The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings.

BACKGROUND: Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas. METHODS: A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding 'work as done'. Data were analysed using an adapted "Qualitative Rapid Appraisal, Rigorous Analysis" approach. RESULTS: Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients "falling through the cracks." Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision. CONCLUSIONS: The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of 'work-as-done' may help OPCs to sustain high-quality care in the face of escalating service demand

Providing outpatient cancer care for CALD patients: a qualitative study

Objective There have been few descriptions of how outpatient cancer care is provided to patients from culturally and linguistically diverse (CALD) communities. As populations who experience disparities in cancer care access and outcomes, deeper understanding is needed to help identify those factors which can shape the receipt of multidisciplinary care in ambulatory settings. This paper reports on data collected and analysed as part of a multicentre characterisation of care in Australian public hospital cancer outpatient clinics (OPCs). Results Analysis of data from our ethnographic study of four OPCs identified three themes: “Identifying CALD patient language-related needs”; “Capacity and resources to meet CALD patient needs”, and “Making it work for CALD communities.” The care team comprises not only clinicians but also families and non-clinical staff; OPCs serve as “touchpoints” facilitating access to a range of therapeutic services. The findings highlight the potential challenges oncology professionals negotiate in providing care to CALD communities and the ways in which clinicians adapt their practices, formulate strategies and use available resources to support care delivery

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

Background: The EMPA KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. Methods: EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. Findings: Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5–2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62–0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16–1·59), representing a 50% (42–58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). Interpretation: In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. Funding: Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council

Hallazgos Hematológicos en Iguana Verde Suramericana (Iguana iguana), de Ejemplares Ubicados en Zona Urbana y Suburbana de Villavicencio (Meta)

