Referral Protocols Research Articles

Missed Opportunities of Integration of Palliative Care: Frequency, Causes, and Profile of Missed Visits in an Oncologic Palliative Care Outpatient Unit

ContextMany patients with cancer are referred to palliative care (PC) outpatient clinics but do not attend consultations, which increases the difficultly of integrating PC in a timely manner. ObjectivesTo evaluate the frequency, causes, and profile of missing first-time consultations in a PC outpatient clinic. MethodsData from patients with advanced cancer who were scheduled for first-time visits to the PC outpatient clinic from September 2018 to August 2019 were analyzed. Missed consultation was defined as a nonperformed consultation with no prior notice of cancellation, and missed opportunity of palliative care (MOPC) was defined as a nonperformed consultation regardless of being notified in advance. The causes of the absence were identified by telephone using a standardized form. Logistic regression models were used to identify the profile of patients who have MOPC. ResultsAbout 1468 patients were scheduled for first-time visits to the PC outpatient clinic; missed consultation = 21.7% (n = 275) and MOPC = 32.5% (n = 478). Of the total number of patients who had MOPC, 86 (18%) were later seen in a median time (percentile p25–p75) of 29.5 days (range 7.0–66.5). The most common cause of MOPC was death before consultation (n = 92; 29.8%). Referral to PC using a standardized protocol (odds ratio 0.787; P = 0.044) and residence in distant cities (odds ratio 2.394; P < 0.001) were independently associated with MOPC. ConclusionApproximately one-third of patients eligible for PC miss the opportunity to be included earlier; only 18% of them are consulted later. Use of standardized referral protocols may help to reduce these absence rates.

A Quality Improvement Project to Provide Early Referral to Palliative Care Clinic for Advanced Oral Cancer Patients (TH341A)

•Identify palliative care needs, referral timings and reasons for delay in referral to palliative care clinic for advanced oral cancer patients.•Develop, test and sustain interventions to provide early referral to palliative care clinic for advanced oral cancer patients. Recent literature affirms the benefits of early palliative care in advanced cancer patients. The prevalence of oral cancer is high in India and often patients present at advanced stages at the time of diagnosis. Bleak scope of curative treatment and high symptomatic burden detracts from the quality of life of these patients. The aim of this study was to provide early referral to a palliative care clinic for advanced oral cancer patients. This initiative was carried out at Dr B. R. Ambedkar, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, India in collaboration with quality improvement leaders at Stanford University. A multidisciplinary team consisting of oncologists, surgeons, nurses, administrative staff, palliative care physicians and overseas quality improvement mentors was formed. Using A3 methodology, we applied improvement tools to understand the current situation. A cause and effect analysis revealed absence of referral guidelines and misalignment of what was deemed appropriate early referral as the major factors contributing to the practice of late referral. Our interventions were developing a standard, agreed upon, protocol for providing palliative care referral and consultation, creating awareness through pamphlets, educating oncologists and surgeons through weekly departmental meetings and documenting symptom burden in the medical record. The interventions were sustained by soliciting feedback from oncologists and surgeons during periodic departmental meetings, educating new oncologists and surgeons about referral protocols during their orientation program i.e. once in three months and by auditing patient referral data. Number of days from identification of advanced oral cancer to referral to palliative care clinic decreased from an average of 48 days at baseline to 13 days post-interventions. Early referrals to palliative care clinic are possible using a multidisciplinary team approach focusing on aligning expectations between oncologists, surgeons and palliative care professionals, modifying process maps and standardizing and documenting assessment.

Models of community-based primary care for epilepsy in low- and middle-income countries.

