Surgery in the western Canadian Arctic: The relative impact of family physicians with enhanced surgical skills working collaboratively with specialist surgeons

Introduction

Little is known about the surgical needs of rural, remote or circumpolar populations in Canada; these same regions are also home to half of all Indigenous people in the country. In the present study, we sought to understand the relative impact of family physicians with enhanced surgical skills (FP-ESS) and Specialist Surgeons in the surgical care of a mostly Indigenous rural and remote community in the western Canadian Arctic.

Methods

A descriptive and retrospective quantitative study was conducted to determine the number and range of procedures performed for the defined catchment population of the Beaufort Delta Region of the Northwest Territories, as well as the type of surgical provider and location of that service, over the 5 years from 1 April, 2014, to 31 March, 2019.

Results

FP-ESS physicians in Inuvik performed 79% of all endoscopic and 22% of all surgical procedures, which accounted for nearly half of the total procedures performed. Over 50% of all procedures were performed locally (47.7% by FP-ESS and 5.6% by visiting specialist surgeons). For surgical cases alone, nearly one-third were performed locally, one-third in Yellowknife and the remaining one-third out-of-territory.

Conclusions

This networked model reduces the overall demand on surgical specialists, who can better focus their efforts on surgical care that is beyond the scope of FP-ESS. With nearly half of the procedural needs of this population being met locally by FP-ESS, there are decreased health-care costs, better access and more surgical care closer to home.

Clarification of ethical principle of the beneficence in nursing care: an integrative review

BACKGROUND

Ethics-based nursing practice can transform health care practices. As the biggest human capital in the health care system, nurses are obliged to follow ethical principles in this field. One of these ethical principles; is beneficence, which is considered the core of nursing care. This study aimed to investigate clarification of the principle of beneficence in nursing care and its related challenges.

METHODS

This integrative review was conducted using the Whittemore & Knafl method in 5 stages, including problem identification, searching the literature, evaluating primary sources, analyzing data, and presenting the results. Databases like SID, Irandoc, Magiran, Google Scholar, Web of Science, PubMed, and Scopus were searched using the keywords; "beneficence", "ethic", "nursing" and "care" in English and Persian in the time range of 2010 to 10 February, 2023. After applying inclusion criteria and assessing the articles using Bowling's Quality Assessment Tool, finally, 16 papers were included from 984.

RESULTS

After reviewing and evaluating the qualified articles, the findings were classified into four main categories: (1) nature, (2) applicability, (3) Relevant and influential factors, and (4) challenges related to the ethical principle of beneficence in nursing care.

CONCLUSION

Based on the results of this review it seems that paying attention to clarification the principle of beneficence in nursing care can provide positive outcomes for patients to benefit from this principle and finally, it leads to increasing the well-being and health of patients, reducing their mortality rate, increasing satisfaction and maintaining the respect and human dignity of patients.

Rapid evidence review: Policy actions for the integration of public health and health care in the United States

Objective

To identify policy actions that may improve the interface of public health and health care in the United States.

Methods

A rapid review of publicly-available documents informing the integration of public health and health care, and case examples reporting objective measures of success, with abstraction of policy actions, related considerations, and outcomes.

Results

Across 109 documents, there were a number of recurrent themes related to policy actions and considerations to facilitate integration during peace time and during public health emergencies. The themes could be grouped into the need for adequate and dedicated funding; mandates and shared governance for integration; joint leadership that has the authority/ability to mobilize shared assets; adequately staffed and skilled workforces in both sectors with mutual awareness of shared functions; shared health information systems with modernized data and IT capabilities for both data collection and dissemination of information; engagement with multiple stakeholders in the community to be maximally inclusive; and robust communication strategies and training across partners and with the public.

Conclusion

While the evidence does not support a hierarchy of policies on strengthening the interface of public health and health care, recurrent policy themes can inform where to focus efforts.

Perspectives of culturally and linguistically diverse (CALD) community members regarding mental health services: A qualitative analysis

WHAT IS KNOWN ABOUT THE SUBJECT?: Immigrant, refugee and asylum seeker populations worldwide are at high risk of mental health issues National mental health policies call for recognising Australian society's multicultural characteristics to ensure adequate mental health services to CALD communities Several barriers exist for people from CALD communities in Victoria to access and utilise mental health services Improving mental health professionals' knowledge of mental health service provision and cultural responsiveness can enhance CALD community access to services. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: We analysed the perspectives of people from CALD communities in Victoria regarding their needs and experiences with mental health services. Participants reported diverse perceptions and understanding of mental health issues and services Various challenges were identified regarding health service utilisation for the CALD community in Victoria, including language barriers, stigma towards mental health issues, mental health illiteracy, distrust and lack of familiarity with mainstream mental health services. These challenges were acknowledged by community members even after a long residence in Australia The data generated on the beliefs about mental health issues and consequent help-seeking behaviours highlight the importance of culturally sensitive targeted prevention and early intervention strategies and ongoing commitment to building mental health literacy in the wider community WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The information from the study can be adapted for quality improvement and culturally responsive practices The strategies for effective service delivery drawn by this paper can be a comprehensive resource tool for mental health professionals, organisations and policymakers The findings imply that CALD mental health service users and their families will likely benefit from improved service assessment and quality of mental health care and equity when MHNs undertake cultural competence training and bring that into their practice.

ABSTRACT

INTRODUCTION: Victoria is one of the most multicultural states in Australia. Many CALD communities in Victoria may have encountered complicated migration journeys and complex life stressors during their initial settlement, leading to adverse mental health concerns. This diversity necessitates public policy settings to ensure equity and access in health services planning and delivery. While the MH policies and services take cultural diversity into account, there needs to be more implementation of those components of MH policies that relate to the particular needs of various CALD communities in Victoria. Even though mental health services prevent and address mental health issues, many barriers can impair CALD community access and utilisation of mental health services. Furthermore, the recent Royal Commission inquiry into the Victorian Mental Health system drives a renewed policy imperative to ensure meaningful engagement and cultural safety of all people accessing and utilising mental health services (Department of Health, 2023).

AIM

This study focused on the perspectives of people from CALD communities in Victoria regarding their mental health service needs, understandings of and experiences with mental health services to prepare an education package for mental health nurses as part of a larger multi-method research project.

METHOD

A qualitative descriptive design was used to collect and analyse the perspectives of 21 participants in Victoria, using telephone interviews, followed by thematic analysis.

RESULTS

The themes and sub-themes identified were: Settling issues; Perceptions of understanding of mental health issues (help-seeking attitudes toward mental health issues; the need for CALD community education); perceived barriers to accessing and utilising mental health services in Victoria (socio-cultural and language barriers; stigma, labelling and discrimination; knowledge and experience of accessing health facilities); experience with mental health services and professionals.

