The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis.

Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

Organization of shared care networks and their role in overcoming challenges and enhancing outcomes for childhood cancer: A systematic review.

This systematic review examines shared care networks (SCNs) in pediatric oncology as a strategic response to the healthcare challenges in low- and middle-income countries. SCNs integrate specialized hubs with local satellite centers to enhance accessibility and quality of care. Our methodology included a search of PubMed, Embase, Google Scholar, and Scopus, selecting peer-reviewed articles from the last 20 years. We analyzed nine studies, focusing on SCN definitions, models, and outcomes. Findings reveal that SCNs improve clinical outcomes and patient satisfaction, while reducing economic and emotional burdens through standardized protocols and efficient referral systems. Despite the benefits, challenges remain in maintaining consistent care quality and communication across centers. The review underscores the need for further research to quantify benefits, examine long-term outcomes, and refine operational practices to optimize SCNs' effectiveness in pediatric oncology.

Interprofessional follow-up of patients with cancer in France (the SINPATIC study): a preliminary, qualitative study of the patient's perspective.

BACKGROUND: In 2020, 19.2 million people were diagnosed with cancer, and nearly 10 million cancer patients died worldwide. An effective cancer care pathway must be based on coordination, multidisciplinarity, a personalized approach, and collaboration between stakeholders. Follow-up can be improved by good collaboration and communication between GPs and the cancer care team at a common level of organization. OBJECTIVES: To study patients with solid cancers and assess their perceptions of the care pathway, the roles of the healthcare professionals involved, and interprofessional collaboration. METHODS: In a preliminary, qualitative study (part of the SINPATIC study of general practitioners, oncologists, nurses, and patients), adult patients with cancer in the Paris area of France were interviewed between January and April 2018. Using purposive sampling, 10 patients were recruited from hospital departments and primary care. An interview guide explored 3 themes: the care pathway, the stakeholders' roles in follow-up, and interprofessional collaboration. RESULTS: For patients, dealing with cancer is a complex process of awareness, care provision, decision-making, task assignment, a lack of clarification of professional roles, a piecemeal announcement of the diagnosis of cancer by several stakeholders, organizational and administrative difficulties, non-formal collaboration in inertia (tending towards collaboration under construction), and with cancer follow-up that was usually parallel, sometimes shared, rarely sequential. CONCLUSION: This SINPATIC substudy provided us a better understanding of the complexity of the patient care pathway. Looking forward, the present findings might stimulate thoughts on the design and development of interventional studies.

Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial.

BACKGROUND: Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy. METHOD: This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution's financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs. RESULTS: A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups. CONCLUSION: Implementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy. TRIAL REGISTRATION: Clinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).

Barriers and facilitators to implementing a Canadian shared-care ADHD program in pediatric settings in Shanghai: a consolidated framework for implementation research approach.

OBJECTIVES: The vast majority of children with Attention-Deficit Hyperactivity Disorder (ADHD) do not have access to proper diagnosis and treatment in China. The goal of this project is to identify the challenges and facilitators in implementing a Canadian ADHD Shared Care Pathways program in pediatric settings in Shanghai region. METHODS: Purposive semi-structured focus groups were conducted on a total of 13 healthcare practitioners from the Shanghai Xinuha, Ninghai and Chongming hospitals. Two independent researchers conducted a thematic analysis of the data with themes emerging based on the Consolidated Framework for Implementation Research (CFIR). RESULTS: Notable barriers identified by participants included: (1) lack of knowledge in the management of ADHD, primarily among general practitioners; (2) lack of resources such as lack of staff, time, and medication for ADHD; (3) challenges in implementing an international multicentre intervention (such as communication difficulties between teams and integration of resources available in different hospitals); and (4) mental health stigma, difficulties in identifying ADHD patients, and logistical problems related to medication procurement rules put in place by provincial governments. Notable facilitators included: (1) the strong motivation of stakeholders and their confidence in their ability to learn and subsequently execute action plans to achieve the implementation goal; (2) the compatibility between the values and goals of the stakeholders and those of the program despite some cultural tension, a positive learning climate, strong tensions for change, and the high interest of organization leaders in engaging in the program (3) the perceived benefits of the program, such as standardization of the diagnostic and treatment process, and engaging primary care providers in ADHD management; and (4) the strong relationship between participating institutions and schools as well as provincial health initiatives available to support collaborative models of care. Mixed factors to implementation were also explored. CONCLUSIONS: Appropriate training of health care providers, cultural adaptation of the program, increase public awareness about ADHD to decrease stigma, as well as strong project management and guidelines that clearly describe the role and expectations of each team member appeared essential to successful implementation.

