ERS International Congress 2021: highlights from the Interstitial Lung Diseases Assembly

This article provides an overview of scientific highlights in the field of interstitial lung disease (ILD), presented at the virtual European Respiratory Society Congress 2021. A broad range of topics was discussed this year, ranging from translational and genetic aspects to novel innovations with the potential to improve the patient pathway. Early Career Members summarize a selection of interesting findings from different congress sessions, together with the leadership of Assembly 12 – Interstitial Lung Disease.

Increase in the Length of Lung Cancer Patient Pathway Before First-Line Therapy: A 6-Year Nationwide Analysis From Hungary

Objective: This study aimed to examine the characteristics of the lung cancer (LC) patient pathway in Hungary during a 6-years period.Methods: This nationwide, retrospective study included patients newly diagnosed with LC (ICD-10 C34) between January 1, 2011, and December 31, 2016, using data from the National Health Insurance Fund (NHIF) of Hungary. The following patient pathway intervals were examined: system, diagnostic and treatment interval by age, gender, tumor type, study year and first-line LC therapy.Results: During the 6-years study period, 17,386 patients had at least one type of imaging (X-ray or CT/MRI) prior to diagnosis, and 12,063 had records of both X-ray and CT/MRI. The median system interval was 64.5 days, and it was 5 days longer among women, than in men (68.0 vs. 63.0 days). The median system interval was significantly longer in patients with adenocarcinoma compared to those with squamous cell carcinoma or small cell lung cancer (70.4 vs. 64.0 vs. 48.0 days, respectively). Patients who received surgery as first-line treatment had significantly longer median system intervals compared to those receiving chemotherapy (81.4 vs. 62.0 days). The median system interval significantly increased from 62.0 to 66.0 days during the 6-years study period.Conclusion: The LC patient pathway significantly increased in Hungary over the 6-years study period. There were no significant differences in the length of the whole LC patient pathway according to age, however, female sex, surgery as first-line treatment, and adenocarcinoma were associated with longer system intervals.

Clinical and Organizational Impacts of Medical Ordering Settings on Patient Pathway and Community Pharmacy Dispensing Process: The Prospective ORDHOSPIVILLE Study

During the dispensing process of medical orders (MOs), community pharmacists (CPs) can manage drug-related problems (DRPs) by performing pharmacist interventions (PIs). There is little evidence that the PI rate is higher with MOs from hospitals (MOHs) than ambulatory (MOAs) settings, and their impact on the patient and community pharmacy is unknown. The primary objective of this study was to compare the MOH and MOA PI rates. The secondary objective was to describe PIs and their clinical and organizational impacts on patient and community pharmacy workflow. A total of 120 CPs participated in a prospective study. Each CP included 10 MOH and 10 MOA between January and June 2020. DRP and PI description and clinical and organizational impacts between MOH and MOA were assessed and compared. We analyzed 2325 MOs. PIs were significantly more frequent in MOH than in MOA (9.7% versus 4.7%; p < 0.001). The most reported PI was the difficulty of contacting hospital prescribers (n = 45; 52.2%). MOHs were associated with a longer dispensing process time and a greater impact on patient pathway and community pharmacy workflow than MOAs. Lack of communication between hospital and primary care settings partly explains the results. Implementation of clinical pharmacy activities at patient discharge could alleviate these impacts.

A review of trial and real-world data applying a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids

This realist enquiry applying behavioural theory aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid tapering interventions and services from a 2018 international systematic review and a 2019 England-wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid tapering success. A stakeholder group (n=23) generated draft programme theories based around the 14 domains of the theoretical domains framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified six programme theories that included five behavioural mechanisms: prescribers’ knowledge about how to taper; build prescribers’ beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all six mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive-based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.

Waiting Time and Patient Satisfaction in a Subspecialty Eye Hospital in Cameroon Using a Mobile Data Collection Kit: Pre and Post Quality Improvement Intervention (Preprint)

