Multidisciplinary Health Care Research Articles

An examination of referrals declined for chronic pain care: There is increasing mental health complexity within care-seeking patients with chronic pain over time

ABSTRACT Background Chronic pain is a complex disease that requires interprofessional care for effective management. Despite the need for multidisciplinary care, disease and health care inequities can prevent individuals from attaining adequate treatment. Factors such as mental health, cost, and distance to a health care center can contribute to health care accessibility inequality. The aim of this study is to examine declined referrals at the Toronto Academic Pain Medicine Institute (TAPMI) to determine the reason for declining care and number of declined referrals. Methods A retrospective chart review of all declined referrals at TAPMI in 2018 and 2022 was conducted. Referral documentation and the intake decision were extracted from the electronic medical charts by the research team and verified by the clinical intake team. Chi-square tests were conducted to determine whether the proportion of declined referrals changed between the years reviewed. Results The number of declined referrals due to mental health complexities increased significantly from 51 (11%) in 2018 to 180 (18%) in 2022 (χ2 = 10.9, P = 0.0009). A significant rise in the number of declines due to mental health service requests was also observed (χ2 = 24.53, P < 0.00001). Other common reasons for declined referrals in 2018 and 2022 included duplicate service, no primary care provider, and health care service changes. Conclusion Mental health complexities continue to be a significant barrier to health care service acquisition for individuals living with chronic pain. The increase in patient complexity from 2018 to 2022 highlights the need for integrated health care resources.

Perinatal Palliative Care and Ethical Issues

Perinatal palliative care is a specialty that covers the fields of obstetrics, fetal medicine, pediatric palliative medicine and neonatal medicine. In this care, healthcare professionals offer an individualized care plan based on the needs of the fetus/newborn and family members in a multidimensional way with an interdisciplinary team approach. Unlike adult, neonatal and pediatric palliative care, the patient is not only a single person but a mother-fetus couple in perinatal palliative care; therefore this care type is based on family-centered care philosophy. Due to lack of information about preferences or requests of the fetus, families are expected to make the best medical decision for their baby considering their wishes and values. In this respect, it is important for the team members to inform the families during this process and for multidisciplinary healthcare professionals to support them for making the most appropriate decision. This review article examined the importance of perinatal palliative care, ethical issues, and the roles and responsibilities of the nurse.

Implementation of a Provincial Long COVID Care Pathway in Alberta, Canada: Provider Perceptions.

A novel, complex chronic condition emerged from the COVID-19 pandemic: long COVID. The persistent long COVID symptoms can be multisystem and varied. Effective long COVID management requires multidisciplinary, collaborative models of care, which continue to be developed and refined. Alberta's provincial health system developed a novel long COVID pathway. We aimed to clarify the perspectives of multidisciplinary healthcare providers on the early implementation of the provincial long COVID pathway, particularly pathway acceptability, adoption, feasibility, and fidelity using Sandelowki's qualitative description. Provider participants were recruited from eight early-user sites from across the care continuum. Sites represented primary care (n = 4), outpatient rehabilitation (n = 3), and COVID-19 specialty clinics (n = 2). Participants participated in structured or semi-structured virtual interviews (both group and 1:1 were available). Structured interviews sought to clarify context, processes, and pathway use; semi-structured interviews targeted provider perceptions of pathway implementation, including barriers and facilitators. Analysis was guided by Hsieh and Shannon as well as Sandelowski. Across the eight sites that participated, five structured interviews (n = 13 participants) and seven semi-structured interviews (n = 15 participants) were completed. Sites represented primary care (n = 4), outpatient rehabilitation (n = 3), and COVID-19 specialty clinics (n = 2). Qualitative content analysis was used on transcripts and field notes. Provider perceptions of the early implementation outcomes of the provincial long COVID pathway revealed three key themes: process perceptions; awareness of patient educational resources; and challenges of evolving knowledge.

Effectiveness and family experiences of interventions promoting partnerships between families and pediatric and neonatal intensive care units: a mixed methods systematic review.

