Multidisciplinary Appointment Research Articles

Evaluation of Guideline-Directed Medical Therapy for Outpatients Living with Heart Failure with Reduced Ejection Fraction.

Pharmacotherapy is the cornerstone of treatment for heart failure with reduced ejection fraction (HFrEF). The Canadian Cardiovascular Society and Canadian Heart Failure Society have defined guideline-directed medical therapy (GDMT) as 4 foundational medications. Despite strong recommendations for use of GDMT in HFrEF, current practice alignment with guidelines is unknown. The primary objectives were to determine the proportion of patients for whom optimized GDMT for HFrEF was prescribed, to describe the doses of foundational medications achieved, and to describe any documented rationale limiting the optimization of GDMT. The secondary objectives were to describe documented pharmacist activities outside of scheduled multidisciplinary appointments at the heart function clinic (HFC) and to describe heart failure-related hospital encounters in 2021. A retrospective cohort study using medical records of patients with HFrEF who were receiving treatment at the Regina HFC as of December 31, 2021, was conducted. Of the 129 patients included in the study, 61 (47.3%) were prescribed optimized GDMT. Specifically, within the individual foundational medication classes, 82.2% (106/129), 80.6% (104/129), 79.1% (102/129), and 74.4% (96/129) of patients received optimized therapy with a renin-angiotensin system inhibitor, mineralocorticoid receptor antagonist, β-blocker, and sodium-glucose cotransporter 2 inhibitor, respectively. Documented rationale was not available in 35.8% (38/106) of instances of suboptimal utilization of GDMT and in 41.7% (60/144) of instances of suboptimal dosing of GDMT. The most common documented rationale for suboptimal utilization was intolerance to the medication (33.0% [35/106]), and the most common rationale for suboptimal dosing was intolerance to dose increases (57.6% [83/144]). Pharmacists documented a total of 553 patient care activities for 58.9% (76/129) of the patients, outside scheduled multidisciplinary appointments in the HFC. Sixteen patients (12.4%) had heart failure-related hospital encounters a total of 31 times in 2021. Although many patients were receiving the benefits of multidisciplinary care at the Regina HFC, there remained a treatment gap in the use of GDMT for HFrEF. These findings will be used to inform strategies to improve clinic processes, including efficient identification of patients requiring optimization of GDMT, who would benefit the most from multidisciplinary care.

The Impact of COVID-19 on Multidisciplinary Care Delivery to Children with Cerebral Palsy and Other Neuromuscular Complex Chronic Conditions.

The COVID-19 pandemic has caused unprecedented challenges in the care of children with cerebral palsy (CP) and other neuromuscular complex chronic conditions (NCCCs). The purpose of this study is to explore the direct impact of the COVID-19 pandemic on healthcare delivery. From May to August 2020, medical professionals caring for CP and NCCC patients across multiple countries and disciplines completed a self-administered cross-sectional survey comparing practices before and during the COVID-19 pandemic. Of the 79 healthcare workers from eight countries who participated-predominantly pediatric orthopedic surgeons (32%), pediatricians (30%), and pediatric physiatrists (23%)-most of them felt that caring for NCCC patients during the pandemic presented unique difficulties, and they reported a significant decrease in the in-person NCCC clinic volume (p < 0.001), multidisciplinary appointments (p < 0.001), surgical cases (p = 0.008), and botulinum toxin/phenol injections. Most providers affirmed that institutional guidelines for perioperative emergent/urgent and elective procedures, workplace settings, and technology were modified to accommodate the ongoing public health crisis. The usage of telemedicine significantly increased for NCCC patient visits (p < 0.001). During the COVID-19 pandemic, many children with NCCCs lost access to routine, multidisciplinary care. Telemedicine became an integral part of communication and management. In the setting of the COVID-19 pandemic and with the threat of future healthcare disruptions, these data lay the foundation for trending the evolution of healthcare delivery and accelerating best practice guidelines for children with CP and NCCCs.

