Patient Care Plans Research Articles

Closing the Gap: Multidisciplinary Coordination of a Care Plan for Patients with Multimorbidity

Introduction: Multidisciplinary communication and collaboration are of utmost importance in order to transition from fragmented and disease-centered care to patient-centered care for people with multimorbidity. Interdisciplinary coordination of a care plan is a vital part of this collaboration, yet can take many different forms. Our primary aim is to uncover the existing pathways of multidisciplinary communication and collaboration to reach an integrated treatment plan. Our secondary aim is to identify potential limitations and strengths of these pathways, in order to propose ways to improve interdisciplinary coordination, and ultimately improve outcomes of care for patients with multimorbidity in the hospital.
 Methods: Seven focus groups were organized, in both secondary and tertiary hospitals in the Netherlands. Each focus group was centered around a recent, local case study regarding a patient with multimorbidity. All involved health care professionals related to this specific patient were invited to participate in the focus group. Focus groups followed a discussion guide and were transcribed verbatim. Text was fragmented, coded and thematized using the principles of grounded theory. Member checking was performed by experts in the field.
 Results: 20 medical professionals were interviewed from three secondary, and four tertiary hospitals. None of the focus groups included all invited professionals due to their conflicting schedules. Analysis showed that the process of interdisciplinary coordination could be divided into the ‘reason’, ‘timing’, ‘modality’ and ‘outcome’. The ‘reason’ to seek interdisciplinary coordination could be medical complexity, a signal from a patient that indicates uncoordinated care, need for division of care roles, or to explore if care plans are aligned with the patient as a whole. Care providers could opt for different modalities to collaborate, such as: a phone call, referral to a colleague, or organizing a multidisciplinary team meeting. Possible outcomes could be integrating patient goals into the care plan, reduction in care consumption, and/or higher patient satisfaction. Factors of influence were identified for all main elements of this process: e.g. level of experience of the health care professional and available financial structures for different modalities of collaboration.
 Implications: We introduce a process model describing the current pathways in multidisciplinary coordination of care for patients with multimorbidity. This model shows that depending on the reason to collaborate, and with the desirable outcome in mind, different modalities of collaboration and communication are possible. Using case studies, we illustrate how and where current pathways can fall short and new innovative ways of providing care can be developed. For the Netherlands, we are developing a new mode of seeking coordination based on this model which ensures better multidisciplinary collaboration and inclusion of the patient perspective: a structured multidisciplinary patient review (MPR) for patients with multimorbidity. We hope to inspire the international community to adapt this innovative model to their own context of care.
 

Self-management care plans for patients with severe chronic obstructive pulmonary disease: a quality improvement project

Self-management care plans for patients with severe chronic obstructive pulmonary disease: a quality improvement project

Holistic care needs in an inpatient oncology unit: patients versus professionals.

Macmillan Cancer Support advocates that a Holistic Needs Assessment (HNA) is carried out at diagnosis and re-evaluated at significant key milestones throughout the patient journey. This now includes acute admission. However, evidence describing the use of HNAs and prevalence of unmet holistic needs in the acute oncology setting is lacking. This project aims to identify the prevalence of unmet holistic needs of patients in an acute oncology setting, and discern the differences in perception of needs between patients and healthcare professionals (HCPs). Patient and HCP surveys were conducted at 2 time points over a 10-month period. Surveys were co-designed with patient representatives based on the Macmillan Cancer Support 'concerns checklist' and used a 5-point Likert scale, rating the importance of each domain to the patient and HCP and the degree to which they felt the clinical team were aware of their needs. In areas where there was good concordance between patient and HCPs ratings of prevalence, patients still perceived that HCPs were mostly unaware of these needs. Furthermore, HCPs overvalued the importance of advanced care planning and cardiopulmonary resuscitation discussions for patients. There are discrepancies between patient and HCP perceptions of unmet holistic needs in the acute oncology setting.

Family caregiver perspectives on strengths and challenges in the care of pediatric injury patients at a tertiary referral hospital in Northern Tanzania.

