Improvement in resource utilization after development of a clinical pathway for patients with pressure ulcers.

PubMed

Dzwierzynski, W W; Spitz, K; Hartz, A; Guse, C; Larson, D L

1998-11-01

Clinical pathways are interdisciplinary patient care plans intended to reduce variance and improve quality of care while lowering health care cost. This study was undertaken to determine whether the development of a clinical pathway for care of patients with pressure ulcers can indeed decrease health care costs while preserving quality of care. A clinical pathway for surgical reconstruction of pressure ulcers was developed by standardizing the current practices of our plastic surgeon group. The pathway provided direction in optimal scheduling of physician interventions along with nursing, physical and occupational therapies, and spinal cord rehabilitation interventions. It covered all potential elements of patient care, including laboratory, radiology, dietary services, intravenous fluids, and use of specialty beds. It defined patient outcomes and outlined discharge planning. Pathways were distributed throughout all services caring for patients with pressure ulcers. Patient charts and billing data were reviewed for the 16-month periods before and after initiation of the pathway. No other significant changes in treatment occurred during this time frame. Ninety-seven patient charts were examined (54 before pathway and 43 after pathway implementation). Parameters evaluated included length of stay and total charges (including bed use, medications, laboratory tests, and radiology). Patient readmission rate was also examined. A significant reduction in patient length of stay and total charges was achieved after implementation of the clinical pathway. Reduction was seen not only for patients treated with flaps by plastic surgery but also for patients with pressure ulcers who were not specifically targeted such as those from other services. The readmission rate decreased slightly, although not significantly, after the pathway inception. Total cost saving was almost $11,000 per patient (23 percent). In conclusion, implementation of a clinical pathway, because it standardizes care and reduces variations and duplication of care, can reduce health care cost without impairing quality of care in the treatment of decubitus ulcer patients.

Integrative care for the management of low back pain: use of a clinical care pathway.

PubMed

Maiers, Michele J; Westrom, Kristine K; Legendre, Claire G; Bronfort, Gert

2010-10-29

For the treatment of chronic back pain, it has been theorized that integrative care plans can lead to better outcomes than those achieved by monodisciplinary care alone, especially when using a collaborative, interdisciplinary, and non-hierarchical team approach. This paper describes the use of a care pathway designed to guide treatment by an integrative group of providers within a randomized controlled trial. A clinical care pathway was used by a multidisciplinary group of providers, which included acupuncturists, chiropractors, cognitive behavioral therapists, exercise therapists, massage therapists and primary care physicians. Treatment recommendations were based on an evidence-informed practice model, and reached by group consensus. Research study participants were empowered to select one of the treatment recommendations proposed by the integrative group. Common principles and benchmarks were established to guide treatment management throughout the study. Thirteen providers representing 5 healthcare professions collaborated to provide integrative care to study participants. On average, 3 to 4 treatment plans, each consisting of 2 to 3 modalities, were recommended to study participants. Exercise, massage, and acupuncture were both most commonly recommended by the team and selected by study participants. Changes to care commonly incorporated cognitive behavioral therapy into treatment plans. This clinical care pathway was a useful tool for the consistent application of evidence-based care for low back pain in the context of an integrative setting. ClinicalTrials.gov NCT00567333.

Care pathways for organ donation after brain death: guidance from available literature?

PubMed

Hoste, Pieter; Vanhaecht, Kris; Ferdinande, Patrick; Rogiers, Xavier; Eeckloo, Kristof; Blot, Stijn; Hoste, Eric; Vogelaers, Dirk; Vandewoude, Koenraad

2016-10-01

A discussion of the literature concerning the impact of care pathways in the complex and by definition multidisciplinary process of organ donation following brain death. Enhancing the quality and safety of organs for transplantation has become a central concern for governmental and professional organizations. At the local hospital level, a donor coordinator can use a range of interventions to improve the donation and procurement process. Care pathways have been proven to represent an effective intervention in several settings for optimizing processes and outcomes. A discussion paper. A systematic review of the Medline, CINAHL, EMBASE and The Cochrane Library databases was conducted for articles published until June 2015, using the keywords donation after brain death and care pathways. Each paper was reviewed to investigate the effects of existing care pathways for donation after brain death. An additional search for unpublished information was conducted. Although literature supports care pathways as an effective intervention in several settings, few studies have explored its use and effectiveness for complex care processes such as donation after brain death. Nurses should be aware of their role in the donation process. Care pathways have the potential to support them, but their effectiveness has been insufficiently explored. Further research should focus on the development and standardization of the clinical content of a care pathway for donation after brain death and the identification of quality indicators. These should be used in a prospective effectiveness assessment of the proposed pathway. © 2016 John Wiley & Sons Ltd.

Developing a pathway for high-value, patient-centered total joint arthroplasty.

PubMed

Van Citters, Aricca D; Fahlman, Cheryl; Goldmann, Donald A; Lieberman, Jay R; Koenig, Karl M; DiGioia, Anthony M; O'Donnell, Beth; Martin, John; Federico, Frank A; Bankowitz, Richard A; Nelson, Eugene C; Bozic, Kevin J

2014-05-01

Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA. We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9). The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level. We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation. Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

The patient-breast cancer care pathway: how could it be optimized?

PubMed

Baffert, Sandrine; Hoang, Huong Ly; Brédart, Anne; Asselain, Bernard; Alran, Séverine; Berseneff, Hélène; Huchon, Cyrille; Trichot, Caroline; Combes, Aline; Alves, Karine; Koskas, Martin; Nguyen, Thuy; Roulot, Aurélie; Rouzier, Roman; Héquet, Delphine

2015-05-12

A care pathway is defined as patient-focused global care that addresses temporal (effective and coordinated management throughout the illness) and spatial issues (treatment is provided near the health territory in or around the patient's home). Heterogeneity of the care pathways in breast cancer (BC) is presumed but not well evaluated. The OPTISOINS01 study aims to assess every aspect of the care pathway for early BC patients using a temporal and spatial scope. An observational, prospective, multicenter study in a regional health territory (Ile-de-France, France) in different types of structures: university or local hospitals and comprehensive cancer centers. We will include and follow during 1 year 1,000 patients. The study consists of 3 work-packages: - Cost of pathway The aim of this WP is to calculate the overall costs of the early BC pathway at 1 year from different perspectives (society, health insurance and patient) using a cost-of-illness analysis. Using a bottom-up method, we will assess direct costs, including medical direct costs and nonmedical direct costs (transportation, home modifications, home care services, and social services), and indirect costs (loss of production). - Patient satisfaction and work reintegration Three questionnaires will assess the patients' satisfaction and possible return to work: the occupational questionnaire for employed women; the questionnaire on the need for supportive care, SCNS-SF34 ('breast cancer' module, SCNS-BR8); and the OUTPASSAT-35 questionnaire. - Quality, coordination and access to innovation Quality will be evaluated based on visits and treatment within a set period, whether the setting offers a multidisciplinary consultative framework, the management by nurse coordinators, the use of a personalized care plan, the provision of information via documents about treatments and the provision of supportive care. The coordination between structures and caregivers will be evaluated at several levels. Day surgery, home hospitalization and one-stop breast clinic visits will be recorded to assess the patient's access to innovation. The assessment of care pathways encourages the implementation of new payment models. Our approach could help health care professionals and policymakers to establish other cost-of-illness studies and plan the allocation of resources on a patient basis rather than a visit basis.

Registered nurses' experiences with an evidence-based home care pathway for myocardial infarction clients.

PubMed

Young, W; McShane, J; O'Connor, T; Rewa, G; Goodman, S; Jaglal, S B; Cash, L; Coyte, P

2004-01-01

To obtain home health nurses' comments on an evidence-based care pathway for post myocardial infarction. A qualitative design was used. Culturally diverse, lower income area of a large city. All home health nurses from one nursing agency who participated in a comparative study on the impact of the evidence-based care pathway. The largest number of comments made by the nurses were related to the beneficial impact of the pathway on the provision of quality nursing care and on increased job satisfaction. The home health nurses reported that the pathway increased clients' knowledge of medications and diet. In addition, they commented that they were able to use the pathway effectively because of the training they received from the inpatient cardiac nurses. This qualitative study demonstrates the benefits of investing in the implementation of best practice guidelines by home health nurses. However, nursing associations, such as the Canadian Community Health Nurses Initiatives Group, will need to continue to champion for additional funds to support the additional expenses incurred.

Effects of oncological care pathways in primary and secondary care on patient, professional, and health systems outcomes: protocol for a systematic review and meta-analysis.

PubMed

van Hoeve, Jolanda C; Vernooij, Robin W M; Lawal, Adegboyega K; Fiander, Michelle; Nieboer, Peter; Siesling, Sabine; Rotter, Thomas

2018-03-27

The high impact of a cancer diagnosis on patients and their families and the increasing costs of cancer treatment call for optimal and efficient oncological care. To improve the quality of care and to minimize healthcare costs and its economic burden, many healthcare organizations introduce care pathways to improve efficiency across the continuum of cancer care. However, there is limited research on the effects of cancer care pathways in different settings. The aim of this systematic review and meta-analysis described in this protocol is to synthesize existing literature on the effects of oncological care pathways. We will conduct a systematic search strategy to identify all relevant literature in several biomedical databases, including Cochrane library, MEDLINE, Embase, and CINAHL. We will follow the methodology of Cochrane Effective Practice and Organisation of Care (EPOC), and we will include randomized trials, non-randomized trials, controlled before-after studies, and interrupted time series studies. In addition, we will include full economic evaluations (cost-effectiveness analyses, cost-utility analyses, and cost-benefit analyses), cost analyses, and comparative resource utilization studies, if available. Two reviewers will independently screen all studies and evaluate those included for risk of bias. From these studies, we will extract data regarding patient, professional, and health systems outcomes. Our systematic review will follow the PRISMA set of items for reporting in systematic reviews and meta-analyses. Following the protocol outlined in this article, we aim to identify, assess, and synthesize all available evidence in order to provide an evidence base on the effects of oncological care pathways as reported in the literature. PROSPERO CRD42017057592 .

Implementation of a Total Hip Arthroplasty Care Pathway at a High-Volume Health System: Effect on Length of Stay, Discharge Disposition, and 90-Day Complications.

PubMed

Featherall, Joseph; Brigati, David P; Faour, Mhamad; Messner, William; Higuera, Carlos A

2018-06-01

Standardized care pathways are evidence-based algorithms for optimizing an episode of care. Despite the theoretical promise of care pathways, there is an inconsistent literature demonstrating improvements in patient care. The authors hypothesized that implementing a care pathway, across 11 hospitals, would decrease hospital length of stay (LOS), decrease postoperative complications at 90 days, and increase discharges to home. A multidisciplinary team developed an evidence-based care pathway for total hip arthroplasty (THA) perioperative care. All patients receiving THA in 2013 (pre-protocol, historical control), 2014 (transition), and 2015 (full protocol implementation) were included in the analysis. Multivariable regression assessed the relationship of the care pathway to 90-day postoperative complications, LOS, and discharge disposition. Cost savings were estimated using previously published postarthroplasty episode and per diem hospital costs. A total of 6090 primary THAs were conducted during the study period. After adjusting for the covariates, the full protocol implementation was associated with a decrease in LOS (mean ratio, 0.747; 95% confidence interval [CI; 0.727, 0.767]) and an increase in discharges to home (odds ratio, 2.079; 95% CI [1.762, 2.456]). The full protocol implementation was not associated with a change in 90-day complications (odds ratio, 1.023; 95% CI [0.841, 1.245]). Payer-perspective-calculated theoretical cost savings, including both index admission and postdischarge costs, were $2533 per patient. The THA care pathway implementation was successful in reducing LOS and increasing discharges to home. The care pathway was not associated with a change in 90-day complications; further targeted interventions in this area are needed. Despite care standardization efforts, high-volume hospitals and surgeons had higher performance. Extrapolation of theoretical cost savings indicates that widespread THA care pathway adoption could lead to national healthcare savings of $1.2 billion annually. Copyright © 2018 Elsevier Inc. All rights reserved.

Evaluation of A Novel Information-Sharing Instrument for Home-Based Palliative Care

PubMed Central

Sawada, Koichiro; Shimada, Masanari; Kadoya, Shinichi; Endo, Naoki; Ishiguro, Kaname; Takashima, Rumi; Amemiya, Yoko; Fujikawa, Yasunaga; Ikezaki, Tomoaki; Takeuchi, Miyako; Kitazawa, Hidenori; Iida, Hiroyuki; Koseki, Shiro; Morita, Tatsuya; Sasaki, Koji; Kashii, Tatsuhiko; Murakami, Nozomu

2015-01-01

Aim: To examine the feasibility and usefulness of a novel region-based pathway: the Regional Referral Clinical Pathway for Home-Based Palliative Care. Method: This was a feasibility study to evaluate the frequency of variances and the perceived usefulness of pathway using in-depth interviews. All patients with cancer referred to the palliative care team between 2011 and 2013 and received home care services were enrolled. Result: A total of 44 patients were analyzed, and pathway was completed in all the patients. The target outcome was achieved in 61.4% while some variances occurred in 54.5%. Nine categories were identified as the usefulness of the pathway, such as reviewing and sharing information and promoting communication, education, motivation, and relationships. Conclusion: This novel pathway is feasible and seems to be useful. PMID:24814723

An Evaluation of the Implementation of Maternal Obesity Pathways of Care: A Mixed Methods Study with Data Integration

PubMed Central

Heslehurst, Nicola; Dinsdale, Sarah; Sedgewick, Gillian; Simpson, Helen; Sen, Seema; Summerbell, Carolyn Dawn; Rankin, Judith

2015-01-01

Objectives Maternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives. Study Design A simultaneous mixed methods model with data integration was used. Three component studies were given equal priority. 1: Semi-structured qualitative interviews explored obese pregnant women’s experiences of being on the pathways. 2: A quantitative and qualitative postal survey explored healthcare professionals’ experiences of delivering the pathways. 3: A case note audit quantitatively assessed pathway compliance. Data were integrated using following a thread and convergence coding matrix methods to search for agreement and disagreement between studies. Results Study 1: Four themes were identified: women’s overall (positive and negative) views of the pathways; knowledge and understanding of the pathways; views on clinical and weight management advice and support; and views on the information leaflet. Key results included positive views of receiving additional clinical care, negative experiences of risk communication, and weight management support was considered a priority. Study 2: Healthcare professionals felt the pathways were worthwhile, facilitated good practice, and increased confidence. Training was consistently identified as being required. Healthcare professionals predominantly focussed on women’s response to sensitive obesity communication. Study 3: There was good compliance with antenatal clinical interventions. However, there was poor compliance with public health and postnatal interventions. There were some strong areas of agreement between component studies which can inform future development of the pathways. However, disagreement between studies included a lack of shared priorities between healthcare professionals and women, different perspectives on communication issues, and different perspectives on women’s prioritisation of weight management. Conclusion The differences between healthcare professionals’ and women’s priorities and perspectives are important factors to consider when developing care pathways. Shared perspectives could help facilitate more effective implementation of the pathway interventions that have poor compliance. PMID:26018338

A scoping review of adult chronic kidney disease clinical pathways for primary care.

PubMed

Elliott, Meghan J; Gil, Sarah; Hemmelgarn, Brenda R; Manns, Braden J; Tonelli, Marcello; Jun, Min; Donald, Maoliosa

2017-05-01

Chronic kidney disease (CKD) affects ∼10% of the adult population. The majority of patients with CKD are managed by primary care physicians, and despite the availability of effective treatment options, the use of evidence-based interventions for CKD in this setting remains suboptimal. Clinical pathways have been identified as effective tools to guide primary care physicians in providing evidence-based care. We aimed to describe the availability, characteristics and credibility of clinical pathways for adult CKD using a scoping review methodology. We searched Medline, Embase, CINAHL and targeted Internet sites from inception to 31 October 2014 to identify studies and resources that identified adult CKD clinical pathways for primary care settings. Study selection and data extraction were independently performed by two reviewers. From 487 citations, 41 items were eligible for review: 7 published articles and 34 grey literature resources published between 2001 and 2014. Of the 41 clinical pathways, 32, 24 and 22% were from the UK, USA and Canada, respectively. The majority (66%, n = 31) of clinical pathways were static in nature (did not have an online interactive feature). The majority (76%) of articles/resources reported using one or more clinical practice guidelines as a resource to guide the clinical pathway content. Few articles described a dissemination and evaluation plan for the clinical pathway, but most reported the targeted end-users. Our scoping review synthesized available literature on CKD clinical pathways in the primary care setting. We found that existing clinical pathways are diverse in their design, content and implementation. These results can be used by researchers developing or testing new or existing clinical pathways and by practitioners and health system stakeholders who aim to implement CKD clinical pathways in clinical practice. © The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

When Clock Time Governs Interaction: How Time Influences Health Professionals' Intersectoral Collaboration.

PubMed

Bendix Andersen, Anne; Beedholm, Kirsten; Kolbæk, Raymond; Frederiksen, Kirsten

2018-06-01

When setting up patient pathways that cross health care sectors, professionals in emergency units strive to fulfill system requirements by creating efficient patient pathways that comply with standards for length of stay. We conducted an ethnographic field study, focusing on health professionals' collaboration, of 10 elderly patients with chronic illnesses, following them from discharge to their home or other places where they received health care services. We found that clock time not only governed the professionals' ways of collaborating, but acceleration of patient pathways also became an overall goal in health care delivery. Professionals' efforts to save time came to represent a "monetary value," leading to speedier planning of patient pathways and consequent risks of disregarding important issues when treating and caring for elderly patients. We suggest that such issues are significant to the future planning and improvement of patient pathways that involve elderly citizens who are in need of intersectoral health care delivery.

Renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour

PubMed Central

Hunter, Billie; Segrott, Jeremy

2014-01-01

This article presents findings from a study of a clinical pathway for normal labour (Normal Labour Pathway) implemented in Wales, UK. The study was conducted between 2004 and 2006. The pathway aimed to support normal childbirth and reduce unnecessary childbirth interventions by promoting midwife-led care. This article focuses on how the pathway influenced the inter-professional relationships and boundaries between midwives and doctors. Data are drawn from semi-participant observation, focus groups and semi-structured interviews with 41 midwives, and semi-structured interviews with five midwifery managers and six doctors, working in two research sites. Whereas some studies have shown how clinical pathways may act as ‘boundary objects’, dissolving professional boundaries, promoting interdisciplinary care and de-differentiating professional identities, the ‘normal labour pathway’ was employed by midwives as an object of demarcation, which legitimised a midwifery model of care, clarified professional boundaries and accentuated differences in professional identities and approaches to childbirth. The pathway represented key characteristics of a professional project: achieving occupational autonomy and closure. Stricter delineation of the boundary between midwifery and obstetric work increased the confidence and professional visibility of midwives but left doctors feeling excluded and undervalued, and paradoxically reduced the scope of midwifery practice through redefining what counted as normal. PMID:24640992

Chiropractic Integrated Care Pathway for Low Back Pain in Veterans: Results of a Delphi Consensus Process.

PubMed

Lisi, Anthony J; Salsbury, Stacie A; Hawk, Cheryl; Vining, Robert D; Wallace, Robert B; Branson, Richard; Long, Cynthia R; Burgo-Black, A Lucille; Goertz, Christine M

2018-02-01

The purpose of this study was to develop an integrated care pathway for doctors of chiropractic, primary care providers, and mental health professionals who manage veterans with low back pain, with or without mental health comorbidity, within Department of Veterans Affairs health care facilities. The research method used was a consensus process. A multidisciplinary investigative team reviewed clinical guidelines and Veterans Affairs pain and mental health initiatives to develop seed statements and care algorithms to guide chiropractic management and collaborative care of veterans with low back pain. A 5-member advisory committee approved initial recommendations. Veterans Affairs-based panelists (n = 58) evaluated the pathway via e-mail using a modified RAND/UCLA methodology. Consensus was defined as agreement by 80% of panelists. The modified Delphi process was conducted in July to December 2016. Most (93%) seed statements achieved consensus during the first round, with all statements reaching consensus after 2 rounds. The final care pathway addressed the topics of informed consent, clinical evaluation including history and examination, screening for red flags, documentation, diagnostic imaging, patient-reported outcomes, adverse event reporting, chiropractic treatment frequency and duration standards, tailored approaches to chiropractic care in veteran populations, and clinical presentation of common mental health conditions. Care algorithms outlined chiropractic case management and interprofessional collaboration and referrals between doctors of chiropractic and primary care and mental health providers. This study offers an integrative care pathway that includes chiropractic care for veterans with low back pain. Copyright © 2018. Published by Elsevier Inc.

Career Choice of "Fifth Pathway" Graduates from New York State Medical Schools.

ERIC Educational Resources Information Center

Stimmel, Barry; Smith, Harry, Jr.

1985-01-01

Graduates of "fifth pathway" programs at medical schools in New York state between 1976-1978 were studied to determine their professional careers and choice of medical specialties. Fifth pathway graduates, 95 percent from Mexican medical schools, were more likely to select nonprimary care than primary care specialties. (Author/MLW)

Hospitalist management of vaso-occlusive pain crisis in patients with sickle cell disease using a pathway of care.

PubMed

Allen Liles, Edmund; Kirsch, Jonathan; Gilchrist, Michael; Adem, Mukhtar

2014-04-01

Patients with sickle cell disease (SCD) suffer from intermittent vaso-occlusive pain crises (VOCs). These crises lead to frequent hospitalizations, significant morbidity, and increased mortality risk. Care pathways can enhance efficiency and quality of care. Our study sought to evaluate the development and implementation of a care pathway for patients with SCD experiencing VOCs. The University of North Carolina (UNC) Comprehensive Sickle Cell Program provides all levels of care for a large population of patients with sickle cell anemia. All patients admitted to UNC Hospitals with SCD VOCs from January 2009 through June 2011 were evaluated. During this time period, we also assessed sequential prospective cohorts during progressive phases of developing and implementing a quality improvement and pathway of care program for this patient population in our study. The developed pathway entailed geographic localization for VOC patients, a single group of faculty physicians caring for these patients, and early use of patient-controlled analgesia (PCA) to achieve pain control. Physicians from the UNC Hospital Medicine Program were responsible for the initiatives. Cohorts were compared to a baseline historical control. Outcomes of interest included patient length of stay (LOS) in the hospital, 30-day readmission rate, need for transfusion, incidence of acute chest syndrome, use of naloxone, and use of PCA. Compared with an historical baseline cohort, the development and implementation of a VOC care pathway for patients with SCD led to reduction in average hospital LOS by 1.44 days (P < 0.05) and an increase in use of PCAs (P < 0.05). Patient readmission rates, number of transfusions, incidence of acute chest syndrome, and use of naloxone did not significantly change. Hospitalist-led management of patients with SCD VOCs using a care pathway that emphasizes early, aggressive PCA-based pain control is associated with reduced hospital LOS. The LOS reduction seen in our study is clinically meaningful. Notably, other measures of patient outcomes and quality of care metrics did not change significantly, and some trended towards improvement.

Minimal impact of a care pathway for geriatric hip fracture patients.

PubMed

Panella, Massimiliano; Seys, Deborah; Sermeus, Walter; Bruyneel, Luk; Lodewijckx, Cathy; Deneckere, Svin; Sermon, An; Nijs, Stefaan; Boto, Paulo; Vanhaecht, Kris

2018-06-04

Adherence to guidelines for patients with proximal femur fracture is suboptimal. To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes. The European Quality of Care Pathways study is a cluster randomized controlled trial. 26 hospitals in Belgium, Italy and Portugal. Older adults with a proximal femur fracture (n = 514 patients) were included. Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures. In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team. Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied. ClinicalTrials.gov: NCT00962910. Copyright © 2018 Elsevier Ltd. All rights reserved.

Compliance with clinical pathways for inpatient care in Chinese public hospitals.

PubMed

He, Xiao Yan; Bundorf, M Kate; Gu, Jian Jun; Zhou, Ping; Xue, Di

2015-10-06

The National Health and Family Planning Commission of China has issued more than 400 clinical pathways to improve the effectiveness and efficiency of medical care delivered by public hospitals in China. The aim of our study is to determine whether patient care is compliant with national clinical pathways in public general hospitals of Pudong New Area in Shanghai. We identified the clinical pathways established by the National Health and Family Planning Commission of China for 5 common conditions (community-acquired pneumonia, acute myocardial infarction (AMI), heart failure, cesarean section, type-2 diabetes). We randomly selected patients with each condition admitted to one of 7 public general hospitals in Pudong New Area in China in January, 2013. We identified key process indicators (KPIs) for each pathway and, based on chart review for each patient, determined whether the patient's care was compliant for each indicator. We calculated the proportion of care which was compliant with clinical pathways for each indicator, the average proportion of indicators that were met for each patient, and the proportion of patients whose care was compliant for all measures. For selected indicators, we compared compliance rates among hospitals in our study with those from other countries. Average compliance rates across the KPIs for each condition ranged from 61 % for AMI to 89 % for pneumonia. The percent of patient receiving fully compliant care ranged from 0 for AMI and heart failure to 39 % for pneumonia. Compared to the compliance rate for process indicators in the hospitals of other countries, some rates in the hospitals that we audited were higher, but some were lower. Few patients received care that complied with all the pathways for each condition. The reasons for low compliance with national clinical pathways and how to improve clinical quality in public hospitals of China need to be further explored.

The RCPCH care pathway for children at risk of anaphylaxis: an evidence and consensus based national approach to caring for children with life-threatening allergies.

PubMed

Clark, Andrew; Lloyd, Kate; Sheikh, Aziz; Alfaham, Mazin; East, Mandy; Ewan, Pamela; Jewkes, Fiona; King, Rosie; Leech, Susan; Maconochie, Ian; Sinnott, Louise; Sohi, Dalbir; Tomlin, Stephen; Warner, John

2011-11-01

Numerous studies have identified shortcomings in the management of children at risk of severe acute allergic reactions (anaphylaxis). The Science and Research Department at the Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the Department of Health to develop competence based national care pathways for children with allergies. Anaphylaxis is the first completed pathway. The anaphylaxis pathway was developed by a multidisciplinary working group, reviewed by a broad group of stakeholders and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. Pathway development is described under five headings: evidence review, mapping, external review, core knowledge documents and key recommendations. The full pathway can be downloaded from www.rcpch.ac.uk/allergy/anaphylaxis. This document describes the entry points and the ideal pathway of care from self-care through to follow-up. The five key recommendations focus on: (1) prompt administration of adrenaline by intramuscular injection; (2) referral to specialists with competence in paediatric allergies; (3) risk analysis; (4) provision of a self-management plan; and (5) suggested creation of a national anaphylaxis death register. We present the first national care pathway for anaphylaxis, which is based on a critique of published evidence, expert consensus and multi-stakeholder input including patient representation via the Anaphylaxis Campaign. The Project Board urges health professionals to work together across networks to improve care for children at risk of anaphylaxis, in particular during the period after an acute reaction. Additionally, the Project Board strongly recommends the funding of a national anaphylaxis register.

Improving care coordination using organisational routines.

PubMed

Prætorius, Thim

2016-01-01

The purpose of this paper is to systematically apply theory of organisational routines to standardised care pathways. The explanatory power of routines is used to address open questions in the care pathway literature about their coordinating and organising role, the way they change and can be replicated, the way they are influenced by the organisation and the way they influence health care professionals. Theory of routines is systematically applied to care pathways in order to develop theoretically derived propositions. Care pathways mirror routines by being recurrent, collective and embedded and specific to an organisation. In particular, care pathways resemble standard operating procedures that can give rise to recurrent collective action patterns. In all, 11 propositions related to five categories are proposed by building on these insights: care pathways and coordination, change, replication, the organisation and health care professionals. Research limitations/implications - The paper is conceptual and uses care pathways as illustrative instances of hospital routines. The propositions provide a starting point for empirical research. The analysis highlights implications that health care professionals and managers have to consider in relation to coordination, change, replication, the way the organisation influences care pathways and the way care pathways influence health care professionals. Originality/value - Theory on organisational routines offers fundamental, yet unexplored, insights into hospital processes, including in particular care coordination.

[Care pathway of children managed by the Bouches-du-Rhone Child Welfare Services].

PubMed

Martin, Anaïs; Jego-Sablier, Maeva; Prudhomme, Johanne; Champsaur, Laurence

2017-12-05

To describe the care pathway of children managed by the Bouches-du-Rhône Child Welfare Services and to propose ways to improve this care pathway. ESSPER-ASE 13 survey is a descriptive and cross-sectional survey carried out between April 2013 and April 2014, which included 1,092 children under the age of 18 years placed in a Bouches-du-Rhône Child Welfare Services children's home or foster care. This survey studied the physical and mental health and the medical follow-up characteristics of these children. This article focuses on care pathway data. 82% of children were followed by general practitioners, while 15% of children, essentially children under the age of 6 years in child care, were followed by Maternal and Infant Protection (Protection Maternelle et Infantile). The care pathway of these children involved multiple actors and was dominated by psychological follow-up. On average, the children were followed by 2 professionals (specialist or paramedical professional) in addition to the medical examiner. In terms of prevention, children's immunization coverage rates were better than national rates. Coordination of the numerous actors is essential, including the creation of a referring physician.

Maternal education and child nutritional status in Bolivia: finding the links.

PubMed

Frost, Michelle Bellessa; Forste, Renata; Haas, David W

2005-01-01

This study models various pathways linking maternal education and child nutritional status in Bolivia, using a national sample of children. Pathways examined include socioeconomic status, health knowledge, modern attitudes towards health care, female autonomy, and reproductive behavior. The data come from the 1998 Bolivia Demographic and Health Survey. Logistic regression results suggest that socioeconomic factors are the most important pathways linking maternal education and child nutritional status, and that modern attitudes about health care also explain the impact of education. Health care knowledge accounts for less of the effect of maternal education on child nutritional status, with autonomy being the weakest pathway. Other pathways, such as reproductive behaviors, appear to influence nutritional status independent of maternal education. Overall, the pathways examined accounted for 60 percent of the effect of maternal education on child nutritional status.

The impact of care pathways for exacerbation of Chronic Obstructive Pulmonary Disease: rationale and design of a cluster randomized controlled trial

PubMed Central

2010-01-01

Background Hospital treatment of chronic obstructive pulmonary disease (COPD) frequently does not follow published evidences. This lack of adherence can contribute to the high morbidity, mortality and readmissions rates. The European Quality of Care Pathway (EQCP) study on acute exacerbations of COPD (NTC00962468) is undertaken to determine how care pathways (CP) as complex intervention for hospital treatment of COPD affects care variability, adherence to evidence based key interventions and clinical outcomes. Methods An international cluster Randomized Controlled Trial (cRCT) will be performed in Belgium, Italy, Ireland and Portugal. Based on the power analysis, a sample of 40 hospital teams and 398 patients will be included in the study. In the control arm of the study, usual care will be provided. The experimental teams will implement a CP as complex intervention which will include three active components: a formative evaluation of the quality and organization of care, a set of evidence based key interventions, and support on the development and implementation of the CP. The main outcome will be six-month readmission rate. As a secondary endpoint a set of clinical outcome and performance indicators (including care process evaluation and team functioning indicators) will be measured in both groups. Discussion The EQCP study is the first international cRCT on care pathways. The design of the EQCP project is both a research study and a quality improvement project and will include a realistic evaluation framework including process analysis to further understand why and when CP can really work. Trial Registration number NCT00962468 PMID:21092098

Developing Effective and Efficient care pathways in chronic Pain: DEEP study protocol.

PubMed

Durham, Justin; Breckons, Matthew; Araujo-Soares, Vera; Exley, Catherine; Steele, Jimmy; Vale, Luke

2014-01-21

Pain affecting the face or mouth and lasting longer than three months ("chronic orofacial pain", COFP) is relatively common in the UK. This study aims to describe and model current care pathways for COFP patients, identify areas where current pathways could be modified, and model whether these changes would improve outcomes for patients and use resources more efficiently. The study takes a prospective operations research approach. A cohort of primary and secondary care COFP patients (n = 240) will be recruited at differing stages of their care in order to follow and analyse their journey through care. The cohort will be followed for two years with data collected at baseline 6, 12, 18, and 24 months on: 1) experiences of the care pathway and its impacts; 2) quality of life; 3) pain; 4) use of health services and costs incurred; 5) illness perceptions. Qualitative in-depth interviews will be used to collect data on patient experiences from a purposive sub-sample of the total cohort (n = 30) at baseline, 12 and 24 months. Four separate appraisal groups (public, patient, clincian, service manager/commissioning) will then be given data from the pathway analysis and asked to determine their priority areas for change. The proposals from appraisal groups will inform an economic modelling exercise. Findings from the economic modelling will be presented as incremental costs, Quality Adjusted Life Years (QALYs), and the incremental cost per QALY gained. At the end of the modelling a series of recommendations for service change will be available for implementation or further trial if necessary. The recent white paper on health and the report from the NHS Forum identified chronic conditions as priority areas and whilst technology can improve outcomes, so can simple, appropriate and well-defined clinical care pathways. Understanding the opportunity cost related to care pathways benefits the wider NHS. This research develops a method to help design efficient systems built around one condition (COFP), but the principles should be applicable to a wide range of other chronic and long-term conditions.

Effectiveness of clinical pathways for total knee and total hip arthroplasty: literature review.

PubMed

Kim, Stephen; Losina, Elena; Solomon, Daniel H; Wright, John; Katz, Jeffrey N

2003-01-01

Although many hospitals have implemented clinical pathways to standardize the process of care, the effectiveness of clinical pathways for total hip and knee arthroplasties has not been reviewed critically. We searched for articles comparing outcomes of total hip or knee arthroplasty for patients who were treated using clinical pathways as opposed to patients treated without these pathways. Eleven studies met criteria for inclusion. Ten used historical controls, and 1 was a randomized trial. The studies had important methodological limitations. In general, the articles showed that patients treated using pathways experienced shorter hospital stays and lower costs, with comparable clinical outcomes as compared with patients treated without clinical pathways. We concluded that clinical pathways appear successful in reducing costs and length of stay in the acute care hospital, with no compromise in patient outcomes. However, interpretation of these studies is complicated by substantial methodological limitations, particularly the use of historical controls and failure to account for length of stay in rehabilitation facilities. Copyright 2003, Elsevier Science (USA). All rights reserved.

[New integrated care model for older people admitted to Intermediate Care Units in Catalonia: A quasi-experimental study protocol].

PubMed

Santaeugènia, Sebastià J; García-Lázaro, Manuela; Alventosa, Ana María; Gutiérrez-Benito, Alícia; Monterde, Albert; Cunill, Joan

To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia. The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources. This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies. Copyright © 2016 SEGG. Publicado por Elsevier España, S.L.U. All rights reserved.

Integrating care for neurodevelopmental disorders by unpacking control: A grounded theory study

PubMed Central

Waxegård, Gustaf; Thulesius, Hans

2016-01-01

Background To establish integrated healthcare pathways for patients with neurodevelopmental disorders (ND) such as autism spectrum disorder and attention-deficit hyperactivity disorder is challenging. This study sets out to investigate the main concerns for healthcare professionals when integrating ND care pathways and how they resolve these concerns. Methods Using classic grounded theory (Glaser), we analysed efforts to improve and integrate an ND care pathway for children and youth in a Swedish region over a period of 6 years. Data from 42 individual interviews with a range of ND professionals, nine group interviews with healthcare teams, participant observation, a 2-day dialogue conference, focus group meetings, regional media coverage, and reports from other Swedish regional ND projects were analysed. Results The main concern for participants was to deal with overwhelming ND complexity by unpacking control, which is control over strategies to define patients’ status and needs. Unpacking control is key to the professionals’ strivings to expand constructive life space for patients, to squeeze health care to reach available care goals, to promote professional ideologies, and to uphold workplace integrity. Control-seeking behaviour in relation to ND unpacking is ubiquitous and complicates integration of ND care pathways. Conclusions The Unpacking control theory expands central aspects of professions theory and may help to improve ND care development. PMID:27609793

Meeting the ambition of measuring the quality of hospitals' stroke care using routinely collected administrative data: a feasibility study.

PubMed

Palmer, William L; Bottle, Alex; Davie, Charlie; Vincent, Charles A; Aylin, Paul

2013-09-01

To examine the potential for using routinely collected administrative data to compare the quality and safety of stroke care at a hospital level, including evaluating any bias due to variations in coding practice. A retrospective cohort study of English hospitals' performance against six process and outcome indicators covering the acute care pathway. We used logistic regression to adjust the outcome measures for case mix. Hospitals in England. Stroke patients (ICD-10 I60-I64) admitted to English National Health Service public acute hospitals between April 2009 and March 2010, accounting for 91 936 admissions. The quality and safety were measured using six indicators spanning the hospital care pathway, from timely access to brain scans to emergency readmissions following discharge after stroke. There were 182 occurrences of hospitals performing statistically differently from the national average at the 99.8% significance level across the six indicators. Differences in coding practice appeared to only partially explain the variation. Hospital administrative data provide a practical and achievable method for evaluating aspects of stroke care across the acute pathway. However, without improvements in coding and further validation, it is unclear whether the cause of the variation is the quality of care or the result of different local care pathways and data coding accuracy.

The INTERPRET-DD study of diabetes and depression: a protocol.

PubMed

Lloyd, C E; Sartorius, N; Cimino, L C; Alvarez, A; Guinzbourg de Braude, M; Rabbani, G; Uddin Ahmed, H; Papelbaum, M; Regina de Freitas, S; Ji, L; Yu, X; Gaebel, W; Müssig, K; Chaturvedi, S K; Srikanta, S S; Burti, L; Bulgari, V; Musau, A; Ndetei, D; Heinze, G; Romo Nava, F; Taj, R; Khan, A; Kokoszka, A; Papasz-Siemieniuk, A; Starostina, E G; Bobrov, A E; Lecic-Tosevski, D; Lalic, N M; Udomratn, P; Tangwongchai, S; Bahendeka, S; Basangwa, D; Mankovsky, B

2015-07-01

People with diabetes are at an increased risk of developing depression and other psychological disorders. However, little is known about the prevalence, correlates or care pathways in countries other than the UK and the USA. A new study, the International Prevalence and Treatment of Diabetes and Depression Study (INTERPRET-DD) aims to address this dearth of knowledge and identify optimal pathways to care across the globe. INTERPRET-DD is a 2-year longitudinal study, taking place in 16 countries' diabetes outpatients' facilities, investigating the recognition and management of depressive disorders in people with Type 2 diabetes. Clinical interviews are used to diagnose depression, with clinical and other data obtained from medical records and through patient interviews. Pathways to care and the impact of treatment for previously unrecognized (undocumented) depression on clinical outcomes and emotional well-being are being investigated. Initial evidence indicates that a range of pathways to care exist, with few of them based on available recommendations for treatment. Pilot data indicates that the instruments we are using to measure both the symptoms and clinical diagnosis of depression are acceptable in our study population and easy to use. Our study will increase the understanding of the impact of comorbid diabetes and depression and identify the most appropriate (country-specific) pathways via which patients receive their care. It addresses an important public health problem and leads to recommendations for best practice relevant to the different participating centres with regard to the identification and treatment of people with comorbid diabetes and depression. © 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.

A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014.

PubMed

Cook, Benjamin Lê; Hou, Sherry Shu-Yeu; Lee-Tauler, Su Yeon; Progovac, Ana Maria; Samson, Frank; Sanchez, Maria Jose

2018-06-01

Racial/ethnic minorities in the United States are more likely than Whites to have severe and persistent mental disorders and less likely to access mental health care. This comprehensive review evaluates studies of mental health and mental health care disparities funded by the National Institute of Mental Health (NIMH) to provide a benchmark for the 2015 NIMH revised strategic plan. A total of 615 articles were categorized into five pathways underlying mental health care and three pathways underlying mental health disparities. Identified studies demonstrate that socioeconomic mechanisms and demographic moderators of disparities in mental health status and treatment are well described, as are treatment options that support diverse patient needs. In contrast, there is a need for studies that focus on community- and policy-level predictors of mental health care disparities, link discrimination- and trauma-induced neurobiological pathways to disparities in mental illness, assess the cost effectiveness of disparities reduction programs, and scale up culturally adapted interventions.

Who cares? Pathways to psychiatric care for young people experiencing a first episode of psychosis.

PubMed

Lincoln, C V; McGorry, P

1995-11-01

The authors reviewed the literature to better understand pathways to psychiatric care among young persons experiencing a first episode of psychosis. Because no discrete body of literature exists about how young people with psychotic illness gain access to psychiatric services, the authors examined three related areas: illness recognition, help-seeking, and referral pathways. Automated and manual searches of primarily medical and psychological sources from 1977 to 1995 were conducted. The review found evidence of delay in obtaining early treatment among young people with an emerging psychosis, although comparisons between studies are difficult. Early psychiatric intervention is believed to significantly aid recovery and is an increasingly important clinical issue. Recognizing psychiatric illness is problematic for professionals and nonprofessionals. Understanding of help seeking by patients experiencing a first psychotic episode and of their referral pathways is limited. Taken together, studies suggest factors affecting access to treatment but provide neither sufficient empirical information nor an adequate conceptual framework to better target secondary prevention strategies. Formulation of a pathways-to-care model appears to offer a useful way of understanding mental health care use. Exploration of consumer experiences would enrich the model. Strategies to reduce treatment delay could then be developed and evaluated. Increased consumer involvement might help ensure that services are better tailored to patients' needs.

Pathways and consequences of unsafe abortion: a comparison among women with complications after induced and spontaneous abortions in Madhya Pradesh, India.

PubMed

Banerjee, Sushanta K; Andersen, Kathryn L; Warvadekar, Janardan

2012-09-01

This study aimed to understand women's pathways of seeking care for postabortion complications in Madhya Pradesh, India. The study recruited 786 women between July and November 2007. Data were collected on service provision, abortion-related complications, care-seeking behavior, knowledge about abortion legality and availability, methods used, symptoms, referral source, and out-of-pocket costs. Women seeking care for complications from induced abortion followed more complex pathways to treatment than women with complications of spontaneous abortion. More complex pathways were associated with higher out-of-pocket costs. Improving community awareness on legal aspects, safe abortion methods, and trained providers are necessary to reduce morbidity associated with unsafe abortion. Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Assessment of Gaps in Care and the Development of a Care Pathway for Anemia in Patients with Inflammatory Bowel Diseases.

PubMed

Hou, Jason K; Gasche, Christoph; Drazin, Noam Z; Weaver, Sarah Alandra; Ehrlich, Orna G; Oberai, Ridhima; Zapala, Sophie; Siegel, Corey A; Melmed, Gil

2017-01-01

Anemia is a common complication among patients with inflammatory bowel diseases (IBD) and is associated with high rates of IBD-related complications, resource utilization, and impaired quality of life. Despite practice guidelines for anemia in patients with IBD, gaps remain in the perceptions of anemia among health care providers. The aims of this study were to identify gaps in care and to develop a care pathway for anemia in patients with IBD. The Crohn's & Colitis Foundation of America anemia care pathway was developed by a committee using principles of cognitive task analysis. Focus groups of providers of patients with IBD were performed to identify domains of perceptions and management decisions for anemia and IBD. Knowledge elicitation from subject experts in anemia was conducted using case-based scenarios of patients with IBD and anemia to determine decision-making branch points. The care pathway was modified in an iterative fashion to encompass clinical presentations of anemia in IBD and potential barriers to the recognition, management, and follow-up of anemia. Variations were observed in how providers define iron deficiency, thresholds for treatment of anemia, and route of iron therapy. A care pathway for anemia incorporating the World Health Organization definition of anemia, universal hemoglobin and ferritin screening, evaluation of iron stores using ferritin and transferrin saturation, management of anemia based on adequacy of iron stores, and follow-up was developed. The authors identified domains of how providers perceive and manage patients with IBD and anemia, and developed a care pathway to align clinical practices with guideline recommendations.

Qualitative evaluation of a local coronary heart disease treatment pathway: practical implications and theoretical framework

PubMed Central

2012-01-01

Background Coronary heart disease (CHD) is a common medical problem in general practice. Due to its chronic character, shared care of the patient between general practitioner (GP) and cardiologist (C) is required. In order to improve the cooperation between both medical specialists for patients with CHD, a local treatment pathway was developed. The objective of this study was first to evaluate GPs’ opinions regarding the pathway and its practical implications, and secondly to suggest a theoretical framework of the findings by feeding the identified key factors influencing the pathway implementation into a multi-dimensional model. Methods The evaluation of the pathway was conducted in a qualitative design on a sample of 12 pathway developers (8 GPs and 4 cardiologists) and 4 pathway users (GPs). Face-to face interviews, which were aligned with previously conducted studies of the department and assumptions of the theory of planned behaviour (TPB), were performed following a semi-structured interview guideline. These were audio-taped, transcribed verbatim, coded, and analyzed according to the standards of qualitative content analysis. Results We identified 10 frequently mentioned key factors having an impact on the implementation success of the CHD treatment pathway. We thereby differentiated between pathway related (pathway content, effort, individual flexibility, ownership), behaviour related (previous behaviour, support), interaction related (patient, shared care/colleagues), and system related factors (context, health care system). The overall evaluation of the CHD pathway was positive, but did not automatically lead to a change of clinical behaviour as some GPs felt to have already acted as the pathway recommends. Conclusions By providing an account of our experience creating and implementing an intersectoral care pathway for CHD, this study contributes to our knowledge of factors that may influence physicians’ decisions regarding the use of a local treatment pathway. An improved adaptation of the pathway in daily practice might be best achieved by a combined implementation strategy addressing internal and external factors. A simple, direct adaptation regards the design of the pathway material (e.g. layout, PC version), or the embedding of the pathway in another programme, like a Disease Management Programme (DMP). In addition to these practical implications, we propose a theoretical framework to understand the key factors’ influence on the pathway implementation, with the identified factors along the microlevel (pathway related factors), the mesolevel (interaction related factors), and system- related factors along the macrolevel. PMID:22584032

Qualitative evaluation of a local coronary heart disease treatment pathway: practical implications and theoretical framework.

PubMed

Kramer, Lena; Schlößler, Kathrin; Träger, Susanne; Donner-Banzhoff, Norbert

2012-05-14

Coronary heart disease (CHD) is a common medical problem in general practice. Due to its chronic character, shared care of the patient between general practitioner (GP) and cardiologist (C) is required. In order to improve the cooperation between both medical specialists for patients with CHD, a local treatment pathway was developed. The objective of this study was first to evaluate GPs' opinions regarding the pathway and its practical implications, and secondly to suggest a theoretical framework of the findings by feeding the identified key factors influencing the pathway implementation into a multi-dimensional model. The evaluation of the pathway was conducted in a qualitative design on a sample of 12 pathway developers (8 GPs and 4 cardiologists) and 4 pathway users (GPs). Face-to face interviews, which were aligned with previously conducted studies of the department and assumptions of the theory of planned behaviour (TPB), were performed following a semi-structured interview guideline. These were audio-taped, transcribed verbatim, coded, and analyzed according to the standards of qualitative content analysis. We identified 10 frequently mentioned key factors having an impact on the implementation success of the CHD treatment pathway. We thereby differentiated between pathway related (pathway content, effort, individual flexibility, ownership), behaviour related (previous behaviour, support), interaction related (patient, shared care/colleagues), and system related factors (context, health care system). The overall evaluation of the CHD pathway was positive, but did not automatically lead to a change of clinical behaviour as some GPs felt to have already acted as the pathway recommends. By providing an account of our experience creating and implementing an intersectoral care pathway for CHD, this study contributes to our knowledge of factors that may influence physicians' decisions regarding the use of a local treatment pathway. An improved adaptation of the pathway in daily practice might be best achieved by a combined implementation strategy addressing internal and external factors. A simple, direct adaptation regards the design of the pathway material (e.g. layout, PC version), or the embedding of the pathway in another programme, like a Disease Management Programme (DMP). In addition to these practical implications, we propose a theoretical framework to understand the key factors' influence on the pathway implementation, with the identified factors along the microlevel (pathway related factors), the mesolevel (interaction related factors), and system- related factors along the macrolevel.

[Challenges in geriatric rehabilitation: the development of an integrated care pathway].

PubMed

Everink, Irma Helga Johanna; van Haastregt, Jolanda C M; Kempen, Gertrudis I J M; Dielis, Leen M J; Maessen, José M C; Schols, Jos M G A

2015-04-01

Coordination and continuity of care within geriatric rehabilitation is challenging. To tackle these challenges, an integrated care pathway within geriatric rehabilitation care (hospital, geriatric rehabilitation and follow-up care in the home situation) has been developed. The aim of this article is to expound the process of developing the integrated care pathway, and to describe and discuss the results of this process (which is the integrated care pathway). Developing the integrated care pathway was done by the guidance of the first four steps of the theoretical framework for implementation of change from Grol and Wensing: (1) development of a specific proposal for change in practice; (2) analysis of current care practice; (3) analysis of the target group and setting; and (4) development and selection of interventions/strategies for change. The organizations involved in geriatric rehabilitation argued that the integrated care pathway should focus on improving the process of care, including transfer of patients, handovers and communication between care organizations. Current practice, barriers and incentives for change were analyzed through literature research, expert consultation, and interviews with the involved caregivers and by establishing working groups of health care professionals, patients and informal caregivers. This resulted in valuable proposals for improvement of the care process, which were gathered and combined in the integrated care pathway. The integrated care pathway entails agreements on (a) the triage process in the hospital; (b) active engagement of patients and informal caregivers in the care process; (c) timely and high quality handovers; and (d) improved communication between caregivers.

Veterans' experiences initiating VA-based mental health care.

PubMed

Bovin, Michelle J; Miller, Christopher J; Koenig, Christopher J; Lipschitz, Jessica M; Zamora, Kara A; Wright, Patricia B; Pyne, Jeffrey M; Burgess, James F

2018-05-21

Military veterans who could benefit from mental health services often do not access them. Research has revealed a range of barriers associated with initiating United States Department of Veterans Affairs (VA) care, including those specific to accessing mental health care (e.g., fear of stigmatization). More work is needed to streamline access to VA mental health-care services for veterans. In the current study, we interviewed 80 veterans from 9 clinics across the United States about initiation of VA mental health care to identify barriers to access. Results suggested that five predominant factors influenced veterans' decisions to initiate care: (a) awareness of VA mental health services; (b) fear of negative consequences of seeking care; (c) personal beliefs about mental health treatment; (d) input from family and friends; and (e) motivation for treatment. Veterans also spoke about the pathways they used to access this care. The four most commonly reported pathways included (a) physical health-care appointments; (b) the service connection disability system; (c) non-VA care; and (d) being mandated to care. Taken together, these data lend themselves to a model that describes both modifiers of, and pathways to, VA mental health care. The model suggests that interventions aimed at the identified pathways, in concert with efforts designed to reduce barriers, may increase initiation of VA mental health-care services by veterans. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Integrating disease management and wound care critical pathways in home care.

PubMed

Barr, J E

1999-10-01

This article discusses the need for an integration of the concepts of disease management and critical pathways as a foundation of a healthcare delivery system. The steps in the process for development, implementation, and evaluation of a wound care critical pathway are reviewed and variance classifications are defined. Co-pathways and algorithms are presented as methodologies for dealing with variances. A template of a wound care critical pathway that has been developed for use in the home care setting is included.

The African, Caribbean and European (ACE) Pathways to Care study: a qualitative exploration of similarities and differences between African-origin, Caribbean-origin and European-origin groups in pathways to care for psychosis

PubMed Central

Ferrari, Manuela; Flora, Nina; Anderson, Kelly K; Tuck, Andrew; Archie, Suzanne; Kidd, Sean; McKenzie, Kwame

2015-01-01

Objectives This paper reports on a qualitative exploration of the reasons for differences in pathways to care and duration of untreated psychosis (DUP) in the African, Caribbean and European (ACE) Pathways to Care study from the perspective of respondents to the study and their families. Setting Ontario, Canada. Participants Thirty-four participants in total. Twenty-five young people who had experienced a first episode of psychosis and nine family members. Participants were part of the ACE Pathways to Care study. Design We implemented six focus groups. Furthermore, we implemented four in-depth interviews with two African-origin young women, one Caribbean-origin woman, and one European-origin woman with lived experience of psychosis. Results Factors that influenced help-seeking delays across the three groups were: personal awareness of symptoms, family members’ knowledge of psychotic symptoms and knowledge of mental health services. Youth and their family members described how stigma played a key role in pathways to care by stopping them from asking for help. The way in which stigma operated on the three groups’ members, from feeling ashamed to feeling guilty for their mental illnesses, helped to explain differences in DUP between the groups. Guilt feelings emerged as a prominent theme among members from the African and Caribbean groups and it was not discussed in the European focus group. Delay in entering into first-episode psychosis programmes was also influenced by the stigma perceived by young people in healthcare settings. This had an impact on the therapeutic relationships, disclosure of symptoms and overall trust in the healthcare system. Conclusions The findings of this paper suggest that stigma, especially internalised stigma, may operate in different ways in European-origin, African-origin and Caribbean-origin groups. These findings could inform the development of more equitable services for people in early stages of psychosis. PMID:25588783

First choice of treatment place in the pathways to epileptic care at the outpatient department of University of Gondar Hospital, Northwest Ethiopia: Cross-sectional institutional based study.

PubMed

Bifftu, Berhanu Boru; Dachew, Berihun Assefa; Tiruneh, Bewket Tadesse; Alemu, Wondale Getinet

2017-01-01

Epilepsy treatment gap range from 87% to 98%. In spite of this, there is a gross inadequacy of the availability, accessibility and affordability of Anti-Epileptic Drugs. In countries like Ethiopia, where most populations are less aware about mental health problems, most people seek help for their illness from traditional healers. Thus, the main purpose of this study was to assess the pathways to epilepsy care and associated factors. Cross-sectional study design utilized among 409 participants selected by systematic random sampling technique. Pathways to epilepsy care were assessed by using the WHO Pathway Study tool. Multivariable logistic regression was done to identify factors associated with pathways to epileptic care. Overall, 162 (39.6%) of participants first contacted with modern treatment. Two hundred and forty seven (60.4%) of participants counted traditional healers and religious healers were the most common (47.2%). Being men, attending higher education, urban residence, short duration of illness, social support and age at the onset of illness were factors associated with first contact with modern treatment. Modern treatment was not the first place of choice for the majority of the respondents. Strengthening awareness creation program about epilepsy and its treatment is highly recommended with special emphases to urban dwellers and less educated people.

Pathway to care for drug resistant tuberculosis cases identified during a retrospective study conducted in high TB burden wards in Mumbai

PubMed Central

Lobo, Eunice; Shah, Shimoni; Rangan, Sheela; Dholakia, Yatin; Mistry, Nerges

2018-01-01

Background: Mumbai is witnessing a rising incidence of all forms of drug resistant tuberculosis (DR-TB). Methods: A population-based, retrospective study was conducted between April and July 2014, in 15 high TB burden wards in Mumbai, to capture the patient pathways to TB care. A total of 23 DR-TB patients were identified and their pathways to access DR-TB care were recorded using semi-structured interviews. Results: The total DR-TB pathway time of new patients (who did not report any past episode of TB) (180 days; IQR 123,346) was found to be more than twice that of retreatment patients (who reported a past episode of TB) (69 days; IQR 42,128). Conclusions: The unacceptable delay for diagnosis and treatment of DR-TB in Mumbai advocates for consistent implementation of early screening of patients using rapid gene-based technologies. PMID:29863175

Pathway to care for drug resistant tuberculosis cases identified during a retrospective study conducted in high TB burden wards in Mumbai.

PubMed

Lobo, Eunice; Shah, Shimoni; Rangan, Sheela; Dholakia, Yatin; Mistry, Nerges

2018-05-10

Background: Mumbai is witnessing a rising incidence of all forms of drug resistant tuberculosis (DR-TB). Methods: A population-based, retrospective study was conducted between April and July 2014, in 15 high TB burden wards in Mumbai, to capture the patient pathways to TB care. A total of 23 DR-TB patients were identified and their pathways to access DR-TB care were recorded using semi-structured interviews. Results: The total DR-TB pathway time of new patients (who did not report any past episode of TB) (180 days; IQR 123,346) was found to be more than twice that of retreatment patients (who reported a past episode of TB) (69 days; IQR 42,128). Conclusions: The unacceptable delay for diagnosis and treatment of DR-TB in Mumbai advocates for consistent implementation of early screening of patients using rapid gene-based technologies.

HEART Pathway Accelerated Diagnostic Protocol Implementation: Prospective Pre-Post Interrupted Time Series Design and Methods.

PubMed

Mahler, Simon A; Burke, Gregory L; Duncan, Pamela W; Case, Larry D; Herrington, David M; Riley, Robert F; Wells, Brian J; Hiestand, Brian C; Miller, Chadwick D

2016-01-22

Most patients presenting to US Emergency Departments (ED) with chest pain are hospitalized for comprehensive testing. These evaluations cost the US health system >$10 billion annually, but have a diagnostic yield for acute coronary syndrome (ACS) of <10%. The history/ECG/age/risk factors/troponin (HEART) Pathway is an accelerated diagnostic protocol (ADP), designed to improve care for patients with acute chest pain by identifying patients for early ED discharge. Prior efficacy studies demonstrate that the HEART Pathway safely reduces cardiac testing, while maintaining an acceptably low adverse event rate. The purpose of this study is to determine the effectiveness of HEART Pathway ADP implementation within a health system. This controlled before-after study will accrue adult patients with acute chest pain, but without ST-segment elevation myocardial infarction on electrocardiogram for two years and is expected to include approximately 10,000 patients. Outcomes measures include hospitalization rate, objective cardiac testing rates (stress testing and angiography), length of stay, and rates of recurrent cardiac care for participants. In pilot data, the HEART Pathway decreased hospitalizations by 21%, decreased hospital length (median of 12 hour reduction), without increasing adverse events or recurrent care. At the writing of this paper, data has been collected on >5000 patient encounters. The HEART Pathway has been fully integrated into health system electronic medical records, providing real-time decision support to our providers. We hypothesize that the HEART Pathway will safely reduce healthcare utilization. This study could provide a model for delivering high-value care to the 8-10 million US ED patients with acute chest pain each year. Clinicaltrials.gov NCT02056964; https://clinicaltrials.gov/ct2/show/NCT02056964 (Archived by WebCite at http://www.webcitation.org/6ccajsgyu).

Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should It Become the Standard of Care?

PubMed

Kaoutzanis, Christodoulos; Ganesh Kumar, Nishant; O'Neill, Dillon; Wormer, Blair; Winocour, Julian; Layliev, John; McEvoy, Matthew; King, Adam; Braun, Stephane A; Higdon, K Kye

2018-04-01

Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program. The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed. Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups. Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings. Therapeutic, III.

Developing care pathways--lessons from the Steele Review implementation in England.

PubMed

Rooney, Eric

2014-02-01

This paper sets out to discuss the concept of care pathways, review their definition, features and implementation and using an example from the NHS dental system in England guide the development of an elder care pathway. Care pathways have developed from quality management approaches in industry and focus on a number of steps which are intended to lead to expected outcomes. The existing definition and descriptors of care pathways serve well, but miss the complex process underlying the development of pathways, their structure, implementation and evaluation. The literature identifies key features of clinical pathways and from the developing field of implementation science, the factors likely to support pathway implementation. Pathways must be generic enough to enable them to be applicable broadly, but specific enough for them to be locally relevant and population specific. The development of care pathways in the National Health Service (NHS) Dental Service in England is described and when compared with the implementation science literature exhibits features identified as positive factors for implementation. As a result a contribution to the pathway definition literature is offered. Learning from the literature and the practical experience described from England, the process for developing dental care pathways for dependent elders should begin with the creation of a high level pathway, which is cognisant of the clinical and implementation science evidence base. © 2014 John Wiley & Sons A/S and The Gerodontology Society. Published by John Wiley & Sons Ltd.

Clinical pathways for primary care: current use, interest and perceived usability.

PubMed

Waters, Richard C; Toy, Jennifer M; Drechsler, Adam

2018-02-26

Translating clinical evidence to daily practice remains a challenge and may improve with clinical pathways. We assessed interest in and usability of clinical pathways by primary care professionals. An online survey was created. Interest in pathways for patient care and learning was assessed at start and finish. Participants completed baseline questions then pathway-associated question sets related to management of 2 chronic diseases. Perceived pathway usability was assessed using the system usability scale. Accuracy and confidence of answers was compared for baseline and pathway-assisted questions. Of 115 participants, 17.4% had used clinical pathways, the lowest of decision support tool types surveyed. Accuracy and confidence in answers significantly improved for all pathways. Interest in using pathways daily or weekly was above 75% for the respondents. There is low utilization of, but high interest in, clinical pathways by primary care clinicians. Pathways improve accuracy and confidence in answering written clinical questions.

Integration of Personalized Healthcare Pathways in an ICT Platform for Diabetes Managements: A Small-Scale Exploratory Study.

PubMed

Fico, Giuseppe; Fioravanti, Alessio; Arredondo, Maria Teresa; Gorman, Joe; Diazzi, Chiara; Arcuri, Giovanni; Conti, Claudio; Pirini, Giampiero

2016-01-01

The availability of new tools able to support patient monitoring and personalized care may substantially improve the quality of chronic disease management. A personalized healthcare pathway (PHP) has been developed for diabetes disease management and integrated into an information and communication technology system to accomplish a shift from organization-centered care to patient-centered care. A small-scale exploratory study was conducted to test the platform. Preliminary results are presented that shed light on how the PHP influences system usage and performance outcomes.

A fast-track anaemia clinic in the Emergency Department: cost-analysis of intravenous iron administration for treating iron-deficiency anaemia.

PubMed

Quintana-Díaz, Manuel; Muñoz-Romo, Raúl; Gómez-Ramírez, Susana; Pavía, José; Borobia, Alberto M; García-Erce, José A; Muñoz, Manuel

2017-09-01

A fast-track anaemia clinic (FTAC) for the management of moderate-to-severe iron-deficiency anaemia (IDA) was established in our Emergency Department in 2010. In this FTAC, the replacement of packed red cell transfusion by ferric carboxymaltose administration was proven to be safe and effective. The aim of this study was a cost-analysis of IDA management in the FTAC, comparing this management with the previous standard care pathway consisting of packed red cell transfusion, if needed, and referral to outpatient specialised care. A cost study was performed for patients with IDA who were at risk of requiring transfusion (haemoglobin <9 g/dL) but did not require hospitalisation. Total IDA treatment costs in the FTAC were compared to those theoretically incurred if these patients had been managed using the standard care pathway. In addition, a sensitivity analysis considering variations of up to ±30% in ferric carboxymaltose and packed red cell acquisition costs was performed (49 possible scenarios). Between 2012 and 2015, 238 IDA patients were treated in the FTAC. The average treatment cost was € 594±337/patient in the FTAC group and € 672±301/patient in the standard care pathway group, with a saving of € 78±28/patient (95% CI, 22-133; p<0.001). The sensitivity analysis showed that IDA treatment costs in the FTAC (€ 480-722/patient), compared with those of the standard care pathway (€ 550-794/patient), resulted in significant cost-savings for all studied scenarios (€ 51-104/patient; p<0.005). The administration of ferric carboxymaltose for IDA management in a FTAC may be cost-saving compared with the standard care pathway.

Practice nursing in Australia: A review of education and career pathways

PubMed Central

Parker, Rhian M; Keleher, Helen M; Francis, Karen; Abdulwadud, Omar

2009-01-01

Background Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia. Methods Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses. Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer. Results Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector. Conclusion There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways. PMID:19473493

Practice nursing in Australia: A review of education and career pathways.

PubMed

Parker, Rhian M; Keleher, Helen M; Francis, Karen; Abdulwadud, Omar

2009-05-27

Nurses in Australia are often not educated in their pre registration years to meet the needs of primary care. Careers in primary care may not be as attractive to nursing graduates as high-tech settings such as intensive or acute care. Yet, it is in primary care that increasingly complex health problems are managed. The Australian government has invested in incentives for general practices to employ practice nurses. However, no policy framework has been developed for practice nursing to support career development and post-registration education and training programs are developed in an ad hoc manner and are not underpinned by core professional competencies. This paper reports on a systematic review undertaken to establish the available evidence on education models and career pathways with a view to enhancing recruitment and retention of practice nurses in primary care in Australia. Search terms describing education models, career pathways and policy associated with primary care (practice) nursing were established. These search terms were used to search electronic databases. The search strategy identified 1394 citations of which 408 addressed one or more of the key search terms on policy, education and career pathways. Grey literature from the UK and New Zealand internet sites were sourced and examined. The UK and New Zealand Internet sites were selected because they have well established and advanced developments in education and career pathways for practice nurses.Two reviewers examined titles, abstracts and studies, based on inclusion and exclusion criteria. Disagreement between the reviewers was resolved by consensus or by a third reviewer. Significant advances have been made in New Zealand and the UK towards strengthening frameworks for primary care nursing education and career pathways. However, in Australia there is no policy at national level prepare nurses to work in primary care sector and no framework for education or career pathways for nurses working in that sector. There is a need for national training standards and a process of accreditation for practice nursing in Australia to support the development of a responsive and sustainable nursing workforce in primary care and to provide quality education and career pathways.

A Comparative Study of Pathways to Care for Children with Specific Learning Disability and Mental Retardation

PubMed Central

Chakraborty, Suhash; Kommu, John Vijay Sagar; Srinath, Shoba; Seshadri, Shekhar P.; Girimaji, Satish C.

2014-01-01

Context: Early intervention in specific learning disability (SpLD) results in better outcome and prevents comorbidity. Understanding the pathways is therefore important. Aims: To study and compare the pathways to care for children with SpLD and mental retardation (MR) before reaching a tertiary care center. Settings and Design, Material and Methods: A cross-sectional study was conducted for pathways to care of two groups: SpLD and MR with 50 children in each group from 8 to 16 years. MINI-KID for comorbidity and Goldberg's pathway to care instrument was used. The groups were divided into early contact (up to three carers) and late contact (more than three carers) and compared. Statistical Analysis: Data were analyzed using Statistical Packages for Social Sciences (SPSS) version 10.0 software. Results: Majority (n = 24 or 48%) of SpLD children visited “others” (teachers, neighbors, relatives, and guardians of fellow classmates) as first carer. Allopathic practitioners were the first choice for MR children (n = 31 or 62%). Six children (12%) in SpLD group and 10 of MR (20%) group have seen either traditional practitioner or healer as first carer. Maximum referral to the tertiary center in both groups was done by others (62% in SpLD and 56% in MR group). Early contacts in SpLD group belonged to younger age group (P = 0.01). While comparing both groups on the basis of early and late contact, mother's education was found to be significant in early contact group (P = 0.036) and having comorbidity was significant among late contacts (P = 0.038). Conclusions: The pathways to care for SpLD children are more or less similar to MR children whose parents recognize MR late. Both the groups visit multiple carers including traditional healers substantiating the strong belief for supernatural causation of developmental disorders in India. PMID:24701006

Operational integration in primary health care: patient encounters and workflows.

PubMed

Sifaki-Pistolla, Dimitra; Chatzea, Vasiliki-Eirini; Markaki, Adelais; Kritikos, Kyriakos; Petelos, Elena; Lionis, Christos

2017-11-29

Despite several countrywide attempts to strengthen and standardise the primary healthcare (PHC) system, Greece is still lacking a sustainable, policy-based model of integrated services. The aim of our study was to identify operational integration levels through existing patient care pathways and to recommend an alternative PHC model for optimum integration. The study was part of a large state-funded project, which included 22 randomly selected PHC units located across two health regions of Greece. Dimensions of operational integration in PHC were selected based on the work of Kringos and colleagues. A five-point Likert-type scale, coupled with an algorithm, was used to capture and transform theoretical framework features into measurable attributes. PHC services were grouped under the main categories of chronic care, urgent/acute care, preventive care, and home care. A web-based platform was used to assess patient pathways, evaluate integration levels and propose improvement actions. Analysis relied on a comparison of actual pathways versus optimal, the latter ones having been identified through literature review. Overall integration varied among units. The majority (57%) of units corresponded to a basic level. Integration by type of PHC service ranged as follows: basic (86%) or poor (14%) for chronic care units, poor (78%) or basic (22%) for urgent/acute care units, basic (50%) for preventive care units, and partial or basic (50%) for home care units. The actual pathways across all four categories of PHC services differed from those captured in the optimum integration model. Certain similarities were observed in the operational flows between chronic care management and urgent/acute care management. Such similarities were present at the highest level of abstraction, but also in common steps along the operational flows. Existing patient care pathways were mapped and analysed, and recommendations for an optimum integration PHC model were made. The developed web platform, based on a strong theoretical framework, can serve as a robust integration evaluation tool. This could be a first step towards restructuring and improving PHC services within a financially restrained environment.

Fostering development of nursing practices to support integrated care when implementing integrated care pathways: what levers to use?

PubMed

Longpré, Caroline; Dubois, Carl-Ardy

2017-11-29

Care integration has been the focus of recent health system reforms. Given their functions at all levels of the care continuum, nurses have a substantial and primordial role to play in such integration processes. The aim of this study was to identify levers and strategies that organizations can use to support the development of a nursing practice aligned with the requirements of care integration in a health and social services centre (HSSC) in Quebec. The research design was a cross-sectional descriptive qualitative study based on a single case study with nested levels of analysis. The case was a public, multi-disciplinary HSSC in a semi-urban region of Quebec. Semi-structured interviews with 37 persons (nurses, professionals, managers, administrators) allowed for data saturation and ensured theoretical representation by covering four care pathways constituting different care integration contexts. Analysis involved four steps: preparing a predetermined list of codes based on the reference framework developed by Minkman (2011); coding transcript content; developing general and summary matrices to group observations for each care pathway; and creating a general model showing the overall results for the four pathways. The organization's capacity for response with regard to developing an integrated system of services resulted in two types of complementary interventions. The first involved investing in key resources and renewing organizational structures; the second involved deploying a series of organizational and clinical-administrative processes. In resource terms, integration efforts resulted in setting up new strategic services, re-arranging physical infrastructures, and deploying new technological resources. Organizational and clinical-administrative processes to promote integration involved renewing governance, improving the flow of care pathways, fostering continuous quality improvement, developing new roles, promoting clinician collaboration, and strengthening care providers' capacities. However, progress in these areas was offset by persistent constraints. The results highlight key levers organizations can use to foster the implementation and institutionalization of integrative nursing practices. They show that progress in this area requires a combination of strategies using multiple complementary levers. They also suggest that such progress calls for rethinking not only the deployment of certain organizational resources and structures, but also a series of organizational and clinical processes.

Electronic Implementation of Integrated End-of-life Care: A Local Approach

PubMed Central

Schlieper, Daniel; Altreuther, Christiane; Schallenburger, Manuela; Neukirchen, Martin; Schmitz, Andrea

2017-01-01

Introduction: The Liverpool Care Pathway for the Dying Patient is an instrument to deliver integrated care for patients in their last hours of life. Originally a paper-based system, this study investigates the feasibility of an electronic version. Methods: An electronic Liverpool Care Pathway was implemented in a specialized palliative care unit of a German university hospital. Its use is exemplified by means of auditing and analysis of the proportion of recorded items. Results: In the years 2013 and 2014 the electronic Liverpool Care Pathway was used for the care of 159 patients. The uptake of the instrument was high (67%). Most items were recorded. Apart from a high usability, the fast data retrieval allows fast analysis for auditing and research. Conclusions and discussion: The electronic instrument is feasible in a computerized ward and has strong advantages for retrospective analysis. Trial registration: Internal Clinical Trial Register of the Medical Faculty, Heinrich Heine University Düsseldorf, No. 2015124683 (7 December 2015). PMID:28970746

The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections.

PubMed

Gibbs, Jo; Sutcliffe, Lorna J; Gkatzidou, Voula; Hone, Kate; Ashcroft, Richard E; Harding-Esch, Emma M; Lowndes, Catherine M; Sadiq, S Tariq; Sonnenberg, Pam; Estcourt, Claudia S

2016-07-22

Despite considerable international eHealth impetus, there is no guidance on the development of online clinical care pathways. Advances in diagnostics now enable self-testing with home diagnosis, to which comprehensive online clinical care could be linked, facilitating completely self-directed, remote care. We describe a new framework for developing complex online clinical care pathways and its application to clinical management of people with genital chlamydia infection, the commonest sexually transmitted infection (STI) in England. Using the existing evidence-base, guidelines and examples from contemporary clinical practice, we developed the eClinical Care Pathway Framework, a nine-step iterative process. Step 1: define the aims of the online pathway; Step 2: define the functional units; Step 3: draft the clinical consultation; Step 4: expert review; Step 5: cognitive testing; Step 6: user-centred interface testing; Step 7: specification development; Step 8: software testing, usability testing and further comprehension testing; Step 9: piloting. We then applied the Framework to create a chlamydia online clinical care pathway (Online Chlamydia Pathway). Use of the Framework elucidated content and structure of the care pathway and identified the need for significant changes in sequences of care (Traditional: history, diagnosis, information versus Online: diagnosis, information, history) and prescribing safety assessment. The Framework met the needs of complex STI management and enabled development of a multi-faceted, fully-automated consultation. The Framework provides a comprehensive structure on which complex online care pathways such as those needed for STI management, which involve clinical services, public health surveillance functions and third party (sexual partner) management, can be developed to meet national clinical and public health standards. The Online Chlamydia Pathway's standardised method of collecting data on demographics and sexual behaviour, with potential for interoperability with surveillance systems, could be a powerful tool for public health and clinical management.

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death.

PubMed

Hodkinson, Peter; Argent, Andrew; Wallis, Lee; Reid, Steve; Perera, Rafael; Harrison, Sian; Thompson, Matthew; English, Mike; Maconochie, Ian; Ward, Alison

2016-01-01

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided. A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors. The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children. The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.

Implementing best practice in hospital multidisciplinary nutritional care: an example of using the knowledge-to-action process for a research program.

PubMed

Laur, Celia; Keller, Heather H

2015-01-01

Prospective use of knowledge translation and implementation science frameworks can increase the likelihood of meaningful improvements in health care practices. An example of this creation and application of knowledge is the series of studies conducted by and with the Canadian Malnutrition Task Force (CMTF). Following a cohort study and synthesis of evidence regarding best practice for identification, treatment, and prevention of malnutrition in hospitals, CMTF created an evidence-informed, consensus-based pathway for nutritional care in hospitals. The purpose of this paper is to detail the steps taken in this research program, through four studies, as an example of the knowledge-to-action (KTA) process. The KTA process includes knowledge creation and action cycles. The steps of the action cycle within this program of research are iterative, and up to this point have been informed by three studies, with a fourth underway. The first study identified the magnitude of the malnutrition problem upon admission to hospital and how it is undetected and undertreated (study 1). Knowledge creation resulted in an evidence-based pathway established to address care gaps (study 2) and the development of monitoring tools (study 3). The study was then adapted to local context: focus groups validated face validate the evidence-based pathway; during the final phase, study site implementation teams will continue to adapt the pathway (studies 2 and 4). Barriers to implementation were also assessed; focus groups and interviews were conducted to inform the pathway implementation (studies 1, 2, and 4). In the next step, specific interventions were selected, tailored, and implemented. In the final study in this research program, plan-do-study-act cycles will be used to make changes and to implement the pathway (study 4). To monitor knowledge use and to evaluate outcomes, audits, staff surveys, patient outcomes, etc will be used to record process evaluations (studies 3 and 4). Finally, a sustainability plan will be incorporated into the final study of the program (study 4) to sustain knowledge use. Use of frameworks can increase the likelihood of meaningful and sustainable improvements in health care practice. The example of this program of research demonstrates how existing evidence has been used to identify, create, and adapt knowledge, and how multidisciplinary teams have been used to effect changes in the hospital setting. Effective implementation is essential in nutritional health care, and this multidisciplinary program of research provides an example of how the KTA process can facilitate implementation and promote sustainability.

Traversing the network: a user-led Care Pathway approach to the management of Parkinson's disease in the community.

PubMed

Holloway, Margaret

2006-01-01

This article reports on a pilot study to develop and implement a Care Pathway framework for people with Parkinson's disease (PD) and their carers, to facilitate more comprehensive and integrated health and social care, with a streamlining of the transfer of core information around the system. The pathway is user-led, conceptualising the user/carer as the 'communications centre', resourced and supported in the management of their situation by the professionals to achieve their own integrated package of care. The Care Pathway tools, comprising of a local information pack, a Problems/Needs form, a Clinic Summary and a service record sheet, were designed by a working party consisting of service providers, a service user and carer and the researchers. The use of the framework was evaluated by following the progress of a convenience sample of 22 people with PD over a 12-month period. Beginning and end-point data on patient characteristics, social circumstances, severity of illness, and recent/current use of services were collected. The separate tools and the contribution of the framework to the management of the illness were evaluated through semi-structured interviews with participants and their carers and focused interviews with the participating neurologist and specialist nurse, conducted at the end of the 12-month period. Participants' situations showed very little change overall. The people with PD and their carers were generally enthusiastic about the Care Pathway, particularly the problems/needs form which they felt facilitated their active engagement in their own care. Very few service record forms had been used. The neurologist and specialist nurse were equally enthusiastic, and envisaged that full use of the framework with all service providers participating would greatly improve the overall care of their patients. In conclusion the Care Pathway framework is feasible within normal clinic procedures and improves patients' care. However, its effectiveness in contributing to the better management of the illness overall requires further testing.

Perspectives on the Use of Clinical Pathways in Oncology Care.

PubMed

Chiang, Anne C; Ellis, Peter; Zon, Robin

2017-01-01

Pathways and guidelines are valuable tools to provide evidence-based care in oncology. Pathways may be more restrictive than guidelines because they attempt (where possible) to reduce cost, add efficiency, and remove unwarranted variability. Pathways offer an opportunity to measure, report, and improve quality of care; they can drive to evidence-based targeted therapy where appropriate; they can enhance efficiency through standardization; and, finally, they can be a vehicle to enhance participation in clinical trials. Pathway implementation requires understanding and commitment on the part of the physician and leadership as they may initially disrupt workflow, but ultimately have the ability to enhance patient care. ASCO criteria have been published for the development and implementation of high-quality oncology pathway programs. Future challenges for pathways include incorporation of molecular testing and appropriate targeted care in a real-time precision oncology approach.

Using Career Pathways to Guide Students through Programs of Study

ERIC Educational Resources Information Center

Bragg, Debra D.; Krismer, Marianne

2016-01-01

This chapter describes career pathways that evolved through a Trade Adjustment Assistance Community College and Career Training consortium grant designed to help students complete programs of study and enter health care careers.

Clinical pathways for acute coronary syndromes in China: protocol for a hospital quality improvement initiative.