Implementation of a Multidisciplinary Inflammatory Breast Cancer Program for Quality Improvement

BackgroundInflammatory Breast Cancer (IBC) is a rare but aggressive subtype of breast cancer accounting for only 1% to 5% of cases but comprising 7% to 10% of breast cancer deaths. Diagnosis of IBC can be challenging which can lead to delays in diagnosis and treatment. We formed a multidisciplinary IBC program to address the unique challenges of diagnosing and treating patients with IBC. Materials and MethodsWe retrospectively identified patients with an IBC CPT code and collected data on the date of the first visit with medical oncology, surgical oncology, or radiation oncology, date of biopsy, and initiation of neoadjuvant chemotherapy. In 2020, as part of the IBC program at The Ohio State University, the decision tree (DT) was revised to help identify potential IBC patients. These patients were prioritized with a multidisciplinary appointment within 3 days. ResultsAfter adjusting the call center DT, there was a significant decline in the median and mean time from initial contact to chemotherapy initiation and an insignificant decrease in the mean time from contact to biopsy (P = .71884). The median time of contact to chemotherapy was 10 days (range 9-14) in 2020, a decrease of 43% compared to 3 prior years (P = .0068). After initiation of the IBC program, 100% of patients underwent trimodality therapy—neoadjuvant systemic therapy, modified radical mastectomy, and post mastectomy radiation therapy. ConclusionA multidisciplinary IBC program that included scheduling DT with specific questions about IBC symptoms helped identify potential patients and significantly decrease time to treatment and assured completion of trimodality therapy.

Patient-Perceived Satisfaction and Knowledge Uptake in a Combined Cardio-Obstetrics Clinic.

Heart disease is the leading cause of pregnancy-related mortality in the United States and has led to the development of combined cardio-obstetrics (COB) clinics as a model for prenatal care. In other areas of medicine, these types of collaborative care models have shown improvement in morbidity, mortality, and patient satisfaction. There is some data to suggest that a combined COB clinic improves maternal outcomes but there is no data to suggest patients prefer this type of care model. This study aims to evaluate patient satisfaction in a combined COB clinic and whether this type of model enhances perceived communication and knowledge uptake. A quality questionnaire was developed to assess patient perceptions regarding communication, satisfaction, and perceived knowledge. Patients who attended the clinic (n = 960) from 2014-2020 were contacted by email, with a response received from 119 (12.5%). Participants completed a questionnaire assessing satisfaction and perceived knowledge uptake with answers based on a Likert scale (7 representing very satisfied and 1 representing very unsatisfied). Safe and effective contraceptive use was evaluated by multiple choice options. Knowledge was also assessed by comparing contraceptive use before and after the clinic. Participants reported high levels of satisfaction with the clinic (6.2 ± 1.5), provider-to-patient communication (6.1 ± 1.6), and with the multidisciplinary appointment approach (6.3 ± 1.5). As well, participants reported an increase in knowledge about heart disease a result of collaborative counseling. In summary, a multidisciplinary approach to cardio-obstetrics not only improves outcomes but is a patient satisfier.

Development of the Breast Cancer Survivors Symptom Checklist for Use in Follow-Up Multidisciplinary Appointments.

BackgroundBreast cancer survivors are primarily followed up to monitor the effectiveness of treatment and complications and to detect recurrences. Many breast cancer survivors may experience prolonged adverse physical and psychological effects, which should also be addressed at follow-ups. The objective of this study was to develop a brief symptom assessment tool for breast cancer survivors to be used as a guideline for the survivors and all health care professionals conducting the routine follow-up. The second objective was to describe the women’s individual experiences with follow-ups.MethodsA literature review, a focus group of 6 healthcare professionals using a nominal group technique process, and the experience and feedback via qualitative interviews with 16 breast cancer survivors was used to develop the Breast Cancer Survivors Symptom Assessment Checklist (BCS-SC).ResultsThe BCS-SC consists of a set of 13 symptoms/burdens and one question. On a scale from 0 (no symptom) to 10 (worst imaginable), survivors indicated the extent to which they experience each symptom. All survivors perceived the annual follow-ups as important, but none prepared for them. Eight of the 16 survivors reported that they had 2 or more of the symptoms/burdens listed in the BCS-SC. However, only one of the survivors had mentioned her symptom to the doctor at follow-up.ConclusionThe BCS-SC is a comprehensive assessment tool for symptoms/burdens that are common among breast cancer survivors and can aid efforts to optimize their follow-up. Furthermore, the BCS-SC allows for a more patient-initiated and focused consultation, leading to more patient-centered quality care.

