Multidisciplinary Collaborative Care Research Articles

A112 THE EDMONTON PANCREATICOBILIARY INFLAMMATION AND CANCER (EPIC) PROGRAM – A NEW MULTIDISCIPLINARY COORDINATION OF CARE INITIATIVE

Abstract Background Pancreaticobiliary (PB) cancer is associated with a poor prognosis. A timely diagnosis and a coordinated, multidisciplinary effort may improve outcomes as patients navigate the healthcare system for investigations and treatment. Aims To establish and pilot a multidisciplinary (gastroenterology [GI], hepatopancreatic biliary [HPB] surgery, radiology, oncology, palliative medicine, and nutrition) collaborative care pathway (CCP) to coordinate timely referral and access to management for patients with PB cancer. Methods With multidisciplinary expert input, a CCP for PB cancer patients was developed. A donation to our hospital foundation facilitated the hiring of a nurse navigator (NN) to coordinate this process. The EPIC program was initiated as a 6-month pilot project on 01/07/23 for all consecutive patients referred to the University of Alberta Hospital with suspected PB cancer. Referrals were triaged by GI and HPB surgery into resectable, borderline resectable, or unresectable arms of the CCP. EUS biopsy and/or ERCP for stent were performed as needed. A referral to medical oncology was made after a diagnosis was established. Descriptive statistics were completed. Results At 3 months, 64 patients (39 M, 25 F), mean age 67±12 years (range 19-95 years), were referred to EPIC. Presenting symptoms were abdominal pain (73%), weight loss (40%), jaundice (27%), nausea/vomiting (21%), itching (8%), and new-onset diabetes (5%). Site of cancer was pancreas (77%, 49/64), bile duct (20%, 13/64), and ampulla (3%, 2/64). Timelines to care access were compared with a similar pre-CCP patient cohort as shown in Table. Conclusions The role of the NN is to reduce variability and coordinate timely referral, scheduling, and follow-up based on the care pathway, and to serve as a point of contact for ongoing patient issues. The EPIC program pilot is on track to meet the timelines set forth in the care pathway. Primary care outreach to increase awareness of symptoms and for prompt investigation may further improve access to care in these patients. Note: negative numbers indicate days where the GI/HPB review occurred before the CT/MRI, or intervention before GI/HPB review EPIC COLLABORATIVE CARE PATHWAY Funding Agencies None

Cardiovascular disease and lung cancer.

Lung cancer is the second most common cancer worldwide and the leading cause of cancer-related death. While survival rates have improved with advancements in cancer therapeutics, additional health challenges have surfaced. Cardiovascular disease (CVD) is a leading cause of morbidity and mortality in patients with lung cancer. CVD and lung cancer share many risk factors, such as smoking, hypertension, diabetes, advanced age, and obesity. Optimal management of this patient population requires a full understanding of the potential cardiovascular (CV) complications of lung cancer treatment. This review outlines the common shared risk factors, the spectrum of cardiotoxicities associated with lung cancer therapeutics, and prevention and management of short- and long-term CVD in patients with non-small cell (NSCLC) and small cell (SCLC) lung cancer. Due to the medical complexity of these patients, multidisciplinary collaborative care among oncologists, cardiologists, primary care physicians, and other providers is essential.

Development of the core competency-based entrustable professional activities for Master of Nursing Specialist (MNS) graduates in China

Background Advanced nursing practice and education with a Master’s degree as the necessary preparation, is viewed as a major strategy to cultivate senior nursing talents. Competencies are central to advanced nursing practice and education, but how can competencies be measured? Entrustable professional activities (EPAs) have been used widely in medicine as a practical approach for bridging the gaps between competency and clinical practice. Considering the paucity of research in EPAs for nursing graduates in China, it is needed to develop EPAs specifically for Chinese Master of Nursing Specialist (MNS) graduates to improve patient safety and quality patient care. Objectives To develop and evaluate a core competency-based EPAs framework for Chinese MNS graduates. Methods A four-stage approach was adopted for the EPAs development, including: (1) forming a research team, (2) drafting an initial EPAs framework, (3) reviewing EPAs framework, and (4) conducting EPAs consensus assessment. Results A framework containing twelve EPAs was developed, including: 1) perform health assessments, 2) identify and prioritize nursing diagnoses, 3) formulate and implement care plan, 4) perform basic and specialized care operations, 5) recognize and manage medication needs of patients, 6) assess and manage patients with mental health problems, 7) recognize and assist in rescuing critically ill patients, 8) perform transition and handover, 9) participate in multidisciplinary team collaborative care, 10) provide health education and nursing consultation, 11) formulate and implement discharge plans, and 12) instruct nursing students in a clinical setting. The I-CVI score for the two rounds of Delphi ranged from 0.92 ∼ 1.00 and 0.96 ∼ 1.00, respectively. The mean of Equal’s score for the three domains ranged from 4.20 ∼ 4.47, 4.25 ∼ 4.51, and 4.23 ∼ 4.37, respectively. Conclusion The developed EPAs framework in this study is a reliable tool to assess the core competencies of Chinese MNS graduates in clinical practice and assist with their curricula design.

