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1.  Team Dynamics, Decision Making, and Attitudes Toward Multidisciplinary Cancer Meetings: Health Professionals' Perspectives 
Journal of Oncology Practice  2010;6(6):e17-e20.
As the complexity of cancer treatment increases so too has the need for coordination between health care professionals. Multidisciplinary meetings are a useful tool in treating patients with cancer and are shown to improve survival and adherence to evidence based-guidelines.
Multidisciplinary cancer care is a standard feature of high quality care. In many centers, the multidisciplinary meeting (MDM) is an integral component. A qualitative study was performed to explore health professionals' attitudes towards this model of care, the decision making processes, and dynamics among team members.
A series of focus groups was conducted with health professionals who attend MDMs at our institution. Focus groups followed a semistructured format with open-ended questions. A thematic analysis was performed.
Four focus groups were held, attended by 23 participants including allied health professionals, specialist nurses, medical oncologists, and surgeons. All participants believed the primary objective of the MDM was to develop an individualized treatment plan. Several other key themes emerged. The MDM provided opportunities to improve communication, efficiency, and education as well as enhance professional relationships. Medical information was prioritized ahead of psychosocial details, with allied health professionals describing difficulty contributing to MDM discussion. Patient attendance at MDMs was opposed by health professionals because of concerns about the patient's ability to cope with the information discussed and the effect their presence would have on the dynamics of the decision-making process.
Health professionals endorse MDMs as a useful tool in treating patients with cancer. Within this forum, both opportunities and constrains exist, with many benefits extending beyond the meeting itself into other clinical areas. Further study is warranted to establish an evidence base to ensure that both the possibilities and the limitations of this model of care are fully understood.
PMCID: PMC2988673  PMID: 21358945
2.  Home mechanical ventilation and specialised health care in the community: Between a rock and a hard place 
Home mechanical ventilation probably represents the most advanced and complicated type of medical treatment provisioned outside a hospital setting. The aim of this study was both to explore the challenges experienced by health care professionals in community health care services when caring for patients dependent on home mechanical ventilation, continual care and highly advanced technology, and their proposed solutions to these challenges.
Using qualitative research methods, a grounded theory influenced approach was used to explore the respondents' experiences and proposed solutions. A total of 34 multidisciplinary respondents from five different communities in Norway were recruited for five focus groups.
The core category in our findings was what health care professionals in community health care services experience as "between a rock and a hard place," when working with hospitals, family members, and patients. We further identified four subcategories, "to be a guest in the patient's home," "to be accepted or not," "who decides," and "how much can we take." The main background for these challenges seems to stem from patients living and receiving care in their private homes, which often leads to conflicts with family members. These challenges can have a negative effect on both the community health caregivers' work environment and the community health service's provision of professional care.
This study has identified that care of individuals with complex needs and dependent on home mechanical ventilation presents a wide range of immense challenges for community health care services. The results of this study point towards a need to define the roles of family caregivers and health care professionals and also to find solutions to improve their collaboration. The need to improve the work environment for caregivers directly involved in home-care also exists. The study also shows the need for more dialogue concerning eligibility requirements, rights, and limitations of patients in the provision and use of ventilatory support in private homes.
PMCID: PMC3121583  PMID: 21605365
3.  Multidisciplinary integration in the context of integrated care - results from the North West London Integrated Care Pilot 
In the context of integrated care, Multidisciplinary Group meetings involve participants from diverse professional groups and organisations and are potential vehicles to advance efficiency improvements within the local health economy. We advance a novel method to characterise the communication within Multidisciplinary Group meetings measuring the extent to which participants integrate and whether this integration leads to improved working.
We purposively selected four Multidisciplinary Group meetings and conducted a content analysis of audio-recorded and transcribed Case Discussions. Two coders independently coded utterances according to their ‘integrative intensity’ which was defined against three a-priori independent domains - the Level (i.e. Individual, Collective and Systems); the Valence (Problem, Information and Solution); the Focus (Concrete and Abstract). Inter- and intra-rater reliability was tested with Kappa scores on one randomly selected Case Discussion. Standardised weighted mean integration scores were calculated for Case Discussions across utterance deciles, indicating how integrative intensity changed during the conversations.
Twenty-three Case Discussions in four different Multidisciplinary Groups were transcribed and coded. Inter- and intra-rater reliability was good as shown by the Prevalence and Bias-Adjusted Kappa Scores for one randomly selected Case Discussion. There were differences in the proportion of utterances per participant type (Consultant 14.6%; presenting general practitioner 38.75%; Chair 7.8%; non-presenting general practitioner 2.25%; Allied Health Professional 4.8%). Utterances were predominantly coded at low levels of integrative intensity; however, there was a gradual increase (R 2 = 0.71) in integrative intensity during the Case Discussions. Based on the analysis of the minutes and action points arising from the Case Discussions, this improved integration did not translate into actions moving forward.
