Strategies to improve care for older adults who present to the emergency department: a systematic review.

BACKGROUND: The aim of this systematic review was to examine the relationship between strategies to improve care delivery for older adults in ED and evaluation measures of patient outcomes, patient experience, staff experience, and system performance. METHODS: A systematic review of English language studies published since inception to December 2022, available from CINAHL, Embase, Medline, and Scopus was conducted. Studies were reviewed by pairs of independent reviewers and included if they met the following criteria: participant mean age of ≥ 65 years; ED setting or directly influenced provision of care in the ED; reported on improvement interventions and strategies; reported patient outcomes, patient experience, staff experience, or system performance. The methodological quality of the studies was assessed by pairs of independent reviewers using The Joanna Briggs Institute critical appraisal tools. Data were synthesised using a hermeneutic approach. RESULTS: Seventy-six studies were included in the review, incorporating strategies for comprehensive assessment and multi-faceted care (n = 32), targeted care such as management of falls risk, functional decline, or pain management (n = 27), medication safety (n = 5), and trauma care (n = 12). We found a misalignment between comprehensive care delivered in ED for older adults and ED performance measures oriented to rapid assessment and referral. Eight (10.4%) studies reported patient experience and five (6.5%) reported staff experience. CONCLUSION: It is crucial that future strategies to improve care delivery in ED align the needs of older adults with the purpose of the ED system to ensure sustainable improvement effort and critical functioning of the ED as an interdependent component of the health system. Staff and patient input at the design stage may advance prioritisation of higher-impact interventions aligned with the pace of change and illuminate experience measures. More consistent reporting of interventions would inform important contextual factors and allow for replication.

Establishing multifactorial risk factors for adult-onset hearing loss: A systematic review with topic modelling and synthesis of epidemiological evidence.

BACKGROUND: This systematic review explores the multifaceted nature of risk factors contributing to adult-onset HL. The objective was to synthesise the most recent epidemiological evidence to generate pooled proportional incidences for the identified risk factors. METHODS: We conducted an extensive search of electronic databases (MEDLINE, EMBASE, and psychINFO) for studies providing epidemiological evidence of risk factors associated with hearing loss. Topic modelling using Latent Dirichlet Allocation (LDA) was first conducted to determine how many risk factor themes were available from the papers. Data were analysed by calculating the pooled proportional incidence using a meta-analysis of proportions. RESULTS: From the 72 studies reviewed, six key risk factor themes emerged through LDA topic modelling. The review identified ototoxicity, primarily caused by cancer treatments and antibiotics, infectious diseases like COVID-19, occupational noise exposure, lifestyle factors, health conditions, biological responses, and age progression as significant risk factors for HL. The highest proportional incidence was found with cancer-related ototoxicity at 55.4% (95%CI: 39.0-70.7), followed closely by ototoxicity from infectious diseases at 50.0% (95%CI: 28.5-71.5). This high proportional incidence suggests the need to explore less destructive therapies and proactively monitor hearing function during treatments. CONCLUSIONS: The findings of this review, combined with the synthesis of epidemiological evidence, enhance our understanding of hearing loss (HL) pathogenesis and highlight potential areas for intervention, thereby paving the way for more effective prevention and management of adult-onset hearing loss in our ageing global population.

Clinician attitudes towards cancer treatment guidelines in Australia.

OBJECTIVES: Clinical Practice Guidelines (CPGs) are designed to guide treatment decisions, yet adherence rates vary widely. To characterise perceived barriers and facilitators to cancer treatment CPG adherence in Australia, and estimate the frequency of previous qualitative research findings, a survey was distributed to Australian oncologists. RESULTS: The sample is described and validated guideline attitude scores reported for different groups. Differences in mean CPG attitude scores across clinician subgroups and associations between frequency of CPG use and clinician characteristics were calculated; with 48 respondents there was limited statistical power to find differences. Younger oncologists (< 50 years) and clinicians participating in three or more Multidisciplinary Team Meetings were more likely to routinely or occasionally use CPGs. Perceived barriers and facilitators were identified. Thematic analysis was conducted on open-text responses. Results were integrated with previous interview findings and presented in a thematic, conceptual matrix. Most barriers and facilitators identified earlier were corroborated by survey results, with minor discordance. Identified barriers and facilitators require further exploration within a larger sample to assess their perceived impact on cancer treatment CPG adherence in Australia, as well as to inform future CPG implementation strategies. This research was Human Research Ethics Committee approved (2019/ETH11722 and 52019568810127, ID:5688).

