Oncology team members' perceptions of a virtual navigation tool for cancer patients

ObjectivesThe Internet has become an important source of health information for patients and health care providers (HCPs) alike. Whereas studies have begun to document the effects of the internet on health behaviors and outcomes, surprisingly few studies have explored HCPs’ perceptions of the internet as a key resource accessed by patients. However, as HCPs are seen as pivotal in guiding patients toward these resources, it is timely to study their perceptions. Therefore, the present inquiry explores HCPs’ views of a recently developed high quality virtual navigation tool called the Oncology Interactive Navigator? (OIN).DesignUsing a qualitative approach, in-depth interviews were conducted with 16 members of a multidisciplinary colorectal oncology team and volunteers at a large Cancer Centre in Montreal, Quebec, Canada.ResultsContent analysis revealed emerging themes centering on key benefits including: perceptions of a highly accessible, comprehensive high quality repository of cancer information; a means to further enhance HCP-patient communication and trust; and a significant catalyst to patient–family communication and support. Perceived drawbacks included patient (e.g., socio-demographic profile) and system's (e.g., professional roles and time constraints) characteristics that may limit OIN? full implementation and uptake.ConclusionsThe findings underscore the relevance of virtual navigation tools to ensure optimal person-centred care in cancer. Findings also suggest how virtual tools such as the OIN? can best be used in practice as well as they guide strategies to adopt to optimize implementation of similar innovations in health care.     

A longitudinal qualitative study to explore and optimize self-management in mild to end stage chronic kidney disease patients with limited health literacy: Perspectives of patients and health care professionals

ObjectivesLimited health literacy (LHL) is associated with faster kidney deterioration. Health care professionals (HCPs) promote self-management to maintain kidney function, which is difficult for patients with LHL. Evidence lacks on perceived barriers and best strategies to optimize their self-management. Our study aims to explore experiences with and barriers for self-management from the perspectives of LHL patients and HCPs to identify strategies to optimize self-management.MethodsWe performed a longitudinal qualitative study with semi-structured in-depth interviews and focus group discussions among CKD patients and LHL (n = 24) and HCPs (n = 37) from general practices and hospitals.ResultsFour themes arose among patients: (1) CKD elusiveness, (2) suboptimal intake of knowledge (3) not taking a front-seat role, and (4) maintaining change. Among HCPs, three themes emerged: (1) not recognizing HL problems, (2) lacking effective strategies, and (3) health care barriers.ConclusionWe suggest three routes to optimize self-management: providing earlier information, applying person-centered strategies to maintain changes, and improving competencies of HCPs.Practice implicationsHCPs need to explain CKD self-management better to prevent kidney deterioration. New interventions, based on behavioral approaches, are needed to optimize self-management. HCPs need training to improve recognition and support of LHL patients.     

Fast track SSTI management program based on a rapid molecular test (GeneXpert® MRSA/SA SSTI) and antimicrobial stewardship

PurposeThis study examines the impacts of a skin and soft tissue infection (SSTI) management program involving a rapid diagnostic algorithm (Gram stain plus real-time PCR, GeneXpert® MRSA/SA SSTI) performed directly on clinical samples plus antimicrobial stewardship (AMS) counseling of the responsible physician.MethodsParticipants were 155 consecutive adult inpatients with SSTI and good quality clinical samples submitted to the microbiology laboratory from April 2016 to January 2017. Results of the rapid test and AMS recommendations were phoned through to the responsible physician. The comparison group was a historical cohort.ResultsMost SSTI were surgical wound infections (41.3% vs 38.1% for the intervention and comparison groups respectively) followed by diabetic foot (14.2% and 18.1%), abscesses (13.5% both) and cellulitis (12.9% both). Isolated microorganisms were mostly Gram-negative bacilli (two-thirds), followed by Staphylococcus aureus (SA). The ratio methicillin-susceptible SA (MSSA) to methicillin-resistant SA (MRSA) was 4:1. Improvements in the intervention cohort were: DOT (22.0 vs. 24.3 days, p = 0.007), treatment duration per SSTI episode (14.1 vs. 15.0 days, p = 0.072), treatment cost (433.1 vs. 533.3 €, p = 0.039), length of stay (18.6 vs 20.7 days, p = 0.031), related mortality (1 vs. 4 patients, p = 0.022) and Clostridium difficile infection (CDI) (4 vs. 8 patients, p = 0.050). In 48 cases (31.4%) in the intervention group, advice was given to improve empiric antibiotic treatment.ConclusionThis type of program could help adjust antibiotic treatment when inappropriate, reducing antibiotic use and costs, length of stay, CDI and related mortality.     

