Improving patients' experiences of diagnosis and treatment of vertebral fracture: co-production of knowledge sharing resources.

BACKGROUND: Osteoporosis involves changes to bones that makes them prone to fracture. The most common osteoporotic fracture is vertebral, in which one or more spinal vertebrae collapse. People with vertebral fracture are at high risk of further fractures, however around two-thirds remain undiagnosed. The National Institute for Health and Care Excellence (NICE) recommends bone protection therapies to reduce this risk. This study aimed to co-produce a range of knowledge sharing resources, for healthcare professionals in primary care and patients, to improve access to timely diagnosis and treatment. METHODS: This study comprised three stages: 1. In-depth interviews with primary care healthcare professionals (n = 21) and patients with vertebral fractures (n = 24) to identify barriers and facilitators to diagnosis and treatment. 2. A taxonomy of barriers and facilitators to diagnosis were presented to three stakeholder groups (n = 18), who suggested ways of identifying, diagnosing and treating vertebral fractures. Fourteen recommendations were identified using the nominal group technique. 3. Two workshops were held with stakeholders to co-produce and refine the prototype knowledge sharing resources (n = 12). RESULTS: Stage 1: Factors included lack of patient information about symptoms and risk factors, prioritisation of other conditions and use of self-management. Healthcare professionals felt vertebral fractures were harder to identify in lower risk groups and mistook them for other conditions. Difficulties in communication between primary and secondary care meant that patients were not always informed of their diagnosis, or did not start treatment promptly. Stage 2: 14 recommendations to improve management of vertebral fractures were identified, including for primary care healthcare professionals (n = 9) and patients (n = 5). Stage 3: The need for allied health professionals in primary care to be informed about vertebral fractures was highlighted, along with ensuring that resources appealed to under-represented groups. Prototype resources were developed. Changes included help-seeking guidance and clear explanations of medical language. CONCLUSIONS: The study used robust qualitative methods to co-produce knowledge sharing resources to improve diagnosis. A co-production approach enabled a focus on areas stakeholders thought to be beneficial to timely and accurate diagnosis and treatment. Dissemination of these resources to a range of stakeholders provides potential for substantial reach and spread.

Multiple hospital organisational factors are associated with adverse patient outcomes post-hip fracture in England and Wales: the REDUCE record-linkage cohort study.

OBJECTIVES: Despite established standards and guidelines, substantial variation remains in the delivery of hip fracture care across the United Kingdom. We aimed to determine which hospital-level organisational factors predict adverse patient outcomes in the months following hip fracture. METHODS: We examined a national record-linkage cohort of 178,757 patients aged ≥60 years who sustained a hip fracture in England and Wales in 2016-19. Patient-level hospital admissions datasets, National Hip Fracture Database and mortality data were linked to metrics from 18 hospital-level organisational-level audits and reports. Multilevel models identified organisational factors, independent of patient case-mix, associated with three patient outcomes: length of hospital stay (LOS), 30-day all-cause mortality and emergency 30-day readmission. RESULTS: Across hospitals mean LOS ranged from 12 to 41.9 days, mean 30-day mortality from 3.7 to 10.4% and mean readmission rates from 3.7 to 30.3%, overall means were 21.4 days, 7.3% and 15.3%, respectively. In all, 22 organisational factors were independently associated with LOS; e.g. a hospital's ability to mobilise >90% of patients promptly after surgery predicted a 2-day shorter LOS (95% confidence interval [CI]: 1.2-2.6). Ten organisational factors were independently associated with 30-day mortality; e.g. discussion of patient experience feedback at clinical governance meetings and provision of prompt surgery to >80% of patients were each associated with 10% lower mortality (95%CI: 5-15%). Nine organisational factors were independently associated with readmissions; e.g. readmissions were 17% lower if hospitals reported how soon community therapy would start after discharge (95%CI: 9-24%). CONCLUSIONS: Receipt of hip fracture care should be reliable and equitable across the country. We have identified multiple, potentially modifiable, organisational factors associated with important patient outcomes following hip fracture.

Neglected bodily senses in women living with vertebral fracture: a focus group study.