Pediatric injuries are a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). It is important that injured children get quality care in order to improve their outcomes. Injured children are nearly always accompanied by family member caregivers invested in their outcome, and who will be responsible for their recovery and rehabilitation after discharge. The purpose of this study was to identify family member caregiver perspectives on strengths and challenges in pediatric injury care throughout hospitalization at a tertiary hospital in Northern Tanzania. This study was conducted at a zonal referral hospital in Northern Tanzania. Qualitative semi-structured in-depth interviews (IDIs) were conducted by trained interviewers who were fluent in English and Swahili in order to examine the strengths and challenges in pediatric injury care. IDIs were completed from November 2020 to October 2021 with 30 family member caregivers of admitted pediatric injured patients. De-identified transcripts were synthesized in memos and analyzed through a team-based, thematic approach informed by applied thematic analysis. Strengths and challenges were identified throughout the hospital experience, including emergency medicine department (EMD) care, inpatient wards care, and discharge. Across the three phases, strengths were identified such as how quickly patients were evaluated and treated, professionalism and communication between healthcare providers, attentive nursing care, frequent re-evaluation of a patient's condition, and open discussion with caregivers about readiness for discharge. Challenges identified related to lack of communication with caregivers, perceived inability of caregivers to ask questions, healthcare providers speaking in English during rounds with lack of interpretation into the caregivers' preferred language, and being sent home without instructions for rehabilitation, ongoing care, or guidance for follow-up. Caregiver perspectives highlighted strengths and challenges throughout the hospital experience that could lead to interventions to improve the care of pediatric injury patients in Northern Tanzania. These interventions include prioritizing communication with caregivers about patient status and care plan, ensuring all direct communication is in the caregivers' preferred language, and standardizing instructions regarding discharge and follow-up.

Nutrition support management of organ transplant recipients in the acute posttransplant phase.

Patients who undergo solid organ transplant can have an extensive and challenging postoperative course. The chronicity of the disease state prior to transplant in combination with transplant-specific complications and immunosuppressant medications can lead to distinct challenges that are not observed in other critically ill patients. Although the manifestation of posttransplant complications may be specific to the organ being transplanted, there are common transplant challenges that affect nutrition therapy in these patients. Effects of malnutrition, metabolic aberrations, and posttransplant organ dysfunction should be considered when developing a nutrition care plan for patients in the immediate posttransplant phase. This article addresses the various complications that can arise in the immediate posttransplant phase among patients undergoing solid organ transplant and the appropriate nutrition interventions or considerations for this specialized patient population.

Intensifying supportive care is associated with improved survival in gastric cancer patients with malignant ascites.

Gastric cancer patients with malignant ascites often have poor functional status and malnutrition that preclude receipt of systemic therapies. Thus, these patients have a very poor prognosis. Beginning in 2019, our multidisciplinary gastric cancer disease-oriented team implemented a more aggressive supportive care plan for gastric cancer patients with malignant ascites. The initiative included measures such as supplemental enteral nutrition, ascites drainage, and initiation of chemotherapy on an inpatient basis. We compared outcomes for gastric cancer patients who presented with synchronous malignant ascites treated before and after the implementation of the care plan. We performed a retrospective review of our institutional database to identify patients diagnosed with gastric adenocarcinoma and synchronous malignant ascites between 2010 and 2022. We compared overall survival (OS) between patients diagnosed from 2010 to 2018, which will be referred to as the historical control era and patients diagnosed from 2019 to 2022, which will be called the aggressive supportive care era. Fifty-four patients were included in our analysis; 31 patients were treated in the historical control time frame, and 23 patients were treated during the aggressive supportive care era. Demographic, clinical, and pathologic characteristics were similar between groups. 3% of historical controls received supplemental tube feeds at diagnosis as compared to 30% of the aggressive supportive care cohort (p < 0.01). 3% of historical controls received their first cycle of chemotherapy in the inpatient setting versus 39% of patients treated during the aggressive supportive care era (p < 0.01). The median number of chemotherapy cycles received was 5 among historical controls and 9.5 among aggressive supportive care era patients (p = 0.02). There was no difference in the number of days spent as an inpatient between the two groups. The median OS for historical control patients was 5.4 months as compared with 10.4 months for patients treated during aggressive supportive care era (p = 0.04). Gastric cancer patients with synchronous malignant ascites treated during a timeframe when our multidisciplinary team implemented more aggressive supportive care measures had improved OS as compared with historic controls. Our results suggest that aggressive supportive measures for these patients with highly challenging clinical issues and poor prognosis can prolong survival. Specifically, initiation of chemotherapy in the inpatient setting and supplemental nutrition should be considered for patients at high risk for treatment intolerance.