Stakeholder experiences of deprescribing psychotropic medicines for challenging behaviour in people with intellectual disabilities

Purpose Evidence of overprescribing of psychotropic medicines to manage challenging behaviour in people with intellectual disabilities has led to national programmes within the UK to promote deprescribing, such as stopping the overprescribing of medication in people (with learning disabilities, autism or both). To successfully implement deprescribing initiatives, we need to understand how to engage stakeholders in the process. Design/methodology/approach In a published systematic review, we reported evidence about the process of deprescribing psychotropic medicines for people of all ages with intellectual disabilities and challenging behaviour. As a part of the original review, we searched for evidence about stakeholders’ experiences of the psychotropic deprescribing process, which was synthesised and reported within the current study. Findings Six studies were identified. Involving carers and people with intellectual disabilities, providing ongoing support and improving access to non-pharmacological interventions, including positive behaviour support, may contribute to successful outcomes, including reducing or stopping psychotropic medicines and improving quality of life. Implementing psychotropic deprescribing requires a multidisciplinary collaborative care approach and education for stakeholders. Originality/value There have been no previous reviews of stakeholder experiences of deprescribing psychotropic medications for people with intellectual disabilities and challenging behaviour. The existing literature is scant, and further research is needed.

Optimizing Management of AML: Insights from a Community-Based Quality Improvement Initiative

Background There has been groundbreaking progress in the molecular diagnosis, risk stratification, and treatment landscape for acute myeloid leukemia (AML), allowing providers to tailor a personalized therapy approach for individual patients. Despite these advances, many barriers to optimal AML treatment exist in integrating targeted therapies, selecting guideline-aligned treatments and managing adverse events. To address these challenges, we conducted a quality improvement (QI) study in community oncology clinics to assess current practice patterns and develop strategies to overcome barriers to optimal care for patients with AML. Methods The QI initiative comprised baseline provider surveys and pre- and post-surveys of providers participating in small-group, team-based audit-feedback (AF) sessions. Survey questions were designed to assess knowledge, confidence, and experiences with targeted therapies for AML. Care teams from each clinic, along with an expert AML physician, participated in AF sessions to (a) assess system-specific practice gaps identified via the provider surveys, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Between 1/2022-6/2022, 104 hematology/oncology providers completed baseline surveys and 54 care team members from the enrolled clinics participated in the AF sessions (Table 1). Results Provider Surveys: Providers' top reported challenges encountered in managing patients with AML were individualizing treatment plans (33%) and supportive care counseling (21%). Moreover, the most challenging issue encountered in selecting therapies for patients with AML was selecting optimal therapies for individual patients (27%). Factors considered most important in treatment decision-making, in addition to clinical guidelines, included effects on quality of life (51%) and treatment effectiveness (51%). Additionally, top parameters guiding treatment decision-making include age (63%) and karyotype/molecular abnormalities (60%). Clinicians reported the most difficulty in managing myelosuppression (34%) associated with novel AML therapies. When asked their top barriers to engaging patients with AML in shared decision-making, providers reported patient's low health literacy (29%) and not enough time to engage in SDM (25%). AF Sessions: Providers participating in the small group AF sessions reported testing for and interpreting results of molecular and genetic features (30%) and individualizing treatment plans (28%) as top challenges. Following the AF session, clinicians reported improvements in high/very high confidence in their ability to select guideline-aligned treatment for patients with AML (70% to 96%) and ability to manage adverse effects of novel AML treatments (76% to 96%). Care teams also set goals to improve individualized treatment plans and adverse event management, stay up to date with clinical guidelines and knowledge of novel therapies, and increase multidisciplinary collaborative care for patients with AML. Action plans to achieve these goals include enhancing knowledge of clinical evidence for new and emerging therapies for AML and developing personalized treatment plans incorporating patient-specific factors and preferences (Figure 1). Conclusions Through this QI initiative, clinical teams identified barriers to optimal AML care and created and implemented specific action plans focused on increasing knowledge of AML therapies, optimizing personalized treatment plans and improving adverse events management. Meaningful confidence gains were observed in aligning treatment plans to guideline recommendations and managing adverse effects of treatment. These data underscore clinical practice gaps to address in future initiatives to support safe, effective, and evidence-based integration of targeted therapies into AML care to optimize patient outcomes. Study Sponsor Statement The study reported in this abstract was funded by educational grants from AbbVie, Inc. and Astellas. The grantors had no role in the study design, execution, analysis, or reporting.

