Shared medical appointments for patients with a nondiabetic physical chronic illness: A systematic review.

OBJECTIVES: Shared medical appointments are group appointments, with an optional individual consultation, for patients diagnosed with chronic illnesses. Shared medical appointments improve diabetes management, but little is known about their use for other illnesses. The objective was to determine the effect that shared medical appointments have on patients with a physical chronic illness, healthcare providers, and the healthcare system. METHODS: A systematic review was conducted searching databases from January 1970 to September 2016. Eligible trials evaluated shared medical appointments for patients with a homogeneous chronic illness, excluding diabetes and mental illness. Screening, data extraction, and risk of bias were conducted independently by two authors. Analysis was descriptive. RESULTS: Of 2364 citations, nine randomized trials were included. Shared medical appointments were evaluated for cardiovascular illnesses (four studies), breast cancer, chronic kidney disease, Parkinson's disease, stress urinary incontinence, and carpal tunnel syndrome. Compared to usual care, no negative effects on patient quality of life, knowledge and satisfaction were reported. One study reported no difference in healthcare provider satisfaction. Another study showed fewer hospital admissions for patients who attended shared medical appointments. DISCUSSION: Few rigorous studies evaluated the use of shared medical appointments for chronic illnesses. Overall, there appears to be no patient harms. Further studies should include more objective outcomes and larger sample sizes.

The effect of surgery report cards on improving radical prostatectomy quality: the SuRep study protocol.

BACKGROUND: The goal of radical prostatectomy is to achieve the optimal balance between complete cancer removal and preserving a patient's urinary and sexual function. Performing a wider excision of peri-prostatic tissue helps achieve negative surgical margins, but can compromise urinary and sexual function. Alternatively, sparing peri-prostatic tissue to maintain functional outcomes may result in an increased risk of cancer recurrence. The objective of this study is to determine the effect of providing surgeons with detailed information about their patient outcomes through a surgical report card. METHODS: We propose a prospective cohort quasi-experimental study. The intervention is the provision of feedback to prostate cancer surgeons via surgical report cards. These report cards will be distributed every 3 months by email and will present surgeons with detailed information, including urinary function, erectile function, and surgical margin outcomes of their patients compared to patients treated by other de-identified surgeons in the study. For the first 12 months of the study, pre-operative, 6-month, and 12-month patient data will be collected but there will be no report cards distributed to surgeons. This will form the pre-feedback cohort. After the pre-feedback cohort has completed accrual, surgeons will receive quarterly report cards. Patients treated after the provision of report cards will comprise the post-feedback cohort. The primary comparison will be post-operative function of the pre-feedback cohort vs. post-feedback cohort. The secondary comparison will be the proportion of patients with positive surgical margins in the two cohorts. Outcomes will be stratified or case-mix adjusted, as appropriate. Assuming a baseline potency of 20% and a baseline continence of 70%, 292 patients will be required for 80% power at an alpha of 5% to detect a 10% improvement in functional outcomes. Assuming 30% of patients may be lost to follow-up, a minimum sample size of 210 patients is required in the pre-feedback cohort and 210 patients in the post-feedback cohort. DISCUSSION: The findings from this study will have an immediate impact on surgeon self-evaluation and we hypothesize surgical report cards will result in improved overall outcomes of men treated with radical prostatectomy.

Follow-up Care for Survivors of Prostate Cancer - Clinical Management: a Program in Evidence-Based Care Systematic Review and Clinical Practice Guideline.