Rates of adherence to cancer treatment guidelines in Australia and the factors associated with adherence: A systematic review.

Adherence to cancer treatment clinical practice guidelines (CPGs) varies enormously across Australia, despite being associated with improved patient outcomes. This systematic review aims to characterize adherence rates to active-cancer treatment CPGs in Australia and related factors to inform future implementation strategies. Five databases were systematically searched, abstracts were screened for eligibility, a full-text review and critical appraisal of eligible studies performed, and data extracted. A narrative synthesis of factors associated with adherence was conducted, and the median adherence rates within cancer streams calculated. A total of 21,031 abstracts were identified. After duplicates were removed, abstracts screened, and full texts reviewed, 20 studies focused on adherence to active-cancer treatment CPGs were included. Overall adherence rates ranged from 29% to 100%. Receipt of guideline recommended treatments was higher for patients who were younger (diffuse large B-cell lymphoma [DLBCL], colorectal, lung, and breast cancer); female (breast and lung cancer), and male (DLBCL and colorectal cancer); never smokers (DLBCL and lung cancer); non-Indigenous Australians (cervical and lung cancer); with less advanced stage disease (colorectal, lung, and cervical cancer), without comorbidities (DLBCL, colorectal, and lung cancer); with good-excellent Eastern Cooperative Oncology Group performance status (lung cancer); living in moderately accessible places (colon cancer); and; treated in metropolitan facilities (DLBLC, breast and colon cancer). This review characterized active-cancer treatment CPG adherence rates and associated factors in Australia. Future targeted CPG implementation strategies should account for these factors, to redress unwarranted variation particularly in vulnerable populations, and improve patient outcomes (Prospero number: CRD42020222962).

Clinical practice guideline adherence in oncology: A qualitative study of insights from clinicians in Australia.

BACKGROUND: The burden of cancer is large in Australia, and rates of cancer Clinical Practice Guideline (CPG) adherence is suboptimal across various cancers. METHODS: The objective of this study is to characterise clinician-perceived barriers and facilitators to cancer CPG adherence in Australia. Semi-structured interviews were conducted to collect data from 33 oncology-focused clinicians (surgeons, radiation oncologists, medical oncologists and haematologists). Clinicians were recruited in 2019 and 2020 through purposive and snowball sampling from 7 hospitals across Sydney, Australia, and interviewed either face-to-face in hospitals or by phone. Audio recordings were transcribed verbatim, and qualitative thematic analysis of the interview data was undertaken. Human research ethics committee approval and governance approval was granted (2019/ETH11722, #52019568810127). RESULTS: Five broad themes and subthemes of key barriers and facilitators to cancer treatment CPG adherence were identified: Theme 1: CPG content; Theme 2: Individual clinician and patient factors; Theme 3: Access to, awareness of and availability of CPGs; Theme 4: Organisational and cultural factors; and Theme 5: Development and implementation factors. The most frequently reported barriers to adherence were CPGs not catering for patient complexities, being slow to be updated, patient treatment preferences, geographical challenges for patients who travel large distances to access cancer services and limited funding of CPG recommended drugs. The most frequently reported facilitators to adherence were easy accessibility, peer review, multidisciplinary engagement or MDT attendance, and transparent CPG development by trusted, multidisciplinary experts. CPGs provide a reassuring framework for clinicians to check their treatment plans against. Clinicians want cancer CPGs to be frequently updated utilising a wiki-like process, and easily accessible online via a comprehensive database, coordinated by a well-trusted development body. CONCLUSION: Future implementation strategies of cancer CPGs in Australia should be tailored to consider these context-specific barriers and facilitators, taking into account both the content of CPGs and the communication of that content. The establishment of a centralised, comprehensive, online database, with living wiki-style cancer CPGs, coordinated by a well-funded development body, along with incorporation of recommendations into point-of-care decision support would potentially address many of the issues identified.

