Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

ObjectiveTo prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.MethodsPatients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.ResultsTwenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37–57) and 49 (IQR: 45–56) years were included. Median time between injury and initial visit was 12 (IQR 6–19) days for operative and 21 (IQR 12–48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).ConclusionIn a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Applying Salutogenesis in Midwifery Practice

This chapter presents midwifery as unique amongst the healthcare professions because it mostly focuses on physiological processes and a period of transition in the life of a woman and her family. Thus, midwives work across a childbearing continuum and the health-ease dis-ease continuum. The “midwifery model of care” and its approach to childbearing focuses on wellness rather than illness and works closely with women to help them mobilize their own resources to move towards greater health. But the contrasting pathogenic approach to maternity care is still ubiquitous in contemporary healthcare provision with over-medicalization of childbirth and overuse of interventions, which can also cause more harm than good.While there is resonance between midwifery practice and salutogenesis, research examining the relationship is still in its infancy. Few researchers explicitly draw on salutogenic theory. Of these, few studies and scoping reviews are described in more detail. They suggest that there is an alignment between salutogenesis and midwifery practice.The chapter concludes by stressing that salutogenesis, with its focus on health rather than pathology, offers a promising way forward to underline that much of midwifery work is health promotion and must be operationalized accordingly in midwifery practice.

Delivering outpatient virtual clinics during the COVID-19 pandemic: early evaluation of clinicians’ experiences

BackgroundThe COVID-19 pandemic has put health systems across the world under significant pressure. In March 2020, a national directive was issued by the National Health Service (NHS) England instructing trusts to scale back face-to-face outpatient appointments, and rapidly implement virtual clinics.MethodsA multidisciplinary team of change managers, analysts and clinicians were assembled to evaluate initial implementation of virtual clinics at Guy’s and St Thomas’ NHS Foundation Trust. In-depth interviews were conducted with clinicians who have delivered virtual clinics during the pandemic. An inductive thematic approach was used to analyse clinicians’ early experiences and identify enablers for longer term sustainability.ResultsNinety-five clinicians from specialist services across the trust were interviewed between April and May 2020 to reflect on their experiences of delivering virtual clinics during Wave I COVID-19. Key reflections include the perceived benefits of virtual consultations to patients and clinicians; the limitations of virtual consultations compared with face-to-face consultations; and the key enablers that would optimise and sustain the delivery of virtual pathways longer term.ConclusionsIn response to the pandemic, outpatient services across the trust were rapidly redesigned and virtual clinics implemented. As a result, services have been able to sustain some level of service delivery. However, clinicians have identified challenges in delivering this model of care and highlighted enablers needed to sustaining the delivery of virtual clinics longer term, such as patient access to diagnostic tests and investigations closer to home.

Salutogenic Approaches to Dementia Care

In this chapter, the authors address salutogenic approaches in dementia care support, using a resident-centred model of care. Securing patients’ sense of coherence in care settings requires shifting the locus of decision-making power from only staff, to include residents. In this approach, patients manage more tasks themselves, they get not only what they need but also what they want and they engage meaningfully with others and with life in general. The authors explain that implementing salutogenic models of dementia care is not a simple task. It involves reimagining approaches to interpersonal communication, the thoughtful development of meaningful and enjoyable activities, and creative inclusion and engagement of friends and family. Supportive design of facilities includes spaces that provide choice, opportunities for social interaction, and memory-triggering cues that inform persons living with dementia about where they are, who they are, what there is to do to keep occupied, who other people are – in sum, environments that remind them that they are meaningfully engaged, safe and happy. The authors contend that replacing old-fashioned approaches to care with life-affirming environments is richly rewarding. They explain that success in making this switch requires professionals to pivot away from models that see dementia primarily as a disease to be cured, towards seeing living with dementia in terms of maximum health and well-being. They conclude that salutogenesis is a useful theory to guide this transition.

The personal recovery movement in Singapore – past, present and future

The personal recovery movement is beginning to gain traction within Singapore’s mental healthcare systems. We believe it is timely to give a broad overview of how it developed and provide suggestions on how it can evolve further. From the early custodial care in the 1800s to the community-centric programmes of the 1900s and early 2000s, we now find ourselves at the forefront of yet another paradigm shift towards a more consumer-centric model of care. The following decades will allow personal recovery practitioners and researchers to innovate and identify unique but culturally appropriate care frameworks. We also discuss how the movement can continue to complement existing mental healthcare systems and efforts. Keywords: Asia, legislation, lived experience, mental health services, personal recovery

Public administration strategy of healthcare system for seniors

The goal of the study is to restructure society’s attitude toward the needs of the elderly. The article addresses the methodology of state social policy and possible innovations in funding and economic methods for public administration in the healthcare system for seniors. The novelty of the work is ensured by the concept of managed older age and a start-up proposal to create the State Direct Investment Fund “Senior Generation” functioning as an entity responsible for the development of the organizational foundations for gerontology and geriatrics services. The practical significance of the study lies in the optimization of the modern management model of care for the older generation and a philosophical study of age as a potential in management in both individual and societal regards. This strategy can serve as a basis for public administration of the healthcare system for the elderly accounting for the diversity of seniors as a social stratum.

The economic impact of rostering junior doctors to triage to assist nursing staff in the early part of the patient journey through the emergency department

Objective This study aims to determine whether redeploying junior doctors to assist at triage represents good value for money and a good use of finite staffing resources. Methods We undertook a cost-minimisation analysis to produce new evidence, from an economic perspective, about the costs associated with reallocating junior doctors in the emergency department. We built a decision-analytic model, using a mix of prospectively collected data, routinely collected administrative databases and hospital costings to furnish the model. To measure the impact of uncertainty on the model’s inputs and outputs, probabilistic sensitivity analysis was undertaken, using Monte Carlo simulation. Results The mean costs for usual care were $27,035 (95% CI $27,016 to $27,054), while the mean costs for the new model of care were $25,474, (95% CI $25,453 to $25,494). As a result, the mean difference was -$1,561 (95% CI -$1,533 to -$1,588), with the new model of care being a less costly approach to managing staffing allocations, in comparison to the usual approach. Conclusion Our study shows that redeploying a junior doctor from the fast-track area of the department to assist at triage provides a modest reduction in cost. Our findings give decision-makers who seek to maximise benefit from their finite budget, support to reallocate personnel within the ED.