Referrals from community optometrists to the hospital eye service in England.

PURPOSE: In the UK, most referrals to the hospital eye service (HES) originate from community optometrists (CO). This audit investigates the quality of referrals, replies, and communication between CO and the HES. METHODS: Optometric referrals and replies were extracted from three practices in England. If no reply letter was found, the records were searched at each local HES unit, and additional replies or records copied. De-identified referrals, replies and records were audited by a panel against established standards to evaluate whether the referrals were necessary, accurate and directed to the appropriate professional. The referral rate (RR) and referral reply rate (RRR) were calculated. RESULTS: A total of 459 de-identified referrals were extracted. The RR ranged from 3.6%-8.7%. The proportion of referred patients who were seen in the HES unit was 63%-76%. From the CO perspective, the proportion of referrals for which they received replies ranged from 26%-49%. Adjusting the number of referrals for cases when it would be reasonable to expect an HES reply, RRR becomes 38%-62%. Patients received a copy of the reply in 3%-21% of cases. Referrals were made to the appropriate service in over 95% of cases, were judged necessary in 93%-97% and were accurate in 81%-98% of cases. The referral reply addressed the reason for the referral in 93%-97% and was meaningful in 94%-99% of cases. The most common conditions referred were glaucoma, cataract, anterior segment lesions, and neurological/ocular motor anomalies. The CO/HES dyad (pairing) in the area with the lowest average household income had the highest RR. CONCLUSIONS: In contrast with the Royal College of Ophthalmologists/College of Optometrists joint statement on sharing patient information, CO referrals often do not elicit a reply to the referring CO. Replies from the HES to COs are important for patient care, benefitting patients and clinicians, and minimising unnecessary HES appointments.

Resultados de la asistencia compartida con medicina interna en un servicio de cirugía oral y maxilofacial / Results of comanagement with internal medicine in oral and maxillofacial surgery department

ANTECEDENTES Y OBJETIVO: La edad de los pacientes ingresados para tratamiento por los servicios de cirugía oral y maxilofacial (COMF) es progresivamente más alta, con la comorbilidad asociada que eso conlleva, y supone un incremento sustancial de las interconsultas a los servicios de medicina interna (MI), que no alcanzan la efectividad requerida. Una alternativa para mejorar la atención a los pacientes es la colaboración entre ambos servicios mediante la asistencia compartida (AC). El objetivo de este artículo es estudiar la repercusión y el efecto del empleo de la AC en los pacientes de COMF. MÉTODOS: Estudio observacional retrospectivo de los pacientes ≥ 16 años ingresados desde el 12 de marzo de 2017 hasta el 12 de marzo de 2019 en COMF, con AC con MI desde el 12 de marzo de 2018. Las variables analizadas son edad, sexo, tipo de ingreso, si fue intervenido quirúrgicamente, peso administrativo asociado a GRD, número total de diagnósticos al alta, índice de comorbilidad de Charlson (ICh), exitus, reingresos urgentes y estancia hospitalaria. RESULTADOS: Los pacientes con AC fueron de menor edad (2,8 años, intervalo de confianza del 95 % [IC 95 %] 0,1 a 5,6), pero con mayor número de diagnósticos (0,8; IC 95 % 0,4 a 1,2) y una tendencia a mayor ICh (0,3; IC 95 % -0,1 a 0,6) y peso administrativo (0,04; IC 95 % -0,03 a 0,1). Al ajustar, observamos que la AC redujo el 22,7 % la estancia en CMF, 1 día (IC 95 % -1,8 a -0,3), el 40 % los reingresos urgentes y el 50 % la mortalidad, ambos no significativos. El descenso de la estancia supone una disminución de costes de, como mínimo, 231.816,7 €. CONCLUSIONES: La edad de los enfermos ingresados para tratamiento por los servicios de cirugía oral y maxilofacial es cada vez más alta, que se asocia con una mayor comorbilidad. El empleo de la asistencia compartida con medicina interna en el manejo de los pacientes ingresados en cirugía oral y maxilofacial se asocia a una disminución de la estancia y los costes, en línea con lo observado en otros servicios quirúrgicos

