Full integration of oncology and palliative care relies on the specific knowledge and skills of two modes of care: the tumour-directed approach, the main focus of which is on treating the disease; ...and the host-directed approach, which focuses on the patient with the disease. This Commission addresses how to combine these two paradigms to achieve the best outcome of patient care. Randomised clinical trials on integration of oncology and palliative care point to health gains: improved survival and symptom control, less anxiety and depression, reduced use of futile chemotherapy at the end of life, improved family satisfaction and quality of life, and improved use of health-care resources. Early delivery of patient-directed care by specialist palliative care teams alongside tumour-directed treatment promotes patient-centred care. Systematic assessment and use of patient-reported outcomes and active patient involvement in the decisions about cancer care result in better symptom control, improved physical and mental health, and better use of health-care resources. The absence of international agreements on the content and standards of the organisation, education, and research of palliative care in oncology are major barriers to successful integration. Other barriers include the common misconception that palliative care is end-of-life care only, stigmatisation of death and dying, and insufficient infrastructure and funding. The absence of established priorities might also hinder integration more widely. This Commission proposes the use of standardised care pathways and multidisciplinary teams to promote integration of oncology and palliative care, and calls for changes at the system level to coordinate the activities of professionals, and for the development and implementation of new and improved education programmes, with the overall goal of improving patient care. Integration raises new research questions, all of which contribute to improved clinical care. When and how should palliative care be delivered? What is the optimal model for integrated care? What is the biological and clinical effect of living with advanced cancer for years after diagnosis? Successful integration must challenge the dualistic perspective of either the tumour or the host, and instead focus on a merged approach that places the patient's perspective at the centre. To succeed, integration must be anchored by management and policy makers at all levels of health care, followed by adequate resource allocation, a willingness to prioritise goals and needs, and sustained enthusiasm to help generate support for better integration. This integrated model must be reflected in international and national cancer plans, and be followed by developments of new care models, education and research programmes, all of which should be adapted to the specific cultural contexts within which they are situated. Patient-centred care should be an integrated part of oncology care independent of patient prognosis and treatment intention. To achieve this goal it must be based on changes in professional cultures and priorities in health care.
Nearly half of Americans with diagnosed hypertension have uncontrolled blood pressure (BP) while some integrated healthcare systems, such as Kaiser Permanente Northern California, have achieved ...control rates upwards 90%.
We adapted Kaiser Permanente's evidence-based treatment protocols in a racially and ethnically diverse population at 12 safety-net clinics in the San Francisco Health Network. The intervention consisted of 4 elements: a hypertension registry, a simplified treatment intensification protocol that included fixed-dose combination medications containing diuretics, standardized BP measurement protocol, and BP check visits led by registered nurse and pharmacist staff. The study population comprised patients with hypertension who made ≥1 primary care visits within the past 24 months (n=15 917) and had a recorded BP measurement within the past 12 months. We conducted a postintervention time series analysis from August 2014 to August 2016 to assess the effect of the intervention on BP control for 24 months for the pilot site and for 15 months for 11 other San Francisco Health Network clinics combined. Secondary outcomes were changes in use of guideline-recommended medication prescribing. Rates of BP control increased at the pilot site (68%-74%;
<0.01) and the 11 other San Francisco Health Network clinic sites (69%-74%;
<0.01). Statistically significant improvements in BP control rates (
<0.01) at the 11 San Francisco Health Network clinic sites occurred in all racial and ethnic groups (blacks, 60%-66%; whites, 69%-75%; Latinos, 67%-72%; Asians, 78%-82%). Use of fixed-dose combination medications increased from 10% to 13% (
<0.01), and the percentage of angiotensin-converting enzyme inhibitor prescriptions dispensed in combination with a thiazide diuretic increased from 36% to 40% (
<0.01).
Evidence-based system approaches to improving BP control can be implemented in safety-net settings and could play a pivotal role in achieving improved population BP control and reducing hypertension disparities.
ABSTRACT
BACKGROUND
Implementing new programs and practices is challenging, even when they are mandated. Implementation Facilitation (IF) strategies that focus on partnering with sites show promise ...for addressing these challenges.
OBJECTIVE
Our aim was to evaluate the effectiveness of an external/internal IF strategy within the context of a Department of Veterans Affairs (VA) mandate of Primary Care–Mental Health Integration (PC-MHI).
DESIGN
This was a quasi-experimental, Hybrid Type III study. Generalized estimating equations assessed differences across sites.
PARTICIPANTS
Patients and providers at seven VA primary care clinics receiving the IF intervention and national support and seven matched comparison clinics receiving national support only participated in the study.
INTERVENTION
We used a highly partnered IF strategy incorporating evidence-based implementation interventions.
MAIN MEASURES
We evaluated the IF strategy using VA administrative data and RE-AIM framework measures for two 6-month periods.