Too much theory and not enough practice? The challenge of implementation science application in healthcare practice.

BACKGROUND: Implementation science (IS) should contribute to maintaining high standards of care across healthcare systems and enhancing care practices. However, despite the evident need for greater and more rapid uptake and integration of evidence in practice, IS design and methodology fall short of the needs of effective translation. AIM: In this paper we examine what it is about IS that makes it so appealing for effective uptake of interventions in routine practice, and yet so difficult to achieve. We propose a number of ways that implementation scientists could build mutual relationships with healthcare practitioners and other stakeholders including public members to ensure greater shared care practices, and highlight the value of IS training, collaborative educational events, and co-designed research. DISCUSSION: More consideration should be given to IS applications in healthcare contexts. Implementation scientists can make a valuable contribution by mobilizing theory and improving practice. However, goals for an evidence-based system may be more appropriately achieved through greater outreach and collaboration, with methods that are flexible to support rapid implementation in complex adaptive systems. Collective learning and mutual trust can be cultivated by embedding researchers into healthcare services while offering greater opportunities for practitioners to learn about, and engage in, implementation research. CONCLUSION: To bridge the worlds of healthcare practice and IS, researchers could be more consistent in the relationships they build with professionals and the public, communicating through a shared language and co-joining practical approaches to effective implementation. This will build capacity for improved collaboration and foster respectful, interdisciplinary relationships.

Peer support and social network groups among people living with epilepsy: A scoping review.

BACKGROUND: Peer support is a unique connection formed between people who share similar experiences of illness. It is distinct from, but complementary to other forms of support or care provided by family and friends, healthcare professionals, and other service providers. The role of peer support in contributing to the wellbeing and care of people living with epilepsy (PLWE) is increasingly recognized, including via online networks and group therapy. However, little overall synthesis is available to map and conceptualize the different ways peer support contributes to the wellbeing or care of PLWE, or how it occurs via formally and informally organized social network settings. METHODS: A scoping review of peer-reviewed literature published between 1998 and 2021 was conducted using Medline, Psychinfo, Embase, Scopus, and CINAHL databases. Included studies comprised empirical research that involved people with epilepsy as the primary participants; included 'peer social support' in the study question or study setting, and included outcome measures related to peer social support or peer-related groupings. RESULTS: A total of 17 articles were included in the review. The functions of peer support for PLWE can be described as either emotional or instrumental. Emotional peer support includes a sense of empathy and encouragement gained from another person with a shared experience of illness, which can help to improve confidence for those challenged by isolation and stigma. Instrumental peer support refers to the more practical and tangible support provided by peers about treatment and support services, which can improve self-management and clarify misinformation. The mechanisms by which peer support and peer social networks materialize includes face-to-face meetings, online group gatherings, and telephone calls. As well as through organized channels, peer support can be fostered incidentally through, for example, research participation, or in clinical settings. Barriers to PLWE receiving opportunities for peer support include the perceived stigma of living with epilepsy, the high cost of transportation, or poor access to the internet to reach and meet others; enablers include the anonymity afforded by online forums and perceived trust in one's peers or forum organizers. CONCLUSIONS: This nuanced conceptualization of the different types of peer support and peer support networks, as well as the variety of barriers and enablers of peer support for PLWE, will serve to inform more effectively designed clinical care practices and service delivery tailored to the needs of PLWE. This review will inform future research in peer support as an important and emerging area of investigation.

Adherence to clinical practice guidelines (CPGs) for the treatment of cancers in Australia and the factors associated with adherence: a systematic review protocol.

