Team Meetings Research Articles

“Developing a manual clinical trials screening process in a diverse southern gynecologic oncology practice”

ObjectiveThere is no standard clinical trial screening process in gynecologic oncology. In our low resource, highly diverse gynecologic oncology patient population, we sought to create an equitable, adaptable, manual screening process. MethodsOur objective is to describe our clinical trial screening process and success in improving trial enrollment. An Institutional Review Board (IRB) approved quality improvement (QI) project was implemented in July 2022 to evaluate trial access. Screenable events were defined. Potential patients were those with a screenable event: new patients or diagnoses, regimen changes, progressions, and recurrences. Events were categorized into screen positive or screened no trial available. Screen positives were further categorized as screen positive, enrollment failure events or enrollments. Data about patients were collected via weekly research team meetings. Monthly meetings occurred to review progress. The data were compared to trials available, number of patients with trail available, and those that enrolled. Reasons for enrollment fails were tracked. ResultsOver time, “screen no trial available” (SNTA) rates stayed stable, but enrollment rates increased. Patient preference accounted for 32.8 % of enrollment failures (n = 42), pre-existing symptoms 23.4 % (n = 30), and location 21.1 % (n = 27). During increased employee turnover, there was a rise in enrollment fails due to staffing (n = 6, 4.7 %). We describe an effective process of clearly defining and tracking our patient population and ‘screenable events’ for which all patients are screened and offered trial participation if eligible. ConclusionsWe show that we improved understanding of the patient population, built a clinical trial portfolio better matched to population served, exceeded national averages for enrolling patients on trials, and are improving number eligible.

Transcatheter closure of patent ductus arteriosus with mitral regurgitation in children: Clinical outcome and improvement of mitral regurgitation after procedure with echocardiogram follow-up

Background: Patent ductus arteriosus (PDA) is a prevalent pediatric heart condition, often causing heart failure and pulmonary hypertension. Mitral regurgitation, a common occurrence, may be improved by CMRI after PDA closure, suggesting improved follow-up. Objectives: The purpose of this retrospective study is to evaluate the clinical outcomes and follow-up echocardiogram results following transcatheter PDA closure in these patients, with the view of proposing an effective treatment strategy. On other words, the goal is to improve the follow-up of children with PDA and mitral regurgitation five years after PDA closure in which the issue of long-term follow-up of these children still needs to be assessed. Methods: The Queen Alia Heart Institute conducted retrospective study that examined the outcomes and follow-up of children with open PDA with only mitral regurgitation (MR) who underwent closure, outcomes, and follow-up by echocardiography from January 2018 to March 2022. The patient cohort included 46 children who were discussed in heart team meetings and were candidates for catheterization for device closure due to no resolution of the shunts proposed for transcatheter closure of PDA with color Doppler echocardiography. Transcatheter closure was performed with general anesthesia or conscious sedation, and continuous hemodynamic monitoring was performed for at least 30 minutes to ensure stabilization. The study also reviewed the management and outcomes of children with isolated MR and no intervention for PDA. Current intervention techniques for transcatheter closure in patients diagnosed with PDA and MR are divided into four main strategies: Lesson-Severn wire-controlled occlusion, Sideris muscular device implantation, inter-procedural MR availability assessment before device deployment, and secondary transcatheter or interventional strategy due to remaining MR. Advances in treatment have allowed patients to receive intervention at younger ages and benefit from a reduced dose of radiation. Results: A study comparing children with and without PDA and MDI showed significant improvements in post-intervention EROA, RV volume, RVEF, LVEDVi, and LVFS compared to pre-intervention values. The subgroup analysis revealed that after PDA closure, MR drainage volume decreased, while ventricular volume and function were compensated. The study also found that the improvement and EROA reduction might be related to sex rather than age. The results showed no statistical difference in hospitalization rates between the two groups, but the DuctAngio group had a higher proportion of patients with symptoms and poor health. The study also found that patients with MR showed better patient experience, highlighting the potential improvements in pediatric cardiology. Conclusions: The study found that transcatheter closure of significant PDA with MR improved MR in most patients rapidly and at midterm follow-up, with immediate symptomatic improvement and cardiac remodeling, without long-term MR progression.

