The patient advisor, an organizational resource as a lever for an enhanced oncology patient experience (PAROLE-onco): a longitudinal multiple case study protocol.

BACKGROUND: Quebec is one of the Canadian provinces with the highest rates of cancer incidence and prevalence. A study by the Rossy Cancer Network (RCN) of McGill university assessed six aspects of the patient experience among cancer patients and found that emotional support is the aspect most lacking. To improve this support, trained patient advisors (PAs) can be included as full-fledged members of the healthcare team, given that PA can rely on their knowledge with experiencing the disease and from using health and social care services to accompany cancer patients, they could help to round out the health and social care services offer in oncology. However, the feasibility of integrating PAs in clinical oncology teams has not been studied. In this multisite study, we will explore how to integrate PAs in clinical oncology teams and, under what conditions this can be successfully done. We aim to better understand effects of this PA intervention on patients, on the PAs themselves, the health and social care team, the administrators, and on the organization of services and to identify associated ethical and legal issues. METHODS/DESIGN: We will conduct six mixed methods longitudinal case studies. Qualitative data will be used to study the integration of the PAs into clinical oncology teams and to identify the factors that are facilitators and inhibitors of the process, the associated ethical and legal issues, and the challenges that the PAs experience. Quantitative data will be used to assess effects on patients, PAs and team members, if any, of the PA intervention. The results will be used to support oncology programs in the integration of PAs into their healthcare teams and to design a future randomized pragmatic trial to evaluate the impact of PAs as full-fledged members of clinical oncology teams on cancer patients' experience of emotional support throughout their care trajectory. DISCUSSION: This study will be the first to integrate PAs as full-fledged members of the clinical oncology team and to assess possible clinical and organizational level effects. Given the unique role of PAs, this study will complement the body of research on peer support and patient navigation. An additional innovative aspect of this study will be consideration of the ethical and legal issues at stake and how to address them in the health care organizations.

Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty for osteoarthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of patient decision aids (PtDA) compared to usual education on appropriate and timely access to total joint arthroplasty in patients with osteoarthritis. METHOD: A randomized controlled trial (RCT) with patients undergoing orthopedic screening. Control and intervention arms received usual education; intervention arm also received a PtDA and a surgeon preference report. Wait times (primary outcome) were described using stratified Kaplan-Meier survival curves with patients censored at the time of death or loss to follow-up, and multivariable Cox proportional hazards regression. Secondary outcomes were compared using stratified Cochran-Mantel-Haenszel chi-squared tests. RESULTS: 343 patients were randomized to intervention (n = 174) or control (n = 169). The typical patient was 66 years old, retired, living with someone, and 51% had high school education or less. The intervention was associated with a trend towards reduction in wait time (hazard ratio (HR) 1.25, 95% confidence interval (CI) 0.99-1.60, P = 0.0653). Median wait times were 3 weeks shorter in intervention than in control at the community site with no difference at the academic site. Good decision quality was reached by 56.1% intervention and 44.5% control (Relative risk (RR) 1.25; 95% CI 1.00-1.56, P = 0.050). Surgery rates were 73.2% intervention and 80.5% controls (RR 0.91: 95% CI 0.81-1.03) with 12 intervention (7.3%) and eight control participants (4.9%) returning to have surgery within 2 years (P = 0.791). CONCLUSION: Compared to controls, decision aid recipients had shorter wait times at one site, fewer surgeries, and were more likely to reach good decision quality, but overall effect was not statistically significant. TRIALS REGISTRATION: The full trial protocol is available at ClinicalTrials.Gov (NCT00911638).

Contribution of patient-advisors during rehabilitation for replantation of digits improves patient-reported functional outcomes: A presentation of concept.

Clinical approach to surgical patients has evolved to include previous patients as part of the treating team in the role of "patient-advisors". Knowing that compliance to rehabilitation protocols is significant for a successful functional hand replantation, we set out to quantify functional patient-reported outcomes in individuals enrolled in a Patient-Advisor Program (PAP). We performed a prospective cohort pilot study of all patients admitted for a finger replantation between July 2015 to January 2016. All patients were offered to partake in the PAP, or else they would constitute the control group. Primary endpoints were functional outcomes as reported by patients at 6-8weeks and 4-6months of follow-up. Secondary endpoints were patient-reported pain and quality of life questionnaires. In total, 62 patients were admitted for finger replantation in the studied period, in which 50 agreed to participate in the study, including 7 in the patient-advisors group and 43 in the control group. Patients from the patient-advisors group fared better on mean scores of the Disabilities of the Arm, Shoulder and Hand than controls (29.6 vs 34.8 respectively at 4-6months). Improvements in the McGill Pain Questionnaire were also greater in the studied group (19.9 vs 33.3 at 4-6months). Replantation patients benefiting from the PAP demonstrated superior functional outcomes on self-reported questionnaires, which could be explained by a better understanding of rehabilitation protocols and compliance when previous patients are active members of the treating team.