INTRODUCTION: Clinical practice guidelines (CPGs) synthesise the latest evidence to support clinical and patient decision-making. CPG adherent care is associated with improved patient survival outcomes; however, adherence rates are low across some cancer streams in Australia. Greater understanding of specific barriers to cancer treatment CPG adherence is warranted to inform future implementation strategies.This paper presents the protocol for a systematic review that aims to determine cancer treatment CPG adherence rates in Australia across a variety of common cancers, and to identify any factors associated with adherence to those CPGs, as well as any associations between CPG adherence and patient outcomes. METHODS AND ANALYSIS: Five databases will be searched, Ovid Medline, PsychInfo, Embase, Scopus and Web of Science, for eligible studies evaluating adherence rates to cancer treatment CPGs in Australia. A team of reviewers will screen the abstracts in pairs according to predetermined inclusion criteria and then review the full text of eligible studies. All included studies will be assessed for quality and risk of bias. Data will be extracted using a predefined data extraction template. The frequency or rate of adherence to CPGs, factors associated with adherence to those CPGs and any reported patient outcome rates (eg, relative risk ratios or 5-year survival rates) associated with adherence to CPGs will be described. If applicable, a pooled estimate of the rate of adherence will be calculated by conducting a random-effects meta-analysis. The systematic review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. ETHICS AND DISSEMINATION: Ethics approval will not be required, as this review will present anonymised data from other published studies. Results from this study will form part of a doctoral dissertation (MB), will be published in a journal, presented at conferences, and other academic presentations. PROSPERO REGISTRATION NUMBER: CRD42020222962.

Dimensions of safety culture: a systematic review of quantitative, qualitative and mixed methods for assessing safety culture in hospitals.

BACKGROUND: The study of safety culture and its relationship to patient care have been challenged by variation in definition, dimensionality and methods of assessment. This systematic review aimed to map methods to assess safety culture in hospitals, analyse the prevalence of these methods in the published research literature and examine the dimensions of safety culture captured through these processes. METHODS: We included studies reporting on quantitative, qualitative and mixed methods to assess safety culture in hospitals. The review was conducted using four academic databases (PubMed, CINAHL, Scopus and Web of Science) with studies from January 2008 to May 2020. A formal quality appraisal was not conducted. Study purpose, type of method and safety culture dimensions were extracted from all studies, coded thematically, and summarised narratively and using descriptive statistics where appropriate. RESULTS: A total of 694 studies were included. A third (n=244, 35.2%) had a descriptive or exploratory purpose, 225 (32.4%) tested relationships among variables, 129 (18.6%) evaluated an intervention, while 13.8% (n=96) had a methodological focus. Most studies exclusively used surveys (n=663; 95.5%), with 88 different surveys identified. Only 31 studies (4.5%) used qualitative or mixed methods. Thematic analysis identified 11 themes related to safety culture dimensions across the methods, with 'Leadership' being the most common. Qualitative and mixed methods approaches were more likely to identify additional dimensions of safety culture not covered by the 11 themes, including improvisation and contextual pressures. DISCUSSION: We assessed the extent to which safety culture dimensions mapped to specific quantitative and qualitative tools and methods of assessing safety culture. No single method or tool appeared to measure all 11 themes of safety culture. Risk of publication bias was high in this review. Future attempts to assess safety culture in hospitals should consider incorporating qualitative methods into survey studies to evaluate this multi-faceted construct.

Identification and referral of patients with refractory epilepsy from the primary to the tertiary care interface in New South Wales, Australia.

