The effects of multi-disciplinary integrated care on healthcare utilization: Evidence from a natural experiment in the UK.

Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi-disciplinary group (MDG) meetings for discussion of high-risk patients, introduced in one socio-economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population-level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.

Teaming in the contemporary fertility clinic: creating a culture to optimize patient care.

When a diverse group of individuals is working together in the contemporary fertility clinic to provide time-sensitive and complex care for patients, a high degree of coordination and collaboration must take place. When performed dynamically, this process is referred to as teaming. Although the positive impact of teamwork in health care settings has been well established in the literature, the concept of teaming has limited foundation in the clinic. This review will provide an overview of how teaming can be used to improve patient care in today's fertility clinics. Approaches to integrating teaming into the clinic that will be discussed include framing, the creation of a psychologically safe environment for staff input, and facilitating collaborative constructs to support teaming. Best practices to implement teaming and how to address challenges to teaming in today's clinical environment will also be addressed.

Addressing What Matters.

This article is the second in a series, Supporting Family Caregivers in the 4Ms of an Age-Friendly Health System, published in collaboration with the AARP Public Policy Institute as part of the ongoing Supporting Family Caregivers: No Longer Home Alone series. The 4Ms of an Age-Friendly Health System (What Matters, Medication, Mentation, and Mobility) is an evidence-based framework for assessing and acting on critical issues in the care of older adults across settings and transitions of care. Engaging the health care team, including older adults and their family caregivers, with the 4Ms framework can help to ensure that every older adult gets the best care possible, is not harmed by health care, and is satisfied with the care they receive. The articles in this series present considerations for implementing the 4Ms framework in the inpatient hospital setting and incorporating family caregivers in doing so. Resources for both nurses and family caregivers, including a series of accompanying videos developed by AARP and the Rush Center for Excellence in Aging and funded by The John A. Hartford Foundation, are also provided. Nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

The PReliMinAry (Pain Relief in Major Amputation) Survey.

OBJECTIVES: Major Lower Limb Amputation (MLLA) is associated with significant peri- and post-operative pain and has been identified as a research priority by patient and healthcare groups. The PReliMinAry survey was designed to evaluate existing MLLA analgesia strategies; identifying areas of equipoise and informing future research. METHODS: A targeted multi-national, multi-disciplinary survey was conducted via SurveyMonkey® (October 5, 2020-November 3, 2020) and advertised via social media and society email lists. The 10-questions explored 'pain-team' services, pre-operative neuroleptic medication, pre-incision peripheral nerve blocks and catheters, surgically placed nerve catheters, post-operative adjunctive regimens, future research engagement and equipoise. RESULTS: Seventy-six responses were received from 60 hospitals worldwide. Twelve hospitals(20%) had a dedicated MLLA pain team, 7(12%) had none. Most pain teams (n = 52; 87%) assessed pain with a 0-10 numerical rating scale. Over half of respondents "never" preloaded patients with oral neuroleptic agents(n= 42/76; 55%). Forty-seven hospitals(78%) utilized patient controlled opioid analgesia. Most hospitals are able to provide pre-incision loco-regional peripheral nerve blocks, nerve catheters and surgical nerve catheters (95%, 77%, and 90% respectively), but use was variable. Ultrasound(US) guided peripheral nerve catheters were "infrequently" or "never" used in 57% of hospitals, whilst 23% "infrequently" or "never" utilize surgically placed nerve catheters. CONCLUSIONS: The survey revealed a preference towards 'single-shot' nerve blocks and surgical catheters. A difference between the use of US guided nerve catheters and those surgically placed likely reflects the difference of literature evaluating these techniques. Most respondents felt there was equipoise surrounding future trials evaluating nerve blocks/catheters, but less so for surgical catheters.

