Improvement Of Clinical Services Research Articles

The Impact of Continuous Lenalidomide Maintenance Treatment on People Living with Multiple Myeloma - a Single-Centre Qualitative Service Evaluation

Background: Randomised trials examining continuous lenalidomide maintenance after autologous stem cell transplantation (ASCT) in patients with multiple myeloma (MM) have demonstrated progression free survival (PFS) and overall survival benefit compared to placebo. In 2021 the UK National Institute of Clinical Excellence (NICE) approved lenalidomide maintenance for all newly diagnosed National Health Service (NHS) patients receiving ASCT after induction chemotherapy. Patient-reported outcomes from observational studies suggest lenalidomide causes tolerable adverse effects. However, clinical trial data demonstrate that neutropenia, fatigue, neuropathy, and gastrointestinal issues are common, particularly in the first six months of treatment, and that lenalidomide increases the risk of secondary malignancies. Before lenalidomide maintenance was used in this setting, individuals would typically enter a treatment-free phase after ASCT, where they might experience a reasonable quality of life (QoL) without treatment burden. Studies suggest that medication breaks allow patients to detach from the ‘illness’ experience, but with continuous lenalidomide that opportunity is lost. Whilst the PFS benefit of lenalidomide maintenance is proven, both short- and longer-term toxicities reported in clinical trials suggest the trade-off between efficacy and harm should be considered. In-depth information about how continuous lenalidomide impacts individuals' QoL is scant. The overall objective of this qualitative service evaluation was to examine patients' experience of lenalidomide maintenance, including perceived impact on QoL and experience of side-effects. It was anticipated that findings would result in clinical service improvement through the delivery of communication better suited to patients' needs and priorities when facing treatment choices. Methods: We conducted 20 one-to-one semi-structured interviews with purposively selected patients (10 female and 10 male) from a specialist MM center in London. All participants had undergone induction chemotherapy followed by ASCT and were receiving continuous lenalidomide. Ages ranged from 45 to 71 years (median 58). The sample comprised 12 White British, 2 Black Caribbean, 1 Black African, 1 Asian Indian, 2 from other ethnic groups and 2 with undisclosed ethnicity. Lenalidomide treatment duration varied; seven patients had received lenalidomide for 1-6 months, five for 7-12 months, five for 13-18 months, one for 19-24 months, and two for over 24 months. Reflexive thematic analysis was used for data analysis. Results: Four themes were developed from the data: 1) Lenalidomide: understanding its role and rationale, 2) Reframing the loss of a treatment-free period to a return to normal life, 3) The reality of being on continuous lenalidomide maintenance: balancing hopes with hurdles, 4) Gratitude and Grievances: Exploring patients' mixed perceptions of care and communication. Most patients believed lenalidomide maintenance would double remission time and were compelled by the relative certainty it offered, which contrasted with the unpredictability of MM. Many participants reported that lenalidomide helped to diminish fears about relapse, and thus most did not feel they were missing out on a treatment break. The impact of lenalidomide maintenance on patients' QoL varied; younger patients reported no/negligible side-effects, while several older patients with comorbidities described significant symptom burden, such as skin rashes, debilitating fatigue, unpredictable gastric disturbances and bone pain, occasionally leading to treatment discontinuation which caused distress at the perceived loss of prolonged remission. The transition from frontline to maintenance treatment required a return to greater patient autonomy as medical support was reduced. Some patients described anxiety and depression in this period, suggesting the need for greater support. The study also highlighted specific challenges that younger patients experience, such as concerns about sexual transmission and fertility, which merits further research. Conclusions: Understanding the real-world symptom burden in MM is key as continuous treatment becomes routine. Qualitative research on the impact of treatment could lead to a more comprehensive understanding, helping patients cope with the increasingly chronic nature of this disease.

The Impact of Ethical Leadership on the Nursing Profession in Iran: A Systematic Review

Introduction: Ethical leadership plays a key role in professional settings. Nurses play an essential role in care provision and health promotion. The present study aimed to determine the impact of ethical leadership on the nursing profession in Iran. The objective of this study was the assessment of the relationship between ethical leadership and the improvement of clinical services by nurses. Methods: Terms defined as MESH keywords were searched in PubMed, Scopus, ProQuest, SID, and Magiran up to October 2022. In this study, only observational and qualitative studies were selected and included. Results: A total of 16 studies met the inclusion criteria. The results showed the association of ethical leadership with moral courage, self-efficacy, turnover, general health, errors, organizational citizenship, moral distress, job satisfaction, stress, risk management, and psychological empowerment. It was shown that ethical leadership is in direct association with nursing performance. Conclusions: The present study confirmed the positive effect of nursing ethical leadership on the nursing profession. Further studies are needed to examine the association between ethical leadership and clinical outcomes in patients.

