Textbook oncologic outcome in pancreaticoduodenectomy: Do regionalization efforts make sense?

BACKGROUND AND OBJECTIVES: Few empiric studies evaluate the effects of regionalization on pancreatic cancer care. METHODS: We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy for clinical stage I/II pancreatic adenocarcinoma between 2006 and 2015. Facilities were categorized by annual pancreatectomy volume. Textbook oncologic outcome was defined as a margin negative resection, appropriate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of adjuvant chemotherapy. Multivariable regression adjusted for comorbid disease, pathologic stage, and facility characteristics was used to evaluate the relationship between facility volume and textbook outcome. RESULTS: Sixteen thousand six hundred and two patients underwent pancreaticoduodenectomy; 3566 (21.5%) had a textbook outcome. Operations performed at high volume centers increased each year (45.8% in 2006 to 64.2% in 2015, p < 0.001) as did textbook outcome rates (14.3%-26.2%, p < 0.001). Surgical volume was associated with textbook outcome. High volume centers demonstrated higher unadjusted rates of textbook outcome (25.4% vs. 11.8% p < 0.01) and increased adjusted odds of textbook outcome relative to low volume centers (odds ratio: 2.39, [2.02, 2.85], p < 0.001). Textbook outcome was associated with improved overall survival independent of volume. CONCLUSIONS: Regionalization of care for pancreaticoduodenectomy to high volume centers is ongoing and is associated with improved quality of care.

Variation in Diagnosis, Treatment, and Outcome of Esophageal Cancer in a Regionalized Care System in Ontario, Canada.

Importance: Esophageal cancer remains one of the most deadly cancers, ranking sixth highest among cancers leading to the greatest years of life lost. Objective: To determine how patients with esophageal cancer are diagnosed and treated in Ontario's regionalized thoracic surgery centers. Design, Setting, and Participants: This cohort study included patients diagnosed with esophageal cancer between January 1, 2010, and December 31, 2018, identified from the Ontario Cancer Registry, in a single-payer health care system with regionalization of thoracic surgery in the province of Ontario, Canada. Exposures: Exposures included incidence of esophageal cancer and stage at diagnosis; time from the first health care visit until treatment; and the use of specialist consultations, endoscopic ultrasonography, positron emission tomography and computed tomography, endomucosal resection, esophagectomy, neoadjuvant therapy, adjuvant therapy, radiation alone, and chemotherapy alone or in combination with other treatment. Main Outcomes and Measures: Outcome measures included wait times, health care use, treatment, and overall survival. Data were analyzed from March 2020 to February 2021. Results: There were 10 364 patients (mean [SD] age, 68.3 [11.9] years; 7876 men [76%]) identified during the study period. The incidence of esophageal cancer increased over the study period from 1041 in 2010 to 1309 in 2018, which was driven by a 30% increase in the number of adenocarcinomas. The time from first health care encounter to start of treatment was a median 93 days (interquartile range, 56-159 days). Endoscopic ultrasonography was observed for 12% of patients, and positron emission tomography and computed tomography (CT) in 45%. Use of endoscopic mucosal resection was observed for 8% of patients with stage 0 to I disease. A total of 114 of 547 patients (21%) receiving endoscopic resection had a subsequent esophagectomy. Only 2778 patients (27%) had consultations with a thoracic surgeon, a medical oncologist, and a radiation oncologist, whereas 1514 patients (15%) did not see any of these specialists. Of 3047 patients who had an esophagectomy, those receiving neoadjuvant therapy had better overall survival (median survival, 36 months; 95% CI, 32-39 months) than patients who received esophagectomy alone (median survival, 27 months; 95% CI, 24-30 months) or those who received esophagectomy with adjuvant therapy (median survival, 36 months; 95% CI, 32-44 months) despite significant early mortality (log-rank P < .001). There was significant variation in treatment modality across hospitals: esophagectomy ranged from 5% to 39%; esophagectomy after neoadjuvant therapy ranged from 33% to 93%; and esophagectomy followed by adjuvant therapy ranged from 0 to 34% (P < .001). Perioperative mortality was higher at 30 days for patients receiving esophagectomy at low-volume centers (odds ratio [OR], 3.66; 95% CI, 2.01-6.66) and medium-volume centers (OR, 2.07; 95% CI, 1.33-3.23) compared with high-volume centers (P < .001). A longer wait time until treatment was associated with better overall survival (median overall survival was 15 to 17 days vs 5 to 8 days for patients who received treatment earlier than 30 days vs 30 days or longer after diagnosis; P < .001). Conclusions and Relevance: The results of this cohort study suggest that despite regionalization, there was significant regional variability in volumes at designated centers and in the evaluation and treatment course for patients with esophageal cancer across Ontario.

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline.

