Implementation Of Care Pathway Research Articles

Implementing a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: a mixed-methods analysis of implementation using the Consolidated Framework for Implementation Research

BackgroundImplementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR).MethodsThis was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4–8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data.ResultsQualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points).ConclusionsThe nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication.

A77 IMPLEMENTATION OF GUT LINK-IBS; RESULTS OF A SEMI-STRUCTURED INTERVIEW OF PRIMARY CARE PROVIDERS

BackgroundThe Division of Digestive Care and Endoscopy in Halifax, Nova Scotia has had longstanding challenges with GI referral volume outstripping divisional capacity resulting in limited access to specialist care. Many referrals for functional bowel disorders (FBD) are returned to referring providers. Although this helps rationalize limited system resources, it often impairs access to appropriate and necessary GI care. The co-development and implementation of clinical care pathways across gastroenterology and primary care may help to improve access to high-quality GI care.AimsThe project aimed to engage primary healthcare providers (PHCPs) to identify environmental and behavioral barriers and facilitators for managing undifferentiated lower GI disorders in primary care. Data generated from stakeholder engagement will be used to develop, implement, and evaluate strategies for referral and management of FBD. A real-world, functional clinical care pathway that supports the implementation of evidence-based practices in the diagnosis and management of functional GI conditions within primary care will enhance care and timely access to specialist.MethodsThis is a qualitative study using semi-structured interviews of PHCPs working in Nova Scotia. Interview questions were developed and guided by the evidence-based implementation science frameworks. Physicians were recruited through existing primary care networks. Participants were offered a Zoom™virtual semi-structured interview. A brief intake questionnaire was administered to collect baseline demographics. Interviews were recorded and transcribed for data analysis. Data were categorized into coding schemes and themes were created using an inductive coding approach.ResultsAs of October 2021, 9 interviews have been conducted. Average participant age was 44 years, with the majority identifying practice in a group or collaborative care setting (n=7, 78%). Five worked in urban practice settings and the remainder in rural areas. Preliminary major themes included:1. A lack of satisfaction with access to gastrointestinal care, with most physicians noting it to be worse than access to other specialist services.2. Management of FBDs were felt to be within the scope of primary care practice3. Access to diagnostic tests like fecal calprotectin with appropriate education on its use as a diagnostic tool would be useful.4. PHCP’s suggested care pathways be easy to use, require minimal time, and ideally be implemented within their pre-existing EMR or in paper form.ConclusionsPHCPs acknowledge a significant burden of undifferentiated lower GI complaints in their practice and poor access to gastroenterology services. All participants were open to helping develop and use a clinical care pathway for the investigation and management of undifferentiated lower GI symptoms. Data collection and analysis are ongoing.Funding AgenciesNone

Improving the Time to Antibiotic Administration in Paediatric Febrile Neutropenia: Implementation of a Clinical Care Pathway in Saudi Arabia

The aim of this quality improvement practice project was to improve noted delays in the time to antibiotic administration in paediatric febrile neutropenic patients seen at King Faisal Specialist Hospital and Research Centre (KFSH&RC), Saudi Arabia. Larrabee’s 6-step Model for Change of evidence-based practice guided the project. Clinical audit, nursing knowledge survey, comprehensive literature and international clinical guideline review were used to identify and design a clinical care pathway for paediatric febrile neutropenic patients at KFSH&RC. Post-implementation clinical audit showed a reduction in time to antibiotic administration and increased self-efficacy and knowledge among nursing staff in relation to managing the care of febrile neutropenic patients. This reflects similar improvements seen internationally in other centres following the introduction of a clinical pathway. This nursing led practice change was the first of its kind for KFSH&RC. It demonstrated that with support from key stakeholders, Larrabee’s model for evidence- based practice change can be used for introducing a nurse-led clinical care pathway in Saudi Arabia. Highlights •A new clinical care pathway introduced in Saudi Arabia improved time to antibiotic administration in paediatric febrile neutropenic patients. •Implementing a nurse-led clinical care pathway increased nurses’ confidence with managing children with febrile neutropenia and the skills and knowledge related to the accessing and delivering medication via central access devices •With key local stakeholder support evidence-based change frameworks such as that proposed by Larrabee can be used to improve nursing management in Saudi Arabia.

