Development Of Clinical Services Research Articles

Development of hospital clinical pharmacy services in Denmark from 2008 to 2023

ObjectivesThe role of the hospital pharmacist is evolving, and in many countries pharmacists play an increasingly patient-centred role in healthcare. This study aimed to investigate the development of Danish hospital...

‘We are still here, we are survivors’: patients’ experiences of attending a multidisciplinary group-based support programme following subarachnoid haemorrhage

Purpose People who survive a subarachnoid haemorrhage (SAH) often face enduring health challenges including physical disability, fatigue, cognitive impairments, psychological difficulties, and reduced quality of life. While group interventions have shown positive results in addressing similar issues in chronic conditions, the evidence involving SAH specifically is still sparse. This service evaluation aimed to explore SAH survivors’ experiences of attending a multidisciplinary group-based support programme tailored to address unmet needs identified in previous literature, with the ultimate aim to refine future iterations of the programme and improve quality of care post-SAH. Materials and Methods Semi-structured interviews were carried out with 12 individuals who attended the programme. The resulting data were analysed thematically. Results Four overarching themes emerged from the analysis: (1) Barriers to accessing support after a SAH, (2) Factors acting as enablers of recovery, (3) Sharing lived experience to support one another, (4) Feeling connected while navigating a group format. Conclusions Lack of communication, fear, loneliness, and cognitive impairments can act as barriers to engagement with support, while acceptance and adjustment, holistic multidisciplinary input, and psychological support may represent successful enablers of recovery. Implications for future iterations of the programme as well as clinical rehabilitation and service development are discussed.

Comparison of Outpatient and Inpatient Consultations Requested from Child and Adolescent Psychiatry

Objective: This study aims to examine the sociodemographic and clinical characteristics of child and adolescent psychiatry consultations and to compare characteristics of outpatient and inpatient consultations. Methods: A total of 354 patients who were consulted to child and adolescent psychiatry department of a university hospital were included in the study. Data were collected regarding sociodemographic characteristics of patients, departments requesting consultation, diagnoses, and treatment methods. Results: The cases included in the study had a mean age of 10.6±4.8 years,with 51.4% being girls. Adolescent girls formed the majority of the inpatient group. The pediatric neurology outpatient clinic had the highest frequency of requested consultations (22.3%), and the most common reason for consultation was a suicide attempt (12.1%). Of the cases for which consultation was requested, 67.8% were diagnosed with at least one psychiatric disorder, and the most common diagnoses were anxiety disorders, with 12.7%. In the inpatient group, impulsive suicide attempts and depressive disorders were more frequent compared to the outpatient group, while intellectual disability was less common. Parent education was provided for 97.2% of the cases, pharmacological treatment was recommended for 44.6% of the cases, and the most commonly prescribed medications were selective serotonin reuptake inhibitors. Psychotherapy and special education were significantly more common in the outpatient group compared to the inpatient treatment group. Conclusion: The current study revealed significant differences in consultations requested from child and adolescent psychiatry between the outpatient and inpatient groups regarding consultation reasons, diagnoses, and treatment modalities. The findings provide valuable information for clinical practice and service development.

Using interRAI Assessment for Research: Developing a National Research Agenda in Aotearoa New Zealand

interRAI provides a suite of standardized, validated instruments used to assess health and psychosocial well-being, and to inform person-centered care planning. Data obtained from these standardized tools can also be used at a population level for research and to inform policy, and interRAI is currently used in more than 40 countries globally. We present a brief overview of the use of interRAI internationally within research and policy settings, and then introduce how interRAI is used within the universal public health system in Aotearoa New Zealand (NZ), including considerations relating to Māori, the Indigenous people of NZ. In NZ, improvement in interRAI data utilization for research purposes was called for from aged care, health providers, and researchers, to better use these data for quality improvement and health advancement for New Zealanders. A national research network has been established, providing a medium for researchers to form relationships and collaborate on interRAI research with a goal of translating routinely collected interRAI data to improve clinical care, patient experience, service development, and quality improvement. In 2023, the network members met (hybrid: in-person and online) and identified research priorities. These were collated and developed into a national interRAI research agenda by the NZ interRAI Research Network Working Group. Research priorities included reviewing the interRAI assessment processes, improving methods for data linkage to national data sets, exploring how Indigenous Data Sovereignty can be upheld, as well as a variety of clinically focused research topics. Implications for Practice, Policy, and Research: This appears to be the first time national interRAI research priorities have been formally identified. Priorities identified have the potential to inform quality and clinical improvement activities and are likely of international relevance. The methodology described to cocreate the research priorities will also be of wider significance for those looking to do so in other countries.

