Establishing and maintaining a remote vascular surgery aortic program: A single-center 5-year experience at the Veterans Affairs.

OBJECTIVE: We sought to detail the process of establishing a surgical aortic telehealth program and report the outcomes of a 5-year experience. METHODS: A telehealth program was established between two regional Veterans Affairs hospitals, one of which was without a comprehensive aortic surgical program, until such a program was established at the referring institution. A retrospective review was performed of all patients who underwent aortic surgery from 2014 to 2019. The operative data, demographics, perioperative complications, and follow-up data were reviewed. RESULTS: From 2014 to 2019, 109 patients underwent aortic surgery for occlusive and aneurysmal disease. Preoperative evaluation and postoperative follow-up were done remotely via telehealth. The median age of the patients was 68 years, 107 were men (98.2%), 28 (25.7%) underwent open aortic repair, and 81 (74.3%) underwent endovascular repair. Of the 109 patients, 101 (92.7%) had a median follow-up of 24.3 months, 5 (4.6%) were lost to follow-up or were noncompliant, 2 (1.8%) were noncompliant with their follow-up imaging studies but responded to telephone interviews, and 1 (0.9%) moved to another state. At the 30-day follow-up, eight patients (7.3%) required readmission. Four complications were managed locally, and four patients (3.6%) required transfer back to the operative hospital for additional care. CONCLUSIONS: Telehealth is a great tool to provide perioperative care and long-term follow-up for patients with aortic pathologies in remote locations. Most postoperative care and complications can be managed remotely, and patient compliance for long-term follow-up is high.

Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative.

BACKGROUND AND OBJECTIVES: Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS: Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS: Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

Implementing an emergency department vascular access team: A quality review of training, competency, and outcomes.

Peripheral intravenous catheters are frequently used devices in emergency departments. Many patients now present with difficult anatomy and are labeled as difficult intravenous access patients. A common technology to address this challenge is ultrasound. While studies have examined the ability to train emergency staff, few have addressed how this should be done and the outcomes associated with such training. No studies were found with dedicated vascular access specialist teams in emergency departments. An emergency department vascular access specialist team was formed at a hospital in Bangor, Maine, United States to train, validate, and proctor clinicians with ultrasound-guided peripheral intravenous devices. A quality review of this process was compiled and determined that appropriate clinicians with dedicated training and guidance can achieve higher levels of procedural success. Furthermore, evidence substantiates that frequent practice is linked to a higher quality of care and that a significant need for such teams is present. This review examines how a team was implemented and its impact both department- and facility-wide. It is possible that hospitals benefit from the services of vascular access specialists to provide higher quality care. Successful implementation of such specialist teams requires foundational knowledge and skills in vascular access with ongoing quality measures to ensure competency and compliance with evidence-based practices.

COVID-19 pandemic and STEMI: pathway activation and outcomes from the pan-London heart attack group.

OBJECTIVES: To understand the impact of COVID-19 on delivery and outcomes of primary percutaneous coronary intervention (PPCI). Furthermore, to compare clinical presentation and outcomes of patients with ST-segment elevation myocardial infarction (STEMI) with active COVID-19 against those without COVID-19. METHODS: We systematically analysed 348 STEMI cases presenting to the PPCI programme in London during the peak of the pandemic (1 March to 30 April 2020) and compared with 440 cases from the same period in 2019. Outcomes of interest included ambulance response times, timeliness of revascularisation, angiographic and procedural characteristics, and in-hospital clinical outcomes RESULTS: There was a 21% reduction in STEMI admissions and longer ambulance response times (87 (62-118) min in 2020 vs 75 (57-95) min in 2019, p<0.001), but that this was not associated with a delays in achieving revascularisation once in hospital (48 (34-65) min in 2020 vs 48 (35-70) min in 2019, p=0.35) or increased mortality (10.9% (38) in 2020 vs 8.6% (38) in 2019, p=0.28). 46 patients with active COVID-19 were more thrombotic and more likely to have intensive care unit admissions (32.6% (15) vs 9.3% (28), OR 5.74 (95%CI 2.24 to 9.89), p<0.001). They also had increased length of stay (4 (3-9) days vs 3 (2-4) days, p<0.001) and a higher mortality (21.7% (10) vs 9.3% (28), OR 2.72 (95% CI 1.25 to 5.82), p=0.012) compared with patients having PPCI without COVID-19. CONCLUSION: These findings suggest that PPCI pathways can be maintained during unprecedented healthcare emergencies but confirms the high mortality of STEMI in the context of concomitant COVID-19 infection characterised by a heightened state of thrombogenicity.