BACKGROUND: Revision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making. AIM: To provide guidelines for surgeons and units delivering revision KR services. METHODS: A formal consensus process was followed by BASK's Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data. RESULTS: There are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR. This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model. CONCLUSIONS: Revision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.

Potential reduction of hospital stay length with outpatient management of low-risk febrile neutropenia in a regional cancer center.

BACKGROUND: Febrile neutropenia is a serious complication of chemotherapy. The Multinational Association for Supportive Care in Cancer (MASCC) risk index score identifies patients at low risk of serious complications. Outpatient management programs have been successfully piloted in other Australian metropolitan cancer centers. AIM: To assess current management of febrile neutropenia at our regional cancer center and determine potential impacts of an outpatient management program. METHOD: We performed a retrospective review of medical records for all patients admitted at our regional institution with febrile neutropenia between 1 January 2016, and 31 December 2018. We collected information regarding patient characteristics, determined the MASCC risk index score, and if low risk, we determined the eligibility for outpatient care and potential reduction in length of stay and cost benefit. RESULTS: A total of 98 hospital admissions were identified. Of these, 66 had a MASCC low-risk index score. Fifty-eight patients met the eligibility criteria for outpatient management. Seventy-one percent were female. The most common tumor type was breast cancer. Forty-eight percent were treated with curative intent. The median length of stay was 3 days. The median potential reduction in length of stay for each admission was 2 days. The total potential reduction in length of stay was 198 days. No admission resulted in serious complications. CONCLUSION: This review demonstrates a significant number of hospital admission days can be avoided. We intend to conduct a prospective pilot study at our center to institute an outpatient management program for such low-risk patients with potential reduction in hospital length of stay. This will have significant implications on health resource usage, service provision planning, and patient quality of life.

Timeliness of cancer care in a regional Victorian health service: A comparison of high-volume (Lung) and low-volume (oesophagogastric) tumour streams.

BACKGROUND: Timeliness of cancer care is vital for improved survival and quality of life of patients. Service and care centralisation at larger-volume centres has been associated with improved outcomes. However, there is a lack of systematic data on the impact of tumour stream volume on timeliness of care. AIMS: To investigate and compare timeliness of care for lung cancer, a high-volume (more commonly diagnosed) tumour stream, and oesophagogastric (OG) cancer, a low-volume (less commonly diagnosed) tumour stream, at a regional health service in Victoria, Australia. METHODS: A retrospective cohort study comprising random samples of 75 people newly diagnosed with lung cancer (International Classification of Diseases and Related Health Problems-10 [ICD-10] diagnosis codes C34 in the Victorian Cancer Registry [VCR]) and 50 people newly diagnosed with OG cancer (ICD-10 diagnosis codes C15 or C16 in VCR) at one regional Victorian health service between 2016 and 2017. Binary logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between patient factors and suboptimal timeliness of care. RESULTS: In comparison to OG cancer patients, lung cancer patients had reduced odds of suboptimal timeliness of care in reference to times outside OCP for referral to diagnosis (OR [95% CI] = 0.34 [0.14 to 0.83]) but increased odds of suboptimal timeliness for diagnosis to treatment (OR [95% CI] = 2.48 [1.01 to 6.09]). CONCLUSION: In the low-volume OG cancer stream, patients had longer wait times from referral to an MDM, where treatment decisions occur, but shorter time to commencement of first treatment. Conversely in the high-volume lung cancer group, there was delayed initiation of first treatment following presentation at MDM. There is need to explore ways to fast-track MDM presentation and commencement of therapy among people diagnosed with low-volume and high-volume cancers, respectively.

Facilitated Regional Collaboration and In-Hospital Surgical Complication.

BACKGROUND: Surgical quality improvement efforts are challenging due to the multidisciplinary nature of care, difficulties obtaining reliable data, and variability in quality metrics. The objective of this analysis was to assess whether participation in a regional collaborative quality initiative was associated with decreased in-hospital surgical complication in South Carolina. STUDY DESIGN: In-hospital surgical complication rates were determined using a statewide all-payer claims data set. Retrospective, univariate, and longitudinal multivariable analyses were performed and adjustments were made to account for aggregated hospital-level patient characteristics. RESULTS: The analysis included 275,387 general surgery cases performed in South Carolina hospitals between January 2016 and December 2018. Eight hospitals involved in the South Carolina Surgical Quality Collaborative (SCSQC) performed 56,179 cases and 51 non-SCSQC hospitals performed 219,208 cases. Univariate analysis revealed SCSQC hospitals performed operations in older patients (p < 0.0001) and patients with higher mean Charlson Comorbidity Index scores (p < 0.0001). SCSQC hospitals had higher mean in-hospital surgical complication rates at the surgery level compared with non-SCSQC hospitals (8.3% vs 7.0%; p < 0.0001). However, in multivariable analyses, the rate ratio for in-hospital surgical complication in SCSQC hospitals was 0.994 (95% CI, 0.989 to 0.998; p = 0.008) per month compared with non-SCSQC hospitals. This suggests a 21.6% (95% CI, 7.2% to 39.6%) proportional decrease in the rate of in-hospital surgical complication during 3 years associated with participation in the regional collaborative quality initiative. CONCLUSIONS: Structured collaboration between facilities, reliable data abstraction support, timely data review, and active member participation resulted in outcomes improvements for participating hospitals compared with hospitals that did not participate in a regional collaborative quality initiative.