Tobacco and its negative impact: a case report

One of the most valuable possessions one may have is good health. Nowadays, it is acknowledged that oral health and general health go hand in hand. Oral health can be characterized as a level of wellness for the mouth and associated tissues that enable someone to eat, speak, and interact socially without experiencing any active illness, discomfort, or embarrassment and that adds to overall well-being. Because of their widespread occurrence and major social impact, oral illnesses might be categorized as a public health issue. One strategy for the management of complicated health disorders is multidisciplinary collaborative care, which includes care coordination among clinicians. This case presentation describes a collaborative effort between healthcare providers and a patient enrolled in a tobacco cessation clinic. This is a case of a smoker aged 57 years, who started reducing cigarettes and had quit smoking 6 months prior based on the health belief model but his improvement in quality of life was not significant.

Advances in multidisciplinary team-based collaborative care models in the nutritional management of patients with hepatocellular carcinoma

Liver cancer is a common and highly prevalent malignancy in China, and is a high prevalence of malnutrition. With the continuous innovation of medical technology and nursing model, the multidisciplinary teamwork nursing model has become inevitable for the care of liver cancer patients. This study reviews the concept of MDT nursing model, its development status at home and abroad and its application in the postoperative nutritional management of hepatocellular carcinoma patients, aiming to provide a basis for clinical hepatocellular carcinoma nutritional management.

Collaborative Care to Treat Chronic Pain after Traumatic Brain Injury: A Randomized Controlled Trial

<h3>Research Objectives</h3> To examine the effectiveness of collaborative care (CC) compared to usual care (UC) to treat chronic pain in individuals with traumatic brain injury (TBI). <h3>Design</h3> Randomized Controlled Trial. <h3>Setting</h3> TBI Rehabilitation Clinics. <h3>Participants</h3> 158 individuals with TBI who were followed in Rehabilitation clinics and endorsed chronic pain. <h3>Interventions</h3> CC included up to 12 visits with a care manager focused on cognitive behavioral treatment (CBT) for pain and coordination with TBI expert group (Psychologist, Physiatrist, Psychiatrist and Neurology Headache Specialist) for medical recommendations. <h3>Main Outcome Measures</h3> Pain Interference as measured by the Brief Pain Inventory (BPI: 0=pain does not interfere to 10=pain completely interferes). <h3>Results</h3> 79 individuals were randomized to each group (CC and UC). 58% were female, injured 4 years ago on average (SD=5.9), 65% had mild TBI, with 19% severe TBI. Of those in CC, 90% completed 11 or 12 sessions. At 4 months post randomization, the CC group had significantly lower pain interference (3.46, SD=2.17) compared to UC (5.03, SD=2.28; p<.001). This difference was maintained at 8 months post randomization (CC=3.61(2.22); UC=4.68(2.51); P=.04). In addition, pain severity (0=no pain, to 10=worst pain) was significantly lower in the CC group at 4 months (3.63, SD=1.95) compared to UC (4.90, SD=2.07). Pain severity was not significantly different at 8 months (p=.07) though lower for both groups (CC=3.51(2.07); UC+4.40(2.27). <h3>Conclusions</h3> Collaborative Care, including CBT for pain and TBI-expert medical recommendations, is a promising approach to reduce pain interference after TBI. Chronic pain is often considered difficult to treat, and implementation of multi-disciplinary CC in Rehabilitation Clinics could benefit patients, providers, and payors as an evidence-based and cost-effective strategy for decreasing disability and increasing function. <h3>Author(s) Disclosures</h3> Authors have no conflicts.

