The importance of understanding and measuring health system structural, functional, and clinical integration

OBJECTIVE

We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration.

DATA SOURCES

Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019.

STUDY DESIGN

Exploratory study using thematic comparative analysis to describe factors that may lead to high performance.

DATA COLLECTION

We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs.

PRINCIPAL FINDINGS

Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise."

CONCLUSIONS

Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

Interorganizational Context When Implementing Multisector Partnered Programs: A Qualitative Analysis of Veteran Directed Care

As the number of Veterans enrolled in the Veterans Health Administration (VHA) and at risk for needing Long Term Services and Supports increases, VHA is shifting from institutional to Home and Community Based Services, such as the Veteran-Directed Care (VDC) program. VDC is a multi-sector program implemented as a collaboration between individual VHA medical centers (VAMCs) and Aging and Disability Network Agencies (ADNAs), entities that sit outside the VHA. Factors that affect establishment of effective multi-sector programs such as VDC are poorly understood, limiting ability to effectively deliver and scale programs. We conducted a qualitative study to describe factors affecting the interorganizational implementation context of VDC. Using constructs from the Consolidated Framework for Implementation Research (CFIR), we interviewed VDC coordinators from seven different VAMC-ADNA partnerships that initiated the VDC program between 2017 and 2018. We identified eight CFIR determinants which manifested similarly for the VAMCs and ADNAs: evidence strength and quality, relative advantage, adaptability, tension for change, access to knowledge and information, self-efficacy; engaging, and champions. We identified three CFIR determinants that varied dramatically across VAMCs and ADNAs: available resources, implementation climate, and relative priority. Our results suggest that interorganizational context plays a critical and dynamic role within multi-sector collaborations.

A framework for student-led education conferences

Attendance at conferences as part of undergraduate studies is key in health professional education for exploring speciality interests, sharing research, exchanging expertise and passing on knowledge. In addition, conferences offer valuable opportunities to present work and the potential to win prizes and network with others in the field. This article provides insight and guidance into how student-led and designed health science and education conferences can be implemented more effectively. It is aimed at students hoping to organise conferences and also to clinical educators and staff who help facilitate these. We present recommendations, a framework of steps to be followed and a case study, as well as an exploration of the challenges that COVID-19 has presented and how these have been overcome.

Developing Medical Affairs Leaders Who Create the Future

Medical affairs has evolved over recent years from a support, to a partner, to a strategic leadership function. In the future, there will be significant changes in healthcare and pharmaceutical industries, and many of these will be due to technological advances and digitalisation. Medical affairs will be largely influenced by these developments in terms of partnerships with key stakeholders, embracing innovation and patient-centric healthcare, and demonstrating value for novel treatment options. In order to secure future success within their roles, medical affairs professionals will have to demonstrate specific capabilities founded on communications and behavioural change, business leadership acumen, knowledge acquisition and self-development, and the ability to generate real-world evidence from insights and expertise within data science and analytics. It will be our responsibility as medical affairs leaders to create this foundation for the leaders of tomorrow.

Evaluation of a Council Structure and Meeting Format for Pharmacy Student Government in the Co-Curriculum

Objective. To evaluate student perceptions of a transformed pharmacy student government structure and meeting format. Methods. The structure and general assembly meeting format of the University of North Carolina at Chapel Hill (UNC) Eshelman School of Pharmacy Student Senate (ie, student government) underwent a transformation from that of a forum to that of a council in an effort to address concerns regarding limited information exchange, minimal discussion, and unengaged meeting participants. To evaluate student perceptions of the new senate council format, members who attended at least one council meeting during the academic year were asked to complete a 12-item survey evaluating interorganizational relations, communication, collaboration, and efficiencies. Descriptive statistics were used to summarize students' agreement with 10 survey items. Thematic analysis was employed to identify common themes in students' responses to the two open-ended survey items. Results. The majority of students agreed or strongly agreed that the senate council facilitated interorganizational relations (86%), communication (93%), and collaboration (86%). Ninety-three percent of respondents agreed or strongly agreed that the senate council improved efficiencies, while 96% preferred the new senate council meeting format over the previous senate meeting format. Common qualitative themes included improved engagement during council meetings because of the "no laptop" policy and facilitation of open conversation by having a roundtable format and smaller number of members in attendance. Overall, 93% of students indicated they were satisfied or highly satisfied with the new meeting format. Conclusion. Student perceptions suggest that the new senate council structure and meeting format was effective at improving interorganizational relations, communication, collaboration, and efficiencies within student body government.