PubMed

Rong, Ye; Turnbull, Fiona; Patel, Anushka; Du, Xin; Wu, Yangfeng; Gao, Runlin

2010-09-01

Clinical pathways have been shown to be effective in improving quality of care for patients admitted to hospital for acute coronary syndromes (ACS) in high-income countries. However, their utility has not formally been evaluated in low- or middle-income countries. The Clinical Pathways for Acute Coronary Syndromes in China program is a 7-year study with the overall goal of reducing evidence-practice gaps in the management of patients admitted to hospitals in China with suspected ACS. The program comprises 2 phases: a prospective survey of current management of ACS patients to identify the areas that evidence-based patient care can be potentially improved, and a quality care initiative to maximize the use of evidence-based investigations and treatments for ACS patients in China. In this article, we outline the details of the study protocol, including key aspects of the development, implementation, and evaluation of the quality improvement initiative (clinical pathway) for management of patients with suspected ACS.

The African, Caribbean and European (ACE) Pathways to Care study: a qualitative exploration of similarities and differences between African-origin, Caribbean-origin and European-origin groups in pathways to care for psychosis.

PubMed

Ferrari, Manuela; Flora, Nina; Anderson, Kelly K; Tuck, Andrew; Archie, Suzanne; Kidd, Sean; McKenzie, Kwame

2015-01-14

This paper reports on a qualitative exploration of the reasons for differences in pathways to care and duration of untreated psychosis (DUP) in the African, Caribbean and European (ACE) Pathways to Care study from the perspective of respondents to the study and their families. Ontario, Canada. Thirty-four participants in total. Twenty-five young people who had experienced a first episode of psychosis and nine family members. Participants were part of the ACE Pathways to Care study. We implemented six focus groups. Furthermore, we implemented four in-depth interviews with two African-origin young women, one Caribbean-origin woman, and one European-origin woman with lived experience of psychosis. Factors that influenced help-seeking delays across the three groups were: personal awareness of symptoms, family members' knowledge of psychotic symptoms and knowledge of mental health services. Youth and their family members described how stigma played a key role in pathways to care by stopping them from asking for help. The way in which stigma operated on the three groups' members, from feeling ashamed to feeling guilty for their mental illnesses, helped to explain differences in DUP between the groups. Guilt feelings emerged as a prominent theme among members from the African and Caribbean groups and it was not discussed in the European focus group. Delay in entering into first-episode psychosis programmes was also influenced by the stigma perceived by young people in healthcare settings. This had an impact on the therapeutic relationships, disclosure of symptoms and overall trust in the healthcare system. The findings of this paper suggest that stigma, especially internalised stigma, may operate in different ways in European-origin, African-origin and Caribbean-origin groups. These findings could inform the development of more equitable services for people in early stages of psychosis. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Electronic patient information systems and care pathways: the organisational challenges of implementation and integration.

PubMed

Dent, Mike; Tutt, Dylan

2014-09-01

Our interest here is with the 'marriage' of e-patient information systems with care pathways in order to deliver integrated care. We report on the development and implementation of four such pathways within two National Health Service primary care trusts in England: (a) frail elderly care, (b) stroke care, (c) diabetic retinopathy screening and (d) intermediate care. The pathways were selected because each represents a different type of information and data 'couplings', in terms of task interdependency with some pathways/systems reflecting more complex coordinating patterns than others. Our aim here is identify and explain how health professionals and information specialists in two organisational National Health Service primary care trusts organisationally construct and use such systems and, in particular, the implications this has for issues of professional and managerial control and autonomy. The article is informed by an institutionalist analysis. © The Author(s) 2013.

Mapping patient pathways and estimating resource use for point of care versus standard testing and treatment of chlamydia and gonorrhoea in genitourinary medicine clinics in the UK.

PubMed

Adams, Elisabeth J; Ehrlich, Alice; Turner, Katherine M E; Shah, Kunj; Macleod, John; Goldenberg, Simon; Meray, Robin K; Pearce, Vikki; Horner, Patrick

2014-07-23

We aimed to explore patient pathways using a chlamydia/gonorrhoea point-of-care (POC) nucleic acid amplification test (NAAT), and estimate and compare the costs of the proposed POC pathways with the current pathways using standard laboratory-based NAAT testing. Workshops were conducted with healthcare professionals at four sexual health clinics representing diverse models of care in the UK. They mapped out current pathways that used chlamydia/gonorrhoea tests, and constructed new pathways using a POC NAAT. Healthcare professionals' time was assessed in each pathway. The proposed POC pathways were then priced using a model built in Microsoft Excel, and compared to previously published costs for pathways using standard NAAT-based testing in an off-site laboratory. Pathways using a POC NAAT for asymptomatic and symptomatic patients and chlamydia/gonorrhoea-only tests were shorter and less expensive than most of the current pathways. Notably, we estimate that POC testing as part of a sexual health screen for symptomatic patients, or as stand-alone chlamydia/gonorrhoea testing, could reduce costs per patient by as much as £16 or £6, respectively. In both cases, healthcare professionals' time would be reduced by approximately 10 min per patient. POC testing for chlamydia/gonorrhoea in a clinical setting may reduce costs and clinician time, and may lead to more appropriate and quicker care for patients. Further study is warranted on how to best implement POC testing in clinics, and on the broader clinical and cost implications of this technology. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Role of care pathways in interprofessional teamwork.

PubMed

Scaria, Minimol Kulakkottu

2016-08-24

Cohesive interprofessional teamwork is essential to successful healthcare services. Interprofessional teamwork is the means by which different healthcare professionals - with diverse knowledge, skills and talents - collaborate to achieve a common goal. Several interventions are available to improve teamwork in the healthcare setting. This article explores the role of care pathways in improving interprofessional teamwork. Care pathways enhance teamwork by promoting coordination, collaboration, communication and decision making to achieve optimal healthcare outcomes. They result in improved staff knowledge, communication, documentation and interprofessional relations. Care pathways also contribute to patient-centred care and increase patient satisfaction.

Mental Health Pathways from Interpersonal Violence to Health-Related Outcomes in HIV-Positive Sexual Minority Men

ERIC Educational Resources Information Center

Pantalone, David W.; Hessler, Danielle M.; Simoni, Jane M.

2010-01-01

Objective: We examined mental health pathways between interpersonal violence (IPV) and health-related outcomes in HIV-positive sexual minority men engaged with medical care. Method: HIV-positive gay and bisexual men (N = 178) were recruited for this cross-sectional study from 2 public HIV primary care clinics that treated outpatients in an urban…

[Geriatric Trauma Center DGU®: Evaluation of clinical and economic parameters : A pilot study in a german university hospital].

PubMed

Knobe, M; Böttcher, B; Coburn, M; Friess, T; Bollheimer, L C; Heppner, H J; Werner, C J; Bach, J-P; Wollgarten, M; Poßelt, S; Bliemel, C; Bücking, B

2018-04-19

Previous studies on orthogeriatric models of care suggest that there is substantial variability in how geriatric care is integrated in the patient management and the necessary intensity of geriatric involvement is questionable. The aim of the current prospective cohort study was the clinical and economic evaluation of fragility fracture treatment pathways before and after the implementation of a geriatric trauma center in conformity with the guidelines of the German Trauma Society (DGU). A comparison of three different treatment models (6 months each) was performed: A: Standard treatment in Orthopaedic Trauma; B: Special care pathways with improvement of the quality management system and implementation of standard operating procedures; C: Interdisciplinary treatment with care pathways and collaboration with geriatricians (ward round model). In the 151 examined patients (m/w 47/104; 83.5 (70-100) years; A: n = 64, B: n = 44, C: n = 43) pathways with orthogeriatric comanagement (C) improved frequency of postoperative mobilization (p = 0.021), frequency of osteoporosis prophylaxis (p = 0.001) and the discharge procedure (p = 0.024). In comparison to standard treatment (A), orthogeriatric comanagement (C) was associated with lower rates of mortality (9% vs. 2%; p = 0.147) and cardio-respiratory complications (39% vs. 28%; p = 0.235) by trend. In this context, there were low rates of myocardial infarction (6% vs. 0%), dehydration (6% vs. 0%), cardiac dysrhythmia (8% vs. 0%), pulmonary decompensation (28% vs. 16%), electrolyt dysbalance (34% vs. 19%) and pulmonary edema (11% vs. 2%). Duration of stay in an intensive care unit was 29 h (A) and 18 h (C) respectively (p = 0.205), with consecutive reduction in costs. A sole establishment of a special care pathway for older hip fracture patients (B) showed a lower rate of myocardial infarction (A: 11%, B: 0%, C: 0%; p = 0.035). There was a clear tendency to a better overall result in patients receiving multidisciplinary orthogeriatric treatment using a ward visit model of orthogeriatric comanagement, with lower rates of cardiorespiratory complications and mortality. While special care pathways could reduce the rate of myocardial infarction in hip fracture patients, costs and revenues showed no difference between all care models evaluated. However, patients with hip fracture or periprosthetic fracture represent cohorts at clinical and economic risk as well.

Systems for implementing best practice for a chronic disease: management of osteoarthritis of the hip and knee.

PubMed

Brand, C; Cox, S

2006-03-01

Effective implementation of evidence-based care has been associated with better health outcomes; however, evidence-based clinical practice guidelines have been used with varying success. This study aimed to develop integrative tools to support implementation of best practice recommendations for nonsurgical management of osteoarthritis (OA) of the hip and knee and to identify barriers to effective implementation. Published, peer reviewed clinical practice guidelines were updated and translated into an OA care pathway. Key decision nodes in the pathway were identified by a Multidisciplinary Working Group. Qualitative research methods were used to inform pathway development and to identify barriers and enablers for pathway implementation. Qualitative components included purposively selected stakeholder focus groups, key informant interviews and patient process mapping of 10 patient journeys in different settings over a 3-month period. All interviews, facilitated by a trained project officer, were semistructured, recorded, then thematically analysed and summarized. An OA care pathway, clinician and patient toolkits were developed that met the needs of multidisciplinary end-users. Several system- and setting-specific barriers to pathway implementation were identified. Opportunities to improve patient access, interprofessional communication, patient information and education and continuity of care processes were identified. Integrative tools for implementation of best evidence care for patients with OA of the hip and knee were tailored to end-user needs and preferences. Multiple barriers exist that potentially limit effective implementation of best evidence. Comprehensive assessment of barriers and enablers to effective guideline or pathway implementation is recommended before implementation and evaluation.

Urological cancer care pathways: development and use in the context of systematic reviews and clinical practice guidelines.

PubMed

Maclennan, Sara Jane; Maclennan, Steven J; Imamura, Mari; Omar, Muhammad Imran; Vale, Luke; Lam, Thomas; Royle, Pamela; Royle, Justine; Swami, Satchi; Pickard, Rob; McClinton, Sam; Griffiths, T R Leyshon; Dahm, Philipp; N'dow, James

2011-06-01

Making healthcare treatment decisions is a complex process involving a broad stakeholder base including patients, their families, health professionals, clinical practice guideline developers and funders of healthcare. This paper presents a review of a methodology for the development of urological cancer care pathways (UCAN care pathways), which reflects an appreciation of this broad stakeholder base. The methods section includes an overview of the steps in the development of the UCAN care pathways and engagement with clinical content experts and patient groups. The development process is outlined, the uses of the urological cancer care pathways discussed and the implications for clinical practice highlighted. The full set of UCAN care pathways is published in this paper. These include care pathways on localised prostate cancer, locally advanced prostate cancer, metastatic prostate cancer, hormone-resistant prostate cancer, localised renal cell cancer, advanced renal cell cancer, testicular cancer, penile cancer, muscle invasive and metastatic bladder cancer and non-muscle invasive bladder cancer. The process provides a useful framework for improving urological cancer care through evidence synthesis, research prioritisation, stakeholder involvement and international collaboration. Although the focus of this work is urological cancers, the methodology can be applied to all aspects of urology and is transferable to other clinical specialties.

The implementation of an end-of-life integrated care pathway in a Chinese population.

PubMed

Lo, S-H; Chan, C-Y; Chan, C-H; Sze, W-k; Yuen, K-K; Wong, C-S; Ng, T-Y; Tung, Y

2009-08-01

The integrated care pathway is used in end-of-life care to improve quality of care; the Liverpool Care Pathway (LCP) has been used in Europe and North America. Tuen Mun Hospital is a regional hospital in Hong Kong, China. The End-of-life Care Pathway (ECP) based on the concepts used in the Liverpool Care Pathway, was developed, with modification to suit the local condition. Criteria for entry onto the ECP were that the multidisciplinary team agreed the patient was dying, and was at least two of the following: bedbound; semi-comatose; only able to take sips of fluid; no longer able to take tablets. The ECP template replaced all other inpatient documents. The ECP was implemented in the palliative care unit for terminal cancer patients. An audit was performed to review the result. Fifty-one Chinese patients were included in the audit with mean age 64. The median duration of ECP use was 24 hours. All patients had current medication assessed and non-essential drugs were discontinued. The audit result suggested integrated care pathway in end-of-life care could be implemented successfully in an Oriental culture. The acceptance of using the ECP as a standard clinical practice takes time and education. Appropriate template design and supervision are the keys to success.

Op HERRICK primary care casualties: the forgotten many.

PubMed

Nelson, T G; Wall, C; Driver, J; Simpson, R

2012-09-01

The number of battle casualties generated during war is far outnumbered by non-battle casualties. Each year the current conflict in Afghanistan sees hundreds of service personnel medically evacuated direct from the front line to the care of their home units' primary care facility. To date these casualties remain undiscovered by medical research. This is the first study to look at the care pathway of primary care casualties from Operation HERRICK using information from the Defence Patient Tracking System (DPTS). Information relating to all casualties from Afghanistan discharged at the airhead between 1 January 2009 and 31 December 2010 was collected from the DPTS. Common conditions were identified and information relating to the follow up care extracted to provide an overview of the care pathway. 387 aeromedical evacuations were identified as primary care casualties. The three commonest conditions were musculoskeletal (183 cases), mental health (29) and noise-induced hearing loss (26). 205 (53%) were not seen outside of primary care for the tracked condition. 166 (81%) of those that remained under primary care had two or less consultations during the time period of the study. The mean time frame between the 1st and 2nd consultation was 5.4 weeks. A significant number of aeromedical evacuations from Afghanistan are for primary care casualties. The DPTS can be used to provide a basic overview of the care pathway of repatriated personnel. Little contact with the medical services would appear to occur for these types of casualties. There is a significant gap in military medical research looking at primary care casualties repatriated from operations.

Assessing national provision of care: variability in bariatric clinical care pathways.

PubMed

Telem, Dana A; Majid, Saniea F; Powers, Kinga; DeMaria, Eric; Morton, John; Jones, Daniel B

2017-02-01

The American Society for Metabolic and Bariatric Surgery (ASMBS) Quality Improvement and Patient Safety (QIPS) Committee hypothesized that collecting and sharing clinical pathways could provide a valuable resource to new and existing bariatric programs. To shed light on the variability in practice patterns across the country by analyzing pathways. United States Centers of Excellence METHODS: From June 2014 to April 2015, clinical pathways pertaining to preoperative, intraoperative, and postoperative management of bariatric patients were solicited from the ASMBS executive council (EC), QIPS committee members, and state chapter presidents. Pathways were de-identified and then analyzed based on predetermined metrics pertaining to preoperative, intraoperative, and postoperative care. Concordance and discordance were then analyzed. In total, 31 pathways were collected; response rate was 80% from the EC, 77% from the QIPS committee, and 21% from state chapter presidents. The number of pathways sent in ranged from 1 to 10 with a median of 3 pathways per individual or institution. The majority of pathways centered on perioperative care (80%). Binary assessment (presence or absence) of variables found a high concordance (defined by greater than 65% of pathways accounting for that parameter) in only 6 variables: nutritional evaluation, psychological evaluation, intraoperative venous thromboembolism (VTE) prophylaxis, utilization of antiemetics in the postoperative period, a dedicated pain pathway, and postoperative laboratory evaluation. There is considerable national variation in clinical pathways among practicing bariatric surgeons. Most pathways center on Metabolic and Bariatric Surgery Accredited Quality Improvement Program (MBSAQIP) accreditation parameters, patient satisfaction, or Surgical Care Improvement Protocol (SCIP) measures. These pathways provide a path toward standardization of improved care. Copyright © 2016. Published by Elsevier Inc.

"Better pathways of care": suggested improvements to the emergency department management of people with advanced cancer.

PubMed

Jelinek, George A; Boughey, Mark; Marck, Claudia H; Phillip, Jennifer; Weil, Jennifer; Lane, Heather; Weiland, Tracey J

2014-01-01

It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions. This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semistructured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care. Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education. The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.

Development and Evaluation of an Educational E-Tool to Help Patients With Non-Hodgkin's Lymphoma Manage Their Personal Care Pathway.

PubMed

Stienen, Jozette Jc; Ottevanger, Petronella B; Wennekes, Lianne; Dekker, Helena M; van der Maazen, Richard Wm; Mandigers, Caroline Mpw; van Krieken, Johan Hjm; Blijlevens, Nicole Ma; Hermens, Rosella Pmg

2015-01-09

An overload of health-related information is available for patients on numerous websites, guidelines, and information leaflets. However, the increasing need for personalized health-related information is currently unmet. This study evaluates an educational e-tool for patients with non-Hodgkin's lymphoma (NHL) designed to meet patient needs with respect to personalized and complete health-related information provision. The e-tool aims to help NHL patients manage and understand their personal care pathway, by providing them with insight into their own care pathway, the possibility to keep a diary, and structured health-related information. Together with a multidisciplinary NHL expert panel, we developed an e-tool consisting of two sections: (1) a personal section for patients' own care pathway and their experiences, and (2) an informative section including information on NHL. We developed an ideal NHL care pathway based on the available (inter)national guidelines. The ideal care pathway, including date of first consultation, diagnosis, and therapy start, was used to set up the personal care pathway. The informative section was developed in collaboration with the patient association, Hematon. Regarding participants, 14 patients and 6 laymen were asked to evaluate the e-tool. The 24-item questionnaire used discussed issues concerning layout (6 questions), user convenience (3 questions), menu clarity (3 questions), information clarity (5 questions), and general impression (7 questions). In addition, the panel members were asked to give their feedback by email. A comprehensive overview of diagnostics, treatments, and aftercare can be established by patients completing the questions from the personal section. The informative section consisted of NHL information regarding NHL in general, diagnostics, therapy, aftercare, and waiting times. Regarding participants, 6 patients and 6 laymen completed the questionnaire. Overall, the feedback was positive, with at least 75% satisfaction on each feedback item. Important strengths mentioned were the use of a low health-literacy level, the opportunity to document the personal care pathway and experiences, and the clear overview of the information provided. The added value of the e-tool in general was pointed out as very useful for preparing the consultation with one's doctor and for providing all information on one website, including the opportunity for a personalized care pathway and diary. The majority of the revisions concerned wording and clarity. In addition, more explicit information on immunotherapy, experimental therapy, and psychosocial support was added. We have developed a personal care management e-tool for NHL patients. This tool contains a unique way to help patients manage their personal care pathway and give them insight into their NHL by providing health-related information and a personal diary. This evaluation showed that our e-tool meets patients' needs concerning personalized health-related information, which might serve as a good example for other oncologic diseases. Future research should focus on the possible impact of the e-tool on doctor-patient communication during consultations.

Genetics and the Placebo Effect: the Placebome

PubMed Central

Hall, Kathryn T.; Loscalzo, Joseph; Kaptchuk, Ted J.

2015-01-01

Placebos are indispensable controls in randomized clinical trials (RCTs), and placebo responses significantly contribute to routine clinical outcomes. Recent neurophysiological studies reveal neurotransmitter pathways that mediate placebo effects. Evidence that genetic variations in these pathways can modify placebo effects raises the possibility of using genetic screening to identify placebo responders and thereby increase RCT efficacy and improve therapeutic care. Furthermore, the possibility of interaction between placebo and drug molecular pathways warrants consideration in RCT design. The study of genomic effects on placebo response, “the placebome”, is in its infancy. Here, we review evidence from placebo studies and RCTs to identify putative genes in the placebome, examine evidence for placebo-drug interactions, and discuss implications for RCTs and clinical care. PMID:25883069

Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis.

PubMed

Elmusharaf, Khalifa; Byrne, Elaine; AbuAgla, Ayat; AbdelRahim, Amal; Manandhar, Mary; Sondorp, Egbert; O'Donovan, Diarmuid

2017-08-29

Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility. This study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software. Once the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care. Our findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.

Duration of untreated psychosis and pathway to care in Riyadh, Saudi Arabia.

PubMed

Al Fayez, Hanan; Lappin, Julia; Murray, Robin; Boydell, Jane

2017-02-01

Recent studies of 'duration of untreated psychosis' (DUP) indicate that some patients remain untreated in the community for some time. Considerable emphasis has been placed on reducing the DUP. However, most studies investigating DUP have been conducted in Western countries, where well-developed primary care systems are available. This study aims to describe DUP and its association with both demographic factors and pathways to care in Riyadh, Saudi Arabia. A retrospective study of 421 new case records of all Saudi schizophrenia patients over a 2-year period in six governmental hospitals in Riyadh, Saudi Arabia. The median DUP was 1.41 years (interquartile range 0.35-2.81 years). The longest time to contact was 9.86 years but 90% had a DUP shorter than 5 years. Older age at onset, single marital status and higher educational level were associated with shorter DUP. Long DUP was associated with help seeking from traditional healers. In Saudi Arabia, it usually takes longer for patients to seek help from psychiatric services after their first psychosis onset than it does in Western countries. The results suggest that the DUP is influenced by both demographic factors and pathways to care. © 2015 Wiley Publishing Asia Pty Ltd.

Linking Family Economic Hardship to Early Childhood Health: An Investigation of Mediating Pathways.

PubMed

Hsu, Hui-Chin; Wickrama, Kandauda A S

2015-12-01

The underlying mechanisms through which family economic adversity influences child health are less understood. Taking a process-oriented approach, this study examined maternal mental health and investment in children, child health insurance, and child healthcare as mediators linking family economic hardship (FEH) to child health. A structural equation modeling was applied to test the hypothesized mediating model. After adjustment for sociodemographic risk factors, results revealed: (1) a significant direct path linking FEH to poor child health (effect size = .372), and (2) six significant mediating pathways (total effect size = .089). In two mediating pathways, exposures to FEH undermined mothers' mental health: in the first pathway poor maternal mental health led to decreased parental investment, which, in turn, contributed to poor child health, whereas in the second pathway the adverse effect of poor maternal mental health was cascaded through child unmet healthcare need, which resulted in poor child health. One pathway involved child insurance status, where the effect of FEH increased the likelihood to be uninsured, which led to unmet healthcare need, and, in turn, to poor health. Three pathways involved preventive care: in one pathway FEH contributed to poor preventive care, which led to unmet healthcare need and then to poor health; in the other two pathways where poor preventive care respectively gave rise to decreased investment in children or poor maternal mental health, which further contributed to poor child health. Results suggest that the association between FEH and children's health is mediated by multiple pathways.

Evaluation of the impact of a clinical pathway on the organization of a multidisciplinary dental sleep clinic.

PubMed

Ten Berge, D M; Braem, M J; Altenburg, A; Dieltjens, M; Van de Heyning, P H; Vanhaecht, K; Vanderveken, O M

2014-05-01

Clinical pathways are used to organize complex care processes by providing structure and standardization. The multidisciplinary approach of oral appliance (OA) therapy for sleep-disordered breathing (SDB) is a complex and dynamic process suitable for such a structured pathway approach. A clinical pathway for patients referred for OA therapy was developed and implemented. The aim of this study was to evaluate the impact of this clinical pathway on the time to delivery of the OA and the organization of the multidisciplinary dental sleep clinic (MDSC). The latter was achieved using the care process self-evaluation tool (CPSET). First, development and implementation of the clinical pathway gave structure and shortened the mean time to delivery by 102 days (240 ± 70 vs. 138 ± 33 days) (Mann-Whitney U: P < 0.001). Second, the CPSET scores were obtained in a cohort of 49 healthcare professionals involved in the pathway. Overall, patient-focused organization received the highest scores (80.5 ± 9.0%), whereas cooperation with primary care received the lowest score (66.7 ± 12.4%). This is the first project on clinical pathways in OA therapy for SDB. The implementation of the pathway in our MDSC has created a significant shortening of the time to delivery. A first evaluation of the clinical pathway using the CPSET scores indicates that all disciplines involved should be thoroughly informed in an ongoing approach.

Pathways to Depression Care: Help-Seeking Experiences of Low-Income Latinos with Diabetes and Depression

PubMed Central

Cabassa, Leopoldo J.

2013-01-01

This qualitative study examines help-seeking pathways to depression care of low-income Latinos with diabetes and major depression. A purposive sample (N = 19) of Spanish-speaking, immigrant, low-income Latinos was selected from a randomized clinical trial targeting Latinos with diabetes and major depression. Four focus groups followed by 10 in-depth qualitative interviews were conducted. Narratives were analyzed using the constant comparative method informed by grounded theory. Need for formal care was described in relation to acute somatic symptoms, functional impairment, and mood changes. Treatment initiation occurred through family members and primary care physicians who encouraged or inhibited help-seeking. Adherence to depression care focused on interpersonal aspects of care, evaluated symptom relief, and improved functioning. Help-seeking barriers included self-reliance, language barriers, stigma, competing health demands, and structural barriers. Findings from this study highlight potential points of intervention for developing culturally-appropriate collaborative care approaches for low-income Latinos with diabetes and major depression. PMID:22367667

Managed care strategy for mental health services.

PubMed

Jones, A

In the UK, managed care is beginning to be recognized as a cost effective, quality-driven system which can be used to structure patient care. This article examines the potential use of managed care pathways in mental health services, focusing on clients with schizophrenia. The strengths of managed care include the effective coordination of healthcare resources, the clear accountable audit of mental health practice and the re-engineering of mental health practice to improve patient outcomes. Problems in designing representative care pathways and encouraging healthcare providers to implement care pathways are some of the disadvantages of this system.

Development, implementation, and compliance of treatment pathways in radiation medicine.

PubMed

Potters, Louis; Raince, Jadeep; Chou, Henry; Kapur, Ajay; Bulanowski, Daniel; Stanzione, Regina; Lee, Lucille

2013-01-01

While much emphasis on safety in the radiation oncology clinic is placed on process, there remains considerable opportunity to increase safety, enhance outcomes, and avoid ad hoc care by instituting detailed treatment pathways. The purpose of this study was to review the process of developing evidence and consensus-based, outcomes-oriented treatment pathways that standardize treatment and patient management in a large multi-center radiation oncology practice. Further, we reviewed our compliance in incorporating these directives into our day-to-day clinical practice. Using the Institute of Medicine guideline for developing treatment pathways, 87 disease specific pathways were developed and incorporated into the electronic medical system in our multi-facility radiation oncology department. Compliance in incorporating treatment pathways was assessed by mining our electronic medical records (EMR) data from January 1, 2010 through February 2012 for patients with breast and prostate cancer. This retrospective analysis of data from EMR found overall compliance to breast and prostate cancer treatment pathways to be 97 and 99%, respectively. The reason for non-compliance proved to be either a failure to complete the prescribed care based on grade II or III toxicity (n = 1 breast, 3 prostate) or patient elected discontinuance of care (n = 1 prostate) or the physician chose a higher dose for positive/close margins (n = 3 breast). This study demonstrates that consensus and evidence-based treatment pathways can be developed and implemented in a multi-center department of radiation oncology. And that for prostate and breast cancer there was a high degree of compliance using these directives. The development and implementation of these pathways serve as a key component of our safety program, most notably in our effort to facilitate consistent decision-making and reducing variation between physicians.

Elderly patients’ participation in emergency medical services when offered an alternative care pathway

PubMed Central

Vicente, Veronica; Castren, Maaret; Sjöstrand, Fredrik; Sundström, Birgitta Wireklint

2013-01-01

As organizational changes in the healthcare system are in progress, to enhance care quality and reduce costs, it is important to investigate how these changes affect elderly patients’ experiences and their rights to participate in the choice of healthcare. The aim of this study is to describe elderly patients’ lived experience of participating in the choice of healthcare when being offered an alternative care pathway by the emergency medical services, when the individual patient's medical needs made this choice possible. This study was carried out from the perspective of caring science, and a phenomenological approach was applied, where data were analysed for meaning. Data consist of 11 semi-structured interviews with elderly patients who chose a healthcare pathway to a community-based hospital when they were offered an alternative level of healthcare. The findings show that the essence of the phenomenon is described as “There was a ray of hope about a caring encounter and about being treated like a unique human being”. Five meaningful constituents emerged in the descriptions: endurable waiting, speedy transference, a concerned encounter, trust in competence, and a choice based on memories of suffering from care. The conclusion is that patient participation in the choice of a healthcare alternative instead of the emergency department is an opportunity of avoiding suffering from care and being objectified. PMID:23445898

The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results of a clinical trial.

PubMed

Flikweert, Elvira R; Izaks, Gerbrand J; Knobben, Bas A S; Stevens, Martin; Wendt, Klaus

2014-05-30

Hip fractures frequently occur in older persons and severely decrease life expectancy and independence. Several care pathways have been developed to lower the risk of negative outcomes but most pathways are limited to only one aspect of care. The aim of this study was therefore to develop a comprehensive care pathway for older persons with a hip fracture and to conduct a preliminary analysis of its effect. A comprehensive multidisciplinary care pathway for patients aged 60 years or older with a hip fracture was developed by a multidisciplinary team. The new care pathway was evaluated in a clinical trial with historical controls. The data of the intervention group were collected prospectively. The intervention group included all patients with a hip fracture who were admitted to University Medical Center Groningen between 1 July 2009 and 1 July 2011. The data of the control group were collected retrospectively. The control group comprised all patients with a hip fracture who were admitted between 1 January 2006 and 1 January 2008. The groups were compared with the independent sample t-test, the Mann-Whitney U-test or the Chi-squared test (Phi test). The effect of the intervention on fasting time and length of stay was adjusted by linear regression analysis for differences between the intervention and control group. The intervention group included 256 persons (women, 68%; mean age (SD), 78 (9) years) and the control group 145 persons (women, 72%; mean age (SD), 80 (10) years). Median preoperative fasting time and median length of hospital stay were significantly lower in the intervention group: 9 vs. 17 hours (p < 0.001), and 7 vs. 11 days (p < 0.001), respectively. A similar result was found after adjustment for age, gender, living condition and American Society of Anesthesiologists (ASA) classification. In-hospital mortality was also lower in the intervention group: 2% vs. 6% (p < 0.05). There were no statistically significant differences in other outcome measures. The new comprehensive care pathway was associated with a significant decrease in preoperative fasting time and length of hospital stay.

Do nursing homes for older people have the support they need to provide end-of-life care? A mixed methods enquiry in England

PubMed Central

Seymour, Jane E; Kumar, Arun; Froggatt, Katherine

2011-01-01

Nursing homes are a common site of death, but older residents receive variable quality of end-of-life care. We used a mixed methods design to identify external influences on the quality of end-of-life care in nursing homes. Two qualitative case studies were conducted and a postal survey of 180 nursing homes surrounding the case study sites. In the case studies, qualitative interviews were held with seven members of nursing home staff and 10 external staff. Problems in accessing support for end-of-life care reported in the survey included variable support by general practitioners (GPs), reluctance among GPs to prescribe appropriate medication, lack of support from other agencies, lack of out of hours support, cost of syringe drivers and lack of access to training. Most care homes were implementing a care pathway. Those that were not rated their end-of-life care as in need of improvement or as average. The case studies suggest that critical factors in improving end-of-life care in nursing homes include developing clinical leadership, developing relationships with GPs, the support of ‘key’ external advocates and leverage of additional resources by adoption of care pathway tools. PMID:21282349

Establishing pathways for access to pharmacist-provided patient care.

PubMed

Schommer, Jon C; Doucette, William R; Planas, Lourdes G

2015-01-01

To describe the pathways being established for access to pharmacist-provided patient care and supply recommendations for the next steps in this process. A series of reports published by the American Pharmacists Association regarding pharmacist-provided patient care services. Community pharmacies and integrated health organizations have emerged as the two predominant pathways for patient access to pharmacist-provided patient care. We view these two pathways as complementary in helping cover patients' entire medication therapy needs as they traverse acute and chronic health care services. However, gaps in access to pharmacist-provided care remain, especially during transitions in care. In further establishing pathways for access to pharmacist-provided patient care, we propose that the application of collaboration theory will help close gaps that currently exist between health care organizations. Such an approach carries risk and will require trust among participating organizations. This approach is also likely to require updating and contemporizing pharmacy practice acts and other statutes to allow pharmacists to practice at maximum capacity within new models of care. To perform their new roles and create sustainable business models to support these new functions, pharmacists will need to be paid for their services. To this end, changes will need to be made to payment and documentation systems, incentives, and contracting approaches to develop proper reimbursement and accounting for pharmacists' new roles.

First care givers of mentally ill patients: a multicenter study.

PubMed

Pradhan, S C; Singh, M M; Singh, R A; Das, J; Ram, D; Patil, B; Jain, A K; Thomas, J K

2001-04-01

Pathways to psychiatric care were evaluated among three hundred and eighty four first-contact psychiatric patients from five socio-culturally different regions of India by a modified version of World Health Organization encounter form for 'pathways in psychiatric care'. Concerning first caregivers, out of 384 respondents 34.1% had chosen the psychiatrists, 29.4% the general practitioners and 26% had chosen faith healers and exorcists. Choice for the first caregiver was not influenced by gender differences, literacy status and family type. Mostly the subjects hailing from rural areas and those presenting with somatic symptoms chose psychiatrist as their first caregivers.

Destroying myths.

PubMed

Moeen ul Haq, Sheikh; Butt, Mehmood; Ali, Raza; Bhattacharya, Amlan

2008-01-01

Palliative care emergencies such as spinal cord compression require prompt diagnosis and treatment to get the best results. Hospitals dealing with these emergencies need to develop pathways of care for these patients based on best evidence derived from hard data. The authors looked at all spinal cord compressions that presented to their hospital over a 10-year period. The authors found that the commonest day of presentation of this condition was on Mondays and not Fridays as had been widely believed prior to this study. Hospitals are encouraged to look at hard data and not anecdotes when developing pathways of care for their patients.

Rising utilization of inpatient pediatric asthma pathways.

PubMed

Kaiser, Sunitha V; Rodean, Jonathan; Bekmezian, Arpi; Hall, Matt; Shah, Samir S; Mahant, Sanjay; Parikh, Kavita; Morse, Rustin; Puls, Henry; Cabana, Michael D

2018-02-01

Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally. (1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways. We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables). Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05). From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

A critical pathway for the frail elderly cardiac patient.

PubMed

Wit, Mirjam; Schaap, Annet; Umans, Victor

2011-12-01

The medical community needs to better respond to the predictable complexities associated with admission of frail and elderly cardiac patients who may need specific attention and care programs. The nurse practitioner can play an important role to continue and coordinate nursing and medical care. We propose a new critical pathway designed to improve cardiac and nursing care for frail elderly cardiac patients admitted with heart failure or atrial fibrillation. The critical pathway is developed by the nurse practitioner who will act as a pathway coordinator and take care of the medical care of these patients in a teaching hospital setting. This critical pathway is applied to all patients aged >75 years who are admitted for heart failure or atrial fibrillation. The pathway implementation identified 5 important socio-medical parameters that may account for a delayed length of stay, even in patients without a complicated medical situation: delirium and fall prevention, nutritional awareness, fluid restriction efforts, and information optimization of patients and spouses. We developed a critical care pathway for the frail elderly patients who are admitted for heart failure or atrial fibrillation. In doing so, we have been able to change the medical and social management of these patients at a general cardiology ward in a teaching hospital.

A study of pathway of care in children and adolescents with attention deficit hyperactivity disorder.

PubMed

Arya, Amit; Agarwal, Vivek; Yadav, Suresh; Gupta, Pawan Kumar; Agarwal, Manu

2015-10-01

Attention deficit hyperactivity disorder (ADHD) is associated with impairment in all aspects of the patient's life. Despite availability of effective treatments for ADHD, a majority of the patient lack access to or have a significant delay in seeking help. This study aimed to assess the pathway of care in ADHD among patients attending the outpatient psychiatric services of a tertiary care centre in India. 57 newly registered cases of the age group 6-16 years with the diagnosis of ADHD as per DSM-IV-TR criteria were included in the study. Pathway of care was assessed on the semi structured proforma. The mean duration of delay in seeking help for ADHD symptoms was 3.96 Years (SD=1.96). Only 50% of the subjects consulted psychiatrists as first contact. Majority of the patients (45.61%) were referred by school teachers. Major reason given by the family members was that the patient was naughty rather than having any disorder for not seeking treatment in (89.47%). Our study showed that there was lack of recognition of ADHD at the level of other qualified practitioners and subsequent delay in referral to CAMHS. Sociocultural beliefs affected the help seeking by the parents. Copyright © 2015 Elsevier B.V. All rights reserved.

Reasons and pathways of first-time consultations at child and adolescent mental health services in Italy: an observational study.

PubMed

Pedrini, Laura; Sisti, Davide; Tiberti, Alessandra; Preti, Antonio; Fabiani, Michela; Ferraresi, Linda; Palazzi, Stefano; Parisi, Roberto; Ricciutello, Cosimo; Rocchi, Marco B L; Squarcia, Antonella; Trebbi, Stefano; Tullini, Andrea; De Girolamo, Giovanni

2015-01-01

An increasing number of young people have made contact with the Child and Adolescent Mental Health Services (CAMHS). However, only a small proportion of the population with emotional problems, actually seek specialized care. Research concerning the help-seeking process and pathways to care of a clinical sample could help to develop effective health policies to facilitate access to specialized care. To analyze the access pattern for CAMHS, reasons of contact and care pathways of a consecutive sample of first-time patients. Our aim was to analyze the association between source of referral, socio-demographic and clinical variables. Standardized assessment instruments and information concerning access patterns and care pathways were collected from 399 patients at first-time contact with CAMHS in a Northern Italian Region. Most patients were referred to CAMHS by school teachers (36 %) or health professionals (32 %), while only 17 % of the parents sought help by themselves. School issues (50 %) and emotional problems (17 %) were the most frequent reasons for contact. The proportion of first-time contacts with no diagnosis of mental disorder at their first consultation did not differ by source of referral. Parents of children who did not receive a clinical diagnosis of mental disorders described them as "psychosocially impaired" and their condition as "clinically severe" likewise parents of patients who received a psychiatric diagnosis. Patients with externalizing problems were more frequently referred by the parents themselves, while youth with internalizing problems were more often referred through health professionals. Families with non-traditional structures (adoptive, foster care, mono-parental) were more likely to consult CAMHS directly, while immigrant youth were more often referred by teachers. Socio-demographic and clinical characteristics can affect pathways to care. To improve early access to care for children and adolescents with ongoing mental disorders, a plan for proper action addressed to teachers and health professionals may well be important. This would improve their ability to recognize emotional and behavioral problems and use proper referral pathways, while informative intervention addressed to non-Italian families should inform them about the functioning and the mission of CAMHS.

Impact of Care Pathway-Based Approach on Outcomes in a Specialist Intellectual Disability Inpatient Unit

ERIC Educational Resources Information Center

Devapriam, John; Alexander, Regi; Gumber, Rohit; Pither, Judith; Gangadharan, Satheesh

2014-01-01

Specialist intellectual disability inpatient units have come under increased scrutiny, leading to questions about the quality of service provision in this sector. A care pathway-based approach was implemented in such a unit and its impact on outcome variables was measured. The care pathway-based approach resulted in the turnover of more patients,…

Improving the care pathway for women who request Caesarean section: an experience-based co-design study.

PubMed

Kenyon, Sara L; Johns, Nina; Duggal, Sandhya; Hewston, Ruth; Gale, Nicola

2016-11-09

Maternal request for Caesarean section is controversial and yet the NICE Caesarean section Guideline recommends that that if this is requested, following discussion of the risks and benefits, women should be supported in their choice. There was a desire to improve the pathway at Birmingham Women's NHS Foundation Trust. Experience-based co-design methodology uses service user and clinicians experiences collected using qualitative methods to jointly re-design services. Firstly semi-structured interviews were conducted to elicit the views and experiences of health care professionals and women who requested Caesarean section (with and without medical indication). Analysis identified key themes arising from the health care professionals' interviews and 'touch points' (key moments or events related to the experience of care) arising from the interviews with women.. Separate workshops were then held with each group to ensure these resonated and to identify key areas for service improvement. At the first joint workshop a pathway using 'audio clips' demonstrating women's agreed 'touch points' prompted discussion and joint working began to change the pathway. A final second workshop was held to agree changes to the pathway. Interviews were conducted with health care professionals (n = 22, 10 consultant obstetricians and 12 midwives) and women (n = 15). The women's 'touch points' included repetition of request, delay in the decision for Caesarean section to be made, feeling judged, and that information was poor with similar findings identified from the health care professionals. Joint working resulted in a revised pathway for women who request Caesarean section. Changes to the pathway for women as a result of the work include written information about 'The way your baby may be born' which is given to the woman followed by a discussion about mode of birth around the 16 week appointment. If the woman wishes to have a Caesarean section, referral is made to appropriate health care professionals (e.g., Consultant Midwife, counsellor) only if support and information would be useful. If Caesarean section is requested, woman is referred to a consultant obstetrician for an appointment at 20/40, with a decision by 28/40. Recording this in the notes minimises repeated challenge described by women. Final consent and timing of Caesarean section remain as recommended. This has resulted in changes to the pathway agreed by a co-design process and which are acceptable to both health care professionals and women. Use of such methodologies should be considered more frequently when implementing service change.

Feasibility of a physical activity pathway for Irish primary care physiotherapy services.

PubMed

Barrett, Emer M; Hussey, Juliette; Darker, Catherine D

2017-03-01

To establish consensus on a physical activity pathway suitable for use by physiotherapists in Irish primary care. The physical activity pathway "Let's Get Moving" was examined to agree recruitment criteria and seek consensus on component parts. Modified Delphi approach which attempts to achieve a convergence of opinion, over a series of iterations. Three rounds of questionnaires were used. Primary care. 41 senior physiotherapists working in primary care for a median of 6 years (IQR 3.7 to 8.5). Statements achieving consensus; defined as at least 70% of participants scoring a 6 or a 7, indicating high agreement, on a 7 point Likert scale. The response rate was 98%. There was a high degree of consensus for many components of the pathway. Participants agreed that all patients attending physiotherapy should be eligible for recruitment onto the pathway as well as accepting referrals from other health professionals and direct access from the public. Private physiotherapists highlighted concerns about recruiting fee paying patients onto the pathway. The pathway should be integrated into other preventative and chronic disease programmes in primary care. Modifications to the original pathway included the use of a pedometer in addition to the General Practice Physical Activity Questionnaire. Training needs in physical activity screening and motivational interviewing, as well as additional staffing were identified to support implementation. The Physical Activity Pathway "Let's Get Moving" was accepted as a clinically feasible resource to primary care physiotherapists with some modifications and with the support of additional resources. Copyright © 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Pathways to psychiatric care in European prison systems.

PubMed

Dressing, Harald; Salize, Hans-Joachim

2009-01-01

The aims of this study were to describe and analyse the concepts of provision of mental health services for prison inmates in 24 countries in the European Union and the EFTA. Data were gathered by means of a structured questionnaire that was completed by national experts in the participating countries. This article stresses the different organizational models of mental health care for inmates, different legal standards for screening their mental health status and different pathways to psychiatric care and aftercare. The study revealed serious shortcomings. Even the most rudimentary health reporting standards for mental health care in prison are lacking almost everywhere in Europe. Psychiatric screening and assessment procedures at prison entry and during imprisonment differ substantially and do not fulfil recognized quality standards. In many countries, the appointment of inadequately trained staff to perform such screenings increases considerably the risk that mental disorders or psychiatric needs of the inmates will remain undetected. Furthermore, the pathways to care in the case of an acute psychotic episode differ significantly, since referral to prison hospitals, medical prison wards, forensic hospitals, or general psychiatric hospital are used in various combinations depending on different national legal regulations and on the availability of services or other regional circumstances. Therefore, the collaborating experts place the quality of European prison mental health care into serious question. (c) 2009 John Wiley & Sons, Ltd.

Patients' experiences and care needs during the diagnostic phase of an Integrated Brain Cancer Pathway: A Case Study.

PubMed

Vedelø, Tina Wang; Sørensen, Jens Christian Hedemann; Delmar, Charlotte

2018-03-31

To identify and describe patients' experiences and care needs throughout the diagnostic phase of an Integrated Brain Cancer Pathway. A malignant brain tumour is a devastating diagnosis, which may cause psychical symptoms and cognitive deficits. Studies have shown that the shock of the diagnosis, combined with the multiple symptoms, affect patients' ability to understand information and express needs of care and support. Unmet needs have been reported within this group of patients, however, the experiences and care needs of patients going through the diagnostic phase of a standardised Integrated Brain Cancer Pathway have not previously been explored. A Case Study design was used to provide detailed information of the complex needs of patients being diagnosed with a malignant brain tumour. Research interviews and direct participant observation of four patients during hospital admission, brain surgery and discharge were conducted in a Danish university hospital. Systematic text condensation was used to analyse the data material. Four major themes were identified: information needs, balancing hope and reality while trying to perceive the unknown reality of brain cancer, not knowing what to expect and participants' perceptions of the relationship with the health care providers. The analysis revealed that participants were in risk of having unmet information needs and that contextual factors seemed to cause fragmented care that led to feelings of uncertainty and loss of control. Brain tumour patients have complex care needs and experience a particular state of vulnerability during the diagnostic phase. Through personal relationships based on trust with skilled health care providers, participants experienced an existential recognition and alleviation of emotional distress. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Patients or volunteers? The impact of motivation for trial participation on the efficacy of patient decision Aids: a secondary analysis of a Cochrane systematic review.

PubMed

Brown, James G; Joyce, Kerry E; Stacey, Dawn; Thomson, Richard G

2015-05-01

Efficacy of patient decision aids (PtDAs) may be influenced by trial participants' identity either as patients seeking to benefit personally from involvement or as volunteers supporting the research effort. To determine if study characteristics indicative of participants' trial identity might influence PtDA efficacy. We undertook exploratory subgroup meta-analysis of the 2011 Cochrane review of PtDAs, including trials that compared PtDA with usual care for treatment decisions. We extracted data on whether participants initiated the care pathway, setting, practitioner interactions, and 6 outcome variables (knowledge, risk perception, decisional conflict, feeling informed, feeling clear about values, and participation). The main subgroup analysis categorized trials as "volunteerism" or "patienthood" on the basis of whether participants initiated the care pathway. A supplementary subgroup analysis categorized trials on the basis of whether any volunteerism factors were present (participants had not initiated the care pathway, had attended a research setting, or had a face-to-face interaction with a researcher). Twenty-nine trials were included. Compared with volunteerism trials, pooled effect sizes were higher in patienthood trials (where participants initiated the care pathway) for knowledge, decisional conflict, feeling informed, feeling clear, and participation. The subgroup difference was statistically significant for knowledge only (P = 0.03). When trials were compared on the basis of whether volunteerism factors were present, knowledge was significantly greater in patienthood trials (P < 0.001), but there was otherwise no consistent pattern of differences in effects across outcomes. There is a tendency toward greater PtDA efficacy in trials in which participants initiate the pathway of care. Knowledge acquisition appears to be greater in trials where participants are predominantly patients rather than volunteers. © The Author(s) 2015.

"As soon as you've had the baby that's it…" a qualitative study of 24 postnatal women on their experience of maternal obesity care pathways.

PubMed

Dinsdale, Sarah; Branch, Kay; Cook, Lindsay; Shucksmith, Janet

2016-07-22

Maternal obesity is associated with risks to mother and infant, and has implications for healthcare costs. United Kingdom (UK) levels of maternal obesity are rising, with higher prevalence in North East (NE) England, where this study was set. Pregnancy is often seen as an opportune time for intervention - a 'teachable moment' - which is ripe for promoting behaviour change. In response to rising obesity levels, a National Health Service (NHS) Foundation Trust in NE England implemented three maternal obesity care pathways contingent on Body Mass Index (BMI) at time of booking: pathway 1 for those with BMI ≥30 kg/m(2); pathway 2 for BMI ≥35 kg/m(2); and pathway 3 for BMI ≥40 kg/m(2). These incorporated relevant antenatal, intrapartum and postnatal clinical requirements, and included a focus on weight management intervention. This evaluation explored the accounts of postnatal women who had been through one of these pathways in pregnancy. The study used a generic qualitative approach. Semi-structured interviews were carried out to explore the views and experiences of 24 recent mothers (aged 20-42), living in NE England, who had commenced on one of the pathways during pregnancy. Interviews explored experiences of weight management support during and after pregnancy, and perceived gaps in this support. Data were analysed using thematic content analysis. Three main themes emerged reflecting women's views and experiences of the pathways: communication about the pathways; treating obese pregnant women with sensitivity and respect; and appropriate and accessible lifestyle services and information for women during and after pregnancy. An overarching theme: differences in care, support and advice, was evident when comparing the experiences of women on pathways 1 or 2 with those on pathway 3. This study indicated that women were not averse to risk management and weight management intervention during and after pregnancy. However, in order to improve reach and effectiveness, such interventions need to be well communicated and offer constructive, individualised advice and support. The postnatal phase may also offer an opportune moment for intervention, suggesting that the simple notion of seeing pregnancy alone as a window of opportunity or a 'teachable moment' should be reconsidered.

Effects of a digital clinical pathway for elective electrocardioversion for atrial fibrillation on quality of care.

PubMed

Valente, Mattia; Zwaan, Esther; Wit, Mirjam; Kimman, Geert P; Umans, Victor

2010-12-01

Clinical pathways attempt to increase efficiency by organizing the care-delivery process into individual analyzable steps. However, full advantage may only be taken if the process is governed by a "process care taker." Currently, new opportunities are emerging for nurses to become involved as health care experts and may become an intermediate between patient and clinical team. We evaluate a digital clinical pathway for electrocardioversion in atrial fibrillation with a nurse-coordinator in the ongoing consecutive experience in clinical practice. The introduction of a digital pathway into the hospital information system allows continuous surveillance of clinical outcome indicators as well as variance indicators. This article describes a service evaluation and the implementation and effects of introducing a clinical pathway. However, when comparing the 2 eras, the primary goals were improved guideline-adherence and reduced walk-through times in the 600 consecutive pathway patients versus 100 consecutive control patients. The pathway was launched in January 2008. Up to January 2009, 600 all-comer, elective patients were treated using this integrated digital clinical pathway, without exception. Treatment and outpatient check-up appointments are made immediately for all patients. The pathway enabled the cardiologist to complete the risk calculator and drug therapy recommendations significantly better when compared with control patients and also reduced walk-through times significantly. Patient satisfaction rose from 8.7 to 9.1 (P < 0.01) using the pathway. A nurse-led clinical pathway for cardioversion patients is safely and efficaciously introduced in a teaching hospital. The pathway improved guideline-adherence. These results emphasize the importance of a nurse-coordinator who is an intermediary between atrial fibrillation patients and the clinical care team.

Testing Self-Efficacy as a Pathway that Supports Self-Care among Family Caregivers in a Psychoeducational Intervention

ERIC Educational Resources Information Center

Savundranayagam, Marie Y.; Brintnall-Peterson, Mary

2010-01-01

This study investigated the extent to which a psychoeducational intervention supports family-centered care by influencing health risk and self-care behaviors of caregivers of individuals with Alzheimer's disease (N = 325). Moreover, this study investigated the extent to which changes in self-efficacy explained changes in health risk and self-care…

Reducing Amputations in People with Diabetes (RAPID): Evaluation of a New Care Pathway

PubMed Central

MacRury, Sandra; Main, Fiona; Gorman, Jane; Jones, Sandra; Macfarlane, David

2018-01-01

People with diabetes are at increased risk of foot ulcers, which, if left untreated, can lead to infection, gangrene, and subsequent amputation. Management by a multidisciplinary diabetes foot team has been shown to reduce amputation rates; however, accessing specialist treatment is made particularly difficult when living in remote and rural locations, such as many individuals cared for within NHS Highland. The RAPID project was made up of two phases: firstly, to evaluate the technical feasibility of a new integrated care pathway using innovative technology, and secondly, to establish process enhancement of the pathway to justify a larger-scale study. Omni-HubTM enabled a face-to-face consultation by the community podiatrist to be enhanced by virtual consultation with members of the multidisciplinary foot team, including specialist diabetes podiatrists and a diabetes consultant. The technical feasibility study provided recommended changes focused around adaptations to the equipment used and the best means to gain successful connectivity. The process enhancement study demonstrated positive outcomes in the process with positive effects both in the service received by patients and experiences of healthcare professionals involved. The RAPID project provides evidence and justification for a larger-scale empirical study to test an embedded pathway and technology solution, which will inform policy change and a paradigm shift in the management of foot ulceration in the community. PMID:29772673

Reducing Amputations in People with Diabetes (RAPID): Evaluation of a New Care Pathway.

PubMed

MacRury, Sandra; Stephen, Kate; Main, Fiona; Gorman, Jane; Jones, Sandra; Macfarlane, David

2018-05-16

People with diabetes are at increased risk of foot ulcers, which, if left untreated, can lead to infection, gangrene, and subsequent amputation. Management by a multidisciplinary diabetes foot team has been shown to reduce amputation rates; however, accessing specialist treatment is made particularly difficult when living in remote and rural locations, such as many individuals cared for within NHS Highland. The RAPID project was made up of two phases: firstly, to evaluate the technical feasibility of a new integrated care pathway using innovative technology, and secondly, to establish process enhancement of the pathway to justify a larger-scale study. Omni-Hub TM enabled a face-to-face consultation by the community podiatrist to be enhanced by virtual consultation with members of the multidisciplinary foot team, including specialist diabetes podiatrists and a diabetes consultant. The technical feasibility study provided recommended changes focused around adaptations to the equipment used and the best means to gain successful connectivity. The process enhancement study demonstrated positive outcomes in the process with positive effects both in the service received by patients and experiences of healthcare professionals involved. The RAPID project provides evidence and justification for a larger-scale empirical study to test an embedded pathway and technology solution, which will inform policy change and a paradigm shift in the management of foot ulceration in the community.

[Assessing and making safe the medicine use pathway in paediatrics].

PubMed

Didelot, Nicolas; Guerrier, Catherine; Didelot, Anne; Fritsch, Sandrine; Pelte, Jean-Pierre; Socha, Marie; Javelot, Hervé

2016-01-01

Based on an assessment of adverse events in a follow-up care and rehabilitation unit in paediatrics, audits were carried out of the medicine use pathway. The evaluation grid taken from this study today serves as a basis for the audits carried out on the medicine use pathway on a national level. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Enhanced recovery pathways in pancreatic surgery: State of the art

PubMed Central

Pecorelli, Nicolò; Nobile, Sara; Partelli, Stefano; Cardinali, Luca; Crippa, Stefano; Balzano, Gianpaolo; Beretta, Luigi; Falconi, Massimo

2016-01-01

Pancreatic surgery is being offered to an increasing number of patients every year. Although postoperative outcomes have significantly improved in the last decades, even in high-volume centers patients still experience significant postoperative morbidity and full recovery after surgery takes longer than we think. In recent years, enhanced recovery pathways incorporating a large number of evidence-based perioperative interventions have proved to be beneficial in terms of improved postoperative outcomes, and accelerated patient recovery in the context of gastrointestinal, genitourinary and orthopedic surgery. The role of these pathways for pancreatic surgery is still unclear as high-quality randomized controlled trials are lacking. To date, non-randomized studies have shown that care pathways for pancreaticoduodenectomy and distal pancreatectomy are safe with no difference in postoperative morbidity, leading to early discharge and no increase in hospital readmissions. Hospital costs are reduced due to better organization of care and resource utilization. However, further research is needed to clarify the effect of enhanced recovery pathways on patient recovery and post-discharge outcomes following pancreatic resection. Future studies should be prospective and follow recent recommendations for the design and reporting of enhanced recovery pathways. PMID:27605881

Pathways of Adult Children Providing Care to Older Parents

ERIC Educational Resources Information Center

Barnett, Amanda E.

2013-01-01

Guided by life course and stress process theory, this study investigated pathways of adult child caregivers' family (caregiving, marital, parenting) and nonfamily (employment) roles. Eight waves of data from the Health and Retirement Study were analyzed for 1,300 adult child caregivers. Latent class analysis provided strong evidence for a 4-class…

Women's Pathways to Abortion Care in South Carolina: A Qualitative Study of Obstacles and Supports.

PubMed

Margo, Judy; McCloskey, Lois; Gupte, Gouri; Zurek, Melanie; Bhakta, Seema; Feinberg, Emily

2016-12-01

Women seeking timely and affordable abortion care may face myriad challenges, including high out-of-pocket costs, transportation demands, scheduling difficulties and stigma. State-level regulations may exacerbate these burdens and impede women's access to a full range of care. Women's reports of their experiences can inform efforts to improve pathways to abortion care. In 2014, semistructured qualitative interviews were conducted with 45 women obtaining abortions in South Carolina, which has a restrictive abortion environment. Interviews elicited information about women's pathways to abortion, including how they learned about and obtained care, whether they received professional referrals, and the supports and obstacles they experienced. Transcripts were examined using thematic analysis to identify key themes along the pathways, and a process map was constructed to depict women's experiences. Twenty participants reported having had contact with a health professional or crisis pregnancy center staff for pregnancy confirmation, and seven of them received an abortion referral. Women located abortion clinics through online searches, previous experience, and friends or family. Financial strain was the most frequently cited obstacle, followed by transportation challenges. Women reported experiencing emotional strain, stress and stigma, and described the value of receiving social support. Because of financial pressures, the regulation with the greatest impact was the one prohibiting most insurance plans from covering abortion care. Further research on experiences of women seeking abortion services, and how these individuals are affected by evolving state policy environments, will help shape initiatives to support timely, affordable and safe abortion care in a climate of increasing restrictions. Copyright © 2016 by the Guttmacher Institute.

Pathways to Lung Cancer Diagnosis: A Qualitative Study of Patients and General Practitioners about Diagnostic and Pretreatment Intervals.

PubMed

Rankin, Nicole M; York, Sarah; Stone, Emily; Barnes, David; McGregor, Deborah; Lai, Michelle; Shaw, Tim; Butow, Phyllis N

2017-05-01

Pathways to lung cancer diagnosis and treatment are complex. International evidence shows significant variations in pathways. Qualitative research investigating pathways to lung cancer diagnosis rarely considers both patient and general practitioner views simultaneously. To describe the lung cancer diagnostic pathway, focusing on the perspective of patients and general practitioners about diagnostic and pretreatment intervals. This qualitative study of patients with lung cancer and general practitioners in Australia used qualitative interviews or a focus group in which participants responded to a semistructured questionnaire designed to explore experiences of the diagnostic pathway. The Model of Pathways to Treatment (the Model) was used as a framework for analysis, with data organized into (1) events, (2) processes, and (3) contributing factors for variations in diagnostic and pretreatment intervals. Thirty participants (19 patients with lung cancer and 11 general practitioners) took part. Nine themes were identified during analysis. For the diagnostic interval, these were: (1) taking patient concerns seriously, (2) a sense of urgency, (3) advocacy that is doctor-driven or self-motivated, and (4) referral: "knowing who to refer to." For the pretreatment interval, themes were: (5) uncertainty, (6) psychosocial support for the patient and family before treatment, and (7) communication among the multidisciplinary team and general practitioners. Two cross-cutting themes were: (8) coordination of care and "handing over" the patient, and (9) general practitioner knowledge about lung cancer. Events were perceived as complex, with diagnosis often being revealed over time, rather than as a single event. Contributing factors at patient, system, and disease levels are described for both intervals. Patients and general practitioners expressed similar themes across the diagnostic and pretreatment intervals. Significant improvements could be made to health systems to facilitate better patient and general practitioner experiences of the diagnostic pathway. This novel presentation of patient and general practitioner perspectives indicates that systemic interventions have a role in timely and appropriate referrals to specialist care and coordination of investigations. Systemic interventions may alleviate concerns about urgency of diagnostic workup, communication, and coordination of care as patients transition from primary to specialist care.

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement.

PubMed

Chimento, George F; Thomas, Leslie C

2017-09-01

The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH. The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

Cost analysis of the History, ECG, Age, Risk factors, and initial Troponin (HEART) Pathway randomized control trial.

PubMed

Riley, Robert F; Miller, Chadwick D; Russell, Gregory B; Harper, Erin N; Hiestand, Brian C; Hoekstra, James W; Lefebvre, Cedric W; Nicks, Bret A; Cline, David M; Askew, Kim L; Mahler, Simon A

2017-01-01

The HEART Pathway is a diagnostic protocol designed to identify low-risk patients presenting to the emergency department with chest pain that are safe for early discharge. This protocol has been shown to significantly decrease health care resource utilization compared with usual care. However, the impact of the HEART Pathway on the cost of care has yet to be reported. We performed a cost analysis of patients enrolled in the HEART Pathway trial, which randomized participants to either usual care or the HEART Pathway protocol. For low-risk patients, the HEART Pathway recommended early discharge from the emergency department without further testing. We compared index visit cost, cost at 30 days, and cardiac-related health care cost at 30 days between the 2 treatment arms. Costs for each patient included facility and professional costs. Cost at 30 days included total inpatient and outpatient costs, including the index encounter, regardless of etiology. Cardiac-related health care cost at 30 days included the index encounter and costs adjudicated to be cardiac-related within that period. Two hundred seventy of the 282 patients enrolled in the trial had cost data available for analysis. There was a significant reduction in cost for the HEART Pathway group at 30 days (median cost savings of $216 per individual), which was most evident in low-risk (Thrombolysis In Myocardial Infarction score of 0-1) patients (median savings of $253 per patient) and driven primarily by lower cardiac diagnostic costs in the HEART Pathway group. Using the HEART Pathway as a decision aid for patients with undifferentiated chest pain resulted in significant cost savings. Copyright © 2016 Elsevier Inc. All rights reserved.

Ethics and end of life care: the Liverpool Care Pathway and the Neuberger Review.

PubMed

Wrigley, Anthony

2015-08-01

The Liverpool Care Pathway for the Dying has recently been the topic of substantial media interest and also been subject to the independent Neuberger Review. This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered of poor incidences of practice by the Review is of genuine concern for end of life care, the inferences drawn from this evidence are inconsistent with the causes for the concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high quality care because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care. I conclude that improvements in training, communication and ethical decision-making, without the added demand to end the Liverpool Care Pathway, would have resulted in a genuine advance in end of life care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Care pathway, towards the establishment of tailored funding: Reasons and criteria for success.

PubMed

Emery, Grégory; Le Fur, Camille; Epis-de-Fleurian, Anne-Aurélie; Josseran, Anne

2018-02-01

Care pathways are often at the forefront of political thinking about health care practices in France without ever finding a durable means for their extension. Closely linked to funding of healthcare system, they have, once again, been the object of so many economical discussions in 2017, as part of a more optimistic climate of governance which is therefore more open to change. Our changing system, the development and increasingly chronic nature of diseases, the scale of technological breakthroughs, these are all factors driving this topic forward. The object of this work, after a necessary study of the semantics of the term "pathway" and even "funding", was to identify all prerequisites and good practices for the stakeholders to develop a pilot pathway and then its relevant implementation in France. To do so, the members of the Round Table have relied on the presentation of examples of care pathways in order to identify triggers to a progressive, adapted extension to the whole territory. The group has identified key elements and priorities for the establishment of public funding beyond existing funding to incentive team work, particularly in the case of treatment rupture points and/or when they have diverging interests. Finally, creating a climate of confidence among patients, professionals, hospitals, the ARS, payers and manufacturers in handling change management will become the key challenges of the implementation of future pathways. Copyright © 2018 Société française de pharmacologie et de thérapeutique. Published by Elsevier Masson SAS. All rights reserved.

The Liverpool Care Pathway for cancer patients dying in hospital medical wards: a before-after cluster phase II trial of outcomes reported by family members.

PubMed

Costantini, Massimo; Pellegrini, Fabio; Di Leo, Silvia; Beccaro, Monica; Rossi, Carla; Flego, Guia; Romoli, Vittoria; Giannotti, Michela; Morone, Paola; Ivaldi, Giovanni P; Cavallo, Laura; Fusco, Flavio; Higginson, Irene J

2014-01-01

Hospital is the most common place of cancer death but concerns regarding the quality of end-of-life care remain. Preliminary assessment of the effectiveness of the Liverpool Care Pathway on the quality of end-of-life care provided to adult cancer patients during their last week of life in hospital. Uncontrolled before-after intervention cluster trial. The trial was performed within four hospital wards participating in the pilot implementation of the Italian version of the Liverpool Care Pathway programme. All cancer patients who died in the hospital wards 2-4 months before and after the implementation of the Italian version of Liverpool Care Pathway were identified. A total of 2 months after the patient's death, bereaved family members were interviewed using the Toolkit After-Death Family Interview (seven 0-100 scales assessing the quality of end-of-life care) and the Italian version of the Views of Informal Carers - Evaluation of Services (VOICES) (three items assessing pain, breathlessness and nausea-vomiting). An interview was obtained for 79 family members, 46 (73.0%) before and 33 (68.8%) after implementation of the Italian version of Liverpool Care Pathway. Following Italian version of Liverpool Care Pathway implementation, there was a significant improvement in the mean scores of four Toolkit scales: respect, kindness and dignity (+16.8; 95% confidence interval = 3.6-30.0; p = 0.015); family emotional support (+20.9; 95% confidence interval = 9.6-32.3; p < 0.001); family self-efficacy (+14.3; 95% confidence interval = 0.3-28.2; p = 0.049) and coordination of care (+14.3; 95% confidence interval = 4.2-24.3; p = 0.007). No significant improvement in symptom' control was observed. These results provide the first robust data collected from family members of a preliminary clinically significant improvement, in some aspects, of quality of care after the implementation of the Italian version of Liverpool Care Pathway programme. The poor effect for symptom control suggests areas for further innovation and development.

The Strengthening Families Initiative and Child Care Quality Improvement: How Strengthening Families Influenced Change in Child Care Programs in One State

ERIC Educational Resources Information Center

Douglass, Anne; Klerman, Lorraine

2012-01-01

Research Findings: This study investigated how the Strengthening Families through Early Care and Education initiative in Illinois (SFI) influenced change in 4 child care programs. Findings indicate that SFI influenced quality improvements through 4 primary pathways: (a) Learning Networks, (b) the quality of training, (c) the engagement of program…

Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care.

PubMed

Paton, Fiona; Wright, Kath; Ayre, Nigel; Dare, Ceri; Johnson, Sonia; Lloyd-Evans, Brynmor; Simpson, Alan; Webber, Martin; Meader, Nick

2016-01-01

Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery. To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway. Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies. When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority. Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis. One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well. Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams. This study is registered as PROSPERO CRD42014013279. The National Institute for Health Research HTA programme.

PRM Programmes of Care and PRM Care Pathways: European Approach, Developments in France

ERIC Educational Resources Information Center

de Korvin, Georges; Yelnik, Alain P.; Ribinik, Patricia; Calmels, Paul; Le Moine, Francis; Delarque, Alain

2013-01-01

The development of European Union of Medical Specialists (UEMS) physical and rehabilitation medicine programmes of care (PRMPC) and physical and rehabilitation medicine care pathways (PRMCP) in France is a good example of the positive interaction between European and national organizations. PRMPC were defined at the European level to offer a…

IT-supported integrated care pathways for diabetes: A compilation and review of good practices.

PubMed

Vrijhoef, Hubertus Jm; de Belvis, Antonio Giulio; de la Calle, Matias; de Sabata, Maria Stella; Hauck, Bastian; Montante, Sabrina; Moritz, Annette; Pelizzola, Dario; Saraheimo, Markku; Guldemond, Nick A

2017-06-01

Integrated Care Pathways (ICPs) are a method for the mutual decision-making and organization of care for a well-defined group of patients during a well-defined period. The aim of a care pathway is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To describe this concept, different names are used, e.g. care pathways and integrated care pathways. Modern information technologies (IT) can support ICPs by enabling patient empowerment, better management, and the monitoring of care provided by multidisciplinary teams. This study analyses ICPs across Europe, identifying commonalities and success factors to establish good practices for IT-supported ICPs in diabetes care. A mixed-method approach was applied, combining desk research on 24 projects from the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) with follow-up interviews of project participants, and a non-systematic literature review. We applied a Delphi technique to select process and outcome indicators, derived from different literature sources which were compiled and applied for the identification of successful good practices. Desk research identified sixteen projects featuring IT-supported ICPs, mostly derived from the EIP on AHA, as good practices based on our criteria. Follow-up interviews were then conducted with representatives from 9 of the 16 projects to gather information not publicly available and understand how these projects were meeting the identified criteria. In parallel, the non-systematic literature review of 434 PubMed search results revealed a total of eight relevant projects. On the basis of the selected EIP on AHA project data and non-systematic literature review, no commonalities with regard to defined process or outcome indicators could be identified through our approach. Conversely, the research produced a heterogeneous picture in all aspects of the projects' indicators. Data from desk research and follow-up interviews partly lacked information on outcome and performance, which limited the comparison between practices. Applying a comprehensive set of indicators in a multi-method approach to assess the projects included in this research study did not reveal any obvious commonalities which might serve as a blueprint for future IT-supported ICP projects. Instead, an unexpected high degree of heterogeneity was observed, that may reflect diverse local implementation requirements e.g. specificities of the local healthcare system, local regulations, or preexisting structures used for the project setup. Improving the definition of and reporting on project outcomes could help advance research on and implementation of effective integrated care solutions for chronic disease management across Europe.

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process.

PubMed

Shaw, Joanne M; Price, Melanie A; Clayton, Josephine M; Grimison, Peter; Shaw, Tim; Rankin, Nicole; Butow, Phyllis N

2016-01-01

People with cancer and their families experience high levels of psychological morbidity. However, many cancer services do not routinely screen patients for anxiety and depression, and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context. A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Co-operative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point Likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the Likert scale. Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after two Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings. This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.

Youth at ultra high risk for psychosis: using the Revised Network Episode Model to examine pathways to mental health care.

PubMed

Boydell, Katherine M; Volpe, Tiziana; Gladstone, Brenda M; Stasiulis, Elaine; Addington, Jean

2013-05-01

This paper aims to identify the ways in which youth at ultra high risk for psychosis access mental health services and the factors that advance or delay help seeking, using the Revised Network Episode Model (REV NEM) of mental health care. A case study approach documents help-seeking pathways, encompassing two qualitative interviews with 10 young people and 29 significant others. Theoretical propositions derived from the REV NEM are explored, consisting of the content, structure and function of the: (i) family; (ii) community and school; and (iii) treatment system. Although the aspects of the REV NEM are supported and shape pathways to care, we consider rethinking the model for help seeking with youth at ultra high risk for psychosis. The pathway concept is important to our understanding of how services and supports are received and experienced over time. Understanding this process and the strategies that support positive early intervention on the part of youth and significant others is critical. © 2012 Wiley Publishing Asia Pty Ltd.

What is a clinical pathway? Refinement of an operational definition to identify clinical pathway studies for a Cochrane systematic review.

PubMed

Lawal, Adegboyega K; Rotter, Thomas; Kinsman, Leigh; Machotta, Andreas; Ronellenfitsch, Ulrich; Scott, Shannon D; Goodridge, Donna; Plishka, Christopher; Groot, Gary

2016-02-23

Clinical pathways (CPWs) are a common component in the quest to improve the quality of health. CPWs are used to reduce variation, improve quality of care, and maximize the outcomes for specific groups of patients. An ongoing challenge is the operationalization of a definition of CPW in healthcare. This may be attributable to both the differences in definition and a lack of conceptualization in the field of clinical pathways. This correspondence article describes a process of refinement of an operational definition for CPW research and proposes an operational definition for the future syntheses of CPWs literature. Following the approach proposed by Kinsman et al. (BMC Medicine 8(1):31, 2010) and Wieland et al. (Alternative Therapies in Health and Medicine 17(2):50, 2011), we used a four-stage process to generate a five criteria checklist for the definition of CPWs. We refined the operational definition, through consensus, merging two of the checklist's criteria, leading to a more inclusive criterion for accommodating CPW studies conducted in various healthcare settings. The following four criteria for CPW operational definition, derived from the refinement process described above, are (1) the intervention was a structured multidisciplinary plan of care; (2) the intervention was used to translate guidelines or evidence into local structures; (3) the intervention detailed the steps in a course of treatment or care in a plan, pathway, algorithm, guideline, protocol or other 'inventory of actions' (i.e. the intervention had time-frames or criteria-based progression); and (4) the intervention aimed to standardize care for a specific population. An intervention meeting all four criteria was considered to be a CPW. The development of operational definitions for complex interventions is a useful approach to appraise and synthesize evidence for policy development and quality improvement.

Is physiotherapy self-referral with telephone triage viable, cost-effective and beneficial to musculoskeletal outpatients in a primary care setting?

PubMed

Mallett, Ross; Bakker, Edward; Burton, Maria

2014-12-01

The aim of the present study was to establish if physiotherapy self-referral (SR) is viable, cost effective and beneficial to musculoskeletal outpatients in a primary care setting. In an urban National Health Service (NHS) primary care physiotherapy service, waiting times, attendance rates and treatment ratios (thus, episode-of-care costs) were deemed unsustainable. The introduction of 'Any Qualified Provider' is imminent and will drive NHS physiotherapy services to compete directly with private counterparts. Current literature, healthcare policy and the Chartered Society of Physiotherapy strongly advocate SR to promote value for money and improve the patient experience. A repeated measure prospective cohort study introduced an SR pathway parallel to existing general practice (GP) referrals and compared costs, attendance and data relating to the patient experience across groups. SR referral groups were found to have a higher proportion of female patients presenting with acute conditions. Cost minimization analysis indicated an average 32.3% reduction in episode-of-care cost with an SR-initiated intervention. An estimated cost minimization of between £84,387.80 and £124,472.06 was calculated if SR were to be expanded service-wide. SR referral reduced waiting times and improved patient satisfaction relating to waiting times and communication compared with traditional pathways. The results of the present study showed that the introduction of the described SR pathway was feasible, cost-effective and offered comparable care. Certain aspects of the SR patient experience compared more favourably than those studied in traditional GP referral routes. They also added to an existing body of evidence supporting SR with a variety of administrative processes in various socioeconomic settings. Copyright © 2014 John Wiley & Sons, Ltd.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial.

PubMed

Jabbour, Mona; Curran, Janet; Scott, Shannon D; Guttman, Astrid; Rotter, Thomas; Ducharme, Francine M; Lougheed, M Diane; McNaughton-Filion, M Louise; Newton, Amanda; Shafir, Mark; Paprica, Alison; Klassen, Terry; Taljaard, Monica; Grimshaw, Jeremy; Johnson, David W

2013-05-22

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. ClinicalTrials.gov: NCT01815710.

Patients' Views of Treatment-Focused Genetic Testing (TFGT): Some Lessons for the Mainstreaming of BRCA1 and BRCA2 Testing.

PubMed

Wright, Sarah; Porteous, Mary; Stirling, Diane; Lawton, Julia; Young, Oliver; Gourley, Charlie; Hallowell, Nina

2018-05-11

This paper explores patients' views and experiences of undergoing treatment-focused BRCA1 and BRCA2 genetic testing (TFGT), either offered following triaging to clinical genetics (breast cancer) or as part of a mainstreamed care pathway in oncology (ovarian cancer). Drawing on 26 in-depth interviews with patients with breast or ovarian cancer who had undergone TFGT, this retrospective study examines patients' views of genetic testing at this point in their care pathway, focusing on issues, such as initial response to the offer of testing, motivations for undergoing testing, and views on care pathways. Patients were amenable to the incorporation of TFGT at an early stage in their cancer care irrespective of (any) prior anticipation of having a genetic test or family history. While patients were glad to have been offered TFGT as part of their care, some questioned the logic of the test's timing in relation to their cancer treatment. Crucially, patients appeared unable to disentangle the treatment role of TFGT from its preventative function for self and other family members, suggesting that some may undergo TFGT to obtain information for others rather than for self.

Tobacco use disorder treatment in primary care

PubMed Central

Kunyk, Diane; Els, Charl; Papadakis, Sophia; Selby, Peter

2014-01-01

Abstract Objective To test a team-based, site-specific, multicomponent clinical system pathway designed for enhancing tobacco use disorder treatment by primary care physicians. Design A prospective cohort study. Setting Sixty primary care sites in Alberta. Participants A convenience sample of 198 primary care physicians from the population of 2857. Main outcome measures Data collection occurred between September 2010 and February 2012 on 3 distinct measures. Twenty-four weeks after the intervention, audits of the primary care practices assessed the adoption and sustainability of 10 tobacco clinical system pathway components, a survey measured changes in physicians’ treatment intentions, and patient chart reviews examined changes in physicians’ consistency with the treatment algorithm. Results The completion rate by physicians was 89.4%. An intention-to-treat approach was undertaken for statistical analysis. Intervention uptake was demonstrated by positive changes at 4 weeks in how many of the 10 clinical system measures were performed (mean [SD] = 4.22 [1.60] vs 8.57 [1.46]; P < .001). Physicians demonstrated significant favourable changes in 9 of the 12 measures of treatment intention (P < .05). The 18 282 chart reviews documented significant increases in 6 of the 8 algorithm components. Conclusion Our findings suggest that the provision of a tobacco clinical system pathway that incorporates other members of the health care team and builds on existing office infrastructures will support positive and sustainable changes in tobacco use disorder treatment by physicians in primary care. This study reaffirms the substantive and important role of supporting how treatment is delivered in physicians’ practices. PMID:25022640

Challenges and Solutions in the Implementation of the School-Based Pathway to Care Model: The Lessons from Nova Scotia and beyond

ERIC Educational Resources Information Center

Kutcher, Stan; Wei, Yifeng

2013-01-01

Most mental disorders often onset during the adolescent years, providing opportunities for educators, health care providers, and related stakeholders to work collaboratively in addressing adolescent mental health care needs. This report describes early implementations of various components of the School-Based Pathway to Care Model currently…

Ethnic diversity and pathways to care for a first episode of psychosis in Ontario.

PubMed

Archie, S; Akhtar-Danesh, N; Norman, R; Malla, A; Roy, P; Zipursky, R B

2010-07-01

To examine ethnic variations in the pathways to care for persons accessing early intervention (EI) services in Ontario. The pathways to care and the duration of untreated psychosis were assessed for first-episode psychosis patients who entered specialized EI services in Ontario. The sample was assigned to the following ethnic classifications: the White (Caucasian), Black (African descent), and Asian (ancestry from the continent) groups, plus all the "other ethnicities" group. There were 200 participants: 78% were male; 61% from the White, 15% Black, 13% Asian, and 11% were from the other ethnicities group. At the first point of contact, more participants used nonmedical contacts (12%), such as clergy and naturopathic healers, than psychologists (8%) or psychiatrists (7%). There were no ethnic differences for duration of untreated psychosis (median 22 weeks) or for initiation of help seeking by family/friends (53%), police (15%), or self (33%). After adjusting for relevant clinical and demographic factors, the Asian and other ethnicities groups were 4 and 3 times (respectively) more likely than the White or Black groups (P = .017) to use emergency room services as the first point of contact in the pathways to care. Participants from the Asian group experienced less involuntary hospitalizations (P = .023) than all the other groups. Yet overall, there were many more similarities than significant differences in the pathways to care. EI services should monitor the pathways to care for young people of diverse ethnic backgrounds to address any disparities in accessing care.