OBJECTIVES: This mixed-method feasibility study conducted in New South Wales (NSW), Australia, aimed to explore clinical practices around the identification of patients with refractory epilepsy and referral from primary care to Tertiary Epilepsy Centers. The perceptions of general practitioners, neurologists, and adults living with refractory epilepsy were considered. METHODS: Fifty-two data collection events were achieved through 22 semi-structured interviews with six neurologists and 12 adults who currently have, or have had refractory epilepsy, and four family members, 10 clinical observations of patient consultations and 20 surveys with general practitioners. A thematic analysis was conducted on the qualitative data alongside assessment of observational fieldnotes and survey data. FINDINGS: Two main themes emerged: 1) Patient healthcare pathways and care experiences highlighted the complex and deeply contextualized experiences of both patients and healthcare professionals, from first identification of people's seizures, in primary and community care settings, to referral to Tertiary Epilepsy Centers, shedding light on a fragmented, nonstandardized referral process, influenced by both individual and shared-care practices. 2) Factors impacting referrals and patient pathways indicated that onward referral to a Tertiary Epilepsy Center is affected by the knowledge, or the lack thereof, of healthcare professionals regarding treatment options. Barriers include limited person-centered care, shared decision-making, and refractory epilepsy education for healthcare professionals, which can delay patients' disease identification and can hinder speedy referral pathways and processes, in Australia for up to 17 years. In addition, person-centered communication around care pathways is affected by relationships between clinicians, patients, and family members. CONCLUSION: This study has identified a noticeable lack of standardized care across epilepsy-related healthcare sectors, which recognizes a need for developing and implementing clearer epilepsy-related guidelines and Continuing Professional Development in the primary and community care settings. This, however, requires greater collaboration and commitment in the primary, community, and tertiary care sectors to address the ongoing misconceptions around professional roles and responsibilities to optimize shared-care practices. Ultimately, prioritizing person-centered care on both patients' and professionals' agendas, in order to improve satisfaction with care experiences of people living with complex epilepsy.

Adults' cochlear implant journeys through care: a qualitative study.

BACKGROUND: Cochlear implants (CIs) can provide a sound sensation for those with severe sensorineural hearing loss (SNHL), benefitting speech understanding and quality of life. Nevertheless, rates of implantation remain low, and limited research investigates journeys from traditional hearing aids to implantable devices. METHOD: Fifty-five adults (≥ 50 years), hearing aid users and/or CI users, General Practitioners, and Australian and United Kingdom audiologists took part in a multi-methods study. Focus groups, interviews, and surveys were thematically analysed. RESULTS: One hundred forty-three data-capture events disclosed 2 themes: 1) "The burden of hearing loss and the impact of Cochlear Implants", and 2) "Professional Support and Practice, and HCPs Roles and Responsibilities". CONCLUSIONS: Care experience can include convoluted, complex journeys towards cochlear implantation. The significant impact of this, as hearing loss progresses, motivates people to consider implants, but they and healthcare professionals need clear supported with defined referral pathways, and less system complexity.

Clinicians' attitudes and perceived barriers and facilitators to cancer treatment clinical practice guideline adherence: a systematic review of qualitative and quantitative literature.

BACKGROUND: Clinical Practice Guidelines (CPGs) synthesize the best available evidence to guide clinician and patient decision making. There are a multitude of barriers and facilitators to clinicians adhering to CPGs; however, little is known about active cancer treatment CPG adherence specifically. This systematic review sought to identify clinician attitudes, and perceived barriers and facilitators to active cancer treatment CPG adherence. METHODS: A systematic search was undertaken of five databases; Ovid Medline, PsychInfo, Embase, Scopus, CINAHL, and PROQUEST. The retrieved abstracts were screened for eligibility against inclusion criteria, and a full text review was conducted of all eligible studies. Data were extracted, and a quality assessment was conducted of all included studies. The qualitative papers were thematically analyzed. Attitudes, barriers, and facilitating factors extracted from the quantitative papers were categorized within the qualitative thematic framework. RESULTS: The search resulted in the identification of 9676 titles. After duplicates were removed, abstracts screened, and full texts reviewed, 15 studies were included. Four themes were identified which related to negative clinician attitudes and barriers to active cancer treatment CPG adherence: (1) concern over CPG content and currency of CPGs; (2) concern about the evidence underpinning CPGs; (3) clinician uncertainty and negative perceptions of CPGs; and (4) organizational and patient factors. The review also identified four themes related to positive attitudes and facilitators to active cancer treatment CPG adherence: (5) CPG accessibility and ease of use; (6) endorsement and dissemination of CPGs and adequate access to treatment facilities and resources; (7) awareness of CPGs and belief in their relevance; and (8) belief that CPGs support decision making, improve patient care, reduce clinical variation, and reduce costs. CONCLUSION: These results highlight that adherence to active cancer treatment CPG recommendations by oncology clinicians is influenced by multiple factors such as attitudes, practices, and access to resources. The review has also revealed many similarities and differences in the factors associated with general CPG, and active cancer treatment CPG, adherence. These findings will inform tailored implementation strategies to increase adherence to cancer treatment CPGs. TRIAL REGISTRATION: PROSPERO (2019) CRD42019125748.