Titulo en ingles: Haematological findings regarding south-American green iguana (Iguana iguana) from exampled located in the urban and suburban area around Villavicencio (Meta department, Colombia)RESUMEN: Se determinaron los parámetros hematológicos básicos en la iguana verde suramericana (Iguana iguana), una especie en via de extinción, de ejemplares ubicados en la zona urbana y suburbana de la ciudad de Villavicencio Meta, se muestrearon 44 animales sanos, mediante  punción de la vena coccígea ventral, en donde se tuvieron en cuenta las variables sexo y peso corporal. Las determinaciones incluyeron recuentos de glóbulos rojos 1,78 ± 0,55 millón/mm3, leucocitos (2,53 ± 0,92 Miles/mm3), trombocitos (25,820,45 ± 18,997,85 mm3), hematocrito (36,91 ± 10,53 %), concentración de hemoglobina (12,17 ± 4,73 g/dl) e índices eritrocíticos. Los resultados del estudio morfológico y del recuento diferencial de glóbulos blancos mostraron un predominio de linfocitos (39.09%), seguido por los Eosinófilos (30.36%), basófilos (9.64 %), Heterófilos (9.43%), Neutrófilos (7.73 %) y monocitos (4.11%). Se encontraron diferencias significativas en función del sexo (p<0.05), únicamente en el recuento total de glóbulos rojos, presentándose mas alto para las hembras con un valor de 1.97 ± 0.55 millón/mm3 y 1.63 ± 0.51 millón/mm3 para los machos. Con respecto a la variable masa corporal se encontraron diferencias significativas (p <0.05) para el % de Neutrófilos en el recuento diferencial de glóbulos blancos, presentándose  más bajo en iguanas con pesos menores de 1000 g. En conclusión, se establecieron parámetros hematológicos para la iguana verde suramericana (Iguana iguana) en la zona urbana y suburbana de la ciudad de Villavicencio, los cuales pueden servir como punto de partida para el conocimiento de los parámetros hematológicos de las iguanas existentes en la Orinoquia y en Colombia, así como ayuda para el diagnóstico. Estos hallazgos son punto de referencia que contribuirá con la sanidad y preservación de esta especie.PALABRAS CLAVES: Iguana verde, hematologia, especies silvestresSUMMARY: Basic haematological parameters were determined in the south-American green iguana (Iguana iguana), an endangered species. Forty-four of the examples located in urban and suburban areas around the city of Villavicencio in the Meta department of Colombia were found to be healthy by puncturing the ventral coccigeal vein, taking variables such as gender and body weight into account. The determinations included 1.78 ± 0.55 million/mm3 red blood cell count, leukocyte (2.53 ± 0.92 x 1,000/mm3), thrombocyte (25,820.45 ± 18,997.85 mm3), haematocrite (36.91 ± 10.53%), haemoglobin concentration (12.17 ± 4.73 g/dl) and erythrocyte indices. Morphological study and differential white blood cell count results revealed a predominance of lymphocytes (39.09%), followed by eosinophils (30.36%), basophils (9.64%), heterophils (9.43%), neutrophils (7.73%) and monocytes (4.11%). Significant differences were found regarding gender (p<0.05); only total red blood count presented a higher value for females (1.97 ± 0.55 million/mm3 compared to 1.63 ± 0.51 million/mm3 for males). Significant differences (p <0.05) were found for body weight, differential white blood cell count for % neutrophils being lower in iguanas having less than 1,000 g weight. Haematological parameters were thus established for the south-American green iguana (Iguana iguana) in Villavicencio’s urban and suburban areas which could serve as a starting point for ascertaining haematological parameters for iguanas from Orinoquia and throughout Colombia, as well as supporting diagnosis. These findings represent a reference point contributing towards this species’ healthiness and preservation.Key words: green iguana, haematology, wild specieTitulo en ingles: Haematological findings regarding south-American green iguana (Iguana iguana) from exampled located in the urban and suburban area around Villavicencio (Meta department, Colombia)RESUMEN: Se determinaron los parámetros hematológicos básicos en la iguana verde suramericana (Iguana iguana), una especie en via de extinción, de ejemplares ubicados en la zona urbana y suburbana de la ciudad de Villavicencio Meta, se muestrearon 44 animales sanos, mediante  punción de la vena coccígea ventral, en donde se tuvieron en cuenta las variables sexo y peso corporal. Las determinaciones incluyeron recuentos de glóbulos rojos 1,78 ± 0,55 millón/mm3, leucocitos (2,53 ± 0,92 Miles/mm3), trombocitos (25,820,45 ± 18,997,85 mm3), hematocrito (36,91 ± 10,53 %), concentración de hemoglobina (12,17 ± 4,73 g/dl) e índices eritrocíticos. Los resultados del estudio morfológico y del recuento diferencial de glóbulos blancos mostraron un predominio de linfocitos (39.09%), seguido por los Eosinófilos (30.36%), basófilos (9.64 %), Heterófilos (9.43%), Neutrófilos (7.73 %) y monocitos (4.11%). Se encontraron diferencias significativas en función del sexo (p<0.05), únicamente en el recuento total de glóbulos rojos, presentándose mas alto para las hembras con un valor de 1.97 ± 0.55 millón/mm3 y 1.63 ± 0.51 millón/mm3 para los machos. Con respecto a la variable masa corporal se encontraron diferencias significativas (p <0.05) para el % de Neutrófilos en el recuento diferencial de glóbulos blancos, presentándose  más bajo en iguanas con pesos menores de 1000 g. En conclusión, se establecieron parámetros hematológicos para la iguana verde suramericana (Iguana iguana) en la zona urbana y suburbana de la ciudad de Villavicencio, los cuales pueden servir como punto de partida para el conocimiento de los parámetros hematológicos de las iguanas existentes en la Orinoquia y en Colombia, así como ayuda para el diagnóstico. Estos hallazgos son punto de referencia que contribuirá con la sanidad y preservación de esta especie.PALABRAS CLAVES: Iguana verde, hematologia, especies silvestresSUMMARY: Basic haematological parameters were determined in the south-American green iguana (Iguana iguana), an endangered species. Forty-four of the examples located in urban and suburban areas around the city of Villavicencio in the Meta department of Colombia were found to be healthy by puncturing the ventral coccigeal vein, taking variables such as gender and body weight into account. The determinations included 1.78 ± 0.55 million/mm3 red blood cell count, leukocyte (2.53 ± 0.92 x 1,000/mm3), thrombocyte (25,820.45 ± 18,997.85 mm3), haematocrite (36.91 ± 10.53%), haemoglobin concentration (12.17 ± 4.73 g/dl) and erythrocyte indices. Morphological study and differential white blood cell count results revealed a predominance of lymphocytes (39.09%), followed by eosinophils (30.36%), basophils (9.64%), heterophils (9.43%), neutrophils (7.73%) and monocytes (4.11%). Significant differences were found regarding gender (p<0.05); only total red blood count presented a higher value for females (1.97 ± 0.55 million/mm3 compared to 1.63 ± 0.51 million/mm3 for males). Significant differences (p <0.05) were found for body weight, differential white blood cell count for % neutrophils being lower in iguanas having less than 1,000 g weight. Haematological parameters were thus established for the south-American green iguana (Iguana iguana) in Villavicencio’s urban and suburban areas which could serve as a starting point for ascertaining haematological parameters for iguanas from Orinoquia and throughout Colombia, as well as supporting diagnosis. These findings represent a reference point contributing towards this species’ healthiness and preservation.Key words: green iguana, haematology, wild speci