How Do Children With Medical Complexity Die? A Scoping Review.

Introduction: Advancement in medical expertise and technology has led to a growing cohort of children with medical complexity (CMC), who make up a rising proportion of childhood deaths. However, end of life in CMC is poorly understood and little is known about illness trajectories, communication, and decision-making experiences. Objective: To synthesize existing literature and characterize the end-of-life experience in CMC. Methods: A literature search of MEDLINE, CINAHL, PsycINFO, Scopus, Embase, and Google Scholar was conducted up to August 26, 2021. Studies reporting CMC at end of life were included and the extracted data were analyzed descriptively. Findings: Of 1535 publications identified, 23 studies were included. Most studies (15/23 [65%]) were published from 2015 to 2021 and were quantitative in nature (20/23 [87%]). The majority of studies that extracted data from a single country (18/20 [90%]) originated from North America. Study outcomes were categorized into four main domains: (1) place of death (2) health care use (3) interventions received or withdrawn (4) communication, and end-of-life experiences. The weighted percentage of in-hospital CMC deaths was 80.6%. Studies reported that CMC had increased health care use and were subjected to more intensive interventions at end of life compared with non-CMC. Qualitative studies highlighted the following themes: Intrinsic prognostic uncertainty, differing perspectives of the child's quality of life, the chronic illness experience, a desire to have parental expertise acknowledged, surprise at the terminal event, the experience of multiple losses, with an overarching theme of the need for compassionate care at end of life. Conclusions: This scoping review highlighted important characteristics of end of life in CMC, outlining the emerging evidence and knowledge gaps on this topic. A better understanding of this cohort of seriously and chronically ill children would serve to inform clinical practice, service development, and future research.

End of life care in chronic limb threatening ischemia: a retrospective cohort study

ObjectiveChronic limb-threatening ischemia (CLTI) is the end-stage of peripheral artery disease, defined as 2 or more weeks of rest pain and/or tissue loss from objectively proven obstructive arterial disease. Mortality is high, yet literature on end-of-life and palliative care in this setting is scarce. Palliative care is care that is aimed at alleviating the physiological and psychological symptoms and addresses the social and spiritual needs of patients and family/carers. End-of-life care is an umbrella term for palliative care given alongside disease-modifying care. The aim of this study was to evaluate predictors of end-of-life and palliative care and corresponding outcomes using surgical revascularization and amputation as surrogate markers for CLTI. MethodsThis was a retrospective single-center cohort study of people with CLTI who underwent either surgical revascularization (bypass) or amputation between January 2018 and December 2019. Palliative care input was defined as a dedicated palliative care consultation by a palliative care professional, medical doctor, surgeon, or advanced care practitioner. Data was collected on patient demographics, cause and place of death, and palliative and end-of-life care outcomes, which included documentation of preferred place of care/death and care priorities, family involvement in advance care planning discussions, key workers allocated to coordinate palliative care, use of community palliative care registers, hospice referral, time spent in hospital and the intensive care unit toward the end of life, and realization of documented care objectives. The data was analyzed to determine predictors of palliative care and tangible outcomes. ResultsOne-hundred and eighty-six patients were included (116 bypass and 70 amputation) with a median age of 67.5 years (interquartile range, 58-76 years) and most were male (73.7%) with a median survival of 46 months (interquartile range, 21-54 months) and a 2-year survival of 72% (95% confidence interval, 66%-79%). Palliative care consultations occurred for 10.8% of patients, with the median time from consultation to death of 5 days. Of the deceased, only a few had preferred place of care/death (8.1%), care priorities (18.3%), and family involvement during advance care planning (15.1%) documented in their notes. Cause of death was most commonly due to sepsis (n = 30), malignancy (n = 11), and myocardial infarction (n = 10). Mortality and in-hospital death were significantly higher in patients who underwent amputation in comparison to bypass surgery. There was an association of both cardiac and renal dysfunction with palliative care input. Patients with palliative care input were more likely to have documentation of preferred place of care/death, care priorities, and resuscitation decisions; and family involvement in advance care planning decisions. However, this did not translate into a reduction in hospital readmission or time spent in the hospital or intensive care unit towards the end of life. ConclusionsPatients with CLTI are not being offered palliative care in line with The National Institute for Health and Care Excellence or The Vascular Society of Great Britain and Ireland guidance. There was an association between palliative care input and end-of-life care quality. However, input occurred too close to death to have a very significant effect. Further research, development of clinical pathways and services, and better integration between palliative and vascular services is needed to improve the end-of-life care of patients living with CLTI.