Report of the 2019-2020 Strategic Engagement Standing Committee

For the American Association of Colleges of Pharmacy (AACP) strategic engagement is critical to the success of colleges and schools of pharmacy in expanding pharmacy and public health practice, meeting programmatic needs, and fulfilling institutional missions. The 2019-2020 Strategic Engagement Committee was charged with exploring the collaborative relationships colleges and schools have within their state to advance pharmacy practice. More specifically, this committee was tasked to examine those relationships with current state pharmacy and medical associations. This report seeks to provide insights from this work and share recommendations to assist AACP in facilitating practice transformation. To uncover current schools' relationships with state and medical associations, the committee utilized AACP's ability in convening members to conduct focus groups at INsight 2020 and one-on-one interviews with key faculty members. Overall, partnerships with state pharmacy associations are successful or growing, whereas there is still work to be done in developing relationships and collaborating with medical and health care societies. We found that there are several schools with "best practices" related to state association collaborations and look to highlight exemplar practices in this report as they are critical towards practice transformations.

Lessons of COVID-19: A roadmap for post-pandemic science

The response to the COVID-19 crisis across most research institutions mandated ceasing nonessential research activities in order to minimize the spread of the virus in our communities. With minimal notice, experiments were terminated, cell lines were frozen, mouse colonies were culled, and trainees were prevented from performing bench research. Still, despite the interruption of experimental productivity, the shutdown has proven for many PIs and trainees that doing and thinking science are not activities that are bound to the laboratory. Furthermore, the shutdowns have solidified important emerging trends and forced us to further innovate to get the most out of working remotely. We hope that some of these innovations, hard-gained in this difficult time, will persist and develop into new paradigms-lessons that will improve our science and our relationship to the climate and community beyond the current pandemic.

Cross-Sector Collaboration for a Healthy Living Environment-Which Strategies to Implement, Why, and in Which Context?

BACKGROUND

Working toward a healthy living environment requires organizations from different policy domains and nongovernment partners involved in public health and the living environment to collaborate across sectors. The aim of this study is to understand how this cross-sector collaboration for a healthy living environment can be achieved.

METHODS

The realist evaluation approach was used to investigate what strategies can be used in which contexts to achieve cross-sector collaboration. The "Collaborative Adaptive Health Networks" framework was used as a theoretical framework. Seventeen partners of three Dutch projects collaborating for a healthy living environment in different regions were interviewed about their experiences during the initiating phase of their projects.

RESULTS

Seven themes for achieving cross-sector collaboration were identified, namely creating a feeling of equivalence, building trust, bridging different perspectives, providing clarity regarding roles and tasks, creating commitment, creating active engagement, and understanding whom to engage and when. For each theme, the strategies that were used, and why, were specified.

CONCLUSION

This study provides new insights in how cross-sector collaboration for a healthy living environment can be achieved in different contexts. Whether the start of a cross-sectoral collaboration is successful is largely influenced by the choice of leadership and the interorganizational relations.

Sampling method for surveying complex and multi-institutional partnerships: lessons from the Global Polio Eradication Initiative

BACKGROUND

Complex global initiatives, like the Global Polio Eradication Initiative (GPEI), have prevented millions of paralyses and improved the health status of diverse populations. Despite the logistical challenges these initiatives must overcome at several levels, scant methods exist for systematically identifying and reaching a range of actors involved in their implementation. As a result, efforts to document the lessons learned from such initiatives are often incomplete. This paper describes the development and application of the Synthesis and Translation of Research and Innovations from Polio Eradication (STRIPE) systematic approach for identifying a comprehensive sample of actors involved in the GPEI.