OBJECTIVE: Older women are at particular risk of osteoporosis. Among women with osteoporosis, fractures of the vertebra (vertebral fracture) are common, hard to detect and associated with risk of further fracture. Identifying vertebral fracture in a timely manner allows instigation of preventive measures to reduce the risk of further fracture. Although detection of vertebral fracture requires spinal radiograph, many women do not receive referral. To begin development of a screening tool to identify women in need of referral we undertook a qualitative study to characterize women's experiences of vertebral fracture, using Eccleston's 'Ten Neglected Bodily Senses'. METHODS: Four qualitative focus groups were conducted with women who had been diagnosed with vertebral fracture (n = 19, age 60-91 years). Data were audio-recorded, transcribed and analysed thematically using the 'Ten Neglected Bodily Senses'. RESULTS: Women's experiences of vertebral fractures related to seven senses: pain, movement, fatigue, balance, pressure, appetite and breathing. Pain was the dominant sense and all participants explained how pain increased with activity, reaching a crescendo, and described strategies to minimize this disruption. Most participants had become physically shorter, making some feel 'squashed', putting pressure on other body parts. Some described appetite loss or a sense of restricted breathing. Participants experienced a sense of being 'pulled' forwards, impacting on balance and exacerbating fear of falling. CONCLUSION: The study found senses that have not been previously described in the experiences of women with vertebral fracture. These will be used to inform the design of a new screening tool for use in primary care.

Fertility Preservation Toolkit: A Clinician Resource to Assist Clinical Discussion and Decision Making in Pediatric and Adolescent Oncology.

PURPOSE: Fertility preservation (FP) discussions in children with cancer presents unique challenges due to ethical considerations, lack of models-of-care, and the triadic nature of discussions. This study evaluated a fertility toolkit for clinicians involved in FP discussions with pediatric, adolescent, and young adult patients and parents. MATERIALS AND METHODS: A survey-based, longitudinal study of clinicians at The Royal Children's Hospital Melbourne involved in FP discussions undertaken at 3 time-points: 2014, alongside an education session for baseline assessment of oncofertility practices (survey 1); after each toolkit use to evaluate case-specific implementation (survey 2); 2016, to evaluate impact on clinical practice (survey 3). RESULTS: Fifty-nine clinicians completed survey 1. Over 66% reported baseline dissatisfaction with the existing FP system; 56.7% were not confident in providing up-to-date information. Only 34.5% "often" or "always" provided verbal information; 14.0% "often" or "always" provided written information. Survey 2 was completed after 11 consultations. All clinicians were satisfied with the discussions and outcomes using the toolkit. Thirty-nine clinicians completed survey 3. Over 70% felt confident providing up-to-date FP knowledge, 67.7% "often" or "always" provided verbal information, and 35.4% "often" or "always" provided written information. CONCLUSIONS: Clinicians desire improvement in FP practice. The toolkit provided significant perceived and actual benefits.

Information needs of adolescent and young adult cancer patients and their parent-carers.

PURPOSE: This study aimed to explore health-related information needs of adolescent and young adults (AYAs) and their parent-carers and to examine demographic and clinical variables associated with unmet information needs, including patient activation. METHODS: In a national cross-sectional study, 196 Australian AYAs diagnosed with cancer between 15 and 25 years and within 24 months of diagnosis and 204 parent-carers reported on total and unmet needs for cancer and health-related information. Fifty-one percent of AYAs were male, 81% had completed treatment and 86% were treated in adult hospitals. RESULTS: AYAs and parents reported high levels of total need for information. The mean number of unmet needs was 5.63 and 6.82 for AYAs and parents, respectively. AYAs reported the highest unmet needs in relation to their cancer (e.g. late effects and cancer recurrence, and having children in the future). The highest unmet parent information needs were related to medical information about their child as well as information on financial issues for their children and themselves. Unmet information need was associated with psychological distress (posttraumatic stress symptoms) for AYAs and parents. Patient activation was negatively associated with unmet information needs for AYAs. Demographic and treatment variables were not significantly associated with information needs. CONCLUSION: These findings indicate the importance of information needs for AYAs and their carers. The association between patient activation and information needs suggests that promoting young people's engagement with healthcare is a key opportunity within AYA care. Parent information needs and associated emotional distress additionally highlight the importance of family-centered care.