The objective of this mixed methods review was to examine the effectiveness and family experiences of interventions promoting partnerships between families and the multidisciplinary health care team in pediatric and neonatal intensive care units. Hospitalization of infants and children in neonatal intensive care units and pediatric intensive care units has a significant effect on their families, including increased stress, anxiety, and depression. Available evidence syntheses focused on specific family-centered care, but not on partnership, which is another aspect that may improve the families' outcomes and experiences. This review focused on effectiveness and experiences of interventions by health professionals in partnership with families of infants or children hospitalized in an intensive care unit. The type of intervention was a partnership between the health care team and the family, and focused on outcomes of stress, anxiety, depression, quality of life, attachment, or satisfaction with family-centered care. The JBI methodology for convergent segregated mixed methods systematic reviews was followed using the standardized JBI critical appraisal and data extraction tools. Ten databases were searched from January 2000 to April 2022. Findings of quantitative studies were statistically pooled through meta-analyses and those that could not pooled were reported in a narrative format. Qualitative studies were pooled through meta-synthesis. This review included 6 qualitative and 42 quantitative studies. There was mixed methodological quality and all studies were included regardless of methodological quality. Meta-analyses showed positive improvements in anxiety, satisfaction with family-centered care, and stress, yet no conclusive effects in attachment and depression. These results should be interpreted with caution due to high heterogeneity. Qualitative analysis resulted in 2 synthesized findings: "Interventions that incorporate partnerships between families and the health care team can improve the family's experience and capacity to care for the child" and "Having a child in intensive care can be an experience of significant impact for families" Integration of quantitative and qualitative evidence revealed some congruence between findings; however, the paucity of qualitative evidence minimized the depth of this integration. Partnership interventions can have a positive impact on parents of children in intensive care units, with improvements seen in stress, anxiety, and satisfaction with family-centered care. PROSPERO CRD42019137834.

Who really decides? Feeding decisions 'made' by caregivers of children with cerebral palsy.

There are no definitive guidelines for clinical decisions for children with cerebral palsy (CP) requiring enteral feeds. Traditionally, medical doctors made enteral feeding decisions, while patients were essentially treated passively within a paternalistic 'doctor knows best' approach. Although a more collaborative approach to decision-making has been promoted globally as the favoured model among healthcare professionals, little is known about how these decisions are currently made practically. This study aimed to identify the significant individuals, factors and views involved in the enteral feeding decision-making process for caregivers of children with CP within the South African public healthcare sector. A single-case research design was used in this qualitative explorative study. Data were collected using semi-structured interviews and analysed using reflexive thematic analysis. Four primary individuals were identified by the caregivers in the decision-making process: doctors, speech therapists, caregivers' families and God. Four factors were identified as extrinsically motivating: (1) physiological factors, (2) nutritional factors, (3) financial factors and (4) environmental factors. Two views were identified as intrinsically motivating: personal beliefs regarding enteral feeding tubes, and feelings of fear and isolation. Enteral feeding decision-making within the South African public healthcare sector is currently still dominated by a paternalistic approach, endorsed by a lack of caregiver knowledge, distinct patient-healthcare provider power imbalances and prescriptive multidisciplinary healthcare dialogues.Contribution:This study has implications for clinical practice, curriculum development at higher education training facilities, and institutional policy changes and development, thereby contributing to the current knowledge and clinical gap(s) in the area.

Multidisciplinary First-Line Healthcare Leaders' Roles and Experiences During the COVID-19 Pandemic in Ontario Canada.