Establishing a clinical ethics support service: lessons from the first 18 months of a new Australian service – a case study

BackgroundAlthough the importance of clinical ethics in contemporary clinical environments is established, development of formal clinical ethics services in the Australia health system has, to date, been ad hoc. This study was designed to systematically follow and reflect upon the first 18 months of activity by a newly established service, to examine key barriers and facilitators to establishing a new service in an Australian hospital setting.Methods: how the study was performed and statistical tests usedA qualitative case study approach was utilised. The study gathered and analysed data using observations of service committee meetings, document analysis of agendas and minutes, and semi-structured interviews with committee members to generate semantic themes. By interpreting the thematic findings in reference to national capacity building resources, this study also aimed to provide practice-based reflections for other health agencies.Results: the main findingsAn overarching theme identified in the data was a strong commitment to supporting clinicians facing difficult patient care decisions and navigating difficult discussions with patients and families. Another key theme was the role of the new clinical ethics support service in providing clinicians with a pathway to raise system-wide issues with the organisation Executive. While there was strong clinical engagement, consumer and community participation remained a challenge, as did unresolved governance issues and a need for clearer policy relationship between the service and the organisation.Conclusions: brief summary and potential implicationsConsidering these themes in relation to the national capacity building resources, the study identifies three areas likely to require ongoing development and negotiation. These are: the role of the clinical ethics support service as a link between the workforce and the Executive; the incorporation of consumers and patients; and ethical reasoning. To improve the effectiveness of the service, it is necessary to increase clarity on the service’s role at the governance and policy level, as well as develop strategies for engaging consumers, patients and families. Finally, the capacity of the service to reflect on complex cases may be enhanced through explicit discussions of various different ethical frameworks and ways of deliberating.

Addressing Women’s Psychosocial Needs Following an Adverse Prenatal Diagnosis: Qualitative Findings Inform SARF Model Development

ABSTRACT Adverse prenatal diagnoses, regardless of the women’s choice of continuing the pregnancy or terminating it, can impact a women’s psychological and psychosocial wellbeing. Supportive interventions during this time are important. However, understanding what is deemed useful and best practice is complex and multifaceted. To understand the need for support during this time, the authors undertook a research study where 12 women were interviewed. The women spoke about feeling pressured by time in making a decision regarding their pregnancy option and having limited psychoeducation and support provided. They also spoke about post-traumatic growth in their grief experience. To assist health professionals, the authors have addressed the following areas in the study’s findings and discussion sections: the lack of appropriate information delivery skills of the professionals, the need for an assessment of each woman’s unique needs, the need for appropriate referrals to be given, and the need for appropriate follow-ups of the women. The SARF (Skills, Assessment, Referral, and Follow-up) model, presented in this article as a synthesis of this research, has the potential to inform the development of clinical services and social work practice to support women’s care following adverse prenatal diagnosis. IMPLICATIONS Psychosocial assessments are vital in providing good quality care to women after a poor prenatal diagnosis. The model can provide guidance to ensure that psychosocial assessments and explorations of values are undertaken before referring women to follow-up services. Given social workers’ experience in providing psychosocial assessments and their recommendations, social work clinicians should be utilised in health settings to their full scope of practice.