P10 Psychologist? But the pain is not all in my head…

P10 Psychologist? But the pain is not all in my head…

Tackling cardiovascular prevention after coronary disease settled: the challenges of guideline implementation

Funding AcknowledgementsType of funding sources: None.PurposeCardiovascular disease (CVD) as it is known, is a multifactorial disease that needs to be addressed exactly in that way. Knowledge deficit regarding symptoms and unadjusted lifestyles are still the most relevant nursing diagnoses identified as main causes for readmissions in patients with CVD (1). Recent guidelines evidenced that after a CVD event, patients should attend to their lifestyle choices and health behaviors, in order to avoid future events, as this works in a cardioprotective way (2). Having programs structured in a way that makes it possible to involve both population and person-centered strategies all teamed up, could be a way of involving patients in their own care, tackling several recommendations at the same time. Our aim is to describe the implementation of a cardiovascular disease prevention program with a multidisciplinary approach and identify the most prevalent CVD risk factors during the first trimester of its implementation.MethodsIn order to improve patient outcomes post-discharge, the program was outlined as follows: firstly. a Multidisciplinary Appointment was structured, with a Cardiologist and a Nurse, where also family is invited, to assess risk factors, therapeutic adherence and quality of life. According to the patient's needs and preferences they can be assigned to the Cardiac Rehabilitation Lab, to the Education Group Sessions on CVD risk factors where a Nutritionist, Psychiatrist and Physiatrist also participate according to the sessions' topic. For more personalized approach it also comprises: Therapeutic Groups and Mental Health Appointment; Nutrition Appointment; and Nursing Counseling at Outpatient clinics for family and person-centered approach. To assess the program at its third month baseline the focus group method was used for patients and professionals perspectives.ResultsThe program was implemented from October to December 2021. During that time 24 patients were admitted. Nursing Counseling was needed for almost all patients for different reasons. Out of those, 50% were assigned to the group sessions, 33.33% were assigned to the Cardiac Rehab, 12.5% were oriented to the Nutrition consults and 20,83% to the Mental Health consults. Even though we offered therapeutic groups as an option for some patients, none of them were willing to go. Regarding the modifiable risk factors, 70% of patients had 3 or more risk factors, showing that we do have a high risk population to tackle. Putting it into perspective, the most prevalent risk factors were dyslipidemia (70.83%), tobacco use (70.83%), obesity (54.17%) and hypertension (50%).ConclusionsManaging a multidisciplinary program can be demanding, and there were several challenges to this program’s implementation such as: short-staffing, structural issues, covid-19 prevention issues, digital systems, agendas, etc.). But focusing on patients' needs and preferences, helped us to do our utmost to make this program happen.

Supporting the Transition to Adulthood for Youth With Spina Bifida: A Call for Neuropsychology-Informed Interventions.

Supporting the Transition to Adulthood for Youth With Spina Bifida: A Call for Neuropsychology-Informed Interventions.

Feasibility of Delivering Pediatric-to-Adult Transition Education during Annual Comprehensive Clinic Appointments and Patient-Reported Outcomes: A Quality Improvement Study

