Developing care pathways--lessons from the Steele Review implementation in England

Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome

PURPOSE

The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care.

METHOD

We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria.

RESULTS

Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response.

CONCLUSIONS

This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.

Implementing online evidence-based care pathways: A mixed-methods study across primary and secondary care

AIM

To understand what contextual influences, mechanisms and outcomes affect the implementation and use of localised, online care pathways (HealthPathways) in primary and secondary care.

DESIGN AND PROCEDURE

Mixed-measures design. Quantitative data included number of page views and conditions viewed. Qualitative data from semistructured interviews and focus groups were gathered over a 6-month period, and analysed using NVivo software.

SETTING

The first HealthPathways UK site, South Tyneside, England.

PARTICIPANTS

General practitioners, nurses, practice managers, hospital consultants and system leaders (managers, commissioners) (n=76).

RESULTS

Use of the pathways significantly increased over time. Themes were developed showing how online care pathways were used-leadership, pre-existing networks and relationships; development of systems and processes for care pathways, the use of online care pathways to support decision-making and referral, and perceived availability of resources. Inter-related themes were arranged into configurations consisting of contextual influences, mechanisms and outcomes. Recommendations were made for future implementations, such as improved data collection processes to understand how and why there was variance in the use of pathways.

CONCLUSIONS

This study was early in the implementation process; however, emerging themes will facilitate the future implementation and use of online care pathways. Recommendations are made for further research to include other health and social care users and patients to inform future developments.

Can conditional health policies be justified? A policy analysis of the new NHS dental contract reforms

Conditional policies, which emphasise personal responsibility, are becoming increasingly common in healthcare. Although used widely internationally, they are relatively new within the UK health system where there have been concerns about whether they can be justified. New NHS dental contracts include the introduction of a conditional component that restricts certain patients from accessing a full range of treatment until they have complied with preventative action. A policy analysis of published documents on the NHS dental contract reforms from 2009 to 2016 was conducted to consider how conditionality is justified and whether its execution is likely to cause distributional effects. Contractualist, paternalistic and mutualist arguments that reflect notions of responsibility and obligation are used as justification within policy. Underlying these arguments is an emphasis on preserving the finite resources of a strained NHS. We argue that the proposed conditional component may differentially affect disadvantaged patients, who do not necessarily have access to the resources needed to meet the behavioural requirements. As such, the conditional component of the NHS dental contract reform has the potential to exacerbate oral health inequalities. Conditional health policies may challenge core NHS principles and, as is the case with any conditional policy, should be carefully considered to ensure they do not exacerbate health inequities.

The Seattle Care Pathway for securing oral health in older patients

There is a need for a structured, evidence based approach to care for older dental patients. The following article describes the development of the Seattle Care Pathway based upon a workshop held in 2013. An overview is provided on the key issues of older persons dental care including the demography shift, the concept of frailty, the need for effective prevention and treatment to be linked to levels of dependency and the need for a varied and well educated work force. The pathway is presented in tabular form and further illustrated by the examples in the form of clinical scenarios. The pathway is an evidence based, pragmatic approach to care designed to be globally applicable but flexible enough to be adapted for local needs and circumstances. Research will be required to evaluate the pathways application to this important group of patients.

Care pathways for dementia: current perspectives

Uncertainty appears to typify the experience of living with dementia. With an uncertain illness trajectory and unpredictable levels of deterioration and stability in symptoms, people with a diagnosis of dementia may live with uncertainty and anxiety and find it hard to make plans or decisions for their future. People with memory problems and caregivers seeking a diagnosis of dementia may also potentially find themselves navigating a labyrinth-like maze of services, practitioners, assessments, and memory tests, with limited understanding of test scores and little information about what support is available. In this context of uncertainty, the apparent clarity and certainty of a “dementia care pathway” may be attractive. However, the term “dementia care pathway” has multiple and overlapping meanings, which can potentially give rise to further confusion if these are ill-defined or a false consensus is presumed. This review distinguishes four meanings: 1) a mechanism for the management and containment of uncertainty and confusion, useful for the professional as well as the person with dementia; 2) a manual for sequencing care activities; 3) a guide to consumers, indicating eligibility for care activities, or a guide to self-management for dementia dyads, indicating the appropriateness of care activities; and 4) a manual for “walking with” the person. Examples of these approaches are presented from UK dementia services with illustrations of existing care pathways and associated time points, specifically focusing on: 1) early symptom identification and first service encounters, 2) assessment process, 3) diagnostic disclosure, 4) postdiagnostic support, and 5) appropriate interventions. We review the evidence around these themes, as well as discuss service pathways and referral routes used by some services in England and internationally. We conclude that the attraction of the term “care pathway” is seductive, but caution is needed in taking shared understandings for granted.