We characterise the Multidisciplinary Groups as having consultative characteristics with some trend towards collaboration, but that best resemble Community-Based Ward Rounds. Although integration scores do increase from the beginning to the end of the Case Discussions, this does not tend to translate into actions for the groups to take forward. The role of the Chair and the improved participation of non-presenting general practitioners and Allied Health Professionals seems important, particularly as the latter contribute well to higher integrative scores. Traditional communication patterns of medical dominance seem to be being perpetuated in the Multidisciplinary Groups. This suggests that more could be done to sensitise participants to the value of full participation from all the members of the group. The method we have developed could be used for ongoing and future evaluations of integrated care projects.
PMCID: PMC3817952  PMID: 24198737
health care delivery; communication; health services; multidisciplinary groups
4.  The health care standard vascular risk management. Toward patient oriented care based on the chronic care model 
Highlighting the content, process and structural aspects of production of a health care standard vascular risk management (HCS-V) based on the chronic care model in The Netherlands.
In 2008, the Dutch government published a white paper about care for chronically ill patients focussing on the development of health care standards, coherence between prevention and cure, support of self-management and tuning the components of multidisciplinary care. A health care standard (HCS) describes the content of care for a specific health problem and the way that care is delivered. It combines content with philosophy, process and structure. In 2006 patients' organizations initiated a Platform aiming to formulate a HCS-V taking the patient as focus of care, organization and payment system. This Platform consists of 28 interest groups: patients' representatives, health care professionals, health care insurers, policymakers and scientific organizations. The Platform formulated the following principles for the HCS-V:
– to consider as target group all people known with an elevated risk for vascular diseases and patients already suffering from cardiovascular diseases;
– to take as starting point existing guidelines on vascular risk management, opinions of patients and the daily practice;
– to use as framework the chronic care model of WHO focusing on its four internal elements: support of self-management, design of the caring process, decision support and clinical information systems;
– to appoint one health care professional as the key-person for management and delivery of care;
– to promote that every patient, supported by this key-person, formulates his own care plan;
– to promote an active follow-up;
– to describe the care in functional terms avoiding the choice between locality of care or between health care professionals.
The HCS-V consists of four parts: 1) for professionals 2) for patients 3) quality-indicators 4) existing professional guidelines for vascular risk management. The CCM proved to be applicable as framework. In 2008 all Platform members have authorized the HCS-V. The Dutch government welcomed the concept and granted an experiment with eight pilot projects which will be supported by an external organization and evaluated scientifically. The Dutch Health Authority has decided that from 2010 the HCS-V will be used as the basis for financing vascular risk management. The philosophy behind HCS-V has inspired the development of a HCS for other chronic problems.
Application of the HCS-V requires a fundamental change of organization of care and education of professionals. Publication of this HCS-V is just one step in a process to achieve that the patient is really the focus of care.
PMCID: PMC2807109
chronic care model; health care standard; vascular risk
5.  Are members of multidisciplinary teams in breast cancer aware of each other's informational roles? 
Quality in Health Care : QHC  2001;10(2):70-75.
Aim—To conduct a commissioned survey of multidisciplinary breast team members' expectations of their own and each other's roles in providing different kinds of information to women with breast cancer.
Design—Questionnaire based survey.
Setting and participants—Health professionals from five multidisciplinary breast care centres within a Sussex health authority.
Main outcome measures—Interdisciplinary awareness of informational roles played by different team members.
Results and conclusions—The results of the team survey suggest that, in most cases, health professionals fulfilled the roles expected of them by the team, with two or three individuals identified as the main providers of information for each topic. However, many more professionals were involved in major discussions without the team's knowledge. The professional consistently playing a major "unseen" role was the breast nurse specialist.
Key Words: multidisciplinary teamwork; breast cancer; communication
PMCID: PMC1757990  PMID: 11389314
6.  Mental Health in Inuit Youth from Nunavik: Clinical Considerations on a Transcultural, Interdisciplinary, Community-oriented Approach 
This paper discusses the organization of mental health care for youth in Nunavik and considers how best to adapt care to the sociocultural and geographical specificities of this region.
Services are described and discussed by a general practitioner and a community worker in Nunavik.
Current social and medical care delivery in Nunavik is provided by professionals who are largely non-Inuit and who are supported by Inuit community workers and interpreters. Community workers are key players in the provision of social and mental health care for youth. Efforts are made to adapt care to the sociocultural specificities of Inuit youth, and to locally-based multidisciplinary care addressing the multiple determinants of mental health.