Communicating with older adults with long-term conditions about self-management goals: A systematic review and thematic synthesis

ObjectiveTo synthesise a body of fine-grained observational research on communication between healthcare professionals (HCPs), older adults, and carers regarding self-management goals and actions.MethodsWe conducted a systematic review, searching nine electronic databases and the grey literature. Two reviewers independently selected for inclusion following a two-stage process and studies and discrepancies were resolved through consultation with the review team.Results898 records were retrieved, and eight studies were included in the review. Aggregative thematic analysis resulted in 13 categories of communication practices across three decision-making domains: (1) initiating: actions occurring prior to the commitment point; (2) proposing: putting forward a course of action; and (3) committing and closing: committing (or not) to the course of action.ConclusionsDespite an increasing emphasis on the importance of personalised care planning and shared decision-making (SDM) to support older people’s health and wellbeing, HCPs did not consistently practice this approach and, in some cases, worked in opposition to it.Practice implicationsWe encourage HCPs to prepare older adults to engage actively with SDM and the goal setting process by employing patient-centred communication resources. These could assist with identifying different types of goals that are realistic and relevant to patients in daily life.     

Barriers and facilitators to discussing HPV with head and neck cancer patients: A qualitative study using the theoretical domains framework

ObjectiveThe incidence of human papillomavirus-associated head and neck cancers (HPV-HNC) is increasing worldwide. Research in other clinical contexts has shown that healthcare professionals (HCPs) can find discussing HPV with patients challenging. However, limited research has been conducted in HNC. This study aimed to investigate barriers and facilitators to, discussing HPV among HCPs caring for patients with HNC in Ireland.MethodsSemi-structured telephone/face-to-face interviews were conducted with HCPs. Barriers and facilitators to discussing HPV with patients were identified using the Theoretical Domains Framework (TDF).Results20 HCPs (8 clinicians, 3 nurses, 9 allied healthcare professionals) were interviewed. Barriers to discussing HPV included professionals' lack of HPV knowledge, difficulties in talking about sexual issues with patients and lack of privacy to discuss HPV in busy clinic settings. Facilitators included increasing public and patient awareness of the link between HPV and HNC and professional education and skills development.ConclusionsThis is the first theoretically informed study to identify barriers and facilitators to discussing HPV with HNC patients. HCPs consider HPV discussions to be an essential part of HNC patient care.Practice implicationsUnderstanding the issues associated with patient-provider HPV communication will help develop effective interventions to support HCPs in their HPV discussions.     

Impact of returning unsolicited genomic results to nongenetic health care providers in the eMERGE III Network

PurposeAs genomic sequencing becomes more common, medically actionable secondary findings will increasingly be returned to health care providers (HCPs), who will be faced with managing the resulting patient care. These findings are generally unsolicited, ie, unrelated to the sequencing indication and/or ordered by another clinician.MethodsTo understand the impact of receiving unsolicited results, we interviewed HCPs who received genomic results for patients enrolled in the Electronic Medical Records and Genomics (eMERGE) Phase III Network, which returned results on >100 actionable genes to eMERGE participants and HCPs.ResultsIn total, 16 HCPs across 3 eMERGE sites were interviewed about their experience of receiving a positive (likely pathogenic or pathogenic), negative, or variant of uncertain significance result for a patient enrolled in eMERGE Phase III and about managing their patient on the basis of the result. Although unsolicited, HCPs felt responsible for managing the patient’s resulting medical care. HCPs indicated that clinical utility depended on the actionability of results, and whereas comfort levels varied, confidence was improved by the availability of subspecialist consults. HCPs were concerned about patient anxiety, insurability, and missing an actionable result in the electronic health record.ConclusionOur findings help inform best practices for return of unsolicited genomic screening findings in the future.     

