 or more. There were inadequacies in the care delivered to women in each visit compared to that expected in such areas as obstetrics, physical examinations and haematological tests. Maternity care clinicians attributed the cost of prenatal booking fees in the background of poverty and poor family support systems as key factors hindering women’s access to prenatal services.Conclusions:The current prenatal care pathway at MCH requires improvement in the areas of referral, adherence to appointment by pregnant women and visiting prenatal care early. Clinicians also need to adhere to standard clinical tests recommended for each specific pregnant woman’s visit. In the Zimbabwean setting with limited resources, where the number of visits is already low, pathways with reduced visits may not be appropriate. An investment into prenatal care by the government is recommended to enable the utilisation of interventions such as e-health technologies that may improve care delivery as well as adherence to best practices. E-health and mobile health technologies involving e-referrals, e-booking, decision support, and reminder systems are recommended for clinicians to manage and deliver appropriate care to patients as well as pregnant women to adhere to scheduled visits.

Insights into heart failure hospitalizations, management, and services during and beyond COVID-19.

Coronavirus disease 2019 (COVID‐19) is caused by severe acute respiratory syndrome coronavirus‐2. The clinical presentation of this virus mainly manifests in the respiratory system but may also lead to severe complications in the cardiovascular system. The global burden of COVID‐19 has led to an unprecedented need to gain further insight into patient outcomes, management, and clinical practice. This review aims to provide an overview of the current literature on heart failure (HF) hospitalizations, management, and care pathways for supporting patients during and beyond this pandemic. A literature review of five areas of interest was conducted and included: (i) HF hospitalization; (ii) recognizing the needs and supporting HF patients during COVID‐19; (iii) supporting rehabilitation services; (iv) transitioning to a telehealth framework; and (v) the need for evidence. Patients with new‐onset or existing HF are particularly vulnerable, but a significant reduction in HF hospital admissions has been reported. During these periods of uncertainty, the current care pathways for acute and elective cardiac patients have had to change with the relocation of HF services to protect the vulnerable and reduce transmission of COVID‐19. Optimizing community HF services has the potential to reduce the pressures on secondary care during the recovery from this pandemic. Telemedicine and virtual health care are emerging technologies and overcome the risk of in‐person exposure. Successful remote delivery of cardiac rehabilitation services has been reported during the pandemic. Delivery of a robust telehealth framework for HF patients will improve communication between clinician and patient. The reduction in HF admissions is a concern for the future and may result in unintended mortality. New‐onset and current HF patients must understand their diagnosis and future prognosis and seek help and support using the appropriate platform when needed. Realigning HF services and the use of telemedicine and virtual health care has great potential but needs to be carefully understood to ensure engagement and approval in this population to overcome barriers and challenges.

Bridging the Gap in Community Care for Patients With Borderline Personality Disorder: Protocol for Qualitative Inquiry Into Patient, Caregiver, and Clinician Perspectives on Service Gaps and Potential Solutions for Severe Emotion Dysregulation.

BackgroundBorderline personality disorder (BPD) is characterized by severe emotion dysregulation that is often complicated by comorbid diagnoses, deliberate self-harm, and chronic suicidal ideation. Unfortunately, current care pathways for individuals with BPD are strained by limited resources, inadequate training, and an overuse of emergency departments and crisis teams. Such barriers result in delayed access to effective treatment, which increases risk of deterioration, disability, and morbidity. A first step toward addressing these limitations of the current care pathway is to understand key stakeholders’ lived experiences in this pathway and their perspectives on potential solutions.ObjectiveThe purpose of this paper is to present a protocol for a study that explores the lived experiences of the current care pathway from the perspectives of patients with BPD, as well as their caregivers and clinicians.MethodsA qualitative approach is most appropriate for the exploratory nature of the research objective. Accordingly, 3 to 6 patients with a diagnosis of BPD, 3 caregivers of individuals with BPD, and 3 clinicians of patients diagnosed with BPD will be invited to participate in individual, semistructured interviews that focus on service experiences.ResultsIt is anticipated that results will yield insight into the lived experiences of patients with BPD, caregivers, and clinicians and provide a better understanding of the perceived gaps in services and potential solutions. Results are expected to be available in 12 months.ConclusionsThis paper describes a protocol for a qualitative study that seeks to understand the lived experiences and perspectives of key stakeholders (patients, caregivers, and clinicians) on the current care pathway for BPD. Results will provide a basis for future research in this area and will have the potential to inform training, practice, and policy.International Registered Report Identifier (IRRID)DERR1-10.2196/14885

Empowering Patients and Health Professionals to Address Sexual Health in the Context of Anorectal Malformations and Hirschsprung's Disease.