While efforts to adapt care are ongoing, the ideal model of care integrating transcultural, multidisciplinary and community-oriented approaches are yet to become a reality. Increased communication among care providers is suggested as a way to strengthen the current collaborative model of care. Future goals include having a majority of care being provided locally and building community ownership and governance of care institutions.
PMCID: PMC3338178  PMID: 22548109
Inuit youth; Nunavik; mental health care; enfants et adolescents inuit; Nunavik; soins de santé mentale
7.  Barriers and facilitators to implement shared decision making in multidisciplinary sciatica care: a qualitative study 
The Dutch multidisciplinary sciatica guideline recommends that the team of professionals involved in sciatica care and the patient together decide on surgical or prolonged conservative treatment (shared decision making [SDM]). Despite this recommendation, SDM is not yet integrated in sciatica care. Existing literature concerning barriers and facilitators to SDM implementation mainly focuses on one discipline only, whereas multidisciplinary care may involve other barriers and facilitators, or make these more complex for both professionals and patients. Therefore, this qualitative study aims to identify barriers and facilitators perceived by patients and professionals for SDM implementation in multidisciplinary sciatica care.
We conducted 40 semi-structured interviews with professionals involved in sciatica care (general practitioners, physical therapists, neurologists, neurosurgeons, and orthopedic surgeons) and three focus groups among patients (six to eight per group). The interviews and focus groups were audiotaped and transcribed in full. Reported barriers and facilitators were classified according to the framework of Grol and Wensing. The software package Atlas.ti 7.0 was used for analysis.
Professionals reported 53 barriers and 5 facilitators, and patients 35 barriers and 18 facilitators for SDM in sciatica care. Professionals perceived most barriers at the level of the organizational context, and facilitators at the level of the individual professional. Patients reported most barriers and facilitators at the level of the individual professional. Several barriers and facilitators correspond with barriers and facilitators found in the literature (e.g., lack of time, motivation) but also new barriers and facilitators were identified. Many of these new barriers mentioned by both professionals and patients were related to the multidisciplinary setting, such as lack of visibility, lack of trust in expertise of other disciplines, and lack of communication between disciplines.
This study identified barriers and facilitators for SDM in the multidisciplinary sciatica setting, by both professionals and patients. It is clear that more barriers than facilitators are perceived for implementation of SDM in sciatica care. Newly identified barriers and facilitators are related to the multidisciplinary care setting. Therefore, an effective implementation strategy of SDM in a multidisciplinary setting such as in sciatica care should focus on these barriers and facilitators.
PMCID: PMC3765956  PMID: 23968140
Sciatica; Lumbar radicular syndrome; Implementation strategy; Shared decision making; Barriers and facilitators; Multidisciplinary; Patients; Professionals; Providers
8.  Management of chest pain: exploring the views and experiences of chiropractors and medical practitioners in a focus group interview 
We report on a multidisciplinary focus group project related to the appropriate care of chiropractic patients who present with chest pain. The prevalence and clinical management, both diagnosis and treatment, of musculoskeletal chest pain in ambulatory medical settings, was explored as the second dimension of the focus group project reported here.
This project collected observational data from a multidisciplinary focus group composed of both chiropractic and medical professionals. The goals of the focus group were to explore the attitudes and experiences of medical and chiropractic clinicians regarding their patients with chest pain who receive care from both medical and chiropractic providers, to identify important clinical or research questions that may inform the development of 'best practices' for coordinating or managing care of chest pain patients between medical and chiropractic providers, to identify important clinical or research questions regarding the diagnosis and treatment of chest pain of musculoskeletal origin, to explore various methods that might be used to answer those questions, and to discuss the feasibility of conducting or coordinating a multidisciplinary research effort along this line of inquiry. The convenience-sample of five focus group participants included two chiropractors, two medical cardiologists, and one dual-degreed chiropractor/medical physician. The focus group was audiotaped and transcripts were prepared of the focus group interaction. Content analysis of the focus group transcripts were performed to identify key themes and concepts, using categories of narratives.
Six key themes emerged from the analysis of the focus group interaction, including issues surrounding (1) Diagnosis; (2) Treatment and prognosis; (3) Chest pain as a chronic, multifactorial, or comorbid condition; (4) Inter-professional coordination of care; (5) Best practices and standardization of care; and (6) Training and education.
This study carries implications for chiropractic clinical training relative to enhancing diagnostic competencies in chest pain, as well as the need to ascertain and improve those skills, competencies, and standards for referrals and sharing of clinical information that may improve cross-disciplinary coordination of care for chest pain patients.