Impact of Pharmacist-Led Clinics on Health Outcomes of Patients With Diabetes at a Ministry of Health Diabetes & Endocrinology Center, Saudi Arabia: A Retrospective Study.

Objectives: Saudi Arabia is one of the most diabetes-prone countries in the world. The physician‐centered model of care constitutes the standard of care around the country. The study aimed to evaluate the impact of clinical pharmacist care on diabetes management in comparison to standard physician-based care.Materials and methods: a retrospective chart review was conducted of patients with type 2 diabetes mellitus (T2DM) seen by the clinical pharmacist at the Diabetes & Endocrinology Center, King Fahad Specialist Hospital located in Buraydah, Saudi Arabia between September 2019 to June 2020.Results: Thirty-two diabetic patients were included. The mean age is 55.75±10.72 years with 65.6% of patients being females. Hemoglobin A1c (HbA1c) was significantly decreased within nine months compared to baseline (9.33±1.80 vs.10.30±1.66), p=0.017.Conclusions: The multidisciplinary collaborative care involving pharmacists achieved superior diabetes outcomes for patients with diabetes. Involving pharmacists resulted in a significant HbA1c reduction within nine months. Moreover, pharmacists’ care helped optimize medication therapy and decreased the frequency of hypoglycemia.

Effects of Continuous Care Combined with Evidence-Based Nursing on Mental Status and Quality of Life and Self-Care Ability in Patients with Liver from Breast Cancer: A Single-Center Randomized Controlled Study.

Objective To explore the multidisciplinary collaborative extended care combined with EBN to improve breast cancer liver metastasis patients' psychological status and self-care ability. Background In the past ten years, the number of breast cancer patients with liver metastases has increased year by year, becoming a global public health problem. Studies have shown that 30% of breast cancer patients with liver metastases show varying degrees of anxiety and depression, and their quality of life is significantly lower than that of the normal population. Multidisciplinary collaborative continuous care can improve the prognosis of breast cancer treatment to a certain extent and is the key to meeting the needs of cancer patients. Materials and Methods The clinical data of 96 patients with liver metastases from breast cancer were selected as the study subjects and divided into a comparison group and an observation group of 48 cases each according to a random number table. Among them, the comparison group implemented evidence-based nursing (EBN) and the observation group implemented multidisciplinary collaborative extended care based on the comparison group. The effects of psychological status, quality of life, self-care ability, and sleep quality were compared between the two groups before and after nursing care. Results After nursing, the sleep quality scores, increased awakening scores, sleep quality that shows weakness because important things are not steady or strong scores, and night terrors scores of the two groups of breast cancer patients with liver the spread of diseases through the body were very much improved, and the sleep quality scores of the instance of watching, noticing, or making a statement group were much lower than those of the comparison group (P < 0.05). After nursing, the fear and stress-related score, depression score, tiredness and distress score, and anger score of the two groups of breast cancer patients with liver (the spread of diseases through the body) were very much improved, and the mental state score of the instance of watching, noticing, or making a statement group was much lower than that of the comparison group (P < 0.05). The scores of self-care skills, self-responsibility, health knowledge, and self-idea of patients in the instance of watching, noticing, or making a statement group after nursing were higher than those in the comparison group (P < 0.05). After nursing, the scores of mental energy, social interaction, emotional restriction, and mental status of patients in (instance of watching, noticing, or making a statement) were much higher than those in the comparison group (P < 0.05). Conclusion Multidisciplinary collaborative continuous nursing combined with EBN can effectively improve the sleep quality and psychological state of patients with breast cancer and liver metastases and improve self-care ability.

Benefits of multidisciplinary collaborative care team-based nursing services in treating pressure injury wounds in cerebral infarction patients.

