Use of non-invasive diagnostic tools for metabolic dysfunction-associated steatohepatitis: A qualitative exploration of challenges and barriers.

BACKGROUND AND AIMS: Non-invasive tests (NITs) are underutilized for diagnosis and risk stratification in metabolic dysfunction-associated steatotic liver disease (MASLD), despite good accuracy. This study aimed to identify challenges and barriers to the use of NITs in clinical practice. METHODS: We conducted a qualitative exploratory study in Germany, Italy, United Kingdom and United States. Phase 1 participants (primary care physicians, hepatologists, diabetologists, researchers, healthcare administrators, payers and patient advocates; n = 29) were interviewed. Phase 2 participants (experts in MASLD; n = 8) took part in a group discussion to validate and expand on Phase 1 findings. Finally, we triangulated perspectives in a hybrid deductive/inductive thematic analysis. RESULTS: Four themes hindering the use of NITs emerged: (1) limited knowledge and awareness; (2) unclear referral pathways for patients affected by liver conditions; (3) uncertainty over the value of NITs in monitoring and managing liver diseases; and (4) challenges justifying system-level reimbursement. Through these themes, participants perceived a stigma associated with liver diseases, and primary care physicians generally lacked awareness, adequate knowledge and skills to use recommended NITs. We identified uncertainties over the results of NITs, specifically to guide lifestyle intervention or to identify patients that should be referred to a specialist. Participants indicated an ongoing need for research and development to improve the prognostic value of NITs and communicating their cost-effectiveness to payers. CONCLUSIONS: This qualitative study suggests that use of NITs for MASLD is limited due to several individual and system-level barriers. Multi-level interventions are likely required to address these barriers.

Challenges in the care of patients with RET-altered thyroid cancer: a multicountry mixed-methods study.

BACKGROUND: The discovery of driver oncogenes for thyroid carcinomas and the identification of genomically targeted therapies to inhibit those oncogenes have altered the treatment algorithm in thyroid cancer (TC), while germline testing for RET mutations has become indicated for patients with a family history of RET gene mutations or hereditary medullary TC (MTC). In the context of an increasing number of selective RET inhibitors approved for use, this paper aims to describe challenges and barriers affecting providers' ability to deliver optimal care for patients with RET-altered TC across the patient healthcare journey. METHODS: A mixed-method educational and behavioral needs assessment was conducted in Germany (GER), Japan (JPN), the United Kingdom (UK), and the United States (US) prior to RET-selective inhibitor approval. Participants included medical oncologists (MO), endocrinologists (EN) and clinical pathologists (CP) caring for patients affected with TC. Data collection tools were implemented in three languages (English, German, Japanese). Qualitative data were coded and thematically analyzed in NVivo. Quantitative data were analyzed via frequency and crosstabulations in SPSS. The findings presented here were part of a broader study that also investigated lung cancer challenges and included pulmonologists. RESULTS: A total of 44 interviews and 378 surveys were completed. Suboptimal knowledge and skills were self-identified among providers, affecting (1) assessment of genetic risk factors (56%, 159/285 of MOs and ENs), (2) selection of appropriate genetic biomarkers (59%, 53/90 of CPs), (3) treatment plan initiation (65%, 173/275 of MOs and ENs), (4) management of side effects associated with multitargeted tyrosine kinase inhibitors (78%, 116/149 of MOs and ENs), and (5) transfer of patients into palliative care services (58%, 160/274 of MOs and ENs). Interviews underscored the presence of systemic barriers affecting the use of RET molecular tests and selective inhibitors, in addition to suboptimal knowledge and skills necessary to manage the safety and efficacy of targeted therapies. CONCLUSION: This study describes concrete educational needs for providers involved in the care of patients with RET-altered thyroid carcinomas. Findings can be used to inform the design of evidence-based education and performance improvement interventions in the field and support integration into practice of newly approved RET-selective inhibitors.

Challenges in diagnosis and biomarker testing for RET-altered lung and thyroid cancer care: an international mixed-method study.