Reforma Sanitária e o estado de São Paulo 1970-1980: particularidades regionais e formação de seus trabalhadores / Health reform and the state of São Paulo between 1970 and 1980: regional dimensions and worker training / Reforma Sanitaria y el Estado de São Paulo 1970-1980: particularidades regionales y formación de sus trabajadores

Os estudos em perspectiva histórica da Reforma Sanitária, entre 1970-1980 no Brasil, ganharam diversos matizes analíticos e autores. Porém, ainda se ressente da necessidade de sua compreensão mediante particularidades regionais e uma visão que busque contextos capazes de elucidar ou ao menos refletir acerca daquilo que pode ser abarcado em uma lógica vivida por grupos determinados, instituições e movimentos alinhados ao pensamento social em saúde. Acrescido a essa questão está o projeto de formação de sanitaristas no período, que a historiografia aponta como relevante para o fortalecimento do ideário da Reforma Sanitária. Dentro dessa motivação e análise crítica, buscamos apresentar um estudo histórico de dimensão regional sobre as experiências médico-sanitárias vividas no período no Estado de São Paulo. (AU)

Studies of the history of Brazil's health reform conducted between 1970 and 1980 have gained various nuances and authors. However, there is still a need to understand the regional dimensions of the reform using an approach that examines contexts that are capable of elucidating or at least reflecting on the perspectives of specific groups, institutions and movements aligned with social thinking in health. An additional question is the sanitarian training program at the time, which historiography depicts as being relevant to the strengthening of the ideology behind the health reform. Motivated by the above and critical analysis, we present a historical study of the regional dimensions of the health reform investigating medical-sanitary experiences lived during the period in the state of São Paulo. (AU)

Los estudios en perspectiva histórica de la Reforma Sanitaria, entre 1970-1980 en Brasil, obtuvieron diversos matices analíticos y autores. Sin embargo, todavía se resiente de la necesidad de su comprensión a partir de particularidades regionales y de una visión que busque contextos capaces de elucidar o al menos de reflexionar sobre aquello que puede abarcarse en una lógica vivida por grupos determinados, instituciones y movimientos alineados al pensamiento social en salud. Añadido a esta cuestión está el proyecto de formación de sanitaristas en el período que la historiografía señala como relevante para el fortalecimiento del ideario de la Reforma Sanitaria. Dentro de esa motivación y análisis crítico, buscamos presentar un estudio histórico de dimensión regional sobre las experiencias médico-sanitarias vividas en el período en el Estado de São Paulo. (AU)

Ley nacional del cáncer Claudio Mora: metas y desafíos a futuro / Claudio Mora National Cancer Law: Goals and challenges for the future