Investigating the Effect of Temperature Therapy on the Severity of Restless Legs Syndrome: Systematic Review and Meta-Analysis.

Background: Restless legs syndrome (RLS) is a sensorimotor disorder leading to disturbance of resting, discomfort, stress, and impaired daytime activity in the sufferers. The present systematic review and meta-analysis was conducted to determine the effect of temperature therapy on the severity of RLS.Methods: The electronic databases of Google Scholar, ProQuest, Scopus, PubMed, Web of Science, and State Inpatient Databases (SID) were searched from inception to August 2022. The Cochrane Collaboration's Risk of Bias Tool was used to check the quality of included studies. Meta-analysis was performed by calculating standardized mean differences (SMDs), using random effects model, and running Comprehensive Meta-Analysis (CMA) software version 2.Results: The included studies (n=6) comprised 177 participants, whose mean age was 49.85 years old. The results of the meta-analysis showed temperature therapy could reduce the severity of RLS (SMD=-1.520, 95% CI: -2.122 to -0.918). Regarding the source of heterogeneity, meta-regression results indicated the efficacy of the intervention in reducing the severity of RLS enhanced significantly by increasing the duration of the intervention in each session (β=-0.039, 95% CI -0.076 to -0.002, P<0.001). The results also showed increasing the duration (β=-0.039, 95% CI -0.076 to -0.002, P<0.001) and the temperature of the intervention in each session (β=-0.016, 95% CI -0.028 to -0.003, P<0.05) significantly enhanced the efficacy of the intervention in reducing the severity of RLS. The results also indicated that, among patients with underlying clinical conditions, the effectiveness of temperature therapy was higher in hemodialysis patients (β=-2.006, 95% CI -2.736 to -1.276, P<0.05).Conclusion: The present study findings suggested temperature therapy could mildly reduce the severity of RLS symptoms. It was also found that the highest efficacy of this intervention could be achieved when the higher temperature was used in fewer treatment sessions in hemodialysis patients. Based on our findings, this intervention can be included in the care plan of patients with RLS considering the settings described to achieve the highest efficacy.

The Efficacy of Self-care Behaviors, Educational Interventions, and Follow-up Strategies on Hospital Readmission and Mortality Rates in Patients with Heart Failure.

Heart failure (HF), a worldwide epidemic with significant morbidity and mortality risks, is frequently secondary to cardiovascular disorders and probably is the common final way to survive patients. Almost 25% of hospitalized patients with acute HF are expected to be readmitted within 30 days post-discharge, and the rates of rehospitalization increase to almost one-third at 60 days and 60 percent within one year of discharge. Although care planning for patients with heart failure is complex, multidisciplinary, and resource-dependent, optimal self-care management along with appropriate educational intervention and follow-up strategy could be able to reduce readmissions, decline the duration of hospitalization, increase life expectancy, decrease the rates of mortality, and reduce costs of healthcare services for patients with HF. However, there are contradictions in previous reports about the efficacy of self-care, mainly due to patients' non-adherence to self-care behaviors. Therefore, the current study aimed to review the investigations on the effectiveness of self-care of HF patients in reducing hospital readmissions and increasing quality of life, and discuss novel approaches for predischarge educational interventions and postdischarge follow-up strategies.

PubMed4Hh: A Point-of-Care Mobile App for Evidence-Based Clinical Decision Support for Nurse Residents in Maryland.