KEY RESULTS
Evaluation of RE-AIM measures from the first 6-month period indicated that PC patients at IF clinics had nine times the odds (OR=8.93,
p
<0.001) of also being seen in PC-MHI (Reach) compared to patients at non-IF clinics. PC providers at IF clinics had seven times the odds (OR=7.12, p=0.029) of referring patients to PC-MHI (Adoption) than providers at non-IF clinics, and a greater proportion of providers’ patients at IF clinics were referred to PC-MHI (Adoption) compared to non-IF clinics (β=0.027,
p
<0.001). Compared to PC patients at non-IF sites, patients at IF clinics did not have lower odds (OR=1.34,
p
=0.232) of being referred for first-time mental health specialty clinic visits (Effectiveness), or higher odds (OR=1.90,
p
=0.350) of receiving same-day access (Implementation). Assessment of program sustainability (
Maintenance
) was conducted by repeating this analysis for a second 6-month time period. Maintenance analyses results were similar to the earlier period.
CONCLUSION
The addition of a highly partnered IF strategy to national level support resulted in greater Reach and Adoption of the mandated PC-MHI initiative, thereby increasing patient access to VA mental health care.
Summary
This paper discusses the progress and prospects of China's complex health care reform beginning in 2009. The Chinese government's undertaking of systemic reform has achieved laudable ...achievements, including the expansion of social health insurance, the reform of public hospitals, and the strengthening of primary care. An innovative policy tool in China, policy experimentation under hierarchy, played an important role in facilitating these achievements. However, China still faces gaps and challenges in creating a single payer system, restructuring the public hospitals, and establishing an integrated delivery system. Recently, China issued the 13th 5‐year plan for medical reform, setting forth the goals, policy priorities, and strategies for health reform in the following 5 years. Moreover, the Chinese government announced the “Healthy China 2030” blueprint in October 2016, which has the goals of providing universal health security for all citizens by 2030. By examining these policy priorities against the existing gaps and challenges, we conclude that China's health care reform is heading in the right direction. To effectively implement these policies, we recommend that China should take advantage of policy experimentation to mobilize bottom‐up initiatives and encourage innovations.
The outbreak of coronavirus disease 2019 (COVID‐19) has rapidly spread globally since being identified as a public health emergency of major international concern and has now been declared a pandemic ...by the World Health Organization (WHO). In December 2019, an outbreak of atypical pneumonia, known as COVID‐19, was identified in Wuhan, China. The newly identified zoonotic coronavirus, severe acute respiratory syndrome coronavirus‐2 (SARS‐CoV‐2), is characterized by rapid human‐to‐human transmission. Many cancer patients frequently visit the hospital for treatment and disease surveillance. They may be immunocompromised due to the underlying malignancy or anticancer therapy and are at higher risk of developing infections. Several factors increase the risk of infection, and cancer patients commonly have multiple risk factors. Cancer patients appear to have an estimated twofold increased risk of contracting SARS‐CoV‐2 than the general population. With the WHO declaring the novel coronavirus outbreak a pandemic, there is an urgent need to address the impact of such a pandemic on cancer patients. This include changes to resource allocation, clinical care, and the consent process during a pandemic. Currently and due to limited data, there are no international guidelines to address the management of cancer patients in any infectious pandemic. In this review, the potential challenges associated with managing cancer patients during the COVID‐19 infection pandemic will be addressed, with suggestions of some practical approaches.
Implications for Practice
The main management strategies for treating cancer patients during the COVID‐19 epidemic include clear communication and education about hand hygiene, infection control measures, high‐risk exposure, and the signs and symptoms of COVID‐19. Consideration of risk and benefit for active intervention in the cancer population must be individualized. Postponing elective surgery or adjuvant chemotherapy for cancer patients with low risk of progression should be considered on a case‐by‐case basis. Minimizing outpatient visits can help to mitigate exposure and possible further transmission. Telemedicine may be used to support patients to minimize number of visits and risk of exposure. More research is needed to better understand SARS‐CoV‐2 virology and epidemiology.
Cancer patients have an increased risk of contracting COVID‐19. This article addresses the challenges associated with managing cancer patients during the COVID‐19 infection pandemic and suggests some practical approaches.
Background: Serious shortcomings remain in clinical care in the United States despite widespread use of improvement strategies for enhancing clinical performance based on knowledge transfer ...approaches. Recent calls to transform primary care practice to a patient-centered medical home present even greater challenges and require more effective approaches. Methods: Our research team conducted a series of National Institutes of Health funded descriptive and intervention projects to understand organizational change in primary care practice settings, emphasizing a complexity science perspective. The result was a developmental research effort that enabled the identification of critical lessons relevant to enabling practice change. Results: A summary of findings from a 15-year program of research highlights the limitations of viewing primary care practices in the mechanistic terms that underlie current or traditional approaches to quality improvement. A theoretical perspective that views primary care practices as dynamic complex adaptive systems with "agents" who have the capacity to learn, and the freedom to act in unpredictable ways provides a better framework for grounding quality improvement strategies. This framework strongly emphasizes that quality improvement interventions should not only use a complexity systems perspective, but also there is a need for continual reflection, careful tailoring of interventions, and ongoing attention to the quality of interactions among agents in the practice. Conclusions: It is unlikely that current strategies for quality improvement will be successful in transforming current primary care practice to a patient-centered medical home without a stronger guiding theoretical foundation. Our work suggests that a theoretical framework guided by complexity science can help in the development of quality improvement strategies that will more effectively facilitate practice change.