Actualmente el cáncer es la segunda causa de muerte en la población chilena; sin embargo, en algunas regiones del país como Arica y Parinacota, Antofagasta, La Serena, Los Lagos y Aysén, en Atacama y La Araucanía ya es la primera (1), inmediatamente apenas por debajo de las afecciones al sistema circulatorio y cardiovascular, y se espera que, al final de la próxima década, llegue a ser la primera causa de muerte en el país (2). Por otra parte, con respecto a los años de vida perdidos en Chile, el cáncer es la primera causa de años de vida perdidos por muerte prematura (175.741 años equivalentes al 22,5% del total de años). Si a lo anterior sumamos los años de vida perdidos por discapacidad, el cáncer es responsable de 221.529 AVISA (Años de vida ajustados por discapacidad), ubicándolo en el séptimo lugar de grupos de causas de carga de enfermedad.(3) Por su incidencia, el cáncer se ha constituido en un problema de salud pública indiscutible e insoslayable, por cuya gravedad demanda al sistema de salud chileno la máxima atención y el mejor de los esfuerzos en las tareas de las pesquisas temprana en toda la población, con el fin de minimizarsusefectos combinados enlasociedad demanera transversal y en cualquier contexto en el que ocurra, debido a la dificultad que significa para el sistema de salud chileno su pesquisa temprana en todos los ciudadanos, sumado a la escasez de recursos tanto humanos como materiales, por lo costos involucrados en su abordaje, es un importante problema social y económico, con repercusión y costos que afectan a laspersonas, sus familiasy comunidades, así como al sistema de salud y al país en su conjunto. (2) A la fecha, en Chile, grandes esfuerzos se han hecho para reducir estas brechas. El mayor de ellos es el programa GES (Garantías explícitas enSalud), mediante el cual los pacientes de acuerdo a su diagnóstico e independientemente de su capacidad de pago o seguro de salud asociado, región geográfica o nivel educacional, son asegurados con una canasta de prestaciones estandarizada, con tiempos de atención antes definidos, asegurando así acceso, oportunidad, protección financiera y calidad delprestador. (4) No obstante luego de 15 años de iniciado elprograma de prestaciones GES, persisten estas diferencias tanto por nivel socioeconómico, y/o educacional, queinfluyen negativamente sobre los estándares de atención de los diferentes prestadores de salud, en razón que diversos estudios se han observado diferencias estadisticamente significativas en las tasas de mortalidad entre el sistema público y privado de 3,12 a 5,8 veces más mortalidad en los pacientes atendidos por FONASA (Fondo nacional de Salud) , respecto a los prestadores privados provenientes de ISAPRES (Instituciones de salud previsional). (5) La ley Nacional del Cáncer recibe el nombre del doctor Claudio Mora a modo de homenaje póstumo, pues él encarnó la dualidad de paciente oncológico y profesional al ser tratado por un cáncer de páncreas, junto al Dr. Jorge Jiménez de la Jara, y la senadora Carolina Goic, quienes fueron grandes impulsores de esta ley, que cuenta con $80 mil millones de pesos anuales ($20 mil millones para infraestructura y $60 mil millones para tratamientos que hoy no son cubiertos por el GES ni por la Ley Ricarte Soto), además de $200 millones anuales por ocho años para la construcción de la Red Nacional Oncológica.(6) La ley nacional del cáncer es un proyecto a largo plazo que requiere de una red oncológica integrada de profesionales y de la coordinación de un equipo interdisciplinario que presenta deficiencias tanto en el número como en la especializaciónde sus equipos médicos. En el presente contexto de la pandemia por coronavirus iniciada en Chile el 1 de marzo de 2020, contrapuesto a lo anterior la disminución de los diagnósticos de cáncer es un hecho, como consecuencia directa de la priorización de camas crítica como camas básicas y de intermedio para atender pacientes infectados por coronavirus, a pesar de lo anterior ha entrado en vigencia la Ley Nacional de Cáncer, es decir, la nueva Ley 21.258, que pretende asegurar que se proporcione un óptimo diagnóstico, tratamiento y seguimiento a los pacientes. (7)

Beyond the black stump: rapid reviews of health research issues affecting regional, rural and remote Australia.