Throughout the COVID-19 pandemic, first-line healthcare leaders across the healthcare system played crucial roles leading, motivating, and supporting staff. This study aims to describe multidisciplinary first-line healthcare leaders' experiences during the COVID-19 pandemic in Ontario, Canada using transformational and crisis leadership theory. A descriptive two-phase (quantitative & qualitative) design was conducted in the spring of 2021. Phase 1 employed an online survey sent via email to first-line leaders from various sectors who were members of healthcare professional associations in Ontario. Participants included nurse managers, professional practice leaders (e.g., occupational and physiotherapists), advanced practice nurses, and clinical educators. In Phase 2, a subset (n = 19) of the Phase 1 participants were interviewed to gain a deeper understanding of these leaders' experiences including role impact and support available. Semistructured individual interviews were conducted and recorded via Zoom©. Inductive and deductive analysis approaches identified key themes. This paper reports the qualitative findings from Phase 2. Leaders' behaviors were representative of the key dimensions of transformational and complexity leadership theories. Recommendations for leading during a crisis included: engaging in self-care activities to manage the personal impact of the crisis; teamwork and collaborative leadership; and support from fellow first-line leaders and senior leaders. Findings can inform healthcare leadership education programs designed to manage future crises for both academic and practice settings. Descriptions of first-line healthcare leaders' roles and experiences during multiple waves of the COVID-19 pandemic validated their important contributions within various health sectors.

Determinants of the Health-Promoting Behaviors Among Community-Dwelling Older Adults with Non-communicable Diseases During the Post-Covid-19 Era

Background: While research has explored the health-promoting behaviors (HPBs) of older adults on a global scale during the first and second waves of COVID-19, there is limited knowledge about the factors that influence HPBs among older adults with non-communicable diseases (NCDs) in the "new normal" following the COVID-19 era. Objectives: The aim of this study was to identify the factors that affect HPBs among community-dwelling older adults with NCDs. Methods: This cross-sectional study involved surveying 250 older adults with NCDs in both urban and rural communities within Ubon Ratchathani province, northeast Thailand, between September 10 and November 10, 2022, during the COVID-19 pandemic. Data collection was conducted using a self-administered questionnaire, which included the Self-rated Abilities Scale for Health Practice, Health Literacy Scale, Access to COVID-19 Preventive Material, Lubben Social Network Scale, and Health-Promoting Behaviors Scale. The analysis utilized descriptive statistics and hierarchical regression analysis, setting the significance level at P &lt; 0.05 for all analyses. Results: Among the 250 older adults with NCDs surveyed, 65.60% had hypertension. These individuals demonstrated HPBs at a good level, along with a high level of perceived self-efficacy, good health literacy, adequate access to COVID-19 preventive materials, and greater social engagement. The analysis indicated that perceived self-efficacy (β = 0.343, P &lt; 0.001), attitudes towards smoking (β = 0.226, P &lt; 0.001), age (β = 0.204, P &lt; 0.001), health literacy (β = 0.199, P = 0.016), and access to COVID-19 preventive materials (β = 0.123, P = 0.026) were significant predictors of HPBs in older adults with NCDs. Conclusions: The results suggest that improved access to COVID-19 preventive materials, enhanced health literacy, and increased self-efficacy contribute to better health-promoting behaviors among older adults with NCDs. Multidisciplinary healthcare teams should consider these factors in their intervention strategies to achieve a deeper understanding and better health outcomes. Future research should investigate the causal relationships among these variables and examine older adults’ perceptions of HPBs in long-term care settings, particularly in the "new normal" era.

A study to assess the knowledge regarding antenatal care among pregnant women at District Hospital of Bareilly (U.P.) with a view to develop an information booklet

