The Trans-Hospital: Multidisciplinary Care to Patients with Abdominal Aortic Aneurysm: Evidence-based practice in collaborative teams

Abstract

A key feature of modern healthcare systems is the introduction of pathways – or treatment chains – to drive standardization of care and the practice of evidence-based-medicine (EBM) as expressed in clinical practice guidelines. Information Systems and Quality Improvement programs form a central support framework for this policy. However, guideline-based care is complicated by the fact that many care processes are continually changing. In particular, the development period for medical technology and the corresponding therapies in which they are used can span decades. Further complicating this matter is the advance in multidisciplinary care teams. This contrast between emerging clinical therapies that change and develop over time, and a support framework designed to promote standardization of care makes it interesting as a research topic. The PhD research has targeted the following principle research aims:

• Gain insights into how multidisciplinary teams deal with the challenges of evolving clinical therapies while working in frameworks designed to promote standardized care.

• Use these insights to identify principles for how work in evolving clinical therapies can be more systematically supported and enhanced.

The present research has been undertaken in the context of a care process for Abdominal Aortic Aneurysm (AAA) patients, in which a multidisciplinary team of experts in vascular surgery and radiology provides advanced EndoVascular Aneurysm Repair (EVAR).

Management of an AAA includes active vascular surgical surveillance to monitor and detect changes in the aneurysm with the prospect of preemptive surgery. Left untreated, the aneurysm can rupture which is usually fatal. There are two types of surgery: open repair that carries a major risk for the patient, and the less invasive EVAR, that uses a medical device implant: the stent-graft. Suitability for EVAR depends on anatomical features of the aorta, restricting the use of this treatment. EVAR is mainly practiced at university clinics, and after 15 - 20 years of development, there are still no definite guidelines.

The PhD project comprises two studies with a collection of four papers. The first study focuses on the care process in the AAA surveillance program of one university hospital and two collaborating community hospitals. The main findings can be summarized as: Conceptualization of the notion ‘Community of guidance’ to illustrate that evidence as communal may secure medical treatment in the often very long period of technical-surgical development without formalized institutions, training, or guidelines. The influence of key contextual factors intertwined with expertise traits is, however, central for EVAR progress. Secondly, the notion ‘Resilience behavior’ was adopted to characterize how the clinicians mitigated risks to compensate for the lacks in existing support framework.

The second study builds on the findings from the first study and provides, to the best of my knowledge, the first Norwegian nationwide study that reports on patterns of incidence, handling, and outcome for the cohort of patients hospitalized with aneurysm rupture.

Three principles were found to be critically important for future clinical work support: 1) to account for the move from single care provider to actors that team up across professional and hospital boundaries, 2) to establish tools that allow learning from past experiences both for individual as well as cohorts of patients, and 3) to establish tools that can support long-term monitoring of patients to limit the number of drop-outs.

The overall contribution of this work is a proposed knowledge-based model for multidisciplinary surgical evidence-based practice. This model provides a useful framework to guide policies on future organizational and technological solutions that can support care providers’ practice of care.