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Background: The number of older people in prison is growing. As a result, there will also be more prisoners suffering from dementia. The support and management of this population is likely to present multiple challenges to the prison system. Objectives: To examine the published literature on the care and supervision of people living in prison with dementia and on transitioning into the community; to identify good practice and recommendations that might inform the development of prison dementia care pathways. Methods: A scoping review methodology was adopted with reporting guided by the PRISMA extension for scoping reviews checklist and explanation. Results: Sixty-seven papers were included. Most of these were from high income countries, with the majority from the United Kingdom (n = 34), followed by the United States (n = 15), and Australia (n = 12). One further paper was from India. Discussion: The literature indicated that there were difficulties across the prison system for people with dementia along the pathway from reception to release and resettlement. These touched upon all aspects of prison life and its environment, including health and social care. A lack of resources and national and regional policies were identified as important barriers, although a number of solutions were also identified in the literature, including the development of locally tailored policies and increased collaboration with the voluntary sector. Conclusion: To our knowledge, this is the most comprehensive and inclusive review of the literature on dementia care pathways in prison to date. It has identified a number of important areas of concern and opportunities for future research across the prison system, and its operations. This will hopefully lead to the identification or adaptation of interventions to be implemented and evaluated, and facilitate the development of dementia care pathways in prisons. [ABSTRACT FROM AUTHOR]

Background: Care pathways are generally paper-based and can cause communication failures between multidisciplinary teams, potentially compromising the safety of the patient. Computerized care pathways may facilitate better communication between clinical teams. This study aimed to investigate whether an electronic care pathway (e-pathway) reduces delays in surgery and hospital length of stay compared to a traditional paper-based care pathway (control) in hip fracture patients.Methods: A single-centre evaluation with a retrospective control group was conducted in the Orthogeriatric Ward, Nepean Hospital, New South Wales, Australia. We enrolled patients aged > 65 years that were hospitalized for a hip fracture in 2008 (control group) and 2012 (e-pathway group). The e-pathway provided the essential steps in the care of patients with hip fracture, including examinations and treatment to be carried out. Main outcome measures were delay in surgery and hospital length of stay; secondary outcomes were in-hospital mortality and discharge location.Results: A total of 181 patients were enrolled in the study (129 control; 54 e-pathway group). There was a significant reduction in delay to surgery in the e-pathway group compared to control group in unadjusted (OR = 0.19; CI 0.09-0.39; p < 0.001) and adjusted (OR = 0.22; CI 0.10-0.49; p < 0.001) models. There were no significant differences between groups for length of stay (median 11 vs 12 days; p = 0.567), in-hospital mortality (1 vs 7 participants; p = 0.206) or discharge location (p = 0.206).Conclusions: This pilot study suggests that, compared to a paper-based care pathway, implementation of an e-pathway for hip fracture patients results in a reduction in total number of delays to surgery, but not hospital length of stay. Further evaluation is warranted using a larger cohort investigating both clinical and patient-reported outcome measures. [ABSTRACT FROM AUTHOR]

In this paper, a conceptual framework for investigating the PPP model as it relates to hospitals is proposed. When the PPP model is applied to healthcare (hospitals), it is possible to discover the path to success by developing a critical assessment and deriving a clear model. It is concluded that most PPP model implementations in hospitals around the world have produced favorable outcomes, both in terms of the performance of healthcare units and in terms of cost-effectiveness. Additionally, a path-to-success model that applies to hospitals is offered, taking into account six PPP model dimensions: (i) Environment; (ii) Potentiate Benefits; (iii) Constant Measure; (iv) Evaluation; (v) Management; and (vi) Enhance Strengths. The PPP model only applies case by case and under specific requirements that should be met cumulatively to provide additional value to healthcare's quality of service. The right conditions are created, the right benefits are amplified, public concerns are frequently assessed, private contributions are carefully considered, and all pressing challenges are managed by enhancing both public and private strengths. Leading decision- and action-making processes in corporate, governmental, and social sectors is the goal of managing PPP models. [ABSTRACT FROM AUTHOR]

Abstract Background The number of older people in prison is growing. As a result, there will also be more prisoners suffering from dementia. The support and management of this population is likely to present multiple challenges to the prison system. Objectives To examine the published literature on the care and supervision of people living in prison with dementia and on transitioning into the community; to identify good practice and recommendations that might inform the development of prison dementia care pathways. Methods A scoping review methodology was adopted with reporting guided by the PRISMA extension for scoping reviews checklist and explanation. Results Sixty-seven papers were included. Most of these were from high income countries, with the majority from the United Kingdom (n = 34), followed by the United States (n = 15), and Australia (n = 12). One further paper was from India. Discussion The literature indicated that there were difficulties across the prison system for people with dementia along the pathway from reception to release and resettlement. These touched upon all aspects of prison life and its environment, including health and social care. A lack of resources and national and regional policies were identified as important barriers, although a number of solutions were also identified in the literature, including the development of locally tailored policies and increased collaboration with the voluntary sector. Conclusion To our knowledge, this is the most comprehensive and inclusive review of the literature on dementia care pathways in prison to date. It has identified a number of important areas of concern and opportunities for future research across the prison system, and its operations. This will hopefully lead to the identification or adaptation of interventions to be implemented and evaluated, and facilitate the development of dementia care pathways in prisons.

