Factors that determine patients considering medication for the disease of obesity: an IMI2 SOPHIA study

OBJECTIVE

Obesity-related problems can now be managed with effective nutritional therapy, pharmacotherapy, and surgeries that achieve >10% weight loss. Assessing patient preferences, treatment choices, and factors affecting patients can improve treatment compliance and efficacy. Our aim was to identify factors affecting patient preference and subsequent choice of pharmacotherapy among those seeking treatment for obesity-related disorders.

METHODS

A participatory action study using purposeful sampling recruited 33 patients with obesity complications. They were referred to specialist clinics in non-alcoholic fatty liver disease, diabetes mellitus, hypertension, and chronic kidney disease. Sixteen males and seventeen females aged 18-70 years, with BMI > 35 kg/m2 were recruited. Before the interview, participants watched a 60-minute video explaining nutritional therapy, pharmacotherapy, and surgery in equipoise. Data were collected in semi-structured interviews; Reflective thematic analysis was used. This sub study focuses only on patients who expressed specific attitudes (positive or negative) towards pharmacotherapy.

RESULTS

Ten (30%) patients expressed a view on pharmacotherapy. Eight (24%) patients chose pharmacotherapy alone, whereas two (6%) patients chose pharmacotherapy combined with nutritional therapy. In this sub study focusing on pharmacotherapy, five themes were identified related to choosing whether or not to take medication: (1) attitudes towards pharmacotherapy, (2) attitudes toward size of obesity and its complications, (3) weighing the benefits and risks of treatment, (4) knowledge and reassurance of health professionals, and (5) costs associated with drug therapy.

CONCLUSION

The primary concerns regarding pharmacotherapy for intentional weight loss were efficacy, side effects, lifelong dosing, pharmacokinetics, and cost. Providing access to information about all the pharmacotherapies and the benefits is likely to result in greater penetrance of treatment.

Value-based health care in translation: From global popularity to primary care for Dutch elderly patients

In this article we examine the fragmented interpretation and implementation of a remarkably popular concept, value-based health care (VBHC). By building on a case study of a project team working on the development of value-based primary care services for elderly patients, we shed new light on the way in which VBHC transitions from theory to practice. The concept of 'translation' is used to theoretically frame our analysis. Between June 2021 and May 2022, we gathered data through participant observation (50 h), semi-structured interviews (n = 20) and document analysis (n = 16). Our findings show how VBHC inspired new ways of working, and that, in line with previous studies, parts of the original concept have been neglected, while others have been modified. We identified three reasons for VBHC's locally varied applications: VBHC transforms to enable a growing support base, the originally radical idea is applied conservatively and the concept tends to get mixed up with other policy objectives. In all, VBHC appears to be successful in catalysing cross-disciplinary interaction aimed at improving value for patients.

Shifting gears: Creating equity informed leaders for effective learning health systems

Leadership is vital to a well-functioning and effective health system. This importance was underscored during the COVID-19 pandemic. As disparities in infection and mortality rates became pronounced, greater calls for equity-informed healthcare emerged. These calls led some leaders to use the Learning Health System (LHS) approach to quickly transform research into healthcare practice to mitigate inequities causing these rates. The LHS is a relatively new framework informed by many within and outside health systems, supported by decision-makers and financial arrangements and encouraged by a culture that fosters quick learning and improvements. Although studies indicate the LHS can enhance patients' health outcomes, scarce literature exists on health leaders' use and incorporation of equity into the LHS. This article begins addressing this gap by examining how equity can be incorporated into LHS activities and discussing ways leaders can ensure equity is considered and achieved in rapid learning cycles.

Effectiveness and Experiences of Quality Improvement Interventions in Older Adult Care: Protocol for a Mixed Methods Systematic Review

BACKGROUND

Quality improvement (QI) interventions are designed to resolve the recurring challenges of care for older individuals, such as working conditions for staff, roles of older individuals in their own care and their families, and relevant stakeholders. Therefore, there is a need to map the impacts of QI interventions in older adult care settings and further improve health and social care systems associated with older adults.

OBJECTIVE

This review aims to compile and synthesize the best available evidence regarding the effectiveness of policy and practice QI interventions in older adult care. The secondary aim is to understand the care of older individuals and QI intervention-related experiences and perspectives of stakeholders, care providers, older individuals, and their families.

METHODS

The mixed methods review will follow the standard methodology used by Joanna Briggs Institute. The published studies will be searched through CINAHL, MEDLINE, PsycINFO, ASSIA, and Web of Science, and the unpublished studies through Mednar, Trove, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative analyses of patients undergoing older adult care and any health and care professionals involved in the care delivery for older adults; a broad range of QI interventions, including assistive technologies, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; the context of older adult care setting; and a broad range of outcomes, including patient safety. The standard procedure for reporting, that is, PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, will be followed.

RESULTS

A result-based convergent synthesis design will be used in which both quantitative and qualitative studies will be analyzed separately, and the results of both syntheses will be then integrated during a final (convergent) synthesis. The integration will compare the findings of quantitative and qualitative evidence using tables in light of the results of both syntheses.

CONCLUSIONS

This comprehensive review is expected to reflect on the insights into some QI interventions and their impact, outline some common challenges of quality for older adult care, and benefit both the practical usefulness of care service activities and the society at large.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/56346.

The Right to Equal Health: Best Practice Priorities for Māori with Bipolar Disorder from Staff Focus Groups

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Māori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Māori, studies show that Māori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Māori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Māori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Māori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Māori patients with BD and their whānau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Māori with BD.

A Discourse Study on Handover Communication Among Care Providers in a Residential Care Home for Persons with Intellectual Disabilities

Abundant research has focused on handovers among nurses and/or doctors in hospitals; far less is known about handovers among care providers in non-clinical contexts, such as care homes for the elderly or the disabled. Focusing on handovers in a residential care home for persons with intellectual disabilities (RCHID), this study argues that handover communication in non-clinical settings is equally important. Ineffective handovers can lead to the deterioration of the residents' health conditions, chaotic situations and even injuries to both care providers and care recipients. Staff in RCHIDs rely heavily on handover communication to obtain information about the residents' needs and to offer appropriate care services. Combining discourse analysis with interactional sociolinguistics, this study analyzes written and spoken discourses involved in handover communication among care providers in a typical RCHID in Hong Kong to investigate what and how communicative functions were achieved through the participants' language use. The data were collected by convenience sampling, including handwritten notes and handover recordings of twelve sessions. Then a group interview of seven care providers was conducted to obtain supplementary data. Findings suggest that handover communication includes informational and interpersonal functions. While information delivery is the main purpose, care providers also establish relationships with one another through small talk about care home residents. The results suggest potential drawbacks of the handovers, including illegible notes, inconsistent information collection, and low interactivity. This study proposes a model that elucidates the correlation between discourse, handover communication and healthcare services, and suggests strategies to enhance such communication.

Barriers to healthcare-worker adherence to infection prevention and control practices in British Columbia during the coronavirus disease 2019 (COVID-19) pandemic: A cross-sectional study

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of robust infection prevention and control (IPAC) practices to maintain patient and staff safety. However, healthcare workers (HCWs) face many barriers that affect their ability to follow these practices. We identified barriers affecting HCW adherence to IPAC practices during the pandemic in British Columbia, Canada.

DESIGN

Cross-sectional web-based survey.

SETTING

Acute care, long-term care or assisted living, outpatient, mental health, prehospital care, and home care.

PARTICIPANTS

Eligible respondents included direct-care providers and IPAC professionals working in these settings in all health authorities across British Columbia.