BACKGROUND: The introduction of new targeted therapies for RET-altered lung and thyroid cancers (LC/TC) has impacted pathologists' practice by making genomic testing more relevant. Variations in health systems and treatment access result in distinct clinical challenges and barriers. This study aimed to assess practice gaps and challenges experienced by pathologists involved in the diagnosis of RET-altered LC/TC, including biomarker testing, to inform educational solutions. METHODS: Pathologists in Germany, Japan, the UK, and US participated in this ethics-approved mixed-methods study, which included interviews and surveys (data collected January-March 2020). Qualitative data was thematically analysed, quantitative data was analysed with chi-square and Kruskal-Wallis H-tests, and both were triangulated. RESULTS: A total of 107 pathologists took part in this study. Knowledge gaps were reported regarding genomic testing for LC/TC in Japan (79/60%), the UK (73/66%), and the US (53/30%). Skill gaps were reported when selecting genomic biomarker tests to diagnose TC in Japan (79%), the UK (73%) and US (57%) and when performing specific biomarker tests, especially in Japan (82% for RET) and in the UK (75% for RET). Japanese participants (80%) reported uncertainty about what information to share with the multidisciplinary team to ensure optimal patient-centered care. At the time of data collection, pathologists in Japan faced access barriers to using RET biomarker tests: only 28% agreed that there are relevant RET genomic biomarker tests available in Japan, versus 67% to 90% in other countries. CONCLUSIONS: This study identified areas where pathologists need additional continuing professional development opportunities to enhance their competencies and better support delivery of care to patients with RET-altered lung or thyroid tumours. Addressing identified gaps and improving competencies of pathologists in this field should be emphasised in continuing medical education curricula and through quality improvement initiatives. Strategies deployed on an institutional and health system level should aim to improve interprofessional communication and genetic biomarker testing expertise.

Challenges associated with the integration of immuno-oncology agents in clinical practice.

BACKGROUND: The availability of new immuno-oncology therapeutics markedly impacts oncology clinicians' treatment decision-making. To effectively support healthcare professionals (HCPs) in their practice, it is important to better understand the challenges and barriers that can accompany the introduction of these agents. This study aimed to establish the types and causes of clinical challenges posed by the introduction of new immuno-oncology agents. METHODS: The mixed-methods design included qualitative in-depth interviews and group discussions with HCPs, in which participants discussed clinical challenges and potential underlying reasons for these challenges. Qualitative findings informed a quantitative survey. This survey investigated the extent and distribution of challenges using HCPs' self-rating of knowledge, skill, confidence, and exposure to system-level effects. These two phases were conducted sequentially with distinctly stratified samples of oncologists, nurse practitioners (NPs), physician assistants (PAs), pathologists, clinical pharmacists, interventional radiologists, rheumatologists, pulmonologists, and emergency department physicians. Participants were from the United States and had various levels of clinical experience and represented both academic and community-based settings. RESULTS: The final sample included 107 HCPs in the qualitative phase and 554 in the quantitative phase. Analyses revealed clinical challenges related to the use of pharmacodiagnostics. For example, 47% of pathologists and 42% of oncologists reported skill gaps in identifying the appropriate marker and 46% of oncologists, 61% of PAs, 66% of NPs, 74% of pulmonologists and 81% of clinical pharmacists reported skill gaps in selecting treatment based on test results. Challenges also emerged regarding the integration of immuno-oncology agents, as oncologists, rheumatologists, pulmonologists, clinical pharmacists, PAs, and NPs reported knowledge gaps (74-81%) of the safety profiles of recently approved agents. In addition, 90% of clinical pharmacists reported skill gaps weighing the risks and benefits of treating patients with immuno-oncology agents while affected by lupus. Finally, patient communication challenges were identified: HCPs reported difficulties discussing essential aspects of immunotherapy to patients as well as how they might compare to other types of therapies. CONCLUSION: The challenges highlighted in this study reveal substantial educational gaps related to the integration of immuno-oncology agents into practice for various groups of HCPs. These findings provide a strong base of evidence for future educational initiatives.

Gaps and barriers in the implementation and functioning of antimicrobial stewardship programmes: results from an educational and behavioural mixed methods needs assessment in France, the United States, Mexico and India.

Background: Evidence shows limited adherence to antimicrobial stewardship (AMS) principles. Objectives: To identify educational gaps and systemic barriers obstructing adherence to AMS principles. Methods: A mixed-methods study combining a thematic analysis of qualitative interviews (January-February 2021) and inferential analysis of quantitative surveys (May-June 2021) was conducted. Participants from France, the USA, Mexico and India were purposively sampled from online panels of healthcare professionals to include infectious disease physicians, infection control specialists, clinical microbiologists, pharmacologists or pharmacists expected to apply AMS principles in their practice setting (e.g. clinic, academic-affiliated or community-based hospital). A gap analysis framework guided this study. Results: The final sample included 383 participants (n = 33 interviews; n = 350 surveys). Mixed-methods findings indicated suboptimal knowledge and skills amongst participants to facilitate personal and collective application of AMS principles. Survey data indicated a gap in ideal versus current knowledge of AMS protocols, especially amongst pharmacologists (Δ0.95/4.00, P < 0.001). Gaps in ideal versus current skill levels were also measured and were highest amongst infectious control specialists (Δ1.15/4.00, P < 0.001), for convincing hospital executives to allocate resources to AMS programmes. Already existing systemic barriers (e.g. insufficient dedicated time/funding/training) were perceived as being aggravated during the COVID-19 pandemic (72% of survey participants agreed). Reported gaps were highest in India and France. Conclusions: The educational needs of professionals and countries included in this study can inform future continuous professional development activities in AMS. Additional funding should be considered to address perceived systemic barriers. Local assessments are warranted to validate results and suitability of interventions.

