scholarly journals National Thoracic Surgery Standards Implementation: Barriers, Enablers, and Opportunities

2021 ◽  
Vol 28 (1) ◽  
pp. 405-416
Author(s):  
Angel Arnaout ◽  
Anubha Prashad ◽  
Nadine Dunk ◽  
Jess Rogers ◽  
Annemarie Edwards ◽  
...  
Keyword(s):  
Focus Group ◽  
Thoracic Surgery ◽  
Patient Outcomes ◽  
Surgical Care ◽  
Treatment Decision ◽  
Audit And Feedback ◽  
Pathology Report ◽  
Implementation Barriers ◽  
Standards Implementation ◽  
Study Results

Background: Diagnosis and surgical treatment decision making for thoracic cancers is complex. Moreover, there is demonstrated variability in how each province in Canada delivers cancer care, resulting in disparities in patient outcomes. Recently, the Canadian Partnership Against Cancer (CPAC) published pan-Canadian evidence-based standards for the care of thoracic surgery cancer patients. This study was undertaken to assess the degree to which these standards were currently met in practice and to further understand the determinants to their implementation nationally. Methods: This study was undertaken in two parts: (1) a national survey of thoracic surgeons to assess the perceived extent of implementation of these standards in their institution and province; and (2) formation of a focus group with a representative sample of thoracic surgeons across Canada in a qualitative study to understand the determinants of successful standards implementation. Results: 37 surgeons (33% response rate) participated in the survey; 78% were from academic hospitals. The top categories of standards that were under-implemented included (a) quality assurance processes, data collection and clinician audit and feedback, and (b) ongoing regional planning and workload assessments for thoracic surgeons, and (c) pathology turnaround time target of two weeks and the use of a standardized synoptic pathology report format. Enablers, barriers, and opportunities for standards implementation contextualized the discussion within the focus group. Conclusion: Study results demonstrated variation in the implementation of surgery standards across Canada and identified the determinants to the delivery of high quality surgical care. Future work will need to include the promotion and development of quality improvement strategies and effective resource allocation that is aligned with the implementation of thoracic cancer surgery standards in order to improve patient outcomes.

scholarly journals Thoracic surgery in the COVID-19 era: an Italian university hospital experience

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Riccardo Taje ◽  
Stefano Elia ◽  
Benedetto Cristino ◽  
Federico Tacconi ◽  
Gianluca Natali ◽  
...  
Keyword(s):  
Thoracic Surgery ◽  
Surgical Care ◽  
Primary Outcome Measure ◽  
University Hospital ◽  
Mortality And Morbidity ◽  
Number Of Patients ◽  
Study Results ◽  
Group A ◽  
Advanced Stages ◽  
Free Rate

Abstract Background Aims of this study were to assess the results of anti-COVID19 measures applied to maintain thoracic surgery activity at an Italian University institution through a 12-month period and to assess the results as compared with an equivalent non-pandemic time span. Methods Data and results of 646 patients operated on at the department of Thoracic Surgery of the Tor Vergata University Policlinic in Rome between February 2019 and March 2021 were retrospectively analyzed. Patients were divided in 2 groups: one operated on during the COVID-19 pandemic (pandemic group) and another during the previous non-pandemic 12 months (non-pandemic group). Primary outcome measure was COVID-19 infection-free rate. Results Three patients developed mild COVID-19 infection early after surgery resulting in an estimated COVID-19 infection-free rate of 98%. At intergroup comparisons (non-pandemic vs. pandemic group), a greater number of patients was operated before the pandemic (352 vs. 294, p = 0.0013). In addition, a significant greater thoracoscopy/thoracotomy procedures rate was found in the pandemic group (97/151 vs. 82/81, p = 0.02) and the total number of chest drainages (104 vs. 131, p = 0.0001) was higher in the same group. At surgery, tumor size was larger (19.5 ± 13 vs. 28.2 ± 21; p < 0.001) and T3-T4/T1-T2 ratio was higher (16/97 vs. 30/56; p < 0.001) during the pandemic with no difference in mortality and morbidity. In addition, the number of patients lost before treatment was higher in the pandemic group (8 vs. 15; p = 0.01). Finally, in 7 patients admitted for COVID-19 pneumonia, incidental lung (N = 5) or mediastinal (N = 2) tumors were discovered at the chest computed tomography. Conclusions Estimated COVID-19 infection free rate was 98% in the COVID-19 pandemic group; there were less surgical procedures, and operated lung tumors had larger size and more advanced stages than in the non-pandemic group. Nonetheless, hospital stay was reduced with comparable mortality and morbidity. Our study results may help implement efficacy of the everyday surgical care.

