Equitable access to quality trauma systems in low-income and middle-income countries: assessing gaps and developing priorities in Ghana, Rwanda and South Africa.

Injuries in low-income and middle-income countries are prevalent and their number is expected to increase. Death and disability after injury can be reduced if people reach healthcare facilities in a timely manner. Knowledge of barriers to access to quality injury care is necessary to intervene to improve outcomes. We combined a four-delay framework with WHO Building Blocks and Institution of Medicine Quality Outcomes Frameworks to describe barriers to trauma care in three countries in sub-Saharan Africa: Ghana, South Africa and Rwanda. We used a parallel convergent mixed-methods research design, integrating the results to enable a holistic analysis of the barriers to access to quality injury care. Data were collected using surveys of patient experiences of injury care, interviews and focus group discussions with patients and community leaders, and a survey of policy-makers and healthcare leaders on the governance context for injury care. We identified 121 barriers across all three countries. Of these, 31 (25.6%) were shared across countries. More than half (18/31, 58%) were predominantly related to delay 3 ('Delays to receiving quality care'). The majority of the barriers were captured using just one of the multiple methods, emphasising the need to use multiple methods to identify all barriers. Given there are many barriers to access to quality care for people who have been injured in Rwanda, Ghana and South Africa, but few of these are shared across countries, solutions to overcome these barriers may also be contextually dependent. This suggests the need for rigorous assessments of contexts using multiple data collection methods before developing interventions to improve access to quality care.

Colorectal cancer with Synchronous liver-limited Metastases: the protocol of an Inception Cohort study (CoSMIC).

INTRODUCTION: Colorectal cancer is the fourth most common cancer in the UK and an important cause of cancer-related death. In 20% of patients, there is metastasis to the liver or beyond at the time of diagnosis. The management of synchronous disease is complex. Conventional surgery removes the colorectal primary first, followed by chemotherapy, with resection of liver metastases as a final step. Advances in the availability and safety of liver surgery, anaesthesia and critical care have made two alternative options feasible. The first is synchronous resection of the primary and liver metastases. The second is resection of the metastatic disease as the first step, termed the reverse or liver-first approach. Currently, evidence is inadequate to inform the selection of care pathway for patients with colorectal cancer and synchronous liver-limited metastases. Specifically, optimal pathways are not defined and there is a dearth of prospectively recorded cohort-defining factors influencing treatment selection or outcome. METHODS AND ANALYSIS: Colorectal cancer with Synchronous liver-limited Metastases: an Inception Cohort (CoSMIC) is an inception cohort study of patients with a new diagnosis of colorectal cancer with synchronous liver-limited metastases. The sequence of treatment received, and factors influencing treatment decisions, will be evaluated against European Society of Medical Oncology guidelines. Clinical data will be collected, and quality of life, morbidity, mortality and long-term outcome compared for different treatment sequences adjusted for prognostic factors. Disease-free survival or progression will be measured at 1, 2 and 5 years. A nested qualitative study will ascertain patient experiences and clinician perspectives on delivery of care. ETHICS AND DISSEMINATION: The full study protocol was independently peer reviewed by Professor Kees de Jong (University of Maastricht, Holland). CoSMIC has ethical approval from the National Health Service Research Ethics Committee (14/NW/1397). Results will be disseminated to healthcare professionals and patient groups, and may be used to design a definitive trial addressing areas of equipoise in treatment pathways, as well as optimising current pathways to improve outcomes and experiences. TRIAL REGISTRATION NUMBER: NCT02456285, pre-results.

Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study.

BACKGROUND: Person-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient's world. Patient-centeredness has been commonly defined through physician's behaviors aimed at delivering patient-centered care. Yet, it is unclear how 'person-centeredness' is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context. METHODS: We conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison. RESULTS: We identified six themes representing core 'ingredients' of person-centeredness in the integrated care context: "Holism", "Naming", "Heed", "Compassion", "Continuity of care", and "Agency and Empowerment", all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt 'unseen' by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional 'Space' to be 'seen' and heard vs. feeling 'translucent', 'unseen', and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a 'dyad', the meanings patients attributed to 'care', and the theoretical correspondence between 'person-centeredness' and 'integrated care'. CONCLUSIONS: Person-centeredness is a crucial issue for patients in integrated care, yet it was variably achieved in the current pilot. Patients in the context of integrated care, as in other contexts, strive to have their own unique physical and emotional 'space' to be 'seen' and heard. Integrated care models can benefit from incorporating person-centeredness as a core element.

Achieving provider engagement: providers' perceptions of implementing and delivering integrated care.

The literature on integrated care is limited with respect to practical learning and experience. Although some attention has been paid to organizational processes and structures, not enough is paid to people, relationships, and the importance of these in bringing about integration. Little is known, for example, about provider engagement in the organizational change process, how to obtain and maintain it, and how it is demonstrated in the delivery of integrated care. Based on qualitative data from the evaluation of a large-scale integrated care initiative in London, United Kingdom, we explored the role of provider engagement in effective integration of services. Using thematic analysis, we identified an evolving engagement narrative with three distinct phases: enthusiasm, antipathy, and ambivalence, and argue that health care managers need to be aware of the impact of professional engagement to succeed in advancing the integrated care agenda.

Integrated care pilot in north-west London: a mixed methods evaluation.

INTRODUCTION: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. METHODS: The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). RESULTS: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. CONCLUSION: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.