Fast-track hospital end-of-life discharge pathway: is it actually fast? National clinical audit

ObjectivesTo determine adherence to Department of Health and Social Care target of fast-track pathway discharge for end-of-life care within 48 hours.MethodsMulticentre audit in England using retrospective analysis of patient records for fast-track pathway tools submitted between 1 March 2019 and 31 March 2019.ResultsMost patients (72%) were not discharged within the 48-hour target. There was significant variability in success between hospital sites. Delays in discharge were most frequently considered to be secondary to delays in sourcing packages of care and 24-hour care facility placements. Involvement of specialist discharge nurses in paperwork submission improved rates by Commissioning Care Groups. Patients who died in hospital had significantly longer admissions than those who were discharged (discharged 19 days (IQR 11–28) vs died 28 days (IQR 18–42); p=0.039). This was entirely accounted for by increased numbers of days between admission and first suggestion of fast-track pathway discharge in those who died in hospital (discharged 9 days (IQR 5–19), died 15 days (IQR 9–33); p=0.003).ConclusionsWe demonstrated a delay in the fast-track pathway discharge process with significant variation in success of the discharge process at different geographical locations.

Assessment of the effects of methodological choice in continuity of care research: a real-world example with dyslipidaemia cohort

ObjectiveTo determine if the choice of methodological elements affects the results in continuity of care studies.DesignThis is a retrospective cohort study. The association between continuity of care and clinical outcome was investigated using the Continuity of Care Index. The association was explored in 12 scenarios based on four definitions of the relative timing of continuity and outcome measurements in three populations (three Ps × four Ts).SettingNational Health Insurance claims from all primary and secondary care facilities in South Korea between 2007 and 2015.ParticipantsParticipants were patients diagnosed with dyslipidaemia, made ≥2 ambulatory visits and were newly prescribed with ≥1 antihyperlipidaemic agent at an ambulatory setting in 2008. Three study populations were defined based on the number of ambulatory visits: 10 084 patients in population 1 (P1), 8454 in population 2 (P2) and 4754 in population 3 (P3).Main outcome measureHospitalisation related to one of the four atherosclerotic cardiovascular diseases, including myocardial infarction, stable or unstable angina, ischaemic stroke and transient ischaemic attack.ResultsConcurrent measure of continuity and outcome (T1) showed a significantly higher risk of hospitalisation (adjusted HRs: 2.73–3.07, p<0.0001) in the low continuity of care group, whereas T2, which measured continuity until the outcome occurred, showed no risk difference between the continuity of care groups. T3, which measured continuity as a time-varying variable, had adjusted HRs of 1.31–1.55 (p<0.05), and T4, measuring continuity for a predefined period and measuring outcomes in the remaining period, had adjusted HRs of 1.34–1.46 (p<0.05) in the low continuity of care. Within each temporal relationship, the effect estimates became more substantial as the inclusion criteria became stricter.ConclusionsThe study design in continuity of care studies should be planned carefully because the results are sensitive to the temporal relationship between continuity and outcome and the population selection criteria.

NCOG-08. BIOPSY-ONLY GLIOBLASTOMA (BO-GBM) AS A HETEROGENEOUS GROUP OF PATIENTS

BACKGROUND “Biopsy-only” glioblastoma is associated with a heterogeneous functional and survival outcome. It is an understudied group of patients which has been reported to represent 21% of histologically confirmed GBM in the US National Cancer Data Base. Pattern of care included radiotherapy-temozolomide (RT-TMZ) completed in 15% of patients, any other form of oncologic treatment in 60%, and supportive care alone in 25% of patients. Our objective was to explore treatment and prognosis of BO-GBM. MATERIAL AND METHODS Patients with BO-GBM included in a prospective regional glioma SIRIC cohort in 2014-2017 were retrospectively reviewed for patient characteristics, MRI finding, treatment allocation and delivery. PFS and OS were analyzed. RESULTS Of 535 patients included in the cohort, 449 patients were included at initial surgery, of which 158 patients (35%) underwent biopsy only. Of 158 patients, 18 were excluded for missing data leaving 139 patients for the present analysis. Fifty-four (39%) were referred to RT-TMZ, 68 (49%) considered unfitted for RT received chemotherapy upfront (CT-UF), 17 (12%) were referred to palliative care. Groups differed at baseline for age (mean 60 and 68 years, for RT-TMZ, CT-UF respectively); KPS (70, 60 for RT-TMZ, CT-UF); mean tumor surface (793, 1420 mm2 for RT-TMZ, CT-UF); and tumor extension (bilateral in 6.4% and 29.3% for RT-CT and CT-UF respectively). Median OS was 14 months (95% CI, 9.65-18.71) and 8 months (95% CI, 4.62-7.67) for RT-TMZ, CT-UF respectively. CONCLUSION Inoperable GBM constitute a large and heterogeneous population in which one third of patients are amenable to standard of care, with survival outcome close to the one of patients who underwent surgery. Patients considered unfit for RT-CT at diagnosis exhibit a poor survival outcome. Thus, reliable criteria are needed to help selecting patients for adequate treatment while new strategies are warranted for BO-GBM unfit for RT.

