Measuring health care experiences that matter to Indigenous people in Australia with cancer: identifying critical gaps in existing tools.

BACKGROUND: Measurement of patients' healthcare experiences is increasingly used as an indicator of quality of care, but there are concerns that existing measures omit information that is meaningful to patients and that results may not be used systematically to inform service improvement. Further, current approaches may be inadequate for some population groups, such as Indigenous people in Australia, whose healthcare experience is impacted by the context of colonisation and discordance between Indigenous understandings of health and the Western biomedical health system. This study aimed to assess the extent to which existing patient experience measures used in Australia collect information about critical aspects of cancer care, as previously identified by Indigenous people affected by cancer and their health care providers. METHODS: A two-stage process was used to examine the adequacy of existing patient experience measures for Indigenous people in Australia: (1) relevant tools and measures were identified and assessed, and four measures selected as suitable comparators; (2) comparators were examined in detail and mapped against topics identified in earlier research as important to Indigenous people with cancer. Gaps in topic coverage in comparators were identified. RESULTS: No comparators completely captured the critical aspects of cancer care identified by Indigenous people affected by cancer and their health care providers. The number of topics 'partially' captured by the four comparators ranged from 4 to 7 out of 9. While most topics were partially covered, the lack of questions around culture and cultural safety was notable. CONCLUSIONS: Existing tools are likely to miss key aspects of Indigenous peoples' experiences of cancer care in Australia. Failure to adequately assess care experiences related to cultural safety may compromise efforts to improve health outcomes. Addressing gaps requires development of experience measures that are strengths-based, reflect an Indigenous worldview and measure aspects of experience relevant to Indigenous people.

Understanding Indigenous Australians' experiences of cancer care: stakeholders' views on what to measure and how to measure it.

BACKGROUND: Disparities in cancer outcomes amongst Indigenous Australians reflect a pattern of reduced access to and engagement with health services. A growing emphasis on patient-centred care has increased efforts to measure patient experiences, but it is unclear whether existing approaches: a) assess the most critical aspects of care that shape the experiences of Indigenous people with cancer; and b) facilitate the engagement and participation of Indigenous people with the measurement of care experiences. METHODS: Two rounds of semi-structured interviews and focus groups were used to elicit stakeholders' views on priorities for measuring the cancer care experiences of Indigenous cancer patients and on the acceptability of various methods for capturing such information. Participants included Indigenous people affected by cancer (n = 17), health professionals (n = 28) and individuals in both groups (n = 7). Recruitment occurred through a national web-based network and through four cancer services in urban and regional areas in three jurisdictions across Australia. RESULTS: Several aspects of cancer care were identified as critical in shaping Indigenous patients' experiences. Key themes included: feeling safe in the system; importance of Indigenous staff; barriers to care; the role of family and friends; effective communication and education; and coordination of care and transition between services. Those participants affected by carers' wellbeing and palliative care strongly advocated for the importance of these topics. Participants expressed support for a face-to-face interview with a trusted person as the most appropriate means of collecting cancer care experience information. CONCLUSIONS: While existing experience measurement tools would partially capture some important aspects of care, other critical areas would likely be missed. Appropriate tools and approaches, developed by and with Indigenous people, are urgently needed to determine the extent to which health services are meeting the needs of Indigenous people with cancer, and to identify areas for action to improve these services.

Improving outcomes for Aboriginal and Torres Strait Islander people with cancer requires a systematic approach to understanding patients' experiences of care.

Indigenous Australians experience a greater burden of cancer than other Australians, but there is little systematic information about their experiences of cancer care. Patient-centred care is increasingly recognised as one of the core domains of quality care, alongside clinical effectiveness and patient safety. Qualitative studies have identified significant issues relating to Indigenous patients' experiences of cancer care, but these data are often insufficient to inform and evaluate health service improvement. We need to establish appropriate methods that will lead to systematic, routinely collected, accurate, population-based data on the experiences of care of Indigenous people with cancer, and determine how best to translate these data into improvements in the delivery of care to this population. Genuine Indigenous leadership and involvement will be necessary, with the whole approach underpinned by the primary aim of improving health outcomes for this population.