The objective of the study are to assess knowledge regarding antenatal care among pregnant women. To associate knowledge of pregnant women with their selected demographic variable that is age, area, qualification, occupation, religion, type of family, living of area, dietary pattern. To develop a information booklet on knowledge of antenatal care for pregnant women. Nurses being one of the members in multidisciplinary health care team must have adequate knowledge of the Antenatal Care. The researcher felt the need of a structured interview schedule for pregnant women and intended to assess the knowledge regarding antenatal care . The descriptive research design was used to assess the knowledge regarding Antenatal care among pregnant women of District Hospital Bareilly, (U.P). In view of the nature of problem and to accomplish the objectives of the study, a structured interview schedule to assess the knowledge regarding Antenatal care among pregnant women was prepared and used. Validity of the tool was ensured by consulting the guides and experts in the fields of statistics, medicines and Nursing and reliability (0.78) of the tool was tested. The study was carried out in District Hospital Bareilly (U.P) pregnant women were selected by Non probability purposive sampling technique. Structured interview schedule was used to collect the needed data. Data was analyzed by using descriptive and inferential statistics. Pregnant women knowledge regarding antenatal care is very good .Divided into 4 parts. Excellent 11(36.66%), V.Good15(50%) , Good 4(13.33%) Poor 0 (0%). Hence the total mean average is 706 and mean percentage is 78.43%. Thus by conducting this study we conclude that pregnant women having very good knowledge regarding antenatal care. Keywords: Assess; Knowledge; Antenatal care; pregnant women

Caries indicators in relation to healthcare access and hygienic-dietary habits in Spanish preschoolers.

Dental caries continues to be a public healthcare problem due to its high prevalence and morbidity. It was proposed to evaluate caries indicators in relation to healthcare access and hygienic-dietary habits in Spanish preschoolers. A cross-sectional study was carried out on a random sample consisting of 343 patients ranging from 3 to 5 years of age in the primary care setting, the main measurements were: dental care access, hygienic-dietary habits, and caries registration according to WHO criteria. The prevalence of caries was 35.3% and mean ± standard deviation (SD) dft was 1.51 ± 2.93. Preschoolers who had ever visited the dentist had a higher dft occurrence than those who had never attended the dentist. The lower prevalence of caries was significantly associated with the frequency of two daily brushings versus non-daily brushing (p = 0.007; 25.3% vs. 47.1%) and was 10.7% lower in patients who had the habit of night brushing (p = 0.041). The consumption of sugary liquids between meals implied a higher dft index. The high prevalence of early childhood caries and the dental care access associated with poor oral health suggest the need to implement a multidisciplinary oral healthcare program that involves both healthcare and dental healthcare professionals in Primary Health Care Units without forgetting the participation of the community and local administrations.

“Cooperation between physicians and physios fosters trust you know”: a qualitative study exploring patients’ experience with first-contact physiotherapy for low back pain in French primary care

BackgroundPhysiotherapists working in collaboration with family physicians in French multidisciplinary primary healthcare clinics are now able to manage acute low back pain patients as first-contact practitioners in advanced practice roles. This includes medical act delegation such as making a medical diagnosis and prescribing medication. The aim of this study is to explore patients’ experience and perceptions when attending a first-contact physiotherapist (FCP) in an advanced practice collaborative primary care model for acute low back pain (LBP).MethodsA qualitative study using semi-structured interviews was conducted. Patients that consulted a FCP for acute LBP care in new collaborative model were included. Interviews were transcribed verbatim and inductive thematic analysis was performed to generate themes related to patients’ experience and perceptions.ResultsTen patients were interviewed (3 women, 7 men; mean age 36.5 ± 9.63 years). All LBP participants experienced important level of pain and disability. Four overarching themes related to patients’ experience with the new FCP model were formalized: 1) “Going to see a physiotherapist who specializes in painful movements, well that makes sense to me”, 2) “Physiotherapist offered to give me exercises to do at home to relieve the back pain”, 3) “I went there feeling confident”, 4) “The physiotherapist can do more than just send you to see more appropriate people”. Participants highlighted the need to receive timely and high-quality care and were receptive with being autonomously managed by a FCP. Overall, patients’ experiences with FCP model of care were positive. Participants were highly confident in the FCP’s ability to perform delegated medical tasks including making a medical diagnosis and prescribing oral medication such as analgesic drugs. Patients felt that a greater expansion of FCPs’ scope of practice was needed to improve the model.ConclusionFindings from this study can inform the implementation of FCP in countries where patients are not typically granted FCP by underlining that patients are favourable towards the advance practice model as such models support timely and high-quality care. Further research is needed to better determine the future advance practice physiotherapists’ scope of practice in French primary and secondary care settings.