This paper examines the effects of New Public Management reforms on the information infrastructure underpinning the work of public service professionals. Focussing on the case of the British National Health Service (NHS), the paper argues that hospital accounting reforms played a significant role in the emergence of standardised models of clinical practice. The paper moreover argues that, under the label 'care pathways', such standardised models of clinical practice became embedded in the information infrastructure of the NHS and concludes by discussing their implications for the work of doctors and hospital accountants. [ABSTRACT FROM AUTHOR]

Background: The Sarcoma Policy Checklist was created by a multidisciplinary expert group to provide policymakers with priority areas to improve care for sarcoma patients.Main Body: This paper draws on this research, by looking more closely at how France, Germany, Italy, Spain, Sweden and the United Kingdom are addressing each of these priority areas. It aims to highlight key gaps in research, policy and practice, as well as ongoing initiatives that may impact the future care of sarcoma patients in different European countries. A pragmatic review of the published and web-based literature was undertaken. Telephone interviews were conducted in each country with clinical and patient experts to substantiate findings. Research findings were discussed within the expert group and developed into five core policy recommendations. The five identified priority areas were: the development of designated and accredited centres of reference; more professional training; multidisciplinary care; greater incentives for research and innovation; and more rapid access to effective treatments. Most of the countries studied have ongoing initiatives addressing many of these priorities; however, many are in early stages of development, or require additional funding and resources.Conclusion: Gaps in access to quality care are particularly concerning in many of Europe's lower-resourced countries. Equitable access to information, clinical trials, innovative treatments and quality specialist care should be available to all sarcoma patients. Achieving this across Europe will require close collaboration between all stakeholders at both the national and European level. [ABSTRACT FROM AUTHOR]

Objective To estimate the budget impact from the perspective of the Irish health-care system attributable to a reconfiguration in the diagnostic care pathway for patients with suspected RA by adopting an early identification and referral model (EIM). Methods The budget impact model evaluated the total health-care use and costs attributable to an EIM to diagnose patients with suspected RA relative to the reference scenario of current practice. The modelling also assessed a primary outcome of effect, which examined how many patients can be diagnosed by a rheumatologist within 3 months of symptom onset. The budget impact analysis model was estimated over a 5-year time frame. Results The EIM generated a cost saving for the Irish health-care system of €237 547 over the time frame relative to current practice. The cost savings were realized owing to a reduction in the number of general practitioner (GP) visits of 18 790 and a reduction in diagnostic tests carried out by GPs. The results showed that 1027 (510%) more patients were diagnosed within 3 months of symptom onset in the EIM compared with current practice. Conclusion This paper has presented an alternative rheumatologist-led service design that can be used in diagnosing patients with suspected RA. The rheumatologist-led service provision detailed in this study has the potential simultaneously to reduce demand for primary care services and to improve the health outcomes of patients. The use of an EIM sees rheumatologist activity incorporate patient demand. [ABSTRACT FROM AUTHOR]

Background: Patients with mental health problems experience numerous transitions into and out of hospital. Aim: The review studies assessing clinical care pathways between psychiatric hospitalization and community health services. Methods: We used publications between 2009–2020 to allow a broad scoping review of the published research. Sixteen review-articles were identified, 12 primary studies were chosen, both on care pathways in the transition between psychiatric hospital and community. Results: Organizational issues: Systems and procedures to ensure clear responsibilities and transparency at each stage of the pathways of care. Resources: Information-technology in objectively improving patient outcome. Information/documentation: Providing patients with adequate structured information and documented plans at the appropriate time. Patient/families: Continuous collaborative decision-making. Clinical care and teamwork: Collaboration between mental health and other professionals to guarantee that planned activities meet patient need. Ethical issues: Respectful communication and patient-centred, non-humiliating care. Conclusions: System and procedures ensure clear responsibilities and transparency. Information technology support decision-making and referral and objectively improve patient outcomes in care pathways. Collaboration between mental health and other professionals guarantee that planned activities meet patients' needs along with regular meetings sharing key information. Around-the-clock ambulant-teams important to transition success. Informed-shared decision-making between parties, support patient participation and respectful communication. [ABSTRACT FROM AUTHOR]