To review systematically community-based primary care interventions for epilepsy in low- and middle-income countries to rationalize approaches and outcome measures in relation to epilepsy care in these countries. A systematic search of PubMed, EMBASE, Global Index Medicus, CINAHL, and Web of Science was undertaken to identify trials and implementation of provision of antiseizure medications, adherence reinforcement, and/or health care provider or community education in community-based samples of epilepsy. Data on populations addressed, interventions, and outcomes were extracted from eligible articles. The 24 reports identified comprise mostly care programs addressing active convulsive epilepsy. Phenobarbital has been used most frequently, although other conventional antiseizure medications (ASMs) have also been used, but none of the newer. Tolerability rates in these studies are high, but overall attrition is considerable. Other approaches include updating primary health care providers, reinforcing treatment adherence in clinics, and raising community awareness. In these programs, the coverage of existing treatment gap in the community, epilepsy-related mortality, and comorbidity burden are only fleetingly addressed. None, however, explicitly describe sustainability plans. Cost-free provision, mostly of phenobarbital, has resulted in short-term seizure freedom in roughly half of the people with epilepsy in low- and middle-income countries. Future programs should include a range of ASMs. These should cover apart from seizure control and treatment adherence, primary health care provider education, community awareness, and referral protocols for specialist care. Programs should incorporate impact assessment at the local level. Sustainability in the long term as much as resilience and scalability should be addressed in future initiatives.

Clinical audit of rectal cancer patient referrals for papillon contact brachytherapy

Abstract Background and purpose: Papillon treatment is a form of contact X-ray brachytherapy (CXB) which is used as an alternative to surgery for rectal cancer. This study aimed to audit patients who were referred for and treated with CXB over a 6-year period against guidelines derived from a critical review of the evidence base. Materials and methods: Patient demographics, tumour characteristics and outcome data were gathered for 31 patients referred for CXB. A critical review of the evidence identified consensus referral criteria and outcome data against which to audit patients. Results: Referral criteria were derived from six published studies. These applied to patients unfit for surgery or stoma-averse. All referred patients had a visible tumour or scar with a tumour size under 3 cm and sited less than 12 cm from the anal verge. Nodal status varied from N0 to N2, but there was no metastatic disease present. The audited cohort demonstrated demographic equivalence, while the initial clinical complete response and recurrence rates were also comparable. Conclusion: This audit confirmed the validity of referral and treatment protocols and should guide future referrals until evidence from ongoing studies becomes available. These findings should contribute to the development of robust national guidelines.

Optimising the outcomes of index admission laparoscopic cholecystectomy and bile duct exploration for benign biliary emergencies: A service model

Presenter: Zubir Ahmed MD, PhD | University of Glasgow Background: Despite overwhelming evidence of its clear benefit, the rate of early laparoscopic cholecystectomy +/- bile duct exploration for acute biliary presentations such as cholecystitis and choledocholithiasis remains low mainly due to logistical and operational constraints. The aim of this study is to describe a service model that has been implemented to optimise the outcome of index admission laparoscopic cholecystectomy and bile duct exploration. In this study we demonstrated how a clear referral protocol, a refined logistical set-up and targeted job planning support the delivery of a service for all benign biliary emergencies in the United Kingdom. Methods: Patients undergoing emergency biliary surgery were identified and analysed from a prospectively maintained database containing 5555 consecutive laparoscopic cholecystectomy. The majority of biliary emergencies are referred to a dedicated biliary firm according to a clear protocol. The workload is recognised in job planning with an agreed target of 60% emergency surgery. Preoperative imaging is limited to ultrasound scanning with very small numbers of patients with suspected bile duct stones undergoing MRCP or ERCP. Maximum utilisation of theatre for biliary emergencies is achieved through scheduled lists, rapid access and emergency lists. Results: There were 2399 (43.2%) emergency cases in the database. The median age was 52 years with 70% female. The majority of cases were admitted with biliary colic (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by other surgical team, 8% from other hospitals and 6% from physicians. 80% underwent surgery within 5 days of referral with 19% operated on same day of referral and 21% within 1 day of referral. 44% of laparoscopic cholecystectomies were performed on elective lists, 29% on semi elective “CEPOD” lists and 26% while on-call. The median operating time was 75 minutes, median total hospital stay was 7 days. The conversion rate was 0.7%, complication rate of 4.8% and a mortality rate of 0.1%. Conclusion: Early index admission laparoscopic cholecystectomy for all benign gallstone disease has been shown in this study to have low rates of morbidity and mortality. This was due to an established service model made possible with timely referral, flexibility of open lists and access to emergency theatre. In addition to optimal clinical results there are also clear advantages to other important outcome parameters such as number of episodes, hospital stay and presentation to resolution time.