"Kyushu-style" collaboration between the implantable ventricular assist device implantation and management centers: a republication of the article published in Japanese journal of artificial organs.

Collaboration between the implantation centers, management centers, and regional core hospitals is a key factor in securing long-term implantable ventricular assist device (VAD) management. In Kyushu, a management system for patients with implantable VADs has been established at the prefectural and regional levels. Presently, six implantable VAD implantation centers and seven management centers exists in the eight prefectures of Kyushu and Okinawa, with at least one specialized VAD centers in each prefecture. This collaborative management system allows patients with VADs to receive seamless treatment based on the same management concept wherever they live. In fact, approximately half of the present outpatients treated at our center reside outside the prefecture and are managed in collaboration with management centers and regional core hospitals. Among our patients, there were no significant differences in survival or rehospitalization-free rates between patients with VADs in and out of the prefecture, suggesting that the place of residence did not affect the outcome. With the increase in the number of patients with VADs and the diversification of patients, patient management has become more complex. Mutual collaboration between the implantation centers, management centers, and regional core hospitals, is essential to improve the quality of VAD management. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 85-88), with some modifications.

Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care.

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

Towards the implementation of law n. 219/2017 on informed consent and advance directives for patients with psychiatric disorders and dementia. Physicians' knowledge, attitudes and practices in four northern Italian health care facilities.

BACKGROUND: On December 2017 the Italian Parliament approved law n. 219/2017 "Provisions for informed consent and advance directives" regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person's autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey among physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. METHODS: A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). RESULTS: Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians' opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. CONCLUSIONS: Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations.

Remote assessment and monitoring with advanced wound therapy to optimise clinical outcomes, access and resources.

OBJECTIVE: Patients in rural communities may have limited access to wound care; however, this may be mitigated by using a shared care approach. This study assessed the impact of a remote assessment and monitoring tool in combination with adjunctive continuous topical oxygen therapy (cTOT) in patients with diabetes and hard-to-heal wounds. METHOD: Patients with hard-to-heal wounds (defined as no visible improvement in the previous four weeks) were enrolled to this 12-week pilot study to validate a shared care approach using an Advanced Digital Wound Care Platform-telehealth (ADWCPt) system (eKare Inc., US) coupled with cTOT. Patient and wound assessments were reviewed by the clinician either remotely, via telehealth calls, or at the clinic, and the number of face-to-face clinic visits was recorded. Patient health status scores were captured before and after the study, along with feedback on usability of the remote platform and cTOT device. RESULTS: The wounds in all eight patients studied reduced in size over 12 weeks (mean percentage area reduction 92.0%), and two wounds were completely re-epithelialised. Another wound almost healed (99.2% wound area reduction). Clinical interactions consisted of self-assessments (n=80, 50.0%), video assessments with the clinician (n=27, 16.9%), and face-to-face interactions in clinic (n=53, 33.1%). Operational efficiencies encompassed a 54.0% increase in the number of clinical interactions, whereas clinical time was reduced by 25.8%. Health status scores improved across all eight patients and feedback on the shared approach and cTOT device was favourable. CONCLUSION: A shared care model with ADWCPt coupled with an innovative cTOT device saved time and resources, improving patient access and engagement, along with a marked improvement in the wound healing trajectory.

Translation and adaptation of Shared Care Instrument-Revised for the older adults and their caregivers in Taiwan.