Adaptive strategies used by surgical teams under pressure: an interview study among senior healthcare professionals in four major hospitals in the United Kingdom

BackgroundHealthcare systems are operating under substantial pressures, and often simply cannot provide the standard of care they aspire to within the available resources. Organisations, managers, and individual clinicians make constant adaptations in response to these pressures, which are typically improvised, highly variable and not coordinated across clinical teams. The purpose of this study was to identify and describe the types of everyday pressures experienced by surgical teams and the adaptive strategies they use to respond to these pressures.MethodsWe conducted interviews with 20 senior multidisciplinary healthcare professionals from surgical teams in four major hospitals in the United Kingdom. The interviews explored the types of everyday pressures staff were experiencing, the strategies they use to adapt, and how these strategies might be taught to others.ResultsThe primary pressures described by senior clinicians in surgery were increased numbers and complexity of patients alongside shortages in staff, theatre space and post-surgical beds. These pressures led to more difficult working conditions (e.g. high workloads) and problems with system functioning such as patient flow and cancellation of lists. Strategies for responding to these pressures were categorised into increasing or flexing resources, controlling and prioritising patient demand and strategies for managing the workload (scheduling for efficiency, communication and coordination, leadership, and teamwork strategies).ConclusionsTeams are deploying a range of strategies and making adaptations to the way care is delivered. These findings could be used as the basis for training programmes for surgical teams to develop coordinated strategies for adapting under pressure and to assess the impact of different combinations of strategies on patient safety and surgical outcomes.

Giving voice to the voiceless: Understanding the perceived needs of dementia family carers in Soweto, a South African township.

This qualitative study aimed to provide family caregivers with an independent platform to reflect on and identify their needs in the role of dementia caregiver. Thirty caregivers were interviewed using a semi-structured approach, and data analysis followed a reflective thematic analysis method. The study revealed that Black African caregivers in townships require sufficient information and orientation to dementia-specific services, psychoeducation on dementia as a disease and its behavioural manifestations, as well as practical skills to manage the disease process. Caregivers expressed the need for in-depth, accessible education to boost their confidence and resilience in handling the challenges of dementia caregiving. They also proposed community initiatives to raise awareness, promote knowledge, and facilitate early detection and diagnosis of dementia. Additional needs included informational and educational workshops, resources like transportation services and helplines, day care facilities, media campaigns, and collaboration with the government for funding and policy change. New caregivers were advised to seek comprehensive education, support, and services while preserving the dignity of their family members with dementia. Remarkably, the identified needs and community initiatives aligned with the priority areas outlined by ADI for a National Dementia Plan, which South Africa currently lacks. The study highlights the importance of developing a National Dementia Plan in South Africa through collaboration among stakeholders, including communities, policy-makers, and multidisciplinary healthcare teams, while ensuring that individuals and families affected by dementia have a voice.

Is it "all in the bag?"Multidisciplinary perspectives on ostomy surgery in pediatric IBD across the ImproveCareNow network.

Pediatric inflammatory bowel disease (IBD) is a chronic illness with various treatments, including ostomy surgery. Ostomy-related medical decision-making (MDM) is complex for multidisciplinary healthcare professionals (HCPs). This study sought to understand national multidisciplinary HCPs' perceptions about pediatric IBD ostomy surgery in the United States. This cross-sectional REDCap survey recruited HCPs in pediatric IBD HCP roles from the ImproveCareNow (ICN) Learning Health System. The survey gathered data on, (1) demographics, (2) participants'perspectives on patients/families'ostomy perceptions,(3) participants'own perspectives on ostomies, and (4) participants'perspectives on multidisciplinary collaboration in ostomy surgery. Participants (n = 69, across n = 30 American ICN sites) were 84% White, 62% female, and 54% gastroenterologists. In reflecting on patients/families'perceptions, participants endorsed most (86%) view ostomies as a "failure," various psychosocial concerns (e.g., 97% endorsed body image concerns), and most (81%) have moderate to significant stigma about ostomies. In reflecting on their own perceptions, nearly half (44%) endorsed some to moderate stigma about ostomies and felt ostomy discussions were difficult when families had negative perceptions (88%). Over half (54%) endorsed currently having multidisciplinary care for pediatric IBD surgery. Most (70%) endorsed variability in the amount and/or quality of multidisciplinary collaboration. MDM related to pediatric IBD ostomy surgery presents nuanced clinical complexities for HCPs. This work underscores interest in multidisciplinary care, notable ostomy-related psychosocial needs, and ostomy-related stigma. Future work should develop systematic approaches to multidisciplinary pediatric IBD ostomy care, bolster psychosocial support, and evaluate how systematic care may impact psychosocial, and healthcare utilization outcomes.

