GPs' perspective on End-of-Life Care - an evaluation based on the German version of the General Practice End of Life Care Index.

Objective: General practitioners (GPs) play a key role in the provision of general outpatient palliative care (AAPV) for the majority of patients at the end of life. The aim of this study was to evaluate the quality of End-of-Life Care (EoLC) from a GPs' perspective using the German version of the General Practice End of Life Care Index (GP-EoLC-I). Methods: Between autumn 2018 and spring 2019, all registered and eligible GPs in two counties in Lower Saxony (n=190) were asked to participate in a survey on EoLC using the German version of the self-assessment questionnaire GP-EoLC-I. The index comprises two subscales: clinical care (13 items) and practice organisation (12 items). The summated index of both subscales measures the quality of EoLC by GPs (25 items; range 14-40). The questionnaire was supplemented by questions on sociodemographic data, indicators for good palliative care (PC) and requirements to improve PC. Quantitative data were analysed by descriptive statistics and free text answers by conventional content analysis according to Hsieh and Shannon. Results: 52 GPs (females: n=16) of 34 practices (single practices: n=26) participated in the study. The mean GP-EoLC-I was 27.5 (SD 4.5). The items revealed potential for improvement: systematic identification of patients with potential PC needs, multidisciplinary case conferences to discuss PC patients, application of care protocols and symptom assessment tools, documentation of patients' wishes and beliefs as well as inclusion of family and carers. Regarding the indicators for good PC, the most relevant indicators from the GPs' perspective were collaboration and coordination, integration of relatives, advance care planning and documentation. As requirements to improve PC, GPs highlighted further training and the use of standardised tools such as instruments to support the systematic identification of PC patients. Conclusions: To our knowledge for the first time in Germany, an internationally tested self-assessment questionnaire measuring the quality of EoLC by GPs was applied. The GP-EoLC-I in this study was slightly lower than the index of GPs in the United Kingdom. Including relatives and family carers, implementing tools to support early identification of PC patients and strengthening cooperation between GPs and other stakeholders in PC may be promising approaches to improve general PC and EoLC in Germany.

Hepatitis C Virus (HCV) Care Continuum Outcomes and HCV Community Viral Loads Among Patients in an Opioid Treatment Program.

BACKGROUND: Hepatitis C virus (HCV) remains endemic among people who use drugs (PWUD). Measures of HCV community viral load (CVL) and HCV care continuum outcomes may be valuable for ascertaining unmet treatment need and for HCV surveillance and control. METHODS: Data from patients in an opioid treatment program during 2013-2016 were used to (1) identify proportions of antibody and viral load (VL) tested, linked-to-care, and treated, in 2013-2014 and 2015-2016, and pre- and postimplementation of qualitative reflex VL testing; (2) calculate engaged-in-care HCV CVL and "documented" and "estimated" unmet treatment need; and (3) examine factors associated with linkage-to-HCV-care. RESULTS: Among 11 267 patients, proportions of HCV antibody tested (52.5% in 2013-2014 vs 73.3% in 2015-2016), linked-to-HCV-care (15.7% vs 51.8%), and treated (12.0% vs 44.7%) all increased significantly. Hispanic ethnicity was associated with less linkage-to-care, and Manhattan residence was associated with improved linkage-to-care. The overall engaged-in-care HCV CVL was 4 351 079 copies/mL (standard deviation = 7 149 888); local HCV CVLs varied by subgroup and geography. Documented and estimated unmet treatment need decreased but remained high. CONCLUSIONS: After qualitative reflex VL testing was implemented, care continuum outcomes improved, but gaps remained. High rates of unmet treatment need suggest that control of the HCV epidemic among PWUD will require expansion of HCV treatment coverage.

Implementation Research as Applied Science: Bridging the Research to Practice Gap.

Implementation research is intended to address challenges posed by the slow adoption of evidence-based science by the medical and health promotion practice community. A case study approach is used to illustrate and discuss the use of Quality improvement and Evaluation as an applied approach to implementation science in contrast of more classic purposes of research. Quality improvement was the implementation model used to facilitate organizational change needed to adopt the use of texting to report sexually transmitted infection test results in over a fifth of Florida's larger county health departments. Both quantitative and qualitative methods were used to evaluate implementation. All seven participating county health departments were successful in enrolling clients in texting with extensive variation (24% to 72%) in texting enrollment at the end of the 10-month study. Statistically significant outcomes for those enrolled in texting were recorded through Florida's online sexually transmitted infection reporting system in the form of increased number of people receiving early (1-4 days) treatment and reductions in delayed (≥8 days) or no treatment. This study illustrates an applied approach to implementation research which may be critical to adapt emerging evidence and technologies to the multiple and complex characteristics of the diverse populations served by health promotion institutions.