Attitudes,knowledge and practice behaviours of oncology health care professionals towards lesbian,gay, bisexual,transgender, queer and intersex (LGBTQI) patients and their carers: A mixed-methods study

ObjectiveThere is growing recognition that health care professionals (HCPs) and policy makers are insufficiently equipped to provide culturally competent care to lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) cancer patients and their families. We examined HCP attitudes, knowledge, and practices regarding LGBTQI cancer care using a mixed-methods research design.MethodSurveys were completed by 357 oncology HCPs in nursing (40%), medical (24%), allied health (19%), and clinical leadership roles (11%); 48 of the surveyed HCPs were interviewed.ResultsMost HCPs reported being comfortable treating LGBTQI patients, but reported low levels of confidence and knowledge and systemic barriers to LGBTQI cancer care. Most wanted more education and training, particularly on trans and gender-diverse people (TGD) and those born with intersex variations.ConclusionEducation of HCPs and health system changes are required to overcome barriers to the provision of culturally competent cancer care for LGBTQI patients.Practice implicationsThese findings reinforce the need for inclusion of LGBTQI content in HCP education and professional training curricula, and institutional support for LGBTQI-inclusive practice behaviours. This includes administrative and visual cues to signal safety of LGBTQI patients within cancer care, facilitating inclusive environments, and the provision of tailored patient-centred care.     

Investigation and management of prosthetic joint infection in knee replacement: A BASK Surgical Practice Guideline

BackgroundThe burden of knee replacement prosthetic joint infection (KR PJI) is increasing.KR PJI is difficult to treat, outcomes can be poor and it is financially expensive and limited evidence is available to guide treatment decisions.AimTo provide guidelines for surgeons and units treating KR PJI.MethodsGuideline formation by consensus process undertaken by BASK's Revision Knee Working Group, supported by outputs from UK-PJI meetings.ResultsImproved outcomes should be achieved through provision of care by revision centres in a network model. Treatment of KR PJI should only be undertaken at specialist units with the required infrastructure and a regular infection MDT.This document outlines practice guidelines for units providing a KR PJI service and sets out:

• •The necessary infrastructure required to provide a high-quality KR PJI service
• •The MDT composition — who and when
• •The KR PJI care pathway
• •Medical and surgical treatment strategies
• •The indications for referral to tertiary units (Major Revision Centres)
• •Outcome metrics and auditable standards

ConclusionsKR PJI patients treated within the NHS should be provided the best care possible. This report sets out guidance and support for surgeons and units to achieve this.     

The effectiveness of a person-centred communication skills training programme for the health care professionals of a large hospital in Denmark

ObjectiveAs a part of an evaluation of a large-scale communication skills training (CST) programme, this study aimed to investigate the effect on health care professionals’ (HCPs) self-efficacy (SE) and perceived importance (PI) of the skills taught.MethodsA pre-post intervention design was used, and 1647 HCPs responded to the SE-12 questionnaire. Changes in self-efficacy were examined at an item and scale level.ResultsThe responses of 74% of the HCPs who replied to at least two of the three questionnaires were analysed. A significant increase in the SE-12 scale scores by 12.45 points between Q1 (baseline) and Q2 (immediately after the intervention) across all professions was found. There was a small albeit statistically significant decrease in the SE-12 scale scores by 2.06 points between Q2 and Q3 (24 weeks after the intervention).ConclusionThe implementation of the CST course significantly improved the self-efficacy of HCPs. The findings were supported by an increase in the number of HCPs who considered the skills that they had acquired to be very important.Practice implicationsThe findings suggest that the large-scale implementation of evidence-based CST programmes can yield the same outcomes that have been observed in smaller and better controlled studies.     