P067 Motivators, facilitators and barriers for patients and healthcare professionals towards exercise programmes in inflammatory rheumatic diseases: a qualitative literature review

Abstract Background/Aims Physical activity and exercise are often recommended to patients with inflammatory rheumatic diseases, based on the EULAR 2018 physical activity and 2021 self-management guidelines. However, multiple internal and external factors often play a role in facilitating the uptake of these interventions. The aim of this literature review is to critically appraise the motivators, facilitators and barriers to disease management, specifically exercise programmes, in patients with inflammatory rheumatic diseases and the healthcare professionals involved in their care. This is done with a view to help further guide our clinical practice and service development. Methods Pre-defined search terms were used to identify papers published in English, studying any form of physical activity/exercise interventions for inflammatory rheumatic diseases. This included seronegative spondyloarthritis (including axial/psoriatic/enteropathic/reactive arthritis), rheumatoid arthritis, and broadly grouped connective tissue diseases including systemic lupus erythematosus, systemic sclerosis and myositis. Databases included MEDLINE via PubMed, CINAHL, Embase and Cochrane Database of systematic reviews from January 2018 onwards. Qualitative data regarding any motivators, facilitators and barriers to exercise for patients and health care professions were extracted. 427 studies were identified and screened of which 12 were included in the final analysis. Results In seronegative spondyloarthritis, the main motivators for patients included a reduction in disease activity and disability. Facilitators included social support and support from health care professionals, including the wider multidisciplinary team. Major barriers included lack of time, fatigue, pain and economic concerns. Similarly, in rheumatoid arthritis, main motivators were improvement in pain, function and strength with facilitators being social and healthcare professional support. The major barrier seen across all studies was fatigue. For the broad connective tissue diseases, motivators included general improvement in symptoms and knowledge of the benefits of physical activity. Facilitators included social and healthcare professional support as well as access to suitable exercise facilities. Finally, barriers included lack of understanding of exercise interventions and disease burden. For healthcare professionals, similar findings were found in both seronegative spondyloarthritis and rheumatoid arthritis with major motivators being increased quality of care provision and improvements in disease activity. Facilitators included ability to access high quality educational materials, and barriers included limited experience of exercise prescribing and the challenges of telehealth. No studies were identified for the viewpoints of healthcare professionals in other connective tissue diseases. Conclusion Exercise programmes have an important role in the management of patients with inflammatory rheumatic diseases. By gaining a better understanding of the motivators, facilitators and barriers towards exercise in both patients and healthcare professionals, we can further develop interventions that address these domains and help better integrate physical activity into routine patient care. Particular importance should be placed on training healthcare professionals across the multidisciplinary team to facilitate the uptake of physical activity interventions. Disclosure R. Amarnani: None. M. Hadjidemetriou: None. K. Ainsworth: None. F. Chiwah: None. S. Katti: None. A. Mundell: None. G.S. Metsios: None. C. Lester: None.

Effect of a pharmacist-based toxicology consult service on appropriate use of intravenous N-acetylcysteine for acetaminophen toxicity: A retrospective cohort study.

Incorporating clinical pharmacists on the medical team has been associated with fewer medication errors and increased error interception. Due to the logistical complexities of the intravenous (IV) N-acetylcysteine (NAC) regimen for acetaminophen toxicity, many opportunities for medication errors exist. A pharmacist-based toxicology consultation service was implemented at our institution, allowing pharmacists to formally aid in the management of toxicology patients throughout their hospital admission, including those with acetaminophen toxicity. The purpose of this study was to evaluate the effect of a house-wide pharmacist-based toxicology consult service on errors associated with IV NAC treatment for patients admitted with acetaminophen toxicity. A retrospective, pre-post cohort study was conducted on patients who received IV NAC for acetaminophen toxicity. The intervention evaluated was the implementation of a pharmacist-based toxicology consult service, known as the pharmacy toxicology team. The primary end point was the incidence of an error associated with IV NAC. An error was defined as the composite of inappropriate dose, administration rate, initiation, continuation, or discontinuation. Eighty-four patients were included; 30 patients in the pregroup, and 54 patients in the postgroup. Fewer patients experienced an error in the postgroup compared to the pregroup (30% vs 63%, P = 0.003). The implementation of this unique pharmacist-based toxicology consult service was associated with fewer patients experiencing an error related to IV NAC therapy for acetaminophen toxicity. Application of this data may aid in the justification for development of clinical pharmacist-based toxicology consult services at other institutions.