Sex-Specific Clinical Outcomes of the PACT-HF Randomized Trial

Background: Transitional care may have different effects in males and females hospitalized for heart failure. We assessed the sex-specific effects of a transitional care model on clinical outcomes following hospitalization for heart failure. Methods: In this stepped-wedge cluster randomized trial of adults hospitalized for heart failure in Ontario, Canada, 10 hospitals were randomized to a group of transitional care services or usual care. Outcomes in this exploratory analysis were composite all-cause readmission, emergency department visit, or death at 6 months; and composite all-cause readmission or emergency department visit at 6 months. Models were adjusted for stepped-wedge design and patient age. Results: Among 2494 adults, mean (SD) age was 77.7 (12.1) years, and 1258 (50.4%) were female. The first composite outcome occurred in 371 (66.3%) versus 433 (64.1%) males (hazard ratio [HR], 1.04 [95% CI, 0.86–1.26]; P =0.67) and in 326 (59.9%) versus 463 (64.8%) females (HR, 0.83 [95% CI, 0.69–1.01]; P =0.06) in the intervention and usual care groups, respectively ( P =0.012 for sex interaction). The second composite outcome occurred in 357 (63.8%) versus 417 (61.7%) males (HR, 1.03 [95% CI, 0.85–1.24]; P =0.76) and 314 (57.7%) versus 450 (63.0%) females (HR, 0.81 [95% CI, 0.67–0.99]; P =0.037) in the intervention and usual care groups, respectively ( P =0.024 for sex interaction). The sex differences were driven by a reduction in all-cause emergency department visits among females (HR, 0.66 [95% CI, 0.51–0.87]; P =0.003), but not males (HR, 1.10 [95% CI, 0.85–1.43]; P =0.46), receiving the intervention ( P <0.001 for sex interaction). Conclusions: A transitional care model offered a reduction in all-cause emergency department visits among females but not males following hospitalization for heart failure. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02112227.

Interventions to Improve Hydration in Older Adults: A Systematic Review and Meta-Analysis

Dehydration is common in the elderly, especially when hospitalised. This study investigated the impact of interventions to improve hydration in acutely unwell or institutionalised older adults for hydration and hydration linked events (constipation, falls, urinary tract infections) as well as patient satisfaction. Four databases were searched from inception to 13 May 2020 for studies of interventions to improve hydration. Nineteen studies (978 participants) were included and two studies (165 participants) were meta-analysed. Behavioural interventions were associated with a significant improvement in hydration. Environmental, multifaceted and nutritional interventions had mixed success. Meta-analysis indicated that groups receiving interventions to improve hydration consumed 300.93 mL more fluid per day than those in the usual care groups (95% CI: 289.27 mL, 312.59 mL; I2 = 0%, p < 0.00001). Overall, there is limited evidence describing interventions to improve hydration in acutely unwell or institutionalised older adults. Behavioural interventions appear promising. High-quality studies using validated rather than subjective methods of assessing hydration are needed to determine effective interventions.

PENGARUH DUKUNGAN SUAMI DAN KADER POSYANDU TERHADAP MINAT IBU MENGGUNAKAN KB IMPLAN

Berdasarkan Profil Kesehatan Indonesia cakupan KB implant sebesar 11,20%. Proporsi KB aktif implan di Jawa Timur sebesar 10,23%. Data dari Dinas Kesehatan Kota Probolinggo tahun 2019, di Kelurahan Sumbertaman terdapat KB Aktifnya yaitu 1.470 PUS dan Implan (146 PUS) serta yang ber KB di RW 1 sebanyak 21 orang. Tujuan menganalisis Pengaruh Dukungan Suami Dan Kader Posyandu terhadap Minat Ibu Menggunakan KB Implan di RW 1 Kelurahan Sumbertaman Kota Probolinggo. Desain penelitian analitik korelasional dengan metode cross sectional. Penelitian dilaksanakan Bulan Mei - Juni di kelurahan Sumbertaman Kota Probolinggo dengan 107 sampel. Data dianalisis dengan uji Spearman dan Regresi Ordinal ?: 0,05. Hasil penelitian menunjukkan dukungan suami sangat mendukung sebesar 47 responden (43,9%), dukungan kader posyandu kurang mendukung sebesar 59 responden (55,1%), minat ibu dalam menggunakan alat kontrasepsi implant dengan kategori minat tinggi sebesar 57 responden (53,5%) dengan p value : 0,000. Kesimpulan ada Pengaruh Dukungan Suami Dan Kader Posyandu Terhadap Minat Ibu Menggunakan KB Implan. Saran bagi puskesmas/tenaga kesehatan meningkatkan pemberian edukasi secara berkala kepada suami dan keluarga tentang pentingnya menggunakan alat kontrasepsi dan membentuk kelompok peduli KB. Kata kunci: Dukungan Suami, Dukungan Kader Posyandu, Minat Ibu, Alat Kontrasepsi Implan ABSTRACT Based on the Indonesian Health Profile, the coverage of implant family planning is 11.20%. The proportion of active implant family planning in East Java is 10.23%. Data from the Probolinggo Health Office in 2019, in Sumbertaman Village there were, namely 1,470 Childbearing Age Couple and implants (146 Childbearing Age Couple ) and 21 people who had an interest in implant Contraceptive in RW 1. The purpose was to analize the influence between husband support and Posyandu cadres to maternal interest in using implant family planning in RW 1, Sumbertaman, Probolinggo. The design of this research is correlational analytic using cross sectional method. The research was conducted on May - June in Sumbertaman, Probolinggo with 107 samples. Data collection analyzed by Spearman test and Ordinal Regression ?: 0.05. The results showed husband's support in the very supportive category was 47 respondents (43.9%), the support of posyandu cadres with less supportive criteria was 59 respondents (55.1%), the mother's interest in using implant contraceptives with high interest categories was 57 respondents (53,5%) with p value: 0,000. The conclusion of the study shows there is a influence between husband support and Posyandu cadres to maternal interest in using implant family planning. Suggestions are put forward for health centers / health workers to increase the provision of regular education to husbands and families about the importance of using contraceptives and to form family planning care groups or family planning villages. Keywords: Husband's Support, Posyandu Cadre Support, Mother's Interest, Implant Contraceptives