Major trauma critical pathway: preliminary results from the monitoring system in the regional network and in a hub center in Rome metropolitan area.

OBJECTIVE: The aim of this study is to collect the two years' data regarding the Integrated Trauma Management System (SIAT) by capturing the activity of its three Hubs in the Italian Lazio Region and test the performance of one of the Hubs' (Fondazione Policlinico Universitario A. Gemelli - IRCCS, FPG -IRCCS) Major Trauma Clinical Pathway's (MTCP) monitoring system, introducing the preliminary results through volume, process and outcome indicators. MATERIALS AND METHODS: A retrospective analysis on SIAT was conducted on years 2016 to 2018, by collecting outcome and timeliness indicators through the Lazio Informative System whereas the MTCP was monitored through set of indicators from the FPG - IRCCS Informative System belonging to randomly selected clinical records of the established period. RESULTS: Hubs managed 11.3% of the 998,240 patients admitted in SIAT. All patients eligible for MTCP were "Flagged", and 83% underwent a CT within 2 hours; intra-hospital mortality was 13% whereas readmission rates 16.9%. CONCLUSIONS: SIAT converges the most severe patients to its Hubs. The MTCP monitoring system was able to measure a total of 9 out of 13 indicators from the original panel. This research may serve as a departing point to conduct a pre-post analysis on the performance of the MTCP.

Regionalization of Congenital Heart Surgery in the United States.

The objective of this study is to simulate regionalization of congenital heart surgery (CHS) in the United States and assess the impact of such a system on travel distance and mortality. Patients ≤18 years of age who underwent CHS were identified in 2012 State Inpatient Databases. Operations were stratified by the Risk Adjustment for Congenital Heart Surgery, version 1 (RACHS-1) method, with high risk defined as RACHS-1 levels 4-6. Regionalization was simulated by progressive closure of hospitals, beginning with the lowest volume hospital. Patients were moved to the next closest hospital. Analyses were conducted (1) maintaining original hospital mortality rates and (2) estimating mortality rates based on predicted surgical volumes after absorbing moved patients. One hundred fifty-three hospitals from 36 states performed 1 or more operation (19,064 operations). With regionalization wherein, all hospitals performed >310 operations, 37 hospitals remained, from 12.5% to 17.4% fewer deaths occurred (83-116/666), and median patient travel distance increased from 38.5 to 69.6 miles (P < 0.01). When only high-risk operations were regionalized, 3.9-5.9% fewer deaths occurred (26-39/666), and the overall mortality rate did not change significantly. Regionalization of CHS in the United States to higher volume centers may reduce mortality with minimal increase in patient travel distance. Much of the mortality reduction may be missed if solely high-risk patients are regionalized.

A Network Approach to Stroke Systems of Care.

The landscape of stroke systems of care is evolving as patients are increasingly transferred between hospitals for access to higher levels of care. This is driven by time-sensitive disability-reducing interventions such as mechanical thrombectomy. However, coordination and triage of patients for such treatment remain a challenge worldwide, particularly given complex eligibility criteria and varying time windows for treatment. Network analysis is an approach that may be applied to this problem. Hospital networks interlinked by patients moved from facility to facility can be studied using network modeling that respects the interdependent nature of the system. This allows understanding of the central hubs, the change of network structure over time, and the diffusion of innovations. This topical review introduces the basic principles of network science and provides an overview on the applications and potential interventions in stroke systems of care.

Extracorporeal membrane oxygenation support in acute circulatory failure: A plea for regulation and better organization.