BACKGROUND AND OBJECTIVE: The age of patients admitted for treatment by Oral and Maxillofacial Surgery (OMFS) services is progressively higher, with the associated comorbidity that this entails, and supposes a substantial increase in referrals to the Internal Medicine (IM) services, which do not reach the required effectiveness. An alternative to improve patient care is collaboration between both services through shared care (SC). The objective of this article is to study the repercussion and effect of the use of shared care in Oral and Maxillofacial patients. METHODS: Retrospective observational study of patients aged ≥ 16 years admitted from 3/12/2017 to 3/12/2019 at OMFS, with SC with IM from 3/12/2018. The variables analyzed are age, sex, type of admission, whether the patient underwent surgery, administrative weight associated with DRG, total number of diagnoses at discharge, Charlson's comorbidity index (HCI), death, urgent readmissions and hospital stay. RESULTS: Patients with AC were younger (2.8 years, 95 % confidence interval [95 % CI] 0.1 to 5.6), but with a greater number of diagnoses (0.8, 95 % CI 0.4 to 1.2) and a trend towards higher CIh (0.3; 95 % CI -0.1 to 0.6) and administrative weight (0.04; 95 % CI -0.03 to 0.1 ). When adjusting, we observed that CA reduced the stay in the CMF by 22.7 %, 1 day (CI 95 % -1.8 to -0.3), 40 % the urgent readmissions and 50 % the mortality, both not significant. The decrease in the stay implies a reduction in costs of, at least, € 231,816.7. CONCLUSIONS: The age of patients admitted for treatment by Oral and Maxillofacial Surgery services is increasingly higher, which is associated with greater comorbidity. The use of shared care with Internal Medicine in the management of patients admitted to Oral and Maxillofacial Surgery is associated with a decrease in stay and costs, in line with what was observed in other surgical services

Modelos colaborativos hospitalarios de asistencia compartida e interconsultas a demanda. ¿Cuál ofrece mejores resultados en Cirugía Ortopédica y Traumatología? / Collaborative hospital models for shared care and on-demand interconsultations. Which offer the best results for Orthopaedic Surgery and Trauma?

ANTECEDENTES Y OBJETIVO: Los enfermos quirúrgicos hospitalizados están aumentando su complejidad médica, incrementando la necesidad de apoyo por Medicina Interna. Este apoyo se realiza mediante la interconsulta, la cual presenta problemas que han inducido el desarrollo de la asistencia compartida (AC). Nuestro objetivo es comparar los resultados asistenciales alcanzados por los modelos de interconsulta y AC en Cirugía Ortopédica y Traumatología. MATERIAL Y MÉTODO: Estudio observacional, prospectivo, multicéntrico, de los enfermos hospitalizados de urgencia en Cirugía Ortopédica y Traumatología recogidos en el registro REINA-SEMI, atendidos por Medicina Interna mediante interconsulta o AC. Se registraron las características demográficas, comorbilidad, complicaciones médicas, estancia hospitalaria y mortalidad. RESULTADOS: Se incluyeron 697 pacientes, 415 con AC y 282 con interconsulta. Los de AC tenían más edad (78,9 vs. 74,3; p <0,001), se operaron más (89,9 vs. 78,7%; p <0,001), tuvieron menos complicaciones médicas (50,4 vs. 62,8%; p <0,001) y su estancia hospitalaria fue menor (10 vs. 18 días; p <0,001), sin diferencias en la comorbilidad ni mortalidad. Los factores independientes asociados a estancia superior a 15 días fueron: insuficiencia cardiaca (OR: 3,4; IC 95%: 1,8-6,1; p <0,001), sexo (hombre) (OR: 1,9; IC 95%: 1,2-3,1; p = 0,004), trastorno electrolítico (OR: 2,4; IC 95%: 1,3-4,4; p = 0,003), infección respiratoria (OR: 1,9; IC 95%: 1,04-3,7; p = 0,035), demora quirúrgica (OR: 1,1; IC 95%: 1,08-1,2; p <0,001) y ser atendido mediante el modelo de interconsulta a demanda (OR: 3,5; IC 95%: 2,3-5,4; p <0,001). CONCLUSIONES: La AC ofrece mejores resultados asistenciales que las interconsultas en pacientes ingresados de urgencia en Cirugía Ortopédica y Traumatología