The Impact of Workflow Interruptions on Multidisciplinary Team Communication in Hybrid Healthcare Settings

Workflow interruptions are skyrocketing in the contemporary workplace, especially in collaborative team environments. The reliance on (communication) technologies and accessibility through email and phone creates increasing avenues for frequent teamwork interruptions. In this study, we investigate in fourteen multidisciplinary team meetings in hybrid healthcare settings (1) which workflow interruptions naturally emerge and (2) how these interruptions influence the communicative processes within the team. We find evidence for an interruptive meeting environment, characterized by videoconferencing issues, disruptive beepers/phones that go off, and people leaving and entering the meeting room during patient discussions. Contrary to what was expected, team members initially respond to the interruption with positive statements (i.e., humor) as a coping mechanism, which decreases significantly in the minutes after the interruptive event. After the interruptive episode, significantly more negative statements, as well as conversational repetitiveness occurs. This research contributes to understanding naturally occurring workflow interruptions in actual organizational healthcare teams, by providing objective and fine-grained empirical insights into how workflow interruptions affect changes in the teams’ communication.

ASO Visual Abstract: Do Surgical Oncology Multidisciplinary Team Meetings Make a Difference?

ASO Visual Abstract: Do Surgical Oncology Multidisciplinary Team Meetings Make a Difference?

Military spouse and key stakeholder perspectives of effective messaging for US service members on secure storage of personal firearms: a qualitative study

BackgroundSecure firearm storage is a proposed method for reducing intentional and unintentional firearm injury and death among US military service members. However, little is known about suggested key messengers and...

Embedding rehabilitation into cancer care continuum: an implementation study.

To implement and evaluate a rehabilitation-inclusive service delivery model at a tertiary cancer hospital. The "Rehab-Toolkit", a structured assessment tool comprising validated functional measures, was introduced in an inpatient cancer service. Consecutive inpatients were enrolled, and a Reach, Effectiveness, Adoption, Implementation, and Maintenance framework guided the analysis of barriers and facilitators for subacute care at clinic and system levels. The implementation of the Rehab-Toolkit was incorporated into routine inpatient care. Major pre-implementation barriers included: absence of routine standardized functional assessment tools, limited coordination amongst acute and subacute care providers, low awareness of rehabilitation medicine amongst patients and professionals, and insufficient engagement of subacute care with interdisciplinary stakeholders in clinical decision-making. Following the intervention, there was a notable increase in awareness and the contributory role of subacute rehabilitation services, rehabilitation "needs" assessment, and referral pathways. Recommendations for process change included: development of clinical pathways, establishment of subacute referral systems and discharge coordinator roles, inclusion of subacute rehabilitation services in acute interdisciplinary team meetings, enhanced staff education and knowledge. Integration of rehabilitation services into cancer care can proactively manage functional morbidity. While the implementation process proved feasible and effective, robust process evalu-ation and longer term follow-up are necessary for sustained success.

Implementation of a nationwide program for total pancreatectomy and islet autotransplantation in chronic pancreatitis: A Scandinavian single-center observational study.

Tailoring surgical treatment is mandatory to optimize outcomes in chronic pancreatitis. Total pancreatectomy (TP) offers pain relief in a subset of patients. TP with islet autotransplantation (IAT) has the potential to reduce the burden of postsurgical diabetes. We present the first Scandinavian prospective study assessing outcomes following total pancreatectomy and islet autotransplantation (TPIAT) in chronic pancreatitis. Our aim was to assess short- and long-term outcomes following implementation of a nationwide program of TPIAT at a tertiary reference center for pancreatic surgery in Norway. A prospective, observational single-center study enrolling consecutive patients undergoing TPIAT for chronic pancreatitis at Oslo University Hospital. The selection of potential candidates for TPIAT was based on discussions at multidisciplinary team (MDT) meetings, focusing on tailored surgery in chronic pancreatitis. Patients were finally evaluated in a dedicated TPIAT team. The outcome measures included pain relief, quality of life (QoL) assessed by EORTC QLQ-C30, complications, and glycemic control. Between August 2017 and November 2022, 15 patients underwent TPIAT. The follow-up rate was 87% with a median follow-up of 26 months (range = 14-65). Pain relief was achieved in 92%. EORTC QLQ-C30 analysis revealed clinically significant improvements in 28 of 30 domains, particularly in pain and role- and social-functioning. The Clavien-Dindo ≥IIIa complications occurred in one patient. There was no 90 days mortality. All patients maintained C-peptide positivity, although none of the patients reached insulin independence. TPIAT was as a safe and effective treatment for a selected group of patients with chronic pancreatitis, providing substantial pain relief and enhanced QoL. Islet autotransplantation prevented complete insulin deficiency, reducing diabetes severity postpancreatectomy. Dedicated chronic pancreatitis MDT meetings were key factor in the success of the program.

