Development of a framework for reporting health service models for managing rheumatoid arthritis

The purpose of this study was to develop a framework for reporting health service models for managing rheumatoid arthritis (RA). We conducted a search of the health sciences literature for primary studies that described interventions which aimed to improve the implementation of health services in adults with RA. Thereafter, a nominal group consensus process was used to synthesize the evidence for the development of the reporting framework. Of the 2,033 citations screened, 68 primary studies were included which described 93 health service models for RA. The origin and meaning of the labels given to these health service delivery models varied widely and, in general, the reporting of their components lacked detail or was absent. The six dimensions underlying the framework for reporting RA health service delivery models are: (1) Why was it founded? (2) Who was involved? (3) What were the roles of those participating? (4) When were the services provided? (5) Where were the services provided/received? (6) How were the services/interventions accessed and implemented, how long was the intervention, how did individuals involved communicate, and how was the model supported/sustained? The proposed framework has the potential to facilitate knowledge exchange among clinicians, researchers, and decision makers in the area of health service delivery. Future work includes the validation of the framework with national and international stakeholders such as clinicians, health care administrators, and health services researchers

Including the voice of children:Towards patient-centered care

Patient-centered care (PCC) is characterized by the provision of care that respects and responds to individual patient preferences, needs and values, and ensures that patient’s wishes guide all clinical decisions. PCC places the patient, not the disease, at the center of health care and promotes a collaboration between patient, family, and clinicians to provide care that is tailored to the patient’s wishes and needs. Although the importance of PCC is recognized, its implementation is difficult because it requires a different mindset and changing roles of patients, parents, and clinicians. This thesis focused on scientific approaches and the development of tools to enhance PCC in children. Three aspects of PCC were examined; pediatric patient engagement, Patient Reported Outcome Measures (PROMs), and Patient Reported Experience Measures (PREMs). The first part of the thesis provides a synopsis of the existing literature on pediatric patient engagement and discusses the development of a tool to enhance pediatric patient engagement. The second part of the thesis focuses on facilitators and barriers in the implementation of PROMs in clinical practice, using the KLIK PROM portal and the PROMIS measures as an example. The last part of the thesis provides an overview of the available PREMs in pediatrics

Post-graduate Integration Programs for Recently Graduated Nurse Practitioners: A Rapid Review

Aim The purpose of this paper is to present a rapid review of the literature that describes and evaluates post-graduate professional integration programs for recently graduated nurse practitioners. Background Recently graduated nurse practitioners face numerous challenges upon entry to practice, these include high patient caseloads, lack of confidence and difficulty integrating into the interprofessional team. In response to these challenges, numerous post-graduate professional integration programs have emerged to support the transition of recently graduated nurse practitioners into practice. Design A rapid review was conducted following McMaster University Rapid Review Guidebook’s Guidelines. Method Studies describing and evaluating post-graduate professional integration programs for nurse practitioners who recently graduated from master’s or doctoral programs were included. The Template for Intervention Description and Replication (TIDieR) guidelines were used to assess the quality of the description of the programs in the included studies. A narrative synthesis was completed. Results Among 2,261 records yielded from the electronic search, 27 studies on 26 post-graduate professional integration programs were included in this review. The quality of the description of the programs included was high. Three types of programs were identified in this review: residency programs, fellowship programs, and transition to practice programs. Studies suggested that post-graduate professional integration programs increase the confidence level, degree of satisfaction, skill acquisition, knowledge, and productivity of recently graduated nurse practitioners. Conclusions Post-graduate professional integration programs represent promising avenues to support the transition of recently graduated nurse practitioners into practice. Future research is needed to better understand the relative benefits and effectiveness of different post-graduate professional integration program structures across specific outcomes. Résumé But Le but de cet article est de présenter une revue rapide de la littérature décrivant et évaluant les programmes postuniversitaires d’intégration professionnelle destinés aux infirmières et infirmiers praticiens spécialisés récemment diplômés. Contexte Les infirmières et infirmiers praticiens spécialisés récemment diplômés sont confrontés à de nombreux défis dès leur entrée dans la pratique, notamment une charge de travail élevée, un manque de confiance et des difficultés à s’intégrer dans l’équipe interprofessionnelle. En réponse à ces défis, de nombreux programmes postuniversitaires d’intégration professionnelle ont vu le jour pour soutenir la transition vers la pratique. Méthode Une revue rapide de la littérature a été effectuée en suivant les lignes directrices du Guide pour les revues rapides de la McMaster University. Des études décrivant et évaluant un programme postuniversitaire d’intégration professionnelle destiné aux infirmières et infirmiers praticiens spécialisés récemment diplômés d’un programme de maîtrise ou de doctorat ont été incluses. Le Template for Intervention Description and Replication (TIDieR) a été utilisé pour évaluer la qualité de la description des programmes dans les études incluses. Une synthèse narrative a été réalisée. Résultats Parmi les 2 261 documents issus du repérage électronique, 27 études portant sur 26 programmes postuniversitaires d’intégration professionnelle ont été incluses dans cette revue. La qualité de la description des programmes inclus était élevée. Trois types de programmes ont été identifiés dans cette revue : les programmes de résidence, les programmes de bourses de recherche et les programmes de transition à la pratique. Des études suggèrent que les programmes postuniversitaires d’intégration professionnelle augmentent le niveau de confiance, le degré de satisfaction, le développement de compétences, l’acquisition de connaissances et la productivité des infirmières et infirmiers praticiens spécialisés récemment diplômés. Conclusion Les programmes postuniversitaires d’intégration professionnelle représentent des avenues prometteuses pour soutenir la transition vers la pratique des infirmières et infirmiers praticiens spécialisés récemment diplômés. Des recherches futures sont nécessaires pour mieux comprendre les avantages relatifs et l’efficacité des différentes structures de programmes postuniversitaires d’intégration professionnelle pour des résultats précis

