Immunotherapy for advanced and recurrent malignant pleural mesothelioma.

OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of immune checkpoint inhibitors (single-agent or combination therapy) in people with advanced malignant pleural mesothelioma in a first-line or salvage setting.

Telemedicine as a tool for continuing medical education.

BACKGROUND: There is a growing interest in the use of digital technologies to foster learning in the health professions, along with the drive to expand teleconsultations arising from the COVID-19 pandemic. This study aims to explore whether telemedicine between levels of care can act as continuous medical education (CME) tool for general practitioners (GPs) and hospital consultants at the referral cardiology department. METHODS: This qualitative study was embedded in an organizational case study of the introduction of a new service model in the Portuguese health system. Semi-structured interviews were audio-recorded and pseudonymized. The transcribed interviews were stored, coded, and content analysis was performed in MAXQDA. RESULTS: A total of 11 physicians were interviewed. GPs and cardiologists recognized that telemedicine between levels of care could act as a CME tool. Although they departed with different expectations, telemedicine helped them collaborate as a multidisciplinary team, exchanging feedback about clinical decisions, and constructing knowledge collaboratively. Telemedicine also supplemented existing learning meetings. The consequences of technology adoption may be viewed as a result of the actors involved (including the technology itself), characteristics of the context (including the organization), and an interaction between such factors. CONCLUSION: Teleconsultations can be a learning opportunity for the health professionals involved. Our findings suggest that, in the context of the Portuguese health system, telemedicine as a CME tool helped to build multidisciplinary teams which exchanged feedback and constructed shared knowledge to improve patients' outcomes. It also helped to identify practice-changing contents to be included in face-to-face educational meetings.

Mobile technologies to support healthcare provider to healthcare provider communication and management of care.

BACKGROUND: The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes. OBJECTIVES: To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers' performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts. SELECTION CRITERIA: Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care. DATA COLLECTION AND ANALYSIS: We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: We included 19 trials (5766 participants when reported), most were conducted in high-income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties. Mobile technologies used by primary care providers to consult with hospital specialists We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants); - probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants); - may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported); - probably make little or no difference to patient-reported quality of life and health-related quality of life (2 trials, 622 participants) or to clinician-assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions; - may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists; - may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants). Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department We assessed the certainty of evidence for this group of trials as moderate. Mobile technologies: - probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference -12 minutes, 95% CI -19 to -7; 1 trial, 345 participants); - probably reduce participants' length of stay in the emergency department by a few minutes (median difference -30 minutes, 95% CI -37 to -25; 1 trial, 345 participants). We did not identify trials that reported on providers' adherence, participants' health status and well-being, healthcare provider and participant acceptability and satisfaction, or costs. Mobile technologies used by community health workers or home-care workers to consult with clinic staff We assessed the certainty of evidence for this group of trials as moderate to low. Mobile technologies: - probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants); - may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants); - may make little or no difference to participants' disease activity or health-related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants); - probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants). We did not identify any trials that reported on providers' adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs. AUTHORS' CONCLUSIONS: Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants' health status and well-being, satisfaction, or costs.

Teleconsultations and their implications for health care: A qualitative study on patients' and physicians' perceptions.

BACKGROUND: Digitization in everyday medical practice has gained importance along with the drive to expand teleconsultations arising from the COVID-19 pandemic. Previous qualitative research on teleconsultations has focused on synchronous communication between patients and clinicians. This study aims to explore physicians' and patients' perspectives on the adoption of teleconsultations between primary care and the referral cardiology department. METHODS: Participants were recruited for semi-structured interviews between September 2019 and January 2020. The interviews were audio-recorded and pseudonymized. The transcribed interviews were stored, coded, and content analysis was performed in MAXQDA. RESULTS: A total of 29 participants were interviewed. Patients and physicians merged in their views on 'process' issues, i.e., those concerning a better prioritization of patients and an improved collaborative practice, albeit with possible technological constraints. Physicians recognized that teleconsultations presented an educational opportunity for managing patients' health problems. Our findings suggest that not all patients would require equally intensive collaborative activities across the health system. The barriers described included difficulties using the system (technical issues) and concerns about workload as a consequence of the disruption of traditional clinical routines. Increasing the range of collaborative strategies available to health care providers may require a broader assessment of the way that care processes are structured between levels of care. Patients revealed strong support for teleconsultation on the grounds of interprofessional collaboration and avoidance of unnecessary hospital visits. CONCLUSIONS: The implementation of teleconsultations between levels of care may be facilitated when patients, caregivers and physicians see the added value of this service, that adequate resources are put in place and that there is flexible implementation. This work adds an in-depth understanding of participants' perceptions of this intervention in a case study. Obtaining context-dependent knowledge will help program leaders better understand how to establish telemedicine services as a real-world sustainable option.

Interaction at the primary-secondary care interface: Patients' and physicians' perceptions of teleconsultations.

Introduction: Previous qualitative research on teleconsultations has focused on synchronous communication between a patient and a clinician. This study aims to explore physicians' and patients' perceptions of the interaction on the interface between primary care and the Cardiology service of a referral hospital through teleconsultations. Methods: This qualitative study was embedded in an organizational case study concerning the introduction and rollout of a new service model that took place at the point of care. The patients and physicians were recruited for semi-structured interviews until thematic saturation was achieved, between September 2019 - January 2020. The interviews were audiorecorded and anonymized. The transcribed interviews were stored, coded, and analyzed in MAXQDA, following the steps for conventional content analysis. Results: A total of 29 participants were interviewed. Patients and physicians presented clear views about the role of the GP and the cardiologist and their function in overall structure of healthcare. GPs felt their role was to bring expertise in the patient which could supplement the cardiologists' expertise on the condition. However, GPs had to renegotiate roles in the teleconsultations when they saw themselves in a new situation, together with another physician and the patient. Conclusions: Our findings suggest that joint teleconsultations can promote continuity of care for patients in the primary/secondary care interface. Active coordination between physicians with delineation of roles throughout primary-secondary care interface is needed to manage selected patients who may benefit the most from shared care.