Distress screening and supportive care referrals used by telephone-based health services: a systematic review.

People affected by chronic diseases such as cancer report high levels of distress and a need for psychosocial support. It is unclear whether telephone-based services for people affected by chronic disease are a practical setting for implementing distress screening, referral protocols and rescreening to direct supportive care where it is needed. This systematic review aimed to describe the published literature regarding distress screening and supportive care referral practices in telephone-based services for people affected by chronic diseases such as cancer. A systematic literature search of MEDLINE, Embase, PsycInfo, CINAHL, Cochrane and Scopus was conducted in February 2018. Included quantitative studies involved: patients or caregivers affected by chronic diseases including cancer and describe a health service assessing psychosocial needs or distress via telephone. Extracted data included the type of cancer or other chronic disease, sample size, screening tool, referral or rescreening protocols, and type of health service. The search identified 3989 potential articles with additional searches returning 30 studies (n = 4019); fourteen were eligible for full-text review. Of the 14 studies, 13 included cancer patients. Studies were across multiple settings and identified nine distress screening tools in use. The reviewed studies indicate that validated distress-screening tools are being used via telephone to identify distress, particularly in relation to cancer. Screening-driven supportive care referrals are also taking place in telephone-based services. However, not all services use an established referral protocol. Ongoing rescreening of callers' distress is also limited despite it being an important recommendation from psycho-oncology guidelines.

Organisational and Clinical Approach to Osteoporosis in Rheumatology: OP-SER-Excellence Survey and Consensus.

To determine and analyse the organisational approach adopted by Spanish rheumatologists to osteoporosis (OP) to define strategic priorities. A group of experts designed a questionnaire on OP in the rheumatologist practice. The survey was sent to the Spanish Society of Rheumatology (SER) members. Through the Delphi round, strategic priorities were agreed upon in OP. The priorities are: 1) The SER should promote the inclusion of OP in 100% of the services and expand the training offer; 2) Rheumatology services should promote the role of the nurse in OP, promote quality indicators and referral protocols agreed with primary care in addition to promoting their training in this area; 3) The SER and Rheumatology services should promote electronic consultation, OP monographic clinics and participation in Fracture Liaison Service units. Strategic priorities in OP help identify areas of improvement at organisational, structural and quality standards level in this pathology.

Clinical audit of rectal cancer patient referrals for Papillon contact brachytherapy

AbstractBackground and purpose:Papillon treatment is a form of contact X-ray brachytherapy (CXB) which is used as an alternative to surgery for rectal cancer. This study aimed to audit patients who were referred for and treated with CXB over a 6-year period against guidelines derived from a critical review of the evidence base.Materials and methods:Patient demographics, tumour characteristics and outcome data were gathered for 31 patients referred for CXB. A critical review of the evidence identified consensus referral criteria and outcome data against which to audit patients.Results:Referral criteria were derived from six published studies. These applied to patients unfit for surgery or stoma-averse. All referred patients had a visible tumour or scar with a tumour size under 3 cm and sited less than 12 cm from the anal verge. Nodal status varied from N0 to N2, but there was no metastatic disease present. The audited cohort demonstrated demographic equivalence, while the initial clinical complete response and recurrence rates were also comparable.Conclusion:This audit confirmed the validity of referral and treatment protocols and should guide future referrals until evidence from ongoing studies becomes available. These findings should contribute to the development of robust national guidelines.