BACKGROUND AND OBJECTIVES: Hospitalized surgical patients are increasing in medical complexity, thereby increasing the need for support by internal medicine departments. This support is provided through interconsultations, which present problems that have resulted in the development of shared care (SC). Our objective was to compare the healthcare results achieved by the SC and interconsultation models in Orthopaedic Surgery and Trauma. MATERIALS AND METHODS: We conducted an observational, prospective, multicentre study of patients hospitalized for emergency Orthopaedic Surgery and Trauma recorded in the REINA-SEMI registry, treated by internal medicine departments through interconsultation or SC. We recorded the demographic characteristics, comorbidity, medical complications, hospital stay and mortality. RESULTS: The study included 697 patients, 415 with SC and 282 with interconsultations. The SC patients were older (78.9 vs. 74.3; P<.001) underwent more operations (89.9 vs. 78.7%; P<.001), had fewer medical complications (50.4 vs. 62.8%; P<.001) and had shorter hospital stays (10 vs. 18 days; P<.001), with no differences in comorbidity or mortality. The following independent factors were associated with stays longer than 15 days: heart failure (OR 3.4; 95% CI 1.8-6.1; P<.001), the male sex (OR 1.9; 95% CI 1.2-3.1; P=.004), electrolyte disorder (OR 2.4; 95% CI 1.3-4.4; P=.003), respiratory infection (OR 1.9; 95% CI 1.04-3.7; P=.035), surgical delay (OR 1.1; 95% CI 1.08-1.2; P<.001) and treatment using the interconsultation on demand model (OR 3.5; 95% CI 2.3-5.4; P<.001). CONCLUSIONS: SC offers better healthcare results than interconsultations for patients hospitalized for emergency Orthopaedic Surgery and Trauma

La asistencia compartida, una forma distinta de organizar la colaboración con los servicios quirúrgicos / Shared-care, a different method for organising the collaboration with surgery departments

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Implementing integrated behavioral health: Testing associations between shared clinical time and space and provider referrals.

INTRODUCTION: Behavioral health provider (BHP) availability is widely acknowledged as an important factor in the effectiveness of an integrated care approach within primary care. However, there is little research providing evidence of the impact of BHP availability on physician uptake of integrated behavioral health (IBH) services. METHOD: This quasi-experimental study examines whether shared clinical time and space with a BHP is associated with providers' number of standard IBH referrals and proportion of warm handoffs within total behavioral health (BH) referrals. Data are from 2 family medicine outpatient clinics with 1 shared, part-time BHP and were gathered across 4 months (2,847 unique patients served) using electronic health record chart review of patients referred for BH services. RESULTS: Results of a Poisson regression indicated greater shared time and space between BHP and providers is significantly associated with a greater number of providers' standard IBH referrals, χ²(df = 1, N = 15) = 13.67, p = .000. Results of general linear modeling indicate greater shared time and space is also associated with a greater proportion of warm handoffs (percentage of total referrals). A 1-unit increase in percentage of schedule overlap was associated with a 110% increase in likelihood of a family medicine provider making a warm handoff, Exp(ß) = 2.10, p = .007. DISCUSSION: This exploratory study provides initial evidence to support the notion that shared time and space between BHPs and physicians is an essential component of effective integrated care. Future research is needed to evaluate how shared time and space impact the accessibility, adoption, and effectiveness of the BHP. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Making health a shared value: Lessons from nurse-designed models of care.

