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Introduction: Including healthcare professionals dealing with cardiovascular diseases, Heart Team is a concept/structure designed for selecting diagnostic strategies, facilitating therapeutic decisions, and improving cardiovascular outcomes in patients with complex heart pathologies, requiring input from different subspecialties and the necessity of a multidisciplinary approach. The aim of this narrative review is to search for and to summarize current evidence regarding Heart Team and to underline the future directions for the development of this concept., Methods: We searched the electronic database of PubMed, SCOPUS, and Cochrane CENTRAL for studies including Heart Team. Forty-eight studies were included, if reference was made to Heart Team structure and functionality., Results: We depicted the structure and the timeline of Heart Team, along with actual evidence-based recommendations from European Guidelines. We underlined the importance of quality of knowledge-sharing and decision-making inside the Team, analyzing bad decisions which did not reflect members' true beliefs due to " uniformity pressure, closed mindedness, and illusion of invulnerability ." The observation that Guidelines' indications regarding Heart Team carry a level C indication underlines the very future of this Team: randomized controlled trials proving solid benefits in an evidence-based world., Conclusions: Envisioned as a tool for optimizing the management of various complex cardiovascular pathologies, Heart Team should simplify and facilitate the activity in the cardiovascular ward. Finally, these facts should be translated into better cardiovascular outcomes and a lower psychological distress among Team participants. Despite all future changes, there must always be a constant part: the patient should remain at the very center of the Team., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Alexandru Burlacu et al.)

A multidisciplinary approach is currently a necessary and standard approach in treatment of cancer patients. The main goals of the multidisciplinary approach include coordinated highly effective interaction of medical specialists to timely identify, prescribe and conduct planned treatment, as well as prevention and correction of adverse events of treatment to achieve most lasting effect of treatment. The article discusses role of multidisciplinary team, including an oncologist, urologist, pathomorphologist, molecular genetics, radiologist, medical oncologist, radiation therapist, neurosurgeon, orthopedic surgeon, endovascular, thoracic and abdominal surgeons for effective treatment of oncourological patients. To solve existing problems, it is necessary to create common standards for the treatment of oncological diseases, develop and improve an oncological care system, improve logistics and improve skills of specialists or train specialists in the required profile.

Background: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful., Methods: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations., Results: Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day rehospitalizations at 7, 14, and 30 days postdischarge with significance achieved at 14 and 30 days. Compared to before the intervention, reductions in both ED visits and hospitalizations as well as increases in clinic visits were seen at 1, 3, and 6 months. CPP involvement was associated with lower rehospitalizations (7.7% vs 18.8%; P = .04)., Conclusion: A multidisciplinary outpatient-based transitions program embedded in the PCMH increased access to primary care and reduced hospital and ED utilization. Face-to-face CPP involvement significantly lowered rehospitalizations. This program describes a standardized approach to complex care needs with defined roles, a model that may be generalizable and reproduced in other medical homes.

Purpose: The integral role of pharmacists in supporting population health initiatives in the patient-centered medical home (PCMH) model of care is described., Summary: Population health initiatives focus on the health outcomes of a group of patients; in the PCMH model, such groups of patients, known as panels, may be defined as patients assigned to a care team or provider. The basic characteristics of the PCMH model include physician-led, team-based practice; coordinated and integrated care within the PCMH and in the patient's community; provision of safe, evidence-based, high-quality care; incorporation of health information technology and continuous quality improvement strategies into panel identification, documentation, and care processes; improved access to care (e.g., through expanded scheduling and innovative communication methods); and value-based payments for participating healthcare professionals. Pharmacists can assist in management of patient panels to help achieve quality and performance metrics through activities typically including comprehensive medication reviews, identification of medication-related problems, and development of care plans and individualized treatment goals. Pharmacists practicing in PCMH settings focus on evaluating and optimizing medication regimens, including therapy initiation and dosage adjustment, to achieve targeted therapeutic outcomes and prevent adverse events. Pharmacists' role in population health management varies according to the PCMH characteristics and setting., Conclusion: Pharmacists support population health in the PCMH by improving medication use, quality, and safety. Pharmacists' impact on PCMH quality measures and health outcomes of their patient panels should continue to be evaluated., (Copyright © 2017 by the American Society of Health-System Pharmacists, Inc. All rights reserved.)