[Palliative care pathways of older patients].

PubMed

Zubieta, Lourdes; Hébert, Réjean; Raîche, Michel

To determine the palliative care pathways of older patients in Sherbrooke, Qc by examining their transfers to other facilities. This analysis was conducted by linking 3 databases: emergency department, hospitalizations and nursing homes. The study period ranged from January 2011 to December 2015. SPSS was used for statistical analysis. The study only included palliative care patients. 25% of patients waited less than 7 days for transfer, and 74% waited less than 3 weeks. 64.9% of patients were transferred to a long-term facility for dependent adults (LTF), 15.2% returned home or were transferred to private accommodation, and 15.9% were transferred to an intermediate care facility. One-half of patients subsequently changed facility, mainly those in homes or intermediate care. Palliative care patient bed occupation rates represented 1% of available bed-days and less than 2% of total beds for 86.4% of days. Only 12% of patients returned to hospital within 90 days after discharge. The number of beds occupied by palliative care patients does not seem to disrupt the hospital capacity. The majority of the palliative care patients were well managed, as reflected by the low readmission rate. Our results indicate good management of transfers and an adequate supply of long-term care facilities and home services.

Reduction of Inpatient Hospital Length of Stay in Lumbar Fusion Patients With Implementation of an Evidence-Based Clinical Care Pathway.

PubMed

Bradywood, Alison; Farrokhi, Farrokh; Williams, Barbara; Kowalczyk, Mark; Blackmore, C Craig

2017-02-01

Quality improvement with before and after evaluation of the intervention. To improve lumbar spine postoperative care and quality outcomes through a series of Lean quality improvement events designed to address root causes of error and variation. Lumbar spine fusion procedures are common, but highly variable in process of care, outcomes, and cost. We implemented a standardized lumbar spine fusion clinical care pathway through a series of Lean quality improvement events. The pathway included an evidence-based electronic order set; a patient visual tool; and multidisciplinary communication, and was designed to delineate expectations for patients, staff, and providers. To evaluate the effectiveness of the intervention, we performed a quality improvement study with before and after evaluation of consecutive patients from January 2012 to September 2014. Outcomes were hospital length of stay and quality measures before and after the April 1, 2013 intervention. Data were analyzed with chi-square and t tests for before and after comparisons, and were explored graphically for temporal trends with statistical process control charts. Our study population was 458 patients (mean 65 years, 65% women). Length of stay decreased from 3.9 to 3.4 days, a difference of 0.5 days (CI 0.3, 0.8, P < 0.001). Discharge disposition also improved with 75% (183/244) being discharged to home postintervention versus 64% (136/214) preintervention (P = 0.002). Urinary catheter removal also improved (P = 0.003). Patient satisfaction scores were not significantly changed. Applying Lean methods to produce standardized clinical pathways is an effective way of improving quality and reducing waste for lumbar spine fusion patients. We believe that quality improvements of this type are valuable for all spine patients, to provide best care outcomes at lowest cost. 4.

A care pathway analysis of tuberculosis patients in benin: Highlights on direct costs and critical stages for an evidence-based decision-making.

PubMed

Laokri, Samia; Amoussouhui, Arnaud; Ouendo, Edgard M; Hounnankan, Athanase Cossi; Anagonou, Séverin; Gninafon, Martin; Kassa, Ferdinand; Tawo, Léon; Dujardin, Bruno

2014-01-01

Free tuberculosis control fail to protect patients from substantial medical and non-medical expenditure, thus a greater degree of disaggregation of patient cost is needed to fully capture their context and inform policymaking. A retrospective cross-sectional study was conducted on a convenience sample of six health districts of Southern Benin. From August 2008 to February 2009, we recruited all smear-positive pulmonary tuberculosis patients treated under the national strategy in the selected districts. Direct out-of-pocket costs associated with tuberculosis, time delays, and care-seeking pattern were collected from symptom onset to end of treatment. Population description and outcome data were reported for 245 patients of whom 153 completed their care pathway. For them, the median overall direct cost was USD 183 per patient. Payments to traditional healers, self-medication drugs, travel, and food expenditures contributed largely to this cost burden. Patient, provider, and treatment delays were also reported. Pre-diagnosis and intensive treatment stages were the most critical stages, with median expenditure of USD 43 per patient and accounting for 38% and 29% of the overall direct cost, respectively. However, financial barriers differed depending on whether the patient lived in urban or rural areas. This study delivers new evidence about bottlenecks encountered during the TB care pathway. Financial barriers to accessing the free-of-charge tuberculosis control strategy in Benin remain substantial for low-income households. Irregular time delays and hidden costs, often generated by multiple visits to various care providers, impair appropriate patient pathways. Particular attention should be paid to pre-diagnosis and intensive treatment. Cost assessment and combined targeted interventions embodied by a patient-centered approach on the specific critical stages would likely deliver better program outcomes.

Local co-ordination and case management can enhance Indigenous eye care – a qualitative study

PubMed Central

2013-01-01

Background Indigenous adults suffer six times more blindness than other Australians but 94% of this vision loss is unnecessary being preventable or treatable. We have explored the barriers and solutions to improve Indigenous eye health and proposed significant system changes required to close the gap for Indigenous eye health. This paper aims to identify the local co-ordination and case management requirements necessary to improve eye care for Indigenous Australians. Methods A qualitative study, using semi-structured interviews, focus groups, stakeholder workshops and meetings was conducted in community, private practice, hospital, non-government organisation and government settings. Data were collected at 21 sites across Australia. Semi-structured interviews were conducted with 289 people working in Indigenous health and eye care; focus group discussions with 81 community members; stakeholder workshops involving 86 individuals; and separate meetings with 75 people. 531 people participated in the consultations. Barriers and issues were identified through thematic analysis and policy solutions developed through iterative consultation. Results Poorly co-ordinated eye care services for Indigenous Australians are inefficient and costly and result in poorer outcomes for patients, communities and health care providers. Services are more effective where there is good co-ordination of services and case management of patients along the pathway of care. The establishment of clear pathways of care, development local and regional partnerships to manage services and service providers and the application of sufficient workforce with clear roles and responsibilities have the potential to achieve important improvements in eye care. Conclusions Co-ordination is a key to close the gap in eye care for Indigenous Australians. Properly co-ordinated care and support along the patient pathway through case management will save money by preventing dropout of patients who haven’t received treatment and a successfully functioning system will encourage more people to enter for care. PMID:23822115

Improving pathways to primary health care among LGBTQ populations and health care providers: key findings from Nova Scotia, Canada.

PubMed

Gahagan, Jacqueline; Subirana-Malaret, Montse

2018-06-13

This study explores the perceived barriers to primary health care as identified among a sample of Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) identified individuals and health care providers in Nova Scotia, Canada. These findings, based on a province-wide anonymous online survey, suggest that additional efforts are needed to improve pathways to primary health among LGBTQ populations and in deepening our understanding of how to advance the unique primary health needs of these populations. Data were collected from the LGBTQ community through an online, closed-ended anonymous survey. Inclusion criteria for participation were self-identifying as LGBTQ, offering primary health care to LGBTQ patients, being able to understand English, being 16 years of age or older, and having lived in Nova Scotia for at least one year. A total of 283 LGBTQ respondents completed the online survey which included sociodemographic questions, perceptions of respondents' health status, and their primary health care experiences. In addition, a total of 109 health care providers completed the survey based on their experiences providing care in Nova Scotia, and in particular, their experiences and perceptions regarding LGBTQ access to primary health care and physician-patient interactions. Our results indicate that, in several key areas, the primary health care needs of LGBTQ populations in Nova Scotia are not being met and this may in turn contribute to their poor health outcomes across the life course. A framework of intersectionality and health equity was used to interpret and analyze the survey data. The key findings indicate the need to continue improving pathways to primary health care among LGBTQ populations, specifically in relation to additional training and related supports for health care providers who work with these populations.

Introducing care pathway commissioning to primary dental care: measuring performance.

PubMed

Harris, R; Bridgman, C; Ahmad, M; Bowes, L; Haley, R; Saleem, S; Singh, R; Taylor, S

2011-12-09

Care pathways have been used in a variety of ways: firstly to support quality improvement through standardising clinical processes, but also for secondary purposes, by purchasers of healthcare, to monitor activity and health outcomes and to commission services. This paper focuses on reporting a secondary use of care pathways: to commission and monitor performance of primary dental care services. Findings of a project involving three dental practices implementing a system based on rating patients according to their risk of disease and need for care are outlined. Data from surgery-based clinical databases and interviews from commissioners and providers are reported. The use of both process and outcome key performance indicators in this context is discussed, as well as issues which arise such as attributability of outcome measures and strategic approaches to improving quality of care.

Identifying the Barriers and Enablers to Nutrition Care in Head and Neck and Esophageal Cancers: An International Qualitative Study.

PubMed

Martin, Lisa; de van der Schueren, Marian A E; Blauwhoff-Buskermolen, Susanne; Baracos, Vickie; Gramlich, Leah

2016-03-01

The goal of this work was to identify barriers and enablers to the implementation of nutrition care in head and neck and esophageal (HNE) cancers and to prioritize barriers to help improve the nutrition care process. This study used a multimethod qualitative study design (including semistructured interviews, focus group). Interviews (n = 29) were conducted at 5 European sites providing care and treatment to patients with HNE cancers. A focus group (n = 21) reviewed and corroborated interview findings and identified priorities for nutrition care. Participants were healthcare providers and researchers with direct experience in the field of HNE cancer. Five themes with accompanying barriers and enablers were identified related to nutrition care: (1) evidence for the benefit of nutrition interventions, (2) implementation of nutrition care processes (assessment, intervention, and follow-up), (3) characteristics of healthcare providers, (4) site factors, and (5) patient characteristics. Focus group discussions identified 2 priorities that must be acted on to improve nutrition care: (1) improve the evidence base and (2) develop standardized nutrition care pathways. Themes related to nutrition care in HNE cancers were similar between sites, but barriers and enablers differed. Interview and focus group participants agreed the following actions will result in improvements in nutrition care: (1) enhance the evidence base to test the benefit of nutrition interventions, with a focus on resolving specific controversies regarding nutrition therapy, and (2) establish a minimum data set with a goal to create standardized nutrition care pathways where roles and responsibilities for care are clearly defined. © 2014 American Society for Parenteral and Enteral Nutrition.

Design and validation of a critical pathway for hospital management of patients with severe traumatic brain injury.

PubMed

Espinosa-Aguilar, Amilcar; Reyes-Morales, Hortensia; Huerta-Posada, Carlos E; de León, Itzcoatl Limón-Pérez; López-López, Fernando; Mejía-Hernández, Margarita; Mondragón-Martínez, María A; Calderón-Téllez, Ligia M; Amezcua-Cuevas, Rosa L; Rebollar-González, Jorge A

2008-05-01

Critical pathways for the management of patients with severe traumatic brain injury (STBI) may contribute to reducing the incidence of hospital complications, length of hospitalization stay, and cost of care. Such pathways have previously been developed for departments with significant resource availability. In Mexico, STBI is the most important cause of complications and length of stay in neurotrauma services at public hospitals. Although current treatment is designed basically in accordance with the Brain Trauma Foundation guidelines, shortfalls in the availability of local resources make it difficult to comply with these standards, and no critical pathway is available that accords with the resources of public hospitals. The purpose of the present study was to design and to validate a critical pathway for managing STBI patients that would be suitable for implementation in neurotrauma departments of middle-income level countries. The study comprised two phases: design (through literature review and design plan) and validation (content, construct, and appearance) of the critical pathway. The validated critical pathway for managing STBI patients entails four sequential subprocesses summarizing the hospital's care procedures, and includes three components: (1) nodes and criteria (in some cases, indicators are also included); (2) health team members in charge of the patient; (3) maximum estimated time for compliance with recommendations. This validated critical pathway is based on the current scientific evidence and accords with the availability of resources of middle-income countries.

Home visits as part of a new care pathway (iAID) to improve quality of care and quality of life in ostomy patients: a cluster-randomized stepped-wedge trial.

PubMed

Sier, M F; Oostenbroek, R J; Dijkgraaf, M G W; Veldink, G J; Bemelman, W A; Pronk, A; Spillenaar-Bilgen, E J; Kelder, W; Hoff, C; Ubbink, D T

2017-08-01

Morbidity in patients with an ostomy is high. A new care pathway, including perioperative home visits by enterostomal therapists, was studied to assess whether more elaborate education and closer guidance could reduce stoma-related complications and improve quality of life (QoL), at acceptable cost. Patients requiring an ileostomy or colostomy, for any inflammatory or malignant bowel disease, were included in a 15-centre cluster-randomized 'stepped-wedge' study. Primary outcomes were stoma-related complications and QoL, measured using the Stoma-QOL, 3 months after surgery. Secondary outcomes included costs of care. The standard pathway (SP) was followed by 113 patients and the new pathway (NP) by 105 patients. Although the overall number of stoma-related complications was similar in both groups (SP 156, NP 150), the proportion of patients experiencing one or more stoma-related complications was significantly higher in the NP (72% vs 84%, risk difference 12%; 95% CI: 0.3-23.3%). Although in the NP more patients had stoma-related complications, QoL scores were significantly better (P < 0.001). In the SP more patients required extra care at home for their ostomy than in the NP (60.6% vs 33.7%, respectively; risk difference 26.9%, 95% CI: 13.5-40.4%). Stoma revision was done more often in the SP (n = 11) than in the NP (n = 2). Total costs in the SP did not differ significantly from the NP. The NP did not reduce the number of stoma-related complications but did lead to improved quality of care and life, against similar costs. Based on these results the NP, including perioperative home visits by an enterostomal therapist, can be recommended. Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.

People Experiencing Chronic Homelessness

MedlinePlus

... Housing Affordable Housing Rapid Re-Housing Supportive Housing Foster Education Connections Build Career Pathways Integrate Health Care ... Housing Affordable Housing Rapid Re-Housing Supportive Housing Foster Education Connections Build Career Pathways Integrate Health Care ...

Services for children with developmental co-ordination disorder: an evaluation against best practice principles.

PubMed

Pentland, Jacqueline; Maciver, Donald; Owen, Christine; Forsyth, Kirsty; Irvine, Linda; Walsh, Mike; Crowe, Miriam

2016-01-01

The National Health Service in Scotland published a best practice framework to support occupational therapists and physiotherapists to deliver effective services for children with developmental co-ordination disorder (DCD); however, adherence is variable. To highlight areas for development, this study compared the care pathway within a paediatric DCD service against the NHS Scotland framework. A partnership of researchers and clinicians based in the United Kingdom conducted a qualitative study with 37 participants (N = 13 interview participants, N = 24 workshop participants). In-depth interviews and/or workshops were used to map the DCD service against the NHS framework. Identified gaps were aligned with four key stages of the care pathway. Qualitative analysis software was used to analyse the data. Core principles to guide future development were identified for each phase of the pathway. These core principles related to the NHS framework and focused on issues such as involving the family, defining clear pathways and enhancing children's participation. Participants identified potential strategies for service improvement such as developing community-based interventions and information provision. Challenges when providing services for children with DCD include confusing service pathways and poor partnership working. It is, therefore, important that clinicians utilise collaborative working strategies that support children's participation. There are numerous challenges related to the implementation of best practice principles into the provision of therapy services for children with developmental coordination disorder (DCD). It is important that AHPs seek ways of engaging parents and educational professionals at all stages of the care pathway in order to ensure optimum service provision for the child. Addressing participation is an important aspect and community-based strategies may be particularly beneficial, both as a preventative activity and as an intervention approach.

Ethnic Diversity and Pathways to Care for a First Episode of Psychosis in Ontario

PubMed Central

Archie, S.; Akhtar-Danesh, N.; Norman, R.; Malla, A.; Roy, P.; Zipursky, R. B.

2010-01-01

Objective: To examine ethnic variations in the pathways to care for persons accessing early intervention (EI) services in Ontario. Method: The pathways to care and the duration of untreated psychosis were assessed for first-episode psychosis patients who entered specialized EI services in Ontario. The sample was assigned to the following ethnic classifications: the White (Caucasian), Black (African descent), and Asian (ancestry from the continent) groups, plus all the “other ethnicities” group. Results: There were 200 participants: 78% were male; 61% from the White, 15% Black, 13% Asian, and 11% were from the other ethnicities group. At the first point of contact, more participants used nonmedical contacts (12%), such as clergy and naturopathic healers, than psychologists (8%) or psychiatrists (7%). There were no ethnic differences for duration of untreated psychosis (median 22 weeks) or for initiation of help seeking by family/friends (53%), police (15%), or self (33%). After adjusting for relevant clinical and demographic factors, the Asian and other ethnicities groups were 4 and 3 times (respectively) more likely than the White or Black groups (P = .017) to use emergency room services as the first point of contact in the pathways to care. Participants from the Asian group experienced less involuntary hospitalizations (P = .023) than all the other groups. Yet overall, there were many more similarities than significant differences in the pathways to care. Conclusion: EI services should monitor the pathways to care for young people of diverse ethnic backgrounds to address any disparities in accessing care. PMID:18987101

Evaluation of the Dignity Care Pathway for community nurses caring for people at the end of life.

PubMed

Johnston, Bridget; Östlund, Ulrika; Brown, Hilary

2012-10-01

People nearing the end of life fear loss of dignity, and a central tenet of palliative care is to help people die with dignity. The Dignity Care Pathway (DCP) is an intervention based on the Chochinov theoretical model of dignity care. It has four sections: a manual, a Patient Dignity Inventory, reflective questions, and care actions. The feasibility and acceptability of the DCP were evaluated using a qualitative design with a purposive sample of community nurses. Data was collected from April to October 2010 using in-depth interviews, reflective diaries, and case studies and then analysed using framework analysis. The DCP was acceptable to the community nurses, helped them identify when patients were at the end of life, identified patients' key concerns, and aided nurses in providing holistic end-of-life care. It requires the nurse to have excellent communication skills. Some of the nurses found it hard to initiate a conversation on dignity-conserving care. The DCP helps nurses to deliver individualised care and psychological care, which has previously been identified as a difficult area for community nurses. All of the nurses wished to continue to use the DCP and would recommend it to others.

Cost and Survival Analysis Before and After Implementation of Dana-Farber Clinical Pathways for Patients With Stage IV Non-Small-Cell Lung Cancer.

PubMed

Jackman, David M; Zhang, Yichen; Dalby, Carole; Nguyen, Tom; Nagle, Julia; Lydon, Christine A; Rabin, Michael S; McNiff, Kristen K; Fraile, Belen; Jacobson, Joseph O

2017-04-01

Increasing costs and medical complexity are significant challenges in modern oncology. We explored the use of clinical pathways to support clinical decision making and manage resources prospectively across our network. We created customized lung cancer pathways and partnered with a commercial vendor to provide a Web-based platform for real-time decision support and post-treatment data aggregation. Dana-Farber Cancer Institute (DFCI) Pathways for non-small cell lung cancer (NSCLC) were introduced in January 2014. We identified all DFCI patients who were diagnosed and treated for stage IV NSCLC in 2012 (before pathways) and 2014 (after pathways). Costs of care were determined for 1 year from the time of diagnosis. Pre- and postpathway cohorts included 160 and 210 patients with stage IV NSCLC, respectively. The prepathway group had more women but was otherwise similarly matched for demographic and tumor characteristics. The total 12-month cost of care (adjusted for age, sex, race, distance to DFCI, clinical trial enrollment, and EGFR and ALK status) demonstrated a $15,013 savings after the implementation of pathways ($67,050 before pathways v $52,037 after pathways). Antineoplastics were the largest source of cost savings. Clinical outcomes were not compromised, with similar median overall survival times (10.7 months before v 11.2 months after pathways; P = .08). After introduction of a clinical pathway in metastatic NSCLC, cost of care decreased significantly, with no compromise in survival. In an era where comparative outcomes analysis and value assessment are increasingly important, the implementation of clinical pathways may provide a means to coalesce and disseminate institutional expertise and track and learn from care decisions.

Racial and Socioeconomic Differences Manifest in Process Measure Adherence for Enhanced Recovery After Surgery Pathway.

PubMed

Leeds, Ira L; Alimi, Yewande; Hobson, Deborah R; Efron, Jonathan E; Wick, Elizabeth C; Haut, Elliott R; Johnston, Fabian M

2017-10-01

Adherence to care processes and surgical outcomes varies by population subgroups for the same procedure. Enhanced recovery after surgery pathways are intended to standardize care, but their effect on process adherence and outcomes for population subgroups is unknown. This study aims to demonstrate the association between recovery pathway implementation, process measures, and short-term surgical outcomes by population subgroup. This study is a pre- and post-quality improvement implementation cohort study. This study was conducted at a tertiary academic medical center. A modified colorectal enhanced recovery after surgery pathway was implemented. Patients were included who had elective colon and rectal resections before (2013) and following (2014-2016) recovery pathway implementation. Thirty-day outcomes by race and socioeconomic status were analyzed using a difference-in-difference approach with correlation to process adherence. We identified 639 cases (199 preimplementation, 440 postimplementation). In these cases, 75.2% of the patients were white, and 91.7% had a high socioeconomic status. Groups were similar in terms of other preoperative characteristics. Following pathway implementation, median lengths of stay improved in all subgroups (-1.0 days overall, p ≤ 0.001), but with no statistical difference by race or socioeconomic status (p = 0.89 and p = 0.29). Complication rates in both racial and socioeconomic groups were no different (26.4% vs 28.8%, p = 0.73; 27.3% vs 25.0%, p = 0.86) and remained unchanged with implementation (p = 0.93, p = 0.84). By race, overall adherence was 31.7% in white patients and 26.5% in nonwhite patients (p = 0.32). Although stratification by socioeconomic status demonstrated decreased overall adherence in the low-status group (31.8% vs 17.1%, p = 0.05), white patients were more likely to have regional pain therapy (57.1% vs 44.1%, p = 0.02) with a similar trend seen with socioeconomic status. Data were collected primarily for quality improvement purposes. Differences in outcomes by race and socioeconomic status did not arise following implementation of an enhanced recovery pathway. Differences in process measures by population subgroups highlight differences in care that require further investigation. See Video Abstract at http://links.lww.com/DCR/A386.

Impact of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass.

PubMed

Stanley, A C; Barry, M; Scott, T E; LaMorte, W W; Woodson, J; Menzoian, J O

1998-06-01

To determine the effect of a critical pathway on postoperative length of stay and outcomes after infrainguinal bypass. A critical pathway for care of patients after infrainguinal bypass was introduced in December 1995 to coordinate postoperative care at our institution. We compared care of 67 consecutively treated patients before institution of the pathway with care of 69 consecutively treated patients with the critical pathway in place. Data collection was done by means of chart review. Univariate analyses were used to identify differences between prepathway and postpathway patients and to identify factors influencing postoperative length of stay. Multivariate analysis was used to identify factors that influenced length of stay and to examine the effect of use of the pathway after adjusting for other factors. Patients on the pathway were similar to prepathway controls with respect to comorbid illnesses, vascular risk factors, indications for surgical treatment, type of conduit, and type of operation. Factors associated with longer postoperative stays included distal anastomoses to tibial rather than popliteal vessels (p = 0.02), preexisting cardiac disease (p = 0.005), postoperative complications (p = 0.0003), lower preoperative hematocrit (p = 0.01), and elevated preoperative creatinine level (p = 0.006). Overall, pathway patients had somewhat shorter postoperative lengths of stay (median value 7 days; range 2 to 29 days) than prepathway patients (median value 6 days; range 2 to 35; p = 0.01), and the two groups had similar frequencies of postoperative complications, readmission, and 6-month mortality. However, patients on the pathway were more likely to be discharged to an intermediate-care facility rather than directly home. After 12 patients with extraordinarily prolonged postoperative stays were excluded, multivariate analysis indicated that pathway patients had significantly shorter postoperative stays (p = 0.001). However, the difference was not significant if patients with extraordinarily long postoperative stays were included in the analysis (p = 0.28). Use of a critical pathway was associated with a modest decrease in postoperative length of stay for most patients. This was accomplished without an adverse effect on readmission, complication, or mortality rates. However, the decrease in stay may have been achieved primarily by discharging more patients to intermediate-care facilities. The pathway did not appear to have any effect when the subset of patients with extraordinarily long stays because of complex medical problems was included.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING.

PubMed

Franco, Matheus Cavalcante; Nakao, Frank Shigueo; Rodrigues, Rodrigo; Maluf-Filho, Fauze; Paulo, Gustavo Andrade de; Libera, Ermelindo Della

2015-12-01

Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes.

PubMed

Messing, Barbara Pisano; Ward, Elizabeth C; Lazarus, Cathy; Ryniak, Keri; Kim, Melissa; Silinonte, Jessica; Gold, Dorothy; Thompson, Carol B; Pitman, Karen T; Blanco, Ray; Sobel, Ryan; Harrer, Karen; Ulmer, Karen; Neuner, Geoffrey; Patel, Kruti; Tang, Mei; Lee, Gregory

2018-06-19

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.

Factors influencing the pathways in response to complaints.

PubMed

Hsieh, Sophie Yahui

2010-01-01

The purpose of this paper is to explore hospital staff response to patient complaints and the factors influencing the response pathway. The paper uses an exploratory study in a large Taiwanese hospital purposefully chosen as a case study site. The critical incident technique (CIT) is implemented, using a questionnaire along with non-participant observations in which the results have been triangulated. A total of 59 cases were collected. The study found when facing "humaneness" complaints, hospital staff attempted to investigate the event and then explain the facts to the complainant or empathise with him/her and then refer the problem to the relevant unit. In response to complaints combining "communication" and "care/treatment and humaneness", staff tended to investigate the event's details and then directly explain them to the complainant. When complaints involved "care/treatment", staff tended to empathise with the complainant, investigate the facts and explain them to the complainant. Additionally, the organisational response to complaints was influenced by who made complaints; its type, severity, complaining method and patient status. The literature revealed that the case study is the most common organisational study method. However, this approach is criticised for not offering findings that can be generalised. Complaint nature is the major factor influencing the response pathway. If healthcare managers intend to reduce complaint rates then they need to carefully classify the complaint's nature. Different complaints have different handling procedures and guidelines to help managers resolve complaints in the first place. There are extensive studies focusing on investigating complaints and their resolution. These studies tend not to demonstrate various means of handling patient complaints. Neither do they describe how different complaints might lead to different outcomes. Therefore, this paper explores hospital staff response to patient complaints and the factors influencing the pathways in response to complaints.

Clinical- and cost-effectiveness of the STAR care pathway compared to usual care for patients with chronic pain after total knee replacement: study protocol for a UK randomised controlled trial.

PubMed

Wylde, Vikki; Bertram, Wendy; Beswick, Andrew D; Blom, Ashley W; Bruce, Julie; Burston, Amanda; Dennis, Jane; Garfield, Kirsty; Howells, Nicholas; Lane, Athene; McCabe, Candy; Moore, Andrew J; Noble, Sian; Peters, Tim J; Price, Andrew; Sanderson, Emily; Toms, Andrew D; Walsh, David A; White, Simon; Gooberman-Hill, Rachael

2018-02-21

Approximately 20% of patients experience chronic pain after total knee replacement. There is little evidence for effective interventions for the management of this pain, and current healthcare provision is patchy and inconsistent. Given the complexity of this condition, multimodal and individualised interventions matched to pain characteristics are needed. We have undertaken a comprehensive programme of work to develop a care pathway for patients with chronic pain after total knee replacement. This protocol describes the design of a randomised controlled trial to evaluate the clinical- and cost-effectiveness of a complex intervention care pathway compared with usual care. This is a pragmatic two-armed, open, multi-centred randomised controlled trial conducted within secondary care in the UK. Patients will be screened at 2 months after total knee replacement and 381 patients with chronic pain at 3 months postoperatively will be recruited. Recruitment processes will be optimised through qualitative research during a 6-month internal pilot phase. Patients are randomised using a 2:1 intervention:control allocation ratio. All participants receive usual care as provided by their hospital. The intervention comprises an assessment clinic appointment at 3 months postoperatively with an Extended Scope Practitioner and up to six telephone follow-up calls over 12 months. In the assessment clinic, a standardised protocol is followed to identify potential underlying causes for the chronic pain and enable appropriate onward referrals to existing services for targeted and individualised treatment. Outcomes are assessed by questionnaires at 6 and 12 months after randomisation. The co-primary outcomes are pain severity and pain interference assessed using the Brief Pain Inventory at 12 months after randomisation. Secondary outcomes relate to resource use, function, neuropathic pain, mental well-being, use of pain medications, satisfaction with pain relief, pain frequency, capability, health-related quality of life and bodily pain. After trial completion, up to 30 patients in the intervention group will be interviewed about their experiences of the care pathway. If shown to be clinically and cost-effective, this care pathway intervention could improve the management of chronic pain after total knee replacement. ISRCTN registry ( ISRCTN92545361 ), prospectively registered on 30 August 2016.

He Tamariki Kokoti Tau-Tackling Preterm: a data-linkage methodology to explore the clinical care pathway in preterm deliveries.

PubMed

Filoche, Sara; Cram, Fiona; Beard, Angela; Sim, Dalice; Geller, Stacie; Edmonds, Liza; Robson, Bridget; Lawton, Beverley

2018-05-21

Significant health inequities exist around maternal and infant health for Māori, the indigenous people of Aotearoa New Zealand - and in particular around a premature (preterm) delivery. Māori babies are more likely to be born preterm (8.1%, compared to an overall rate of 7.4%) and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study. This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Māori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Māori whānau (family). Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries - both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities.

Improving pathways into mental health care for black and ethnic minority groups: a systematic review of the grey literature.

PubMed

Moffat, Joanne; Sass, Bernd; McKenzie, Kwame; Bhui, Kamaldeep

2009-01-01

Black and ethnic minorities show different pathways to care services and different routes out of care. These often involve non-statutory sector services. In order to improve access to services, and to develop appropriate and effective interventions, many innovations are described but the knowledge about how to improve pathways to recovery has not been synthesized. Much of this work is not formally published. Hence, this paper addresses this oversight and undertakes a review of the grey literature. The key components of effective pathway interventions include specialist services for ethnic minority groups, collaboration between sectors, facilitating referral routes between services, outreach and facilitating access into care, and supporting access to rehabilitation and moving out of care. Services that support collaboration, referral between services, and improve access seem effective, but warrant further evaluation. Innovative services must ensure that their evaluation frameworks meet minimum quality standards if the knowledge gained from the service is to be generalized, and if it is to inform policy.

Cost-effectiveness development for the postoperative care of craniotomy patients: a safe transitions pathway in neurological surgery.

PubMed

Osorio, Joseph A; Safaee, Michael M; Viner, Jennifer; Sankaran, Sujatha; Imershein, Sarah; Adigun, Ezekiel; Weigel, Gabriela; Berger, Mitchel S; McDermott, Michael W

2018-05-01

OBJECTIVE The authors' institution is in the top 5th percentile for hospital cost in the nation, and the neurointensive care unit (NICU) is one of the costliest units. The NICU is more expensive than other units because of lower staff/patient ratio and because of the equipment necessary to monitor patient care. The cost differential between the NICU and Neuro transitional care unit (NTCU) is $1504 per day. The goal of this study was to evaluate and to pilot a program to improve efficiency and lower cost by modifying the postoperative care of patients who have undergone a craniotomy, sending them to the NTCU as opposed to the NICU. Implementation of the pilot will expand and utilize neurosurgery beds available on the NTCU and reduce the burden on NICU beds for critically ill patient admissions. METHODS Ten patients who underwent craniotomy to treat supratentorial brain tumors were included. Prior to implementation of the pilot, inclusion criteria were designed for patient selection. Patients included were less than 65 years of age, had no comorbid conditions requiring postoperative intensive care unit (ICU) care, had a supratentorial meningioma less than 3 cm in size, had no intraoperative events, had routine extubation, and underwent surgery lasting fewer than 5 hours and had blood loss less than 500 ml. The Safe Transitions Pathway (STP) was started in August 2016. RESULTS Ten tumor patients have utilized the STP (5 convexity meningiomas, 2 metastatic tumors, 3 gliomas). Patients' ages ranged from 29 to 75 years (median 49 years; an exception to the age limit of 65 years was made for one 75-year-old patient). Discharge from the hospital averaged 2.2 days postoperative, with 1 discharged on postoperative day (POD) 1, 7 discharged on POD 2, 1 discharged on POD 3, and 1 discharged on POD 4. Preliminary data indicate that quality and safety for patients following the STP (moving from the operating room [OR] to the neuro transitional care unit [OR-NTCU]) are no different from those of patients following the traditional OR-NICU pathway. No patients required escalation in level of nursing care, and there were no readmissions. This group has been followed for greater than 1 month, and there were no morbidities. CONCLUSIONS The STP is a new and efficient pathway for the postoperative care of neurosurgery patients. The STP has reduced hospital cost by $22,560 for the first 10 patients, and there were no morbidities. Since this pilot, the authors have expanded the pathway to include other surgical cases and now routinely schedule craniotomy patients for the (OR-NTCU) pathway. The potential cost reduction in one year could reach $500,000 if we reach our potential of 20 patients per month.

Validation of theoretical pathway between discrimination, diabetes self-care and glycemic control.

PubMed

Dawson, Aprill Z; Walker, Rebekah J; Campbell, Jennifer A; Egede, Leonard E

2016-07-01

This study examined the mechanisms through which discrimination influences diabetes self-care and glycemic control in patients with diabetes by using structured equation modeling. 615 patients were recruited from two adult primary care clinics in the southeastern United States. Measures were based on a theoretical model and included perceived discrimination, social support, social cohesion, and perceived stress. Structured equation modeling examined the relationship with diabetes self-care and glycemic control. The final model (chi2(211)=328.82, p<0.0001, R(2)=0.99, RMSEA=0.03 and CFI=0.98) shows that higher stress is directly significantly related to a decreased self-care (r=-0.59, p <0.001) and increased HbA1c (r=0.27, p<0.05). There was no significant direct association between discrimination, social support or social cohesion, and glycemic control or self-care. There was, however, a direct significant association between increased discrimination (r=0.46, p<0.001), decreased social support (r=-0.34, p<0.001), increased social cohesion (r=0.14, p<0.05) and increased stress. These results support the hypothesized pathway of discrimination on health outcomes, showing both a direct and indirect influence through stress on HbA1c in adults with diabetes. Understanding the pathways through which discrimination influences diabetes outcomes is important for providing more comprehensive and effective care. These results suggest future interventions targeting patients with diabetes should take discrimination-induced stress into account. Copyright © 2016 Elsevier Inc. All rights reserved.

Finding the Missing Patients With Tuberculosis: Lessons Learned From Patient-Pathway Analyses in 5 Countries.

PubMed

Hanson, Christy; Osberg, Mike; Brown, Jessie; Durham, George; Chin, Daniel P

2017-11-06

Despite significant progress in diagnosis and treatment of tuberculosis over the past 2 decades, millions of patients with tuberculosis go unreported every year. The patient-pathway analysis (PPA) is designed to assess the alignment between tuberculosis care-seeking patterns and the availability of tuberculosis services. The PPA can help programs understand where they might find the missing patients with tuberculosis. This analysis aggregates and compares the PPAs from case studies in Kenya, Ethiopia, Indonesia, the Philippines, and Pakistan. Across the 5 countries, 24% of patients with tuberculosis initiated care seeking in a facility with tuberculosis diagnostic capacity. Forty-two percent of patients sought care at level 0 facilities, where there was generally no tuberculosis diagnostic capacity; another 42% of patients sought care at level 1 facilities, of which 39% had diagnostic capacity. Sixty-six percent of patients initially sought care in private facilities, which had considerably less tuberculosis diagnostic capacity than public facilities; only 7% of notified cases were from the private sector. The GeneXpert system was available in 14%-41% of level 2 facilities in the 3 countries for which there were data. Tuberculosis treatment capacity tracked closely with the availability of diagnostic capacity. There were substantial subnational differences in care-seeking patterns and service availability. The PPA can be a valuable planning and programming tool to ensure that diagnostic and treatment services are available to patients where they seek care. Patient-centered care will require closing the diagnostic gap and engaging the private sector. Extensive subnational differences in patient pathways to care call for differentiated approaches to patient-centered care. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.

Finding the Missing Patients With Tuberculosis: Lessons Learned From Patient-Pathway Analyses in 5 Countries

PubMed Central

Hanson, Christy; Osberg, Mike; Brown, Jessie; Durham, George; Chin, Daniel P

2017-01-01

Abstract Background Despite significant progress in diagnosis and treatment of tuberculosis over the past 2 decades, millions of patients with tuberculosis go unreported every year. The patient-pathway analysis (PPA) is designed to assess the alignment between tuberculosis care-seeking patterns and the availability of tuberculosis services. The PPA can help programs understand where they might find the missing patients with tuberculosis. Methods This analysis aggregates and compares the PPAs from case studies in Kenya, Ethiopia, Indonesia, the Philippines, and Pakistan. Results Across the 5 countries, 24% of patients with tuberculosis initiated care seeking in a facility with tuberculosis diagnostic capacity. Forty-two percent of patients sought care at level 0 facilities, where there was generally no tuberculosis diagnostic capacity; another 42% of patients sought care at level 1 facilities, of which 39% had diagnostic capacity. Sixty-six percent of patients initially sought care in private facilities, which had considerably less tuberculosis diagnostic capacity than public facilities; only 7% of notified cases were from the private sector. The GeneXpert system was available in 14%–41% of level 2 facilities in the 3 countries for which there were data. Tuberculosis treatment capacity tracked closely with the availability of diagnostic capacity. There were substantial subnational differences in care-seeking patterns and service availability. Discussion The PPA can be a valuable planning and programming tool to ensure that diagnostic and treatment services are available to patients where they seek care. Patient-centered care will require closing the diagnostic gap and engaging the private sector. Extensive subnational differences in patient pathways to care call for differentiated approaches to patient-centered care. PMID:29117351

A Multidisciplinary Clinical Pathway Decreases Rib Fracture-Associated Infectious Morbidity and Mortality in High-Risk Trauma Patients

DTIC Science & Technology

2006-01-01

cough. Pain was assessed during incentive spirometry or coughing using a visual analogue scale (score from 1 to 10) with failure being a score...fracture multidisciplinary clinical pathway. SIMU Surgical Intermediate Care Unit; STICU Shock Trauma Intensive Care Unit; IS incentive spirometry ...monitored bed (Surgical Intermediate Care Unit or Shock Trauma Intensive Care Unit) where they received patient-controlled analgesia and incentive

An Enhanced Recovery after Surgery Pathway for Microvascular Breast Reconstruction Is Safe and Effective

PubMed Central

Astanehe, Arezoo; Temple-Oberle, Claire; Nielsen, Markus; de Haas, William; Lindsay, Robert; Matthews, Jennifer; McKenzie, David C; Yeung, Justin

2018-01-01

Background: The aim of this study was to develop, implement, and evaluate a standardized perioperative enhanced recovery after surgery (ERAS) clinical care pathway in microsurgical abdominal-based breast reconstruction. Methods: Development of a clinical care pathway was informed by the latest ERAS guideline for breast reconstruction. Key features included shortened preoperative fasting, judicious fluids, multimodal analgesics, early oral nutrition, early Foley catheter removal, and early ambulation. There were 3 groups of women in this cohort study: (1) traditional historical control; (2) transition group with partial implementation; and (3) ERAS. Narcotic use, patient-reported pain scores, antiemetic use, time to regular diet, time to first walk, hospital length of stay, and 30-day postoperative complications were compared between the groups. Results: After implementation of the pathway, the use of parenteral narcotics was reduced by 88% (traditional, 112 mg; transition, 58 mg; ERAS, 13 mg; P < 0.0001), with no consequent increase in patient-reported pain. Patients in the ERAS cohort used less antiemetics (7.0, 5.3, 2.2 doses, P < 0.0001), returned to normal diet 19 hours earlier (46, 39, 27 hours, P < 0.0001), and walked 25 hours sooner (75, 70, 50 hours, P < 0.0001). Overall, hospital length of stay was reduced by 2 days in the ERAS cohort (6.6, 5.6, 4.8 days, P < 0.0001), without an increase in rates of major complications (9.5%, 10.1%, 8.3%, P = 0.9). Conclusions: A clinical care pathway in microsurgical breast reconstruction using the ERAS Society guideline promotes successful early recovery. PMID:29464164

Short- and long-term effects of clinical pathway on the quality of surgical non-small cell lung cancer care in China: an interrupted time series study.

PubMed

Wang, Xinyu; Su, Shaofei; Jiang, Hao; Wang, Jiaying; Li, Xi; Liu, Meina

2018-05-01

To examine the short- and long-term effect of clinical pathway for non-small cell lung cancer surgery on the length of stay, the compliance of quality indicators and risk-adjusted post-operative complication rate. A retrospective quasi-experimental study from June 2011 to October 2015. A tertiary cancer hospital in China. Patients diagnosed as non-small cell lung cancer who underwent curative resection. Clinical pathway was implemented at January 2013. Hence, the study period was divided into three periods: pre-pathway, from June 2011 to December 2012; short-term period, from January 2013 to December 2013; long-term period, from January 2014 to October 2015. Three length of hospital stay indicators, four process performance indicators and one outcome indicator. ITS showed there was a significant decline of 2 days (P = 0.0421) for total length of stay and 2.23 days (P = 0.0199) for post-operative length of stay right after the implementation of clinical pathway. Short-term level changes were found in the compliance rate of required number of lymph node sampling (-8.08%, P = 0.0392), and risk-adjusted complication rate (9.02%, P = 0.0001). There were no statistically significant changes in other quality of care indicators. The clinical pathway had a positive impact on the length of stay but showed a transient negative effect on complication rate and the quality of lymph node sampling.

Medication discrepancies across multiple care transitions: A retrospective longitudinal cohort study in Italy.

PubMed

Bonaudo, Marco; Martorana, Maria; Dimonte, Valerio; D'Alfonso, Alessandra; Fornero, Giulio; Politano, Gianfranco; Gianino, Maria Michela

2018-01-01

Medication discrepancies are defined as unexplained differences among regimens across different sites of care. The problem of medication discrepancies that occur during the entire care pathway from hospital admission to a local care setting discharge (namely all types of settings dedicated to formal care other than hospitals) has received little attention in the medical literature. The present study aims to (1) determine the prevalence of medication discrepancies that occur during the entire care pathway from hospital admission to local care setting discharge, (2) describe the discrepancy and medication type, and (3) identify potential risk factors for experiencing medication discrepancies in patient care transitions. Evidence from an integrated health care system, such as the Italian one, may explain results from other studies in different healthcare systems. A retrospective longitudinal cohort study of patients admitted from July 2015 to July 2016 to the Giovanni Bosco Hospital serving Turin, Italy and its surrounding territory was performed. Discrepancies were recorded at the following four care transitions: T1: Hospital admission; T2: Hospital discharge; T3: Admission into local care settings; T4: Discharge from local care settings. All evaluations were based on documented regimens and were performed by a team (doctor, nurse and pharmacists). Of 366 included patients, 25.68% had at least one discrepancy. The most frequent type of discrepancy was from medication omission (N = 74; 71.15%). Only discharge from a long-stay care setting (T4) was significantly associated with the onset of discrepancies (p = 0.045). When considering a lack of adequate documentation, not as missing data but as a discrepancy, 43.72% of patients had at least one discrepancy. This study suggests that an integrated health care system, such as Italian system, may influence the prevalence of discrepancies, thus highlighting the need for structured multidisciplinary and, if possible, computerized medication reconciliation to prevent medication discrepancies and improve the quality of medical documentation.

Guiding Principles for Data Architecture to Support the Pathways Community HUB Model

PubMed Central

Zeigler, Bernard P.; Redding, Sarah; Leath, Brenda A.; Carter, Ernest L.; Russell, Cynthia

2016-01-01

Introduction: The Pathways Community HUB Model provides a unique strategy to effectively supplement health care services with social services needed to overcome barriers for those most at risk of poor health outcomes. Pathways are standardized measurement tools used to define and track health and social issues from identification through to a measurable completion point. The HUB use Pathways to coordinate agencies and service providers in the community to eliminate the inefficiencies and duplication that exist among them. Pathways Community HUB Model and Formalization: Experience with the Model has brought out the need for better information technology solutions to support implementation of the Pathways themselves through decision-support tools for care coordinators and other users to track activities and outcomes, and to facilitate reporting. Here we provide a basis for discussing recommendations for such a data infrastructure by developing a conceptual model that formalizes the Pathway concept underlying current implementations. Requirements for Data Architecture to Support the Pathways Community HUB Model: The main contribution is a set of core recommendations as a framework for developing and implementing a data architecture to support implementation of the Pathways Community HUB Model. The objective is to present a tool for communities interested in adopting the Model to learn from and to adapt in their own development and implementation efforts. Problems with Quality of Data Extracted from the CHAP Database: Experience with the Community Health Access Project (CHAP) data base system (the core implementation of the Model) has identified several issues and remedies that have been developed to address these issues. Based on analysis of issues and remedies, we present several key features for a data architecture meeting the just mentioned recommendations. Implementation of Features: Presentation of features is followed by a practical guide to their implementation allowing an organization to consider either tailoring off-the-shelf generic systems to meet the requirements or offerings that are specialized for community-based care coordination. Discussion: Looking to future extensions, we discuss the utility and prospects for an ontology to include care coordination in the Unified Medical Language System (UMLS) of the National Library of Medicine and other existing medical and nursing taxonomies. Conclusions and Recommendations: Pathways structures are an important principle, not only for organizing the care coordination activities, but also for structuring the data stored in electronic form in the conduct of such care. We showed how the proposed architecture encourages design of effective decision support systems for coordinated care and suggested how interested organizations can set about acquiring such systems. Although the presentation focuses on the Pathways Community HUB Model, the principles for data architecture are stated in generic form and are applicable to any health information system for improving care coordination services and population health. PMID:26870743

Surgical data science: The new knowledge domain

PubMed Central

Vedula, S. Swaroop; Hager, Gregory D.

2017-01-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future. PMID:28936475

Surgical data science: The new knowledge domain.

PubMed

Vedula, S Swaroop; Hager, Gregory D

2017-04-01

Healthcare in general, and surgery/interventional care in particular, is evolving through rapid advances in technology and increasing complexity of care with the goal of maximizing quality and value of care. While innovations in diagnostic and therapeutic technologies have driven past improvements in quality of surgical care, future transformation in care will be enabled by data. Conventional methodologies, such as registry studies, are limited in their scope for discovery and research, extent and complexity of data, breadth of analytic techniques, and translation or integration of research findings into patient care. We foresee the emergence of Surgical/Interventional Data Science (SDS) as a key element to addressing these limitations and creating a sustainable path toward evidence-based improvement of interventional healthcare pathways. SDS will create tools to measure, model and quantify the pathways or processes within the context of patient health states or outcomes, and use information gained to inform healthcare decisions, guidelines, best practices, policy, and training, thereby improving the safety and quality of healthcare and its value. Data is pervasive throughout the surgical care pathway; thus, SDS can impact various aspects of care including prevention, diagnosis, intervention, or post-operative recovery. Existing literature already provides preliminary results suggesting how a data science approach to surgical decision-making could more accurately predict severe complications using complex data from pre-, intra-, and post-operative contexts, how it could support intra-operative decision-making using both existing knowledge and continuous data streams throughout the surgical care pathway, and how it could enable effective collaboration between human care providers and intelligent technologies. In addition, SDS is poised to play a central role in surgical education, for example, through objective assessments, automated virtual coaching, and robot-assisted active learning of surgical skill. However, the potential for transforming surgical care and training through SDS may only be realized through a cultural shift that not only institutionalizes technology to seamlessly capture data but also assimilates individuals with expertise in data science into clinical research teams. Furthermore, collaboration with industry partners from the inception of the discovery process promotes optimal design of data products as well as their efficient translation and commercialization. As surgery continues to evolve through advances in technology that enhance delivery of care, SDS represents a new knowledge domain to engineer surgical care of the future.

Emergency general surgery in the geriatric patient.

PubMed

Desserud, K F; Veen, T; Søreide, K

2016-01-01

Emergency general surgery in the elderly is a particular challenge to the surgeon in charge of their care. The aim was to review contemporary aspects of managing elderly patients needing emergency general surgery and possible alterations to their pathways of care. This was a narrative review based on a PubMed/MEDLINE literature search up until 15 September 2015 for publications relevant to emergency general surgery in the geriatric patient. The number of patients presenting as an emergency with a general surgical condition increases with age. Up to one-quarter of all emergency admissions to hospital may be for general surgical conditions. Elderly patients are a particular challenge owing to added co-morbidity, use of drugs and risk of poor outcome. Frailty is an important potential risk factor, but difficult to monitor or manage in the emergency setting. Risk scores are not available universally. Outcomes are usually severalfold worse than after elective surgery, in terms of both higher morbidity and increased mortality. A care bundle including early diagnosis, resuscitation and organ system monitoring may benefit the elderly in particular. Communication with the patient and relatives throughout the care pathway is essential, as indications for surgery, level of care and likely outcomes may evolve. Ethical issues should also be addressed at every step on the pathway of care. Emergency general surgery in the geriatric patient needs a tailored approach to improve outcomes and avoid futile care. Although some high-quality studies exist in related fields, the overall evidence base informing perioperative acute care for the elderly remains limited. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

Comprehensive School Mental Health: An Integrated "School-Based Pathway to Care" Model for Canadian Secondary Schools

ERIC Educational Resources Information Center

Wei, Yifeng; Kutcher, Stan; Szumilas, Magdalena

2011-01-01

Adolescence is a critical period for the promotion of mental health and the treatment of mental disorders. Schools are well-positioned to address adolescent mental health. This paper describes a school mental health model, "School-Based Pathway to Care," for Canadian secondary schools that links schools with primary care providers and…

Critical pathways for the management of stroke and intracerebral hemorrhage: a survey of US hospitals.

PubMed

Cooper, David; Jauch, Edward; Flaherty, Matthew L

2007-03-01

Thirty-day mortality rates in patients with spontaneous intracerebral hemorrhage (ICH) range from 35% to 50%, with only 10-20% of the survivors regaining functional independence. This high mortality and morbidity argues for the optimization of emergency medical services (EMS), emergency department (ED), and in-patient treatment paradigms. With the development of interventional strategies for ICH, both pharmacologic and surgical, time to treatment will be critical to improving outcomes. Similar to acute ischemic stroke care, proper preparation and role definition will be critical for efficient evaluation and treatment. We studied the existence and structure of ICH management protocols in US hospitals. A national survey of Emergency Medicine physicians was conducted to gather information regarding the existence of stroke and ICH treatment protocols at their institutions. A clearly established pathway for the management of ischemic stroke exists in most hospitals (78%). By contrast, only 30% of hospitals have a clearly defined pathway for ICH. Thus, while most hospitals are able to perform rapid computed tomography (CT) scans to diagnose ICH, the management of these patients post-CT is more fragmented and variable. Few hospitals have comprehensive protocols that include treatment policies for raised intracranial pressure or formal policies for the transfer of patients to centers with neurocritical care/neurosurgical resources. Integration of ICH critical pathways into stroke protocols could potentially improve the high mortality and disability associated with this condition and might facilitate ongoing studies of ICH-specific interventions. With stroke neurologists and neurocritical care specialists showing an increasing interest in ICH management, development of critical pathways may allow for a standardized approach to best treatment practices within institutions and networks as evidence grows for new treatments and management strategies. This may also allow a redefinition of the roles of team members, including ED and critical care physicians, neurologists, and neurosurgeons.

Care satisfaction, hope, and life functioning among adults with bipolar disorder: data from the first 1000 participants in the Systematic Treatment Enhancement Program.

PubMed

Morris, Chad D; Miklowitz, David J; Wisniewski, Stephen R; Giese, Alexis A; Thomas, Marshall R; Allen, Michael H

2005-01-01

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is designed to evaluate the longitudinal outcome of patients with bipolar disorder. The STEP-BD disease-management model is built on evidence-based practices and a collaborative care approach designed to maximize specific and nonspecific treatment mechanisms. This prospective study examined the longitudinal relationships between patients' satisfaction with care, levels of hope, and life functioning in the first 1000 patients to enter STEP-BD. The study used scores from the Care Satisfaction Questionnaire, Beck Hopelessness Scale, Range of Impaired Functioning Tool, Young Mania Rating Scale, and Montgomery-Asberg Depression Rating Scale at 5 time points during a 1-year interval. Analyses tested mediational pathways between care satisfaction, hope, and life functioning, depression, and mania using mixed-effects (random and fixed) regression models. Increases in care satisfaction were associated with decreased hopelessness (P < .01) but not related to symptoms of depression or mania. Similarly, decreased hopelessness was associated with better life functioning (P < .01) but not related to symptoms of depression or mania. Depression was independently associated with poorer life functioning (P < .0001). This study provided support for the hypothesized mediational pathway between care satisfaction, hopelessness, and life functioning. Findings suggest that providing care that maximizes patient hope may be important. By so doing, patients might overcome the learned helplessness/hopelessness that often accompanies a cyclical illness and build a realistic illness-management strategy.

Managed care and critical pathway development: the joint replacement experience.

PubMed

Benham, A J

1999-01-01

This article examines the economic, social, ethical, and political issues affecting total joint replacement patients in a managed care environment. Using general systems theory as a framework, it examines the interrelated historical events that have shaped the development of both joint replacement procedures and managed care, and discusses the extent to which these two phenomena have been mutually influential. Specifically, the article examines the initial development, implementation, and continuing evolution of clinical pathways as an easily identified and relatively discrete manifestation of managed care for the joint replacement population. While the overall impact of managed care is beyond the scope of this presentation, it is hoped that a focus on the practical application of clinical pathways to joint replacement will allow some general principles to emerge that may be useful for both patients and practitioners operating in other aspects of the managed care environment.

Guiding Principles for Data Architecture to Support the Pathways Community HUB Model.

PubMed

Zeigler, Bernard P; Redding, Sarah; Leath, Brenda A; Carter, Ernest L; Russell, Cynthia

2016-01-01

The Pathways Community HUB Model provides a unique strategy to effectively supplement health care services with social services needed to overcome barriers for those most at risk of poor health outcomes. Pathways are standardized measurement tools used to define and track health and social issues from identification through to a measurable completion point. The HUB use Pathways to coordinate agencies and service providers in the community to eliminate the inefficiencies and duplication that exist among them. Experience with the Model has brought out the need for better information technology solutions to support implementation of the Pathways themselves through decision-support tools for care coordinators and other users to track activities and outcomes, and to facilitate reporting. Here we provide a basis for discussing recommendations for such a data infrastructure by developing a conceptual model that formalizes the Pathway concept underlying current implementations. The main contribution is a set of core recommendations as a framework for developing and implementing a data architecture to support implementation of the Pathways Community HUB Model. The objective is to present a tool for communities interested in adopting the Model to learn from and to adapt in their own development and implementation efforts. Experience with the Community Health Access Project (CHAP) data base system (the core implementation of the Model) has identified several issues and remedies that have been developed to address these issues. Based on analysis of issues and remedies, we present several key features for a data architecture meeting the just mentioned recommendations. Presentation of features is followed by a practical guide to their implementation allowing an organization to consider either tailoring off-the-shelf generic systems to meet the requirements or offerings that are specialized for community-based care coordination. Looking to future extensions, we discuss the utility and prospects for an ontology to include care coordination in the Unified Medical Language System (UMLS) of the National Library of Medicine and other existing medical and nursing taxonomies. Pathways structures are an important principle, not only for organizing the care coordination activities, but also for structuring the data stored in electronic form in the conduct of such care. We showed how the proposed architecture encourages design of effective decision support systems for coordinated care and suggested how interested organizations can set about acquiring such systems. Although the presentation focuses on the Pathways Community HUB Model, the principles for data architecture are stated in generic form and are applicable to any health information system for improving care coordination services and population health.

Service evaluation of the implementation of a digitally-enabled care pathway for the recognition and management of acute kidney injury.

PubMed

Connell, Alistair; Montgomery, Hugh; Morris, Stephen; Nightingale, Claire; Stanley, Sarah; Emerson, Mary; Jones, Gareth; Sadeghi-Alavijeh, Omid; Merrick, Charles; King, Dominic; Karthikesalingam, Alan; Hughes, Cian; Ledsam, Joseph; Back, Trevor; Rees, Geraint; Raine, Rosalind; Laing, Christopher

2017-01-01

Acute Kidney Injury (AKI), an abrupt deterioration in kidney function, is defined by changes in urine output or serum creatinine. AKI is common (affecting up to 20% of acute hospital admissions in the United Kingdom), associated with significant morbidity and mortality, and expensive (excess costs to the National Health Service in England alone may exceed £1 billion per year). NHS England has mandated the implementation of an automated algorithm to detect AKI based on changes in serum creatinine, and to alert clinicians. It is uncertain, however, whether 'alerting' alone improves care quality. We have thus developed a digitally-enabled care pathway as a clinical service to inpatients in the Royal Free Hospital (RFH), a large London hospital. This pathway incorporates a mobile software application - the "Streams-AKI" app, developed by DeepMind Health - that applies the NHS AKI algorithm to routinely collected serum creatinine data in hospital inpatients. Streams-AKI alerts clinicians to potential AKI cases, furnishing them with a trend view of kidney function alongside other relevant data, in real-time, on a mobile device. A clinical response team comprising nephrologists and critical care nurses responds to these AKI alerts by reviewing individual patients and administering interventions according to existing clinical practice guidelines. We propose a mixed methods service evaluation of the implementation of this care pathway. This evaluation will assess how the care pathway meets the health and care needs of service users (RFH inpatients), in terms of clinical outcome, processes of care, and NHS costs. It will also seek to assess acceptance of the pathway by members of the response team and wider hospital community. All analyses will be undertaken by the service evaluation team from UCL (Department of Applied Health Research) and St George's, University of London (Population Health Research Institute).

Implementation of a Care Pathway for Primary Palliative Care in 5 research clusters in Belgium: quasi-experimental study protocol and innovations in data collection (pro-SPINOZA).

PubMed

Leysen, Bert; Van den Eynden, Bart; Gielen, Birgit; Bastiaens, Hilde; Wens, Johan

2015-09-28

Starting with early identification of palliative care patients by general practitioners (GPs), the Care Pathway for Primary Palliative Care (CPPPC) is believed to help primary health care workers to deliver patient- and family-centered care in the last year of life. The care pathway has been pilot-tested, and will now be implemented in 5 Belgian regions: 2 Dutch-speaking regions, 2 French-speaking regions and the bilingual capital region of Brussels. The overall aim of the CPPPC is to provide better quality of primary palliative care, and in the end to reduce the hospital death rate. The aim of this article is to describe the quantitative design and innovative data collection strategy used in the evaluation of this complex intervention. A quasi-experimental stepped wedge cluster design is set up with the 5 regions being 5 non-randomized clusters. The primary outcome is reduced hospital death rate per GPs' patient population. Secondary outcomes are increased death at home and health care consumption patterns suggesting high quality palliative care. Per research cluster, GPs will be recruited via convenience sampling. These GPs -volunteering to be involved will recruit people with reduced life expectancy and their informal care givers. Health care consumption data in the last year of life, available for all deceased people having lived in the research clusters in the study period, will be used for comparison between patient populations of participating GPs and patient populations of non-participating GPs. Description of baseline characteristics of participating GPs and patients and monitoring of the level of involvement by GPs, patients and informal care givers will happen through regular, privacy-secured web-surveys. Web-survey data and health consumption data are linked in a secure way, respecting Belgian privacy laws. To evaluate this complex intervention, a quasi-experimental stepped wedge cluster design has been set up. Context characteristics and involvement level of participants are important parameters in evaluating complex interventions. It is possible to securely link survey data with health consumption data. By appealing to IT solutions we hope to be able to partly reduce respondent burden, a known problem in palliative care research. ClinicalTrials.gov Identifier: NCT02266069.

Views and experiences of using integrated care pathways (ICPs) for caring for people in the last days to hours of life: results from a cross-sectional survey of UK professionals.

PubMed

Collins, K A; Hughes, P M; Ibbotson, R; Foy, G; Brooks, D

2016-09-01

To determine the views and experiences of health and social care professionals on using integrated care pathways (ICPs)for caring for people in the last days to hours of life. Online cross-sectional questionnaire survey of UK professionals working in UK primary and secondary care settings. 1331 professionals returned completed questionnaires. Ninety-three per cent (1138/1228) of respondents used the Liverpool Care Pathway (LCP) or local variant. Eighty-eight (1089/1234) felt ICPs enabled professionals to provide better care for individuals and their families/carers. ICPs were viewed as promoting patient-centred holistic care, improving pain and symptom control, providing guidance and standards and improving communication with patients/families. Sixty-two per cent (770/1234) had no concerns regarding the use of ICPs. Areas of concern included incorrect use and implementation of the ICP, poor communication with families, junior level staff making decisions and insufficient education and support. There was strong support for using ICPs for caring for people in the last days to hours of life. ICPs were viewed as supporting high-quality patient-centred holistic care. Given the recommendations of the More Care Less Pathway report, those that develop the guidance and support that replace the LCP need to incorporate the aspects of this that have resulted in the benefits seen by professionals within this survey, but also learn from the instances where ICPs have failed to prevent poor care, or worse, have contributed to it. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Patients' Experiences of Cancer Diagnosis as a Result of an Emergency Presentation: A Qualitative Study.

PubMed

Black, Georgia; Sheringham, Jessica; Spencer-Hughes, Vicki; Ridge, Melanie; Lyons, Mairead; Williams, Charlotte; Fulop, Naomi; Pritchard-Jones, Kathy

2015-01-01

Cancers diagnosed following visits to emergency departments (ED) or emergency admissions (emergency presentations) are associated with poor survival and may result from preventable diagnostic delay. To improve outcomes for these patients, a better understanding is needed about how emergency presentations arise. This study sought to capture patients' experiences of this diagnostic pathway in the English NHS. Eligible patients were identified in a service evaluation of emergency presentations and invited to participate. Interviews, using an open-ended biographical structure, captured participants' experiences of healthcare services before diagnosis and were analysed thematically, informed by the Walter model of Pathways to Treatment and NICE guidance in an iterative process. Twenty-seven interviews were conducted. Three typologies were identified: A: Rapid investigation and diagnosis, and B: Repeated cycles of healthcare seeking and appraisal without resolution, with two variants where B1 appears consistent with guidance and B2 has evidence that management was not consistent with guidance. Most patients' (23/27) experiences fitted types B1 and B2. Potentially avoidable breakdowns in diagnostic pathways caused delays when patients were conflicted by escalating symptoms and a benign diagnosis given earlier by doctors. ED was sometimes used as a conduit to rapid testing by primary care clinicians, although this pathway was not always successful. This study draws on patients' experiences of their diagnosis to provide novel insights into how emergency presentations arise. Through these typologies, we show that the typical experience of patients diagnosed through an emergency presentation diverges significantly from normative pathways even when there is no evidence of serious service failures. Consultations were not a conduit to diagnosis when they inhibited patients' capacity to appraise their own symptoms appropriately and when they resulted in a reluctance to seek further healthcare. The findings also point to potentially avoidable breakdowns in the diagnostic process. In particular, to encourage patients to return to the GP if symptoms escalate, a stronger emphasis is needed on diagnostic uncertainty in discussions between patients and doctors in both primary and secondary care. To improve appropriate access to rapid investigations, systems are needed for primary care to communicate directly with secondary care at the time of referral.

Examining the Needs of Paediatric Nurses Caring for Children and Young People Presenting with Self-Harm/Suicidal Behaviour on General Paediatric Wards: Findings from a Small-Scale Study

ERIC Educational Resources Information Center

Fisher, Gemma; Foster, Celeste

2016-01-01

This article reports on the process and findings from a small-scale qualitative research study. The study intended to develop an evidence-based care plan/pathway for children and young people in paediatric inpatient settings presenting with self-harm/suicidal behaviour. The article includes a critical review of unanticipated challenges of…

Evaluating the Quality of Colorectal Cancer Care across the Interface of Healthcare Sectors

PubMed Central

Ludt, Sabine; Urban, Elisabeth; Eckardt, Jörg; Wache, Stefanie; Broge, Björn; Kaufmann-Kolle, Petra; Heller, Günther; Miksch, Antje; Glassen, Katharina; Hermann, Katja; Bölter, Regine; Ose, Dominik; Campbell, Stephen M.; Wensing, Michel; Szecsenyi, Joachim

2013-01-01

Background Colorectal cancer (CRC) has a high prevalence in western countries. Diagnosis and treatment of CRC is complex and requires multidisciplinary collaboration across the interface of health care sectors. In Germany, a new nationwide established program aims to provide quality information of healthcare delivery across different sectors. Within this context, this study describes the development of a set of quality indicators charting the whole pathway of CRC-care including data specifications that are necessary to operationalize these indicators before practice testing. Methods Indicators were developed following a systematic 10 step modified ‘RAND/UCLA Appropriateness Method’ which involved a multidisciplinary panel of thirteen participants. For each indicator in the final set, data specifications relating to sources of quality information, data collection procedures, analysis and feedback were described. Results The final indicator set included 52 indicators covering diagnostic procedures (11 indicators), therapeutic management (28 indicators) and follow-up (6 indicators). In addition, 7 indicators represented patient perspectives. Primary surgical tumor resection and pre-operative radiation (rectum carcinoma only) were perceived as most useful tracer procedures initiating quality data collection. To assess the quality of CRC care across sectors, various data sources were identified: medical records, administrative inpatient and outpatient data, sickness-funds billing code systems and patient survey. Conclusion In Germany, a set of 52 quality indicators, covering necessary aspects across the interfaces and pathways relevant to CRC-care has been developed. Combining different sectors and sources of health care in quality assessment is an innovative and challenging approach but reflects better the reality of the patient pathway and experience of CRC-care. PMID:23658684

A path analysis study of factors influencing hospital staff perceptions of quality of care factors associated with patient satisfaction and patient experience.

PubMed

Leggat, Sandra G; Karimi, Leila; Bartram, Timothy

2017-11-16

Hospital staff are interested in information on patient satisfaction and patient experience that can help them improve quality of care. Staff perceptions of quality of care have been identified as useful proxies when patient data are not available. This study explores the organizational factors and staff attitudes that influence staff perceptions of the quality of the care they provide in relation to patient satisfaction and patient experience. Cross sectional survey completed by 258 staff of a large multi-campus, integrated metropolitan hospital in Australia. Structured equation modelling was used to analyse the data. Our data suggest that different perceived organizational factors and staff attitudes contribute to different pathways for patient satisfaction and patient experience indicators. Hospital staff in our sample were more likely to indicate they provided the care that would result in higher patient satisfaction if they felt empowered within a psychologically safe environment. Conversely their views on patient experience were related to their commitment towards their hospital. There was no relationship between the staff perceptions of patient satisfaction and the staff response to the friends and family test. This study provides empirical evidence that staff perceptions of the quality of care they provide that is seen to be related to patient satisfaction and patient experience are enacted through different pathways that reflect differing perceptions of organizational factors and workplace psychological attitudes.

Pathways between childhood/adolescent adversity, adolescent socioeconomic status, and long-term cardiovascular disease risk in young adulthood.

PubMed

Doom, Jenalee R; Mason, Susan M; Suglia, Shakira F; Clark, Cari Jo

2017-09-01

The current study investigated mediators between childhood/adolescent adversities (e.g., dating violence, maltreatment, homelessness, and parental death), low socioeconomic status (SES) during adolescence, and cardiovascular disease (CVD) risk in young adulthood. The purpose of these analyses was to understand whether SES during adolescence and childhood/adolescent adversities affect CVD risk through similar pathways, including maternal relationship quality, health behaviors, financial stress, medical/dental care, educational attainment, sleep problems, and depressive symptoms. Using the National Longitudinal Study of Adolescent to Adult Health (N = 14,493), which has followed US adolescents (Wave 1; M = 15.9 years) through early adulthood (Wave 4; M = 28.9 years), associations were examined between childhood/adolescent adversity and SES to 30-year CVD risk in young adulthood. The outcome was a Framingham-based prediction model of CVD risk that included age, sex, body mass index, smoking, systolic blood pressure, diabetes, and antihypertensive medication use at Wave 4. Path analysis was used to examine paths through the adolescent maternal relationship to young adult mediators of CVD risk. Childhood/adolescent adversity significantly predicted greater adult CVD risk through the following pathways: maternal relationship, health behaviors, financial stress, lack of medical/dental care, and educational attainment; but not through depressive symptoms or sleep problems. Lower SES during adolescence significantly predicted greater adult CVD risk through the following pathways: health behaviors, financial stress, lack of medical/dental care, and educational attainment, but not maternal relationship, depressive symptoms, or sleep problems. Childhood/adolescent adversities and SES affected CVD risk in young adulthood through both similar and unique pathways that may inform interventions. Copyright © 2017 Elsevier Ltd. All rights reserved.

It helps me live, sends my children to school, and feeds me: a qualitative study of how food and cash incentives may improve adherence to treatment and care among adults living with HIV in Tanzania.

PubMed

Czaicki, Nancy L; Mnyippembe, Agatha; Blodgett, Madeline; Njau, Prosper; McCoy, Sandra I

2017-07-01

Financial and in-kind incentives have been shown to improve outcomes along the HIV care cascade, however the potential mechanismsthrough which they work remain unclear. To identify the pathways through which incentives improve retention in care and adherence to antiretroviral therapy (ART), we conducted a qualitative study with participants in a trial evaluating conditional food and cash incentives for HIV-positive food insecure adults in Shinyanga, Tanzania. We found that the incentives acted through three pathways to potentially increase retention in care and adherence to ART: (1) addressing competing needs and offsetting opportunity costs associated with clinic attendance, (2) alleviating stress associated with attending clinic and meeting basic needs, and (3) by potentially increasing motivation. Participants did not report any harmful events associated with the incentives, but reported myriad beneficial effects on household welfare. Understanding how incentives are used and how they impact outcomes can improve the design of future interventions.

Mother-infant home care drives quality in a managed care environment.

PubMed

Malnory, M

1997-04-01

Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting equivalent patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.

[Pathway of a patient within a healthcare unit].

PubMed

Haegeman, Nicolas; Béziat, Olivier; Cavero, Laure; Biau, Audrey

2016-01-01

Care in prison must be based as much as possible on the model used for the general population. The system of psychiatric care in prisons comprises three levels of provision. The presentation of the pathway of a young patient with severe mental disorders shows the possibilities and the difficulties involved in caring within a healthcare unit. Copyright © 2016. Published by Elsevier Masson SAS.

Diverse pathways to care for children with stomach pain in a Canadian cosmopolitan city.

PubMed

Fortin, Sylvie; Gauthier, Annie; Gomez, Liliana; Bibeau, Gilles; Rasquin, Andrée; Faure, Christophe

2014-09-01

In Montreal, Quebec, 31% of the population is born outside Canada. Yet, only 9% of patient consultations for symptoms associated with functional gastrointestinal disorders (FGIDs) are from immigrants at the Paediatric Gastroenterology Clinic at Sainte-Justine's University Hospital Centre. This discrepancy inspired a multidisciplinary exploratory study (anthropological and paediatric) to examine the sociological, interpretative and pragmatic aspects of immigrant and non-immigrant patients and family life with FGIDs. This paper examines the discrepancy between immigrant and non-immigrant paediatric patients with FGIDs and presents the different pathways to care utilised by families. Semi-structured interviews were carried out between November 2008 and June 2009, with children and their parents. In total, 38 families were recruited: with 27 families (including a child experiencing abdominal pain, his/her siblings, mother and/or father as well as any other significant individual living in the family home) from the community and 11 from the paediatric gastroenterology clinic. A comparative analysis between the immigrant and non-immigrant groups focused on perceptions, meanings and actions taken to relieve/alleviate symptoms. Immigrant and non-immigrant families alternate and combine different therapeutic environments: home, alternative healing therapies and medical paths to care. Our analysis suggests that culture (as a set of values, beliefs and ways of being), as well as social interactions within family life and the clinic, shape pathways to care. The analysis highlights the centrality of receptiveness--and more widely the social dimensions--of all medical encounters. Treatment disparities between immigrant and non-immigrant families in pathways to care help us to understand these patients' social world and the intricate relationships between values and social milieux, between culture, practices of symptom management and rationales guiding diverse therapeutic actions. © 2014 John Wiley & Sons Ltd.

Pathways to First-Episode Care for Psychosis in African-, Caribbean-, and European-Origin Groups in Ontario

PubMed Central

Anderson, Kelly K; Flora, Nina; Ferrari, Manuela; Tuck, Andrew; Archie, Suzanne; Kidd, Sean; Tang, Taryn; Kirmayer, Laurence J; McKenzie, Kwame

2015-01-01

Objective: To compare the pathways to care and duration of untreated psychosis (DUP) for people of Black-African, Black-Caribbean, or White-European origin with first-episode psychosis (FEP). Methods: We recruited a sample of 171 patients with FEP of Black-African, Black-Caribbean, and White-European origin from hospital- and community-based early intervention services (EIS) in the cities of Toronto and Hamilton. We compared the 3 groups on DUP and key indicators of the pathway to care. Results: We observed differences in pathways to care across the 3 groups. Black-Caribbean participants had an increased odds of referral from an inpatient unit to EIS (OR 3.33; 95% CI 1.46 to 7.60) and a decreased odds of general practitioner involvement on the pathway to care (OR 0.17; 95% CI 0.07 to 0.46), as well as fewer total contacts (exp[β] 0.77; 95% CI 0.60 to 0.99) when compared with White-European participants. Black-African participants had an increased odds of contact with the emergency department at first contact (OR 3.78; 95% CI 1.31 to 10.92). The differences in the DUP between groups were not statistically significant. Conclusions: Our findings suggest that there are significant differences in the pathways to EIS for psychosis for people of African and Caribbean origin in our Canadian context. It is essential to gain a comprehensive understanding of the pathways that different population groups take to mental health services, and the reasons behind observed differences, to inform the development of equitable services, targeting patients in the critical early stages of psychotic disorder. PMID:26174526

Pathways to First-Episode Care for Psychosis in African-, Caribbean-, and European-Origin Groups in Ontario.

PubMed

Anderson, Kelly K; Flora, Nina; Ferrari, Manuela; Tuck, Andrew; Archie, Suzanne; Kidd, Sean; Tang, Taryn; Kirmayer, Laurence J; McKenzie, Kwame

2015-05-01

To compare the pathways to care and duration of untreated psychosis (DUP) for people of Black-African, Black-Caribbean, or White-European origin with first-episode psychosis (FEP). We recruited a sample of 171 patients with FEP of Black-African, Black-Caribbean, and White-European origin from hospital- and community-based early intervention services (EIS) in the cities of Toronto and Hamilton. We compared the 3 groups on DUP and key indicators of the pathway to care. We observed differences in pathways to care across the 3 groups. Black-Caribbean participants had an increased odds of referral from an inpatient unit to EIS (OR 3.33; 95% CI 1.46 to 7.60) and a decreased odds of general practitioner involvement on the pathway to care (OR 0.17; 95% CI 0.07 to 0.46), as well as fewer total contacts (exp[β] 0.77; 95% CI 0.60 to 0.99) when compared with White-European participants. Black-African participants had an increased odds of contact with the emergency department at first contact (OR 3.78; 95% CI 1.31 to 10.92). The differences in the DUP between groups were not statistically significant. Our findings suggest that there are significant differences in the pathways to EIS for psychosis for people of African and Caribbean origin in our Canadian context. It is essential to gain a comprehensive understanding of the pathways that different population groups take to mental health services, and the reasons behind observed differences, to inform the development of equitable services, targeting patients in the critical early stages of psychotic disorder.

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands.

PubMed

Holtzer-Goor, K M; Gaultney, J G; van Houten, P; Wagg, A S; Huygens, S A; Nielen, M M J; Albers-Heitner, C P; Redekop, W K; Rutten-van Mölken, M P; Al, M J

2015-01-01

Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands. A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs. With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved. Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furthermore, the study also highlighted that various areas of the continence care process lack data, which would be valuable to collect through the introduction of the NS in a study setting.

Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway--is investment always improvement?

PubMed

Krummenauer, Frank; Guenther, Klaus-Peter; Kirschner, Stephan

2011-12-14

Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider. A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation≤100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff. An individual marginal cost effectiveness relation≤100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p=0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86-150 €/%) versus 118 €/% WOMAC gain (93-173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on. The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider).

Cost effectiveness of total knee arthroplasty from a health care providers' perspective before and after introduction of an interdisciplinary clinical pathway - is investment always improvement?

PubMed Central

2011-01-01

Background Total knee arthroplasty (TKA) is an effective, but also cost-intensive health care intervention for end stage osteoarthritis. This investigation was designed to evaluate the cost-effectiveness of TKA before versus after introduction of an interdisciplinary clinical pathway from a University Orthopedic Surgery Department's cost perspective as an interdisciplinary full service health care provider. Methods A prospective trial recruited two sequential cohorts of 132 and 128 consecutive patients, who were interviewed by means of the WOMAC questionnaire. Direct process costs from the health care providers' perspective were estimated according to the German DRG calculation framework. The health economic evaluation was based on margiual cost-effectveness ratios (MCERs); an individual marginal cost effectiveness relation ≤ 100 € per % WOMAC index increase was considered as primary endpoint of the confirmatory cohort comparison. The interdisciplinary clinical pathway under consideration primarily consisted of a voluntary preoperative personal briefing of patients concerning postoperatively expectable progess in health status and optimum use of walking aids after surgery. All patients were supplied with written information on these topics, attendance of the personal briefing also included preoperative training for postoperative mobilisation by the Department's physiotherapeutic staff. Results An individual marginal cost effectiveness relation ≤ 100 €/% WOMAC index increase was found in 38% of the patients in the pre pathway implementation cohort versus in 30% of the post pathway implementation cohort (Fisher p = 0.278). Both cohorts showed substantial improvement in WOMAC scores (39 versus 35% in median), whereas the cohort did not differ significantly in the median WOMAC score before surgery (41% for the pre pathway cohort versus 44% for the post pathway cohort). Despite a locally significant decrease in costs (4303 versus 4194 € in median), the individual cost/benefit relation became worse after introduction of the pathway: for the first cohort the MCER was estimated 108 € per gained % WOMAC index increase (86 - 150 €/%) versus 118 €/% WOMAC gain (93 - 173 €/%) in the second cohort after pathway implementation. In summary, the proposed critical pathway for TKA could be shown to be significantly cost efficient, but not cost effective concerning functional outcome, when the above individual marginal cost effectiveness criterion was concentrated on. Conclusions The introduction of an interdisciplinary clinical pathway does not necessarily improve patient related outcomes. On the contrary, cost effectiveness from the health care providers' perspective may even turn out remarkably reduced in the setting considered here (functional outcome assessment after treatment by a full service health care provider). PMID:22168149

The usefulness of lean six sigma to the development of a clinical pathway for hip fractures.