PMCID: PMC1236944  PMID: 16138920
Chest Pain; Chiropractic; Medical Education; Coordination of Care
9.  Economic evidence on integrated care for stroke patients; a systematic review 
Given the high incidence of stroke worldwide and the large costs associated with the use of health care resources, it is important to define cost-effective and evidence-based services for stroke rehabilitation. The objective of this review was to assess the evidence on the relative cost or cost-effectiveness of all integrated care arrangements for stroke patients compared to usual care. Integrated care was defined as a multidisciplinary tool to improve the quality and efficiency of evidence-based care and is used as a communication tool between professionals to manage and standardize the outcome-orientated care.
A systematic literature review of cost analyses and economic evaluations was performed. Study characteristics, study quality and results were summarized.
Fifteen studies met the inclusion criteria; six on early-supported discharge services, four on home-based rehabilitation, two on stroke units and three on stroke services. The follow-up per patient was generally short; one year or less. The comparators and the scope of included costs varied between studies.
Six out of six studies provided evidence that the costs of early-supported discharge are less than for conventional care, at similar health outcomes. Home-based rehabilitation is unlikely to lead to cost-savings, but achieves better health outcomes. Care in stroke units is more expensive than conventional care, but leads to improved health outcomes. The cost-effectiveness studies on integrated stroke services suggest that they can reduce costs. For future research we recommend to focus on the moderate and severely affected patients, include stroke severity as variable, adopt a societal costing perspective and include long-term costs and effects.
PMCID: PMC3601509  PMID: 23593053
stroke; integrated care; rehabilitation; costs; economics; review
10.  What constitutes an excellent allied health care professional? A multidisciplinary focus group study 
Determining what constitutes an excellent allied health care professional (AHCP) is important, since this is what will guide the development of curricula for training future physical therapists, oral hygienists, speech therapists, diagnostic radiographers, and dietitians. This also determines the quality of care.
To describe perspectives of AHCPs on which characteristics are commonly associated with an excellent AHCP.
AHCPs’ perspectives were derived from three focus group discussions. Twenty-one health care professionals participated. The final analysis of the focus group discussions produced eight domains, in which content validity was obtained through a Delphi panel survey of 27 contributing experts.
According to the survey, a combination of the following characteristics defines an excellent AHCP: (1) cognizance, to obtain and to apply knowledge in a broad multidisciplinary health care field; (2) cooperativity, to effectively work with others in a multidisciplinary context; (3) communicative, to communicate effectively at different levels in complex situations; (4) initiative, to initiate new ideas, to act proactively, and to follow them through; (5) innovative, to devise new ideas and to implement alternatives beyond current practices; (6) introspective, to self-examine and to reflect; (7) broad perspective, to capture the big picture; and (8) evidence-driven, to find and to use scientific evidence to guide one’s decisions.
The AHCPs perspectives can be used as a reference for personal improvement for supervisors and professionals in clinical practice and for educational purposes. These perspectives may serve as a guide against which talented students can evaluate themselves.
PMCID: PMC3775675  PMID: 24049449
clinical excellence; focus group; health care; honors programs; multidisciplinary care
11.  Improving Community Healthcare for Patients with Parkinson's Disease: The Dutch Model 
Parkinson's Disease  2012;2012:543426.
Because of the complex nature of Parkinson's disease, a wide variety of health professionals are involved in care. Stepwise, we have addressed the challenges in the provision of multidisciplinary care for this patient group. As a starting point, we have gained detailed insight into the current delivery of allied healthcare, as well as the barriers and facilitators for optimal care. To overcome the identified barriers, a tertiary referral centre was founded; evidence-based guidelines were developed and cost-effectively implemented within regional community networks of specifically trained allied health professionals (the ParkinsonNet concept). We increasingly use ICT to bind these professional networks together and also to empower and engage patients in making decisions about their health. This comprehensive approach is likely to be feasible for other countries as well, so we currently collaborate in a European collaboration to improve community care for persons with Parkinson's disease.
PMCID: PMC3306968  PMID: 22496990
12.  Clinical vocabulary as a boundary object in multidisciplinary care management of multiple chemical sensitivity, a complex and chronic condition 
Research has shown that accurate and timely communication between multidisciplinary clinicians involved in the care of complex and chronic health conditions is often challenging. The domain knowledge for these conditions is heterogeneous, with poorly categorized, unstructured, and inconsistent clinical vocabulary. The potential of boundary object as a technique to bridge communication gaps is explored in this study.
A standardized and controlled clinical vocabulary was developed as a boundary object in the domain of a complex and chronic health condition, namely, multiple chemical sensitivity, to improve communication among multidisciplinary clinicians. A convenience sample of 100 patients with a diagnosis of multiple chemical sensitivity, nine multidisciplinary clinicians involved in the care of patients with multiple chemical sensitivity, and 36 clinicians in the community participated in the study.