An up-to-date telemedicine integrated clinical pathway for adult patients with congenital heart disease

Clinical management of adult patients with congenital heart disease (GUCH) is a difficult task for multiple reasons, which include their own pathology and clinical history complexity, diagnostic complexity and organization of care. GUCH specialists are present in very small numbers and are concentrated in few centers, thus generating considerable transfer problems for patients. During the COVID-19 pandemic, telemedicine has become the standard of care, ensuring health assistance continuity, and implementing communication channels between patients and health professionals. We suggest to stratify GUCH patients into three groups, which correspond to different levels of risk (low, moderate and high, respectively) to develop complications over time, using a GUCH-specific multiparametric complexity score; so, each patient pathway will be defined according to the specific group, with indication of site, timing and type of clinical and instrumental evaluations, including virtual visits and consults. In conclusion, practical tools are provided for the implementation of updated care pathways for GUCH patients, who finally are inserted in a new model of care in which even if in-person visit still represents the crucial moment of each patient care pathway, on the other hand, telemedicine incorporation could contribute to improving and making even more complete and effective GUCH patient care.

Trust in pathways? Professionals\u2019 sensemaking of care pathways in the Norwegian mental health services system

BackgroundIn January 2019, care pathways within specialist mental health and substance abuse treatment services were officially launched in Norway. The care pathway introduced timeframes for assessment and treatment, allowing a maximum of 6 weeks to finish assessment and provide the patient with a diagnosis, in addition to allowing a maximum of 6 weeks from diagnosis to the first evaluation. The different action points required coding. The system was based on goals to improve services by focusing on user participation, coordinated patient flow, avoidance of unnecessary waiting time, improvement of equal access to services regardless of geographic location, and increased emphasis on physical health and lifestyle.The purpose of our study was to examine how mental health professionals made sense of care pathways and furthermore, how issues of trust affected the process of implementation.MethodsOur multiple case study included four outpatient clinics for adults in four community mental health centres (CMHCs) in different parts of Norway. Qualitative data were collected through in-depth individual and focus group interviews and analysed using systematic text condensation. The informants were treatment personnel and leaders in four different outpatient clinics for adults.ResultsThe results indicated four distinct themes or reactions to the care pathway and its implementation: 1) lack of clarity regarding the overall goals and content of the care pathway; 2) the increased burden of coding, registration and administrative work, which professionals experienced as a stressor; 3) an IT and medical record system that did not correspond to the coding of the care pathway; and 4) an unrealistic distinction between assessment and treatment. These themes/reactions increased the health professionals’ distrust towards the care pathway, and a process of sensemaking encouraged them to reduce the importance of the care pathway system and its implementation.ConclusionTheories of trust help in understanding how mental health professionals interpret care pathway implementation. Distrust and resistance towards the care pathways overshadow some of the overall quality goals of the care pathway, a view that was indeed shared by mental health professionals.

Study Protocol: IMPETUS: Implementing a Uniform Stroke Care Pathway in Medical Colleges of India: IMPETUS Stroke.

Introduction:In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India.Methods and Analysis:This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases.Discussion:Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Cognitive, social, and behavioral manifestations of the co-occurrence of autism spectrum disorder and attention-deficit/hyperactivity disorder: A systematic review.