A new model for investigating the effective factors in the development of modern clinical and health services in the time of COVID-19

Excessive information exposure and misleading information in controlling COVID-19 disease have affected the dimensions of people's lives and caused mental health problems. Healthcare effectiveness is a critical subject worldwide. Thus, engaging resources in the progress and use of e-health technologies are very crucial, especially in the COVID-19 era. Due to the sensitivity of this issue and the world health organization's attention to developing new clinical and health services in the pandemic, this article introduces and presents a new model. This new model investigates the factors influencing the development of modern clinical and health services during the pandemic era. Also, this research presents a new model to investigate the technological, management, environmental, social, and cultural factors and perceived usefulness and ease of use influencing the development of modern clinical and health services throughout COVID-19. The questionnaire survey technique is utilized for gathering data. The authors contacted about 300 potential respondents. To statistically analyze the questionnaires, Smart-PLS 3.2 software is used. The outcomes illustrate a great strength of the suggested model. The results demonstrate that technological, management, social, cultural, and environmental factors positively affect perceived usefulness and ease of use. They also show that perceived usefulness and ease of use are significant factors in developing modern clinical and health services.

Exploring the working environment of Hospital Managers: a mixed methods study investigating stress, stereotypes, psychological safety and individual resilience

BackgroundHospital managers are responsible for the delivery of organisational strategy, development of clinical services and maintaining quality standards. There is limited research on hospital managers, in particular how stress manifests and impacts managers and the presence of individual resilience. Managers must work closely with clinical colleagues, however these relationships can be hindered by the perception of stereotyping and differing priorities. This study aimed to explore the working environment of hospital managers, focusing upon the unique stresses faced, psychological safety and the presence of resilience.MethodsThis study utilised mixed methodology using an embedded approach. Participants were purposively recruited from all levels of hospital management within one National Health Service Trust in London, United Kingdom. An exploration of managers experiences was undertaken using semi-structured qualitative interviews. Psychological safety and individual resilience were additionally assessed using validated surveys. Qualitative data were analysed iteratively using inductive thematic analysis, and triangulated with quantitative data. Kruskal-Wallis statistical analysis was performed to evaluate differences in resilience and psychological safety according to seniority and background experience.ResultsTwenty-two managers were recruited and interviewed, with 20 returning completed surveys. Key findings from the thematic analysis included the importance of good working relationships with clinical colleagues, the persistence of some stereotyping, and feeling unsupported in times of challenge. Stresses described included the bureaucracy involved when delivering change, conflict with colleagues and target driven expectations.Participants described their own psychological safety as lower than desired, supported by quantitative data; but recognised its importance and strived to create it within their own teams. Sixteen participants had ‘normal’ scores for resilience, with senior managers more likely to have higher scores than those more junior (p=0.011).ConclusionPositive working relationships, high psychological safety and individual resilience are important for organisational safety and individual wellbeing. Our data illustrate unique stressors faced by hospital managers, provide detail on sometimes challenging working relationships, and demonstrate scope to improve both the psychological safety and resilience of those in managerial positions. A map for senior healthcare leaders was constructed, facilitating the identification of modifiable areas within their organisation to promote good working relationships and improve the working environment of hospital managers.