DISCUSSION

Community participation, mental health professional education and robust research regarding the mental health needs of CALD people are some of the recommended strategies to improve access and utilisation of mental health services in Victoria.

IMPLICATIONS FOR PRACTICE

The current study can contribute to the existing knowledge, understanding, practice and quality improvement as it vividly portrays the issues of various CALD communities in Victoria. The findings of this study imply that CALD MH service users and their families are likely to benefit in terms of improved service assessment and quality of MH care and equity when MHNs undertake CC training and bring that into their practice.

Women's choices of hospital for breast cancer surgery in Italy: Quality and equity implications

This paper employs mixed logit regression to investigate the effects of providers characteristics on women's choice of hospital for breast surgery. Patient level data are used to model choices in Tuscany region, Italy. In particular, we focus on the effects of travel time and hospital quality indicators including quality standard (volumes of breast surgery), measurement of process (waiting times) and quality of surgical procedures. Variation in preferences related to individual characteristics such as age, education and travel distance from the hospital are also considered. Findings show that, on average, women prefer closer hospital with longer waiting times and higher quality (high volumes of interventions). We found preference heterogeneity associated to education: travel distance affects choice especially among less educated women (regardless of age), while among younger women (<65 years), less educated ones prefer shorter waiting times. These results could be used to optimize the allocation of resources toward breast cancer units that meet quality and efficacy standards to increase the efficiency and responsiveness of breast cancer care.

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 a more unbiased approach to understand comparative mortality trends across different countries, the range of uncertainty around estimates, and the nature of observed mortality peaks.

Effects of preoperative nutritional status on disability-free survival after cardiac and thoracic aortic surgery: a prospective observational study

PURPOSE

Preoperative malnutrition is associated with postoperative complications, prolonged intensive care unit stay, and mortality, leading to functional disability after non-cardiac surgery. However, its effects on cardiac and thoracic aortic surgery outcomes remain unknown. We examined the effects of preoperative malnutrition on disability-free survival after surgery and assessed the perioperative 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS2.0) score based on the preoperative nutritional status.

METHODS

We included individuals aged ≥ 55 years who underwent elective cardiac and/or thoracic aortic surgery between April 1, 2016 and December 28, 2018 in a tertiary center. The nutritional status was assessed preoperatively using the Mini Nutritional Assessment Short Form, with scores < 12 points indicating a poor nutritional status. The JapanSCORE2 was calculated for surgical risk prediction. Our primary outcome was disability-free survival 1 year after surgery (WHODAS2.0 score: < 16%). The odds ratio of poor nutritional status for disability-free survival was calculated using multiple logistic regression analysis after adjusting for age, JapanSCORE2, and duration of surgery.

RESULTS

One hundred patients were followed up for 1 year. Preoperatively, 41 of them had a poor nutritional status. The disability-free survival rates 1 year postoperatively were 46.3% (19/41) and 64.4% (38/59) in patients with and without poor preoperative nutritional status, respectively. The adjusted odds ratio of poor nutritional status for disability-free survival at 1 year after surgery was 0.42 (95% confidence interval, 0.17-0.99).

CONCLUSION

Patients with a poor preoperative nutritional status had less likely to show disability-free survival 1 year after cardiac and thoracic aortic surgery.

Global migration: Moral, political and mental health challenges

Global migration is expected to continue to increase as climate change, conflict and economic disparities continue to challenge peoples' lives. The political response to migration is a social determinant of mental health. Despite the potential benefits of migration, many migrants and refugees face significant challenges after they resettle. The papers collected in this thematic issue of Transcultural Psychiatry explore the experience of migration and highlight some of the challenges that governments and healthcare services need to address to facilitate the social integration and mental health of migrants. Clinicians need training and resources to work effectively with migrants, focusing on their resilience and on long-term adaptive processes. Efforts to counter the systemic discrimination and structural violence that migrants often face need to be broad-based, unified, and persistent to make meaningful change. When migrants are free to realize their talents and aspirations, they can help build local communities and societies that value diversity.

Implementation Strategies for Preventing Healthcare-Associated Infections across the Surgical Pathway: An Italian Multisociety Document

Healthcare-associated infections (HAIs) result in significant patient morbidity and can prolong the duration of the hospital stay, causing high supplementary costs in addition to those already sustained due to the patient’s underlying disease. Moreover, bacteria are becoming increasingly resistant to antibiotics, making HAI prevention even more important nowadays. The public health consequences of antimicrobial resistance should be constrained by prevention and control actions, which must be a priority for all health systems of the world at all levels of care. As many HAIs are preventable, they may be considered an important indicator of the quality of patient care and represent an important patient safety issue in healthcare. To share implementation strategies for preventing HAIs in the surgical setting and in all healthcare facilities, an Italian multi-society document was published online in November 2022. This article represents an evidence-based summary of the document.

Can fundamental care be advanced using the science of care framework?

AIMS

This manuscript aims to provide a description of an evidence-informed Science of Care practice-based research and innovation framework that may serve as a guiding framework to generate new discoveries and knowledge around fundamental care in a more integrated manner.

BACKGROUND

New ways of thinking about models of care and implementation strategies in transdisciplinary teams are required to accelerate inquiry and embed new knowledge and innovation into practice settings. A new way of thinking starts with an explicit articulation and commitment to the core business of the healthcare industry which is to provide quality fundamental care.

DESIGN

This discursive paper delineates an iteratively derived Science of Care research and innovation framework (Science of Care Framework) that draws from a targeted literature review.

METHOD

The Science of Care Framework integrates caring science with safety and symptom sciences with implementation, improvement, innovation and team sciences. Each science dimension is described in terms of seminal and evolving evidence and theoretical explanations, focusing on how these disciplines can support fundamental care.

CONCLUSIONS

The Science of Care Framework can serve as a catalyst to guide future efforts to propel new knowledge and discoveries around fundamental care and how best to implement it into clinical practice through a transdisciplinary lens.

IMPACT ON NURSING SCIENCE, PRACTICE, OR DISCIPLINARY KNOWLEDGE

The Science of Care Framework can accelerate nursing discipline-specific knowledge generation alongside inter and transdisciplinary insights. The novel articulation of the Science of Care Framework can be used to guide further inquiries that are co-designed, and led, by nurses into integrated models of care and innovations in clinical practice.

