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Co-design is increasingly employed as a user-centric method to create healthcare change. In healthcare co-design, small groups of consumers and healthcare workers come together to identify processes, policies or service elements that require improvement and to design solutions. Multiple frameworks have emerged to guide the health work force and health researchers how to conduct co-design and support consumer members to engage in the process effectively. Frameworks have sought to address the propensity for co-design to exacerbate inequities for consumers with complex care needs or in under-served populations. Advice regarding the need to consider and ensure co-design is accessible to an increasingly diverse health workforce is, however, lacking. Drawing on our experience co-designing with diverse consumer and healthcare-worker populations, we discuss the implications of co-design for the healthcare workforce.

Introduction: Consumer engagement is central to high-quality cancer service delivery and is a recognised strategy to minimise healthcare-associated harm. Strategies developed to enhance consumer engagement specifically in relation to preventing healthcare harm include questioning health professionals, raising concerns about possible mistakes or risks in care and encouraging patients and caregivers to report suspected errors. Patients from ethnic minority backgrounds are particularly vulnerable to unsafe care, but current engagement strategies have not been developed specifically for (and with) this population. Using an adapted approach to experience-based codesign (EBCD) to support the target population, the aim of the project is to codesign consumer engagement interventions to increase consumer engagement and safety in New South Wales and Victorian cancer inpatient, outpatient and day procedure services., Methods and Analysis: A mixed-method project will be undertaken at six study sites. Our EBCD approach includes a preparatory phase in which we will provide training and support to the codesign participants, in addition to recruiting and training consumer cofacilitators for the codesign workshops. The project will follow the EBCD process of gathering and synthesising observational data from each cancer service, with interview data from consumers and staff. With the resulting in-depth understanding of the safety threats commonly experienced by ethnic minority consumers in each site, we will work through feedback events and codesign groups with consumers and staff to determine how they can be more involved with their care to minimise the potential for patient harm. Consumer engagement interventions will be coproduced in each of the six participating services that are tailored to the ethnic minority populations served., Ethics and Dissemination: Ethics approval has been obtained from the Western Sydney Local Health District Human Research Ethics Committee. The project will provide strategies for ethnic minority consumers to engage with cancer services to minimise healthcare-associated harm that may be applied to diverse healthcare settings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This paper describes the process of developing a shared cancer care approach in follow-up, and identifies the e-health options that support an interactive e-care plan shared between a public cancer service, general practitioners (GPs) and cancer survivors. Type of program/service: The cancer service improvement initiative for shared care in follow-up targets colorectal cancer patients who have completed active treatment and who agree to shared care between specialists, GPs and other care team members. The intiative is supported by an agreed shared care pathway and an interactive e-care plan that is dynamic, can be shared and has functionalities that support collaboration. Design and development: A consultative process with stakeholders (local and state health services, a Primary Health Network, GPs and a consumer) was undertaken. Responses from individual consultations (25 stakeholders) were collated and commonalities identified to inform a workshop with 13 stakeholders to obtain consensus on the care pathway and e-health solution. Implications for policy and practice were identified throughout the process., Outcomes: The stakeholders agreed to a shared care pathway, which included assessment and consent, GP engagement, tailoring the care plan and communicating results and information as tasks are completed. The nurse coordinator monitored care. No interactive e-care plans were available at national, state or local health service levels. A web-based GP interactive e-care plan was selected. The main concerns raised were uncertainty about the security of e-health systems not controlled by the local health service and sharing clinical information with external health providers, engaging GPs, and patient anxiety about the capacity of general practice to provide care. The e-care plan provided a low-risk solution to sharing patient information and supported collaborative care. Challenges to share e-care plans have implications for policy and practice., Lessons Learnt: Stakeholders and the project team agreed that finding an e-health system that supported shared cancer care in follow-up and addressed the security and information sharing concerns could not all be adequately addressed at the local level. A GP interactive e-care plan provides a promising solution to a number of the barriers., Competing Interests: None declared.

Background: Patients undergoing surgery for bowel cancer now have a routine screening test to assess their genetic predisposition to this and other cancers (Lynch syndrome). A result indicating a high risk should trigger referral to a genetic clinic for diagnostic testing, information, and management. Appropriate management of Lynch syndrome lowers morbidity and mortality from cancer for patients and their family, but referral rates are low. The aim of this project was to increase referral rates for patients at high risk of Lynch syndrome at two Australian hospitals, using the Theoretical Domains Framework (TDF) Implementation approach., Methods: Multidisciplinary teams at each hospital mapped the referral process and discussed barriers to referral. A 12-month retrospective audit measured baseline referral rates. The validated Influences on Patient Safety Behaviours Questionnaire was administered to evaluate barriers using the TDF. Results were discussed in focus groups and interviews, and interventions co-designed, guided by theory. Continuous monitoring audits assessed change in referral rates., Results: Teams (n = 8, 11) at each hospital mapped referral processes. Baseline referral rates were 80% (4/5) from 71 screened patients and 8% (1/14) from 113 patients respectively. The questionnaire response rate was 51% (36/71). Most significant barrier domains were: 'environmental context;' 'memory and decision making;' 'skills;' and 'beliefs about capabilities.' Focus groups and interviews with 19 healthcare professionals confirmed these domains as significant. Fifteen interventions were proposed considering both emerging and theory-based results. Interventions included: clarification of pathology reports, education, introduction of e-referrals, and inclusion of genetic status in documentation. Audits continued to December 2016 showing a change in pathology processes which increased the accuracy of screening. The referral rate remained low: 46% at Hospital A and 9% Hospital B. Results suggest patients who have their referral deferred for some reason are not referred later., Conclusion: Lynch syndrome is typical of low incidence problems likely to overwhelm the system as genomic testing becomes mainstream. It is crucial for health researchers to test methods and define generalizable solutions to address this problem. Whilst our approach did not improve referrals, we have deepened our understanding of barriers to referral and approaches to low frequency conditions.