METHODS

We conducted a web-based survey from August to September 2021 to assess respondent knowledge and attitudes toward IPAC within the context of the COVID-19 pandemic. Respondents were asked to rate the extent to which various barriers affected their ability to follow IPAC practices throughout the pandemic and to make suggestions for improvement.

RESULTS

The final analysis included 2,488 responses; 36% of respondents worked in acute care. Overall, perceptions of IPAC practice among non-IPAC professionals were positive. The main self-perceived barriers to adherence included inadequate staffing to cover absences (58%), limited space in staff rooms (57%), multibed rooms (51%), and confusing messages about IPAC practices (51%). Common suggestions for improvement included receiving more support from IPAC leadership and clearer communication about required IPAC practices.

CONCLUSIONS

Our findings highlight frontline HCW perspectives regarding priority areas of improvement for IPAC practices. They will inform policy and guideline development to prevent transmission of COVID-19 and future emerging infections.

Enrichment of core competencies to maximize health system impact: An analysis of an embedded research training program

Introduction

The Health System Impact (HSI) Fellowship is an embedded research training program that aims to prepare doctoral trainees and postdoctoral fellows for stronger career readiness and greater impact as emerging leaders within and beyond the academy, including in learning health systems (LHS). The program supports fellows to develop 10 leadership and research competencies that comprise the Enriched Core Competency Framework in Health Services and Policy Research through a combination of experiential learning, mentorship, and professional development training. This study tracks competency development of HSI fellows over time and examines fellows' perspectives on which program design elements support their competency development.

Methods

A competency assessment tool developed for the program was independently completed by 95 postdoctoral and 36 doctoral fellows (self-assessments) and their respective 203 dyad (academic and health system) supervisors in the 2017 to 2019 program cohorts, who independently rated the strength of fellows' 10 competencies at baseline and several points thereafter. Competency strength ratings were analyzed to understand change over time and differences in ratings across groups (between fellows' sex, supervisor type, and supervisor vs. fellow). Program design element ratings were examined to understand perspectives on their contribution toward fellows' competency development.

Results

Fellows' competency strength significantly improved in all 10 domains over time, based on independent assessments by the fellows and their dyad supervisors. Supervisors tended to rate the fellows' competency strength higher than the fellows did. Differences in competency ratings between male and female fellows (self-assessments) and between academic and health system supervisors were either negligble or not significant. Fellows identified all nine program design elements as enriching their competency development.

Conclusion

The HSI Fellowship provides an opportunity for fellows to develop the full suite of enriched core competencies and to prepare a cadre of emerging leaders with the skills and experience to contribute to the advancement of LHS.

Identifying performance indicators to measure overall performance of telephone triage - a scoping review

OBJECTIVE

This article aims to summarize performance indicators used in telephone triage services research, and make recommendations for the selection of valid indicators to measure the performance of telephone triage. We describe what kind of frameworks, performance indicators, or variables have been used for evaluating telephone triage performance by systematically mapping the telephone triage performance measurement. The objective was to find measures for each Triple Aim dimension.

DESIGN

A scoping review method was used following Joanna Briggs Institute guidelines. Using this method, we defined indicators to measure the performance of telephone triage. We used the Triple Aim framework to identify indicators to measure the overall performance of telephone triage. The Triple Aim framework consists of improving the patient experience of care, improving the health of populations, and reducing cost per capita.

SETTING

The scoping review was performed using CINAHL, Medline, EBSCOhost, and PubMed electronic databases. The eligibility criterion was research published in English between 2015 and 2023. The inclusion focused on the use and performance of telephone triage services and system-focused studies.

RESULTS

A total of 1098 papers were screened for inclusion, with 57 papers included in our review. We identified 13 performance indicators covering all Triple Aim dimensions: waiting times, access, patient satisfaction, the accuracy of triage decision, severity and urgency of the symptoms, triage response, patient compliance with the advice given, follow-up healthcare service use, and running costs of service. We didn't find any earlier framework covering all Triple Aim dimensions properly.

CONCLUSIONS

Measuring the performance of telephone triage requires an extensive and comprehensive approach. We presented performance indicators that may be included in the framework for measuring the performance of telephone triage to support overall performance measurements of telephone triage.

Development and Initial Validation of a Questionnaire Measuring Self-management Strategies that Promote Psychological Health at Work

BACKGROUND

Self-management strategies have been identified as a promising avenue to promote mental health and functioning at work. However, the absence of a validated questionnaire to assess the use of strategies that can be adopted in the workplace has limited empirical research on this topic. This study seeks to develop and validate a questionnaire measuring mental health self-management strategies used by workers to promote their mental health and functioning at work: the Workplace Mental Health Self-Management Questionnaire (WMHSQ).

METHODS

An initial list of 72 self-management strategies was generated from the content of 25 interviews conducted with workers experiencing depressive or anxiety symptoms. Content experts on mental health at work identified the 47 most relevant items. To validate the WMHSQ, 365 workers completed the WMHSQ and criterion-related measures (depressive and anxiety symptoms, work functioning, self-management and coping). Two weeks later, 235 participants completed the WMHSQ once again.

RESULTS

Principal component analysis revealed a four-factor solution composed of 21 self-management strategies: Managing Thoughts and Emotions, Managing Recovery, Managing Relationships and Managing Tasks. The WMHSQ shows adequate internal consistency and test-retest reliability. Correlational analyses support convergent and concurrent validity.

LIMITATIONS

Since this is an initial psychometric validation of the WMHSQ, only an exploratory factor analysis was performed. It will therefore be important to validate the structure of this new psychometric tool through confirmatory factor analysis in a subsequent study.

CONCLUSIONS

The strategies identified in the WMHSQ can form the basis for developing practical tools and interventions to promote mental health self-management at work.

The Limitations and Potentials of Evaluating Economic Aspects of Community-Based Health Promotion: A Critical Review

Community-based health promotion (CBHP) interventions are promising approaches to address public health problems; however, their economic evaluation presents unique challenges. This review aims to explore the opportunities and limitations of evaluating economic aspects of CBHP, focusing on the assessment of intervention costs and outcomes, and the consideration of political-level changes and health equity. A systematic search of the PubMed, Web of Science and PsycInfo databases identified 24 CBHP interventions, the majority of which targeted disadvantaged communities. Only five interventions included a detailed cost/resource assessment. Outcomes at the operational level were mainly quantitative, related to sociodemographics and environment or health status, while outcomes at the political level were often qualitative, related to public policy, capacity building or networks/collaboration. The study highlights the limitations of traditional health economic evaluation methods in capturing the complexity of CBHP interventions. It proposes the use of cost-consequence analysis (CCA) as a more comprehensive approach, offering a flexible and multifaceted assessment of costs and outcomes. However, challenges remain in the measurement and valuation of outcomes, equity considerations, intersectoral costs and attribution of effects. While CCA is a promising starting point, further research and methodological advancements are needed to refine its application and improve decision making in CBHP.

Population-based integrated care funding values and guiding principles: An empirical qualitative study

There is wide agreement on the benefits of integrated care; yet funding barriers persist. We suggest that funding models could currently hinder quality of care and that identifying values is necessary to designing adequate funding models. Yet it is currently unclear what are these values that ought to shape healthcare policy decisions. To fill in this gap, we conducted semi-structure interviews with fourteen health policy officials, managers, and researchers to elicit and explore how they conceptualize the values and guiding principles underlying these funding policies. Our findings suggest that values guide population-based integrated funding models, namely: accountability & integrity, transparency, equity, and innovation. Overall, funding mechanisms could incentivize integrated population-based care when the following conditions are met: a) there is transparent governance, with a whole-system approach, political will, and engagement and collaboration across health system partners, organizations and institutions, b) regulatory and evaluative frameworks support accountability including in decision-making, in outcomes and quality of care, as well as financial accountability; c) funding is equitable with a fair distribution of resources and supports accessibility to services; and d) funding mechanisms design and implementation include innovation enabling change, which are continuously evaluated. These values and guiding principles could be used in the development of funding models and future studies need to evaluate the effect of these values on decisions made by policy makers with respect to funding allocations and investments.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

Disinfection of flexible fibre-optic endoscopes out-of-hours: confidential telephone survey of ENT units in England - 20 years on

BACKGROUND

Flexible upper aerodigestive endoscopy is often performed in the emergency setting. To prevent nosocomial infection on-call clinicians must have access to decontaminated endoscopes.