PubMed

Niemeijer, Gerard C; Flikweert, Elvira; Trip, Albert; Does, Ronald J M M; Ahaus, Kees T B; Boot, Anja F; Wendt, Klaus W

2013-10-01

The objective of this study was to show the usefulness of lean six sigma (LSS) for the development of a multidisciplinary clinical pathway. A single centre, both retrospective and prospective, non-randomized controlled study design was used to identify the variables of a prolonged length of stay (LOS) for hip fractures in the elderly and to measure the effect of the process improvements--with the aim of improving efficiency of care and reducing the LOS. The project identified several variables influencing LOS, and interventions were designed to improve the process of care. Significant results were achieved by reducing both the average LOS by 4.2 days (-31%) and the average duration of surgery by 57 minutes (-36%). The average LOS of patients discharged to a nursing home reduced by 4.4 days. The findings of this study show a successful application of LSS methodology within the development of a clinical pathway. Further research is needed to explore the effect of the use of LSS methodology at clinical outcome and quality of life. © 2012 John Wiley & Sons Ltd.

Women's secure hospital care pathways in practice: a qualitative analysis of clinicians views in England and Wales.

PubMed

Somers, Nadia; Bartlett, Annie

2014-10-01

In England and Wales women form a small but significant group within the wider, largely male, secure hospital population. Secure hospitals are designed to assess and treat individuals with both mental health problems and significant criminal behaviour. The theoretical approach to the care of secure hospital women is increasingly informed by a grasp of gender-specific issues. However, there is a lack of evidence on the adequacy of current structures and processes of care delivery. This qualitative study explores the nature and quality of care pathways for women in low and medium secure hospital beds by eliciting participants' views of factors enhancing or impeding care. Beds are publicly funded and provided either by the National Health Service (NHS) or the Independent Sector (IS). Participants from both sectors were local experts (40 Consultant Psychiatrists, 7 Service Managers) who were well placed to describe their immediate health environment. Evidence from the study indicates that participants were focused on the physical relocation of women to less secure conditions, even though many women do not readily achieve this.Participants were alert to potential conflicts between ideal care and affordable care. Ideal care was compromised by the absence of suitable local services (beds or community placements), curtailed episodes of care and changes of care team. It was promoted by an awareness of the specific needs of women, continuity of care and support for teams unfamiliar with women's needs. Future service design must address these challenges in care delivery, incorporating a better understanding of and response to the ways the system can echo women's experiences of trauma and their negative attachment histories. Specifically, critical transitions in care must not be allowed to further reinforce the discontinuity, failure and rejection experienced by individual women earlier in their lives.

Investigating the sustainability of careers in academic primary care: a UK survey.

PubMed

Calitri, Raff; Adams, Ann; Atherton, Helen; Reeve, Joanne; Hill, Nathan R

2014-12-14

The UK National Health Service (NHS) is undergoing institutional reorganisation due to the Health and Social Care Act-2012 with a continued restriction on funding within the NHS and clinically focused academic institutions. The UK Society for Academic Primary Care (SAPC) is examining the sustainability of academic primary care careers within this climate and preliminary qualitative work has highlighted individual and organisational barriers. This study seeks to quantify the current situation for academics within primary care. A survey of academic primary care staff was undertaken. Fifty-three academic primary care departments were selected. Members were invited to complete a survey which contained questions about an individual's career, clarity of career pathways, organisational culture, and general experience of working within the area. Data were analysed descriptively with cross-tabulations between survey responses and career position (early, mid-level, senior), disciplinary background (medical, scientist), and gender. Pearson chi-square test was used to determine likelihood that any observed difference between the sets arose by chance. Responses were received from 217 people. Career pathways were unclear for the majority of people (64%) and 43% of the workforce felt that the next step in their career was unclear. This was higher in women (52% vs. men 25%; χ(2)(3) = 14.76; p = 0.002) and higher in those in early career (50% vs. senior career, 25%) and mid-career(45%; vs. senior career; χ(2)(6) = 29.19, p < 0.001). The workforce appeared geographically static but unstable with only 50% of people having their contract renewed or extended. The majority of people (59%) have never been promoted by their institution. There were perceptions of gender equality even in the context of females being underrepresented in senior positions (19% vs. males 39%; χ(2)(3) = 8.43, p = 0.015). Despite these findings, the majority of the workforce reported positive organisational and cultural experiences. Sustainability of a academic primary care career is undermined by unclear pathways and a lack of promotion. If the discipline is to thrive, there is a need to support early and mid-career individuals via greater transparency of career pathways. Despite these findings staff remained positive about their careers.

Development and implementation of an online clinical pathway for adult chronic kidney disease in primary care: a mixed methods study.

PubMed

Donald, Maoliosa; McBrien, Kerry; Jackson, Wes; Manns, Braden J; Tonelli, Marcello; King-Shier, Kathryn; Jindal, Kailash; Lewanczuk, Richard Z; Scott-Douglas, Nairne; Braun, Ted; Straus, Sharon E; Naugler, Christopher; Elliott, Meghan J; Jun, Min; Hemmelgarn, Brenda R

2016-08-17

Primary care physicians and other primary health care professionals from Alberta, Canada identified a clinical pathway as a potential tool to facilitate uptake of clinical practice guidelines for the diagnosis, management and referral of adults with chronic kidney disease. We describe the development and implementation of a chronic kidney disease clinical pathway (CKD-CP; www.ckdpathway.ca ). The CKD-CP was developed and implemented based on the principles of the Knowledge-To-Action Cycle framework. We used a mixed methods approach to identify the usability and feasibility of the CKD-CP. This included individual interviews, an online survey and website analytics, to gather data on barriers and facilitators to use, perceived usefulness and characteristics of users. Results are reported using conventional qualitative content analysis and descriptive statistics. Eighteen individual interviews were conducted with primary care physicians, nephrologists, pharmacists and nurse practitioners to identify themes reflecting both barriers and facilitators to integrating the CKD-CP into clinical practice. Themes identified included: communication, work efficiency and confidence. Of the 159 participants that completed the online survey, the majority (52 %) were first time CKD-CP users. Among those who had previously used the CKD-CP, 94 % agreed or strongly agreed that the pathway was user friendly, provided useful information and increased their knowledge and confidence in the care of patients with CKD. Between November 2014 and July 2015, the CKD-CP website had 10,710 visits, 67 % of which were new visitors. The 3 most frequently visited web pages were home, diagnose and medical management. Canada, Indonesia and the United States were the top 3 countries accessing the website during the 9 month period. An interactive, online, point-of-care tool for primary care providers can be developed and implemented to assist in the care of patients with CKD. Our findings are important for making refinements to the CKD -CP website via ongoing discussions with end-users and the development team, along with continued dissemination using multiple strategies.

Clinical audit system as a quality improvement tool in the management of breast cancer.

PubMed

Vijayakumar, Chellappa; Maroju, Nanda Kishore; Srinivasan, Krishnamachari; Reddy, K Satyanarayana

2016-11-01

Quality improvement is recognized as a major factor that can transform healthcare management. This study is a clinical audit that aims at analysing treatment time as a quality indicator and explores the role of setting a target treatment time on reducing treatment delays. All newly diagnosed patients with breast cancer between September 2011 and August 2013 were included in the study. Clinical care pathway for breast cancer patients was standardized and the timeliness of care at each step of the pathway was calculated. Data collection was spread over three phases, baseline, audit cycle I, and audit cycle II. Each cycle was preceded by a quality improvement intervention, and followed by analysis. A total of 334 patients with breast cancer were included in the audit. The overall time from first visit to initiation of treatment was 66.3 days during the baseline period. This improved to 40.4 and 28.5 days at the end of Audit cycle I and II, respectively. The idealized target time of 28 days for initiating treatment was achieved in 5, 23.5, and 65.2% of patients in the baseline period, Audit cycle I, and Audit Cycle II, respectively. There was improvement noted across all steps of the clinical care pathway. This study confirms that audit is a powerful tool in quality improvement programs and helps achieve timely care. Gains achieved through an audit process may not be sustainable unless underlying patient factors and resource deficits are addressed. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.

Implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): protocol of a randomised, controlled trial.

PubMed

Rebbeck, Trudy; Leaver, Andrew; Bandong, Aila Nica; Kenardy, Justin; Refshauge, Kathryn; Connelly, Luke; Cameron, Ian; Mitchell, Geoffrey; Willcock, Simon; Ritchie, Carrie; Jagnoor, Jagnoor; Sterling, Michele

2016-04-01

Whiplash-associated disorders (WAD) are a huge worldwide health and economic burden. The propensity towards developing into chronic, disabling conditions drives the rise in health and economic costs associated with treatment, productivity loss and compulsory third party insurance claims. Current treatments fail to address the well-documented heterogeneity of WAD and often result in poor outcomes. A novel approach is to evaluate whether the care provided according to the estimated risk of poor prognosis improves health outcomes while remaining cost-effective. (1) Does a guideline-based clinical pathway of care improve health outcomes after whiplash injury compared to usual care? (2) Does risk of recovery have a differential effect on health outcomes for the clinical pathway of care? (3) Is the clinical pathway of care intervention cost-effective? (4) What are the variations in professional practice between usual care and the clinical pathway of care? Multi-centre, randomised, controlled trial conducted over two Australian states: Queensland and New South Wales. 236 people with WAD (grade I-III, within 6 weeks of injury) and their primary healthcare providers. A clinical pathway of care, with care matched to the predicted risk of poor recovery. Participants at low risk of ongoing pain and disability (hence, predicted to fully recover) will receive up to three sessions of guideline-based advice and exercise with their primary healthcare provider. Participants at medium/high risk of developing ongoing pain and disability will be referred to a specialist (defined as a practitioner with expertise in whiplash) who will conduct a more in-depth physical and psychological assessment. As a result, the specialist will liaise with the original primary healthcare provider and determine one of three further pathways of care. Usual care provided by the primary healthcare provider that is based on clinical judgment. Primary (global rating of change and neck-related disability) and secondary (self-efficacy, pain intensity, general health and disability and psychological health) outcomes will be collected using validated scales. Direct (eg, professional care, transportation costs, time spent for care, co-payments) and indirect (eg, lost economic productivity) costs will be obtained through an electronic cost diary. Health and cost outcomes will be assessed at baseline, 3, 6 and 12 months after randomisation. Professional practice outcomes will be evaluated through questionnaires completed by healthcare providers and their patients at 3 months. Potential participants (patients) will be identified through emergency departments, primary health clinics and advertisements. Eligible participants will complete baseline assessments and will be categorised into low or medium/high risk of poor recovery using a clinical prediction rule. After this assessment, participants will be randomly allocated to either a control group (n=118) or intervention group (n=118), stratified by risk subgroup and treatment site. The participants' nominated primary healthcare providers will be informed of their involvement in the trial. Consent will be obtained from the primary healthcare providers to participate and to obtain information about professional practice. Participants in the intervention group will additionally have access to an interactive website that provides information about whiplash and recovery relative to their risk category. Analysis will be conducted on an intention-to-treat basis. Outcomes will be analysed independently through cross-sectional analyses using generalised linear models methods, with an appropriate link function, to test for an intervention effect, adjusted for the baseline values. The risk category will be tested for its association with treatment effect by adding risk group to the regression equation. Cost-effectiveness will be calculated using utility weights and the resulting measure will be cost per quality-adjusted life year (QALY) saved. Professional practice outcomes will be analysed using descriptive statistics. This research is significant as it will be the first study to address the heterogeneity of whiplash by implementing a clinical pathway of care that matches evidence-based interventions to projected risk of poor recovery. The results of this trial have the potential to change clinical practice for WAD, thereby maximising treatment effects, improving patient outcomes, reducing costs and maintaining the compulsory third party system. Copyright © 2016. Published by Elsevier B.V.

Implementation strategies in pediatric neurocritical care.

PubMed

Markham, Christopher; Proctor, Enola K; Pineda, Jose A

2017-06-01

Brain-directed critical care for children is a relatively new area of subspecialization in pediatric critical care. Pediatric neurocritical care teams combine the expertise of neurology, neurosurgery, and critical care medicine. The positive impact of delivering specialized care to pediatric patients with acute neurological illness is becoming more apparent, but the optimum way to implement and sustain the delivery of this is complicated and poorly understood. We aim to provide emerging evidence supporting that effective implementation of pediatric neurocritical care pathways can improve patient survival and outcomes. We also provide an overview of the most effective strategies across the field of implementation science that can facilitate deployment of neurocritical care pathways in the pediatric ICU. Implementation strategies can broadly be grouped according to six categories: planning, educating, restructuring, financing, managing quality, and attending to the policy context. Using a combination of these strategies in the last decade, several institutions have improved patient morbidity and mortality. Although much work remains to be done, emerging evidence supports that implementation of evidence-based care pathways for critically ill children with two common neurological diagnoses - status epilepticus and traumatic brain injury - improves outcomes. Pediatric and neonatal neurocritical care programs that support evidence-based care can be effectively structured using appropriately sequenced implementation strategies to improve outcomes across a variety of patient populations and in a variety of healthcare settings.

From generic pathways to ICT-supported horizontally integrated care: the SmartCare approach and convergence with future Internet assembly.

PubMed

Urošević, Vladimir; Mitić, Marko

2014-01-01

Successful service integration in policy and practice requires both technology innovation and service process innovation being pursued and implemented at the same time. The SmartCare project (partially EC-funded under CIP ICT PSP Program) aims to achieve this through development, piloting and evaluation of ICT-based services, horizontally integrating health and social care in ten pilot regions, including Kraljevo region in Serbia. The project has identified and adopted two generic highest-level common thematic pathways in joint consolidation phase - integrated support for long-term care and integrated support after hospital discharge. A common set of standard functional specifications for an open ICT platform enabling the delivery of integrated care is being defined, around the challenges of data sharing, coordination and communication in these two formalized pathways. Implementation and system integration on technology and architecture level are to be based on open standards, multivendor interoperability, and leveraging on the current evolving open specification technology foundations developed in relevant projects across the European Research Area.

Developing integrated patient pathways using hybrid simulation

NASA Astrophysics Data System (ADS)

Zulkepli, Jafri; Eldabi, Tillal

2016-10-01

Integrated patient pathways includes several departments, i.e. healthcare which includes emergency care and inpatient ward; intermediate care which patient(s) will stay for a maximum of two weeks and at the same time be assessed by assessment team to find the most suitable care; and social care. The reason behind introducing the intermediate care in western countries was to reduce the rate of patients that stays in the hospital especially for elderly patients. This type of care setting has been considered to be set up in some other countries including Malaysia. Therefore, to assess the advantages of introducing this type of integrated healthcare setting, we suggest develop the model using simulation technique. We argue that single simulation technique is not viable enough to represent this type of patient pathways. Therefore, we suggest develop this model using hybrid techniques, i.e. System Dynamics (SD) and Discrete Event Simulation (DES). Based on hybrid model result, we argued that the result is viable to be as references for decision making process.

Prevention and diagnosis of invasive fungal disease in high-risk patients within an integrative care pathway.

PubMed

Barnes, Rosemary A; Stocking, Kate; Bowden, Sarah; Poynton, Matthew H; White, P Lewis

2013-09-01

The aim of this study was to assess the clinical utility of enhanced diagnostics on the management of invasive fungal disease in high risk patients within an integrated care pathway and to audit compliance and efficacy of antifungal prophylaxis. A cohort of 549 high risk haematology and stem-cell transplant recipients was followed over a 5 year period. The routine standard of care involved the use of antimould prophylaxis and a neutropenic care pathway utilizing twice weekly antigen and PCR testing. Prophylaxis with itraconazole was poorly tolerated and therapeutic levels could not be maintained. Antigen testing and PCR showed good clinical utility in the management of invasive aspergilosis with high sensitivity (98%) and negative predictive value (99.6%) when both tests were used together, allowing a diagnosis IA to be excluded and obviating the need for empirical antifungal agents. When used serially, multiple positive PCR and antigen test results enabled accurate diagnosis of IA with a specificity of 95% and a positive likelihood ratio of 11. Biomarkers preceded clinical signs in 85% of proven and probable invasive disease. The combination of both tests showed optimum clinical utility for the diagnosis and management of IA in this high risk group. Copyright © 2013 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Clinical pathway across tertiary and community care after an interventional cardiology procedure.

PubMed

Doran, K; Sampson, B; Staus, R; Ahern, C; Schiro, D

1997-01-01

Many patients who receive medical interventional cardiology procedures at a tertiary hospital live outside the metropolitan area and may experience fragmentation in care, less emotional support by family members, inaccurate and delayed communication, and lack of educational follow-up on discharge from the hospital. A clinical pathway titled "Heart Health Care Patterns" was developed to link acute phase, recovery phase, rehabilitation phase, and enhancement/maintenance phase. The 12-month clinical pathway combines Gordon's Functional Health Patterns and the Omaha System developed by the Omaha Visiting Nurse Association. The rating scale for outcomes assesses the patient at different phases to provide objective data and information throughout the year.

How Does Caregiver Well-Being Relate to Perceived Quality of Care in Patients With Cancer? Exploring Associations and Pathways

PubMed Central

Kent, Erin E.; Mollica, Michelle; Rowland, Julia H.

2016-01-01

Purpose Perceived quality of care (QOC) is an increasingly important metric of care quality and can be affected by such factors among patients with cancer as quality of life and physician trust. This study sought to evaluate whether informal caregiver well-being was also associated with perceived QOC among patients with cancer and assessed potential pathways that link these factors. Methods This study used data from the Cancer Care Outcomes Research and Surveillance (CanCORS) consortium. Patients with lung and colorectal cancer enrolled in CanCORS (N = 689) nominated an informal caregiver to participate in a caregiving survey. Both groups self-reported sociodemographic, psychosocial, and caregiving characteristics; cancer characteristics were obtained from the CanCORS core data set. Multivariable logistic regression was used to assess the association between caregiver psychosocial factors and subsequent patient-perceived QOC, controlling for earlier patient-perceived QOC and covariates. Secondary analysis examined potential pathways that link these factors. Results Patients whose informal caregiver had higher levels of depressive symptoms were significantly more likely to report fair or poor QOC (odds ratio, 1.06; 95% CI, 1.01 to 1.13). When caregivers reported fair or poor self-rated health, patients were more than three times more likely to report fair or poor perceived QOC (odds ratio, 3.76; 95% CI, 1.76 to 9.55). Controlling for patient psychosocial factors and physician communication and coordination of medical care reduced the effect size and/or statistical significance of these relationships. Conclusion Informal caregivers are an important part of the care team and their well-being is associated with patient-perceived QOC. Engaging informal cancer caregivers as part of the care team and conducting ongoing risk stratification screening and intervention to optimize their health may improve patient-reported outcomes and QOC. PMID:27573657

[Hospital at home care for children with leukaemia].

PubMed

Justin, Manuela

2015-01-01

The care pathway of a child with leukaemia is long and often difficult. The different professionals work together to ensure optimal care management. Hospital at home forms part of this pathway in partnership with the inhospital departments, the general practitioner and the day hospital. This link between the different professionals is assured by the hospital at home child health nurse coordinator. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

The 'radiographer-referrer game': image interpretation dynamics in rural practice.

PubMed

Squibb, Kathryn; Smith, Anthony; Dalton, Lisa; Bull, Rosalind M

2016-03-01

Effective interprofessional communication is intrinsic to safe health care. Despite the identified positive impact of collaborative radiographic interpretation between rural radiographers and referrers, communication difficulties still exist. This article describes the strategies that Australian rural radiographers use for communication of their radiographic opinion to the referring doctor. In a two-phase interpretive doctoral study completed in 2012, data were collected from radiographers working in rural New South Wales, Western Australia and Tasmania using a paper based questionnaire followed by in-depth semistructured interviews. Data were analysed thematically in order to identify, analyse and report the emergent themes. The overarching theme was Patient Advocacy, where in the interest of patient care radiographers took measures to ensure that a referring doctor did not miss radiographic abnormalities. Strong interprofessional relationships enabled direct communication pathways. Interprofessional boundaries shaped by historical hierarchical relationships, together with a lack of confidence and educational preparation for radiographic interpretation result in barriers to direct communication pathways. These barriers prompted radiographers to pursue indirect communication pathways, such as side-stepping and hint and hope. A lack of formal communication pathways and educational preparation for this role has resulted in radiographers playing the radiographer-referrer game to overtly or covertly assist referrers in reaching a radiographic diagnosis. The findings from this study may be used to plan interventions for strengthening interprofessional communication pathways and improve quality of healthcare for patients.

Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction.

PubMed

Oh, Christine; Moriarty, James; Borah, Bijan J; Mara, Kristin C; Harmsen, William S; Saint-Cyr, Michel; Lemaine, Valerie

2018-06-01

Enhanced recovery after surgery (ERAS) pathways have been shown in multiple surgical specialties to decrease hospital length of stay (LOS) after surgery. ERAS in breast reconstruction has been found to decrease hospital LOS and inpatient opioid use. ERAS protocols can facilitate a patient's recovery and can potentially increase the quality of care while decreasing costs. A standardized ERAS pathway was developed through multidisciplinary collaboration. It addressed all phases of surgical care for patients undergoing free-flap breast reconstruction utilizing an abdominal donor site. In this retrospective cohort study, clinical variables associated with hospitalization costs for patients who underwent free-flap breast reconstruction with the ERAS pathway were compared with those of historical controls, termed traditional recovery after surgery (TRAS). All patients included in the study underwent surgery between September 2010 and September 2014. Predicted costs of the study groups were compared using generalized linear modeling. A total of 200 patients were analyzed: 82 in the ERAS cohort and 118 in the TRAS cohort. Clinical variables that were identified to potentially affect costs were found to have a statistically significant difference between groups and included unilateral versus bilateral procedures (p = 0.04) and the need for postoperative blood transfusion (p = 0.03). The cost regression analysis on the two cohorts was adjusted for these significant variables. Adjusted mean costs of patients with ERAS were found to be $4,576 lesser than those of the TRAS control group ($38,688 versus $43,264). Implementation of the ERAS pathway was associated with significantly decreased costs when compared to historical controls. There has been a healthcare focus toward prudent resource allocation, which dictates the need for plastic surgeons to recognize economic evaluation of clinical practice. The ERAS pathway can increase healthcare accountability by improving quality of care while simultaneously decreasing the costs associated with autologous breast reconstruction. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

[Development of a clinical pathway for the attention of patients with amyotrophic lateral sclerosis in a regional network. ALS Assistance Network-Comunidad de Madrid].

PubMed

Rodríguez de Rivera, F J; Grande, M; García-Caballero, J; Muñoz-Blanco, J; Mora, J; Esteban, J; Guerrero, A; Matias-Guiu, J; de Andrés-Colsa, R; Buey, C; Díez-Tejedor, E

2007-01-01

Amyotrophic lateral sclerosis (ALS) requires complex multidisciplinary attention. Clinical pathways are assistance plans for certain diseases with a predictable course. These plans are established in isolated centers, not in multicenter regions. The aim is to develop a clinical pathway capable of organizing and homogenizing assistance given in ALS Assistance Network-Comunidad de Madrid which is made up of five hospitals, from the beginning until the end of the disease. In successive meetings, neurologists of these hospitals and members of the Madrid Health Service evaluated published therapeutic guidelines and other documents used in ALS assistance. A clinical pathway was developed adapting this information to social-health care conditions in the Comunidad de Madrid following the FOCUS-PDCA model. A clinical pathway was created consisting of a scientist-technical framework which arranges the attention in relationship to the diagnosis and treatment, according to the degree of disease progression and a chronogram. This is accompanied by several patient information documents on the disease and the tests that are required, and a patient assistance evaluation form. The standards are established to reach and to promote 354 constant improvement in patient care. Clinical pathway for the ALS assistance in a regional network organizes the attention and cares that the patients must receive from the beginning to the end of the disease. This arrangement and homogenization of the attention improves the quality of patient care, diminishes variability and rationalizes the use of the health care resources.

Caregiver Stress and Noncaregiver Stress: Exploring the Pathways of Psychiatric Morbidity

ERIC Educational Resources Information Center

Amirkhanyan, Anna A.; Wolf, Douglas A.

2003-01-01

Purpose: This study examines depressive symptoms among adult children of elderly parents; it views the parents' care needs and child's care activities as two separate stressors, different combinations of which may affect both caregiving and noncaregiving family members. Design and Methods: A sample of 4,380 women and 3,965 men from the first wave…

How Effective Are Clinical Pathways With and Without Online Peer-Review? An Analysis of Bone Metastases Pathway in a Large, Integrated National Cancer Institute-Designated Comprehensive Cancer Center Network

DOE Office of Scientific and Technical Information (OSTI.GOV)

Beriwal, Sushil, E-mail: beriwals@upmc.edu; Rajagopalan, Malolan S.; Flickinger, John C.

2012-07-15

Purpose: Clinical pathways are an important tool used to manage the quality in health care by standardizing processes. This study evaluated the impact of the implementation of a peer-reviewed clinical pathway in a large, integrated National Cancer Institute-Designated Comprehensive Cancer Center Network. Methods: In 2003, we implemented a clinical pathway for the management of bone metastases with palliative radiation therapy. In 2009, we required the entry of management decisions into an online tool that records pathway choices. The pathway specified 1 or 5 fractions for symptomatic bone metastases with the option of 10-14 fractions for certain clinical situations. The datamore » were obtained from 13 integrated sites (3 central academic, 10 community locations) from 2003 through 2010. Results: In this study, 7905 sites were treated with 64% of courses delivered in community practice and 36% in academic locations. Academic practices were more likely than community practices to treat with 1-5 fractions (63% vs. 23%; p < 0.0001). The number of delivered fractions decreased gradually from 2003 to 2010 for both academic and community practices (p < 0.0001); however, greater numbers of fractions were selected more often in community practices (p < 0.0001). Using multivariate logistic regression, we found that a significantly greater selection of 1-5 fractions developed after implementation online pathway monitoring (2009) with an odds ratio of 1.2 (confidence interval, 1.1-1.4) for community and 1.3 (confidence interval, 1.1-1.6) for academic practices. The mean number of fractions also decreased after online peer review from 6.3 to 6.0 for academic (p = 0.07) and 9.4 to 9.0 for community practices (p < 0.0001). Conclusion: This is one of the first studies to examine the efficacy of a clinical pathway for radiation oncology in an integrated cancer network. Clinical pathway implementation appears to be effective in changing patterns of care, particularly with online clinical peer review as a valuable aid to encourage adherence to evidence-based practice.« less

Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state

PubMed Central

Sattin, Davide; De Torres, Laura; Dolce, Giuliano; Arcuri, Francesco; Estraneo, Anna; Cardinale, Viviana; Piperno, Roberto; Zavatta, Elena; Formisano, Rita; D’Ippolito, Mariagrazia; Vassallo, Claudio; Dessi, Barbara; Lamberti, Gianfranco; Antoniono, Elena; Lanzillotti, Crocifissa; Navarro, Jorge; Bramanti, Placido; Marino, Silvia; Zampolini, Mauro; Scarponi, Federico; Avesani, Renato; Salvi, Luca; Ferro, Salvatore; Mazza, Luigi; Fogar, Paolo; Feller, Sandro; De Nigris, Fulvio; Martinuzzi, Andrea; Buffoni, Mara; Pessina, Adriano; Corsico, Paolo; Leonardi, Matilde

2017-01-01

Summary Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided. PMID:29042005

Pathways to ambulatory sensitive hospitalisations for Māori in the Auckland and Waitemata regions.

PubMed

Barker, Carol; Crengle, Sue; Bramley, Dale; Bartholomew, Karen; Bolton, Patricia; Walsh, Michael; Wignall, Jean

2016-10-28

Ambulatory Sensitive Hospitalisations (ASH) are a group of conditions potentially preventable through interventions delivered in the primary health care setting. ASH rates are consistently higher for Māori compared with non-Māori. This study aimed to establish Māori experience of factors driving the use of hospital services for ASH conditions, including barriers to accessing primary care. A telephone questionnaire exploring pathways to ASH was administered to Māori (n=150) admitted to Auckland and Waitemata District Health Board (DHB) hospitals with an ASH condition between January 1st-June 30th 2015. A cohort of 1,013 participants were identified; 842 (83.1%) were unable to be contacted. Of the 171 people contactable, 150 agreed to participate, giving an overall response rate of 14.8% and response rate of contactable patients of 87.7%. Results demonstrated high rates of self-reported enrolment, utilisation and preference for primary care. Many participants demonstrated appropriate health seeking behaviour and accurate recall of diagnoses. While financial barriers to accessing primary care were reported, non-financial barriers including lack of after-hours provision (12.6% adults, 37.7% children), appointment availability (7.4% adults, 17.0% children) and lack of transport (13.7% adults, 20.8% children) also featured in participant responses. Interventions to reduce Māori ASH include: timely access to primary care through electronic communications, increased appointment availability, extended opening hours, low cost after-hours care and consistent best management of ASH conditions in general practice through clinical pathways. Facilitated enrolment of ASH patients with no general practitioner could also reduce ASH. Research into transport barriers and enablers for Māori accessing primary care is required to support future interventions.

Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study.

PubMed

Kisa, Rose; Baingana, Florence; Kajungu, Rehema; Mangen, Patrick O; Angdembe, Mangesh; Gwaikolo, Wilfred; Cooper, Janice

2016-08-31

Access to mental health care services for patients with neuropsychiatric disorders remains low especially in post-conflict, low and middle income countries. Persons with mental health conditions and epilepsy take many different paths when they access formal and informal care for their conditions. This study conducted across three countries sought to provide preliminary data to inform program development on access to care. It thus sought to assess the different pathways persons with severe mental disorders and epilepsy take when accessing care. It also sought to identify the barriers to accessing care that patients face. Six in depth interviews, 27 focus group discussions and 77 key informants' interviews were conducted on a purposively selected sample of health care workers, policy makers, service users and care takers in Uganda, Liberia and Nepal. Data collected along predetermined themes was analysed using Atlas ti software in Uganda and QSR Nvivo 10 in Liberia and Nepal Individual's beliefs guide the paths they take when accessing care. Unlike other studies done in this area, majority of the study participants reported the hospital as their main source of care. Whereas traditional healers lie last in the hierarchy in Liberia and Nepal, they come after the hospital as a care option in Uganda. Systemic barriers such as: lack of psychotropic medicines, inadequate mental health specialists and services and negative attitudes of health care workers, family related and community related barriers were reported. Access to mental health care services by persons living with severe mental disorders and epilepsy remains low in these three post conflict countries. The reasons contributing to it are multi-faceted ranging from systemic, familial, community and individual. It is imperative that policies and programming address: negative attitudes and stigma from health care workers and community, regular provision of medicines and other supplies, enhancement of health care workers skills. Ultimately reducing the accessibility gap will also require use of expert clients and families to strengthen the treatment coalition.

Building Data-Driven Pathways From Routinely Collected Hospital Data: A Case Study on Prostate Cancer

PubMed Central

Clark, Jeremy; Cooper, Colin S; Mills, Robert; Rayward-Smith, Victor J; de la Iglesia, Beatriz

2015-01-01

Background Routinely collected data in hospitals is complex, typically heterogeneous, and scattered across multiple Hospital Information Systems (HIS). This big data, created as a byproduct of health care activities, has the potential to provide a better understanding of diseases, unearth hidden patterns, and improve services and cost. The extent and uses of such data rely on its quality, which is not consistently checked, nor fully understood. Nevertheless, using routine data for the construction of data-driven clinical pathways, describing processes and trends, is a key topic receiving increasing attention in the literature. Traditional algorithms do not cope well with unstructured processes or data, and do not produce clinically meaningful visualizations. Supporting systems that provide additional information, context, and quality assurance inspection are needed. Objective The objective of the study is to explore how routine hospital data can be used to develop data-driven pathways that describe the journeys that patients take through care, and their potential uses in biomedical research; it proposes a framework for the construction, quality assessment, and visualization of patient pathways for clinical studies and decision support using a case study on prostate cancer. Methods Data pertaining to prostate cancer patients were extracted from a large UK hospital from eight different HIS, validated, and complemented with information from the local cancer registry. Data-driven pathways were built for each of the 1904 patients and an expert knowledge base, containing rules on the prostate cancer biomarker, was used to assess the completeness and utility of the pathways for a specific clinical study. Software components were built to provide meaningful visualizations for the constructed pathways. Results The proposed framework and pathway formalism enable the summarization, visualization, and querying of complex patient-centric clinical information, as well as the computation of quality indicators and dimensions. A novel graphical representation of the pathways allows the synthesis of such information. Conclusions Clinical pathways built from routinely collected hospital data can unearth information about patients and diseases that may otherwise be unavailable or overlooked in hospitals. Data-driven clinical pathways allow for heterogeneous data (ie, semistructured and unstructured data) to be collated over a unified data model and for data quality dimensions to be assessed. This work has enabled further research on prostate cancer and its biomarkers, and on the development and application of methods to mine, compare, analyze, and visualize pathways constructed from routine data. This is an important development for the reuse of big data in hospitals. PMID:26162314

A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study

PubMed Central

2012-01-01

Background Clinical pathways (CPs) are used to improve the outcomes of acute stroke, but their use in stroke care is questionable, because the evidence on their effectiveness is still inconclusive. The objective of this study was to evaluate whether CPs improve the outcomes and the quality of care provided to patients after acute ischemic stroke. Methods This was a multicentre cluster-randomized trial, in which 14 hospitals were randomized to the CP arm or to the non intervention/usual care (UC) arm. Healthcare workers in the CP arm received 3 days of training in quality improvement of CPs and in use of a standardized package including information on evidence-based key interventions and indicators. Healthcare workers in the usual-care arm followed their standard procedures. The teams in the CP arm developed their CPs over a 6-month period. The primary end point was mortality. Secondary end points were: use of diagnostic and therapeutic procedures, implementation of organized care, length of stay, re-admission and institutionalization rates after discharge, dependency levels, and complication rates. Results Compared with the patients in the UC arm, the patients in the CP arm had a significantly lower risk of mortality at 7 days (OR = 0.10; 95% CI 0.01 to 0.95) and significantly lower rates of adverse functional outcomes, expressed as the odds of not returning to pre-stroke functioning in their daily life (OR = 0.42; 95 CI 0.18 to 0.98). There was no significant effect on 30-day mortality. Compared with the UC arm, the hospital diagnostic and therapeutic procedures were performed more appropriately in the CP arm, and the evidence-based key interventions and organized care were more applied in the CP arm. Conclusions CPs can significantly improve the outcomes of patients with ischemic patients with stroke, indicating better application of evidence-based key interventions and of diagnostic and therapeutic procedures. This study tested a new hypothesis and provided evidence on how CPs can work. Trial registration ClinicalTrials.gov ID: [NCT00673491]. PMID:22781160

Public health safety and environment in inadequate hospital and healthcare settings: a review.

PubMed

Baguma, D

2017-03-01

Public health safety and environmental management are concerns that pose challenges worldwide. This paper briefly assesses a selected impact of the environment on public health. The study used an assessment of environmental mechanism to analyse the underlying different pathways in which the health sector is affected in inadequate hospital and health care settings. We reviewed the limited available evidence of the association between the health sector and the environment, and the likely pathways through which the environment influences health. The paper also models the use of private health care as a function of costs and benefits relative to public care and no care. The need to enhancing policies to improve the administration of health services, strengthening interventions on environment using international agreements, like Rio Conventions, including measures to control hospital-related infection, planning for human resources and infrastructure construction development have linkage to improve environment care and public health. The present study findings partly also demonstrate the influence of demand for health on the environment. The list of possible interventions includes enhancing policies to improve the administration of health services, strengthening Rio Conventions implementation on environmental concerns, control of environmental hazards and public health. Copyright © 2016 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Clinical Pathways and the Patient Perspective in the Pursuit of Value-Based Oncology Care.

PubMed

Ersek, Jennifer L; Nadler, Eric; Freeman-Daily, Janet; Mazharuddin, Samir; Kim, Edward S

2017-01-01

The art of practicing oncology has evolved substantially in the past 5 years. As more and more diagnostic tests, biomarker-directed therapies, and immunotherapies make their way to the oncology marketplace, oncologists will find it increasingly difficult to keep up with the many therapeutic options. Additionally, the cost of cancer care seems to be increasing. Clinical pathways are a systematic way to organize and display detailed, evidence-based treatment options and assist the practitioner with best practice. When selecting which treatment regimens to include on a clinical pathway, considerations must include the efficacy and safety, as well as costs, of the therapy. Pathway treatment regimens must be continually assessed and modified to ensure that the most up-to-date, high-quality options are incorporated. Value-based models, such as the ASCO Value Framework, can assist providers in presenting economic evaluations of clinical pathway treatment options to patients, thus allowing the patient to decide the overall value of each treatment regimen. Although oncologists and pathway developers can decide which treatment regimens to include on a clinical pathway based on the efficacy of the treatment, assessment of the value of that treatment regimen ultimately lies with the patient. Patient definitions of value will be an important component to enhancing current value-based oncology care models and incorporating new, high-quality, value-based therapeutics into oncology clinical pathways.

A Health Economics Response to the Review of the Liverpool Care Pathway

PubMed Central

Coast, Joanna

2013-01-01

Abstract Background: In 2011 the Palliative Care Funding Review highlighted concerns about the funding, provision, and quality of care at the end of life. Two years on, an independent review of the Liverpool Care Pathway—prompted by a storm of negative media coverage— has raised concerns around a lack of funding, availability of support for the dying and their relatives, and patient centered care. There are recommendations to increase funding through a national tariff for palliative care services, address inconsistencies, and replace the Liverpool Care Pathway with individual end-of-life care plans. Objective: This paper explores the economic implications of the review's recommendations and links these to inadequacies with the current economic framework currently recommended for use in the United Kingdom by the National Institute for Health and Care Excellence, before highlighting aspects of ongoing research aimed at addressing these inadequacies. Methods: As well as the published report More Care, Less Pathway, we draw upon preliminary qualitative evidence from 19 semistructured interviews conducted with academics specializing in economics and/or end-of-life care. Conclusions: While there is a need for increased funding in the short term (highlighted in recent reviews), increasing funding to services that have little evidence base appears to be an irresponsible long-term strategy. Hence there should also be increased investment in research and increased emphasis in particular on developing economic tools to evaluate services. PMID:24199790

Adding Value to Total Joint Arthroplasty Care in an Academic Environment: The Utah Experience.

PubMed

Pelt, Christopher E; Anderson, Mike B; Erickson, Jill A; Gililland, Jeremy M; Peters, Christopher L

2018-06-01

Adding value in a university-based academic health care system provides unique challenges when compared to other health care delivery models. Herein, we describe our experience in adding value to joint arthroplasty care at the University of Utah, where the concept of value-based health care reform has become an embraced and driving force. To improve the value, new resources were needed for care redesign, physician leadership, and engagement in alternative payment models. The changes that occurred at our institution are described. Real-time data and knowledgeable personnel working behind the scenes, while physicians provide clinical care, help move clinical pathway redesigns. Engaged physicians are essential to the successful implementation of value creation and care pathway redesign that can lead to improvements in value. An investment of money and resources toward added infrastructure and personnel is often needed to realize large-scale improvements. Alignment of providers, payers, and hospital administration, including by means of gainsharing programs, can lead to improvements. Although significant care pathway redesign efforts may realize substantial initial cost savings, savings may be asymptotic in nature, which calls into question the likely sustainability of programs that incentivize or penalize payments based on historical targets. Copyright © 2018 Elsevier Inc. All rights reserved.

Constipation services for children: the role of health visitor teams.

PubMed

Smith, Denise; Derrett, Sarah

Constipation among children is a prevalent condition, yet poorly understood. There is little empirical evidence for 'best possible' configurations of services. This article presents a survey of Walsall health visitor team members (HVTMs) which aimed to identify the types of advice and care provided to young children with constipation, pathways to care and ideas for service improvement. Most HVTM consultations were parent-initiated. Few GPs referred children to HVTMs. HVTMs most commonly provided advice about fluids and diet -- only one prescribed medication. HVTMs identified the need for early intervention, consistent information for parents and a clear pathway for all health professionals to follow. Currently, a team from the local primary and hospital NHS trusts is developing an integrated care pathway for paediatric constipation. Success of such pathways depends on their adoption by GPs and hospital-based health professionals, and on evidence of efficacy arising from their evaluation.

Preventing Child Behavior Problems and Substance Use: The Pathways Home Foster Care Reunification Intervention

PubMed Central

DeGarmo, David S.; Reid, John B.; Fetrow, Becky A.; Fisher, Philip A.; Antoine, Karla D.

2013-01-01

This paper evaluated the Pathways Home manualized selective preventive intervention designed to prevent reunification failures once children are returned home to their biological parent(s) after first time stays in foster care (n = 101). The theoretically based intervention focused on support and parent management practices designed to prevent the development of child behavior problems including internalizing and externalizing problems, and substance use. Intent to treat analyses employed probability growth curve approaches for repeated telephone assessments over 16 weeks of intervention. Findings showed that relative to services as usual reunification families, the Pathways Home families demonstrated better parenting strategies that were in turn associated with reductions in problem behaviors over time. Growth in problem behaviors in turn predicted foster care re-entry. Maternal substance use cravings were a risk factor for growth in problem behaviors that were buffered by participation in the Pathways Home intervention. PMID:23914130

Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries

PubMed Central

den Herder-van der Eerden, Marlieke; van Wijngaarden, Jeroen; Preston, Nancy; Linge-Dahl, Lisa; Radbruch, Lukas; Van Beek, Karen; Menten, Johan; Busa, Csilla; Csikos, Agnes; Vissers, Kris; van Gurp, Jelle; Hasselaar, Jeroen

2018-01-01

Background: Integrated palliative care aims at improving coordination of palliative care services around patients’ anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking. Aim: To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe. Design: Qualitative group interview design. Setting/participants: A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses (n = 66; 46%) and physicians (n = 50; 35%). Results: The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services. Conclusion: Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings. PMID:29436279

Integrated palliative care is about professional networking rather than standardisation of care: A qualitative study with healthcare professionals in 19 integrated palliative care initiatives in five European countries.

PubMed

den Herder-van der Eerden, Marlieke; van Wijngaarden, Jeroen; Payne, Sheila; Preston, Nancy; Linge-Dahl, Lisa; Radbruch, Lukas; Van Beek, Karen; Menten, Johan; Busa, Csilla; Csikos, Agnes; Vissers, Kris; van Gurp, Jelle; Hasselaar, Jeroen

2018-06-01

Integrated palliative care aims at improving coordination of palliative care services around patients' anticipated needs. However, international comparisons of how integrated palliative care is implemented across four key domains of integrated care (content of care, patient flow, information logistics and availability of (human) resources and material) are lacking. To examine how integrated palliative care takes shape in practice across abovementioned key domains within several integrated palliative care initiatives in Europe. Qualitative group interview design. A total of 19 group interviews were conducted (2 in Belgium, 4 in the Netherlands, 4 in the United Kingdom, 4 in Germany and 5 in Hungary) with 142 healthcare professionals from several integrated palliative care initiatives in five European countries. The majority were nurses ( n = 66; 46%) and physicians ( n = 50; 35%). The dominant strategy for fostering integrated palliative care is building core teams of palliative care specialists and extended professional networks based on personal relationships, shared norms, values and mutual trust, rather than developing standardised information exchange and referral pathways. Providing integrated palliative care with healthcare professionals in the wider professional community appears difficult, as a shared proactive multidisciplinary palliative care approach is lacking, and healthcare professionals often do not know palliative care professionals or services. Achieving better palliative care integration into regular healthcare and convincing the wider professional community is a difficult task that will take time and effort. Enhancing standardisation of palliative care into education, referral pathways and guidelines and standardised information exchange may be necessary. External authority (policy makers, insurance companies and professional bodies) may be needed to support integrated palliative care practices across settings.

Identifying care actions to conserve dignity in end-of-life care.

PubMed

Brown, Hilary; Johnston, Bridget; Ostlund, Ulrika

2011-05-01

Community nurses have a central role in the provision of palliative and end-of-life care; helping people to die with dignity is an important component of this care. To conserve dignity, care should comprise a broad range of actions addressing the distress that might impact on the patient's sense of dignity. These care actions need to be defined. This study aims to suggest care actions that conserve dignity at the end of life based on evidence from local experience and community nursing practice. Data were collected by focus group interviews and analysed by framework analysis using the Chochinov model of dignity as a predefined framework. Suggestions on care actions were given in relation to all themes. As part of a multi-phase project developing and testing a dignity care pathway, this study might help community nurses to conserve dying patients' dignity.

How socioeconomic inequalities impact pathways of care for coronary artery disease among elderly patients: study protocol for a qualitative longitudinal study

PubMed Central

Schröder, Sara L; Fink, Astrid; Schumann, Nadine; Moor, Irene; Plehn, Alexander; Richter, Matthias

2015-01-01

Introduction Several studies have identified that socioeconomic inequalities in coronary artery disease (CAD) morbidity and mortality lead to a disadvantage in patients with low socioeconomic status (SES). International studies have shown that socioeconomic inequalities also exist in terms of access, utilisation and quality of cardiac care. The aim of this qualitative study is to provide information on the impact of socioeconomic inequalities on the pathway of care for CAD, and to establish which factors lead to socioeconomic inequality of care to form and expand existing scientific theories. Methods and analysis A longitudinal qualitative study with 48 patients with CAD, aged 60–80 years, is being conducted. Patients have been recruited consecutively at the University Hospital in Halle/Saale, Germany, and will be followed for a period of 6 months. Patients are interviewed two times face-to-face using semistructured interviews. Data are transcribed and analysed based on grounded theory. Ethics and dissemination Only participants who have been informed and who have signed a declaration of consent have been included in the study. The study complies rigorously with data protection legislation. Approval of the Ethical Review Committee at the Martin-Luther University Halle-Wittenberg, Germany was obtained. The results of the study will be presented at several congresses, and will be published in high-quality peer-reviewed international journals. Trial registration number This study has been registered with the German Clinical Trials Register and assigned DRKS00007839. PMID:26553827

Psychosocial Health Status of Persons Seeking Treatment for Exposure to Libby Amphibole Asbestos

PubMed Central

Weinert, Clarann; Hill, Wade G.; Winters, Charlene A.; Kuntz, Sandra W.; Rowse, Kimberly; Hernandez, Tanis; Black, Brad; Cudney, Shirley

2011-01-01

A cross-sectional exploratory study was conducted to describe the psychosocial health status of persons seeking health care for exposure to Libby amphibole asbestos (LAA). Health indicators including depression, stress, acceptance of illness, and satisfaction with access and financial aspects of care were obtained via electronic and paper-pencil survey. The exposure pathway and demographic data were gleaned from the health record. Of the 386 participants, more than one-third (34.5%) demonstrated significant levels of psychological distress. The oldest group of women had the lowest levels of depression and stress and the highest acceptance of illness. Gender, age, and satisfaction with financial resources were significantly related to depression, stress, and acceptance of illness. Satisfaction with access to care was significant only for stress. No differences in depression, stress, and acceptance of illness were found based on residence, exposure pathway, or insurance status. PMID:22007326

When health systems are barriers to health care: challenges faced by uninsured Mexican kidney patients.

PubMed

Kierans, Ciara; Padilla-Altamira, Cesar; Garcia-Garcia, Guillermo; Ibarra-Hernandez, Margarita; Mercado, Francisco J

2013-01-01

Chronic Kidney Disease disproportionately affects the poor in Low and Middle Income Countries (LMICs). Mexico exemplifies the difficulties faced in supporting Renal Replacement Therapy (RRT) and providing equitable patient care, despite recent attempts at health reform. The objective of this study is to document the challenges faced by uninsured, poor Mexican families when attempting to access RRT. The article takes an ethnographic approach, using interviewing and observation to generate detailed accounts of the problems that accompany attempts to secure care. The study, based in the state of Jalisco, comprised interviews with patients, their caregivers, health and social care professionals, among others. Observations were carried out in both clinical and social settings. In the absence of organised health information and stable pathways to renal care, patients and their families work extraordinarily hard and at great expense to secure care in a mixed public-private healthcare system. As part of this work, they must navigate challenging health and social care environments, negotiate treatments and costs, resource and finance healthcare and manage a wide range of formal and informal health information. Examining commonalities across pathways to adequate healthcare reveals major failings in the Mexican system. These systemic problems serve to reproduce and deepen health inequalities. A system, in which the costs of renal care are disproportionately borne by those who can least afford them, faces major difficulties around the sustainability and resourcing of RRTs. Attempts to increase access to renal therapies, therefore, need to take into account the complex social and economic demands this places on those who need access most. This paper further shows that ethnographic studies of the concrete ways in which healthcare is accessed in practice provide important insights into the plight of CKD patients and so constitute an important source of evidence in that effort.

A proposed clinical research support career pathway for noninvestigators.

PubMed

Smith, Sheree; Gullick, Janice; Ballard, Jacqueline; Perry, Lin

2018-06-01

To discuss the international experience of clinical research support for noninvestigator roles and to propose a new pathway for Australia, to promote a sustainable research support workforce capable of delivering high-quality clinical research. Noninvestigator research support roles are currently characterized by an ad hoc approach to training, with limited role delineation and perceived professional isolation with implications for study completion rates and participant safety. A focused approach to developing and implementing research support pathways has improved patient recruitment, study completion, job satisfaction, and research governance. The Queensland and New South Wales state-based Nurses' Awards, the Australian Qualifications Framework, and a University Professional (Research) Staff Award. Research nurses in the clinical environment improve study coordination, adherence to study protocol, patient safety, and clinical care. A career pathway that guides education and outlines position descriptions and skill sets would enhance development of the research support workforce. This pathway could contribute to changing the patient outcomes through coordination and study completion of high-quality research. A wide consultative approach is required to determine a cost-effective and feasible approach to implementation and evaluation of the proposed pathway. © 2018 John Wiley & Sons Australia, Ltd.

Family Perspectives on Pathways to Mental Health Care for Children and Youth in Rural Communities

ERIC Educational Resources Information Center

Boydell, Katherine M.; Pong, Raymond; Volpe, Tiziana; Tilleczek, Kate; Wilson, Elizabeth; Lemieux, Sandy

2006-01-01

Context: There is insufficient literature documenting the mental health experiences and needs of rural communities, and a lack of focus on children in particular. This is of concern given that up to 20% of children and youth suffer from a diagnosable mental health problem. Purpose: This study examines issues of access to mental health care for…

Critical pathways in the emergency department improve treatment modalities for patients with ST-elevation myocardial infarction in a European hospital.

PubMed

Pelliccia, Francesco; Cartoni, Domenico; Verde, Monica; Salvini, Paolo; Mercuro, Giuseppe; Tanzi, Pietro

2004-12-01

The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn. The aim of this study was to investigate the impact of critical pathway on processes of care and outcome for patients presenting to the emergency department (ED) of a large urban European hospital because of possible ST-elevation MI. Critical pathways for management of acute chest pain at our ED were developed in 1998 and have been revised every year. Accordingly, the records of all patients referred in 1997 to the ED because of chest pain (before pathway implementation) and in 2001 (after last pathway revision) were reviewed. An ST-elevation MI was diagnosed at ED in 520 of 5,066 (10.3%) patients with chest pain in 1997, and in 452 of 4,843 (9.3%) patients with chest pain in 2001. Patients were managed according to the ED cardiologists' decisions in 1997, whereas they entered the pathways for ST-elevation MI in 2001, with predefined criteria for diagnosis, thrombolysis, percutaneous coronary intervention, and admission to the coronary care unit. Comparison of treatment modalities disclosed that more patients were given thrombolysis in 1997 (49 vs. 16%, p<0.05), whereas in 2001 more patients were sent to primary angioplasty (63 vs. 11%, p<0.05). Also in 2001, patients more often received aspirin (90 vs. 61%, p<0.05) and intravenous beta blockers (60 vs. 35%, p<0.05) soon after arrival at the ED. Comparison between 1997 and 2001 revealed that admission rates to the coronary care unit (69 vs. 78%, NS) and cardiac wards were similar (19 vs. 10%, NS). Conversely, compared with 1997, patients hospitalized in 2001 had a shorter length of stay (12 +/- 5 vs. 18 +/- 6 days, p<0.05), as well as fewer major adverse coronary events (21 vs. 30%, p<0.05) and lower all-cause in-hospital mortality (12 vs. 20%, p<0.05). The quality of care indicators improved with time, as door-to-electrocardiogram interval (10 +/- 6 vs. 19 +/- 9 min, p<0.05), door-to-needle time (25 +/- 10 vs. 35 +/- 10 min, p<0.05), and door-to-balloon interval (70 +/- 15 vs. 99 +/- 20 min, p<0.05) were shorter in 2001 than in 1997. A critical pathway for ST-elevation MI at the ED increases the use of evidence-based treatment strategies and improves outcome and quality of care of patients presenting to a European hospital because of acute chest pain.

Physical and rehabilitation medicine (PRM) care pathways: adults with severe traumatic brain injury.

PubMed

Pradat-Diehl, P; Joseph, P-A; Beuret-Blanquart, F; Luauté, J; Tasseau, F; Remy-Neris, O; Azouvi, P; Sengler, J; Bayen, É; Yelnik, A; Mazaux, J-M

2012-11-01

This document is part of a series of guidelines documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These reference documents focus on a particular pathology (here patients with severe TBI). They describe for each given pathology patients' clinical and social needs, PRM care objectives and necessary human and material resources of the pathology-dedicated pathway. 'Care pathways in PRM' is therefore a short document designed to enable readers (physician, decision-maker, administrator, lawyer, finance manager) to have a global understanding of available therapeutic care structures, organization and economic needs for patients' optimal care and follow-up. After a severe traumatic brain injury, patients might be divided into three categories according to impairment's severity, to early outcomes in the intensive care unit and to functional prognosis. Each category is considered in line with six identical parameters used in the International Classification of Functioning, Disability and Health (World Health Organization), focusing thereafter on personal and environmental factors liable to affect the patients' needs. Copyright © 2012. Published by Elsevier Masson SAS.

Anesthesia for the patient undergoing total knee replacement: current status and future prospects

PubMed Central

Turnbull, Zachary A; Sastow, Dahniel; Giambrone, Gregory P; Tedore, Tiffany

2017-01-01

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation. PMID:28331362

Anesthesia for the patient undergoing total knee replacement: current status and future prospects.

PubMed

Turnbull, Zachary A; Sastow, Dahniel; Giambrone, Gregory P; Tedore, Tiffany

2017-01-01

Total knee arthroplasty (TKA) has become one of the most common orthopedic surgical procedures performed nationally. As the population and surgical techniques for TKAs have evolved over time, so have the anesthesia and analgesia used for these procedures. General anesthesia has been the dominant form of anesthesia utilized for TKA in the past, but regional anesthetic techniques are on the rise. Multiple studies have shown the potential for regional anesthesia to improve patient outcomes, such as a decrease in intraoperative blood loss, length of stay, and patient mortality. Anesthesiologists are also moving toward multimodal analgesia, which includes peripheral nerve blockade, periarticular injection, and preemptive analgesia. The goal of multimodal analgesia is to improve perioperative pain control while minimizing systemic narcotic consumption. With improved postoperative pain management and rapid patient rehabilitation, new clinical pathways have been engineered to fast track patient recovery after orthopedic procedures. The aim of these clinical pathways was to improve quality of care, minimize unnecessary variations in care, and reduce cost by using streamlined procedures and protocols. The future of TKA care will be formalized clinical pathways and tracks to better optimize perioperative algorithms with regard to pain control and perioperative rehabilitation.

Shortened length of stay and hospital cost reduction with implementation of an accelerated clinical care pathway after elective colon resection.

PubMed

Stephen, Antonia E; Berger, David L

2003-03-01

Patient care pathways have been developed for operative procedures with documented improvements in length of stay and cost without compromising outcome. The average hospital stay after colonic resection is 5 to 10 days. This study describes a clinical pathway for colon resections and examines patient outcome before and after institution of the pathway. One hundred thirty-eight patients underwent elective colon resections at our institution by a single surgeon before (n = 52) and after (n = 86) introduction of a clinical pathway. Length of stay, postoperative complications, readmissions, and cost per patient were compared between the 2 groups. Mean total length of stay (+/- standard deviation [SD]) was less in the postclinical pathway patients (3.7 +/- 1.5 days) compared to preclinical pathway patients (6.6 +/- 3.3 days) (P <.001). When adjusted for age, sex, diagnosis, and type of operation, the difference in length of stay remains statistically significant (P <.001). There was 1 readmission in the prepathway group and 8 readmissions in the postpathway group. When the readmissions were added to the original admissions, the mean length of stay in the postpathway patients was 4.2 +/- 2.8 days and in the prepathway patients was 6.9 +/- 4.1 days (P <.001). The average cost per patient (+/- standard error of the mean), with readmission costs added, was 9310 +/- 5170 US dollars in the prepathway group and 7070 +/- 3670 US dollars in the postpathway group (P =.002). The institution of a clinical pathway for elective, open colon resections can be done safely with improvements in cost and length of stay.

African Immigrants in Low-Wage Direct Health Care: Motivations, Job Satisfaction, and Occupational Mobility.

PubMed

Covington-Ward, Yolanda

2017-06-01

This study explores motivations, job satisfaction, and overall perceived occupational mobility for African immigrants working in low-wage direct health care occupations. The study uses qualitative semi-structured interviews with a sample of thirty African immigrant workers in the greater Pittsburgh metropolitan area. Results show that four major themes captured the motivations of interviewees for doing direct care work: passion for care work, quick money, easily obtained employment, and direct care work as a pathway to other health occupations. The majority of the interviewees were satisfied with their jobs, yet almost all of them saw their occupations as temporary or transitional employment. Most of the interviewees also saw their jobs as lacking occupational mobility. In light of the increased national demand for direct care workers, the growing numbers of immigrants in the direct care labor force, and the high turnover and low retention rates of direct care workers overall, the study suggests that more must be done to make direct care work attractive and rewarding for African immigrant workers.

Integrated care pathways for airway diseases (AIRWAYS-ICPs).

PubMed

Bousquet, J; Addis, A; Adcock, I; Agache, I; Agusti, A; Alonso, A; Annesi-Maesano, I; Anto, J M; Bachert, C; Baena-Cagnani, C E; Bai, C; Baigenzhin, A; Barbara, C; Barnes, P J; Bateman, E D; Beck, L; Bedbrook, A; Bel, E H; Benezet, O; Bennoor, K S; Benson, M; Bernabeu-Wittel, M; Bewick, M; Bindslev-Jensen, C; Blain, H; Blasi, F; Bonini, M; Bonini, S; Boulet, L P; Bourdin, A; Bourret, R; Bousquet, P J; Brightling, C E; Briggs, A; Brozek, J; Buhl, R; Bush, A; Caimmi, D; Calderon, M; Calverley, P; Camargos, P A; Camuzat, T; Canonica, G W; Carlsen, K H; Casale, T B; Cazzola, M; Cepeda Sarabia, A M; Cesario, A; Chen, Y Z; Chkhartishvili, E; Chavannes, N H; Chiron, R; Chuchalin, A; Chung, K F; Cox, L; Crooks, G; Crooks, M G; Cruz, A A; Custovic, A; Dahl, R; Dahlen, S E; De Blay, F; Dedeu, T; Deleanu, D; Demoly, P; Devillier, P; Didier, A; Dinh-Xuan, A T; Djukanovic, R; Dokic, D; Douagui, H; Dubakiene, R; Eglin, S; Elliot, F; Emuzyte, R; Fabbri, L; Fink Wagner, A; Fletcher, M; Fokkens, W J; Fonseca, J; Franco, A; Frith, P; Furber, A; Gaga, M; Garcés, J; Garcia-Aymerich, J; Gamkrelidze, A; Gonzales-Diaz, S; Gouzi, F; Guzmán, M A; Haahtela, T; Harrison, D; Hayot, M; Heaney, L G; Heinrich, J; Hellings, P W; Hooper, J; Humbert, M; Hyland, M; Iaccarino, G; Jakovenko, D; Jardim, J R; Jeandel, C; Jenkins, C; Johnston, S L; Jonquet, O; Joos, G; Jung, K S; Kalayci, O; Karunanithi, S; Keil, T; Khaltaev, N; Kolek, V; Kowalski, M L; Kull, I; Kuna, P; Kvedariene, V; Le, L T; Lodrup Carlsen, K C; Louis, R; MacNee, W; Mair, A; Majer, I; Manning, P; de Manuel Keenoy, E; Masjedi, M R; Melen, E; Melo-Gomes, E; Menzies-Gow, A; Mercier, G; Mercier, J; Michel, J P; Miculinic, N; Mihaltan, F; Milenkovic, B; Molimard, M; Momas, I; Montilla-Santana, A; Morais-Almeida, M; Morgan, M; N'Diaye, M; Nafti, S; Nekam, K; Neou, A; Nicod, L; O'Hehir, R; Ohta, K; Paggiaro, P; Palkonen, S; Palmer, S; Papadopoulos, N G; Papi, A; Passalacqua, G; Pavord, I; Pigearias, B; Plavec, D; Postma, D S; Price, D; Rabe, K F; Radier Pontal, F; Redon, J; Rennard, S; Roberts, J; Robine, J M; Roca, J; Roche, N; Rodenas, F; Roggeri, A; Rolland, C; Rosado-Pinto, J; Ryan, D; Samolinski, B; Sanchez-Borges, M; Schünemann, H J; Sheikh, A; Shields, M; Siafakas, N; Sibille, Y; Similowski, T; Small, I; Sola-Morales, O; Sooronbaev, T; Stelmach, R; Sterk, P J; Stiris, T; Sud, P; Tellier, V; To, T; Todo-Bom, A; Triggiani, M; Valenta, R; Valero, A L; Valiulis, A; Valovirta, E; Van Ganse, E; Vandenplas, O; Vasankari, T; Vestbo, J; Vezzani, G; Viegi, G; Visier, L; Vogelmeier, C; Vontetsianos, T; Wagstaff, R; Wahn, U; Wallaert, B; Whalley, B; Wickman, M; Williams, D M; Wilson, N; Yawn, B P; Yiallouros, P K; Yorgancioglu, A; Yusuf, O M; Zar, H J; Zhong, N; Zidarn, M; Zuberbier, T

2014-08-01

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Improving post-stroke recovery: the role of the multidisciplinary health care team.

PubMed

Clarke, David J; Forster, Anne

2015-01-01

Stroke is a leading cause of serious, long-term disability, the effects of which may be prolonged with physical, emotional, social, and financial consequences not only for those affected but also for their family and friends. Evidence for the effectiveness of stroke unit care and the benefits of thrombolysis have transformed treatment for people after stroke. Previously viewed nihilistically, stroke is now seen as a medical emergency with clear evidence-based care pathways from hospital admission to discharge. However, stroke remains a complex clinical condition that requires health professionals to work together to bring to bear their collective knowledge and specialist skills for the benefit of stroke survivors. Multidisciplinary team working is regarded as fundamental to delivering effective care across the stroke pathway. This paper discusses the contribution of team working in improving recovery at key points in the post-stroke pathway.

After the Liverpool Care Pathway--development of heuristics to guide end of life care for people with dementia: protocol of the ALCP study.

PubMed

Davies, N; Manthorpe, J; Sampson, E L; Iliffe, S

2015-09-02

End of life care guidance for people with dementia is lacking and this has been made more problematic in England with the removal of one of the main end of life care guidelines which offered some structure, the Liverpool Care Pathway. This guidance gap may be eased with the development of heuristics (rules of thumb) which offer a fast and frugal form of decision-making. To develop a toolkit of heuristics (rules of thumb) for practitioners to use when caring for people with dementia at the end of life. A mixed-method study using a co-design approach to develop heuristics in three phases. In phase 1, we will conduct at least six focus groups with family carers, health and social care practitioners from both hospital and community care services, using the 'think-aloud' method to understand decision-making processes and to develop a set of heuristics. The focus group topic guide will be developed from the findings of a previous study of 46 interviews of family carers about quality end-of-life care for people with dementia and a review of the literature. A multidisciplinary development team of health and social care practitioners will synthesise the findings from the focus groups to devise and refine a toolkit of heuristics. Phase 2 will test the use of heuristics in practice in five sites: one general practice, one community nursing team, one hospital ward and two palliative care teams working in the community. Phase 3 will evaluate and further refine the toolkit of heuristics through group interviews, online questionnaires and semistructured interviews. This study has received ethical approval from a local NHS research ethics committee (Rec ref: 15/LO/0156). The findings of this study will be presented in peer-reviewed publications and national and international conferences. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Feasibility of personalised remote long-term follow-up of people with cochlear implants: a randomised controlled trial.

PubMed

Cullington, Helen; Kitterick, Padraig; Weal, Mark; Margol-Gromada, Magdalena

2018-04-20

Substantial resources are required to provide lifelong postoperative care to people with cochlear implants. Most patients visit the clinic annually. We introduced a person-centred remote follow-up pathway, giving patients telemedicine tools to use at home so they would only visit the centre when intervention was required. To assess the feasibility of comparing a remote care pathway with the standard pathway in adults using cochlear implants. Two-arm randomised controlled trial. Randomisation used a minimisation approach, controlling for potential confounding factors. Participant blinding was not possible, but baseline measures occurred before allocation. University of Southampton Auditory Implant Service: provider of National Health Service care. 60 adults who had used cochlear implants for at least 6 months. Control group (n=30) followed usual care pathway.Remote care group (n=30) received care remotely for 6 months incorporating: home hearing in noise test, online support tool and self-adjustment of device (only 10 had compatible equipment). Primary: change in patient activation; measured using the Patient Activation Measure.Secondary: change in hearing and quality of life; qualitative feedback from patients and clinicians. One participant in the remote care group dropped out. The remote care group showed a greater increase in patient activation than the control group. Changes in hearing differed between the groups. The remote care group improved on the Triple Digit Test hearing test; the control group perceived their hearing was worse on the Speech, Spatial and Qualities of Hearing Scale questionnaire. Quality of life remained unchanged in both groups. Patients and clinicians were generally positive about remote care tools and wanted to continue. Adults with cochlear implants were willing to be randomised and complied with the protocol. Personalised remote care for long-term follow-up is feasible and acceptable, leading to more empowered patients. ISRCTN14644286. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Feasibility of personalised remote long-term follow-up of people with cochlear implants: a randomised controlled trial

PubMed Central

Kitterick, Padraig; Weal, Mark; Margol-Gromada, Magdalena

2018-01-01

Introduction Substantial resources are required to provide lifelong postoperative care to people with cochlear implants. Most patients visit the clinic annually. We introduced a person-centred remote follow-up pathway, giving patients telemedicine tools to use at home so they would only visit the centre when intervention was required. Objectives To assess the feasibility of comparing a remote care pathway with the standard pathway in adults using cochlear implants. Design Two-arm randomised controlled trial. Randomisation used a minimisation approach, controlling for potential confounding factors. Participant blinding was not possible, but baseline measures occurred before allocation. Setting University of Southampton Auditory Implant Service: provider of National Health Service care. Participants 60 adults who had used cochlear implants for at least 6 months. Interventions Control group (n=30) followed usual care pathway. Remote care group (n=30) received care remotely for 6 months incorporating: home hearing in noise test, online support tool and self-adjustment of device (only 10 had compatible equipment). Main outcome measures Primary: change in patient activation; measured using the Patient Activation Measure. Secondary: change in hearing and quality of life; qualitative feedback from patients and clinicians. Results One participant in the remote care group dropped out. The remote care group showed a greater increase in patient activation than the control group. Changes in hearing differed between the groups. The remote care group improved on the Triple Digit Test hearing test; the control group perceived their hearing was worse on the Speech, Spatial and Qualities of Hearing Scale questionnaire. Quality of life remained unchanged in both groups. Patients and clinicians were generally positive about remote care tools and wanted to continue. Conclusions Adults with cochlear implants were willing to be randomised and complied with the protocol. Personalised remote care for long-term follow-up is feasible and acceptable, leading to more empowered patients. Trial registration number ISRCTN14644286. PMID:29678970

The implications of e-health system delivery strategies for integrated healthcare: lessons from England.

PubMed

Eason, Ken; Waterson, Patrick

2013-05-01

This paper explores the implications that different technical strategies for sharing patient information have for healthcare workers and, as a consequence, for the extent to which these systems provide support for integrated care. Four technical strategies were identified and the forms of coupling they made with healthcare agencies were classified. A study was conducted in England to examine the human and organizational implications of systems implemented by these four strategies. Results were used from evaluation reports of two systems delivered as part of the NPfIT (National Programme for Information Technology) and from user responses to systems delivered in two local health communities in England. In the latter study 40 clinical respondents reported the use of systems to support integrated care in six healthcare pathways. The implementation of a detailed care record system (DCRS) in the NPfIT was problematic because it could not meet the diverse needs of all healthcare agencies and it required considerable local customization. The programme evolved to allow different systems to be delivered for each local health community. A national Summary Care Record (SCR) was implemented but many concerns were raised about wide access to confidential patient information. The two technical strategies that required looser forms of coupling and were under local control led to wide user adoption. The systems that enabled data to be transferred between local systems were successfully used to support integrated care in specific healthcare pathways. The portal approach gave many users an opportunity to view patient data held on a number of databases and this system evolved over a number of years as a result of requests from the user community. The UK national strategy to deliver single shared database systems requires tight coupling between many users and has led to poor adoption because of the diverse needs of healthcare agencies. Sharing patient information has been more successful when local systems have been developed to serve particular healthcare pathways or when separate databases are viewable through a portal. On the basis of this evidence technical strategies that permit the local design of tight coupling are necessary if information systems are to support integrated care in healthcare pathways. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Pathways into mental health care for UK veterans: a qualitative study.

PubMed

Mellotte, Harriet; Murphy, Dominic; Rafferty, Laura; Greenberg, Neil

2017-01-01

Background : It is well established that veterans suffering from mental health difficulties under use mental health services. Objective : This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans' help-seeking and pathways to care. Method : The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results : Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans' help-seeking in future; these focussed on enhancing both veterans and health professionals' knowledge regarding mental health difficulties. Conclusions : This study identified a number of barriers and enablers that may impact a veteran's journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.

Pathways into mental health care for UK veterans: a qualitative study

PubMed Central

Mellotte, Harriet; Murphy, Dominic; Rafferty, Laura; Greenberg, Neil

2017-01-01

ABSTRACT Background: It is well established that veterans suffering from mental health difficulties under use mental health services. Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans’ help-seeking and pathways to care. Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans’ help-seeking in future; these focussed on enhancing both veterans and health professionals’ knowledge regarding mental health difficulties. Conclusions: This study identified a number of barriers and enablers that may impact a veteran’s journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours. PMID:29163864

Patient pathway: the ideal approach.

PubMed

Corless, Lynsey; Brew, Iain

2018-02-07

Hepatic encephalopathy (HE) can be a devastating complication of cirrhosis, affecting patients and their families. Multidisciplinary community and specialist teams must work together with patients and their families to recognise HE, identify and treat problems early, and minimise time spent unwell or in hospital. Primary care provides an ideal setting for patient education and reinforcement of the salient points on self-care. In the acute setting, the use of care pathways can ensure that the critical aspects of pharmacological, dietetic and supportive care are offered in a timely fashion to reduce morbidity and mortality. This article discusses strategies that can be used in primary and secondary care to help teams deliver excellent practice in HE management.

Managing patient pathways to achieve lung cancer waiting time targets: mixed methods study

PubMed Central

Ip, Hugh; Amer, Tarik; Dangoor, Michael; Zamir, Affan; Gibbings-Isaac, Darryl; Kochhar, Ranjeev; Heymann, Timothy

2012-01-01

Objectives England's National Health Service (NHS) introduced a 62-day target, from referral to treatment, to make lung cancer patient pathways more efficient. This study aims to understand pathway delays that lead to breaches of the target when patients need care in both secondary and tertiary setting, so more than one institution is involved. Design Mixed methods cross case analysis. Setting Two tertiary referral hospitals in London. Participants Database records of 53 patients were analysed. Nineteen sets of patient notes were used for pathway mapping. Seventeen doctors, four nurses, eight managers and administrators were interviewed. Main outcome measures Qualitative methods include pathway mapping and semi-structured interviews. Quantitative analysis of patient pathway times from cancer services records. Results The majority of the patient pathway (68.4%) is spent in secondary centres. There is more variability in the processes of secondary centres but tertiary centres do not have perfect processes either. Three themes emerged from discussions: information flows, pathway performance and the role of the multidisciplinary approach. Conclusions The actions of secondary centres have a greater influence on whether a patient breaches the 62-day target, compared with tertiary centres. Nevertheless variability exists in both, with potential for improvement. PMID:23162682

Transitions of Care Model Inclusive of Unplanned Care Improves the Patient Experience

PubMed Central

Cox, Jon; Teague, Stephanie; Beck, Eric

2016-01-01

A major emphasis in health care is creating an experience whereby patients receive the right care at the right time from the right provider in the right setting at the right cost. Over the past several decades, there has been considerable effort in the area of medical management, with prior authorization, gatekeeper utilization management regimens, and other techniques designed to guide patients and caregivers into desired treatment pathways. Alternatively, the concept of demand management may be employed to achieve these desired outcomes by giving patients meaningful, expanded choices beyond traditional acute-care settings. The implementation of a novel, patient-centered, unplanned care delivery model is described along with illustrative case studies. PMID:28725828

Durations and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India.

PubMed

Mistry, Nerges; Rangan, Sheela; Dholakia, Yatin; Lobo, Eunice; Shah, Shimoni; Patil, Akshaya

2016-01-01

Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai. A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values. The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation. Achieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays.

Durations and Delays in Care Seeking, Diagnosis and Treatment Initiation in Uncomplicated Pulmonary Tuberculosis Patients in Mumbai, India

PubMed Central

Mistry, Nerges; Rangan, Sheela; Dholakia, Yatin; Lobo, Eunice; Shah, Shimoni; Patil, Akshaya

2016-01-01

Background Timely diagnosis and treatment initiation are critical to reduce the chain of transmission of Tuberculosis (TB) in places like Mumbai, where almost 60% of the inhabitants reside in overcrowded slums. This study documents the pathway from the onset of symptoms suggestive of TB to initiation of TB treatment and examines factors responsible for delay among uncomplicated pulmonary TB patients in Mumbai. Methods A population-based retrospective survey was conducted in the slums of 15 high TB burden administrative wards to identify 153 self-reported TB patients. Subsequently in-depth interviews of 76 consenting patients that fit the inclusion criteria were undertaken using an open-ended interview schedule. Mean total, first care seeking, diagnosis and treatment initiation duration and delays were computed for new and retreatment patients. Patients showing defined delays were divided into outliers and non-outliers for all three delays using the median values. Results The mean duration for the total pathway was 65 days with 29% of patients being outliers. Importantly the mean duration of first care seeking was similar in new (24 days) and retreatment patients (25 days). Diagnostic duration contributed to 55% of the total pathway largely in new patients. Treatment initiation was noted to be the least among the three durations with mean duration in retreatment patients twice that of new patients. Significantly more female patients experienced diagnostic delay. Major shift of patients from the private to public sector and non-allopaths to allopaths was observed, particularly for treatment initiation. Conclusion Achieving positive behavioural changes in providers (especially non-allopaths) and patients needs to be considered in TB control strategies. Specific attention is required in counselling of TB patients so that timely care seeking is effected at the time of relapse. Prioritizing improvement of environmental health in vulnerable locations and provision of point of care diagnostics would be singularly effective in curbing pathway delays. PMID:27018589

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review

PubMed Central

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R. Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-01-01

Background The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. Methods We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. Results We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Conclusion Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. PMID:29511005

Effectiveness of implementation interventions in improving physician adherence to guideline recommendations in heart failure: a systematic review.

PubMed

Shanbhag, Deepti; Graham, Ian D; Harlos, Karen; Haynes, R Brian; Gabizon, Itzhak; Connolly, Stuart J; Van Spall, Harriette Gillian Christine

2018-03-06

The uptake of guideline recommendations that improve heart failure (HF) outcomes remains suboptimal. We reviewed implementation interventions that improve physician adherence to these recommendations, and identified contextual factors associated with implementation success. We searched databases from January 1990 to November 2017 for studies testing interventions to improve uptake of class I HF guidelines. We used the Cochrane Effective Practice and Organisation of Care and Process Redesign frameworks for data extraction. Primary outcomes included: proportion of eligible patients offered guideline-recommended pharmacotherapy, self-care education, left ventricular function assessment and/or intracardiac devices. We reported clinical outcomes when available. We included 38 studies. Provider-level interventions (n=13 studies) included audit and feedback, reminders and education. Organisation-level interventions (n=18) included medical records system changes, multidisciplinary teams, clinical pathways and continuity of care. System-level interventions (n=3) included provider/institutional incentives. Four studies assessed multi-level interventions. We could not perform meta-analyses due to statistical/conceptual heterogeneity. Thirty-two studies reported significant improvements in at least one primary outcome. Clinical pathways, multidisciplinary teams and multifaceted interventions were most consistently successful in increasing physician uptake of guidelines. Among randomised controlled trials (RCT) (n=10), pharmacist and nurse-led interventions improved target dose prescriptions. Eleven studies reported clinical outcomes; significant improvements were reported in three, including a clinical pathway, a multidisciplinary team and a multifaceted intervention. Baseline assessment of barriers, staff training, iterative intervention development, leadership commitment and policy/financial incentives were associated with intervention effectiveness. Most studies (n=20) had medium risk of bias; nine RCTs had low risk of bias. Our study is limited by the quality and heterogeneity of the primary studies. Clinical pathways, multidisciplinary teams and multifaceted interventions appear to be most consistent in increasing guideline uptake. However, improvements in process outcomes were rarely accompanied by improvements in clinical outcomes. Our work highlights the need for improved research methodology to reliably assess the effectiveness of implementation interventions. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Antidepressant Medication Management among Older Patients Receiving Home Health Care

PubMed Central

Bao, Yuhua; Shao, Huibo; Bruce, Martha L.; Press, Matthew J.

2014-01-01

Objective Antidepressant management for older patients receiving home health care (HHC) may occur through two pathways: nurse-physician collaboration (without patient visits to the physician) and physician management through office visits. This study examines the relative contribution of the two pathways and how they interplay. Methods Retrospective analysis was conducted using Medicare claims of 7,389 depressed patients 65 or older who received HHC in 2006–7 and who possessed antidepressants at the start of HHC. A change in antidepressant therapy (vs. discontinuation or refill) was the main study outcome and could take the form of a change in dose, switch to a different antidepressant, or augmentation (addition of a new antidepressant). Logistic regressions were estimated to examine how use of home health nursing care, patient visits to physicians, and their interactions predict a change in antidepressant therapy. Results About 30% of patients experienced a change in antidepressants versus 51% who refilled and 18% who discontinued. Receipt of mental health specialty care was associated with a statistically significant, 10–20 percentage-point increase in the probability of antidepressant change; receipt of primary care was associated with a small and statistically significant increase in the probability of antidepressant change among patients with no mental health specialty care and above-average utilization of nursing care. Increased home health nursing care in absence of physician visits was not associated with increased antidepressant change. Conclusions Active antidepressant management resulting in a change in medication occurred on a limited scale among older patients receiving HHC. Addressing knowledge and practice gaps in antidepressant management by primary care providers and home health nurses and improving nurse-physician collaboration will be promising areas for future interventions. PMID:25158915

Exploring the Viability of School-Based Support for Vulnerable Children: A Case Study of Two Township Schools in Johannesburg. CREATE Pathways to Access. Research Monograph No. 46

ERIC Educational Resources Information Center

Williams, Samantha E.