BACKGROUND: The aging population in Taiwan has resulted in an increase in the dependent population and the care load on caregivers. Shared care is an interpersonal process in which support is "traded" to "handle" chronic illnesses by home-care patients and family caregivers. The scale of shared care has received little attention in the Taiwanese cultural context. Thus, this study examined the reliability and validity of the Taiwanese versions of Shared Care Instrument-Revised (SCI-R). METHODS: The content validity, construct validity, and discriminant validity were used to test the validity of the translated questionnaires. The Cronbach's α was used to examine reliability. A total of 500 older adults and their caregivers were recruited from three counties in Taiwan. RESULTS: The reliability and validity of the Chinese version of the scale were within the acceptable range. The Cronbach's α was between 0.838 and 0.95. However, the scale's reliability was higher than that of the original version. This might be because of the inclusion of participants with less severe diseases than the participants in the original study, high social expectations in the Chinese traditional culture, and a large number of similar items. Future research should simplify the items and consider adopting diverse participant selection criteria. CONCLUSIONS: The results of this study can be used to understand shared care in Taiwan.

Acceptability of a shared cancer follow-up model of care between general practitioners and radiation oncologists: A qualitative evaluation.

INTRODUCTION: Facilitators to implement shared cancer follow-up care into clinical practice include mechanisms to allow the oncologist to continue overseeing the care of their patient, two-way information sharing and clear follow-up protocols for general practitioners (GPs). This paper aimed to evaluate patients, GPs and radiation oncologists (ROs) acceptance of a shared care intervention. METHODS: Semi-structured interviews were conducted pre- and post intervention with patients that were 3 years post radiotherapy treatment for breast, colorectal or prostate cancer, their RO, and their GP. Inductive and deductive thematical analysis was employed. RESULTS: Thirty-two participants were interviewed (19 patients, 9 GPs, and 4 ROs). Pre intervention, there was support for GPs to play a greater role in cancer follow-up care, however, patients were concerned about the GPs cancer-specific skills. Patients, GPs and ROs were concerned about increasing the GPs workload. Post intervention, participants were satisfied that the GPs had specific skills and that the impact on GP workload was comparable to writing a referral. However, GPs expressed concern about remuneration. GPs and ROs felt the model provided patient choice and were suitable for low-risk, stable patients around 2-3 years post treatment. Patients emphasised that they trusted their RO to advise them on the most appropriate follow-up model suited to their individual situation. The overall acceptance of shared care depended on successful health technology to connect the GP and RO. There were no differences in patient acceptance between rural, regional, and cancer types. ROs presented differences in acceptance for the different cancer types, with breast cancer strongly supported. CONCLUSION: Patients, GPs and ROs felt this shared cancer follow-up model of care was acceptable, but only if the RO remained directly involved and the health technology worked. There is a need to review funding and advocate for health technology advances to support integration. PATIENT OR PUBLIC CONTRIBUTION: Patients treated with curative radiotherapy for breast, colorectal and prostate cancer, their RO and their GPs were actively involved in this study by giving their consent to be interviewed.

Implementation and evaluation of a shared care model between oncologists and pharmacists for breast cancer patients at a Canadian regional ambulatory cancer centre.

BACKGROUND: The introduction of CDK 4/6 inhibitors for breast cancer patients has contributed to increased ambulatory patient visits for oncologists. The Medication Assessment by Pharmacist program aims to evaluate the impact of oncology pharmacists performing medication assessment follow-up visits. METHODS: Breast cancer patients on a CDK 4/6 inhibitor deemed suitable by their oncologist for pharmacist assessment could be booked for a pharmacist medication assessment appointment at alternate treatment cycles. RESULTS: Between February 2019 to November 2021, 29 of 128 patients (22.7%) were selected for 46 total Medication Assessment by Pharmacist visits resulting in 920 min of clinic time savings for physicians. There were similar rates of adhering to provincial protocols for scheduling visits (99% vs. 96%, p = 0.12) and monitoring investigations (98% vs. 98%, p = 0.96) between those enrolled in Medication Assessment by Pharmacist or not. Surveys completed by medical oncologists and pharmacists demonstrated that nine of nine oncologists felt Medication Assessment by Pharmacist reduced workload and wanted Medication Assessment by Pharmacist expanded to additional oncology drugs. Pharmacist-completed surveys revealed that nine of nine pharmacists felt Medication Assessment by Pharmacist increased job satisfaction, and allowed further application of clinical skills. All agreed that patients were receptive to meeting with pharmacists. According to survey results, 33% of oncologists versus 100% of pharmacists routinely asked about medication adherence, new medications or supplements. CONCLUSION: Integrating pharmacists into a shared care model reduces ambulatory patient visits for oncologists without deviating from provincial protocol guidelines for monitoring and visits for patients on CDK 4/6 inhibitors. Leveraging the medication expertise of pharmacists also increases the frequency of addressing medication adherence and concurrent therapies. Medication Assessment by Pharmacist may be an effective strategy in alleviating projected shortages of oncology providers.