Co-design of the Spinal Cord Injury Health Maintenance Tool to Support Self-Management: A Mixed-Methods Approach.

There is a lack of consumer-friendly tools to empower and support people living with spinal cord injury (SCI) to self-manage complex health needs in community. This article describes the co-design process of the new SCI Health Maintenance Tool (SCI-HMT). Co-design of the SCI-HMT using a mixed-methods approach included a rapid review, e-Delphi surveys with range of multidisciplinary health care professionals (n = 62), interviews of participants with SCI (n = 18) and general practitioners (n = 4), focus groups (n = 3 with 7, 4, and 4 participants with SCI, respectively), design workshops with stakeholders (n = 11, 8), and end-user testing (n = 41). The SCI-HMT (healthmaintenancetool.com) was developed based on participatory research with data synthesis from multiple sources. Five priority health maintenance issues for bladder, bowel, skin, pain, and autonomic dysreflexia were originally covered. Best practice recommendations, red flag conditions, referrals, and clinical pathways were agreed on through an e-Delphi technique. Qualitative analysis identified six broad key concepts for self-management, including early symptom recognition, role of SCI peers, knowledge sharing with primary care, general practitioners as gatekeepers, and shared decision-making and highlighted a need to place much stronger emphasis on mental health and well-being. Design workshops and end-user testing provided key insights about user experience, functionality, and content for the SCI-HMT. The co-design process engaging end users, including people with SCI and general practitioners, enabled a shared understanding of the problem and identification of important needs and how to meet them. Informed by this process, the SCI-HMT is a freely accessible resource supporting SCI self-management, shared decision-making, and early problem identification.

Remote pulmonary rehabilitation for interstitial lung disease: developing the model using experience-based codesign

BackgroundRemote delivery may improve access to pulmonary rehabilitation (PR). Existing studies are largely limited to individuals with COPD, and the interventions have lacked codesign elements to reflect the needs and...

Abstract WP53: Bringing Comprehensive Stroke Care Home: Supporting Early Supported Discharge

Background and Issues: Despite holding the highest certification as a Comprehensive Stroke Center, the project site's 'Discharge-to-Home' performance for ischemic stroke survivors ranked below the median compared to similar academic medical centers. Although an innovative Early Supported Discharge (ESD) program was available for patients who met geographical criteria, the utilization of these services was not optimal. Purpose: This Quality Improvement initiative aimed to investigate the impact of an early collaborative discharge planning process led by a multidisciplinary healthcare team on 'Discharge-to-Home' rates of ischemic stroke patients eligible for the site's ESD program, Homeward Stroke Recovery. Methods: Meleis' Transition Theory was used to shape the development of streamlined workflows, simplifying the identification of eligible patients and reducing the time taken to refer them to Homeward Stroke Recovery through enhancements to the electronic medical record system. Additionally, robust team education was provided to improve discharge coordination and improve the utilization of available ESD services. Existing system data was leveraged, and new data flows were created to monitor program-specific metrics. Descriptive statistics were used to examine the effect of an early collaborative discharge planning process on ‘Homeward Stroke Recovery Discharge Rates’ for ischemic stroke survivors. Results: There was a notable increase of 5.6% in the 'Homeward Stroke Recovery Discharge Rate' from Fiscal Year 2022 to Fiscal Year 2023 (rising from 43.9% to 49.5%). Conclusions: In conclusion, this Quality Improvement project successfully addressed the challenge of suboptimal 'Discharge-to-Home' rates for ischemic stroke patients eligible for the site’s ESD program. The observed 5.6% increase in the 'Homeward Stroke Recovery Discharge Rate' between Fiscal Year 2022 and Fiscal Year 2023 reflects the positive impact of the interventions performed, highlighting the importance of multidisciplinary teamwork and systematic improvements in healthcare delivery.