scholarly journals Implementation of the Canadian National Standards in Breast Cancer Surgical Care: Gaps, Barriers, Enablers and Opportunities

2021 ◽  
Vol 28 (1) ◽  
pp. 565-573
Author(s):  
Angel Arnaout ◽  
Anubha Prashad ◽  
Nadine Dunk ◽  
Jess Rogers ◽  
Christian Finley ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Focus Group ◽  
Care Delivery ◽  
Surgical Care ◽  
Treatment Decision ◽  
National Standards ◽  
Breast Cancer Surgery ◽  
Breast Cancers ◽  
Breast Cancer Patients ◽  
National Implementation

Background: Diagnosis and surgical treatment decision making for breast cancers has become increasingly complex. Recently, Canadian Partnership Against Cancer (CPAC) published pan-Canadian evidence-based surgical standards for the care of breast cancer patients. This study was undertaken to assess the degree to which these standards were currently met in practice and to further understand the determinants of their implementation nationally. Methods: This study was undertaken in two parts—(1) National survey of breast cancer surgeons to assess the perceived extent of implementation of these standards in their institution and province; (2) Formation of a focus group with a representative sample of breast surgeons across Canada to further understand the barriers and facilitators towards future breast standards implementation. Results: 35 surgeons participated in the survey: 66% were from community hospitals. There were four categories of standards that were the most significantly lacking across the country—(a) processes related to quality assurance, (b) turnaround time for pathology results (c) psychosocial and health-related support for the breast cancer patient and (d) breast reconstruction for patients undergoing mastectomy. The focus group included participants from all ten Canadian provinces. For each standard, the 134 determinants fell into three main categories—individual physician (n = 27, 20%); organizational (n = 46, 34%), and system (n = 61, 46%). While specific determinants were present for each category, surgical standards were more likely to be implemented in practice if (1) they aligned with organizational priorities standards; (2) the individual physicians or physician groups were accountable to the organization and/or cancer jurisdiction regarding compliance with the standard; and (3) if infrastructure or resources existed within the organization or system for the reliable collection of relevant, meaningful, practice changing data combined with the capability of benchmarking, peer–peer comparisons and timely feedback to the surgeons. Conclusion: The results of this study demonstrated variation, barriers and opportunities for the national implementation of CPAC’s breast cancer surgery standards and identified determinants of high-quality breast surgical care delivery.

scholarly journals Examining Distance Learners in Hybrid Synchronous Instruction: Successes and Challenges

2017 ◽  
Vol 21 (4) ◽  
Author(s):  
Enilda Romero-Hall ◽  
Cristiane Rocha Vicentini
Keyword(s):  
Data Analysis ◽  
Focus Group ◽  
The Other ◽  
Distance Learners ◽  
Electronic Journals ◽  
Face To Face ◽  
Individual Interviews ◽  
Study Results ◽  
Successes And Challenges

This paper reports on a case study investigating distance learners participating in graduate-level hybrid synchronous instruction. This research helps inform the design of hybrid synchronous instruction in which face-to-face and distance learners engage in class sessions. Data were collected using electronic journals, individual interviews, and a focus group. The results of the data analysis provide evidence that in this case, hybrid synchronous instruction improved the study habits of distance learners. On the other hand, the case study results also revealed that there are challenging pedogogical aspects which the distance learners had to overcome during hybrid synchronous instruction. Among such challenges were the interactions, relationships, and communication exchanges between distance learners, their face-to-face counterparts, and the instructor.