Barriers and facilitators to the participation and engagement of primary care in shared-care arrangements with community mental health services for preventive care of people with serious mental illness: a scoping review.

BACKGROUND: People with serious mental illness die about 20 years earlier than the general population from preventable diseases. Shared-care arrangements between general practitioners and mental health services can improve consumers' access to preventive care, but implementing shared care is challenging. This scoping review sought to describe current evidence on the barriers and facilitators to the participation and engagement of primary care (specifically general practitioners) in shared-care arrangements with community mental health services for preventive health care of this population. METHODS: We searched Medline, Embase, CINAHL, Scopus, APA PsychINFO and EBM Reviews from 2010 to 2022. Data was extracted against a Microsoft Excel template developed for the review. Data was synthesised through tabulation and narrative methods. RESULTS: We identified 295 records. After eligibility screening and full-text review, seven studies were included. Facilitators of engagement included a good fit with organisation and practice and opportunities to increase collaboration, specific roles to promote communication and coordination and help patients to navigate appointments, multidisciplinary teams and teamwork, and access to shared medical/health records. Barriers included a lack of willingness and motivation on the part of providers and low levels of confidence with tasks, lack of physical structures to produce capacity, poor alignment of funding/incentives, inability to share patient information and challenges engaging people with severe mental illness in the service and with their care. CONCLUSION: Our results were consistent with other research on shared care and suggests that the broader literature is likely to be applicable to the context of general practitioner/mental health services shared care. Specific challenges relating to this cohort present difficulties for recruitment and retention in shared care programs. Sharing "goals and knowledge, mutual respect" and engaging in "frequent, timely, accurate, problem-solving communication", supported by structures such as shared information systems are likely to engage primary care in shared care arrangements more than the traditional focus on incentives, education, and guidelines.

Socio-Organizational Dimensions: The Key to Advancing the Shared Care Record Agenda in Health and Social Care.

Integrating health and social care delivery with the help of digital technologies is a grand challenge. We argue that previous attempts have largely failed to achieve their objectives because implementers and decision makers disregard the complex socio-organizational dimensions of change associated with initiatives. These include structural and organizational complexity inhibiting the development of shared care pathways; professional jurisdictions, interests, and expertise; and existing data and governance structures. We provide an overview of those dimensions that can inform strategic decisions going forward, thereby contributing to the chances of success of shared care initiatives.

Maternal satisfaction with joint and sole child physical placement arrangements following separation in Wisconsin and Finland.

Families (and sometimes courts) make important decisions regarding child physical custody arrangements post-separation, and shared parenting arrangements are increasingly common in most developed countries. Shared arrangements may be differentially associated with parental satisfaction, and these associations may vary across countries. Using data from surveys of separated mothers in Wisconsin and Finland, the present study explores this possibility and is guided by three aims: (a) to identify child and family characteristics associated with sole and shared child placements 6 or more years after separation; (b) to estimate associations of children's post-separation placements with maternal satisfaction with placements and expense sharing; (c) to examine whether the relationship between post-separation placement and maternal satisfaction varies by mothers' earnings and the quality of parents' relationships. We find that Finnish mothers with shared placement are more satisfied with their placement than are their counterparts with sole placement, while we find the inverse is true for Wisconsin mothers. Moreover, parental satisfaction with shared placement, overall and relative to sole placement, varies greatly depending on the quality of a mother's relationship with the other parent; and differences in relationship quality in Wisconsin and Finland may help explain the difference in satisfaction with shared placement in the two locations. In both Finland and Wisconsin, we find mothers with shared placement are more satisfied with the way expenses are shared between parents than are mothers with sole placement. Associations between placement and satisfaction are robust to extensive controls for child and maternal characteristics.