Background: Malaria is a major public health issue in Guinea and care-seeking behaviour is dominated by self-medication and delayed access to appropriate care. However early and appropriate care-seeking are essential to control and reduce complicate forms and mortality, particularly for the most vulnerable. This study was conducted to analyse the diagnostic pathway, and the factors associated with early and appropriate care-seeking for malaria patients in the Republic of Guinea. Methods: A cross-sectional study was carried out between December 2022 to March 2023 in nine health districts within health facilities and at community level. The study population was confirmed malaria patients with RDT or microscopy. Kroeger's conceptual framework was used to design the questionnaire. Conventional recourse was defined as using a healthcare facility or community services, early and appropriate care-seeking was defined as within 24 h of symptom onset in a conventional recourse, and care pathway as the sequence of recourses followed by each patient. Sankey alluvial plots were used to represent patients' diagnostic pathways, and logistic regression to identify factors associated with early and appropriate care-seeking. Results: A total of 3300 malaria patients were studied, of which 1632 (49.45%) were female and 1132 (34.30%) were under 5 years of age, with a median age of 23 months. At the time of the survey, 1337 (40.52%), 1423 (43.12%), and 437 (13.85%) of patients were respectively in their first, second and third recourse. A total of 2002 (60.67%) patients had sought care from a conventional recourse as a first line. Of all patients, 1757 (53.25%) had sought care within 24 h, while 28.55% had sought early and appropriate care. In the initial stages of treatment, self-medication was the most common approach, used by 1214 (37.30%). Patients from the health districts of Boffa (Lower Guinea, coastal region) OR = 0.48 95% CI 0.33–0.70, Dabola (Upper Guinea, savanna region) OR = 0.43 95% CI 0.30–0.63 and Labe (Middle Guinea, mountain region) OR = 0.63 CI 95% 0.43–0.91 (p < 0.05) were more likely to delay appropriate care-seeking, when compared to those in Dixinn, (Conakry). However, the under 5-year-old group OR = 1.55 95% CI 1.30–1.85 (p < 0.001) and the availability of a stable monthly household income OR = 4.98 95% CI 3.03, 8.27 (p < 0.001) were positively associated with early and appropriate care seeking. Conclusion: A low rate of early and appropriate care-seeking was observed. Patients sought care through multiple means, often resulting in a delay in adequate management. The results show the need to deploy strategies adapted to the needs of communities. [ABSTRACT FROM AUTHOR]

Introduction people with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explored current service provision to help inform the development of a new intervention. Methods qualitative approaches were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. These data were analysed using a thematic, iterative analysis. Findings while a wide range of services potentially relevant to people with dementia was identified, there were no dedicated services for people with dementia with fall-related injuries in our three geographical areas. Factors influencing service uptake included a lack of knowledge of local provision amongst professionals and underdeveloped information sharing systems. Some aspects of current service organisation were incompatible with the needs of people with dementia. These include an emphasis on time-limited interventions; lack of longer-term follow-up; and service delivery in environments that could be challenging for people with dementia. Conclusions care pathways for people with dementia who fall are fragmented and unclear. This is likely to preclude people with dementia from receiving all appropriate support and contribute to poor recovery following a fall. The findings highlight the need for new approaches to service organisation and delivery which address the specific needs of people with dementia who fall. [ABSTRACT FROM AUTHOR]

Background ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe. Oesophageal and gastric: essential requirements for quality care • Oesophageal and gastric (OG) cancers are a challenging tumour group with a poor prognosis and wide variation in outcomes among European countries. Increasing numbers of older people are contracting the diseases, and treatments and care pathways are becoming more complex in both curative and palliative settings. • High-quality care can only be a carried out in specialised OG cancer units or centres which have both a core multidisciplinary team and an extended team of allied professionals, and which are subject to quality and audit procedures. Such units or centres are far from universal in all European countries. • It is essential that, to meet European aspirations for comprehensive cancer control, healthcare organisations implement the essential requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship. Conclusion Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality OG cancer service. The ERQCC expert group is aware that it is not possible to propose a ‘one size fits all’ system for all countries, but urges that access to multidisciplinary units or centres must be guaranteed for all those with OG cancer. [ABSTRACT FROM AUTHOR]

Background ECCO essential requirements for quality cancer care (ERQCC) are explanations and descriptions of challenges, organisation and actions that are necessary to give high-quality care to patients who have a specific type of cancer. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe. Melanoma: essential requirements for quality care • Melanoma, the most-deadly skin cancer, is rising in incidence among fair-skinned people in Europe. Increasing complexity of care for advanced disease in clinical areas such as staging and new therapies requires attention to a number of challenges and inequalities in a diverse patient group. • Care for advanced melanoma must only be carried out in, or in collaboration with, specialist melanoma centres which have both a core multidisciplinary team and an extended team of allied professionals, and which are subject to quality and audit procedures. Access to such units is far from universal in all European countries. • It is essential that, to meet European aspirations for high-quality comprehensive cancer control, healthcare organisations implement the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis to treatment and follow-up, to improve survival and quality of life for patients. Conclusion Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality service for melanoma. The ERQCC expert group is aware that it is not possible to propose a ‘one size fits all’ system for all countries, but urges that access to multidisciplinary teams and specialised treatments is guaranteed to all patients with melanoma. [ABSTRACT FROM AUTHOR]

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence‐based approach to care pathways suited to real‐life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over‐the‐counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self‐management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self‐medicate, are often non‐adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary. [ABSTRACT FROM AUTHOR]