Using FRAME Documentation to Achieve RE-AIM Goals During Iterative, Stakeholder-Engaged Refinement of a Family Management Intervention for Parents of Preterm Infants.

To co-identify adaptations with key stakeholders needed to optimise elements of a video-based intervention (i.e., PREEMIE PROGRESS [PP]), which trains parents in evidence-based family management skills to care for their very preterm infant in the neonatal intensive care unit (NICU). Descriptive qualitative study oriented with a pragmatic philosophy, informed by the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework and the framework for reporting adaptations and modifications-expanded (FRAME). Semistructured interviews to identify potential adaptations with key stakeholders: family management researchers (n = 5), clinicians (n = 9), technology experts (n = 5) and parents of preterm infants (n = 17). Weekly design team meetings to select and implement high-priority adaptations necessary for the next research phase. Monthly NICU parent partnership meetings to review adaptations and make recommendations for potential adaptations with conflicting data. Stakeholders (N = 36) suggested 98 potential adaptations: 32 (33.0%) were completed, 8 (8.2%) were abandoned, 5 (5.2%) have work that is ongoing and 52 (53.6%) were tabled for future research phases. Content adaptations (70, 71.4%) were the most frequently suggested adaptation type. Potential adaptations mostly addressed RE-AIM dimensions of effectiveness (43, 43.9%), and implementation (46, 46.9%) and were directed at the parent (i.e., intervention recipient) level (79, 81.4%). Use of the RE-AIM framework ensured we systematically identified needed adaptations with key stakeholders across a range of dimensions that would improve PP for parents now and in future phases of this research. Co-identifying potential adaptations with key stakeholders, paired with FRAME documentation, can help nurses prioritise adaptations most appropriate for each phase of implementation. Our paper highlights for nurse clinicians and researchers how FRAME documentation of potential adaptations can support stakeholder engagement and a systematic approach to incorporating adaptations throughout all phases of the research process, thereby shortening the evidence to practice gap. COREQ guidelines for qualitative reporting. The research team was supported by members of the NICU's Parent Partnership Council (PPC), whose mission is to promote family-centred care improvement projects and research within the NICU. This committee is comprised of nursing, physician, allied health leadership and parents of infants previously hospitalised in the NICU. The NICU PPC met monthly to review conflicting data on potential adaptations and provide recommendations on adaptation decisions.

Do Surgical Oncology Multidisciplinary Team Meetings Make a Difference?

Multidisciplinary team (MDT) meetings are important but resource-expensive components of surgical and oncologic care. This cohort study investigated the effectiveness of surgical MDT meetings by assessing the predictability of MDT meeting recommendations, the degree that patient management plans are changed by discussion, and the incidence of recommendation implementation. Multidisciplinary team meetings at The Queen Elizabeth Hospital in South Australia were audited for upper gastrointestinal (UGI) and colorectal (CR) surgical units from August 2021 to June 2022. All cases referred for MDT meeting discussion were included. Prospectively obtained pre-MDT meeting management plans were compared with formal MDT meeting recommendations to assess for concordance and degree of change. Patient records were assessed after 8 months for MDT meeting recommendation implementation. Multivariable analysis of patient factors was performed to identify associations between MDT meeting recommendation predictability and implementation. In 438 patient cases, discussed during 30 MDT meetings, 317 (72.37%) were correctly predicted. Specifically, 226 (51.6%) were correct with no change, 28 (6.39%) were correct with minor changes, 40 (9.13%) were correct with moderate changes, and 23 (5.25%) were correct with major changes. The UGI and CR cohorts differed significantly in moderate changes (P = 0.0217). The female patients were 1.62 times more likely than the male patients to have pre-MDT meeting management plans predicted (P = 0.0201). Formal MDT meeting recommendations were implemented in 380 (89.62%) cases. The MDT meetings changed management for almost 1 in 2 patients discussed. Other than female sex, no identifiable patient factors increased the likelihood of predictability, and no factors predicted recommendation implementation.