Paradoxes of French accreditation.

The accreditation system introduced into the French healthcare system in 1996 has five particular characteristics: (1) it is mandatory for all healthcare establishments; (2) it is performed by an independent government agency; (3) surveyors have to report all instances of non-compliance with safety regulations; (4) the accreditation report is delivered to regional administrative authorities and a summary is made available to the public; and (5) regional administrative authorities can use the information contained in the accreditation report to revise hospital budgets. These give rise to a number of paradoxes: (1) the fact that accreditation is mandatory lends itself to ambiguity and likens the process to an inspection; (2) the fact that decision makers can use the information contained in the accreditation report for resource allocation can incite establishments to adopt strategic behaviours aimed merely at complying with the accreditation manual; and (3) there is a tendency for establishments to reduce quality processes to nothing more than the completion of accreditation and to focus efforts on standardizing practices and resolving safety issues to the detriment of organizational development. All accreditation systems must be aware of these paradoxes and decide on the level of government involvement and the relationship between accreditation and resource allocation. With time, accreditation in France could benefit from both a professionally driven system and from the increased amount of freedom to focus on quality improvement which is necessary for organizational development.

[Implementation of quality management in French hospitals: staff interplay and induced changes]. / Implantation de la gestion de la qualité dans les hôpitaux français, jeux d'acteurs et transformations induites.

BACKGROUND: French hospitals have been encouraged to develop quality processes, in particular through the implementation of a mandatory accreditation. Our objectives were to study the models of quality management used in hospitals and to identify the induced changes in organisation and practices. METHODS: This multiple case study related to 9 acute care hospitals selected among the hospitals whose quality process were relatively old. The study was based on interviews related to 78 people including 26 administrative staff members, 33 physicians and 19 chief nurses. Implementation analysis and strategic analysis were applied. RESULTS: Accreditation played a major part in the institutionalisation of quality processes. Implementation appeared more complete in the small size and private statute hospitals compared to the large public statute hospitals. But the main factors accounting for implementation variability were the level of involvement of the executive directors and participation of doctors in the quality process' leadership. The most important changes were establishment of specific structures, appearance of new professions and elaboration of quality documentation. In the hospitals where the quality process was strongly implemented, there was a trend to the de-compartmentalization between the professions and between the structures and phenomena of employees'development and empowerment. CONCLUSION: Institutionalisation of quality management is recent and the level of implementation varies greatly among hospitals. Involving doctors remains a major challenge for the development of quality management so that the quality can lead changes in hospital.

[Evaluation of the immediate transfusion reaction incident reporting system at the Brest University Hospital Center]. / Evaluation du système de notification des incidents transfusionnels immédiats au CHU de Brest.

The Haemovigilance Unit of Brest University Hospital has had a reporting system of transfusion reactions since october 1994. Reporting "any unexpected or undesirable effect due or likely to be due to the administering of blood cell components" must be done on an answering machine immediately or in the next eight hours. The main goal of the evaluation of this epidemiological surveillance system was to assess its sensitivity, its positive predictive value, its acceptability, its timeliness and its simplicity, according to the Centers for Disease Control criteria. An exhaustive monitoring of the immediate transfusion reactions (ITR) occurring within the 24 hours following the procedure was conducted from April 1, to June 30, 1998. Two sources of information were used, the spontaneous notification to the Haemovigilance Unit using the answering machine, and a telephone survey of the nurse responsible for the transfusion or post-transfusion follow-up. During the survey, 19 ITR, among which 12 were reported to the Haemovigilance Unit on the answering machine, were recorded. The incidence rate of the I.T.R. was estimated at 5@1000 transfused blood cell components. The sensitivity of the notification system was estimated at 63% (95% confidence interval: 41-85) and the positive predictive value at 70% (95% confidence interval: 48-92). This notification system is operational. The function of sanitary alert is ensured at the primary level of the system surveillance. The undernotification of the ITR (37% of false negative) must be corrected by specific recommendations.