Eighty-two percent of the multidisciplinary and inconsistent vocabulary was standardized using the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED® CT as a reference terminology. Over 80% of the multidisciplinary clinicians agreed on the overall usefulness of having a controlled vocabulary as a boundary object. Over 65% of clinicians in the community agreed on the overall usefulness of the vocabulary.
The results from this study are promising and will be further evaluated in the domain of another complex chronic condition, ie, chronic pain. The study was conducted as a preliminary analysis for developing a boundary object in a heterogeneous domain of knowledge.
PMCID: PMC3093953  PMID: 21594060
multidisciplinary care; complex and chronic conditions; multiple chemical sensitivity; boundary objects
13.  Family meetings in palliative care: Multidisciplinary clinical practice guidelines 
BMC Palliative Care  2008;7:12.
Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.
The guidelines were developed via the following methods: (1) A literature review; (2) Conceptual framework; (3) Refinement of the guidelines based on feedback from an expert panel and focus groups with multidisciplinary specialists from three palliative care units and three major teaching hospitals in Melbourne, Australia.
The literature review revealed that no comprehensive exploration of the conduct and utility of family meetings in the specialist palliative care setting has occurred. Preliminary clinical guidelines were developed by the research team, based on relevant literature and a conceptual framework informed by: single session therapy, principles of therapeutic communication and models of coping and family consultation. A multidisciplinary expert panel refined the content of the guidelines and the applicability of the guidelines was then assessed via two focus groups of multidisciplinary palliative care specialists. The complete version of the guidelines is presented.
Family meetings provide an opportunity to enhance the quality of care provided to palliative care patients and their family carers. The clinical guidelines developed from this study offer a framework for preparing, conducting and evaluating family meetings. Future research and clinical implications are outlined.
PMCID: PMC2542352  PMID: 18710576
14.  Simulation for the Training of Human Performance and Technical Skills: The Intersection of How We Will Train Health Care Professionals in the Future 
The aims of this research are to begin to understand health care teams in their operational environment, establish metrics of performance for these teams, and validate a series of scenarios in simulation that elicit team and technical skills. The focus is on defining the team model that will function in the operational environment in which health care professionals work.
Simulations were performed across the United States in 70- to 1000-bed hospitals. Multidisciplinary health care teams analyzed more than 300 hours of videos of health care professionals performing simulations of team-based medical care in several different disciplines. Raters were trained to enhance inter-rater reliability.
The study validated event sets that trigger team dynamics and established metrics for team-based care. Team skills were identified and modified using simulation scenarios that employed the event-set-design process. Specific skills (technical and team) were identified by criticality measurement and task analysis methodology.
In situ simulation, which includes a purposeful and Socratic Method of debriefing, is a powerful intervention that can overcome inertia found in clinician behavior and latent environmental systems that present a challenge to quality and patient safety. In situ simulation can increase awareness of risks, personalize the risks, and encourage the reflection, effort, and attention needed to make changes to both behaviors and to systems.
PMCID: PMC2931260  PMID: 21975987
15.  Pragmatic randomised trial to evaluate the use of patient held records for the continuing care of patients with cancer 
Quality in Health Care : QHC  2001;10(3):159-165.
Objective—To evaluate the use of a multidisciplinary record held by patients with cancer in the community.
Design—Pragmatic randomised controlled trial.
Setting—The environs of Swansea in south west Wales.
Participants—501 patients under the care of the Department of Oncology, Singleton Hospital, Swansea.
Intervention—A patient held record used by the patient and healthcare professionals.
Main outcome measures—Health related quality of life (EORTC QLQ-C30) measured at entry into the study and at 6 months; patients' views at 6 months; healthcare professionals' views collected after the completion of patient follow up; NHS resource and booklet use.
Results—1148 patients were eligible for the study; 501 were recruited (44%) and 344 completed the study (172 in each group). There was no significant difference between the two groups in change in quality of life or NHS resource use. The patient held record did not have an impact on communication but was significantly helpful to patients in preparing for appointments, reducing difficulties in monitoring their own progress, and helping them to feel more in control (p<0.05). Fifty three percent of patients would have preferred not to have a patient held record. There was a low level of use of the record by healthcare professionals but most of those who remembered using it indicated that they would prefer patients to have it.
Conclusions—The patient held record is valued by some patients and professionals but has no significant impact on the quality of life of patients or NHS resource use. It has a positive impact on quality by helping patients feel more in control and prepare for meetings with healthcare staff. Patients who find it useful tend to be younger and have more professionals involved in their care. It is recommended that it should be made available to patients on request and used by them according to need.