Monitoring improvements in nationwide anesthesia capacity over time is critical to ensuring that population anesthesia needs are being met and identifying areas for targeted health systems ...interventions. Anesthesia resources in Bangladesh were previously measured using a cross-sectional nationwide hospital-based survey in 2012. No follow-up studies have been conducted since then.
A follow-up cross-sectional study was performed in 16 public hospitals; 8 of which are public district hospitals, and 8 are medical college (tertiary) hospitals in Bangladesh. A survey tool assessing hospital anesthesia capacity, developed by Vanderbilt University Medical Center, was utilized. Nationwide data were obtained from the Ministry of Health and Family Welfare and from the Bangladesh Society of Anaesthesiologists. Institutional Review Board approvals were obtained in the United States and Bangladesh, and informed consent was waived.
Bangladesh has 952 anesthesiologists (0.58 anesthesiologists per 100,000 people), which represents a modest increase from 850 anesthesiologists in 2012. Significant improvements in electricity and clean water availability have occurred since the 2012 survey. Severe deficiencies in patient safety and monitoring equipment (eg, pulse oximetry, electrocardiography, blood pressure, anesthesia machines, and intubation materials) were noted, primarily at the district hospital level.
Despite modest improvements in certain anesthesia metrics over the past several years, the public health care system in Bangladesh still suffers from substantial deficiencies in anesthesia care.
Organizational health literacy is described as an organization-wide effort to transform organization and delivery of care and services to make it easier for people to navigate, understand, and use ...information and services to take care of their health. Several health literacy guides have been developed to assist healthcare organizations with this effort, but their content has not been systematically reviewed to understand the scope and practical implications of this transformation. The objective of this study was to review (1) theories and frameworks that inform the concept of organizational health literacy, (2) the attributes of organizational health literacy as described in the guides, (3) the evidence for the effectiveness of the guides, and (4) the barriers and facilitators to implementing organizational health literacy. Drawing on a metanarrative review method, 48 publications were reviewed, of which 15 dealt with the theories and operational frameworks, 20 presented health literacy guides, and 13 addressed guided implementation of organizational health literacy. Seven theories and 9 operational frameworks have been identified. Six health literacy dimensions and 9 quality-improvement characteristics were reviewed for each health literacy guide. Evidence about the effectiveness of health literacy guides is limited at this time, but experiences with the guides were positive. Thirteen key barriers (conceived also as facilitators) were identified. Further development of organizational health literacy requires a strong and a clear connection between its vision and operationalization as an implementation strategy to patient-centered care. For many organizations, becoming health literate will require multiple, simultaneous, and radical changes. Organizational health literacy has to make sense from clinical and financial perspectives in order for organizations to embark on such transformative journey.
Primary care in Ontario, Canada, has undergone a series of reforms designed to improve access to care, patient and provider satisfaction, care quality, and health system efficiency and ...sustainability. We highlight key features of the reforms, which included patient enrollment with a primary care provider; funding for interprofessional primary care organizations; and physician reimbursement based on varying blends of fee-for-service, capitation, and pay-for-performance. With nearly 75 percent of Ontario's population now enrolled in these new models, total payments to primary care physicians increased by 32 percent between 2006 and 2010, and the proportion of Ontario primary care physicians who reported overall satisfaction with the practice of medicine rose from 76 percent in 2009 to 84 percent in 2012. However, primary care in Ontario also faces challenges. There is no meaningful performance measurement system that tracks the impact of these innovations, for example. A better system of risk adjustment is also needed in capitated plans so that groups have the incentive to take on high-need patients. Ongoing investment in these models is required despite fiscal constraints. We recommend a clearly articulated policy road map to continue the transformation.
Blockchain is a shared distributed digital ledger technology that can better facilitate data management, provenance and security, and has the potential to transform healthcare. Importantly, ...blockchain represents a data architecture, whose application goes far beyond Bitcoin - the cryptocurrency that relies on blockchain and has popularized the technology. In the health sector, blockchain is being aggressively explored by various stakeholders to optimize business processes, lower costs, improve patient outcomes, enhance compliance, and enable better use of healthcare-related data. However, critical in assessing whether blockchain can fulfill the hype of a technology characterized as 'revolutionary' and 'disruptive', is the need to ensure that blockchain design elements consider actual healthcare needs from the diverse perspectives of consumers, patients, providers, and regulators. In addition, answering the real needs of healthcare stakeholders, blockchain approaches must also be responsive to the unique challenges faced in healthcare compared to other sectors of the economy. In this sense, ensuring that a health blockchain is 'fit-for-purpose' is pivotal. This concept forms the basis for this article, where we share views from a multidisciplinary group of practitioners at the forefront of blockchain conceptualization, development, and deployment.
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