The aim of this study is to develop a tool that is aligned with patients’ and health professionals’ needs to address sexual health in the context of anorectal malformations and Hirschsprung’s disease. A multiphased participatory action–research was conducted. First, an inventory of needs was made through interviews (11 patients, 11 professionals), three online focus groups (4 patients, 20 professionals), and a questionnaire (38 patients). Subsequently, four cocreation sessions with in total four patients and nine professionals were organized to translate the needs into a tool (in the form of a website). The websites’ functionality was assessed via a questionnaire (n = 34). The website, directed to patients, their parents, and professionals, stimulates awareness, fills knowledge gaps, and shows possibilities for support. The website is expected to change restrictive attitudes toward sexual health and improve the legitimization of the topic needed for the allocation of resources and sexologists’ involvement in current care pathways.

Ways Ahead: developing a supported self-management programme for people living with low- and intermediate-grade gliomas - a protocol for a multi-method study

IntroductionLiving with and beyond a diagnosis of a low- and intermediate-grade glioma (LIGG) can adversely impact many aspects of people’s lives and their quality of life (QoL). In people with...

Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond.

Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workflow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients suffering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.

Managing access to advanced therapy medicinal products: Challenges for NHS Wales.

Advanced Therapy Medicinal Products (ATMPs), which include gene, somatic cell therapies and tissue-engineered medicines, have the potential to transform current care pathways by offering durable and potentially curative outcomes. However, they are exceptionally expensive, with prices exceeding £1m per patient in some cases. With an expectation that a large number of ATMPs will soon gain marketing authorisation (global market is estimated to reach £9bn to £14bn by 2025), healthcare payers and providers face a number of challenges to facilitate patient access to this new category of medicines. This viewpoint reflects on the experience of introducing ATMPs into the National Health Service in Wales where £1 in every £200 spent on medicines (2019/2020) is expected to be on ATMPs for just 20 patients. Evidence to date makes it apparent that decisions regarding clinical and cost-effectiveness and the scale of the budget impact of implementing ATMPs create both financial and health service risks. Consequently, there are significant policy implications. A critical examination is made of the approaches taken for the health technology assessment and appraisal of ATMPs, the methods of payment and service impacts of these medicines, and the approach taken to horizon scanning and subsequent modelling of the financial impact over the next 10 years.

Diagnosis-to-Ablation Time and Recurrence of Atrial Fibrillation Following Catheter Ablation: A Systematic Review and Meta-Analysis of Observational Studies.

The optimal timing of catheter ablation for atrial fibrillation (AF) in reference to the time of diagnosis is unknown. We sought to assess the impact of the duration between first diagnosis of AF and ablation, or diagnosis-to-ablation time (DAT), on AF recurrence following catheter ablation. We conducted a systematic electronic search for observational studies reporting the outcomes associated with catheter ablation for atrial fibrillation stratified by diagnosis-to-ablation time. The primary meta-analysis using a random effects model assessed AF recurrence stratified by DAT ≤1 year versus >1 year. A secondary analysis assessed outcomes stratified by DAT ≤3 years versus >3 years. Of the 632 screened studies, 6 studies met inclusion criteria for a total of 4950 participants undergoing AF ablation for symptomatic AF. A shorter DAT ≤1 year was associated with a lower relative risk of AF recurrence compared with DAT >1 year (relative risk, 0.73 [95% CI, 0.65-0.82]; P<0.001). Heterogeneity was moderate (I2=51%). When excluding the one study consisting of only patients with persistent AF, the heterogeneity improved substantially (I2=0%, Cochran's Q P=0.55) with a similar estimate of effect (relative risk, 0.78 [95% CI, 0.71-0.85]; P<0.001). Shorter duration between time of first AF diagnosis and AF ablation is associated with an increased likelihood of ablation procedural success. Additional study is required to confirm these results and to explore implementation of earlier catheter AF ablation and patient outcomes within the current AF care pathway. Visual Overview A visual overview is available for this article.