Perceptions of Pharmacy students about their competences for professional practice in community pharmacy

Abstract Pharmaceutical education should enable the development of competences for community pharmacy practice, which is an important field for the pharmacist workforce. The aim of this study was to evaluate the competences perceived by pharmacy interns from a Brazilian pharmacy school for community pharmacy practice. This study adopted a combined quantitative and qualitative approach. The study cohort included undergraduate students who undertook internships in community pharmacy in the final year of the pharmacy course. Students responded to an 11-item structured questionnaire according to a five-point Likert scale that included perceptions of their competences for community pharmacy practice. Among the 693 possible answers, 605 (87.3%) agreed that the course promoted the development of competences for professional practice in community pharmacy. Less than 70% of students perceived themselves as prepared to respond to symptoms and provide non-prescription medicines. Qualitative analysis of the comments revealed three themes: the need to improve patient information skills, improve practice as a member of a health care team, and improve dispensing according to legal requirements. These findings may support improvements in undergraduate pharmacy programs, such as the inclusion of experiential learning, active learning methods, interprofessional education, and development of clinical skills.

Percepções dos profissionais da saúde sobre a presença do acompanhante no nascimento / Perceptions of health professionals about the presence of the accompanying party at birth / Percepciones de los profesionales de la salud sobre la presencia del acompañante al nacimiento

Objetivo: descrever as percepções dos profissionais da saúde sobre a presença do acompanhante no processo do nascimento. Método: estudo descritivo, qualitativo, realizado em um hospital escola, com 29 profissionais da saúde. A coleta de dados foi realizada por meio de entrevistas, entre maio a julho de 2018, sendo analisadas com abordagem baseada no Discurso do Sujeito Coletivo. Resultados: após análise emergiram quatro Ideias Centrais: experiências positivas e a participação do acompanhante, o ambiente desconhecido gera sentimento de insegurança no acompanhante, a presença do acompanhante causa desconforto na equipe de saúde e o profissional barra o acompanhante pela presunção de que ele irá atrapalhar. Conclusão: as percepções dos profissionais se mostraram conflitantes, sendo que alguns percebem a importância e os benefícios do acompanhante no nascimento, e outros apontaram que ele atrapalha a equipe de saúde, pela ansiedade e estresse, prejudicando a equipe de saúde e interferindo de maneira negativa

Objective: to describe the perceptions of health professionals about the presence of a companion in the birth process. Method: a descriptive, qualitative study, carried out in a teaching hospital, with 29 health professionals. Data collection was carried out through interviews, between May and July 2018, being analyzed using an approach based on the Collective Subject Discourse. Results:after analysis, four Central Ideas emerged: positive experiences and the companion's participation, the unknown environment generates feelings of insecurity in the companion, the presence of the companion causes discomfort in the health team and the professional stops the companion due to the presumption that it will hinder. Conclusion: the perceptions of the professionals were conflicting, with some perceiving the importance and benefits of the companion at birth, and others pointed out that it disturbs the health team, due to anxiety and stress, harming the health team and interfering in a negative way

Objetivo: describir las percepciones de los profesionales de la salud sobre la presencia de un acompañante en el proceso del parto. Método: estudio descriptivo, cualitativo, realizado en un hospital universitario, con 29 profesionales de la salud. La recolección de datos se realizó a través de entrevistas, entre mayo y julio de 2018, siendo analizadas con un enfoque basado en el Discurso Colectivo del Sujeto. Resultados: luego del análisis surgieron cuatro Ideas Centrales: experiencias positivas y la participación del acompañante, el entorno desconocido genera sentimientos de inseguridad en el acompañante, la presencia del acompañante provoca malestar en el equipo de salud y el profesional detiene al acompañante por presunción de que dificultará. Conclusión: las percepciones de los profesionales fueron conflictivas, algunos percibieron la importancia y los beneficios del acompañante al nacer, y otros señalaron que perturba al equipo de salud, por ansiedad y estrés, perjudicando al equipo de salud e interfiriendo de manera negativa

Pharmacist involved education program in a multidisciplinary team for oral mucositis: Its impact in head-and-neck cancer patients.