Protocolized referral to endoscopy and Helicobacter pylori detected in stools aimed to decrease endoscopy waiting lists

Background Chile has one of the highest mortality rates by gastric cancer (GC) worldwide. Primary prevention of GC and detection of pre-neoplastic and early neoplastic lesions should be a national priority. Aim To assess the impact of the protocolization of endoscopy referral and the use of H. pylori stool antigen test (HPSA) in the management of dyspepsia to decrease the waiting list for endoscopy and increase the detection of gastric pre-neoplastic and early neoplastic lesions. Material and Methods We included all patients referred to the Endoscopy Unit of a regional hospital, from January 2015 to December 2017. We also included patients with known pre-neoplastic lesions and all those with first degree relatives with GC. We implemented protocols for referral of patients with dyspepsia considering the use of HPSA test, prioritizing to endoscopy those with a higher risk of GC. Results A total of 4,641 endoscopies and 2,631 HPSA tests were carried out. After the adoption of these protocols, we observed a 52% decrease in the waiting time for endoscopy. The GC detection rate in this period was 1.8 to 3.1 cases per 100 endoscopies. After the adoption of the protocols, we observed a significant increase in early GC detection rate (from none in 2015 to 13% in 2017, p = 0.03). Conclusions The protocolization of the referral for endoscopy associated with widespread use of HPSA test in the management of patients with dyspepsia, are successful strategies to decrease waiting lists for endoscopy and optimize the detection rate of pre-neoplastic lesions and early GC.

EP1.11-14 Knowledge and Perspectives of Indian Medical Practitioners to Lung Cancer: A Regional Sample Survey

Lung cancer leads cancer-associated mortality figures in India. According to various cancer registries, It’s a pervasive problem with incidence expected to rise to 67,000 new cases per year by 2020. Especially concerning are limited health resources to tackle this problem in terms of specialty centers and trained staff. Adding to woes are poor knowledge, and practices among general practitioners (GPs) pertaining to lung cancer screening and referral. Thereby putting an additional burden on the constrained Indian health care system as a majority of cases are diagnosed at advanced stages leading to poorer prognosis and high treatment costs. A descriptive online survey was developed and pilot tested for GPs with Bachelor degree in Medicine & Surgery (MBBS) using Google survey forms. Google platform was selected for its wide outreach and use by GPs in northern India. The survey was done over 1 month period and included items related to etiopathology and diagnosis of Lung Cancer. The survey adopted a stratified sampling strategy for representation, and data collected were completely anonymous. A total of 2674 complete responses were collected. Majority of GPs were in the private sector (67.68%) with a mean work experience of 8.93±6.70 years. An average of 10 (10.45±7.10) Lung cancer cases were attended by GPs with majority presenting with non-resolving cough and/or hemoptysis (66%). Most common risk factors reported were cigarette smoking (93.27%) and exposure to chemicals (74.49%). Only a quarter of GPs identified lung cancer mortality being the highest (29.09%) with attribution to smoking (23.60%). Only 69.10% GPs advocated Lung cancer screening for current and past smokers. Only 30.89% GPs affirmed that a substantial reduction in mortality (95%) can be achieved by timely and proper screening. Only a quarter (25.46%) GPs reported low dose CT Scan (LDCT) as best modality lung cancer screening. 1943 (72.66%) GPs reported tissue sample biopsy as a method of diagnosis followed by CT scan (58.18%). Histopathology (85.48%) and molecular markers (74.49%) were frequently reported to guide therapeutic decision making. Based on the survey, It can be concluded that knowledge of Indian GPs for Lung cancer is deficient in wake of high disease burden. Poor suspicion and detection of lung malignancy at early stages devoid patients of better prognosis and outcomes. Therefore it is recommended that sensitization workshops and training of GPs in opportunistic cancer screening and referral protocols be done.

Surgical referral systems in low- and middle-income countries: A review of the evidence.

Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance.

A prospective study of spectrum & outcomes of obstetric referral patterns in a tertiary care centre in central Karnataka

Introduction and Objectives: The women in reproductive age group of 15-45 years are vulnerable and at risk due to obstetric emergencies. 92% of maternal deaths are due to delay in referral and case management. 1 Hence for providing essential obstetric care, referral system needs to be strengthened. This study is aimed at reviewing the primary reasons and pattern of obstetric cases referred to a tertiary care centre and management of its complications. Design: It is a prospective observational analysis of antenatal/post-partum patients over a period of 1-year in a multi-disciplinary intensive care unit (ICU) at a tertiary care centre. We studied 50 patients. Results: 76% of the patients in this study were referred from peripheral health centres. 77.34% patients had obstetric complications. Commonest risk factor for ICU admission was hypertensive disorders of pregnancy and obstetric haemorrhage. Other major risk factors were heart disease and sepsis. Major cause of maternal mortality was multi-organ-dysfunction and sepsis secondary to massive obstetric haemorrhage. Conclusion: The multi-disciplinary team approach in intensive care units, close monitoring, symptomatic treatment, prompt surgical intervention and safe motherhood initiative would reduce the current Maternal Mortality Rate. Development of standard referral protocol, availability of tertiary care, proper training in this regard is much needed. Keywords: Obstetric emergencies, Referral system, Intensive care units.