Emergent implantation of temporary mechanical circulatory support using venoarterial ECMO (ECLS for extracorporeal Life Support) is increasingly adopted in various indications of acute circulatory failure refractory to optimal medical treatment. To implant such devices, but also to provide appropriate daily management, expertise and adapted technical platform are required. Organization, coordination and regulation of such program are not clearly established in our country. We propose a dedicated territorial organization to improve and facilitate management of these specific and most severe patients.

Simplification and optimization of transcatheter aortic valve implantation - fast-track course without compromising safety and efficacy.

Transcatheter aortic valve implantation (TAVI) has become an established therapeutic option for patients with symptomatic, severe aortic valve stenosis. Ageing of the Western and Asian population and expansion of indications for TAVI will lead to a substantial increase in the number of TAVI procedures performed worldwide within the next decades. In line with the maturation of TAVI over the past few years, there has also been a significant simplification and optimisation of the TAVI procedure. A minimalist TAVI procedure and fast-track TAVI course have been shown to have distinct advantages over the more traditional TAVI approach. The aim of this manuscript is to discuss strategies of TAVI simplification and optimization, with special focus on fast-track TAVI, without compromising safety and efficacy.

Safe working in a 7-day service. Experience of hip fracture care as documented by the UK National Hip Fracture Database.

Objective: to describe differences in care and 30-day mortality of patients admitted with hip fracture on weekends (Saturday-Sunday) compared to weekdays (Monday-Friday), and their relationship to the organisation of care. Methods: data came from the National Hip Fracture Database (NHFD) linked to ONS mortality data on 52,599 patients presenting to 162 units in England between 1 January and 31 December 2014. This was combined with information on geriatrician staffing and major trauma centre (MTC) status. 30-day mortality and care were compared for patients admitted at weekends and weekdays; separately for patients treated in units grouped by the mean level of input by geriatricians, weekend geriatrician clinical cover and MTC status. Differences were adjusted for variation in patients' characteristics. Results: there was no evidence of differences in 30-day mortality between patients admitted at weekends compared to weekdays (7.2 vs 7.5%, P = 0.3) before or after adjusting for patient characteristics in either MTCs or general hospitals. The proportion receiving a preoperative geriatrician assessment was lower at weekends (42.8 vs 60.7%, P < 0.001). 30-day mortality was lower in units with higher levels of geriatrician input, but there was no weekend mortality effect associated with lower levels of input or absence of weekend cover. Conclusion: there was no evidence of a weekend mortality effect among patients treated for hip fracture in the English NHS. It appears that clinical teams provide comparably safe and effective care throughout the week. However, greater geriatrician involvement in teams was associated with overall lower mortality.

Structure and work process in primary care and hospitalizations for sensitive conditions.

OBJECTIVE: The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions. METHODS: In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (ß) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%). RESULTS: In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (ß = -0.001) and private insurance (ß = -0.01) had a negative association, and the human development index (ß = 1.13), the proportion of older adults (ß = 0.05) and children under the age of five (ß = 0.05), and the coverage of the Community Health Agent Strategy (ß = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (ß = -0.14) and availability of vaccines (ß = -0.16) showed a negative association, and availability of medications showed a positive association (ß = 0.16). In the proximal level, only the variable of matrix support (ß = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013. CONCLUSIONS: The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities. OBJETIVO: Investigar se características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica estão associadas ao número de internações por condições sensíveis à atenção primária. MÉTODOS: Neste estudo ecológico, foram analisados dados de municípios brasileiros relativos a características sociodemográficas, de cobertura de programas assistenciais, de estrutura das unidades básicas de saúde e processo de trabalho das equipes de atenção básica. Os dados foram obtidos do primeiro ciclo do Programa de Melhoria do Acesso e Qualidade da Atenção Básica, do Departamento de Informática do Sistema Único de Saúde, do Instituto Brasileiro de Geografia e Estatística e do Programa das Nações Unidas. Estimaram-se as associações por meio de coeficientes de regressão binomial negativa (ß) e respectivos intervalos de confiança a 95%, com abordagem hierarquizada em três blocos (alpha = 5%). RESULTADOS: Na análise ajustada, para o desfecho em 2013, no bloco distal, a cobertura do Programa Bolsa Família (ß = -0,001) e de plano privado (ß = -0,01) apresentaram associação negativa; e o índice de desenvolvimento humano (ß = 1,13), a proporção de pessoa idosa (ß = 0,05) e de menor de cinco anos (ß = 0,05) e a cobertura da Estratégia de Agentes Comunitários de Saúde (ß = 0,002) mostraram associação positiva com internações por condições sensíveis à atenção primária. No bloco intermediário, apresentaram associação negativa o horário mínimo (ß = -0,14) e a disponibilidade de vacina (ß = -0,16); e associação positiva, a disponibilidade de medicamentos (ß = 0,16). No bloco proximal, apenas a variável apoio matricial (ß = 0,10) mostrou associação positiva. Na análise ajustada do número de internações por condições sensíveis à atenção primária em 2014, as variáveis apresentaram o mesmo sentido de associação de 2013. CONCLUSÕES: Características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica impactam no número de internações por condições sensíveis à atenção primária nos municípios brasileiros.

