What is bad news in fertility care? A qualitative analysis of staff and patients' accounts of bad and challenging news in fertility care.

STUDY QUESTION: What do fertility staff and patients think is bad news in fertility care? SUMMARY ANSWER: Staff and patients agree bad news is any news that makes patients less likely to achieve parenthood spontaneously or access and do successful treatment, but their appraisals of how bad the news is are differently influenced by specific news features and the context of its delivery. WHAT IS KNOWN ALREADY: Bad news is common in fertility care, but staff feel unprepared to share it and four in 10 patients react to it with unanticipated emotional or physical reactions. Research has paid much attention to how bad news should be shared, but considerably less to what news is perceived as bad, despite the fact this may dictate elements of its delivery. STUDY DESIGN, SIZE, DURATION: Two cross-sectional, online, mixed-method surveys (active 7 January-16 July 2022) were distributed to fertility staff and patients across the UK and Europe. PARTICIPANTS/MATERIALS, SETTING, METHODS: Staff inclusion criteria were being a healthcare professional working in fertility care and having experience of sharing bad news at least once a month. Patients' inclusion criteria were being adults and having had a conversation in which staff shared or explained bad news concerning their fertility care within the last 2 months. Surveys were created in English using Qualtrics, reviewed by patients and healthcare professionals, and distributed via social media, Prolific, fertility organizations, and scientific societies. Patients were asked, regarding the last time bad news were shared with them, 'What was the bad news?' and 'What other news would you consider bad news in fertility care?'. Staff were asked to 'List the three most challenging topics of bad news you share with your patients'. Staff and patient data were separately thematically analysed to produce basic codes, organized into sub-themes and themes. Themes emerging from patients' and staff data were compared and synthesized into meta themes. MAIN RESULTS AND THE ROLE OF CHANCE: Three hundred thirty-four staff accessed the survey, 286 consented, and 217 completed (65% completion rate). Three hundred forty-four patients accessed the survey, 304 consented, and 222 completed (64% completion rate). Eighty-five percent of participants were women, 62% resided in Europe, and 59% were in private care. Average staff age was 45.2 (SD = 12.0), 44% were embryologists or lab technicians, 40% were clinicians (doctors, consultants, or physicians), and 8% nurses or midwifes. Average patient age was 32.2 (SD = 6.4) and 54% had children. Staff answers originated 100 codes, 19 sub-themes and six themes. Patients' answers produced 196 codes, 34 sub-themes, and 7 themes. Staff and patient themes were integrated into three meta-themes reflecting main topics of bad news. These were Diagnosis and negative treatment events and outcomes, Inability to do (more) treatment, and Care and patient factors disrupting communication. Staff and patients agreed that some news features (uncertain, disruptive, definitive) made news more challenging but disagreed in relation to other features (e.g. unexpected/expected). Patient factors made bad news more challenging to staff (e.g. difficult emotions) and care factors made bad news more challenging to patients (e.g. disorganized care). LIMITATIONS, REASONS FOR CAUTION: Participants were self-selected, and most were women from private European clinics. Questions differed for staff and patients, focused on subjective perceptions of news, and did not measure news impact. WIDER IMPLICATIONS OF THE FINDINGS: The badness of fertility news is not only a product of the extent to which the news compromises parenthood goals but also of its features (timing, nature, number) and the context in which the news is delivered. Guidance on sharing bad news in fertility care needs to go beyond easing the process for patients to also consider staff experiences. Guidance may need to be tailored to news features and context. STUDY FUNDING/COMPETING INTEREST(S): Cardiff University funded the research. S.G., J.B., O'.H., and A.D. report funding from the Higher Education Funding Council for Wales and the European Society for Human Reproduction and Embryology (ESHRE) to develop fertiShare: a sharing bad news eLearning course for fertility care. fertiShare will be distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence (CC BY-NC-SA 4.0). No other conflicts are reported in relation to this work. TRIAL REGISTRATION NUMBER: N/A.

A large outbreak of the Kappa mutation of COVID-19 in Cork, Ireland, April-May 2021.

BACKGROUND: In May 2021, the B.1.617 variant of SARS-CoV-2 emerged in Ireland, and both Delta and Kappa sub-lineages were initially deemed variants of concern (VOCs) on a precautionary basis. We describe a large outbreak of SARS-CoV-2 B.1.617.1 (Kappa mutation) linked to a private gathering among third level students in Cork, Ireland. METHODS: Surveillance data were available from the Health Service Executive COVID Care Tracker. The epidemiological sequence of infection for each new case in this outbreak was tracked and whole genome sequencing was requested on all linked cases. Enhanced public health control measures were implemented by the Department of Public Health HSE-South to contain onward spread of VOCs, including retrospective contact tracing, lengthy isolation and quarantine periods for cases and close contacts. Extensive surveillance efforts were used to describe and control onward transmission. RESULTS: There were 146 confirmed SARS-CoV-2 cases linked to the outbreak. All sequenced cases (53/146; 36%) confirmed Kappa mutation. The median age was 21 years (range 17-65). The majority (88%) had symptoms of SARS-CoV-2 infection. There were 407 close contacts; the median was 3 per case (range 0-14). There were no known hospitalisations, ICU admissions or deaths. Vaccination data was unavailable, but the outbreak pre-dated routine availability of COVID-19 vaccines among younger adults in Ireland. CONCLUSION: Enhanced public health control measures for new and emerging variants of SARS-CoV-2 may be burdensome for cases and close contacts. The overall public health benefit of enhanced controls may only become apparent when evidence on disease transmissibility and severity becomes more complete.