32 How do Children with Medical Complexity Die? A Scoping Review

Abstract Background While children with medical complexity (CMC) are recognized as an emerging and unique cohort, end of life remains poorly understood and little is known about illness trajectory, decision making and communication experiences for this group of patients and their families. Objectives This scoping review aimed to describe existing literature on the characteristics of end of life in CMC. Design/Methods The study was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Electronic databases (MEDLINE, CINAHL, PsycINFO, Scopus, Embase) were searched up to June 2021. Studies reporting children, adolescents and young adults who were at end of life and fulfilled the definitional framework of medical complexity by Cohen et al were included by two independent reviewers. Data on study aims, design, methods, outcome measures and key findings were extracted, followed by quantitative and qualitative analysis of the results. Results Of 1535 publications initially identified, 23 studies were included. In terms of study characteristics, 20 (87.0%) studies were quantitative, 15 (65.2%) were published from 2015 to 2021 and 14 (70.0%) originated from the USA. Study outcomes were categorized into 5 main groups: (1) Place of death (30.8%), (2) Health care use (23.1%), (3) Interventions received or withdrawn (17.9%) (4) Decision making and communication (12.8%) and (5) Others (15.4%). These outcomes were found to be associated with sociodemographic factors and CMC diagnostic categories. Majority of CMC deaths occurred in hospitals and the mean proportion of hospital deaths reported was 68.8% (33.5% to 91.9%). Studies evaluated health care utilization at end of life in various settings including hospice, home care, hospital and the intensive care unit. Interventions studied in this cohort included mechanical ventilation, cardiopulmonary resuscitation, hemodialysis, procedures and medication use. Studies reported that CMC were subjected to more intensive interventions when compared to non-CMC. The 2 main themes which emerged from qualitative studies were that of advance care planning experiences and the unique end of life experiences of CMC and their families. Conclusion This scoping review highlighted the unique characteristics of end of life in CMC and outlined the emerging body of literature as well as knowledge gaps on this topic. A better understanding of this cohort of CMC would serve to inform clinical practice, service development and future research opportunities.

The All-Ireland Guidelines for the diagnosis, assessment and management of lymphoedema.

The last decade has produced a plethora of lymphoedema-based research. As such, a new All-Ireland Guideline for lymphoedema diagnosis, assessment and management was required to replace the 2008 CREST Guideline. A research team was commissioned to work with healthcare staff and service users following international research standards practice. An evidence-based clinical practice guideline was developed to aid clinicians in the diagnosis, assessment, and management of lymphoedema. Recommendations were formulated based on the evidence available to answer each clinical question and were assigned a grade based on the strength of the evidence. In the absence of sufficient evidence and in an effort to maximise clinical applicability, recommendations were also based on expert opinion, which was gathered via guideline member consensus. The recommendations from the guideline, which aim to provide healthcare professionals with clear, evidence-based guidance on the diagnosis, assessment and management of patients with all types of lymphoedema, should be communicated at all levels regarding responsibility for implementation in clinical care and service development. Audit should be a core component of the implementation. A budget impact analysis should be completed to determine additional costs required to fully implement the guideline.

Impact of COVID-19 on digital practice in UK paediatric speech and language therapy and implications for the future: A national survey.

BackgroundThe COVID‐19 pandemic and subsequent measures to reduce transmission risk has led to unprecedented digital transformation across health, education and social care services. This includes UK paediatric speech and language therapy (SLT), which sits at the crossroads of these services. Given the rapid onset of this pandemic‐induced digital transition, there is now a need to capture, reflect and learn from the SLT profession so that benefits can be sustained, and barriers addressed.AimsTo survey the impact of COVID‐19 remote working on UK paediatric SLTs’ digital views and experiences using the Capability, Opportunity, Motivation and Behaviour (COM‐B) model.Methods & ProceduresAn online survey was conducted from May to October 2020. Respondents were asked to rate their use of technology in service delivery before and during the pandemic, to select factors facilitating digital practice, and to provide open‐response aspirations for the future role of technology in paediatric SLT which were analysed thematically using the COM‐B behaviour change model.Outcomes & ResultsA total of 424 UK paediatric SLTs responded to the survey. Findings indicate a marked increase in clinicians’ perception of their frequency, convenience and confidence with digital practice during COVID‐19 compared with before the pandemic. Respondents identified that specialist training (27%), funding for workplace devices (22%) and supportive leadership (19%) were most likely to facilitate sustained digital practice. Clinicians hoped for a blended approach going forward with technology enhancing existing best practice. Further prominent themes included digital accessibility for all and maintaining the increased opportunity for multidisciplinary working that videoconferencing has afforded. More service‐specific aspirations were bespoke technological solutions as well as parents/carers being able to engage remotely with school‐based provisions.Conclusions & ImplicationsDuring COVID‐19, paediatric SLTs’ recognition and acceptance of how technology can augment practice has accelerated, with particular value being placed on inclusivity, choice, training, resources, leadership and indication of effectiveness. These are important considerations to help guide the profession towards the long‐term digital enhancement of SLT services.WHAT THIS PAPER ADDSWhat is already known on the subject The COVID‐19 pandemic led to an unprecedented interest in the use of technology across SLT practice. Studies are emerging nationally and internationally to identify the digital priorities of the SLT workforce, the areas of digital SLT provision that are thriving or lacking, and the evidence to guide clinical practice and service development. What this study adds to existing knowledge This is the first UK‐wide COVID‐19 survey solely focusing on the digital practice of paediatric SLTs. The findings provide critical insights into SLT perception of how practice has been impacted in the early stages of the COVID‐19 pandemic, including digital trends that are service, condition and demographic specific. Tools and channels required to support sustained beneficial change are also discussed. What are the potential or actual clinical implications of this work? This paper demonstrates the potential for digital solutions to enhance SLT practice, as long as implementation is guided by clinicians’ experiences and perspectives. The findings lay groundwork for service development work, such as the creation of training packages, updating of clinical guidelines and care pathways, and development of processes to ensure equitable allocation of evidence‐based resources.