Referral linkage among public health facilities in Ethiopia: A qualitative explanatory study of facilitators and barriers for emergency obstetric referral in Addis Ababa city administration

BackgroundIn developing countries including Ethiopia, maternal mortality ratio remains unacceptably high. During pregnancy and childbirth, a woman may acquire one or more of obstetric complications including hemorrhage, sepsis, hypertension and obstructed labor. Early diagnosed and referral of women who experienced obstetric complications to a specialty center can save the life of women and babies. However, several factors might affect the referral procedures of these women. Therefore, this study was aimed at assessing the facilitators and barriers of obstetric referral in selected public health facilities of Addis Ababa city administration, Ethiopia. MethodsA qualitative study design was employed to obtain the narratives of 12 healthcare workers and three recently referred mothers. The study included a regional health bureau, a lead hospital and a health center. Thematic analysis was employed to present to present the findings of the study and open code software was used to code and generate the themes. ResultsThis study revealed several barriers and some facilitators of obstetric referral. Early identification of complications, exercising teamwork, availability of referral protocol, availability of ambulance and effective communication system were the major reported factors which enhanced obstetric referral. Several themes including poor perception of clients, poor supportive supervision, lack of staff motivation and shortage of beds and medical equipment, lack of competence among the staffs and shortage of ambulance at health center were emerged as barriers of obstetric referral. ConclusionsThis study revealed several barriers of obstetric referral in the Addis Ababa city administration although a number of facilitators of obstetric referral exist. All of the reported barriers are related to the existing health system that need a collective action of all the actors to eliminate the barriers while enhancing the facilitators of obstetric referral.

Patterns of, and barriers to supportive care needs assessment and provision for Australian women with gynecological cancer and their caregivers: a mixed-methods study of clinical practice.

To document the current clinical practice in 2017 for assessment of supportive care needs and provision of supportive care to women with gynecological cancer and their caregivers in Australia, and to identify the main enablers and barriers to care provision. A total of 64 health professionals who care for Australian women with gynecological cancer responded to an electronic survey which explored their use of needs assessment, service-level processes and protocols for support service provision, and identified enablers and barriers to provision of care to both patients and caregivers. Eight respondents underwent an additional in-depth interview to elaborate on enablers, barriers, and gaps in the provision of supportive care. Mostly, needs assessment for women and caregivers was part of current practice but done without validated tools or a checklist. Only 30% of respondents reported having documented referral pathways. Most respondents simply recorded a plan for meeting needs within the patients' medical record (63% for patients; 46% for caregivers) rather than using a formalized care plan (15% for patients; 6% for caregivers). The interviewees' comments supported survey results that having sufficient time to discuss issues was both the most important enabling factor and the greatest barrier to successful supportive care provision. The interviewees further discussed variations in needs based on age, cultural background, and phases within the cancer care continuum, and that best practice supportive care should involve a multidisciplinary team and customizable protocols. There is much room for improvement in the assessment of needs and provision of supportive care to women with gynecological cancer and their caregivers. Approaches to optimize use of consultation time (e.g., needs assessment tools and referral protocols) are necessary. Flexibility in the form and mode of delivery of support may be required to meet diverse personal preferences and incorporate caregivers.

Solid organ donation from the emergency department - A systematic review.