BACKGROUNDCerebral infarction patients need to be bedridden for long periods of time often resulting in pressure injuries, which may represent a serious threat to patients' life and health. An effective nursing program should be adopted for timely intervention in patients with pressure wounds.AIMTo explore the value of nursing services based on a multidisciplinary collaborative treatment team in patients with pressure injury wounds following cerebral infarction.METHODSPatients with cerebral infarction pressure injury wounds in our hospital from December 2016 to January 2021 were selected and divided into one study group and one control group based on the simple random number table method. The control group was treated with conventional nursing care (CNC), and the study group was treated with care services based on multidisciplinary collaborative care (MDCC). The Pressure Ulcer Scale for Healing (PUSH), healing effect, Self-Perceived Burden Score (SPBS), and satisfaction with the intervention were calculated before and after 2 and 4 wk of intervention in both groups.RESULTSSixty-two patients were enrolled, and 31 patients were assigned to each group. The results of the interventions were as follows: (1) There was no significant difference between the PUSH scores of the MDCC group (11.19 ± 2.46) and CNC group (12.01 ± 2.79) before the intervention (P > 0.05), and the PUSH scores were lower after 2 and 4 wk of intervention in the MDCC group (6.63 ± 1.97 and 3.11 ± 1.04) than in the CNC group (8.78 ± 2.13 and 4.96 ± 1.35 points) (P < 0.05); (2) The rate of wound healing in the MDCC group (96.77%) was higher than that in the CNC group (80.65%) (P < 0.05); (3) There was no significant difference between the SPBS scores of emotional factors (21.15 ± 3.11), economic factors (9.88 ± 2.15), and physical factors (8.19 ± 2.23) in the two groups before the intervention. The scores of emotional factors (13.51 ± 1.88), economic factors (6.38 ± 1.44), and physical factors (5.37 ± 1.08) were lower in the MDCC group than in the CNC group (16.89 ± 2.05, 7.99 ± 1.68 and 7.06 ± 1.19) after 4 wk of intervention (P < 0.05); and (4) Satisfaction with the intervention was higher in the MDCC group (93.55%) than in the CNC group (74.19%) (P < 0.05).CONCLUSIONInterventions for patients with cerebral infarction pressure wounds based on an MDCC treatment team can effectively reduce patients' self-perceived burden, improve pressure wound conditions, facilitate wound healing, and increase patient satisfaction with the intervention.

Asthma Severity and Control and Their Association With Perinatal Mental Illness.

Growing evidence suggests asthma increases perinatal mental illness risk, but few studies have explored the impact of asthma severity and control. Our objective was to explore the association between asthma severity and control and perinatal mental illness risk and the impact of asthma exacerbations during pregnancy on postpartum mental illness risk. This was a population-based retrospective cohort study of all women in Ontario, Canada, from 2005 to 2015 with a singleton live birth who used public drug insurance, excluding women with recent history of mental illness. We constructed modified Poisson regression models to assess the risk of perinatal mental illness, defined as a mood or anxiety, psychotic or substance use disorder, self-harm or other mental illness diagnosed from conception to 365 days postnatally. Models controlled for socio-demographic factors and medical history. There were 62,583 women in the cohort (46.7% between 15 - 24 years), of whom 22.7% had asthma (94.3% mild, 5.7% moderate/severe; 86.5% controlled and 13.5% uncontrolled). After adjustment, there was increased risk of perinatal mental illness with mild asthma (adjusted relative risk [RR]: 1.12; 95% confidence interval [CI], 1.09 to 1.16) and moderate/severe asthma (aRR: 1.16; 95% CI, 1.04 to 1.30) compared to no asthma. Controlled asthma (aRR: 1.11; 95% CI, 1.08 to 1.15) and uncontrolled asthma (aRR: 1.19; 95% CI, 1.11 to 1.27) were also associated with increased perinatal mental illness risk compared to no asthma. Women with worsened asthma during pregnancy had the highest risk of postpartum mental illness compared to no change in asthma status (by severity: aRR: 1.57; 95% CI, 1.36 to 1.80; by control: aRR: 1.37; 95% CI, 1.22 to 1.54). Asthma is associated with increased risk of perinatal mental illness, particularly in the presence of asthma exacerbations in pregnancy. The results support multidisciplinary collaborative care programmes throughout the perinatal period, especially among women with asthma exacerbations during pregnancy.

Multi-institutional and multi-disciplinary care: A successfully managed aortic dissection in the third trimester of pregnancy.