[A standard data set for the evaluation of venous leg ulcers in selective contracts : National consensus]. / Standarddatensatz für die Evaluation bei Selektivverträgen bei Ulcus cruris : Nationaler Konsensus.

BACKGROUND: Selective agreements are becoming increasingly important in health care management. To date, no standard recommendations for the evaluation of selective contracts are available. OBJECTIVES: Against this background, a recommendation on the evaluation of selective contracts in patients with leg ulcers (LU) was developed and approved by the nationwide consensus conference. MATERIALS AND METHODS: Based on a systematic literature review and followed by a manual search through other possible evaluation indicators in the care of patients with LU, a Delphi-based consensus process was performed by various scientific societies, professional associations, insurances and supply networks. RESULTS: For the evaluation of efficiency and quality of care, a recommendation on the evaluation of selective agreements with patients with LU was consented in six meetings and in five multistage online surveys. In total, 44 evaluation indicators were identified in the quality subareas structure, process, and outcome. The outcome indicators are divided into clinical, patient-related, and cost-related indicators. CONCLUSIONS: The developed evaluation indicators represent the quality of care in patients with LU. The indicators can be applied individually, depending on the agreed contract-specific supply target. After implementation of this national standard, the comparability of selective agreements in the management of patients with LU can be ensured and consolidated.

La calidad integrada a los procesos asistenciales. Experiencia en Chile en unidades de anatomía patológica / Integrated quality in clinical procedures: experience from pathology departments in Chile

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Structure and work process in primary care and hospitalizations for sensitive conditions / Estrutura e processo de trabalho na atenção primária e internações por condições sensíveis

ABSTRACT OBJECTIVE The objective of this study is to investigate whether the characteristics of the structure of primary health units and the work process of primary care teams are associated with the number of hospitalizations for primary care sensitive conditions. METHODS In this ecological study, we have analyzed data of Brazilian municipalities related to sociodemographic characteristics, coverage of care programs, structure of primary health units, and work process of primary care teams. We have obtained the data from the first cycle of the Brazilian Program for Improving Access and Quality of the Primary Care, of the Department of Information Technology of the Brazilian Unified Health System, the Brazilian Institute of Geography and Statistics, and the United Nations Development Programme. The associations have been estimated using negative binomial regression coefficients (β) and respective 95% confidence intervals, with a hierarchical approach in three levels (alpha = 5%). RESULTS In the adjusted analysis for the outcome in 2013, in the distal level, the coverage of the Bolsa Família Program (β = -0.001) and private insurance (β = -0.01) had a negative association, and the human development index (β = 1.13), the proportion of older adults (β = 0.05) and children under the age of five (β = 0.05), and the coverage of the Community Health Agent Strategy (β = 0.002) showed positive association with hospitalizations for primary care sensitive conditions. In the intermediate level, minimum hours (β = -0.14) and availability of vaccines (β = -0.16) showed a negative association, and availability of medications showed a positive association (β = 0.16). In the proximal level, only the variable of matrix support (β = 0.10) showed a positive association. The variables in the adjusted analysis of the number of hospitalizations for primary care sensitive conditions in 2014 presented the same association as in 2013. CONCLUSIONS The characteristics of the structure of primary health units and the work process of the primary care teams impact the number of hospitalizations for primary care sensitive conditions in Brazilian municipalities.