What factors impact on the implementation of clubfoot treatment services in low and middle-income countries?: a narrative synthesis of existing qualitative studies.

BACKGROUND: Around 100,000 children are born annually with clubfoot worldwide and 80% live in low and middle-income counties (LMICs). Clubfoot is a condition in which children are born with one or both feet twisted inwards and if untreated it can limit participation in everyday life. Clubfoot can be corrected through staged manipulation of the limbs using the Ponseti method. Despite its efficacy and apparent availability, previous research has identified a number of challenges to service implementation. The aim of this study was to synthesise these findings to explore factors that impact on the implementation of clubfoot services in LMICs and strategies to address them. Understanding these may help practitioners in other settings develop more effective services. METHODS: Five databases were searched and articles screened using six criteria. Articles were appraised using the Critical Appraisal Skills Programme (CASP) checklist. 11 studies were identified for inclusion. A thematic analysis was conducted. RESULTS: Thematic analysis of the included studies showed that a lack of access to resources was a challenge including a lack of casting materials and abduction braces. Difficulties within the working environment included limited space and a need to share treatment space with other clinics. A shortage of healthcare professionals was a concern and participants thought that there was a lack of time to deliver treatment. This was exacerbated by the competing demands on clinicians. Lack of training was seen to impact on standards, including the nurses and midwives attending to the child at birth that were failing to diagnose the condition. Financial constraints were seen to underlie many of these problems. Some participants identified failures in communication and cooperation within the healthcare system such as a lack of awareness of clinics. Strategies to address these issues included means of increasing resource availability and the delivery of targeted training. The use of non-governmental organisations to provide financial support and methods to disseminate best practice were discussed. CONCLUSIONS: This study identified factors that impact on the implementation of clubfoot services in LMIC settings.Findings may be used to improve service delivery.

Unmet need for healthcare services in adolescents and young adults with cancer and their parent carers.

PURPOSE: Cancer in adolescents in and young adults (AYA) has the potential to disrupt health, well-being and developmental trajectories. This study aimed to describe the healthcare support service needs of AYAs with cancer and parent carers and to explore the association of unmet need and emotional distress. METHODS: As part of a national Australian survey of 15-25 year olds with cancer and a nominated parent carer, 196 AYAs reported total and unmet need for 10 clinical services and 204 parents reported on their child's and their own healthcare service needs. Proportions of total and unmet need for specific clinical services are reported. The association of unmet service needs and distress (measured using the Posttraumatic Stress Disorder Checklist) was also examined. RESULTS: AYAs and parent carers expressed high total need for clinical services during treatment. Leading AYA unmet needs were for an exercise therapist (37%), genetic counsellor (30%), dietitian (26%), peer support group (26%) and educational and vocational advisor (24%). After treatment, AYAs and parents had fewer total needs. However, 60% of AYA and 38% of parents had two or more unmet needs, similar to during treatment. Female gender and receiving treatment in an adult setting were significantly associated with unmet need for clinical services. After treatment, higher distress levels in AYAs and parents were associated with two or more unmet service needs. DISCUSSION: AYAs and parents had high levels of total and unmet service need, which were associated with greater emotional distress. These results highlight opportunities to re-orientate services to better meet AYA and parent needs.

What factors affect patient access and engagement with clubfoot treatment in low- and middle-income countries? Meta-synthesis of existing qualitative studies using a social ecological model.