General practitioner perspectives on a shared-care model for paediatric patients post-intensive care: A cross-sectional survey.

INTRODUCTION: While paediatric critical illness mortality rates in Australia are declining, the growing cohort of paediatric intensive care unit (PICU) survivors means an increasing number of children facing substantial health challenges after their discharge from intensive care. General practitioners (GPs) play a key role in provision of comprehensive health care to children and families and are ideally positioned to provide developmental surveillance and support the care of both the child and family following critical illness. METHODS: An anonymous, cross-sectional survey of 60 GPs, reached via private invitation (19% response) or via social media weblink, was conducted where the GPs were asked about their current confidence and knowledge in managing children post PICU. This included awareness of short- and long-term problems, of paediatric intensive care syndrome in paediatrics (PICS-p), and of educational materials. Lastly, a parent-completed screening questionnaire and shared-care pathway were proposed to GPs for their feedback on perceived benefit and willingness to participate. Data were analysed using frequency distributions and chi-square statistics. RESULTS: Ninety-three percent of GPs had some level of confidence in caring for a child post PICU admission and low confidence in their knowledge of potential short- and long-term complications. Eighty percent of GPs had not heard of PICS-p, and 93% were unaware of educational materials available on this topic. Ninety-five percent of GPs perceived that the proposed patient-screening tool and shared-care pathways would be beneficial, and 70% predicted that they would definitely use educational materials if accessible through GP central repositories. CONCLUSION: To reduce ongoing health problems for children recovering from critical illness, the family GP plays a pivotal role in providing community-level developmental care, particularly in Australia. Increasing GP confidence and knowledge through education is essential, and using a parent-completed screening questionnaire and shared-care pathway to improve care may be beneficial. GPs must also be involved in the implementation stages of future shared-care models.

Italian law n. 219/2017 on consent and advance directives: survey among Ethics Committees on their involvement and possible role.

BACKGROUND: On December 2017 the Italian Parliament approved law n. 219/2017 "Provisions for informed consent and advance directives" regarding challenging legal and bioethical issues related to healthcare decisions and end-of-life choices. The law does not contain an explicit reference to Ethics Committees (ECs), but they could still play a role in implementing the law. METHODS: A questionnaire-based survey was performed among the ECs of the Italian Institute for Research and Care belonging to the Network of neuroscience and neurorehabilitation, with the aim of (1) knowing whether the ECs participated and, if so, how in the process of implementation of law n. 219/2017 in the referring institutes; (2) investigating the point of view of the ECs regarding their possible involvement in the process; (3) exploring the contribution ECs can provide to give effective implementation to the law principles and provisions. RESULTS: Seventeen ECs out of thirty took part in the survey; the characteristics of the responding and non-responding committees are similar, so the responding ECs can be regarded as representative of all ECs in the Network. Nine ECs did not discuss the law in anyway: the main reason for this is that the referring institutions (6) and the health care professionals (3) did not ask for an EC intervention. Nevertheless, the large majority of the ECs believe that their involvement in the implementation of the law as a whole is appropriate (8) or absolutely appropriate (6), while 3 of them are neutral. No EC believes that the involvement is inappropriate. The aspect of the law on which the 14 ECs converge in considering the EC involvement appropriate/absolutely appropriate is the one related to the health facilities obligation to guarantee the full and proper implementation of the principles of the law. CONCLUSIONS: Our survey confirms that ECs believe they can play a role in the implementation of law n. 219/2017, although this does not entirely correspond to what the committees have actually done in reality. This role could be better exercised by ECs specifically established for clinical practice, which would have a composition, functioning and a mandate better suited to the purpose. This supports the call for a national regulation of ECs for clinical practice.