scholarly journals Financing Product Design for Fisheries Through Sharia Micro-Finance Institutions

2019 ◽  
pp. 1144-1149
Author(s):  
Anas Alhifni ◽  
Tuti Kurnia ◽  
Biyati Ahwarumi ◽  
Rully Trihantana
Keyword(s):  
Focus Group ◽  
Product Design ◽  
Focus Group Discussion ◽  
Group Discussion ◽  
Qualitative Approach ◽  
Family Needs ◽  
Limited Access ◽  
Study Results

Fishermen in Indonesia have limited access to financial assistant from banks because they do not meet criteria set by the bank. One institution that could be able to provide access and solve this problem is sharia micro-finance institution (SMFI). This study aims for identifying fishermen needs on SMFI financing products and proposing the most suitable financing design which can be applied through SMFI. The study uses qualitative approach by adopting phenomenology technique and holding a focus group discussion (FGD) to acquire the intended design. The study results showed that in general, fishermen of Palabuhan Ratu need financing product from SMFI like consumptive financing for living or family needs and productive financing that can be used to support the sustainability of their business such as purchasing equipment, boats, fishing tools and so on. The proposed design which formulated by this study incorporates double-approaches financing design; firstly, optimizing SMFI’s role as Baitul mall (house of fund) through two Islamic contracts model i.e. Qard or Qardhul Hasan and Temporary Waqf; secondly, both optimizing SMFI as Baitut Tamwil (house of financing) through three financing products that is Parallel Istishna (PI), Syirkah Mudharaba Mutlaqa (SMM) and Ijarah Muntahia Bit Tamlik (IMBT).

scholarly journals Gene Expression Analyses in Early Breast Carcinoma — Quo Vadis?

2017 ◽  
Vol 14 (04) ◽  
pp. 209-213
Author(s):  
Katrin Almstedt ◽  
Carsten Denkert ◽  
Marcus Schmidt
Keyword(s):  
Gene Expression ◽  
Breast Carcinoma ◽  
Treatment Decision ◽  
Consensus Conference ◽  
Oncotype Dx ◽  
Level Of Evidence ◽  
Hormone Receptor Positive ◽  
Study Results ◽  
Gene Expression Signatures ◽  
Quo Vadis

AbstractIn order to establish whether adjuvant therapy should be administered in patients with breast carcinoma, it is decisive to have as precise as possible an assessment of the risk of recurrence. In this context, gene expression — and thus gene expression signatures as well — have become a focus of attention as prognostic factors. For practical application, it is important to be able to analyze gene expression signatures in formalin-fixed, paraffin-embedded tumor tissue. Careful analytic and clinical validations and a high level of evidence (LoE) are required in order to avoid imprecise risk classification and thus potential overtreatment or undertreatment of the patients. Among the commercially available gene expression signatures, the Working Group on Gynecological Oncology (Arbeitsgemeinschaft Gynäkologische Onkologie, AGO) currently grades MammaPrint® and Oncotype DX® as having LoE IA, with prospective study results; and Endopredict® and Prosigna® as having LoE IB. The panel members at this year’s St. Gallen consensus conference also voted by a majority in favor of the possible usage of Oncotype DX®, MammaPrint®, Prosigna®, EndoPredict®, and Breast Cancer Index®. These multigene tests can be used in selected patients with hormone receptor–positive and HER2-negative findings if none of the other criteria allow a treatment decision to be made.

scholarly journals Pathology outcomes in patients with transurethral bladder tumour resection in a Turkish population: A retrospective analysis

2018 ◽  
Vol 90 (1) ◽  
pp. 8
Author(s):  
Salih Budak ◽  
Cem Yücel ◽  
Mehmet Zeynel Keskin ◽  
Mehmet Yoldas ◽  
Erdem Kısa ◽  
...  
Keyword(s):  
Bladder Cancer ◽  
Histopathological Examination ◽  
Tnm Classification ◽  
Bladder Tumour ◽  
Treatment Strategies ◽  
Turkish Population ◽  
Tumour Resection ◽  
Pathology Report ◽  
Study Results ◽  
Rare Tumours