Perspectives of healthcare professionals and patients on the application of mindfulness in individuals with chronic obstructive pulmonary disease

ObjectiveTo explore the views of healthcare professionals (HCPs) and patients towards mindfulness for individuals with COPD.MethodsA qualitative study design informed by and analyzed using deductive thematic analysis. Twenty HCPs, with at least one year’s clinical experience in COPD management and 19 individuals with moderate to severe COPD participated in semi-structured interviews.ResultsAnalysis revealed seven themes. 1. Mindfulness is difficult to articulate and separate from relaxation. 2. Mindfulness has a role in disease management. 3. Mindfulness therapy should be optional. 4. Preferred techniques include; breathing meditation, music and body scan. 5. Mindfulness should be delivered by knowledgeable, enthusiastic and compassionate trainers. 6. Preferred mode of delivery is shorter sessions delivered alongside pulmonary rehabilitation, with refresher courses 7. Efficacy should be assessed using psychological outcome measures and qualitative methodologies.ConclusionsMindfulness appears to be an attractive therapy for individuals with COPD. An understanding of the perspectives of HCPs and patients should inform the delivery of such programs.Practical implicationIndividuals with COPD were comfortable using breathing to reduce anxiety. Stigma and negative preconceptions were considered barriers to participation. Short sessions delivered by experienced trainers were preferred. A combination of methodologies should be used to examine effectiveness.     

Self-management support activities in primary care: A qualitative study to compare provision across common health problems

ObjectiveTo explore the views of primary care teams about the provision of self-management support to patients with common health problems.MethodsSemi-structured interviews were conducted with twenty-one members of the primary care team from thirteen general practices. Interviews were transcribed verbatim, and analysed using the ‘Framework’ approach.ResultsThree categories and six sub-categories illustrating different self-management support activities across common health problems were identified from the analysis of interviews, and contributed to one major theme and one cross-cutting theme. Referral and signposting were frequently used to facilitate patient engagement with external services and resources. Practitioners faced some challenges in balancing medical management and psychosocial support and motivating patients to engage with self-management.ConclusionsPrimary care teams described providing a wide range of self-management support activities, but the pattern of use varied for different types of health problem. These patterns may have been influenced, in part, by general practices focusing upon achieving financially incentivised quality improvement goals.Practice implicationsTo improve self-management support, practitioners need a digital repository of services/resources, motivational interviewing skills, an understanding of the optimum duration and pattern of consultations, and incentivised targets that match a biopsychosocial model of care.     

Revision knee replacement surgery in the NHS: A BASK surgical practice guideline

BackgroundRevision knee replacement (KR) is both challenging for the surgical team and expensive for the healthcare provider. Limited high quality evidence is available to guide decision-making.AimTo provide guidelines for surgeons and units delivering revision KR services.MethodsA formal consensus process was followed by BASK’s Revision Knee Working Group, which included surgeons from England, Wales, Scotland and Northern Ireland. This was supported by analysis of National Joint Registry data.ResultsThere are a large number of surgeons operating at NHS sites who undertake a small number of revision KR procedures. To optimise patient outcomes and deliver cost-effective care high-volume revision knee surgeons working at high volume centres should undertake revision KR.This document outlines practice guidelines for units providing a revision KR service and sets out: The current landscape of revision KR in England, Wales and Northern Ireland. Service organisation within a network model. The necessary infrastructure required to provide a sustainable revision service. Outcome metrics and auditable standards. Financial mechanisms to support this service model.ConclusionsRevision KR patients being treated in the NHS should be provided with the best care available. This report sets out a framework to both guide and support revision KR surgeons and centres to achieve this aim.     