2010-01-01

The South African Department of Education is working with multiple non-governmental organisations (NGOs) to transform schools into "caring schools" that emphasise: health promotion, safety, care for orphans and vulnerable children, quality education, community engagement and respect for rights and equality. Using a qualitative case study…

Benchmarking the perioperative process: II. Introducing anesthesia clinical pathways to improve processes and outcomes and to reduce nursing labor intensity in ambulatory orthopedic surgery.

PubMed

Williams, B A; DeRiso, B M; Engel, L B; Figallo, C M; Anders, J W; Sproul, K A; Ilkin, H; Harner, C D; Fu, F H; Nagarajan, N J; Evans, J H; Watkins, W D

1998-11-01

(1) To introduce anesthesia clinical pathways as a management tool to improve the quality of care; (2) to use the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as a template for data collection and analysis; and (3) to determine the effects of anesthesia clinical pathways on surgical processes, outcomes, and costs in common ambulatory orthopedic surgery. Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathways existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. Regional anesthesia options were routinely offered to patients in the clinical pathway. Ambulatory surgery center in a teaching hospital. The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients underwent clinical pathway anesthesia care in which the intraoperative and postoperative anesthesia process was standardized with respect to symptom management, drugs, and equipment used. 1995-1996 patients did not have a standardized intraoperative and postoperative anesthetic course with respect to the management of common symptoms or to specific drugs and supplies used. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by the use of the anesthesia clinical pathway, were measured. Clinical pathway anesthesia care of ACLR in 1996-1997, which actively incorporated regional anesthesia options, reduced pharmacy and materials cost variability; slightly increased turnover time; improved intraoperative anesthesia and surgical efficiency, recovery times, and unexpected admission rates; and decreased the number of required nursing interventions for common postoperative symptoms. Clinical pathway patient management systems in anesthesia care are likely to produce useful outcome data of current practice patterns when compared with historical controls. This management tool may be useful in simultaneously containing costs and improving process efficiency and patient outcomes.

Outpatient virtual clinical encounters after complex surgery for cancer: a prospective pilot study of "TeleDischarge".

PubMed

Katz, Matthew H G; Slack, Rebecca; Bruno, Morgan; McMillan, Jermaine; Fleming, Jason B; Lee, Jeffrey E; Bednarski, Brian; Papadopoulos, John; Matin, Surena F

2016-05-01

Outpatient clinical encounters are used to promote recovery after complex surgical procedures for cancer. These care episodes are resource intensive. Virtual clinical encounters (VCEs) can now be conducted using widely available videoconferencing technologies. However, whether these technologies may be used to monitor postoperative recovery is unknown. In this pilot study, we provided care using a comprehensive "TeleDischarge" protocol to 15 patients after pancreatectomy. In addition to routine follow-up, all patients participated in two scheduled and an unlimited number of unscheduled VCEs using mobile hardware and secure videoconferencing software. We evaluated feasibility, patient satisfaction, postoperative adverse events, and health care human resource utilization. The median age of enrolled patients was 63 y (range, 52-83 y) and 93% underwent pancreatoduodenectomy. Twenty-eight scheduled VCEs (93%) were completed successfully, and only one unscheduled VCE was requested. Twelve patients (80%) felt their postoperative care was enhanced by VCEs and 14 (93%) felt that VCEs should be a regular part of postoperative care. Minor interventions in four patients (27%) were performed on the basis of clinical data gathered during a VCE. On a per patient basis, the TeleDischarge pathway was estimated to take 36 min longer and to have a direct labor cost $39 greater than the standard pathway. Secure VCEs can be conducted using widely available hardware and software solutions. Although cancer patients support the introduction of mobile technology into postoperative care, further studies are needed to identify ways in which such technology can be used most effectively and efficiently to reduce barriers to recovery. Copyright © 2016 Elsevier Inc. All rights reserved.

Information retrieval pathways for health information exchange in multiple care settings.

PubMed

Kierkegaard, Patrick; Kaushal, Rainu; Vest, Joshua R

2014-11-01

To determine which health information exchange (HIE) technologies and information retrieval pathways healthcare professionals relied on to meet their information needs in the context of laboratory test results, radiological images and reports, and medication histories. Primary data was collected over a 2-month period across 3 emergency departments, 7 primary care practices, and 2 public health clinics in New York state. Qualitative research methods were used to collect and analyze data from semi-structured interviews and participant observation. The study reveals that healthcare professionals used a complex combination of information retrieval pathways for HIE to obtain clinical information from external organizations. The choice for each approach was setting- and information-specific, but was also highly dynamic across users and their information needs. Our findings about the complex nature of information sharing in healthcare provide insights for informatics professionals about the usage of information; indicate the need for managerial support within each organization; and suggest approaches to improve systems for organizations and agencies working to expand HIE adoption.

Clinical Pathways: Recommendations for Putting Patients at the Center of Value-Based Care.

PubMed

Abrahams, Edward; Balch, Alan; Goldsmith, Patricia; Kean, Marcia; Miller, Amy M; Omenn, Gilbert; Sonet, Ellen; Sprandio, John; Tyne, Courtney; Westrich, Kimberly

2017-08-15

Two major trends that have been affecting the provision of oncology care in the United States are a shift from volume-based to value-based care and a push toward patient-centered healthcare. However, these two trends are not always completely aligned with each other. Value-based payment models, including clinical pathways, are one strategy being implemented by oncology stakeholders to help encourage the uptake of value-based oncology care. If structured with the patient in mind, they can improve quality of care for patients with cancer, decrease inappropriate care while enabling appropriate personalization of care, and constrain rising prices by demanding a stronger link between cost and value. If not structured appropriately, they can limit patient choice, impede access to innovative treatments, and encourage one-size-fits-all oncology care. Clin Cancer Res; 23(16); 4545-9. ©2017 AACR . ©2017 American Association for Cancer Research.

The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units.

PubMed

Vogus, Timothy J; Sutcliffe, Kathleen M

2011-01-01

Prior research has found that safety organizing behaviors of registered nurses (RNs) positively impact patient safety. However, little research exists on the joint benefits of safety organizing and other contextual factors that help foster safety. Although we know that organizational practices often have more powerful effects when combined with other mutually reinforcing practices, little research exists on the joint benefits of safety organizing and other contextual factors believed to foster safety. Specifically, we examined the benefits of bundling safety organizing with leadership (trust in manager) and design (use of care pathways) factors on reported medication errors. A total of 1033 RNs and 78 nurse managers in 78 emergency, internal medicine, intensive care, and surgery nursing units in 10 acute-care hospitals in Indiana, Iowa, Maryland, Michigan, and Ohio who completed questionnaires between December 2003 and June 2004. Cross-sectional analysis of medication errors reported to the hospital incident reporting system for the 6 months after the administration of the survey linked to survey data on safety organizing, trust in manager, use of care pathways, and RN characteristics and staffing. Multilevel Poisson regression analyses indicated that the benefits of safety organizing on reported medication errors were amplified when paired with high levels of trust in manager or the use of care pathways. Safety organizing plays a key role in improving patient safety on hospital nursing units especially when bundled with other organizational components of a safety supportive system.

Time to diagnosis and treatment for cancer patients in the Netherlands: Room for improvement?

PubMed

Helsper, Charles C W; van Erp, Nicole N F; Peeters, Petra P H M; de Wit, Niek N J

2017-12-01

Reducing the duration of the diagnostic cancer care pathway is intensively pursued. The aim of this study was to chart the diagnostic pathway for the five most common cancers in the Netherlands. A retrospective cohort study using cancer patients' anonymised primary care data (free text and coded) linked to the Netherlands Cancer Registry. We determined the median duration of the following: 1. Primary care intervals (IPCs): the first cancer-related general practitioner consultation to referral, 2. Referral intervals (IRs): referral to diagnosis, 3. Treatment intervals (ITs): diagnosis to treatment and the overarching intervals, 4. Diagnostic intervals (IDs): IPC and IR combined and 5. Health care intervals (IHCs): IPC, IR and IT combined. For 465, 309, 197, 237 and 149 patients diagnosed with breast-, colorectal-, lung-, prostate cancer and melanoma, respectively; median IPC, IR and ID durations were shortest for breast cancer and melanoma (ID duration 7 and 21 days, respectively), intermediate for lung- and colon cancer (ID duration 49 and 54 days) and the longest for prostate cancer (ID duration 137 days). For all cancers, the duration of intervals increased steeply for the 10-25% with longest durations. For colorectal cancer, increasing ID durations showed increasing proportions of time attributable to primary care (IPC). Approximately 10-25% of cancer patients show substantially long duration of diagnostic intervals. Reducing primary care delay seems particularly relevant for colorectal cancer. Copyright © 2017 Elsevier Ltd. All rights reserved.

Rationale and Design of the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study

PubMed Central

Coburn, Brian W; Cheetham, T Craig; Rashid, Nazia; Chang, John M; Levy, Gerald D; Kerimian, Artak; Low, Kimberly J; Redden, David T; Bridges, S Louis; Saag, Kenneth G; Curtis, Jeffrey R; Mikuls, Ted R

2016-01-01

Background Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA < 6.0 mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. Methods To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18 years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA < 6.0 mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. Conclusion Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients. PMID:27449546

Rationale and design of the randomized evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study.

PubMed

Coburn, Brian W; Cheetham, T Craig; Rashid, Nazia; Chang, John M; Levy, Gerald D; Kerimian, Artak; Low, Kimberly J; Redden, David T; Bridges, S Louis; Saag, Kenneth G; Curtis, Jeffrey R; Mikuls, Ted R

2016-09-01

Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA<6.0mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA<6.0mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Plasma Glycoproteomics Reveals Sepsis Outcomes Linked to Distinct Proteins in Common Pathways

PubMed Central

DeLeon-Pennell, Kristine Y.; Nguyen, Nguyen T.; de Castro Brás, Lisandra E.; Flynn, Elizabeth R.; Cannon, Presley L.; Griswold, Michael E.; Jin, Yu-Fang; Puskarich, Michael A.; Jones, Alan E.; Lindsey, Merry L.

2015-01-01

Objective Sepsis remains a predominant cause of mortality in the ICU, yet strategies to increase survival have proved largely unsuccessful. This study aimed to identify proteins linked to sepsis outcomes using a glycoproteomic approach to target extracellular proteins that trigger downstream pathways and direct patient outcomes. Design Plasma was obtained from the LacTATEs cohort. N-linked plasma glycopeptides were quantified by solid-phase extraction coupled with mass spectrometry. Glycopeptides were assigned to proteins using RefSeq and visualized in a heat map. Protein differences were validated by immunoblotting, and proteins were mapped for biological processes using Database for Annotation, Visualization and Integrated Discovery and for functional pathways using Kyoto Encyclopedia of Genes and Genomes databases. Setting Hospitalized care. Measurements and Main Results A total of 501 glycopeptides corresponding to 234 proteins were identified. Of these, 66 glycopeptides were unique to the survivor group and corresponded to 54 proteins, 60 were unique to the nonsurvivor group and corresponded to 43 proteins, and 375 were common responses between groups and corresponded to 137 proteins. Immunoblotting showed that nonsurvivors had increased total kininogen; decreased total cathepsin-L1, vascular cell adhesion molecule, periostin, and neutrophil gelatinase–associated lipocalin; and a two-fold decrease in glycosylated clusterin (all p < 0.05). Kyoto Encyclopedia of Genes and Genomes analysis identified six enriched pathways. Interestingly, survivors relied on the extrinsic pathway of the complement and coagulation cascade, whereas nonsurvivors relied on the intrinsic pathway. Conclusion This study identifies proteins linked to patient outcomes and provides insight into unexplored mechanisms that can be investigated for the identification of novel therapeutic targets. (Crit Care Med 2015; XX:00–00) PMID:26086942

Hearing Impairment Affects Dementia Incidence. An Analysis Based on Longitudinal Health Claims Data in Germany

PubMed Central

Teipel, Stefan; Óvári, Attila; Kilimann, Ingo; Witt, Gabriele; Doblhammer, Gabriele

2016-01-01

Recent research has revealed an association between hearing impairment and dementia. The objective of this study is to determine the effect of hearing impairment on dementia incidence in a longitudinal study, and whether ear, nose, and throat (ENT) specialist care, care level, institutionalization, or depression mediates or moderates this pathway. The present study used a longitudinal sample of 154,783 persons aged 65 and older from claims data of the largest German health insurer; containing 14,602 incident dementia diagnoses between 2006 and 2010. Dementia and hearing impairment diagnoses were defined according to International Classification of Diseases, Tenth Revision, codes. We used a Kaplan Meier estimator and performed Cox proportional hazard models to explore the effect of hearing impairment on dementia incidence, controlling for ENT specialist care, care level, institutionalization, and depression. Gender, age, and comorbidities were controlled for as potential confounders. Patients with bilateral (HR = 1.43, p<0.001) and side-unspecified (HR = 1.20, p<0.001) hearing impairment had higher risks of dementia incidence than patients without hearing impairment. We found no significant effect for unilateral hearing impairment and other diseases of the ear. The effect of hearing impairment was only partly mediated through ENT specialist utilization. Significant interaction between hearing impairment and specialist care, care level, and institutionalization, respectively, indicated moderating effects. We discuss possible explanations for these effects. This study underlines the importance of the association between hearing impairment and dementia. Preserving hearing ability may maintain social participation and may reduce the burden associated with dementia. The particular impact of hearing aid use should be the subject of further investigations, as it offers potential intervention on the pathway to dementia. PMID:27391486

Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial.

PubMed

Røsstad, Tove; Salvesen, Øyvind; Steinsbekk, Aslak; Grimsmo, Anders; Sletvold, Olav; Garåsen, Helge

2017-04-17

Improved discharge arrangements and targeted post-discharge follow-up can reduce the risk of adverse events after hospital discharge for elderly patients. Although more care is to shift from specialist to primary care, there are few studies on post-discharge interventions run by primary care. A generic care pathway, Patient Trajectory for Home-dwelling elders (PaTH) including discharge arrangements and follow-up by primary care, was developed and introduced in Central Norway Region in 2009, applying checklists at defined stages in the patient trajectory. In a previous paper, we found that PaTH had potential of improving follow-up in primary care. The aim of this study was to establish the effect of PaTH-compared to usual care-for elderly in need of home care services after discharge from hospital. We did an unblinded, cluster randomised controlled trial with 12 home care clusters. Outcomes were measured at the patient level during a 12-month follow-up period for the individual patient and analysed applying linear and logistic mixed models. Primary outcomes were readmissions within 30 days and functional level assessed by Nottingham extended ADL scale. Secondary outcomes were number and length of inpatient hospital care and nursing home care, days at home, consultations with the general practitioners (GPs), mortality and health related quality of life (SF-36). One-hundred and sixty-three patients were included in the PaTH group (six clusters), and 141 patients received care as usual (six clusters). We found no statistically significant differences between the groups for primary and secondary outcomes except for more consultations with the GPs in PaTH group (p = 0.04). Adherence to the intervention was insufficient as only 36% of the patients in the intervention group were assessed by at least three of the four main checklists in PaTH, but this improved over time. Lack of adherence to PaTH rendered the study inconclusive regarding the elderly's functional level, number of readmissions after hospital discharge, and health care utilisation except for more consultations with the GPs. A targeted exploration of prerequisites for implementation is recommended in the pre-trial phase of complex intervention studies. Clinical Trials.gov NCT01107119 , retrospectively registered 2010.04.18.

Use of a clinical pathway to improve the acute management of vaso-occlusive crisis pain in pediatric sickle cell disease.

PubMed

Ender, Katherine L; Krajewski, Jennifer A; Babineau, John; Tresgallo, Mary; Schechter, William; Saroyan, John M; Kharbanda, Anupam

2014-04-01

The most common, debilitating morbidity of sickle cell disease (SCD) is vaso-occlusive crisis (VOC) pain. Although guidelines exist for its management, they are generally not well-followed, and research in other pediatric diseases has shown that clinical pathways improve care. The purpose of our study was to determine whether a clinical pathway improves the acute management of sickle cell vaso-occlusive crisis (VOC) pain in the pediatric emergency department (PED). Pain management practices were prospectively investigated before and after the initiation of a clinical pathway in the PED of an urban, tertiary care center with 50,000 ED visits per year and approximately 200 active sickle cell patients. The pathway included instructions for triage, monitoring, medication administration, and timing of assessments and interventions. Data were eligible from 35 pre-pathway and 33 post-pathway visits. Primary outcome was time interval to administration of first analgesic medication. Statistical analysis was by Student's t-test, using natural-log-transformed data for outcomes with skewed distribution curves. Time interval to first analgesic improved from 74 to 42 minutes (P = 0.012) and to first opioid from 94 to 46 minutes (P = 0.013). The percentage of patients who received ketorolac increased from 57% to 82% (P = 0.03). Decrease in time interval to subsequent pain score assessment was not statistically significant (110 to 72 minutes (P = 0.07)), and change in pain score was not different (P = 0.25). The use of a clinical pathway for sickle cell VOC in the PED can improve important aspects of pain management and merits further investigation and implementation. © 2013 Wiley Periodicals, Inc.

PATHway I: design and rationale for the investigation of the feasibility, clinical effectiveness and cost-effectiveness of a technology-enabled cardiac rehabilitation platform.

PubMed

Claes, Jomme; Buys, Roselien; Woods, Catherine; Briggs, Andrew; Geue, Claudia; Aitken, Moira; Moyna, Niall; Moran, Kieran; McCaffrey, Noel; Chouvarda, Ioanna; Walsh, Deirdre; Budts, Werner; Filos, Dimitris; Triantafyllidis, Andreas; Maglaveras, Nicos; Cornelissen, Véronique A

2017-06-30

Exercise-based cardiac rehabilitation (CR) independently alters the clinical course of cardiovascular diseases resulting in a significant reduction in all-cause and cardiac mortality. However, only 15%-30% of all eligible patients participate in a phase 2 ambulatory programme. The uptake rate of community-based programmes following phase 2 CR and adherence to long-term exercise is extremely poor. Newer care models, involving telerehabilitation programmes that are delivered remotely, show considerable promise for increasing adherence. In this view, the PATHway (Physical Activity Towards Health) platform was developed and now needs to be evaluated in terms of its feasibility and clinical efficacy. In a multicentre randomised controlled pilot trial, 120 participants (m/f, age 40-80 years) completing a phase 2 ambulatory CR programme will be randomised on a 1:1 basis to PATHway or usual care. PATHway involves a comprehensive, internet-enabled, sensor-based home CR platform and provides individualised heart rate monitored exercise programmes (exerclasses and exergames) as the basis on which to provide a personalised lifestyle intervention programme. The control group will receive usual care. Study outcomes will be assessed at baseline, 3 months and 6 months after completion of phase 2 of the CR programme. The primary outcome is the change in active energy expenditure. Secondary outcomes include cardiopulmonary endurance capacity, muscle strength, body composition, cardiovascular risk factors, peripheral endothelial vascular function, patient satisfaction, health-related quality of life (HRQoL), well-being, mediators of behaviour change and safety. HRQoL and healthcare costs will be taken into account in cost-effectiveness evaluation. The study will be conducted in accordance with the Declaration of Helsinki. This protocol has been approved by the director and clinical director of the PATHway study and by the ethical committee of each participating site. Results will be disseminated via peer-reviewed scientific journals and presentations at congresses and events. NCT02717806. This trial is currently in the pre-results stage. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Measuring the cost of care in benign prostatic hyperplasia using time-driven activity-based costing (TDABC).

PubMed

Kaplan, A L; Agarwal, N; Setlur, N P; Tan, H J; Niedzwiecki, D; McLaughlin, N; Burke, M A; Steinberg, K; Chamie, K; Saigal, C S

2015-03-01

Determining '"value'" in health care, defined as outcomes per unit cost, depends on accurately measuring cost. We used time-driven activity-based costing (TDABC) to determine the cost of care in men with benign prostatic hyperplasia (BPH) - a common urologic condition. We implemented TDABC across the entire care pathway for BPH including primary and specialist care in both inpatient and outpatient settings. A team of expert stakeholders created detailed process maps, determined space and product costs, and calculated personnel capacity cost rates. A model pathway was derived from practice guidelines and calculated costs were applied. Although listed as 'optional' in practice guidelines, invasive diagnostic testing can increase costs by 150% compared with the standalone urology clinic visit. Of five different surgical options, a 400% cost discrepancy exists between the most and least expensive treatments. TDABC can be used to measure cost across an entire care pathway in a large academic medical center. Sizable cost variation exists between diagnostic and surgical modalities for men with BPH. As financial risk is shifted toward providers, understanding the cost of care will be vital. Future work is needed to determine outcome discrepancy between the diagnostic and surgical modalities in BPH. Copyright © 2014 Elsevier Inc. All rights reserved.

American Society for Enhanced Recovery: Advancing Enhanced Recovery and Perioperative Medicine.

PubMed

Gan, Tong J; Scott, Michael; Thacker, Julie; Hedrick, Traci; Thiele, Robert H; Miller, Timothy E

2018-06-01

As the population ages, the increasing surgical volume and complexity of care are expected to place additional care delivery burdens in the perioperative setting. In this age of integrated multidisciplinary care of the surgical patients, there is increasing recognition that an evidence-based perioperative pathway is associated with the optimal outcomes. These pathways, collectively referred to as Enhanced Recovery Pathways, have resulted in shortened length of hospital stay, reduced complications, and variance in outcomes, as well as earlier return to baseline activities. The American Society for Enhanced Recovery (ASER) is a multispecialty, nonprofit international organization, dedicated to the practice of enhanced recovery in perioperative patients through education and research. Perioperative Quality Initiatives were formed whose intent is to organize a series of consensus conferences on topics of interest related to perioperative medicine. The journal affiliation between American Society for Enhanced Recovery and Anesthesia & Analgesia will enable these evidence-based practices to be disseminated widely and swiftly to the practicing perioperative health care professionals so they can be adopted to improve the quality of perioperative surgical care.

Opening the black box: the impact of an oncology management program consisting of level I pathways and an outbound nurse call system.

PubMed

Hoverman, J Russell; Klein, Ira; Harrison, Debra W; Hayes, Jad E; Garey, Jody S; Harrell, Robyn; Sipala, Maria; Houldin, Scott; Jameson, Melissa D; Abdullahpour, Mitra; McQueen, Jessica; Nelson, Greg; Verrilli, Diana K; Neubauer, Marcus

2014-01-01

The Innovent Oncology Program aims to improve the value of cancer care delivered to patients. McKesson Specialty Health and Texas Oncology (TXO) collaborated with Aetna to launch a pilot program. The study objectives were to evaluate the impact of Innovent on Level I Pathway compliance, implement the Patient Support Services program, and measure the rate and costs associated with chemotherapy-related emergency room (ER) visits and hospital admissions. This was a prospective, nonrandomized evaluation of patients enrolled in Innovent from June 1, 2010, through May 31, 2012. Data from the iKnowMed electronic health record, the McKesson Specialty Health financial data warehouse, and Aetna claims data warehouse were analyzed. A total of 221 patients were included and stratified according to disease and age groups; 76% of ordered regimens were on pathway; 24% were off pathway. Pathway adherence improved from TXO baseline adherence of 63%. Of the 221 patients, 81% enrolled in PSS. Within the breast, colorectal, and lung cancer groups, 14% and 24% of patients had an ER visit and in-patient admission (IPA; baseline) versus 10% and 18% in Innovent, respectively; average in-patient days decreased from 2.1 to 1.2 days, respectively. Total savings combined for the program was $506,481. Implementation of Innovent positively affected patient care in several ways: Fewer ER visits and IPAs occurred, in-patient days decreased, cancer-related use costs were reduced, and on-pathway adherence increased.

Structured syncope care pathways based on lean six sigma methodology optimises resource use with shorter time to diagnosis and increased diagnostic yield.

PubMed

Martens, Leon; Goode, Grahame; Wold, Johan F H; Beck, Lionel; Martin, Georgina; Perings, Christian; Stolt, Pelle; Baggerman, Lucas

2014-01-01

To conduct a pilot study on the potential to optimise care pathways in syncope/Transient Loss of Consciousness management by using Lean Six Sigma methodology while maintaining compliance with ESC and/or NICE guidelines. Five hospitals in four European countries took part. The Lean Six Sigma methodology consisted of 3 phases: 1) Assessment phase, in which baseline performance was mapped in each centre, processes were evaluated and a new operational model was developed with an improvement plan that included best practices and change management; 2) Improvement phase, in which optimisation pathways and standardised best practice tools and forms were developed and implemented. Staff were trained on new processes and change-management support provided; 3) Sustaining phase, which included support, refinement of tools and metrics. The impact of the implementation of new pathways was evaluated on number of tests performed, diagnostic yield, time to diagnosis and compliance with guidelines. One hospital with focus on geriatric populations was analysed separately from the other four. With the new pathways, there was a 59% reduction in the average time to diagnosis (p = 0.048) and a 75% increase in diagnostic yield (p = 0.007). There was a marked reduction in repetitions of diagnostic tests and improved prioritisation of indicated tests. Applying a structured Lean Six Sigma based methodology to pathways for syncope management has the potential to improve time to diagnosis and diagnostic yield.

Structured Syncope Care Pathways Based on Lean Six Sigma Methodology Optimises Resource Use with Shorter Time to Diagnosis and Increased Diagnostic Yield

PubMed Central

Martens, Leon; Goode, Grahame; Wold, Johan F. H.; Beck, Lionel; Martin, Georgina; Perings, Christian; Stolt, Pelle; Baggerman, Lucas

2014-01-01

Aims To conduct a pilot study on the potential to optimise care pathways in syncope/Transient Loss of Consciousness management by using Lean Six Sigma methodology while maintaining compliance with ESC and/or NICE guidelines. Methods Five hospitals in four European countries took part. The Lean Six Sigma methodology consisted of 3 phases: 1) Assessment phase, in which baseline performance was mapped in each centre, processes were evaluated and a new operational model was developed with an improvement plan that included best practices and change management; 2) Improvement phase, in which optimisation pathways and standardised best practice tools and forms were developed and implemented. Staff were trained on new processes and change-management support provided; 3) Sustaining phase, which included support, refinement of tools and metrics. The impact of the implementation of new pathways was evaluated on number of tests performed, diagnostic yield, time to diagnosis and compliance with guidelines. One hospital with focus on geriatric populations was analysed separately from the other four. Results With the new pathways, there was a 59% reduction in the average time to diagnosis (p = 0.048) and a 75% increase in diagnostic yield (p = 0.007). There was a marked reduction in repetitions of diagnostic tests and improved prioritisation of indicated tests. Conclusions Applying a structured Lean Six Sigma based methodology to pathways for syncope management has the potential to improve time to diagnosis and diagnostic yield. PMID:24927475

One Chance to Get it Right: understanding the new guidance for care of the dying person.

PubMed

Sykes, Nigel

2015-09-01

Following criticism of the Liverpool Care of the Dying Pathway (LCP), widely used to guide care of dying people in British health-care settings, the UK Government set up an independent review which in 2013 recommended that use of the LCP be discontinued. In response, the Leadership Alliance for the Care of Dying People, a coalition of a wide range of stakeholders, recently published guidance entitled One Chance to Get it Right. This guidance contains five Priorities of Care for the dying person that are intended to guide clinical staff and will inform Care Quality Commission inspections of health-care providers. This article summarizes the background to One Chance to Get it Right and the guidance it contains. One Chance to Get it Right, More Care, Less Pathway and related guidance documents. The need to improve the standard of end-of-life care in every clinical setting. The value of a pathway-based approach to end-of-life care in a context where well-implemented programmes of staff education in the subject are lacking. Public concern with, and scrutiny of, the quality of dying in the UK health-care system, particularly in hospitals but also the ability of patients to die well at home where that is their place of choice. Effective methods of teaching end of life care to all clinical staff; the effect upon families of caring for a dying relative at home; the optimum type, quantity and source of external support to informal carers that is perceived by them as adequate and enables the ill person to die well in in their own home; fuller understanding of the physiology of dying. © The Author 2015. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Integrated palliative care in the Spanish context: a systematic review of the literature.

PubMed

Garralda, Eduardo; Hasselaar, Jeroen; Carrasco, José Miguel; Van Beek, Karen; Siouta, Naouma; Csikos, Agnes; Menten, Johan; Centeno, Carlos

2016-05-13

Integrated palliative care (IPC) involves bringing together administrative, organisational, clinical and service aspects in order to achieve continuity of care between all actors involved in the care network of patients receiving palliative care (PC) services. The purpose of this study is to identify literature on IPC in the Spanish context, either in cancer or other advanced chronic diseases. Systematic review of the literature about IPC published in Spain between 1995 and 2013. Sources searched included PubMed, Cochrane Library, Cinahl, the national palliative care Journal (Medicina Paliativa), and Google. Evidence on IPC in care models, pathways, guidelines and other relevant documents were searched. Additionally, data were included from expert sources. Elements of IPC were considered based on the definition of IPC and the Emmanuel´s IPC tool. The main inclusion criterion was a comprehensive description of PC integration. Out of a total of 2,416 titles screened, 49 were included. We found two models describing IPC interventions achieving continuity and appropriateness of care as a result, 12 guidelines or pathways (most of them with a general approach including cancer and non-cancer and showing a theoretical IPC inclusion as measured by Emmanuel's tool) and 35 other significant documents as for their context relevance (17 health strategy documents, 14 analytical studies and 4 descriptive documents). These last documents comprised respectively: regional and national plans with an IPC inclusion evidence, studies focused on IPC into primary care and resource utilisation; and descriptions of fruitful collaboration programmes between PC teams and oncology departments. The results show that explications of IPC in the Spanish literature exist, but that there is insufficient evidence of its impact in clinical practice. This review may be of interest for Spanish-speaking countries and for others seeking to know the status of IPC in the literature in their home nations.

Improving care standards for patients with spinal trauma combining a modified e-Delphi process and stakeholder interviews: a study protocol.

PubMed

Sharwood, Lisa N; Stanford, Ralph; Middleton, James W; Burns, Brian; Joseph, Anthony; Flower, Oliver; Rigby, Oran; Ball, Jonathon; Dhaliwal, Shelly

2017-01-19

Around 300 people sustain a new traumatic spinal cord injury (TSCI) in Australia each year; a relatively low incidence injury with extremely high long-term associated costs. Care standards are inconsistent nationally, lacking in consensus across important components of care such as prehospital spinal immobilisation, timing of surgery and timeliness of transfer to specialist services. This study aims to develop 'expertly defined' and agreed standards of care across the majority of disciplines involved for these patients. A modified e-Delphi process will be used to gain consensus for best practice across specific clinical early care areas for the patient with TSCI; invited participants will include clinicians across Australia with relevant and significant expertise. A rapid literature review will identify available evidence, including any current guidelines from 2005 to 2015. Level and strength of evidence identified, including areas of contention, will be used to formulate the first round survey questions and statements. Participants will undertake 2-3 online survey rounds, responding anonymously to questionnaires regarding care practices and indicating their agreement or otherwise with practice standard statements. Relevant key stakeholders, including patients, will also be interviewed face to face. Ethics approval for this study was obtained by the NSW Population & Health Services Research Ethics Committee on 14 January 2016 (HREC/12/CIPHS/74). Seeking comprehensive understanding of how the variation in early care pathways and treatment can be addressed to achieve optimal patient outcomes and economic costs; the overall aim is the agreement to a consistent approach to the triage, treatment, transport and definitive care of acute TSCI victims. The agreed practice standards of care will inform the development of a Clinical Pathway with practice change strategies for implementation. These standards will offer a benchmark for state-wide and potentially national policy. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care.

PubMed

Boisvert, Isabelle; Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices.

Reactivity Of Substituted Chlorines And Ensuing Dechlorination Pathways Of Select PCB Congeners With Pd/Mg Bimetallics

EPA Science Inventory

Conflicting accounts occur on the reactivity of substituted chlorines and the ensuing dechlorination pathway of PCBs undergoing catalytic hydrodechlorination (HDCl). In order to understand these relationships, intermediates and dechlorination pathways of carefully selected 17 co...

Improving hip fracture outcomes with integrated orthogeriatric care: a comparison between two accepted orthogeriatric models.

PubMed

Middleton, Mark; Wan, Bettina; da Assunçao, Ruy

2017-05-01

our orthopaedic trauma unit serves a large elderly population, admitting 400-500 hip fractures annually. A higher than expected mortality was detected amongst these patients, prompting a change in the hip fracture pathway. The aim of this study was to assess the impact of a change in orthogeriatric provision on hip fracture outcomes and care quality indicators. the hip fracture pathway was changed from a geriatric consultation service to a completely integrated service on a dedicated orthogeriatric ward. A total of 1,894 consecutive patients with hip fractures treated in the 2 years before and after this intervention were analysed. despite an increase in case complexity, the intervention resulted in a significant reduction in mean length of stay from 27.5 to 21 days (P < 0.001), a significant reduction in mean time to surgery from 41.8 to 27.2 h (P < 0.001) and a significant 22% reduction in 30-day mortality (13.2-10.3%, P = 0.04). After controlling for the effects of age, gender, American Society of Anesthesiology (ASA) Grade and abbreviated mental test score (AMTS), the effect of integrating orthogeriatric services into the hip fracture pathway significantly reduced the risk of mortality (odds ratio 0.68, P = 0.03). changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly improved mortality and performance indicators. This is the first study to directly compare two accepted models of orthogeriatric care in the same hospital. © The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Influencing Pathways to Quality of Life and HbA1c in Patients With Diabetes: A Longitudinal Study That Inform Evidence-Based Practice.

PubMed

Hsu, Hui-Chun; Lee, Yau-Jiunn; Wang, Ruey-Hsia

2018-04-01

Determining possible associated factors and the influencing pathways to hemoglobin A1C (HbA1C) levels and quality of life (QoL) will facilitate the development of effective interventions to improve the physical and psychosocial health of patients with type 2 diabetes mellitus (T2DM). To test a hypothesized model that addressed the pathways among personal characteristics, social support, diabetes distress, and self-care behaviors to HbA1C and QoL. A total of 382 adults with T2DM were recruited. Self-reported questionnaires and medical records were used to collect data regarding personal characteristics, diabetes distress, and social support at baseline. The self-care behaviors characters were collected 6 months later, as well as QoL and HbA1C levels 1 year later. The 12-month QoL directly affected 12-month HbA1C levels. The 6-month self-care behaviors directly affected 12-month QoL, and indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline diabetes distress directly affected 12-month QoL. Moreover, baseline diabetes distress indirectly affected 12-month HbA1C levels through 12-month QoL. Baseline social support directly affected baseline diabetes distress and 6-month self-care behaviors. In addition, baseline social support indirectly affected 12-month QoL through baseline diabetes distress. Baseline social support also indirectly affected 12-month QoL through 6-month self-care behaviors. Enhancing QoL is important to improve HbA1C levels. Enhancing self-care behaviors is essential to improve subsequent HbA1C control and QoL. Reducing diabetes distress is crucial to improve subsequent QoL. Improving social support is suggested a favorable strategy to reduce diabetes distress and enhance subsequent self-care behaviors in patients with T2DM. © 2018 Sigma Theta Tau International.

"There are too many steps before you get to where you need to be": help-seeking by patients with first-episode psychosis.

PubMed

Anderson, Kelly K; Fuhrer, Rebecca; Malla, Ashok K

2013-08-01

There has been substantial research on pathways to care in first-episode psychosis (FEP); however, few studies have used a qualitative research paradigm or have been done from the perspective of the person experiencing the psychotic episode. We sought to describe the experiences of patients with FEP on their pathway to care and to identify factors that help or hinder help-seeking efforts. Using a qualitative descriptive approach, we conducted semi-structured interviews with 16 patients recruited from an early intervention program. Data were analyzed using content analysis to organize the findings into themes. Self-stigma and a pervasive lack of knowledge regarding the symptoms of psychosis and availability of services were barriers to help-seeking. Participants highlighted the crucial role of significant others in initiating the help-seeking process. Participants typically described a complex series of contacts along the pathway to care which resulted in feelings of being misunderstood and losing control, but many individuals identified unexpected benefits of their experience. Our findings suggest a shift in the philosophy and orientation of service delivery towards the creation of services that address these concerns and are relevant to the young people who utilize them.

Development of a model of dementia support and pathway for culturally and linguistically diverse communities using co-creation and participatory action research

PubMed Central

Goeman, Dianne; King, Jordan; Koch, Susan

2016-01-01

Objective To develop an inclusive model of culturally sensitive support, using a specialist dementia nurse (SDN), to assist people with dementia from culturally and linguistically diverse (CALD) communities and their carers to overcome barriers to accessing health and social care services. Design Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and stakeholders. Setting An SDN support model embedded within a home nursing service in Melbourne, Australia was implemented between October 2013 and October 2015. Participants People experiencing memory loss or with a diagnosis of dementia from CALD backgrounds and their carers and family living in the community setting and expert stakeholders. Data collection and analysis Reflections from the SDN on interactions with participants and expert stakeholder opinion informed the CALD dementia support model and pathway. Results Interaction with 62 people living with memory loss or dementia from CALD backgrounds, carers or family members receiving support from the SDN and feedback from 13 expert stakeholders from community aged-care services, consumer advocacy organisations and ethnic community group representatives informed the development and refinement of the CALD dementia model of care and pathway. We delineate the three components of the ‘SDN’ model: the organisational support; a description of the role; and the competencies needed. Additionally, we provide an accompanying pathway for use by health professionals delivering care to consumers with dementia from CALD backgrounds. Conclusions Our culturally sensitive model of dementia care and accompanying pathway allows for the tailoring of health and social support to assist people from CALD backgrounds, their carers and families to adjust to living with memory loss and remain living in the community as long as possible. The model and accompanying pathway also have the potential to be rolled out nationally for use by health professionals across a variety of health services. PMID:27927662

Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings.

PubMed

Yamada, Janet; Potestio, Melissa L; Cave, Andrew J; Sharpe, Heather; Johnson, David W; Patey, Andrea M; Presseau, Justin; Grimshaw, Jeremy M

2017-12-20

This study aimed to apply a theory-based approach to identify barriers and enablers to implementing the Alberta Primary Care Asthma Pediatric Pathway (PCAPP) into clinical practice. Phase 1 included an assessment of assumptions underlying the intervention from the perspectives of the developers. Phase 2 determined the perceived barriers and enablers for: 1) primary care physicians' prescribing practices, 2) allied health care professionals' provision of asthma education to parents, and 3) children and parents' adherence to their treatment plans. Interviews were conducted with 35 individuals who reside in Alberta, Canada. Phase 1 included three developers. Phase 2 included 11 primary care physicians, 10 allied health care professionals, and 11 parents of children with asthma. Phase 2 interviews were based on the 14 domains of the Theoretical Domains Framework (TDF). Transcribed interviews were analyzed using a directed content analysis. Key assumptions by the developers about the intervention, and beliefs by others about the barriers and enablers of the targeted behaviors were identified. Eight TDF domains mapped onto the assumptions of the pathway as described by the intervention developers. Interviews with health care professionals and parents identified nine TDF domains that influenced the targeted behaviors: knowledge, skills, beliefs about capabilities, social/professional role and identity, beliefs about consequences, environmental context and resources, behavioral regulation, social influences, and emotions. Barriers and enablers perceived by health care professionals and parents that influenced asthma management will inform the optimization of the PCAPP prior to its evaluation.

The value transformation of health care: Impact on neuromuscular and electrodiagnostic medicine.

PubMed

Narayanaswami, Pushpa; Suk, Millie; Jones, Lyell K

2017-10-01

Beginning in 2017, most physicians who participate in Medicare are subject to the Medicare Access and CHIP Reauthorization Act (MACRA), the milestone legislation that signals the US health care system's transition from volume-based to value-based care. Here we review emerging trends in development of value-based healthcare systems in the US. MACRA and the resulting Quality Payment Program create 2 participation pathways, the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (AAPM) pathway. Although there are several program incentives for AAPM participation, to date there have been few AAPM options for specialists. MIPS and its widening bonus and penalty window will likely be the primary participation pathway in the early years of the program. Value-based payment has the potential to reshape health care delivery in the United States, with implications for neuromuscular and electrodiagnostic (EDX) specialists. Meaningful quality measures are required for neuromuscular and EDX specialists. Muscle Nerve 56: 679-683, 2017. © 2017 Wiley Periodicals, Inc.

Experiences of adults with high-care needs and their family members with housing and support pathways in Australia.

PubMed

McIntyre, Deborah; Fleming, Jennifer; Foster, Michele; Tweedy, Sean

2017-09-01

Many adults aged less than 65 years with high-care needs resulting from acquired disabilities are unable to access age-appropriate housing and support, and reside in residential aged care or live with family members who may struggle to navigate the disability support system. This qualitative study aimed to investigate the experiences of adults with high-care needs and their family members regarding pathways related to housing and support. Two in-depth semi-structured interviews were conducted six months apart with 21 people aged 18 to 65 with high-care needs of varying etiology and living in different housing settings. Nineteen family members involved in decision-making about housing and supports were also interviewed. Thematic data analysis yielded five themes: (1) Traveling in different directions; (2) "the fight, the battle and the war"; (3) willing but wanting; (4) uncertainty and vulnerability; and (5) redefining social roles and relationships. Current disability policy is not satisfying the housing and support requirements of adults with high-care needs and their families. The findings provide rigorous, empirical evidence which indicate the urgent need to improve access to affordable, individualized housing and support packages, including financial, practical and informational support for family members involved in caring roles. Implications for Rehabilitation Individual preferences are an important consideration in housing and support arrangements for younger people with high-care needs alongside needs-based solutions. Individualized funding approaches may provide flexibility of care and choice in housing and support for people with disability. Family members willingly provide substantial informal care, support and advocacy for younger people with high needs but perceive their role as a constant "battle". Payment of family members in recognition of caring work was perceived as a solution to relieve family hardship and ensure optimal care.

Communication of Career Pathways Through Associate Degree Program Web Sites: A Baseline Assessment.

PubMed

Becker, Ellen A; Vargas, Jenny

2018-05-08

The American Association for Respiratory Care sponsored a series of conferences that addressed the competency of the future workforce of respiratory therapists (RTs). Based upon the findings from those conferences, several initiatives emerged that support RTs earning a baccalaureate (or bachelor's) degree. The objective of this study was to identify the ways that associate degree programs communicate career pathways toward a baccalaureate degree through their Web sites. This cross-sectional observational study used a random sample of 100 of the 362 associate degree programs approved by the Commission on Accreditation for Respiratory Care. Data were collected from 3 specific categories: demographic data, baccalaureate completion information, and the Web page location for the program. The presence of statements related to any pathway toward a bachelor's degree, transfer credits, articulation agreements, and links for baccalaureate completion were recorded. The descriptive statistics in this study were reported as total numbers and percentages. Of the 100 programs in the random sample, only 89 were included in the study. Only 39 (44%) programs had links on their program Web site that had any content related to bachelor's degrees, 16 (18%) identified college transfer courses toward a bachelor's degree, and 26 (29%) programs included baccalaureate articulation agreements on their Web site. A minority of associate degree programs communicated career pathway information to their prospective and current students through program Web sites. An informative Web site would make the path more transparent for entry-level students to meet their future educational needs as their careers progress. Copyright © 2018 by Daedalus Enterprises.

Pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycemic control in patients with type 2 diabetes mellitus.

PubMed

Lee, Yau-Jiunn; Shin, Shyi-Jang; Wang, Ruey-Hsia; Lin, Kun-Der; Lee, Yu-Li; Wang, Yi-Hsien

2016-02-01

To validate a hypothesized model exploring the influencing pathways of empowerment perceptions, health literacy, self-efficacy, and self-care behaviors to glycosylated hemoglobin (HbA1c) levels in patients with type 2 diabetes (T2DM). Overall, 295 patients with T2DM were recruited from five endocrine clinics in Taiwan through convenience sampling. Data regarding personal characteristics, empowerment perceptions, health literacy, self-efficacy, self-care behaviors, and HbA1c levels were collected. A structural equation modeling was used to validate the hypothesized model. Significant direct pathways were determined from empowerment perceptions to health literacy, from health literacy to self-efficacy, from self-efficacy to self-care behaviors, and from self-care behaviors to HbA1c levels. The empowerment perceptions and health literacy relatively influenced self-efficacy and self-care behaviors. Self-efficacy and self-care behaviors relatively influenced glycemic control in patients with T2DM. Modifying self-care behaviors have been demonstrated to be the most essential for improving glycemic control. To improve self-care behaviors, healthcare providers should target improving self-efficacy, and enhancing health literacy can be considered to be a potential strategy for improving self-efficacy. To enhance health literacy, healthcare providers could use an empowerment approach rather than an authoritative approach that emphasizes patient compliance in managing patients with T2DM. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

PubMed Central

Siletz, Anaar E.; Singer, Emily S.; Faltermeier, Claire; Hu, Q. Lina; Ko, Clifford Y.; Golladay, Gregory J.; Kates, Stephen L.; Wick, Elizabeth C.; Maggard-Gibbons, Melinda

2018-01-01

Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients. PMID:29468091

Pathway cross-talk network analysis identifies critical pathways in neonatal sepsis.

PubMed

Meng, Yu-Xiu; Liu, Quan-Hong; Chen, Deng-Hong; Meng, Ying

2017-06-01

Despite advances in neonatal care, sepsis remains a major cause of morbidity and mortality in neonates worldwide. Pathway cross-talk analysis might contribute to the inference of the driving forces in bacterial sepsis and facilitate a better understanding of underlying pathogenesis of neonatal sepsis. This study aimed to explore the critical pathways associated with the progression of neonatal sepsis by the pathway cross-talk analysis. By integrating neonatal transcriptome data with known pathway data and protein-protein interaction data, we systematically uncovered the disease pathway cross-talks and constructed a disease pathway cross-talk network for neonatal sepsis. Then, attract method was employed to explore the dysregulated pathways associated with neonatal sepsis. To determine the critical pathways in neonatal sepsis, rank product (RP) algorithm, centrality analysis and impact factor (IF) were introduced sequentially, which synthetically considered the differential expression of genes and pathways, pathways cross-talks and pathway parameters in the network. The dysregulated pathways with the highest IF values as well as RP<0.01 were defined as critical pathways in neonatal sepsis. By integrating three kinds of data, only 6919 common genes were included to perform the pathway cross-talk analysis. By statistic analysis, a total of 1249 significant pathway cross-talks were selected to construct the pathway cross-talk network. Moreover, 47 dys-regulated pathways were identified via attract method, 20 pathways were identified under RP<0.01, and the top 10 pathways with the highest IF were also screened from the pathway cross-talk network. Among them, we selected 8 common pathways, i.e. critical pathways. In this study, we systematically tracked 8 critical pathways involved in neonatal sepsis by integrating attract method and pathway cross-talk network. These pathways might be responsible for the host response in infection, and of great value for advancing diagnosis and therapy of neonatal sepsis. Copyright © 2017 Elsevier Ltd. All rights reserved.

Empowering change: realist evaluation of a Scottish Government programme to support normal birth.

PubMed

Cheyne, Helen; Abhyankar, Purva; McCourt, Christine

2013-10-01

midwife-led care has consistently been found to be safe and effective in reducing routine childbirth interventions and improving women's experience of care. Despite consistent UK policy support for maximising the role of the midwife as the lead care provider for women with healthy pregnancies, implementation has been inconsistent and the persistent use of routine interventions in labour has given rise to concern. In response the Scottish Government initiated Keeping Childbirth Natural and Dynamic (KCND), a maternity care programme that aimed to support normal birth by implementing multiprofessional care pathways and making midwife-led care for healthy pregnant women the national norm. the evaluation was informed by realist evaluation. It aimed to explore and explain the ways in which the KCND programme worked or did not work in different maternity care contexts. the evaluation was conducted in three phases. In phase one semi-structured interviews and focus groups were conducted with key informants to elicit the programme theory. At phase two, this theory was tested using a multiple case study approach. Semi-structured interviews and focus groups were conducted and a case record audit was undertaken. In the final phase the programme theory was refined through analyses and interpretation of the data. the setting for the evaluation was NHS Scotland. In phase one, 12 national programme stakeholders and 13 consultant midwives participated. In phase two case studies were undertaken in three health boards; overall 73 participants took part in interviews or focus groups. A case record audit was undertaken of all births in Scotland during one week in two consecutive years before and after pathway implementation. government and health board level commitment to, and support of, the programme signalled its importance and facilitated change. Consultant midwives tailored change strategies, using different approaches in response to the culture of care and inter-professional relationships within contexts. In contexts where practice was already changing KCND was seen as validating and facilitating. In areas where a more medical culture existed there was strong resistance to change from midwives and medical staff and robust implementation strategies were required. Overall the pathways appeared to enable midwives to achieve change. our study highlighted the importance of those involved in a change programme working across levels of hierarchy within an organisation and from the macro-context of national policy and institutions to the meso-context of regional health service delivery and the micro-context of practitioner's experiences of providing care. The assumptions and propositions that inform programmes of change, which are often left at a tacit level and unexamined by those charged with implementing them, were made explicit. This examination illuminated the roles of the three key change mechanisms adopted in the KCND programme - appointment of consultant midwives as programme champions, multidisciplinary care pathways, and midwife-led care. It revealed the role of the commitment mechanism, which built on the appointment of the local change champions. The analysis indicated that the process of change, despite these clear mechanisms, needed to be adapted to local contexts and responses to the implementation of KCND. initial formative evaluation should be conducted prior to development of complex healthcare programmes to ensure that (1) the interventions will address the changes required, (2) key stakeholders who may support or resist change are identified, and (3) appropriate facilitation strategies are developed tailored to context. © 2013 Elsevier Ltd. All rights reserved.

Ethnic variations in pathways to acute care and compulsory detention for women experiencing a mental health crisis.

PubMed

Lawlor, Caroline; Johnson, Sonia; Cole, Laura; Howard, Louise M

2012-01-01

Much recent debate on excess rates of compulsory detention and coercive routes to care has focused on young black men; evidence is less clear regarding ethnic variations among women and factors that may mediate these. To explore ethnic variations in compulsory detentions of women, and to explore the potential role of immediate pathways to admission and clinician-rated reasons for admission as mediators of these differences. All women admitted to an acute psychiatric inpatient ward or a women's crisis house in four London boroughs during a 12-week period were included. Data were collected regarding their pathways to care, clinician-rated reasons for admission, hospital stays, and social and clinical characteristics. Two hundred and eighty seven (287) women from white British, white other, black Caribbean, black African and black other groups were included. Adjusting for social and clinical characteristics, all groups of black patients and white other patients were significantly more likely to have been compulsorily admitted than white British patients; white British patients were more likely than other groups to be admitted to a crisis house and more likely than all the black groups to be admitted because of perceived suicide risk. Immediate pathways to care differed: white other, black African and black other groups were less likely to have referred themselves in a crisis and more likely to have been in contact with the police. When adjustment was made for differences in pathways to care, the ethnic differences in compulsory admission were considerably reduced. There are marked ethnic inequities not only between white British and black women, but also between white British and white other women in experiences of acute admission. Differences between groups in help-seeking behaviours in a crisis may contribute to explaining differences in rates of compulsory admission.

The effect of care pathways for hip fractures: a systematic review.

PubMed

Leigheb, Fabrizio; Vanhaecht, Kris; Sermeus, Walter; Lodewijckx, Cathy; Deneckere, Svin; Boonen, Steven; Boto, Paulo Alexandre Faria; Mendes, Rita Veloso; Panella, Massimiliano

2012-07-01

We performed a systematic review for primary studies on care pathways (CPs) for hip fracture (HF). The online databases MEDLINE-PubMed, Ovid-EMBASE, CINAHL-EBSCO host, and The Cochrane Library (Cochrane Central Register of Clinical Trials, Health Technology Assessment Database, NHS Economic Evaluation Database) were searched. Two researchers reviewed the literature independently. Primary studies that met predefined inclusion criteria were assessed for their methodological quality. A total of 15 publications were included: 15 primary studies corresponding with 12 main investigations. Primary studies were evaluated for clinical outcomes, process outcomes, and economic outcomes. The studies assessed a wide range of outcome measures. While a number of divergent clinical outcomes were reported, most studies showed positive results of process management and health-services utilization. In terms of mortality, the results provided evidence for a positive impact of CPs on in-hospital mortality. Most studies also showed a significantly reduced risk of complications, including medical complications, wound infections, and pressure sores. Moreover, time-span process measures showed that an improvement in the organization of care was achieved through the use of CPs. Conflicting results were observed with regard to functional recovery and mobility between patients treated with CPs compared to usual care. Although our review suggests that CPs can have positive effects in patients with HF, the available evidence is insufficient for formal recommendations. There is a need for more research on CPs with selected process and outcome indicators, for in-hospital and postdischarge management of HF, with an emphasis on well-designed randomized trials.

Process mining routinely collected electronic health records to define real-life clinical pathways during chemotherapy.

PubMed

Baker, Karl; Dunwoodie, Elaine; Jones, Richard G; Newsham, Alex; Johnson, Owen; Price, Christopher P; Wolstenholme, Jane; Leal, Jose; McGinley, Patrick; Twelves, Chris; Hall, Geoff

2017-07-01

There is growing interest in the use of routinely collected electronic health records to enhance service delivery and facilitate clinical research. It should be possible to detect and measure patterns of care and use the data to monitor improvements but there are methodological and data quality challenges. Driven by the desire to model the impact of a patient self-test blood count monitoring service in patients on chemotherapy, we aimed to (i) establish reproducible methods of process-mining electronic health records, (ii) use the outputs derived to define and quantify patient pathways during chemotherapy, and (iii) to gather robust data which is structured to be able to inform a cost-effectiveness decision model of home monitoring of neutropenic status during chemotherapy. Electronic Health Records at a UK oncology centre were included if they had (i) a diagnosis of metastatic breast cancer and received adjuvant epirubicin and cyclosphosphamide chemotherapy or (ii) colorectal cancer and received palliative oxaliplatin and infusional 5-fluorouracil chemotherapy, and (iii) were first diagnosed with cancer between January 2004 and February 2013. Software and a Markov model were developed, producing a schematic of patient pathways during chemotherapy. Significant variance from the assumed care pathway was evident from the data. Of the 535 patients with breast cancer and 420 with colorectal cancer there were 474 and 329 pathway variants respectively. Only 27 (5%) and 26 (6%) completed the planned six cycles of chemotherapy without having unplanned hospital contact. Over the six cycles, 169 (31.6%) patients with breast cancer and 190 (45.2%) patients with colorectal cancer were admitted to hospital. The pathways of patients on chemotherapy are complex. An iterative approach to addressing semantic and data quality issues enabled the effective use of routinely collected patient records to produce accurate models of the real-life experiences of chemotherapy patients and generate clinically useful information. Very few patients experience the idealised patient pathway that is used to plan their care. A better understanding of real-life clinical pathways through process mining can contribute to care and data quality assurance, identifying unmet needs, facilitating quantification of innovation impact, communicating with stakeholders, and ultimately improving patient care and outcomes. Copyright © 2017 Elsevier B.V. All rights reserved.

Appropriateness of cases presenting in the emergency department following ambulance service secondary telephone triage: a retrospective cohort study

PubMed Central

Eastwood, Kathryn; Smith, Karen; Morgans, Amee; Stoelwinder, Johannes

2017-01-01

Objective To investigate the appropriateness of cases presenting to the emergency department (ED) following ambulance-based secondary telephone triage. Design A pragmatic retrospective cohort analysis of all the planned and unplanned ED presentations within 48 hours of a secondary telephone triage. Setting The secondary telephone triage service, called the Referral Service, and the hospitals were located in metropolitan Melbourne, Australia and operated 24 hours a day, servicing 4.25 million people. The Referral Service provides an in-depth secondary triage of cases classified as low acuity when calling the Australian emergency telephone number. Population Cases triaged by the Referral Service between September 2009 and June 2012 were linked to ED and hospital admission records (N=44,523). Planned ED presentations were cases referred to the ED following the secondary triage, unplanned ED presentations were cases that presented despite being referred to alternative care pathways. Main outcome measures Appropriateness was measured using an ED suitability definition and hospital admission rates. These were compared with mean population data which consisted of all of the ED presentations for the state (termed the ‘average Victorian ED presentation’). Results Planned ED presentations were more likely to be ED suitable than unplanned ED presentations (OR 1.62; 95% CI 1.5 to 1.7; p<0.001) and the average Victorian ED presentation (OR 1.85; 95% CI 1.01 to 3.4; p=0.046). They were also more likely to be admitted to the hospital than the unplanned ED presentation (OR 1.5; 95% CI 1.4 to 1.6; p<0.001) and the average Victorian ED presentation (OR 2.3, 95% CI 2.24 to 2.33; p<0.001). Just under 15% of cases diverted away from the emergency care pathways presented in the ED (unplanned ED attendances), and 9.5% of all the alternative care pathway cases were classified as ED suitable and 6.5% were admitted to hospital. Conclusions Secondary telephone triage was able to appropriately identify many ED suitable cases, and while most cases referred to alternative care pathways did not present in the ED. Further research is required to establish that these were not inappropriately triaged away from the emergency care pathways. PMID:29038180

Automated generation of patient-tailored electronic care pathways by translating computer-interpretable guidelines into hierarchical task networks.

PubMed

González-Ferrer, Arturo; ten Teije, Annette; Fdez-Olivares, Juan; Milian, Krystyna

2013-02-01

This paper describes a methodology which enables computer-aided support for the planning, visualization and execution of personalized patient treatments in a specific healthcare process, taking into account complex temporal constraints and the allocation of institutional resources. To this end, a translation from a time-annotated computer-interpretable guideline (CIG) model of a clinical protocol into a temporal hierarchical task network (HTN) planning domain is presented. The proposed method uses a knowledge-driven reasoning process to translate knowledge previously described in a CIG into a corresponding HTN Planning and Scheduling domain, taking advantage of HTNs known ability to (i) dynamically cope with temporal and resource constraints, and (ii) automatically generate customized plans. The proposed method, focusing on the representation of temporal knowledge and based on the identification of workflow and temporal patterns in a CIG, makes it possible to automatically generate time-annotated and resource-based care pathways tailored to the needs of any possible patient profile. The proposed translation is illustrated through a case study based on a 70 pages long clinical protocol to manage Hodgkin's disease, developed by the Spanish Society of Pediatric Oncology. We show that an HTN planning domain can be generated from the corresponding specification of the protocol in the Asbru language, providing a running example of this translation. Furthermore, the correctness of the translation is checked and also the management of ten different types of temporal patterns represented in the protocol. By interpreting the automatically generated domain with a state-of-art HTN planner, a time-annotated care pathway is automatically obtained, customized for the patient's and institutional needs. The generated care pathway can then be used by clinicians to plan and manage the patients long-term care. The described methodology makes it possible to automatically generate patient-tailored care pathways, leveraging an incremental knowledge-driven engineering process that starts from the expert knowledge of medical professionals. The presented approach makes the most of the strengths inherent in both CIG languages and HTN planning and scheduling techniques: for the former, knowledge acquisition and representation of the original clinical protocol, and for the latter, knowledge reasoning capabilities and an ability to deal with complex temporal and resource constraints. Moreover, the proposed approach provides immediate access to technologies such as business process management (BPM) tools, which are increasingly being used to support healthcare processes. Copyright © 2012 Elsevier B.V. All rights reserved.

Wound care clinical pathway: a conceptual model.

PubMed

Barr, J E; Cuzzell, J

1996-08-01

A clinical pathway is a written sequence of clinical processes or events that guides a patient with a defined problem toward an expected outcome. Clinical pathways are tools to assist with the cost-effective management of clinical outcomes related to specific problems or disease processes. The primary obstacles to developing clinical pathways for wound care are the chronic natures of some wounds and the many variables that can delay healing. The pathway introduced in this article was modeled upon the three phases of tissue repair: inflammatory, proliferative, and maturation. This physiology-based model allows clinicians to identify and monitor outcomes based on observable and measurable clinical parameters. The pathway design, which also includes educational and behavioral outcomes, allows the clinician to individualize the expected timeframe for outcome achievement based on individual patient criteria and expert judgement. Integral to the pathway are the "4P's" which help standardize the clinical processes by wound type: Protocols, Policies, Procedures, and Patient education tools. Four categories into which variances are categorized based on the cause of the deviation from the norm are patient, process/system, practitioner, and planning/discharge. Additional research is warranted to support the value of this clinical pathway in the clinical arena.

Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology.

PubMed

Eubank, Breda H; Mohtadi, Nicholas G; Lafave, Mark R; Wiley, J Preston; Bois, Aaron J; Boorman, Richard S; Sheps, David M

2016-05-20

Patients presenting to the healthcare system with rotator cuff pathology do not always receive high quality care. High quality care occurs when a patient receives care that is accessible, appropriate, acceptable, effective, efficient, and safe. The aim of this study was twofold: 1) to develop a clinical pathway algorithm that sets forth a stepwise process for making decisions about the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary healthcare settings; and 2) to establish clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology to inform decision-making processes within the algorithm. A three-step modified Delphi method was used to establish consensus. Fourteen experts representing athletic therapy, physiotherapy, sport medicine, and orthopaedic surgery were invited to participate as the expert panel. In round 1, 123 best practice statements were distributed to the panel. Panel members were asked to mark "agree" or "disagree" beside each statement, and provide comments. The same voting method was again used for round 2. Round 3 consisted of a final face-to-face meeting. In round 1, statements were grouped and reduced to 44 statements that met consensus. In round 2, five statements reached consensus. In round 3, ten statements reached consensus. Consensus was reached for 59 statements representing five domains: screening, diagnosis, physical examination, investigations, and treatment. The final face-to-face meeting was also used to develop clinical pathway algorithms (i.e., clinical care pathways) for three types of rotator cuff pathology: acute, chronic, and acute-on-chronic. This consensus guideline will help to standardize care, provide guidance on the diagnosis and treatment of rotator cuff pathology, and assist in clinical decision-making for all healthcare professionals.

Pathways towards chronic care-focused healthcare systems: evidence from Spain.

PubMed

García-Goñi, Manuel; Hernández-Quevedo, Cristina; Nuño-Solinís, Roberto; Paolucci, Francesco

2012-12-01

Increasing healthcare expenditure is a matter of concern in many countries, particularly in relation to the underlying drivers of such escalation that include ageing, medical innovation, and changes in the burden of disease, such as the growing prevalence of chronic diseases. Most healthcare systems in developed countries have been designed to 'cure' acute episodes, rather than to 'manage' chronic conditions, and therefore they are not suitably or efficiently organized to respond to the changing needs and preferences of users. New models of chronic care provision have been developed to respond to the changing burden of disease and there is already considerable practical experience in several different countries showing their advantages but also the difficulties associated with their implementation. In this paper, we focus on the Spanish experience in terms of policy changes and pilot studies focused on testing the feasibility of moving towards chronic care models. In particular, we discuss a framework that identifies and analyses ten key prerequisites to achieving high performing chronic care-based healthcare systems and apply it to the current Spanish National Health System (NHS). We find that the design of the Spanish NHS already meets some of these pre-requisites. However, other features are still in their early stages of development or are being applied only in limited geographical and clinical contexts. We outline the policies that are being implemented and the pathway that the Spanish NHS is taking to address the crucial challenge of the transition towards an optimal health system focused on chronic care. Given the current evidence and trends, we expect that the pathway for developing a chronicity strategy being followed by the Spanish NHS will significantly transform its current healthcare delivery model in the next few years. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.

PubMed

Childers, Christopher P; Siletz, Anaar E; Singer, Emily S; Faltermeier, Claire; Hu, Q Lina; Ko, Clifford Y; Golladay, Gregory J; Kates, Stephen L; Wick, Elizabeth C; Maggard-Gibbons, Melinda

2018-01-01

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Integrated care through disease-oriented clinical care pathways: experience from Japan’s regional health planning initiatives

PubMed Central

Okamoto, Etsuji; Miyamoto, Masaki; Hara, Kazuhiro; Yoshida, Jun; Muto, Masaki; Hirai, Aizan; Tatsumi, Haruyuki; Mizuno, Masaaki; Nagata, Hiroshi; Yamakata, Daisuke; Tanaka, Hiroshi

2011-01-01

Introduction In April 2008, Japan launched a radical reform in regional health planning that emphasized the development of disease-oriented clinical care pathways. These ‘inter-provider critical paths’ have sought to ensure effective integration of various providers ranging among primary care practitioners, acute care hospitals, rehabilitation hospitals, long-term care facilities and home care. Description of policy practice All 47 prefectures in Japan developed their Regional Health Plans pursuant to the guideline requiring that these should include at least four diseases: diabetes, acute myocardial infarction, cerebrovascular accident and cancer. To illustrate the care pathways developed, this paper describes the guideline referring to strokes and provides examples of the new Regional Health Plans as well as examples of disease-oriented inter-provider clinical paths. In particular, the paper examines the development of information sharing through electronic health records (EHR) to enhance effective integration among providers is discussed. Discussion and conclusion Japan’s reform in 2008 is unique in that the concept of ‘disease-oriented regional inter-provider critical paths’ was adopted as a national policy and all 47 prefectures developed their Regional Health Plans simultaneously. How much the new regional health planning policy has improved the quality and outcome of care remains to be seen and will be evaluated in 2013 after the five-year planned period of implementation has concluded. Whilst electronic health records appear to be a useful tool in supporting care integration they do not guarantee success in the application of an inter-provider critical path. PMID:22128281

Filipino Health Care Aides and the Nursing Home Labour Market in Winnipeg.

PubMed

Novek, Sheila

2013-12-01

Canada’s nursing homes have become increasingly dependent on immigrant health care aides. More than any other ethnic group, Filipino women are over-represented among health care aides in the Canadian health care system. This qualitative study explored the employment experiences of Filipino health care aides in nursing homes from their own perspectives as well as those of policy stakeholders. Fourteen in-depth interviews were conducted with Filipino health care aides and long-term-care policy stakeholders in Winnipeg, Manitoba. The results indicated that migrant social networks act as pathways linking immigrant women with employment opportunities in nursing homes. The composition of the labour force is also shaped by management strategies and labour market accommodations that respond to, and reinforce, these social networks. These findings have implications for workforce planning and the quality of care provision in nursing homes.

[From literature to academic history:the position and pathway of acupuncture theory research].

PubMed

Zhang, Shujian

2017-03-12

There are two clues in academic inheritance of acupuncture, including theoretical inheritance and empirical inheritance. Up to now, the mainstream of acupuncture theory has not been in conformity with empirical clinic, and could not explain new clinical techniques. The existing acupuncture theories are in need of strict re-examination, and new academic achievements shall be carefully absorbed. The literature review, concepts research and academic history study are considered as key pathways of acupuncture theory research.

Improving Tracheostomy Care Delivery: Instituting Clinical Care Pathways and Nursing Education to Improve Patient Outcomes.

PubMed

Colandrea, Maria; Eckardt, Patricia

2016-01-01

The complication rates for tracheostomy patients could be serious and life threatening. As a result, length of stay (LOS) increases and patient outcomes can be negatively impacted. Examples of complications include accidental decannulation, bleeding and total occlusion. Studies suggest there is an inconsistency in tracheostomy care among providers and institutions. Other studies suggest stronger patient outcomes can result from improved staff training and appropriate protocols. The purpose of this study was to develop and test a clinical care pathway (CCP) and nursing education program to improve tracheostomy patient outcomes. The use of a CCP and nursing education program at a tertiary VA Medical Center will: decrease length of stay (LOS). decrease 30 day tracheostomy readmissions. increase patient's readiness for discharge. increase nurses' comfort level with performing tracheostomy care. increase nurses' overall competence with performing tracheostomy care. A quasi-experimental pilot study examining the effect of a CCP compared LOS and complication rates of tracheostomy patients from admission to discharge. The population included veterans from a mid-Atlantic VA Medical Center. This study involved three phases. Phase 1: Administer the Readiness for Hospital Discharge Scale (RHDS) to tracheostomy patients' preintervention. Phase 2: Provide nurses with an educational program pre and post test assessment. Phase 3: Implement the CCP and evaluate patients' readiness for discharge. Comparing the pre-intervention sample of veterans (n = 10) to the post-intervention sample (n = 6), there was an increase in LOS by 1 day. There was a 15 point increase in RHDS from 165 (SD 25.8) to 180 (SD 14.42). This pilot was underpowered with an n = 6, so there was no significant difference in LOS and 30 day readmission rates. Bootstrapping of sample resulted in RHDS p = . 039 and readmission p = .007. A paired-samples t-test was conducted to assess nurses' competence in performing tracheostomy care and nursing comfort level in regards to providing tracheostomy care and discharge education. There was a significant increase in the post-test scores, nursing comfort level providing tracheostomy care and nurses' comfort level providing patient tracheostomy discharge education. The significance of this project improved overall tracheostomy care offered at a mid-Atlantic VA Medical Center. Standardizing tracheostomy care and properly educating nurses and patients, increased patients readiness for hospital discharge and decreased their readmission rates related to tracheostomies.

When Health Systems Are Barriers to Health Care: Challenges Faced by Uninsured Mexican Kidney Patients

PubMed Central

Kierans, Ciara; Padilla-Altamira, Cesar; Garcia-Garcia, Guillermo; Ibarra-Hernandez, Margarita; Mercado, Francisco J.

2013-01-01

Background Chronic Kidney Disease disproportionately affects the poor in Low and Middle Income Countries (LMICs). Mexico exemplifies the difficulties faced in supporting Renal Replacement Therapy (RRT) and providing equitable patient care, despite recent attempts at health reform. The objective of this study is to document the challenges faced by uninsured, poor Mexican families when attempting to access RRT. Methods The article takes an ethnographic approach, using interviewing and observation to generate detailed accounts of the problems that accompany attempts to secure care. The study, based in the state of Jalisco, comprised interviews with patients, their caregivers, health and social care professionals, among others. Observations were carried out in both clinical and social settings. Results In the absence of organised health information and stable pathways to renal care, patients and their families work extraordinarily hard and at great expense to secure care in a mixed public-private healthcare system. As part of this work, they must navigate challenging health and social care environments, negotiate treatments and costs, resource and finance healthcare and manage a wide range of formal and informal health information. Conclusions Examining commonalities across pathways to adequate healthcare reveals major failings in the Mexican system. These systemic problems serve to reproduce and deepen health inequalities. A system, in which the costs of renal care are disproportionately borne by those who can least afford them, faces major difficulties around the sustainability and resourcing of RRTs. Attempts to increase access to renal therapies, therefore, need to take into account the complex social and economic demands this places on those who need access most. This paper further shows that ethnographic studies of the concrete ways in which healthcare is accessed in practice provide important insights into the plight of CKD patients and so constitute an important source of evidence in that effort. PMID:23349868

Effectiveness of an interactive platform, and the ESC/HFA heartfailurematters.org website in patients with heart failure: design of the multicentre randomized e-Vita heart failure trial.

PubMed

Wagenaar, Kim P; Broekhuizen, Berna D L; Dickstein, Kenneth; Jaarsma, Tiny; Hoes, Arno W; Rutten, Frans H

2015-12-01

Electronic health support (e-health) may improve self-care of patients with heart failure (HF). We aim to assess whether an adjusted care pathway with replacement of routine consultations by e-health improves self-care as compared with usual care. In addition, we will determine whether the ESC/HFA (European Society of Cardiology/Heart Failure Association) website heartfailurematters.org (HFM website) improves self-care when added to usual care. Finally, we aim to evaluate the cost-effectiveness of these interventions. A three-arm parallel randomized trial will be conducted. Arm 1 consists of usual care; arm 2 consists of usual care plus the HFM website; and arm 3 is the adjusted care pathway with an interactive platform for disease management (e-Vita platform), with a link to the HFM website, which replaces routine consultations with HF nurses at the outpatient clinic. In total, 414 patients managed in 10 Dutch HF outpatient clinics or in general practice will be included and followed for 12 months. Participants are included if they have had an established diagnosis of HF for at least 3 months. The primary outcome is self-care as measured by the European Heart Failure Self-care Behaviour scale (EHFScB scale). Secondary outcomes are quality of life, cardiovascular- and HF-related mortality, hospitalization, and its duration as captured by hospital and general practitioner registries, use of and user satisfaction with the HFM website, and cost-effectiveness. This study will provide important prospective data on the impact and cost-effectiveness of an interactive platform for disease management and the HFM website. unique identifier: NCT01755988. © 2015 The Authors European Journal of Heart Failure © 2015 European Society of Cardiology.

Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data.

PubMed

Widdifield, Jessica; Bernatsky, Sasha; Thorne, J Carter; Bombardier, Claire; Jaakkimainen, R Liisa; Wing, Laura; Paterson, J Michael; Ivers, Noah; Butt, Debra; Lyddiatt, Anne; Hofstetter, Catherine; Ahluwalia, Vandana; Tu, Karen

2016-01-01

The Wait Time Alliance recently established wait time benchmarks for rheumatology consultations in Canada. Our aim was to quantify wait times to primary and rheumatology care for patients with rheumatic diseases. We identified patients from primary care practices in the Electronic Medical Record Administrative data Linked Database who had referrals to Ontario rheumatologists over the period 2000-2013. To assess the full care pathway, we identified dates of symptom onset, presentation in primary care and referral from electronic medical records. Dates of rheumatologist consultations were obtained by linking with physician service claims. We determined the duration of each phase of the care pathway (symptom onset to primary care encounter, primary care encounter to referral, and referral to rheumatologist consultation) and compared them with established benchmarks. Among 2430 referrals from 168 family physicians, 2015 patients (82.9%) were seen by 146 rheumatologists within 1 year of referral. Of the 2430 referrals, 2417 (99.5%) occurred between 2005 and 2013. The main reasons for referral were osteoarthritis (32.4%) and systemic inflammatory rheumatic diseases (30.6%). Wait times varied by diagnosis and geographic region. Overall, the median wait time from referral to rheumatologist consultation was 74 (interquartile range 27-101) days; it was 66 (interquartile range 18-84) days for systemic inflammatory rheumatic diseases. Wait time benchmarks were not achieved, even for the most urgent types of referral. For systemic inflammatory rheumatic diseases, most of the delays occurred before referral. Rheumatology wait times exceeded established benchmarks. Targeted efforts are needed to promote more timely access to both primary and rheumatology care. Routine linkage of electronic medical records with administrative data may help fill important gaps in knowledge about waits to primary and specialty care.

Measuring the quality of end of life management in patients with advanced kidney disease: results from the pan-Thames renal audit group.

PubMed

McAdoo, Stephen P; Brown, Edwina A; Chesser, Alistair M; Farrington, Ken; Salisbury, Emma M

2012-04-01

Despite a recent increased awareness of the need for quality End of Life (EOL) care for patients with advanced kidney disease, there is no established method for measuring or auditing outcomes relating to EOL care in this population. We designed a one-page proforma, which was used to collect data on various aspects of EOL care relating to all deaths of patients on dialysis and patients dying on specialist renal wards, over a predefined 8-week period in 10 hospitals in London and South-East England. One hundred and thirty-eight deaths were recorded over the 8-week study period. The majority of patients (83%) were receiving maintenance haemodialysis prior to their terminal presentation. About 69% of deaths occurred during an in-patient hospital admission-of these, 36% were considered 'unexpected' and most quality markers of good EOL management were significantly less likely to be achieved in these patients, including use of palliative care strategies, good symptom control and overall quality of death. Thirty-six per cent of patients were from various ethnic minorities, and in this group, there was a trend towards lower use of palliative care pathways and lower rates of withdrawal from dialysis. This study confirms that it is possible to measure many important outcomes relating to quality of EOL care using a proforma completed at the time of death. Our findings suggest that many aspects of good EOL care are under-achieved in our region. This, in part, is due to a failure to recognize the worsening trajectory of the deteriorating patient, resulting in missed opportunities for EOL care planning and appropriate symptom control. Our observations suggest that there is a need for improved education and training in this area, particularly in detection of the dying patient, the value of advance care planning and the utility of tools such as the Liverpool Care Pathway.

Automatic variance analysis of multistage care pathways.

PubMed

Li, Xiang; Liu, Haifeng; Zhang, Shilei; Mei, Jing; Xie, Guotong; Yu, Yiqin; Li, Jing; Lakshmanan, Geetika T

2014-01-01

A care pathway (CP) is a standardized process that consists of multiple care stages, clinical activities and their relations, aimed at ensuring and enhancing the quality of care. However, actual care may deviate from the planned CP, and analysis of these deviations can help clinicians refine the CP and reduce medical errors. In this paper, we propose a CP variance analysis method to automatically identify the deviations between actual patient traces in electronic medical records (EMR) and a multistage CP. As the care stage information is usually unavailable in EMR, we first align every trace with the CP using a hidden Markov model. From the aligned traces, we report three types of deviations for every care stage: additional activities, absent activities and violated constraints, which are identified by using the techniques of temporal logic and binomial tests. The method has been applied to a CP for the management of congestive heart failure and real world EMR, providing meaningful evidence for the further improvement of care quality.

Facial palsy: what can the multidisciplinary team do?

PubMed Central

Butler, Daniel P; Grobbelaar, Adriaan O

2017-01-01

The functional and psychosocial impact of facial paralysis on the patient is significant. In response, a broad spectrum of treatment options exist and are provided by a multitude of health care practitioners. The cause and duration of the facial weakness can vary widely and the optimal care pathway varies. To optimize patient outcome, those involved in the care of patients with facial palsy should collaborate within comprehensive multidisciplinary teams (MDTs). At an international level, those involved in the care of patients with facial paralysis should aim to create standardized guidelines on which outcome domains matter most to patients to aid the identification of high quality care. This review summarizes the causes and treatment options for facial paralysis and discusses the subsequent importance of multidisciplinary care in the management of patients with this condition. Further discussion is given to the extended role of the MDT in determining what constitutes quality in facial palsy care to aid the creation of accepted care pathways and delineate best practice. PMID:29026314

Shared decision making and the pathways approach in the prenatal and postnatal management of the trisomy 13 and trisomy 18 syndromes.