Factors associated with the implementation of dialectical behavior therapy by Spanish speaking mental health professionals who treat suicide risk

BackgroundThe lack of training for professionals on how to manage suicide risk is an important barrier to effective intervention. Dialectical Behavior Therapy Intensive Training™ (DBT-IT) includes specific training for suicide and has shown promising results to enhance implementation of DBT. To our knowledge, no published studies have evaluated the effect of DBT-IT on therapists’ attitudes towards treating suicide risk and among Spanish-speaking mental health professionals. The main aim of this study was to evaluate the effect of DBT-IT on therapists’ attitudes regarding treating suicide risk and its relationship with the implementation of DBT before and after receiving DBT-IT.MethodsA total of 242 mental health workers (76.4% women, mean age 35.38, SD = 9.17; 77.7% from Latin America; 22.3% from Spain) who had received a DBT-IT participated in the study. Self-efficacy (Efficacy in Assessing and Managing Suicide Risk Scale) and concerns (Concerns about Treating Suicidal Clients Scale) in treating suicide, perceived burnout (Copenhagen Burnout Inventory), confidence in applying DBT (Behavioral Anticipation and Confidence Questionnaire), barriers to implementation (Barriers to Implementation Inventory), implementation of DBT and reach were measured via online survey at parts 1 (pre-training) and 2 (post-training, after 9 months of implementation) of the DBT-IT.ResultsDifferences between pre-training and post-training (n = 61) indicated statistically significant improvements in self-efficacy, concerns about the lack of training and competence in treating suicide, and confidence in applying DBT. Statistically significant increases in the rates of DBT treatment modes implementation (except for individual therapy) and mindfulness practice, as well as the number of team members and consultation team hours, were also found. Findings also indicated statistically significant positive correlations between burnout and concerns about treating suicidal clients, as well as with structural and administrative implementation barriers, and between self-efficacy in managing suicide, confidence in applying DBT and implementation of DBT treatment modes. Participants with more implementation barriers reported lower rates of consultation team meetings and phone coaching implementation.ConclusionsDBT-IT could be an adequate training model to increase self-efficacy and confidence in treating suicide risk as well as to facilitate implementation of DBT treatment modes by Spanish-speaking mental health professionals.Clinical trial numberNot applicable.

Initiating Prognostic Talk During Hospice Multidisciplinary Team Meetings: A Conversation Analytic Study.

Objective: Guidelines recommend that patients' prognoses should be discussed by the palliative care multidisciplinary team. However, there is a lack of evidence on how multidisciplinary teams carry out prognostic discussions, and especially how prognostic talk is initiated during team meetings. This study explored how prognostic talk is initiated and responded to during meetings of a hospice multidisciplinary team. Methods: Video-recordings of 24 inpatient multidisciplinary team meetings in a UK hospice were collected from May to December 2021. A total of 65 multidisciplinary team members participated in the meetings. Recordings were transcribed and analysed using Conversation Analysis. Results: Prognostic talk was initiated during multidisciplinary team members' patient case presentations. Case presentations followed a certain template, and prognoses could be initiated as responses to template items such as the patient's Phase of Illness and Karnofsky's Performance Status score and the patient's main diagnosis and issues. Prognoses also occurred as accounts for a lack of template item responses. Beyond the patient case presentation, prognostic talk was initiated in relation to discharge planning. Prognoses appeared with sequences of assessments that accounted for them. When a prognosis was provided, it received confirming minimal responses from other team members. Conclusions: Patients' prognoses were embedded into other care discussions during meetings of a hospice multidisciplinary team. These findings can be used to inform the development of clinical guidelines and interventions aiming at improving multidisciplinary team discussions around prognosis in the future.