Development of an antimicrobial stewardship program in an integrated healthcare system.

PURPOSE: The development of an inpatient antimicrobial stewardship program (ASP) in an integrated healthcare system is described. SUMMARY: With increasing national focus on reducing inappropriate antimicrobial use, state and national regulatory mandates require hospitals to develop ASPs. In 2015, BJC HealthCare, a multihospital health system, developed a system-level, multidisciplinary ASP team to assist member hospitals with ASP implementation. A comprehensive gap analysis was performed to assess current stewardship resources, activities and compliance with CDC core elements at each facility. BJC system clinical leads facilitated the development of hospital-specific leadership support statements, identification of hospital pharmacy and medical leaders, and led development of staff and patient educational components. An antimicrobial-use data dashboard was created for reporting and tracking the impact of improvement activities. Hospital-level interventions were individualized based on the needs and resources at each facility. Hospital learnings were shared at bimonthly system ASP meetings to disseminate best practices. The initial gap analysis revealed that BJC hospitals were compliant in a median of 6 ASP elements (range, 4-8) required by regulatory mandates. By leveraging system resources, all hospitals were fully compliant with regulatory requirements by January 2017. CONCLUSION: BJC's ASP model facilitated the development of broad-based stewardship activities, including education modules for patients and providers and clinical decision support, while allowing hospitals to implement activities based on local needs and resource availability.

Evaluation of an Academic-Community Partnership to Implement MTM Services in Rural Communities to Improve Pharmaceutical Care for Patients with Diabetes and/or Hypertension.

BACKGROUND: Although the current methods of medication therapy management (MTM) delivery have demonstrably improved therapeutic, safety, economic, and humanistic health outcomes, patient- and prescriber-level barriers persist, limiting its reach and effectiveness. OBJECTIVE: To assess telephonic- and community-based clinical pharmacy services in improving health indicators for rural, underserved patients. METHODS: In 2014, an established MTM provider created a novel, collaborative pilot program with independent retail and community health center pharmacies to provide comprehensive, telephonic MTM services to rural Arizonans. This pilot program used a combined telephonic- and community-based pharmacist approach in the provision of MTM services for rural, underserved Arizona populations. Adults with diabetes mellitus and/or hypertension, seen by a prescriber or who filled prescriptions at a contracted, rural facility in 2014, were eligible to participate. Initial MTM telephonic consultations were conducted, and recommendations were communicated to patients' prescribers and/or pharmacists. Patients received a follow-up telephone call at standard intervals, depending on risk severity. RESULTS: A total of 517 patients participated, and 237 medication-related and 1,102 health promotion interventions were completed. Positive trends were observed in fasting blood glucose, postprandial glucose, and diastolic blood pressure. Broad variation in prescriber acceptance of pharmacist recommendations was observed (27%-60%). CONCLUSIONS: Study results provide initial evidence to support the efficacy of collaborative efforts in the provision of MTM services for improving health indicators and safety measures while potentially reducing health care disparities. While the results are encouraging, future research is warranted in more diverse populations and settings. DISCLOSURES: This work was supported in part by funding from the Centers for Disease Control and Prevention via a multiyear, interagency grant from the Arizona Department of Health Services. The findings and conclusions presented in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention nor the Arizona Department of Health Services. Study concept and design were contributed by M. Johnson, Jastrzab, Hall-Lipsy, Martin, and Warholak. M. Johnson took the lead in data collection, along with K. Johnson, Martin, Jastrzab, and Hall-Lipsy. Data interpretation was performed by Jastrzab, Warholak, and Taylor. The manuscript was written by K. Johnson, M. Johnson, and Jastrzab, along with the other authors, and revised by M. Johnson, Tate, and Taylor, along with Jastrzab, K. Johnson, and Hall-Lipsy. The data from this manuscript were previously presented in poster and podium format by Jastrzab and Johnson at the American Public Health Annual Meeting; Chicago, Illinois; October 31-November 4, 2015.