Do Physician Assistant Training Programs Adequately Prepare PAs to Address Nutritional Issues in Clinical Practice?

PURPOSE: The purpose of this study was to determine physician assistants' (PAs') current level of confidence to engage in nutrition-related tasks and their satisfaction with the nutrition education they received in PA school. METHODS: To achieve this goal, a mixed-methods approach that consisted of 3 data collection phases (qualitative online discussions, quantitative survey, and qualitative interviews) was used to explore and measure PAs' perceptions of the education they received in PA school and through other sources and how confident they felt addressing nutrition-related issues in clinical practice. RESULTS: While 80% of PAs endorse the idea that PAs should be more involved in providing nutritional care to patients, the majority reported basic or no knowledge of the nutritional implications of chronic conditions (69%), inflammatory bowel disease (69%), nutritional needs over the lifespan (67%), and food allergies and intolerances (64%). Barriers to patient care included knowledge-related challenges when selecting lab tests based on patient profile (46%) and identifying needs based on various gastrointestinal diseases (67%) and when using diagnostic data to identify deficiencies (74%). Overall, 59% of PAs reported being slightly or very dissatisfied with the nutrition-related content in the curricula used to formally train PAs. CONCLUSIONS: The primary goal of every PA program is to prepare its graduates to be competent to enter clinical practice. Regarding nutrition, these data indicate that programs are failing to do so. PAs lack the confidence and ability to provide optimal nutritional care, which is staggering considering that nutrition is the first line of treatment in the prevention and management of numerous chronic diseases.

Educational needs of fertility healthcare professionals using ART: a multi-country mixed-methods study.

RESEARCH QUESTION: What are the most pressing educational needs of fertility healthcare professionals using assisted reproductive technologies (ART)? DESIGN: This mixed-methods study combined qualitative interviews with quantitative surveys. Participants included physicians and nurses specialized in reproductive endocrinology or in obstetrics/gynaecology, and laboratory specialists, with a minimum of 3 years of experience, practising in Australia, Brazil, Canada, China, France, Germany, India, Italy, Japan, Mexico, Spain or the UK. Maximum variation purposive sampling was used to ensure a mix of experience and settings. Interviews were transcribed and coded through thematic analysis. Quantitative data were analysed using frequency tables, cross-tabulations and chi-squared tests to compare results by reimbursement context. RESULTS: A total of 535 participants were included (273 physicians, 145 nurses and 117 laboratory specialists). Knowledge gaps, skills gaps and attitude issues were identified in relation to: (i) ovarian stimulation (e.g. knowledge of treatments and instruction protocols for ovarian stimulation), (ii) embryo culture and cryopreservation/vitrification (e.g. diverging opinions on embryo freezing, (iii) embryo assessment (e.g. performing genetic testing), (iv) support of luteal phase and optimizing pregnancy outcomes (e.g. knowledge of assessment methods for endometrial receptivity), and (v) communication with patients (e.g. reluctance to address emotional distress). CONCLUSIONS: This descriptive, exploratory study corroborates previously reported gaps in fertility care and identifies potential causes of these gaps. Findings provide evidence to inform educational programmes for healthcare professionals who use ART in their practice and calls for the development of case-based education and interprofessional training programmes to improve care for patients with fertility issues.

Challenges in multiple sclerosis care: Results from an international mixed-methods study.