PubMed

Andrews, Sasha E; Downey, Ann G; Showalter, David Scott; Fitzgerald, Heather; Showalter, Vivian P; Carey, John C; Hulac, Peter

2016-09-01

The medical management of infants with the trisomy 13 and trisomy 18 syndromes is challenging and controversial. Both conditions have high neonatal and infant mortality, and surviving children display significant cognitive and motor disabilities. Currently, there exists a tension in the neonatal and perinatal communities regarding care. One view holds that management should consist solely of comfort care, while another opinion recommends offering medical and surgical intervention in appropriate situations. The purpose of this manuscript is to present a model for the care of fetuses and infants with trisomy 13 and 18 during the prenatal, perinatal, and postnatal periods. Adopting the pathways approach as a framework, we have identified several pertinent decision points, characterizing the goals of care and the resources needed for the decision points at various times. Additionally, we identified themes surrounding parental and professional experiences. The authors propose a care model for trisomy 13 and 18 that uses shared decision making as its foundational principle and the pathways approach as the method. Our model requires further investigation as a strategy for care in order to render it useful in other complex medical situations. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Factors affecting profitability for craniotomy.

PubMed

Popp, A John; Scrime, Todd; Cohen, Benjamin R; Feustel, Paul J; Petronis, Karen; Habiniak, Sharon; Waldman, John B; Vosburgh, Margaret M

2002-04-15

The authors studied factors influencing hospital profitability after craniotomy in patients who underwent craniotomy coded as diagnosis-related group (DRG) 1 (17 years of age with nontraumatic disease without complication) and who met their hospital's craniotomy pathway criteria and had a hospital length of stay 4 days or less during a 20-month period. Data in all patients meeting these criteria (76 cases) were collected and collated from various hospital databases. Twenty-one cases were profitable and 55 were not. Variables traditionally influencing cost of care, such as surgeon, procedure, length of operation, and pharmacy use had no significant effect on whether a patient was profitable. The most important influence on profitability was the individual payor. Cases in which care was reimbursed under the prospective payment system based on DRGs were nearly always profitable whereas those covered by per diem plans were nearly always nonprofitable. 1) Hospital information systems should be customized to deliver consolidated data for timely analysis of cost of care for individual patients. This information may be useful in negotiating profitable contracts. 2) A clinical pathway was successful in reducing the difference in cost of care between profitable and nonprofitable postcraniotomy cases. 3) In today's health care environment both cost containment and revenue assume importance in determining profitability.

The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge.

PubMed

Mahler, Simon A; Riley, Robert F; Hiestand, Brian C; Russell, Gregory B; Hoekstra, James W; Lefebvre, Cedric W; Nicks, Bret A; Cline, David M; Askew, Kim L; Elliott, Stephanie B; Herrington, David M; Burke, Gregory L; Miller, Chadwick D

2015-03-01

The HEART Pathway is a decision aid designed to identify emergency department patients with acute chest pain for early discharge. No randomized trials have compared the HEART Pathway with usual care. Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%-9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. The HEART Pathway reduces objective cardiac testing during 30 days, shortens length of stay, and increases early discharges. These important efficiency gains occurred without any patients identified for early discharge suffering MACE at 30 days. URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01665521. © 2015 American Heart Association, Inc.

Pathways and Partnerships for Child Care Excellence

ERIC Educational Resources Information Center

Office of Child Care, 2011

2011-01-01

More than 12 million American children regularly rely on child care to support their healthy development and school success. Of these, over 1.6 million children receive a child care subsidy from the Child Care and Development Fund (CCDF) program each month. In addition, CCDF helps leverage child care investments from the Temporary Assistance for…

Dental neglect as a marker of broader neglect: a qualitative investigation of public health nurses’ assessments of oral health in preschool children

PubMed Central

2013-01-01

Background Child neglect is a pernicious child protection issue with adverse consequences that extend to adulthood. Simultaneously, though it remains prevalent, childhood dental caries is a preventable disease. Public health nurses play a pivotal role in assessing oral health in children as part of general health surveillance. However, little is known about how they assess dental neglect or what their thresholds are for initiating targeted support or instigating child protection measures. Understanding these factors is important to allow improvements to be made in care pathways. Methods We investigated public health nurses’ assessment of oral health in preschool children in relation to dental neglect and any associations they make with child neglect more broadly. A qualitative study was conducted in Scotland during 2011/12. Sixteen public health nurses were recruited purposively from one health region. Individual, semi-structured interviews were undertaken and data were analyzed inductively using a framework approach. Categories were subsequently mapped to the research questions. Results Public health nurses assess oral health through proxy measures, opportunistic observation and through discussion with parents. Dental neglect is rarely an isolated issue that leads on its own to child protection referral. It tends to be other presenting issues that initiate a response. Threshold levels for targeted support were based on two broad indicators: social issues and concerns about child (and parental) dental health. Thresholds for child protection intervention were untreated dental caries or significant dental pain. Barriers to intervention are that dental neglect may be ‘unseen’ and ‘unspoken’. The study revealed a communication gap in the care pathway for children where a significant dental problem is identified. Conclusions Public health nurses take their child protection role seriously, but rarely make a link between dental caries and child neglect. Clear guidance on oral health assessment is required for public health nurses. Establishing formal communication pathways between child dental care providers and public health nurses may help close gaps in care pathways. However, further research is required into how these communication mechanisms can be improved. PMID:23601415

Intersection of AHR and Wnt Signaling in Development, Health, and Disease

PubMed Central

Schneider, Andrew J.; Branam, Amanda M.; Peterson, Richard E.

2014-01-01

The AHR (aryl hydrocarbon receptor) and Wnt (wingless-related MMTV integration site) signaling pathways have been conserved throughout evolution. Appropriately regulated signaling through each pathway is necessary for normal development and health, while dysregulation can lead to developmental defects and disease. Though both pathways have been vigorously studied, there is relatively little research exploring the possibility of crosstalk between these pathways. In this review, we provide a brief background on (1) the roles of both AHR and Wnt signaling in development and disease, and (2) the molecular mechanisms that characterize activation of each pathway. We also discuss the need for careful and complete experimental evaluation of each pathway and describe existing research that explores the intersection of AHR and Wnt signaling. Lastly, to illustrate in detail the intersection of AHR and Wnt signaling, we summarize our recent findings which show that 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)-induced disruption of Wnt signaling impairs fetal prostate development. PMID:25286307

Everybody wants it done but nobody wants to do it: an exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer.

PubMed

Rankin, Nicole M; Butow, Phyllis N; Thein, Thida; Robinson, Tracy; Shaw, Joanne M; Price, Melanie A; Clover, Kerrie; Shaw, Tim; Grimison, Peter

2015-01-22

This study aimed to explore barriers to and enablers for future implementation of a draft clinical pathway for anxiety and depression in cancer patients in the Australian context. Health professionals reviewed a draft clinical pathway and participated in qualitative interviews about the delivery of psychosocial care in their setting, individual components of the draft pathway, and barriers and enablers for its future implementation. Five interrelated themes were identified: ownership; resources and responsibility; education and training; patient reluctance; and integration with health services beyond oncology. The five themes were perceived as both barriers and enablers and provide a basis for an implementation plan that includes strategies to overcome barriers. The next steps are to design and deliver the clinical pathway with specific implementation strategies that address team ownership, endorsement by leaders, education and training modules designed for health professionals and patients and identify ways to integrate the pathway into existing cancer services.

How socioeconomic inequalities impact pathways of care for coronary artery disease among elderly patients: study protocol for a qualitative longitudinal study.

PubMed

Schröder, Sara L; Fink, Astrid; Schumann, Nadine; Moor, Irene; Plehn, Alexander; Richter, Matthias

2015-11-09

Several studies have identified that socioeconomic inequalities in coronary artery disease (CAD) morbidity and mortality lead to a disadvantage in patients with low socioeconomic status (SES). International studies have shown that socioeconomic inequalities also exist in terms of access, utilisation and quality of cardiac care. The aim of this qualitative study is to provide information on the impact of socioeconomic inequalities on the pathway of care for CAD, and to establish which factors lead to socioeconomic inequality of care to form and expand existing scientific theories. A longitudinal qualitative study with 48 patients with CAD, aged 60-80 years, is being conducted. Patients have been recruited consecutively at the University Hospital in Halle/Saale, Germany, and will be followed for a period of 6 months. Patients are interviewed two times face-to-face using semistructured interviews. Data are transcribed and analysed based on grounded theory. Only participants who have been informed and who have signed a declaration of consent have been included in the study. The study complies rigorously with data protection legislation. Approval of the Ethical Review Committee at the Martin-Luther University Halle-Wittenberg, Germany was obtained. The results of the study will be presented at several congresses, and will be published in high-quality peer-reviewed international journals. This study has been registered with the German Clinical Trials Register and assigned DRKS00007839. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Structural drivers and social protection: mechanisms of HIV risk and HIV prevention for South African adolescents.

PubMed

Cluver, Lucie Dale; Orkin, Frederick Mark; Meinck, Franziska; Boyes, Mark Edward; Sherr, Lorraine

2016-01-01

Social protection is high on the HIV-prevention agenda for youth in sub-Saharan Africa. However, questions remain: How do unconditional cash transfers work? What is the effect of augmenting cash provision with social care? And can "cash plus care" social protection reduce risks for adolescents most vulnerable to infection? This study tackles these questions by first identifying mediated pathways to adolescent HIV risks and then examining potential main and moderating effects of social protection in South Africa. This study was a prospective observational study of 3515 10-to-17-year-olds (56.7% female; 96.8% one-year retention). Within randomly selected census areas in four rural and urban districts in two South African provinces, all homes with a resident adolescent were sampled between 2009/2010 and 2011/2012. Measures included 1) potential structural drivers of HIV infection such as poverty and community violence; 2) HIV risk behaviours; 3) hypothesized psychosocial mediating factors; and 4) types of social protection involving cash and care. Using gender-disaggregated analyses, longitudinal mediation models were tested for potential main and moderating effects of social protection. Structural drivers were associated with increased onset of adolescent HIV risk behaviour (p<0.001, B=0.06, SE=0.01), fully mediated by increased psychosocial problems. Both cash and care aspects of social protection were associated with reductions in HIV risk behaviour and psychosocial deprivations. In addition, cash social protection moderated risk pathways: for adolescent girls and boys experiencing more acute structural deprivation, social protection had the greatest associations with HIV risk prevention (e.g. moderation effects for girls: B=-0.08, p<0.002 between structural deprivation and psychosocial problems, and B=-0.07, p<0.001 between psychosocial problems and HIV risk behaviour). Adolescents with the greatest structural deprivation are at higher risk of HIV, but social protection has the greatest prevention effects for the most vulnerable. Social protection comprising unconditional cash plus care was associated with reduced risk pathways through moderation and main effects, respectively. Our findings suggest the importance of social protection within a combination package of HIV-prevention approaches.

Creation and Execution of a Novel Anesthesia Perioperative Care Service at a Veterans Affairs Hospital.

PubMed

Alvis, Bret D; King, Adam B; Pandharipande, Pratik P; Weavind, Liza M; Avila, Katelin; Leisy, Philip J; Ajmal, Muhammad; McHugh, Michael; Keegan, Kirk A; Baker, David A; Walia, Ann; Hughes, Christopher G

2017-11-01

Physician-led perioperative surgical home models are developing as a method for improving the American health care system. These models are novel, team-based approaches that help to provide continuity of care throughout the perioperative period. Another avenue for improving care for surgical patients is the use of enhanced recovery after surgery pathways. These are well-described methods that have shown to improve perioperative outcomes. An established perioperative surgical home model can help implementation, efficiency, and adherence to enhanced recovery after surgery pathways. For these reasons, the Tennessee Valley Healthcare System, Nashville Veterans Affairs Medical Center created an Anesthesiology Perioperative Care Service that provides comprehensive care to surgical patients from their preoperative period through the continuum of their hospital course and postdischarge follow-up. In this brief report, we describe the development, implementation, and preliminary outcomes of the service.

Support for infants and young people with sight loss: a qualitative study of sight impairment certification and referral to education and social care services

PubMed Central

Boyce, Tammy; Dahlmann-Noor, Annegret; Bowman, Richard; Keil, Sue

2015-01-01

Objectives To examine the experience of infants, children and their parents, the role of ophthalmologists and other health, social care and education professionals in the certification and registration processes and examine the relationship between certification and referrals and pathways to support. Design Qualitative study. Setting Telephone interviews with health and, social care professionals, qualified teachers of children and young people with vision impairment (QTVIs) and parents of infants/children in England. Participants 52 health, social care and education professionals who are part of the certification or registration process. 26 parents of infants and children with vision impairment. Results Referrals to education do not require a Certificate of Vision Impairment (CVI); however, the majority of parents received support from education and social services only after an offer of the CVI, which was often dependent on having a formal diagnosis. Parents stated they wanted support sooner, particularly parents of children with additional complex needs who experienced longer delays. Areas with multidisciplinary teams and support roles such as eye clinic liaison officers (ECLOs) appeared to have more reliable referral pathways. Conclusions For infants and children with vision impairment, there should be a consistent mechanism for triggering education and social care support even with uncertainty about diagnosis and/or prognosis. All professionals involved in the certification and registration processes (ophthalmologists, optometrists, ECLOs, orthoptists, social workers, QTVIs) can better communicate the value and benefits of certification and registration. PMID:26685033

Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study.

PubMed

Shaw, Deborah; Siriwardena, Aloysius Niroshan

2014-08-03

Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians' adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics' attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence. We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data. Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians' and patients' expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma. This qualitative study provides insight into paramedics' perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.

Integrated Transitions of Care for Patients With Rare Pulmonary Diseases.

PubMed

Moreo, Kathleen; Lattimer, Cheri; Lett, James E; Heggen-Peay, Cherilyn L; Simone, Laura

Many continuing education (CE) resources are available to support case management professionals in developing competencies in transitions of care (TOC) that apply generally across disease areas. However, CE programs and tools are lacking for advanced TOC competencies in specific disease areas. This article describes 2 projects in which leading TOC, case management, and CE organizations collaborated to develop CE-accredited interdisciplinary pathways for promoting safe and effective TOC for patients with rare pulmonary diseases, including pulmonary arterial hypertension (PAH) and idiopathic pulmonary fibrosis (IPF). The interdisciplinary pathways apply to PAH and IPF case management practice and TOC across settings that include community-based primary care and specialty care, PAH or IPF centers of expertise, acute care and post-acute settings, long-term care, rehabilitation and skilled nursing facilities, and patients' homes. Both PAH and IPF are chronic, progressive respiratory diseases that are associated with severe morbidity and mortality, along with high health care costs. Because they are relatively rare diseases with nonspecific symptoms and many comorbidities, PAH and IPF are difficult to diagnose. Early diagnosis, referral to centers of expertise, and aggressive treatment initiation are essential for slowing disease progression and maintaining quality of life and function. Both the rarity and complexity of PAH and IPF pose unique challenges to ensuring effective and safe TOC. Expert consensus and evidence-based approaches to meeting these challenges, and thereby improving PAH and IPF patient outcomes, are presented in the 2 interdisciplinary TOC pathways that are described in this article. In coordinating care for patients with complex pulmonary diseases such as PAH and IPF, case managers across practice settings can play key roles in improving workflow processes and communication, transition planning, coordinating TOC with centers of expertise, coordinating care and TOC for patients with comorbidities, providing patient and caregiver education, promoting engagement between patients and the team, advancing the care plan, and improving ongoing adherence to treatment in order to maximize the patient's pulmonary function. Details regarding these interprofessional roles and responsibilities are provided in the full interdisciplinary TOC pathways for PAH and IPF.

Decision-Making in Audiology: Balancing Evidence-Based Practice and Patient-Centered Care

PubMed Central

Clemesha, Jennifer; Lundmark, Erik; Crome, Erica; Barr, Caitlin; McMahon, Catherine M.

2017-01-01

Health-care service delivery models have evolved from a practitioner-centered approach toward a patient-centered ideal. Concurrently, increasing emphasis has been placed on the use of empirical evidence in decision-making to increase clinical accountability. The way in which clinicians use empirical evidence and client preferences to inform decision-making provides an insight into health-care delivery models utilized in clinical practice. The present study aimed to investigate the sources of information audiologists use when discussing rehabilitation choices with clients, and discuss the findings within the context of evidence-based practice and patient-centered care. To assess the changes that may have occurred over time, this study uses a questionnaire based on one of the few studies of decision-making behavior in audiologists, published in 1989. The present questionnaire was completed by 96 audiologists who attended the World Congress of Audiology in 2014. The responses were analyzed using qualitative and quantitative approaches. Results suggest that audiologists rank clinical test results and client preferences as the most important factors for decision-making. Discussion with colleagues or experts was also frequently reported as an important source influencing decision-making. Approximately 20% of audiologists mentioned utilizing research evidence to inform decision-making when no clear solution was available. Information shared at conferences was ranked low in terms of importance and reliability. This study highlights an increase in awareness of concepts associated with evidence-based practice and patient-centered care within audiology settings, consistent with current research-to-practice dissemination pathways. It also highlights that these pathways may not be sufficient for an effective clinical implementation of these practices. PMID:28752808

Estimated cost of a health visitor-led protocol for perinatal mental health.

PubMed

Oluboyede, Yemi; Lewis, Anne; Ilott, Irene; Lekka, Chrysanthi

2010-06-01

Anecdotally, protocols, care pathways and clinical guidelines are time consuming to develop and sustain, but there is little research about the actual costs of their development, use and audit.This is a notable gap considering the pervasiveness of such documents that are intended to reduce unacceptable variations in practice by standardising care processes. A case study research design was used to calculate the resource use costs of a protocol for perinatal mental health, part of the core programme for health visitors in a primary care trust in the west of England. The methods were in-depth interviews with the operational lead for the protocol (a health visitor) and documentary analysis. The total estimated cost of staff time over a five-year period (2004 to 2008) was Euro 73,598, comprising Euro 36,162 (49%) for development and Euro 37,436 (51%) for implementation. Although these are best estimates dependent upon retrospective data, they indicate the opportunity cost of staff time for a single protocol in one trust over five years. When new protocols, care pathways or clinical guidelines are proposed, the costs need to be considered and weighed against the benefits of engaging frontline staff in service improvements.

Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement.

PubMed

Mina, D Santa; Sabiston, C M; Au, D; Fong, A J; Capozzi, L C; Langelier, D; Chasen, M; Chiarotto, J; Tomasone, J R; Jones, J M; Chang, E; Culos-Reed, S N

2018-04-01

Recent guidelines concerning exercise for people with cancer provide evidence-based direction for exercise assessment and prescription for clinicians and their patients. Although the guidelines promote exercise integration into clinical care for people with cancer, they do not support strategies for bridging the guidelines with related resources or programs. Exercise program accessibility remains a challenge in implementing the guidelines, but that challenge might be mitigated with conceptual frameworks ("pathways") that connect patients with exercise-related resources. In the present paper, we describe a pathway model and related resources that were developed by an expert panel of practitioners and researchers in the field of exercise and rehabilitation in oncology and that support the transition from health care practitioner to exercise programs or services for people with cancer. The model acknowledges the nuanced distinctions between research and exercise programming, as well as physical activity promotion, that, depending on the available programming in the local community or region, might influence practitioner use. Furthermore, the pathway identifies and provides examples of processes for referral, screening, medical clearance, and programming for people after a cancer diagnosis. The pathway supports the implementation of exercise guidelines and should serve as a model of enhanced care delivery to increase the health and well-being of people with cancer.

The cost-effectiveness of changes to the care pathway used to identify depression and provide treatment amongst people with diabetes in England: a model-based economic evaluation.

PubMed

Kearns, Ben; Rafia, R; Leaviss, J; Preston, L; Brazier, J E; Palmer, S; Ara, R

2017-01-24

Diabetes is associated with premature death and a number of serious complications. The presence of comorbid depression makes these outcomes more likely and results in increased healthcare costs. The aim of this work was to assess the health economic outcomes associated with having both diabetes and depression, and assess the cost-effectiveness of potential policy changes to improve the care pathway: improved opportunistic screening for depression, collaborative care for depression treatment, and the combination of both. A mathematical model of the care pathways experienced by people diagnosed with type-2 diabetes in England was developed. Both an NHS perspective and wider social benefits were considered. Evidence was taken from the published literature, identified via scoping and targeted searches. Compared with current practice, all three policies reduced both the time spent with depression and the number of diabetes-related complications experienced. The policies were associated with an improvement in quality of life, but with an increase in health care costs. In an incremental analysis, collaborative care dominated improved opportunistic screening. The incremental cost-effectiveness ratio (ICER) for collaborative care compared with current practice was £10,798 per QALY. Compared to collaborative care, the combined policy had an ICER of £68,017 per QALY. Policies targeted at identifying and treating depression early in patients with diabetes may lead to reductions in diabetes related complications and depression, which in turn increase life expectancy and improve health-related quality of life. Implementing collaborative care was cost-effective based on current national guidance in England.

Impact of value based breast cancer care pathway implementation on pre-operative breast magnetic resonance imaging utilization.

PubMed

McCray, Devina K S; Grobmyer, Stephen R; Pederson, Holly J

2017-02-01

Bilateral breast magnetic resonance imaging (MRI) is commonly used in the diagnostic workup of breast cancer (BC) to assess extent of disease and identify occult foci of disease. However, evidence for routine use of pre-operative MRI is lacking. Breast MRI is costly and can lead to unnecessary tests and treatment delays. Clinical care pathways (care paths) are value-based guidelines, which define management recommendations derived by expert consensus and available evidence based data. At Cleveland Clinic, care paths created for newly diagnosed BC patients recommend selective use of pre-operative MRI. We evaluated the number of pre-operative MRIs ordered before and after implementing an institution wide BC care paths in April 2014. A retrospective review was conducted of BC cases during the years 2012, 2014, and part of 2015. Patient, tumor and treatment characteristics were collected. Pre-operative MRI utilization was compared before and after care path implementation. We identified 1,515 BC patients during the study period. Patients were more likely to undergo pre-operative MRI in 2012 than 2014 (OR: 2.77; P<0.001; 95% CI: 1.94-3.94) or 2015 (OR: 4.14; P<0.001; 95% CI: 2.51-6.83). There was a significant decrease in pre-operative MRI utilization between 2012 and 2014 (P<0.001) after adjustment for pre-operative MRIs ordered for care path indications. Implementation of online BC care paths at our institution was associated with a decreased use of pre-operative MRI overall and in patients without a BC care path indication, driving value based care through the reduction of pre-operative breast MRIs.

A career path in clinical pathways.

PubMed

Bower, K A

1998-03-01

Much like the development of a clinical path, the creation of a career path requires knowledge of patterns of behavior, needs for standardized education and skill development, along with variance analysis and individualized care. This nationally known nursing entrepreneur tells the story of her involvement in the development of case management and clinical pathways and how she turned that into a successful business that has changed how patient care is managed nationally and internationally.

Creating a culture of professional development: a milestone pathway tool for registered nurses.

PubMed

Cooper, Elizabeth

2009-11-01

The nursing shortage continues to be a significant threat to health care. Creating a culture of professional development in health care institutions is one way to combat this shortage. Professional development refers to a constant commitment to maintain one's knowledge and skill base. Increasing professional development opportunities in the health care setting has been shown to affect nurse retention and satisfaction. Several approaches have been developed to increase professional development among nurses. However, for the most part, these are "one size fits all" approaches that direct nurses to progress in lock step fashion in skill and knowledge acquisition within a specialty. This article introduces a milestone pathway tool for registered nurses designed to enhance professional development that is unique to the individual nurse and the specific nursing unit. This tool provides a unit-specific concept map, a milestone pathway template, and a personal professional development plan. Copyright 2009, SLACK Incorporated.

Electronic SSKIN pathway: reducing device-related pressure ulcers.

PubMed

Campbell, Natalie

2016-08-11

This article describes how an interprofessional project in a London NHS Foundation Trust was undertaken to develop an intranet-based medical device-related pressure ulcer prevention and management pathway for clinical staff working across an adult critical care directorate, where life-threatening events require interventions using medical devices. The aim of this project was to improve working policies and processes to define key prevention strategies and provide clinicians with a clear, standardised approach to risk and skin assessment, equipment use, documentation and reporting clinical data using the Trust's CareVue (electronic medical records), Datix (incident reporting and risk-management tool) and eTRACE (online clinical protocol ordering) systems. The process included the development, trial and local implementation of the pathway using collaborative teamwork and the SSKIN care bundle tool. The experience of identifying issues, overcoming challenges, defining best practice and cascading SSKIN awareness training is shared.

Older people's care experience in community and general hospitals: a comparative study.

PubMed

Green, John; Forster, Anne; Young, John; Small, Neil; Spink, Joanna

2008-07-01

Community hospitals are an important component of the post-acute care pathway for older people. The objective of this study was to describe and contrast patients' and carers' experiences of community and general hospitals. Interviews with patients and carers revealed similarities in the perceptions of care between the two settings. These included appreciation of staff sensitivity, a sense of security, encouragement of independence and lack of activity. The community hospital was appreciated for its location, atmosphere, accommodation, greater sense of freedom, quality of food and staff attitudes. UK health policy promotes the development of community hospitals. This should be progressed in a way that retains key strengths of the specific service they offer.

Developing a clinical care pathway for obese pregnant women: A quality improvement project.

PubMed

Fealy, Shanna; Hure, Alexis; Browne, Graeme; Prince, Carol

2014-12-01

Obesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) ≥ 30 kg/m(2), defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted. To plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI ≥ 35 kg/m(2) at their first antenatal visit. The project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia. Eighty-two women with a BMI ≥ 35 kg/m(2) were eligible for the alternative care pathway, offered between January and December 2010. The alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation. Despite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening. Crown Copyright © 2014. Published by Elsevier Ltd. All rights reserved.

Using best practice to create a pathway to improve management of irritable bowel syndrome: aiming for timely diagnosis, effective treatment and equitable care.

PubMed

Williams, Marianne; Barclay, Yvonne; Benneyworth, Rosie; Gore, Steve; Hamilton, Zoe; Matull, Rudi; Phillips, Iain; Seamark, Leah; Staveley, Kate; Thole, Steve; Greig, Emma

2016-10-01

Irritable bowel syndrome (IBS) costs the National Health Service almost £12 million per annum. Despite national guidelines advising primary care management, these have failed to stem secondary care referrals of patients with likely IBS for unnecessary and costly assessment and investigation without necessarily achieving resolution of their symptoms. In 2011, an integrated team from primary and secondary care developed a business case using baseline data to create a Somerset-wide IBS pathway using Clinical Commissioning Group funding. This provided face-to-face general practitioners (GP) education, developed a diagnostic pathway and funded faecal calprotectin (FC) testing to exclude inflammatory pathology for patients aged 16-45 years with likely IBS and no alarm symptoms. For those with FC≤50 μg/g, we provided a management algorithm and community-based dietetic treatment. Audit results measured usage and outcomes from FC testing, changes in patterns and costs of new patients reviewed in gastroenterology outpatients and dietetic IBS treatment outcomes. The proportion of new patient slots used reduced from 14.3% to 8.7% over 10 months while overall costs reduced by 25% for patients with no alarm symptoms and likely IBS aged 16-45 years. FC results confirmed research findings with no inflammatory pathology, if FC≤50 μg/g over 2 years. 63% of patients had satisfactory control of their IBS after specialist dietetic input with 74% reporting improved quality of life. The combination of GP education, providing diagnosis and management pathways, using FC to exclude inflammatory pathology and providing an effective treatment for patients with likely IBS appeared successful in our pilot. This proved cost-effective, reduced secondary care involvement and improved patient care.

An integrated wound-care pathway, supported by telemedicine, and competent wound management-Essential in follow-up care of adults with diabetic foot ulcers.

PubMed

Smith-Strøm, Hilde; Iversen, Marjolein M; Graue, Marit; Skeie, Svein; Kirkevold, Marit

2016-10-01

Diabetic foot ulcers are a feared complication of diabetes. Care delivered via telemedicine is suggested to be a more integrated care pathway to manage diabetic foot ulcers than traditionally delivered healthcare. Our aim was to explore patients' experiences with telemedicine follow-up care as compared to traditional care. Interpretive description was used as an analysis strategy. Data were collected using individual semi-structured interviews in the context of a larger ongoing clustered randomized controlled trial. Twenty-four patients (13 in the intervention group; 11 in the control group), aged 38-88 years were purposively recruited from the RCT in order to obtain a diverse sample in terms of group composition (intervention vs. control), age, gender, marital status, setting, and comorbidities present. The control group received traditional care. Three themes emerged from the interpretive analysis: competence of healthcare professionals, continuity of care, and easy access. This was independed of types of follow-up that had limited impact on the patients' follow-up experiences. Competence of healthcare professionals and continuity of care were crucial, because they can either enhance or jeopardize wound care. If these two latter factors were absent, patients would lose confidence in the wound care process. If this happened, patients pointed out that the expert knowledge of a specialist clinic was essential to receive good care. When telemedicine functioned optimally, telemedicine was an advantage in the treatment, because the images quickly captured changes in the wound healing that immediately could be corrected. Easy access is important for patients, but the importance of accessibility appears to be primary when the other two factors were present. The best wound care pathway for patients with diabetes foot ulcers is depended on a combination of competence and professional skills in wound management, and continuity of care. If telemedicine is functioning as intended, it can be an important additional tool. Copyright © 2016. Published by Elsevier Ireland Ltd.

Effects of clinical pathways for chronic obstructive pulmonary disease (COPD) on patient, professional and systems outcomes: protocol for a systematic review.

PubMed

Plishka, Christopher; Rotter, Thomas; Kinsman, Leigh; Hansia, Mohammed Rashaad; Lawal, Adegboyega; Goodridge, Donna; Penz, Erika; Marciniuk, Darcy D

2016-08-11

Chronic obstructive pulmonary disease (COPD) is a respiratory syndrome characterized by progressive, partially reversible airway obstruction and lung hyperinflation. COPD has a substantial burden which is seen in both patient quality of life and healthcare costs. One proposed method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs aim to guide evidence-based practice and improve the interaction between health services. They bring the best available evidence to a range of healthcare professionals by adapting evidence-based clinical guidelines to a local context and detailing the essential steps in the assessment and care of patients. The aim of this systematic review is to synthesize existing literature on the effects of CPWs for the treatment or management of COPD. We will screen search hits from search strategies developed for a Cochrane Effective Practice and Organisation of Care (EPOC) systematic review on the use of CPWs in primary care and a Cochrane EPOC review on the use of CPWs in hospitals. These searches were run in a range of databases. Studies will be screened independently by two reviewers. All studies identified by our search strategy will be considered regardless of study design as long as they meet the operational definition for clinical pathways developed by Kinsman et al. (BMC Medicine 8, 2010) and focus on the treatment or management of COPD. All included studies will be evaluated for risk of bias utilizing methodologies set out by the Cochrane collaboration. Data regarding patient, professional and systems outcomes will be extracted from all included studies. Data will be presented in both narrative and tabular form. The systematic review outlined in this protocol aims to identify, assess and synthesise all available evidence on the effects of CPWs regarding the treatment and management of COPD. As a result, this review will provide an evidence base for decision makers regarding the practicality, cost effectiveness, patient benefit and best practices regarding the implementation of CPWs for the care of COPD.

An evaluation of routine specialist palliative care for patients on the Liverpool Care Pathway.

PubMed

Thompson, Jo; Brown, Jayne; Davies, Andrew

2014-01-01

This report describes a service evaluation of the 'added value' of routine specialist palliative care team (SPCT) involvement with patients on the Liverpool Care Pathway for the Dying Patient (LCP). In the authors' hospital, patients that are commenced on the LCP are routinely referred to the SPCT. They are reviewed on the day of referral and then at least every other day, depending on the clinical situation. The data for this report was obtained by reviewing the SPCT's clinical database and the patients' LCP proformas. The SPCT intervened in the care of 80% of 158 newly referred patients, e.g. for alteration of continuous subcutaneous infusion (23%) or alteration of use of non-pharmacological interventions (21%). Furthermore, 11% of patients were taken off the LCP, around one quarter of whom were later put back on. The authors' model of care could overcome many of the issues relating to the LCP and would ameliorate the developing vacuum of care for patients at the end of life.

Developing a one-stop tinnitus service: outcomes of a joined up management strategy: a retrospective observational cohort study.

PubMed

Farr, Matthew R B; Moraleda Deleito, Javier; Xu, Yanmin; Ray, Jaydip

2016-02-01

The pressure to deliver quality care with finite resources means that dealing with single-symptom conditions like tinnitus in an efficient and individualized manner has never been more important. Both primary and secondary care practitioners have an obligation to explore efficient delivery of simple management pathways. Commissioners of health care are in a unique position to affect evidence-based strategic change in the management of uncomplicated tinnitus. This study is an attempt to explore one such option. We present the outcomes of a tinnitus patient pathway designed for one-stop management, thereby minimizing unnecessary additional appointments. A retrospective observational cohort study of 452 patients referred to a NHS one-stop tinnitus clinic from 2008 to 2012. Clinical care guided was through the use of a structured approach to history taking, neurotological examination and management. 294 out of 452 (65%) of patients referred had unilateral tinnitus. The most common associated complaints were hearing loss (387/452, 86%) and hyperacusis (329/452, 73%). 210 (46%) of patients had their presenting complaint dealt with in a single clinic visit. A structured system for referral and management of tinnitus within the health system ensures patients have timely access to evidence-based investigation and treatment. A consistent approach to imaging aimed at identifying retrocochlear pathology can benefit patients through early diagnosis of central pathology and the reassurance provided by a negative scan. © 2015 John Wiley & Sons, Ltd.

Optimising perioperative care for hip and knee arthroplasty in South Africa: a Delphi consensus study.

PubMed

Plenge, U; Nortje, M B; Marais, L C; Jordaan, J D; Parker, R; van der Westhuizen, N; van der Merwe, J F; Marais, J; September, W V; Davies, G L; Pretorius, T; Solomon, C; Ryan, P; Torborg, A M; Farina, Z; Smit, R; Cairns, C; Shanahan, H; Sombili, S; Mazibuko, A; Hobbs, H R; Porrill, O S; Timothy, N E; Siebritz, R E; van der Westhuizen, C; Troskie, A J; Blake, C A; Gray, L A; Munting, T W; Steinhaus, H K S; Rowe, P; van der Walt, J G; Isaacs Noordien, R; Theron, A; Biccard, B M

2018-05-09

A structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. However, in low- and middle-income countries (LMICs), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. To inform similar practice in LMICs for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for LMICs. Applying a Delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 South African provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. Thirty of the thirty-three stakeholders completed the 3 months Delphi study. The first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. These items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category. The consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. It is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in LMICs.

[Clinical features, care pathways and behaviors of patients with high level of cardiovascular risk: transversal study in south-west region of France].

PubMed

Gay, Bernard; Couffinhal, Thierry; Saillour-Glénisson, Florence; Sevin, Floriane; Kret, Marion; Michel, Philippe

2013-11-01

To screen and to follow-up the patients with high cardiovascular risk in general practice may amplify the decrease of the cardiovascular morbi-mortality observed since a few years. The objective of this study is to identify the patients with high cardiovascular risk and to describe the management of these patients by general practitioners in Aquitaine. Transversal study of a sample of patients from 18 to 70 years old with high cardiovascular risk (combining at least 3 factors), included by voluntary general practitioners (GP). Forty-seven GP included 102 patients, presenting on average 3.7 risk factors among which 2.6 modifiable. The target values were reached for 59 % of patients with high blood pressure, 56 % of patients with diabetes and 53 % of patients with high cholesterol level. The analysis of care pathways identified the cardiologist as the privileged interlocutor. The doctors thought that seven patients out of 10 could change their risk behaviors. For the patients, the scale of declared importance to change was 6.6 on 10 for tobacco, 6.0 for food habits and 6.2 for physical activity. The confidence in their capacity to change was 3.8 on 10 for the tobacco, 5.2 for the food habits and 4.7 for the physical activity. Although doctors' sample is not representative, these results give an original overview of the management of patients with high cardiovascular risk and their care pathways. Medical treatments were globally in accordance with guidelines. The difficulty to change risk behaviors illustrates the necessity of patient therapeutic education. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

DNA Repair in Prostate Cancer: Biology and Clinical Implications.

PubMed

Mateo, Joaquin; Boysen, Gunther; Barbieri, Christopher E; Bryant, Helen E; Castro, Elena; Nelson, Pete S; Olmos, David; Pritchard, Colin C; Rubin, Mark A; de Bono, Johann S

2017-03-01

For more precise, personalized care in prostate cancer (PC), a new classification based on molecular features relevant for prognostication and treatment stratification is needed. Genomic aberrations in the DNA damage repair pathway are common in PC, particularly in late-stage disease, and may be relevant for treatment stratification. To review current knowledge on the prevalence and clinical significance of aberrations in DNA repair genes in PC, particularly in metastatic disease. A literature search up to July 2016 was conducted, including clinical trials and preclinical basic research studies. Keywords included DNA repair, BRCA, ATM, CRPC, prostate cancer, PARP, platinum, predictive biomarkers, and hereditary cancer. We review how the DNA repair pathway is relevant to prostate carcinogenesis and progression. Data on how this may be relevant to hereditary cancer and genetic counseling are included, as well as data from clinical trials of PARP inhibitors and platinum therapeutics in PC. Relevant studies have identified genomic defects in DNA repair in PCs in 20-30% of advanced castration-resistant PC cases, a proportion of which are germline aberrations and heritable. Phase 1/2 clinical trial data, and other supporting clinical data, support the development of PARP inhibitors and DNA-damaging agents in this molecularly defined subgroup of PC following success in other cancer types. These studies may be an opportunity to improve patient care with personalized therapeutic strategies. Key literature on how genomic defects in the DNA damage repair pathway are relevant for prostate cancer biology and clinical management is reviewed. Potential implications for future changes in patient care are discussed. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

FY08 DRMRP Clinical Trial: Strengthening Pathways to PTSD Recovery Using Systems-Level Intervention

DTIC Science & Technology

2015-09-01

telephone cognitive-behavioral therapy , continuous RN nurse care management, and computer-automated care management support. Both arms can refer patients... physically occurring at the study sites. These closure reports were approved by the local DDEAMC and lead WRNMMC IRBs in May 2015 and by HRPO in June... physical symptom burden (as measured by the PHQ-15), improved mental health functioning (as measured by the SF-12 mental component), but no changes for

A Qualitative Study of Medical Oncologists’ Experiences of Their Profession and Workforce Sustainability

PubMed Central

Broom, Alex; Wong, W. K. Tim; Kirby, Emma; Sibbritt, David; Karikios, Deme; Harrup, Rosemary; Lwin, Zarnie

2016-01-01

Background Medical oncology is a steadily evolving field of medical practice and professional pathway for doctors, offering value, opportunity and challenge to those who chose this medical specialty. This study examines the experiences of a group of Australian medical oncologists, with an emphasis on their professional practice, career experiences, and existing and emerging challenges across career stages. Methods In-depth qualitative interviews were conducted with 22 medical oncologists, including advanced trainees, early-career consultants and senior consultants, focusing on: professional values and experiences; career prospects and pathways; and, the nexus of the characteristics of the profession and delivery of care. Results The following themes were emergent from the interviews: the need for professional reinvention and the pressure to perform; the importance, and often absence, of mentoring and feedback loops; the emotional labour of oncology; and, the impact of cascading workload volume on practice sustainability. Conclusions Understanding professional experiences, career trajectories and challenges at the workforce level are crucial for understanding what drives the oncological care day-to-day. The results indicate that there are considerable potential tensions between the realities of professional, workforce demands and expectations for patient care. Such tensions have real and significant consequences on individual medical oncologists with respect to their futures, aspirations, satisfaction with work, caring practices, interactions with patients and potentially therapeutic outcomes. PMID:27902706

Pathways to care and psychological problems of general practice patients in a "gate keeper" and an "open access" health care system: a comparison of Germany and the Netherlands.

PubMed

Linden, M; Gothe, H; Ormel, J

2003-12-01

The comparison of different health care systems is one way to give empirical evidence to health care reform and policy. The differences between health care systems in which general practitioners serve as gate keepers in comparison to systems in which patients are free to contact every physician and specialist they like are a question of high interest. This study compares the Netherlands and Germany, two countries with very similar political, social, and health system structures, but different types of access to the health care system. While Germany offers unconstrained access to specialist ambulatory care, the Netherlands restricts health care utilization by giving primary care a 'gate keeper' function not allowing patients direct access to specialist care. Data from the WHO international collaborative study on psychological problems in general health care (Ustün and Sartorius 1995) were analysed with respect to pathways to care, treatment, and health status. In an initial cross-sectional assessment, in 3-month and 12-month follow-ups, contacts to physicians or hospital admission have also been monitored. There were only marginal differences between the Dutch and the German sample in the sociodemographic characteristics as well as in the diagnostic status with respect to mental disorders. In the Netherlands, 95.5%, and in Germany, 68.8% of the patients presented their 'reason for visit' for the first time to any physician at this index contact with a general practitioner. During the following 3 months, 24% of the Dutch patients, but 60.2% of the German patients, additionally contacted other physicians ( P < 0.001). At 12 months, this rate was 62.9% vs. 78.6% ( P < 0.001). During the 12-month follow-up period, there were 15.7 0/00 hospital admissions in Germany vs. 25.4 0/00 in the Netherlands ( P < 0.005) [corrected]. Family physicians in a gate keeper system reduce the number of contacts to other physicians and the intensity of treatment, while at the same time the rate of hospital admissions is increased.

Enhanced Recovery after Urological Surgery: A Contemporary Systematic Review of Outcomes, Key Elements, and Research Needs.

PubMed

Azhar, Raed A; Bochner, Bernard; Catto, James; Goh, Alvin C; Kelly, John; Patel, Hiten D; Pruthi, Raj S; Thalmann, George N; Desai, Mihir

2016-07-01

Enhanced Recovery after Surgery (ERAS) programs are multimodal care pathways that aim to decrease intra-operative blood loss, decrease postoperative complications, and reduce recovery times. To overview the use and key elements of ERAS pathways, and define needs for future clinical trials. A comprehensive systematic MEDLINE search was performed for English language reports published before May 2015 using the terms "postoperative period," "postoperative care," "enhanced recovery after surgery," "enhanced recovery," "accelerated recovery," "fast track recovery," "recovery program," "recovery pathway", "ERAS," and "urology" or "cystectomy" or "urologic surgery." We identified 18 eligible articles. Patient counseling, physical conditioning, avoiding excessive alcohol and smoking, and good nutrition appeared to protect against postoperative complications. Fasting from solid food for only 6h and perioperative liquid-carbohydrate loading up to 2h prior to surgery appeared to be safe and reduced recovery times. Restricted, balanced, and goal-directed fluid replacement is effective when individualized, depending on patient morbidity and surgical procedure. Decreased intraoperative blood loss may be achieved by several measures. Deep vein thrombosis prophylaxis, antibiotic prophylaxis, and thermoregulation were found to help reduce postsurgical complications, as was a multimodal approach to postoperative nausea, vomiting, and analgesia. Chewing gum, prokinetic agents, oral laxatives, and an early resumption to normal diet appear to aid faster return to normal bowel function. Further studies should compare anesthetic protocols, refine analgesia, and evaluate the importance of robot-assisted surgery and the need/timing for drains and catheters. ERAS regimens are multidisciplinary, multimodal pathways that optimize postoperative recovery. This review provides an overview of the use and key elements of Enhanced Recovery after Surgery programs, which are multimodal, multidisciplinary care pathways that aim to optimize postoperative recovery. Additional conclusions include identifying effective procedures within Enhanced Recovery after Surgery programs and defining needs for future clinical trials. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Remote Ambulatory Management of Veterans with Obstructive Sleep Apnea

PubMed Central

Fields, Barry G.; Behari, Pratima Pathak; McCloskey, Susan; True, Gala; Richardson, Diane; Thomasson, Arwin; Korom-Djakovic, Danijela; Davies, Keith; Kuna, Samuel T.

2016-01-01

Study Objectives: Despite significant medical sequelae of obstructive sleep apnea (OSA), the condition remains undiagnosed and untreated in many affected individuals. We explored the feasibility of a comprehensive, telemedicine-based OSA management pathway in a community-based Veteran cohort. Methods: This prospective, parallel-group randomized pilot study assessed feasibility of a telemedicine-based pathway for OSA evaluation and management in comparison to a more traditional, in-person care model. The study included 60 Veterans at the Philadelphia Veterans Affairs Medical Center and two affiliated community-based outpatient clinics. Telemedicine pathway feasibility, acceptability, and outcomes were assessed through a variety of quantitative (Functional Outcomes of Sleep Questionnaire, dropout rates, positive airway pressure [PAP] adherence rates, participant satisfaction ratings) and qualitative (verbal feedback) metrics. Results: There was no significant difference in functional outcome changes, patient satisfaction, dropout rates, or objectively measured PAP adherence between groups after 3 months of treatment. Telemedicine participants showed greater improvement in mental health scores, and their feedback was overwhelmingly positive. Conclusions: Our pilot study suggests that telemedicine-based management of OSA patients is feasible in terms of patient functional outcomes and overall satisfaction with care. Future studies should include larger populations to further elucidate these findings while assessing provider- and patient-related cost effectiveness. Citation: Fields BG, Behari PP, McCloskey S, True G, Richardson D, Thomasson A, Korom-Djakovic D, Davies K, Kuna ST. Remote ambulatory management of veterans with obstructive sleep apnea. SLEEP 2016;39(3):501–509. PMID:26446115

Development of a model of dementia support and pathway for culturally and linguistically diverse communities using co-creation and participatory action research.

PubMed

Goeman, Dianne; King, Jordan; Koch, Susan

2016-12-07

To develop an inclusive model of culturally sensitive support, using a specialist dementia nurse (SDN), to assist people with dementia from culturally and linguistically diverse (CALD) communities and their carers to overcome barriers to accessing health and social care services. Co-creation and participatory action research, based on reflection, data collection, interaction and feedback from participants and stakeholders. An SDN support model embedded within a home nursing service in Melbourne, Australia was implemented between October 2013 and October 2015. People experiencing memory loss or with a diagnosis of dementia from CALD backgrounds and their carers and family living in the community setting and expert stakeholders. Reflections from the SDN on interactions with participants and expert stakeholder opinion informed the CALD dementia support model and pathway. Interaction with 62 people living with memory loss or dementia from CALD backgrounds, carers or family members receiving support from the SDN and feedback from 13 expert stakeholders from community aged-care services, consumer advocacy organisations and ethnic community group representatives informed the development and refinement of the CALD dementia model of care and pathway. We delineate the three components of the 'SDN' model: the organisational support; a description of the role; and the competencies needed. Additionally, we provide an accompanying pathway for use by health professionals delivering care to consumers with dementia from CALD backgrounds. Our culturally sensitive model of dementia care and accompanying pathway allows for the tailoring of health and social support to assist people from CALD backgrounds, their carers and families to adjust to living with memory loss and remain living in the community as long as possible. The model and accompanying pathway also have the potential to be rolled out nationally for use by health professionals across a variety of health services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Integrating emotional and psychological support into the end-stage renal disease pathway: a protocol for mixed methods research to identify patients' lower-level support needs and how these can most effectively be addressed.

PubMed

Taylor, Francesca; Taylor, Celia; Baharani, Jyoti; Nicholas, Johann; Combes, Gill

2016-08-02

As a result of difficulties related to their illness, diagnosis and treatment, patients with end-stage renal disease experience significant emotional and psychological problems, which untreated can have considerable negative impact on their health and wellbeing. Despite evidence that patients desire improved support, management of their psychosocial problems, particularly at the lower-level, remains sub-optimal. There is limited understanding of the specific support that patients need and want, from whom, and when, and also a lack of data on what helps and hinders renal staff in identifying and responding to their patients' support needs, and how barriers to doing so might be overcome. Through this research we therefore seek to determine what, when, and how, support for patients with lower-level emotional and psychological problems should be integrated into the end-stage renal disease pathway. The research will involve two linked, multicentre studies, designed to identify and consider the perspectives of patients at five different stages of the end-stage renal disease pathway (Study 1), and renal staff working with them (Study 2). A convergent, parallel mixed methods design will be employed for both studies, with quantitative and qualitative data collected separately. For each study, the data sets will be analysed separately and the results then compared or combined using interpretive analysis. A further stage of synthesis will employ data-driven thematic analysis to identify: triangulation and frequency of themes across pathway stages; patterns and plausible explanations of effects. There is an important need for this research given the high frequency of lower-level distress experienced by end-stage renal disease patients and lack of progress to date in integrating support for their lower-level psychosocial needs into the care pathway. Use of a mixed methods design across the two studies will generate a holistic patient and healthcare professional perspective that is more likely to identify viable solutions to enable implementation of timely and integrated care. Based on the research outputs, appropriate support interventions will be developed, implemented and evaluated in a linked follow-on study.

The effect of the size of fluorescent dextran on its endocytic pathway.

PubMed

Li, Lei; Wan, Tao; Wan, Min; Liu, Bei; Cheng, Ran; Zhang, Rongying

2015-05-01

Fluorescent dextrans are commonly used as macropinocytic probes to study the properties of endocytic cargoes; however, the effect of the size of dextrans on endocytic mechanisms has not been carefully analyzed. By using chemical and siRNA inhibition of individual endocytic pathways, we evaluated the internalization of two commonly used dextrans, Dex10 (dextran 10 kDa) and Dex70 (dextran 70 kDa), in mammalian HeLa cells and Caenorhabditis elegans coelomocytes. We revealed that Dex70 enters these two cell types predominantly via clathrin- and dynamin-independent and amiloride-sensitive macropinocytosis process; Dex10, on the other hand, enters the two cell types through clathrin-/dynamin-dependent micropinocytosis in addition to macropinocytosis. In addition, although different-sized dextrans follow different endocytic processes, they share common post-endocytic events. Herein, though straightforward, our studies support that the size of nanomaterials could play a paramount role in their inclusion into endocytic vesicles and suggest that care should be taken while selecting endocytic pathway markers. Based on our results, we propose that Dex70 is a better probe for macropinocytosis, whereas Dex10 and smaller molecules are better for probing general fluid-phase endocytosis, which includes macropinocytic and micropinocytic processes. © 2015 International Federation for Cell Biology.

Aboriginal experiences of cancer and care coordination: Lessons from the Cancer Data and Aboriginal Disparities (CanDAD) narratives.

PubMed

Reilly, Rachel; Micklem, Jasmine; Yerrell, Paul; Banham, David; Morey, Kim; Stajic, Janet; Eckert, Marion; Lawrence, Monica; Stewart, Harold B; Brown, Alex

2018-04-24

Aboriginal people with cancer experience worse outcomes than other Australians for a range of complex and interrelated reasons. A younger age at diagnosis, higher likelihood of more advanced cancer or cancer type with poorer prognosis, geographic isolation and cultural and language diversity mean that patient pathways are potentially more complex for Aboriginal people with cancer. In addition, variation in the quality and acceptability of care may influence cancer outcomes. This study sought to understand how care coordination influences Aboriginal people's experiences of cancer treatment. Interviews with 29 Aboriginal patients or cancer survivors, 11 carers and 22 service providers were carried out. Interviews were semi-structured and sought to elicit experiences of cancer and the health-care system. The manifest content of the cancer narratives was entered onto a cancer pathway mapping tool and underlying themes were identified inductively. The practice of cancer care coordination was found to address the needs of Aboriginal patients and their families/carers in 4 main areas: "navigating the health system"; "information and communication"; "things to manage at home"; and "cultural safety". The CanDAD findings indicate that, when the need for cancer care coordination is met, it facilitated continuity of care in a range of ways that may potentially improve cancer outcomes. However, the need remains unmet for many. Findings support the importance of dedicated care coordination to enable Aboriginal people to receive adequate and appropriate patient-centred care, so that the unacceptable disparity in cancer outcomes between Aboriginal and non-Aboriginal people can be addressed. © 2018 The Authors. Health Expectations published by John Wiley & Sons Ltd.

Impact of transitional care on endocrine and anthropometric parameters in Prader–Willi syndrome

PubMed Central

Paepegaey, A C; Coupaye, M; Jaziri, A; Ménesguen, F; Dubern, B; Polak, M; Oppert, J M; Tauber, M; Pinto, G; Poitou, C

2018-01-01

Context The transition of patients with Prader–Willi syndrome (PWS) to adult life for medical care is challenging because of multiple comorbidities, including hormone deficiencies, obesity and cognitive and behavioral disabilities. Objective To assess endocrine management, and metabolic and anthropometric parameters of PWS adults who received (n = 31) or not (n = 64) transitional care, defined as specialized pediatric care followed by a structured care pathway to a multidisciplinary adult team. Patients and study design Hormonal and metabolic parameters were retrospectively recorded in 95 adults with PWS (mean ± s.d. age 24.7 ± 8.2 years, BMI: 39.8 ± 12.1 kg/m²) referred to our Reference Center and compared according to transition. Results Among the entire cohort, 35.8% received growth hormone (GH) during childhood and 16.8% had a GH stimulation test after completion of growth. In adulthood, 14.7% were treated with GH, 56.8% received sex-hormone therapy, whereas 91.1% were hypogonadic and 37.9% had undergone valid screening of the corticotropic axis. The main reason for suboptimal endocrine management was marked behavioral disorders. Patients receiving transitional care were more likely to have had a GH stimulation test and hormonal substitutions in childhood. They also had a lower BMI, percentage of fat mass, improved metabolic parameters and fewer antidepressant treatments. Transitional care remained significantly associated with these parameters in multivariate analysis when adjusted on GH treatment. Conclusion A coordinated care pathway with specialized pediatric care and transition to a multidisciplinary adult team accustomed to managing complex disability including psychiatric troubles are associated with a better health status in adults with PWS. PMID:29666169

A multi-group path analysis of the relationship between perceived racial discrimination and self-rated stress: how does it vary across racial/ethnic groups?

PubMed

Yang, Tse-Chuan; Chen, Danhong

2018-04-01

The objective of this study was to answer three questions: (1) Is perceived discrimination adversely related to self-rated stress via the social capital and health care system distrust pathways? (2) Does the relationship between perceived discrimination and self-rated stress vary across race/ethnicity groups? and (3) Do the two pathways differ by one's race/ethnicity background? Using the Philadelphia Health Management Corporation's Southeastern Pennsylvania Household Survey, we classified 9831 respondents into 4 race/ethnicity groups: non-Hispanic White (n = 6621), non-Hispanic Black (n = 2359), Hispanic (n = 505), and non-Hispanic other races (n = 346). Structural equation modeling was employed to simultaneously estimate five sets of equations, including the confirmatory factor analysis for both social capital and health care distrust and both direct and indirect effects from perceived discrimination to self-rated stress. The key findings drawn from the analysis include the following: (1) in general, people who experienced racial discrimination have higher distrust and weaker social capital than those without perceived discrimination and both distrust and social capital are ultimately related to self-rated stress. (2) The direct relationship between perceived discrimination and self-rated stress is found for all race/ethnicity groups (except non-Hispanic other races) and it does not vary across groups. (3) The two pathways can be applied to non-Hispanic White and Black, but for Hispanic and non-Hispanic other races, we found little evidence for the social capital pathway. For non-Hispanic White, non-Hispanic Black, and Hispanic, perceived discrimination is negatively related to self-rated stress. This finding highlights the importance of reducing interpersonal discriminatory behavior even for non-Hispanic White. The health care system distrust pathway can be used to address the racial health disparity in stress as it holds true for all four race/ethnicity groups. On the other hand, the social capital pathway seems to better help non-Hispanic White and Black to mediate the adverse effect of perceived discrimination on stress.

Bridging the Gap between Theory and Practice in Integrated Care: The Case of the Diabetic Foot Pathway in Tuscany

PubMed Central

Bini, Barbara; Ruggieri, Tommaso Grillo; Piaggesi, Alberto; Ricci, Lucia

2016-01-01

Introduction and Background: As diabetic foot (DF) care benefits from integration, monitoring geographic variations in lower limb Major Amputation rate enables to highlight potential lack of Integrated Care. In Tuscany (Italy), these DF outcomes were good on average but they varied within the region. In order to stimulate an improvement process towards integration, the project aimed to shift health professionals’ focus on the geographic variation issue, promote the Population Medicine approach, and engage professionals in a community of practice. Method: Three strategies were thus carried out: the use of a transparent performance evaluation system based on benchmarking; the use of patient stories and benchmarking analyses on outcomes, service utilization and costs that cross-checked delivery- and population-based perspectives; the establishment of a stable community of professionals to discuss data and practices. Results: The project enabled professionals to shift their focus on geographic variation and to a joint accountability on outcomes and costs for the entire patient pathways. Organizational best practices and gaps in integration were identified and improvement actions towards Integrated Care were implemented. Conclusion and Discussion: For the specific category of care pathways whose geographic variation is related to a lack of Integrated Care, a comprehensive strategy to improve outcomes and reduce equity gaps by diffusing integration should be carried out. PMID:29042842

Contact Between Police and People With Mental Disorders: A Review of Rates.

PubMed

Livingston, James D

2016-08-01

There is widespread belief that people with mental disorders are overrepresented in police encounters. The prevalence of such interactions is used as evidence of extensive problems in our health care and social support systems. The goal of this study was to estimate the rates of police arrests among people with mental disorders, police involvement in pathways to mental health care, and police calls for service involving persons with mental disorders. A systematic review was performed with seven multidisciplinary databases. Additional studies were identified by reviewing the reference lists of all included records and by using the "related articles" and "cited articles" tools in the Web of Science database. Studies were included if they were published in peer-reviewed journals, reported primary research findings, and were written in English. Eighty-five unique studies covering 329,461 cases met inclusion criteria. Data reported in 21 studies indicated that one in four people with mental disorders have histories of police arrest. Data from 48 studies indicated that about one in ten individuals have police involved in their pathway to mental health care. Data reported in 13 studies indicated that one in 100 police dispatches and encounters involve people with mental disorders. These estimates illuminate the magnitude of the issue and supply an empirically based reference point to scholars and practitioners in this area. The findings are useful for understanding how local trends regarding police involvement in the lives of people with mental disorders compare with rates in the broader research literature.

Economic modelling of diagnostic and treatment pathways in National Institute for Health and Care Excellence clinical guidelines: the Modelling Algorithm Pathways in Guidelines (MAPGuide) project.

PubMed

Lord, J; Willis, S; Eatock, J; Tappenden, P; Trapero-Bertran, M; Miners, A; Crossan, C; Westby, M; Anagnostou, A; Taylor, S; Mavranezouli, I; Wonderling, D; Alderson, P; Ruiz, F

2013-12-01

National Institute for Health and Care Excellence (NICE) clinical guidelines (CGs) make recommendations across large, complex care pathways for broad groups of patients. They rely on cost-effectiveness evidence from the literature and from new analyses for selected high-priority topics. An alternative approach would be to build a model of the full care pathway and to use this as a platform to evaluate the cost-effectiveness of multiple topics across the guideline recommendations. In this project we aimed to test the feasibility of building full guideline models for NICE guidelines and to assess if, and how, such models can be used as a basis for cost-effectiveness analysis (CEA). A 'best evidence' approach was used to inform the model parameters. Data were drawn from the guideline documentation, advice from clinical experts and rapid literature reviews on selected topics. Where possible we relied on good-quality, recent UK systematic reviews and meta-analyses. Two published NICE guidelines were used as case studies: prostate cancer and atrial fibrillation (AF). Discrete event simulation (DES) was used to model the recommended care pathways and to estimate consequent costs and outcomes. For each guideline, researchers not involved in model development collated a shortlist of topics suggested for updating. The modelling teams then attempted to evaluate options related to these topics. Cost-effectiveness results were compared with opinions about the importance of the topics elicited in a survey of stakeholders. The modelling teams developed simulations of the guideline pathways and disease processes. Development took longer and required more analytical time than anticipated. Estimates of cost-effectiveness were produced for six of the nine prostate cancer topics considered, and for five of eight AF topics. The other topics were not evaluated owing to lack of data or time constraints. The modelled results suggested 'economic priorities' for an update that differed from priorities expressed in the stakeholder survey. We did not conduct systematic reviews to inform the model parameters, and so the results might not reflect all current evidence. Data limitations and time constraints restricted the number of analyses that we could conduct. We were also unable to obtain feedback from guideline stakeholders about the usefulness of the models within project time scales. Discrete event simulation can be used to model full guideline pathways for CEA, although this requires a substantial investment of clinical and analytic time and expertise. For some topics lack of data may limit the potential for modelling. There are also uncertainties over the accessibility and adaptability of full guideline models. However, full guideline modelling offers the potential to strengthen and extend the analytical basis of NICE's CGs. Further work is needed to extend the analysis of our case study models to estimate population-level budget and health impacts. The practical usefulness of our models to guideline developers and users should also be investigated, as should the feasibility and usefulness of whole guideline modelling alongside development of a new CG. This project was funded by the Medical Research Council and the National Institute for Health Research through the Methodology Research Programme [grant number G0901504] and will be published in full in Health Technology Assessment; Vol. 17, No. 58. See the NIHR Journals Library website for further project information.

A novel personal health system with integrated decision support and guidance for the management of chronic liver disease.

PubMed

Kiefer, Stephan; Schäfer, Michael; Bransch, Marco; Brimmers, Peter; Bartolomé, Diego; Baños, Janie; Orr, James; Jones, Dave; Jara, Maximilian; Stockmann, Martin

2014-01-01

A personal health system platform for the management of patients with chronic liver disease that incorporates a novel approach to integrate decision support and guidance through care pathways for patients and their doctors is presented in this paper. The personal health system incorporates an integrated decision support engine that guides patients and doctors through the management of the disease by issuing tasks and providing recommendations to both the care team and the patient and by controlling the execution of a Care Flow Plan based on the results of tasks and the monitored health status of the patient. This Care Flow Plan represents a formal, business process based model of disease management designed off-line by domain experts on the basis of clinical guidelines, knowledge of care pathways and an organisational model for integrated, patient-centred care. In this way, remote monitoring and treatment are dynamically adapted to the patient's actual condition and clinical symptoms and allow flexible delivery of care with close integration of specialists, therapists and care-givers.

Understanding carers' lived experience of stigma: the voice of families with a child on the autism spectrum.

PubMed

Broady, Timothy R; Stoyles, Gerard J; Morse, Corinne

2017-01-01

Existing research suggests that there are several unique challenges associated with caring for a child on the autism spectrum. Despite a growing evidence base regarding autism spectrum disorders and their increasing prevalence, children on the autism spectrum and their families continue to perceive stigmatisation from various sources throughout the community. These perceptions of stigma can profoundly impact the quality of life of these children and their carers alike. This exploratory study sought to investigate carers' perceptions of stigma in caring for a child with high functioning autism. Fifteen carers from Sydney and the South Coast regions of New South Wales, Australia, participated in semi-structured interviews regarding their caring experiences and any perceived encounters with stigma. Four domains of stigmatising experiences were identified: (i) lack of knowledge, (ii) judgement, (iii) rejection and (iv) lack of support. These domains were each reported to exist in four main contexts: (i) school, (ii) public, (iii) family and (iv) friends. These domains and contexts established a framework which provided a detailed account of how and where carers felt stigmatised, including the suggestion of a stigmatising pathway through the four domains. The main contexts in which stigma was perceived also appeared to be related, with those carers who experienced stigma in one context being more likely to report similar experiences in other contexts. Any attempts to empower carers in the face of stigmatisation should therefore consider each of these domains, the pathway that connects them and the relationship between different social contexts. Through identifying this pathway, supportive services can be acutely aware of how carers may perceive potentially stigmatising experiences and therefore provide appropriate interventions or support for the relevant stage of the pathway. © 2015 John Wiley & Sons Ltd.

Analysis Of End-Of-Life Care, Out-Of-Pocket Spending, And Place Of Death In 16 European Countries And Israel.

PubMed

Orlovic, Martina; Marti, Joachim; Mossialos, Elias

2017-07-01

In Europe the aging of the population will pose considerable challenges to providing high-quality end-of-life care. The complexity of providing care and the large spectrum of actors involved make it difficult to understand the care pathways and how these are influenced by financial and institutional factors. We examined a large, multicountry data set with waves of data from the period 2006-13 to determine the differences in health care usage, out-of-pocket spending, and place of death in sixteen European countries and Israel. Our results reveal the importance of the funding mechanisms of long-term care. They also illuminate the effect of patients' characteristics on end-of-life care pathways. We found that in countries where public financing and organization of long-term care are particularly strong, patients at the end of life are more likely to have reduced hospitalizations and a higher share of out-of-hospital deaths. Understanding end-of-life care patterns is crucial to developing policies to address the urgent public health priority that this aspect of health care presents. Project HOPE—The People-to-People Health Foundation, Inc.

Lost in care pathway: a qualitative investigation on the health system delay of extra pulmonary tuberculosis patients in Bangladesh.

PubMed

Sarker, Malabika; Mohammad, Din; Paul, Sukanta; Akter, Rahima; Islam, Shayla; Biswas, Goutam; Hossain, Asheque; Islam, Akramul

2017-03-28

Although extra pulmonary tuberculosis (EPTB) has long been known as a major public health concern globally, the complex healthcare-seeking pathways of EPTB patients are not widely studied. This study aims to explore the pattern of healthcare-seeking pathways of rural and urban EPTB patients registered with the BRAC TB control programme. BRAC is a Bangladesh-based non-governmental organization dedicated to alleviating poverty through empowering the poor. Data were collected through 60 in-depth interviews with rural and urban EPTB patients in Bangladesh. The findings reveal that the rural EPTB patients encountered a substantial diagnostic delay as compared to the urban patients. However, the difference between the average number of healthcare providers consulted by the rural verses the urban EPTB patients was not significant. This study also shows that the healthcare-seeking journey of rural and urban EPTB patients usually starts either at pharmacies or private facilities. Through exploring the detailed nature of the pathway, this study reveals the ways in which non-medical informants, mainly relatives and friends, can benefit patients. The private and informal healthcare providers should receive appropriate training on the diagnosis of EPTB. Such training could effectively shorten the long and complex healthcare-seeking pathways of EPTB patients.

Exploring midwifery students' views and experiences of caseload midwifery: A cross-sectional survey conducted in Victoria, Australia.

PubMed

Dawson, Kate; Newton, Michelle; Forster, Della; McLachlan, Helen

2015-02-01

in Australia, models of maternity care that offer women continuity of care with a known midwife have been promoted. Little is known about the intentions of the future midwifery workforce to work in such models. This study aimed to explore midwifery students' views and experiences of caseload midwifery and their work intentions in relation to the caseload model following graduation. cross-sectional survey. Victoria, Australia. 129 midwifery students representing all midwifery course pathways (Post Graduate Diploma, Bachelor of Midwifery, Bachelor of Nursing/Bachelor of Midwifery) in Victoria. midwifery students from all course pathways considered that continuity of care is important to women and indicated that exposure to continuity models during their course was very positive. Two-thirds of the students (67%) considered that the continuity experiences made them want to work in a caseload model; only 5% reported that their experiences had discouraged them from continuity of care work in the future. Most wanted a period of consolidation to gain experience as a midwife prior to commencing in the caseload model. Perceived barriers to caseload work were being on-call, and challenges in regard to work/life balance and family commitments. midwifery students in this study were very positive about caseload midwifery and most would consider working in caseload after a period of consolidation. Continuity of care experiences during students' midwifery education programmes appeared to provide students with insight and understanding of continuity of care for both women and midwives. Further research should explore what factors influence students' future midwifery work, whether or not their plans are fulfilled, and whether or not the caseload midwifery workforce can be sustained. Copyright © 2014 Elsevier Ltd. All rights reserved.

Midwifery 2030: a woman's pathway to health. What does this mean?

PubMed

ten Hoope-Bender, Petra; Lopes, Sofia Tavares Castro; Nove, Andrea; Michel-Schuldt, Michaela; Moyo, Nester T; Bokosi, Martha; Codjia, Laurence; Sharma, Sheetal; Homer, Caroline

2016-01-01

The 2014 State of the World's Midwifery report included a new framework for the provision of woman-centred sexual, reproductive, maternal, newborn and adolescent health care, known as the Midwifery2030 Pathway. The Pathway was designed to apply in all settings (high-, middle- and low-income countries, and in any type of health system). In this paper, we describe the process of developing the Midwifery2030 Pathway and explain the meaning of its different components, with a view to assisting countries with its implementation. The Pathway was developed by a process of consultation with an international group of midwifery experts. It considers four stages of a woman's reproductive life: (1) pre-pregnancy, (2) pregnancy, (3) labour and birth, and (4) postnatal, and describes the care that women and adolescents need at each stage. Underpinning these four stages are ten foundations, which describe the systems, services, workforce and information that need to be in place in order to turn the Pathway from a vision into a reality. These foundations include: the policy and working environment in which the midwifery workforce operates, the effective coverage of sexual, reproductive, maternal, newborn and adolescent services (i.e. going beyond availability and ensuring accessibility, acceptability and high quality), financing mechanisms, collaboration between different sectors and different levels of the health system, a focus on primary care nested within a functional referral system when needed, pre- and in-service education for the workforce, effective regulation of midwifery and strengthened leadership from professional associations. Strengthening of all of these foundations will enable countries to turn the Pathway from a vision into reality. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa

PubMed Central

Bukenya, Dominic; Darong, Gabriel; Wamoyi, Joyce; McLean, Estelle; Skovdal, Morten; Ddaaki, William; Ondeng’e, Kenneth; Bonnington, Oliver; Seeley, Janet; Hosegood, Victoria; Wringe, Alison

2017-01-01

Objectives There are concerns that medical pluralism may delay patients’ progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade. Methods We conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism. Results Medical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds. Conclusion Medical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa. PMID:28736393

Traditional healers, faith healers and medical practitioners: the contribution of medical pluralism to bottlenecks along the cascade of care for HIV/AIDS in Eastern and Southern Africa.

PubMed

Moshabela, Mosa; Bukenya, Dominic; Darong, Gabriel; Wamoyi, Joyce; McLean, Estelle; Skovdal, Morten; Ddaaki, William; Ondeng'e, Kenneth; Bonnington, Oliver; Seeley, Janet; Hosegood, Victoria; Wringe, Alison

2017-07-01

There are concerns that medical pluralism may delay patients' progression through the HIV cascade-of-care. However, the pathways of impact through which medical pluralism influence the care of people living with HIV (PLHIV) in African settings remain unclear. We sought to establish the manifestation of medical pluralism among PLHIV, and explore mechanisms through which medical pluralism contributes bottlenecks along the HIV care cascade. We conducted a multicountry exploratory qualitative study in seven health and demographic surveillance sites in six eastern and southern African countries: Uganda, Kenya, Tanzania, Malawi, Zimbabwe and South Africa. We interviewed 258 PLHIV at different stages of the HIV cascade-of-care, 48 family members of deceased PLHIV and 53 HIV healthcare workers. Interviews were conducted using shared standardised topic guides, and data managed through NVIVO 8/10/11. We conducted a thematic analysis of healthcare pathways and bottlenecks related to medical pluralism. Medical pluralism, manifesting across traditional, faith-based and biomedical health-worlds, contributed to the care cascade bottlenecks for PLHIV through three pathways of impact. First, access to HIV treatment was delayed through the nature of health-related beliefs, knowledge and patient journeys. Second, HIV treatment was interrupted by availability of alternative options, perceived failed treatment and exploitation of PLHIV by opportunistic traders and healers. Lastly, the mixing of biomedical healthcare providers and treatment with traditional and faith-based options fuelled tensions driven by fear of drug-to-drug interactions and mistrust between providers operating in different health-worlds. Medical pluralism contributes to delays and interruptions of care along the HIV cascade, and mistrust between health providers. Region-wide interventions and policies are urgently needed in sub-Saharan Africa to minimise potential harm and consequences of medical pluralism for PLHIV. The role of sociocultural beliefs in mediating bottlenecks necessitate adoption of culture-sensitive approaches intervention designs and policy reforms appropriate to the context of sub-Saharan Africa. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Physical and rehabilitation medicine (PRM) care pathways: "patients after rotator cuff tear surgery".

PubMed

Ribinik, P; Calmels, P; Barrois, B; Le Moine, F; Yelnik, A P

2011-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after rotator cuff tear surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients' needs, in accordance with the International Classification of Functioning (ICF) (WHO). 2011 Elsevier Masson SAS. All rights reserved.

Physical and rehabilitation medicine (PRM) care pathways: "patients after knee ligament surgery".

PubMed

Calmels, P; Ribinik, P; Barrois, B; Le Moine, F; Yelnik, A-P

2011-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Federation of PRM (Fedmer). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after knee ligament surgery are classified into four care sequences and two clinical categories, taking into account personal and environmental factors that could influence patients' needs, in accordance with the International Classification of Functioning (WHO). 2011 Elsevier Masson SAS. All rights reserved.

The Impact of Alternative Payment Models on Oncology Innovation and Patient Care.

PubMed

Miller, Amy M; Omenn, Gilbert S; Kean, Marcia A

2016-05-15

Oncology care is in a time of major transformation. Scientific discovery is driving breakthroughs in prevention, diagnostics, and treatment, resulting in tremendous gains for patients as the number of cancer survivors continues to grow on an annual basis. At the same time, there is mounting pressure across the healthcare system to contain costs while improving the quality of cancer care. In response to this pressure, private and government payers are increasingly turning to tools such as alternative payment models (APM) and clinical pathways to improve the efficiency of care, inform coverage decisions, and support shared decision-making. As APMs, clinical pathways and other tools are utilized more broadly, it will be critical that these models support the evidence-based use of innovative biomedical advances, including personalized medicine, and deliver patient-centered, high-value care. Clin Cancer Res; 22(10); 2335-41. ©2016 AACR. ©2016 American Association for Cancer Research.

Ethnic variations in pathways to acute care and compulsory detention for women experiencing a mental health crisis

PubMed Central

Lawlor, Caroline; Cole, Laura; Howard, Louise M.

2012-01-01

Background: Much recent debate on excess rates of compulsory detention and coercive routes to care has focused on young black men; evidence is less clear regarding ethnic variations among women and factors that may mediate these. Aim: To explore ethnic variations in compulsory detentions of women, and to explore the potential role of immediate pathways to admission and clinician-rated reasons for admission as mediators of these differences. Method: All women admitted to an acute psychiatric inpatient ward or a women’s crisis house in four London boroughs during a 12-week period were included. Data were collected regarding their pathways to care, clinician-rated reasons for admission, hospital stays, and social and clinical characteristics. Results: Two hundred and eighty seven (287) women from white British, white other, black Caribbean, black African and black other groups were included. Adjusting for social and clinical characteristics, all groups of black patients and white other patients were significantly more likely to have been compulsorily admitted than white British patients; white British patients were more likely than other groups to be admitted to a crisis house and more likely than all the black groups to be admitted because of perceived suicide risk. Immediate pathways to care differed: white other, black African and black other groups were less likely to have referred themselves in a crisis and more likely to have been in contact with the police. When adjustment was made for differences in pathways to care, the ethnic differences in compulsory admission were considerably reduced. Discussion: There are marked ethnic inequities not only between white British and black women, but also between white British and white other women in experiences of acute admission. Differences between groups in help-seeking behaviours in a crisis may contribute to explaining differences in rates of compulsory admission. PMID:21059630

The role of technology in reducing health care costs. Final project report

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sill, A.E.; Warren, S.; Dillinger, J.D.

1997-08-01

Sandia National Laboratories applied a systems approach to identifying innovative biomedical technologies with the potential to reduce U.S. health care delivery costs while maintaining care quality. This study was conducted by implementing both top-down and bottom-up strategies. The top-down approach used prosperity gaming methodology to identify future health care delivery needs. This effort provided roadmaps for the development and integration of technology to meet perceived care delivery requirements. The bottom-up approach identified and ranked interventional therapies employed in existing care delivery systems for a host of health-related conditions. Economic analysis formed the basis for development of care pathway interaction modelsmore » for two of the most pervasive, chronic disease/disability conditions: coronary artery disease (CAD) and benign prostatic hypertrophy (BPH). Societal cost-benefit relationships based on these analyses were used to evaluate the effect of emerging technology in these treatment areas. 17 figs., 48 tabs.« less

[Care guidance and management of cooperative healthcare networks].

PubMed

Eble, S; Rampoldt, T

2013-04-01

Selective agreements offer the possibility to the health insurers to influence the control of care, a chance that they urgently need because of cost pressure. The concepts of care can be developed top-down and then a health insurer can make an offer. Or these concepts are developed bottom-up that means a chance for the healthcare providers who want to actively shape the medical care. An essential component for all these concepts is to be able to calculate and administrate funding and control. Pathways are necessary for controlling the treatment which not only have to be developed but also have to be put into practice. The pathway acute sacroiliac pain developed by the Lübeck doctors' network will be described here as an example of a successful implementation.

Effect of Patient-Focused Clinical Pathway on Anxiety, Depression and Satisfaction of Patients With Coronary Artery Disease: A Quasi-Experimental Study.

PubMed

Fakhr-Movahedi, Ali; Soleimani, Mohsen; Ghazvininejad, Razeyeh; Maher, Mohammad Kazem; Ghorbani, Raheb

2015-09-01

Coronary artery diseases (CAD) are associated with psychological problems such as anxiety and depression in patients. Thus, management of these problems can consider as an important intervention by health care workers, especially nurses. The purpose of this study was to investigate the effectiveness of patient-focused clinical pathway on anxiety, depression and satisfaction of patients with CAD. In this quasi-experimental study, 138 patients suffering from CAD in a coronary care unit of a referral teaching hospital affiliated to Semnan University of Medical Sciences in Semnan, Iran, were recruited using a convenience sampling method. The participants were assigned to two groups: Clinical pathway (CP) and routine (RUT) care. The level of anxiety and depression of patients were measured in admission and discharge in both groups. Also, the level of patients' satisfaction was measured at the time of discharge. Data were analyzed using descriptive and inferential statistics. Prevalence rates of anxiety and depression in total of patients were 7.2% and 8.7%, respectively. In terms of anxiety, the mean of difference between pretest and posttest scores in the CP group (0.52 ± 1.39) was higher compared to the RUT group (-0.17 ± 1.69) and there was a significant difference between the two group (P = 0.009). In terms of depression, the mean of this difference in the CP group (0.75 ± 2.05) was higher compared to the RUT group (0.00 ± 1.08), as there was a significant difference between the two group (P = 0.024). Also, the mean of patients' satisfaction scores in the CP group (3.69 ± 0.39) was higher compared to the RUT group (3.45 ± 0.47) and there was a significant difference between the two groups (P = 0.002). According to the positive effects of CP on patients with CADs, it can be considered as a useful, safe and simple instrument for the improvement of patients' outcomes. Thus, the findings of this study can provide a new insight in patient care for clinical nurses.

ICare-ACS (Improving Care Processes for Patients With Suspected Acute Coronary Syndrome): A Study of Cross-System Implementation of a National Clinical Pathway.