RESUMO OBJETIVO Investigar se características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica estão associadas ao número de internações por condições sensíveis à atenção primária. MÉTODOS Neste estudo ecológico, foram analisados dados de municípios brasileiros relativos a características sociodemográficas, de cobertura de programas assistenciais, de estrutura das unidades básicas de saúde e processo de trabalho das equipes de atenção básica. Os dados foram obtidos do primeiro ciclo do Programa de Melhoria do Acesso e Qualidade da Atenção Básica, do Departamento de Informática do Sistema Único de Saúde, do Instituto Brasileiro de Geografia e Estatística e do Programa das Nações Unidas. Estimaram-se as associações por meio de coeficientes de regressão binomial negativa (β) e respectivos intervalos de confiança a 95%, com abordagem hierarquizada em três blocos (alpha = 5%). RESULTADOS Na análise ajustada, para o desfecho em 2013, no bloco distal, a cobertura do Programa Bolsa Família (β = -0,001) e de plano privado (β = -0,01) apresentaram associação negativa; e o índice de desenvolvimento humano (β = 1,13), a proporção de pessoa idosa (β = 0,05) e de menor de cinco anos (β = 0,05) e a cobertura da Estratégia de Agentes Comunitários de Saúde (β = 0,002) mostraram associação positiva com internações por condições sensíveis à atenção primária. No bloco intermediário, apresentaram associação negativa o horário mínimo (β = -0,14) e a disponibilidade de vacina (β = -0,16); e associação positiva, a disponibilidade de medicamentos (β = 0,16). No bloco proximal, apenas a variável apoio matricial (β = 0,10) mostrou associação positiva. Na análise ajustada do número de internações por condições sensíveis à atenção primária em 2014, as variáveis apresentaram o mesmo sentido de associação de 2013. CONCLUSÕES Características da estrutura das unidades básicas de saúde e do processo de trabalho das equipes de atenção básica impactam no número de internações por condições sensíveis à atenção primária nos municípios brasileiros.

Process for massage therapy practice and essential assessment.

BACKGROUND: Little evidence exists about processes in massage therapy practice. Investigating current frameworks is warranted. This qualitative study is a secondary data analysis using grounded theory to understand how massage therapy experts describe massage therapy practice. METHODS: 31 massage therapy experts were invited to a 2-day symposium to discuss best practices for the profession. Through qualitative analysis, memoing, and discussion, the data were summarized into themes. RESULTS: Three themes were identified around massage therapy practice: 1) client centered, 2) structure for practice, and 3) influencing factors. Each theme is clarified and expanded. DISCUSSION: Conceptual models were developed for research and clinical practice and a definition for massage therapy practice was identified. Challenges and limitations are discussed. CONCLUSION: The goal of providing these models is to give massage therapists tools to deliver the best possible care. The models need testing to see if they help advance the profession.

Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system.

BACKGROUND: According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. METHODS: Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. RESULTS: Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). CONCLUSION: Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. LEVEL OF EVIDENCE: Prognostic study, level III.

The second national audit of intermediate care.

Intermediate care services have developed internationally to expedite discharge from hospital and to provide an alternative to an emergency hospital admission. Inconsistencies in the evidence base and under-developed governance structures led to concerns about the care quality, outcomes and provision of intermediate care in the NHS. The National Audit of Intermediate Care was therefore established by an interdisciplinary group. The second national audit reported in 2013 and included crisis response teams, home-based and bed-based services in approximately a half of the NHS. The main findings were evidence of weak local strategic planning, considerable under-provision, delays in accessing the services and lack of mental health involvement in care. There was a very high level of positive patient experience reported across all types of intermediate care, though reported involvement with care decisions was less satisfactory.

Conditions for production of interdisciplinary teamwork outcomes in oncology teams: protocol for a realist evaluation.