Designing Oral Health Curriculum That Facilitates Greater Integration of Oral Health Into Overall Health

For several decades, health professions education has been transforming; pedagogical constructs such as active learning, recorded lectures, electronic assessment, asynchronous content delivery, and interprofessional education and practice. However, the typical oral health curriculum has need for further transformation to ensure graduates' ability to function in an integrated health system. There is significant literature outlining associations between oral health and overall health, therefore, it is paramount that oral health learners develop skills to collaborate in an integrated model. Satcher, in 2000, outlined the gravity of oral health inequities and the importance of oral health. He said, “Too little time is devoted to oral health and disease topics in the education of non-dental health professional.” However, on the contrary typical oral health curriculum provide knowledge acquisition of topics related to overall health but isn't specifically designed to guide integrated care. In order to increase integrated care, groups like the Interprofessional Education Collaborative (IPEC) have developed competencies for interprofessional education and collaborative practice that guides the training of health professionals. One way to improve integration is accreditation standards that guide transformation as well incorporate IPEC competencies. Having competencies is important to prepare learners to function in clinics like Kaiser Permanente's medical-dental integration model that rely upon teams and teamwork and clarity of roles and responsibilities. This manuscript outlines principle of oral health curriculum that facilitate graduates ability to work in an integrated health system and how that contributes to the improvement overall health of patients.

Acceptability of a Mobile-Health Living Kidney Donor Advocacy Program for Black Wait-Listed Patients

Marked racial disparities exist in rates of living donor kidney transplantation (LDKT). The Living Organ Video Educated Donors (LOVED) program is a distance-based, mobile health program designed to help Black kidney transplant wait-list patients advocate for a living donor. This study reported on the acceptability outcomes to aid in future refinements. Participants were randomized to LOVED (n = 24, mean age = 50.9 SD (9.2) years), male = 50%) and usual care groups (n = 24 (mean age 47.9 SD (10.0), male 50%). Four LOVED groups completed an eight-week intervention that consisted of six online video education modules and eight group video chat sessions led by a Black navigator. Qualitative analysis from post-study focus groups resulted in six themes: (1) video chat sessions provided essential support and encouragement, (2) videos motivated and made participants more knowledgeable, (3) connectivity with tablets was acceptable in most areas, (4) material was culturally sensitive, (5) participation was overall a positive experience and (6) participants were more willing to ask for a kidney now. The video chat sessions were pertinent in participant satisfaction, though technology concerns limited program implementation. Results showed that the LOVED program was acceptable to engage minorities in health behavior changes for living donor advocacy but barriers exist that require future refinement.

A qualitative investigation of adolescent participation in Care Groups for improved maternal and child nutrition: experiences from rural Zimbabwe

The Amalima program in Matabeleland North and Matabeleland South Provinces of Zimbabwe, an intervention funded by the United States Agency for International Development (USAID) Office of Food for Peace, promoted Care Groups from 2014-2020. Care Groups are community peer- to- peer support groups that provide a platform for promoting optimal nutrition and health for pregnant and lactating women, as well as children 6-23 months of age through training sessions run by community group leaders to promote recommended maternal, infant and young child nutrition practices. A qualitative study was conducted to describe adolescent mother inclusion and participation in Care Groups, highlighting key enablers and barriers for participation. A total of 28 in-depth interviews were conducted with adolescents in Care Groups, as well as adolescents not participating in Care Groups. Focus group discussions were also held with family members of adolescents. The key enablers for Care Group participation by adolescent mothers were found to include the motivation to learn how to take care of their children, the social and interactive benefits, family support, and positive facilitator attitudes. Key barriers to participation were workload and chores at home, lack of family support, and lack of adolescent-friendly approaches amongst facilitators. Key recommendations include training facilitators on adolescent-friendly approaches and group dynamics so they can better understand and relate to adolescents.