This work aimed to review recent research on the characteristics of individuals who have both autism spectrum disorder and attention-deficit/hyperactivity disorder due to their high co-occurrence. Thirty-four studies were analyzed and main findings summarized in two content domains focusing on areas that could enhance our understanding of the cognitive and behavioral characteristics of individuals with autism spectrum disorder + attention-deficit/hyperactivity disorder (ASD+). Most of the results suggested that ASD+ is a co-occurring condition associated with more severe impairments in cognitive functioning, adaptive behavior, and increased likelihood to present more emotional/behavioral problems. These results will be helpful to provide improved care plans for individuals with both attention-deficit/hyperactivity disorder and autism spectrum disorder.

Effect of the Implementation of a Local Care Pathway on the Transient Ischemic Attack Management in Emergency Departments.

Recent studies have demonstrated that urgent care decreases the risk of subsequent stroke after transient ischemic attack (TIA). In response to heterogeneous TIA management observed in our area, we developed a structured pathway, in accordance with current guidelines and adapted to local resources. We aim to assess the effect of local implementation of this care pathway on TIA management in emergency departments (EDs) in the Rhône area (France). EDs of 5 centers that had a minimum of 30 TIA/year in Lyon and Bourgoin-Jallieu participated. The first 30 consecutive patients who had a TIA as main diagnosis admitted to one of these EDs from January 1 to December 31, 2013 and from January 1 to December 31, 2016, that is, before-and-after care pathway implementation, respectively, were retrospectively included in the study. The primary outcome was the adequate management of TIA defined as having had appropriate workup and antithrombotic treatment within 24 hours. A total of 141 patients were included in 2013 and 150 in 2016. There was a significant increase of complete (intracrania and extracranial) vessel imaging from 2013 to 2016 (n=42, 29.8% in 2013 vs. n=118, 78.7% in 2016; P<0.001). Computed tomography angiography was more often performed to assess intracranial and/or extracranial vessel imaging in 2016 compared with 2013 (n=54, 34.8% in 2013 vs. n=116, 77.3% in 2016; P<0.001). Overall, the rate of patients receiving adequate management significantly increased from 2013 to 2016 (n=36, 25.5% in 2013 vs. n=101, 67.3% in 2016; P<0.001). Implementation of a local care pathway, in accordance with current guidelines and adapted to local resources, improved TIA management in EDs, mostly by increasing the rate of vessel imaging by computed tomography angiography.

A Quality Improvement Project to Decrease Length of Stay after Total Hip and Total Knee Arthroplasty Surgery at a Veteran Affairs Academic Medical Center

Background: The purpose of this Quality Improvement Project (QIP) was to design and implement a multidisciplinary and multimodal pathway aimed at improving the length of stay (LOS) for total hip (THA) and total knee arthroplasty (TKA) patients at the Clement J Zablocki Veteran Affairs Medical Center. Methods: We performed a retrospective data analysis to establish a pre-pathway baseline for comparison and a prospective observational cohort analysis after implementation of the new protocol. We collected data on patients that underwent anterior THA (aTHA), posterior THA (pTHA), and TKA who were admitted before and after implementation of the multidisciplinary total joint pathway. Within the pre-pathway group, we collected data on 165 patients (102 TKA, 30 pTHA, and 33 aTHA) from May 1st, 2017 to January 31st, 2018. For the post-pathway group, we collected data on 208 patients (132 TKA, 36 pTHA, 40 aTHA) from February 1st, 2018 to December 31st, 2018. Demographic information (gender, race, BMI, ASA status, medical comorbidities) was also collected. One-way ANOVA and Chi-Squared tests were performed to determine significance between the groups. Results: Overall, there was no significant change in demographics between our pre and post-pathway groups. The TKA pre-pathway group average LOS was 3.06±1.32 days vs. 2.23±1.06 days in the TKA post-pathway LOS group (p<0.0001). The posterior THA pre-pathway group average LOS was 3.67±1.47 days vs. 2.81±1.83 days in posterior THA post-pathway group (p=0.0420). The anterior THA pre-pathway group LOS was 2.73±2.07 days vs. 2.10±1.78 days in anterior THA post-pathway group (p=0.1678). In addition, there was a decrease in 30-day readmission rates for both THA (6.7% to 2.3%) and TKA (5.0% to 3.3%) within our study period. Conclusions: We found that by focusing on pre-operative education, utilization of pre-operative physical therapy sessions, and post-operative mobilization within our new total joint pathway, the average LOS for our THA and TKA patients either met or fell below the VA LOS national averages. In addition, LOS within our institution was significantly decreased for posterior THA patients and TKA patients after implementation of the multidisciplinary clinical care pathway. The benefits of the new pathway were not seen in the anterior THA group.