RESULTS

The survey for collecting lessons learned from the GPEI was conducted at the global level and within seven countries that represented GPEI operational contexts. Standard organizational and operational levels, as well as goals of program activities, were defined across contexts. Each survey iteration followed similar methodologies to theorize a target population or "universe" of all polio-related actors in the study area, enumerate a source population of specific individuals within the target population, and administer the survey to individuals within the source population. Based on the systematic approach used to obtain a comprehensive sample for lessons learned in GPEI, steps for obtaining a comprehensive sample for studying complex initiatives can be summarized as follows: (i) State research goal(s); (ii) Describe the program of interest; (iii) Define a sampling universe to meet these criteria; (iv) Estimate the size of the sampling universe; (v) Enumerate a source population within the universe that can be feasibly reached for sampling; (vi) Sample from the source population; and (vii) Reflect on the process to determine strength of inferences drawn.

CONCLUSIONS

The application of these methods can inform future evaluations of complex public health initiatives, resulting in better adoption of lessons learned, ultimately improving efficacy and efficiency, and resulting in significant health gains. Their use to administer the STRIPE lessons learned survey reflects experiences related to implementation challenges and strategies used to overcome barriers from actors across an extensive range of organizational, programming, and contextual settings.

Federated learning in medicine: facilitating multi-institutional collaborations without sharing patient data

Several studies underscore the potential of deep learning in identifying complex patterns, leading to diagnostic and prognostic biomarkers. Identifying sufficiently large and diverse datasets, required for training, is a significant challenge in medicine and can rarely be found in individual institutions. Multi-institutional collaborations based on centrally-shared patient data face privacy and ownership challenges. Federated learning is a novel paradigm for data-private multi-institutional collaborations, where model-learning leverages all available data without sharing data between institutions, by distributing the model-training to the data-owners and aggregating their results. We show that federated learning among 10 institutions results in models reaching 99% of the model quality achieved with centralized data, and evaluate generalizability on data from institutions outside the federation. We further investigate the effects of data distribution across collaborating institutions on model quality and learning patterns, indicating that increased access to data through data private multi-institutional collaborations can benefit model quality more than the errors introduced by the collaborative method. Finally, we compare with other collaborative-learning approaches demonstrating the superiority of federated learning, and discuss practical implementation considerations. Clinical adoption of federated learning is expected to lead to models trained on datasets of unprecedented size, hence have a catalytic impact towards precision/personalized medicine.

How can cities tackle hoarding? Examining an intervention program bringing together fire and health authorities in Vancouver

Hoarded homes can pose a threat to public safety, with heightened risks of fire hazards, pest infestations and noxious odours in both the home and neighbouring dwellings. Communities across North America are responding to these public safety concerns through a harm reduction approach. This descriptive study explores the implementation and outcomes of the City of Vancouver's approach involving a partnership between fire prevention and public health. Data were collected from the team's 2016-2018 case tracking systems, consisting of health records and team intervention record, as well as notes taken from case briefing meetings. Study objectives included describing the intervention model, providing descriptive statistics on clients and their clutter volume, the interventions undertaken, and exploring predictors of clutter volume and case outcome through exploratory analyses. The sample included 82 cases involving severely hoarded conditions or more moderate hoarding conditions paired with additional client vulnerabilities (e.g. health conditions, frailty). Results from paired samples t-tests and regression analysis, suggest the Hoarding Action Response Team's (HART) model of a community-based intervention for hoarding was associated with clutter reduction and tenancy preservation. HART successfully maintained engagement with most clients, and most cases were closed within six home visits. Despite these successes, the team dealt with several barriers including client avoidance and limited resources. This paper provides guidance for communities who are working to develop a coordinated response to problems associated with hoarding and begins to establish expectations for what can be achieved through a community-based hoarding intervention model.

The Impact of Comprehensive Community Initiatives on Population-Level Child, Youth, and Family Outcomes: A Systematic Review

Comprehensive community initiatives (CCIs) represent a popular method for creating systemic change, yet there is a dearth of evidence on their effectiveness (Zaff, Pufall Jones, Donlan, Lin, & Anderson, 2016). This article presents a systematic review of the evidence on the population-level impact of CCIs, focusing specifically on documented effects from studies using an experimental or quasi-experimental design. Of 1,947 articles identified through a database and hand search, 25 articles examining six different CCIs-most of which employed prevention science frameworks-met the review inclusion criteria. The results of this review show that CCIs can strengthen protective factors and reduce risk factors, delay initiation of and reduce substance use, and reduce the likelihood of, and delay engagement in, violent and/or delinquent behaviors. Impacts have been documented as soon as one year after initial intervention, and as early as 7^th grade, with effects sustained as long as seven years post-intervention, and as late as a year post-high school. However, relative to the prevalence of CCIs as a practical intervention, the evidence base is small, potentially dated, and focused on a narrow set of outcomes and populations. Recommendations for interpreting the evidence base are discussed, including methodological limitations and implications for future work.