CHAPTER 1: RETAIL INITIATIVES TO IMPROVE THE HEALTHINESS OF FOOD ENVIRONMENTS IN RURAL, REGIONAL AND REMOTE COMMUNITIES: Objective: To synthesise the evidence for effectiveness of initiatives aimed at improving food retail environments and consumer dietary behaviour in rural, regional and remote populations in Australia and comparable countries, and to discuss the implications for future food environment initiatives for rural, regional and remote areas of Australia. STUDY DESIGN: Rapid review of articles published between January 2000 and May 2020. DATA SOURCES: We searched MEDLINE (EBSCOhost), Health and Society Database (Informit) and Rural and Remote Health Database (Informit), and included studies undertaken in rural food environment settings in Australia and other countries. DATA SYNTHESIS: Twenty-one articles met the inclusion criteria, including five conducted in Australia. Four of the Australian studies were conducted in very remote populations and in grocery stores, and one was conducted in regional Australia. All of the overseas studies were conducted in rural North America. All of them revealed a positive influence on food environment or consumer behaviour, and all were conducted in disadvantaged, rural communities. Positive outcomes were consistently revealed by studies of initiatives that focused on promotion and awareness of healthy foods and included co-design to generate community ownership and branding. CONCLUSION: Initiatives aimed at improving rural food retail environments were effective and, when implemented in different rural settings, may encourage improvements in population diets. The paucity of studies over the past 20 years in Australia shows a need for more research into effective food retail environment initiatives, modelled on examples from overseas, with studies needed across all levels of remoteness in Australia. Several retail initiatives that were undertaken in rural North America could be replicated in rural Australia and could underpin future research. CHAPTER 2: WHICH INTERVENTIONS BEST SUPPORT THE HEALTH AND WELLBEING NEEDS OF RURAL POPULATIONS EXPERIENCING NATURAL DISASTERS?: Objective: To explore and evaluate health and social care interventions delivered to rural and remote communities experiencing natural disasters in Australia and other high income countries. STUDY DESIGN: We used systematic rapid review methods. First we identified a test set of citations and generated a frequency table of Medical Subject Headings (MeSH) to index articles. Then we used combinations of MeSH terms and keywords to search the MEDLINE (Ovid) database, and screened the titles and abstracts of the retrieved references. DATA SOURCES: We identified 1438 articles via database searches, and a further 62 articles via hand searching of key journals and reference lists. We also found four relevant grey literature resources. After removing duplicates and undertaking two stages of screening, we included 28 studies in a synthesis of qualitative evidence. DATA SYNTHESIS: Four of us read and assessed the full text articles. We then conducted a thematic analysis using the three phases of the natural disaster response cycle. CONCLUSION: There is a lack of robust evaluation of programs and interventions supporting the health and wellbeing of people in rural communities affected by natural disasters. To address the cumulative and long term impacts, evidence suggests that continuous support of people's health and wellbeing is needed. By using a lens of rural adversity, the complexity of the lived experience of natural disasters by rural residents can be better understood and can inform development of new models of community-based and integrated care services. CHAPTER 3: THE IMPACT OF BUSHFIRE ON THE WELLBEING OF CHILDREN LIVING IN RURAL AND REMOTE AUSTRALIA: Objective: To investigate the impact of bushfire events on the wellbeing of children living in rural and remote Australia. STUDY DESIGN: Literature review completed using rapid realist review methods, and taking into consideration the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement for systematic reviews. DATA SOURCES: We sourced data from six databases: EBSCOhost (Education), EBSCOhost (Health), EBSCOhost (Psychology), Informit, MEDLINE and PsycINFO. We developed search terms to identify articles that could address the research question based on the inclusion criteria of peer reviewed full text journal articles published in English between 1983 and 2020. We initially identified 60 studies and, following closer review, extracted data from eight studies that met the inclusion criteria. DATA SYNTHESIS: Children exposed to bushfires may be at increased risk of poorer wellbeing outcomes. Findings suggest that the impact of bushfire exposure may not be apparent in the short term but may become more pronounced later in life. Children particularly at risk are those from more vulnerable backgrounds who may have compounding factors that limit their ability to overcome bushfire trauma. CONCLUSION: We identified the short, medium and long term impacts of bushfire exposure on the wellbeing of children in Australia. We did not identify any evidence-based interventions for supporting outcomes for this population. Given the likely increase in bushfire events in Australia, research into effective interventions should be a priority. CHAPTER 4: THE ROLE OF NATIONAL POLICIES TO ADDRESS RURAL ALLIED HEALTH, NURSING AND DENTISTRY WORKFORCE MALDISTRIBUTION: Objective: Maldistribution of the health workforce between rural, remote and metropolitan communities contributes to longstanding health inequalities. Many developed countries have implemented policies to encourage health care professionals to work in rural and remote communities. This scoping review is an international synthesis of those policies, examining their effectiveness at recruiting and retaining nursing, dental and allied health professionals in rural communities. STUDY DESIGN: Using scoping review methods, we included primary research - published between 1 September 2009 and 30 June 2020 - that reported an evaluation of existing policy initiatives to address workforce maldistribution in high income countries with a land mass greater than 100 000 km2 . DATA SOURCES: We searched MEDLINE, Ovid Embase, Ovid Emcare, Informit, Scopus, and Web of Science. We screened 5169 articles for inclusion by title and abstract, of which we included 297 for full text screening. We then extracted data on 51 studies that had been conducted in Australia, the United States, Canada, United Kingdom and Norway. DATA SYNTHESIS: We grouped the studies based on World Health Organization recommendations on recruitment and retention of health care workers: education strategies (n = 27), regulatory change (n = 11), financial incentives (n = 6), personal and professional support (n = 4), and approaches with multiple components (n = 3). CONCLUSION: Considerable work has occurred to address workforce maldistribution at a local level, underpinned by good practice guidelines, but rarely at scale or with explicit links to coherent overarching policy. To achieve policy aspirations, multiple synergistic evidence-based initiatives are needed, and implementation must be accompanied by well designed longitudinal evaluations that assess the effectiveness of policy objectives. CHAPTER 5: AVAILABILITY AND CHARACTERISTICS OF PUBLICLY AVAILABLE HEALTH WORKFORCE DATA SOURCES IN AUSTRALIA: Objective: Many data sources are used in Australia to inform health workforce planning, but their characteristics in terms of relevance, accessibility and accuracy are uncertain. We aimed to identify and appraise publicly available data sources used to describe the Australian health workforce. STUDY DESIGN: We conducted a scoping review in which we searched bibliographic databases, websites and grey literature. Two reviewers independently undertook title and abstract screening and full text screening using Covidence software. We then assessed the relevance, accessibility and accuracy of data sources using a customised appraisal tool. DATA SOURCES: We searched for potential workforce data sources in nine databases (MEDLINE, Embase, Ovid Emcare, Scopus, Web of Science, Informit, the JBI Evidence-based Practice Database, PsycINFO and the Cochrane Library) and the grey literature, and examined several pre-defined websites. DATA SYNTHESIS: During the screening process we identified 6955 abstracts and examined 48 websites, from which we identified 12 publicly available data sources - eight primary and four secondary data sources. The primary data sources were generally of modest quality, with low scores in terms of reference period, accessibility and missing data. No single primary data source scored well across all domains of the appraisal tool. CONCLUSION: We identified several limitations of data sources used to describe the Australian health workforce. Establishment of a high quality, longitudinal, linked database that can inform all aspects of health workforce development is urgently needed, particularly for rural health workforce and services planning. CHAPTER 6: RAPID REALIST REVIEW OF OPIOID TAPERING IN THE CONTEXT OF LONG TERM OPIOID USE FOR NON-CANCER PAIN IN RURAL AREAS: Objective: To describe interventions, barriers and enablers associated with opioid tapering for patients with chronic non-cancer pain in rural primary care settings. STUDY DESIGN: Rapid realist review registered on the international register of systematic reviews (PROSPERO) and conducted in accordance with RAMESES standards. DATA SOURCES: English language, peer-reviewed articles reporting qualitative, quantitative and mixed method studies, published between January 2016 and July 2020, and accessed via MEDLINE, Embase, CINAHL Complete, PsycINFO, Informit or the Cochrane Library during June and July 2020. Grey literature relating to prescribing,deprescribing or tapering of opioids in chronic non-cancer pain, published between January 2016 and July 2020, was identified by searching national and international government, health service and peek organisation websites using Google Scholar. DATA SYNTHESIS: Our analysis of reported approaches to tapering conducted across rural and non-rural contexts showed that tapering opioids is complex and challenging, and identified several barriers and enablers. Successful outcomes in rural areas appear likely through therapeutic relationships, coordination and support, by using modalities and models of care that are appropriate in rural settings and by paying attention to harm minimisation. CONCLUSION: Rural primary care providers do not have access to resources available in metropolitan centres for dealing with patients who have chronic non-cancer pain and are taking opioid medications. They often operate alone or in small group practices, without peer support and access to multidisciplinary and specialist teams. Opioid tapering approaches described in the literature include regulation, multimodal and multidisciplinary approaches, primary care provider support, guidelines, and patient-centred strategies. There is little research to inform tapering in rural contexts. Our review provides a synthesis of the current evidence in the form of a conceptual model. This preliminary model could inform the development of a model of care for use in implementation research, which could test a variety of mechanisms for supporting decision making, reducing primary care providers' concerns about potential harms arising from opioid tapering, and improving patient outcomes.