Background/objectives: Adjuvant chemotherapy for Stage II colon cancer offers a small (2-3%) overall survival benefit and is not universally recommended. Mismatch repair deficiency (dMMR) confers an improved prognosis identifying patients unlikely to benefit from adjuvant chemotherapy. The aim of this study was to investigate the use of dMMR immunohistochemistry in two major cancer treatment centres., Methods: Prospective data were collected on all patients with resected Stage II colon cancer between 2010 and 2015 across two large Australian hospitals. Data collected included patient demographics, tumour histology, dMMR immunohistochemistry, chemotherapy use, and outcomes., Results: All 355 patients (56.1% female, median age 81) with resected Stage 2 Colon cancer entered on to the surgical database were included in this analysis. MMR testing was performed on 167 patient samples (47%), most occurred post-2013 (73.1% vs. 26.9% patients). dMMR rates were 34.1%. 25 (7.3%) received adjuvant chemotherapy, with no patient >80 years receiving treatment. Presence of ≥2 high-risk feature increased the likelihood of adjuvant chemotherapy. Only 3.6% dMMR patients received chemotherapy; both were young with high-risk features. 27/288 (7.6%) patients (with follow up) relapsed, with 7 disease-free post-resection of metastatic disease, 9 are alive with metastatic disease, and 11 deceased., Conclusions: Unlike clinical trial populations, Stage 2 colon cancer patients are often elderly, have high rates of dMMR tumours, are rarely offered chemotherapy, yet still have excellent outcomes. dMMR immunohistochemistry is being increasingly used to identify Stage 2 patients who do not require chemotherapy., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: This paper aimed to describe the training available and the process taken to establish a robotic colorectal surgery programme in a large Australian academic private hospital. Through this we hope to guide other surgeons and hospitals planning to introduce this technology in circumstances where such guidelines do not exist., Methods: The available training and credentialing pathways are described, including the da Vinci Surgery Training Pathway provided by Intuitive Surgical and hospital-based supports. A proposed 9-point training and credentialing pathway is presented, along with the activities undertaken by each surgeon., Results: From December 2011 to December 2013, 48 robotic colorectal procedures were performed at the Cabrini Hospital. Operations performed were as follows: 23 anterior resections, seven abdominoperineal resections, 11 rectopexies, three proctectomies and ileal pouch-anal anastomosis and four right hemicolectomies. There have been no conversions, and no major complications. There were no robot-specific complications., Conclusion: We believe that this thorough and methodical approach to introducing robotics to colorectal surgery has been safe and effective, and should be applicable to other surgeons and hospitals wishing to introduce robotic technology to colorectal surgery., (© 2014 Royal Australasian College of Surgeons.)

Objective: Colorectal neoplasia screening by computed tomographic colonography (CTC) may lead to the detection of incidental extracolonic findings. We report the prevalence and clinical significance of extracolonic pathology found within a community-based CTC screening program and the cost of clinical follow-up and further investigation of these findings., Methods: A total of 432 asymptomatic subjects at an average risk of colorectal neoplasia, aged 50-69, had screening by CTC using a low radiation dose protocol. Axial images were prospectively examined for extracolonic lesions and those considered clinically relevant were followed up. All clinic visits and further investigations were tallied to calculate the incremental cost to the screening CTC., Results: A total of 146 extracolonic lesions were detected in 118 (27.3%) subjects. Thirty-two (7.4%) subjects had clinically relevant extracolonic abnormalities and nine (2.1%) subjects may derive a clinical benefit from the detection of these lesions. A single CTC costed $171.12, and following up extracolonic findings resulted in an additional $24.37 (14.2%) per CTC. Limiting reporting to the aorta and kidneys would have reduced the number of subjects requiring follow-up to 14 (3.2%), and decreased the cost increment to 4.7% without detriment to clinical outcome., Conclusions: Extracolonic findings of screening CTC are common, but infrequent of clinical importance. The additional burden of following up these findings was modest and could have been further reduced if clear clinical and radiological criteria and pathways for their further investigation were defined.