215 WHAT IMPACT CAN ‘EMERGENCY DEPARTMENT IN THE HOME’ (EDITH) HAVE ON THE OLDER ADULT POPULATION PRESENTING WITH FALLS?

Abstract Background EDITH is a frailty response service providing medical and occupational therapy input to older adults living within the catchment area of a level 4 acute hospital. EDITH aims to reduce avoidable Emergency Department (ED) attendances and utilise alternative care pathways. Falls are common among older people and are often associated with poorer outcomes. Traditionally, older patients who have had a fall and contact emergency services for assistance are transferred to the ED and this can be associated with elevated risks. Additionally, older patients who have had a fall and are discharged on scene by the emergency services are at greater risk of recurring falls in the absence of immediate onward referral to community falls prevention services (Nowak and Hubbard 2009). Methods Paper count method data collection was completed. Inclusion criteria included referrals from the National Ambulance Service within the last 6 months. Results 75 patients met the inclusion criteria; 34 males, 41 females with an average age of 82. 11 patients were conveyed to hospital, giving a conveyance rate of 14.6%, the average conveyance rate for the EDITH service is 7.2%. 3 patients were conveyed to ED, while 8 patients were conveyed to the Medical Assessment Unit (MAU) in the local level 3 hospital. This resulted in 72% of patients that required hospital conveyance being streamed to the MAU; traditionally 100% of these patients would have presented to ED. Overall, 85.4% of patients seen remained at home. Conclusion EDITH are providing targeted medical and occupational therapy assessment(s) for older adults in their homes with successful outcomes. Implementation of alternative care pathways, reduction in avoidable ED attendances and prolonged independence in the home for this patient profile are some of the favourable findings. Reference 1. Nowak A, Hubbard RE. (2009) Falls and frailty: lessons from complex systems. Journal of the Royal Society of Medicine. 102(3):98–102.

Abstract 9728: A Novel Emergency Department Syncope Protocol Reduces Unnecessary Hospital Admissions

Background: More than 1.2 million emergency department (ED) visits for syncope occur each year in the US. Many associated admissions and diagnostic studies may be unnecessary. Objective: To determine the effectiveness of a novel protocol for syncope care in the ED in reducing unnecessary admissions and diagnostic testing. Methods: A multi-disciplinary team developed a decision aid for ED syncope management guided by focused history, physical, and diagnostic testing. Clear indications for diagnostic testing were laid out in the protocol and incorporated into the ED workflow through education and medical record system integration. Patients considered safe for discharge were provided an expedited appointment in a specialty clinic. Rates of admission, utilization of diagnostic studies (head CT, carotid ultrasound, echocardiogram), and rates of return presentation to the ED within 30 days were compared before and after implementation. Results: Between September 2019 and December 2019, 308 syncope patients presented to the ED. Between January 2020 and June 2020 (following implementation), 321 syncope patients presented to the ED. The proportion admitted decreased (44.6% to 30.0%, p&lt;0.001. Figure), while the proportion undergoing diagnostic studies was unchanged (19.5% to 16.0%, p=0.303). The proportion returning to the ED within thirty days was unchanged (11.2% to 10.2%, p=0.769). The proportion referred for expedited follow up to a syncope specialty clinic increased (1.5% to 8.8%, p&lt;0.001). Conclusion: Implementation of an ED syncope care pathway with utilization of a syncope specialty clinic was associated with significantly reduced hospital admissions. Utilization of diagnostic testing and rates of return ED presentation within thirty days were unchanged. Additional studies to evaluate the scalability and cost benefits of this program are warranted.