Key Words: cancer; patient held records; patients' views; professional views
PMCID: PMC1743428  PMID: 11533423
16.  Does community health care require different competencies from physicians and nurses? 
Recently competency approach in Health Professionals’ Education (HPE) has become quite popular and for an effective competency based HPE, it is important to design the curriculum around the health care needs of the population to be served and on the expected roles of the health care providers. Unfortunately, in community settings roles of health providers tend to be described less clearly, particularly at the Primary Health Care (PHC) level where a multidisciplinary and appropriately prepared health team is generally lacking. Moreover, to tailor the education on community needs there is no substantial evidence on what specific requirements the providers must be prepared for.
This study has explored specific tasks of physicians and nurses employed to work in primary or secondary health care units in a context where there is a structural scarcity of community health care providers. In-depth Interviews of 11 physicians and 06 nurses working in community settings of Pakistan were conducted along with review of their job descriptions.
At all levels of health settings, physicians’ were mostly engaged with diagnosing and prescribing medical illness of patients coming to health center and nurses depending on their employer were either providing preventive health care activities, assisting physicians or occupied in day to day management of health center. Geographical location or level of health facility did not have major effect on the roles being expected or performed, however the factors that determined the roles performed by health providers were employer expectations, preparation of health providers for providing community based care, role clarity and availability of resources including health team at health facilities.
Exploration of specific tasks of physicians and nurses working in community settings provide a useful framework to map competencies, and can help educators revisit the curricula and instructional designs accordingly. Furthermore, in community settings there are many synergies between the roles of physicians and nurses which could be simulated as learning activities; at the same time these two groups of health providers offer distinct sets of services, which must be harnessed to build effective, non-hierarchal, collaborative health teams.
PMCID: PMC3893590  PMID: 24387322
Competencies; Community settings; Undergraduate curriculum; Health care providers; Tasks & functions
17.  A comparison of specialist rehabilitation and care assistant support with specialist rehabilitation alone and usual care for people with Parkinson's living in the community: study protocol for a randomised controlled trial 
Trials  2011;12:250.
Parkinson's Disease is a degenerative neurological condition that causes movement problems and other distressing symptoms. People with Parkinson's disease gradually lose their independence and strain is placed on family members. A multidisciplinary approach to rehabilitation for people with Parkinson's is recommended but has not been widely researched. Studies are needed that investigate cost-effective community-based service delivery models to reduce disability and dependency and admission to long term care, and improve quality of life.
A pragmatic three parallel group randomised controlled trial involving people with Parkinson's Disease and live-in carers (family friends or paid carers), and comparing: management by a specialist multidisciplinary team for six weeks, according to a care plan agreed between the professionals and the patient and carer (Group A); multidisciplinary team management and additional support for four months from a trained care assistant (Group B); usual care, no coordinated team care planning or ongoing support (Group C). Follow up will be for six months to determine the impact and relative cost-effectiveness of the two interventions, compared to usual care. The primary outcomes are disability (patients) and strain (carers). Secondary outcomes include patient mobility, falls, speech, pain, self efficacy, health and social care use; carer general health; patient and carer social functioning, psychological wellbeing, health related quality of life. Semi structured interviews will be undertaken with providers (team members, care assistants), service commissioners, and patients and carers in groups A and B, to gain feedback about the acceptability of the interventions. A cost - effectiveness evaluation is embedded in the trial.
The trial investigates components of recent national policy recommendations for people with long term conditions, and Parkinson's Disease in particular, and will provide guidance to inform local service planning and commissioning.
Trial registration
PMCID: PMC3261836  PMID: 22112960
Parkinson's disease; Multidisciplinary rehabilitation; Domiciliary; Randomised controlled trial
18.  Developing a complex intervention to reduce time to presentation with symptoms of lung cancer 
The British Journal of General Practice  2012;62(602):e605-e615.
Lung cancer is the commonest cause of cancer in Scotland and is usually advanced at diagnosis. Median time between symptom onset and consultation is 14 weeks, so an intervention to prompt earlier presentation could support earlier diagnosis and enable curative treatment in more cases.
To develop and optimise an intervention to reduce the time between onset and first consultation with symptoms that might indicate lung cancer.
Design and setting
Iterative development of complex healthcare intervention according to the MRC Framework conducted in Northeast Scotland.
The study produced a complex intervention to promote early presentation of lung cancer symptoms. An expert multidisciplinary group developed the first draft of the intervention based on theory and existing evidence. This was refined following focus groups with health professionals and high-risk patients.