Evidence-based clinical decision-making is considered a core competency for professional nurses. However, barriers such as lack of time in clinical practice; information overload; restricted access to resources; lack of evidence appraisal skills, awareness, and knowledge; and unreliable resources prevent them from adopting evidence-based practice. This study examined the usefulness of the PubMed4Hh (PubMed for Handhelds) mobile application for clinical decision-making at the point of care among Maryland newly licensed RNs. Using iOS and Android smartphones, 178 newly licensed RNs participated in a 6-month trial from November 2019 to April 2020. Nurses manually entered free-text queries or used voice inputs on the "Patient, Intervention, Comparison, Outcome" or "askMEDLINE" search engines. The results retrieved were presented as journal article abstracts or short summaries called "the bottom line," designed for quick reading at the point of care. Both Patient, Intervention, Comparison, Outcome and askMEDLINE were rated highly for their usefulness, and participants said they would continue using PubMed4Hh and recommend it to others. Newly licensed RNs had a significantly higher perception of the usefulness of PubMed4Hh when the results of "the bottom line" or abstracts confirmed, led, or modified their nursing skills, knowledge, or the patient's care plan.

Machine learning-based detection of sarcopenic obesity and association with adverse outcomes in patients undergoing surgical treatment for spinal metastases.

The distributions and proportions of lean and fat tissues may help better assess the prognosis and outcomes of patients with spinal metastases. Specifically, in obese patients, sarcopenia may be easily overlooked as a poor prognostic indicator. The role of this body phenotype, sarcopenic obesity (SO), has not been adequately studied among patients undergoing surgical treatment for spinal metastases. To this end, here the authors investigated the role of SO as a potential prognostic factor in patients undergoing surgical treatment for spinal metastases. The authors identified patients who underwent surgical treatment for spinal metastases between 2010 and 2020. A validated deep learning approach evaluated sarcopenia and adiposity on routine preoperative CT images. Based on composition analyses, patients were classified with SO or nonsarcopenic obesity. After nearest-neighbor propensity matching that accounted for confounders, the authors compared the rates and odds of postoperative complications, length of stay, 30-day readmission, and all-cause mortality at 90 days and 1 year between the SO and nonsarcopenic obesity groups. A total of 62 patients with obesity underwent surgical treatment for spinal metastases during the study period. Of these, 37 patients had nonsarcopenic obesity and 25 had SO. After propensity matching, 50 records were evaluated that were equally composed of patients with nonsarcopenic obesity and SO (25 patients each). Patients with SO were noted to have increased odds of nonhome discharge (OR 6.0, 95% CI 1.69-21.26), 30-day readmission (OR 3.27, 95% CI 1.01-10.62), and 90-day (OR 4.85, 95% CI 1.29-18.26) and 1-year (OR 3.78, 95% CI 1.17-12.19) mortality, as well as increased time to mortality after surgery (12.60 ± 19.84 months vs 37.16 ± 35.19 months, p = 0.002; standardized mean difference 0.86). No significant differences were noted in terms of length of stay or postoperative complications when comparing the two groups (p > 0.05). The SO phenotype was associated with increased odds of nonhome discharge, readmission, and postoperative mortality. This study suggests that SO may be an important prognostic factor to consider when developing care plans for patients with spinal metastases.

Advance Care Planning in Patients with Suspected or Proven COVID: Are We Meeting Our Own Standards?

Given the importance of advance care planning (ACP) in the context of a pandemic, we aimed to assess current adherence to local policy recommending ACP in all hospitalised adult patients with suspected or proven COVID-19 at Liverpool Hospital, Sydney, Australia. A retrospective cohort study. A tertiary referral and teaching hospital. A select sample of adult patients admitted to Liverpool Hospital in 2019-2021 with suspected or proven COVID-19. Proportion of patients with documented ACP and format of ACP. Amongst 209 patients with proven or suspected COVID-19 hospitalised between March 2019 through to September 2021, median frailty score was 3, the median Charlson Comorbidity Score was 4, median age of the patients was 71years, and median length of hospital stay was 5days (range 0-98 days). Almost all patients were tested for COVID-19 (n = 207, 99%) of which 15% (31) were positive. Fewer than a quarter of the patients had documented ACPs (50, 24%) and 17 patients had existing formal advance care directives. Patients who had ACP were older, more likely to be frail and more likely to have higher rates of comorbidity compared to those without ACP. ACP was more commonly discussed with family members (41/50) than patients (25/50) and others (5/50). Adherence to the local ACP policy mandating such discussions was low. This reinforces the need for prioritising ACP discussions, especially for unwell patients such as those with COVID, likely involving further input to improve awareness and rates of formal documentation.