Full support from step 1 to step 5

Comprehensive care from step 1 to step 5 of Integrated Care for Older People programme requires the implementation of a new care pathway. It has to take into account the resources of each territory and to be oriented towards maintaining the capacities of older people.

EP.FRI.390 Improving care for patients with acute bowel obstruction: A closed loop audit

Abstract Aims Acute Bowel Obstruction (ABO) accounts for 10% of emergency surgical admissions and when surgery is required mortality can exceed 10%. Early diagnosis is associated with improved patient outcomes and timely acquisition of abdominal CT scans can help prevent delays. The NCEPOD 2020 report on ABO identified ‘delays in imaging’ as a key area for improvement in the care of these patients, with these delays being exacerbated if an abdominal X-ray (AXR) was performed as well as an abdominal CT. This study looks at ways to expedite the diagnosis of patients presenting with ABO. Methods A retrospective audit of 77 patients admitted from A&amp;E or SAU with ABO from April 2019 to February 2020 was conducted. Imaging modality, time-to-CT scan and time-to-diagnosis was recorded. Results and recommendations were presented locally and an evidence based ABO care pathway was implemented and publicised. 20 patients were audited prospectively, post care pathway implementation. Results 70.1% of patients from the initial audit received a CT-scan and 42% of these patients received an AXR before their eventual CT-scan. The average wait for a definitive radiological diagnosis was 27.8hr. After implementation of the pathway only 18% of patients audited received both modes of imaging and the average time to diagnosis has been reduced to 10.7hr. Conclusions Raising awareness of the appropriate and timely use of CT-scans in the diagnosis of ABO has reduced the number of concomitant AXR for these patients, expediting the making of a definitive diagnosis and improving patient outcomes.

Barriers to symptom management care pathway implementation in pediatric Cancer

BackgroundObjectives were to describe barriers to pediatric cancer symptom management care pathway implementation and the impact of the COVID-19 pandemic on clinical research evaluating their implementation.MethodsWe included 25 pediatric oncology hospitals in the United States that supported a grant submission to perform a cluster randomized trial in which the intervention encompassed care pathways for symptom management. A survey was distributed to site principal investigators prior to randomization to measure contextual elements related to care pathway implementation. Questions included the inner setting measures of the Consolidated Framework for Implementation Research (CFIR), study-specific potential barriers and the impact of the COVID-19 pandemic on clinical research. The Wilcoxon rank sum test was used to compare characteristics of institutions that agreed that their department supported the implementation of symptom management care pathways vs. institutions that did not agree.ResultsOf the 25 sites, one withdrew because of resource constraints and one did not respond, leaving 23 institutions. Among the seven CFIR constructs, the least supported was implementation climate; 57% agreed there was support, 39% agreed there was recognition and 39% agreed there was prioritization for symptom management care pathway implementation at their institution. Most common barriers were lack of person-time to create care pathways and champion their use (35%), lack of interest from physicians (30%) and lack of information technology resources (26%). Most sites reported no negative impact of the COVID-19 pandemic across research activities. Sites with fewer pediatric cancer patients were more likely to agree that staff are supported to implement symptom management care pathways (P = 0.003).ConclusionsThe most commonly reported barriers to implementation were lack of support, recognition and prioritization. The COVID-19 pandemic may not be a major barrier to clinical research activities in pediatric oncology.

Lessons from an Educational Invasive Fungal Disease Conference on Hospital Antifungal Stewardship Practices across the UK and Ireland.