A significant gap exists between people awaiting an organ transplant and organ donors. The purpose of this study was to determine what percent of successful donors come from the emergency department (ED), whether there are any missed donors, and to identify factors associated with successful and missed donation. This systematic review used electronic searches of EMBASE, MEDLINE, and CINAHL according to PRISMA guidelines on July 7, 2017. We included primary literature in adults describing successful and missed organ donation. Two authors independently screened articles, and discrepancies were resolved through consensus. Quality was assessed using the STROBE checklist. This systematic review identified 1,058 articles, and 25 articles were included. For neurologic determination of death, ED patients comprised 4%-50% of successful donors and 3.6%-8.9% of successful donors for donation after circulatory determination of death. ED death reviews revealed up to 84% of missed neurologic determination of death, and 46.2% of missed circulatory determination of death donors who died in the ED are missed due to a failure to refer for consideration of organ donation. Clinical heterogeneity precluded pooling of the data to conduct a meta-analysis. The ED is a source of actual and missed donors. Potential donors are often missed due to incorrect assumptions regarding eligibility criteria and failure of the healthcare team to refer for consideration of donation. ED healthcare professionals should be aware of organ donation referral protocols at their institution to ensure that no organ donors are missed.

Consensus standards of healthcare for adults and children with inflammatory bowel disease in the UK

ObjectiveSymptoms and clinical course during inflammatory bowel disease (IBD) vary among individuals. Personalised care is therefore essential to effective management, delivered by a strong patient-centred multidisciplinary team, working within a...

Real-life management of patients with breakthrough cancer pain caused by bone metastases in Spain.

Purpose: We aimed to explore the characteristics, and real-life therapeutic management of patients with breakthrough cancer pain (BTcP) caused by bone metastases in Spain, and to evaluate physicians’ opinion of and satisfaction with prescribed BTcP therapy.Participants and methods: For the purposes of this study, an ad-hoc questionnaire was developed consisting of two domains: a) organizational aspects and care standards; b) clinical and treatment variables of bone metastatic BTcP patients. In addition, physicians’ satisfaction with their prescribed BTcP therapy was assessed. Specialists collected data from up to five patients receiving treatment for BTcP caused by bone metastasis, all patients gave their consent to participate prior to inclusion.Results: A total of 103 cancer pain specialists (radiation oncologists [38.8%], pain specialists [33.0%], and palliative care (PC) specialists [21.4%]) were polled, and data on 386 BTcP patients with bone metastatic disease were collected. Only 33% of the specialists had implemented specific protocols for BTcP management, and 19.4% had established referral protocols for this group of patients. Half of all participants (50.5%) address quality of life and quality of care in their patients; however, only 27.0% did so from the patient’s perspective, as they should do. Most patients had multiple metastases and were prescribed rapid-onset fentanyl preparations (71.2%), followed by immediate-release morphine (9.3%) for the treatment of BTcP. Rapid-onset fentanyl was prescribed more often in PC units (79.0%) than in pain units (75.9%) and radiation oncology units (61.1%) (p<0.01). Furthermore, most physicians (71.8%) were satisfied with the BTcP therapy prescribed.Conclusions: Our results demonstrate the need for routine assessment of quality of life in patients with bone BTcP. These findings also underscore the necessity for a multidisciplinary therapeutic strategy for breakthrough pain in clinical practice in Spain.

Who misses the newborn hearing screening? Five years’ experience in Friuli-Venezia Giulia Region (Italy)