The experience of pain and pain management among culturally and linguistically diverse communities living in Australia

The studies presented in this thesis enlighten contemporary understandings of the experience of chronic pain for CALD (culturally and linguistically diverse) communities. Each study is an original piece of scientific work that contributes to the field of research in chronic pain and provides healthcare providers with tangible opportunities to culturally adapt their interventions.Taken together, the studies also provide a practical guide for future researchers seeking to engage CALD communities. Finally, this thesis argues that for healthcare to be responsive to the needs of multicultural Australia, change needs to be enacted more broadly. Educational institutions, professional organisations and healthcare accreditation agencies have a role to play to ensure that CALD patients and communities are part of initiatives seeking to address the multifaceted disparities in healthcare that exist for CALD communities

Better post-operative prediction and management of chronic pain in adults after total knee replacement:the multidisciplinary STAR research programme including RCT

Background: The treatment of osteoarthritis with knee replacement aims to reduce pain and disability. However, some people experience chronic pain. Objectives: To improve outcomes for people with chronic pain after knee replacement by identifying post-surgical predictors and effective interventions, characterising patient pathways and resource use, developing and evaluating a new care pathway, and exploring non-use of services. Design: The programme comprised systematic reviews, national database analyses, a cohort study, intervention development, a randomised controlled trial, health economic analyses, qualitative studies and stakeholder engagement. Extensive and meaningful patient and public involvement underpinned all studies. Setting: NHS, secondary care, primary care. Participants: People with, or at risk of, chronic pain after knee replacement and health-care professionals involved in the care of people with pain. Interventions: A care pathway for the management of people with pain at 3 months after knee replacement. Main outcome measures: Patient-reported outcomes and cost-effectiveness over 12 months. Data sources: Literature databases, the National Joint Registry, Hospital Episode Statistics, patient- reported outcomes, the Clinical Practice Research Datalink, the Clinical Outcomes in Arthroplasty Study, the Support and Treatment After joint Replacement randomised trial, interviews with 90 patients and 14 health-care professionals, and stakeholder events. Review methods: Systematic reviews of cohort studies or randomised trials, using meta-analysis or narrative synthesis. Results: In the Clinical Outcomes in Arthroplasty Study cohort, 14% of people experienced chronic pain 1 year after knee replacement. By 5 years, 65% reported no pain, 31% fluctuated and 4% remained in chronic pain. People with chronic pain had a worse quality of life, higher primary care costs, and more frequent analgesia prescriptions, particularly for opioids, than those not in chronic pain. People with chronic pain after knee replacement who made little or no use of services often felt nothing more could be done, or that further treatments may have no benefit or cause harm. People described a feeling of disconnection from their replaced knee. Analysis of UK databases identified risk factors for chronic pain after knee replacement. Pre- operative predictors were mild knee pain, smoking, deprivation, body mass index between 35 and 40 kg/m2 and knee arthroscopy. Peri- and post-operative predictors were mechanical complications, infection, readmission, revision, extended hospital stay, manipulation under anaesthetic and use of opioids or antidepressants. In systematic reviews, pre-operative exercise and education showed no benefit in relation to chronic pain. Peri-operative interventions that merit further research were identified. Common peri- operative treatments were not associated with chronic pain. There was no strong evidence favouring specific post-operative physiotherapy content. We evaluated the Support and Treatment After joint Replacement care pathway in a multicentre randomised controlled trial. We randomised 363 people with pain at 3 months after knee replacement from eight NHS Trusts in England and Wales. At 12 months’ follow-up, the intervention group had lower mean pain severity (adjusted difference –0.65, 95% confidence interval –1.17 to -0.13; p = 0.014) and pain interference (adjusted difference –0.68, 95% confidence interval –1.29 to -0.08; p = 0.026), as measured on the Brief Pain Inventory subscales (scale 0–10). People receiving the Support and Treatment After joint Replacement pathway had lower NHS and Personal Social Services costs (–£724, 95% confidence interval –£150 to £51) and higher quality-adjusted life-years (0.03, 95% confidence interval –0.008 to 0.06) than those with usual care. The Support and Treatment After joint Replacement pathway was cost-effective with an incremental net monetary benefit at the £20,000 per quality-adjusted life-year threshold of £1256 (95% confidence interval £164 to £2348), indicating a 98.79% probability that the intervention is the cost-effective option. Participants found the Support and Treatment After joint Replacement pathway acceptable, with opportunities to receive information and discuss concerns while ensuring further treatment and support. In systematic reviews considering treatments for chronic pain after surgery we identified some unifactorial interventions that merit further research after knee replacement. Health-care professionals delivering and implementing the Support and Treatment After joint Replacement pathway valued its focus on neuropathic pain and psychosocial issues, enhanced patient care, formalised referrals, and improved pain management. Stakeholders supported pathway implementation. Limitations: Database analyses were limited to factors recorded in data sets. Pain was only measured 6 months after surgery. However, analyses including large numbers of centres and patients should be generalisable across the NHS. In many studies found in systematic reviews, long-term pain was not a key outcome. Conclusions: The Support and Treatment After joint Replacement pathway is a clinically effective and cost-effective, acceptable intervention for the management of chronic pain after knee replacement. Unifactorial interventions merit further study before inclusion in patient care. People with pain should be empowered to seek health care, with the support of health-care professionals. Future work: Future work should include research relating to the implementation of the Support and Treatment After joint Replacement pathway into the NHS, an assessment of its long-term clinical effectiveness and cost-effectiveness and wider application, and an evaluation of new interventions for incorporation in the pathway. It will also be important to design and conduct research to improve communication between patients and health-care professionals before surgery; explore whether or not education and support can enable earlier recognition of chronic pain; consider research that may identify how to support people’s feelings of disconnectedness from their new knee; and design and evaluate a pre-surgical intervention based on risk factors. Study registration: All systematic reviews were registered on PROSPERO (CRD42015015957, CRD42016041374 and CRD42017041382). The Support and Treatment After joint Replacement randomised trial was registered as ISRCTN92545361. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 11, No. 3. See the NIHR Journals Library website for further project information