METHODS

A telephone survey of 104 ENT units in England replicated previous cycles conducted 10 and 20 years ago. The on-call clinician was asked about decontamination practices, training and cross-cover.

RESULTS

Seventy-one clinicians participated of which 68 had an endoscope available out-of-hours. Twenty-five (36.8 per cent) used single-use endoscopes. Twenty-three (51.1 per cent) of the 45 clinicians using re-usable endoscopes decontaminated them themselves, an increase from 43.3 per cent in 2013 and from 35.1 per cent in 2002. Overall 91.2 per cent had safe practices, up from 68.7 per cent in 2013 and 48 per cent in 2002. One hundred per cent had been trained in decontamination, compared to 37.3 per cent in 2013 and 12.1 per cent in 2002. On-call clinicians from the ENT department increased to 91.5 per cent, compared to 63 per cent in 2013.

CONCLUSION

There has been a dramatic increase in patient safety, underpinned by the introduction of single-use endoscopes, increased training and reduced cross-cover.

Evaluating engagement with equity in Canadian provincial and territorial primary care policies: Results of a jurisdictional scan

Equitable access to primary care is essential to achieving more equitable health outcomes, yet evidence suggests that structurally marginalized populations are less likely to have benefited from varied primary care reforms in Canada. Our objective is to determine how equity is incorporated in public primary care policy and strategy documents across Canada. We conducted string term and snowball searches for provincial/territorial primary care policy documents published between 01 January 2018 and 30 June 2022, extracted the policy objective, and applied a rubric to evaluate each document's engagement with equity. We performed content analysis of the documents which acknowledged inequities and articulated a related policy response. Of the 224 identified documents that discussed primary care policy: 63 (28 %) identified one or more structurally marginalized group(s) experiencing inequities related to primary care, 64 (29 %) identified a structurally marginalized group and articulated a policy response, and 16 (7 %) articulated a detailed policy response to address inequities. Even where policy responses were articulated, in most cases these did not directly address the acknowledged inequities. The absence of measurable goals, meaningful community consultation, and tenuous connections between the policy response and inequities mentioned may help explain persistent inequities in primary care across Canada.

The effect of a prospective intervention program with automated monitoring of hand hygiene performance in long-term and acute-care units at a Veterans Affairs medical center

OBJECTIVE

To measure the impact of an automated hand hygiene monitoring system (AHHMS) and an intervention program of complementary strategies on hand hygiene (HH) performance in both acute-care and long-term care (LTC) units.

DESIGN

Prospective, nonrandomized, before-and-after intervention study.

SETTING

Single Veterans Affairs Medical Center (VAMC), with 2 acute-care units and 6 LTC units.

METHODS

An AHHMS that provides group HH performance rates was implemented on 8 units at a VAMC from March 2021 through April 2022. After a 4-week baseline period and 2.5-week washout period, the 52-week intervention period included multiple evidence-based components designed to improve HH compliance. Unit HH performance rates were expressed as the number of dispenses (events) divided by the number of patient room entries and exits (opportunities) × 100. Statistical analysis was performed with a Poisson general additive mixed model.

RESULTS

During the 4-week baseline period, the median HH performance rate was 18.6 (95% CI, 16.5-21.0) for all 8 units. During the intervention period, the median HH rate increased to 21.6 (95% CI, 19.1-24.4; P < .0001), and during the last 4 weeks of the intervention period (exactly 1 year after baseline), the 8 units exhibited a median HH rate of 25.1 (95% CI, 22.2-28.4; P < .0001). The median HH rate increased from 17.5 to 20.0 (P < .0001) in LTC units and from 22.9 to 27.2 (P < .0001) in acute-care units.

CONCLUSIONS

The intervention was associated with increased HH performance rates for all units. The performance of acute-care units was consistently higher than LTC units, which have more visitors and more mobile veterans.

A qualitative analysis of free-text patient satisfaction responses in Care Response, a database of patient-reported outcome and experience measures

BACKGROUND

Databases have become important tools in improving health care. Care Response is a database containing information on tens of thousands of chiropractic patients internationally. It has been collecting patient-reported outcomes and patient satisfaction information for more than 10 years. The purpose of this study was to contribute to the understanding of patient perceptions and priorities for chiropractic care by analysing free text entered into the patient reported experience measure (PREM) questionnaires within the Care Response system.

METHODS

There were two questions of interest on the PREM for this study. One requested information about "good points" patients perceived about patients' care experience, and the other requested information on "improvements" that could make the experience better. We conducted a word frequency analysis using a word counting macro in Microsoft Word, then used those results as a starting point for a qualitative analysis. Data were collected on 30 May 2022.

RESULTS

The people who participated in the Care Response system often reported positive experiences with their chiropractors, including that they had reduced pain, improved function, and felt validated in their clinical condition. In addition, they appreciated having diagnostic and treatment procedures explained to them. They valued friendly, professional, and on-time service. The negative experiences were the opposite: being rushed through treatment, that the treatment was not worth the cost, or that they weren't treated professionally, empathetically, or with respect for them as individuals. The most important themes that emerged under "good points" were satisfaction (with care), value (as a person), safety, comfort, and professionalism. Their opposites, dissatisfaction, lack of value, lack of safety, lack of comfort, and lack of professionalism emerged as the most important themes under "improvements". We report some nuances of patient experience that have not previously been explored in the literature.

CONCLUSIONS

Respondents seemed to value effective care provided in a safe, professional, friendly, and aesthetically pleasing environment. Chiropractors should note these priorities and engage with patients according to them. Education institutions should consider how good practice in these areas might be incorporated into curricula.

Thinking and Enacting the Patient Medical Home Under Pandemic Conditions: A Qualitative Study From Primary Care in Alberta, Canada

BACKGROUND

The COVID-19 (C19) pandemic shocked primary care systems around the world. Those systems responded by supporting patients in the community, and acute care facilities in crisis. In Canada, the Patient Medical Home (PMH) is a widely adopted care model that aims to operationalize the tenets and principles of Primary Health Care (PHC) as developed since the Alma-Ata Declaration. This paper describes how personnel working in and with Primary Care Networks (PCNs) in Alberta, Canada deployed the PMH model and its underlying PHC principles to frame and respond to the C19 shock.

METHODS

Using purposive and snowball sampling techniques, we interviewed 57 participants who worked in public health and primary care, including community-based family physicians. We used interpretive description to analyze the interviews.

RESULTS

PCN staff and physicians described how the PMH model was foundational to normal operations, and how C19 responses were framed by the patient-centric, team-delivered, and continuous care principles the model shares with PHC. Specifically, participants described ensuring access to care, addressing the social determinants of health, being patient centered, and redeploying and expanding PHC teams to accomplish these goals.

DISCUSSION

Delivering PHC through the PMH allowed physicians and allied health staff to deliver patient-centered, team-based, holistic bio-medical services to Albertans. In tailoring services to meet the specific social and health needs of the populations served by each PCN, healthcare providers were able to ensure relevant support remained available and accessible.