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline.

BACKGROUND: The burden of knee replacement prosthetic joint infection (KR PJI) is increasing. KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions. AIM: To provide guidelines for surgeons and units treating KR PJI. METHODS: Guideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings. RESULTS: Improved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT. This document outlines practice guidelines for units providing a KR PJI service and sets out: CONCLUSIONS: KR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.

The effect of the introduction of an electronic booking system to appropriately prioritise gastroscopies at a regional hospital in South Africa.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) guidelines state that patients with dyspepsia as well as alarm symptoms, or those that are 55 years and older with new onset dyspepsia, urgently require an upper endoscopy within two weeks. The 'Be Clear on Cancer Campaign' launched by Public Health England estimated that 9% of deaths due to gastric and oesophageal cancers could have been avoided if the diagnosis was made at an earlier stage. Worcester Provincial Hospital (WPH) is a regional hospital in the Western Cape, South Africa, that due to resource constraints was unable to comply with these guidelines. An electronic endoscopy booking system was implemented in June 2014 to assist referring clinicians. OBJECTIVES: To evaluate the ability of the booking system to appropriately prioritise and accommodate clinically appropriate patients for an urgent gastroscopy within 2 weeks at WPH. METHODS: Retrospective analysis of patients booked for urgent gastroscopies using the online booking system at WPH from July 2014 to June 2017. RESULTS: A total of 1 589 gastroscopies were performed, with 1 085 (65%) categorised as urgent by the booking system algorithm, during the study period. The median (interquartile range) waiting time for urgent gastroscopies was 19 (8 - 31) days and 437 (40%) patients underwent a gastroscopy within the recommended 2-week period. Of the patients undergoing gastroscopy within 2 weeks, 87 (20%) were diagnosed with upper gastrointestinal malignancies and 73 (17%) had significant benign pathology (stricture or ulcer). A total of 150 malignancies were diagnosed in the urgent patients of whom 87 (58%) were scoped within 2 weeks. CONCLUSIONS: The volume of patients requiring urgent gastroscopy at WPH outstrips the available resources. The introduction of the online algorithm-based booking system was effective in prioritising patients. The use of this system facilitated a malignancy diagnosis rate which compares favourably with similar fast track endoscopy services in more developed countries.

COVID-19 outbreak: organisation of a geriatric assessment and coordination unit. A French example.