OBJECTIVES: This retrospective study examined how a pharmacist-involved education program in a multidisciplinary team (PEMT) for oral mucositis (OM) affected head-and-neck cancer (HNC) patients receiving concurrent chemoradiotherapy (CCRT). MATERIALS AND METHODS: Total samples data of 53 patients during the stipulated timeframe were retrospectively collected from electronic medical records from February 2017 to January 2019. We compared the presence/absence of OM (OM: yes/no) between patients with and without PEMT (PEMT: yes/no) as the primary endpoint and OM severity as the secondary endpoint. The following information was surveyed: age, gender, weight loss, steroid or immunosuppressant use, hematological values (albumin, white blood cell count, blood platelets, and neutrophils), cancer grade, primary cancer site, type and use of mouthwash and moisturizer, opioid use (yes/no, days until the start of opioid use, and dose, switch to tape), and length of hospital day (LOD). The two groups were compared using Fisher's exact test for qualitative data and the Mann-Whitney U test for quantitative data, and a significance level of p<0.05 was set. RESULTS: The group managed by PEMT had significantly lower weight loss and a significantly lower incidence of local anesthetic and opioid use and switch to tape compared with the group not managed by PEMT (p<0.05). The two groups showed no significant difference in OM (yes/no) or OM severity. The PEMT group had significantly shorter LOD at 57 (53-64) days compared with the non-PEMT group at 63.5 (57-68) days (p<0.05). CONCLUSIONS: Our results showed that PEMT did not improve OM (yes/no) or OM severity in HNC patients undergoing CCRT. However, the PEMT group had a lower incidence of grades 3 and 4 OM than the non-PEMT group, although not significantly. In addition, PEMT contributed to oral pain relief and the lowering of the risk for OM by reduction in weight loss.

Temporal Trends and Drivers of Heart Team Utilization in Transcatheter Aortic Valve Replacement: A Population-Based Study in Ontario, Canada.

Background The multidisciplinary Heart Team (HT) is recommended for management decisions for transcatheter aortic valve replacement (TAVR) candidates, and during TAVR procedures. Empiric evidence to support these recommendations is limited. We aimed to explore temporal trends, drivers, and outcomes associated with HT utilization. Methods and Results TAVR candidates were identified in Ontario, Canada, from April 1, 2012 to March 31, 2019. The HT was defined as having a billing code for both a cardiologist and cardiac surgeon during the referral period. The procedural team was defined as a billing code during the TAVR procedure. Hierarchical logistical models were used to determine the drivers of HT. Median odds ratios were calculated to quantify the degree of variation among hospitals. Of 10 412 patients referred for TAVR consideration, 5489 (52.7%) patients underwent a HT during the referral period, with substantial range between hospitals (median odds ratio of 1.78). Utilization of a HT for TAVR referrals declined from 69.9% to 41.1% over the years of the study. Patient characteristics such as older age, frailty and dementia, and hospital characteristics including TAVR program size, were found associated with lower HT utilization. In TAVR procedures, the procedural team included both cardiologists and cardiac surgeons in 94.9% of cases, with minimal variation over time or between hospitals. Conclusions There has been substantial decline in HT utilization for TAVR candidates over time. In addition, maturity of TAVR programs was associated with lower HT utilization.

Towards improved genetic diagnosis of human differences of sex development.

Despite being collectively among the most frequent congenital developmental conditions worldwide, differences of sex development (DSD) lack recognition and research funding. As a result, what constitutes optimal management remains uncertain. Identification of the individual conditions under the DSD umbrella is challenging and molecular genetic diagnosis is frequently not achieved, which has psychosocial and health-related repercussions for patients and their families. New genomic approaches have the potential to resolve this impasse through better detection of protein-coding variants and ascertainment of under-recognized aetiology, such as mosaic, structural, non-coding or epigenetic variants. Ultimately, it is hoped that better outcomes data, improved understanding of the molecular causes and greater public awareness will bring an end to the stigma often associated with DSD.

A Glimpse Into the Magnet® Program Office: The High-Performing Senior Magnet® Program Analyst Team.

The Magnet Recognition Program® has a dedicated team of RNs and non-RNs who are committed to advancing nursing and supporting healthcare organizations on their Magnet® journeys. Healthcare organizations who are either Magnet-designated or applicants for Magnet designation regularly communicate with the various members of the Magnet program office team. This perspective will highlight the roles of the senior Magnet program analysts and the assistant director of Magnet program operations.

Intraoperative consultation of vascular surgeons is increasing at a major American trauma center.