Background: The concept of Perioperative Surgical Home has been gaining significant attention in surgical centers. This model is delivering and improving coordinated care in a cost-effective manner to patients undergoing surgical procedures. It starts with the decision for surgical intervention, continues to the intraoperative and postoperative periods, and follows into long-term recovery. Constant re-evaluation of outcomes and modifications of delivery provides a feedback loop for improvement. Children's Hospital Los Angeles initiated a new protocol in June 2014 to manage children undergoing Posterior Spinal Fusion (PSF) with the goal to improve patient experience and lower the hospital length of stay and cost., Methods: A retrospective chart review identified patients who underwent a PSF for idiopathic scoliosis before and after initiation of a new treatment protocol designed by a team of anesthesiologists, surgeons, nurses, and physical therapists. The new protocol included preoperative teaching of parents and patients, intraoperative anesthetic and surgical management, and immediate to long-term postoperative medical management. In addition to demographics, we examined length of stay, cost of hospitalization, pain scores on discharge, length of patient-controlled analgesia use, time to first solid food intake, and time to ambulation., Results: Thirty-six patients were identified preinitiation and postinitiation of the protocol (total n = 72). There was no statistically significant difference in age, sex, use of intrathecal morphine, or estimated blood loss. Patients enrolled in the new protocol had higher American Society of Anesthesiologists classification (P = .003), significantly lower duration of patient-controlled analgesia use, time to first solid food intake, and time to ambulation (P= .001). The pain scores were higher at the time of discharge, although the difference was not statistically significant. Length of stay was significantly shorter in the new protocol group (P = .001), accounting for $292,560 in cost savings for the hospital., Conclusions: These data show that the cooperation of different teams in designing new management guidelines for patients requiring a PSF can significantly decrease the total length of stay and cost of hospitalization without altering quality of care.

MVZ provide community-based health care services improving integrated primary care and specialist care and allow hospital to outsource outpatient activities. They also provide patient-centered care and promote internal and external multidisciplinary coordination. MVZ can provide an example for possible changes to private specialist organisation and structuring of hospital services in France, while MSP mainly focus on primary care and only a few specialist CS have been created..

Family physicians are increasingly incorporating other health care providers into their practice teams to better meet the needs of increasingly complex and comorbid patients. While a majority of family physicians report working with a nurse practitioner, only 21% work with a behavioral health specialist. A better understanding of optimal team composition and function in primary care is essential to realizing the promise of a patient-centered medical home and achieving the triple aim., (© Copyright 2016 by the American Board of Family Medicine.)

Medicine is no longer a single's game, it's a team sport. Long true in surgical specialties where the operative effort led by the chief surgeon is a carefully choreographed ballet of surgical assistants, surgical nurses, anesthesiologist, and other technical staff, now medical subspecialists are also assisted by teams composed of advanced practice nurses, physician assistants, social workers, and pharmacists. In primary care, the new vehicle for care teams is the Patient Centered Medical Home (PCMH; Kellerman & Kirk, 2007), which is designed to serve 85%-90% of patients' needs with the broadest "basket of services" possible., ((c) 2015 APA, all rights reserved).)

Background: In recent years, physician groups, government agencies and third party payers in the United States of America have promoted a Patient-centered Medical Home (PCMH) model that fosters a team-based approach to primary care. Advocates highlight the model's collaborative approach where physicians, mid-level providers, nurses and other health care personnel coordinate their efforts with an aim for high-quality, efficient care. Early studies show improvement in quality measures, reduction in emergency room visits and cost savings. However, implementing the PCMH presents particular challenges to physician training programs, including institutional commitment, infrastructure expenditures and faculty training., Discussion: Teaching programs must consider how the objectives of the PCMH model align with recent innovations in resident evaluation now required by the Accreditation Council of Graduate Medical Education (ACGME) in the US. This article addresses these challenges, assesses the preliminary success of a pilot project, and proposes a viable, realistic model for implementation at other institutions.

Building from a foundation of rapid innovation, the 21(st) century is poised to offer considerable new approaches to providing modern diabetes care. The focus of this paper is the evolving role of diabetes care providers collaboratively working with patients and families toward the goals of achieving optimal clinical and psychosocial outcomes for individuals living with diabetes. Advances in monitoring, treatment and technology have been complemented by trends toward patient-centered care with expertise from multiple health care disciplines. The evolving clinical care delivery system extends far beyond adjustment of insulin regimens. Effective integration of patient-centered strategies, such as shared-decision making, motivational interviewing techniques, shared medical appointments, and multidisciplinary team collaboration, into a dynamic model of diabetes care delivery holds promise in reaching glycemic targets and improving patients' quality of life.