Primary Care Providers' Perspectives on Errors of Omission.

BACKGROUND: Despite recent focus on patient safety in primary care, little attention has been paid to errors of omission, which represent significant gaps in care and threaten patient safety in primary care but are not well studied or categorized. The purpose of this study was to develop a typology of errors of omission from the perspectives of primary care providers (PCPs) and understand what factors within practices lead to or prevent these omissions. METHODS: A qualitative descriptive design was used to collect data from 26 PCPs, both physicians and nurse practitioners, from the New York State through individual interviews. One researcher conducted all interviews, which were audiotaped, transcribed verbatim, and analyzed in ATLAS.ti, Berlin by 3 researchers using content analysis. They immersed themselves into data, read transcripts independently, and conducted inductive coding. The final codes were linked to each other to develop the typology of errors of omission and the themes. Data saturation was reached at the 26th interview. RESULTS: PCPs reported that omitting patient teaching, patient followup, emotional support, and addressing mental health needs were the main categories of errors of omission. PCPs perceived that time constraints, unplanned patient visits and emergencies, and administrative burden led to these gaps in care. They emphasized that organizational support and infrastructure, effective teamwork and communication, and preparation for the patient encounter were important safeguards to prevent errors of omission within their practices. DISCUSSION: Errors of omission are common in primary care and could threaten patient safety. Efforts to eliminate them should focus on strengthening organizational attributes of practices, improving teamwork and communication, and assigning manageable workload to PCPs. CONCLUSIONS: Practice and policy change is necessary to address gaps in care and prevent them before they result in patient harm.

'Mind the gap' between the development of therapeutic innovations and the clinical practice in oncology: A proposal of the European Organisation for Research and Treatment of Cancer (EORTC) to optimise cancer clinical research.

In Europe, most of the cancer clinical research dedicated to therapeutic innovations aims primarily at regulatory approval. Once an anticancer drug enters the common market, each member state determines its real-world use based on its own criteria: pricing, reimbursement and clinical indications. Such an innovation-centred clinical research landscape might neglect patient-relevant issues in real-world setting, such as comparative effectiveness of distinct treatment options or long-term safety monitoring. The European Organisation for Research and Treatment of Cancer (EORTC) advocates reforming the current 'innovation-centred' system to a truly 'patient-centred' paradigm with systematically coordinated applied clinical research in conjunction with drug development, featuring the following strategy.

New horizons in the implementation and research of comprehensive geriatric assessment: knowing, doing and the 'know-do' gap.

In this paper, we outline the relationship between the need to put existing applied health research knowledge into practice (the 'know-do gap') and the need to improve the evidence base (the 'know gap') with respect to the healthcare process used for older people with frailty known as comprehensive geriatric assessment (CGA). We explore the reasons for the know-do gap and the principles of how these barriers to implementation might be overcome. We explore how these principles should affect the conduct of applied health research to close the know gap. We propose that impaired flow of knowledge is an important contributory factor in the failure to implement evidence-based practice in CGA; this could be addressed through specific knowledge mobilisation techniques. We describe that implementation failures are also produced by an inadequate evidence base that requires the co-production of research, addressing not only effectiveness but also the feasibility and acceptability of new services, the educational needs of practitioners, the organisational requirements of services, and the contribution made by policy. Only by tackling these issues in concert and appropriate proportion, will the know and know-do gaps for CGA be closed.

The Preparation-Practice Gap: An Integrative Literature Review.

BACKGROUND: The purpose of this integrative literature review was to evaluate and synthesize the evidence regarding the existence, extent, and significance of a preparation-practice gap-namely, the deficits in knowledge and skills that novice nurses may demonstrate on entry into the clinical setting and the identified best practices to narrow this gap. METHOD: An integrative literature review was performed. RESULTS: A final set of 50 articles were included in the review. Three main themes permeate the evidence: a preparation-practice gap exists; this gap is costly; and closing the preparation-practice gap will likely rely on changes in undergraduate education and on-the-job remediation (i.e., nurse residency or preceptor programs). CONCLUSIONS: The preparation-practice gap is a challenge that has faced the nursing profession for years. Efforts to close this gap can be justified on the hopes of decreasing turnover (and its attendant costs), boosting morale of novice nurses and their preceptors, decreasing stress among the novice nurses, and improving patient safety.