Clinicians' attitudes to oncology clinical practice guidelines and the barriers and facilitators to adherence: a mixed methods study protocol.

INTRODUCTION: Clinical practice guidelines (CPGs) are designed to reduce inappropriate clinical variation and improve the quality of care. Barriers to CPGs include a lack of awareness of CPGs, access to them, time pressures and concerns regarding the evidence underpinning CPG development, implementation and dissemination. The objectives of this study are to assess clinicians' attitudes to CPGs for cancer treatment and the perceived barriers to and facilitators of CPG adherence in order to inform the implementation of cancer treatment CPGs. METHODS AND ANALYSIS: A mixed methods study will be conducted using a three-phase, sequential design, with each phase informing the next. In phase 1, a qualitative study using recorded interviews will investigate clinicians' attitudes to CPGs for cancer treatment and perceptions of barriers and facilitators to CPG adherence (n=30); interview transcripts will be analysed thematically. In phase 2, a survey will quantify the frequency of attitudes, barriers and facilitators identified in phase 1, in a broader clinical sample (n=200). In phase 3, a workshop forum will be held to facilitate discussions examining the implications of phase 1 and 2 findings for cancer CPG implementation strategies (n=40) leading to recommendations for improvements to practice. The workshop discussion will be recorded, and the transcript will be analysed thematically. ETHICS AND DISSEMINATION: This study has received ethics approval in New South Wales, Australia (2019/ETH11722, #52019568810127). Study findings will be published in peer-reviewed journals and will form part of a doctoral thesis and be presented at national and international conferences.

What are the attitudes of health professionals regarding patient reported outcome measures (PROMs) in oncology practice? A mixed-method synthesis of the qualitative evidence.

BACKGROUND: The adoption of Patient Reported Outcome Measures (PROMs) in cancer care has been widely advocated, but little is known about the evidence for the implementation of PROMs in practice. Qualitative research captures the perspectives of health professionals as end-users of PROMs and can be used to inform adoption efforts. This paper presents a systematic review and synthesis of qualitative research conducted to address the question: What are the attitudes of health professionals towards PROMs in oncology, including any barriers and facilitators to the adoption of PROMS, reported in qualitative evidence? METHODS: Systematic searches of qualitative evidence were undertaken in four databases and reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies published in English between 1998 and 2018, which reported qualitative findings about the attitudes of health professionals working in oncology towards PROMs were eligible. Studies were assessed using the Critical Appraisal Skills Programme's Qualitative Research Checklist. A sentiment analysis was conducted on primary text to examine the polarity (neutral, positive or negative) of health professionals' views of PROMs. Qualitative meta-synthesis was conducted using a constant comparative analysis. RESULTS: From 1227 articles after duplicates were removed, with 1014 excluded against the screening criteria, 213 full text articles remained and were assessed; 34 studies met the inclusion criteria and were included. The majority of studies were of good quality. Sentiment analysis on primary text demonstrated an overall positive polarity from the expressed opinions of health professionals. The meta-synthesis showed health professionals' attitudes in four domains: identifying patient issues and needs using PROMs; managing and addressing patient issues; the care experience; and the integration of PROMs into clinical practice. CONCLUSIONS: From the accounts of health professionals, the fit of PROMs with existing practice, how PROMs are valued, capacity to respond to PROMs and the supports in place, formed the key factors which may impede or promote adoption of PROMs in routine practice. To assist policy-makers and services involved in implementing these initiatives, further evidence is required about the relationship between PROMs data collection and corresponding clinical actions. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019119447, 6th March, 2019.