Frameworks, guidelines, and tools to develop a learning health system for Indigenous health: An environmental scan for Canada

Introduction

First Nations, Inuit, and Métis (FNIM) peoples experience systemic health disparities within Ontario's healthcare system. Learning health systems (LHS) is a rapidly growing interdisciplinary area with the potential to address these inequitable health outcomes through a comprehensive health system that draws on science, informatics, incentives, and culture for ongoing innovation and improvement. However, global literature is in its infancy with grounding theories and principles still emerging. In addition, there is inadequate information on LHS within Ontario's health care context.

Methods

We conducted an environmental scan between January and April 2021 and again in June 2022 to identify existing frameworks, guidelines, and tools for designing, developing, implementing, and evaluating an LHS.

Results

We found 37 relevant sources. This paper maps the literature and identifies gaps in knowledge based on five key pillars: (a) data and evidence-driven, (b) patient-centeredness, (c) system-supported, (d) cultural competencies enabled, and (e) the learning health system.

Conclusion

We provide recommendations for implementation accordingly. The literature on LHS provides a starting point to address the health disparities of FNIM peoples within the healthcare system but Indigenous community partnerships in LHS development and operation will be key to success.

Perceptions and Current Practices in Patient-Centered Care: A Qualitative Study of Ryan White HIV Providers in South Florida

Background: Patient-centered care (PCC) improves HIV adherence and retention, though lack of consensus on its conceptualization and understanding how it is interpreted has hindered implementation. Methods: We recruited 20 HIV providers at Ryan White Programs in FL for in-depth interviews. Thematic analysis identified core consistencies pertaining to: 1) provider perceptions, 2) current practices promoting PCC. Results: Provider perceptions of PCC emerged under four domains: 1) holistic, 2) individualized care, 3) respect for comfort and security, and 4) patient engagement and partnership. PCC practices occurred at multiple levels: 1) individual psychosocial and logistical support, 2) interpersonal support within patient-provider relationships through respectful communication and active engagement, and 3) institutional practices including feedback mechanisms, service integration, patient convenience, and diverse staffing. Conclusions: Our findings highlight the central tenets of PCC as respectful, holistic, individualized, and engaging care. We offer an HIV-adapted framework of PCC as a multilevel construct to guide future intervention.

Risk and protective factors for pregnancy-related urinary incontinence until 1 year postpartum: A cohort study using patient-reported outcome measures in Italy

OBJECTIVE

To investigate the epidemiology of pregnancy-related urinary incontinence (UI) and the related risk factors, focusing also on women's characteristics related to maternity pathway utilization.

METHODS

In this prospective cohort study, we used patient-reported data obtained from the systematic survey on the maternity pathway that all pregnant women in Tuscany, Italy, can join. We selected 8410 women who completed-between March 2019 and November 2022-all five follow-up questionnaires from the first trimester until 12 months postpartum, each including a UI-specific patient-reported outcome measure. We performed panel regression models to explore the related risk factors.

RESULTS

Prevalence of UI was 4.4% at the first trimester, 23.7% at the third trimester, and 15.6%, 12.6%, and 12.4% at 3, 6, and 12 months postpartum. UI occurrence and severity were higher in older, overweight/obese, and unemployed women. High-risk pregnancy and discomfort during pregnancy were risk factors. Receiving a cesarean section reduced the risk, while spontaneous tears, episiotomy, and high birth weight increased it. Women who experienced delays in pregnancy examinations because of long waiting times and women who had planned pregnancy had a higher risk, while performing during-pregnancy pelvic-floor-muscle training was protective.

CONCLUSION

Besides confirming the classic risk and protective factors for UI, we also found novel determinants related to the proper maternity pathway utilization.

Implementation of community physiotherapy in primary care: one-year results of an on-call physiotherapy service

BACKGROUND

Primary health care systems have a key role in meeting health needs of community, including function. The aim of this paper is to describe the population involved in the Community Physiotherapist project and their health outcomes over a one-year period.

METHODS

The Community Physiotherapist is an on-call service which requires a request by general practitioners or medical specialists. Reason for prescription, waiting time for service delivery, diagnostic categories, provided intervention, number of interventions and outcomes were recorded for everyone included in the project. Possible differences in characteristics between individuals referred by medical specialists and general practitioners were also investigated.

RESULTS

From January to December 2022, 409 individuals were referred to the Community Physiotherapist pathway. Functional goals were achieved in 79.5% of interventions, without reported adverse events. In most cases physiotherapists provided counselling or caregiver training and 3.3% of individuals needed a full rehabilitation program. The groups of individuals referred by the two types of prescribers showed no significant differences, apart, as expected, from their median age.

CONCLUSIONS

The introduction of the Community Physiotherapist model within the primary care setting allows to provide appropriate, effective and safe interventions. Sharing the project among all the health professionals helped to support its appropriateness and effectiveness. Results also indicate that a new organizational model, such as the Community Physiotherapist, will take a long time to be implemented.

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study

INTRODUCTION

Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care.

METHODS AND ANALYSIS

In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events.

ETHICS AND DISSEMINATION

We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Unveiling Consumer Preferences and Intentions for Cocreated Features of a Combined Diet and Physical Activity App: Cross-Sectional Study in 4 European Countries

BACKGROUND

Numerous mobile health apps are marketed globally, and these have specific features including physical activity tracking, motivational feedback, and recipe provision. It is important to understand which features individuals prefer and whether these preferences differ between consumer groups.

OBJECTIVE

In this study, we aimed to identify consumers' most preferred features and rewards for a mobile app that targets healthy eating and physical activity and to reduce the number of individual mobile health app features to a smaller number of key categories as perceived by consumers. In addition, we investigated the impact of differences in consumers' BMI and self-efficacy on their intention to use and willingness to pay for such an app. Finally, we identified the characteristics of different target groups of consumers and their responses toward app features via cluster analysis.

METHODS

A total of 212 participants from France, Italy, the United Kingdom, and Germany were recruited via the web to answer questions about app features, motivation, self-efficacy, demographics, and geographic factors. It is important to note that our study included an evenly distributed sample of people in the age range of 23 to 50 years (23-35 and 35-50 years). The app features in question were generated from a 14-day cocreation session by a group of consumers from the United Kingdom and the Republic of Ireland.

RESULTS

"Home work out suggestions," "exercise tips," and "progress charts" were the most preferred app features, whereas "gift vouchers" and "shopping discounts" were the most preferred rewards. "Connections with other communication apps" was the least preferred feature, and "charitable giving" was the least preferred reward. Importantly, consumers' positive attitude toward the "social support and connectedness and mindfulness" app feature predicted willingness to pay for such an app (β=.229; P=.004). Differences in consumers' health status, motivational factors, and basic demographics moderated these results and consumers' intention to use and willingness to pay for such an app. Notably, younger and more motivated consumers with more experience and knowledge about health apps indicated more positive attitudes and intentions to use and willingness to pay for this type of app.

CONCLUSIONS

This study indicated that consumers tend to prefer app features that are activity based and demonstrate progress. It also suggested a potential role for monetary rewards in promoting healthy lifestyle behaviors. Moreover, the results highlighted the role of consumers' health status, motivational factors, and socioeconomic status in predicting their app use. These results provide up-to-date, practical, and pragmatic information for the future design and operation of mobile health apps.

