EPOCK study protocol: a mixed-methods research program evaluating cancer care coordination nursing occupations in France as a complex intervention.

BACKGROUND: Facing the increasing cancer incidence and cancer survivorship, many national strategic cancer plans have identified cancer care coordination as a priority for health service improvement. However, the high variability of practices, the diversity of definitions and underlying concepts increases the existing difficulty to standardise, replicate, transpose and assess care coordination within the French health system context. The EPOCK national study aims at evaluating practices and the working context of hospital-based cancer care coordination nurses, based on a previously designed reference framework for care coordination within the French health system context. METHODS: EPOCK is based on a comprehensive evaluation of nursing professions in cancer care coordination, considered as a complex intervention. Phase 1 (theoretical phase) will define and design a theoretical reference framework for care coordination in France through an international literature review, aiming to identify relevant models and all components of the expected framework and a structured consensus method, the Nominal group technique, aiming to select and prioritise the most relevant components already found in the literature review with regard to the French healthcare system; phase 2 (Operational phase) will consist in an in-depth analysis of practices, contexts, perceptions and attitudes related to care coordination occupations by nurses in oncology and all stakeholders (related professionals, patients and their caregivers) through a multicentric cross-sectional mixed-method evaluative study. The observed practices and contexts will be finally compared with the theoretical reference framework using both inductive and deductive approaches. DISCUSSION: This study will result in an evaluation framework identifying key models and key elements relative to cancer care coordination interventions that can be used to guide management of cancer care coordination nursing occupations within the French healthcare system. EPOCK would also assist in public decision-making to identify optimal targets, skills profiles and scope of actions for cancer coordination professions. Finally, EPOCK will describe typology of nurse practices in cancer care coordination and thus obtain precise preliminary information essential for drafting a medico-economic evaluation study of these new nursing professions' impact. TRIAL REGISTRATION: Clinicaltrial.gov registration: NCT03350776 , 11/22/2017.

Design and validation of a questionnaire to assess organizational culture in French hospital wards.

BACKGROUND: Although many organizational culture questionnaires have been developed, there is a lack of any validated multidimensional questionnaire assessing organizational culture at hospital ward level and adapted to health care context. Facing the lack of an appropriate tool, a multidisciplinary team designed and validated a dimensional organizational culture questionnaire for healthcare settings to be administered at ward level. METHODS: A database of organizational culture items and themes was created after extensive literature review. Items were regrouped into dimensions and subdimensions (classification validated by experts). Pre-test and face validation was conducted with 15 health care professionals. In a stratified cluster random sample of hospitals, the psychometric validation was conducted in three phases on a sample of 859 healthcare professionals from 36 multidisciplinary medicine services: 1) the exploratory phase included a description of responses' saturation levels, factor and correlations analyses and an internal consistency analysis (Cronbach's alpha coefficient); 2) confirmatory phase used the Structural Equation Modeling (SEM); 3) reproducibility was studied by a test-retest. RESULTS: The overall response rate was 80 %; the completion average was 97 %. The metrological results were: a global Cronbach's alpha coefficient of 0.93, higher than 0.70 for 12 sub-dimensions; all Dillon-Goldstein's rho coefficients higher than 0.70; an excellent quality of external model with a Goodness of Fitness (GoF) criterion of 0.99. Seventy percent of the items had a reproducibility ranging from moderate (Intra-Class Coefficient between 50 and 70 % for 25 items) to good (ICC higher than 70 % for 33 items). CONCLUSIONS: COMEt (Contexte Organisationnel et Managérial en Etablissement de Santé) questionnaire is a validated multidimensional organizational culture questionnaire made of 6 dimensions, 21 sub-dimensions and 83 items. It is the first dimensional organizational culture questionnaire, specific to healthcare context, for a unit level assessment showing robust psychometric properties (validity and reliability). This tool is suited for research purposes, especially for assessing organizational context in research analysing the effectiveness of hospital quality improvement strategies. Our tool is also suited for an overall assessment of ward culture and could be a powerful trigger to improve management and clinical performance. Its psychometric properties in other health systems need to be tested.

[Combined quantitative and qualitative methods to identify local facilitators of and barriers to physician's adherence to clinical practice guidelines]. / Analyse qualitative et quantitative des déterminants à l'application de recommandations professionnelles (RP) par les médecins.