Multi-disciplinary collaborative care for pregnant women with complex and emergent conditions is essential. Logistical planning, clear communication and human factor awareness are all non-clinical skills which need to be utilised in order to maximise outcomes. We describe the case of a proximal aortic dissection in the late third trimester of pregnancy diagnosed in a peripheral hospital that was transferred to a cardiothoracic centre for successful operative management 160 km away. This required the time-sensitive mobilisation and liaison of a receiving cardiothoracic, anaesthesiology and perfusionist team in conjunction with obstetric and midwifery support from an affiliated maternity hospital, as well as the national neonatal transport team. We emphasise the importance of multidisciplinary team management in complex cases and how imperative good inter-disciplinary communication is to ensure safe inter-hospital transfer.

Elimination of Hepatitis C Virus in a Dialysis Population: A Collaborative Care Model in Taiwan

Hemodialysis facilities are high-risk environments for the spread of hepatitis C virus (HCV). Eliminating HCV from all dialysis facilities in a community may be achieved more effectively under a collaborative care model. Quality improvement study of multidisciplinary collaborative care teams including nephrologists, gastroenterologists, and public health practitioners. All dialysis patients in Changhua County, Taiwan were treated using an interdisciplinary collaborative care model implemented within a broader Changhua-Integrated Program to Stop HCV Infection (CHIPS-C). Provision of an HCV care cascade to fill 3 gaps, including screening and testing, diagnosis, and universal direct-acting antiviral (DAA) treatment implemented by collaborating teams of dialysis practitioners and gastroenterologists working under auspices of Changhua Public Health Bureau. Outcome measures included quality indicators pertaining to 6 steps in HCV care ranging from HCV screening to treatment completion to cure. A descriptive analysis. A total of 3,657 patients from 31 dialysis facilities were enrolled. All patients completed HCV screening. The DAA treatment initiation rate and completion rate were 88.9% and 94.0%, respectively. The collaborative care model achieved a cure rate of 166 (96.0%) of 173 patients. No virologic failure occurred. The cumulative treatment ratios for patients with chronic HCV infection increased from 5.3% before interferon-based therapy (2017) to 25.6% after restricted provision of DAA (2017-2018), and then to 89.1% after universal access to DAA (2019). Unclear impact of this collaborative care program on incident dialysis patients entering dialysis facilities each year and on patients with earlier stages of chronic kidney disease. A collaborative care model in Taiwan increased the rates of diagnosis and treatment for HCV in dialysis facilities to levels near those established by the World Health Organization.

Use of Glucagon-Like Peptide-1 Receptor Agonists in Patients With Type 2 Diabetes and Cardiovascular Disease

Recent randomized clinical trials have demonstrated that glucagon-like peptide-1 receptor agonists (GLP-1RAs) reduce cardiovascular events in at-risk individuals with type 2 diabetes. Despite these findings, GLP-1RAs are underused in eligible patients, particularly by cardiologists. To date, randomized clinical trials of albiglutide, dulaglutide, liraglutide, and injectable semaglutide have reported favorable cardiovascular outcomes. Most recently approved for clinical use, oral semaglutide has a favorable safety profile and is currently undergoing regulatory evaluation and further study for cardiovascular outcomes. Professional society guidelines now recommend GLP-1RA therapy for cardiovascular risk mitigation in patients with type 2 diabetes and established atherosclerotic cardiovascular disease (ASCVD) or multiple ASCVD risk factors, independent of glucose control or background antihyperglycemic therapy (other diabetes medications being used). Additional conditions suitable for GLP-1RA therapy include obesity and advanced chronic kidney disease (estimated glomerular filtration rate <30 mL/min/1.73 m2), for which cardiovascular risk-reducing options are limited. Out-of-pocket costs and secondary advantages (eg, weight loss) may inform shared decision-making discussions regarding potential therapies. GLP-1RA therapy has a favorable safety profile. Its most common adverse effect is gastrointestinal upset, which typically wanes during the early weeks of therapy and may be mitigated by starting at the lowest dose and escalating as tolerated. Depending on baseline glycemic control, sulfonylureas and insulin may need to be decreased before GLP-1RA initiation; without concurrent use of insulin or sulfonylureas, GLP-1RAs are not associated with hypoglycemia. Multidisciplinary follow-up and collaborative care with primary care physicians and/or endocrinologists are important. Findings from this review suggest that GLP-1RAs are safe, are well tolerated, and improve cardiovascular outcomes, largely independent of their antihyperglycemic properties, but they remain underused by cardiologists. This review provides a practical resource for cardiologists for initiating GLP-1RAs and managing the therapy in patients with type 2 diabetes and established ASCVD or high risk for ASCVD.