Managed care and school-based health centers. Use of health services.

OBJECTIVE: To explore the use of physical and mental health services for adolescents who are enrolled in managed care and have access to a school-based health center (SBHC), compared with adolescents enrolled in managed care without access to an SBHC. DESIGN: Retrospective cohort designed with age, sex, and socioeconomic status matching to compare the use of health services for adolescent members of Kaiser Permanente of Colorado (who had access to SBHCs) with those with no access. PARTICIPANTS: The study included 342 adolescents, resulting in 3394 visits that occurred during 3 academic years. During the study, 240 adolescents with access to an SBHC were compared with 116 adolescents without access to an SBHC. MAIN OUTCOME MEASURES: The use of primary and subspecialty medical, mental health, and substance abuse treatment services; the use of after-hours (emergent or urgent) care; and comprehensive preventive health supervision visits and documentation of screening for high-risk health behaviors. RESULTS: Adolescents with access to SBHCs were more than 10 times more likely to make a mental health or substance abuse visit (98% of these visits were made at the SBHC) (P < .001). Adolescents with SBHC access had an after-hours (emergent or urgent) care visit rate of 0.33 to 0.52 visits per year less (38%-55% fewer visits) than adolescents without SBHC access, and, overall, made almost 1 additional medical visit per year. A greater percentage, 80.2%, of adolescents with access to SBHCs had at least 1 comprehensive health supervision visit compared with 68.8% of adolescents without access (P = .04). In addition, the adolescents with access were screened for high-risk behaviors at a higher rate. CONCLUSIONS: School-based health centers seem to have a synergistic effect for adolescents enrolled in managed care in providing comprehensive health supervision and primary health and mental health care and in reducing after-hours (emergent or urgent) visits. School-based health centers are particularly successful in improving access to and treatment for mental health problems and substance abuse.

Extending health maintenance organization insurance to the uninsured. A controlled measure of health care utilization.

OBJECTIVE: To investigate the utilization of health care services of previously uninsured low-income patients after becoming insured by a health maintenance organization (HMO). DESIGN: Retrospective study of utilization in a previously uninsured study group compared with an age- and sex-matched randomly selected control group of commercial HMO enrollees. SETTING: Group model HMO. PATIENTS: A study group of 346 previously uninsured low-income patients and 382 controls. MEASURES: utpatient visits for primary and specialty care, outpatient pharmacy, laboratory, and radiology use, and inpatient admissions and hospital days over a 2-year period. Self-reported health status measures were obtained to control for differences in health status. PRINCIPAL FINDINGS: There were no differences between the study and control groups in hospital admissions, hospital days, and measures of outpatient laboratory, pharmacy, and radiology use. The odds of having an outpatient visit per patient per month was 30% higher for the study group. Approximately half the increase in the odds ratio for outpatient visits was related to the worse self-perceived health status of the study group. While both groups utilized more services in the early phase of their enrollment, the intensity of this start-up effect was similar for both groups. CONCLUSIONS: Compared with a commercial group of the same age and sex, the patterns of utilization were similar and the financial costs of care were only moderately more for a previously uninsured group provided with comprehensive HMO insurance. With the growth of managed care, these data should be beneficial in the development of health care programs for the growing number of uninsured Americans.

Community nursing in The Netherlands.

Major developments and changes are currently taking place in the Dutch health care system and community nurses are reacting now to assure they have their proper place in the future setup. Community nurses in other Western countries can perhaps find new ways to contribute to their national health schemes by following their example.

Behavior therapy of anxiety disorders: motivating the resistant patient.

The authors discuss several psychotherapy techniques that mix well and are often indispensable adjuncts in the behavioral therapy of treatment-resistant anxiety-disorder patients. These include psychoeducation, family therapy, psychodynamic interpretations, paradoxical injunctions, and assertiveness training. Multimodal approaches are often indicated with patients who would otherwise not tolerate exposure treatment.

Printed information for the lay public on cardiovascular disease.

Booklets from several countries on various aspects of cardiovascular disease, intended for distribution to the public and to patients, could be classified into three categories dealing with primary prevention, secondary prevention, and management. Much material was duplicated, whereas some diseases were completely ignored. Only two types of booklets should be available. One would deal with preventive measures for all cardiovascular diseases, while the other would be a series of booklets on individual conditions, combining information on secondary prevention and on management.