OBJECTIVES: To conduct a systematic synthesis of previous research to identify factors that affect treatment-seeking for clubfoot and community-level interventions to improve engagement in low- and middle-income counties. METHODS: A search of five databases was conducted, and articles screened using six criteria. Quality was appraised using the Critical Appraisal Skills Programme checklist. Eleven studies were identified for inclusion. Analysis was informed by a social ecological model, which specifies five inter-related factors that may affect treatment-seeking: intrapersonal, interpersonal, institutional, community or socio-cultural factors and public policy. RESULTS: Intrapersonal barriers experienced were a lack of income and additional responsibilities. At the interpersonal level, support from fathers, the extended family and wider community affected on treatment-seeking. Institutional or organisational factors included long distances to treatment centres, insufficient information about treatments and challenges following treatment. Guardians' beliefs about the causes of clubfoot shaped behaviour. At the level of public policy, two-tiered healthcare systems made it difficult for some groups to access timely care. Interventions to address these challenges included counselling sessions, outreach clinics, brace recycling and a range of education programmes. CONCLUSIONS: This study identifies factors that affect access and engagement with clubfoot treatment across diverse settings and strategies to address them.

Making the case for a fracture liaison service: a qualitative study of the experiences of clinicians and service managers.

BACKGROUND: To develop services, healthcare professionals must make business cases to managerial bodies within Hospital Trusts and if approved, to commissioning bodies. Patients with hip fracture are at high risk of subsequent fracture. To prevent this, guidance recommends structuring fracture prevention services around coordinator based models. These are known as Fracture Liaison Services (FLS). METHODS: 33 semi-structured qualitative interviews were conducted with healthcare professionals with experience of making business cases for FLS. Data was analysed thematically. RESULTS: Challenges in the development of business cases included collecting all the relevant data and negotiating compartmentalised budgets that impeded service development. Participants described communication and cooperation between providers and commissioners as variable. They felt financial considerations were the most important factor in funding decisions, while improved quality of care was less influential. Other factors included national guidelines and political priorities. The personalities of clinicians championing services, and the clinical interests of commissioners were seen to influence the decision-making process, suggesting that participants felt that decisions were not always made on the basis of evidence-based care. Effective strategies included ways of providing support, demonstrating potential cost effectiveness and improved quality of care. Using a range of sources including audit data collected on the successful Glasgow FLS, and improving cooperation between stakeholders was advocated. Participants felt that the work of commissioners and providers should be better integrated and suggested strategies for doing this. CONCLUSIONS: This study provides information to healthcare professionals about how best to develop business cases for FLS. We conclude with recommendations on how to develop effective cases. These include using guidance such as toolkits, aligning the aims of FLS with national priorities and benchmarking services against comparators. Introducing a 'Local Champion' to work alongside the service manager and establishing a multi-disciplinary working team would facilitate communication between stakeholders. Involving commissioners in service design would help integrate the roles of purchasers and providers.

Model of multidisciplinary teamwork in hip fracture care: a qualitative interview study.

OBJECTIVES: Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals' views about the core components of multidisciplinary teamwork in hip fracture care. DESIGN: The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork. SETTING: Four hospitals in England. PARTICIPANTS: Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers. RESULTS: Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed. CONCLUSIONS: Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies.

An online clinical decision tool to screen for vertebral fragility fractures (Vfrac) in older women presenting with back pain in general practice: protocol for a feasibility study in preparation for a future cluster randomised controlled trial.

This feasibility study for a future definitive randomized trial assesses the use and acceptability of a new clinical decision tool to identify risk of a vertebral fracture and those who should be referred for spinal radiography in women aged 65 or over presenting to primary care with back pain. PURPOSE: Approximately 12% of older adults have vertebral fragility fractures, but currently fewer than one-third are diagnosed, potentially limiting access to bone protection treatment. Vfrac is a vertebral fracture screening tool which classifies individuals into high or low risk of having a vertebral fracture, allowing targeting of spinal radiographs to high-risk individuals. The objective of this study was to investigate the feasibility of conducting a cluster randomized controlled trial to evaluate the use of an online version of Vfrac in primary care. METHODS: The study will run in six general practices, with three given the Vfrac tool for use on older women (> 65 years) consulting with back pain and three using standard clinical processes for managing such back pain. Anonymised data covering a 12-month period will be collected from all sites on consultations by older women with back pain. Focus groups will be undertaken with healthcare professionals and patients on whom the tool was used to understand the acceptability of Vfrac and identify factors that impact its use. These patients will be sent a paper version of the Vfrac questionnaire to self-complete at home. Outputs of the self-completion Vfrac (high versus low risk) will be compared with the face-to-face Vfrac (high versus low risk), and agreement assessed using Cohen's kappa. RESULTS: This study will evaluate the use and acceptability of Vfrac within primary care and determine if data on resource use can be collected accurately and comprehensively. CONCLUSIONS: This article describes the protocol of the Vfrac feasibility study. TRIAL REGISTRATION: ISRCTN18000119 (registered 01/03/2022) and ISRCTN12150779 (registered 10/01/2022).

