A decade on: has the use of integrated care pathways made a difference in Lanarkshire?

Care pathways in forensic mental health services in New Zealand

On entering forensic mental health services (FMHS) patients progress along forensic care pathways (FCP) that aim to maximise well-being and reduce risk of reoffending. They progress through high-, medium-, and low-secure psychiatric units with changing care and security needs. There is minimal literature examining FCP or their efficacy. This retrospective study describes the characteristics of patients admitted to an acute FMHS and explores the clinical, sociodemographic, and legal factors that influence FCP progression. Most patients were referred from prison (65.1%) and presented with violent index offending (62.4%) and psychotic disorder (80.6%). Young Maori men with psychosis predominated the forensic population. Logistic regression revealed violent index offending and diagnosis were determinants of following FCP, while violent offending and longer duration of stay were predictive of FCP progression. This study found no reduction in re-hospitalisation rates or inpatient length of stay over a three year follow-up for patients that completed the FCP.

Clinical variation in the organization of clinical pathways in esophagogastric cancer, a mixed method multiple case study

Background

Among esophagogastric cancer patients, the probability of having undergone treatment with curative intent has been shown to vary, depending on the hospital of diagnosis. However, little is known about the factors that contribute to this variation. In this study, we sought to understand the organization of clinical pathways and their association with variation in practice.

Methods

A mixed-method study using quantitative and qualitative data was conducted. Quantitative data were obtained from the Netherlands Cancer Registry (e.g., outpatient clinic consultations and diagnostic procedures). For qualitative data, thematic content analysis was performed using semi-structured interviews (n = 30), observations of outpatient clinic consultations (n = 26), and multidisciplinary team meetings (MDTM, n = 16) in eight hospitals, to assess clinicians’ perspectives regarding the clinical pathways.

Results

Quantitative analyses showed that patients more often underwent surgical consultation prior to the MDTM in hospitals associated with a high probability of receiving treatment with curative intent, but more often consulted with a geriatrician in hospitals associated with a low probability of such treatment. The organization of clinical pathways was analyzed quantitatively at three levels: regional, local, and patient levels. At a regional level, hospitals differed in terms of the number of patients discussed during the MDTM. At the local level, the revision of radiological images and restaging after neoadjuvant treatment varied. At the patient level, some hospitals routinely conduct fitness tests, whereas others estimated the patient’s physical fitness during an outpatient clinic consultation. Few clinicians performed a standard geriatric consultation in older patients to assess their mental fitness and frailty.

Conclusion

Surgical consultation prior to MDTM was more often conducted in hospitals associated with a high probability of receiving treatment with curative intent, whereas a geriatrician was consulted more often in hospitals associated with a low probability of receiving such treatment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07845-2.

Evaluation of a Collaborative Protocolized Approach by Community Pharmacists and General Medical Practitioners for an Australian Minor Ailments Scheme: Protocol for a Cluster Randomized Controlled Trial

Background

Internationally, governments have been investing in supporting pharmacists to take on an expanded role to support self-care for health system efficiency. There is consistent evidence that minor ailment schemes (MASs) promote efficiencies within the health care system. The cost savings and health outcomes demonstrated in the United Kingdom and Canada open up new opportunities for pharmacists to effect sustainable changes through MAS delivery in Australia.

Objective

This trial aims to evaluate the clinical, economic, and humanistic impact of an Australian Minor Ailments Service (AMAS) compared with usual pharmacy care in a cluster randomized controlled trial (cRCT) in Western Sydney, Australia.

Methods

The cRCT design has an intervention group and a control group, comparing individuals receiving a structured intervention (AMAS) with those receiving usual care for specific health ailments. Participants will be community pharmacies, general practices, and patients located in Western Sydney Primary Health Network (WSPHN) region. A total of 30 community pharmacies will be randomly assigned to either intervention or control group. Each will recruit 24 patients, aged 18 years or older, presenting to the pharmacy in person with a symptom-based or product-based request for one of the following ailments: reflux, cough, common cold, headache (tension or migraine), primary dysmenorrhea, or low back pain. Intervention pharmacists will deliver protocolized care to patients using clinical treatment pathways with agreed referral points and collaborative systems boosting clinician-pharmacist communication. Patients recruited in control pharmacies will receive usual care. The coprimary outcomes are rates of appropriate recommendation of nonprescription medicines and rates of appropriate medical referral. Secondary outcomes include self-reported symptom resolution, health services resource utilization, and EuroQoL Visual Analogue Scale. Differences in primary outcomes between groups will be analyzed at the individual patient level accounting for correlation within clusters with generalized estimating equations. The economic impact of the model will be evaluated by cost-utility and cost-effectiveness analysis compared with usual care.

Results

The study began in July 2018. Thirty community pharmacies were recruited. Pharmacists from the 15 intervention pharmacies were trained. A total of 27 general practices consented. Pharmacy patient recruitment began in August 2018 and was completed on March 31, 2019.