Electronic versus paper patient-reported outcome measure compliance rates: A retrospective analysis

OBJECTIVE

Patient-reported outcome measures (PROMs) are key tools used to inform clinical research and patient-centered care. Application of data collected from PROMs, however, may be limited by incomplete responses, and little is known regarding the efficacy of varied PROM delivery methods. The objective of this study was to compare PROMs compliance when delivered via paper and electronic formats.

METHODS

Elective adult spinal deformity patients were screened for inclusion. Data collected included demographics, type of surgery, PROMs compliance, and discharge care. Descriptive statistics and multivariate analysis (MVA) were performed to compare pre- and postoperative compliance rates.

RESULTS

Of the 474 included patients, 177 were administered paper PROMs, while 297 were electronic. Preoperatively, 101 patients (57.1%) had any portion of their paper PROMs available; 179 (60.3%) had any of their electronic PROMs available (p = 0.492). Among all patients, 76 (42.9%) and 170 (57.2%) had all of their completed preop PROMs available (p = 0.003). Among patients with any of their preop PROMs completed, 75.2% with paper and 95.0% with electronic were completed in their entirety (p < 0.001). Similar trends were observed among postoperative PROMs. MVA demonstrated electronic delivery as the only significant correlate with pre- and post-operative PROMs compliance (p < 0.001 and p = 0.003, respectively).

CONCLUSIONS

No differences were observed across modalities when considering any available PROMs, yet electronic PROM delivery was associated with higher completion of PROMs. In order to improve the quality of patient-reported data, electronic delivery with alternative methods of quality improvement may be considered to increase PROMs retention rates.

Caring for the Caregiver (C4C): An Integrated Stepped Care Model for Caregivers of Children With Medical Complexity

Children with medical complexity (CMC) are a medically fragile subset of children who rely on parental caregivers for substantial care needs. Caregivers of CMC often experience adverse health outcomes such as depression and anxiety, sleep deprivation, financial hardships, and social isolation. Caregivers of CMC are at risk of premature mortality, which is thought to be mediated by chronic and elevated stress, as well as psychiatric morbidity risk. Access to mental health care, where the needs of both the caregiver and child are considered, can enable caregivers to meet high caregiving demands and improve both child and caregiver outcomes. We describe the Caring for the Caregiver (C4C) model, a novel integrated stepped care model consisting of collaboration between a psychiatrist and a pediatric complex care program. This model provides support in 3 steps: 1) early identification of distress, 2) social work assessment, intervention and psychotherapy, and 3) psychiatric care, including diagnosis or medication initiation, for caregivers of CMC. This innovative model will be the first to embed support for the mental health needs of caregivers of CMC within a pediatric team, facilitating access to psychiatric care and serving as a foundation for future integrated stepped care models.

An urgent call for the environmental sustainability of health systems: A 'sextuple aim' to care for patients, costs, providers, population equity and the planet

Health systems have a duty to protect the health and well-being of individuals and populations. Yet, healthcare contributes about 4.6% of global greenhouse gas emissions. Health systems need to question and improve established practices, assume strong environmental leadership, and aim for ambitious, sometimes radical, actions in favour of the climate. In this paper, we interrogate the suitability and feasibility of integrating the aim of 'environmental sustainability' to form the 'Sextuple Aim.' Environmental sustainability may be in tension with, but also a potential lever to meet the other cardinal aims: (1) quality and experience of patient care; (2) population health; (3) quality of work and satisfaction of healthcare providers; (4) equity and inclusion; and (5) cost reduction. We propose policy and practical avenues to help move towards the Sextuple Aim.

Effectiveness of measures to preserve labour and childbirth companionship at the times of COVID-19 outbreak

INTRODUCTION

Although childbirth services were accessible after COVID-19 outbreak, the measures taken by the Italian Government for contagion containment required some restrictions on the presence of trusted persons for mothers, forcing them to isolation during hospitalization. To preserve companionship, the Regional Health Authority of Tuscany issued a resolution providing partners with the possibility to be present during labour and childbirth for non-asymptomatic women.

OBJECTIVES

In this study, we: 1) analyse the impact of pandemic on companionship in terms of significant reduction of the possibility for women to be accompanied by a trusted person during labour and childbirth; and 2) ascertain if the regional resolution issued was effective in containing the reduction of companionship.

METHODS

We performed an interrupted time series analysis to measure the variation of the possibility for women to be accompanied by a trusted person during labour and childbirth, in response to formalization of lock-down due to COVID-19 outbreak and the introduction of the regional resolution aimed at contrasting negative effects on companionship.

RESULTS AND CONCLUSIONS

The ITS analysis showed that there was a significant decrease in the women-reported experience of companionship in the month of the formalization of lock-down, namely March 2020, followed by a slight increase in the upcoming months. A trend reversal was observed after May 2020, when the regional resolution was fully operational.

Rationing in pediatric hospitalizations during COVID-19: A step back to move forward

The latest Omicron variant of the novel coronavirus has itself created a novel situation-bringing attention to the topic of healthcare rationing among hospitalized pediatric patients. This may be the first time that many pediatricians, nurses, parents, and public health officials have been compelled to engage in uncomfortable discussions about the allocation of medical care/resources. Simply put, finite budgets, resources, and a dwindling healthcare workforce do not permit all patients to receive unlimited medical care. Triage and bedside rationing decisions are happening in a range of difficult everyday circumstances both implicitly and explicitly, but in ways not recognized by even the best ethically framed intentions. Clinicians and hospital administrators have largely been left on their own "to flatten the rationing curve" in hopes that resources never have to be explicitly rationed at their facility. Unfortunately, the downstream result is a misinformed and distrustful public (i.e. parents, guardians, and caregivers) filled with people who are already burdened with inflammatory pseudoscience narratives and deficits in health literacy. This paper aims to elevate a more thoughtful conversation about healthcare rationing by analyzing some existing ethical principles/framework developed for rationing decision making during previous emergency responses and drawing from the day-to-day clinical perspectives of a frontline pediatric acute care/hospitalist.

Early Career Outcomes of Embedded Research Fellows: An Analysis of the Health System Impact Fellowship Program

BACKGROUND

This descriptive study reports the early career outcomes of postdoctoral fellows who completed a novel embedded fellowship training program, the Canadian Institutes of Health Research (CIHR) Health System Impact (HSI) Fellowship. The program was designed to support impact-oriented career paths of doctoral graduates, build research capacity within health system organizations, and help to advance learning health systems in Canada.

METHODS

Employment of fellowship alumni upon completion of the program were tracked using internet searches of publicly accessible online sources and complemented with program survey data.