BACKGROUND: Nurse-designed models of community-based care reflect a broad definition of health; family- and community-centricity; relationships; and group and public health approaches. PURPOSE: To examine how nurse-designed models of care have addressed "making health a shared value" based on the framework of the Culture of Health. METHOD: A mixed-methods design included an online survey completed by 37 of 41 of "Edge Runners" (American Academy of Nursing-designated nurse innovators) and telephone interviews with 13 of the 37. Data were analyzed using descriptive statistics and standard content analysis. FINDINGS: Two main areas of "making health a shared value" were increasing the perceptions that individual health is interdependent with the health of the community and community health promotion. Themes were the value of social support (interventions that engage an individual's inner circle and a group environment to reveal shared experiences); messaging (a holistic definition of health, the value of both culturally- and medically-accurate information, and the business case); and building trust (expertise sits locally and trust takes time). DISCUSSION: Refinement of the COH framework may be warranted and can provide strategies for making health a shared value within a community. Shifting the orientation of healthcare organizations must be a long-term, deliberate goal.

A taxonomy of hospitals participating in Medicare accountable care organizations.

BACKGROUND: Medicare was an early innovator of accountable care organizations (ACOs), establishing the Medicare Shared Savings Program (MSSP) and Pioneer programs in 2012-2013. Existing research has documented that ACOs bring together an array of health providers with hospitals serving as important participants. PURPOSE: Hospitals vary markedly in their service structure and organizational capabilities, and thus, one would expect hospital ACO participants to vary in these regards. Our research identifies hospital subgroups that share certain capabilities and competencies. Such research, in conjunction with existing ACO research, provides deeper understanding of the structure and operation of these organizations. Given that Medicare was an initiator of the ACO concept, our findings provide a baseline to track the evolution of ACO hospitals over time. METHODOLOGY/APPROACH: Hierarchical clustering methods are used in separate analyses of MSSP and Pioneer ACO hospitals. Hospitals participating in ACOs with 2012-2013 start dates are identified through multiple sources. Study data come from the Centers for Medicare and Medicaid Services, American Hospital Association, and Health Information and Management Systems Society. RESULTS: Five-cluster solutions were developed separately for the MSSP and Pioneer hospital samples. Both the MSSP and Pioneer taxonomies had several clusters with high levels of health information technology capabilities. Also distinct clusters with strong physician linkages were present. We examined Pioneer ACO hospitals that subsequently left the program and found that they commonly had low levels of ambulatory care services or health information technology. CONCLUSION: Distinct subgroups of hospitals exist in both the MSSP and Pioneer programs, suggesting that individual hospitals serve different roles within an ACO. Health information technology and physician linkages appear to be particularly important features in ACO hospitals. PRACTICE IMPLICATIONS: ACOs need to consider not only geographic and service mix when selecting hospital participants but also their vertical integration features and management competencies.

The impact of accountable care organization participation on hospital patient experience.

BACKGROUND: Accountable care organizations (ACOs) are being implemented rapidly across the Unites States. Previous studies indicated an increasing number of hospitals have participated in ACOs. However, little is known about how ACO participation could influence hospitals' performance. PURPOSE: This study aims to examine the impact of Medicare ACO participation on hospitals' patient experience. METHODOLOGY/APPROACH: Difference-in-difference analyses were conducted to compare 10 patient experience measures between hospitals participating in Medicare ACOs and those not participating. RESULTS: In general, hospitals participating in Pioneer ACOs had significantly improved scores on nursing communication and doctor communication. Shared Savings Program (SSP) ACO participation did not show significant improvement of patient experience. Subgroup analyses indicate that, for hospitals in the middle and top tertile groups in terms of baseline experience, Pioneer ACO and SSP ACO participation was associated with better patient experience. For hospitals in the bottom tertile, Pioneer ACO and SSP ACO participation had no association with patient experience. CONCLUSION: ACO participation improved some aspects of patient experience among hospitals with prior good performance. However, hospitals with historically poor performance did not benefit from ACO participation. PRACTICE IMPLICATIONS: Prior care coordination and quality improvement experience position Medicare ACOs for greater success in terms of patient experience. Hospital leaders need to consider the potential negative consequences of ACO participation and the hospital's preparedness for care coordination.