Self-management for pulmonary fibrosis: Insights from people living with the disease and healthcare professionals

ObjectivePeople with pulmonary fibrosis (PF) consider self-management essential for maintaining health. This study aims to explore the needs and expectations of PF self-management from the patient and healthcare professionals (HCPs) perspectives.MethodsSemi-structured interviews were conducted with people with PF and HCPs. Purposive sampling was used to recruit participants. Thematic analysis was performed using the principles of grounded theory.Results18 individuals with PF and 15 HCPs were interviewed. Common self-management components reported included exercise, nutrition, maintaining healthy mind, avoiding infections, recognising deterioration and seeking help, managing symptoms and treatments, social support, and end-of-life planning. Both groups felt that effective self-management required individualised strategies, supports, and reliable information. People with PF identified access to personal health data and self-acceptance as part of self-management. HCPs highlighted the importance of accessible supports and managing patient expectations of disease course and treatments. Some HCPs concerned about missed detection of deterioration and suggested that self-management strategies for PF may differ to other lung diseases.ConclusionThis study identified components important for self-management in PF and provides a basis for designing a PF self-management package. Practice implications: Self-management of PF can be facilitated with individualised support from HCPs and reliable information that is accessible.     

Time to Authorized Clearance From Sport-Related Concussion: The Influence of Health Care Provider and Medical Facility

ContextReturn to play after sport-related concussion (SRC) requires authorized clearance from a health care provider (HCP). The variability in HCPs and facilities where athletes seek care may influence return time.ObjectiveTo identify the initial examiner, HCPs who authorize clearance to return to play, and medical facilities that authorize clearance to return to play for high school student-athletes after SRC and compare authorized clearance time by HCPs and medical facilities.DesignProspective cohort study.SettingHigh school.Patients or Other ParticipantsStudent-athletes (n = 16 001) with SRC participating in athletics sponsored by the Michigan High School Athletic Association.Main Outcome Measure(s)Frequencies of initial examiner and authorized clearance for each HCP (doctor of osteopathic medicine, medical doctor, nurse practitioner, physician assistant) and medical facility (neurologist''s office; team physician, primary care physician or pediatrician''s office [PCP]; hospital; urgent/ready care) for each case of SRC. We calculated Kaplan-Meier curves and Peto tests to evaluate differences in the median time to authorized clearance between HCPs and facilities. Only cases with a date on which clearance to return to play was authorized (80.3%; n = 12 856) were included in the authorized clearance and time-to-return analyses.ResultsAn athletic trainer was at least 1 of the initial examiners in 71.3% (n = 11 404) of SRC cases; 81.2% (n = 12 990) had only 1 initial examiner. We observed an association between the initial examiner and the medical facility providing clearance for athletic director (χ² = 52.6, P < .001, V = .06), athletic trainer (χ² = 172.0, P < .001, V = .12), coach (χ² = 161.5, P < .001, V = .11), doctor of osteopathic medicine (χ² = 59.4, P < .001, V = .07), and nurse practitioner (χ² = 10.0, P = .04, V = .12). Clearance was authorized most frequently by a medical doctor (63.9%, n = 8218) and at a PCP (70.8%, n = 9099). Median (interquartile range) time to authorized clearance varied by facility (urgent/ready care = 7 days [4–11 days], hospital = 9 days [6–14 days], PCP = 10 days [6–14 days], team physician = 12 days [8–16 days], neurologist''s office = 13 days [9–20 days]; P < .001). An athletic trainer was the initial examiner more often for males (74.1%) than for females (65.8%). The medical facility where clearance to return to play was authorized also differed between males (PCP = 69.3%, team physician = 11.3%, neurologist''s office = 8.4%) and females (PCP = 73.6%, team physician = 8.5%, neurologist''s office = 8.3%).ConclusionsClearance to return to play after SRC was frequently provided by a medical doctor and at a PCP. The median time to return to unrestricted participation after SRC varied by HCP and medical facility. Future researchers should elucidate the reasons for these differences and determine why athletes seek care at different types of medical facilities.     