RESULTS

Descriptive analyses show that all 87 eligible alumni included in the study are currently employed (100% of 87), with 92% employed in Canada. Their employment spans several sectors, including in academic (37%), public (29%), healthcare delivery (17%), and private (14%) sectors. Altogether, 32% of alumni held hybrid roles with an affiliation in academia and another sector. The most common position types were senior scientist (42%), professorships (18%), and director, manager or administrator roles (12%). Program reporting data indicate that these employment outcomes are generally consistent with the group's career aspirations reported at the start of the fellowship program, and that the program receives high ratings from fellows in the extent it is believed to support their career preparedness and readiness (4.49 out of 5).

CONCLUSION

We find that HSI Fellow alumni are employed mostly in research-related roles in a range of sectors including, but not limited to academia, that they positively perceive the program's success in elevating their career readiness and potential to make an impact - suggesting that the program may help equip fellows with the skills, readiness and networks for a broad array of employment sectors and roles. The findings are a promising signal of the demand for research talent and the growing capacity for learning health systems in Canada.

Telerehabilitation Delivery in Canada and the Netherlands: Results of a Survey Study

BACKGROUND

Following the onset of the COVID-19 pandemic, telerehabilitation (TR) has been expanding to address the challenges and risks of in-person delivery. It is likely that a level of TR delivery will continue after the pandemic because of its advantages, such as reducing geographical barriers to service. Many pandemic-related TR initiatives were put in place quickly. Therefore, we have little understanding of current TR delivery, barriers and facilitators, and how therapists anticipate integrating TR into current practice. Knowing this information will allow the incorporation of competencies specifically related to the use and provision of TR into professional profiles and entry-to-practice education, thereby promoting high-quality TR care.

OBJECTIVE

This study aimed to obtain a descriptive overview of current TR practice among rehabilitation therapists in Canada and the Netherlands and identify perceived barriers to and facilitators of practice.

METHODS

A web-based cross-sectional survey was conducted with occupational, physical, and respiratory therapists and dietitians in Canada (in French and English) and the Netherlands (in Dutch and English) between November 2021 and March 2022. Recruitment was conducted through advertisements on social media platforms and email invitations facilitated by regulatory and professional bodies. The survey included demographic and practice setting information; whether respondents delivered TR, and if so, components of delivery; confidence and satisfaction ratings with delivery; and barriers to and facilitators of use. TR satisfaction and uptake were measured using the Telehealth Usability Questionnaire and modified Technology Acceptance Model. Data were first summarized descriptively, and then, comparisons were conducted between professions.

RESULTS

Overall, 723 survey responses were received, mostly from Canada (n=666, 92.1%) and occupational therapists (n=434, 60%). Only 28.1% (203/723) reported receiving specific training in TR, with 1.2% (9/723) indicating that it was part of their professional education. Approximately 19.5% (139/712) reported not using TR at all, whereas most participants (366/712, 51.4%) had been using this approach for 1 to 2 years. Services delivered were primarily teleconsultation and teletreatment with individuals. Respondents offering TR were moderately satisfied with their service delivery and found it to be effective; 90.1% (498/553) indicated that they were likely to continue offering TR after the pandemic. Technology access, confidence, and setup were rated the highest as facilitators, whereas technology issues and the clinical need for physical contact were the most common barriers.

CONCLUSIONS

Professional practice and experience with TR were similar in both countries, suggesting the potential for common strategic approaches. The high prevalence of current practice and strong indicators of TR uptake suggest that therapists are likely to continue TR delivery after the pandemic; however, most therapists (461/712, 64.7%) felt ill prepared for practice, and the need to target TR competencies during professional and postprofessional education is critical. Future studies should explore best practice for preparatory and continuing education.

What Factors Explain Low Adoption of Digital Technologies for Health Financing in an Insurance Setting? Novel Evidence From a Quantitative Panel Study on IMIS in Tanzania

BACKGROUND

Digital information management systems for health financing are implemented on the assumption thatdigitalization, among other things, enables strategic purchasing. However, little is known about the extent to which thesesystems are adopted as planned to achieve desired results. This study assesses the levels of, and the factors associated withthe adoption of the Insurance Management Information System (IMIS) by healthcare providers in Tanzania.

METHODS

Combining multiple data sources, we estimated IMIS adoption levels for 365 first-line health facilities in2017 by comparing IMIS claim data (verified claims) with the number of expected claims. We defined adoption as abinary outcome capturing underreporting (verified

RESULTS

We found a median (interquartile range [IQR]) difference of 77.8% (32.7-100) between expected and verifiedclaims, showing a consistent pattern of underreporting across districts, regions, and months. Levels of underreportingvaried across regions (ANOVA: F=7.24, P<.001) and districts (ANOVA: F=4.65, P<.001). Logistic regression resultsshowed that higher service volume, share of people insured, and greater distance to district headquarter were associatedwith a higher probability of underreporting.

CONCLUSION

Our study shows that the adoption of IMIS in Tanzania may be sub-optimal and far from policy-makers'expectations, limiting its capacity to provide the necessary information to enhance strategic purchasing in the healthsector. Countries and agencies adopting digital interventions such as openIMIS to foster health financing reform areadvised to closely track their implementation efforts to make sure the data they rely on is accurate. Further, our studysuggests organizational and infrastructural barriers beyond the software itself hamper effective adoption.

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Key Words

• Adoption
• Digital Health Intervention
• Health Financing
• Health Insurance
• Strategic Purchasing
• Tanzania

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MESH Headings

• Humans
• Tanzania
• Healthcare Financing
• Digital Technology
• Insurance, Health
• Universal Health Insurance

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Affiliation(s)

Leon Schuetze Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
Siddharth Srivastava Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland University of Basel, Basel, Switzerland
Naasegnibe Kuunibe Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany Faculty of Integrated Development Studies, University for Development Studies, Wa, Ghana
Elizeus Josephat Rwezaula Health Promotion and System Strengthening Project (HPSS), Dodoma, Tanzania
Abdallah Missenye Kongwa District Council, Dodoma, Tanzania
Manfred Stoermer Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland University of Basel, Basel, Switzerland
Manuela De Allegri Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany

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Analysis of factors influencing the job satisfaction of medical staff in tertiary public hospitals, China: A cross-sectional study

Introduction

Since the outbreak of the novel coronavirus pneumonia (COVID-19), China has entered normalization phase of its epidemic prevention and control measures that emphasizes 'precise prevention and control,' 'dynamic zeroing', and 'universal vaccination'. However, medical staff continue to face physical and mental stress. The present study aimed to investigate the job satisfaction of medical staff in China, as well as any associated factors.

Methods

2,258 medical staff completed a questionnaire specially designed for this study. Independent samples t-tests, one-way analysis of variance, and binary logistic regression were used to analyze associated factors.