Expansion of clinical pharmacy through increased use of outpatient pharmacists for anticoagulation services.

PURPOSE: The expansion of clinical pharmacy services through increased use of outpatient pharmacists for anticoagulation services is described. SUMMARY: Due to the high demand for clinical pharmacist services by patients and medical staff at Harris Health System in Houston, Texas, and the strict budgetary restrictions to improve the quality of care through cost-neutral services, a new telephone anticoagulation monitoring service, provided by clinical pharmacists, was established at four of the busiest anticoagulation ambulatory care centers within the system. One clinical staff pharmacist was trained in each of the four clinics by a clinical pharmacy specialist. Each pharmacist received roughly two weeks of training to provide this service. Implementation of the new anticoagulation monitoring service occurred on April 1, 2013. Data collected between October 2011 and April 2014 revealed significantly more visits per month for the clinical pharmacy service after the implementation of the telephone anticoagulation monitoring service (p=0.011). Redistribution of workflow resulted in a 16% increase in clinical pharmacy patient volume at the ambulatory care clinics (p=0.011). The percentage of International Normalized Ratio values in the therapeutic range, the proportion of hospitalizations due to thromboembolic or bleeding events, work hours per prescription volume, project completion rates, and the number of students precepted did not significantly differ between groups. CONCLUSION: The implementation of a clinical pharmacy telephone service for patients receiving anticoagulation at an outpatient center resulted in increased patient clinic visits without adversely affecting patient outcomes or increasing personnel or costs.

Impact of Point-of-Care Implementation in Pharmacist-Run Anticoagulation Clinics Within a Community-Owned Health System: A Two-Year Retrospective Analysis.

BACKGROUND: Point-of-care (POC) testing devices allow laboratory monitoring to be performed in various settings and accessed immediately. OBJECTIVE: To evaluate the outcomes of monitoring anticoagulation patients in pharmacistmanaged, multicenter clinics utilizing i-STAT POC machines. METHODS: This study was a retrospective, multicenter chart review of 150 patients before and after implementation of the POC intervention for anticoagulation monitoring. Data collected included international normalized ratio (INR) results, indication for warfarin, minor and major bleeds, thromboembolic events, emergency room (ER) visits, and hospitalizations before and after i-STAT POC implementation. RESULTS: The time in therapeutic INR range (TTR) was significantly higher after i-STAT POC implementation than before implementation (60.4% ± 21.2% and 52.5% ± 21.5%, respectively; P = .0001). There were no reports of major bleeding during the study period. Twenty-three minor bleeds were reported after i-STAT POC implementation compared to 19 events before implementation (P < .0001). One thromboembolic event was reported after i-STAT POC implementation. There was a significant difference in the number of hospitalizations before i-STAT POC implementation as opposed to after implementation (2 and 0, respectively; P < .0001). There was also a significant increase in ER visits after i-STAT POC implementation (P < .0001). CONCLUSION: The results of the study indicate improvement in TTR in pharmacist-managed anticoagulation clinics by 7.8%. Although the use of the i-STAT POC machine detected an increase in minor bleeds, thromboembolic events, and ER visits, there was a decrease in hospitalization. The outcomes of this multicenter study indicate that implementation on this scale provides improvement in regard to safety and cost.

Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

OBJECTIVE: The aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation. DESIGN: This study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Of those eligible, 87 (64%) enrolled; 75 (86%) were retained at 12 mos. Measures included demographic/health information, four neuropsychologic measures, the Locomotor Capability Index-5, the Gronigen Activity Restriction Scale, prosthetic use, community participation, and social integration. RESULTS: Better performance on the Short Portable Mental Status Questionnaire at 4 mos was associated with greater 12-mo mobility and social integration. Better attention and working memory abilities 6 wks after amputation were associated with increased 12-mo prosthetic wear; and at 4 mos after amputation, with greater 12-mo mobility. Better verbal memory at 6 wks was associated with greater 12-mo social integration and community participation as well as increased prosthetic wear. CONCLUSIONS: These findings highlight the potential value in including a brief, formal cognitive assessment in addition to a general mental status screen. Specific domains of cognitive function are differentially associated with functional outcomes and may inform amputation rehabilitation decisions.