Evaluation of the acceptability and usability of the MAGIC-GLASS virtual reality solution as part of the care pathway in people with acute, sub-acute and chronic stroke: a study protocol

Background: Intensive rehabilitation is one of the most important aspects of care for people with stroke, and there is evidence that it leads to better recovery and higher levels of independence. However, pressure on resources in government funded secondary and primary healthcare settings means that for many people with stroke, intense rehabilitation is not available. Effective and efficient ways of increasing rehabilitation intensity, engagement, and motivation for rehabilitation are needed; as well as innovative treatment approaches that enable people with stroke to self-manage this rehabilitation. Technology offers a solution; virtual reality (VR) computer games have the potential to enhance engagement, improve adherence, and outcomes in stroke rehabilitation therapy. However, their integration into current health care pathways needs to be tested.Aims: The aim of the trial is to test the feasibility of incorporating VR computer games into a stroke rehabilitation system called ‘MAGIC-GLASS’, and its integration into the current care pathway for people with stroke.Design: Multicenter, prospective uncontrolled, pre-post intervention study.Setting: Participants will be recruited from Stroke Services, GP Practices or via Stroke Support Groups, and the intervention will be carried out in the hospital setting, or at home after discharge.Population: Adults (≥18 years) who have had a stroke.Interventions: Magic Glass is a clinician facilitated VR-based stroke rehabilitation system. Clinical facilitation includes a minimum of one initial face-to-face contact followed by up to 13 weekly/fortnightly remote contacts (to month six) with a clinician.Outcomes: The usability and acceptability of the intervention; process and resource requirements for the new care pathway; changes in clinical outcomes and potential cost-effectiveness of the solution will be measured to assess change from baseline to six months post intervention.Sample size: In order to have 50 patients in the subgroups identified (time since stroke; severity of stroke; age) we plan to recruit 300 participants, 150 in Northern Ireland and 150 in Italy. Fifty is considered the optimal sample size for this feasibility analysis.Duration: 18 months. Follow up will be post intervention (up to six months post entry into the study). The nested qualitative study will start once the first cohort of participants has completed and will continue throughout the intervention period.

Abstract TP174: Identifying Predictors for Final Diagnosis of Ischemic Events in an Emergency Department Observation Unit

Introduction: Transient neurologic events have high rates of diagnostic uncertainty. Emergency department observation units (ED-OU) allow an accelerated diagnostic work up for suspected transient ischemic attacks (TIAs). However, clinical decision support regarding which patients to admit to these units is lacking. This study aimed to identify clinical features that differentiate true ischemic events from nonischemic transient neurological attacks (NI-TNA) among patients admitted to an ED-OU for suspected TIA. Methods: A retrospective analysis was performed on consecutive patients admitted to the ED-OU at a single academic center for suspected TIA. Demographics, vascular risk factors, presenting symptoms, and details of the clinical presentation were abstracted from chart review. Final discharge diagnosis was dichotomized to either ischemic event (TIA or minor stroke, TIAMS) or NI-TNA based on the treating vascular neurologist’s final diagnosis. Standard statistical tests were used for comparison testing between the two groups. Significantly different factors with p&lt;0.2 on univariate analysis were carried forward in a multivariable logistic regression model. Results: Of 186 consecutive patients, 101 (54%) had a final diagnosis of NI-TNA and 85 (46%) of TIAMS. The median population ABCD2 score was 4 [IQR 3-4]. On univariate analysis, older age (63 vs. 70, p&lt;0.01), history of atrial fibrillation (AF) (12% vs. 26%, p=0.01), and facial weakness (5% vs. 14% p=0.03) were associated with TIAMS. Headache (24% vs. 12%, p=0.04) and symptom duration&gt;60min (57% vs. 40%, p=0.02) were associated with NI-TNA. On multivariable analysis, only symptom duration&gt;60 minutes predicted NI-TNA (OR 0.39, p=0.04) and only history of AF (OR 2.53, p=0.03) predicted TIAMS. Facial weakness was strongly predictive of TIAMS (OR 3.22, p=0.05), but not significant. Conclusion: We identified two clinical features that distinguished TIAMS from NI-TNA among patients admitted to an ED-OU for suspected TIA.These may be helpful in emergency room triage of TIAMS. Data from ED-OU can be used to identify factors associated with cerebral ischemia and improve current care pathways for patients with suspected TIA, so diagnostic evaluation is received in the most appropriate setting.