Health Care Costs at the End of Life for Patients with Idiopathic Pulmonary Fibrosis. Evaluation of a Pilot Multidisciplinary Collaborative Interstitial Lung Disease Clinic.

Rationale: Even though idiopathic pulmonary fibrosis (IPF) is a disease with high morbidity and mortality and no cure, palliative care is rarely implemented, leading to high symptom burden and unmet care needs. In 2012, we implemented a multidisciplinary collaborative (MDC) care model linking clinic and community multidisciplinary teams to provide an early integrated palliative approach, focusing on early symptom management and advance care planning.Objectives: To evaluate the differences in resource use and associated costs of end-of-life care between patients with IPF who received early integrated palliative care and patients with IPF who received conventional treatment.Methods: Using administrative health data, we identified all patients in the Province of Alberta, Canada, who presented to a hospital with an IPF diagnosis between January 1, 2012, and December 31, 2018, and died within this time frame. We compared three groups of patients: those who received MDC care (our clinic patients), specialist care (SC; respirologist), or non-specialist care (NSC; no contact with a respiratory clinic). The primary outcomes were healthcare resource use and costs in the year before death.Results: Of 2,768 patients across the three study groups, in the last year of life, MDC patients were more than three times as likely as SC patients to have received antifibrotic therapies (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.8-5.2), almost twice as likely to have received pulmonary rehabilitation (OR, 1.9; 95% CI, 1.1-3.4), and 36% more likely to have received opiates (OR, 1.4; 95% CI, 0.8-2.3). The median total healthcare costs in the last 3 months of life were approximately C$7,700 lower for MDC patients than for those receiving SC, driven primarily by fewer hospitalizations and emergency department visits. MDC patients were also less likely to die in the hospital (44.9% MDC vs. 64.9% SC vs. 66.8% NSC; P < 0.001) and had the highest rates of no hospitalization in the last year of life.Conclusions: An integrated palliative approach in IPF is associated with improvements in the quality of end-of-life care and reduction in costs. Transformation of care models is required to deliver palliative care for patients with IPF. MDC teams within such models can address the high burden of unmet needs for symptom management, advance care planning, and community support in this complex population.

A CRITICAL REVIEW AND LOCAL AUDIT OF THE PREVALENCE OF MENTAL ILL-HEALTH IN HEART FAILURE PATIENTS

Objective: To establish if depression results in poor adherence to therapy in patients with heart diseases.&#x0D; Methods: This concept scoping study was conducted in two phases; the first was a systematic review of the literature, and the second part was local data analysis. Statistical analysis was performed using RevMan® V.5.3 (Cochrane Community).&#x0D; Results: Patients who received multidisciplinary collaborative care showed significantly reduced major adverse cardiac outcomes in patients with cardiovascular diseases. They also demonstrated higher rates of self-reported remission of depression. The review also showed endpoint mortality after PCI was associated with patients having depression. Local population data showed that 26% of heart failure patients had mental ill health comorbidity, however, only 12% had a formal diagnosis recorded.&#x0D; Conclusion: Depression is associated with poor cardiac outcomes in patients with coronary artery disease. It is widespread in patients with cardiovascular disease and must be screened for throughout the management plan.

A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol

Annually approximately 2–3 million Americans are so severely injured that they require inpatient hospitalization. The study team, which includes patients, clinical researchers, front-line provider and policy maker stakeholders, has been working together for over a decade to develop interventions that target improvements for US trauma care systems nationally. This pragmatic randomized trial compares a multidisciplinary team collaborative care intervention that integrates front-line trauma center staff with peer interventionists, versus trauma team notification of patient emotional distress with mental health consultation as enhanced usual care. The peer-integrated collaborative care intervention will be supported by a novel emergency department exchange health information technology platform. A total of 424 patients will be randomized to peer-integrated collaborative care (n = 212) and surgical team notification (n = 212) conditions. The study hypothesizes that patient's randomized to peer integrated collaborative care intervention will demonstrate significant reductions in emergency department health service utilization, severity of patient concerns, post traumatic stress disorder symptoms, and physical limitations when compared to surgical team notification. These four primary outcomes will be followed-up at 1- 3-, 6-, 9- and 12-months after injury for all patients. The Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) method will be used to assess implementation processes. Data from the primary outcome analysis and implementation process assessment will be used to inform an end-of-study policy summit with the American College of Surgeons Committee on Trauma. The policy summit will facilitate acute care practice changes related to patient-centered care transitions over the course of a single 5-year funding cycle.Trial registration: (Clinicaltrials.govNCT03569878).