Adolescents on an inpatient unit and their healthcare providers: what's working and what's not.

Adolescents admitted to hospital can face unique medical and psychosocial challenges, and may be treated by healthcare providers who do not recognize or adequately address these needs. Our goal was to better understand the experiences of both patients and providers at a local level. We designed a cross-sectional survey-based study of two participant groups: (1) adolescent patients (aged 10-19) admitted to general medical wards at a tertiary pediatric hospital and (2) pediatric healthcare providers representing multiple disciplines. A total of 65 individuals participated: 25 adolescents (mean age 14.6; range 11-17) and 40 multidisciplinary healthcare providers. Most adolescents reported being treated respectfully (88 %) and taken seriously (92 %) by their providers. Several identified structure and routine, a break from daily stressors, and quality time with loved ones as positive aspects to hospitalization, while the use of correct gender pronouns, privacy, and age-appropriate leisure activities were cited areas for improvement. The majority of providers reported enjoying caring for adolescents (82 %) and forging therapeutic connections with them (87 %). Several areas of discomfort were noted, including gender and sexuality, substance use, and suicidality. Identified care gaps included inadequate training/education, suboptimal ward environments, and lack of community resources. Hospitals should recognize adolescent patients' needs for privacy, youth-centered communication, and developmentally-appropriate spaces. Pediatric healthcare professionals generally enjoy providing care to adolescents in the in-patient setting, however, often have insufficient training in addressing adolescent-specific health and psychosocial issues.

ADJUBIL: A phase II study of immunotherapy with durvalumab and tremelimumab in combination with capecitabine or without capecitabine in adjuvant situation for biliary tract cancer.

TPS583 Background: Despite improvements in multidisciplinary healthcare, patients with biliary tract cancer (BTC) have a poor outcome and effective treatment options are limited. Only 20 % of patients are eligible for surgical resection with curative intent, with 5-year overall survival rates &lt; 10 % for all patients. Data on adjuvant chemotherapy alone for BTC are conflicting, and the SOC is treatment with capecitabine according to the UK BILCAP trial, even though BILCAP was formally negative. Based on the positive data for durvalumab in the TOPAZ-1 trial in BTC and for the STRIDE regimen in HCC according to the Himalaya trial data, the evaluation of the IO combination in the adjuvant setting seems promising. Also, the MediTreme trial showed promising response rates in BTC. Preclinical studies indicate that the antibody combination leads to stronger and more durable anti-tumour effects than single therapies, as it synergistically modulates the tumour's immunosuppressive microenvironment, which is particularly pronounced in cholangiocarcinoma. The aim of the ADJUBIL trial is to evaluate the clinical activity of the anti-PD-L1 (programmed-death 1 ligand) antibody durvalumab and the anti-CTLA-4 (cytotoxic T- lymphocyte-associated antigen 4) antibody tremelimumab in combination with or without capecitabine in patients with respectable BTC in the adjuvant setting. This is a randomized phase II study with a pick-the-winner design. The winner of ADJUBIL could be tested against the current SOC capecitabine in a subsequent phase 2/3 trial. Methods: The ADJUBIL trial is an open-label, multicenter phase II study, including patients with BTC after curative surgery (R0/R1) with no previous systemic treatment. Patients are randomized (1:1) to receive either tremelimumab (300 mg, one dose on C1D1) plus durvalumab (1500 mg every 4 weeks; max. 12 months), with or without capecitabine (1250 mg/m2 twice a day on day 1-14 of 3-weekly cycles; max. 8 cycles). 40 evaluable patients will be enrolled in the study to receive anticancer treatment until disease recurrence or intolerable toxicities. Primary objective is to assess the anti-tumor activity of the treatment in both arms by the recurrence-free survival rate after 12 months. Secondary endpoints are recurrence-free survival, overall survival, toxicity, and quality of life. Exploratory endpoints are to identify predictive biomarkers for recurrence-free survival and overall survival. Study start of the ADJUBIL trial was in June 2021. By September 2023, 15 centers in Germany have been activated and 23 out of 40 planned patients have been enrolled. The first 5 patients in each arm were subject to a safety lead-in phase with close monitoring of (serious) adverse events. The safety assessment revealed no concerns. The study is ongoing. Clinical trial information: NCT05239169 .

