Service Redesign Research Articles

Interventions to improve access to cancer care in underserved populations in high income countries: a systematic review

BackgroundUnderserved populations both globally and in Canada face serious cancer inequities that result from systemic economic, environmental, and social conditions. These pose barriers in access to cancer care and lead to suboptimal cancer care experiences and outcomes. Knowledge of effective interventions to improve access to cancer care is needed to inform the design of tailored interventions for these populations.AimTo identify interventions and programs to improve access to cancer care for underserved populations in high income countries with universal health coverage (UHC) and the United States (US) throughout the cancer care continuum.MethodsWe conducted a systematic review following the PRISMA standards. We searched Medline, EMBASE, PsycINFO, CINAHL, Scopus, and the Cochrane Library. Inclusion criteria: quantitative and qualitative studies published in English in the last 10 years (2013–2023), describing interventions/programs to improve access to cancer care for underserved populations (18 years and over). We included studies in the US given the body of scholarship on equity in cancer care in that country. Screening, data extraction and analysis were undertaken by two independent reviewers.ResultsOur search yielded 7,549 articles, and 74 met the inclusion criteria. Of these, 56 were conducted in the US, 8 in Australia, 6 in Canada, and 4 in the United Kingdom. Most (90.5%) were quantitative studies and 47.3% were published between 2020–2023. Seven types of interventions were identified: patient navigation, education and counselling, virtual health, service redesign, financial support, improving geographical accessibility and multicomponent interventions. Interventions were mainly designed to mitigate language, distance, financial, lack of knowledge and cultural barriers. Most interventions focused on access to cancer screening, targeted rural populations, racialized groups and people with low socioeconomic status, and were conducted in community-based settings. The majority of interventions or programs significantly improved access to cancer care.ConclusionOur systematic review findings suggest that interventions designed to remove specific barriers faced by underserved populations can improve access to cancer care. Few studies came from countries with UHC. Research is required to understand tailored interventions for underserved populations in countries with UHC.

Key requirements for achieving EU-wide programme change

Abstract Issue Across the world, thousands of projects aim for equitable improvement in health for people who are experiencing ongoing avoidable stigma, discrimination and disadvantage however very little change is often achieved. Description of the problem In this presentation we explore key requirements for project-level change to ensure EU-wide programme change is achieved. Results The two most common causes of project failure are a) the innovation is not suitable, needed or wanted (also called theory failure) or b) implementation failure. This presentation shares strategies to mitigate risks of project failure through co-design processes and communication, drawing from 30 years of experience from the entire implementation process from ideation to scale up. These experiences include projects from over 30 countries, including partnerships with the World Health Organization, governments and industry focused on health literacy, self-management, care pathways, workplace health, hospital services redesign, First Nations health and migrant health. Common success factors include balancing top-down needs with co-designed inputs and with previous preferred or good practice (which may have come from controlled trial evidence generated in different contexts). The intervention must co-implemented to serve stakeholder’s needs at all levels, from citizens to decision makers. Lessons The United Nations (UN) and private sector apply system-wide approaches to affect large scale change. This knowledge is valuable for large public health programmes aiming to integrate equity and diversity in project processes to minimize implementation failure.

8756 Telemonitoring Use For Uncontrolled Type 2 Diabetes Management: A Systematic Review And Meta-Analysis Of Randomized Controlled Trials