First draft intervention components included: information communicated persuasively, demonstrations of early consultation and its benefits, behaviour change techniques, and involvement of spouses/partners. Focus groups identified patient engagement, achieving behavioural change, and conflict at the patient–general practice interface as challenges and measures were incorporated to tackle these. Final intervention delivery included a detailed self-help manual and extended consultation with a trained research nurse at which specific action plans were devised.
The study has developed an intervention that appeals to patients and health professionals and has theoretical potential for benefit. Now it requires evaluation.
PMCID: PMC3426599  PMID: 22947581
early diagnosis; health services research; lung cancer; primary health care
19.  Listening to local voices: adapting rapid appraisal to assess health and social needs in general practice. 
BMJ : British Medical Journal  1994;308(6930):698-700.
OBJECTIVES--To explore the use of rapid appraisal in defining the health and social needs of a community and to formulate joint action plans between the residents and service providers. DESIGN--Collection of data by an extended primary care team from three sources: existing documents about the neighbourhood, interviews with a range of informants, and direct observations to build a profile of the community. SETTING--Council estate of 670 homes in Edinburgh. MAIN OUTCOME MEASURES--Perceived problems of the community and suggestions for change. RESULTS--The interviews and focus groups identified six priorities for change, many of which were not health related. These changes have been or are being implemented. CONCLUSIONS--An expanded primary care team can use rapid appraisal as a first step in identifying and meeting local health needs. It facilitates a multidisciplinary approach and complements quantitative methods of assessing need.
PMCID: PMC2539376  PMID: 8142796
20.  The role of pharmacists in developing countries: the current scenario in Pakistan 
During the past few years, the pharmacy profession has expanded significantly in terms of professional services delivery and now has been recognized as an important profession in the multidisciplinary provision of health care. In contrast to the situation in developed countries, pharmacists in developing countries are still underutilized and their role as health care professionals is not deemed important by either the community or other health care providers. The aim of this paper is to highlight the role of pharmacists in developing countries, particularly in Pakistan. The paper draws on the literature related to the socioeconomic and health status of Pakistan's population, along with background on the pharmacy profession in the country in the context of the current directions of health care.
The paper highlights the current scenario and portrays the pharmacy profession in Pakistan. It concludes that although the pharmacy profession in Pakistan is continuously evolving, the health care system of Pakistan has yet to recognize the pharmacist's role. This lack of recognition is due to the limited interaction of pharmacists with the public. Pharmacists in Pakistan are concerned about their present professional role in the health care system. The main problem they are facing is the shortage of pharmacists in pharmacies. Moreover, their services are focused towards management more than towards customers. For these reasons, the pharmacist's role as a health care professional is not familiar to the public.
PMCID: PMC2714831  PMID: 19594916
21.  The development, implementation and evaluation of an outpatient palliative radiotherapy programme 
Improve the quality of integrated care and support to oncology outpatients receiving palliative radiotherapy.
Oncology patients receiving palliative radiotherapy experience major transitions. These patients are currently offered shortened outpatient treatment. In 2004–2005, research by RU students showed deficiencies in information, continuity in care, and in communication between health care providers. To improve integrated care and transmural cooperation multidisciplinary teams contributed to developing a protocol and checklist called ‘Transmural Programme Palliative Radiotherapy’ (TZPR).
The RU Centre of Expertise Transitions in Care evaluated the process of regional implementation and the value of TZPR on patient and organizational level. Themes were needs, logistic process, symptom control, psychosocial support and after-care. A mixed methods design was used: semi-structured interviews with 20 caregivers and patients; a focus group discussion with 7 caregivers; a questionnaire for both patients and control group.
Health professionals are positive about the content and implementation of TZPR. They experienced an improvement in the quality of integrated care and support to patients. Preliminary results from the patients' perspective are expected mid-2009. The participatory approach guarantees the desired integrated care.
PMCID: PMC2807066
palliative care; radiotherapy; oncology patients; quality of care
22.  PHL4/411: Getting Practice on the Internet 
Increasingly, patients are using the Internet as a source of health information, and in the near future it will become normal for patients to seek information on health care services via the Internet. Practices who wish to have an Internet presence face the awkward prospect of either designing and maintaining their own site at considerable expense in manpower and equipment or seeking an expensive commercial solution that may not be seen as a valid use of health professionals' budgets.
The project was a collaborative effort between Tayside Health Board, Tayside Centre for General Practice and the Department of Applied Computing (University of Dundee), a multidisciplinary team whose members are known for their innovative research. The aim of this project was to develop, implement and maintain Internet and NHSiS Intranet Web sites for all Tayside GPs, Dentists, Community Pharmacists, Opticians and Professions Allied to Medicine (PAMS), giving our region a "national first" by displaying an entire Region's primary care web sites on the Internet and NHSiS Intranet. The Holding of information that is to be displayed on the Practice Web Sites on Tayside Health Board's Centralised database allows control of information, utilising Internet technology to allow practices around Tayside to access and control their own practice data residing on the central servers situated at Tayside Health Board.