Personal data is highly affected by the witnessed digital transformation of healthcare processes. This process relies deeply on the connectivity and decentralization of healthcare systems and data repositories. In this context, value creation and quality enhancement are obviously leveraged, however both health providers and individuals could be exposed to many risks ranging from privacy violations to medical identity theft and personal harm. Hence, it is essential that healthcare stakeholders ensure privacy protection and systemic compliance to personal data regulations such as HIPPA (Health Insurance Portability and Accountability Act) and GDPR (General Data Protection Regulation). Taking clinical processes as a starting point is very important to highlight the personal data in use and to assess whether such usage is justifiable and subsequently allow privacy management decisions to be made. In this paper we combine BPMN (Business Process Model and Notation) and DMN (Decision Model and Notation) to model clinical care pathways as standard business processing constituting the hospital information system. Business process modelling presents a useful mean to model clinical care pathways. It allows a complete discovery of data processing scenarios. DMN (Decision Model and Notation) is implemented in BPMN models to present the rules that lead to a decision in easy-to-read tables which are executed directly by a decision engine. In addition, the integration of verifiable security labels of the manipulated data, we make sure compliance to legislation is ensured at the level of decision rules for each decision table of the DMN. [ABSTRACT FROM AUTHOR]

Abstract Background Care pathways are generally paper-based and can cause communication failures between multidisciplinary teams, potentially compromising the safety of the patient. Computerized care pathways may facilitate better communication between clinical teams. This study aimed to investigate whether an electronic care pathway (e-pathway) reduces delays in surgery and hospital length of stay compared to a traditional paper-based care pathway (control) in hip fracture patients. Methods A single-centre evaluation with a retrospective control group was conducted in the Orthogeriatric Ward, Nepean Hospital, New South Wales, Australia. We enrolled patients aged > 65 years that were hospitalized for a hip fracture in 2008 (control group) and 2012 (e-pathway group). The e-pathway provided the essential steps in the care of patients with hip fracture, including examinations and treatment to be carried out. Main outcome measures were delay in surgery and hospital length of stay; secondary outcomes were in-hospital mortality and discharge location. Results A total of 181 patients were enrolled in the study (129 control; 54 e-pathway group). There was a significant reduction in delay to surgery in the e-pathway group compared to control group in unadjusted (OR = 0.19; CI 0.09–0.39; p

Abstract Background Care pathways (CPs) are helpful in reducing unwanted variation in clinical care. Most studies of CPs show they improve clinical outcomes but there is little known about the long-term impact of CPs as part of a sustained quality management program. Head and neck (HN) surgery with free flap reconstruction is complex, time-consuming and expensive. Complications are common and therefore CPs applied to this patient population are the focus of this paper. In this paper we report outcomes from a 9 year experience designing and using CPs in the management of patients undergoing major head and neck resection with free flap reconstruction. Methods The Calgary quality management program and CP design is described the accompanying article. Data from CP managed patients undergoing major HN surgery were prospectively collected and compared to a baseline cohort of patients managed with standard care. Data were retrospectively analyzed and intergroup comparisons were made. Results Mobilization, decannulation time and hospital length of stay were significantly improved in pathway-managed patients (p = 0.001). Trend analysis showed sustained improvement in key performance indicators including complications. Return to the OR, primarily to assess a compromised flap, is increasing. Conclusions Care pathways when deployed as part of an ongoing quality management program are associated with improved clinical outcomes in this complex group of patients.

Background ECCO essential requirements for quality cancer care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to patients who have a specific tumour type. They are written by European experts representing all disciplines involved in cancer care. ERQCC papers give oncology teams, patients, policymakers and managers an overview of the elements needed in any healthcare system to provide high quality of care throughout the patient journey. References are made to clinical guidelines and other resources where appropriate, and the focus is on care in Europe. Sarcoma: essential requirements for quality care • Sarcomas – which can be classified into soft tissue and bone sarcomas – are rare, but all rare cancers make up more than 20% of cancers in Europe, and there are substantial inequalities in access to high-quality care. Sarcomas, of which there are many subtypes, comprise a particularly complex and demanding challenge for healthcare systems and providers. This paper presents essential requirements for quality cancer care of soft tissue sarcomas in adults and bone sarcomas. • High-quality care must only be carried out in specialised sarcoma centres (including paediatric cancer centres) which have both a core multidisciplinary team and an extended team of allied professionals, and which are subject to quality and audit procedures. Access to such units is far from universal in all European countries. • It is essential that, to meet European aspirations for high-quality comprehensive cancer control, healthcare organisations implement the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis and follow-up, to treatment, to improve survival and quality of life for patients. Conclusion Taken together, the information presented in this paper provides a comprehensive description of the essential requirements for establishing a high-quality service for soft tissue sarcomas in adults and bone sarcomas. The ECCO expert group is aware that it is not possible to propose a ‘one size fits all’ system for all countries, but urges that access to multidisciplinary teams is guaranteed to all patients with sarcoma. [ABSTRACT FROM AUTHOR]

This commentary piece reviews the paper by Cowden et al. on Characteristics on Non-fatal overdoses. [ABSTRACT FROM AUTHOR]