OBJECTIVE: Vascular surgeons are often called to aid other surgical specialties for complex exposure, hemorrhage control, or revascularization. The evolving role of the vascular surgeon in the management of intraoperative emergencies involving trauma patients remains undefined. The primary aims of this study included determining the prevalence of intraoperative vascular consultation in trauma, describing how these interactions have changed over time, and characterizing the outcomes achieved by vascular surgeons in these settings. We hypothesized that growing endovascular capabilities of vascular surgeons have resulted in an increased involvement of vascular surgery faculty in the management of the trauma patient over time. METHODS: A retrospective review of all operative cases at a single level I trauma center where a vascular surgeon was involved, but not listed as the primary surgeon, between 2002 and 2017 was performed. Cases were abstracted using Horizon Surgical Manager, a documentation system used in our operating room to track staff present, the type of case, and use. All elective cases were excluded. RESULTS: Of the 256 patients initially identified, 22 were excluded owing to the elective or joint nature of the procedure, leaving 234 emergent operative vascular consultations. Over the 15-year study period, a 529% increase in the number of vascular surgery consultations was seen, with 65% (n = 152) being intraoperative consultations requiring an immediate response. Trauma surgery (n = 103 [44%]) and orthopedic surgery (n = 94 [40%]) were the most common consulting specialties, with both demonstrating a trend of increasing consultations over time (general surgery, 1400%; orthopedic surgery, 220%). Indications for consultation were extremity malperfusion, hemorrhage, and concern for arterial injury. The average operative time for the vascular component of the procedures was 2.4 hours. Of patients presenting with ischemia, revascularization was successful in 94% (n = 116). Hemorrhage was controlled in 99% (n = 122). In-hospital mortality was relatively low at 7% (n = 17). Overall, despite the increase in intraoperative vascular consultations over time, a concomitant increase in the proportion of procedures done using endovascular techniques was not seen. CONCLUSIONS: Vascular surgeons are essential team members at a level I trauma center. Vascular consultation in this setting is often unplanned and often requires immediate intervention. The number of intraoperative vascular consultations is increasing and cannot be attributed solely to an increase in endovascular hemorrhage control, and instead may reflect the declining experience of trauma surgeons with vascular trauma. When consulted, vascular surgeons are effective in quickly gaining control of the situation to provide exposure, hemorrhage control, or revascularization.

Pulmonary Embolism Response Team utilization during the COVID-19 pandemic.

Coronavirus disease 2019 (COVID-19) may predispose patients to venous thromboembolism (VTE). Limited data are available on the utilization of the Pulmonary Embolism Response Team (PERT) in the setting of the COVID-19 global pandemic. We performed a single-center study to evaluate treatment, mortality, and bleeding outcomes in patients who received PERT consultations in March and April 2020, compared to historical controls from the same period in 2019. Clinical data were abstracted from the electronic medical record. The primary study endpoints were inpatient mortality and GUSTO moderate-to-severe bleeding. The frequency of PERT utilization was nearly threefold higher during March and April 2020 (n = 74) compared to the same period in 2019 (n = 26). During the COVID-19 pandemic, there was significantly less PERT-guided invasive treatment (5.5% vs 23.1%, p = 0.02) with a numerical but not statistically significant trend toward an increase in the use of systemic fibrinolytic therapy (13.5% vs 3.9%, p = 0.3). There were nonsignificant trends toward higher in-hospital mortality or moderate-to-severe bleeding in patients receiving PERT consultations during the COVID-19 period compared to historical controls (mortality 14.9% vs 3.9%, p = 0.18 and moderate-to-severe bleeding 35.1% vs 19.2%, p = 0.13). In conclusion, PERT utilization was nearly threefold higher during the COVID-19 pandemic than during the historical control period. Among patients evaluated by PERT, in-hospital mortality or moderate-to-severe bleeding were not significantly different, despite being numerically higher, while invasive therapy was utilized less frequently during the COVID-19 pandemic.

Trends in the treatment of pancreatic cancer in Japan.