Objectives: Transurethral bladder tumour resection (TURBT) is the common surgical method used in the diagnosis, staging and treatment of patients with bladder tumour. Most of the rare tumours other than the urothelial carcinomas of the bladder are in advanced stage on diagnosis and necessitate aggressive treatment. In our study, we aimed to the histologic types of bladder cancer and to determine the regional incidence of rare bladder cancer types in our region. Materials and methods: We retrospectively evaluated 815 patients who underwent TURBT surgery between January 2010 and March 2016 in our clinic with a diagnosis of bladder cancer and at least 1 year follow-up. Patients with tumour histopathological examination including histological tumour type, grade and were reported. Thirty-nine patients with an unclear pathology report (neighboring organ invasion, cautery artifact, etc) and 17 patients whose data could not be accessed were excluded from the study. The patients who had received chemotherapy or radiotherapy due to any type of malignancy (23) were also excluded from the study. Results: The outcomes of 736 patients operated in our clinics due to bladder tumour were evaluated. The mean age was 65.2 ± 8.4; 135 were female and 601 were male. Among them 711 patients with urothelial carcinoma were reported (94.2%). According to TNM classification, stage Ta was observed in 270 patients (37.9%), stage T1 in 297 (41.7%), and stage T2 in 144 (20.3%). Non-urothelial cancers were reported in 25 cases (3.3%). Conclusion: The incidence of bladder carcinoma varies between regions. The results of our study are similar to those of the western countries. Increased smoking and exposure to environmental carcinogenetic agents may lead to altered incidences and histological types of bladder tumours. Revision of regional tumour records may be useful to develop and evaluate future treatment strategies.

Pharmacologic Considerations Surrounding Sedation, Delirium, and Sleep in Critically Ill Adults: A Narrative Review

2019 ◽  
Vol 32 (3) ◽  
pp. 271-291 ◽  
Author(s):  
Pamela L. Smithburger ◽  
Mona K. Patel
Keyword(s):  
Patient Outcomes ◽  
Patient Management ◽  
Randomized Trials ◽  
Narrative Review ◽  
Sleep Disruption ◽  
Conflicting Evidence ◽  
Study Results ◽  
Pharmacologic Management ◽  
Critically Ill Adults ◽  
Ill Adults

Introduction Agitation, delirium, and sleep dysfunction in the intensive care unit (ICU) are common occurrences that result in negative patient outcomes. With the recent publication of the 2018 Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PAD-IS), several areas are of particular interest due to emerging literature or conflicting results of research. Objective To highlight areas where emerging literature or variable study results exist and to provide the clinician with recommendations regarding patient management. Methods The 2018 PAD-IS guidelines were reviewed, and areas of emerging literature or lack of consensus of included investigations surrounding pharmacologic management of sedation, delirium, and sleep in the ICU were identified. A review and appraisal of the literature was conducted specifically to address the identified areas. Prospective, randomized trials were included in this narrative review. Results Four areas with emerging data or conflicting evidence were identified and included: use of propofol or dexmedetomidine for sedation, pharmacologic prevention of delirium, treatment of delirium, and pharmacologic strategies to improve sleep. Conclusion A comprehensive approach to the prevention and management of delirium, sedation, and sleep in the ICU is necessary to optimize patient outcomes.