Why Travel for Complex Cancer Surgery? Americans React to 'Brand-Sharing' Between Specialty Cancer Hospitals and Their Affiliates.

INTRODUCTION: Leading cancer hospitals have increasingly shared their 'brand' with smaller hospitals through affiliations. Because each brand evokes a distinct reputation for the care provided, 'brand-sharing' has the potential to impact the public's ability to differentiate the safety and quality within hospital networks. The general public was surveyed to determine the perceived similarities and differences in the safety and quality of complex cancer surgery performed at top cancer hospitals and their smaller affiliate hospitals. METHODS: A national, web-based KnowledgePanel (GfK) survey of American adults was conducted. Respondents were asked about their beliefs regarding the quality and safety of complex cancer surgery at a large, top-ranked cancer hospital and a smaller, local hospital, both in the presence and absence of an affiliation between the hospitals. RESULTS: A total of 1010 surveys were completed (58.1% response rate). Overall, 85% of respondents felt 'motivated' to travel an hour for complex surgery at a larger hospital specializing in cancer, over a smaller local hospital. However, if the smaller hospital was affiliated with a top-ranked cancer hospital, 31% of the motivated respondents changed their preference to the smaller hospital. When asked to compare leading cancer hospitals and their smaller affiliates, 47% of respondents felt that surgical safety, 66% felt guideline compliance, and 53% felt cure rates would be the same at both hospitals. CONCLUSIONS: Approximately half of surveyed Americans did not distinguish the quality and safety of surgical care at top-ranked cancer hospitals from their smaller affiliates, potentially decreasing their motivation to travel to top centers for complex surgical care.

[Value of shared electronic health records for the management of homeless people]. / Prise en charge des personnes sans chez-soi : intérêt du dossier médical partagé ?

AIM: To assess the acceptability for GPS to use the French shared Electronic Health Record (Dossier Médical Partagé, "DMP") when caring for Homeless People (HP). METHODS: Mixed, sequential, qualitative-quantitative study. The qualitative phase consisted of semi-structured interviews with GPs involved in the care of HP. During the quantitative phase, questionnaires were sent to 150 randomized GPs providing routine healthcare in Marseille. Social and practical acceptability was studied by means of a Likert Scale. RESULTS: 19 GPs were interviewed during the qualitative phase, and 105 GPs answered the questionnaire during the quantitative phase (response rate: 73%). GPs had a poor knowledge about DMP. More than half (52.5%) of GPs were likely to effectively use DMP for HP. GPs felt that the "DMP" could improve continuity, quality, and security of care for HP. They perceived greater benefits of the use the DMP for HP than for the general population, notably in terms of saving time (p = 0.03). However, GPs felt that HP were vulnerable and wanted to protect their patients; they worried about security of data storage. GPs identified specific barriers for HP to use DMP: most of them concerned practical access for HP to DMP (lack of social security card, or lack of tool for accessing internet). CONCLUSION: A shared electronic health record, such as the French DMP, could improve continuity of care for HP in France. GPs need to be better informed, and DMP functions need to be optimized and adapted to HP, so that it can be effectively used by GPs for HP.

Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes.

Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.

[Are emergency physicians influenced by nonmedical aspects in their choice of the hospital : Observations in 280 victims of out-of-hospital cardiac arrest in times of hospital alliances]. / Sind Notärzte bei der Wahl der Zielklinik durch nichtmedizinische Aspekte beeinflusst : Beobachtungen an 280 Patienten nach außerklinischem Herzstillstand in Zeiten der Krankenhauskooperationen.