Older people are particularly affected by the COVID-19 outbreak because of their vulnerability as well as the complexity of health organisations, particularly in the often-compartmentalised interactions between community, hospital and nursing home actors. In this endemic situation, with massive flows of patients requiring holistic management including specific and intensive care, the appropriate assessment of each patient's level of care and the organisation of specific networks is essential. To that end, we propose here a territorial organisation of health care, favouring communication between all actors. This organisation of care is based on three key points: To use the basis of territorial organisation of health by facilitating the link between hospital settings and geriatric sectors at the regional level.To connect private, medico-social and hospital actors through a dedicated centralised unit for evaluation, geriatric coordination of care and decision support. A geriatrician coordinates this multidisciplinary unit. It includes an emergency room doctor, a supervisor from the medical regulation centre (Centre 15), an infectious disease physician, a medical hygienist and a palliative care specialist.To organise an ad hoc follow-up channel, including the necessary resources for the different levels of care required, according to the resources of the territorial network, and the creation of a specific COVID geriatric palliative care service. This organisation meets the urgent health needs of all stakeholders, facilitating its deployment and allows the sustainable implementation of a coordinated geriatric management dynamic between the stakeholders on the territory.

Regionalization of Lung Cancer Surgery Improves Outcomes in an Integrated Health Care System.

BACKGROUND: Current literature favors a volume-outcome relationship in pulmonary lobectomy that prompted centralization of these operations abroad, in national, single-payer health care settings. This study examined the impact of regionalization on outcomes after lung cancer resection within a US integrated health care system. METHODS: This study retrospectively reviewed major pulmonary resections (lobectomy, bilobectomy, pneumonectomy) for lung cancer that were performed before (2011 to 2013; n = 782) and after (2015 to 2017; n = 845) thoracic surgery regionalization during 2014. RESULTS: Case migration from 16 regionwide sites to 5 designated centers was complete by 2016. Facility volume increased from 17.4 to 48.3 cases/y (P = .002), and surgeon volume increased from 12.5 to 19.9 cases/y (P = .001). The postregionalization era was characterized by increased video-assisted thoracoscopic surgery (86% from 57%; P < .001), as well as decreased intensive care unit use (-1.0 days; P < .001) and hospital length of stay (-3.0 days; P < .001). Postregionalization patients experienced fewer total (26.2% from 38.6%; P < .001) and major (9.6% from 13.6%; P = .01) complications. The association between regionalization and decreased length of stay and morbidity was independent of surgical approach and case volume in mixed multivariate models. CONCLUSIONS: After the successful implementation of thoracic surgery regionalization in our US health care network, pulmonary resection volume increased, and practice shifted to majority video-assisted thoracoscopic surgery and minimum intensive care unit utilization. Regionalization was independently associated with significant reductions in length of stay and morbidity.

Exploration of Disparities in Regions and Specialized Fields of Day Surgery System.

The main objective of this paper was to find similarities among eight Slovak regions from the viewpoint of five specialized day surgery fields and among specialized day surgery fields from the viewpoint of Slovak regions on the basis of day surgery operated and hospitalized patient counts. Day surgery data of paediatric patients and of adult patients from the National Health Information Centre during the years 2009-2017 were used. Correspondence analysis in two dimensions of the Slovak regions and of specialized day surgery fields was applied in order to achieve the paper's objective. The Kosice Region differs most from the overall national average in both groups of paediatric day surgery. This is caused by its largest proportions in the fields of Gynaecology (29.7%) and Urology (48.0%) (operated patients), and in the fields of Gynaecology (60.5%) and Surgery (21.6%) (hospitalized patients). The most different specialized day surgery fields from overall average are: Urology (operated paediatric patients), Gynaecology (hospitalized paediatric patients), Otorhinolaryngology (operated adult patients) and Ophthalmology (hospitalized adult patients). Urogenital system day surgery procedures (Gynaecology, Urology) are separated from other three fields (i.e., Surgery, Ophthalmology, Otorhinolaryngology) either in the first or in the second dimension of the singular value matrix decomposition.

Adjuvant endocrine therapy for breast cancer patients: impact of a health system outreach program to improve adherence.

PURPOSE: Reports suggest that up to 50% of women with hormone receptor-positive (HR+) breast cancer (BC) do not complete the recommended 5 years of adjuvant endocrine therapy (AET). We examined the impact of an outreach program at Kaiser Permanente Northern California (KPNC) on adherence and discontinuation of AET among patients who initiated AET. METHODS: We assembled a retrospective cohort of all KPNC patients diagnosed with HR+, stage I-III BC initiating AET before (n = 4287) and after (n = 3580) implementation of the outreach program. We compared adherence proportions and discontinuation rates before and after program implementation, both crude and adjusted for age, race/ethnicity, education, income, and stage. We conducted a pooled analysis of data from six Cancer Research Network (CRN) sites that had not implemented programs for improving AET adherence, using identical methods and time periods, to assess possible secular trends. RESULTS: In the pre-outreach period, estimated adherence in years 1, 2, and 3 following AET initiation was 75.2%, 71.0%, and 67.3%; following the outreach program, the estimates were 79.4%, 75.6%, and 72.2% (p-values < .0001 for pairwise comparisons). Results were comparable after adjusting for clinical and demographic factors. The estimated cumulative incidence of discontinuation was 0.22 (0.21-0.24) and 0.18 (0.17-0.19) at 3 years for pre- and post-outreach groups (p-value < .0001). We found no evidence of an increase in adherence between the study periods at the CRN sites with no AET adherence program. CONCLUSION: Adherence and discontinuation after AET initiation improved modestly following implementation of the outreach program.