Personalised antimicrobial management in secondary care

Background: The growing threat of Antimicrobial Resistance (AMR) requires innovative methods to promote the sustainable effectiveness of antimicrobial agents. Hypothesis: This thesis aimed to explore the hypothesis that personalised decision support interventions have the utility to enhance antimicrobial management across secondary care. Methods: Different research methods were used to investigate this hypothesis. Individual physician decision making was mapped and patient experiences of engagement with decision making explored using semi-structured interviews. Cross-specialty engagement with antimicrobial management was investigated through cross-sectional analysis of conference abstracts and educational training curricula. Artificial intelligence tools were developed to explore their ability to predict the likelihood of infection and provide individualised prescribing recommendations using routine patient data. Dynamic, individualised dose optimisation was explored through: (i) development of a microneedle based, electrochemical biosensor for minimally invasive monitoring of beta-lactams; and (ii) pharmacokinetic (PK)-pharmacodynamic (PD) modelling of a new PK-PD index using C-Reactive protein (CRP) to predict the pharmacodynamics of vancomycin. Ethics approval was granted for all aspects of work explored within this thesis. Results: Mapping of individual physician decision making during infection management demonstrated several areas where personalised, technological interventions could enhance antimicrobial management. At specialty level, non-infection specialties have little engagement with antimicrobial management. The importance of engaging surgical specialties, who have relatively high rates of antimicrobial usage and healthcare associated infections, was observed. An individualised information leaflet, co-designed with patients, to provide personalised infection information to in-patients receiving antibiotics significantly improved knowledge and reported engagement with decision making. Artificial intelligence was able to enhance the prediction of infection and the prescribing of antimicrobials using routinely available clinical data. Real-time, continuous penicillin monitoring was demonstrated using a microneedle based electrochemical sensor in-vivo. A new PK-PD index, using C-Reactive Protein, was able to predict individual patient response to vancomycin therapy at 96-120 hours of therapy. Conclusion: Through co-design and the application of specific technologies it is possible to provide personalised antimicrobial management within secondary care.Open Acces

A collaborative chain out of phase

Purpose: To understand the needs of information in the collaboration between health personnel in hospitals and care nursing personnel in municipal care in the process of discharging care-needing older patients from hospitals. Theory: The analytical perspective is a process of patient transition, in which responsible actors in health and municipal care have to collaborate in certain patterns, within a tight time schedule, restricted by the different organizational framework of a hospital or a municipality within which individual actors are situated. Methods: Step 1: Qualitative studies with nursing personnel in six municipalities and nurses in the hospitals serving the actual municipalities. Step 2: A survey addressed to key informants in municipal care in a representative sample of Norwegian municipalities. Results: The formal routines of information exchange associated with these kinds of discharges are too slow and out of phase with informational needs. Seventy percent of our respondent stated that information delivered through formal routines had already been collected by informal contacts. Formal routines were usually weakest for patients to be taken care of in their own homes—where the need for information in many cases was greater than for patients going to local institutions