Changes in cognitive function from presurgery to 4 months postsurgery in individuals undergoing dysvascular amputation.

OBJECTIVE: To describe cognition among individuals with new amputations at 3 time points: presurgical, 6 weeks postamputation, and 4 months postamputation. DESIGN: Prospective cohort. SETTING: Medical centers. PARTICIPANTS: Referred sample Veterans who were primarily men (N=80) experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Patients were screened for the absence of gross cognitive impairment using the Short Portable Mental Status Questionnaire (SPMSQ). Of those 87 individuals who were eligible, 64% enrolled; 29 were enrolled presurgically and have cognitive data for all 3 time points, and 58 were enrolled postamputation. Eighty of the 87 individuals enrolled by 6 weeks remained enrolled at 4 months. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and general health information, general mental status (SPMSQ), and 4 brief, well-established neuropsychological measures. RESULTS: Most mean neuropsychological test scores fell in the low average or average range. For most participants, overall cognitive status improved from pre- to postsurgery and then remained stable between 6 weeks and 4 months. There were significant improvements between pre- and postsurgical test scores in verbal learning and memory, and these remained unchanged between 6 weeks and 4 months. Better 4 month cognitive performance was associated with higher perceived general health. CONCLUSIONS: Overall cognitive performance is poorest presurgically. Though there is improvement between pre- and postamputation, cognition appears generally stable between 6 weeks and 4 months.

Polycystic ovary syndrome: a review of treatment options with a focus on pharmacological approaches.

Oral contraceptives, antidiabetes drugs, and statins are some of the therapies used to address the symptoms of this complex hormonal condition. Weight loss and surgery may also be beneficial as non-drug options.

Concurrent (tandem) cervical and lumbar spinal stenosis: a 10-yr review of 54 hospitalized patients.

OBJECTIVE: To determine the frequency of concurrent cervical and lumbar spinal stenosis (i.e., "tandem spinal stenosis" [TSS]) in a 10-yr review of hospital admissions. DESIGN: In a retrospective study of 460,964 hospital admissions to our 1,000-bed academic community hospital, we identified a base population of 54 patients with TSS. These patients presented with multiple complaints, including neurogenic claudication, progressive gait disturbances, and neurologic signs of both upper and lower motor neuron dysfunction, among others. Since 1964 when TSS was first described, estimates of its frequency have varied widely, ranging from a low of 5% to a high of 28%. RESULTS: Of the 54 cases of TSS identified among the 460,964 patient admissions during a 10-yr period, 36 were men and 18 were women. A total of 51 were >51 yrs of age. For all ages, the frequency rate of TSS in this series was 12 per 100,000 admissions. CONCLUSION: With TSS, the symptoms of either the cervical or the lumbar type initially predominate. Often, only after the primary pathology is treated does the secondary problem become evident. Although TSS occurred relatively infrequently in this series, its potential presence should not be overlooked.

"Young" cervical spinal stenotic: a review of 118 patients younger than 51 years of age.

A 10-yr retrospective review of 460,964 admissions to a 1,000-bed community teaching hospital identified 555 patients with a diagnosis of cervical spinal stenosis. Of this number, 118 were classified as "young." With an occurrence rate of 26 per 100,000, in this series there was not a significant difference in sex throughout the decade. During the first 5 yrs of this study, 186 patients with cervical spinal stenosis were identified, of whom 37 were <51 yrs of age. Of 369 patients in the remaining 5-yr period with cervical spinal stenosis, 81 were <51 yrs of age. The proportion of those <51 yrs old between the two 5-yr periods was not statistically different. Although spinal stenosis, both cervical and lumbar, has been regarded as a disorder of the elderly, 21% of those with cervical spinal stenosis and 10% with lumbar spinal stenosis can be anticipated to be <51 yrs of age.