Abstract Disclosure: F.A. Kelly: None. M.G. Leite: None. R.Y. Ura Sudo: None. F.A. Moraes: None. V. Morbach: None. E. Pasqualotto: None. I.P. da Silva: None. M.S. Barros: None. P.G. Lima: None. A.D. Lôbo: None. F.D. Pessôa: None. J.C. Cardoso: None. L.M. Lopes: None. M.B. Jardine: None. M.P. Lima: None. A.M. De Almeida: None. I.B. Andrade: None. M. Cavalcanti Souza: None. In the dynamic landscape of healthcare, the integration of telemedicine is reshaping how chronic conditions, such as type 2 diabetes (T2D), are managed. As we delve into the evolving paradigm of healthcare delivery, there is a growing interest in understanding the potential of telemedicine compared to traditional or "usual care" models for T2D. The prevalence of T2D globally underscores the need for innovative, patient-centric solutions that go beyond geographical constraints. Telemedicine, with its promise of real-time monitoring, improved patient engagement, and personalized care, stands out as a potential game-changer in the pursuit of optimal diabetes management. We aimed to perform a meta-analysis of the strategic redesign of healthcare services, harnessing information and communication technology (ICT) to enhance T2D management and glycemic control, providing timely interventions, and improving patient outcomes. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review (PRISMA) guidelines. PubMed, Web of Science, Scopus, and Cochrane databases were searched for randomized controlled trials (RCTs) comparing ICT interventions to usual care for T2D management. A random-effects model was used to calculate the mean differences (MDs) with 95% confidence intervals (CIs). Heterogeneity was evaluated with I² statistics. Statistical analysis was performed with Software R, version 4.3.1.A total of 46 studies comprising 26,129 patients were included, of whom 16,443 were randomized to ICT and 9,686 to usual care. Compared with usual care, ICT significantly reduced HbA1c (MD -0.36%; 95% CI -0.49, -0.23; p<0.001; I²=74%) and fast blood glucose (FBG) (MD -0.37 mg/dL; 95% CI -0.58, -0.15; p<0.001; I²=47%). There was no significant difference between groups for body mass index (MD -0.17 Kg/m²; 95% CI -0.47, 0.13; p=0.274; I²=89%), total cholesterol (MD -0.06 mmol/L; 95% CI -0.18, 0.05; p=0.287; I²=68%), low-density lipoprotein cholesterol (LDL-c) (MD -0.37 mmol/L; 95% CI -/ 0.93, 0.19; p=0.193, I²=97%), high-density lipoprotein cholesterol (HDL-c) (MD -0.29 mg/dL; 95% CI -0.78, 0.20; p=0.249; I²=92%), triglyceride (MD 0.02 mmol/L; 95% CI -0.33, 0.37; p=0.896; I²=99%).In this meta-analysis of RCTs of patients with T2D, ICT was associated with a significant reduction in HbA1c and FBG, compared with usual care. Presentation: 6/1/2024

Acceptability and timing considerations when administering patient-reported outcome measures (PROMs) among people with chronic health conditions who are culturally and linguistically diverse (CALD): a qualitative study protocol

IntroductionPatient-reported outcome measures (PROMs) are validated and standardised questionnaires that capture patients’ own reports of their symptoms, functioning and well-being. PROMs can facilitate communication between patients and clinicians, reduce symptom...

An innovative linked Electronic Health Record derived data ecosystem for understanding the complexities of health and ageing.

ObjectiveWe describe the creation of an Electronic Health Record (EHR) derived linked data platform within the Australian National Centre for Healthy Ageing (NCHA). ApproachOur approach involved establishing a core set of EHR data suitable for research from the sole public health provider within a defined geographic region. Relevant items were selected based on published literature and consensus processes and curated within a specialised research data warehouse. Curation involved: data validation, quality assessment, internal linkage between episodes and data harmonisation/merging. An AI supported natural language processing pipeline was implemented to extract text-based data. Approvals were obtained from government agencies to link commonwealth claims data (primary care, medication, aged care, death) and state administrative hospital data, for all residents aged ≥60 years. Publicly available datasets were scoped for inclusion and collaborations established to incorporate local council data. ResultsA core of 113 curated items for >900,000 people over 10 years have been established across 4 hospitals and 10 community/outpatient services. Linked state and commonwealth data were obtained for 179,089 residents aged >60 years (Jan 2010-May 2021, linkage accuracy 98.4%). Environmental (greenery, air pollution, walkability) and Census data have been incorporated for each neighbourhood (Statistical Area 1). Data access, extraction and release has been tested through over 30 use-case projects in: dementia, residential aged care, medication use, homelessness, environmental impacts on health and ageing and health service redesign. ImplicationsThe NCHA Data Platform provides an international exemplar for the use of linked EHR data in advancing population health research.