INTRODUCTION: Emergency physicians are responsible for the out-of-hospital treatment of victims from out-of-hospital cardiac arrest (OHCA), not only with regard on the medical treatment, but also in terms of the choice of the most suitable hospital. We therefore wanted to determine whether nonmedical processes such as hospital alliances lead to changing rates of hospital admissions of patients following OHCA. MATERIALS AND METHODS: All patients who were admitted in our hospital following OHCA between 1 January 2008 and 30 June 2015 were identified and their data were anonymously stored in a central database. Afterward, we divided the study period into three periods: (1) the period prior to the publication of the ERC guidelines 2010, (2) the period after the publication of the ERC guidelines 2010, and (3) the period after a contract for hospital alliances with another hospital in town was signed. RESULTS: Of the 280 OHCA victims, we could analyze the emergency physician's reports of 238 victims from nontraumatic OHCA; there were 143 men (60.1 %) and 95 women (39.9 %) with an age of 69.1 ± 13.7 years. Following the changes in the guidelines in 2010, we observed a 42.8 % increase of hospital admissions from 2.15 admissions per month to 3.07 in period 2 following OHCA compared to period 1. After signing of the hospital alliance, there was an additional increase of 42.3 % to an average of 4.37 hospital admissions per month. DISCUSSION AND CONCLUSION: According to our data, it might be possible that not only medical influences (e.g., changes in the guidelines) but also nonmedical aspects (e.g., hospital alliances) might influence the choice of hospital for the further treatment of victims from OHCA.

Understanding specialist sharing: A mixed-method exploration in an increasingly price-competitive hospital market.

INTRODUCTION: Medical specialists seem to increasingly work in- and be affiliated to- multiple organizations. We define this phenomenon as specialist sharing. This form of inter-organizational cooperation has received scant scholarly attention. We investigate the extent of- and motives behind- specialist sharing, in the price-competitive hospital market of the Netherlands. METHODS: A mixed-method was adopted. Social network analysis was used to quantitatively examine the extent of the phenomenon. The affiliations of more than 15,000 medical specialists to any Dutch hospital were transformed into 27 inter-hospital networks, one for each medical specialty, in 2013 and in 2015. Between February 2014 and February 2016, 24 semi-structured interviews with 20 specialists from 13 medical specialties and four hospital executives were conducted to provide in-depth qualitative insights regarding the personal and organizational motives behind the phenomenon. RESULTS: Roughly, 20% of all medical specialists are affiliated to multiple hospitals. The phenomenon occurs in all medical specialties and all Dutch hospitals share medical specialists. Rates of specialist sharing have increased significantly between 2013 and 2015 in 14 of the 27 specialties. Personal motives predominantly include learning, efficiency, and financial benefits. Increased workload and discontinuity of care are perceived as potential drawbacks. Hospitals possess the final authority to decide whether and which specialists are shared. Adhering to volume norms and strategic considerations are seen as their main drivers to share specialists. DISCUSSION: We conclude that specialist sharing should be interpreted as a form of inter-organizational cooperation between healthcare organizations, facilitating knowledge flow between them. Although quality improvement is an important perceived factor underpinning specialist sharing, evidence of enhanced quality of care is anecdotal. Additionally, the widespread occurrence of the phenomenon and the underlying strategic considerations could pose an antitrust infringement.

Benefits and risks of shared services in healthcare.