Results

Overall, 48.4% of the participants expressed satisfaction with their job; the highest-scoring dimension was interpersonal relationships (3.83 ± 0.73), while the lowest scoring dimension was salary and benefits (3.13 ± 0.94). The logistic regression model indicated that job satisfaction among medical staff is associated with being aged 40-49 years [odds ratio (OR) = 2.416] or > 50 years (OR = 2.440), having an above-undergraduate education level (OR = 1.857), holding a position other than doctor [i.e., nurse (OR = 3.696) or 'other' (OR = 2.423)], having a higher income (OR = 1.369), and having fewer monthly overtime shifts (OR = 0.735-0.543). Less than half of the medical staff expressed satisfaction with their job, indicating that the overall level is not high.

Discussion

This research enriches the study of medical workers' job satisfaction during periods when epidemic prevention and control has become familiar and routine. To improve medical workers' job satisfaction, administrators should seek to enhance medical staff's remuneration, reduce their work pressure, and meet their needs (where reasonable).

The uses of Patient Reported Experience Measures in health systems: A systematic narrative review

BACKGROUND

Many governments have programmes collecting and reporting patient experience data, captured through Patient Reported Experience Measures (PREMs). Our study aims to capture and describe all the ways in which PREM data are used within healthcare systems, and explore the impacts of using PREMs at one level (e.g. national health system strategy) on other levels (e.g. providers).

METHODS

We conducted a narrative review, underpinned by a systematic search of the literature.

RESULTS

1,711 unique entries were identified through the search process. After abstract screening, 142 articles were reviewed in full, resulting in 28 for final inclusion. A majority of papers describe uses of PREMs at the micro level, focussed on improving quality of front-line care. Meso-level uses were in quality-based financing or for performance improvement. Few macro-level uses were identified. We found limited evidence of the impact of meso‑ and macro- efforts to stimulate action to improve patient experience at the micro-level.

CONCLUSIONS

PREM data are used as performance information at all levels in health systems. The use of PREM data at macro- and meso‑ levels may have an effect in stimulating action at the micro-level, but there is a lack of systematic evidence, or evaluation of these micro-level actions. Longitudinal studies would help better understand how to improve patient experience, and interfaces between PREM scores and the wider associated positive outcomes.

A qualitative study of unpaid caregivers of persons living with dementia and their interactions with health and community-based services and providers

BACKGROUND AND OBJECTIVES

Unpaid caregivers frequently feel underprepared and without adequate training, support, or access to services and resources to care for persons living with dementia. Health and community-based services and providers are critical to support persons living with dementia and their unpaid caregivers. The objective of this research is to understand how unpaid caregivers of persons living with dementia interact with health and community-based services and providers.

RESEARCH DESIGN AND METHODS

We used a qualitative descriptive approach to analyze data from one-on-one semi-structured interviews with unpaid caregivers of persons living with dementia (N = 25). We used framework analysis to organize themes and sub-themes within the systems approach to healthcare delivery.

FINDINGS

Participants described a need for additional guidance, information, and support from health and community-based services and providers. This need was described by participants at 4 levels: individual, care team, organization, and political and economic environment. Participants were active in proposing potential solutions to challenges at all 4 levels, including improving provider awareness and training in dementia, opportunities to provide resources and referrals upon dementia diagnosis, a central clearinghouse for information and resources for persons living with dementia and caregivers, and opportunities to close service gaps.

DISCUSSION AND IMPLICATIONS

Findings of this study highlight the need for increased involvement of caregivers of persons living with dementia as community stakeholders for improving care and services. Recommendations to promote high quality care and better support unpaid caregivers by developing interventions to address multiple aspects of healthcare delivery are consistent with recent legislation and are important areas of future research.

'It absolutely needs to move out of that structure': Māori with bipolar disorder identify structural barriers and propose solutions to reform the New Zealand mental health system

OBJECTIVES

This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system.

DESIGN

A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD.

CONCLUSION

A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau.

Trust as a key measure of quality and safety after the restriction of family contact in Canadian long-term care settings during the COVID-19 pandemic

Family caregivers in Canadian long-term care homes are estimated to provide 10 h per week of direct care to approximately 30% of residents through roles including mobility support, mealtime assistance, personal care, social interaction, psychological care, care coordination, and advocacy. Despite these contributions, they continue to be viewed as visitors rather than as key participants in the interdependent relationships that support the long-term care sector. Their marginalization was evident during the COVID-19 pandemic, as Canadian public health policy focused on preventing them from entering long-term care, rather than supporting personal risk management, symptom screening, personal protective equipment, and other mechanisms for safe involvement in care. Several iatrogenic resident outcomes have been attributed to this, including decreased cognitive function, decreased mobility, increased incontinence, weight loss, increased depression and anxiety, increased responsive behaviours amongst those living with dementia, and increased delirium. In this commentary article, we argue that family caregiver presence was conflated as a risk when instead, it contributed to unintended harm. We identify nine well-known human social cognitive predispositions that may have contributed to this. We then examine their implications for trust in long-term care, and consider how quality and safety can be further fostered in long-term care by working in partnership with family caregivers to rebuild trust through enquiry and collaboration. We advocate incorporating trust as an essential measure of quality health service.

How do people living with chronic conditions and their informal caregivers experience primary care? A phenomenological-hermeneutical study

AIMS AND OBJECTIVES

Gaining insight in how people living with chronic conditions experience primary healthcare within their informal network.

BACKGROUND

The primary healthcare system is challenged by the increasing number of people living with chronic conditions. To strengthen chronic care management, literature and policy plans point to a person-centred approach of care (PCC). A first step to identify an appropriate strategy to implement PCC is to gain more insight into the care experiences of these people and their informal caregivers.

DESIGN

A phenomenological-hermeneutical philosophy is used. The study is in line with the Consolidated Criteria for Reporting Qualitative Research Guidelines (COREQ).

METHOD

In-depth, semi-structured interviews with people living with chronic conditions and informal caregiver dyads (PCDs) (n = 16; 32 individuals) were conducted. An open-ended interview guide was used to elaborate on the PCDs' experiences regarding primary care. A purposive, maximal variation sampling was applied to recruit the participants.

RESULTS

Based on sixteen PCDs' reflections, ten themes were identified presenting their experiences with primary care and described quality care as listening and giving attention to what people with chronic conditions want, to what they strive for, and above all to promote their autonomy in a context wherein they are supported by a team of formal caregivers, family and friends.

CONCLUSION

To meet the PCDs' needs, self-management should be addressed in an interprofessional environment in which the PCD is an important partner. The findings may facilitate a shift to encourage PCDs in their strengths by enabling them to share their personal goals and by working towards meaningful activities in team collaboration.