How do community health workers institutionalise: An analysis of Brazil’s CHW programme

ABSTRACT Community health workers (CHWs) are framed as the link between communities and the formal health system. CHWs must establish trusting relationships with the community and with the broader health service. How to find the optimal balance between the various strands of work for CHWs, and how to formalise this, has been the focus of different studies. We performed an extensive documentary analysis of federal legislation in Brazil to understand the institutionalisation of the CHW workforce in Brazil over the last 3 decades. The paper offers three contributions to the literature: the development and application of an analytical framework to consider the institutionalisation process of CHWs; a historical analysis of the professional institutionalisation of CHW in Brazil; and the identification of the paradoxes that such institutionalisation faces: firstly, institutionalisation focused on improving CHW remuneration created difficulties in hiring and paying these professionals; when CHW are incorporated within state bureaucracy they start to lose their autonomy as community agents; and that the effectiveness of CHW programmes depends on the improvement of clinical services in the most deprived areas.

Single-lead ECGs (AliveCor) are a feasible, cost-effective and safer alternative to 12-lead ECGs in community diagnosis and monitoring of atrial fibrillation

BackgroundCommunity management of atrial fibrillation (AF) often requires the use of electrocardiographic (ECG) investigation. Patients discharged following treatment of AF with fast ventricular response (fast AF) can require numerous ECGs...

Un estudio antropológico-jurídico de la conducta ética del etnógrafo en el espacio hospitalario en México

El presente trabajo busca reflexionar sobre las implicaciones éticas y legales de las prácticas etnográficas del antropólogo médico y/o de la salud dentro de los espacios hospitalarios, así como la validez, eficacia y legitimación de su participación en ellos. Partimos de reconocer que en estos espacios convergen diversos actores sociales normados por un marco regulatorio sanitario, y que a razón de su construcción disciplinaria, se presentan tensiones axiológicas que hace las veces necesario generar nuevos mecanismos jurídico-éticos de aproximación a los usuarios a través de los cuales el antropólogo encuentre una entrada en el desempeño de sus investigaciones para la contribución de la mejora de los servicios hospitalarios, sin olvidar que la adscripción de principios deónticos para la antropología no puede desvincularse de la historicidad social de la disciplina y de la ética.

Virtual Heart Failure Clinic - An Integrated Care Programme Support for General Practice

Introduction: Heart Failure is a serious chronic disease affecting 2% of the population in Ireland, with high hospitalisation rates. National policy “ Slainte Care” directs that care in Ireland should be shifted to Primary Care. The Integrated Care Programme Model of Care addresses heart failure by improving diagnosis and enabling General Practitioners to manage patients in the community, with ready access to specialist medical support. Virtual Clinics: A pilot project was set up in 2016 which enables General Practitioners to discuss their heart failure cases, which they would otherwise be referring to hospital, with the Heart Failure Specialist and with a GP group via video link. A Clinical Nurse Specialist helps General Practitioners to identify heart failure patients. Necessary diagnostic testing i.e. BNP testing and referring for echocardiography if appropriate is carried out using standard pathways. The other GPs participate in the discussion and avail of the learning opportunity. Aim: The Clinic aims to build General Practitioners confidence in a diagnosis and management of heart failure. Population and Stakeholders: Previous audits identify that heart failure is not well proactively managed in primary care in Ireland and in many cases are presenting episodically at acute care services. The stakeholders are the GPs with the community nurse specialists and the Heart Failure Specialist. The pilot study commenced at the end of 2016 and patients commenced to be seen in 2017. Highlights: 72 virtual clinics held to date and 270 patients reviewed, coming from 50 General Practitioners. 80% of patients NOT referred on to hospital following the clinic which would have otherwise been referred. 30% of these were avoided admissions and 50% were avoided OPD appointments. Knowledge transfer – 94% of GPs said they were now better able to manage heart failure. 76% of GPs said their confidence in diagnosis had improved. 14834 kms of travel avoided for patients. Sustainability and Transferability: Clinicians in the area have received this new service well, and are eager to extend its coverage. The hospital service costs are being met ongoing and there are plans for expansion, as this is seen to be a cost saving initiative. Payments for General Practitioners for extension of this service are being considered under the new GP Contract nationally. Conclusions and Discussion: Significant numbers of patients who were referred to the virtual clinical are not referred to specialist out patients and admitted which would otherwise be the case. Given long waiting times this is a clinical service improvement for patients and a cost saving measure. Qualitative results from GP interviews show promising increases in confidence by General Practitioners in managing heart failure in the community. The transferability of the service depends on adequate funding being made available in other areas and on heart failure specialist champions being prepared to develop this clinic with GP colleagues. Lessons Learned: Innovative clinically led pilot programmes for integrating care are successful in improving clinical care for patients and can provide cost saving solutions.