BACKGROUND Waiting time could considerably increase the cost to both the clinic and the patient, as well as be a major predictor of the satisfaction of eye care users. Efficiently managing waiting time remains a challenge in hospitals. Waiting time management will become even more crucial in the post-pandemic era. A key consideration when improving waiting time is the involvement of eye care users. This study aimed at improving patient waiting time and satisfaction through the use of Plan-Do-Study-Act quality improvement cycles. OBJECTIVE The study’s objectives were to (1) determine the waiting time and patient satisfaction, (2) measure the association between waiting time and patient satisfaction, and (3) determine the effectiveness of the Plan-Do-Study-Act model in improving waiting time and satisfaction. METHODS This was a pre and post-quality improvement study among patients consulting with the Magrabi ICO Cameroon Eye Institute, aged 19-80 years. We made use of Plan-Do-Study-Act (PDSA) cycles to carry out improvement audits of waiting time and satisfaction over 6 weeks. A mobile data collection kit (ODK) was used for real-time tracking of waiting, service, and idling times at each service point. Subjects were also asked whether or not they were satisfied with waiting time at the point of exit. Data from 25 pre-intervention and 24 post-intervention subjects were analyzed in Stata14. An unpaired t-test was used to assess the statistical significance of observed differences in times pre and post-intervention. Logistic regression was used to examine the association between satisfaction and waiting time. RESULTS Forty-nine subjects were recruited with mean(SD) age 49(15.7) years. The pre-intervention mean(SD) waiting, service, and idling times were 449.6(96.6) minutes, 111.9(47.0) minutes, and 337.7(98.1) minutes respectively. There was no significant association between patient wait time and satisfaction (Odds Ratio=1.0; 95% CI: 0.99 to 1.0, P=.26; Chi2=.25). The use of Plan-Do-Study-Act led to a 14.5% (65.4/449.6) improvement in waiting time (t=2.0, df=47, P=.05) and a non-significant increase in patient satisfaction from 32% (8/25) to 33.3% (8/24) (z=0.1, P=.9). CONCLUSIONS The use of PDSA led to a borderline statistically significant reduction of 65.4 minutes in waiting time over 6 weeks and an insignificant improvement in satisfaction, suggesting that quality improvement efforts have to be done over a considerable period to be able to produce significant changes. The study provides a good basis for quality improvement in limited-resource settings making use of block appointment systems, with comprehensive subspecialty eye care services. We recommend shortening the patient pathway and other measures including a phasic appointment system, automated patient time monitor, robust ticketing, patient pathway supervision, standard triaging, task shifting, doctor consultation planning, patient education, and additional registration staff.

Trust in pathways? Professionals’ sensemaking of patient pathways in Norwegian mental health services

Background: In January 2019, the official launch of new guidelines within specialist mental health services and substance abuse treatment in Norway took place, with treatment organized according to structured patient pathways. The pathway system introduced maximum lengths for assessment, treatment, and evaluation and the coding of the different steps. The system was based on overall goals to improve services by focusing on user participation, coordinated patient flow, avoidance of unnecessary waiting time, more equal services independent of geographic location, and greater emphasis on somatic health and lifestyle. The purpose of our study was to examine the implementation of patient pathways within mental health services, and more specifically how trust emerges and influences the final outcome. Methods: Our study included four outpatient clinics for adults in four community health centres in different parts of Norway. The informants consisted of treatment personnel, leaders, and pathway coordinators, and data were collected through qualitative group and individual interviews. Results: The results indicated four distinct themes or reactions towards the patient pathway system. These themes were unclarity regarding the overall goals and content of the patient pathway; increased coding, registration and administrative work, which professionals experienced as stressors; an IT and journal system that did not correspond with the coding of the patient pathway; and an unrealistic distinction between assessment and treatment. All of the above encouraged health professionals to reduce the importance of patient pathways, as well as increase their resistance towards health authorities. Conclusions: To understand how and why health professionals made sense of the patient pathway, theory on trust can be used to show how professionals within health care interpret the implementation of patient pathways as a desire to control more areas and work practices within mental health care, leading to their distrust towards the new system Trial registration: Not neccessary

Diagnosis and Management of Heart Failure in Elderly Patients from Hospital Admission to Discharge: Position Paper

Multidisciplinary management of worsening heart failure (HF) in the elderly improves survival. To ensure patients have access to adequate care, the current HF and French health authority guidelines advise establishing a clearly defined HF patient pathway. This pathway involves coordinating multiple disciplines to manage decompensating HF. Yet, recent registry data indicate that insufficient numbers of patients receive specialised cardiology care, which increases the risk of rehospitalisation and mortality. The patient pathway in France involves three key stages: presentation with decompensated HF, stabilisation within a hospital setting and transitional care back out into the community. In each of these three phases, HF diagnosis, severity and precipitating factors need to be promptly identified and managed. This is particularly pertinent in older, frail patients who may present with atypical symptoms or coexisting comorbidities and for whom geriatric evaluation may be needed or specific geriatric syndrome management implemented. In the transition phase, multi-professional post-discharge management must be coordinated with community health care professionals. When the patient is discharged, HF medication must be optimised, and patients educated about self-care and monitoring symptoms. This review provides practical guidance to clinicians managing worsening HF in the elderly.