"My Biggest Fear Is She'll Die Alone": Care Partner Perspectives of Institutional COVID-19 Visitor Restrictions in Ontario, Canada

In March 2020, the Government of Ontario, Canada implemented public health measures, including visitor restrictions in institutional care settings, to protect vulnerable populations, including older adults (> 65 years), against COVID-19 infection. Prior research has shown that visitor restrictions can negatively influence older adults' physical and mental health and can cause increased stress and anxiety for care partners. This study explores the experiences of care partners separated from the person they care for because of institutional visitor restrictions during the COVID-19 pandemic. We interviewed 14 care partners between the ages of 50 and 89; 11 were female. The main themes that emerged were changing public health and infection prevention and control policies, shifting care partner roles as a result of visitor restrictions, resident isolation and deterioration from the care partner perspective, communication challenges, and reflections on the impacts of visitor restrictions. Findings may be used to inform future health policy and system reforms.

Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?"

Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation.

CONTEXT

Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems.

METHODS

A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time.

FINDINGS

The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation.

CONCLUSIONS

Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.

Are We Capturing the Socioeconomic Burden of Rare Genetic Disease? A Scoping Review of Economic Evaluations and Cost-of-Illness Studies

BACKGROUND AND OBJECTIVES

Rare diseases have a significant impact on patients, families, the health system, and society. Measuring the socioeconomic burden is crucial to valuing interventions for rare diseases. Healthcare system costs are significant, but so are costs to other government sectors, patients, families, and society. To understand the breadth of costs captured in rare disease studies, we examined the cost categories and elements of socioeconomic burden captured in published studies.

METHODS

A scoping review was conducted using five electronic databases to identify English language economic evaluations and cost-of-illness studies of interventions for rare diseases (2011-21). We mapped costs using a previously developed evidence-informed framework of socioeconomic burden costs for rare disease.

RESULTS

Of 4890 studies identified, 48 economic evaluations and 22 cost-of-illness studies were included. While 18/22 cost-of-illness studies utilized a societal perspective, only 7/48 economic evaluations incorporated societal costs. Most reported cost categories related to medical costs, with medication and hospitalizations being the most common elements for both study designs. Costs borne by patients, families, and society were reported less among economic evaluations than cost-of-illness studies. These included: productivity (10% vs 77%), travel/accommodation (6% vs 68%), government benefits (4% vs 18%), and family impacts (0% vs 50%).

CONCLUSIONS

Contrary to cost-of-illness analyses, most of the included economic evaluations did not account for the hidden burden of rare diseases, that is, costs borne by patients, families, and societies. Including these types of costs in future studies would provide a more comprehensive picture of the burden of disease, providing empirical data to inform how we value and make decisions regarding rare disease interventions, health policy, and resource allocation.

Samis in the city. A qualitative study of mental health and well-being among Samis in Stockholm

Indigenous people globally suffer from poorer health than majority populations. For the Sami, the indigenous people living in the north of Norway, Sweden, Finland and Russia, physical health conditions seem to be comparable to the population in general, but there are concerns about mental health. Studies have shown a higher risk of suicide, especially for young men active in traditional reindeer herding in the north. There is less knowledge about the mental health of Samis that have migrated to the cities. In this study, we interviewed 25 Samis, recruited through convenience sampling in the Stockholm area, about their perceptions of health and well-being, the importance of the Sami background and culture, their views of mental health services and the need of adapting them to Sami needs. Throughout the process, the researchers collaborated closely with the Stockholm Sami Association, in an approach of participatory research. The interviews were analysed with thematic analysis. For the participants, a secure Sami identity and being treated with respect for their identity was seen as essential for mental health and well-being. Informants' emphasis on respect for their Sami identity and belonging can be seen as a call for restoration of basic human rights. Historical experiences, current harassments and political decisions affected their health. The informants wished caregivers to increase their knowledge of Sami history and traditions.

The effect of geographic location and payor type on provincial-wide delivery of the GLA:D program for hip and knee osteoarthritis in Alberta, Canada

Objective

The Good Life with osteoArthritis: Denmark (GLA:D™) program for knee and hip osteoarthritis has been shown to be effective, but evaluations have yet to explore whether effectiveness differs by program context. The present study explores whether there are differences in effectiveness of the GLA:D™ program for treatment of hip and knee osteoarthritis across program location (i.e., rural, urban, metro) and program payor (i.e., public, private) within Alberta, Canada.

Design

The study population was adults with hip or knee osteoarthritis attending the 8-week GLA:D™ supervised exercise and education programme in Alberta between Sep 2017-Mar 2020. Outcomes of interest were joint-related pain and quality of life (HOOS/KOOS), health quality of life (EQ-5D-5L), and performance-based functional (30-s chair stand test; 40-m walk test) measures. Minimally clinically important changes were calculated for each outcome and ANOVA and chi-square tests were used to determine statistical significance by program location or payor.

Results

Of the 1321 eligible participants, 974 (73.7%) completed the baseline questionnaire, about 50% of participants participated in a metro area and 60% paid privately for the program. There were no statistically significant differences in improvements of joint-related pain, joint-related quality of life, health-related quality of life, or performance-based functional measures by program location or program payor, except for participants who received the program in a publicly covered primary care clinic who experienced significantly larger improvements in joint-related pain.

Conclusion

The implementation of the GLA:D™ program for the treatment of knee and hip osteoarthritis in Alberta is effective across a range of contexts.

Variations in wait times for imaging services: a register-based study of self-reported wait times for specific examinations in Norway

BACKGROUND

While the number of medical images has increased substantially, the demand has outpaced access, resulting in long wait times in many countries. Long wait times are a key problem for patient safety and quality of care as they can result in prolonged suffering, delayed diagnosis and treatment, as well as poorer prognosis and loss of lives. Surprisingly, little is known about wait times for imaging services.

OBJECTIVE

Investigate wait times for specific imaging services in Norway and to compare wait times with the total number of examinations and their development over time.

METHODS

Data from the wait time registry at the Norwegian Directorate of Health from 2018 to 2021 as well as data on outpatient imaging provided by the Norwegian Health Economics Administration (HELFO) and in-patient data afforded by fourteen hospital trusts and hospitals in Norway were analysed. Data include the total number of imaging examinations according to the Norwegian Classification of Radiological Procedures (NCRP). Analyses were performed with descriptive statistics.

RESULTS

Wait times vary through the months of the year. Conventional X-ray (XR) had the shortest wait times (3.0-4.4 weeks), and Magnetic Resonance Imaging (MRI) and ultrasound (US) had the lengthiest (8.7-12.0 and 7.9-11.4 weeks respectively). The wait times were lengthiest during the summer and winter holidays. Variations in wait times were also found for specific examination types between Norway's four public health regions. In addition, there was variation over time within the health regions. The wait times with the private health providers were substantially lower than with the public health providers. From 2018 to 2021, the wait time for MRIs increased by 6.6%, while the number of examinations (per 10,000) increased by 8.6%. Those regions with the highest number of examinations per 1,000 inhabitants per year had the lowest wait times.

CONCLUSION

Wait times for diagnostic imaging procedures varied with time, region, and modality in Norway from 2018 to 2021. Long wait times may entail many negative consequences for patients, professionals, and the healthcare system. Reducing long wait times is an obvious way to improve the quality, safety, and efficiency of care.

How do navigation programs address the needs of those living in the community with advanced, life-limiting Illness? A realist evaluation of programs in Canada

BACKGROUND

We sought to identify innovative navigation programs across Canadian jurisdictions that target their services to individuals affected by life-limiting illness and their families, and articulate the principal components of these programs that enable them to address the needs of their clients who are living in the community.

METHODS

This realist evaluation used a two-phased approach. First, we conducted a horizon scan of innovative community-based navigation programs across Canadian jurisdictions to identify innovative community-based navigation programs that aim to address the needs of community-dwelling individuals affected by life-limiting illness. Second, we conducted semi-structured interviews with key informants from each of the selected programs. Informants included individuals responsible for managing and delivering the program and decision-makers with responsibility and/or oversight of the program. Analyses proceeded in an iterative manner, consistent with realist evaluation methods. This included iteratively developing and refining Context-Mechanism-Outcome (CMO) configurations, and developing the final program theory.