Screening for psychological well-being in childhood cancer survivors: a preliminary assessment of the feasibility of the strength and difficulties questionnaire as a parent-proxy report.

This article describes the feasibility of utilizing the Strengths and Difficulties Questionnaire (SDQ) as a brief psychosocial screener among survivors of pediatric cancer. Participants were parents of a child/adolescent diagnosed with cancer who were off treatment (n = 35) and a subset of adolescents (n = 14). Parent-proxy report using the SDQ was significantly associated with the Child Health Questionnaire. Parents who self-reported long-term uncertainty about their child's illness were more likely to report child psychosocial difficulties. A trend for concordance between patient and parent-proxy report of the SDQ was observed. These preliminary results highlight the potential utility of the SDQ as a screening tool for detection of child/adolescent psychosocial well-being. Further research, with larger samples, is needed to support these results.

REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE): protocol for a mixed-methods study.

INTRODUCTION: Substantial variation in the delivery of hip fracture care, and patient outcomes persists between hospitals, despite established UK national standards and guidelines. Patients' outcomes are partly explained by patient-level risk factors, but it is hypothesised that organisational-level factors account for the persistence of unwarranted variation in outcomes. The mixed-methods REducing unwarranted variation in the Delivery of high qUality hip fraCture services in England and Wales (REDUCE) study, aims to determine key organisational factors to target to improve patient care. METHODS AND ANALYSIS: Quantitative analysis will assess the outcomes of patients treated at 172 hospitals in England and Wales (2016-2019) using National Hip Fracture Database data combined with English Hospital Episodes Statistics; Patient Episode Database for Wales; Civil Registration (deaths) and multiple organisational-level audits to characterise each service provider. Statistical analyses will identify which organisational factors explain variation in patient outcomes, and typify care pathways with high-quality consistent patient outcomes. Documentary analysis of 20 anonymised British Orthopaedic Association hospital-initiated peer-review reports, and qualitative interviews with staff from four diverse UK hospitals providing hip fracture care, will identify barriers and facilitators to care delivery. The COVID-19 pandemic has posed a major challenge to the resilience of services and interviews will explore strategies used to adapt and innovate. This system-wide understanding will inform the development, in partnership with key national stakeholders, of an 'Implementation Toolkit' to inform and improve commissioning and delivery of hip fracture services. ETHICS AND DISSEMINATION: This study was approved: quantitative study by London, City and East Research Ethics Committee (20/LO/0101); and qualitative study by Faculty of Health Sciences University of Bristol Research Ethics Committee (Ref: 108284), National Health Service (NHS) Health Research Authority (20/HRA/71) and each NHS Trust provided Research and Development approval. Findings will be disseminated through scientific conferences, peer-reviewed journals and online workshops.

Visual storytelling: a beneficial but challenging method for health research with young people.

Visual storytelling is a new research approach drawing on established methods of photovoice and photo elicitation. It appears well suited to research with young people. We explored the feasibility of this approach, reflecting on benefits and challenges encountered while using it during a study of chronic disease self-management in adolescents. During in-depth interviews, 68 participants were questioned about the value of visual storytelling. Thematic analysis was applied. Visual storytelling was valued for (a) being a draw card during recruitment and increasing positive feelings about the research; (b) being fun; (c) promoting self-understanding; and (d) promoting expression, communication, and focus during interviews. Deciding what to photograph was difficult. More time and effort was required by researchers than for a standard qualitative interview study. The technique facilitated rich interviews, drawing into focus details of young peoples' lives that otherwise might not have been discussed.

