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.

Decision Games as an Element of Managerial Improvement in Crisis Management

In order to ensure effective counteraction to contemporary security threats, maximum limitation of human losses, property and natural environment losses, a multi-level and multi-element system of crisis management has been organized in Poland, covering all levels of government and local government administration as well as specialist services, guards, separate inspections and non-governmental organisations. The effectiveness of this system, most of whose participants are not full-time employees, depends, among other things, on proper training and preparation of managerial staff. One of the most important contemporary methods of training and improvement of managerial staff is the method of “decision games”, which should be aimed at training the managers of crisis management systems in solving complex problems and shaping intellectual features that affect the efficiency of action and creative thinking of decision-makers, especially during the search for rational solutions to problems, in conditions of difficult to determine risk. This method has many advantages, including the possibility of implementing theoretical knowledge about crisis management into practical solutions, practising in conditions which decision-makers may encounter in reality, the coverage of practically the whole area of decision-making in crisis management, or the implementation of the acquired knowledge and skills into practical actions but on “paper” in conditions free from the risk of human losses or property or natural environment losses due to wrong decisions.

The use of musical interactions to collaborate with teaching staff and specialist services at a special education school.

<p>This research aimed to investigate how a student music therapist used musical interactions to collaborate with teaching staff and specialist services at a special education school in New Zealand. Music therapists in this context are able to collaborate by assisting and supporting other therapy professionals and staff. I was particularly interested in how the ‘music’ served as a collaborative tool within the school and what was meaningful that developed from these musical interactions between school members. Through secondary analysis of my reflective clinical journal notes I was able to explore how I used musical interactions to collaborate. Data was coded, sorted into meaning units, and themes were then drawn out using thematic analysis. The findings suggested that musical interactions promoted staff experiences of music making with others as well as supporting student goals, by corresponding to the classroom learning agenda. Musical interactions gave support in resourcing staff to become facilitators of music in the classroom, as well as supporting the little moments when life at a special education setting can be challenging. Lastly, musical interactions were perceived to build a sense of community within the school. Music-making and facilitation of music in mostly informal settings seemed to support connecting and relationship building between students and staff.</p>

The use of musical interactions to collaborate with teaching staff and specialist services at a special education school.

<p>This research aimed to investigate how a student music therapist used musical interactions to collaborate with teaching staff and specialist services at a special education school in New Zealand. Music therapists in this context are able to collaborate by assisting and supporting other therapy professionals and staff. I was particularly interested in how the ‘music’ served as a collaborative tool within the school and what was meaningful that developed from these musical interactions between school members. Through secondary analysis of my reflective clinical journal notes I was able to explore how I used musical interactions to collaborate. Data was coded, sorted into meaning units, and themes were then drawn out using thematic analysis. The findings suggested that musical interactions promoted staff experiences of music making with others as well as supporting student goals, by corresponding to the classroom learning agenda. Musical interactions gave support in resourcing staff to become facilitators of music in the classroom, as well as supporting the little moments when life at a special education setting can be challenging. Lastly, musical interactions were perceived to build a sense of community within the school. Music-making and facilitation of music in mostly informal settings seemed to support connecting and relationship building between students and staff.</p>

Co-designing new tools for collecting, analysing and presenting patient experience data in NHS services: working in partnership with patients and carers

Background The way we collect and use patient experience data is vital to optimise the quality and safety of health services. Yet, some patients and carers do not give feedback because of the limited ways data is collected, analysed and presented. In this study, we worked together with researchers, staff, patient and carer participants, and patient and public involvement and engagement (PPIE) contributors, to co-design new tools for the collection and use of patient experience data in multiple health settings. This paper outlines how the range of PPIE and research activities enabled the co-design of new tools to collect patient experience data. Methods Eight public contributors represented a range of relevant patient and carer experiences in specialist services with varied levels of PPIE experience, and eleven members of Patient and Participation Groups (PPGs) from two general practices formed our PPIE group at the start of the study. Slide sets were used to trigger co-design discussions with staff, patient and carer research participants, and PPIE contributors. Feedback from PPIE contributors alongside verbatim quotes from staff, patient and carer research participants is presented in relation to the themes from the research data. Results PPIE insights from four themes: capturing experience data; adopting digital or non-digital tools; ensuring privacy and confidentiality; and co-design of a suite of new tools with guidance, informed joint decisions on the shaping of the tools and how these were implemented. Our PPIE contributors took different roles during co-design and testing of the new tools, which supported co-production of the study. Conclusions Our experiences of developing multiple components of PPIE work for this complex study demonstrates the importance of tailoring PPIE to suit different settings, and to maximise individual strengths and capacity. Our study shows the value of bringing diverse experiences together, putting patients and carers at the heart of improving NHS services, and a shared approach to managing involvement in co-design, with the effects shown through the research process, outcomes and the partnership. We reflect on how we worked together to create a supportive environment when unforeseen challenges emerged (such as, sudden bereavement).