Background: Due to the demographic development depressive disorders in old age are becoming a central and urgent healthcare challenge., Objectives: The article reviews effective approaches towards treatment of depression in the elderly., Methods: A literature review of complex interventions improving depression care was carried out., Results: Robust evidence exists for the use of collaborative care models which incorporate collaboration between mental health and medical providers in the primary care setting (e.g. general practitioners and specialists), regular monitoring, case management, and evidence-based treatment. Staged treatment approaches seem to be appropriate by which initially use treatment strategies of low intensity. For patients with limited mobility, home-based approaches have proven to be particularly practical and effective., Conclusion: Multidisciplinary and multimodal treatment approaches represent an effective and efficient way of healthcare provision for late life depression. In Germany, only few initiatives inspired by successful international models have so far been identified.

Background: With the reorganization of primary care into Patient Aligned Care Teams (PACT) teams, the Veteran Affairs Health System (VA) aims to ensure all patients receive care based on patient-centered medical home (PCMH) principles. However, some patients receive the preponderance of care from specialty rather than primary care clinics because of the special nature of their clinical conditions. We examined seven VA (HIV) clinics as a model to test the extent to which such patients receive PCMH-principled care., Objective: To examine the extent to which HIV specialty care in VA conforms to PCMH principles., Design: Qualitative study., Participants: Forty-one HIV providers from seven HIV clinics and 20 patients from four of these clinics., Approach: We conducted semi-structured interviews with HIV clinic providers and patients about care practices and adherence to PCMH principles. Using an iterative approach, data was analyzed using both a content analysis and an a priori, PCMH-principled coding strategy., Key Results: Patients with HIV receive varying levels of PCMH-principled care across a range of VA HIV clinic structures. The more PCMH-principled HIV clinics largely functioned as PCMHs; patients received integrated, coordinated, comprehensive primary care within a dedicated HIV clinic. In contrast, some clinics were unable to meet the criteria of being a patient's medical home, and instead functioned primarily as a place to receive HIV-related services with limited care coordination. Patients from the less PCMH-principled clinics reported less satisfaction with their care., Conclusions: Even in a large, integrated healthcare system, there is wide variation in patients' receipt of PCMH-principled care in specialty care settings. In order to meet the goal of having all patients receiving PCMH-principled care, there needs to be careful consideration of where primary and specialty care services are delivered and coordinated. The best mechanisms for ensuring that patients with complex medical conditions receive PCMH-principled care may need to be tailored to different specialty care contexts.

Background: High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams ("teamlets") as a core feature., Objective: To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets., Design: Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012., Participants: We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices., Main Measures: Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support., Key Results: Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member's roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA's medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans' experiences of primary care and also resulted in improved communication among staff., Conclusions: The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.

Background: The Veterans Health Administration (VA) Patient Aligned Care Teams (PACT) initiative is designed to deliver a medical home model of care associated with better patient outcomes, but success will depend in part on the model's acceptability and sustainability among clinic employees., Objective: We sought to identify key themes in the experience of primary care providers, nurse care managers, clerical and clinical associates, and clinic administrators implementing PACT, with the aim of informing recommendations for continued development of the model and its components., Design: Observational qualitative study; data collection from 2010 to 2013, using role-stratified and team focus groups and semi-structured interviews., Participants: 241 of 337 (72 %) identified primary care clinic employees in PACT team or administrative roles, from 15 VA clinics in Oregon and Washington., Approach: Data coded and analyzed using conventional content analysis techniques., Key Results: Overall, participants were enthusiastic about the PACT concept, but felt necessary resources for success were not yet in place. Well-functioning teams were perceived as key to successful implementation. Development of such teams depended on adequate staffing, training, and dedicated time for team development. Changes within the broader VA system were also seen as necessary, including devolving greater control to the clinic level and improving system alignment with the PACT model. PACT advocates from among clinic and institutional level leadership were identified as a final key ingredient for success. These themes were consistent despite differences in clinic settings and characteristics., Conclusions: PACT implementation faced significant challenges in its early years. Realizing PACT's transformative potential will require acting on the needs identified by clinic workers in this study: ensuring adequate staffing in all team roles, devoting resources to in-depth training for all employees in communication and other skills needed to maximize team success, and aligning the broader VA hospital system with PACT's decentralized, team-based approach.