OGC SO03 - Impact of recent European consensus guidelines on Oligometastic Disease (OMD) and potential case load of Oesophagogastric cancer resections

Abstract Background To evaluate the impact of recently devised oligometastatic disease (OMD) criteria as per the European consensus guidelines on the eligibility of Oesophagogastric (OG) cancer patients for curative treatment. Method A retrospective analysis was conducted on OG cancer cases discussed at multidisciplinary team (MDT) meetings at a tertiary university hospital from January 2018 to December 2023. Inclusion criteria included T2-T4a adenocarcinomas, T2-T4b squamous cell carcinomas, small cell carcinoma and adeno-squamous carcinomas that were classified as M1 disease. Exclusion criteria were T4b adenocarcinomas, M1 peritoneal disease, non-adeno/ squamous carcinoma histology, M1 peritoneal cytology, and head and neck squamous cell carcinomas proximal to the thoracic inlet. Data on patient demographics, T stage, histology, and metastatic sites were analysed to identify those meeting the oligometastatic disease criteria. Results 483 of 696 were diagnosed as M1 disease. OMD was found in 59 cases (12.2%), with a median age of 72 years (43 males, 16 females). T stage distribution: 3 T2, 36 T3, 20 T4. Histology: 39 adenocarcinomas, 19 squamous cell carcinomas, 1 small cell carcinoma. Metastatic sites: non-regional lymph nodes (77.9%), liver (13.6%), lung (5.1%), bone (1.7%), adrenal (1.7%) Location of Lymph Node Involvement: 1Para-aortic11 (23.9%)2Right supra-clavicular7 (15.2%)3Porto-caval6 (13.0%)4Retro-crural5 (10.9%)5Upper mediastinal5 (10.9%)6Left Supraclavicular5 (10.9%)7Coeliac4 (8.6%)8SMA3 (6.6%) Conclusion Our data would suggest that 12.2% of patients discussed in the MDT may potentially be candidates for a curative intent treatment pathway. Although the long-term outcomes remain unclear, this approach may define a subgroup of patients who may benefit from curative intent treatment with the highest site being para-aortic nodes.

Implementing Resourcefulness Training© with Parent Caregivers of Children Dependent on Medical Technology During the COVID-19 Pandemic: Lessons Learned from a Randomized Controlled Trial.

Parent caregivers of children requiring life-saving medical technology (e.g., mechanical ventilation) report higher levels of stress and poorer health than other caregivers, often neglecting health-promoting behaviors for themselves. This article describes an iterative implementation science strategy used to improve intervention delivery for a randomized controlled trial testing a telehealth, cognitive-behavioral resourcefulness intervention with this population during the COVID-19 pandemic. This process consisted of reflective team meetings and content analysis. Initial adjustments were made after content analysis of pilot study materials before intervention delivery including an intervention script, checklist, online daily log, Health Insurance Portability and Accountability Act (HIPAA)-compliant texting option, training material access, and fidelity checks. In vivo adjustments were implemented in four areas: recruitment/engagement, participation and use of resources, in-person delivery, and virtual delivery. Our efforts to streamline intervention delivery were enhanced by incorporating an iterative implementation science strategy including analysis and adjustment of intervention delivery procedures to decrease participant burden and promote intervention adherence. Reflective team meetings and a collaborative, problem-solving approach to resolve the various barriers and challenges with the randomized controlled trial were integral components of intervention delivery. This study informs future intervention research by providing details of barriers faced, pragmatic adjustments made to intervention implementation, and lessons learned (NCT0410524; www.clinicaltrials.gov).

Format Matters: Comparing the Inclusiveness and Effectiveness of Hybrid and Remote Meetings

The surge in remote and hybrid work has provided many benefits in terms of flexibility and autonomy, but it also presents challenges when it comes to team collaboration and meetings. Using a mixed-methods field study, we compare hybrid and remote meeting configurations to better understand how to improve the inclusiveness and effectiveness of these different meeting modalities. Our findings indicate that overall, fully-remote meetings are the most inclusive and effective. Fully-remote meetings are perceived as more inclusive of remote attendees despite their lower chat usage compared to hybrid meetings. We also find that people's preferred format varies depending on the purpose or type of meeting and the skill set of the meeting moderator. We provide recommendations for improving meeting inclusion and effectiveness in both hybrid and remote meetings, such as training moderators and integrating chats with the main meeting.