RESULTS

Twenty-seven navigation programs were identified from the horizon scan. Using specific eligibility criteria, 11 programs were selected for subsequent interviews and in-depth examination. Twenty-three participants were interviewed from these programs, which operated in five Canadian provinces. The programs represented a mixture of community (non-profit or volunteer), research-initiated, and health system programs. The final program theory was articulated as: navigation programs can improve client outcomes if they have supported and empowered staff who have the time and flexibility to personalize care to the needs of their clients.

CONCLUSIONS

The findings highlight key principles (contexts and mechanisms) that enable navigation programs to develop client relationships, personalize care to client needs, and improve client outcomes. These principles include staff (or volunteer) knowledge and experience to coordinate health and social services, having a point of contact after hours, and providing staff (and volunteers) time and flexibility to develop relationships and respond to individualized client needs. These findings may be used by healthcare organizations - outside of navigation programs - to work towards more person-centred care.

Navigating a Pandemic: Leadership Dynamics and Challenges within Infection Prevention and Control Units in Israel

This study investigates the impact of the coronavirus disease 2019 (COVID-19) pandemic on leadership within infection prevention and control (IPC) units across public hospitals in Israel. Through qualitative interviews with ten IPC managers from nine hospitals, equivalent to 30% of the country's acute care facilities, the research uncovers significant changes in managerial approaches due to the health crisis. The results reveal four main themes: (1) Enhanced managerial autonomy and leadership skills, with a noted rise in self-efficacy against the pandemic's backdrop; (2) Shifted perceptions of IPC units by upper management, recognizing their strategic value while identifying the need for a more profound understanding of IPC operations; (3) The increased emphasis on adaptability and rapid decision-making for effective crisis management; (4) The dual effect on job satisfaction and well-being, where greater commitment coincides with risks of burnout. The study underscores the essential nature of effective IPC leadership during emergencies, highlighting the need for clear communication, prompt action, and empathetic leadership. The conclusions point to the necessity for continuous research into IPC leadership, promoting strategic advancements in management to bolster IPC units against future health threats.

An After-Hours Virtual Care Service for Children With Medical Complexity and New Medical Technology: Mixed Methods Feasibility Study

BACKGROUND

Family caregivers (FCs) of children with medical complexity require specialized support to promote the safe management of new medical technologies (eg, gastrostomy tubes) during hospital-to-home transitions. With limited after-hours services available to families in home and community care, medical device complications that arise often lead to increased FC stress and unplanned emergency department (ED) visits. To improve FC experiences, enable safer patient discharge, and reduce after-hours ED visits, this study explores the feasibility of piloting a 24/7 virtual care service (Connected Care Live) with families to provide real-time support by clinicians expert in the use of pediatric home care technologies.

OBJECTIVE

This study aims to establish the economic, operational, and technical feasibility of piloting the expansion of an existing nurse-led after-hours virtual care service offered to home and community care providers to FCs of children with newly inserted medical devices after hospital discharge at Toronto's Hospital for Sick Children (SickKids).

METHODS

This exploratory study, conducted from October 2020 to August 2021, used mixed data sources to inform service expansion feasibility. Semistructured interviews were conducted with FCs, nurses, and hospital leadership to assess the risks, benefits, and technical and operational requirements for sustainable and cost-effective future service operations. Time and travel savings were estimated using ED visit data in SickKids' electronic medical records (Epic) with a chief complaint of "medical device problems," after-hours medical device inquiries from clinician emails and voicemails, and existing service operational data.

RESULTS

A total of 30 stakeholders were interviewed and voiced the need for the proposed service. Safer and more timely management of medical device complications, improved caregiver and provider experiences, and strengthened partnerships were identified as expected benefits, while service demand, nursing practice, and privacy and security were identified as potential risks. A total of 47 inquiries were recorded over 2 weeks from March 26, 2021, to April 8, 2021, with 51% (24/47) assessed as manageable via service expansion. This study forecasted annual time and travel savings of 558 hours for SickKids and 904 hours and 22,740 km for families. Minimal technical and operational requirements were needed to support service expansion by leveraging an existing platform and clinical staff. Of the 212 ED visits related to "medical device problems" over 6 months from September 1, 2020, to February 28, 2021, enteral feeding tubes accounted for nearly two-thirds (n=137, 64.6%), with 41.6% (57/137) assessed as virtually manageable.

CONCLUSIONS

Our findings indicate that it is feasible to pilot the expansion of Connected Care Live to FCs of children with newly inserted enteral feeding tubes. This nurse-led virtual caregiver service is a promising tool to promote safe hospital-to-home transitions, improve FC experiences, and reduce after-hours ED visits.

Use of adapted or modified methods with people with dementia in research: A scoping review

People with dementia are excluded from research due to methodological challenges, stigma, and discrimination. Including perspectives of people with dementia across a spectrum of abilities is essential to understanding their perspectives and experiences. Engaging people living with dementia in qualitative research can require adaptation of methods.Qualitative research is typically considered when researchers seek to understand the perspectives, lived experiences, or opinions of individuals' social reality. This scoping review explores current use of adapted methods with people with dementia in qualitative research, including methods used and impacts on the engagement as it relates to meeting accessibility needs. This review considered rationales for adaptations provided by authors, particularly whether authors identified a human rights or justice rationale for adapting methods to promote accessibility and engagement.This review began with a search of primary studies using qualitative research methods published in English in OECD countries from 2017 to 2022. Two reviewers screened titles and abstracts for inclusion. Full texts were reviewed, and data from included studies were extracted using a pre-determined chart. Content analysis of rationales was conducted and reviewed by all authors. Studies were assessed for findings related to impacts of adapted methods.Twenty-eight studies met inclusion criteria. Adaptations to qualitative research methods ranged from minor changes, such as maintaining a familiar interviewer, to more extensive novel methods such as photo-elicitation techniques. Twenty-seven studies provided a rationale for adapting their methods. No studies assessed impacts of their methodology on engagement or accessibility. Five studies observed that their methodology supported engagement.This review helps understand the breadth of adaptations that researchers have made to qualitative research methods to include people with dementia in research. Research is needed to explore adaptations and their impact on engagement of persons with dementia with a range of abilities and backgrounds.

Excess death estimates from multiverse analysis in 2009-2021

Excess death estimates have great value in public health, but they can be sensitive to analytical choices. Here we propose a multiverse analysis approach that considers all possible different time periods for defining the reference baseline and a range of 1 to 4 years for the projected time period for which excess deaths are calculated. We used data from the Human Mortality Database on 33 countries with detailed age-stratified death information on an annual basis during the period 2009-2021. The use of different time periods for reference baseline led to large variability in the absolute magnitude of the exact excess death estimates. However, the relative ranking of different countries compared to others for specific years remained largely unaltered. The relative ranking of different years for the specific country was also largely independent of baseline. Averaging across all possible analyses, distinct time patterns were discerned across different countries. Countries had declines between 2009 and 2019, but the steepness of the decline varied markedly. There were also large differences across countries on whether the COVID-19 pandemic years 2020-2021 resulted in an increase of excess deaths and by how much. Consideration of longer projected time windows resulted in substantial shrinking of the excess deaths in many, but not all countries. Multiverse analysis of excess deaths over long periods of interest can offer an approach that better accounts for the uncertainty in estimating expected mortality patterns, comparative mortality trends across different countries, and the nature of observed mortality peaks.