BACKGROUND: Interdisciplinary teamwork (ITW) is designed to promote the active participation of several disciplines in delivering comprehensive cancer care to patients. ITW provides mechanisms to support continuous communication among care providers, optimize professionals' participation in clinical decision-making within and across disciplines, and foster care coordination along the cancer trajectory. However, ITW mechanisms are not activated optimally by all teams, resulting in a gap between desired outcomes of ITW and actual outcomes observed. The aim of the present study is to identify the conditions underlying outcome production by ITW in local oncology teams. METHODS: This retrospective multiple case study will draw upon realist evaluation principles to explore associations among context, mechanisms and outcomes (CMO). The cases are nine interdisciplinary cancer teams that participated in a previous study evaluating ITW outcomes. Qualitative data sources will be used to construct a picture of CMO associations in each case. For data collection, reflexive focus groups will be held to capture patients' and professionals' perspectives on ITW, using the guiding question, 'What works, for whom, and under what circumstances?' Intra-case analysis will be used to trace associations between context, ITW mechanisms, and patient outcomes. Inter-case analysis will be used to compare the different cases' CMO associations for a better understanding of the phenomenon under study. DISCUSSION: This multiple case study will use realist evaluation principles to draw lessons about how certain contexts are more or less likely to produce particular outcomes. The results will make it possible to target more specifically the actions required to optimize structures and to activate the best mechanisms to meet the needs of cancer patients. This project could also contribute significantly to the development of improved research methods for conducting realist evaluations of complex healthcare interventions. To our knowledge, this study is the first to use CMO associations to improved empirical and theoretical understanding of interdisciplinary teamwork in oncology, and its results could foster more effective implementation in clinical practice.

The influence of integrated tuberculosis and human immunodeficiency virus service delivery on patient outcomes.

SETTING: Public health clinics in Cape Town, South Africa. OBJECTIVE: To examine the influence of integrated tuberculosis (TB) and human immunodeficiency virus (HIV) service delivery on mortality, TB cure and successful treatment completion and loss to follow-up of TB-HIV co-infected patients on concurrent anti-tuberculosis and antiretroviral treatment (ART). DESIGN: A survey instrument was used to measure the degree to which TB and HIV services were jointly delivered, and patient data were collected retrospectively from clinic sites and the Department of Health. Six domains measuring integrated TB and HIV service delivery were modelled to assess their relationship with patient outcomes. RESULTS: Two domains, integrated TB and ART service delivery and the delivery of TB and HIV care by one clinical team, were associated with lowered odds of death. Care by the same clinical team was also associated with reduced loss to follow-up. CONCLUSION: Overall, these findings show that the organization and delivery of health services are important factors that influence health outcomes. These findings strongly support efforts by local governments to integrate TB and ART services, and may help to alleviate concerns that restructuring of TB programs could have a negative impact on long-standing gains.

[Quality healthcare and pharmaceutical care practice indicators to HIV+ patient]. / Indicadores para la calidad asistencial y la atención farmacéutica al paciente VIH+

OBJECTIVE: To identify and to promote improvements in the quality of the sanitary attention to the HIV+ patients in the Clinical Units of the hospitals in our country, there being included and reinforcing the perspective of Pharmaceutical Care. METHODS: To carry out the project, during the period January- June 2012, the following phases were defined. First, a bibliographical review was realized and reading criticizes related to the pathology HIV and quality criteria. Later, a presencial qualitative investigation phase was carried out with the expert participants. The first one was carried out by means of two technologies: the nominal group and a variant of groups of discussion. The application of the technologies was supported by an technical support that allowed the codification and valuation organized. The last phase of the project consisted of a meeting presencial, where there were outlined the aims of the first meeting and put jointly all the work that the subgroups of work had elaborated to agree on the contents. Of the first selection of ideas, the equipment of investigation worked and prioritized those elements that describe and give response to the raised aims. Concretely, the correct definition of the safety and quality indicators in the area of the hospital pharmacist, there being elaborated a card that was describing every aspect to bear in mind for the later measurement of the indicator. Finally, a plan of actions was elaborated to improve the clinical practice synthesized according to his level of priority. RESULTS: Across the methodology of the project, the experts identified the quality criterias in pharmaceutical care procedure. The principal barriers identified were: asistencial pressure, personnel management system's, security and ignorance of the pharmacotherapy, lack of quality culture and difficulties of access to the information. Principals clinical risks identified were: mistakes in the guidelines with the changes of treatments, lack of information of the whole medication of the patient, lack in resources and time adapted to realize the processes, lack of communication between professionals, ignorance of interactions or adverse events. The principal results that were extracted from the analysis of situation were that the priority line of action had to happen for a link between patients, specialists and primary care. It should promote the clinical management of the units of HIV, the access to the information for all the professionals who realize pharmacoterapeutical follow-up to these patients and the major implication on the part of these. Finally, 29 quality indicators were defined in the pharmaceutical care to the HIV+ patient distributed in structure, processes and results and the plan of improvement for the attention and his level of priority considered. DISCUSSION: This document gives response to the increasing demand for homogenizing the clinical practice and establishing common criteria of quality that result a benefit for the sanitary system and, in consequence, for the professionals and the patients.