Individuals with bleeding disorder diagnoses require developmentally sensitive care across the lifespan, particularly as they gain knowledge and skills necessary to successfully tackle their illness-specific needs as independent adults (Breakey et al., 2010). The current study describes one phase of a larger quality improvement (QI) initiative aimed at improving transition from pediatric to adult care (TAC) at one US Hemophilia and Thrombosis Center (HTC). Our aim was to assess the feasibility of delivering transition specific education to youth-caregiver dyads during youth annual multidisciplinary clinic appointments. Youth-caregiver dyads were selected given previous research revealing that both patients and their parents express worries about related to TAC (Geerts et al., 2008). Education included discussion of the knowledge and skills necessary for autonomous management of one's bleeding disorder (e.g., illness basics, treatment, communication, and healthy living). During an 8-month period, 101 youth-caregiver dyads were approached. Patients were between the ages of 12 and 25 (M age = 17.66, SD = 3.45). Approximately half of patients were diagnosed with hemophilia A (53.5%) and 16.8% were female. Of the 101 patients approached, 90 completed the transition education discussion. On average, these discussions took 12.80 minutes (SD = 8.49) and ranged from 5 to 50 minutes. Social work delivered the bulk of these discussions (78.7%) and spent an average of 10.61 minutes (SD = 5.76) with youth and caregivers. While the intention was to deliver transition education to youth-caregiver dyads, this only occurred in 37 discussions. Other discussions included the patient only (n = 31), caregiver only (n = 20), or had missing data (n = 1). In instances when a youth-caregiver dyad was approached, but a discussion did not take place, barriers to completing the discussion were identified. “Provider” was listed most frequently (n = 5) as a barrier (e.g., youth sent home by medical team prior to transition discussion occurring; miscommunication between members of multidisciplinary team; low staffing of those trained to deliver transition discussion). Even in instances when a transition discussion did take place, barriers to having the discussion were identified. “Patient” barriers were the most frequently listed (n = 13), followed by barriers related to “Time” (n = 11), and barriers related to “Clinic” (n = 3). At the end of the transition discussion, youth and/or caregivers were encouraged to identify a goal for improving their skills or knowledge in one of the four areas discussed during their appointment. Of those having transition discussions, 72 created a transition goal. The majority of participants reported goals related to Treatment (e.g., infusion skills; n = 36) followed by goals related to Communication (n = 18), Healthy Living (n = 11), and Bleeding Disorder Basics (n = 7). There was a statistically significant difference in the type of goal of expressed by youth and/or caregivers when the patient was 17 years old or younger vs those older than 18, X 2 (3, N = 72) = 9.49, p = 0.024. Generally, more youth reported goals related to Treatment (e.g., infusion skills) than predicted by chance in both age groups. Patients or patient caregivers were contacted via phone between 5 and 14 months following their transition discussion. Approximately 1/3 of the patients who completed transition discussion, responded and provided ratings on progress toward meeting their transition goal. Ratings (M = 4.24, SD = 2.63) were made on a Likert-type scale ranging from 1 (no progress made) to 10 (maximum progress made). The information gleaned from this QI initiative revealed that delivery of transition-specific education within the CU-HTC annual multidisciplinary appointments is feasible and in some cases, served as the impetus necessary for accomplishing transition-specific goals. The results from this initiative have been instrumental in subsequent transition-related efforts related to: (a) fostering full engagement across the multidisciplinary team in TAC efforts utilizing HEMO-Milestones Tool (Croteau et al., 2016); (b) adopting specific materials developed to assess TAC in individuals with bleeding disorder diagnoses (i.e., American Society of Hematology Hemophilia Transition Readiness Assessment); and (c) reducing time between patient goal-setting and follow-up from the HTC. DisclosuresWang: Novo Nordisk: Consultancy, Other: Clinical trial investigator; Bioverativ: Consultancy, Other: Clinical trial investigator; Bayer: Consultancy, Other: Clinical trial investigator; Octapharma: Other; uniQure: Consultancy, Other: Clinical trial investigator; Pfizer/Spark: Other: clinical trial investigator; Genentech: Consultancy, Other: Clinical trial investigator; BioMarin: Consultancy, Other: Clinical trial investigator; CSL Behring: Consultancy, Other: Clinical trial investigator; Takeda: Consultancy, Other: Clinical trial investigator; Hema Biologics: Consultancy, Other: Clinical trial investigator. Buckner: CSL Behring: Honoraria; Tremeau Pharmaceuticals: Consultancy, Honoraria; Genetech: Honoraria; Bayer: Honoraria; Spark: Honoraria; Sanofi: Honoraria; Novo Nordisk: Honoraria; Pfizer: Honoraria; BioMarin: Consultancy, Honoraria; Takeda: Honoraria; American Thrombosis: Membership on an entity's Board of Directors or advisory committees; Hemostasis Network: Membership on an entity's Board of Directors or advisory committees; uniQure: Consultancy, Honoraria.