Translating research into practice: Protocol for a community-engaged, stepped wedge randomized trial to reduce disparities in breast cancer treatment through a regional patient navigation collaborative

BACKGROUND

Racial and socioeconomic disparities in breast cancer mortality persist. In Boston, MA, Black, Non-Hispanic women and Medicaid-insured individuals are 2-3 times more likely to have delays in treatment compared to White or privately insured women. While evidence-based care coordination strategies for reducing delays exist, they are not systematically implemented across healthcare settings.

METHODS

Translating Research Into Practice (TRIP) utilizes community engaged research methods to address breast cancer care delivery disparities. Four Massachusetts Clinical and Translational Science Institute (CTSI) hubs collaborated with the Boston Breast Cancer Equity Coalition (The Coalition) to implement an evidence-based care coordination intervention for Boston residents at risk for delays in breast cancer care. The Coalition used a community-driven process to define the problem of care delivery disparities, identify the target population, and develop a rigorous pragmatic approach. We chose a cluster-randomized, stepped-wedge hybrid type I effectiveness-implementation study design. The intervention implements three evidence-based strategies: patient navigation services, a shared patient registry for use across academic medical centers, and a web-based social determinants of health platform to identify and address barriers to care. Primary clinical outcomes include time to first treatment and receipt of guideline-concordant treatment, which are captured through electronic health records abstraction. We will use mixed methods to collect the secondary implementation outcomes of acceptability, adoption/penetration, fidelity, sustainability and cost.

CONCLUSION

TRIP utilizes an innovative community-driven research strategy, focused on interdisciplinary collaborations, to design and implement a translational science study that aims to more efficiently integrate proven health services interventions into clinical practice.

[Partnership experience between an international and local NGO in Djibouti]

INTRODUCTION

This article relates and analyzes a partnership between a local and an international organization settled both in Djibouti.Purpose of research: From the very beginning, ongoing observational and analytical assessment allowed for a complete study of the entire partnership process, from the initial replies to calls for projects to the completion of projects.

RESULTS

Results are given from two angles. A factual narrative of the partnership first illustrates some behaviors, and then the whole partnership is analyzed.

CONCLUSIONS

Authors conclude that structural, functional and ethical asymmetry between both structures, as they are not of equal weight. Although they may be willing to work together and are complementary, this asymmetry produces a force-ratio absolutely unsuitable for project enhancement. Moreover, it pleads for aid localization and for local structures dedicated to development.localization and for local structures dedicated to humane development.

Tobacco Industry Interference Index: Implementation of the World Health Organization's Framework Convention on Tobacco Control Article 5.3 in India

In India, there has been no attempt to measure the implementation of World Health Organization's Framework Convention on Tobacco Control Article 5.3, which provides guidelines to address tobacco industry interference (TII). This study draws on a desk review conducted to assess the frequency and severity of TIIs and the government's response, reported between January and December 2017. This study highlights that the government of India does not allow tobacco industry to participate in policy development. However, the industry interferes by collaborating with the government's allied organizations. The tobacco industry has diversified as food industry in India, and directly or indirectly supports various government programs, by investing through their corporate social responsibility schemes. In addition, there are limited legislative measures to allow transparency in adoption of Article 5.3 guidelines across the country. Hence, the findings of this study underscore an exigent need to adopt and implement Article 5.3 at the national level in India.

Mental health care in Berlin

Aim

To provide information on the mental health care system in Berlin, Germany.

Method

Using available data we report on the spectrum of mental health care services provided in Berlin, the number of professionalsworking in these sectors, funding arrangements, pathways into care, and user/carer involvement.