Clinical update on public and private psychiatric practice shared-care partnerships - Can the twain work together?

OBJECTIVE: We explore the previous research and current context regarding opportunities for shared-care partnerships between public and private psychiatric practice. CONCLUSIONS: Since the early 2000s, when there was impetus for the development of public-private psychiatric shared-care models as part of a previous National Mental Health Strategy, there has been surprisingly little research and policy development. Given an apparent exodus of psychiatrists to private practice due to current challenges facing the public health sector, it is timely to reconsider models of private and public sector shared-care that may improve the quality of public mental healthcare.

Comorbidity Management in Black Women Diagnosed with Breast Cancer: the Role of Primary Care in Shared Care.

BACKGROUND: Black women are more likely to have comorbidity at breast cancer diagnosis compared with White women, which may account for half of the Black-White survivor disparity. Comprehensive disease management requires a coordinated team of healthcare professionals including primary care practitioners, but few studies have examined shared care in the management of comorbidities during cancer care, especially among racial/ethnic minorities. OBJECTIVE: To examine whether the type of medical team composition is associated with optimal clinical care management of comorbidities. DESIGN: We used the Women's Circle of Health Follow-up Study, a population-based cohort of Black women diagnosed with breast cancer. The likelihood of receiving optimal comorbidity management after breast cancer diagnosis was compared by type of medical team composition (shared care versus cancer specialists only) using binomial regression. PARTICIPANTS: Black women with a co-diagnosis of diabetes and/or hypertension at breast cancer diagnosis between 2012 and 2016 (N = 274). MAIN MEASURES: Outcome-optimal clinical care management of diabetes (i.e., A1C test, LDL-C test, and medical attention for nephropathy) and hypertension (i.e., lipid screening and prescription for hypertension medication). Main predictor-shared care, whether the patient received care from both a cancer specialist and a primary care provider and/or a medical specialist within the 12 months following a breast cancer diagnosis. KEY RESULTS: Primary care providers were the main providers involved in managing comorbidities and 90% of patients received shared care during breast cancer care. Only 54% had optimal comorbidity management. Patients with shared care were five times (aRR: 4.62; 95% CI: 1.66, 12.84) more likely to have optimal comorbidity management compared with patients who only saw cancer specialists. CONCLUSIONS: Suboptimal management of comorbidities during breast cancer care exists for Black women. However, our findings suggest that shared care is more beneficial at achieving optimal clinical care management for diabetes and hypertension than cancer specialists alone.

Optimal timing for hospice-shared care initiation in terminal cancer patients.

PURPOSE: The existing concept suggests early palliative and hospice therapy for a better quality of care (QOC) and less medical expense in terminal cancer patients, but the time points of "early" initiation were defined by pre-set study protocol rather than the real-world data. The study aimed to determine the optimal timing of initiating palliative care for patients with terminal cancer. METHODS: This retrospective population-based study was conducted using a nationwide database. We extracted patients with cancer who were in their last year of lives in the period from 1 January 2010 to 31 December 2013 and categorized them into two groups ("hospice-shared care" (HSC) group and "usual care" (UC) group) after a matching process. Subsequently, we used a generalized linear mixed-effects model to compare the QOC and medical expenses between groups. RESULTS: After the selection and matching process, we enrolled 1714 patients (67.7 ± 13.2 years, 62.7% male) categorized into the HSC and UC groups (n = 857 in each group). The HSC groups showed generally better QOC in the four indices (with emergency room visit, hospitalization, intensive care unit admission, and receiving chemotherapy) than the UC group in those who initiated HSC 8-60 days before death. The HSC group also had significantly lower medical expenses than the UC group in those who initiated HSC 15-90 days before death. CONCLUSIONS: Among patients with terminal cancer, HSC initiation before the last 8 days and 15 days of lives can effectively improve QOC and save medical expenses, respectively.