Incorporating shared decision making into communication with older adults with cancer and their caregivers: Development and evaluation of a geriatric shared decision-making communication skills training module

ObjectiveThe purpose of this study was to evaluate a Communication Skills Training (CST) module for health care providers (HCPs) applying a shared decision-making approach to a meeting with an older adult with cancer and his/her family.MethodsNinety-nine HCPs from community-based centers, cancer centers, and hospitals in the Northeastern U.S. who worked primarily with older adult patients participated in a CST module entitled Geriatric Shared Decision Making. Participants completed pre- and post-training Standardized Patient Assessments (SPAs) and a survey on their confidence in and intent to utilize skills taught.ResultsResults indicated high HCP satisfaction with the module, with over 95 % of participants reporting high endorsement to all five evaluation items. HCPs’ self-efficacy in utilizing communication skills related to geriatric shared decision making significantly increased pre- to post-training. In standardized patient assessments among a subset of providers (n = 30), HCPs demonstrated improvements in three shared decision-making skills: declare agenda, invite agenda, and check preference.ConclusionA geriatric shared decision-making CST workshop for HCPs showed feasibility, acceptability, and improvement in self-efficacy as well as skill uptake.Practice implicationsThis Geriatric Shared Decision-Making CST module provides an intervention for improving provider-patient-family member communication in the context of cancer care for older adults.     

The impact of patient-generated contextual data on communication in clinical practice: A qualitative assessment of patient and clinician perspectives

BackgroundEffective communication is integral to patient-centered care, yet external pressures can impede the ability to discuss important topics. One strategy to facilitate communication is pre-visit collection and sharing of patient contextual data (PCD), including life circumstances such as their beliefs, needs, and concerns.ObjectiveTo understand how patients and care team members perceive the electronic collection of PCD and its impact on communication in the context of a large academic health system that implemented PatientWisdom, a new technology that elicits PCD from patients and integrates within the electronic health record (EHR).MethodsWe conducted focus groups with patients (n = 26) and semi-structured interviews with primary care team members (n = 20). Qualitative analysis of focus group/interviews included an iterative and reflexive inductive technique to uncover emergent themes.ResultsFour themes were reflected among both patient and care team: (1) the technology enhances the patient’s voice; (2) the technology creates a safe space for patients to share sensitive topics; (3) PCD facilitates rapport not only between patient and provider but the entire care team; (4) PCD aligns patient and clinician goals. Two unique themes emerged among patients: (1) PCD provides opportunity for reflection; (2) PCD humanizes patients in the clinical context. One theme was evident in provider comments: collecting PCD may potentially undermine trust if not reviewed by clinical teams.ConclusionPCD collected directly from patients and available within the EHR was seen by patients and care team members as beneficial to communication. PCD collection supports a paradigm shift towards coproduction of health information and a shared responsibility for information gathering but requires investment from patients and care team to ensure the data are effectively utilized.Practice valuePCD may be useful for team-based care, enabling physicians and non-physician staff to more quickly and responsively connect with patients.     

Primary care clinician antibiotic prescribing decisions in consultations for children with RTIs: a qualitative interview study

BackgroundRespiratory tract infections (RTIs) are a major primary care challenge in children because they are common and costly, there is uncertainty regarding their diagnosis, prognosis, and management, and the overuse of antibiotics leads to illness medicalisation and bacterial resistance.AimTo investigate healthcare professional (HCP) diagnostic and antibiotic prescribing decisions for children with RTIs.MethodInterviews were audiorecorded, transcribed, imported into NVivo 9, and analysed thematically.ResultsHCPs varied in the symptom and clinical examination findings used to identify children they thought might benefit from antibiotics. Their diagnostic reasoning and assessment of perceived clinical need for antibiotics used a dual process, combining an initial rapid assessment with subsequent detailed deductive reasoning. HCPs reported confidence diagnosing and managing most minor and severe RTIs. However, residual prognostic uncertainty, particularly for the intermediate illness severity group, frequently led to antibiotic prescribing to mitigate the perceived risk of subsequent illness deterioration. Some HCPs perceived a need for more paediatrics training to aid treatment decisions. The study also identified a number of non-clinical factors influencing prescribing.ConclusionPrognostic uncertainty remains an important driver of HCPs’ antibiotic prescribing. Experience and training in recognising severe RTIs, together with more evidence to help HCPs identify the children at risk of future illness deterioration, may support HCPs’ identification of the children most and least likely to benefit from antibiotics.