Background: Approximately 37 million individuals in the United States (US) have chronic kidney disease (CKD). Patients with CKD have a substantial morbidity and mortality, which contributes to a huge economic burden to the healthcare system. A limited number of clinical pathways or defined workflows exist for CKD care delivery in the US, primarily due to a lower prioritization of CKD care within health systems compared with other areas (e.g., cardiovascular disease [CVD], cancer screening). CKD is a public health crisis and by the year 2040, CKD will become the fifth leading cause of years of life lost. It is therefore critical to address these challenges to improve outcomes in patients with CKD. Methods: The CKD Leaders Network conducted a virtual, 3 h, multidisciplinary roundtable discussion with eight subject-matter experts to better understand key factors impacting CKD care delivery and barriers across the US. A premeeting survey identified topics for discussion covering the screening, diagnosis, risk stratification, and management of CKD across the care continuum. Findings from this roundtable are summarized and presented herein. Results: Universal challenges exist across health systems, including a lack of awareness amongst providers and patients, constrained care team bandwidth, inadequate financial incentives for early CKD identification, non-standardized diagnostic classification and triage processes, and non-centralized patient information. Proposed solutions include highlighting immediate and long-term financial implications linked with failure to identify and address at-risk individuals, identifying and managing early-stage CKD, enhancing efforts to support guideline-based education for providers and patients, and capitalizing on next-generation solutions. Conclusions: Payers and other industry stakeholders have opportunities to contribute to optimal CKD care delivery. Beyond addressing the inadequacies that currently exist, actionable tactics can be implemented into clinical practice to improve clinical outcomes in patients at risk for or diagnosed with CKD in the US. [ABSTRACT FROM AUTHOR]

Background: Rapid diagnostic testing may support improved treatment of COVID patients. Understanding COVID testing and care pathways is important for assessing the impact and cost-effectiveness of testing in the real world, yet there is limited information on these pathways in low-and-middle income countries (LMICs). We therefore undertook an expert consultation to better understand testing policies and practices, clinical screening, the profile of patients seeking testing or care, linkage to care after testing, treatment, lessons learnt and expected changes in 2023. Methods: We organized a qualitative consultation with ten experts from seven LMICs (India, Indonesia, Malawi, Nigeria, Peru, South Africa, and Zimbabwe) identified through purposive sampling. We conducted structured interviews during six regional consultations, and undertook a thematic analysis of responses. Results: Participants reported that, after initial efforts to scale-up testing, the policy priority given to COVID testing has declined. Comorbidities putting patients at heightened risk (e.g., diabetes) mainly relied on self-identification. The decision to test following clinical screening was highly context-/location-specific, often dictated by local epidemiology and test availability. When rapid diagnostic tests were available, public sector healthcare providers tended to rely on them for diagnosis (alongside PCR for Asian/Latin American participants), while private sector providers predominantly used polymerase chain reaction (PCR) tests. Positive test results were generally taken at 'face value' by clinicians, although negative tests with a high index of suspicion may be confirmed with PCR. However, even with a positive result, patients were not always linked to care in a timely manner because of reluctance to receiving care or delays in returning to care centres upon clinical deterioration. Countries often lacked multiple components of the range of therapeutics advised in WHO guidelines: notably so for oral antivirals designed for high-risk mild patients. Severely ill patients mostly received corticosteroids and, in higher-resourced settings, tocilizumab. Conclusions: Testing does not always prompt enhanced care, due to reluctance on the part of patients and limited therapeutic availability within clinical settings. Any analysis of the impact or cost-effectiveness of testing policies post pandemic needs to either consider investment in optimal treatment pathways or constrain estimates of benefits based on actual practice. [ABSTRACT FROM AUTHOR]

Numerous calls at national and international level are leading some countries to seek to redesign the provision of healthcare and services. Care pathways have the potential to improve outcomes by providing a mechanism to coordinate care and reduce fragmentation and ultimately costs. However, their implementation still shows variable results, resulting in them being considered as complex interventions in complex systems. By mobilizing an emerging approach combining action research and grounded theory methodology, we conducted a pilot project on care pathways. We used a strongly inductive process, to mobilize comparison and continuous theoretical sampling to produce theories. Forty-two interviews were conducted, and participant observations were made throughout the project, including 60 participant observations at meetings, workshops and field observations. The investigators kept logbooks and recorded field notes. Thematic analysis was used with an inductive approach. The present model explains the factors that positively or negatively influence the implementation of innovations in care pathways. The model represents interactions between facilitating factors, favourable conditions for the emergence of innovation adoption, implementation process enablers and challenges or barriers including those related specifically to the local context. What seems to be totally new is the embodiment of the mobilizing shared objective of active patient-partner participation in decision-making, data collection and analysis and solution building. This allows, in our opinion, to transcend professional perspectives for the benefit of patient-oriented results. Finally, the pilot project has created expectations in terms of spread and scaling. Future research on care pathway implementation should go further in the evaluation of the multifactorial impacts and develop a methodological framework of care pathway implementation, as the only existing proposition seems limited. Furthermore, from a social science perspective, it would be interesting to analyse the modes of social valuation of the different actors to understand what allows the transformation of collective action. [ABSTRACT FROM AUTHOR]