Real-World Cost Effectiveness of a Policy of KRAS Testing to Inform Cetuximab or Panitumumab for Third-Line Therapy of Metastatic Colorectal Cancer in British Columbia, Canada

BACKGROUND

Cetuximab and panitumumab, two anti-EGFR therapies, are widely used for third-line therapy of metastatic colorectal cancer (mCRC) with wild-type KRAS, but there remains uncertainty around their cost effectiveness. The objective of this analysis was to conduct a real-world cost-effectiveness analysis of the policy change introducing KRAS testing and third-line anti-EGFR therapy mCRC in British Columbia (BC), Canada.

METHODS

We conducted secondary analysis of administrative data for a cohort of mCRC patients treated in BC in 2006-2015. Patients potentially eligible for KRAS testing and third-line therapy after the policy change (July 2009) were matched 2:1 to pre-policy patients using genetic matching on propensity score and baseline covariates. Costs and survival time were calculated over an 8-year time horizon, with bootstrapping to characterize uncertainty around endpoints. Cost effectiveness was expressed using incremental cost-effectiveness ratios (ICER) and the probability of cost effectiveness at a range of thresholds.

RESULTS

The cohort included 1757 mCRC patients (n = 456 pre-policy and n = 1304 post-policy; of those, n = 420 received cetuximab or panitumumab). There was a significant increase in survival and cost following the policy change. Adoption of KRAS testing and anti-EGFR therapy had an ICER of CA$73,759 per life-year gained (LYG) (95% CI 46,133-186,446). In scenario analysis, a reduction in cetuximab and panitumumab cost of at least 50% was required to make the policy change cost effective at a threshold of CA$50,000/LYG.

CONCLUSION

A policy of third-line anti-EGFR therapy informed by KRAS testing may be considered cost effective at thresholds above CA$70,000/LYG. Reduction in drug costs, through price discounts or potential future biosimilars, would make anti-EGFR therapy considerably more cost effective. By using real-world data for a large cohort with long follow-up we can assess the value of a policy of KRAS testing and anti-EGFR therapy achieved in practice.

Developing an integrated performance management and measurement system in healthcare organisations: a Canadian case study

This study proposes a performance management and measurement system for a large healthcare organisation. First, data is collected to analyse and understand the current performance management system. Second, the SWOT (Strengths, Weaknesses, Opportunities, Threats) method is used to identify the main aspects of the performance management system to be improved. Third, based on the scientific literature and SWOT analysis, BSC principles are integrated to this performance management system to better align the organisation's performance objectives and indicators with its strategy. Finally, we develop a performance indicator structure and specify indicators to be used as well as how these indicators could be integrated and shared with higher hierarchical levels in the organisation by using AHP (Analytic Hierarchy Process). Our approach is applied to the program "Physical disability, intellectual disability, and autism spectrum disorder" of CIUSSS du Centre-Sud-de-l'île-de-Montreal, a large healthcare network, in the province of Québec, Canada.

Family physicians partnering for system change: a multiple-case study of Ontario Health Teams in development

BACKGROUND

The Ontario Health Team (OHT) model is a form of integrated care that seeks to provide coordinated delivery of care to communities across Ontario, Canada. Primary care is positioned at the heart of the OHT model, yet physician participation and representation has been severely challenged at planning and governance tables. The purpose of this multiple case study is to examine (1) processes and structures to enable family physician participation in OHTs and (2) describe challenges to family physician participation.

METHODS

We chose a qualitative, exploratory multiple-case study approach following Yin's design and methods. The study took place between June and December 2021.We conducted semi-structured interviews with OHT stakeholders in four communities and carried out an analysis of internal and external documents to contextualize interview findings. Thematic analysis was applied within case and between cases.

RESULTS

Four OHTs participated in this study with thirty-nine participants (17 family physicians; 22 other stakeholders). Over 60 documents were analyzed. Within-case analysis found that structures and processes should be formalized and established to facilitate physician participation. Skepticism, burnout, heavy workload, and the COVID-19 pandemic were challenges to participation. Between-case analysis found that participation varied. Face-to-face communication processes were favoured in all cases and history of collaboration facilitated relationship-building. All cases faced similar challenges to physician participation despite regional differences.

CONCLUSIONS

The implementation of OHTs demonstrates that integrated care models can address critical health system issues through a collective approach. Physician participation is vital to the development of an OHT, however, recognition of their challenges (skepticism, burnout, COVID-19 pandemic) to participating must be acknowledged first. To ensure that models like OHTs thrive, physicians must be meaningfully engaged in various aspects and levels of governance and delivery.

COVID-19 risks in private equity nursing homes in Hesse, Germany - a retrospective cohort study

BACKGROUND

Private-equity-owned nursing homes (PENH) represent the strongest form of profit orientation in the nursing care market. Private equity firms aim to increase the profitability of nursing care facilities, which often leads to cost-cutting measures and the use of less qualified staff. Our study aims to fill the existing knowledge gap by examining the association between private equity ownership and COVID-19 related infections and deaths among residents and staff during the COVID-19 pandemic.

METHODS

We analyzed outbreak and mortality data for the period from 20/03/2020 to 05/01/2022 from 32 long-term care facilities in the Federal State of Hesse, Germany, which included 16 PENH that were propensity score matched on regional population density and number of beds with 16 non-PENH. We used logistic regression to determine the odds ratios (OR) for above-median values for the independent variables of PENH-status, number of beds, proportion of single rooms, registered nurses' ratio, and copayments.

RESULTS

PENH had substantially fewer outbreaks in number, but longer and larger outbreaks among nursing home residents, as well as a markedly increased proportion of deceased residents. The odds of the outcome "infections & deaths" were 5.38 (p <. 05) times higher among PENH compared to non-PENH.

CONCLUSIONS

The study indicates a need for further research into the quality of care in PENH to inform evidence-based policy decisions, given the higher infection and death rates. Improved documentation and public visibility of PENH is also recommended, in line with existing practices for for-profit and non-profit nursing homes in Germany. Given our findings, regulatory bodies should closely observe PENH operational practices.

Exploring the impact of evaluation on learning and health innovation sustainability: protocol for a realist synthesis

BACKGROUND

Within the Learning Health System (LHS) model, learning routines, including evaluation, allow for continuous incremental change to take place. Within these learning routines, evaluation assists in problem identification, data collection, and data transformation into contextualized information, which is then re-applied to the LHS environment. Evaluation that catalyzes learning and improvement may also contribute to health innovation sustainability. However, there is little consensus as to why certain evaluations seem to support learning and sustainability, while others impede it. This realist synthesis seeks to understand the contextual factors and underlying mechanisms or drivers that best support health systems learning and sustainable innovation.

METHODS

This synthesis will be guided by Pawson and colleagues' 2005 and Emmel and colleagues' 2018 guidelines for conducting realist syntheses. The review process will encompass five steps: (1) scoping the review, (2) building theories, (3) identifying the evidence, (4) evidence selection and appraisal, and (5) data extraction and synthesis. An Expert Committee comprised of leaders in evaluation, innovation, sustainability, and realist methodology will guide this synthesis. Review findings will be reported using the RAMESES guidelines.

DISCUSSION

The use of a realist review will allow for exploration and theorizing about the contextual factors and underlying mechanisms that make evaluations 'work' (or 'not work') to support learning and sustainability. Depending on results, we will attempt to synthesize findings into a series of recommendations for evaluations with the intention to support health systems learning and sustainability. Finalized results will be presented at national and international conferences, as well as disseminated via a peer-reviewed publication.

SYSTEMATIC REVIEW REGISTRATION

This realist synthesis protocol has been registered with PROSPERO ( https://www.crd.york.ac.uk/prospero/  ID 382690).