A Brief Review of Inpatient Palliative Rehabilitation

Cancer patients face many challenges that can have a significant impact on their quality of life (QOL). When patients experience multiple functional impairments due to disease or treatment, their QOL and the efficient use of healthcare resources can be compromised. This is particularly true for patients who are nearing the end of their lives, as the physical and emotional burden of cancer can have a profound effect on both the individual and their caregivers. One approach to improving QOL in these patients is through palliative rehabilitation. Despite being an underutilized and understudied resource, palliative rehabilitation has shown promise in helping patients with advanced cancer retain their dignity and sense of control. By maximizing functional independence and reducing symptom burdens, palliative rehabilitation can provide a vital source of support for patients and their caregivers during this challenging time. Inpatient rehabilitation is one way that palliative rehabilitation can be applied in a healthcare setting. While further research is needed to fully understand the benefits of this approach, it is clear that palliative rehabilitation has the potential to play a key role in helping patients and their caregivers navigate the challenges of cancer treatment and end-of-life care. This approach is specific to the USA context but can be applied in other settings where cancer patients require such care. Keywords: Neoplasms / rehabilitation, Quality of life, Recovery of function, Survivors, Patient Care planning, Palliative.

Advancing Collaboration across the Multiple Myeloma Treatment Journey from Oncology Clinic to CAR T-Cell Center: A Paired Center Transformative Quality Improvement Initiative

Background Treating patients with multiple myeloma (MM) is a complex endeavor that requires effective clinical decision-making from a team of specialists and supporting clinicians. Additionally, treatment with chimeric antigen receptor (CAR) T-cell therapy presents unique challenges, requiring communication and collaboration between the oncology clinic and CAR T-cell treatment centers. To improve collaborative MM care, we conducted a quality improvement (QI) study, bringing together community and academic oncology centers to assess current practice patterns and develop strategies to overcome barriers in the treatment of patients with MM across the continuum of care. Methods This QI initiative is comprised of baseline provider surveys (Community n = 21; Academic n = 18) and pre- and post-surveys of providers (n = 31) participating in small-group, team-based audit-feedback (AF) sessions (Table 1). Survey questions were designed to assess knowledge, confidence, and experiences in keeping up with the latest clinical evidence and guideline recommendations and collaboration and communication practices between centers. Care teams from each clinic, along with a nationally renowned expert MM physician, participated in audit and feedback 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. Results Provider Surveys: When asked their top challenge encountered in managing patients with MM, community-based providers reported keeping up with clinical evidence for new and emerging therapies (48%), whereas academic-based providers reported knowing how to optimally sequence therapies (50%). Further differences between community and academic clinicians were evident in their self-reported confidence in their ability to stay up-to-date with new data on CAR T-cell therapies and other MM treatment (high/very high confidence: 84% academic; 24% community; p &amp;lt; .001), ability to align clinical practices with evidence-based guidelines (high/very high confidence: 72% academic; 34% community; p = .018), and ability to sequence lines of therapy and differentiate between novel therapies for MM (high/very high confidence: 72% academic; 29% community; p = .007). Despite these differences, care teams from both settings reported low percentages of eligible patients have received CAR T-cell therapy for MM, citing patient resistance, cost and difficulty gaining insurance approval as top barriers (Figure 1). When asked to rate the level of communication and collaboration between academic and community centers, 44% of academic providers and 35% of community providers rated very good/excellent. The top barrier among providers not indicating very good/excellent communication from both settings was lack of time for our clinic's staff to communicate. AF Sessions: Providers participating in the small group AF sessions reported gaining access to newer therapies (55%) as their biggest challenge regarding MM management. Clinicians indicated gains in moderate/high/very high confidence in their ability to align treatment decisions with guidelines and clinical evidence for MM (78% to 92%) and ability to sequence treatment options across multiple lines of therapy for patients with MM (80% to 100%). Care teams set goals to enhance knowledge of clinical efficacy and safety of new and emerging therapies for MM. Action plans to achieve these goals include developing a hematology disease specific tumor board to collaborate on patient care plans, further train designated staff members focused on CAR T-cell/MM, discuss relevant new data to improve the team's confidence in therapy sequencing and early referrals to CAR T-cell centers. Conclusions Through this QI initiative, clinical teams identified barriers to optimal MM care, creating and implementing specific action plans to increase knowledge of current and emerging therapies for MM to enhance individualized treatment plans. While meaningful confidence gains were demonstrated, these data underscore clinical practice gaps to address in future initiatives to support evidence-based, collaborative care plans for patients with MM. Study Sponsor Statement The study reported in this abstract was funded by educational grants from Bristol Myers Squibb. The grantors had no role in the study design, execution, analysis, or reporting.