Background Pain affecting the face or mouth and lasting longer than three months ("chronic orofacial pain", COFP) is relatively common in the UK. This study aims to describe and model current care pathways for COFP patients, identify areas where current pathways could be modified, and model whether these changes would improve outcomes for patients and use resources more efficiently. Methods/design The study takes a prospective operations research approach. A cohort of primary and secondary care COFP patients (n = 240) will be recruited at differing stages of their care in order to follow and analyse their journey through care. The cohort will be followed for two years with data collected at baseline 6, 12, 18, and 24 months on: 1) experiences of the care pathway and its impacts; 2) quality of life; 3) pain; 4) use of health services and costs incurred; 5) illness perceptions. Qualitative in-depth interviews will be used to collect data on patient experiences from a purposive sub-sample of the total cohort (n = 30) at baseline, 12 and 24 months. Four separate appraisal groups (public, patient, clincian, service manager/commissioning) will then be given data from the pathway analysis and asked to determine their priority areas for change. The proposals from appraisal groups will inform an economic modelling exercise. Findings from the economic modelling will be presented as incremental costs, Quality Adjusted Life Years (QALYs), and the incremental cost per QALY gained. At the end of the modelling a series of recommendations for service change will be available for implementation or further trial if necessary. Discussion The recent white paper on health and the report from the NHS Forum identified chronic conditions as priority areas and whilst technology can improve outcomes, so can simple, appropriate and well-defined clinical care pathways. Understanding the opportunity cost related to care pathways benefits the wider NHS. This research develops a method to help design efficient systems built around one condition (COFP), but the principles should be applicable to a wide range of other chronic and long-term conditions. [ABSTRACT FROM AUTHOR]

There is limited knowledge on how excess demand for elderly care influences patient outcomes. We used a natural experiment to estimate the causal effect of discharging elderly patients from hospital to municipalities with excess demand. In Norway, hospital in-patients are defined as ready-for-discharge when hospital treatment is completed, but the patient needs further care from municipal services. After this, the municipality of residence is obliged to either provide care for the patient or to pay the hospital a fixed fee per day that the patient spends in hospital. Municipal fee-days may thus indicate excess municipal demand. In the current paper, we studied how excess municipal demand, indicated by the number of fee-days accumulated in the municipality 30 days before an acute admission, influenced patient outcomes. To minimize confounding, we compared patients living within the same municipality, admitted during the same type of day, in the same year, but with varying excess demand. Our outcomes were mortality, resource use and healthcare costs at the primary and secondary care level, within 30 days. Between 2012 and 2016, 354,834 individuals (age≥70 years) had a total of 895,892 acute admissions. There was a 2% increased 30-day mortality per standard deviation change in accumulate fee-days (Hazard ratio (HR) of 1.02, 95% confidence interval (CI) 1.01-1.03). Individuals living in small municipalities (population10,000) had HR of 1.01 (95% CI 1.00-1.03). We found no substantial effect on subsequent healthcare use or costs. Relevance tests supported that fee-days was a good indication of excess demand, and balance tests supported that patients were comparable between periods with different excess demand. In conclusion, our results imply that older patients who are discharged to a municipality with excess demand have slightly elevated mortality, particularly in small municipalities.

Abstract: In recent years there have been several political initiatives in Norway, requiring more research into how multimorbidity and health care pathways in the municipality affect outcomes such as work participation, hospital admissions, disability and quality of life for patients with chronic diseases. Most of the care is provided outside hospitals and has been difficult to capture in large, registry-based studies. Focusing on two important groups, patients with chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders (MSD), the INOREG project aims to reduce these knowledge gaps. In the paper we present 1) the data that are used in the project, 2) the construction of samples, variables and possible methods for analysis and 3) an example on how the data and methods will be applied. The project database is constructed from a novel linkage of national health and welfare registries. The data cover social, primary and specialized care for all COPD and MSD patients in Norway, long-term care data from Oslo and Trondheim municipalities and functioning and quality of life for ca. 2,700 patients treated at physiotherapy clinics in the FYSIOPRIM project. This enables construction of care pathways and outcomes at the individual level from 2008 through 2019. The project will fill knowledge gaps regarding the patterns of care at different levels in the health care system, and the association to outcomes for chronic patient groups. If the project is successful, it will provide improved insight on how to further develop provision and coordination of services to the decision makers, and ideally reduce inequalities in health.