Assistance and health care provided to adolescents with chronic and immunosuppressive conditions in a tertiary university hospital during the COVID-19 pandemic

The coronavirus disease (COVID-19) pandemic has led to social distancing and isolation measures worldwide (,). Quarantine began on July 20, 2020 in Sao Paulo State, Brazil (). Institutional guidelines of the Hospital das Clinicas of FMUSP (HCFMUSP) released on March 18, 2020 recommended postponing medical and multidisciplinary appointments, outpatient procedures, and elective surgeries. As a result, the regular follow-up of a considerably large group of adolescents living with pre-existing chronic conditions was provisionally scheduled at longer intervals or even paused. [...]

1243 A Guinness Book Challenge in Upper Airway Stimulation Activation

Abstract Introduction Upper airway stimulation is a option for CPAP-intolerant patients. Device activation is typically ~4 weeks after the implant procedure. Report of Case A 61yo male with severe OSA had an upper airway stimulation device placed by ENT. At that time, stimulation produced bilateral tongue protrusion. In the immediate post-operative period, after closure, a hematoma, at the inferior chest incision, was discovered and drained with cauterization of the bleeding vessel. Seven weeks after implant, patient reported to our sleep clinic for activation of the device; and at that time, there was no sensation or activation up to the maximum amplitude of 5mV. The device reported an acceptable respiratory waveform, and triggering on and off sets but without sensory outcomes. Changing of the electrode configuration with advanced settings had no effect. Impedance values were acceptable. Tongue movements were grossly intact. At 2 months, ENT evaluation found mild hypoglossal nerve neuropraxia. To assess for a device related issue, x-rays of the neck and chest were performed and showed proper placement of the device. At 3.5 months, neuropraxia had resolved but device activation was unsuccessful, with no sensory or motor activation to 5mV stimulation. Plans were made for a procedure during which the lead electrode or implantable pulse generator would be assessed or replaced. At 4 months after implantation, in a multidisciplinary appointment with Sleep, ENT and the device representative, with a 3 electrode negative pole and the generator as the + pole, at 2.3mV, the device was activated. At the present time, the patient is exploring higher and lower mV settings and a PSG titration is scheduled. Conclusion This is the longest recorded duration (3.5+ months) of unsuccessful post-operative activation; and it occurred ~2 months after clinical signs of hypoglossal nerve neuropraxia had resolved.

Somatic outcomes of young people with chronic diseases participating in transition programs: a systematic review

AbstractIntroductionThere is growing evidence that the health of young people with chronic health conditions deteriorates during the transfer from child-centred to adult-oriented health care. Risks include not only the deterioration of health status in general but also the occurrence of secondary diseases and adverse events. Transition programs have been implemented. However, there is a lack of evidence about whether they reduce these risks and which interventions should be principally included. Evidence-based guidelines for the transition of young people should be introduced. In this study we therefore aim to summarise actual evidence on somatic outcomes during the transition period.MethodsA systematic literature review was conducted. Two independent reviewers searched in electronic databases (Cochrane, Embase, PubMed, Web of Science) for intervention studies that aimed to improve transition. Last update of search was October 31st 2018. Grey literature was also searched. Studies were included if they examined participants aged 11 years or older suffering from a chronic health condition and evaluated interventions aimed to improve somatic outcomes after transition. Controlled trials or studies with a measurement before and after intervention were considered. The certainty of evidence was assessed using the GRADE approach. Additionally, each study was graded using a modified grading scale based on GRADE.Results28 studies met the inclusion criteria. Patients suffered from different chronic conditions such as type 1 diabetes, solid organ transplantation, inflammatory bowel disease or cystic fibrosis. Interventions had different components such as transition checklists, workshops, web-based interventions, transition plans, joint visits or transition coordinators. Outcomes included mortality and morbidity. They varied according to chronic condition. Thirteen studies showed beneficial effects in the intervention group or in post-intervention measurements. The certainty of evidence was very low.ConclusionA considerable number of studies evaluating transition interventions was identified. Transition interventions had some beneficial effects. Workshops, joint visits and longer or multidisciplinary appointments may be particularly effective components. Transition guidelines could be based on these results. However, due to the limitations of the included studies it is difficult to draw firm conclusions. More research is needed to further evaluate the effectiveness of transition interventions. It should address the deficits identified from prior studies, such as poor study design, short follow-up time or small sample sizes.