Educational teams: building professional and organizational learning communities

Quality education that prepares young people to think and make ethically responsible decisions seems to be the only sustainable solution to respond to today’s global challenges. However, this capacity to learn requires a new school grammar, through the creation of conditions, structures and cultures that promote relationships and synergies capable of transforming teachers and school leaders into creative learners and facilitators of learning. In this sense, this study sought to understand the effects of a change in the organizational dynamics of a school, the organization of teaching by educational teams, on the individual, collective and organizational learning of this school organization. To this end, we adopted a fundamentally qualitative research approach, which we operationalized through a case study, based on a quali-quanti approach. We combined a descriptive statistical analysis of two questionnaires with a content analysis of interviews, focus discussion groups, and field notes from classroom observations and educational team meetings. The analysis of all these data points to the fact that effective change in schools and education that promotes deep learning for teachers and, consequently, for students and the organization, requires joint and articulated action not only at the level of structure and leadership, but also at the level of beliefs and school cultures.

The effects of spondylodiscitis on the inflammation burden in infective endocarditis.

This study investigates the effects of spondylodiscitis on the inflammation burden in infective endocarditis patients. Aprospective, observational study was conducted between September 2018 and October 2022 in anon-surgical teaching hospital. Patients with adefinite or possible and treated as infective endocarditis were recruited from the Alkmaar Endocarditis Team meetings. Spondylodiscitis was diagnosed based on symptoms and radiological findings. The inflammation burden was defined as the area under the C‑reactive protein (CRP) curve. 174 consecutive patients with infective endocarditis were included (mean age73years, 34.5% female). Concomitant spondylodiscitis was present in 32patients (18%), frequently associated with Streptococcus species (38%). At admission, the mean level of CRP was significantly higher in patients with concomitant spondylodiscitis (p = 0.004). The median CRP area under the curve was significantly higher in spondylodiscitis patients (4.2 × 106 min.mg/l [1.2 × 105 - 1.6 × 107 min.mg/l] vs 2.0 × 106 min.mg/l [8.7 × 104 - 1.6 × 107 min.mg/l], p < 0.001). This difference remained during the whole treatment period. At 6months of follow-up, rates of mortality and relapse of infective endocarditis were not significantly different. The prevalence of spondylodiscitis in non-referred patients with infective endocarditis was 18%. Endocarditis patients with spondylodiscitis had an increased inflammation burden at and during admission. This difference in normalisation of CRP levels was particularly apparent in the final phase of antibiotic treatment but not related to infectious complications. Despite an augmented inflammation burden, spondylodiscitis was not associated with mortality, cardiac surgery or infectious relapse.

Neoadjuvant chemotherapy in breast cancer: a retrospective pathway assessment in a regional cancer centre.

The optimal care pathway (OCP) for people with breast cancer provides a framework for investigation and management of patients with breast cancer, with delays previously identified regionally. With emphasis on the neoadjuvant pathway, the primary aim of this study was to assess the practicality of implementing the breast cancer OCP timeframes regionally in comparison to nationally referenced standards. A retrospective institutional audit was performed for patients undergoing neoadjuvant therapy for breast cancer. The time from referral to specialist review, completion of investigations, discussion at multidisciplinary team (MDT) meetings, initiation of neoadjuvant chemotherapy (NACT) and surgery were calculated and compared to OCP. Fifty-three patients were included, with 19 patients living rurally (36%). Twenty-four patients (45%) were seen by a specialist surgeon within 2 weeks of referral. Following surgical review, 44 patients (83%) completed investigations within 2 weeks, and 43 patient cases (81%) were discussed at MDT meetings within 2 weeks. Forty-eight patients (91%) were commenced on neoadjuvant treatment within 4 weeks of decision to treat, and 43 patients (81%) underwent surgery within 6 weeks of neoadjuvant treatment completion. Delays from initial referral to NACT were more frequent in rural patients compared to urban (79% vs 94%, P < 0.05). Adherence to OCP timeframes for patients undergoing neoadjuvant therapy in a regional centre was feasible and strategies are needed to bridge gaps identified for rural patients.

Assessment of Professional Practices in the Care Pathway of Patients with Upper Aerodigestive Tract Cancer in a University Hospital.