Background: Care pathways are increasingly being used to enhance the quality of care and optimize the use of resources for health care. Nevertheless, recommendations regarding the sequence of care are mostly based on consensus-based decisions as there is a lack of evidence on effective treatment sequences. In a real-world setting, classical statistical tools were insufficient to consider a phenomenon with such high variability adequately and have to be integrated with novel data mining techniques suitable for identifying patterns in complex data structures. Data-driven techniques can potentially support empirically identifying effective care sequences by extracting them from data collected routinely. The purpose of this study is to perform a state sequence analysis (SSA) to identify different patterns of treatment and to asses whether sequence analysis may be a useful tool for profiling patients according to the treatment pattern. Methods: The clinical application that motivated the study of this method concerns the mental health field. In fact, the care pathways of patients affected by severe mental disorders often do not correspond to the standards required by the guidelines in this field. In particular, we analyzed patients with schizophrenic disorders (i.e., schizophrenia, schizotypal or delusional disorders) using administrative data from 2015 to 2018 from Lombardy Region. This methodology considers the patient's therapeutic path as a conceptual unit, composed of a succession of different states, and we show how SSA can be used to describe longitudinal patient status. Results: We define the states to be the weekly coverage of different treatments (psychiatric visits, psychosocial interventions, and anti-psychotic drugs), and we use the longest common subsequences (dis)similarity measure to compare and cluster the sequences. We obtained three different clusters with very different patterns of treatments. Conclusions: This kind of information, such as common patterns of care that allowed us to risk profile patients, can provide health policymakers an opportunity to plan optimum and individualized patient care by allocating appropriate resources, analyzing trends in the health status of a population, and finding the risk factors that can be leveraged to prevent the decline of mental health status at the population level. [ABSTRACT FROM AUTHOR]

Stroke is the leading global cause of permanent disability and the second leading cause of dementia within the first year of the event. Systematic quality improvement interventions such as Audit & Feedback (A&F) can monitor and improve the performance of post-stroke care in conjunction with the use of quality indicators (QIs). The scientific literature shows limited studies on quality improvement and QIs design for poststroke rehabilitation. In Italy, the National Outcomes Evaluation Programme (PNE) annually provides several QIs concerning the acute wards. On the contrary, indicators for quality assessment of post-acute stroke rehabilitation are not available nationwide. In recent years, the Italian Ministry of Health has funded a national network project, the aim of which is to provide and evaluate the effectiveness of A&F strategies in healthcare improvement. Part of this project is the development of a set of IQs for ischemic stroke rehabilitation used to conduct an A&F. In this study, we describe the design and development process of these QIs from administrative databases and report the results of the pilot test conducted on a small sample of Sicilian rehabilitation facilities, comparing them from 2019 to 2021. Feedback from the participating centers was mainly positive, and the quality indicators were found to be comprehensible and appreciated. However, the study highlighted the need for better adherence to indicators measuring processes of rehabilitation care. The set of quality indicators presented in this study, relevant to inpatient settings, could be considered a starting point on which to base quality improvement initiatives both nationally and internationally. [ABSTRACT FROM AUTHOR]

mHealth, such as apps running on consumer smart devices is becoming increasingly popular and has the potential to profoundly affect healthcare and health outcomes. However, it may be disruptive and results achieved are not always reaching the goals. Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best evidence-based approach to care pathways suited to real-life using mobile technology in allergic rhinitis (AR) and asthma multimorbidity. Patients largely use over-the-counter medications dispensed in pharmacies. Shared decision making centered around the patient and based on self-management should be the norm. Mobile Airways Sentinel networK (MASK), the Phase 3 ARIA initiative, is based on the freely available MASK app (the Allergy Diary, Android and iOS platforms). MASK is available in 16 languages and deployed in 23 countries. The present paper provides an overview of the methods used in MASK and the key results obtained to date. These include a novel phenotypic characterization of the patients, confirmation of the impact of allergic rhinitis on work productivity and treatment patterns in real life. Most patients appear to self-medicate, are often non-adherent and do not follow guidelines. Moreover, the Allergy Diary is able to distinguish between AR medications. The potential usefulness of MASK will be further explored by POLLAR (Impact of Air Pollution on Asthma and Rhinitis), a new Horizon 2020 project using the Allergy Diary. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 60 million people worldwide. Limited evidence on AF management exists from low- and middle-income countries and none from Sri Lanka. We aimed to investigate the existing AF care pathway and patients' perception on AF management to identify barriers and enablers for optimal AF care in Northern Province, Sri Lanka.Methods: A rapid evaluation was undertaken with use of qualitative methods. Local healthcare providers (HCPs) mapped the intended pathway of care for AF patients which was then explored and annotated through 12 iterative sessions with additional HCPs. Topics of inefficiencies identified from the finalised map were used to guide focus group discussions (FGDs) with AF patients. AF patients who were attending the anticoagulation clinic at the only tertiary hospital in Northern Province were recruited and invited to participate using purposive sampling. The topic guide was developed in collaboration with local clinicians and qualitative experts. FGDs were conducted in the native Tamil language and all sessions were recorded, transcribed verbatim and thematically analysed using a deductive approach.Results: The mapped pathway revealed inefficiencies in referral, diagnosis and ongoing management. These were explored through three FGDs conducted with 25 AF patients aged 25 to 70 years. Two key themes that contributed to and resulted in delays in accessing care and ongoing management were health seeking behaviours and atomistic healthcare structures. Four cross-cutting sub-themes identified were decision making, paternalistic approach to care, cost impacts and lifestyle impacts. These are discussed across 10 unique categories with consideration of the local context.Conclusions: Strengthening primary healthcare services, improving public health literacy regarding AF and building patient autonomy whilst understanding the importance of their daily life and family involvement may be advantageous in tackling the inefficiencies in the current AF care pathway in Sri Lanka. [ABSTRACT FROM AUTHOR]