The multidisciplinary clinic approach for bladder cancer treatment in the neoadjuvant therapy era.

475 Background: As urologic oncology becomes increasingly complex, the coordination of optimal and efficient care to patients can be challenging. Within our institution, we initiated a multidisciplinary center (MDC) comprised of urology, oncology and radiation oncology in 1996 to help meet these needs. The positive benefits of this approach have been demonstrated in other settings, but outcomes related to bladder cancer remain unclear, especially in the era of neoadjuvant (NA) therapy. Methods: Patients with localized or node positive muscle invasive bladder cancer (MIBC) without prior treatment were obtained from available multidisciplinary appointment records, dating from 7/5/17 to 9/25/19. Charts were then retrospectively reviewed to gather demographic data, treatment data, and pathological outcomes. Results: 66 patients fitting study criteria were identified. Average age was 71.3 years. 45 (68%) patients from this cohort were deemed to be radical cystectomy (RC) candidates, with 37 RC operations completed at time of record review. Of RC-eligible patients, 35/45 (77%) had received NA therapy, either in the form of neoadjuvant chemotherapy (NAC) and/or immunotherapy (NAI). 3 patients declined RC after receiving NAC. 15 patients underwent chemoradiation treatment (23%), while 7 (11%) underwent supportive care without definitive treatment. Downstaging at RC from MIBC (&lt;=T1) was seen in 12/37 patients (32%), with a pT0 rate of 10% (4/37). Conclusions: The coordination of care in bladder cancer remains a challenge for patients and physicians alike. We believe by utilizing a multidisciplinary approach, efficiency and quality of care increases. National database studies have reported overall utilization of neoadjuvant chemotherapy over the past 10 years, with most recent rates ranging from 14.8-20.9%. Our utilization of neoadjuvant therapy is notably higher at 77%, which also includes early adaptation of NAI in patients deemed ineligible for neoadjuvant NAC. Further studies are needed to examine a contemporary control population outside the multidisciplinary setting, however the above outcomes provide a basis for the integration of care and its positive outcomes in quality improvement.

1370-P: Pediatric to Adult Transition Interventions and Outcomes in Type 1 Diabetes: A Scoping Review

Introduction: Adolescents and young adults (AYA) transitioning from pediatric to adult T1D care struggle with glycemic control and continuity of care while experiencing psychosocial complexities. The purpose of this review was to examine associations between transition interventions and relevant outcomes. Methods: A predefined search strategy was used to retrieve papers published in the past five years evaluating transition programs for AYA with T1D. Nine observational studies and eight controlled trials were independently reviewed by two authors, with discrepancies addressed by a third. Results: A total of 1491 AYA with T1D aged 12-39 (mean 18.5) years were represented in 17 publications. The most frequent intervention components included a transition coordinator (7), transition education (5), a multidisciplinary appointment (4), and a virtual transition program (4). Outcomes most frequently reported included HbA1c (12), satisfaction (10), psychological well-being (7), and continuity of care (7). Associations between interventions and outcomes are presented in Table 1. Conclusions: There is a paucity of recent RCTs evaluating T1D transition interventions. While AYA with T1D reported satisfaction with a variety of interventions, programs including a transition coordinator and multidisciplinary appointment may also positively impact HbA1c, psychological well-being, and continuity of care. Disclosure E.L. Lundgrin: None. J.E. Blanchette: Consultant; Self; Dexcom, Inc., Tandem Diabetes Care. A. Mucci: None.

Psychological Aspects and Psychopharmacologic Treatment in the Very Early Period After Kidney Transplantation: Role of a Multidisciplinary Approach

BackgroundIn the context of kidney transplantation (KT), multidisciplinary interventions, including assessment and management of psychosocial aspects, are important to improve transplant's outcome. The aim of this study was to describe a multidisciplinary team approach to KT, with a specific focus on early detection and treatment of psychological distress and psychopathologic conditions in the early phase postsurgery. MethodsThe multidisciplinary team in kidney transplantation was implemented in January 2016. In this team approach, all transplant recipients are invited to 3 scheduled appointments for a multidisciplinary evaluation at 1, 3, and 6 months posttransplant, including a psychiatric interview, with the aim to assess the patient's adjustment after transplantation and provide support when necessary. ResultsThis pilot study involved all 41 KT recipients consecutively referred for the first multidisciplinary appointment after transplantation. Five subjects (12% of the study sample) presented with a current psychiatric diagnosis. Psychopharmacologic treatment was confirmed or introduced for all these patients. Further psychological support was suggested to 4 other patients (10%). ConclusionKT significantly improves patients' quality of life. However, the percentage of subjects receiving psychopharmacologic treatment and referred for further psychological and psychiatric support (22%) suggests the need for careful monitoring of psychosocial aspects over the long term.