IntroductionPermanent hearing impairment is the most common sensory disorder in newborns. The Universal Newborn Hearing Screening (UNHS) is widely adopted as a cost-effective procedure to achieve early identification and treatment of congenital hearing impairment, with the final goal of an improved linguistic and cognitive outcome for hearing impaired children. The Italian Ministry of Health has recently comprised UNHS in the Essential Level of Health Assistance. Nevertheless, programs still vary both across and within Italian Regions in terms of coverage, testing, referral and tracking protocols. In Friuli-Venezia Giulia region the program for the early identification of newborn and childhood hearing impairment is operative since 2012. In order to minimize the lost to follow-up cases, UNHS and childhood hearing surveillance activities have been organized in close collaboration among birth centres, paediatric audiology services, territorial Family Paediatricians and the sole regional centre for paediatric hearing loss management. Material and methodsWe performed a five years’ retrospective analysis of the UNHS experience in Friuli-Venezia Giulia comparing the UNHS activity of year 2013 and year 2017. The focus of the study concerns the “missing” cases. Three different typologies of “miss” cases (“documentation-miss”, “access-miss” and “pathway-miss”) have been defined in correspondence with main reasons for their occurrence. ResultsBirths in Friuli-Venezia Giulia were 9465 and 8432, respectively in 2013 and 2017. International quality indicators improved with a gain of efficiency in 5 years’ experience. However, “missing” cases were 486 in 2013 and 321 in 2017, mainly due to the lack of an efficient documentation system. ConclusionUNHS programs have proven to be valuable and cost-effective in Friuli-Venezia Giulia and other Italian regions. New resources and efforts are required to achieve a complete standardization and informatisation of the UNHS data to avoid documentation gaps. A possible strategy would point to the opportunity to unify data management systems for all the ongoing newborn screening programs (metabolic, hearing and visual), linking the integrated IT system with the regional repository of current datasets.

Web-Based Skin Cancer Prevention Training for Massage Therapists: Protocol for the Massage Therapists Skin Health Awareness, Referral, and Education Study

BackgroundSkin cancer, the most common cancer in the United States, is costly and potentially deadly. Its burden can be reduced by early detection and prevention activities. The scope of skin cancer requires going beyond traditional health care providers to promote risk reduction. Partnering with the nonbiomedical workforce, such as massage therapists (MTs), may reach more individuals at risk. MTs see much of their clients’ skin and are amenable to performing skin cancer risk reduction activities during massage appointments.ObjectiveThe objective of this study is to describe the Massage Therapists Skin Health Awareness, Referral, and Education protocol, presenting an overview of our systematic approach to developing rigorous e-training for MTs to enable them to be partners in skin cancer risk reduction. We also describe procedures for usability and feasibility testing of the training.MethodsWe developed an integrated electronic learning system that includes electronic training (e-training) technology, simulated client interactions, online data collection instruments, and in-person assessment of MTs’ application of their training.ResultsA total of 20 participants nationally scored the e-training as high for usability and satisfaction. We have screened an additional 77 MTs in Arizona for interest and eligibility, and currently have 37 enrolled participants, of whom 32 have completed the Web-based training.ConclusionsThe structured and rigorous development approach for this skin cancer risk reduction and brief behavioral intervention e-training for MTs begins to fill a gap in skin cancer risk reduction research. Iterative usability testing of our asynchronous Web-based training resulted in positive participant response. Our e-training approach offers greater learner accessibility, increased convenience, and greater scalability than the few existing programs and has the potential to reach many MTs nationally.International Registered Report Identifier (IRRID)DERR1-10.2196/13480

A cross-sectional audit of current practices and areas for improvement of distress screening and management in Australian cancer services: is there a will and a way to improve?

It is unknown how many distressed patients receive the additional supportive care recommended by Australian evidence-based distress management guidelines. The study identifies the (1) distress screening practices of Australian cancer services; (2) barriers to improving practices; and (3) implementation strategies which are acceptable to service representatives interested in improving screening practices. Clinic leads from 220 cancer services were asked to nominate an individual involved in daily patient care to complete a cross-sectional survey on behalf of the service. Questions related to service characteristics; screening and management processes; and implementation barriers. Respondents indicated which implementation strategies were suitable for their health service. A total of 122 representatives participated from 83 services (51%). The majority of respondents were specialist nurses or unit managers (60%). Approximately 38% of representatives' services never or rarely screen; 52% who screen do so for all patients; 55% use clinical interviewing only; and 34% follow referral protocols. The most common perceived barriers were resources to action screening results (74%); lack of time (67%); and lack of staff training (66%). Approximately 65% of representatives were interested in improving practices. Of the 8 implementation strategies, workshops (85%) and educational materials (69%) were commonly selected. Over half (59%) indicated a multicomponent implementation program was preferable. Although critical gaps across all guideline components were reported, there is a broad support for screening and willingness to improve. Potential improvements include additional services to manage problems identified by screening, more staff time for screening, additional staff training, and use of patient-report measures.