RELEVANCE TO CLINICAL PRACTICE

Three strategies-self-management support, goal-oriented care, and interprofessional collaboration-have been suggested to improve the PCDs' primary care experiences. These strategies could guide nursing practice in using more and improve high-quality nursing care.

A multidisciplinary safety briefing for acutely ill and deteriorating patients: A quality improvement project

BACKGROUND

Safety briefings can help promoting situational awareness, interprofessional communication and improve patient safety.

LOCAL PROBLEM

A clinical survey highlighted that 90% of the participants including the medical team and the critical care outreach team nurses perceived the meeting for escalating acutely ill and deteriorating patients during the out-of-hours period (20.00 to 08.00) to have unconstructive and unwelcoming atmosphere with belittling, hostility and unhelpful criticisms. The participants reported that the communication across teams lacked in structure and clear information given; but staff also self-reported lacking confidence in communicating key issues.

METHOD

A quality improvement project with Plan-Do-Study-Act was adopted to design and implement a dedicated multidisciplinary safety briefing with a structured format.

RESULTS

The multidisciplinary safety briefing was to 90% of clinicians, and it took a median of 10 min to complete. Delayed referrals to the critical care outreach team were reduced by 46%. Positive changes included increased situational awareness and clearer communication across teams. Barriers identified were variable usage and need for face-to-face presence. Considering all the findings and the time constraint during the SARS-CoV-2 pandemic, we changed to a telephonic safety briefing directly to the team leaders.

CONCLUSION

A structured multidisciplinary safety briefing can improve patient safety and support management of deteriorating and acutely ill patients on the wards during the out-of-hours period.

Engaging Employers in Apprentice Training: Focus Group Insights from Small-to-Medium-Sized Employers in Ontario, Canada

Several factors have been identified to influence the registration and retention of apprentices in the construction trades. Employer engagement is a key factor to promote growth in apprenticeships in the construction trades as participation rates continue to be low among small-to-medium-sized employers. In this study, we evaluated the effectiveness of the Ontario Electrical League's (OEL) employer mentorship program through the perspectives of small-to-medium-sized employers using a qualitative approach. Two focus groups were conducted virtually with 11 employers. Focus group audio transcripts were recorded and transcribed for thematic analysis. Themes were generated using a data-driven approach to examine the relationships between mentorship program outcomes and perspectives on industry-related recruitment and retention barriers. Three themes were identified: (a) long-term apprentice recruitment and retention challenges; (b) equity and mental health in the workplace; and (c) industry challenges and mentorship program outcomes. Generally, this sample of employers appreciated the value of the OEL mentorship program through praise of the continued educational support, employer management expertise, hiring resources, and apprentice onboarding tools despite industry barriers in trade stigma, equity and mental health in the workplace, and recruitment and retention challenges. Industry partners should work with these small-to-medium-sized employers to develop workplace initiatives and engage external partners to provide ongoing apprenticeship mentorship support to address the recruitment and retention barriers identified in this study.

Identifying Longitudinal CD4:CD8 Ratio Trajectories Indicative of Chronic Renal Disease Risk among People Living with HIV: An Application of Growth Mixture Models

The incidence of chronic kidney disease (CKD) is increasing among people living with HIV (PLWH). Routine monitoring of indicators such as CD4:CD8 ratio might improve the early detection of CKD. Our objective was to identify clinically relevant CD4:CD8 ratio trajectories indicative of CKD risk. Participants were ≥ 18 years old, initiated antiretroviral therapy between 2000 and 2016, and were followed for ≥6 months until 31 March 2017 or last contact date. Outcome was incidence of CKD. Growth mixture models (GMMs) and decay models were used to compare CD4:CD8 ratio trajectories. Following GMM, 4547 (93.5%) participants were classified in Class 1 with 5.4% developing CKD, and 316 (6.5%) participants were classified in Class 2 with 20.9% developing CKD. The final model suggested that participants in Class 2 had 8.72 times the incidence rate of developing CKD than those in Class 1. Exponential decay models indicated a significant CD4:CD8 ratio decline among Class 2 participants who developed CKD. Among those who developed CKD in Class 2, starting at 5.5 years of follow-up, the slope of their ratio trajectory curve changed significantly, and the rate of decline increased dramatically. Routine monitored CD4:CD8 ratios can be an effective strategy to identify early CKD risk among PLWH.

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis

BACKGROUND

With the sharp increase in the involvement of patients (including family and informal caregivers) as active participants, collaborators, advisors and decision-makers in health systems, a new role has emerged: the patient partner. The role of patient partner differs from other forms of patient engagement in its longitudinal and bidirectional nature. This systematic review describes extant work on how patient partners are conceptualized and engaged in health systems. In doing so, it furthers the understanding of the role and activities of patient partners, and best practices for future patient partnership activities.

METHODS

A systematic review was conducted of peer-reviewed literature published in English or French that describes patient partner roles between 2000 and 2021 in any country or sector of the health system. We used a broad search strategy to capture descriptions of longitudinal patient engagement that may not have used words such as "partner" or "advisor".

RESULTS

A total of 506 eligible papers were identified, representing patient partnership activities in mostly high-income countries. These studies overwhelmingly described patient partnership in health research. We identified clusters of literature about patient partnership in cancer and mental health. The literature is saturated with single-site descriptive studies of patient partnership on individual projects or initiatives. There is a lack of work synthesizing impacts, facilitating factors and outcomes of patient partnership in healthcare.

CONCLUSIONS

There is not yet a consolidated understanding of the role, activities or impacts of patient partners. Advancement of the literature has been stymied by a lack of consistently used terminology. The literature is ready to move beyond single-site descriptions, and synthesis of existing pockets of high-quality theoretical work will be essential to this evolution.

An analysis of KwaZulu-Natal clinical psychologists’ multicultural experience

In this article, perspectives of South African clinical psychologists (based in KwaZulu-Natal) regarding multicultural issues in clinical practice and training are presented. The discussion focuses on emergent themes from 13 qualitative semi-structured interviews. Themes from interviews were analysed using thematic analysis and techniques from a grounded theory approach. While the study focused on a number of contextual multicultural issues both in service delivery and in training, this article documents the experiences of clinical psychologists regarding multicultural challenges and concerns, as well as approaches and capacities used to improve service delivery in this area. These perspectives are important in the multicultural and multilingual South African context, where there is limited literature in this area as well as related aspects such as cultural competency. There are many different belief systems as well as historical and sociopolitical factors that may influence how clinicians and individuals presenting for treatment may understand their experience and symptoms. This article seeks to document some of the challenges this may present in terms of service delivery in this context. Understandings of the term cultural competence as well as suggestions (primarily as noted by participants) to address the gap between training, competencies, and the realities of service delivery are also presented. Questions and considerations for future research are also raised.