Repetitive transcranial magnetic stimulation (r-TMS) and selective serotonin reuptake inhibitor-resistance in obsessive-compulsive disorder: A meta-analysis and clinical implications

IntroductionDespite promising results from several randomized controlled trials (RCTs) and meta-analyses, the efficacy of r-TMS as a treatment for OCD remains controversial, at least in part owing to inconsistency in the trial methodologies and heterogeneity in the trial outcomes. This meta-analysis attempts to explain some of this heterogeneity by comparing the efficacy of r-TMS in patients with or without resistance to treatment with selective serotonin reuptake inhibitors (SSRI), defined using standardized criteria. MethodsWe conducted a pre-registered (PROSPERO ID: 241381) systematic review and meta-analysis. English language articles reporting blinded RCTs were retrieved from searches using MEDLINE, PsycINFO, and Cochrane Library databases. Studies were subjected to subgroup analysis based on four stages of treatment resistance, defined using an adaptation of published criteria (1 = not treatment resistant, 2 = one SSRI trial failed, 3 = two SSRI trials failed, 4 = two SSRI trials failed plus one or more CBT trial failed). Meta-regression analyses investigated patient and methodological factors (age, duration of OCD, illness severity, stage of treatment-resistance, or researcher allegiance) as possible moderators of effect size. ResultsTwenty-five independent comparisons (23 studies) were included. Overall, r-TMS showed a medium-sized reduction of Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) scores (Hedge's g: -0.47; 95%CI: - 0.67 to −0.27) with moderate heterogeneity (I2 = 39.8%). Assessment of publication bias using Trim and Fill analysis suggested a reduced effect size that remained significant (g: -0.29; 95%CI: −0.51 to −0.07). Subgroup analysis found that those studies including patients non-resistant to SSRI (stage 1) (g: -0.65; 95%CI: −1.05 to −0.25, k = 7) or with low SSRI-resistance (stage 2) (g:-0.47; 95%CI: −0.86 to −0.09, k = 6) produced statistically significant results with low heterogeneity, while studies including more highly resistant patients at stage 3 (g: −0.39; 95%CI: −0.90 to 0.11, k = 4) and stage 4 (g: -0.36; 95%CI: −0.75 to 0.03, k = 8) did not. Intriguingly, the only significant moderator of the effect size found by meta-regression was the severity of baseline depressive symptoms. All trials showed evidence of researcher allegiance in favour of the intervention and therefore caution is required in interpreting the reported effect sizes. ConclusionThis meta-analysis shows that r-TMS is an effective treatment for OCD, but largely for those not resistant to SSRI or failing to respond to only one SSRI trial. As a consequence, r-TMS may be best implemented earlier in the care pathway. These findings would have major implications for clinical service development, but further well-powered RCTs, which eliminate bias from researcher allegiance, are needed before definitive conclusions can be drawn.

Writing the worlds of genomic medicine: experiences of using participatory-writing to understand life with rare conditions

The diagnostic and treatment possibilities made possible by the development and subsequent mainstreaming of clinical genomics services have the potential to profoundly change the experiences of families affected by rare...