Barriers and Facilitators to Cochlear Implant Uptake in Australia and the United Kingdom.

OBJECTIVES: Hearing loss (HL) affects a significant proportion of adults aged >50 years by impairing communication and social connectedness and, due to its high prevalence, is a growing global concern. Cochlear implants (CIs) are effective devices for many people with severe or greater sensorineural HL who experience limited benefits from hearing aids. Despite this, uptake rates globally are low among adults. This multimethod, multicountry qualitative study aimed to investigate the barriers and facilitators to CI uptake among adults aged ≥50 years. DESIGN: Adult CI and hearing aid users with postlingual severe or greater sensorineural HL, general practitioners, and audiologists were recruited in Australia using purposive sampling, and a comparative sample of audiologists was recruited in England and Wales in the United Kingdom. Participants were interviewed individually, or in a focus group, completed a demographic questionnaire and a qualitative survey. Data were analyzed using thematic analysis. RESULTS: A total of 143 data capture events were collected from 55 participants. The main barriers to CI uptake related to patients' concerns about surgery and loss of residual hearing. Limited knowledge of CIs, eligibility criteria, and referral processes acted as barriers to CIs assessment referrals by healthcare professionals. Facilitators for CI uptake included patients' desire for improved communication and social engagement, and increased healthcare professional knowledge and awareness of CIs. CONCLUSIONS: There are numerous complex barriers and facilitators to CI uptake. Knowledge of these can inform the development of targeted strategies to increase CI referral and surgery for potential beneficiaries.

What is multidisciplinary cancer care like in practice? a protocol for a mixed-method study to characterise ambulatory oncology services in the Australian public sector.

INTRODUCTION: An understanding of the real-world provision of oncology outpatient services can help maintain service quality in the face of escalating demand and tight budgets, by informing the design of interventions that improve the effectiveness or efficiency of provision. The aims of this study are threefold. First, to develop an understanding of cancer services in outpatient clinics by characterising the organisation and practice of multidisciplinary care (MDC). Second, to explore the key areas of: (a) clinical decision-making and (b) engagement with patients' supportive needs. Third, to identify barriers to, and facilitators of, the delivery of quality care in these settings. METHODS AND ANALYSIS: A suite of mixed-methods studies will be implemented at six hospitals providing cancer outpatient clinics, with a staged roll-out. In Stage One, we will examine policies, use unstructured observations and undertake interviews with key health professionals to characterise the organisation and delivery of MDC. In Stage Two, observations of practice will continue, to deepen our understanding, and to inform two focused studies. The first will explore decision-making practices and the second will examine how staff engage with patients' needs; both studies involve interviews, to complement observation. As part of the study of supportive care, we will examine the implications of an introduction of patient-reported measures (PRMs) into care, adding surveys to interviews before and after PRMs roll-out. Data analysis will account for site-specific and cross-site issues using an adapted Qualitative Rapid Appraisal, Rigorous Analysis approach. Quantitative data from clinician surveys will be statistically analysed and triangulated with the related qualitative study findings. ETHICS AND DISSEMINATION: Ethical approval was granted by South Eastern Sydney Local Health District Human Research Ethics Committee (no. 18/207). Findings will be shared with participating hospitals and widely disseminated through publications and presentations.

Comprehensive Researcher Achievement Model (CRAM): a framework for measuring researcher achievement, impact and influence derived from a systematic literature review of metrics and models.