Proactive Risk Management using Healthcare Failure Mode Effect Analysis Tool to Improve Medication Management Process

Proactive risk management program is essential to maintain the quality and safety of patient care, treatment, and services within a healthcare system. According to the Joint Commission, hospitals need to adopt a proactive approach for risk management and develop risk mitigation strategies to reduce or eliminate the potentially harmful impact of possible risk. There are multiple tools that can be used for proactive analysis. Leaders of Evercare hospital Dhaka selected Healthcare FMEA tool to identify the potential failure modes in the current medication management process as it is one of the complex and high processes in healthcare settings. A multidisciplinary Healthcare FMEA team was formed comprising physician, nurse, pharmacist, quality, IT personnel and senior managements of EHD to conduct Healthcare FMEA. After completing Healthcare FMEA, twenty failure modes(n-20) and fifty-nine potential causes(n-59) of failure modes were detected in existing medication management process of EHD. The hazardous score was Two hundred &amp; seventeen (n-217). There were Twelve major failures modes with higher hazardous score. Healthcare FMEA team members decided to eliminate major failures and actions were taken to control these failures. The main objective of this study is to maintain the medication error of EHD within the target (2/1000 patient days) by implementing required strategies and redesigning existing medication management process. The limitation of this study was it is a time-consuming process, it only helps to identify the possibilities of fail; it does not eliminate them, additional efforts are required to develop corrective action. Pulse Vol.15, 2023 P: 28-33

Publicly funded healthcare costs associated with orofacial clefts for children born in Alberta, Canada between 2002 and 2018.

Orofacial clefts (OFCs) include cleft palate (CP), cleft lip (CL), and cleft lip with cleft palate (CLP) and require multidisciplinary healthcare services. Alberta, Canada has a publicly funded, universal access healthcare system. This study determined publicly funded healthcare costs for children with an OFC and compared these costs to children without congenital anomalies. This retrospective population-based cohort analysis used the Alberta Congenital Anomalies Surveillance System to identify children born between 2002 and 2018 with an isolated OFC. They were matched 1:1 to a reference cohort based on sex and year of birth. The study population included 1614 children, from birth to 17 years of age linked to administrative databases to estimate annual inpatient and outpatient costs. Average annual all-cause costs were compared using two-sample independent t tests. The mean total cleft-related costs per patient were highest for children with CLP ($74,138 CAD, standard deviation (SD) $43,447 CAD), followed by CP ($53,062 CAD, SD $74,366 CAD), and CL ($35,288 CAD, SD $49,720 CAD). The mean total all-cause costs per child were statistically significantly higher (p < .001) in children with an OFC ($56,305 CAD, SD $57,744 CAD) compared to children without a congenital anomaly ($18,600 CAD, SD $61,300 CAD). Despite public health strategies to mitigate risk factors, the trend for OFCs has remained stable in Alberta, Canada for over 20 years. The costs reported are useful to other jurisdictions for comparison, and to families, healthcare professionals, service planners, and policy makers.