Risky alcohol use among patients dispensed opioid medications: A clinical community pharmacy study

BackgroundIncluded among the significant risk factors for opioid overdose is concomitant use of other central nervous system depressants, particularly alcohol. Given the continued expansion of community pharmacy in the continuum of care, it is imperative to characterize alcohol use among pharmacy patients dispensed opioids in order to establish a foundation for identification and intervention in these settings. MethodsThis secondary analysis utilized data from a one-time, cross-sectional health assessment conducted among patients dispensed opioid medications in 19 community pharmacies in Indiana and Ohio. Adult, English speaking, patients not receiving cancer care who were dispensed opioid medications were asked to self-report alcohol and substance use, behavioral and physical health, and demographic information. Descriptive and logistic regression analyses were employed to characterize alcohol use/risky alcohol use and patient characteristics associated therewith. ResultsThe analytical sample included 1494 individuals. Participants were on average 49 years of age (Standard Deviation=14.9)—with 6% being persons of color (n = 89). Weekly drinking was reported by 18.1% (n = 204) and daily drinking was reported by 6.8% (n = 77) of the study sample, with a total of 143 (9.6%) participants reporting moderate/high risk drinking.Males (Adjusted Odds Ratio [AOR]=1.94, 95% CI=1.3,2.9), those with higher pain interference (AOR=1.44, 95% CI=1.0,2.0), overdose history (AOR=1.93, 95% CI=1.1,3.5), sedative use (AOR=2.11, 95% CI=1.3,3.5), and tobacco use (AOR=2.41, 95% CI=1.6,3.7) had increased likelihood of moderate/high risk alcohol use (all p < 0.05). ConclusionsMedication labeling and clinical guidelines clearly indicate that patients should abstain from concomitant use of opioids and alcohol. This study has identified rates and associated risk factors of risky alcohol use among a clinical sample of community pharmacy patients dispensed opioid medications. Continuing this line of research and potential clinical service development has the ability to improve patient safety through addressing a significant gap within the current opioid epidemic.

Clinical pharmaceutical services of primary health care of the Federal District: A discussion based on the SWOT matrix

In the epistemic field, several studies demonstrate the importance of pharmaceutical services in health care networks. Nonetheless, literature still addresses the strengths and barriers present in the provision of these services in an incipient way. Thus, this study aimed to understand these contexts in the development of clinical services for primary health care in the Federal District, Brazil. A qualitative study adopted the technique of open-script interview, structured based on the logic of the SWOT matrix. Pharmacists reported weaknesses such as precariousness and scarcity of physical infrastructure, material, and human resources. As threats, they discussed the lack of social recognition, discontinuities of government actions, and lack of preparation of the pharmacist for the provision of clinical services. Regarding themes pertaining to the service’s strengths and opportunities, the advances in propositions and executions of public policies, actions, and governmental programs that have expanded the pharmaceutical workforce in primary care and that are impelling the accomplishment of clinical services were listed. This study contributes to understanding the scenario of the development of clinical pharmaceutical services, and consequently provides subsidies for the actions of planning, evaluation and qualification of health services.

The ACTION Centre as a Model for Patient Engagement and Knowledge Translation in Integrative Oncology Practice, Training, and Research.

Integrative Oncology (IO) programs are increasingly emerging at cancer centers and universities worldwide; often these include some combination of clinical service, research, and/or training. However, one gap that often occurs is in moving research results into practice, due to complexities and differences between research and service delivery models and priorities. We recently created the ACTION (Alberta Complementary Therapy and Integrative Oncology) Centre with the goal of partnering with the provincial public health service to promote and facilitate evidence-based integrative oncology care throughout Alberta. The Centre bridges the silos of academia and clinical care by embodying 3 core principles, to be (1) Patient-oriented, (2) Collaborative, and (3) Evidence-based. The ACTION Centre oversees the implementation of clinical research and academic training, and supports the development of clinical services, as well as patient and provider education. The ACTION Centre has five components which include: (1) Patient and healthcare provider education; (2) Individualized IO consultation and treatment planning; (3) Supporting access to complementary therapies; (4) Clinical trials of IO interventions, and; (5) Student training through the TRACTION (Training in Clinical Trials and Integrative Oncology) program. We offer this model of shareholder collaboration in the hopes that other IO programs may be able to use it as a template to further their own progress, working collaboratively toward the ultimate goal of advancing evidence-based, comprehensive, integrative healthcare to improve the lives of people affected by cancer.