Patient satisfaction with tele-advice during the COVID-19 pandemic

Introduction: The coronavirus pandemic has shed a whole new light on telehealth, which has become an alternative for diagnosis, monitoring, treatment and support without physical contact between patient and healthcare professional. The aim of this study was to examine patient satisfaction with medical services provided with tele-advice during the Covid-19 pandemic. Material and methods: The study was conducted using our own questionnaire via Google Form that was correctly completed by 133 individuals between the ages of 18 and 76 years (mean 33.1 ± 13.1 years) who received medical services via tele-advice. Results: Patients with chronic conditions were statistically more likely to seek specialist services via tele-advice (p = 0.003). Slightly less than one-third of respondents (n = 39; 29.3%) were asked during the tele-advice to attend the clinic / office in person to complete the visit with a physical examination. The vast majority of subjects (n = 95; 71.4%) responded that their health status had not changed since the pandemic and the introduction of tele-advice. Nearly half (n = 64; 48.1%) believed that their health problem had been solved via tele-advice. Only 4.5% of the respondents (n = 6) strongly agreed with the statement that “tele-advice enables proper diagnosis and matching of effective treatment”, 18.0% (n = 24) tended to agree. The vast majority of respondents believed that everyone should be able to choose between tele-advice and a traditional medical visit (n = 121; 91.0%). Conclusions: The majority of people surveyed did not perceive a difference in their health since the pandemic and the introduction of tele-advice. Nearly half of respondents believed that their health problem had been resolved with a telemedicine consultation, with even fewer people convinced that “tele-advice allows for proper diagnosis and matching of effective treatment.” Patients would mostly like to have a choice between tele-visit and in-person visits, with no clear indication of the superiority of one or the other. Continuous improvement of current solutions will certainly contribute to increased patient satisfaction with the medical services provided.

The Increased Burden of Sickle Cell Disease in Italy: Findings from the Greatalys (Generating Real world Evidence Across ITALy In SCD) Study

Introduction. Sickle Cell Disease (SCD) is an evolving public health issue with a significant impact on patient survival, quality of life and costs for health systems also in Italy, a multiethnic country where epidemiology has deeply changed. We present final results from the GREATalyS study that aimed to better understand the SCD burden in Italy in terms of prevalence, clinical features, treatments and resource consumption in the clinical practice setting. Methods. Retrospective observational analysis of administrative databases for health resources consumption from a representative sample of Region/Local Health Units in Italy, covering approximately 15.3 million inhabitants. All patients with ≥1hospitalization (outside Emergency Room, ER) with main or secondary discharge diagnosis of SCD (with/without crisis) identified by ICD-9-CM codes were included between January-2010 to December-2017 (up to December 2018 for epidemiologic analysis). Prevalence of SCD in 2018 was projected to the Italian population. Patients were followed-up from the first diagnosis identified within the inclusion period (index date) to death or end of data availability. Treatments and healthcare resource consumption were evaluated on patients with at least 1 year of data availability before and after index date. SCD treatments were classified as SCD-specific, SCD-related, SCD-complication-related. Both day hospitals and ordinary hospitalizations were evaluated. Vaso-occlusive crisis (VOCs) (identified by hospitalization discharge diagnosis for SCD with crisis) and main SCD organ complications were assessed during follow-up. Mean annual healthcare resource costs were analyzed during follow-up according to the NHS perspective in terms of overall treatments, all-cause hospitalizations and out-patients services. Results. SCD prevalence in 2018 was 13 cases per 100,000 inhabitants. Prevalence projected to Italian population estimated in total 7,977 SCD patients in Italy in 2018 (of whom 1,690 and 6,287 were &lt;18 and ≥18 years, respectively, figure 1): 1,279 were estimated with crisis, 5,894 without crisis and 804 unspecified. The study population included in the analysis comprised 1,816 patients (mean age 43.8 years, 58.4% female). Of them, 74.3% were without diagnosis of crisis, 16.1% with crisis, and 9.6% unspecified. Hematology and general medicine were the most frequent admission/discharge hospital departments for a subcohort of patients for which these data were available. During the first year of follow-up (index date included), 50.7% of patients had one all-cause hospitalization, 27.8% had 2, 10.4% had 3 and 11.1% had ≥4, in the second year 44% had at least one hospitalization, while in the third and fourth years 38.2% and 35.8%, respectively (table 1). During the available follow-up period (mean years±SD: 4.9±2.2) the average length of hospitalization stays (table 2) was around 8 days (ordinary hospitalizations) and 130 days (day hospitals). Proportion of patients with a VOC or one SCD complication was 3.7% and 15.2%, with 2 was 2.3% and 6.2% and with ≥3 was 7.7% and 12.8%, respectively. The mean annual number of SCD specific drugs was 0.6±2.7, of SCD related drugs was 3.2±4.5 and of SCD-complications-related drugs was 8.6±10.5. Antibacterials were the more frequently prescribed drugs (53-63%), followed by drugs for acid related disorders (35-48%) and antithrombotic agents (25-34%). Considering all available follow-up, mean annual number of all drugs was 14.9, of hospitalizations was 1.1 and of outpatient specialist services 5.3. Total mean annual cost per patient was €7,917 (€2,201 for prescribed drugs, €3,320 for hospitalizations, and €2,397 for outpatient specialist services, figure 2). Conclusions. This Italian real-world study may have revealed a SCD sub-population probably not noticed yet to SCD centers of reference, and still probably underestimated since ER flows were not present. Similarly, also VOC could be underestimated as only most severe episodes requiring hospitalization were captured. Proportion of patients with antithrombotic agents might be an indicator of the underlying multiorgan complications. The present data describe an SCD population with high resource utilization and heavy economic burden and warrants further efforts to increase an earlier patient identification that could lead to a timely and comprehensive treatment with less SCD-related complications. Figure 1 Figure 1. Disclosures Forni: Bluebirdbio: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees. Castiglioni: Novartis Farma SpA: Current Employment. Condorelli: Novartis Farma SpA: Current Employment. Valsecchi: Novartis Farma SpA: Current Employment. Premoli: Novartis Farma SpA: Current Employment. Fiocchi: Novaris Farma SpA: Current Employment.