Background: Quality improvement is a central goal of the patient-centered medical home (PCMH) model, and requires the use of relevant performance measures that can effectively guide comprehensive care improvements. Existing literature suggests performance measurement can lead to improvements in care quality, but may also promote practices that are detrimental to patient care. Staff perceptions of performance metric implementation have not been well-researched in medical home settings., Objective: To describe primary care staff (clinicians and other staff) experiences with the use of performance metrics during the implementation of the Veterans Health Administration's (VHA) Patient Aligned Care Team (PACT) model of care., Design: Observational qualitative study; data collection using role-stratified focus groups and semi-structured interviews., Participants: Two hundred and forty-one of 337 (72 %) identified primary care clinic staff in PACT team and clinic administrative/other roles, from 15 VHA clinics in Oregon and Washington., Approach: Data coded and analyzed using conventional content analysis techniques., Key Results: Primary care staff perceived that performance metrics: 1) led to delivery changes that were not always aligned with PACT principles, 2) did not accurately reflect patient-priorities, 3) represented an opportunity cost, 4) were imposed with little communication or transparency, and 5) were not well-adapted to team-based care., Conclusions: Primary care staff perceived responding to performance metrics as time-consuming and not consistently aligned with PACT principles of care. The gaps between the theory and reality of performance metric implementation highlighted by PACT team members are important to consider as the medical home model is more widely implemented.

Background: Despite some clinical guidelines for incorporating integrated psychosocial care (combining psychological screening and psychological intervention, including adequate collaboration with mental health specialists) into routine oncology practice, definitive empirical evidence regarding the effectiveness of such care remains unavailable. Here the findings of recent experimental studies are reviewed to provide guidance regarding this issue., Methods: Comparative studies examining integrated psychosocial care were reviewed., Results: Studies examining interventions that include both screening and psychological care have produced contradictory results regarding effectiveness, but all the studies that have examined the effect of psychological care after the identification of distress using systematic screening have shown positive results., Conclusions: Integrated psychosocial care may affect patients with significant distress, but the adequacy of introducing such care into routine oncology practice remains debatable.

This special issue discusses the ethical issues providers face in collaborative primary care settings. It is organized in three sections: (a) Common Themes, (b) Context-Specific Quandaries, and (c) Research and Training. It provides case examples to illustrate ethical dilemmas, describe professional ethical standards pertinent to the case, identifies gaps in available guidance and how guidelines might be elucidated in state statues (without going into detail about specific states), offers feasible recommendations to BHCs for deciding an ethical course when extant guidance was lacking, and then demonstrates and applies the recommendations to achieve an ethical resolution to the case example., ((PsycINFO Database Record (c) 2013 APA, all rights reserved).)

Unlabelled: Study Type - Therapy (decision analysis) Level of Evidence 2b. What's known on the subject? and What does the study add? The benefits of the multidisciplinary approach in oncology are widely recognised. In particular, managing patients with prostate cancer within a multidisciplinarity and multiprofessional context is of paramount importance, to address the complexity of a disease where patients may be offered multiple therapeutic and observational options handled by different specialists and having severe therapy-induced side-effects. The present study describes the establishing of a multidisciplinary clinic at the Prostate Cancer Programme of Milan Istituto Nazionale dei Tumori, its effects on the quality of care provided, and strategies implemented to meet upcoming needs and improve quality standards. Having analysed the data of the 2260 multidisciplinary clinics held from March 2005 to March 2011, our dynamic and modifiable organisational model was evaluated for ways to optimise the human resources, offer high-quality standards, meet new needs and ultimately reduce costs. The study is focused on the organisational aspects and adds a perspective from one of the major oncological centres of reference in Italy and in Europe., Objectives: To describe the establishing of a multidisciplinary clinic for men with prostate cancer at the Istituto Nazionale Tumori, Milan. • To evaluate the quality of care provided and to describe the management changes implemented to improve standards and meet new needs., Materials and Methods: In March 2005, we established a multidisciplinary clinic comprising weekly clinics and case-discussion sessions. • We have altered the organisational model periodically to meet new needs and improve quality., Results: We held 2260 multidisciplinary clinics up to March 2011. • For stage distribution, patients with low-risk prostate cancer increased to a peak of 61% in 2009, probably because of the anticipation of diagnosis and the active surveillance expertise of the Prostate Cancer Programme at Istituto Nazionale Tumori, Milan. The slight decrease in 2010 might be due to the availability of robot-assisted prostatectomy in several hospitals in Milan, and the start of a multicentre active surveillance protocol in December 2009. • In terms of the efficacy of our multidisciplinary strategy, 11% of drug therapies (mostly hormones) prescribed outside our institute were terminated in the multidisciplinary clinic, and 6% of indications formulated in the multidisciplinary clinics were altered during the case-discussion sessions., Conclusions: The multidisciplinary approach needs to be adaptable to meet new needs and improve quality. • Our experience has proved successful for both physicians and patients. The team agrees on strategies; complex cases are managed by a multidisciplinary team; dedicated psychologists contribute their knowledge and perspectives; and patients report the feeling of being cared for., (© 2012 BJU INTERNATIONAL.)