Conclusions

This study may demonstrate the efficacy of a protocolized intervention to manage minor ailments in the community and will assess the clinical, economic, and humanistic impact of this intervention in Australian pharmacy practice. Pharmacists supporting patient self-care and appropriate self-medication may contribute to greater efficiency of health care resources and integration of self-care in the health system. The proposed model and developed educational content may form the basis of a national MAS service in Australia, using a robust framework for management and referral for common ailments.

Trial Registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12618000286246; http://www.anzctr.org.au/ACTRN12618000286246.aspx

International Registered Report Identifier (IRRID)

DERR1-10.2196/13973

Defining barriers and enablers for clinical pathway implementation in complex clinical settings

BACKGROUND

While clinical pathways have the potential to improve patient outcomes and reduce healthcare costs, their true impact has been limited by variable implementation strategies and suboptimal research designs. This paper explores a comprehensive set of factors perceived by emergency department staff and administrative leads to influence clinical pathway implementation within the complex and dynamic environments of community emergency department settings.

METHODS

This descriptive, qualitative study involved emergency health professionals and administrators of 15 community hospitals across Ontario, Canada. As part of our larger cluster randomized controlled trial, each site was in the preparation phase to implement one of two clinical pathways: pediatric asthma or pediatric vomiting and diarrhea. Data were collected from three sources: (i) a mediated group discussion with site champions during the project launch meeting; (ii) a semi-structured site visit of each emergency department; and (iii) key informant interviews with an administrative lead from each hospital. The Theoretical Domains Framework (TDF) was used to guide the interviews and thematically analyze the data. Domains within each major theme were then mapped onto the COM-B model-capability, opportunity, and motivation-of the Behaviour Change Wheel.

RESULTS

Seven discrete themes and 58 subthemes were identified that comprised a set of barriers and enablers relevant to the planned clinical pathway implementation. Within two themes, three distinct levels of impact emerged, namely (i) the individual health professional, (ii) the emergency department team, and (iii) the broader hospital context. The TDF domains occurring most frequently were Memory, Attention and Decision Processes, Environmental Context and Resources, Behavioural Regulation, and Reinforcement. Mapping these barriers and enablers onto the COM-B model provided an organized perspective on how these issues may be interacting. Several factors were viewed as both negative and positive across different perspectives. Two of the seven themes were limited to one component, while four involved all three components of the COM-B model.

CONCLUSIONS

Using a theory-based approach ensured systematic and comprehensive identification of relevant barriers and enablers to clinical pathway implementation in ED settings. The COM-B system of the Behaviour Change Wheel provided a useful perspective on how these factors might interact to effect change.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01815710 .

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Improved management of stillbirth using a care pathway

Purpose

Each year approximately 3,200 women have a stillbirth in the UK. Although national evidence-based guidance has existed since 2010, case reviews continue to identify suboptimal clinical care and communication with parents. Inconsistencies in management include induction and management of labour and the frequency of investigation after stillbirth. The paper aims to discuss these issues.

Design/methodology/approach

An audit of stillbirths was performed in 2014 in 13 maternity units in the North West of England, this confirmed variation in practice described nationally. An integrated care pathway (ICP) was developed from national guidelines to enable optimal care for the management of stillbirth, reduce variation, standardise investigations and coordinate patient-focussed care. This was launched in 2015 and updated in 2016 to resolve the issues that were apparent after implementation.

Findings

Each participating unit had commenced using the ICP by May 2015. Following implementation there were changes in care, most notably from diverse methods for the induction of labour to guideline-directed induction of labour. There were trends towards better care in terms of information given, choices offered, more appropriate analgesia in labour and improved post-delivery investigation for cause. Staff feedback about the ICP was positive.

Practical implications

The use of this ICP improved care for women who had a stillbirth and their families. Issues with implementing a changed care pathway meant that further iterations were required, ongoing improvement is expected following the refinement of the ICP.

Originality/value

ICPs have been used for various clinical conditions. However, this is the first example of their use in women who had a stillbirth.

Best strategies to implement clinical pathways in an emergency department setting: study protocol for a cluster randomized controlled trial

BACKGROUND

The clinical pathway is a tool that operationalizes best evidence recommendations and clinical practice guidelines in an accessible format for 'point of care' management by multidisciplinary health teams in hospital settings. While high-quality, expert-developed clinical pathways have many potential benefits, their impact has been limited by variable implementation strategies and suboptimal research designs. Best strategies for implementing pathways into hospital settings remain unknown. This study will seek to develop and comprehensively evaluate best strategies for effective local implementation of externally developed expert clinical pathways.

DESIGN/METHODS

We will develop a theory-based and knowledge user-informed intervention strategy to implement two pediatric clinical pathways: asthma and gastroenteritis. Using a balanced incomplete block design, we will randomize 16 community emergency departments to receive the intervention for one clinical pathway and serve as control for the alternate clinical pathway, thus conducting two cluster randomized controlled trials to evaluate this implementation intervention. A minimization procedure will be used to randomize sites. Intervention sites will receive a tailored strategy to support full clinical pathway implementation. We will evaluate implementation strategy effectiveness through measurement of relevant process and clinical outcomes. The primary process outcome will be the presence of an appropriately completed clinical pathway on the chart for relevant patients. Primary clinical outcomes for each clinical pathway include the following: Asthma--the proportion of asthmatic patients treated appropriately with corticosteroids in the emergency department and at discharge; and Gastroenteritis--the proportion of relevant patients appropriately treated with oral rehydration therapy. Data sources include chart audits, administrative databases, environmental scans, and qualitative interviews. We will also conduct an overall process evaluation to assess the implementation strategy and an economic analysis to evaluate implementation costs and benefits.