Purpose - The purpose of this paper is to explore the experiences of staff in a large, public health service involved in transitioning support services to a shared services model. It aims to understand their perceptions of the benefits and risks arising from this change. Design/methodology/approach - Thematic analysis of qualitative data from semi-structured interviews with both service provider and customer agency staff was used to identify, analyze and report patterns of benefits and risks within data. Findings - Staff expressed the need for relevant subject-matter-experts to work within customer agencies to facilitate effective communication between the customer agency and shared services provider, reflecting observations found in out-sourcing literature. Research limitations/implications - Results point to significant challenges continuing to occur for shared services in healthcare. Risks identified suggest a more intimate relationship between clinical and support services than previously discussed. Originality/value - Previous discussion of the shared services model has not considered the skills, knowledge and ability required by staff in the customer agency. This research indicates that in the absence of such consideration, the concepts of the shared services model are weakened.

Utilization and impact of surgical technique on the performance of pelvic lymph node dissection at radical prostatectomy: Results from the Shared Equal Access Regional Cancer Hospital database.

OBJECTIVE: To evaluate performance of pelvic lymph node dissection during radical prostatectomy within an equal access care setting over a period of time, and stratified by prostate cancer risk group and surgical technique. METHODS: We identified men in the Shared Equal Access Regional Cancer Hospital database who had open or robotic-assisted radical prostatectomy from 2006 to 2013. Univariable logistic regression was used to test the association between age, race, body mass index, total biopsy cores, number of positive biopsy cores, risk group, year, center, surgical volume and surgical technique on pelvic lymph node dissection use. Multivariable logistic analysis was used to examine surgical technique and pelvic lymph node dissection performance. Spearman's correlation examined temporal changes in pelvic lymph node dissection utilization stratified by risk group and surgical technique. RESULTS: A total of 1425 men met inclusion criteria; 67% of them underwent pelvic lymph node dissection. On multivariable analysis, robotic-assisted radical prostatectomy was associated with an 92% decreased use of pelvic lymph node dissection in low-risk, 84% decreased in intermediate-risk and 91% decreased in high-risk men (all P < 0.001). In robotic-assisted radical prostatectomy, there was a trend for increased pelvic lymph node dissection utilization over time in high-risk men (Spearman; P = 0.077) reaching ~85% in 2012-2013, which was accompanied by increased use in low-risk men (P = 0.016). For open radical prostatectomy, fewer pelvic lymph node dissections were carried out in low-risk men over time, decreasing to ~35% (P = 0.047) in 2012-2013, whereas rates remained high for high-risk men throughout (~95%; P = 0.621). CONCLUSION: Regardless of risk group, pelvic lymph node dissection is carried out significantly less during robotic-assisted radical prostatectomy. For robotic-assisted radical prostatectomy, pelvic lymph node dissection utilization increased over time for high-risk men, but rates also increased for low-risk men. Further attention to the discrepancy between provided and guideline recommended pelvic lymph node dissection performance is required to improve prostate cancer care.

Telepathology Impacts and Implementation Challenges: A Scoping Review.

CONTEXT: Telepathology is a particular form of telemedicine that fundamentally alters the way pathology services are delivered. Prior reviews in this area have mostly focused on 2 themes, namely technical feasibility issues and diagnosis accuracy. OBJECTIVES: To synthesize the literature on telepathology implementation challenges and broader organizational and societal impacts and to propose a research agenda to guide future efforts in this domain. DATA SOURCES: Two complementary databases were systematically searched: MEDLINE (PubMed) and ABI/INFORM (ProQuest). Peer-reviewed articles and conference proceedings were considered. The final sample consisted of 159 papers published between 1992 and 2013. CONCLUSIONS: This review highlights the diversity of telepathology networks and the importance of considering these distinctions when interpreting research findings. Various network structures are associated with different benefits. Although the dominant rationale in single-site projects is financial, larger centralized and decentralized telepathology networks are targeting a more diverse set of benefits, including extending access to pathology to a whole region, achieving substantial economies of scale in workforce and equipment, and improving quality by standardizing care. Importantly, our synthesis reveals that the nature and scale of encountered implementation challenges also varies depending on the network structure. In smaller telepathology networks, organizational concerns are less prominent, and implementers are more focused on usability issues. As the network scope widens, organizational and legal issues gain prominence.