Testing the Timing: Time Factor in Radiation Treatment for Head and Neck Cancers.

Overall radiation treatment time has long been recognized as an important factor in head and neck tumor control. The concern of tumor growth in waiting time either before starting radiotherapy or during treatment is substantial given its negative impact on clinical outcome. There is an overwhelming evidence that increasing the time to initiate treatment increases the tumor burden and worsens the prognosis. This effect is more pronounced especially in patients with an early stage cancer disease. Delay in treatment initiation is contributed by both health care- and patient-related factors. Health care-related factors include advancement in diagnostic modalities and transfer of patient to academic health care centers accompanied by delayed referrals and long-awaited appointments. Patient-related factors include delayed reporting time and socioeconomic factors. An efficient transition of care along with access of cancer care modalities to community health care centers will not only improve the quality of care in secondary health care centers but also help decrease the patient burden in tertiary centers. A quick and well-structured multidisciplinary appointment program is fundamental in shortening the time required for patient referrals, thus increasing the optimal survival time for Head and Neck cancer patients with early initiation of treatment.

Long‐term follow‐up of children with haemophilia – low incidence of infections with central venous access devices

This study reports on 15years of experience, in a single haemophilia care centre in France, with central venous access devices (VADs) in children with haemophilia. Following the insertion of a central VAD, patients were requested to return to the hospital on a quarterly basis for a multidisciplinary appointment which included clinical examination, chest X-ray, cardiac and major vessels ultrasound and preventive fibrinolysis. The family was urged to return to the Haemophilia Care Centre if complications or problems occurred. The follow-up comprised 50 patients. Data were collected prospectively. The total number of days with a VAD was 86461days and the total number of times the VAD was used was 41192 (approximately every other day). Mean duration of VAD placement was 1269days (range 113-2794days). There were 25 complications, of which 9 haematomas and 5 systemic infections. Two VADs, infected with Staphylococcus aureus, had to be replaced. The infection rate was calculated as 0.0578 infections/1000 catheter days. There were no cases of thrombosis. This study concluded that most VAD infections in children can be avoided, even in patients requiring intense, prolonged treatment. The very low infection rate was achieved through the efforts of a multidisciplinary team, combined with extensive training for all individuals involved, adherence to written protocols and specific monitoring measures.

Improving patient access at a movement disorder clinic by participating in a Process Improvement Program

Our multi-disciplinary neurology team were dissatisfied with long access times for consultation for new referrals. We participated in a rapid process improvement workshop and a structured improvement process. Over a six-month period we were able to reduce our access time for initial appointment for patients with suspected movement disorders from 133 to 20 days. We implemented a ‘carousel’ multi-disciplinary appointment and a standardised clinic form that improved the flow of patients and that we estimate will save 150 hours of physician time and 320 hours of administrative time per year.

High risk clinic for hereditary colorectal neoplasia: a focus for patient care and an opportunity for clinical research

Background Patients with hereditary colorectal neoplasia and their families need specialized care to plan for appropriate surveillance and to ensure that they receive the most favorable treatment. This involves coordinating multidisciplinary appointments on the same day to minimize inconvenience to patients. We have established a special high risk clinic for these patients and their families. In this study we are reporting our activity for the last 5 years. Methods Initially the clinic ran one morning a month but has grown in the last 2 years adding another half day session. Requests for appointments were triaged by registry coordinators. Patients with syndromes of hereditary colorectal neoplasia were eligible for this clinic if the necessary appointments included multiple physicians. The clinic is staffed by one of three colorectal surgeons, one gastroenterologist, one genetic counselor, one hepatobiliary/upper GI surgeon and often by a clinical geneticist.