Toward a new generation of quality registries for neurodevelopmental disorders: the example of NEUROPSYK

Abstract Swedish healthcare quality registries are tools for the evaluation and improvement of clinical services and population-based research. There are presently 11 national quality registries that focus on psychiatric disorders; but none cover all neurodevelopmental disorders (NDDs) as defined by the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Health care professionals have called for more user-friendly; time-saving; and clinically informative registers. To fill this gap, the NEUROPSYK Quality Register was established in 2014 by the Center of Neurodevelopmental Disorders at Karolinska Institutet. Initially, this was a clinical register of child and adolescent psychiatry for the Stockholm County Council. The main objectives of NEUROPSYK are to improve the assessment of and interventions used for individuals with NDDs by doing the following: 1) supporting adequate follow-up related to the implementation of existing regional and national guidelines for assessment and treatment; 2) providing clinical decision-making aids; and 3) conducting large-scale clinical epidemiological research. The registry incorporates all legal requirements for quality registries in Sweden. NEUROPSYK includes patients of all ages diagnosed with NDDs per the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. These diagnoses include autism spectrum disorder, attention-deficit/hyperactivity disorder, intellectual disabilities, communication disorders, specific learning disorders, and motor disorders. Medication and behavioral interventions are recorded and patient outcomes over time are measured with the economical and user-friendly Clinical Global Impression tool, the Global Assessment of Functioning instrument, and patient-reported health-related quality of life. NEUROPSYK minimizes administrative work for health care professionals because it is integrated with structured digital patient records, thereby increasing the likelihood of high coverage and data quality. NEUROPSYK combines several strengths to exemplify a new generation of quality research registers for use in psychiatry and other areas of health care. Read more about NEUROPSYK: http://ki.se/en/kind/neuropsyk-quality-registry-for-neurodevelopmental-disorders

QUALITY MANAGEMENT IN SURGICAL DISCIPLINES

In continuation to our previous article 1 regarding the significance of clinical protocols in surgical disciplines, we would like to present the next two of our protocols, designed after meticulous study of the related literature and after the evaluation of worldwide experts opinion on the subject 2-12. We would like to emphasize again the fact that, clinical protocols act both as a medical as well as a managerial tool, aiming at the improvement of clinical services provided to our patients, with the application of the means available each time at the least possible cost The rationale behind is that since health treatments have a cost and resources are limited, the integration of managerial and financial efficiency within clinical efficiency is crucial 13, 14, 15,16. As Bachtsevani et al. 14 put it, it seems the use of evidence-based guidelines can improve outcomes in relation to organizations in the sense of decreased admission rates, length of stay, and less resource utilization, which reduces costs. Such monitoring mechanisms intend to evaluate, reassess and improve the clinical care not only in terms of outcomes but also in financial terms for the benefit of the patient welfare, and the hospital as an organization denoting in this way the significance of evidence-based medicine 15,17 Evidence has also shown that the greater the strength of the evidence incorporated, the greater the quality of the guideline and the greater its potential to maximize the use of resources and improve quality of healthcare18.

Principles, effectiveness and caveats in screening for cancer

Cancer screening has the potential to prevent or reduce incidence and mortality of the target disease, but may also be harmful and have unwanted side-effects. This review explains the basic principles of cancer screening, common pitfalls in evaluation of effectiveness and harms of screening, and summarizes the evidence for effects and harms of the most commonly used cancer screening tools. Cancer screening has either been established or is considered for breast, lung, prostate, cervical and colorectal cancer. In contrast, screening for gastrointestinal malignancies outside the large bowel is not generally accepted, available or implemented. Oesophageal and gastric carcinoma, and hepatocellular carcinoma, may be subject to screening in certain risk populations, but currently not for population screening based on available technology. Screening for colorectal cancer and cervical cancer by endoscopy and cytology respectively can decrease incidence of the target disease, whereas screening tools for lung, prostate and breast cancer detect early-stage invasive disease and thus do not decrease disease incidence. Overdiagnosis (detection of cancers that will not have become clinically apparent in the absence of screening) is a challenge in lung, prostate and breast cancer screening. The improvement of quality of clinical practice following the introduction of cancer screening programmes is an appreciated 'side-effect', but it is important to disentangle the effect of screening on cancer incidence and mortality from that of quality improvement of clinical services. As new, powerful screening tests emerge-particularly in molecular and genetic fields, but also in radiology and other clinical diagnostics-the basic requirements for screening evaluation and implementation must be borne in mind. Cancer screening has been established for several cancer forms in Europe. The potential for incidence and mortality reduction is good, but harms do exist that need to be addressed, and communicated to the public.

