Palliative care physicians’ motivations for models of practicing in the community: A qualitative descriptive study

Background: Internationally, both primary care providers and palliative care specialists are required to address palliative care needs of our communities. Clarity on the roles of primary and specialist-level palliative care providers is needed in order to improve access to care. This study examines how community-based palliative care physicians apply their roles as palliative care specialists, what motivates them, and the impact that has on how they practice. Design: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care specialists. We asked participants to describe their care processes and the factors that influence how they work. Setting/participants: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care physicians in Ontario, Canada was undertaken between March and June 2020. At interview end, participants indicated whether their practice approaches aligned with one or more models depicted in a conceptual framework that includes consultation (specialist provides recommendations to the family physician) and takeover (palliative care physician takes over all care responsibility from the family physician) models. Results: Of the 14 participants, 4 worked in a consultation model, 8 in a takeover model, and 2 were transitioning to a consultation model. Different motivators were found for the two practice models. In the takeover model, palliative care physicians were primarily motivated by their relationships with patients. In the consultation model, palliative care physicians were primarily motivated by their relationships with primary care. These differing motivations corresponded to differences in the day-to-day processes and outcomes of care. Conclusions: The physician’s personal or internal motivators were drivers in their practice style of takeover versus consultative palliative care models. Awareness of these motivations can aid our understanding of current models of care and help inform strategies to enhance consultative palliative care models.

Virtual Geriatric Mental Health Care Offered Where Needed Most: An Evaluation of a Telehealth Consultation Model

Many VA facilities serving large rural populations do not have geriatric mental health specialists available to assist with managing the aging Veteran population’s complex medical and behavioral comorbidities. We applied mixed-methods to evaluate an innovative model utilizing a geriatric psychiatrist who provides cross-facility consultation in a 5-state region. During a 3-month period, the consultant completed 135 consults and 20 e-consults to settings ranging from outpatient to long-term care. Leadership stakeholder and provider interviews highlight the importance of the availability of the consultant, collaboration with local care teams, staff education, person-centered approach, and work ethic/passion. The core challenges that the consultant helps manage include complex comorbidities, medication questions, and dementia with behavioral disturbance. Initial provider survey responses (n = 11) show high satisfaction with services (100%) and strong agreement (80%) that providers could follow through with recommendations. Next steps include replication of this model in other VA facilities.

Cost and Potential Savings of Electronic Consultation and Its Relationship with Reduction in Atmospheric Pollution

Background: Telemedicine has been incorporated into daily clinical practice. The purpose of this paper is to evaluate the economic impact of electronic consultation as a means of referring patients between Primary Care (PC) services and the referral Cardiology Service (CS) of a tertiary hospital, in particular, the cost of reduced air pollution. Methods: The direct and indirect costs associated with all the interconsultations between PC and a CS of a tertiary hospital were analyzed under a universal single act model versus a prior e-consultation model that selected patients who would later attend the single-act consultation. The cost of pollution from private motor vehicle travel by road has been analyzed with a Cobb–Douglas cost function. Results: The total cost per patient, including the costs associated with death, represented a saving in the model with e-consultation of 25.6%. The economic value for the reduction of contamination would be EUR 12.86 per patient. Conclusions: The introduction of e-consultation in the outpatient management of patients referred from PC to a CS, helps to reduce direct and indirect costs for the patient and the Health Care System. The cost of pollution associated with the trips explains the total cost to a greater extent, except for the first face-to-face consultation.

The Trend of Four Consultation Models in Four Specialties at Four Tertiary Care Hospitals

Background and Aim: Multiple consultation models exist in medical practice. A comprehensive doctor-patient relationship serves as a foundation to bring about a positive outcome in terms of patient health. However, evidence of doctors’ impact on improving patients’ mental and physical health through a specific model is sparse. This study aimed to identify the most common consultation models adopted in four different specialties at four hospitals in Riyadh, Saudi Arabia. Methods: From four tertiary care hospitals of Riyadh, clinicians (n=263) with clinical experience >3 years from Internal Medicine, Surgery, Family Medicine, and Psychiatry departments participated in this observational study. A 27-items questionnaire describing five consultation models was carried out in hard copy and a soft copy using the Snowball sampling method to receive the responses that were analyzed by using SPSS version 23.0 in the form of descriptive results. Results: Out of 263, most clinicians (n=121, 46.0 %) were found to practice a blended consultation approach while dealing with patients. The 2nd most common adopted consultation model was the Deliberative model (n= 109, 41.4%). Other consultation (Informative and Interpretive) models were the least practiced models (1.5%). Conclusion: The blended consultation is found to be the most practiced consultation model. A clinician should adopt an attitude that is flexible and empathetic towards patients’ needs and expectations. Consideration should be given to assisting physicians in adapting their roles for interpersonal styles to the preferences of various patients. This expanded role will result in improved health outcomes for diverse populations utilizing health care. Key words: Deliberative model, Doctor Behavior, Family Medicine, Interpretive Model, Paternalistic Model, Informative Model, Psychiatry

