Impact of the COVID-19 Pandemic on Clinical Pathways for Non-SARS-CoV-2 Related Diseases in the Lazio Region, Italy

Clinical pathways (CPs) are multidisciplinary clinical governance tools necessary for the care management of the patients, whose aim is to outline the best practicable path within a health organization related to an illness or to a complex clinical situation. The COVID-19 pandemic emergency has created the need for an organizational renewal of care pathways based on the principles of “primary health care” recommended by the WHO. In Italy, the Hospitals and Local Health Authorities (ASL) have tried to guarantee the continuity of non-deferrable treatments and the maximum safety of both patients and health professionals. This study analyzes the organizational and managerial responses adopted in pathology-specific care pathways to assess how CPs as diagnostic tools responded to the COVID-19 pandemic in the first two waves. Twenty-four referents of Operational Units (UU OO) from Hospitals (AO) and Local Health Authorities (ASL) of the Lazio Region (Central Italy) that apply four different CPs responded to a survey, which analyzes the managerial and organizational responses of CPs in regard to different contexts. Results show that the structural and organizational adjustments of the CPs have made it possible to maintain an adequate level of care for specific treatment processes, with some common critical aspects that require improvement actions. The adjustments found could be useful for dealing with new outbreaks and/or new epidemics in order to try to mitigate the potential negative impact, especially on the most vulnerable patient categories.

Trust in pathways? Professionals’ sensemaking of care pathways in the Norwegian mental health services system

Background In January 2019, care pathways within specialist mental health and substance abuse treatment services were officially launched in Norway. The care pathway introduced timeframes for assessment and treatment, allowing a maximum of 6 weeks to finish assessment and provide the patient with a diagnosis, in addition to allowing a maximum of 6 weeks from diagnosis to the first evaluation. The different action points required coding. The system was based on goals to improve services by focusing on user participation, coordinated patient flow, avoidance of unnecessary waiting time, improvement of equal access to services regardless of geographic location, and increased emphasis on physical health and lifestyle. The purpose of our study was to examine how mental health professionals made sense of care pathways and furthermore, how issues of trust affected the process of implementation. Methods Our multiple case study included four outpatient clinics for adults in four community mental health centres (CMHCs) in different parts of Norway. Qualitative data were collected through in-depth individual and focus group interviews and analysed using systematic text condensation. The informants were treatment personnel and leaders in four different outpatient clinics for adults. Results The results indicated four distinct themes or reactions to the care pathway and its implementation: 1) lack of clarity regarding the overall goals and content of the care pathway; 2) the increased burden of coding, registration and administrative work, which professionals experienced as a stressor; 3) an IT and medical record system that did not correspond to the coding of the care pathway; and 4) an unrealistic distinction between assessment and treatment. These themes/reactions increased the health professionals’ distrust towards the care pathway, and a process of sensemaking encouraged them to reduce the importance of the care pathway system and its implementation. Conclusion Theories of trust help in understanding how mental health professionals interpret care pathway implementation. Distrust and resistance towards the care pathways overshadow some of the overall quality goals of the care pathway, a view that was indeed shared by mental health professionals.

DEEP Study: Modeling Outcomes and Costs of Persistent Orofacial Pain

Persistent orofacial pain (POFP) affects patients’ daily lives and can lead to significant costs for them and/or the health service provider. This partial economic evaluation examined costs and utilities experienced by individuals with POFP over a 24-mo period and used these data to populate the life course Markov model used to estimate costs and quality-adjusted life years (QALYs) from pain onset over an individual’s life course while receiving usual health care. A total of 202 people receiving care for POFP were followed for 24 mo. Data were collected every 6 mo on pain-related disability (Graded Chronic Pain Scale dichotomized to low [0–IIa] or high [IIb–IV] pain-related disability states), health service utilization, and health-related quality of life measured by QALYs derived from the EQ-5D-5L. Unbalanced regressions were used to demonstrate how costs and QALYs varied according to participant characteristics with the results used to parameterize a Markov model. This probabilistic Markov model was used to estimate the outcomes for a cohort of POFP patients from age 25 y until death as determined by age- and sex-specific mortality rates. Across all time points, complete data were available from 129 participants. A high pain-related disability state led to significantly increased health care cost (£221; 95% confidence interval [CI], 87–355; P < 0.01) and a significant decrease in quality of life (mean difference, –0.08; 95% CI, –0.11 to −0.05; P < 0.0001) over a 24-mo period. The Markov model estimated that the average cost was £27,317 (95% CI, 26,558–28,046) and the average lifetime QALYs were 17.54 (95% CI, 17.38–17.71). The modeling suggests that a cohort of POFP patients from age 25 y would only accrue 18 QALYs per person before death. POFP therefore exerts a considerable impact on health, and it is likely more effective care (pathways) could realize substantial gains in terms of both treatment outcomes and health care utilization. Knowledge of Transfer Statement: Despite a substantial number of consultations, individuals experiencing the care pathways in this study continued to have far from perfect health over their life course. The modeling suggests they would only experience 18 y in “perfect health.” There is considerable scope to improve current care/outcomes and patient experience.

Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey

Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.

Delivering HIV pre-exposure prophylaxis (PrEP) care online: A scoping review.

Objectives: HIV pre-exposure prophylaxis (PrEP), in which people take HIV medication to prevent HIV acquisition, is a highly effective method of HIV prevention; however, global implementation of PrEP is patchy. PrEP provision will need to be upscaled significantly to achieve UNAIDS/WHO goals of elimination of HIV transmission. Online provision of PrEP care could enhance access to, and delivery of, care at scale. We explored the extent to which PrEP care has been delivered online to inform the development of a novel online PrEP clinic. Design: Scoping review. Data sources: Embase, MEDLINE, Web of Science, CINAHL, PsycINFO, ASSIA, PUBMED, Open Grey, and EThOS databases. Eligibility criteria: English language articles describing a service that delivered one or more element of PrEP-related care online, published from 2009 onwards. Data extraction and synthesis: Data were extracted using matrices and synthesised using summary statistics and thematic analysis. The Mixed Methods Appraisal Tool was used to assess study quality. Results: Fifty-nine articles were included: eight randomised controlled trials, 12 non-randomised quantitative studies, 30 descriptive quantitative studies, 14 qualitative studies, and four reviews of online content. Seven studies detailed comprehensive PrEP care pathways that used a combination of online, face-to-face and telephone based care. Of the remaining studies, the majority focused on HIV testing outside a PrEP context. Care tended to be delivered via websites (n=41), video chat, and smartphone apps (both n=10). The acceptability and feasibility of delivering elements of care online was high. Conclusions: Online PrEP care appears feasible and acceptable, offering convenience and a means to overcome some of the reported barriers to face-to-face care. Services tended to focus on a single element of PrEP-related care or use a combination of online, face-to-face and phone-based care. Additional formative work is needed to inform the development of complete online PrEP care pathways.

Organization of an obstetrics unit during the COVID-19 pandemic: a short literature review

The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges for the delivery of high-quality obstetric services to both SARS-CoV-2 positive and negative women. The initial epidemiological pressure, especially in the most affected areas of China and Italy, led the local health services to defining care pathways based on the organizational and logistical availability of the moment. Currently, some aspects of clinical care practices and the management of women with suspected or confirmed SARS-CoV-2 virus infection are well established. The aim of this review article is to provide an outline of the suggested organization of obstetric units during the COVID-19 pandemic, and to mention the challenges we had to face at our institution.