PubMed

Than, Martin P; Pickering, John W; Dryden, Jeremy M; Lord, Sally J; Aitken, S Andrew; Aldous, Sally J; Allan, Kate E; Ardagh, Michael W; Bonning, John W N; Callender, Rosie; Chapman, Laura R E; Christiansen, Jonathan P; Cromhout, Andre P J; Cullen, Louise; Deely, Joanne M; Devlin, Gerard P; Ferrier, Katherine A; Florkowski, Christopher M; Frampton, Christopher M A; George, Peter M; Hamilton, Gregory J; Jaffe, Allan S; Kerr, Andrew J; Larkin, G Luke; Makower, Richard M; Matthews, Timothy J E; Parsonage, William A; Peacock, W Frank; Peckler, Bradley F; van Pelt, Niels C; Poynton, Louise; Richards, A Mark; Scott, Anthony G; Simmonds, Mark B; Smyth, David; Thomas, Oliver P; To, Andrew C Y; Du Toit, Stephen A; Troughton, Richard W; Yates, Kim M

2018-01-23

Efforts to safely reduce length of stay for emergency department patients with symptoms suggestive of acute coronary syndrome (ACS) have had mixed success. Few system-wide efforts affecting multiple hospital emergency departments have ever been evaluated. We evaluated the effectiveness of a nationwide implementation of clinical pathways for potential ACS in disparate hospitals. This was a multicenter pragmatic stepped-wedge before-and-after trial in 7 New Zealand acute care hospitals with 31 332 patients investigated for suspected ACS with serial troponin measurements. The implementation was a clinical pathway for the assessment of patients with suspected ACS that included a clinical pathway document in paper or electronic format, structured risk stratification, specified time points for electrocardiographic and serial troponin testing within 3 hours of arrival, and directions for combining risk stratification and electrocardiographic and troponin testing in an accelerated diagnostic protocol. Implementation was monitored for >4 months and compared with usual care over the preceding 6 months. The main outcome measure was the odds of discharge within 6 hours of presentation RESULTS: There were 11 529 participants in the preimplementation phase (range, 284-3465) and 19 803 in the postimplementation phase (range, 395-5039). Overall, the mean 6-hour discharge rate increased from 8.3% (range, 2.7%-37.7%) to 18.4% (6.8%-43.8%). The odds of being discharged within 6 hours increased after clinical pathway implementation. The odds ratio was 2.4 (95% confidence interval, 2.3-2.6). In patients without ACS, the median length of hospital stays decreased by 2.9 hours (95% confidence interval, 2.4-3.4). For patients discharged within 6 hours, there was no change in 30-day major adverse cardiac event rates (0.52% versus 0.44%; P =0.96). In these patients, no adverse event occurred when clinical pathways were correctly followed. Implementation of clinical pathways for suspected ACS reduced the length of stay and increased the proportions of patients safely discharged within 6 hours. URL: https://www.anzctr.org.au/ (Australian and New Zealand Clinical Trials Registry). Unique identifier: ACTRN12617000381381. © 2017 American Heart Association, Inc.

The cost of changing physical activity behaviour: evidence from a "physical activity pathway" in the primary care setting

PubMed Central

2011-01-01

Background The 'Physical Activity Care Pathway' (a Pilot for the 'Let's Get Moving' policy) is a systematic approach to integrating physical activity promotion into the primary care setting. It combines several methods reported to support behavioural change, including brief interventions, motivational interviewing, goal setting, providing written resources, and follow-up support. This paper compares costs falling on the UK National Health Service (NHS) of implementing the care pathway using two different recruitment strategies and provides initial insights into the cost of changing physical activity behaviour. Methods A combination of a time driven variant of activity based costing, audit data through EMIS and a survey of practice managers provided patient-level cost data for 411 screened individuals. Self reported physical activity data of 70 people completing the care pathway at three month was compared with baseline using a regression based 'difference in differences' approach. Deterministic and probabilistic sensitivity analyses in combination with hypothesis testing were used to judge how robust findings are to key assumptions and to assess the uncertainty around estimates of the cost of changing physical activity behaviour. Results It cost £53 (SD 7.8) per patient completing the PACP in opportunistic centres and £191 (SD 39) at disease register sites. The completer rate was higher in disease register centres (27.3% vs. 16.2%) and the difference in differences in time spent on physical activity was 81.32 (SE 17.16) minutes/week in patients completing the PACP; so that the incremental cost of converting one sedentary adult to an 'active state' of 150 minutes of moderate intensity physical activity per week amounts to £ 886.50 in disease register practices, compared to opportunistic screening. Conclusions Disease register screening is more costly than opportunistic patient recruitment. However, additional costs come with a higher completion rate and better outcomes in terms of behavioural change in patients completing the care pathway. Further research is needed to rigorously evaluate intervention efficiency and to assess the link between behavioural change and changes in quality adjusted life years (QALYs). PMID:21605400

[Results following the implementation of a clinical pathway in the process of care to elderly patients with osteoporotic hip fracture in a second level hospital].

PubMed

Sánchez-Hernández, N; Sáez-López, P; Paniagua-Tejo, S; Valverde-García, J A

2016-01-01

To evaluate the efficiency of a clinical pathway in the management of elderly patients with fragility hip fracture in a second level hospital in terms of length of stay time to surgery, morbidity, hospital mortality, and improved functional outcome. A comparative and prospective study was carried out between two groups of patients with hip fracture aged 75 and older prior to 2010 (n=216), and after a quality improvement intervention in 2013 (n=196). A clinical pathway based on recent scientific evidence was implemented. The degree of compliance with the implemented measures was quantified. The characteristics of the patients in both groups were similar in age, gender, functional status (Barthel Index) and comorbidity (Charlson Index). Median length of stay was reduced by more than 45% in 2013 (16.61 vs. 9.08 days, p=.000). Also, time to surgery decreased 29.4% in the multidisciplinary intervention group (6.23 vs. 4.4 days, p=.000). Patients assigned to the clinical pathway group showed higher medical complications rate (delirium, malnutrition, anaemia and electrolyte disorders), but a lower hospital mortality (5.10 vs. 2.87%, p>.005). The incidence of surgical wound infection (p=.031) and functional efficiency (p=.001) also improved in 2013. An increased number of patients started treatment for osteoporosis (14.80 vs. 76.09%, p=.001) after implementing the clinical pathway. The implementation of a clinical pathway in the care process of elderly patients with hip fracture reduced length of stay and time to surgery, without a negative impact on associated clinical and functional outcomes. Copyright © 2015 SECOT. Published by Elsevier Espana. All rights reserved.

Implementing family communication pathway in neurosurgical patients in an intensive care unit.

PubMed

Kodali, Sashikanth; Stametz, Rebecca; Clarke, Deserae; Bengier, Amanda; Sun, Haiyan; Layon, A J; Darer, Jonathan

2015-08-01

Family-centered care provides family members with basic needs, which includes information, reassurance, and support. Though national guidelines exist, clinical adoption often lags behind in this area. The Geisinger Health System developed and implemented a program for reliable delivery of best practices related to family communication to patients and families admitted to the intensive care unit (ICU). Using a quasiexperimental study design and the 24-item Family Satisfaction in the Intensive Care Unit questionnaire (FSICU-24©) to determine family satisfaction, we measured the impact of a "family communication pathway" facilitated by tools built into the electronic health record on the family satisfaction of neurosurgical patients admitted to the ICU. There was no statistically significant difference noted in family satisfaction as determined by FSICU-24 scores, including the Care and Decision Making constructs between the pre- and post-intervention pilot population. The percentage of families reporting the occurrence of a family conference showed only minimal improvement, from 46.5% before to 52.5% following the intervention (p = 0.565). This was mirrored by low numbers of documented family conferences by providers, suggesting poor uptake despite buy-in, use of electronic checklists, and repeated attempts at education. This paper reviews the challenges to and implications for implementing national guidelines in the area of family communication in an ICU coupled with the principles of clinical reengineering.

A comparison of ED and direct admission care of cancer patients with febrile neutropenia.

PubMed

Owolabi, Diwura K; Rowland, Richard; King, Lauren; Miller, Rick; Hegde, Gajanan G; Shang, Jennifer; Lister, John; Venkat, Arvind

2015-07-01

We compared the quality of care in admitted febrile neutropenic cancer patients presenting through the emergency department (ED) vs those directly admitted (DA) from the clinic or infusion center. We hypothesized that the quality of care would be comparable between these 2 pathways. We conducted a retrospective, observational cohort study of all adult cancer patients hospitalized with subjective or objective fever (≥100.4°F) and documented neutropenia (absolute neutrophil count ≤1000/mm(3)) from January 1, 2011 to June 30, 2013, at 2 hospitals. Two investigators retrieved data including patient age, sex, race, tumor type, blood culture growth, temperature (actual or reported), pathway to admission (ED or DA), time to antibiotic administration, length of stay, and the Multinational Association for Supportive Care in Cancer (MASCC) risk score. The primary outcome measures were time to antibiotic administration, appropriateness of antibiotic(s) administered based on published guidelines, length of stay, and MASCC score-based risk assessment. We used the t test for the difference between 2 means with unequal population variances to compare these outcome measures between ED and DA patients. One hundred twenty-seven visits met inclusion criteria (42 [33%] ED visits, 85 [67%] DA visits). Mean time to antibiotic administration, mean length of stay, appropriateness of antibiotics, and MASCC score-based risk assessment were comparable between ED and DA visits (P>.05 for all comparisons). The quality of care for febrile neutropenia in patients presenting through the ED was comparable to those directly admitted to the hospital in this 2-center study. Copyright © 2015 Elsevier Inc. All rights reserved.

Psychosocial Pathways to Sexually Transmitted Infection (STI) Risk Among Youth Transitioning Out of Foster Care: Evidence from a Longitudinal Cohort Study

PubMed Central

McCarty, Cari; Simoni, Jane; Dworsky, Amy; Courtney, Mark E.

2013-01-01

Purpose To test the fit of a theoretically driven conceptual model of pathways to STI risk among foster youth transitioning to adulthood. The model included: 1) historical abuse and foster care experiences, 2) mental health and attachment style in late adolescence, and 3) STI risk in young adulthood. Methods We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Covariates included gender, race and an inverse probability weight. We also performed moderation analyses comparing models constrained and unconstrained by gender. Results Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Squared Residual of 0.026). Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use. There was also a borderline association with having greater than 5 partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 decreased STI risk. Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models. Conclusions Interventions/policies that: 1) address externalizing trauma sequelae, 2) promote close, stable substitute caregiver relationships, and 3) extend care to age 21 years have the potential to decrease STI risk in this population. PMID:23859955

Direct and indirect effects of nutritional status, physical function and cognitive function on activities of daily living in Japanese older adults requiring long-term care.

PubMed

Kamo, Tomohiko; Nishida, Yuusuke

2014-10-01

To identify the direct and indirect effects of nutritional status, physical function, and cognitive function on activities of daily living in Japanese older adults requiring long-term care. In total, 179 participants aged ≥ 65 years who were eligible for long-term care insurance (mean age 85.5 ± 7.8 years) were recruited for this study. Nutritional status (Mini Nutritional Assessment, Short Form) and physical function (Short Physical Performance Battery) were examined. Activities of daily living, cognitive function and frailty were assessed using the Barthel Index, Mini-Mental State Examination and Clinical Frailty Scale, respectively. Path analysis was used to determine relationships between these factors and the activities of daily living. For Japanese older adults requiring long-term care, pathways were modeled for nutritional status, physical function and the activities of daily living. The total effect of nutritional status was 0.516 (P<0.001). The indirect effect of nutritional status through physical function on the activities of daily living was 0.458 (P<0.001). Finally, no significant direct effect of nutritional status on activities of daily living was observed (b=0.058, P=0.258). The present study identified the complex pathway from nutritional status to the activities of daily living through physical function in aged Japanese people requiring long-term care. These findings suggest that maintaining good nutritional status and nutritional support might delay physical function decline, and prolong the activities of daily living. © 2013 Japan Geriatrics Society.

The new follow-on-biologics law: a section by section analysis of the patent litigation provisions in the Biologics Price Competition and Innovation Act of 2009.

PubMed

Dougherty, Michael P

2010-01-01

An abbreviated pathway for the approval of biosimilar biological products, often called "follow-on biologics," has been enacted into law as part of the health care legislation recently passed by Congress and signed by the President. The subtitle of the health care bill establishing this approval pathway, the Biologics Price Competition and Innovation Act of 2009, includes many provisions governing the identification of patents relevant to a given biosimilar biological product and the assertion of those patents in infringement suits. This article provides a section-by-section analysis of the patent-related provisions of the new approval pathway for biosimilar biological products, and points out several ways in which the new law differs fundamentally from the Hatch-Waxman Act, which provides the approval pathway for generic versions of small molecule drugs.

Australian academic primary health-care careers: a scoping survey.

PubMed

Barton, Christopher; Reeve, Joanne; Adams, Ann; McIntyre, Ellen

2016-01-01

This study was undertaken to provide a snapshot of the academic primary health-care workforce in Australia and to provide some insight into research capacity in academic primary health care following changes to funding for this sector. A convenience sample of individuals self-identifying as working within academic primary health care (n=405) completed an anonymous online survey. Respondents were identified from several academic primary health-care mailing lists. The survey explored workforce demographics, clarity of career pathways, career trajectories and enablers/barriers to 'getting in' and 'getting on'. A mix of early career (41%), mid-career (25%) and senior academics (35%) responded. Early career academics tended to be female and younger than mid-career and senior academics, who tended to be male and working in 'balanced' (teaching and research) roles and listing medicine as their disciplinary background. Almost three-quarters (74%) indicated career pathways were either 'completely' or 'somewhat unclear', irrespective of gender and disciplinary backgrounds. Just over half (51%) had a permanent position. Males were more likely to have permanent positions, as were those with a medical background. Less than half (43%) reported having a mentor, and of the 57% without a mentor, more than two-thirds (69%) would like one. These results suggest a lack of clarity in career paths, uncertainty in employment and a large number of temporary (contract) or casual positions represent barriers to sustainable careers in academic primary health care, especially for women who are from non-medicine backgrounds. Professional development or a mentoring program for primary health-care academics was desired and may address some of the issues identified by survey respondents.

Teaching American Ethnic Geography. Pathways in Geography Series Title No. 18.

ERIC Educational Resources Information Center

Estaville, Lawrence E., Ed.; Rosen, Carol J., Ed.

U.S. ethnic geography is an increasingly important focus of study due to cultural diversity and continued growth of the United States. Geographers are carefully studying the spatial aspects of present U.S. ethnic groups. This collection of essays addresses the important need for creating innovative approaches in teaching U.S. ethnic geography in…

An Interactive Platform to Visualize Data-Driven Clinical Pathways for the Management of Multiple Chronic Conditions.

PubMed

Zhang, Yiye; Padman, Rema

2017-01-01

Patients with multiple chronic conditions (MCC) pose an increasingly complex health management challenge worldwide, particularly due to the significant gap in our understanding of how to provide coordinated care. Drawing on our prior research on learning data-driven clinical pathways from actual practice data, this paper describes a prototype, interactive platform for visualizing the pathways of MCC to support shared decision making. Created using Python web framework, JavaScript library and our clinical pathway learning algorithm, the visualization platform allows clinicians and patients to learn the dominant patterns of co-progression of multiple clinical events from their own data, and interactively explore and interpret the pathways. We demonstrate functionalities of the platform using a cluster of 36 patients, identified from a dataset of 1,084 patients, who are diagnosed with at least chronic kidney disease, hypertension, and diabetes. Future evaluation studies will explore the use of this platform to better understand and manage MCC.

Dissecting the hypothalamic pathways that underlie innate behaviors.

PubMed

Zha, Xi; Xu, Xiaohong

2015-12-01

Many complex behaviors that do not require learning are displayed and are termed innate. Although traditionally the subject matter of ethology, innate behaviors offer a unique entry point for neuroscientists to dissect the physiological mechanisms governing complex behaviors. Since the last century, converging evidence has implicated the hypothalamus as the central brain area that controls innate behaviors. Recent studies using cutting-edge tools have revealed that genetically-defined populations of neurons residing in distinct hypothalamic nuclei and their associated neural pathways regulate the initiation and maintenance of diverse behaviors including feeding, sleep, aggression, and parental care. Here, we review the newly-defined hypothalamic pathways that regulate each innate behavior. In addition, emerging general principles of the neural control of complex behaviors are discussed.

The stress-buffering effects of hope on changes in adjustment to caregiving in multiple sclerosis.

PubMed

Madan, Sindia; Pakenham, Kenneth I

2015-09-01

This study examined the direct and stress-buffering effects of global hope and its components (agency and pathways) on changes in adjustment to multiple sclerosis caregiving over 12 months. A total of 140 carers and their care-recipients completed questionnaires at Time 1 and 12 months later, Time 2. Focal predictors were stress, hope, agency and pathways, and the adjustment outcomes were anxiety, depression, positive affect, positive states of mind and life satisfaction. Results showed that as predicted, greater hope was associated with better adjustment after controlling for the effects of initial adjustment and caregiving and care-recipient illness variables. No stress-buffering effects of hope emerged. Regarding hope components, only the agency dimension emerged as a significant predictor of adjustment. Findings highlight hope as an important protective resource for coping with multiple sclerosis caregiving and underscore the role of agency thinking in this process. © The Author(s) 2013.

The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study

PubMed Central

2010-01-01

Background As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients. The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation. Methods/design The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals. Discussion The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article. Trial registration Current Controlled Trails ISRCTN58135104 PMID:20504313

The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study.

PubMed

Heijnen, Ron W H; Evers, Silvia M A A; van der Weijden, Trudy D E M; Limburg, Martien; Schols, Jos M G A

2010-05-26

As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients.The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation. The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals. The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article. Current Controlled Trails ISRCTN58135104.

Proving that less is more: linking resources to outcomes.

PubMed

Ebener, M K; Baugh, K; Formella, N M

1996-01-01

Advocates of inpatient managed care employing clinical pathways are confident that this patient management strategy reduces cost while promoting optimal patient outcomes. Other health care professionals are concerned that cost reductions place patients at higher risk for adverse health events. Research is needed to demonstrate the true impact of cost-containment strategies on clinical outcomes. The article describes a study in progress comparing patients conventionally managed by their physicians with similar patients whose overall management involved a nurse case manager. This study explores the issue of resource costs that can be linked to clinical and financial outcome measures.

Changing Patient Expectations Decreases Length of Stay in an Enhanced Recovery Program for THA.

PubMed

Tanzer, Dylan; Smith, Karen; Tanzer, Michael

2018-02-01

The implementation of care pathways in hip arthroplasty programs has been shown to result in a decreased length of stay (LOS), but often multiple elements of a care pathway are implemented at the same time. As a result, it is difficult to understand the impact each of the individual modifications has made to the patient's prepathway care. In particular, it is unknown what the role of patient expectations pertaining to anticipated LOS alone is on the LOS after primary THA. (1) Does changing the patient's expectations regarding his or her anticipated LOS, without intentionally changing the rest of the care pathway, result in a change in the patient's LOS after primary THA? (2) Is the resultant LOS associated with the patient's age, gender, or day of the week the surgery was performed? We retrospectively compared the LOS in 100 consecutive patients undergoing THA immediately after the implementation of a 4-day care pathway (4-day Group) with 100 consecutive patients, 3 months later, who were also in the same pathway but were told by their surgeon preoperatively and in the hospital to expect a LOS of 2 days (2-day Group). Aside from reeducation by the surgeon, there was no difference in the surgery or intentional changes to the intraoperative or postoperative management of the two groups. Only the patient and the surgeon were made aware of the accelerated discharge plan. We compared the LOS between the two groups and the number of patients who met their discharge goal. As well, the ability to meet the discharge goal for each group was further determined based on age, gender, and day of the week the surgery was performed. Overall, patients in the 2-day Group had a shorter LOS than those in the 4-day Group (2.9 ± 0.88 days versus 3.9 ± 1.71 days; mean difference 1 day; 95% confidence interval [CI], 0.60-1.36; p = 0.001). In the 2-day Group, the LOS was 2 days in 32% compared with 8% in the 4-day Group (odds ratio, 4.0; 95% CI, 1.76-9.11; p < 0.001). Men in the 4-day Group had a shorter LOS than women (3.4 ± 1.22 days versus 4.2 ± 1.89 days; mean difference 0.8 days; 95% CI, 0.17-1.78; p = 0.019), but there was no difference in LOS by gender in the 2-day Group (2.8 ± 0.81 days versus 3.1 ± 0.93 days; mean difference 0.3 days; 95% CI, -0.14 to 0.61; p = 0.219). For all patients > 40 years and < 90 years of age, a greater percentage of patients in the 2-day Group went home by postoperative day 2 than those in the 4-day Group (32% compared with 7%; odds ratio, 4.6; p < 0.001). In both groups, there was no difference in the LOS if the surgery was on Friday compared with an earlier day of the week (4-day Group: 3.4 ± 0.67 days versus 4.0 ± 1.80 days; p = 0.477 and 2-day Group: 2.8 ± 0.62 days versus 3.0 ± 0.93 days; p = 0.547). We found that a surgeon who sets a clear expectation in terms of LOS could achieve a reduction in this parameter. Although it is impossible to be certain in the context of a retrospective study whether other caregivers adjusted the pathway in response to the surgeon's preferences, and we suspect this probably did occur, this still points to an opportunity on the topic of expectations setting that future studies should explore. This study highlights the influence patient education and expectations has on the effectiveness of care pathways in THA as well as the importance of continuous reinforcement of discharge planning both preoperatively and in the hospital. Level III, therapeutic study.

Multidisciplinary collaboration in primary care: through the eyes of patients.

PubMed

Cheong, Lynn H; Armour, Carol L; Bosnic-Anticevich, Sinthia Z

2013-01-01

Managing chronic illness is highly complex and the pathways to access health care for the patient are unpredictable and often unknown. While multidisciplinary care (MDC) arrangements are promoted in the Australian primary health care system, there is a paucity of research on multidisciplinary collaboration from patients' perspectives. This exploratory study is the first to gain an understanding of the experiences, perceptions, attitudes and potential role of people with chronic illness (asthma) on the delivery of MDC in the Australian primary health care setting. In-depth semi-structured interviews were conducted with asthma patients from Sydney, Australia. Qualitative analysis of data indicates that patients are significant players in MDC and their perceptions of their chronic condition, perceived roles of health care professionals, and expectations of health care delivery, influence their participation and attitudes towards multidisciplinary services. Our research shows the challenges presented by patients in the delivery and establishment of multidisciplinary health care teams, and highlights the need to consider patients' perspectives in the development of MDC models in primary care.

Enhanced recovery pathways in abdominal gynecologic surgery: a systematic review and meta-analysis.

PubMed

de Groot, Jeanny J A; Ament, Stephanie M C; Maessen, José M C; Dejong, Cornelis H C; Kleijnen, Jos M P; Slangen, Brigitte F M

2016-04-01

Enhanced recovery pathways have been widely accepted and implemented for different types of surgery. Their overall effect in abdominal gynecologic surgery is still underdetermined. A systematic review and meta-analysis were performed to provide an overview of current evidence and to examine their effect on postoperative outcomes in women undergoing open gynecologic surgery. Searches were conducted using Embase, Medline, CINAHL, and the Cochrane Library up to 27 June 2014. Reference lists were screened to identify additional studies. Studies were included if at least four individual items of an enhanced recovery pathway were described. Outcomes included length of hospital stay, complication rates, readmissions, and mortality. Quantitative analysis was limited to comparative studies. Effect sizes were presented as relative risks or as mean differences (MD) with 95% confidence intervals (CI). Thirty-one records, involving 16 observational studies, were included. Diversity in reported elements within studies was observed. Preoperative education, early oral intake, and early mobilization were included in all pathways. Five studies, with a high risk of bias, were eligible for quantitative analysis. Enhanced recovery pathways reduced primary (MD -1.57 days, 95% CI CI -2.94 to -0.20) and total (MD -3.05 days, 95% CI -4.87 to -1.23) length of hospital stay compared with traditional perioperative care, without an increase in complications, mortality or readmission rates. The available evidence based on a broad range of non-randomized studies at high risk of bias suggests that enhanced recovery pathways may reduce length of postoperative hospital stay in abdominal gynecologic surgery. © 2015 Nordic Federation of Societies of Obstetrics and Gynecology.

Increased expression of neutrophil-related genes in patients with early sepsis-induced ARDS.

PubMed

Kangelaris, Kirsten Neudoerffer; Prakash, Arun; Liu, Kathleen D; Aouizerat, Bradley; Woodruff, Prescott G; Erle, David J; Rogers, Angela; Seeley, Eric J; Chu, Jeffrey; Liu, Tom; Osterberg-Deiss, Thomas; Zhuo, Hanjing; Matthay, Michael A; Calfee, Carolyn S

2015-06-01

The early sequence of events leading to the development of the acute respiratory distress syndrome (ARDS) in patients with sepsis remains inadequately understood. The purpose of this study was to identify changes in gene expression early in the course of illness, when mechanisms of injury may provide the most relevant treatment and prognostic targets. We collected whole blood RNA in critically ill patients admitted from the Emergency Department to the intensive care unit within 24 h of admission at a tertiary care center. Whole genome expression was compared in patients with sepsis and ARDS to patients with sepsis alone. We selected genes with >1 log2 fold change and false discovery rate <0.25, determined their significance in the literature, and performed pathway analysis. Several genes were upregulated in 29 patients with sepsis with ARDS compared with 28 patients with sepsis alone. The most differentially expressed genes included key mediators of the initial neutrophil response to infection: olfactomedin 4, lipocalin 2, CD24, and bactericidal/permeability-increasing protein. These gene expression differences withstood adjustment for age, sex, study batch, white blood cell count, and presence of pneumonia or aspiration. Pathway analysis demonstrated overrepresentation of genes involved in known respiratory and infection pathways. These data indicate that several neutrophil-related pathways may be involved in the early pathogenesis of sepsis-related ARDS. In addition, identifiable gene expression differences occurring early in the course of sepsis-related ARDS may further elucidate understanding of the neutrophil-related mechanisms in progression to ARDS. Copyright © 2015 the American Physiological Society.

Increased expression of neutrophil-related genes in patients with early sepsis-induced ARDS

PubMed Central

Prakash, Arun; Liu, Kathleen D.; Aouizerat, Bradley; Woodruff, Prescott G.; Erle, David J.; Rogers, Angela; Seeley, Eric J.; Chu, Jeffrey; Liu, Tom; Osterberg-Deiss, Thomas; Zhuo, Hanjing; Matthay, Michael A.; Calfee, Carolyn S.

2015-01-01

The early sequence of events leading to the development of the acute respiratory distress syndrome (ARDS) in patients with sepsis remains inadequately understood. The purpose of this study was to identify changes in gene expression early in the course of illness, when mechanisms of injury may provide the most relevant treatment and prognostic targets. We collected whole blood RNA in critically ill patients admitted from the Emergency Department to the intensive care unit within 24 h of admission at a tertiary care center. Whole genome expression was compared in patients with sepsis and ARDS to patients with sepsis alone. We selected genes with >1 log2 fold change and false discovery rate <0.25, determined their significance in the literature, and performed pathway analysis. Several genes were upregulated in 29 patients with sepsis with ARDS compared with 28 patients with sepsis alone. The most differentially expressed genes included key mediators of the initial neutrophil response to infection: olfactomedin 4, lipocalin 2, CD24, and bactericidal/permeability-increasing protein. These gene expression differences withstood adjustment for age, sex, study batch, white blood cell count, and presence of pneumonia or aspiration. Pathway analysis demonstrated overrepresentation of genes involved in known respiratory and infection pathways. These data indicate that several neutrophil-related pathways may be involved in the early pathogenesis of sepsis-related ARDS. In addition, identifiable gene expression differences occurring early in the course of sepsis-related ARDS may further elucidate understanding of the neutrophil-related mechanisms in progression to ARDS. PMID:25795726

Can attribution theory explain carers' propensity to help men with intellectual disabilities who display inappropriate sexual behaviour?

PubMed

Willner, P; Smith, M

2008-01-01

This study examined the responses of care managers and direct care staff to vignettes of inappropriate sexual behaviour by a man with an intellectual disability. The aim was to test the theory that helping behaviour is determined by emotional responses (positive and negative emotional reactions, and optimism), which in turn are determined by causal attributions (respectively: controllability and stability of the incident depicted in the vignette). The vignettes varied in response topography and the age of the victim. Regression analysis was used to examine the relationships between causal attributions, emotional responses, and willingness to invest extra time and effort in the service user's care. No support was found for the pathway: low controllability --> increased sympathy and/or decreased negative emotions --> increased helping. However, strong support was found for the pathway: low stability --> high optimism --> increased helping, particularly in direct care staff. High levels of sympathy were also associated with increased helping, the effect again being mediated by feelings of optimism. The data provide support for one (but not the other) strand of attribution theory as applied to inappropriate sexual behaviour. The discussion considers the discrepancy between the present data and the far less encouraging literature on attribution theory as applied to challenging behaviour.

Medical economic impact of tracheotomy patients on a hospital system.

PubMed

Altman, Kenneth W; Banoff, Karen Merl; Tong, Charles C L

2015-04-01

Tracheotomy patients are a small portion of hospitalizations, but account for disproportionately high risk and costs. There are many complex decisions that go into the care of these patients, and practice variation is expected to be compounded in a health system. This study sought to characterize the medical economic impact of tracheotomy patients on the hospital system. A retrospective review of the health system's hospital billing software was performed for 2013, and pertinent outcomes measures were tabulated. There were 829 tracheotomies performed in the health system of seven hospitals, with total costs of $128,883,865. Average length of stay was 36.74 days for principal procedures, and 43.36 days for tracheotomy as secondary procedures. Mortality was ∼ 18% overall, and re-admissions were 10.93% for primary, and 14.36% for secondary procedures. A fairly wide variation in each category among the different hospitals was observed. There are potentially many factors that impact variations of care and outcomes in patients with tracheotomy. Due to their large economic impact and risks for morbidity and mortality, a formalized care pathway is warranted. Goals of the pathway should include understanding medical decisions surrounding these complex patients, monitoring pertinent outcomes, reducing practice variation, and improving the efficiency of compassionate care.

How to enhance route learning and visuo-spatial working memory in aging: a training for residential care home residents.

PubMed

Mitolo, Micaela; Borella, Erika; Meneghetti, Chiara; Carbone, Elena; Pazzaglia, Francesca

2017-05-01

This study aimed to assess the efficacy of a route-learning training in a group of older adults living in a residential care home. We verified the presence of training-specific effects in tasks similar to those trained - route-learning tasks - as well as transfer effects on related cognitive processes - visuo-spatial short-term memory (VSSTM; Corsi Blocks Test (CBT), forward version), visuo-spatial working memory (VSWM; CBT, backward version; Pathway Span Tasks; Jigsaw Puzzle Test) - and in self-report measures. The maintenance of training benefits was examined after 3 months. Thirty 70-90-year-old residential care home residents were randomly assigned to the route-learning training group or to an active control group (involved in non-visuo-spatial activities). The trained group performed better than the control group in the route-learning tasks, retaining this benefit 3 months later. Immediate transfer effects were also seen in visuo-spatial span tasks (i.e., CBT forward and backward version and Pathway Span Task); these benefits had been substantially maintained at the 3-month follow-up. These findings suggest that a training on route learning is a promising approach to sustain older adults' environmental learning and some related abilities (e.g., VSSTM and VSWM), even in residential care home residents.

Pelvic pain: a pathway for care developed for both men and women by the British Pain Society.

PubMed

Baranowski, A P; Lee, J; Price, C; Hughes, J

2014-03-01

This paper aims to explain the key points and highlight some of the controversies in the development of the British Pain Society's pelvic pain patient pathway map. Many clinicians lack experience and confidence with this group of patients, and this issue is highlighted. Additionally, the difficulties of classification and definitions in this area are discussed in detail. These are historical causes of disagreement among specialists which can lead to confused clinical care. This group of patients have multiple issues that cross many professional boundaries; they are best managed by the co-ordinated involvement of multiple teams. Patients suffer from significant distress and disability that often needs specialist assessment and intervention (interdisciplinary). This suggests that an integrated approach is required across the historic boundaries of primary and secondary care. A variety of interventions, including opioids and neuromodulation are recommended in the pathway and the controversies surrounding these inclusions are aired in detail.

Integrating Continuing Professional Development With Health System Reform: Building Pillars of Support.

PubMed

Davis, David A; Rayburn, William F

2016-01-01

Clinical failures sparked a widespread desire for health system reform at the beginning of the 21st century, but related efforts have resulted in changes that are either slow or nonexistent. In response, academic medicine has moved in two directions: (1) system-wide reform using electronic health records, practice networks, and widespread data applications (a macro pathway); and (2) professional development of individual clinicians through continuous performance improvement (a micro pathway). Both pathways exist to improve patient care and population health, yet each suffers from limitations in widespread implementation. The authors call for a better union between these two parallel pathways through four pillars of support: (1) an acknowledgment that both pathways are essential to each other and to the final outcome they intend to achieve, (2) a strong faculty commitment to educate about quality improvement and patient safety at all education levels, (3) a reengineering of tools for professional development to serve as effective change agents, and (4) the development of standards to sustain this alignment of pathways. With these pillars of support integrating continuing professional development with health system reform, the authors envision a better functioning system, with improved metrics and value to enhance patient care and population health.

Care of the dying: how do we replace the Liverpool Care Pathway?

PubMed

Davis, Charles; Tomas, Jon

2014-12-01

Death is an inescapable certainty of life. Variability in care for dying persons, however, is present. The Liverpool Care Pathway (LCP) sought to guide care for the last days of life but was phased out after intense scrutiny. A governmental report and rapid review of evidence were considered alongside mass and social media reporting. An evidence review of end-of-life care was undertaken. Any person's death is inherently challenging. Much consideration must be given to holistic needs when approaching death. Communication skills may be lacking for professional and patient alike. The LCP became flawed in use rather than intention or principle. Seeming financial gains from death were concerning to all. We have responsibility for making choices prospectively in order for them to influence our care when we are dying. Normalization of death is key on both micro- and macro communication levels. Perceptions of relevant terminology; review of the definition of dying; improved recognition of the dying process and measuring the impact of communication skills training. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

The governance of quality management in dutch health care: new developments and strategic challenges.

PubMed

Maarse, J A M; Ruwaard, D; Spreeuwenberg, C

2013-01-01

This article gives a brief sketch of quality management in Dutch health care. Our focus is upon the governance of guideline development and quality measurement. Governance is conceptualized as the structure and process of steering of quality management. The governance structure of guideline development in the Netherlands can be conceptualized as a network without central coordination. Much depends upon the self-initiative of stakeholders. A similar picture can be found in quality measurement. Special attention is given to the development of care standards for chronic disease. Care standards have a broader scope than guidelines and take an explicit patient perspective. They not only contain evidence-based and up-to-date guidelines for the care pathway but also contain standards for self-management. Furthermore, they comprise a set of indicators for measuring the quality of care of the entire pathway covered by the standard. The final part of the article discusses the mission, tasks and strategic challenges of the newly established National Health Care Institute (Zorginstituut Nederland), which is scheduled to be operative in 2013.

Implementation and evaluation of a clinical pathway for TRAM breast reconstruction.

PubMed

Hwang, T G; Wilkins, E G; Lowery, J C; Gentile, J

2000-02-01

Among strategies recently proposed to reduce practice variation, promote quality, and control costs in health care delivery, the concept of the clinical pathway has received considerable attention. Because transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction is a common and often costly intervention, this institution sought to evaluate cost and quality outcomes of a clinical pathways program for this procedure. The TRAM reconstruction clinical pathway was implemented in April of 1996 to standardize postoperative care in this patient population. Outcomes of consecutive pathway cases for the first 14 months of the program were assessed in a retrospective cohort design, by using all nonpathway TRAM cases from the 18 months immediately before pathway implementation as controls. Outcomes assessed included length of hospital stay, postoperative complications, total postoperative charges, and total postoperative costs in relative value units. Data on these dependent variables were collected from hospital charts and billing records. The effects of pathway implementation on the outcomes of interest were analyzed by using analysis of covariance to control for potential confounding by other independent variables, including surgical site (unilateral versus bilateral reconstructions), technique (pedicle versus free TRAMs), timing (immediate versus delayed reconstructions), and patient age. Finally, a comparison of variances in the outcomes of interest between the two groups was analyzed by using an Ftest. For all statistical tests, p values of < or = 0.05 were considered significant. Twenty-nine patients were treated in the TRAM pathway group, whereas the control population included 40 nonpathway patients. After implementation of the TRAM pathway, length of stay decreased from 6.0 to 5.2 days; total postoperative charges were reduced from $8587 to $7744; and total postoperative relative value unit utilization declined from 1686 to 1104. Analysis of covariance showed that the decreases in length of hospital stay and relative value units in the TRAM pathway were statistically significant (p = 0.05 and p = 0.007, respectively). By contrast, no significant increase in complications was observed after pathway implementation. Variability in the TRAM pathway group, as measured by SD, decreased significantly for both length of hospital stay (p = 0.039) and relative value units (p = 0.023). Implementation of the TRAM reconstruction clinical pathway resulted in significant declines in length of hospital stay and total costs. These decreases in resource utilization had no significant effect on postoperative complication rates. Although additional research is needed to further assess the impact of clinical pathways, this approach offers considerable promise for improving the cost-effectiveness of health care.

Process and Outcome Study of Multidisciplinary Prosthetic Treatment for Velopharyngeal Dysfunction

ERIC Educational Resources Information Center

Sell, Debbie; Mars, Michael; Worrell, Emma

2006-01-01

Background: A prosthetic approach to velopharyngeal dysfunction (VPD) is not new. However, a collaborative interdisciplinary team approach by a speech-and-language therapist, dental specialist and maxillofacial technician, including accurate fitting using nasendoscopy, has provided an opportunity to define the clinical care pathway, and audit the…

Relationship of supernatural beliefs and first treatment contact in patients with obsessive compulsive disorder: an exploratory study from India.

PubMed

Grover, Sandeep; Patra, Bichitra N; Aggarwal, Munish; Avasthi, Ajit; Chakrabarti, Subho; Malhotra, Savita

2014-12-01

The etiology of mental illness has been attributed to many different causes by people of various cultural backgrounds, including supernatural beliefs. This in turn affects the help-seeking behavior. Aim of this study was to explore the supernatural belief and pathways of care in patients with obsessive compulsive disorder (OCD) attending a tertiary care hospital located in north India. In all, 89 consecutive patients diagnosed with OCD (according to the International Classification of Diseases-10th Revision (ICD-10)) and ≥ 15 years of age were evaluated for their supernatural belief and help seeking. More than half of the patients (54%) believed in supernatural causes and 57.3% attributed their illness to supernatural causes. In addition to supernatural causes, many patients also attributed their illness to stress (household/work-related stress) or chemical imbalance in the body and or mind. About two-thirds of the patients (n = 58; 65.2%) first contacted a psychiatrist for their symptoms of OCD. Those who first contacted faith healers believed in one of the supernatural causations. Patients with OCD hold multiple beliefs regarding the etiology and treatment of mental illness which can affect their pathways to care. © The Author(s) 2014.

Pathways for best practice diffusion: the structure of informal relationships in Canada's long-term care sector.

PubMed

Dearing, James W; Beacom, Amanda M; Chamberlain, Stephanie A; Meng, Jingbo; Berta, Whitney B; Keefe, Janice M; Squires, Janet E; Doupe, Malcolm B; Taylor, Deanne; Reid, Robert Colin; Cook, Heather; Cummings, Greta G; Baumbusch, Jennifer L; Knopp-Sihota, Jennifer; Norton, Peter G; Estabrooks, Carole A

2017-02-03

Initiatives to accelerate the adoption and implementation of evidence-based practices benefit from an association with influential individuals and organizations. When opinion leaders advocate or adopt a best practice, others adopt too, resulting in diffusion. We sought to identify existing influence throughout Canada's long-term care sector and the extent to which informal advice-seeking relationships tie the sector together as a network. We conducted a sociometric survey of senior leaders in 958 long-term care facilities operating in 11 of Canada's 13 provinces and territories. We used an integrated knowledge translation approach to involve knowledge users in planning and administering the survey and in analyzing and interpreting the results. Responses from 482 senior leaders generated the names of 794 individuals and 587 organizations as sources of advice for improving resident care in long-term care facilities. A single advice-seeking network appears to span the nation. Proximity exhibits a strong effect on network structure, with provincial inter-organizational networks having more connections and thus a denser structure than interpersonal networks. We found credible individuals and organizations within groups (opinion leaders and opinion-leading organizations) and individuals and organizations that function as weak ties across groups (boundary spanners and bridges) for all studied provinces and territories. A good deal of influence in the Canadian long-term care sector rests with professionals such as provincial health administrators not employed in long-term care facilities. The Canadian long-term care sector is tied together through informal advice-seeking relationships that have given rise to an emergent network structure. Knowledge of this structure and engagement with its opinion leaders and boundary spanners may provide a route for stimulating the adoption and effective implementation of best practices, improving resident care and strengthening the long-term care advice network. We conclude that informal relational pathways hold promise for helping to transform the Canadian long-term care sector.

The impact of clinical nurse specialists on clinical pathways in the application of evidence-based practice.

PubMed

Gurzick, Martha; Kesten, Karen S

2010-01-01

The purpose of this article was to address the call for evidence-based practice through the development of clinical pathways and to assert the role of the clinical nurse specialist (CNS) as a champion in clinical pathway implementation. In the current health care system, providing quality of care while maintaining cost-effectiveness is an ever-growing battle that institutions face. The CNS's role is central to meeting these demands. An extensive literature review has been conducted to validate the use of clinical pathways as a means of improving patient outcomes. This literature also suggests that clinical pathways must be developed, implemented, and evaluated utilizing validated methods including the use of best practice standards. Execution of clinical pathways should include a clinical expert, who has the ability to look at the system as a whole and can facilitate learning and change by employing a multitude of competencies while maintaining a sphere of influence over patient and families, nurses, and the system. The CNS plays a pivotal role in influencing effective clinical pathway development, implementation, utilization, and ongoing evaluation to ensure improved patient outcomes and reduced costs. This article expands upon the call for evidence-based practice through the utilization of clinical pathways to improve patient outcomes and reduce costs and stresses the importance of the CNS as a primary figure for ensuring proper pathway development, implementation, and ongoing evaluation. Copyright 2010 Elsevier Inc. All rights reserved.

Early life social stress induced changes in depression and anxiety associated neural pathways which are correlated with impaired maternal care.

PubMed

Murgatroyd, Christopher A; Peña, Catherine J; Podda, Giovanni; Nestler, Eric J; Nephew, Benjamin C

2015-08-01

Exposures to various types of early life stress can be robust predictors of the development of psychiatric disorders, including depression and anxiety. The objective of the current study was to investigate the roles of the translationally relevant targets of central vasopressin, oxytocin, ghrelin, orexin, glucocorticoid, and the brain-derived neurotrophic factor (BDNF) pathway in an early chronic social stress (ECSS) based rodent model of postpartum depression and anxiety. The present study reports novel changes in gene expression and extracellular signal related kinase (ERK) protein levels in the brains of ECSS exposed rat dams that display previously reported depressed maternal care and increased maternal anxiety. Decreases in oxytocin, orexin, and ERK proteins, increases in ghrelin receptor, glucocorticoid and mineralocorticoid receptor mRNA levels, and bidirectional changes in vasopressin underscore related work on the adverse long-term effects of early life stress on neural activity and plasticity, maternal behavior, responses to stress, and depression and anxiety-related behavior. The differences in gene and protein expression and robust correlations between expression and maternal care and anxiety support increased focus on these targets in animal and clinical studies of the adverse effects of early life stress, especially those focusing on depression and anxiety in mothers and the transgenerational effects of these disorders on offspring. Copyright © 2015 Elsevier B.V. All rights reserved.

The Introduction of Standard Operating Procedures to Improve Burn Care in the United Kingdom.

PubMed

Lymperopoulos, Nikolaos Spyros; Jeevan, Ranjeet; Godwin, Lindsey; Wilkinson, Donnas; Shokrollahi, Kayvan; James, Malcolm Ian

2015-01-01

United Kingdom (UK) burn units face substantial new obstacles in delivering high quality care because of the advent of full-shift working patterns, cross-specialty cover arrangements, and increased trainee turnover. Junior trainees rely heavily on senior colleagues, who may not be readily accessible. The authors therefore proposed the introduction of standard operating procedures (SOPs), detailed written instructions used to achieve uniformity in performance and to improve outcomes. After undertaking a preliminary strength, weaknesses, opportunities, and threats analysis of their use locally and nationally, the authors set out to systematically develop burn-specific SOPs. The authors first mapped our existing local SOPs to the newly introduced UK national burn care pathway to specify gaps in coverage. The authors then administered a questionnaire to other UK burn units to identify SOPs already used elsewhere. Finally, the authors developed and piloted a robust pathway for the development, introduction, and auditing of new SOPs. The strength, weaknesses, opportunities, and threats analysis identified significant benefits and minimal risks. The mapping exercise identified specific deficiencies in our coverage of the national pathway. All 26 UK burn units responded to our questionnaire; only 12 had one or more SOPs (mean, 2.1). These covered initial assessment, inhalational injuries, drug prescribing, wound care, and gastric protection; none were audited. Locally, the authors have begun to develop the additional SOPs required. SOPs have not been instituted widely in the UK, despite the shift toward a standardized national care pathway and their association with improved outcomes. The authors hope that the systematic approach to their development and implementation demonstrates the feasibility of their wider use within UK regional burn centers and beyond.

From cottage industry to a dominant mode of primary care: stages in the diffusion of a health care innovation (retail clinics).

PubMed

McKinlay, John B; Marceau, Lisa D

2012-09-01

Primary health care is essential to population health and there is increasing need for it, especially with an aging population with multiple comorbidities. Primary health care in the U.S. is widely considered in an ever-deepening crisis. This paper presents a detailed case study of the recent rise of a "disruptive innovation" - retail clinics - which have the potential to transform the face of primary health care in the US. We describe six stages in the diffusion of retail clinics, from cottage industry to a dominant mode for the delivery of primary health care, and consider sociopolitical influences that facilitate and impede their emerging potential. Retail clinics may provide a strategic opportunity to re-engineer the primary health care system, although they may also produce worrisome unanticipated consequences. Discussion concerning the potential threats and opportunities posed by retail clinics occurs in the absence of sound evidence concerning their comparative effectiveness and quality-of-care. This case study identifies the sociopolitical influences and processes that determine whether health care innovations rise or fall, and highlights critically important points along the pathway to health system change. Copyright © 2012 Elsevier Ltd. All rights reserved.

Statistical and methodological issues in the evaluation of case management studies.

PubMed

Lesser, M L; Robertson, S; Kohn, N; Cooper, D J; Dlugacz, Y D

1996-01-01

For the past 3 years, the nursing case management team at North Shore University Hospital in Manhasset, NY, has been involved in a project to implement more than 50 clinical pathways, which provide a written "time line" for clinical events that should occur during a patient's hospital stay. A major objective of this project was to evaluate the efficacy of these pathways with respect to a number of important outcomes, such as length of stay, hospital costs, quality of patient care, and nursing and patient satisfaction. This article discusses several statistics-related issues in the design and evaluation of such case management studies. In particular, the role of a research approach in implementing and evaluating hospital programs, the choice of a comparison (control) group, the exclusion of selected patients from analysis, and the problems of equating pathways with diagnosis-related groups are addressed.

A scoping review of crisis teams managing dementia in older people.

PubMed

Streater, Amy; Coleston-Shields, Donna Maria; Yates, Jennifer; Stanyon, Miriam; Orrell, Martin

2017-01-01

Research on crisis teams for older adults with dementia is limited. This scoping review aimed to 1) conduct a systematic literature review reporting on the effectiveness of crisis interventions for older people with dementia and 2) conduct a scoping survey with dementia crisis teams mapping services across England to understand operational procedures and identify what is currently occurring in practice. For the systematic literature review, included studies were graded using the Critical Appraisal Skills Programme checklist. For the scoping survey, Trusts across England were contacted and relevant services were identified that work with people with dementia experiencing a mental health crisis. The systematic literature review demonstrated limited evidence in support of crisis teams reducing the rate of hospital admissions, and despite the increase in number of studies, methodological limitations remain. For the scoping review, only half (51.8%) of the teams had a care pathway to manage crises and the primary need for referral was behavioral or psychological factors. Evidence in the literature for the effectiveness of crisis teams for older adults with dementia remains limited. Being mainly cohort designs can make it difficult to evaluate the effectiveness of the intervention. In practice, it appears that the pathway for care managing crisis for people with dementia varies widely across services in England. There was a wide range of names given to the provision of teams managing crisis for people with dementia, which may reflect the differences in the setup and procedures of the service. To provide evidence on crisis intervention teams, a comprehensive protocol is required to deliver a standardized care pathway and measurable intervention as part of a large-scale evaluation of effectiveness.

A scoping review of crisis teams managing dementia in older people

PubMed Central

Streater, Amy; Coleston-Shields, Donna Maria; Yates, Jennifer; Stanyon, Miriam; Orrell, Martin

2017-01-01

Background Research on crisis teams for older adults with dementia is limited. This scoping review aimed to 1) conduct a systematic literature review reporting on the effectiveness of crisis interventions for older people with dementia and 2) conduct a scoping survey with dementia crisis teams mapping services across England to understand operational procedures and identify what is currently occurring in practice. Methods For the systematic literature review, included studies were graded using the Critical Appraisal Skills Programme checklist. For the scoping survey, Trusts across England were contacted and relevant services were identified that work with people with dementia experiencing a mental health crisis. Results The systematic literature review demonstrated limited evidence in support of crisis teams reducing the rate of hospital admissions, and despite the increase in number of studies, methodological limitations remain. For the scoping review, only half (51.8%) of the teams had a care pathway to manage crises and the primary need for referral was behavioral or psychological factors. Conclusion Evidence in the literature for the effectiveness of crisis teams for older adults with dementia remains limited. Being mainly cohort designs can make it difficult to evaluate the effectiveness of the intervention. In practice, it appears that the pathway for care managing crisis for people with dementia varies widely across services in England. There was a wide range of names given to the provision of teams managing crisis for people with dementia, which may reflect the differences in the setup and procedures of the service. To provide evidence on crisis intervention teams, a comprehensive protocol is required to deliver a standardized care pathway and measurable intervention as part of a large-scale evaluation of effectiveness. PMID:29042760

Learning trajectories of children with special health care needs across the severity spectrum.

PubMed

Goldfeld, Sharon; O'Connor, Meredith; Quach, Jon; Tarasuik, Joanne; Kvalsvig, Amanda

2015-01-01

A significant proportion of school-aged children experience special health care needs (SCHN) and seek care from pediatricians with a wide range of condition types and severity levels. This study examines the learning pathways of children with established (already diagnosed at school entry) and emerging (teacher identified) SHCN from school entry through the elementary school years. The Longitudinal Study of Australian Children (LSAC) is a nationally representative clustered cross-sequential sample of 2 cohorts of Australian children which commenced in May 2004. Data were analyzed from the LSAC kindergarten cohort (n = 4,983), as well as a subsample of 720 children for whom teachers also completed the Australian Early Development Index checklist, a measure of early childhood development at school entry that includes SHCN. Latent class analysis was utilized to establish 3 academic trajectories from 4-5 to 10-11 years: high (24.3%), average (49.8%), and low (23.6%). Descriptive statistics revealed a trend for both children with established and emerging SHCN to fall into weaker performing learning pathways. Multinomial logistic regression focusing on those children with emerging SHCN confirmed this pattern of results, even after adjustment for covariates (relative risk 3.06, 95% confidence interval 1.03-9.10). Children who additionally had low socioeconomic standing were particularly at risk. Even children with less complex SCHN are at risk for academic failure. Early identification, together with integrated health and educational support, may promote stronger pathways of educational attainment for these children. Achieving these better outcomes will require the involvement of both educational and health practitioners. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.

Systematic review of integrated models of health care delivered at the primary-secondary interface: how effective is it and what determines effectiveness?

PubMed

Mitchell, Geoffrey K; Burridge, Letitia; Zhang, Jianzhen; Donald, Maria; Scott, Ian A; Dart, Jared; Jackson, Claire L

2015-01-01

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary-secondary care. Six elements were identified that were common to these models of integrated primary-secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary-secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Providing High-Quality Support Services to Home-Based Child Care: A Conceptual Model and Literature Review

ERIC Educational Resources Information Center

Bromer, Juliet; Korfmacher, Jon

2017-01-01

Research Findings: Home-based child care accounts for a significant proportion of nonparental child care arrangements for young children in the United States. Yet the early care and education field lacks clear models or pathways for how to improve quality in these settings. The conceptual model presented here articulates the components of…

Using best practice to create a pathway to improve management of irritable bowel syndrome: aiming for timely diagnosis, effective treatment and equitable care

PubMed Central

Williams, Marianne; Barclay, Yvonne; Benneyworth, Rosie; Gore, Steve; Hamilton, Zoe; Matull, Rudi; Phillips, Iain; Seamark, Leah; Staveley, Kate; Thole, Steve; Greig, Emma

2016-01-01

Background Irritable bowel syndrome (IBS) costs the National Health Service almost £12 million per annum. Despite national guidelines advising primary care management, these have failed to stem secondary care referrals of patients with likely IBS for unnecessary and costly assessment and investigation without necessarily achieving resolution of their symptoms. Methods In 2011, an integrated team from primary and secondary care developed a business case using baseline data to create a Somerset-wide IBS pathway using Clinical Commissioning Group funding. This provided face-to-face general practitioners (GP) education, developed a diagnostic pathway and funded faecal calprotectin (FC) testing to exclude inflammatory pathology for patients aged 16–45 years with likely IBS and no alarm symptoms. For those with FC≤50 μg/g, we provided a management algorithm and community-based dietetic treatment. Audit results measured usage and outcomes from FC testing, changes in patterns and costs of new patients reviewed in gastroenterology outpatients and dietetic IBS treatment outcomes. Results The proportion of new patient slots used reduced from 14.3% to 8.7% over 10 months while overall costs reduced by 25% for patients with no alarm symptoms and likely IBS aged 16–45 years. FC results confirmed research findings with no inflammatory pathology, if FC≤50 μg/g over 2 years. 63% of patients had satisfactory control of their IBS after specialist dietetic input with 74% reporting improved quality of life. Conclusions The combination of GP education, providing diagnosis and management pathways, using FC to exclude inflammatory pathology and providing an effective treatment for patients with likely IBS appeared successful in our pilot. This proved cost-effective, reduced secondary care involvement and improved patient care. PMID:27761233

Quality Tuberculosis Care in Indonesia: Using Patient Pathway Analysis to Optimize Public–Private Collaboration

PubMed Central

Surya, Asik; Setyaningsih, Budiarti; Suryani Nasution, Helmi; Gita Parwati, Cicilia; Yuzwar, Yullita E; Osberg, Mike; Hanson, Christy L; Hymoff, Aaron; Mingkwan, Pia; Makayova, Julia; Gebhard, Agnes; Waworuntu, Wiendra

2017-01-01

Abstract Background Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2015, the World Health Organization estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world’s “missing” TB patients. Understanding where patients go for care may enable strategic planning of services to better reach them. Methods A patient pathway analysis (PPA) was conducted to assess the alignment between patient care seeking and the availability of TB diagnostic and treatment services at the national and subnational level in Indonesia. Results The PPA results revealed that only 20% of patients encountered diagnostic capacity at the location where they first sought care. Most initial care seeking occurred in the private sector and case notification lagged behind diagnostic confirmation in the public sector. Conclusions The PPA results emphasize the role that the private sector plays in TB patient care seeking and suggested a need for differentiated approaches, by province, to respond to variances in care-seeking patterns and the capacities of public and private providers. PMID:29117347

Quality Tuberculosis Care in Indonesia: Using Patient Pathway Analysis to Optimize Public-Private Collaboration.

PubMed

Surya, Asik; Setyaningsih, Budiarti; Suryani Nasution, Helmi; Gita Parwati, Cicilia; Yuzwar, Yullita E; Osberg, Mike; Hanson, Christy L; Hymoff, Aaron; Mingkwan, Pia; Makayova, Julia; Gebhard, Agnes; Waworuntu, Wiendra

2017-11-06

Tuberculosis (TB) is the fourth leading cause of death in Indonesia. In 2015, the World Health Organization estimated that nearly two-thirds of the TB patients in Indonesia had not been notified, and the status of their care remained unknown. As such, Indonesia is home to nearly 20% of the world's "missing" TB patients. Understanding where patients go for care may enable strategic planning of services to better reach them. A patient pathway analysis (PPA) was conducted to assess the alignment between patient care seeking and the availability of TB diagnostic and treatment services at the national and subnational level in Indonesia. The PPA results revealed that only 20% of patients encountered diagnostic capacity at the location where they first sought care. Most initial care seeking occurred in the private sector and case notification lagged behind diagnostic confirmation in the public sector. The PPA results emphasize the role that the private sector plays in TB patient care seeking and suggested a need for differentiated approaches, by province, to respond to variances in care-seeking patterns and the capacities of public and private providers. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America.

Structural drivers and social protection: mechanisms of HIV risk and HIV prevention for South African adolescents

PubMed Central

Cluver, Lucie Dale; Orkin, Frederick Mark; Meinck, Franziska; Boyes, Mark Edward; Sherr, Lorraine

2016-01-01

Introduction Social protection is high on the HIV-prevention agenda for youth in sub-Saharan Africa. However, questions remain: How do unconditional cash transfers work? What is the effect of augmenting cash provision with social care? And can “cash plus care” social protection reduce risks for adolescents most vulnerable to infection? This study tackles these questions by first identifying mediated pathways to adolescent HIV risks and then examining potential main and moderating effects of social protection in South Africa. Methods This study was a prospective observational study of 3515 10-to-17-year-olds (56.7% female; 96.8% one-year retention). Within randomly selected census areas in four rural and urban districts in two South African provinces, all homes with a resident adolescent were sampled between 2009/2010 and 2011/2012. Measures included 1) potential structural drivers of HIV infection such as poverty and community violence; 2) HIV risk behaviours; 3) hypothesized psychosocial mediating factors; and 4) types of social protection involving cash and care. Using gender-disaggregated analyses, longitudinal mediation models were tested for potential main and moderating effects of social protection. Results Structural drivers were associated with increased onset of adolescent HIV risk behaviour (p<0.001, B=0.06, SE=0.01), fully mediated by increased psychosocial problems. Both cash and care aspects of social protection were associated with reductions in HIV risk behaviour and psychosocial deprivations. In addition, cash social protection moderated risk pathways: for adolescent girls and boys experiencing more acute structural deprivation, social protection had the greatest associations with HIV risk prevention (e.g. moderation effects for girls: B=−0.08, p<0.002 between structural deprivation and psychosocial problems, and B=−0.07, p<0.001 between psychosocial problems and HIV risk behaviour). Conclusions Adolescents with the greatest structural deprivation are at higher risk of HIV, but social protection has the greatest prevention effects for the most vulnerable. Social protection comprising unconditional cash plus care was associated with reduced risk pathways through moderation and main effects, respectively. Our findings suggest the importance of social protection within a combination package of HIV-prevention approaches. PMID:27086838

The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England

PubMed Central

Seymour, Jane; Clark, David

2018-01-01

Background : The Liverpool Care Pathway for the Dying Patient (‘the LCP’) was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review.  The ensuing debate among clinicians polarised between ‘blaming’ of the LCP and regret at its removal. Employing the concept of ‘boundary objects’, we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods : We use primary and secondary sources in the public domain to assemble a critical and historical review. Results : The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP ‘scandal’ demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the ‘evidence’ required to underpin innovations in palliative care and became a conduit of discord about ‘good’ or ‘bad’ practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care.  Conclusions :  In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions. PMID:29881785

Health information technology and implementation science: partners in progress in the VHA.

PubMed

Hynes, Denise M; Whittier, Erika R; Owens, Arika

2013-03-01

The Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has demonstrated how implementation science can enhance the quality of health care. During this time an increasing number of implementation research projects have developed or utilized health information technology (HIT) innovations to leverage the VA's electronic health record and information systems. To describe the HIT approaches used and to characterize the facilitators and barriers to progress within implementation research projects in the VA QUERI program. Nine case studies were selected from among 88 projects and represented 8 of 14 HIT categories identified. Each case study included key informants whose roles on the project were principal investigator, implementation science and informatics development. We conducted documentation analysis and semistructured in-person interviews with key informants for each of the 9 case studies. We used qualitative analysis software to identify and thematically code information and interview responses. : Thematic analyses revealed 3 domains or pathways critical to progression through the QUERI steps. These pathways addressed: (1) compliance and collaboration with information technology policies and procedures; (2) operating within organizational policies and building collaborations with end users, clinicians, and administrators; and (3) obtaining and maintaining research resources and approvals. Sustained efforts in HIT innovation and in implementation science in the Veterans Health Administration demonstrates the interdependencies of these initiatives and the critical pathways that can contribute to progress. Other health care quality improvement efforts that rely on HIT can learn from the Veterans Health Administration experience.

DUQuE quality management measures: associations between quality management at hospital and pathway levels.

PubMed

Wagner, Cordula; Groene, Oliver; Thompson, Caroline A; Dersarkissian, Maral; Klazinga, Niek S; Arah, Onyebuchi A; Suñol, Rosa

2014-04-01

The assessment of integral quality management (QM) in a hospital requires measurement and monitoring from different perspectives and at various levels of care delivery. Within the DUQuE project (Deepening our Understanding of Quality improvement in Europe), seven measures for QM were developed. This study investigates the relationships between the various quality measures. It is a multi-level, cross-sectional, mixed-method study. As part of the DUQuE project, we invited a random sample of 74 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. Furthermore, data of site visits of external surveyors assessing the participating hospitals were used. Three measures of QM at hospitals level focusing on integral systems (QMSI), compliance with the Plan-Do-Study-Act quality improvement cycle (QMCI) and implementation of clinical quality (CQII). Four measures of QM activities at care pathway level focusing on Specialized expertise and responsibility (SER), Evidence-based organization of pathways (EBOP), Patient safety strategies (PSS) and Clinical review (CR). Positive significant associations were found between the three hospitals level QM measures. Results of the relationships between levels were mixed and showed most associations between QMCI and department-level QM measures for all four types of departments. QMSI was associated with PSS in all types of departments. By using the seven measures of QM, it is possible to get a more comprehensive picture of the maturity of QM in hospitals, with regard to the different levels and across various types of hospital departments.

[Raising women's awareness of cardiovascular risks].

PubMed

Papas, Anne

Professor Claire Mounier-Vehier, a cardiologist and vascular specialist at Lille university regional hospital, is a leading spokesperson for women in the field of the prevention of cardiovascular diseases. One of her many roles is head of the 'heart, arteries and women health care pathway' set up in 2013 at Lille university hospital. She discusses the importance of this specific and multidisciplinary care pathway at a time when epidemiological data show that the management of women's cardiovascular health has become a public health priority. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Factors affecting Mental Health Nurses working with Clients with First Episode Psychosis: A qualitative study.

PubMed

Odeyemi, Constance; Morrissey, Jean; Donohue, Gráinne

2018-06-27

Although there is much research on mental health nurses working with individuals presenting with psychosis, there is a lack of knowledge about the factors that impact the experience of nurses in the presentation specifically of first time psychosis. This study aims to explore the factors that impact on the experience of mental health nurses working with individuals and their families who present with a first time psychosis. This qualitative study was conducted through individual semi-structured interviews with eight mental health nurses recruited from community mental health settings with a minimum of two years post qualification experience. Data was then subjected to a thematic content analysis. This study identified the importance of therapeutic engagement, as well as the need to have clear pathways to care and building capacity through clinical supervision and training when working with this population. Mental Health nurses should engage with additional training, formalized clinical supervision and avail of peer support in order to improve confidence, skills and quality of care, leading to better therapeutic engagement. Pathways to care should be embedded within the wider community to ensure ease of access for individual and their families. There should be more recognition of the social impact on the individual during untreated psychosis with regards to isolation and withdrawal as well as factors which also affect help-seeking behaviours. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Connecting people with cancer to physical activity and exercise programs: a pathway to create accessibility and engagement

PubMed Central

Mina, D. Santa; Sabiston, C.M.; Au, D.; Fong, A.J.; Capozzi, L.C.; Langelier, D.; Chasen, M.; Chiarotto, J.; Tomasone, J.R.; Jones, J.M.; Chang, E.; Culos-Reed, S.N.

2018-01-01

Recent guidelines concerning exercise for people with cancer provide evidence-based direction for exercise assessment and prescription for clinicians and their patients. Although the guidelines promote exercise integration into clinical care for people with cancer, they do not support strategies for bridging the guidelines with related resources or programs. Exercise program accessibility remains a challenge in implementing the guidelines, but that challenge might be mitigated with conceptual frameworks (“pathways”) that connect patients with exercise-related resources. In the present paper, we describe a pathway model and related resources that were developed by an expert panel of practitioners and researchers in the field of exercise and rehabilitation in oncology and that support the transition from health care practitioner to exercise programs or services for people with cancer. The model acknowledges the nuanced distinctions between research and exercise programming, as well as physical activity promotion, that, depending on the available programming in the local community or region, might influence practitioner use. Furthermore, the pathway identifies and provides examples of processes for referral, screening, medical clearance, and programming for people after a cancer diagnosis. The pathway supports the implementation of exercise guidelines and should serve as a model of enhanced care delivery to increase the health and well-being of people with cancer. PMID:29719431

Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature.

PubMed

Asthana, Sheena; Moon, Graham; Gibson, Alex; Bailey, Trevor; Hewson, Paul; Dibben, Chris

2018-05-01

There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place. © 2016 The Authors. Health and Social Care in the Community Published by John Wiley & Sons Ltd.

Trajectories of Social Withdrawal from Grades 1 to 6: Prediction from Early Parenting, Attachment, and Temperament

PubMed Central

Booth-LaForce, Cathryn; Oxford, Monica L.

2015-01-01

From 1092 children in the NICHD Study of Early Child Care and Youth Development, we identified three trajectory patterns of social withdrawal from teacher reports in Grades 1-6: A Normative consistently low group (86%); a Decreasing group (5%) with initially high withdrawal that decreased; and an Increasing group (9%) with initially low withdrawal that increased. Prediction models supported the role of early dysregulated temperament, insensitive parenting, and attachment. Preschool shy temperament was a specific pathway to decreasing withdrawal, and poor inhibitory control, to increasing withdrawal. Children on the increasing pathway were more lonely, solitary, and excluded by peers. Results suggest differentiated pathways to varying trajectories of social withdrawal and highlight the importance of identification of longitudinal patterns in relation to risk. PMID:18793064

Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction.

PubMed

Hydes, Theresa; Hansi, Navjyot; Trebble, Timothy M

2012-01-01

Upper gastrointestinal (UGI) endoscopy is a routine healthcare procedure with a defined patient pathway. The objective of this study was to redesign this pathway for unsedated patients using lean thinking transformation to focus on patient-derived value-adding steps, remove waste and create a more efficient process. This was to form the basis of a pathway template that was transferrable to other endoscopy units. A literature search of patient expectations for UGI endoscopy identified patient-derived value. A value stream map was created of the current pathway. The minimum and maximum time per step, bottlenecks and staff-staff interactions were recorded. This information was used for service transformation using lean thinking. A patient pathway template was created and implemented into a secondary unit. Questionnaire studies were performed to assess patient satisfaction. In the primary unit the patient pathway reduced from 19 to 11 steps with a reduction in the maximum lead time from 375 to 80 min following lean thinking transformation. The minimum value/lead time ratio increased from 24% to 49%. The patient pathway was redesigned as a 'cellular' system with minimised patient and staff travelling distances, waiting times, paperwork and handoffs. Nursing staff requirements reduced by 25%. Patient-prioritised aspects of care were emphasised with increased patient-endoscopist interaction time. The template was successfully introduced into a second unit with an overall positive patient satisfaction rating of 95%. Lean thinking transformation of the unsedated UGI endoscopy pathway results in reduced waiting times, reduced staffing requirements and improved patient flow and can form the basis of a pathway template which may be successfully transferred into alternative endoscopy environments with high levels of patient satisfaction.

Major trauma from suspected child abuse: a profile of the patient pathway.

PubMed

Davies, Ffion C; Lecky, Fiona E; Fisher, Ross; Fragoso-Iiguez, Marisol; Coats, Tim J

2017-09-01

Networked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non-accidental injury is a significant cause of paediatric major trauma and has a different injury and age profile from accidental injury (AI). This paper compares the prehospital and inhospital phases of the patient pathway for children with suspected abuse, with those accidentally injured. The paediatric database of the national trauma registry of England and Wales, Trauma Audit and Research Network, was interrogated from April 2012 (the launch of the major trauma networks) to June 2015, comparing the patient pathway for cases of suspected child abuse (SCA) with AI. In the study population of 7825 children, 7344 (94%) were classified as AI and 481 (6%) as SCA. SCA cases were younger (median 0.4 years vs 7 years for AI), had a higher Injury Severity Score (median 16vs9 for AI), and had nearly three times higher mortality (5.7%vs2.2% for AI). Other differences included presentation to hospital evenly throughout the day and year, arrival by non-ambulance means to hospital (74%) and delayed presentation to hospital from the time of injury (median 8 hours vs 1.8 hours for AI). Despite more severe injuries, these infants were less likely to receive key interventions in a timely manner. Only 20% arrived to a designated paediatric-capable major trauma centre. Secondary transfer to specialist care, if needed, took a median of 21.6 hours from injury(vs 13.8 hours for AI). These data show that children with major trauma that is inflicted rather than accidental follow a different pathway through the trauma system. The current model of major trauma care is not a good fit for the way in which child victims of suspected abuse present to healthcare. To achieve better care, awareness of this patient profile needs to increase, and trauma networks should adjust their conventional responses. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Costs Associated With Access Site and Same-Day Discharge Among Medicare Beneficiaries Undergoing Percutaneous Coronary Intervention: An Evaluation of the Current Percutaneous Coronary Intervention Care Pathways in the United States.

PubMed

Amin, Amit P; Patterson, Mark; House, John A; Giersiefen, Helmut; Spertus, John A; Baklanov, Dmitri V; Chhatriwalla, Adnan K; Safley, David M; Cohen, David J; Rao, Sunil V; Marso, Steven P

2017-02-27

The aim of this study was to examine the independent impact of various care pathways, including those involving transradial intervention (TRI) and same-day discharge (SDD) after elective percutaneous coronary intervention (PCI), on hospital costs. PCI is associated with costs of $10 billion annually. Alternative payment models for PCI are being implemented, but few data exist on strategies to reduce costs. Various PCI care pathways, including TRI and SDD, exist, but their association with costs and outcomes is unknown. In total, 279,987 PCI patients eligible for SDD in the National Cardiovascular Data Registry CathPCI Registry linked to Medicare claims files were analyzed. Hospital costs in 2014 U.S. dollars were estimated using cost-to-charge ratios. Propensity scores for TRI and SDD, with propensity adjustment via inverse probability weighting, was performed. Of the 279,987 PCI procedures, TRI was used in 9.0% (13.5% of which were SDD), and SDD was used in 5.3% of cases (23.1% of which were TRI). TRI (vs. transfemoral intervention) was associated with lower adjusted costs of $916 (95% confidence interval [CI]: $778 to $1,035), as was SDD ($3,502; 95% CI: $3,486 to $3,902). The adjusted cost associated with TRI and SDD was $13,389 (95% CI: $13,161 to $13,607), while the cost associated with transfemoral intervention and non-same-day discharge was $17,076 (95% CI: $16,999 to $17,147), a difference of $3,689 (95% CI: $3,486 to $3,902; p < 0.0001). Shifting current practice from transfemoral intervention non-same-day discharge to TRI SDD by 30% could potentially save a hospital performing 1,000 PCIs each year $1 million and the country $300 million annually. Among Medicare beneficiaries, TRI with SDD was independently associated with fewer complications and lower in-hospital costs. These findings have important implications for changing the current PCI care pathways to improve outcomes and reduce costs. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Non-Genomic Effects of Xenoestrogen Mixtures

PubMed Central

Viñas, René; Jeng, Yow-Jiun; Watson, Cheryl S.

2012-01-01

Xenoestrogens (XEs) are chemicals derived from a variety of natural and anthropogenic sources that can interfere with endogenous estrogens by either mimicking or blocking their responses via non-genomic and/or genomic signaling mechanisms. Disruption of estrogens’ actions through the less-studied non-genomic pathway can alter such functional end points as cell proliferation, peptide hormone release, catecholamine transport, and apoptosis, among others. Studies of potentially adverse effects due to mixtures and to low doses of endocrine-disrupting chemicals have recently become more feasible, though few so far have included actions via the non-genomic pathway. Physiologic estrogens and XEs evoke non-monotonic dose responses, with different compounds having different patterns of actions dependent on concentration and time, making mixture assessments all the more challenging. In order to understand the spectrum of toxicities and their mechanisms, future work should focus on carefully studying individual and mixture components across a range of concentrations and cellular pathways in a variety of tissue types. PMID:23066391

Impact of organizational infrastructure on beta-blocker and aspirin therapy for acute myocardial infarction.

PubMed

Ellerbeck, Edward F; Bhimaraj, Arvind; Hall, Sandra

2006-09-01

Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI). This study was designed to examine the impact of organizational infrastructure on the use of aspirin and beta-blockers during and after AMI. We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and beta-blocker both at admission and discharge. Hospitals varied widely in their inclusion of aspirin and beta-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive beta-blockers on admission and at discharge if beta-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of beta-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion. Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.

Physical and rehabilitation medicine (PRM) care pathways: "patients after total knee arthroplasty".

PubMed

Ribinik, P; Le Moine, F; de Korvin, G; Coudeyre, E; Genty, M; Rannou, F; Yelnik, A; Calmels, P

2012-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after total knee arthroplasty are classified into three care sequences and two clinical categories, each one being treated with the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Physical and rehabilitation medicine (PRM) care pathways: "patients after total hip arthroplasty".

PubMed

Ribinik, P; Le Moine, F; de Korvin, G; Coudeyre, E; Genty, M; Rannou, F; Yelnik, A; Calmels, P

2012-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for or a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Patients after total hip arthroplasty are classified into three care sequences and two clinical categories, each one being treated with the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Toward a Unified Integration Approach: Uniting Diverse Primary Care Strategies Under the Primary Care Behavioral Health (PCBH) Model.

PubMed

Sandoval, Brian E; Bell, Jennifer; Khatri, Parinda; Robinson, Patricia J

2018-06-01

Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.

An instrument for broadened risk assessment in antenatal health care including non-medical issues

PubMed Central

Vos, Amber A.; van Veen, Mieke J.; Birnie, Erwin; Denktaş, Semiha; Steegers, Eric A.P.; Bonsel, Gouke J.

2015-01-01

Introduction Growing evidence on the risk contributing role of non-medical factors on pregnancy outcomes urged for a new approach in early antenatal risk selection. The evidence invites to more integration, in particular between the clinical working area and the public health domain. We developed a non-invasive, standardized instrument for comprehensive antenatal risk assessment. The current study presents the application-oriented development of a risk screening instrument for early antenatal detection of risk factors and tailored prevention in an integrated care setting. Methods A review of published instruments complemented with evidence from cohort studies. Selection and standardization of risk factors associated with small for gestational age, preterm birth, congenital anomalies and perinatal mortality. Risk factors were weighted to obtain a cumulative risk score. Responses were then connected to corresponding care pathways. A cumulative risk threshold was defined, which can be adapted to the population and the availability of preventive facilities. A score above the threshold implies multidisciplinary consultation between caregivers. Results The resulting digital score card consisted of 70 items, subdivided into four non-medical and two medical domains. Weighing of risk factors was based on existing evidence. Pilot-evidence from a cohort of 218 pregnancies in a multi-practice urban setting showed a cut-off of 16 points would imply 20% of all pregnant women to be assessed in a multidisciplinary setting. A total of 28 care pathways were defined. Conclusion The resulting score card is a universal risk screening instrument which incorporates recent evidence on non-medical risk factors for adverse pregnancy outcomes and enables systematic risk management in an integrated antenatal health care setting. PMID:25780351

Psychosocial pathways to sexually transmitted infection risk among youth transitioning out of foster care: evidence from a longitudinal cohort study.

PubMed

Ahrens, Kym R; McCarty, Cari; Simoni, Jane; Dworsky, Amy; Courtney, Mark E

2013-10-01

To test the fit of a theoretically driven conceptual model of pathways to sexually transmitted infection (STI) risk among foster youth transitioning to adulthood. The model included (1) historical abuse and foster care experiences; (2) mental health and attachment style in late adolescence; and (3) STI risk in young adulthood. We used path analysis to analyze data from a longitudinal study of 732 youth transitioning out of foster care. Covariates included gender, race, and an inverse probability weight. We also performed moderation analyses comparing models constrained and unconstrained by gender. Thirty percent reported they or a partner had been diagnosed with an STI. Probability of other measured STI risk behaviors ranged from 9% (having sex for money) to 79% (inconsistent condom use). Overall model fit was good (Standardized Root Mean Square Residual of .026). Increased risk of oppositional/delinquent behaviors mediated an association between abuse history and STI risk, via increased inconsistent condom use. There was also a borderline association with having greater than five partners. Having a very close relationship with a caregiver and remaining in foster care beyond age 18 years decreased STI risk. Moderation analysis revealed better model fit when coefficients were allowed to vary by gender versus a constrained model, but few significant differences in individual path coefficients were found between male and female-only models. Interventions/policies that (1) address externalizing trauma sequelae; (2) promote close, stable substitute caregiver relationships; and (3) extend care to age 21 years have the potential to decrease STI risk in this population. Copyright © 2013 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.

You have an idea, now what?

PubMed

Gertner, Michael

2006-11-01

The innovation process is often more important than the original idea, particularly when the ultimate goal is to improve patient care through technologically advanced products. Many physicians have great ideas; unfortunately, many of these great ideas are never translated to patient care improvements because of a misunderstanding of "the next step." In many cases, the next step is a step backward to understand the real clinical problem: "the clinical need." With the clinical need in hand, the most efficient path to a product for improved patient care can then be derived. Often, the most efficient pathway involves an appreciation of many issues, including intellectual property, regulatory pathways, finance, and clinical trial strategies. The integration of these issues underlies innovation in biomedical technology.

76 FR 81980 - Agency Information Collection Activities; Submission for OMB Review; Comment Request; Green Jobs...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-12-29

... for OMB Review; Comment Request; Green Jobs and Health Care Impact Evaluation of ARRA-Funded Grants... Administration (ETA) sponsored information collection request (ICR) titled, ``Green Jobs and Health Care Impact... . SUPPLEMENTARY INFORMATION: ETA is undertaking the Green Jobs and Health Care Impact Evaluation of the Pathways...

Physical and rehabilitation medicine (PRM) care pathways: "stroke patients".