Impact of staffing model conversion from a mandatory critical care consultation model to a closed unit model in the medical intensive care unit

Background The intensive care unit (ICU) staffing model affects clinical outcomes of critically ill patients. However, the benefits of a closed unit model have not been extensively compared to those of a mandatory critical care consultation model. Methods This retrospective before-after study included patients admitted to the medical ICU. Anthropometric data, admission reason, Acute Physiology and Chronic Health Evaluation II score, Eastern Cooperative Oncology Group grade, survival status, length of stay (LOS) in the ICU, duration of mechanical ventilator care, and occurrence of ventilator-associated pneumonia (VAP) were recorded. The staffing model of the medical ICU was changed from a mandatory critical care consultation model to a closed unit model in September 2017, and indices before and after the conversion were compared. Results A total of 1,526 patients were included in the analysis. The mean age was 64.5 years, and 954 (62.5%) patients were men. The mean LOS in the ICU among survivors was shorter in the closed unit model than in the mandatory critical care consultation model by multiple regression analysis (5.5 vs. 6.7 days; p = 0.005). Central venous catheter insertion (38.5% vs. 51.9%; p < 0.001) and VAP (3.5% vs. 8.6%; p < 0.001) were less frequent in the closed unit model group than in the mandatory critical care consultation model group. After adjusting for confounders, the closed unit model group had decreased ICU mortality (adjusted odds ratio 0.65; p < 0.001) and shortened LOS in the ICU compared to the mandatory critical care consultation model group. Conclusion The closed unit model was superior to the mandatory critical care consultation model in terms of ICU mortality and LOS among ICU survivors.

The multidisciplinary management of gastric cancer: Experience from a tertiary comprehensive hospital in Shanghai, China

Gastric cancer is a heterogeneous disease which requires a multimodal approach of management. The Department of Gastrointestinal Surgery at Changhai Hospital, a tertiary hospital in Shanghai, established the gastric cancer multidisciplinary team (MDT) clinic based on the guidance of MDT culture in the year of 2017. Our MDT discussion followed a weekly consultation model, with the full-board discussion held once a month, and mini-board communication and discussion made once a week. The stages of MDT management are: pre-operative treatment plan and preparation, post-operative treatment plan, and follow-up treatment and evaluation. As of March 2021, a total of 296 patients visited the MDT clinic. Majority of the patients were gastric carcinoma patients (273/296, 92.2%). Here, we shared our gastric cancer MDT experiences and summarized our strengths and proposed directions for improvement.

Delimitation and classification of coastal wetlands: Implications for the environmental management of the Colombian Continental Caribbean

This article describes the cartographic layer construction process of Colombian Caribbean coastal wetlands at a scale of 1:100,000 and the results obtained in terms of their quantification and typing. Two cartographic layers were constructed and subsequently joined, one of the permanent water bodies and another of temporary water bodies and associated coverages. The layers were generated by multitemporal analysis of 45 Landsat 8-OLI satellite images, based on the NDVI index, uncertainty models by superposition of cartographic attributes, and a flood frequency consultation model on ALOS PALSAR 1 images. As a result, 576,279 ha of coastal wetlands were delimited (1.9 % of total wetlands in Colombia), of which 20.4 % are within protected areas. The cartographic legend makes it possible to typify wetlands based on the coverage and temporality of water bodies; discriminates permanent wetlands (42.7 %) with five categories and temporary wetlands (57.3 %) with 15 categories, mostly distributed in seven large complexes. This study is the first description of the colombian Caribbean coastal wetlands based on a cartographic construction, is methodologically replicable, and will support decision-making in the planning of colombian Caribbean coastal areas, especially for risk management and ecosystem-based adaptation to climate change.