Using System Dynamics for Local Authority Public Health practice in England

A key function of local authority public health teams in England is to undertake a regular health needs assessment of their population. This involves forecasting, among other things, prevalence and incidence of long term conditions and health care service demand. Over the last few years, Kent County Council Public Health has adopted the use of system dynamics modelling (SDM) to not only do this but generate scenarios to simulate the impact of different interventions across different cohorts defined by age groups and diagnosable conditions. These include “no conditions” as well as understand the combined effects of different interventions, demographic changes and wider health determinants. Risk factors, such as smoking, diet and physical activity, were calculated using local linked data for the incidence of single conditions, progression toward complex needs and levels of morbidity including frailty. These were used to create the dynamics of the model. Incidence, prevalence and mortality for each cohort were projected over 25 years with “do nothing” and “Better Health” scenarios. The size of the “no conditions” cohort increased, and the other cohorts decreased in size. The impact of the interventions on life expectancy at birth and healthy life expectancy was significant. SDM heavily influenced local authority commissioning decisions for health improvement services redesign such as smoking cessation, weight management as well as other secondary prevention measures such as hypertension management and cardiovascular disease screening delivered by General Practice and other health service partners.

Navigating the Spectrum of Multi-, Inter-, and Transdisciplinarity in Service Design

Both in academia and in professional practice, multidisciplinarity, interdisciplinarity and transdisciplinarity offer unique pathways to innovation and holistic understanding. But what sets them apart? And why should we care? Imagine diverse experts tackling the redesign of a digital service, improving the experience of citizens or solving a complex service challenge. Each scenario requires different levels of collaboration, reflecting these three approaches. The shift from pooling knowledge to fully integrating and transcending boundaries can transform problem-solving.

Total elbow replacement in England: a protocol for analysis of National Joint Registry and Hospital Episode Statistics data

IntroductionPrimary total elbow replacement (TER) services in England are being restructured with the goal of centralising care to specialised centres. It is important to monitor the impact of this service redesign. This protocol outlines an intended analysis to provide detailed descriptions of the patients who are receiving primary TER, where and by whom TER is being performed, and what the current surgical practices for TER are in England before the reconfiguration.MethodsThis analysis will use the National Joint Registry (NJR) elbow dataset and link it with NHS England Hospital Episode Statistics-Admitted Patient Care (HES-APC). It will include eligible patients from the start of the NJR elbow dataset in April 2012 to December 2022. The main objective is to determine the incidence of TER in England. Age-sex standardised rates will be calculated for groups including different ethnicities, and socioeconomic backgrounds, using the mid-year population data provided by the Office for National Statistics. This planned analysis will summarise patient characteristics such as age, sex, body mass index (BMI), hand dominance, American Society of Anaesthesiologists (ASA) grade, indication for TER, socioeconomic status, and patient co-morbidities. It will also examine implant fixation type, classification, brand/type, and changes over time in implant types used in England. Additionally, it will explore the characteristics and volume of the surgeons and hospitals providing primary TER services, including the grade of the primary surgeons, funding source for surgery, and admission type. The analysis will cover the number of procedures performed by surgeons and hospitals annually in England and in each region of England. Finally, the planned analysis will summarise the elective wait time, postoperative length of stay, and any serious adverse events or re-admissions within 30 and 90 days after the TER.DiscussionThis protocol describes the first deep dive analysis into the NJR elbow dataset to describe the incidence of TER surgery in England and the characteristics of patients who are receiving it. This analysis will summarise current primary TER practices in England before service reconfigurations. The impact of reconfiguration can be monitored by comparing future practice to the outcomes from this study.Trial registration ClinicalTrials.gov, NCT06355011. Registered 02 April 2024, https://clinicaltrials.gov/ct2/show/NCT06355011.