Health care in the United States is notoriously expensive while often failing to deliver the care recommended in published guidelines. There is, therefore, a need to consider our approach to health-care delivery. Cancer care is a good example for consideration because it spans the continuum of health-care issues from primary prevention through long-term survival and end-of-life care. In this monograph, we emphasize that health-care delivery occurs in a multilevel system that includes organizations, teams, and individuals. To achieve health-care delivery consistent with the Institute of Medicine's six quality aims (safety, effectiveness, timeliness, efficiency, patient-centeredness, and equity), we must influence multiple levels of that multilevel system. The notion that multiple levels of contextual influence affect behaviors through interdependent interactions is a well-established ecological view. This view has been used to analyze health-care delivery and health disparities. However, experience considering multilevel interventions in health care is much less robust. This monograph includes 13 chapters relevant to expanding the foundation of research for multilevel interventions in health-care delivery. Subjects include clinical cases of multilevel thinking in health-care delivery, the state of knowledge regarding multilevel interventions, study design and measurement considerations, methods for combining interventions, time as a consideration in the evaluation of effects, measurement of effects, simulations, application of multilevel thinking to health-care systems and disparities, and implementation of the Affordable Care Act of 2010. Our goal is to outline an agenda to proceed with multilevel intervention research, not because it guarantees improvement in our current approach to health care, but because ignoring the complexity of the multilevel environment in which care occurs has not achieved the desired improvements in care quality outlined by the Institute of Medicine at the turn of the millennium.

Aims: Young adults with Type 1 diabetes experience difficulties achieving glucose targets. Clinic attendance can be poor, although health and self-care tend to be better among those who attend regularly. Our aims were to describe staff views about challenges working with this age-group (16-21 years)., Methods: Semistructured interviews were conducted with 14 staff from Sheffield Teaching Hospitals diabetes care team. Interviews were audio-recorded, transcribed and analysed using thematic analysis., Results: Three main themes emerged. Unique challenges working with young adults included staff emotional burden, the low priority given to self-care by young adults and the complexity of the diabetes regimen. Working in a multidisciplinary team was complicated by differences in consultation styles, poor team cohesion and communication. An ideal service should include psychological support for the professional team, identification of key workers, and development of individualized care plans., Conclusions: Staff differed in their views about how to achieve optimal management for young adults, but emphasized the need for greater patient-centred care and a range of interventions appropriate for individual levels of need. They also wanted to increase their own skills and confidence working with this age-group. While these results reflect the views of staff working in only one diabetes centre, they are likely to reflect the views of professionals delivering care to individuals of this age; replication is needed to determine their generalizability., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

The concept of time introduces important complexities in estimating intervention effects, program and evaluation design, and measurement and analysis of individual change in multilevel interventions (MLIs). Despite growing recognition that time is a critical element for assessing both individual-level outcomes and higher-level changes in organizational, community, and policy contexts, most MLI designs and evaluations have not addressed these issues. In this chapter we discuss 1) conceptualizing disease life-course and treatment theory in MLIs, 2) approaches to incorporating time in research and program design for MLIs in cancer treatment and prevention, 3) analysis of time-varying multilevel data in the context of cancer treatment and prevention, and 4) resource considerations and trade-offs of incorporating time as a dimension of MLIs and analysis. Although analytic techniques for analyzing time-related phenomena are becoming more available and powerful, there has not been corresponding progress made in the development of theory to guide the application of these techniques in program design and implementation.