Pancreatic cancer is known to have the poorest prognosis among digestive cancers. With the development of new chemotherapeutic agents and introduction of multidisciplinary therapy, however, the treatment outcomes for pancreatic cancer have dramatically improved over the past two decades. The keys to successful treatment will be accurate assessment of resectability [resectable (R), borderline resectable (BR) or unresectable (UR)] at the time of diagnosis and prompt adoption of an appropriate multidisciplinary treatment strategy. Prep-02/JSAP-05 trial which is an RCT of upfront surgery versus neoadjuvant chemotherapy using GEM and S-1 (GS) and subsequent surgery for R-PDAC in Japan indicated neoadjuvant chemotherapy had a longer overall survival (OS) than those undergoing upfront surgery (36.7M vs. 26.6M, p = 0.015). In a retrospective multicenter study in Japan reported that in BR-PDAC, median survival time (MST) in the pretreatment group was significantly better than that in the upfront surgery group (25.7 months vs. 19.0 months, p = 0.015) according to a propensity score matching analysis. Another retrospective multicenter study with UR-LA PDAC in Japan reported that conversion surgery was more beneficial for patients with more than 8 months of preoperative therapy than those with less than 8 months of that therapy. Various clinical trials on pancreatic cancer are ongoing, and the results of trials on chemotherapeutic regimens and multidisciplinary treatments will be of further interest.

Vision for menopause care in the UK.

Menopause is a major life event affecting all women in a variety of ways, both short and long term. All women should have access to accurate information, available in all forms and through all recognised sources. All healthcare professionals should have a basic understanding of the menopause and know where to signpost women for advice, support and treatment whenever appropriate. Every primary care team should have at least one nominated healthcare professional with a special interest and knowledge in menopause. All healthcare professionals with a special interest in menopause should have access to British Menopause Society Menopause Specialists for advice, support, onward referral and leadership of multidisciplinary education. With the introduction of the comprehensive British Menopause Society Principles and Practice of Menopause Care programme, the society is recognised throughout the UK as the leading provider of certificated menopause and post reproductive health education and training for healthcare professionals. Restrictions imposed by the coronavirus pandemic have been a springboard for the British Menopause Society to bring innovations to the services provided for our membership and for healthcare professionals throughout the UK.

Adapting inpatient addiction medicine consult services during the COVID-19 pandemic.

BACKGROUND: We describe addiction consult services (ACS) adaptations implemented during the Novel Coronavirus Disease 2019 (COVID-19) pandemic across four different North American sites: St. Paul's Hospital in Vancouver, British Columbia; Oregon Health & Sciences University in Portland, Oregon; Boston Medical Center in Boston, Massachusetts; and Yale New Haven Hospital in New Haven, Connecticut. EXPERIENCES: ACS made system, treatment, harm reduction, and discharge planning adaptations. System changes included patient visits shifting to primarily telephone-based consultations and ACS leading regional COVID-19 emergency response efforts such as substance use treatment care coordination for people experiencing homelessness in COVID-19 isolation units and regional substance use treatment initiatives. Treatment adaptations included providing longer buprenorphine bridge prescriptions at discharge with telemedicine follow-up appointments and completing benzodiazepine tapers or benzodiazepine alternatives for people with alcohol use disorder who could safely detoxify in outpatient settings. We believe that regulatory changes to buprenorphine, and in Vancouver other medications for opioid use disorder, helped increase engagement for hospitalized patients, as many of the barriers preventing them from accessing care on an ongoing basis were reduced. COVID-19 specific harm reductions recommendations were adopted and disseminated to inpatients. Discharge planning changes included peer mentors and social workers increasing hospital in-reach and discharge outreach for high-risk patients, in some cases providing prepaid cell phones for patients without phones. RECOMMENDATIONS FOR THE FUTURE: We believe that ACS were essential to hospitals' readiness to support patients that have been systematically marginilized during the pandemic. We suggest that hospitals invest in telehealth infrastructure within the hospital, and consider cellphone donations for people without cellphones, to help maintain access to care for vulnerable patients. In addition, we recommend hospital systems evaluate the impact of such interventions. As the economic strain on the healthcare system from COVID-19 threatens the very existence of ACS, overdose deaths continue rising across North America, highlighting the essential nature of these services. We believe it is imperative that health care systems continue investing in hospital-based ACS during public health crises.