Assessing Aspects of Quality of Life Among Patients with Sickle Cell Disease in Saudi Arabia

Introduction: Sickle cell disease is a genetic disorder that can significantly alter the patient's quality of life. The disease trajectory can lead to acute and chronic complications, mainly resulting from repeated episodes of vascular occlusion. The patients can experience frequent infections and hospitalizations, chronic pain, fatigue, hand-foot syndrome, delayed growth. Therefore, assessing the quality of life among sickle cell patients in Saudi Arabia is pertinent to the devise of a comprehensive plan of patient care. The quality of life can be determined based on numerous markers, including physical health, psychological health, happiness, and physical activity. We aimed to assess the overall quality of life among Saudi sickle cell disease patients living in different regions of the Kingdom. This an ongoing study with open enrollment target of more than 600 patients. Methods: A questionnaire-based survey was conducted among the adult Saudi sickle cell disease population residing in different provinces, who were stable, Saudi nationals and over age of 18 years. The questionnaire assessed the quality of life, including fatigue, general happiness, physical activity, and psychological well-being using standardized questionnaire SF-36 and HADS validated Arabic version. Additional data about blood transfusion and visit to ER were collected The collected data were recorded for each respondent, and the results were statistically analyzed. Results: The included participants' (n=166) mean age 33.6 ± 9.2. years, with respondents belonging to eastern region Qatif (n=48; 28.9%), central region Riyadh (n=75; 45.1%), and southern region Jizan (n=43; 25.9), respectively. The study's cohort had varying educational backgrounds, with the highest number holding a bachelor's degree (n=77; 46.4%); followed by secondary education (n=50; 30.1); master's degree (n=8; 4.8); doctoral degree (n=5; 3.0) and other education (n=18; 10). In total, 17.5% of participants reported excellent reviews about health, and only 9% reported badly. However, the overall quality of life compared to the previous year was much lower, with 10.8% responses as worse. Strenuous activities constrained 40.9% of the participants, 14.5% were constrained by work of medium intensity, and 13.2% felt even a lot of constraint while carrying groceries. Almost 40% of respondents answered negatively when asked about feeling energetic compared to psychological health, where more than 50% of responses were positive. More than 52% of participants felt their ability to do activities at work and otherwise was diminished. More than 80% of participants felt pain over the past four weeks that affected their quality of life. The findings have been graphically summarized in Figure 1. The patients with blood transfusion assessed their health significantly poor than those without transfusion (p-value = 0.0022). Their health conflicted with their daily routine significantly (p-value=0.003), where they were significantly more tired (p-value=0.04), and felt less assured (p-value=0.02). Conclusion: The physical and psychological health-related quality of life is satisfactory among Saudi sickle cell disease patients.. Furthermore, the lack of energy and appropriate physical activity is a serious concern that can negatively impact sickle cell disease patients' overall quality of life. This is a planned cohort to measure quality of life in sickle cell disease in Saudi Arabia at a large scale with link to demographic representation .