OBJECTIVES: Effective researcher assessment is key to decisions about funding allocations, promotion and tenure. We aimed to identify what is known about methods for assessing researcher achievements, leading to a new composite assessment model. DESIGN: We systematically reviewed the literature via the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols framework. DATA SOURCES: All Web of Science databases (including Core Collection, MEDLINE and BIOSIS Citation Index) to the end of 2017. ELIGIBILITY CRITERIA: (1) English language, (2) published in the last 10 years (2007-2017), (3) full text was available and (4) the article discussed an approach to the assessment of an individual researcher's achievements. DATA EXTRACTION AND SYNTHESIS: Articles were allocated among four pairs of reviewers for screening, with each pair randomly assigned 5% of their allocation to review concurrently against inclusion criteria. Inter-rater reliability was assessed using Cohen's Kappa (ĸ). The ĸ statistic showed agreement ranging from moderate to almost perfect (0.4848-0.9039). Following screening, selected articles underwent full-text review and bias was assessed. RESULTS: Four hundred and seventy-eight articles were included in the final review. Established approaches developed prior to our inclusion period (eg, citations and outputs, h-index and journal impact factor) remained dominant in the literature and in practice. New bibliometric methods and models emerged in the last 10 years including: measures based on PageRank algorithms or 'altmetric' data, methods to apply peer judgement and techniques to assign values to publication quantity and quality. Each assessment method tended to prioritise certain aspects of achievement over others. CONCLUSIONS: All metrics and models focus on an element or elements at the expense of others. A new composite design, the Comprehensive Researcher Achievement Model (CRAM), is presented, which supersedes past anachronistic models. The CRAM is modifiable to a range of applications.

Incidence and severity of head injury hospitalisations in Australian children over a 10-year period.

ISSUE ADDRESSED: Child head injuries can cause life-long disability and are a major cause of mortality globally. The incidence and impact of child head injuries in Australia is unknown. This study aimed to quantify the incidence, characteristics and treatment cost and to identify factors associated with the severity of hospitalisations of head injuries in Australian children. METHODS: Linked hospitalisation and mortality data were used to retrospectively examine hospitalisation trends for head injury in children aged ≤16 years and associated factors, in Australia, from 1 July 2002 to 30 June 2012. RESULTS: There were 164 126 hospitalisations of children for head injury during the 10-year period, commonly male (65.5%), or aged ≤5 years (48.3%). The incidence among children aged <1 year and 1-5 years significantly increased by 1.7% (95% CI 0.9-2.6; P < 0.0001) and 1.5% (95% CI 1.1-1.9; P < 0.0001) annually during the study period, respectively. The most common injury mechanisms across all age groups were falls (45.2%) and road trauma (16.0%). Head injury hospitalisations cost $468.9 million, with the higher costs found for children aged 11-16 years, and for the most severe injuries. CONCLUSION: Head injury hospitalisations cost the Australian health system close to half a billion dollars over a 10-year period, with the most serious injuries resulting in lifelong health implications. SO WHAT?: Targeted health promotion strategies such as the promotion of helmet wearing during scooter use, the introduction of cycleways, and impact absorbing surfaces on playgrounds, need to be implemented to reduce the occurrence of head injuries in children.

Relational autonomy in breast diseases care: a qualitative study of contextual and social conditions of patients' capacity for decision-making.

BACKGROUND: A relational approach to autonomy refers to the way in which social conditions and relationships shape a person's self-identity and capacity in decision-making. This article provides an empirical account of how treatment choices for women undergoing breast diseases care are fostered within the dynamics of their relationships with clinicians, family members, and other aspects of their social environment. METHODS: This qualitative study recruited ten women undergoing treatment at a breast programme, and eight clinicians supporting their care, in a private teaching hospital in New South Wales, Australia. Fourteen patient-clinician consultation observations and 17 semi-structured interviews were conducted. Schema analysis of interview transcripts were undertaken by a team of researchers and corroborated by observational fieldnotes. RESULTS: Relational identities of patients influenced the rationale for treatment decision-making. Patients drew on supportive resources from family and medical advice from clinicians to progress with treatment goals. While clinicians held much social power over patients as the medical experts, patients highlighted the need for clinicians to earn their trust through demonstrated professionalism. Information exchange created a communicative space for clinicians and patients to negotiate shared values, promoting greater patient ownership of treatment decisions. As treatment progressed, patients' personal experiences of illness and treatment became a source of self-reflection, with a transformative impact on self-confidence and assertiveness. CONCLUSION: Patients' confidence and self-trust can be fostered by opportunities for communicative engagement and self-reflection over the course of treatment in breast disease, and better integration of their self-identity and social values in treatment decisions.