Invasive fungal disease (IFD) is a growing health burden. High mortality rates, increasing numbers of at-risk hosts, and a limited availability of rapid diagnostics and therapeutic options mean that patients are increasingly exposed to unnecessary antifungals. High rates of prescriptions promote patient exposure to undue toxicity and drive the emergence of resistance. Antifungal stewardship (AFS) aims to guide antifungal usage and reduce unnecessary exposure and antifungal consumption whilst maintaining or improving outcomes. Here, we examine several AFS approaches from hospitals across the UK and Ireland to demonstrate the benefits of AFS practices and support the broader implementation of AFS as both a necessary and achievable strategy. Since the accuracy and turnaround times (TATs) of diagnostic tools can impact treatment decisions, several AFS strategies have included the development and implementation of diagnostic-driven care pathways. AFS informed treatment strategies can help stratify patients on a risk basis ensuring the right patients receive antifungals at the optimal time. Using a multidisciplinary approach is also key due to the complexity of managing and treating patients at risk of IFD. Through knowledge sharing, such as The Gilead Antifungal Information Network (GAIN), we hope to drive practices that improve patient management and support the preservation of antifungals for future use.

Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology

BackgroundThe rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy. MethodsA quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation. ResultsFrom July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03). ConclusionsUtilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.

The experience of patients with diabetes with the use of telemedicine and teleassistance services during the COVID-19 pandemic in Italy: Factors associated with perceived quality and willingness to continue

AimThe purpose of this study is to investigate the individual and contextual determinants of the perceived quality (PQ) of the telemedicine and teleassistance (TMTA) services and the willingness to continue (WC) with them among patients with diabetes using TMTA services during the COVID-19 pandemic in one large region of Italy. MethodsA structured survey was administered to patients with type 1 and 2 diabetes who used TMTA during the first wave of the COVID-19 pandemic. The questionnaire contained questions on TMTA service experience and participants’ socio-demographic characteristics. Multiple regression models investigated the independent factors associated with PQ and WC. ResultsThe final analysis included 569 patients with diabetes (54.7% female), with an average age of 58.1 years. TMTA services’ PQ and WC were high. A higher education and being unemployed were factors associated with an increased WC. Older age was negatively related to PQ. Perceived support from TMTA service was positively associated with PQ and WC. Perceived increase in disease self-management was positively associated with PQ and WC. ConclusionsOur study identified several determinants of PQ and WC. These socio-demographic and TMTA-related factors should be considered in the implementation of care pathways integrating in-person visits with TMTA.

Evaluating Cancer Care Networks; A Case Study of a Lung Cancer Care Network.

Networks are promoted as an organizational form that enables integrated care as well as enhanced patient outcomes. However, implementing networks is complex. It is therefore important to evaluate the quality and effectiveness of networks to ensure it is worth developing and maintaining them. This article describes the development of an evaluation tool for cancer care networks and the results of a pilot study with a regional lung cancer care network. This study used a combination of qualitative and quantitative evaluation methods. The qualitative evaluation was based on a framework with 10 standards for the organization of an oncological (tumor-specific) care network. Data for the quantitative evaluation were obtained from the Dutch Cancer Registry. The evaluation was performed at a network of three hospitals collaborating in the field of lung oncology. The qualitative evaluation framework consisted of 10 standards/questions which were divided into 38 sub-questions. The evaluation showed that in general patients are satisfied with the collaboration in the network. However, some improvement points were found such as the need for more attention for the implementation and periodic evaluation of a regional care pathway. The start of a regional multidisciplinary meeting has been a major step for improving the collaboration. An evaluation tool for (lung) cancer care networks was successfully developed and piloted within a cancer care network. The tool has proven to be a useful method for evaluating collaboration within an oncological network. It helped network partners to understand what they see as important and allowed them to learn about their program's dynamics. Improvement opportunities were successfully identified. To keep the tool up to date continuous improvement is needed, following the Plan Do Check Act (PDCA) cycle.

Postoperative 30-day emergency department utilization after 7294 cranial neurosurgery procedures at a tertiary neuroscience center.