Harnessing complexity: taking advantage of context and relationships in dissemination of school-based interventions.

Schools and school systems are increasingly asked to use evidence-based strategies to promote the health and well-being of students. The dissemination of school-based health promotion research, however, offers particular challenges to conventional approaches to dissemination. Schools and education systems are multifaceted organizations that sit within constantly shifting broader contexts. This article argues that health promotion dissemination needs to be rethought for school communities as complex systems and that this requires understanding and harnessing the dynamic ecology of the sociopolitical context. In developing this argument, the authors draw on their experience of the dissemination process of a multilevel school-based intervention in a complex educational context. Building on this experience, they argue for the need to move beyond conventional dissemination strategies to a focus on active partnerships between developers and users of school-based intervention research and offer a conceptual tool for planning dissemination.

Understanding the role of GPs' gut feelings in diagnosing cancer in primary care: a systematic review and meta-analysis of existing evidence.

BACKGROUND: Growing evidence for the role of GPs' gut feelings in cancer diagnosis raises questions about their origin and role in clinical practice. AIM: To explore the origins of GPs' gut feelings for cancer, their use, and their diagnostic utility. DESIGN AND SETTING: Systematic review and meta-analysis of international research on GPs' gut feelings in primary care. METHOD: Six databases were searched from inception to July 2019, and internet searches were conducted. A segregated method was used to analyse, then combine, quantitative and qualitative findings. RESULTS: Twelve articles and four online resources were included that described varied conceptualisations of gut feelings. Gut feelings were often initially associated with patients being unwell, rather than with a suspicion of cancer, and were commonly experienced in response to symptoms and non-verbal cues. The pooled odds of a cancer diagnosis were four times higher when gut feelings were recorded (OR 4.24, 95% confidence interval = 2.26 to 7.94); they became more predictive of cancer as clinical experience and familiarity with the patient increased. Despite being included in some clinical guidelines, GPs had varying experiences of acting on gut feelings as some specialists questioned their diagnostic value. Consequently, some GPs ignored or omitted gut feelings from referral letters, or chose investigations that did not require specialist approval. CONCLUSION: GPs' gut feelings for cancer were conceptualised as a rapid summing up of multiple verbal and non-verbal patient cues in the context of the GPs' clinical knowledge and experience. Triggers of gut feelings not included in referral guidance deserve further investigation as predictors of cancer. Non-verbal cues that trigger gut feelings appear to be reliant on continuity of care and clinical experience; they tend to remain poorly recorded and are, therefore, inaccessible to researchers.

Enhanced Recovery After Surgery implementation in practice: an ethnographic study of services for hip and knee replacement.

OBJECTIVES: Enhanced Recovery After Surgery (ERAS) programmes aim to improve care quality by optimising components of the care pathway and programmes for hip and knee replacement exist across the UK. However, there is variation in delivery and outcomes. This study aims to understand processes that influence implementation using the Consolidated Framework for Implementation Research (CFIR) to inform the design and delivery of services. DESIGN: An ethnographic study using observations and interviews with staff involved in service delivery. Data were analysed using a thematic analysis, followed by an abductive approach whereby themes were mapped onto the 31 constructs and 5 domains of the CFIR. SETTING: Four hospital sites in the UK delivering ERAS services for hip and knee replacement. PARTICIPANTS: 38 staff participated including orthopaedic surgeons, nurses and physiotherapists. RESULTS: Results showed 17 CFIR constructs influenced implementation in all five domains. Within 'intervention characteristics', participants thought ERAS afforded advantages over alternative solutions and guidance was adaptable. In the 'outer setting', it was felt ERAS should be tailored to patients and education used to empower them in their recovery. However, there were concerns about postdischarge support and tensions with primary care. Within the 'inner setting', effective multidisciplinary collaboration was achieved by transferring knowledge about patients along the care pathway and multidisciplinary working practices. ERAS was viewed as a 'message' that had to be communicated consistently. There were concerns about resources and high volumes of patients. Staff access to information varied. At the domain 'characteristics of individuals', knowledge and beliefs impacted on implementation. Within 'process', involving opinion leaders in development and 'champions' who acted as a central point of contact, helped to engage staff. Formal and informal feedback helped to develop services. CONCLUSIONS: Findings demonstrate successful implementation involves empowering patients to work towards recovery, providing postdischarge support and promoting successful multidisciplinary team working.