Objetivo: Identificar y promover mejoras en la calidad de la atención sanitaria que reciben los pacientes VIH y SIDA en las Unidades Clínicas de los hospitales en nuestro país, incluyéndose y reforzando la perspectiva de Atención Farmacéutica (AF). Metodología: Para llevar a cabo el proyecto, durante el periodo Enero-Junio de 2012 se definieron las siguientes fases de trabajo. Primero, se realizó una revisión bibliográfica y lectura critica relacionada con la patología VIH-SIDA y criterios de calidad. A continuación, se llevó a cabo una fase de investigación cualitativa presencial con los expertos participantes. La primera se llevó a cabo mediante dos técnicas: el grupo nominal y una variante de grupos de discusión. La aplicación de las técnicas estuvo apoyada por un soporte informático que permitió la codificación y valoración jerarquizada de las propuestas mediante un sistema automatizado de votaciones. La última fase del proyecto consistió en una reunión presencial, donde se perfilaron los objetivos de la primera reunión y se puso en común todo el trabajo que los subgrupos de trabajo habían elaborado para consensuar los contenidos. De la primera selección de ideas, el equipo de investigación trabajó y priorizó aquellos elementos que describen y dan respuesta a los objetivos planteados. Concretamente, la correcta definición de los indicadores de calidad y de seguridad en el ámbito de la farmacia hospitalaria, elaborándose una ficha que describía cada aspecto a tener en cuenta para la posterior medición del indicador. Por último, se elaboró un plan de actuaciones para mejorar la práctica clínica, sintetizada según su nivel de prioridad. Resultados: A través de la metodología del proyecto, los expertos identificaron los criterios de calidad en el procedimiento de AF al paciente. Las principales barreras definidas fueron: presión asistencial, Sistemas de gestión de personal, Seguridad y desconocimiento de la farmacoterapia, falta de cultura de calidad y dificultades de acceso a la información. Entre los principales riesgos clínicos identificados destacaron: errores en las pautas con los cambios de tratamientos, falta de información de toda la medicación del paciente, falta de recursos asistenciales y de tiempo adecuado para realizar los procesos, falta de comunicación entre profesionales, desconocimiento de interacciones o eventos adversos Los principales resultados que se extrajeron del análisis de situación fueron que la línea prioritaria de actuación debía pasar por un enlace entre pacientes, especialistas y atención primaria. Igualmente se debería potenciar la gestión clínica de las unidades de VIH, el acceso a la información por todos los profesionales que realizan seguimiento farmacoterapeutico a estos pacientes y la mayor implicación por parte de estos. Por ultimo, se definieron 29 indicadores de calidad en la AF al paciente VIH distribuidos en estructura, procesos y resultados y el plan de mejora para la atención al paciente VIH y su nivel de prioridad considerado. Discusión: Con este documento se da respuesta a la creciente demanda por homogeneizar la labor asistencial y establecer criterios de calidad comunes que redunden un beneficio para el sistema sanitario y, en consecuencia, para los profesionales y los pacientes.