Hospital readmission and the reduction thereof has become a major quality improvement initiative in organized medicine and neurosurgery. However, little research has been performed on why neurosurgical patients utilize hospital emergency rooms (ERs) with or without subsequent admission in the postoperative setting. This study was a retrospective, single-center review of data for all surgical cranial procedures performed from July 2013 to July 2016 in patients who survived to discharge. The study was approved by the institutional review board of the participating medical center. The authors identified 7294 cranial procedures performed during 6596 hospital encounters in 5385 patients. The rate of postoperative ER utilization within 30 days after surgical hospitalization across all procedure types was 13.1 per 100 surgeries performed. The two most common chief complaints were pain (30.7%) and medical complication (18.2%). After identification of relevant surgical and patient factors with univariable analysis, a multivariable backward elimination logistic regression model was constructed in which Ommaya reservoir placement (OR 2.65, p = 0.0008) and cranial CSF shunt placement (OR 1.40, p = 0.0001) were associated with increased ER utilization. Deep brain stimulation electrode placement (OR 0.488, p = 0.0004), increasing hospital length of stay (OR 0.935, p < 0.0001), and increasing patient age (OR 0.988, p < 0.0001) were associated with lower rates of postoperative ER utilization. One-half (50%) of ER visit patients were readmitted to the hospital. New/worsening neurological deficit chief complaint (OR 1.99, p = 0.0088), fever chief complaint (OR 2.41, p = 0.0205), altered mentation chief complaint (OR 2.71, p = 0.0002), patient chronic kidney disease (OR 3.31, p = 0.0037), brain biopsy procedure type (OR 3.50, p = 0.0398), and wound infection chief complaint (OR 31.4, p = 0.0008) were associated with increased rates of readmission to the hospital from the ER in multivariable analysis. The authors report the rates of and reasons for ER utilization in a large cohort of postoperative cranial neurosurgical patients. Factors identified were associated with both increased and decreased use of the ER after cranial surgery, as well as variables associated with readmission to the hospital after postoperative ER visitation. These findings may direct future quality improvement via prospective implementation of care pathways for high-risk procedures.

Evaluation of a Clinic Dedicated to People Aging with HIV at Chelsea and Westminster Hospital: Results of a 10-Year Experience.

Successful management of HIV infection as a chronic condition has resulted in a demographic shift where the proportion of people living with HIV (PLWH) older than 50 years is steadily increasing. A dedicated clinic to PLWH older than 50 years was established at Chelsea and Westminster Hospital in January 2009 and then extended to HIV services across the directorate. We report the results of a service evaluation reviewing 10 years of activities of this clinic between January 2009 and 2019. We aimed to estimate the prevalence of major noninfectious comorbidities, polypharmacy (≥5 medications), and multimorbidity (≥2 non-HIV-related comorbidities) and describe algorithms devised for use in HIV outpatient clinics across the directorate. A cohort of 744 PLWH older than 50 years attending this service were analyzed (93% male; mean age of 56 ± 5.5 years; 84% white ethnicity); 97.7% were on antiretroviral treatment and 95.9% had undetectable HIV-RNA at the time of evaluation. The most common comorbidities diagnosed were dyslipidemia (50.1%), hypertension (21.5%), mental health disorders (depression and/or anxiety disorders, 15.7%), osteoporosis (12.2%), obesity (11.9%), chronic kidney disease (7.5%), and diabetes (5.8%). Low vitamin D levels were found in 62% of patients [43% with vitamin D deficiency (<40 mmol/liter) and 57% with vitamin D insufficiency (40-70 mmol/liter)]. The overall prevalence of polypharmacy and multimorbidity was 46.6% and 69.3%, respectively. This study showed significant rates of non-HIV-related comorbidities and polypharmacy in PLWH older than 50 years, leading on to the implementation of clinical care pathways and new joint HIV/specialty clinics (cardiology, nephrology, neurology, metabolic, menopause, and geriatric) to improve prevention, diagnosis, and management of major comorbidities in people aging with HIV.