Using Simulation to Develop Clinical Reasoning Skills for Registered Practical Nurses New to Acute Care

BackgroundTo address the nursing workforce shortage, registered practical nurses (RPNs) were introduced to acute care areas at The Ottawa Hospital. MethodsThe Kirkpatrick levels were used to evaluate the RPN simulation-based education session. A paired T-test was used to assess statistical significance of patient safety data. ResultsGreater than 81% of RPNs found the simulations to be extremely effective at preparing them for their new role. Patient safety data showed a statistically significant decrease in rapid-response team calls (p = .0431) and a decrease in patient falls that was not quite statistically significant (p = .0506). ConclusionThrough the simulation sessions, the RPNs mastered the fundamentals of being able to assess, construct, implement, and evaluate a plan of patient care, setting the framework for clinical reasoning.

Intracranial Atherosclerosis Disease Associated With Cognitive Impairment and Dementia: Systematic Review and Meta-Analysis.

Intracranial atherosclerosis disease (ICAD) alters cerebrovascular hemodynamics and brain structural integrity. Multiple studies have evaluated the link between ICAD and cognitive impairment, with mixed results. This study aims to systematically review and summarize the current evidence on this link. PubMed, EMBASE, PsycInfo, and Web of Science were searched from 2000 to 2023 without language restriction. Cross-sectional and prospective cohort studies as well as postmortem studies were included. Studies containing data on the link between ICAD, defined as at least 50% stenosis in 1 intracranial vessel, and cognitive impairment and dementia were screened by 2 independent reviewers. A total of 22 (17 observational and 5 postmortem) unique studies, comprising 11 184 individuals (average age range, 59.8-87.6 years; 45.7% women; 36.5% Asian race), were included in the systematic review. Seven of 10 cross-sectional studies and 5 of 7 prospective studies showed a significant association between ICAD and cognitive impairment. In the pooled analysis, ICAD was associated with greater cognitive impairment (measure of association, 1.87 [95% CI, 1.49-2.35]). Meta-regression analyses did not show a significant impact of age, sex, and race. All postmortem studies showed that patients with Alzheimer disease and vascular dementia had a higher burden of ICAD compared with controls. This study shows that ICAD is associated with cognitive impairment and dementia across age, sex, and race groups. Our findings may underscore the need to develop individualized dementia preventive care plans in patients with ICAD.

QOL-10. MULTIDISCIPLINARY MEDICAL CARE SYSTEM FOR BRAIN TUMOR SURVIVORS IN JAPAN

Abstract INTRODUCTION: Brain tumor patients suffer from psychological distress and various aftereffects. Although the number of "brain tumor survivors" has been increasing due to improved outcomes of brain tumor treatment, the support system for them is inadequate in Japan. Therefore, we are examining issues affecting the QOL faced by brain tumor patients and their families, with the aim of establishing a fulfilling medical care system with a multidisciplinary approach. Here, we report on the current status of the multidisciplinary medical care system. METHODS: The EORTC QLQ-C30, 14-item resilience scale, PHQ-9, and Pittsburgh Sleep Quality Index are used to assess QOL. Based on these, an optimal care plan for brain tumor patients was developed through multidisciplinary team of professionals among physicians, nurses, clinical neuropsychologists, speech-language pathologists, occupational therapists, pharmacists, and nutritionists. A brain tumor survivorship program designed to support brain tumor patients, survivors, and care givers was developed, and this program was launched in December 2021. RESULTS AND DISCUSSION: Quality of life assessment of brain tumor patients revealed their problems and unmet needs, which enabled the development of optimal care plans in collaboration with multiple disciplines. In addition, neuropsychological approaches and cognitive behavioral therapy have been utilized as interventions for cognitive dysfunction. The Brain Tumor Survivorship Program has 18 participants as of May 31, 2023. In addition to providing online resources, patient support meetings were held virtually, providing an opportunity for participants to communicate directly with each other. CONCLUSION: We believe it is essential to establish a long-term follow-up system specifically for brain tumor patients. Through the multidisciplinary medical care system, we plan to continue to scientifically investigate and develop a support system for the various survivorship issues that brain tumor patients and their families experience across the trajectory of the illness.