User involvement in the provision of HIV services: some lessons learned from a user group in an HIV treatment centre in London

In recent years attention has been focused on the greater participation of health service users in the identification of health service need, service design and delivery and service evaluation. This approach attempts to improve communication between health professionals and the health communities they serve in order to deliver more effective services. The establishment of user groups in HIV services has been one approach by which clinicians have attempted to establish ways that service users could help in the improvement of clinical services. This research article describes the process in the involvement of a user group in an east London HIV service. It describes the challenges that faced both the service users and the clinical staff and it analyses the factors that led to the discontinuation of the user group. The article discusses factors and challenges that must be addressed before meaningful user involvement in HIV services can be established.

Continuing professional development: a review.

In the UK health sector, continuing professional development for nurses is now clearly identified as necessary to the continued improvement of clinical services. The clinical governance movement that is driving this improvement has had a great effect on the NHS and it is now necessary to demonstrate service maintenance and improvement. Lifelong learning and the enhancement of skills through training or self-development are mentioned as ways of providing staff governance (DoH 1999, SEDH 1999).

Clinical governance.

Clinical governance.

Diagnostic and Interventional Trends in Tetralogy of Fallot and Transposition of the Great Arteries in a Population-Based Study

The goal of this study was to analyze diagnostic and interventional trends in tetralogy of Fallot and transposition of the great arteries in Malta for individuals born during 1920-1994 and calculate birth prevalences. The design was population based, in the setting of a regional hospital providing exclusive diagnostic and follow-up services for the entire population of Malta. Data collection and analysis was retrospective and included comparison with earlier epidemiological studies. Patients included were all Maltese live births diagnosed as having tetralogy of Fallot (TF) and transposition of the great arteries (TGA) born by the end of 1994. There were 109 cases of TF and 30 cases of TGA (n = 30). A significant decline in age at diagnosis and age at surgery was found for both lesions (p < 0.0001), which was associated with a significant decline in perioperative mortality (p = 0.005). Underascertainment was present prior to 1980, however, more cases were diagnosed due to improvement of postmortem services in the early 1980s followed by improvement of clinical services with eventually exclusive premortem diagnosis. The birth prevalence of TGA was 0.31/1000 live births, well within the range described in previous studies, unlike tetralogy of Fallot, which has been found in excess in this population in an earlier study. TF and TGA, the two lesions which comprise the majority of cyanotic congenital heart disease presenting in infancy, have been diagnosed and have undergone intervention at progressively earlier ages over the period under study. This decline was associated with a declining perioperative mortality.

Using client satisfaction surveys to evaluate and improve services in locked and unlocked adult inpatient facilities.

This article describes the implementation, in five inpatient subacute treatment facilities, of a satisfaction survey designed especially for adults with serious and persistent mental illnesses. The survey measures not only global satisfaction but also client perceptions about different treatment modalities and services, important treatment goals, and the philosophy of treatment. Data are presented from 770 completed surveys, illustrating patterns of satisfaction across facilities and services and patterns over time of stability and change in satisfaction. Data are also presented showing how the surveys were used to facilitate and measure improvements in clinical services. Finally, the implications for mental health services delivery are summarized.

ACADEMIC PHYSIATRY

The need for continued and diversified growth of both scholarly and clinical activities within academic physical medicine and rehabilitation (PM&R) departments is discussed with reference to the demands placed on academic departments by the various components of their mission, such as administration, clinical service, education and research. The expansion and improvement of clinical services should include the following components: program development, resources needed, finances required and marketing. Clinical subspecialization of faculty and solid affiliation with nonacademic hospitals and rehabilitation facilities is essential for academic PM&R. The faculty should include three categories: clinical faculty, clinical-research faculty and research faculty. Adequate financial resources must comprise an appropriate balance of academic funds, clinical income and grant sources. Clinical funds will play a greater role as other sources of funds diminish. Any practice plan must recognize the equality of the differing faculty members' practices, whether their interests are clinical, educational or research-oriented. The expansion and intensification of clinical programs by academy PM&R departments could increase competition in the medical community. Sensitivity to the perceptions of other practitioners and institutions, careful planning and cooperation will help the field grow and improve levels of care for the patients we serve in light of the changing medical care environment.