Background: Extending the residency curriculum to 4 years has been proposed as a logical innovation in response to the Future of Family Medicine Report given the increasing complexity of medical care and reduction in available training time due to duty hour restrictions. Middlesex Hospital, a participant in the P⁴ Initiative, is the first family medicine residency program to require a comprehensive 4-year curriculum for all residents., Methods: Over a 4-year time frame, the program transitioned from 8-8-8 to 6-6-6-6 staffing. The existing 3-year educational core of the program was left intact, and six additional core rotations and 7-month tracks of curricular enhancement were added. The residency practice transformed to a Patient-centered Medical Home (PCMH)., Results: Transition to a 4-year residency curriculum has proved smooth. Our funding model is sustainable, and practice income has increased. We have had no difficulty maintaining accreditation despite an innovative curriculum. A 4-year curriculum has resulted in substantially increased applicant interest and improved Match rates. The introduction of tracks has appealed to residents and has generated many positive spin-offs to the educational program as a whole. Transition to a PCMH has been of great value to both our patients and our learners., Conclusions: Transition to a comprehensive 4-year curriculum has been successful and has provided many benefits to our learners, practice, and educational program. Our graduates are substantially better prepared for practice.

Background: Team-based care has consistently been associated with improved clinical outcomes. However, strategies for promoting and sustaining a team-based approach in family medicine practice are more elusive., Methods: We conducted a longitudinal time series cohort study of 30 primary care providers in seven practices to assess the sequential addition of three different chronic disease management feedback reports over 24 months, culminating in a team-based quality improvement intervention linked to feedback, assessing clinical performance and self-reported effectiveness., Results: The proportion of patients at their low density lipoprotein target (<100 mg/dL) improved over the 24-month study period (P<0.001) but the rate of clinical improvement was more modest when feedback data were only presented at an individual and at a team level. When feedback reports were linked to a team-based quality improvement intervention, the results were more robust and were sustained for 12 months following the intervention cycle. Surveyed clinicians reported that the individual and team reports impacted both on their own practice approach and on team functioning., Conclusions: These findings suggest a strategic role for clinical performance feedback linked to team initiated quality improvement initiatives for improving both clinical outcomes and clinical team-based care.

Aims and Background: Bone metastases are responsible for high morbidity in cancer patients. The frequency of pain and other serious complications associated with such metastases depends on the site and type of lesions and preventive therapy. The present paper aims to inform the scientific community about a new organizational health care model specifically designed for patients with bone metastases, in the hope of stimulating the creation of similar initiatives whose goals are to decrease the high morbidity of this pathology, reduce the frequency of complications, limit psychophysical distress of patients, and improve quality of life., Methods: In January 2005, an Osteo-Oncology Center was opened in our institute to provide multidisciplinary care (19 specialists involved) for patients with bone metastases, to train physicians, and to conduct research in the field., Results: In its first three years of activity, 601 multidisciplinary team consultations were made and a total of 425 patients were seen. The most frequent primary tumor site was the lung in males and the breast in females. Upon presentation at the Center, 79% of patients reported experiencing a level of pain (median pain intensity, 3.69) that interfered with normal daily activities. An anonymous questionnaire was also completed on the quality of the service provided: 75% of patients were very satisfied, 23% were satisfied, 1% responded "I don't know", and only 1% expressed dissatisfaction., Conclusions: Our preliminary results confirm the usefulness of a multidisciplinary center for the management of patients with bone metastases, especially in terms of decreasing psychophysical suffering.

The effective management of advanced colorectal cancer has traditionally been viewed in terms of treatment outcome measures such as efficacy (survival, objective response and palliation) and safety. Although these outcomes are of paramount importance and are essential for the evaluation of the effectiveness and tolerability of treatment, they do not take account of the global effect of therapy on patients, society and healthcare systems. Furthermore, they may not reveal important differences between treatments of equivalent anti-tumour efficacy that might influence the overall effectiveness in terms of acceptability of therapy. To achieve this, a broader, patient-centred evaluation of advanced cancer treatment is required that acknowledges the views, experience and perspectives of all involved in the treatment process. To this end, the International Working Group in Colorectal Cancer, a multidisciplinary group that encompasses expertise from a range of relevant fields and disciplines, has advocated a multidisciplinary approach to the treatment of advanced colorectal cancer that is likely to deliver the best possible overall care.