In this paper, a conceptual framework for investigating the PPP model as it relates to hospitals is proposed. When the PPP model is applied to healthcare (hospitals), it is possible to discover the path to success by developing a critical assessment and deriving a clear model. It is concluded that most PPP model implementations in hospitals around the world have produced favorable outcomes, both in terms of the performance of healthcare units and in terms of cost-effectiveness. Additionally, a path-to-success model that applies to hospitals is offered, taking into account six PPP model dimensions: (i) Environment; (ii) Potentiate Benefits; (iii) Constant Measure; (iv) Evaluation; (v) Management; and (vi) Enhance Strengths. The PPP model only applies case by case and under specific requirements that should be met cumulatively to provide additional value to healthcare’s quality of service. The right conditions are created, the right benefits are amplified, public concerns are frequently assessed, private contributions are carefully considered, and all pressing challenges are managed by enhancing both public and private strengths. Leading decision- and action-making processes in corporate, governmental, and social sectors is the goal of managing PPP models.

Introduction: In April 2008, Japan launched a radical reform in regional health planning that emphasized the development of disease-oriented clinical care pathways. These 'inter-provider critical paths' have sought to ensure effective integration of various providers ranging among primary care practitioners, acute care hospitals, rehabilitation hospitals, long-term care facilities and home care. Description of policy practice: All 47 prefectures in Japan developed their Regional Health Plans pursuant to the guideline requiring that these should include at least four diseases: diabetes, acute myocardial infarction, cerebrovascular accident and cancer. To illustrate the care pathways developed, this paper describes the guideline referring to strokes and provides examples of the new Regional Health Plans as well as examples of disease-oriented inter-provider clinical paths. In particular, the paper examines the development of information sharing through electronic health records (EHR) to enhance effective integration among providers is discussed. Discussion and conclusion: Japan's reform in 2008 is unique in that the concept of "disease-oriented regional inter-provider critical paths" was adopted as a national policy and all 47 prefectures developed their Regional Health Plans simultaneously. How much the new regional health planning policy has improved the quality and outcome of care remains to be seen and will be evaluated in 2013 after the five year planned period of implementation has concluded. Whilst electronic health records appear to be a useful tool in supporting care integration they do not guarantee success in the application of an inter-provider critical path.

ABSTRACT INTRODUCTIONThe HealthPathways programme is an online health information system used mainly in primary health care to promote a consistent and integrated approach to patient care. AIMThe aim of this study is to perform a scoping review of the methodologies used in published impact and outcomes evaluations of HealthPathways programmes. METHODSThe review included qualitative, quantitative or mixed-methods evaluations of the impact or outcome of HealthPathways. MEDLINE, Embase, CINAHL and Web of Science databases were searched. Seven programme aims were identified in the impact and outcome evaluation: (1) increased awareness and use of HealthPathways; (2) general practitioners are supported to adopt best practice, patient-centred care; (3) increased appropriate use of resources and services; (4) improved quality of referrals; (5) enhanced consistent care and management of health conditions; (6) improved patient journeys through the local health system; and (7) reduction in health-care cost and increased value for money. RESULTSTwenty-one studies were included in the final review; 15 were research papers and six were reports. ‘Increased awareness and use of HealthPathways' was the most frequent programme aim evaluated (n=12). Quantitative and qualitative research methodologies, as well as prospective and retrospective data collections, have been adopted to evaluate the impact and outcome of HealthPathways. DISCUSSIONAssessing the impacts and outcomes of HealthPathways may be challenging due to limitations in primary data and the interconnectedness of change across the measured aims. Each aim may therefore require specific methodologies sensitive enough to capture the impact that HealthPathways are making over time.

More than 650 inherited metabolic diseases may present with epilepsy or seizures. These diseases are often multisystem, life-long and induce complex needs of patients and families. Multidisciplinary care involves all stages of disease management: diagnostics, specific or symptomatic, acute and chronic treatments, and integrated care that takes into account not only medical, but also manifold psychosocial, educational, vocational and other needs of patients and their caregivers. Care coordination is indispensable to ensure smooth transitions of care across life and disease stages, including management of emergencies, transition from pediatric to adult services and palliative care. Care pathways are highly diverse and have to find the right balance between highly specialized and locally provided services. While multidisciplinary teams consist of many professionals, a named supervising physician in a highly specialized healthcare setting and a care coordinator are highly important. As the greatest burden of care always falls onto the shoulders of patients and/or families, patient empowerment should be a part of every care pathway and include provision of required information, involvement into common decision-making, patient's and family's education, support for self-management, liaison with peer support groups and emotional/ psychological support. Due to the rarity and complexity of these diseases, sufficient expertise may not be available in a national healthcare system and cross-border services (virtual or physical) in the recently developed European Reference Networks should be ensured through the proper organization of referral systems in each EU and EEA country. Finally, digital technologies are particularly important in the provision of services for patients with rare diseases and can significantly increase the availability of highly specialized services and expertise. [ABSTRACT FROM AUTHOR]