Factors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff

BACKGROUND

Digital interventions for health financing, if implemented at scale, have the potential to improve health system performance by reducing transaction costs and improving data-driven decision-making. However, many interventions never reach sustainability, and evidence on success factors for scale is scarce. The Insurance Management Information System (IMIS) is a digital intervention for health financing, designed to manage an insurance scheme and already implemented on a national scale in Tanzania. A previous study found that the IMIS claim function was poorly adopted by health care workers (HCWs), questioning its potential to enable strategic purchasing and succeed at scale.

OBJECTIVE

This study aimed to understand why the adoption of the IMIS claim function by HCWs remained low in Tanzania and to assess implications for use at scale.

METHODS

We conducted 21 semistructured interviews with HCWs and management staff in 4 districts where IMIS was first implemented. We sampled respondents by using a maximum variation strategy. We used the framework method for data analysis, applying a combination of inductive and deductive coding to organize codes in a socioecological model. Finally, we related emerging themes to a framework for digital health interventions for scale.

RESULTS

Respondents appreciated IMIS's intrinsic software characteristics and technical factors and acknowledged IMIS as a valuable tool to simplify claim management. Human factors, extrinsic ecosystem, and health care ecosystem were considered as barriers to widespread adoption.

CONCLUSIONS

Digital interventions for health financing, such as IMIS, may have the potential for scale if careful consideration is given to the environment in which they are placed. Without a sustainable health financing environment, sufficient infrastructure, and human capacity, they cannot unfold their full potential to improve health financing functions and ultimately contribute to universal health coverage.

When Guideline-Concordant Standardized Care Results in Healthcare Disparities

AbstractClinical red blood cell transfusion guidelines have been widely adopted in clinical practice, resulting in standardized transfusion practices in hospitalized patients with anemia. Standardization of transfusion practice has been welcomed by clinicians and health systems as a mechanism for reducing unnecessary, harmful, and costly practice variation that results in healthcare disparities. However, overzealously applied guidelines can have deleterious consequences for individual patients, ultimately resulting in and/or exacerbating healthcare disparities, rather than resolving them. This article provides empirical examples of the adverse consequences from the well-meaning attempt to standardize transfusion practice based on clinical practice guidelines and discusses the ethical implications of standardized transfusion practice.

Conceptualizing learning health systems: A mapping review

Introduction

Health systems worldwide face the challenge of increasing population health with high-quality care and reducing health care expenditure growth. In pursuit for a solution, regional cross-sectoral partnerships aim to reorganize and integrate services across public health, health care and social care. Although the complexity of regional partnerships demands an incremental strategy, it is yet not known how learning works within these partnerships. To understand learning in regional cross-sectoral partnerships for health, this study aims to map the concept Learning Health System (LHS).

Methods

This mapping review used a qualitative text analysis approach. A literature search was conducted in Embase and was limited to English-language papers published in the period 2015-2020. Title-abstract screening was performed using established exclusion criteria. During full-text screening, we combined deductive and inductive coding. The concept LHS was disentangled into aims, design elements, and process of learning. Data extraction and analysis were performed in MAX QDA 2020.

Results

In total, 155 articles were included. All articles used the LHS definition of the Institute of Medicine. The interpretation of the concept LHS varied widely. The description of LHS contained 25 highly connected aims. In addition, we identified nine design elements. Most elements were described similarly, only the interpretation of stakeholders, data infrastructure and data varied. Furthermore, we identified three types of learning: learning as 1) interaction between clinical practice and research; 2) a circular process of converting routine care data to knowledge, knowledge to performance; and performance to data; and 3) recurrent interaction between stakeholders to identify opportunities for change, to reveal underlying values, and to evaluate processes. Typology 3 was underrepresented, and the three types of learning rarely occurred simultaneously.

Conclusion

To understand learning within regional cross-sectoral partnerships for health, we suggest to specify LHS-aim(s), operationalize design elements, and choose deliberately appropriate learning type(s).

Hospital Experiences of Dignity in People Who Inject Drugs

BACKGROUND

Dignity is a complex concept necessary for the adequate treatment of patients in the healthcare setting. Autonomy, self-sufficiency, respect, and equality are concepts used to define dignity. Dignity has not been studied in people who inject drugs (PWID).

OBJECTIVE

This study aimed to determine how PWID maintain or have their dignity threatened during hospitalization in an acute care unit.

DESIGN

The qualitative descriptive study was a deductive thematic analysis of secondary data on PWID experiences with received nursing care. In-depth, semistructured interviews were conducted and transcribed verbatim with a constant comparison method for thematic analysis using NVivo. A priori codes of dignity concepts from the literature and dignity scales were used as a guide to examine the nine qualitative transcripts.

FINDINGS

The three most common threats to dignity during hospitalization were lack of equality compared with other patients, not feeling valued as an individual, and not feeling respected by the healthcare workers providing care. The three most common protectors of dignity were feeling respected by healthcare workers, having autonomy in treatment choices, and feeling valued as an individual.

CONCLUSIONS

Protecting dignity significantly affects whether PWID are willing to seek healthcare in the hospital setting. Preserving dignity in PWID during their hospitalizations can encourage this population to seek care earlier. Nurses must be experienced in caring for PWID and provide nonjudgmental care for this population.

Addressing the move toward universal health in the Caribbean through strengthening the health workforce

This article describes the human resources for health (HRH) policy and action plan development in Barbados, Grenada, and St. Vincent and the Grenadines, the supporting role of the PAHO/WHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, and sub-regional action for supporting continuing country-level HRH strengthening. A policy development process, comprising document/literature review and stakeholder consultations, was used to conduct a situational analysis, which informed the HRH policy and action plan. The policies and action plans centered on HRH priority areas of leadership and governance, HRH planning capacity, strengthening primary health care, optimization of pre- and post-licensure education/training, retention and recruitment, deployment and utilization, inter-sectoral and external partnerships for sustainability, health information systems, and HRH research. A cross-sectional analysis of the findings found that HRH challenges and priority areas were consistent across the countries, resulting in similar policy priority actions that are aligned with the regional lines of action for strengthening HRH for universal access to health and universal health coverage. The results support the value-add in collaborating on a regional level to build capacity for needs-based HRH planning within member countries. The Caribbean-Community (CARICOM), with facilitation by Pan American Health Organization (PAHO) Caribbean Subregional Programme, has established the Human Resources for Health Action Task Force for the Caribbean. The expertise of the Dalhousie University PAHO/WHO Collaborating Centre, provided through the technical assistance, supported the three countries in this important initiative and provides for further opportunities to support PAHO, the Task Force, and countries as they work to achieve their HRH strengthening objectives.