Customer Complaint Service Business Processes Redesign with Artificial Intelligence Technology Using Business Process Reengineering Approach (Study Case: Ceria BRI Application)

This article analyses the business process redesign of Ceria BRI's customer complaint service using Artificial Intelligence (AI) technology with Business Process Reengineering (BPR) approach. This qualitative research with a post-positivism paradigm reveals that making complaints at Ceria BRI currently uses several channels such as telephone, email, social media, and applications. The problems faced include the high number of complaints that received every month in 2023, and some complaints were resolved over Service Level Agreement (SLA). The proposed solution is to redesign the proposed business process design by applying the four stages of Business Process Reengineering (BPR), namely Visioning-Identifying-Analyzing-Redesigning. These steps aim to improve service quality, grow positive interactions with customers, and enhance the internal performance of the Ceria BRI customer complaint service team.

"Dem sey mi mad": a scoping review of the attitudes and beliefs of English-speaking Afro-Caribbeans about psychosis.

The mental health disparities suffered by the English-speaking Afro-Caribbean diaspora living with psychosis in North America and the United Kingdom have been well described for decades, but the root causes of these disparities remain poorly understood. Part of the problem may be that the attitudes and beliefs of Caribbean communities regarding psychosis have never been systematically assessed. Such an inquiry could lay the foundation for changes to how psychiatric services for psychosis are implemented with migrant Caribbean communities. The ideal would be a re-design of services, or cultural adaptation of care, based on input from community members, patients, and their families, with the hope that disparities of care would be reduced or eliminated as clinicians co-create interventions that are more appropriate and acceptable to Caribbean people. To lay the groundwork of such an important endeavor, we investigated the shared attitudes, beliefs, experiences, practices, and traditions of English-speaking Afro-Caribbean people in relation to psychosis and psychiatric care. We conducted a scoping review by searching Medline, PsychINFO and Scopus, reviewing 764 articles, and selecting 220 for thematic content analysis. We highlighted the heterogeneity in the Caribbean diaspora living in North America and the UK. Five principal themes emerged: (1) The enduring effects of colonialism on the psychiatric care of Afro-Caribbean migrants; (2) The effects of adaptation to migration on the experience of psychosis; (3) Pervasive cultural mistrust of psychiatry and mental health institutions; (4) A collective approach to life; and (5) The role of religion and spirituality in the understanding of psychosis. Historical, sociocultural, and geopolitical themes characterize the English Afro-Caribbean experience of psychosis and inform culturally adapted clinical interventions for patients with psychosis and their families. Careful attention to these adaptations will reduce clinical bias and misdiagnosis, optimize adherence to treatment, engage patients and families in recovery, and ultimately, reduce treatment disparities while empowering Afro-Caribbean people and their communities. By bringing forward the themes in this chapter, individual clinicians will be given tools to change how they work with Caribbean people with psychosis in addition to laying the foundation for higher order changes in the mental health professions and society as a whole.

Translating 'proportionate universal healthcare' into meaningful system design to optimize equity in child and family services.

To conduct a child and family health nursing service redesign to improve pathways of access, response and outcomes for all families with children aged 0-5 years. The study was conducted as an iterative, mixed-method study of the process and impact of the service redesign, informed by a participatory action research paradigm and the NSW Agency for Clinical Innovation process for developing a model of care. Diagnostic, solution design, implementation and sustainability phases were undertaken. Quantitative analyses were undertaken of administrative data, and child and family health nurse and client surveys. Qualitative analyses were undertaken of design workshops. The administrative data demonstrated that prior to the redesign service provision was the same for all clients regardless of levels of risk. The design solution, developed through a series of diagnostic and visioning workshops, included multiple new client response pathways. Implementation included development of tools and training. Sustainability of the redistribution of resources to the new pathways was assessed though an evaluation demonstrating a positive impact for families with adversity, with no deleterious effects for families receiving a universal response, and improvements in the emotional labour undertaken by nurses. Despite this, nurse burnout increased post-redesign. The shift from equal services (everyone receives the same) to equitable proportionate universal provision in response to need can be achieved and has positive impacts for nurses and families. This study shows the value of undertaking a systematic and participatory approach to service redesign. A proportionate universalism approach can ensure that early childhood nursing services are available to all in relation to needs. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) check-list was used to guide reporting. No patient or public contribution.