BACKGROUND: The effectiveness of Clinical Practice Guideline (CPG) implementation interventions could be improved by their adaptation to facilitators of and barriers to practice change in each setting. Very few is known about these local factors in French hospitals. Our objectives were to identify the facilitator factors of and barriers to physician's adherence to CPG in internal medicine wards in France and to determine the factors most strongly statistically associated to CPG adherence. METHODS: Combined qualitative and quantitative methods. Two CPGs were chosen as examples. The settings were internal medicine wards of hospitals of the Aquitaine region voluntary to participate. Qualitative analyses were conducted in the internal medicine wards of 5 hospitals in the Aquitaine region selected among the 12 voluntary hospitals to represent the variability of situations. QUANTITATIVE ANALYSIS: A questionnaire was constituted by the factors retrieved through the qualitative analyses and a previous literature review as barriers or facilitator factors to physician's adherence to CPG and asked the physicians on the degree of CPG adherence. It was sent to each physician of the internal medicine wards of the 12 voluntary hospitals. The responses to the questionnaire allowed the analysis of the frequency of each factor and the strength of the statistical association between these factors and CPG adherence. RESULTS: These analyses focused on the importance of the management, particularly the role of ward head and of the exchange between physicians. The attitude to CPGs varied according to the individual positionnement on the professional hierarchy, function of the quantity of research activities and of the local, regional and national radiance of the ward. Organisational difficulties as professionals and patients turn over, work overload, lack of coordination between wards were organisational barriers to CPG adherence. The quantitative analysis confirmed the role of managerial and organisational factors in the CPG adherence. CONCLUSION: Following step was to validate a tool of barriers to CPG adherence identification and to study the effectiveness of this a priori identification in improving CPG adherence.

[Blunt trauma to the infrarenal abdominal aorta with neurologic lesions. Case report and review of the literature]. / Traumatisme fermé de l'aorte abdominale sous-rénale avec lésions neurologiques. Stratégie de prise en charge: à propos d'un cas et d'une revue de la littérature.

We report the case of a 31-year-old female involved in a severe motor vehicle accident. The diagnosis of blunt trauma to the abdominal aorta was not retained initially. The patient was referred to our institution when she developed a delayed paralysis of the lower limbs associated with the disappearance of both femoral pulses. Computed tomography evidenced dissection of the infrarenal aorta and NMR ruled out injury to the spinal cord. An aortoiliac endarteriectomy was then performed. Neurological recovery was partial at 3 months. We reviewed the frequency, the mechanisms and the management of blunt trauma to the abdominal aorta.

[Process assessment: importance and current limits]. / Evaluer les processus en santé: importance et limites actuelles.

Assessment of processes in health care is needed for the measurement of six domains of quality of care (appropriateness, security, respect and caring, availability, continuity and timeliness). We propose here a typology of care, organisational and management processes. Process indicators can be classified according to objectives of the evaluation, type of processes, concerned healthcare professionals, and stage of the process. Process assessment is hindered by two main difficulties. Due to the lack of data about processes in information systems and in medical records, specific data collection is often needed and impede the feasibility of routine evaluation. The second difficulty is related to the lack of information about the properties of the indicators, their appropriateness (capacity to infer improvement actions from the result of the indicators), their operational properties (cost of data collection and acceptability by the concerned professionals), and their measurement properties (reliability and validity). Process assessment is strongly needed because outcome assessment can be not possible or not appropriate. The lack of information about the process-outcome relationship is the major obstacle and the main contra-indication to its use. Validation of process indicators is therefore an important research area for the future.

[Amyloidosis of a coral reef infrarenal aorta]. / Amylose d'une aorte sous-rénale en pierre de corail.

This case concerns a 37-year-old woman with a cruro-gluteal claudication, from which she had been suffering since the age of 33, and which prevented her from walking more than 50 metres. The arteriographic examination revealed preocclusive coralliform proliferations of the infrarenal aorta, with a 30% stenosis of the right internal carotid artery. After 18 months, a straight aorto-aortic tube yielded excellent results. The results of the pathological examination led to the conclusion that this was a secondary aortic amyloidosis with no specific lesions of the aortic wall. This coral reef aorta is distinguished by its infrarenal location (fourth case worldwide), as well as by the major amylotic infiltrations of the endoaortic proliferations and of the aortic wall. In the absence of generalized amyloidosis, we suspect massive localized amyloidosis subsequent to an old inflammatory aortic process compatible with a juvenile atheroma opened in the aortic lumen or more probably a sequel of Takayasu's disease.

[Carotid-jugular fistula after an attempt at placement of a vena cava filter]. / Fistule carotido-jugulaire après tentative de placement d'un filtre cave.

A carotid-jugular fistula complicated the placement of a Green-field filter via the right internal jugular percutaneous passage: the local signs of an arterio-venous fistula were associated with right parietal infarction neurological symptoms. A crossography showed a carotid-jugular fistula and a limited dissection of the original carotid artery. An elective echo-guided compression failed. The surgical treatment eliminated the fistula, fixed the carotid dissection and placed a vena cava filter with an excellent result 34 months later. Percutaneous placement of vena cava filters can lead to rare vascular complications such as carotid-jugular fistulas which can, in certain cases, be treated with an elective external compression or endovascular procedures. Surgery offers a reliable technical solution that is complete and stable in time, particularly with recent fistulas and associated neurological symptoms.