[Comparative evaluation of maternity hospitals in Auvergne: from planning to contracting]. / Evaluation comparative des maternités en Auvergne: de la planification à la contractualisation.

Two reforms of public hospitals have been launched by the French government in 1991 and 1996 aimed at lowering costs and increasing the quality of services and ultimately the safety of patients. As concerns maternity hospitals, several new rules have been imposed upon. For example, those who performed less than 300 births a year should be closed. The basic idea was to concentrate technical resources and human skills in middle-size and important hospitals for saving money, and simultaneously, raising the safety level for mothers and babies. However, negative adverse effects fastly appeared: to avoid closure, some small maternity homes tried to convince future mothers not to go to well-equipped hospitals, even if their cases appeared complex and their health at risk. An experience of partnership between maternity hospitals (care providers), the Sickness Insurance Fund (the financing body) and the Administration was carried out in the Auvergne region. It was based on the observation of a large number of indicators concerning the activity of hospitals, the size and quality of their equipment, the satisfaction of their patients ... etc ... for designing the rights and duties of each partner. Instead of planning from the summit, a process of mutually-agreed contract was established.

[Knowledge and beliefs of 4th-year medical students concerning professional practices in general medicine. Results of a survey conducted at the School of Medicine of Brest]. / Connaissances et croyances des étudiants en 4e année des études de médecine à l'égard des pratiques professionnelles en médecine générale. Résultats d'une enquête conduite à la Faculté de médecine de Brest.

As part of preparations for the first seminar in general practice, organized for medical students in their forth year at the Brest faculty of medicine, students were asked to fill in a questionnaire concerning their beliefs and knowledge concerning general-practice medicine. Fifty-two students, or 89.6% of the class, completed the questionnaires. The results showed that despite the lack of formal contacts with this type of practice during their studies, the students had a good idea of what general-practice medicine is and of the role of the general practitioner in our health-care system. However, this study has illustrated the difficulties students experience in defining their future professional direction, since they receive no information during their training on the different options in medical practice.

Patient safety and systematic reviews: finding papers indexed in MEDLINE, EMBASE and CINAHL.

OBJECTIVE: To develop search strategies for identifying papers on patient safety in MEDLINE, EMBASE and CINAHL. METHODS: Six journals were electronically searched for papers on patient safety published between 2000 and 2006. Identified papers were divided into two gold standards: one to build and the other to validate the search strategies. Candidate terms for strategy construction were identified using a word frequency analysis of titles, abstracts and keywords used to index the papers in the databases. Searches were run for each one of the selected terms independently in every database. Sensitivity, precision and specificity were calculated for each candidate term. Terms with sensitivity greater than 10% were combined to form the final strategies. The search strategies developed were run against the validation gold standard to assess their performance. A final step in the validation process was to compare the performance of each strategy to those of other strategies found in the literature. RESULTS: We developed strategies for all three databases that were highly sensitive (range 95%-100%), precise (range 40%-60%) and balanced (the product of sensitivity and precision being in the range of 30%-40%). The strategies were very specific and outperformed those found in the literature. CONCLUSION: The strategies we developed can meet the needs of users aiming to maximise either sensitivity or precision, or seeking a reasonable compromise between sensitivity and precision, when searching for papers on patient safety in MEDLINE, EMBASE or CINAHL.

The value of a risk factor analysis in clinically suspected deep venous thrombosis.

BACKGROUND: The value of a risk factor analysis in the presence of a clinically suspected deep venous thrombosis (DVT) has been assessed mainly in inpatient populations. The aim of this prospective study was to evaluate the potential association between DVT and acquired circumstances suspected as risk factors, in a cohort of outpatients with a clinically suspected DVT. METHODS: Consecutive outpatients referred for a clinically suspected DVT, with recent clinical signs, not exceeding 1 week, were included. Before venography, all patients were interviewed by a trained physician to detect the presence of risk factors. RESULTS: From March 1992 to February 1994, 277 patients were included; venography was positive in 162 (58.4%). Five independent variables were significantly associated with the occurrence of DVT; in a multivariate analysis, 64.7% of patients were correctly classified; odds ratios for having DVT in the presence of these underlying conditions were respectively: 1.75 for age over 65 years, 1.68 for prior history of venous thromboembolism, 1.69 for high risk circumstances (any type of surgery or leg trauma within the past 3 months), 5.59 for malignancy, and 2.56 for varicose veins. CONCLUSIONS: In outpatients referred for a clinically suspected DVT, recognition of associated conditions might increase the certainty of the diagnosis.