The changing nature of social support for adolescents and young adults with cancer.

PURPOSE: The aim of this study was to explore adolescent and young adult (AYA) experiences and preferences for social support early within the continuum of cancer treatment. METHODS: AYAs aged 15-25 years old at diagnosis were recruited from 6 clinical services that were purposively selected for providing specialist cancer care to AYAs across 3 Australian states and within paediatric and adult services. In-depth, semi-structured interviews were conducted by telephone 6-24 months from diagnosis. The narrative-based interviews included preferences for psychosocial support. Interviews were transcribed and thematic analysis was undertaken using grounded theory methodology. RESULTS: 60 AYAs were interviewed (mean age 20.52 [SD 2.97] years; 58% male; 72% adult settings). Analysis revealed that parents provided the foundation of emotional, informational and instrumental social support, even for older AYAs and those with partners and children. Informal emotional engagement with cancer peers was strongly appreciated during hospital treatment, while healthy peers provided welcome diversion at this time and during the transition towards their usual life. Nurses and allied health staff provided informational support to hospitalised AYAs and also provided a strong source of emotional support. Formal peer support programs were not endorsed by AYAs early in treatment but appreciated to be of greater interest to some following treatment completion. CONCLUSION: Social support was predominantly provided by family, peers and health professionals. The sources and types of support most welcomed by AYAs varied according to the intensity and phase of cancer treatment and where the young person was in their cancer trajectory.

Adolescents with a chronic condition: challenges living, challenges treating.

In this review, we aim to focus attention on the interaction between adolescents with chronic conditions and the health systems that support them. At least 12% of adolescents live with a chronic condition. Some conditions are characterised by increasing incidence (eg, diabetes) or improving survival rates (eg, cystic fibrosis), while others are concerning because of differentially poorer outcomes in adolescents in comparison to both children and adults (eg cancer). Growing evidence suggests that young people with chronic conditions are doubly disadvantaged--engaging in risky behaviours to at least similar if not higher rates as healthy peers, while having the potential for greater adverse health outcomes from these behaviours. In addition to efforts at improving survival, in order to improve their life chances, we need to better understand how the social and emotional outcomes of young people with a chronic disease can be improved, and better support young people's emerging capacity for self-management.

Early Education and Employment Outcomes After Cancer in Adolescents and Young Adults.

PURPOSE: This study describes the early educational and vocational outcomes of Australian adolescents and young adults (AYAs) after cancer diagnosis and examines factors associated with these outcomes. METHODS: Within this cross-sectional national Australian study, 196 AYAs aged 15-25 years at cancer diagnosis and within 6-24 months of diagnosis were recruited from 18 sites. Participants completed a survey that included questions about school and work outcomes, support received regarding necessary changes to education and vocation, and validated measures of anxiety, depression, and post-traumatic stress. RESULTS: Almost half of the sample (43%) was not fully "back on track" with their previous educational and vocational plans. Post-traumatic stress and emotional symptoms were associated with poorer school/work functioning (ß = -0.95, p = 0.009 and ß = -1.27, p = 0.001, respectively). Higher PedsQL school/work functioning was associated with a slightly greater likelihood of being "back on track" with education and work plans (OR 1.03, p = 0.001). AYAs who felt well supported regarding changes to education and work plans more frequently reported receiving support from formal sources and from more sources than those who felt less supported. Unmet need of accessing an educational or vocational advisor was significantly more frequent in adult than in pediatric settings (42% vs. 17%; p = 0.024). Parents were the most common source of educational or vocational support for AYAs rather than professionals. CONCLUSION: This study highlights the connection between school and work participation and mental health in a national sample of AYAs with cancer. It suggests distinct benefits of educational and vocational support.