Embedding sustainability in local welfare systems: bottom-up contributions from social workers and care professionals in public and third sector organisations

ABSTRACT Sustainability, and how it may be embedded in welfare systems and services, is a much-debated topic in social work studies, with implications for the role that social workers and other care professionals play in this process. Analysing a local welfare system, this paper investigates professionals’ experiences of the organisational dimension of social services, and potential factors supporting a service redesign informed to sustainability. Professionals’ perspectives on sustainability, and their views on structural factors, barriers and methodological tools influencing the establishment of sustainable service networks, are explored. Data is drawn from a study exploring views on sustainability in care professionals in Italy (Veneto region). Eight focus groups, involving n = 26 social workers and n = 12 care professionals in Public and Third Sector Organisations were conducted using a photo-elicitation technique. Interviews were thematically analysed and interpreted through Boetto’s ‘transformative eco-social model’ (2017). Results describe the structuring of the eco-social intervention network and the (un)sustainable system aspects. Participants highlighted the benefits of participatory planning approaches, community work, new economic models, and organisational cultures fostering meaningful work. We conclude that social care professionals have a key role in catalysing grassroots change, and local services are privileged settings for building a sustainable, generative welfare.

Integrated care policy recommendations for complex multisystem long term conditions and long COVID

The importance of integrated care for complex, multiple long term conditions was acknowledged before the COVID pandemic but remained a challenge. The pandemic and consequent development of Long COVID required rapid adaptation of health services to address the population’s needs, requiring service redesigns including integrated care. This Delphi consensus study was conducted in the UK and found similar integrated care priorities for Long COVID and complex, multiple long term conditions, provided by 480 patients and health care providers, with an 80% consensus rate. The resultant recommendations were based on more than 1400 responses from survey participants and were supported by patients, health care professionals, and by patient charities. Participants identified the need to allocate resources to: support integrated care, provide access to care and treatments that work, provide diagnostic procedures that support the personalization of treatment in an integrated care environment, and enable structural consultation between primary and specialist care settings including physical and mental health care. Based on the findings we propose a model for delivering integrated care by a multidisciplinary team to people with complex multisystem conditions. These recommendations can inform improvements to integrated care for complex, multiple long term conditions and Long COVID at international level.

Developing an integrated nurse and physiotherapist-led bladder, bowel and pelvic health team.

A service redesign in 2019 led to the formation of an integrated team of nurses and physiotherapists working together to form a bladder, bowel and pelvic health team across two hospitals and the community in Lewisham and Greenwich NHS Trust. The last few years have had their challenges, but the team is now very successful and has won awards for the integration and achievements, particularly in the redesign of the containment product service. Integrating two professional groups has led to excellent team-work and smoother patient journeys.

Multimorbidity: Inequalities, lived experience and the need for service redesign.

Multimorbidity: Inequalities, lived experience and the need for service redesign.

Gestational diabetes mellitus care re‐imagined: women's experiences of a major model of care change at a large metropolitan hospital

Abstract Background: A gestational diabetes mellitus (GDM) pregnancy has significant psychological, time and resource impacts. In 2020–21, a digitally‐supported radical GDM service redesign was undertaken at a Brisbane tertiary centre, producing substantial cost savings without compromising clinical outcomes.Aims: To describe women's experiences within this new model of care (MOC), specifically the app user experience (MOC) (post), compared with a traditional MOC (pre).Methods: The new MOC was evaluated using a pre–post study design. This MOC included a smartphone app‐to‐clinician blood glucose communication platform. A convenience sample of women were surveyed about care experiences and app use pre‐ and post‐implementation. An additional survey queried user app experience at four weeks’ postpartum.Results: Within the service, 34% (n=24) and 22% (n=48) of women were surveyed pre and post MOC introduction, respectively. Pre‐implementation, 50% (n=12) of women missed work to attend appointments and 75% spent 30–120 minutes at the hospital. Questions regarding understanding GDM, initial dietary changes and glucometer use received similar or slightly lower ratings, pre‐ to post‐implementation. Nearly a quarter of women in the app‐experiences survey (24.2%; n=177) showed high levels of satisfaction with care received (91.5%) and with the app for managing GDM (87.1%). Two experience themes that emerged were Enhanced GDM management and Usability issues.Conclusions: The new MOC reduced time impositions associated with attending appointments. Despite the removal of face‐to‐face visits in the new MOC, women still established a connection with their treating team and maintained their understanding of their GDM management. Copyright © 2024 John Wiley & Sons.

Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills.

Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.

Systemic anticancer therapy service redesign

Systemic anticancer therapy service redesign

A multi-criteria decision analysis framework that prioritizes economic policy to enhance value based health care during the COVID-19 pandemic

ObjectiveTo investigate pandemic impacts on Value-Based Health Care (VBHC) globally, using multi-criteria decision analysis (MCDA) to address challenges through prioritizing economic policies.MethodsPreferred Reporting Items for Systematic reviews and Meta Analyses extension for Scoping-Reviews (PRISMA-ScR), PUBMED, Medline, and google-scholar were used to analyze pandemic impacts on VBHC domains. MCDA prioritized economic policies, utilizing the value-measurement model with additive-weighted scores. The criteria weighting-method used direct-rating, ranking and robust deliberation by four experts to priority rank economic policies for each VBHC domain.ResultsCOVID-19 impacted on all VBHC domains: Integrated Practice Units, outcome and cost measurement, Value-Based Reimbursement, Information Technology (IT), regional systems integration, geography of care and VBHC policy and institutions. There were changes in patient complexity, service delivery, activity, models of care, pricing, costs, IT, quality, and health status. COVID-19 pricing impacts included increased capacity costs, Personal Protective Equipment costs, cost per patient, service delivery changes, and telehealth costs. A median of 37% of patients globally avoided care, negatively impacting on diabetes, venous thromboembolism, Parkinson’s disease, kidney disease, myocardial infarction, stroke, and cancer patients. A consequence is inaccurate assessments of health status, underestimated projected health needs, and costs for risk-adjustment, impacting health services. Innovations include telehealth and changing service redesign. New care models include state-wide ICU-COVID Models of Care, Telehealth-Inpatient Physician Services, COVID-linked pathology testing, and increased Hospital in the Home. Artificial Intelligence innovations involved patient-screening, triage, risk-evaluation, care assessment, pathways, and laboratories. Risk-adjustment challenges impacted on Value-Based Reimbursement and patient risk-stratification. MCDA prioritized economic policies, including healthcare system performance, healthcare demand and supply, risk-adjustment, planning and market mechanisms, economic evaluation of healthcare, economic sustainability initiatives, and health determinants.ConclusionCOVID-19 demonstrated the limits of health systems globally, with increasing costs and limited budgets. The economic strategies identified can enhance VBHC globally.

British Models of Person Centered Medicine

Background: The National Health Service (NHS) was established in 1948 as a publicly funded healthcare system in the UK providing universal health coverage that is comprehensive, equitable and free at the point of delivery. The British experience of person centered medicine (PCM) is enshrined in the NHS constitution. Objectives: The objective of this study was to highlight important developments in and evolution of PCM within the NHS in person-centered care (PCC), research and innovations in undergraduate and graduate health education. Methods: This is a narrative overview of the British experience of PCM. Results: It is evident that the British experience and practice of PCM have evolved naturistically over seven decades since the establishment of the NHS. Academic research groups in collaboration with the NHS have introduced person-centered models of care supported by pivotal research in practice. Importantly, person-centered nursing has been widely adopted following the early development of a framework for person-centered nursing and its extensive evaluation. There emerged many initiatives on PCM by National Voices, the Health Foundation, British medical schools and the Royal Medical Colleges. The landmark development was the production by the Royal College of Psychiatrists in the UK of the first blueprint for a postgraduate psychiatric curriculum that is in tune with person-centered psychiatry. Conclusions: It is envisaged that the NHS will evolve and increasingly promote, adopt, codesign and implement PCC approaches adapted to the local, regional and national contexts including services redesign, health education and applied health research. These innovations contribute to the universal development of person-centered healthcare and health education.