AIMS: This clinical practice guideline was developed to provide evidence-based guidance on the frequency by which prostate-specific antigen (PSA) levels should be tested in men after curative-intent treatment for prostate cancer and to define the most appropriate diagnostic testing if biochemical recurrence occurs. MATERIALS AND METHODS: An electronic search using OVID was used to systematically search the MEDLINE and EMBASE databases for systematic reviews and primary literature. A systematic review and practice guideline was written, reviewed and approved by the Guideline Development Group (GDG) and Program in Evidence-Based Care Report Approval Panel. External review by three prostate experts was completed, as well as an online consultation with healthcare professionals who were intended users of the guideline. RESULTS: Three systematic reviews and seven primary studies were included in the evidence base. All identified literature reported on diagnostic imaging properties of diagnostic tests following biochemical recurrence. CONCLUSIONS: Due to a lack of empirical research, few evidenced-based recommendations could be made with respect to a follow-up schedule of PSA testing for prostate cancer survivors following curative-intent treatment, or detailing diagnostic testing upon detection of biochemical recurrence. Accordingly, the GDG focused substantial effort on critical examination of the identified evidence, existing clinical practice guidelines and on obtaining clinical expertise consensus using a modified Delphi method. Overall, the recommendations embedded in this guideline reflect the best practice to date for the efficient and effective clinical follow-up care of prostate cancer survivors.

Symptom practice guide for telephone assessment of patients with cancer treatment-related cardiotoxic dyspnea: Adaptation and evaluation of acceptability.

BACKGROUND: Patients with cancer treatment-related cardiotoxicity, which may manifest as heart failure (HF), can present with dyspnea. Nurses frequently assess, triage and offer self-care strategies to patients experiencing dyspnea in both the cardiology and oncology settings. However, there are no known tools available for nurses to manage patients in the setting of cancer treatment-related cardiotoxicity. The objective of this study was to adapt and evaluate the acceptability of an evidence-informed symptom practice guide (SPG) for use by nurses over the telephone for the assessment, triage, and management of patients experiencing dyspnea due to cancer treatment-related cardiotoxicity. METHODS: The CAN-IMPLEMENT© methodology guided this descriptive study. A systematic search was conducted in four databases to identify cardio-oncology and HF guidelines and systematic reviews. Screening was conducted by two reviewers, with data extracted into a recommendation matrix from eligible guidelines and systematic reviews on: assessment criteria, medications, and/or self-care strategies to manage dyspnea. Healthcare professionals with an expertise in oncology and/or cardiology were recruited using purposeful and snowball sampling. Evaluation of acceptability of the adapted SPG was gathered through semi-structured interviews and a survey with open- and closed-ended questions. Quantitative findings and participant feedback from the interviews and the open-ended survey questions were analyzed descriptively. RESULTS: Of 490 citations, seven HF guidelines were identified. Evidence from these guidelines was added to the original SPG. Eleven healthcare professionals completed the interview and acceptability survey. The adapted SPG was iteratively revised three times during the interviews. The original SPG was adaptable, and participants indicated the adapted SPG was comprehensive, easy to follow, and would be useful in clinical practice. CONCLUSIONS: This study highlights the lack of knowledge tools and available clinical practice guidelines to guide healthcare professionals to assess, triage and/or offer self-care strategies to patients with cancer treatment-related cardiotoxic dyspnea. Moreover, most nurses require assistance to differentiate among the various causes of dyspnea from oncology treatment in order to triage severity appropriately. Further research should focus on evaluating the validity of the adapted SPG in clinical practice.

Wellness Beyond Cancer Program: building an effective survivorship program.