PubMed

Yelnik, A-P; Schnitzler, A; Pradat-Diehl, P; Sengler, J; Devailly, J-P; Dehail, P; D'anjou, M-C; Rode, G

2011-11-01

This document is part of a series of documents designed by the French Physical and Rehabilitation Medicine Society (SOFMER) and the French Federation of PRM (FEDMER). These documents describe the needs for a specific type of patients; PRM care objectives, human and material resources to be implemented, chronology as well as expected outcomes. "Care pathways in PRM" is a short document designed to enable the reader (physicians, decision-maker, administrator, lawyer or finance manager) to quickly apprehend the needs of these patients and the available therapeutic care structures for proper organization and pricing of these activities. Stroke patients are divided into four categories according to the severity of the impairments, each one being treated according to the same six parameters according to the International Classification of Functioning, Disability and Health (WHO), while taking into account personal and environmental factors that could influence the needs of these patients. 2011 Elsevier Masson SAS. All rights reserved.

Child welfare-involved youth with intellectual disabilities: pathways into and placements in foster care.

PubMed

Slayter, Elspeth; Springer, Cheryl

2011-02-01

Existing literature suggests that youth with intellectual disabilities are at increased risk for child maltreatment. Little is known about youth with intellectual disabilities who are supervised by child welfare authorities or living in foster care. Reasons for child welfare system involvement and placement types are explored. In this cross-sectional exploratory study, we drew on data from the Adoption and Foster Care Reporting System (AFCARS) for youth in 46 states, the District of Columbia, and Puerto Rico. A sample of 17,714 youth with intellectual disabilities and a comparison group (n  =  655,536) were identified for 1999. Findings have implications for preventing the removal of youth from caregivers and the promotion of community inclusion of foster youth while in foster care.

Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence.

PubMed

Seah, Richard; Mani-Babu, Sivanadian

2011-01-01

To summarize the best available evidence in the last decade for managing ankle sprains in the community, data were collected using MEDLINE database from January 2000 to December 2009. Terms utilized: 'ankle injury primary care' (102 articles were found), 'ankle sprain primary care' (34 articles), 'ankle guidelines primary care' (25 articles), 'ankle pathways primary care' (2 articles), 'ankle sprain community' (18 articles), 'ankle sprain general practice' (22 articles), 'Cochrane review ankle' (58 articles). Of these, only 33 satisfied the inclusion criteria. The search terms identified many of the same studies. Two independent reviewers reviewed the articles. The study results and generated conclusions were extracted, discussed and finally agreed on. Ankle sprains occur commonly but their management is not always readily agreed. The Ottawa Ankle Rules are ubiquitous in the clinical pathway and can be reliably applied by emergency care physicians, primary care physicians and triage nurses. For mild-to-moderate ankle sprains, functional treatment options (which can consist of elastic bandaging, soft casting, taping or orthoses with associated coordination training) were found to be statistically better than immobilization for multiple outcome measures. For severe ankle sprains, a short period of immobilization in a below-knee cast or pneumatic brace results in a quicker recovery than tubular compression bandage alone. Lace-up supports are a more effective functional treatment than elastic bandaging and result in less persistent swelling in the short term when compared with semi-rigid ankle supports, elastic bandaging and tape. Semi-rigid orthoses and pneumatic braces provide beneficial ankle support and may prevent subsequent sprains during high-risk sporting activity. Supervised rehabilitation training in combination with conventional treatment for acute lateral ankle sprains can be beneficial, although some of the studies reviewed gave conflicting outcomes. Therapeutic hyaluronic acid injections in the ankle are a relatively novel non-surgical treatment but may have a role in expediting return to sport after ankle sprain. There is a role for surgical intervention in severe acute and chronic ankle injuries, but the evidence is limited.

How do nurses, midwives and health visitors contribute to protocol-based care? A synthesis of the UK literature.

PubMed

Ilott, Irene; Booth, Andrew; Rick, Jo; Patterson, Malcolm

2010-06-01

To explore how nurses, midwives and health visitors contribute to the development, implementation and audit of protocol-based care. Protocol-based care refers to the use of documents that set standards for clinical care processes with the intent of reducing unacceptable variations in practice. Documents such as protocols, clinical guidelines and care pathways underpin evidence-based practice throughout the world. An interpretative review using the five-stage systematic literature review process. The data sources were the British Nursing Index, CINAHL, EMBASE, MEDLINE and Web of Science from onset to 2005. The Journal of Integrated Care Pathways was hand searched (1997-June 2006). Thirty three studies about protocol-based care in the United Kingdom were appraised using the Qualitative Assessment and Review Instrument (QARI version 2). The literature was synthesized inductively and deductively, using an official 12-step guide for development as a framework for the deductive synthesis. Most papers were descriptive, offering practitioner knowledge and positive findings about a locally developed and owned protocol-based care. The majority were instigated in response to clinical need or service re-design. Development of protocol-based care was a non-linear, idiosyncratic process, with steps omitted, repeated or completed in a different order. The context and the multiple purposes of protocol-based care influenced the development process. Implementation and sustainability were rarely mentioned, or theorised as a change. The roles and activities of nurses were so understated as to be almost invisible. There were notable gaps in the literature about the resource use costs, the engagement of patients in the decision-making process, leadership and the impact of formalisation and new roles on inter-professional relations. Documents that standardise clinical care are part of the history of nursing as well as contemporary evidence-based care and expanded roles. Considering the proliferation and contested nature of protocol-based care, the dearth of literature about the contribution, experience and outcomes for nurses, midwives and health visitors is noteworthy and requires further investigation. (c) 2010 Elsevier Ltd. All rights reserved.

Where did the acute medical trainees go? A review of the career pathways of acute care common stem acute medical trainees in London.

PubMed

Gowland, Emily; Ball, Karen Le; Bryant, Catherine; Birns, Jonathan

2016-10-01

Acute care common stem acute medicine (ACCS AM) training was designed to develop competent multi-skilled acute physicians to manage patients with multimorbidity from 'door to discharge' in an era of increasing acute hospital admissions. Recent surveys by the Royal College of Physicians have suggested that acute medical specialties are proving less attractive to trainees. However, data on the career pathways taken by trainees completing core acute medical training has been lacking. Using London as a region with a 100% fill rate for its ACCS AM training programme, this study showed only 14% of trainees go on to higher specialty training in acute internal medicine and a further 10% to pursue higher medical specialty training with dual accreditation with internal medicine. 16% of trainees switched from ACCS AM to emergency medicine or anaesthetics during core ACCS training, and intensive care medicine proved to be the most popular career choice for ACCS AM trainees (21%). The ACCS AM training programme therefore does not appear to be providing what it was set out to do and this paper discusses the potential causes and effects. © Royal College of Physicians 2016. All rights reserved.

A Clinical Decision Support System to Assist Pediatric Oncofertility: A Short Report.

PubMed

Hand, Meredith; Kemertzis, Matthew A; Peate, Michelle; Gillam, Lynn; McCarthy, Maria; Orme, Lisa; Heloury, Yves; Sullivan, Michael; Zacharin, Margaret; Jayasinghe, Yasmin

2018-05-07

Fertility preservation discussions with pediatric and adolescent cancer patients can be difficult for clinicians. This study describes the acceptability of a fertility clinician decision support system (CDSS). A cross-sectional study of clinicians at The Royal Children's Hospital, Melbourne. Participants were trained on CDSS purpose, contents, and use. A survey captured the perceived benefits and weaknesses of the CDSS. Thirty-nine clinicians participated. Over 90% felt the CDSS aims and format were clear, and understood the components. Over 80% felt it would enable adherence to clinical pathways, policy, and standards of care. The CDSS provided significant perceived benefits to oncofertility care.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial

PubMed Central

2013-01-01

Background The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for ‘point of care’ management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways. Design/methods We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma—the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis—the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits. Discussion This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways. Trial registration ClinicalTrials.gov: NCT01815710 PMID:23692634

Systematic review of pathways for the delivery of allergy services.

PubMed

Diwakar, Lavanya; Cummins, Carole; Lilford, Richard; Roberts, Tracy

2017-02-07

The incidence and prevalence of allergies worldwide has been increasing and allergy services globally are unable to keep up with this increase in demand. This systematic review aims to understand the delivery of allergy services worldwide, challenges faced and future directions for service delivery. A systematic scoping review of Ovid, EMBASE, HMIC, CINAHL, Cochrane, DARE, NHS EED and INAHTA databases was carried out using predefined inclusion and exclusion criteria. Data on the geographical region, study design and treatment pathways described were collected, and the findings were narratively reported. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. 205 publications were screened and 27 selected for review. Only 3 were prospective studies, and none included a control group. There were no eligible publications identified from North America, Africa, Australia and most parts of Asia. Most publications relate to allergy services in the UK. In general, allergy services globally appear not to have kept pace with increasing demand. The review suggests that primary care practitioners are not being adequately trained in allergy and that there is a paucity of appropriately trained specialists, especially in paediatric allergy. There appear to be considerable barriers to service improvement, including lack of political will and reluctance to allocate funds from local budgets. Demand for allergy services appears to have significantly outpaced supply. Primary and secondary care pathways in allergy seem inadequate leading to poor referral practices, delays in patient management and consequently poor outcomes. Improvement of services requires strong public and political engagement. There is a need for well-planned, prospective studies in this area and a few are currently underway. There is no evidence to suggest that any given pathway of service provision is better than another although data from a few long-term, prospective studies look very promising. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Systematic review of pathways for the delivery of allergy services

PubMed Central

Cummins, Carole; Lilford, Richard; Roberts, Tracy

2017-01-01

Objectives The incidence and prevalence of allergies worldwide has been increasing and allergy services globally are unable to keep up with this increase in demand. This systematic review aims to understand the delivery of allergy services worldwide, challenges faced and future directions for service delivery. Methods A systematic scoping review of Ovid, EMBASE, HMIC, CINAHL, Cochrane, DARE, NHS EED and INAHTA databases was carried out using predefined inclusion and exclusion criteria. Data on the geographical region, study design and treatment pathways described were collected, and the findings were narratively reported. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Results 205 publications were screened and 27 selected for review. Only 3 were prospective studies, and none included a control group. There were no eligible publications identified from North America, Africa, Australia and most parts of Asia. Most publications relate to allergy services in the UK. In general, allergy services globally appear not to have kept pace with increasing demand. The review suggests that primary care practitioners are not being adequately trained in allergy and that there is a paucity of appropriately trained specialists, especially in paediatric allergy. There appear to be considerable barriers to service improvement, including lack of political will and reluctance to allocate funds from local budgets. Conclusions Demand for allergy services appears to have significantly outpaced supply. Primary and secondary care pathways in allergy seem inadequate leading to poor referral practices, delays in patient management and consequently poor outcomes. Improvement of services requires strong public and political engagement. There is a need for well-planned, prospective studies in this area and a few are currently underway. There is no evidence to suggest that any given pathway of service provision is better than another although data from a few long-term, prospective studies look very promising. PMID:28174222

Effects of Clinical Pathways for Common Outpatient Infections on Antibiotic Prescribing

PubMed Central

Jenkins, Timothy C.; Irwin, Amy; Coombs, Letoynia; DeAlleaume, Lauren; Ross, Stephen E.; Rozwadowski, Jeanne; Webster, Brian; Dickinson, L. Miriam; Sabel, Allison L.; MacKenzie, Thomas D.; West, David R.; Price, Connie S.

2013-01-01

Background Antibiotic overuse in the primary care setting is common. Our objective was to evaluate the effect of a clinical pathway-based intervention on antibiotic use. Methods Eight primary care clinics were randomized to receive clinical pathways for upper respiratory infection, acute bronchitis, acute rhinosinusitis, pharyngitis, acute otitis media, urinary tract infection, skin infections, and pneumonia and patient education materials (study group) versus no intervention (control group). Generalized linear mixed effects models were used to assess trends in antibiotic prescriptions for non-pneumonia acute respiratory infections and broad-spectrum antibiotic use for all eight conditions during a 2-year baseline and 1-year intervention period. Results In the study group, antibiotic prescriptions for non-pneumonia acute respiratory infections decreased from 42.7% of cases at baseline to 37.9% during the intervention period (11.2% relative reduction) (p <.0001) and from 39.8% to 38.7%, respectively, in the control group (2.8% relative reduction) (p=0.25). Overall use of broad-spectrum antibiotics in the study group decreased from 26.4% to 22.6% of cases, respectively, (14.4% relative reduction) (p <.0001) and from 20.0% to 19.4%, respectively, in the control group (3.0% relative reduction) (p=0.35). There were significant differences in the trends of prescriptions for acute respiratory infections (p<.0001) and broad-spectrum antibiotic use (p=0.001) between the study and control groups during the intervention period, with greater declines in the study group. Conclusions This intervention was associated with declining antibiotic prescriptions for non-pneumonia acute respiratory infections and use of broad-spectrum antibiotics over the first year. Evaluation of the impact over a longer study period is warranted. PMID:23507206

Towards good dementia care: Awareness and uptake of an online Dementia Pathways tool for rural and regional primary health practitioners.

PubMed

Ollerenshaw, Alison; Wong Shee, Anna; Yates, Mark

2018-04-01

To explore the awareness and usage of an online dementia pathways tool (including decision tree and region-specific dementia services) for primary health practitioners (GPs and nurses) in regional Victoria. Quantitative pilot study using surveys and Google Analytics. A large regional area (48 000 square kilometres, population 220 000) in Victoria. Two hundred and sixty-three GPs and 160 practice nurses were invited to participate, with 42 respondents (GPs, n = 21; practice nurses, n = 21). Primary care practitioners' awareness and usage of the dementia pathways tool. Survey respondents that had used the tool (n = 14) reported accessing information about diagnosis, management and referral. Practitioners reported improvements in knowledge, skills and confidence about core dementia topics. There were 9683 page views between August 2013 and February 2015 (monthly average: 509 page views). The average time spent on page was 2.03 min, with many visitors (68%) spending more than 4 min at the site. This research demonstrates that the tool has been well received by practitioners and has been consistently used since its launch. Health practitioners' valued the content and the availability of local resources. Primary health practitioners reported that the dementia pathways tool provided access to region-specific referral and management resources for all stages of dementia. Such tools have broad transferability in other health areas with further research needed to determine their contribution to learning in the practice setting and over time. © 2017 National Rural Health Alliance Inc.

[Regional geriatric care concept in the District of Lippe : Structural effects and network formation in the case management-based model project].

PubMed

Şahin, Charlotte; Iseringhausen, Olaf; Hower, Kira; Liebe, Constanze; Rethmeier-Hanke, Anja; Wedmann, Bernd

2018-04-01

Regional planning of healthcare requires special consideration for the complex needs of elderly, multimorbid people living in a domestic environment. In the District of Lippe, a hospital (Klinikum Lippe) and network of ambulatory care physicians (Ärztenetz Lippe) developed and tested a geriatric care network based on case management for geriatric patients living in a domestic environment. The establishment of the geriatric care network (e.g. promoting networking acceptance and implementation) was formatively evaluated, e. g. with qualitative methods. Data were acquired by guideline-based interviews with experts and analyzed by qualitative content analysis according to Mayring. Structural effects included forming a cross-sectoral and interdisciplinary network for a functioning care network and a geriatric care pathway. The practical work of case managers (CM) is essential for communication with patients, family members and care providers as well as integrating providers into the network. A critical factor was working together with general practitioners and the close cooperation with the hospital's department of geriatric. The quality of care is improved because of exchange of information between sectors and continuity in the course of care. In the District of Lippe the quality of care was improved and structures of care were integrated by the network according to the needs of the target group. The integrative perspective was achieved in particular by the geriatric care pathway and integration of providers into the communication and care process; however, the scope of this care model could not be extended into routine care due to the rigid and subdivided health care system.

Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study.

PubMed

Riolfi, Mirko; Buja, Alessandra; Zanardo, Chiara; Marangon, Chiara Francesca; Manno, Pietro; Baldo, Vincenzo

2014-05-01

It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative home-care services. The aim of this study was to assess the effectiveness of appropriate palliative home-care services in reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being hospitalized. Retrospective cohort study. We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (North-East Italy), as dying of cancer in 2011. Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team. Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium) were predictive of hospitalization. Our study confirms the effectiveness of palliative home care in enabling patients to spend the final period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for these diseases.

A mobile phone application for the assessment and management of youth mental health problems in primary care: health service outcomes from a randomised controlled trial of mobiletype.

PubMed

Reid, Sophie C; Kauer, Sylvia D; Hearps, Stephen J C; Crooke, Alexander H D; Khor, Angela S; Sanci, Lena A; Patton, George C

2013-06-19

GPs detect at best 50c of mental health problems in young people. Barriers to detecting mental health problems include lack of screening tools, limited appointment times and young people's reluctance to report mental health symptoms to GPs. The mobiletype program is a mobile phone mental health assessment and management application which monitors mood, stress and everyday activities then transmits this information to general practitioners (GPs) via a secure website in summary format for medical review. The current aims were to examine: (i) mobiletype as a clinical assistance tool, ii) doctor-patient rapport and, iii) pathways to care. We conducted a randomised controlled trial in primary care with patients aged 14 to 24 years recruited from rural and metropolitan general practices. GPs identified and referred eligible participants (those with mild or more mental health concerns) who were randomly assigned to either the intervention group (where mood, stress and daily activities were monitored) or the attention-comparison group (where only daily activities were monitored). Both groups self-monitored for 2 to 4 weeks and reviewed the monitoring data with their GP. GPs, participants and researchers were blind to group allocation at randomisation. GPs assessed the mobiletype program as a clinical assistant tool. Doctor-patient rapport was assessed using the General Practice Assessment Questionnaire Communication and Enablement subscales, and the Trust in Physician Scale (TPS). Pathways to care was measured using The Party Project's Exit Interview. Of the 163 participants assessed for eligibility, 118 were randomised and 114 participants were included in analyses (intervention n = 68, attention-comparison n = 46). T-tests showed that the intervention program increased understanding of patient mental health, assisted in decisions about medication/referral and helped in diagnosis when compared to the attention-comparison program. Mixed model analysis showed no differences in GP-patient rapport nor in pathways to care. We conducted the first RCT of a mobile phone application in the mental health assessment and management of youth mental health in primary care. This study suggests that mobiletype has much to offer GPs in the often difficult and time-consuming task of assessment and management of youth mental health problems in primary care. ClinicalTrials.gov NCT00794222.

How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China.

PubMed

Tang, Wenxi; Sun, Xiaowei; Zhang, Yan; Ye, Ting; Zhang, Liang

2015-01-01

While integrated health care system has been proved an effective way to help improving patient health and system efficiency, the exact behaviour model and motivation approach are not so clear in poor rural areas where health human resources and continuous service provision are urgently needed. To gather solid evidence, we initiated a comprehensive intervention project in Qianjiang District, southwest part of rural China in 2012. And after one-year's pilot, we developed an intervention package of team service, comprehensive pathway and prospective- and performance-based payment system. To testify the potential influence of payment interventions, we use clustered randomised controlled trial, 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences. Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway. The outcomes are: quality of care, disease burden, supplier cooperative behaviour and patient utilisation behaviour and system efficiency. Repeated multivariate variance analysis will be used to statistically examine the outcome differences. This is the first trial of its kind to prove the effects and efficiency of integrated care. Though we adopted randomised controlled trial to gather the highest rank of evidence, still the fully randomisation was hard to realise in health policy reform experiment. To compensate, the designer should take efforts on control for the potential confounders as much as possible. With this trial, we assume the effects will come from: (1) improvement on the quality of life through risk factors control and lifestyles change on patient's behaviours; (2) improvement on quality of care through continuous care and coordinated supplier behaviours; (3) improvement on the system efficiency through active interaction between suppliers and patients. The integrated care system needs collaborative work from different levels of caregivers. So it is extremely important to consider the supplier cooperative behaviour. In this trial, we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles. Also, the multidisciplinary team, the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution.

How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China

PubMed Central

Tang, Wenxi; Sun, Xiaowei; Zhang, Yan; Ye, Ting; Zhang, Liang

2015-01-01

Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency, the exact behaviour model and motivation approach are not so clear in poor rural areas where health human resources and continuous service provision are urgently needed. To gather solid evidence, we initiated a comprehensive intervention project in Qianjiang District, southwest part of rural China in 2012. And after one-year's pilot, we developed an intervention package of team service, comprehensive pathway and prospective- and performance-based payment system. Methods To testify the potential influence of payment interventions, we use clustered randomised controlled trial, 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences. Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway. The outcomes are: quality of care, disease burden, supplier cooperative behaviour and patient utilisation behaviour and system efficiency. Repeated multivariate variance analysis will be used to statistically examine the outcome differences. Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care. Though we adopted randomised controlled trial to gather the highest rank of evidence, still the fully randomisation was hard to realise in health policy reform experiment. To compensate, the designer should take efforts on control for the potential confounders as much as possible. With this trial, we assume the effects will come from: (1) improvement on the quality of life through risk factors control and lifestyles change on patient's behaviours; (2) improvement on quality of care through continuous care and coordinated supplier behaviours; (3) improvement on the system efficiency through active interaction between suppliers and patients. Conclusion The integrated care system needs collaborative work from different levels of caregivers. So it is extremely important to consider the supplier cooperative behaviour. In this trial, we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles. Also, the multidisciplinary team, the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution. PMID:26034466

N-of-1-pathways MixEnrich: advancing precision medicine via single-subject analysis in discovering dynamic changes of transcriptomes.

PubMed

Li, Qike; Schissler, A Grant; Gardeux, Vincent; Achour, Ikbel; Kenost, Colleen; Berghout, Joanne; Li, Haiquan; Zhang, Hao Helen; Lussier, Yves A

2017-05-24

Transcriptome analytic tools are commonly used across patient cohorts to develop drugs and predict clinical outcomes. However, as precision medicine pursues more accurate and individualized treatment decisions, these methods are not designed to address single-patient transcriptome analyses. We previously developed and validated the N-of-1-pathways framework using two methods, Wilcoxon and Mahalanobis Distance (MD), for personal transcriptome analysis derived from a pair of samples of a single patient. Although, both methods uncover concordantly dysregulated pathways, they are not designed to detect dysregulated pathways with up- and down-regulated genes (bidirectional dysregulation) that are ubiquitous in biological systems. We developed N-of-1-pathways MixEnrich, a mixture model followed by a gene set enrichment test, to uncover bidirectional and concordantly dysregulated pathways one patient at a time. We assess its accuracy in a comprehensive simulation study and in a RNA-Seq data analysis of head and neck squamous cell carcinomas (HNSCCs). In presence of bidirectionally dysregulated genes in the pathway or in presence of high background noise, MixEnrich substantially outperforms previous single-subject transcriptome analysis methods, both in the simulation study and the HNSCCs data analysis (ROC Curves; higher true positive rates; lower false positive rates). Bidirectional and concordant dysregulated pathways uncovered by MixEnrich in each patient largely overlapped with the quasi-gold standard compared to other single-subject and cohort-based transcriptome analyses. The greater performance of MixEnrich presents an advantage over previous methods to meet the promise of providing accurate personal transcriptome analysis to support precision medicine at point of care.

Implementation of an opioid detoxification management pathway reduces emergency department length of stay.

PubMed

Bellew, Shawna D; Collins, Sean P; Barrett, Tyler W; Russ, Stephan E; Jones, Ian D; Slovis, Corey M; Self, Wesley H

2018-05-25

With the rise of opioid use in the United States, the increasing demand for treatment for opioid use disorders presents both a challenge and an opportunity to develop new care pathways for ED patients seeking opioid detoxification. We set out to improve the care of patients presenting to our ED seeking opioid detoxification by implementing a standardized management pathway and to measure the effects of this intervention. We conducted a before-after study of the effects of an opioid detoxification management pathway on ED length of stay, use of resources (social worker consultation, laboratory tests obtained), and return visits to the same ED within 30 days of discharge. All data were collected retrospectively by review of the electronic health record. Ultimately, 107 patients presented to the ED that met criteria, 52 in the intervention period and 55 in the pre-intervention period. Median ED length of stay in the intervention period was 152 (IQR 93-237) minutes compared to 312 (IQR 187-468) minutes in the pre-intervention period (p<0.001). Patients in the intervention period less frequently had a social work consultation (32.7% vs. 83.6%, p<0.001) or had laboratory tests obtained (32.7% vs 74.5%, p<0.001) and more frequently were prescribed a medication for withdrawal symptoms (57.7% vs. 29.1%, p=0.003). Implementation of an opioid detoxification management pathway reduced ED length of stay, reduced utilization of resources, and increased the proportion of patients prescribed medications for symptom relief. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Implementing critical pathways and a multidisciplinary team approach to cardiovascular disease management.

PubMed

Peterson, Eric D; Albert, Nancy M; Amin, Alpesh; Patterson, J Herbert; Fonarow, Gregg C

2008-09-08

According to several medical registries, there is a need to improve the care of post-myocardial infarction (MI) patients, especially those with left ventricular dysfunction (LVD) and heart failure. This can potentially be achieved by implementing disease management programs, which include critical pathways, patient education, and multidisciplinary hospital teams. Currently, algorithms for critical pathways, including discharge processes, are lacking for post-MI LVD patients. Such schemes can increase the use of evidence-based medicines proved to reduce mortality. Educational programs are aimed at increasing patients' awareness of their condition, promoting medication compliance, and encouraging the adoption of healthy behaviors; such programs have been shown to be effective in improving outcomes of post-MI LVD patients. Reductions in all-cause hospitalizations and medical costs as well as improved survival rates have been observed when a multidisciplinary team (a nurse, a pharmacist, and a hospitalist) is engaged in patient care. In addition, the use of the "pay for performance" method, which can be advantageous for patients, physicians, and hospitals, may potentially improve the care of post-MI patients with LVD.

A nurse-led ambulatory care pathway for patients with deep venous thrombosis in an acute teaching hospital.

PubMed

Deagle, Jennifer; Allen, James; Mani, Raj

2005-06-01

This article describes the management of deep vein thrombosis (DVT) using an ambulatory nurse-led pathway and the compression technique using duplex ultrasound. This pathway permits the management of the "walking wounded" as well as other patients at varying risks of having DVT and in so doing has changed the approach toward the management of this common clinical event. The success of the described pathway is attributed to the development of low molecular weight heparin and the reliability of diagnostics.

Towards improving diagnosis of memory loss in general practice: TIMeLi diagnostic test accuracy study protocol.

PubMed

Creavin, Sam T; Cullum, Sarah J; Haworth, Judy; Wye, Lesley; Bayer, Antony; Fish, Mark; Purdy, Sarah; Ben-Shlomo, Yoav

2016-07-19

People with cognitive problems, and their families, report distress and uncertainty whilst undergoing evaluation for dementia and perceive that traditional diagnostic evaluation in secondary care is insufficiently patient centred. The James Lind Alliance has prioritised research to investigate the role of primary care in supporting a more effective diagnostic pathway, and the topic is also of interest to health commissioners. However, there are very few studies that investigate the accuracy of diagnostic tests for dementia in primary care. We will conduct a prospective diagnostic test accuracy study to evaluate the accuracy of a range of simple tests for diagnosing all-cause-dementia in symptomatic people aged over 70 years who have consulted with their general practitioner (GP). We will invite eligible people to attend a research clinic where they will undergo a range of index tests that a GP could perform in the surgery and also be assessed by a specialist in memory disorders at the same appointment. Participating GPs will request neuroimaging and blood tests and otherwise manage patients in line with their usual clinical practice. The reference standard will be the consensus judgement of three experts (neurologist, psychiatrist and geriatrician) based on information from the specialist assessment, GP records and investigations, but not including items in the index test battery. The target condition will be all-cause dementia but we will also investigate diagnostic accuracy for sub-types where possible. We will use qualitative interviews with patients and focus groups with clinicians to help us understand the acceptability and feasibility of diagnosing dementia in primary care using the tests that we are investigating. Our results will help clinicians decide on which tests to perform in someone where there is concern about possible dementia and inform commissioning of diagnostic pathways.

Increasing patient involvement in the diabetic foot pathway: a pilot randomized controlled trial.

PubMed

McBride, E; Hacking, B; O'Carroll, R; Young, M; Jahr, J; Borthwick, C; Callander, A; Berrada, Z

2016-11-01

This pilot study aimed to explore whether the use of an intervention to increase shared decision-making (Decision Navigation) increased decision self-efficacy and foot-treatment adherence in patients with a diabetic foot ulcer. Fifty-six patients with a diabetic foot ulcer were randomized to receive Decision Navigation (N = 30) or usual care (N = 26). Primary outcomes included decision self-efficacy, adherence to foot treatment as reported by the participant and adherence to foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing rate, health-related quality of life, decision conflict and decision regret. Despite participants rating Decision Navigation as very helpful, mixed analyses of variance revealed no differences in decision self-efficacy or adherence between those receiving Decision Navigation and those receiving usual care. There were no differences between groups with regards to the secondary outcomes, with the exception of decision conflict which increased over time (12 weeks) for those receiving Decision Navigation. An intervention that facilitated patient involvement in treatment decisions did not have any impact on decisional confidence or adherence to foot treatment. This does not provide support for the suggestion that personalized care can improve health-related outcomes at this progressed stage of the patient's disease trajectory. We suggest that the diabetic foot population may benefit from interventions aimed at increasing motivation to engage with care pathways, centred on challenging personal controllability beliefs. © 2016 Diabetes UK.

A Systematic Review on the Existing Screening Pathways for Lynch Syndrome Identification.

PubMed

Tognetto, Alessia; Michelazzo, Maria Benedetta; Calabró, Giovanna Elisa; Unim, Brigid; Di Marco, Marco; Ricciardi, Walter; Pastorino, Roberta; Boccia, Stefania

2017-01-01

Lynch syndrome (LS) is the most common hereditary colon cancer syndrome, accounting for 3-5% of colorectal cancer (CRC) cases, and it is associated with the development of other cancers. Early detection of individuals with LS is relevant, since they can take advantage of life-saving intensive care surveillance. The debate regarding the best screening policy, however, is far from being concluded. This prompted us to conduct a systematic review of the existing screening pathways for LS. We performed a systematic search of MEDLINE, ISI Web of Science, and SCOPUS online databases for the existing screening pathways for LS. The eligibility criteria for inclusion in this review required that the studies evaluated a structured and permanent screening pathway for the identification of LS carriers. The effectiveness of the pathways was analyzed in terms of LS detection rate. We identified five eligible studies. All the LS screening pathways started from CRC cases, of which three followed a universal screening approach. Concerning the laboratory procedures, the pathways used immunohistochemistry and/or microsatellite instability testing. If the responses of the tests indicated a risk for LS, the genetic counseling, performed by a geneticist or a genetic counselor, was mandatory to undergo DNA genetic testing. The overall LS detection rate ranged from 0 to 5.2%. This systematic review reported different existing pathways for the identification of LS patients. Although current clinical guidelines suggest to test all the CRC cases to identify LS cases, the actual implementation of pathways for LS identification has not been realized. Large-scale screening programs for LS have the potential to reduce morbidity and mortality for CRC, but coordinated efforts in educating all key stakeholders and addressing public needs are still required.

Development of an instrument to analyze organizational characteristics in multidisciplinary care pathways; the case of colorectal cancer.

PubMed

Pluimers, Dorine J; van Vliet, Ellen J; Niezink, Anne Gh; van Mourik, Martijn S; Eddes, Eric H; Wouters, Michel W; Tollenaar, Rob A E M; van Harten, Wim H

2015-04-09

To analyze the organization of multidisciplinary care pathways such as colorectal cancer care, an instrument was developed based on a recently published framework that was earlier used in analyzing (monodisciplinary) specialist cataract care from a lean perspective. The instrument was constructed using semi-structured interviews and direct observation of the colorectal care process based on a Rapid Plant Assessment. Six lean aspects that were earlier established that highly impact process design, were investigated: operational focus, autonomous work cell, physical lay-out of resources, multi-skilled team, pull planning and non-value adding activities. To test reliability, clarity and face validity of the instrument, a pilot study was performed in eight Dutch hospitals. In the pilot it proved feasible to apply the instrument and generate the intended information. The instrument consisted of 83 quantitative and 24 qualitative items. Examples of results show differences in operational focus, number of patient visits needed for diagnosis, numbers of staff involved with treatment, the implementation of protocols and utilization of one-stop-shops. Identification of waste and non-value adding activities may need further attention. Based on feedback from involved clinicians the face validity was acceptable and the results provided useful feedback- and benchmark data. The instrument proved to be reliable and valid for broader implementation in Dutch health care. The limited number of cases made statistical analysis not possible and further validation studies may shed better light on variation. This paper demonstrates the use of an instrument to analyze organizational characteristics in colorectal cancer care from a lean perspective. Wider use might help to identify best organizational practices for colorectal surgery. In larger series the instrument might be used for in-depth research into the relation between organization and patient outcomes. Although we found no reason to adapt the underlying framework, recommendations were made for further development to enable use in different tumor- and treatment modalities and in larger (international) samples that allow for more advanced statistical analysis. Waste from defective care or from wasted human potential will need further elaboration of the instrument.

Navigating the Financial Aid System in the Community College: The Lived Experience of Students Formerly in Foster Care

ERIC Educational Resources Information Center

Solemsaas, Rachel

2011-01-01

For many low-income and disadvantaged students formerly in foster care, community colleges are the main post-secondary educational pathway to socioeconomic opportunities. However, students formerly in foster care face many barriers in accessing college as well as actually succeeding in achieving a college degree. Although considerable efforts have…

A Multidisciplinary Self-Directed Learning Module Improves Knowledge of a Quality Improvement Instrument: The HEART Pathway.

PubMed

Hartman, Nicholas D; Harper, Erin N; Leppert, Lauren M; Browning, Brittany M; Askew, Kim; Manthey, David E; Mahler, Simon A

We created and tested an educational intervention to support implementation of an institution wide QI project (the HEART Pathway) designed to improve care for patients with acute chest pain. Although online learning modules have been shown effective in imparting knowledge regarding QI projects, it is unknown whether these modules are effective across specialties and healthcare professions. Participants, including nurses, advanced practice clinicians, house staff and attending physicians (N = 486), were enrolled into an online, self-directed learning course exploring the key concepts of the HEART Pathway. The module was completed by 97% of enrollees (469/486) and 90% passed on the first attempt (422/469). Out of 469 learners, 323 completed the pretest, learning module and posttest in the correct order. Mean test scores across learners improved significantly from 74% to 89% from the pretest to the posttest. Following the intervention, the HEART Pathway was used for 88% of patients presenting to our institution with acute chest pain. Our data demonstrate that this online, self-directed learning module can improve knowledge of the HEART Pathway across specialties-paving the way for more efficient and informed care for acute chest pain patients.

Effects of Educational Music Therapy on State Hope for Recovery in Acute Care Mental Health Inpatients: A Cluster-Randomized Effectiveness Study.

PubMed

Silverman, Michael J

2016-01-01

Background: There has been an increasing emphasis on recovery as the expectation for people with mental health disorders. Purpose: The purpose of this effectiveness study is to determine if group-based educational music therapy can immediately impact state hope for recovery in acute care mental health patients. Research questions included: will acute care mental health inpatients who participate in a single music therapy session have higher agency and pathway aspects of state hope for recovery than patients in a control condition? Will there be differences in state hope for recovery as a result of hope-oriented songwriting or lyric analysis interventions? Method: Participants ( N = 169) were cluster randomized to one of three single-session conditions: lyric analysis, songwriting, or wait-list control. Results: There was no significant between-group difference. However, both music therapy conditions tended to have slightly higher mean pathway, agency, and total state hope scores than the control condition even within the temporal parameters of a single music therapy session. There was no between-group difference in the songwriting and lyric analysis interventions. Conclusion: Although not significant, results support that educational music therapy may impact state hope for recovery within the temporal parameters of a single session. The specific type of educational music therapy intervention did not affect results. Implications for practice, limitations, and suggestions for future research are provided.

Effects of Educational Music Therapy on State Hope for Recovery in Acute Care Mental Health Inpatients: A Cluster-Randomized Effectiveness Study

PubMed Central

Silverman, Michael J.

2016-01-01

Background: There has been an increasing emphasis on recovery as the expectation for people with mental health disorders. Purpose: The purpose of this effectiveness study is to determine if group-based educational music therapy can immediately impact state hope for recovery in acute care mental health patients. Research questions included: will acute care mental health inpatients who participate in a single music therapy session have higher agency and pathway aspects of state hope for recovery than patients in a control condition? Will there be differences in state hope for recovery as a result of hope-oriented songwriting or lyric analysis interventions? Method: Participants (N = 169) were cluster randomized to one of three single-session conditions: lyric analysis, songwriting, or wait-list control. Results: There was no significant between-group difference. However, both music therapy conditions tended to have slightly higher mean pathway, agency, and total state hope scores than the control condition even within the temporal parameters of a single music therapy session. There was no between-group difference in the songwriting and lyric analysis interventions. Conclusion: Although not significant, results support that educational music therapy may impact state hope for recovery within the temporal parameters of a single session. The specific type of educational music therapy intervention did not affect results. Implications for practice, limitations, and suggestions for future research are provided. PMID:27774084

[Interdisciplinary clinical pathway for colorectal cancer].

PubMed

Fischbach, W; Engemann, R

2006-07-01

Limited financial resources in public health care have led to the introduction of clinical pathways as a means to a better effectivity and efficacy. Colorectal cancer met the requirements for establishing such a pathway in a distinguished way: high patient volume, high costs, interdisciplinary multi-modal treatment concepts in a relevant frequency, and existing evidence based guidelines. This article gives an example of a clinical pathway for colorectal cancer as established in our hospital. The potential of such pathways to save costs as well as their implications on treatment results and patients' satisfaction will have to be critically analyzed in the future before their value can be definitely estimated.

Another Baby? Father Involvement and Childbearing in Fragile Families

PubMed Central

Kotila, Letitia E.; Dush, Claire M. Kamp

2013-01-01

An historic number of women in the US have children outside of marriage, and with more than one father, yet little research has examined the association between family process and women’s childbearing decisions. Using a subsample of unmarried women from the Fragile Families and Child Wellbeing Study (N=2028), a study of primarily low-income unmarried parents, we conducted discrete-time survival analysis models to predict whether women had another child with the focal child’s father (same-father birth) or with a new father (new-father birth). Father involvement was measured by engagement, indirect care, accessibility, and financial support. Overall, mothers who reported greater engagement and indirect care from the focal child’s father were more likely to have a same-father birth even when he was not living in her home, and were also less likely to have a new-father birth. Further, mothers who reported greater accessibility and stable financial support from the focal child’s nonresident father were also less likely to have a new-father birth. One pathway through which this may have occurred was that single mothers who perceived less indirect care and accessibility from the focal child’s nonresident father were more likely to begin new romantic relationships. Indeed, whether or not the mother had a new romantic partner partially mediated the association between indirect care and a same-father birth, and fully mediated the association between accessibility and a new-father birth, suggesting that one pathway linking father involvement to a new-father birth was through maternal repartnering. Clinical and policy implications are discussed. PMID:23244460

Facilitators and barriers of implementing enhanced recovery in colorectal surgery at a safety net hospital: A provider and patient perspective.

PubMed

Alawadi, Zeinab M; Leal, Isabel; Phatak, Uma R; Flores-Gonzalez, Juan R; Holihan, Julie L; Karanjawala, Burzeen E; Millas, Stefanos G; Kao, Lillian S

2016-03-01

Enhanced Recovery After Surgery (ERAS) pathways are known to decrease complications and duration of stay in colorectal surgery patients. However, it is unclear whether an ERAS pathway would be feasible and effective at a safety-net hospital. The aim of this study was to identify local barriers and facilitators before the adoption of an ERAS pathway for patients undergoing colorectal operations at a safety-net hospital. Semistructured interviews were conducted to assess the perceived barriers and facilitators before ERAS adoption. Stratified purposive sampling was used. Interviews were audiotaped, transcribed verbatim, and analyzed using content analysis. Analytic and investigator triangulation were used to establish credibility. Interviewees included 8 anesthesiologists, 5 surgeons, 6 nurses, and 18 patients. Facilitators identified across the different medical professions were (1) feasibility and alignment with current practice, (2) standardization of care, (3) smallness of community, (4) good teamwork and communication, and (5) caring for patients. The barriers were (1) difficulty in adapting to change, (2) lack of coordination between different departments, (3) special needs of a highly comorbid and socioeconomically disadvantaged patient population, (4) limited resources, and (5) rotating residents. Facilitators identified by the patients were (1) welcoming a speedy recovery, (2) being well-cared for and satisfied with treatment, (3) adequate social support, (4) welcoming early mobilization, and (5) effective pain management. The barriers were (1) lack of quiet and private space, (2) need for more patient education and counseling, and (3) unforeseen complications. Although limited hospital resources are perceived as a barrier to ERAS implementation at a safety-net hospital, there is strong support for such pathways and multiple factors were identified that may facilitate change. Inclusion of patient perspectives is critical to identifying challenges and facilitators to implementing ERAS changes focused on optimizing patient perioperative health and outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

Integrated tumor and germline whole-exome sequencing identifies mutations in MAPK and PI3K pathway genes in an adolescent with rosette-forming glioneuronal tumor of the fourth ventricle

PubMed Central

Lin, Frank Y.; Bergstrom, Katie; Person, Richard; Bavle, Abhishek; Ballester, Leomar Y.; Scollon, Sarah; Raesz-Martinez, Robin; Jea, Andrew; Birchansky, Sherri; Wheeler, David A.; Berg, Stacey L.; Chintagumpala, Murali M.; Adesina, Adekunle M.; Eng, Christine; Roy, Angshumoy; Plon, Sharon E.; Parsons, D. Williams

2016-01-01

The integration of genome-scale studies such as whole-exome sequencing (WES) into the clinical care of children with cancer has the potential to provide insight into the genetic basis of an individual's cancer with implications for clinical management. This report describes the results of clinical tumor and germline WES for a patient with a rare tumor diagnosis, rosette-forming glioneuronal tumor of the fourth ventricle (RGNT). Three pathogenic gene alterations with implications for clinical care were identified: somatic activating hotspot mutations in FGFR1 (p.N546K) and PIK3CA (p.H1047R) and a germline pathogenic variant in PTPN11 (p.N308S) diagnostic for Noonan syndrome. The molecular landscape of RGNT is not well-described, but these data are consistent with prior observations regarding the importance of the interconnected MAPK and PI3K/AKT/mTOR signaling pathways in this rare tumor. The co-occurrence of FGFR1, PIK3CA, and PTPN11 alterations provides further evidence for consideration of RGNT as a distinct molecular entity from pediatric low-grade gliomas and suggests potential therapeutic strategies for this patient in the event of tumor recurrence as novel agents targeting these pathways enter pediatric clinical trials. Although RGNT has not been definitively linked with cancer predisposition syndromes, two prior cases have been reported in patients with RASopathies (Noonan syndrome and neurofibromatosis type 1 [NF1]), providing an additional link between these tumors and the mitogen-activated protein kinase (MAPK) signaling pathway. In summary, this case provides an example of the potential for genome-scale sequencing technologies to provide insight into the biology of rare tumors and yield both tumor and germline results of potential relevance to patient care. PMID:27626068

The effect of economic development on population health: a review of the empirical evidence.

PubMed

Lange, Simon; Vollmer, Sebastian

2017-01-01

Economic growth is considered an important determinant of population health. Relevant studies investigating the effect of economic growth on health outcomes were identified from Google Scholar and PubMed searches in economics and medical journals. Additional resources generated through economic growth are potentially useful for improving population health. The empirical evidence on the aggregate effect of economic growth on population health is rather mixed and inconclusive. The causal pathways from economic growth to population health are crucial and failure or success in completing the pathways explains differences in empirical findings. Future research should investigate how additional resources can more effectively reach those in need and how additional resources can be used more efficiently. It is particularly relevant to understand why preventive health care in developing countries is very price elastic whereas curative health care is very health inelastic and how this understanding can inform public health policy. © The Author 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Resource utilization in lung cancer diagnostic procedures: Current use and budget consequences.

PubMed

Brinkhof, Sander; Groen, Harry J M; Siesling, Sabine S; IJzerman, Maarten J

2017-01-01

The main objective of this study is to determine the current use of lung cancer diagnostic procedures in two large hospitals in the Netherlands, to explore deviations in guideline adherence between the hospitals, and to estimate the budget impact of the diagnostic work-up as well as the over- and underutilization. A state transition model for the diagnostic pathway for lung cancer patients was developed using existing clinical practice guidelines (CPG) combined with a systematic literature. In addition to the CPGs depicting current practice, diagnostic utilization was gathered in two large hospitals representing an academic tertiary care hospital and a large regional teaching hospital for patients, who were selected from the Netherlands cancer registry. The total population consisted of 376 patients with lung cancer. Not in all cases the guideline was followed, for instance in the usage of MR brain with stage III lung cancer patients (n = 70). The state-transition model predicts an average budget impact for the diagnostic pathway per patient estimated of € 2496 in the academic tertiary care hospital and € 2191 in the large regional teaching hospital. The adherence to the CPG's differed between hospitals, which questions the adherence to CPG's in general. Adherence to CPG's could lead to less costs in the diagnostic pathway for lung cancer patients.

Working Together for Children: Strengthening Transition Pathways

ERIC Educational Resources Information Center

Collie, Louise; Willis, Felicity; Paine, Crystal; Windsor, Corina

2007-01-01

The "Working Together for Children: Strengthening Transition Pathways" Team has identified that there is a gap between the Early Childhood settings and schools within the Dubbo area. Through meetings with early childhood professionals within Dubbo the authors have identified that the current landscape of care and education within their community…

Sequential simulation (SqS) of clinical pathways: a tool for public and patient engagement in point-of-care diagnostics

PubMed Central

Huddy, Jeremy R; Weldon, Sharon-Marie; Ralhan, Shvaita; Painter, Tim; Hanna, George B; Kneebone, Roger; Bello, Fernando

2016-01-01

Objectives Public and patient engagement (PPE) is fundamental to healthcare research. To facilitate effective engagement in novel point-of-care tests (POCTs), the test and downstream consequences of the result need to be considered. Sequential simulation (SqS) is a tool to represent patient journeys and the effects of intervention at each and subsequent stages. This case study presents a process evaluation of SqS as a tool for PPE in the development of a volatile organic compound-based breath test POCT for the diagnosis of oesophagogastric (OG) cancer. Setting Three 3-hour workshops in central London. Participants 38 members of public attended a workshop, 26 (68%) had no prior experience of the OG cancer diagnostic pathway. Interventions Clinical pathway SqS was developed from a storyboard of a patient, played by an actor, noticing symptoms of oesophageal cancer and following a typical diagnostic pathway. The proposed breath testing strategy was then introduced and incorporated into a second SqS to demonstrate pathway impact. Facilitated group discussions followed each SqS. Primary and secondary outcome measures Evaluation was conducted through pre-event and postevent questionnaires, field notes and analysis of audiovisual recordings. Results 38 participants attended a workshop. All participants agreed they were able to contribute to discussions and like the idea of an OG cancer breath test. Five themes emerged related to the proposed new breath test including awareness of OG cancer, barriers to testing and diagnosis, design of new test device, new clinical pathway and placement of test device. 3 themes emerged related to the use of SqS: participatory engagement, simulation and empathetic engagement, and why participants attended. Conclusions SqS facilitated a shared immersive experience for participants and researchers that led to the coconstruction of knowledge that will guide future research activities and be of value to stakeholders concerned with the invention and adoption of POCT. PMID:27625053

Completing the cervical screening pathway: Factors that facilitate the increase of self-collection uptake among under-screened and never-screened women, an Australian pilot study.

PubMed

McLachlan, E; Anderson, S; Hawkes, D; Saville, M; Arabena, K

2018-02-01

To examine factors that enhance under-screened and never-screened women's completion of the self-collection alternative pathway of the Renewed National Cervical Screening Program (ncsp) in Victoria, Australia. With the Australian ncsp changing, starting on 1 December 2017, the Medical Services Advisory Committee (msac) recommended implementing human papillomavirus (hpv) testing using a self-collected sample for under-screened and never-screened populations. In response, a multi-agency group implemented an hpv self-collection pilot project to trial self-collection screening pathways for eligible women. Quantitative data were collected on participation rates and compliance rates with follow-up procedures across three primary health care settings. Forty women who self-collected were interviewed in a semi-structured format, and seven agency staff completed in-depth interviews. Qualitative data were used to identify and understand clinical and personal enablers that assisted women to complete self-collection cervical screening pathways successfully. Eighty-five per cent (10 women) of participants who tested positive for hpv successfully received their results and completed follow-up procedures as required. Two remaining participants also received hpv-positive results. However, agencies were unable to engage them in follow-up services and procedures. The overall participation rate in screening (self-collection or Pap test) was 85.7% (84 women), with 79 women self-collecting. Qualitative data indicated that clear explanations on self-collection, development of trusting, empathetic relationships with health professionals, and recognition of participants' past experiences were critical to the successful completion of the self-collection pathway. When asked about possible inhibitors to screening and to following up on results and appointments, women cited poor physical and mental health, as well as financial and other structural barriers. A well-implemented process, led by trusted, knowledgeable, and engaged health care professionals who can provide appropriate support and information, can assist under-screened and never-screened women to complete the hpv self-collection pathway successfully.

Preconception Motivation and Pregnancy Wantedness: Pathways to Toddler Attachment Security

ERIC Educational Resources Information Center

Miller, Warren B.; Sable, Marjorie R.; Beckmeyer, Jonathon J.

2009-01-01

This research was designed to increase our understanding of how the motivational antecedents to childbearing and emotional responses to pregnancy affect the subsequent attachment bond of a toddler to his or her mother. Using a sample of 1,364 mothers and their newborns from the Study of Early Child Care, we tested a mother-child influence…

Pathways to Medical Home Recognition: A Qualitative Comparative Analysis of the PCMH Transformation Process.

PubMed

Mendel, Peter; Chen, Emily K; Green, Harold D; Armstrong, Courtney; Timbie, Justin W; Kress, Amii M; Friedberg, Mark W; Kahn, Katherine L

2017-12-15

To understand the process of practice transformation by identifying pathways for attaining patient-centered medical home (PCMH) recognition. The CMS Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration was designed to help FQHCs achieve NCQA Level 3 PCMH recognition and improve patient outcomes. We used a stratified random sample of 20 (out of 503) participating sites for this analysis. We developed a conceptual model of structural, cultural, and implementation factors affecting PCMH transformation based on literature and initial qualitative interview themes. We then used conventional cross-case analysis, followed by qualitative comparative analysis (QCA), a cross-case method based on Boolean logic algorithms, to systematically identify pathways (i.e., combinations of factors) associated with attaining-or not attaining-Level 3 recognition. Site-level indicators were derived from semistructured interviews with site leaders at two points in time (mid- and late-implementation) and administrative data collected prior to and during the demonstration period. The QCA results identified five distinct pathways to attaining PCMH recognition and four distinct pathways to not attaining recognition by the end of the demonstration. Across these pathways, one condition (change leader capacity) was common to all pathways for attaining recognition, and another (previous improvement or recognition experience) was absent in all pathways for not attaining recognition. In general, sites could compensate for deficiencies in one factor with capacity in others, but they needed a threshold of strengths in cultural and implementation factors to attain PCMH recognition. Future efforts at primary care transformation should take into account multiple pathways sites may pursue. Sites should be assessed on key cultural and implementation factors, in addition to structural components, in order to differentiate interventions and technical assistance. © Health Research and Educational Trust.

Case Study Approaches for Implementing the 2007 NRC Report “Toxicity Testing in the 21st Century: A Vision and A Strategy”

PubMed Central

Andersen, Melvin E.; Clewell, Harvey J.; Carmichael, Paul L.; Boekelheide, Kim

2013-01-01

The 2007 report “Toxicity Testing in the 21st Century: A Vision and A Strategy” argued for a change in toxicity testing for environmental agents and discussed federal funding mechanisms that could be used to support this transformation within the USA. The new approach would test for in vitro perturbations of toxicity pathways using human cells with high throughput testing platforms. The NRC report proposed a deliberate timeline, spanning about 20 years, to implement a wholesale replacement of current in-life toxicity test approaches focused on apical responses with in vitro assays. One approach to accelerating implementation is to focus on well-studied prototype compounds with known toxicity pathway targets. Through a series of carefully executed case studies with four or five pathway prototypes, the various steps required for implementation of an in vitro toxicity pathway approach to risk assessment could be developed and refined. In this article, we discuss alternative approaches for implementation and also outline advantages of a case study approach and the manner in which the cases studies could be pursued using current methodologies. A case study approach would be complementary to recently proposed efforts to map the human toxome, while representing a significant extension toward more formal risk assessment compared to the profiling and prioritization approaches offered by programs such as the EPA’s ToxCast effort. PMID:21993955

The T.O.S.CA. Project: research, education and care.

PubMed

Bossone, Eduardo; Limongelli, Giuseppe; Malizia, Graziella; Ferrara, Francesco; Vriz, Olga; Citro, Rodolfo; Marra, Alberto Maria; Arcopinto, Michele; Bobbio, Emanuele; Sirico, Domenico; Caliendo, Luigi; Ballotta, Andrea; D'Andrea, Antonello; Frigiola, Alessandro; Isgaard, Jorgen; Saccà, Luigi; Antonio, Cittadini

2011-12-01

Despite recent and exponential improvements in diagnostic-therapeutic pathways, an existing "GAP" has been revealed between the "real world care" and the "optimal care" of patients with chronic heart failure (CHF). We present the T.O.S.CA. Project (Trattamento Ormonale dello Scompenso CArdiaco), an Italian multicenter initiative involving different health care professionals and services aiming to explore the CHF "metabolic pathophysiological model" and to improve the quality of care of HF patients through research and continuing medical education.

Room for improvement: patient, parent, and practitioners' perceptions of foot problems and foot care in juvenile idiopathic arthritis.

PubMed

Hendry, Gordon J; Turner, Debbie E; Lorgelly, Paula K; Woodburn, James

2012-11-01

To explore the perceived impact of disease-related foot problems and foot care in juvenile idiopathic arthritis (JIA) from the perspectives of patients, parents, pediatric rheumatologists, and health professionals. A qualitative study using an interpretative phenomenological approach. Outpatients department, public health service children's hospital. Patients (N=15; 4 adult patients, 2 parents of children with JIA, 3 pediatric rheumatologists, and 6 health professionals) from 2 National Health Service rheumatology centers (1 pediatric and 1 adult). Not applicable. Qualitative outcomes were participants' perceptions elicited using semistructured interviews (telephone or face-to-face) and focus groups using an interpretative phenomenological approach. A data-driven inductive approach to coding and theme development was adopted for transcript analysis. Participants volunteered to take part in a total of 7 interviews and 2 focus groups. The analysis revealed 6 key themes related to the impact of foot problems and perceptions of foot care from respective groups. These were the following: (1) pain, (2) mobility impairment, (3) reduced ability to perform activities of daily living, (4) footwear difficulties, (5) poor referral pathways/delayed access to care, and (6) lack of evidence in support of conservative foot care. Several areas for development of foot care services were identified including a need for improved referral pathways, shorter waiting times for initial consultations, greater attention to patient compliance, and a need for better evidence in support of customized foot orthoses. Several key foot health-related outcomes were identified, which may be of importance for measuring therapeutic response to foot-related interventions. Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.

Expanding the Donor Pool Through Intensive Care to Facilitate Organ Donation: Results of a Spanish Multicenter Study.

PubMed

Domínguez-Gil, Beatriz; Coll, Elisabeth; Elizalde, José; Herrero, Jaime E; Pont, Teresa; Quindós, Brígida; Marcelo, Bella; Bodí, María A; Martínez, Adolfo; Nebra, Agustín; Guerrero, Francisco; Manciño, José M; Galán, Juan; Lebrón, Miguel; Miñambres, Eduardo; Matesanz, Rafael

2017-08-01

Intensive Care to facilitate Organ Donation (ICOD) may help to increase the donor pool. We describe the Spanish experience with ICOD. Achieving Comprehensive Coordination in Organ Donation (ACCORD)-Spain consisted of an audit of the donation pathway from patients who died as a result of a devastating brain injury (possible donors) in 68 hospitals during November 1, 2014, to April 30, 2015. We focused on possible donors whose families were interviewed to discuss organ donation once intensive care with a therapeutic purpose was deemed futile and brain death (BD) was a likely outcome. Of the 1970 possible donors in ACCORD-Spain, in 257, the family was interviewed once the decision had been made not to intubate/ventilate (n = 105), with the patient under intubation/ventilation outside of the intensive care unit (n = 59), or with the patient intubated/ventilated within the intensive care unit (n = 93).Consent to ICOD was obtained in 174 cases. Consent was higher when the donor coordinator participated in the interview (odds ratio, 2.32; 95% confidence interval, 1.33-4.11; P = 0.003). One hundred thirty-one patients developed BD, of whom 117 transitioned to actual donation after BD. Of the 35 patients who did not develop BD, 2 transitioned to actual donation after circulatory death. Sixteen patients subject to ICOD were finally medically unsuitable organ donors.ICOD contributed to 24% of the 491 actual donors registered in ACCORD-Spain. Despite the complexity of the interview, the majority of families consented to ICOD. Estimating the probability of BD and assessing medical suitability are additional challenges of the practice. ICOD represents a clear opportunity to increase the donor pool and ensures organ donation is posed at every end-of-life care pathway.

How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect?

PubMed

Allen, Davina; Rixson, Laura

Across the developed world, we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision. Integrated care pathways (ICPs) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration. ICPs map out a patient's journey, providing coordination of services for users. They aim to have: 'the right people, doing the right things, in the right order, at the right time, in the right place, with the right outcome'. The value for ICPs in supporting the delivery of care across organisational boundaries, providing greater consistency in practice, improving service continuity and increasing collaboration has been advocated by many. However, there is little evidence to support their use, and the need for systematic evaluations in order to measure their effectiveness has been widely identified. A recent Cochrane review assessed the effects of ICPs on functional outcome, process of care, quality of life and hospitalisation costs of inpatients with acute stroke, but did not specifically focus on service integration or its derivatives. To the best of our knowledge, no such systematic review of the literature exists. INCLUSION CRITERIA: Types of participants The review focused on the care of adult patients who had suffered a stroke. It included the full spectrum of services - acute care, rehabilitation and long-term support - in hospital and community settings.Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest, defined for the purpose of this review as 'a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and standardise the outcome orientated care'. Here 'multidisciplinary' is taken to refer to the involvement of two or more disciplines.Types of outcomes Service integration' was the outcome of interest however, this was defined and measured in the selected studies.Types of studies This review was concerned with how 'service integration' was defined in evaluations of ICPs; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on 'service integration'. Studies that made an explicit link between ICPs and service integration were included in the review. Evidence generated from randomised controlled trials, quasi-experimental, qualitative and health economics research was sought. The search was limited to publications after 1980, coinciding with the emergence of ICPs in the healthcare context. Assessment for inclusion of foreign papers was based on the English-language abstract, where available. These were included only if an English translation was available. This review excluded studies that: SEARCH STRATEGY: In order to avoid replication, the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Database and the Cochrane Library were searched to establish that no systematic reviews existed and none were in progress. A three-stage search strategy was then used to identify both published and unpublished studies (see ). Our search strategy located 2123 papers, of which 39 were retrieved for further evaluation. We critically appraised seven papers, representing five studies. These were all evaluation studies and, as is typical in this field, comprised a range of study designs and data collection methods. Owing to the diversity of the study types included in the review, we developed a single-appraisal checklist and data-extractiontool which could be applied to all research designs. The tool drew on the Joanna Briggs Institute (JBI) appraisal checklists for experimental studies and interpretive and critical research, and also incorporated specific information and issues which were relevant for our purposes (see ). This extends the thinking outlined in Lyne et al. in which, drawing on Campbell and Stanley's classic paper, the case is made for developing an appraisal tool which is applicable to all types of evaluation, irrespective of study design.In assessing the quality of the papers, we were sympathetic to the methodological challenges of evaluating complex interventions such as ICPs. We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare contexts. In accordance with the aims of this particular review, we have included studies, which are methodologically weaker than is typical of many systematic reviews because, in our view, in the absence of stronger evidence, they yield useful information. Given the heterogeneity of the included studies, meta-analysis and/or qualitative synthesis was not possible. A narrative summary of the study findings is presented. Therefore, we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits. Implications for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care. This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of resources around the patient without incurring additional increases in length of stay. ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable. Their value in the context of rehabilitation settings in which recovery pathways are more variable is less clear. There is some evidence that ICPs may be effective in bringing about behavioural changes in contexts where deficiencies in service provision have been identified. Their value in contexts where inter-professional working is well established is less clear. While earlier before and after studies show a reduction in length of stay in ICP-managed care, this may reflect wider healthcare trends, and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced. There is some evidence to suggest that ICPs bring about improvements in documentation, but we do not know how far documented practice reflects actual practice. It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use. As none of the studies reviewed included an economic evaluation, moreover, it remains unclear whether the benefits of ICPs justify the costs of their implementation.

Barriers and facilitators to smoking cessation in pregnancy and in the post-partum period: The health care professionals' perspective.

PubMed

Naughton, Felix; Hopewell, Sarah; Sinclair, Lesley; McCaughan, Dorothy; McKell, Jennifer; Bauld, Linda

2018-05-15

Health care professionals and the health care environment play a central role in protecting pregnant and post-partum women and their infants from smoking-related harms. This study aimed to better understand the health professional's perspective on how interactions between women, health care professionals, and the environment influence how smoking is managed. Semi-structured interviews and focus groups. Data were from 48 health care staff involved in antenatal or post-partum care at two UK sites, including midwives, obstetricians, health visitors, GPs, pharmacists, service commissioners, and Stop Smoking Service (SSS) advisors and managers. Thematic analysis was guided by a social-ecological framework (SEF). Themes were divided across three SEF levels and represented factors connected to the management of smoking in the health care context and the beliefs and behaviour of pregnant or post-partum smokers. Organizational level: Service reconfigurations, 'last resort' nicotine replacement therapy prescribing policies, and non-mandatory training were largely negative factors. There were mixed views on opt-out referral pathways and positive views on carbon monoxide monitoring. Interpersonal level: Protection of client-professional relationships often inhibited frank discussions about smoking, and weak interservice relationships affected SSS referral motivation and quality. Individual level: Professionals felt community midwives had primary responsibility for managing smoking, although midwives felt underskilled doing this. Midwives' perceived priority for addressing smoking was influenced by the demands from unrelated organizational initiatives. Opportunities to improve clinical support for pregnant smokers exist at organizational, interservice, and health care professional levels. Interactions between levels reflect the importance of simultaneously addressing different level-specific barriers to smoking cessation in pregnancy. Statement of contribution What is already known on this subject? Few health care professionals discuss smoking cessation support with pregnant or post-partum women. Identified health care professional-related barriers to supporting pregnant and post-partum women to stop smoking include deficits in knowledge and confidence, perceived lack of time, and concerns about damaging client relationships. There is currently a gap in understanding regarding the barriers and facilitators to supporting this group and how interactions between the health care environment and health care professionals influence the way smoking is addressed. What does this study add? This study identifies modifiable factors that can influence cessation support delivery to pregnant and post-partum women. These factors are mapped across organizational, interpersonal, and individual health care professional levels. Service structure, communication pathways, and policies appear to influence what cessation support is offered. Interpersonal and individual factors influence how this support is delivered. © 2018 The Authors. British Journal of Health Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.

Beyond usual care: the economic consequences of expanding treatment options in early pregnancy loss.

PubMed

Dalton, Vanessa K; Liang, Angela; Hutton, David W; Zochowski, Melissa K; Fendrick, A Mark

2015-02-01

The objective of this study was to estimate the economic consequences of expanding options for early pregnancy loss (EPL) treatment beyond expectant management and operating room surgical evacuation (usual care). We constructed a decision model using a hypothetical cohort of women undergoing EPL management within a 30 day horizon. Treatment options under the usual care arm include expectant management and surgical uterine evacuation in an operating room (OR). Treatment options under the expanded care arm included all evidence-based safe and effective treatment options for EPL: expectant management, misoprostol treatment, surgical uterine evacuation in an office setting, and surgical uterine evacuation in an OR. Probabilities of entering various treatment pathways were based on previously published observational studies. The cost per case was US $241.29 lower for women undergoing treatment in the expanded care model as compared with the usual care model (US $1033.29 per case vs US $1274.58 per case, expanded care and usual care, respectively). The model was the most sensitive to the failure rate of the expectant management arm, the cost of the OR surgical procedure, the proportion of women undergoing an OR surgical procedure under usual care, and the additional cost per patient associated with implementing and using the expanded care model. This study demonstrates that expanding women's treatment options for EPL beyond what is typically available can result in lower direct medical expenditures. Copyright © 2015 Elsevier Inc. All rights reserved.

Global pathways to men's caregiving: mixed methods findings from the International Men and Gender Equality Survey and the Men Who Care study.

PubMed

Kato-Wallace, Jane; Barker, Gary; Eads, Marci; Levtov, Ruti

2014-01-01

Promoting men's participation in unpaid care work is part of the Programme of Action for the International Conference on Population and Development. However, men's involvement in care work does not mirror the advances women have made in paid work outside the home. This mixed method study explores which men are more involved in caregiving, and what childhood and adulthood factors influence their level of involvement. Quantitative research presents findings from 1169 men across six countries with children aged 0-4, and a qualitative study presents findings from in-depth interviews with 83 men engaged in atypical caregiving practices. Survey research finds that being taught to care for children, witnessing one's father take care of one's siblings, respondents' present attitudes about gender equality and having outside help (or none, in some cases) were all also associated with men's higher level of involvement. Qualitative research reveals that men's experiences of violence, the normalisation of domestic work as children and life circumstances rather than greater-than-average beliefs in gender equality all propelled them into care work. Findings suggest that engaging more men into care work implies changes to policies and structural realities in the workplace coupled with changing gender attitudes. These insights inform policy and practice aimed at promoting greater involvement in care work by men.

Experiences of women with a diagnosis of breast cancer: a clinical pathway approach.

PubMed

Lindop, E; Cannon, S

2001-06-01

The study presented in this paper formed the first part of a large survey of breast cancer patients in one health authority in England, UK looking at individual needs expressed by women with a diagnosis of breast cancer. The paper provides an account of the experiences of 12 women with a diagnosis of breast cancer. The women represent a wide age range and different stages of illness. The transcribed accounts of the women were analysed by means of Qualitative Solutions and Research, Non-Numerical Unstructured Data Indexing Searching and Theorising (QSR*NUDIST). The study examined the individual experiences of women with a diagnosis of breast cancer and its aftermath as they passed through different stages related to it. The women's experiences are presented within the conceptual framework of the clinical pathway and their accounts represent their journey along the pathway. Various significant points in this journey are portrayed representing the women's reactions to diagnosis, treatment, femininity and body image, support, family and friends, information and after care.

International scientists’ priorities for research on pharmaceutical and personal care products in the environment

EPA Science Inventory

Pharmaceuticals and personal care products (PPCPs) are widely discharged into the environment via diverse pathways. The effects of PPCPs in the environment have potentially important human and ecosystem health implications, so credible, salient, and legitimate scientific evidence...

Using Patient-Pathway Analysis to Inform a Differentiated Program Response to Tuberculosis: The Case of Kenya

PubMed Central

Masini, Enos; Hanson, Christy; Ogoro, Jeremiah; Brown, Jessie; Ngari, Faith; Mingkwan, Pia; Makayova, Julia; Osberg, Mike

2017-01-01

Abstract Background A recent tuberculosis prevalence survey in Kenya found that the country is home to nearly twice as many patients with tuberculosis as previously estimated. Kenya has prioritized identifying and treating the unnotified or missing cases of tuberculosis. This requires a better understanding of patient care seeking and system weaknesses. Methods A patient-pathway analysis (PPA) was completed to assess the alignment between patient care seeking and the availability of tuberculosis diagnostic and treatment services at the national level and for all 47 counties at the subnational level in Kenya. Results It was estimated that more than half of patients initiate care in the public sector. Nationally, just under half of patients encountered tuberculosis diagnostic and treatment capacity where they initiated care. Overall, there was distinct variation in diagnostic and treatment availability across counties and facility levels. Discussion The PPA results emphasized the need for a differentiated approach to tuberculosis care, by county, and the distinct need for better referral systems. The majority of Kenyans actively sought care; improving diagnostic and treatment capacity in the formal and informal private sector, as well as in the public sector, could help identify the majority of missing cases. PMID:29117349

Performance and cost evaluation of health information systems using micro-costing and discrete-event simulation.

PubMed

Rejeb, Olfa; Pilet, Claire; Hamana, Sabri; Xie, Xiaolan; Durand, Thierry; Aloui, Saber; Doly, Anne; Biron, Pierre; Perrier, Lionel; Augusto, Vincent

2018-06-01

Innovation and health-care funding reforms have contributed to the deployment of Information and Communication Technology (ICT) to improve patient care. Many health-care organizations considered the application of ICT as a crucial key to enhance health-care management. The purpose of this paper is to provide a methodology to assess the organizational impact of high-level Health Information System (HIS) on patient pathway. We propose an integrated performance evaluation of HIS approach through the combination of formal modeling using the Architecture of Integrated Information Systems (ARIS) models, a micro-costing approach for cost evaluation, and a Discrete-Event Simulation (DES) approach. The methodology is applied to the consultation for cancer treatment process. Simulation scenarios are established to conclude about the impact of HIS on patient pathway. We demonstrated that although high level HIS lengthen the consultation, occupation rate of oncologists are lower and quality of service is higher (through the number of available information accessed during the consultation to formulate the diagnostic). The provided method allows also to determine the most cost-effective ICT elements to improve the care process quality while minimizing costs. The methodology is flexible enough to be applied to other health-care systems.

Educational inequalities in patient-centred care: patients' preferences and experiences

PubMed Central

2012-01-01

Background Educational attainment is strongly related to specific health outcomes. The pathway in which individual patient-provider interactions contribute to (re)producing these inequalities has yet to be studied. In this article, the focus is on differences between less and more highly educated patients in their preferences for and experiences with patient-centred care., e.g. shared decision making, receiving understandable explanations and being able to ask questions. Methods Data are derived from several Consumer Quality-index (CQ-index) studies. The CQ-index is a family of standardized instruments which are used in the Netherlands to measure quality of care from the patient’s perspective. Results The educational level of patients is directly related to the degree of importance patients attribute to specific aspects of patient-centred care. It has a minor influence on the experienced level of shared decision making, but not on experiences regarding other aspects of patient-centred care. Conclusions All patients regard patient-centred care as important and report positive experiences. However, there is a discrepancy between patient preferences for patient-centred care on one hand and the care received on the other. Less educated patients might receive ‘too much’, and more highly educated patients ‘too little’ in the domains of communication, information and shared decision making. PMID:22900589

Looking for unity in diversity: human cooperative childcare in comparative perspective

PubMed Central

van Schaik, Carel

2017-01-01

Humans engage in cooperative childcare, which includes some elements not found in other animals, such as the presence of post-reproductive helpers, extensive food sharing among adults and a pervasive sexual division of labour. In animals, cooperative offspring care has typically been studied in two different contexts. The first mainly involves helpers contributing care in cooperatively breeding family groups; the second context is allomaternal care in species usually not categorized as cooperative breeders (e.g. plural and communal breeders, often without male care). Comparative analyses suggest that cooperative breeding and allomaternal care in plural and communal breeders have distinct evolutionary origins, with humans fitting neither pathway entirely. Nevertheless, some critical proximate mechanisms of helping, including hormonal regulators, are likely to be shared across species. Other mechanisms may vary among species, such as social tolerance, proactive prosociality or conditional mother–infant bonding. These are presumably associated with specific details of the care system, such as whether all group members contribute, or whether mothers can potentially raise offspring alone. Thus, cooperative offspring care is seen in different contexts across animal lineages, but may nonetheless share several important psychological characteristics. We end by discussing how work on humans may play a unifying role in studying cooperative offspring care. PMID:29237848

Looking for unity in diversity: human cooperative childcare in comparative perspective.

PubMed

Burkart, Judith M; van Schaik, Carel; Griesser, Michael

2017-12-20

Humans engage in cooperative childcare, which includes some elements not found in other animals, such as the presence of post-reproductive helpers, extensive food sharing among adults and a pervasive sexual division of labour. In animals, cooperative offspring care has typically been studied in two different contexts. The first mainly involves helpers contributing care in cooperatively breeding family groups; the second context is allomaternal care in species usually not categorized as cooperative breeders (e.g. plural and communal breeders, often without male care). Comparative analyses suggest that cooperative breeding and allomaternal care in plural and communal breeders have distinct evolutionary origins, with humans fitting neither pathway entirely. Nevertheless, some critical proximate mechanisms of helping, including hormonal regulators, are likely to be shared across species. Other mechanisms may vary among species, such as social tolerance, proactive prosociality or conditional mother-infant bonding. These are presumably associated with specific details of the care system, such as whether all group members contribute, or whether mothers can potentially raise offspring alone. Thus, cooperative offspring care is seen in different contexts across animal lineages, but may nonetheless share several important psychological characteristics. We end by discussing how work on humans may play a unifying role in studying cooperative offspring care. © 2017 The Author(s).

Pain management: a review of organisation models with integrated processes for the management of pain in adult cancer patients.

PubMed

Brink-Huis, Anita; van Achterberg, Theo; Schoonhoven, Lisette

2008-08-01

This paper reports a review of the literature conducted to identify organisation models in cancer pain management that contain integrated care processes and describe their effectiveness. Pain is experienced by 30-50% of cancer patients receiving treatment and by 70-90% of those with advanced disease. Efforts to improve pain management have been made through the development and dissemination of clinical guidelines. Early improvements in pain management were focussed on just one or two single processes such as pain assessment and patient education. Little is known about organisational models with multiple integrated processes throughout the course of the disease trajectory and concerning all stages of the care process. Systematic review. The review involved a systematic search of the literature, published between 1986-2006. Subject-specific keywords used to describe patients, disease, pain management interventions and integrated care processes, relevant for this review were selected using the thesaurus of the databases. Institutional models, clinical pathways and consultation services are three alternative models for the integration of care processes in cancer pain management. A clinical pathway is a comprehensive institutionalisation model, whereas a pain consultation service is a 'stand-alone' model that can be integrated in a clinical pathway. Positive patient and process outcomes have been described for all three models, although the level of evidence is generally low. Evaluation of the quality of pain management must involve standardised measurements of both patient and process outcomes. We recommend the development of policies for referrals to a pain consultation service. These policies can be integrated within a clinical pathway. To evaluate the effectiveness of pain management models standardised outcome measures are needed.

Training Internists to Meet Critical Care Needs in the United States: A Consensus Statement from the Critical Care Societies Collaborative (CCSC)

PubMed Central

Pastores, Stephen M.; Martin, Greg S.; Baumann, Michael H.; Curtis, J. Randall; Farmer, J. Christopher; Fessler, Henry E.; Gupta, Rakesh; Hill, Nicholas S.; Hyzy, Robert C.; Kvetan, Vladimir; MacGregor, Drew A.; O’Grady, Naomi P.; Ognibene, Frederick P.; Rubenfeld, Gordon D.; Sessler, Curtis N.; Siegal, Eric; Simpson, Steven Q.; Spevetz, Antoinette; Ward, Nicholas S.; Zimmerman, Janice L.

2014-01-01

Objectives Multiple training pathways are recognized by the Accreditation Council for Graduate Medical Education (ACGME) for internal medicine (IM) physicians to certify in critical care medicine (CCM) via the American Board of Internal Medicine. While each involves 1 year of clinical fellowship training in CCM, substantive differences in training requirements exist among the various pathways. The Critical Care Societies Collaborative convened a task force to review these CCM pathways and to provide recommendations for unified and coordinated training requirements for IM-based physicians. Participants A group of CCM professionals certified in pulmonary-CCM and/or IM-CCM from ACGME-accredited training programs who have expertise in education, administration, research, and clinical practice. Data Sources and Synthesis Relevant published literature was accessed through a MEDLINE search and references provided by all task force members. Material published by the ACGME, American Board of Internal Medicine, and other specialty organizations was also reviewed. Collaboratively and iteratively, the task force reached consensus using a roundtable meeting, electronic mail, and conference calls. Main Results Internal medicine-CCM–based fellowships have disparate program requirements compared to other internal medicine subspecialties and adult CCM fellowships. Differences between IM-CCM and pulmonary-CCM programs include the ratio of key clinical faculty to fellows and a requirement to perform 50 therapeutic bronchoscopies. Competency-based training was considered uniformly desirable for all CCM training pathways. Conclusions The task force concluded that requesting competency-based training and minimizing variations in the requirements for IM-based CCM fellowship programs will facilitate effective CCM training for both programs and trainees. PMID:24637881

Testing family-centered, function-focused care in hospitalized persons with dementia.

PubMed

Boltz, Marie; Chippendale, Tracy; Resnick, Barbara; Galvin, James E

2015-01-01

Hospital-acquired disability causes decreased quality of life for patients with dementia and family caregivers, and increased societal costs. A comparative, repeated measures study tested the feasibility and preliminary efficacy of the family-centered, function-focused care intervention (Fam-FFC) in dyads of hospitalized, medical patients with dementia and family caregivers (FCGs). The intervention group demonstrated better activities of daily living and walking performance, and less severity/duration of delirium and hospital readmissions, but no significant differences in gait/balance. FCGs showed increased preparedness for caregiving and less anxiety but no significant differences in depression, strain and mutuality. Fam-FFC presents a possible pathway to meeting the Triple Aim of improved patient care, improved patient health and reduced costs for persons with dementia.

Understanding Care Integration from the Ground Up: Five Organizing Constructs that Shape Integrated Practices.

PubMed

Cohen, Deborah J; Balasubramanian, Bijal A; Davis, Melinda; Hall, Jennifer; Gunn, Rose; Stange, Kurt C; Green, Larry A; Miller, William L; Crabtree, Benjamin F; England, Mary Jane; Clark, Khaya; Miller, Benjamin F

2015-01-01

To provide empirical evidence on key organizing constructs shaping practical, real-world integration of behavior health and primary care to comprehensively address patients' medical, emotional, and behavioral health needs. In a comparative case study using an immersion-crystallization approach, a multidisciplinary team analyzed data from observations of practice operations, interviews, and surveys of practice members, and implementation diaries. Practices were drawn from 2 studies of practices attempting to integrate behavioral health and primary care: Advancing Care Together, a demonstration project of 11 practices located in Colorado, and the Integration Workforce Study, a study of 8 practices across the United States. We identified 5 key organizing constructs influencing integration of primary care and behavioral health: 1) Integration REACH (the extent to which the integration program was delivered to the identified target population), 2) establishment of continuum of care pathways addressing the location of care across the range of patient's severity of illness, 3) approach to patient transitions: referrals or warm handoffs, 4) location of the integration workforce, and 5) participants' mental model for integration. These constructs intertwine within an organization's historic and social context to produce locally adapted approaches to integrating care. Contextual factors, particularly practice type, influenced whether specialty mental health and substance use services were colocated within an organization. Interaction among 5 organizing constructs and practice context produces diverse expressions of integrated care. These constructs provide a framework for understanding how primary care and behavioral health services can be integrated in routine practice. © Copyright 2015 by the American Board of Family Medicine.