Pragmatic randomized trial of a distress screening program using an effectiveness-implementation hybrid design.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 5-5
Author(s):  
Erin Elizabeth Hahn ◽  
Corrine E. Munoz-Plaza ◽  
Dana Pounds ◽  
Lindsay Joe Lyons ◽  
Janet S. Lee ◽  
...  
Keyword(s):  
Randomized Trial ◽  
Screening Program ◽  
Medical Center ◽  
Qualitative Interviews ◽  
Audit And Feedback ◽  
Implementation Barriers ◽  
Distress Screening ◽  
Screening Programs ◽  
Adaptive Workflow ◽  
New Diagnosis

5 Background: Implementation of guideline-recommended distress screening in oncology remains challenging. Evidence suggests that multicomponent care pathways to identify distress severity with algorithm-based referral and management are effective, yet testing of pragmatic implementation in community settings remains limited. We conducted a pragmatic randomized trial of a distress screening program in a large healthcare system to evaluate effectiveness and simultaneously examined implementation outcomes. Methods: We designed a highly pragmatic study per the Pragmatic-Explanatory Continuum Indicator Summary-2 with adaptive workflow design. Randomization was at the medical center level (N=6); eligible patients had a new diagnosis of breast cancer (no exclusions). Eligible patients were offered the distress screening program as part of usual care: PHQ-9 screening, algorithm-based scoring and referral, referral tracking, and audit and feedback of performance data. Control sites had access to the PHQ-9 and scoring algorithm. We compared number screened, distress severity, and referral. We conducted qualitative interviews with stakeholders on implementation barriers and facilitators. Results: We enrolled 1,436 eligible patients; 692 control, 744 intervention. Groups were similar in demographic and tumor characteristics (Table); 80% of patients completed screening at intervention sites vs <1% at control sites. Of those screened at intervention sites, 10% scored in the medium/high range indicating need for referral; 94% received an appropriate referral. We conducted 20 interviews; the program was found to be highly feasible and acceptable. Conclusions: Our pragmatic, adaptive approach resulted in the large majority of patients screened and appropriately referred with a high degree of acceptability and feasibility. Our results can promote more widespread, sustained adoption of effective distress screening programs. Clinical trial information: NCT02941614. [Table: see text]

Antimicrobial Stewardship Programs in Inpatient Hospital Settings: A Systematic Review

2014 ◽  
Vol 35 (10) ◽  
pp. 1209-1228 ◽  
Author(s):  
Brittin Wagner ◽  
Gregory A. Filice ◽  
Dimitri Drekonja ◽  
Nancy Greer ◽  
Roderick MacDonald ◽  
...  
Keyword(s):  
Systematic Review ◽  
Patient Outcomes ◽  
Antimicrobial Stewardship ◽  
English Language ◽  
Guideline Implementation ◽  
Hospital Setting ◽  
The United States ◽  
Prescribing Patterns ◽  
Audit And Feedback ◽  
Cochrane Library

ObjectiveEvaluate the evidence for effects of inpatient antimicrobial stewardship programs (ASPs) on patient, prescribing, and microbial outcomes.DesignSystematic review.MethodsSearch of MEDLINE (2000 through November 2013), Cochrane Library, and reference lists of relevant studies. We included English language studies with patient populations relevant to the United States (ie, infectious conditions and prescriptions required for antimicrobials) that evaluated ASP interventions and reported outcomes of interest. Study characteristics and outcomes data were extracted and reviewed by investigators and trained research personnel.ResultsFew intervention types (eg, audit and feedback, guideline implementation, and decision support) substantially impacted patient outcomes, including mortality, length of stay, readmission, or incidence of Clostridium difficile infection. However, most interventions were not powered adequately to demonstrate impacts on patient outcomes. Most interventions were associated with improved prescribing patterns as measured by decreased antimicrobial use or increased appropriate use. Where reported, ASPs were generally associated with improvements in microbial outcomes, including institutional resistance patterns or resistance in the study population. Few data were provided on harms, sustainability, or key intervention components. Studies were typically of short duration, low in methodological quality, and varied in study design, populations enrolled, hospital setting, ASP intent, intervention composition and implementation, comparison group, and outcomes assessed.ConclusionsNumerous studies suggest that ASPs can improve prescribing and microbial outcomes. Strength of evidence was low, and most studies were not designed adequately to detect improvements in mortality or other patient outcomes, but obvious adverse effects on patient outcomes were not reported.

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