Outcomes of Multidisciplinary Care for Pediatric Post-Concussive Symptoms

ObjectiveTo evaluate the effectiveness of a multidisciplinary treatment approach for adolescents experiencing prolonged recovery from concussion.BackgroundAlthough most youth recover from a concussion within 2–4 weeks, an estimated 14% of those injured remain symptomatic at 3 months post-injury. For those experiencing protracted recovery, the 2017 Berlin Concussion in Sport Group Consensus Statement recommends multidisciplinary collaborative care. While recent research utilizing progressive aerobic exercise among adolescents with concussion has shown promise for reduction in symptom burden, limited evidence exists for multidisciplinary care.Design/MethodsParticipants included 39 adolescents (77% female, 87% Caucasian) referred to the Nationwide Children’s Hospital Complex Concussion Clinic. All patients included had persistent (≥30 days post-injury) post-concussion symptoms (SCAT-5 symptom score ≥10). The sample ranged in age from 11-20 years (mean = 15.0, SD = 2.0) and median days since injury was 60 (range = 30–161). 31% of participants had a history of one or more previous concussions, 54% had a history of anxiety or depression, and 26% had a history of ADHD or a learning disorder. The multidisciplinary treatment included sessions with Neurology (mean number of sessions = 2.5), Neuropsychology (mean = 2.1), Physical Therapy (mean = 3.6), and Athletic Training sessions involving graded physical exercise (mean = 4.0), with an average treatment duration of 57.4 days. SCAT-5 symptom rating scales were completed at each visit.ResultsSymptom burden among participants significantly decreased between their initial visit (mean = 49.6, SD = 19.2) and final exercise session (mean = 12.8, SD = 14.1); p &lt; 0.001. Gender did not predict symptom ratings at treatment onset, though males (mean = 5.6) had significantly lower symptom scores than females (mean = 15.0) at their final visit (p &lt; 0.05). Demographic factors and premorbid psychological history did not predict rate of symptom improvement.ConclusionsHigh rates of premorbid psychological problems are evident in children referred for treatment of PCS. Multidisciplinary care involving graded aerobic exercise and psychological intervention shows promise, though specific factors associated with treatment response remain to be elucidated.

MAMA's Risk Stratified, Prenatal Medical Home Model Reduces Preterm Birth for African Americans in LA [22N

INTRODUCTION: MAMA'S Neighborhood (MAMA's) in LA County (LAC) organizes prenatal care into a medical home model of wrap-around services. African American (AA) women are 48% more likely to experience PTB than non-Hispanic whites and experience myriad social stressors; MAMA's was designed to support women experiencing such stressors to reduce PTB risk. MAMA's implemented risk assessments at intake for behavioral health, substance use, housing/food insecurity and medical risk; and stratified risk groups to direct levels of care management and services to address these risks. METHODS: This is a retrospective cohort study, using single site data from a national demonstration project, to compare PTB rates for women in LAC during two phases: Phase 1: January 2014-August 2015, MAMA's introduced a novel risk assessment for social stressors and Phase 2: September 2015-December 2016, implemented risk-stratified population health management and individualized care planning. Multiple births were excluded. Multivariate logistic regression was performed and controlled for: medical comorbidities, smoking, race/ethnicity, age and prior PTB. RESULTS: Phase 1 included 441 women, compared to 435 in Phase 2. PTB among AA women dropped from 18% in Phase 1 to 9% in Phase 2. Regression reveals PTB among AA women was reduced when compared to controls with an adjusted odds ratio of 0.21 (CI 0.062-0.708), p<0.02. CONCLUSION: MAMA's made a clinically and statistically significant impact on PTB for AA women, a critical step in addressing the health equity gap. MAMA's represents a promising value-based strategy leveraging multidisciplinary collaborative care with existing social services in the safety net to improve birth outcomes.