The complexities, coordination, culture and capacities that characterise the delivery of oncology services in the common areas of ambulatory settings.

Background Relatively little is understood about real-world provision of oncology care in ambulatory outpatient clinics (OPCs). This study aimed to: 1) develop an understanding of behaviours and practices inherent in the delivery of cancer services in OPC common areas by characterising the organisation and implementation of this care; and 2) identify barriers to, and facilitators of, the delivery of this care in OPC common areas. Methods A purpose-designed ethnographic study was employed in four public hospital OPCs. Informal field scoping activities were followed by in-situ observations, key informant interviews and document review. A view of OPCs as complex adaptive systems was used as a scaffold for the data collection and interpretation, with the intent of understanding 'work as done'. Data were analysed using an adapted "Qualitative Rapid Appraisal, Rigorous Analysis" approach. Results Field observations were conducted over 135 h, interviews over 6.5 h and documents were reviewed. Analysis found six themes. Staff working in OPCs see themselves as part of small local teams and as part of a broader multidisciplinary care team. Professional role boundaries could be unclear in practice, as duties expanded to meet demand or to stop patients "falling through the cracks." Formal care processes in OPCs were supported by relationships, social capital and informal, but invaluable, institutional expertise. Features of the clinic layout, such as the proximity of departments, affected professional interactions. Staff were aware of inter- and intra-service communication difficulties and employed strategies to minimise negative impacts on patients. We found that complexity, coordination, culture and capacity underpin the themes that characterise this care provision. Conclusions The study advances understanding of how multidisciplinary care is delivered in ambulatory settings and the factors which promote or inhibit effective care practice. Time pressures, communication challenges and competing priorities can pose barriers to care delivery. OPC care is facilitated by: self-organisation of participants; professional acumen; institutional knowledge; social ties and relationships between and within professional groups; and commitment to patient-centred care. An understanding of the realities of 'work-as-done' may help OPCs to sustain high-quality care in the face of escalating service demand.Bróna Nic Giolla Easpaig, Yvonne Tran, Teresa Winata, Klay Lamprell, Diana Fajardo Pulido, Gaston Arnolda, Geoff P. Delaney, Winston Liauw, Kylie Smith, Sandra Avery, Kim Rigg, Johanna Westbrook, Ian Olver, David Currow, Jonathan Karnon, Robyn L. Ward, and Jeffrey Braithwait

Innovative models of healthcare delivery: an umbrella review of reviews

Objective To undertake a synthesis of evidence-based research for seven innovative models of care to inform the development of new hospitals.Design Umbrella review.Setting Interventions delivered inside and outside of acute care settings.Participants Children and adults with one or more identified acute or chronic health conditions.Data sources PsycINFO, Ovid MEDLINE and CINAHL.Primary and secondary outcome measures Clinical indicators and mortality, healthcare utilisation, quality of life, self-management and self-care and patient knowledge.Results A total of 66 reviews were included, synthesising evidence from 1272 primary studies across the 7 models of care. Virtual care was the most common model studied, addressed by 47 (73%) of the reviews. Common outcomes evaluated across reviews were clinical indicators and mortality, healthcare utilisation, self-care and self-management, patient knowledge, quality of life and cost-effectiveness. The findings indicate that the innovative models of healthcare we identified in this review may be effective in managing patients with a range of acute and chronic conditions. Most of the included reviews reported evidence of comparable or improved care.Conclusions A consideration of local infrastructure and individual patient characteristics, such as health literacy, may be critical in determining the suitability of models of care for patients and their implementation in local health systems.Trial registration number 10.17605/OSF.IO/PS6ZU