Results

The health care system in Berlin consists of a network of inpatient, outpatient, ancillary, and rehabilitative facilities, all of which are meant to work in a synergistic fashion. However, although the individual treatment options are generally well-planned, there is still a lack of co-ordination between them. Currently, the entire network is threatened by cuts in state funding for ancillary and rehabilitative services, by further reductions in the number of hospital beds, and by insurance company cuts in prescription drug budgets, such as those used for atypical antipsychotics in outpatient care.

Discussion

Despite many similarities with the situation in other European capitals, the system of mental health care in Berlin suffersfrom a variety of problems related to co-ordination and costs that are unique to the German capital.

Partnerships, Processes, and Outcomes: A Health Equity-Focused Scoping Meta-Review of Community-Engaged Scholarship

In recent decades, there has been remarkable growth in scholarship examining the usefulness of community-engaged research (CEnR) and community-based participatory research (CBPR) for eliminating health inequities.This article seeks to synthesize the extant literature of systematic reviews, scoping reviews, and other related reviews regarding the context, processes, and research designs and interventions underlying CEnR that optimize its effectiveness. Through a scoping review, we have utilized an empirically derived framework of CBPR to map this literature and identify key findings and priorities for future research. Our study found 100 reviews of CEnR that largely support the CBPR conceptual framework.

Core strategies, social processes, and contextual influences of early phases of implementation and statewide scale-up of group prenatal care in South Carolina

This mixed-methods process evaluation examined a state-wide, interagency collaborative in South Carolina that expanded CenteringPregnancy group prenatal care from two to five additional healthcare practices from 2012 to 2015. The evaluation focused on delineating core processes, strategies, and external contextual elements of group prenatal care implementation and scale-up. Success of this scale-up was enhanced by the effective use and creation of windows of opportunity, which allowed stakeholders to pursue actions consistent with their own values, at both state and organizational levels. Most importantly, strong political advocacy and state-level financial commitment for group prenatal care made it possible for clinics throughout South Carolina to begin providing CenteringPregnancy to their patients. Improved understanding of the processes involved in scaling-up pilot interventions may enhance the effectiveness and efficiency of future expansion efforts.

Academic health sciences libraries and affiliated hospitals: a conversation about licensing electronic resources

Objective: Libraries in academic health centers may license electronic resources for their affiliated hospitals, as well as for their academic institutions. This study examined the current practices of member libraries of the Association of Academic Health Sciences Libraries (AAHSL) that provide affiliated hospitals with access to electronic information resources and described the challenges that the libraries experienced in providing access to the affiliated hospitals.Methods: In September 2016, AAHSL library directors received an email with a link to an online survey.Results: By December 2016, representatives from 60 AAHSL libraries responded. Two-thirds of the responding libraries supplied online information resources to more than 1 hospital, and 75% of these libraries provided the hospitals with access both on site and remotely. Most (69%) libraries licensed the same resource for both the academic institution and the hospitals. Cost, license negotiation, and communication with hospital stakeholders were commonly reported challenges.Conclusion: Academic health sciences libraries with affiliated hospitals continue to grapple with licensing and cost issues. This article has been approved for the Medical Library Association’s Independent Reading Program.

Report from the Medical Library Association's InSight Initiative Summit 3: Bridge Building: What Bridges to Build and How

At the Medical Library Association’s Insight Initiative Summit 3, held June 12–13, 2019, academic and hospital librarians joined with publishing industry partners to identify vexing problems in publishing and accessing health sciences information. Through a mixture of panel discussions with health sciences faculty, librarians, and information providers; small-group problem-solving exercises; and large-group consensus-building activities, the summit program invited participants to appreciate each other’s viewpoints and propose a collaborative project leading to tangible outcomes that could ultimately benefit end users. Several vexing problems were identified, including poor communication and mistrust between librarians and publishers, complexities in product pricing structures and licenses, and users’ difficulties in accessing and using vetted information resources. However, librarians and publishers agreed that building a better shared understanding of users’ needs and behavior would be the most useful bridge toward regaining trust, establishing more effective partnerships, and designing and delivering quality information resources that are easily accessible and maximally useful to health sciences researchers, educators, clinicians, and students.