Case mix-based changes in health status: A prospective study of elective surgery patients in Vancouver, Canada

INTRODUCTION

Hospital activity is often measured using diagnosis-related groups, or case mix groups, but this information does not represent important aspects of patients' health outcomes. This study reports on case mix-based changes in health status of elective (planned) surgery patients in Vancouver, Canada.

DATA AND METHODS

We used a prospectively recruited cohort of consecutive patients scheduled for planned inpatient or outpatient surgery in six acute care hospitals in Vancouver. All participants completed the EQ-5D(5L) preoperatively and 6 months postoperatively, collected from October 2015 to September 2020 and linked with hospital discharge data. The main outcome was whether patients' self-reported health status improved among different inpatient and outpatient case mix groups.

RESULTS

The study included 1665 participants with completed EQ-5D(5L) preoperatively and postoperatively, representing a 44.8% participation rate across eight inpatient and outpatient surgical case mix categories. All case mix categories were associated with a statistically significant gain in health status (p < .01 or lower) as measured by the utility value and visual analogue scale score. Foot and ankle surgery patients had the lowest preoperative health status (mean utility value: 0.6103), while bariatric surgery patients reported the largest improvements in health status (mean gain in utility value: 0.1515).

CONCLUSIONS

This study provides evidence that it was feasible to compare patient-reported outcomes across case mix categories of surgical patients in a consistent manner across a system of hospitals in one province in Canada. Reporting changes in health status of operative case mix categories identifies characteristics of patients more likely to experience significant gains in health.

Process mining and data mining applications in the domain of chronic diseases: A systematic review

The widespread use of information technology in healthcare leads to extensive data collection, which can be utilised to enhance patient care and manage chronic illnesses. Our objective is to summarise previous studies that have used data mining or process mining methods in the context of chronic diseases in order to identify research trends and future opportunities. The review covers articles that pertain to the application of data mining or process mining methods on chronic diseases that were published between 2000 and 2022. Articles were sourced from PubMed, Web of Science, EMBASE, and Google Scholar based on predetermined inclusion and exclusion criteria. A total of 71 articles met the inclusion criteria and were included in the review. Based on the literature review results, we detected a growing trend in the application of data mining methods in diabetes research. Additionally, a distinct increase in the use of process mining methods to model clinical pathways in cancer research was observed. Frequently, this takes the form of a collaborative integration of process mining, data mining, and traditional statistical methods. In light of this collaborative approach, the meticulous selection of statistical methods based on their underlying assumptions is essential when integrating these traditional methods with process mining and data mining methods. Another notable challenge is the lack of standardised guidelines for reporting process mining studies in the medical field. Furthermore, there is a pressing need to enhance the clinical interpretation of data mining and process mining results.

A hospital to community exercise referral pathway: results of a pilot project

BACKGROUND

People living with chronic disease should ideally engage with community-based exercise services following hospital-based rehabilitation. However, transition from hospital to community exercise settings is extremely challenging and strategies to support this transition are underdeveloped.

AIMS

The aims of this study were to develop and explore the feasibility of a pilot exercise referral pathway between an acute hospital and community gyms for patients with chronic health conditions and to evaluate patient satisfaction with the exercise referral pathway.

METHODS

A stakeholder-informed exercise referral pathway was developed and offered to patients following completion of a hospital-based exercise programme for a chronic health condition. The pathway was evaluated using a mixed-methods approach. Quantitative data examining participant engagement was used to examine feasibility. Quantitative survey data and qualitative data from semi-structured interviews examined satisfaction with the pathway.

RESULTS

Forty-nine people living with chronic conditions (mean age 72 ± 7.8 years) participated (recruitment rate 59%). The average number of community gym visits over 4 months was 17.4 (range 0-51). Twenty-nine (78%) participants reported that they planned to continue their gym membership when the programme ended. Themed responses from participant interviews (n = 12) highlighted the benefits of a supported transition from hospital to gym membership and the need for more structured exercise support in community gyms.

CONCLUSION

A structured exercise referral pathway to support exercise transition between hospital and community settings in populations with chronic health conditions appears feasible. Participants reported high levels of satisfaction with the referral pathway.

Acute Health Care Provision in Rural Long-Term Care Facilities: A Scoping Review of Integrated Care Models

OBJECTIVES

We aimed to map integrated care models for acute health care in rural long-term care facilities (LTCFs) for future investigation.

DESIGN

Systematic scoping review.

SETTING AND PARTICIPANTS

Residential LTCFs in rural areas worldwide.

METHODS

The common health-related online databases were systematically searched complemented by a manual search of gray literature. Following the 5-stage framework of Arksey and O'Malley, the extent of included literature was identified and findings were summarized using qualitative meta-summary.

RESULTS

A total of 35 references were included for synthesis, predominantly primary research on completed and ongoing projects reporting on integrated health care services in rural LTCFs. Incorporating previous research, we extracted 5 approaches of integrated acute-health care models: (1) Availability of Specialists, (2) Networks, (3) Quality Management (QM) and Organization, (4) Telemedicine, and (5) Telehealth.

CONCLUSIONS AND IMPLICATIONS

This research presents the result of a literature review examining integrated care models as a way to improve acute health care in LTCFs in rural areas. Integrated care models in rural settings can help face the challenging situation and fulfil the complex health care needs of LTCF residents by reducing fragmentation and thereby improve continuity and coordination of acute health care services. These results can guide policy making in creating interventions and support adequate implementation of care models by knowledge translation in health care.

Results from the BETTER WISE trial: a pragmatic cluster two arm parallel randomized controlled trial for primary prevention and screening in primary care during the COVID-19 pandemic

BACKGROUND

Cancer and chronic diseases are a major cost to the healthcare system and multidisciplinary models with access to prevention and screening resources have demonstrated improvements in chronic disease management and prevention. Research demonstrated that a trained Prevention Practitioner (PP) in multidisciplinary team settings can improve achievement of patient level prevention and screening actions seven months after the intervention.

METHODS

We tested the effectiveness of the PP intervention in a pragmatic two-arm cluster randomized controlled trial. Patients aged 40-65 were randomized at the physician level to an intervention group or to a wait-list control group. The intervention consisted of a patient visit with a PP. The PP received training in prevention and screening and use of the BETTER WISE tool kit. The effectiveness of the intervention was assessed using a composite outcome of the proportion of the eligible prevention and screening actions achieved between intervention and control groups at 12-months.

RESULTS

Fifty-nine physicians were recruited in Alberta, Ontario, and Newfoundland and Labrador. Of the 1,005 patients enrolled, 733 (72.9%) completed the 12-month analysis. The COVID-19 pandemic occurred during the study time frame at which time nonessential prevention and screening services were not available and in-person visits with the PP were not allowed. Many patients and sites did not receive the intervention as planned. The mean composite score was not significantly higher in patients receiving the PP intervention as compared to the control group. To understand the impact of COVID on the project, we also considered a subset of patients who had received the intervention and who attended the 12-month follow-up visit before COVID-19. This assessment demonstrated the effectiveness of the BETTER visits, similar to the findings in previous BETTER studies.

CONCLUSIONS

We did not observe an improvement in cancer and chronic disease prevention and screening (CCDPS) outcomes at 12 months after a BETTER WISE prevention visit: due to the COVID-19 pandemic, the study was not implemented as planned. Though benefits were described in those who received the intervention before COVID-19, the sample size was too small to make conclusions. This study may be a harbinger of a substantial decrease and delay in CCDPS activities under COVID restrictions.

TRIAL REGISTRATION

ISRCTN21333761. Registered on 19/12/2016. http://www.isrctn.com/ISRCTN21333761 .