BACKGROUND: Disease-modifying treatment (DMT) selection for people with multiple sclerosis (MS) is challenging. Neurologists and advanced practice nurses (APNs) in MS care may be facing knowledge and confidence gaps when screening patients to initiate or switch between DMTs, assessing the safety of new DMTs and monitoring for adverse events. Healthcare providers are required to demonstrate enhanced patient communication skills, to share treatment decisions and assess treatment adherence. To better inform educational interventions, there is a need to better understand these challenges and uncover their causalities. We undertook an international study across seven countries to identify challenges for neurologists and APNs that may impact DMT choices and optimum care for people with MS (pwMS). METHODS: This mixed methods study involved two concurrent data collection phases, a qualitative phase with semi-structured interviews and a quantitative phase using an online survey. Neurologists (n=333) and APNs (n=135) were recruited from Canada, France, Germany, Italy, Spain, United Kingdom and the United States. All participants had to have a minimum of two years' experience in the care of pwMS and be currently active in clinical practice. RESULTS: A triangulated analysis of qualitative and quantitative data identified multiple challenges. For APNs, these mainly related to diagnosing MS, integrating new agents in their practice, sequential DMT selection, treatment monitoring and providing personalized care. Specifically, two-thirds of APNs reported no or basic knowledge of the 2017 McDonald criteria and over half reported a knowledge gap of new DMTs available (51%) and a skill gap when integrating them into practice (58%). APNs expressed a knowledge gap of treatment sequencing (46%) and a skill gap in making decisions about sequencing (62%). Forty-four percent of APNs reported a gap in their skills of integrating patient's goals into treatment recommendations. For neurologists, the main challenges included managing side effects, aligning care to their patient's personal goals and quality of life (QoL). Specifically, over a third of neurologists reported no or basic knowledge of the characteristics of treatment failure (35%), and 32% reported no or basic skills identifying treatment failure. Skills needed to integrate patient's individual goals into treatment recommendations were reported as none or low by 39% of neurologists. In addition, there were significant differences according to years of practice in the majority (9 out of 14) of confidence items with respect to discussing specific MS-related topics with patients. Significant differences between countries were also identified. CONCLUSION: The complexity of diagnosing MS and the variety of available DMTs for pwMS lead to uncertainties, even among specialized healthcare professionals. These should be addressed through focused education and training to optimize care for pwMS.

Identifying Educational Needs and Practice Gaps of European Hematologists and Hematology Nurses in the Treatment and Management of Multiple Myeloma.

This needs-assessment aimed to identify clinical challenges faced by hematologists and hematology nurses in the diagnosis, treatment, and management of multiple myeloma, as well as contextual barriers hindering optimal care of patients with multiple myeloma. This manuscript focuses on key findings in relation to decision-making regarding new treatment options. A mixed methods study consisting of qualitative (from semistructured interviews) and quantitative data (from an online survey) was conducted in 8 European countries among hematologists and hematology nurses. The triangulated data led to the identification of 3 key findings related to decision-making: (1) Educational needs regarding mechanisms of action and side effect profiles of new therapies, (2) educational needs regarding the sequencing and combination of new agents with current therapies, and (3) contextual barriers to the integration of new agents. Specific knowledge and skill gaps were identified as causalities of the educational needs, providing information to guide future educational programs. Of note, 34% of hematologists and 69% of nurses reported suboptimal knowledge of the mechanisms of action of new agents and 30% of hematologists reported suboptimal skills integrating new agents in combination with current treatments. This needs-assessment highlighted the importance to address the educational needs and their underlying causes through medical education activities to ensure hematologists and hematology nurses are up-to-date with the latest treatments in the field as they become available. The contextual barriers identified should be considered when designing the educational programs to ensure content is applicable to the clinical reality of learners.

SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program.

OBJECTIVE: Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice. METHOD: Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments. SUBJECTS: The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014. RESULTS: Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing. CONCLUSIONS: The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain.

A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future?

BACKGROUND: In North America and other industrialized countries, heart failure (HF) has become a national public health priority. Studies indicate there is significant heterogeneity in approaches to treat and manage HF and suggest targeted changes in health care delivery are needed to reduce unnecessary health care utilization and to optimize patient outcomes. Most recent published studies have reported on the care of HF patients in tertiary care hospitals and the perspective of non-specialist stakeholders on HF management, such as general practitioners and clinics or hospital administrators is rarely considered. This study explores the current state of community-based HF care in Canada as experienced by various healthcare stakeholders providing or coordinating care to HF patients. METHODS: This study employed a qualitative exploratory research design consisting of semi-structured telephone interviews conducted with health care providers and health care administrators working outside of tertiary care in the four most populous Canadian provinces. A modified thematic analysis process was used and the different data sources were triangulated. Findings were collectively interpreted by the authors. RESULTS: Twenty-eight participants were recruited in the study: eight cardiologists, five general practitioners/family physicians, eight nurse practitioners/registered nurses, four hospital pharmacists and three health care administrators/directors. Participants reported a lack of stakeholder engagement throughout the continuum of care, which hinders the implementation of a coordinated approach to quality HF care. Four substantive themes emerged that indicated challenges and gaps in the optimal treatment and management of HF in community settings: 1) challenges in the risk assessment and early diagnosis of HF, 2) challenges in ensuring efficient and consistent transition from acute care setting to the community, 3) challenges of primary care providers to optimally treat and manage HF patients, and 4) challenges in promoting a holistic approach in HF management. CONCLUSIONS: As health systems evolve from tertiary-based care to community-based outpatient services for the management of chronic diseases, this study's findings pinpoint challenges that have been observed in the Canadian context and can stimulate and orient dialogue toward solutions for a more coordinated approach to improve the care of HF patients and reduce pressure on the healthcare system.