The main objective of this study was to evaluate the alignment between treatment decisions made during multidisciplinary team meetings (MTMs) and the treatments received by patients with upper aerodigestive tract cancers. The secondary objective was to identify factors influencing potential discrepancies. This retrospective, single-center study was conducted at a tertiary referral center and included 147 patients diagnosed with squamous cell carcinoma of the upper aerodigestive tract. Patients were divided into two groups based on the match between MTM-decided and actual treatments. Multivariate analysis was performed to assess factors independently associated with discrepancies. Out of 147 patients, 28 (19%) received treatment that did not align with MTM decisions. Among these, eight died before treatment, one patient refused care, five received supportive care, five patients underwent surgery, three received radiotherapy alone, one patient underwent surgery and adjuvant radiochemotherapy, one patient underwent surgery and adjuvant radiotherapy alone, three patients received radiochemotherapy, and one patient received palliative chemotherapy. Independent significant factors associated with non-concordance included poor performance status (PS) and treatment not received at a tertiary reference center. Treatment shifts mainly involved downgrading from curative to palliative care. This study highlights the importance of patient health status in determining deviations from MTM decisions. Further efforts should focus on improving the integration of patient comorbidities and health status into MTM decision-making to optimize care delivery.

Increasing the uptake of advance care directives through staff education and one-on-one support for people facing end-of-life.

An advance care plan outlines a patient's wishes regarding medical treatment or goals of care in the case that they become unable to communicate or to make decisions. An advance care directive (ACD) is an advance care plan that has been formally recorded and has legal status. Despite ACDs playing an important role in person-centred end-of-life care, an earlier retrospective medical records audit demonstrated that only 11% (58/531) of people who died due to a terminal illness had an ACD.The aim of this project was to increase the proportion of patients with a terminal illness completing an ACD. A secondary outcome was to measure the impact of ACDs on hospital and intensive care unit (ICU) admissions in the last 6 months of life.This multifaceted project comprised (1) education for health professionals and the public; (2) individual support for patients on request; (3) development of online resources for health professionals and the general public; and (4) monthly team meetings. The proportion of ACDs completed and hospital and ICU admissions during the last 6 months of life, were extracted via medical record audits.Written consent was required for patients to participate, including being contacted by the project team and accessing their medical records. 112 patients consented to participate in the project and 109 (97%) completed an ACD. There was no reduction in the average number of hospital admissions, while ICU admissions reduced from 14% (n=74) to 0%. The targeted, multifaceted approach to education and support for completion of ACDs, resulted in a significant increase in ACD completion and a major reduction in ICU admissions.

Site Reassignment for Mobile Outreach Teams: Investigating the Effectiveness of Decentralized Decision Making

Problem definition: United Nations Sustainable Development Goal (SDG) 3.8 states that health coverage should be universal by 2030. This is challenging in rural and poor areas. To address this challenge, mobile outreach teams of healthcare workers visit a fixed set of remote sites to provide healthcare services. Because of dynamics in demand and supply, once-rational site-to-team assignment decisions can become far from optimal over time. This paper considers the problem of reassigning sites to teams to maximize effectiveness. Solving this problem through a central planner does not fit the context: outreach teams commonly have a high degree of decision-making autonomy. We study a decentralized approach where subsets of teams collaborate in a series of team meetings to reassign sites. The key question for decision makers is whether and when such an approach is effective. Methodology/results: We propose a mixed-integer programming model for centralized site reassignment. We extend this model to represent the decentralized approach and develop a set of simple decision rules for this approach. We use empirical data from six country outreach programs of the nongovernmental organization MSI Reproductive Choices. Our results suggest that, when properly designed, decentralized decision making performs close to centralized decision making, and even outperforms it in the case of inaccurate information at the central level. The finding remains valid when demand and supply fluctuate, and is insensitive to the chosen objective. Managerial implications: Humanitarian organizations currently deploy mobile outreach teams to provide a wide variety of health services. We present several useful insights for decision makers in humanitarian organizations when making design choices, taking account of context. In particular, we show that decentralized site reassignment provides a feasible and effective alternative to centralized approaches in many contexts. Supplemental Material: The online supplement is available at https://doi.org/10.1287/msom.2021.0437 .