BACKGROUND: The Wellness Beyond Cancer Program (wbcp) was launched in 2012, first accepting patients with colorectal cancer (crc) and, subsequently, those with breast cancer (bca), with the aim of standardizing and streamlining the discharge process from our cancer centre. Patients are discharged either to the wbcp nurse practitioner or to their primary care provider (pcp). The program incorporates survivorship care plans (scps) and education classes; it also has a rapid re-entry system in case of recurrence. The objective of this paper is to describe the process by which a cancer survivorship program was developed at our institution and to present preliminary evaluation results. METHODS: Qualitative surveys were mailed to patients and pcps 1 year after patients had been referred to the wbcp. The surveys addressed knowledge of the program content, satisfaction on the part of patients and providers, and whether scp recommendations were followed. Questions were scored on the level of agreement with each of a list of statements (1 = strongly disagree to 5 = strongly agree). RESULTS: From March 2012 to November 2014, 2630 patients were referred to the wbcp (809 with crc, 1821 with bca). Surveys were received from 289 patients and 412 pcps. Patients and pcps gave similar scores (average: 4) to statements about satisfaction; pcps gave scores below 4 to statements about communication with the wbcp. CONCLUSIONS: At 1 year after discharge, patients and pcps were satisfied with program content, but there is an opportunity to improve on communication and provision of cancer-specific information to the pcps. Using the wbcp to ensure a safe transition to the most appropriate health care provider, we have standardized the discharge process for crc and bca patients.

Exploring a "community of practice" methodology as a regional platform for large-scale collaboration in cancer surgery-the Ottawa approach.

Pressing challenges have forced health care providers to rethink traditional silos and professional boundaries. Communities of practice (cops) have been identified as a means to share knowledge across silos and boundaries. However, clarity sufficient to enable their easy and uniform reproducibility is lacking, leading to a gap between cop conceptualization and implementation. This paper explores a cop structure and outlines a framework that is adaptable, measurable, and implementable across health disciplines in a regional cancer surgery program.

Piloting a regional collaborative in cancer surgery using a "community of practice" model.

BACKGROUND: Patients requiring assessment for cancer surgery encounter a complex series of steps in their cancer journey. Further complicating the process is the fact that care is often delivered in a fragmented, silo-based system. Isolated strategies to improve cancer outcomes within those systems have had inconsistent results. METHODS: A regional quality improvement collaborative was developed based on a community of practice (cop) platform, a hub-and-spoke infrastructure, and a regional steering committee linking cop improvement projects with affiliated hospitals and their strategic priorities. The cop provided an avenue for multidisciplinary teams to collect and compare their performance data and to institute regional standards through literature review, discussion, and consensus. Regional interdisciplinary teams developed a set of quality indicators linked to mutually agreed-upon care standards. A limited regional database supported feedback about performance against both provincial and regional standards. RESULTS: The cop approach helped to develop a multihospital collaboration that facilitated care quality improvements on a regional scale, with clinical outcomes of the improvements able to be measured. The 9 participating hospitals delivered cancer surgery in the specific disease sites according to practitioner-developed and provincially- or regionally-generated care standards and clinical pathways. Compliance with provincial evidence-based clinical guidelines improved (20% increase in 2010-2011 compared with 2006-2007). Other significant improvements included standardization and implementation of regional perioperative pathways in breast, colorectal, and prostate cancer disease sites; rectal cancer surgery centralization; increased use of sentinel lymph node biopsies in breast cancer surgery; and decreased positive surgical margin rates in prostate cancer. CONCLUSIONS: Improved quality is likely a result of diverse confounding factors. The deliberately cultivated multihospital multidisciplinary cops have contributed to positive structural and functional change in cancer surgery in the region. This regional cop model has the potential to play an important role in the development of successful collaborations in care quality improvement.

Preadmission strategies: reducing the length of preoperative stay.

Pursuing efficiency, the Ottawa Civic Hospital implemented a preadmission program which moved as much of the surgical admission procedure as possible to a single preadmission visit. The authors describe the process of researching, planning and implementing the program. They also report the savings it has represented for the hospital and the reaction from surgical patients.

Sensory feedback and the impaired motor system.

A group design study was carried out using regulated feedback to enhance functional recovery in stroke patients. Patients trained on three computerized tasks aimed at improving guided limb motion in the hemiplegic arm. The therapeutic group was able to make use of the sensory feedback to outperform the control group in each of the three tasks. The therapeutic group also showed an adaptation of the improved performance on the three tasks. Further investigation is required to demonstrate that such sensory feedback training results in a corresponding improvement in activities of daily living skills.