DISCUSSION

This study will contribute to the body of evidence supporting effective strategies for clinical pathway implementation, and ultimately reducing the research to practice gaps by operationalizing best evidence care recommendations through effective use of clinical pathways.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01815710.

General practitioner experience and perception of Child and Adolescent Mental Health Services (CAMHS) care pathways: a multimethod research study

OBJECTIVES

This is a pilot study with the objective of investigating general practitioner (GP) perceptions and experiences in the referral of mentally ill and behaviourally disturbed children and adolescents.

DESIGN

Quantitative analyses on patient databases were used to ascertain the source of referrals into Child and Adolescent Mental Health Services (CAMHS) and identify the relative contribution from GP practices. Qualitative semistructured interviews were then used to explore challenges faced by GPs in referring to CAMHS.

SETTING

GPs were chosen from the five localities that deliver CAMHS within the local Trust (Peterborough City, Fenland, Huntingdon, Cambridge City and South Cambridgeshire).

PARTICIPANTS

For the quantitative portion, data involving 19 466 separate referrals were used. Seven GPs took part in the qualitative interviews.

RESULTS

The likelihood of a referral from GPs being rejected by CAMHS was over three times higher compared to all other referral sources combined within the Cambridge and Peterborough NHS Foundation Trust. Interviews showed that detecting the signs and symptoms of mental illness in young people is a challenge for GPs. Communication with referral agencies varies and depends on individual relationships. GPs determine whether to refer on a mixture of the presenting conditions and their perceived likelihood of acceptance by CAMHS; the criteria for the latter were poorly understood by the interviewed GPs.

CONCLUSIONS

There are longstanding structural weaknesses in the services for children and young people in general, reflected in poor multiagency cooperation at the primary care level. GP-friendly guidelines and standards are required that will aid in decision-making and help with understanding the referrals process. We look to managers of both commissioning and providing organisations, as well as future research, to drive forward the development of tools, protocols, and health service structures to help aid the recognition and treatment of mental illness in young people.

Mental Health Payment-by-Results Clusters and the Model of Human Occupation Screening Tool

In the United Kingdom, payment for mental health services follows a system of payment-by-results. A mental health clustering tool, classifying individuals into clusters based on service needs, was developed as a broad-based means of planning care packages. It is yet unknown whether payment-by-results clusters will be reflective of the occupational needs of service users. To evaluate the relationship between service users' membership in service need clusters and occupational groupings based on outcomes from an independent measure on participation and engagement in self-care, productivity, and leisure (Model of Human Occupation Screening Tool [MOHOST]), retrospective medical record data were gathered from 675 service users with a range of psychiatric disorders from two organizations in England. Using six subscales of the MOHOST, the two-step cluster analysis identified occupational groupings. Then the multivariate analysis of variance was used to examine whether the mean scores of the six MOHOST subscales were significantly different across the occupational groupings. Finally, participants' membership in the payment-by-results clusters was compared to their membership in the occupational groupings. Participants fell into one of three levels: high-, middle-, or low-functioning occupational groups. These groups did not bear direct relationships with the individual payment-by-results clusters. This suggests that the mental health clustering tool and the MOHOST are likely targeting different characteristics in the service users.

Integrated care pathway for Clostridium difficile helps patient management

A pilot study using an integrated care pathway (ICP) when caring for patients suffering from Clostridium difficile associated disease (CDAD) was undertaken over a six-month period within six wards in two hospitals. The aim was to standardise practice and improve communications for this group of patients. There was increased staff knowledge and understanding with 91% of nursing staff reporting that the use of a CDAD ICP had improved patient care and treatment. Seventy-seven per cent of staff expressed that communications had improved since using the ICP and 77% felt that accessibility of patient information had improved. Lastly 86% of the staff felt better equipped to nurse patients with CDAD. A literature review yielded no other documented evidence of the use of an ICP for this patient group.

Care pathways for young people who misuse substances: using the evidence to design services

PURPOSE OF REVIEW

To review a selection of the literature on the nature and contents of care pathways. We examine recent work on current trends in intervening to meet the needs of young people who misuse substances.

RECENT FINDINGS

The recent and growing literature encourages us to adopt care pathways as structured models for service delivery. The increased prevalence and the severity and complexity of the problems experienced by young people who misuse substances evidence the requirement for specialist services for them.

SUMMARY

The literature argues for using care pathways to manage better services for intervening with young people who use or misuse substances and recommends their contents. We conclude that care pathways should be based on strategic models of care; however, there remain areas of uncertainty, including those about the balance of services that should be delivered, adoption of prevention programmes, and development of audit tools to monitor the impacts and effectiveness of care pathways. This review provides our recommended list of contents for models of care on which we recommend that associated care pathways should be based.