An Institutional Curriculum for Opioid Prescribing Education: Outcomes From 2017 to 2022

IntroductionPrescription opioids, including those prescribed after surgery, have greatly contributed to the US opioid epidemic. Educating opioid prescribers is a crucial component of ensuring the safe use of opioids among surgical patients. MethodsAn annual opioid prescribing education curriculum was implemented among new surgical prescribers at our institution between 2017 and 2022. The curriculum includes a single 75-min session which is comprised of several components: pain medications (dosing, indications, and contraindications); patients at high risk for uncontrolled pain and/or opioid misuse or abuse; patient monitoring and care plans; and state and federal regulations. Participants were asked to complete an opioid knowledge assessment before and after the didactic session. ResultsPresession and postsession assessments were completed by 197 (89.6%) prescribers. Across the five studied years, the median presession score was 54.5%. This increased to 63.6% after completion of the curriculum, representing a median relative knowledge increase of 18.2%. The median relative improvement was greatest for preinterns and interns (18.2% for both groups); smaller improvements were observed for postgraduate year 2-5 residents (9.1%) and advanced practice providers (9.1%). On a scale of 1 to 10 (with 5 being comfortable), median (interquartile range) self-reported comfort in prescribing opioids increased from 3 (2-5) before education to 5 (4-6) after education (P < 0.001). ConclusionsEach year, the curriculum substantially improved provider knowledge of and comfort in opioid prescribing. Despite increased national awareness of the opioid epidemic and increasing institutional initiatives to improve opioid prescribing practices, there was a sustained knowledge and comfort gap among new surgical prescribers. The observed effects of our opioid education curriculum highlight the value of a simple and efficient educational initiative.

Virtual Multi-disciplinary Team (vMDT) platform improves workflows and productivity within the heart failure pathway for patients in the UK National Health Service (NHS)

Abstract Background We implemented a virtual MDT platform as a technical solution to assist a heart failure MDT. vMDT would enable the team to document discussions and create actions for individual team members that were visible and transparent and thus ensuring rapid completion relating to patient care plans. Patients cases processed via this pathway in comparison to traditional approaches were able to access treatment optimisation and newer heart failure therapies more rapidly. Data from the vMDT platform helped plan for wider transformation. Purpose Integrating care between general practice (GP), community and hospital specialists is the current focus for the National Health Service (NHS) in the UK. An integrated approach necessitated better communication and sharing of information between MDTs. We decided that it was necessary to have the digital infrastructure to deliver this approach. Method The vMDT system harnessed information relevant to the patients heart failure and presented it to MDT members to view and contribute to the patients treatment plan, before, during and after a scheduled MDT meeting. Following the meeting the platform would instantly communicate actions to members of the professional team, ensuring transparency and rapid completion of actions. Processes were simplified, meaning that patients could be referred onwards at the click of a button. The patients could be referred into this pathway by a GP when patients continued to have symptoms. Pathway was made available to GP clinics covering a 200,000 patient population. Led by the commissioning transformation team, who managed the project alongside the GP cardiovascular lead, community heart failure nurse lead, and Hospital heart failure specialist nurse leads. Clinical pharmacists linked to the GP clinics were included and were the ones who would prepare, upload and present the heart failure cases. Results 98% (150 processed over 10 months) of patients referred along this pathway could be managed effectively. 5% would otherwise have been lost to follow up. 100% of actions created through this pathway were completed. 62% had their treatment optimised. Clinician satisfaction improved. Conclusion Virtual MDTs are the rave but there needs to be digital infrastructure to support this novel way of working, especially if we are to scale this up. A digital platform needs to have the safeguards for information security but also needs to align to an improved workflow for the health professionals working within the service. In future we would like to look at whether addition of decision support can further improve productivity and outcomes relating to optimisation of therapy for heart failure patients.

Outcomes of a 3-Year Quality Improvement Study to Improve Advance Care Planning in Patients With Decompensated Cirrhosis.

To report outcomes of a 3-year quality improvement pilot study to improve advance directive (AD) completion. The pilot consisted of champions, education, electronic health record templates, and workflow changes. We assessed changes, predictors, and effects of AD completion. The pilot led to greater (8.3%-36%) and earlier AD completion, particularly among those divorced, with alcohol-associated liver disease, and with higher Model of End-Stage Liver Disease-Sodium score. Decedents whose AD specified nonaggressive goals experienced lower hospital lengths of stay. Advance care planning initiatives are feasible and may reduce health care utilization among decedents requesting less aggressive care.