Specialist cancer services for teenagers and young adults in England: BRIGHTLIGHT research programme

Background When cancer occurs in teenagers and young adults, the impact is far beyond the physical disease and treatment burden. The effect on psychological, social, educational and other normal development can be profound. In addition, outcomes including improvements in survival and participation in clinical trials are poorer than in younger children and older adults with similar cancers. These unique circumstances have driven the development of care models specifically for teenagers and young adults with cancer, often focused on a dedicated purpose-designed patient environments supported by a multidisciplinary team with expertise in the needs of teenagers and young adults. In England, this is commissioned by NHS England and delivered through 13 principal treatment centres. There is a lack of evaluation that identifies the key components of specialist care for teenagers and young adults, and any improvement in outcomes and costs associated with it. Objective To determine whether or not specialist services for teenagers and young adults with cancer add value. Design A series of multiple-methods studies centred on a prospective longitudinal cohort of teenagers and young adults who were newly diagnosed with cancer. Settings Multiple settings, including an international Delphi study of health-care professionals, qualitative observation in specialist services for teenagers and young adults, and NHS trusts. Participants A total of 158 international teenage and young adult experts, 42 health-care professionals from across England, 1143 teenagers and young adults, and 518 caregivers. Main outcome measures The main outcomes were specific to each project: key areas of competence for the Delphi survey; culture of teenagers and young adults care in the case study; and unmet needs from the caregiver survey. The primary outcome for the cohort participants was quality of life and the cost to the NHS and patients in the health economic evaluation. Data sources Multiple sources were used, including responses from health-care professionals through a Delphi survey and face-to-face interviews, interview data from teenagers and young adults, the BRIGHTLIGHT survey to collect patient-reported data, patient-completed cost records, hospital clinical records, routinely collected NHS data and responses from primary caregivers. Results Competencies associated with specialist care for teenagers and young adults were identified from a Delphi study. The key to developing a culture of teenage and young adult care was time and commitment. An exposure variable, the teenagers and young adults Cancer Specialism Scale, was derived, allowing categorisation of patients to three groups, which were defined by the time spent in a principal treatment centre: SOME (some care in a principal treatment centre for teenagers and young adults, and the rest of their care in either a children’s or an adult cancer unit), ALL (all care in a principal treatment centre for teenagers and young adults) or NONE (no care in a principal treatment centre for teenagers and young adults). The cohort study showed that the NONE group was associated with superior quality of life, survival and health status from 6 months to 3 years after diagnosis. The ALL group was associated with faster rates of quality-of-life improvement from 6 months to 3 years after diagnosis. The SOME group was associated with poorer quality of life and slower improvement in quality of life over time. Economic analysis revealed that NHS costs and travel costs were similar between the NONE and ALL groups. The ALL group had greater out-of-pocket expenses, and the SOME group was associated with greater NHS costs and greater expense for patients. However, if caregivers had access to a principal treatment centre for teenagers and young adults (i.e. in the ALL or SOME groups), then they had fewer unmet support and information needs. Limitations Our definition of exposure to specialist care using Hospital Episode Statistics-determined time spent in hospital was insufficient to capture the detail of episodes or account for the variation in specialist services. Quality of life was measured first at 6 months, but an earlier measure may have shown different baselines. Conclusions We could not determine the added value of specialist cancer care for teenagers and young adults as defined using the teenage and young adult Cancer Specialism Scale and using quality of life as a primary end point. A group of patients (i.e. those defined as the SOME group) appeared to be less advantaged across a range of outcomes. There was variation in the extent to which principal treatment centres for teenagers and young adults were established, and the case study indicated that the culture of teenagers and young adults care required time to develop and embed. It will therefore be important to establish whether or not the evolution in services since 2012–14, when the cohort was recruited, improves quality of life and other patient-reported and clinical outcomes. Future work A determination of whether or not the SOME group has similar or improved quality of life and other patient-reported and clinical outcomes in current teenage and young adult service delivery is essential if principal treatment centres for teenagers and young adults are being commissioned to provide ‘joint care’ models with other providers. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.