Lessons learned from relocating an acute surgical unit to a new quaternary referral centre in Adelaide, South Australia: a tale of two hospitals.

BACKGROUND: On 4 September 2017, patient care was relocated from one quaternary hospital that was closing, to another proximate greenfield site in Adelaide, Australia, this becoming the new Royal Adelaide Hospital. There are currently no data to inform how best to transition hospitals. We conducted a 12-week prospective study of admissions under our acute surgical unit to determine the impact on our key performance indicators. We detail our results and describe compensatory measures deployed around the move. METHODS: Using a standard proforma, data were collected on key performance indicators for acute surgical unit patients referred by the emergency department (ED). This was supplemented by data obtained from operative management software and coding data from medical records to build a database for analysis. RESULTS: Five hundred and eight patients were admitted during the study period. Significant delays were seen in times to surgical referral, surgical review and leaving the ED. Closely comparable was time spent in the surgical suite. Uptake of the Ambulatory Care Pathway fell by 67% and the Rapid Access Clinic by 46%. Overall mortality and patient length of stay were not affected. CONCLUSION: We found the interface with ED was most affected. Staff encountered difficulties familiarizing with a new environment and an anecdotally high number of ED presentations. Delays to referral and surgical review resulted in extended patient stay in ED. Once in theatre, care was comparable pre- and post-transition. This was likely from early identification of patients requiring an emergency operation, close consultant surgeon involvement and robust working relationships between surgeons, anaesthetists and nurses.

Regional oncology network between pancreatic centers safeguards waiting times for pancreatoduodenectomy.

Pancreatoduodenectomy (PD) is increasingly performed in high-volume centers, which may compromise waiting times. The aim of this study was to evaluate patient flow and outcome of PD within a regional oncology network of two high-volume centers. A post hoc analysis of a partially retrospective and prospective database was performed of all patients who underwent PD for pancreatic or periampullary neoplasms in both centers of the Gastrointestinal Oncology Center Amsterdam, a collaboration between an academic center and affiliated general teaching hospital, from 2010 to 2014. Outcomes included waiting time to surgery and postoperative morbidity and mortality. A total of 525 PDs were performed, 329 in the academic center (annual volume 66) and 196 in the teaching hospital (annual volume 39). Neoadjuvant treatment was more often used in the academic center, other baseline characteristics were similar. Overall time to surgery was 26 days, which was significantly less in the teaching hospital. The major postoperative morbidity rate was 38.3% (n = 201), and the 30- and 90-day mortality was 2.3% and 3.6%. A regional oncology network between an academic center and a general teaching hospital for PD can be an attractive option to safeguard waiting times in selected patients, without compromising outcome.

Tuberculosis infection control in a South African rural regional hospital emergency centre: Prioritisation for patients and healthcare workers.

South Africa (SA) is in the midst of a tuberculosis (TB) epidemic and has one of the highest TB incidence rates globally. Despite increasing global commitment to eliminate TB, SA appears to be falling behind in this regard. This article examines key challenges to effective TB infection control from a rural regional hospital perspective. It uses the Eden District in Western Cape Province as an example to share lessons learnt. This quality-improvement project identifies four priorities for improving TB infection control in George Hospital and the Eden District: (i) prioritising TB infection control in local policy; (ii) improving the quality of TB screening in the emergency centre; (iii) increasing the number of TB patients followed up; and (iv) implementing TB infection control training for all staff. This project demonstrates the role of an emergency centre in TB screening, highlighting that this should not only be a priority for primary care, but also for secondary and tertiary care. Simple interventions, such as training of local healthcare workers in TB infection control and good-quality TB screening, can initiate a behavioural change. It also stresses the importance of good communication and co-ordination of care across primary and secondary care, ensuring that patients are not lost to follow-up. Local policy needs to reflect these straightforward interventions, empowering local healthcare workers and managers to increase responsibility and accountability for TB infection control.TB is preventable, and infection control needs to become a priority throughout SA primary, secondary and tertiary care. This project highlights that simple interventions, such as engaging local healthcare workers in a co-ordinated multisystem and multidisciplinary approach, could help to reduce the number of missing TB cases and bring SA's TB epidemic under control.