User friendly software was developed to allow all of Tayside's primary care Professionals to create and maintain their own customised patient orientated Web sites. No level of Internet Programming is required to successfully use the system, the software produced will be provided with full user documentation and a support help line, with a facilitator to help with problems on site when deemed necessary. The software captured the data entered by the practices, constructed the Web site for the practice from a template design that was customised to the practice's details. The resultant Internet Documents are then published onto the servers located at Tayside Health Board (from where they can be viewed from any location on the NHSiS Intranet), whilst also being ported onto the public servers at SHOW (Scottish Health on the Web), from which they can be viewed by anyone with an Internet connection.
This project laid the foundations of good IM&T communication between Tayside Health Boardand Practices. Utilising cutting edge Internet technology, this project presented the opportunity to pilot and test novel systems of "data capture" - a natural progression from which would be the development of a paper free service administration where paper forms could be replaced by an electronic equivalent.
PMCID: PMC1761713
Internet; General Practices; Health Care
23.  The Professional Attitudes and Clinical Practices of Men and Women Generalists 
Canadian Family Physician  1989;35:59-63.
Data from a 1983-84 Quebec generalists' survey were used to compare the professional attitudes and clinical practices of women physicians with those of their male colleagues. The survey was conducted on a random sample of 736 Quebec generalists and achieved a 83.7% response rate. Analyses were performed separately for fee-for-service physicians and for salaried physicians working in local community health centers (CLSCS). Results showed more gender differences among fee-for-service physicians than among salaried physicians. Women in private practice were more likely than their male colleagues to value the multidisciplinary, social, and humanistic aspects of patient care. For their part, women salaried physicians reported being significantly more involved in the social and preventive dimensions of health care than their male colleagues. Important attitudinal differences were observed between fee-for-service and salaried generalists, regardless of gender. This study suggests that neither the medical training nor the organizational constraints of the work setting succeed in levelling off all gender differences. The findings also suggest that women physicians can help promote aspects of health care to which much importance has been attributed in recent years.
PMCID: PMC2280434  PMID: 21253268
general practice; physician attitudes; physician gender
Spinal pain of mechanical origin, with or without referred pain, is a serious health problem suffered by many Australians. In order to help patients with this ailment, and to investigate this costly and debilitating condition, the National Centre for Multidisciplinary Studies of Back Pain was established at Townsville General Hospital as a joint venture between James Cook University of North Queensland and the Northern Regional Health Authority.
The Centre has a multidisciplinary clinical team including a chiropractor. The Centre functions successfully, contributes to the public health of the community and shows that a multidisciplinary clinical team which includes a chiropractor can work harmoniously in an Australian hospital setting. The need for such a centre is demonstrated by an ever increasing demand for its professional services in Townsville as indicated by a review of the number of new patients and overall patient visits. The Centre could act as a model for the inclusion of chiropractic into the Australian hospital setting.
PMCID: PMC2050619  PMID: 17987142
Chiropractic; hospitals; medicine; clinical trial; history.
25.  A multidisciplinary primary care team consultation in a socio-economically deprived community: An exploratory randomised controlled trial 
Psychosocial problems in socioeconomically deprived communities are not always amenable to traditional medical approaches. Mothers living in these areas are a particularly vulnerable group. The objective of this study was to evaluate the effectiveness of a lengthened multi-disciplinary team consultation in primary care in reducing anxiety and depression in mothers.
This was a prospective randomised controlled trial of a multidisciplinary team consultation against normal care. 94 mothers were recruited from three general practices from an area of extreme socio-economic deprivation. Mothers randomised into the intervention group attended a multidisciplinary consultation with up to four case-specific health care professionals. Consultations addressed medical, psychological and social problems and lasted up to one hour. Conventional primary care continued to be available to the intervention families. Control group families received normal primary care services. The outcomes measured were anxiety and depression as using the Hospital Anxiety and Depression Scale (HADS), health status using SF36v2, and quality of life using the abbreviated Schedule for the Evaluation of Individual Quality of Life (SEIQoL-DW) at baseline, 6 months and 12 months.
Ordered logistic regression was used to analyse the data. There was no significant difference found between intervention and control groups after 6 months and 12 months in all of the measured outcomes.
The new lengthened multi-disciplinary team consultation did not have any impact on the mental health, general health, and quality of life of mothers after 6 and 12 months. Other methods of primary health care delivery in socio-economically deprived communities need to be evaluated.
PMCID: PMC3032651  PMID: 21261966

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