A Data-Driven Approach to Support the Understanding and Improvement of Patients' Journeys: A Case Study Using Electronic Health Records of an Emergency Department

OBJECTIVES

Given the increasing availability of electronic health records, it has become increasingly feasible to adopt data-driven approaches to capture a deep understanding of the patient journeys. Nevertheless, simply using data-driven techniques to depict the patient journeys without an integrated modeling and analysis approach is proving to be of little benefit for improving patients' experiences. Indeed, a model of the journey patterns is necessary to support the improvement process.

METHODS

We presented a 3-phase methodology that integrates a process mining-based understanding of patient journeys with a stochastic graphical modeling approach to derive and analyze the analytical expressions of some important performance indicators of an emergency department including mean and variance of patients' length of stay (LOS).

RESULTS

Analytical expressions were derived and discussed for mean and variance of LOS times and discharge and admission probabilities. LOS differed significantly depending on whether a patient was admitted to the hospital or discharged. Moreover, multiparameter sensitivity equations are obtained to identify which activities contribute the most in reducing the LOS at given operating conditions so decision makers can prioritize their improvement initiatives.

CONCLUSIONS

Data-driven based approaches for understanding the patient journeys coupled with appropriate modeling techniques yield a promising tool to support improving patients' experiences. The modeling techniques should be easy to implement and not only should be capable of deriving some key performance indicators of interest but also guide decision makers in their improvement initiatives.

Analyzing models of patient-centered care in Canada through a scoping review and environmental scan

Aim

The objective of this study was to identify and synthesize models of patient-centered care in Canada and compare them with the normative models described in the literature.

Subject and methods

Patient-centered care has gained momentum in the twenty-first century as a component of quality care. During the Covid-19 pandemic, the crisis often shifts the focus to the disease rather than the patient. The multiplicity of Canadian systems, including the federal, provincial, and territorial contexts, made a good case to search for a variety of models. This study was conducted using a scoping review method supported by an environmental scan to identify patient-centered care models in Canada.

Results

The study identified 19 patient-centered interventions across Canada. The interventions included bedside interventions, patient-engagement projects at the organizational level, and citizen advisory panels at the system level. The organizational model was the most common. The goals of interventions ranged from enhancing the patient's experience of care to identifying ways to cut costs. In most organizational-level projects, there was a marked tendency to engage patients as members of quality improvement committees. Respecting patient dignity and autonomy in one-on-one clinical interactions was minimally addressed in the models.

Conclusion

Health systems are not only technical, biomedical organizations but also socio-political institutions with goals of financial protection, the fair distribution of services and resources, and the meaningful inclusion of the citizens in the system, and thus patients need to be respected as individuals and as collectives within the healthcare system.

Psychosocial Distress in Patients With Advanced CKD by Racial Group and Immigrant Status: A Canadian Cross-sectional Study

RATIONALE & OBJECTIVE

Patients with advanced chronic kidney disease (CKD) have been reported to experience profound psychosocial distress. Other work has established that patients with CKD from marginalized populations (including individuals who on the basis of race often face racism and related discrimination, termed "racialization") experience health care inequities. Given limited information on the intersection of these 2 phenomena, we assessed the association of psychosocial distress with racialized status and immigrant status in Canadians with advanced CKD.

STUDY DESIGN

Secondary analysis of cross-sectional data.

SETTING & PARTICIPANTS

536 patients with advanced CKD (estimated glomerular filtration rate<30mL/min/1.73m², with or without kidney replacement therapy) from multiple clinical centers in Toronto.

EXPOSURE

Racialized status (individuals who identify as Asian or as African, Caribbean, or Black Canadian), immigrant status, and combined immigrant-racialized status.

OUTCOME

Psychosocial distress, defined as the presence of depression, anxiety, or social difficulties (ie, a score of≥10 points on the Patient Health Questionnaire 9, Generalized Anxiety Disorder 7, or Social Distress 16 scales, respectively).

ANALYTICAL APPROACH

The independent associations of racialized status and immigrant status with psychosocial distress, depression, anxiety, and social difficulties were examined using univariable- and multivariable-adjusted logistic regression.

RESULTS

Mean age of the 536 participants was 57±16 (SD) years, 62% were male, and 45% were immigrants. Of the sample, 58% were White, 22% were African, Caribbean, or Black Canadian, and 20% were Asian. Psychosocial distress was present in 36% of participants (depression in 19%, anxiety in 12%, and social difficulties in 31%). To assess the combined impact of racialized and immigrant status, we created a variable with mutually exclusive categories: White nonimmigrant, racialized nonimmigrant, White immigrant, and racialized immigrant participants. In our final multivariable-adjusted model, compared with White nonimmigrant participants, racialized immigrant participants were more likely to have psychosocial distress (OR, 2.96 [95% CI, 1.81-4.81]), depression (OR, 1.87 [95% CI, 1.05-3.34]), and social difficulties (OR, 3.36 [95% CI, 2.03-5.57]). Overall similar associations were seen for racialized nonimmigrants and for White immigrants.

LIMITATIONS

Convenience sample; small subgroups; combined exposure variable grouping Asian and African, Caribbean, and Black participants together; lack of data about mechanisms.

CONCLUSIONS

Both racialized and immigrant status based on self-report of demographic characteristics were associated with psychosocial distress among patients with advanced CKD. These patients may benefit from culturally competent psychosocial support.

PLAIN-LANGUAGE SUMMARY

Psychosocial distress is frequent in patients with advanced chronic kidney disease and impacts quality of life and clinical outcomes. Psychosocial distress may be especially scarring in people who are racialized (marginalized on account of their membership in a particular racial group) and/or who are immigrants. We assessed the association of psychosocial distress with racialized and immigrant status in Canadians with advanced chronic kidney disease. Among 536 participants from multiple medical centers in Toronto, we found that racialized and immigrant participants were more likely to have psychosocial distress, depression, and social difficulties compared with White nonimmigrant participants. This is likely related to the multiple intersectional challenges, including experience with racism and discrimination that racialized immigrant patients may face. Further studies are needed to elucidate the specific factors that contribute to more distress. The potential impact of culturally competent and safe support for these patients will also need to be studied.

Development of a video-based evidence synthesis knowledge translation resource: Drawing on a user-centred design approach

Objectives

We aimed to develop a video animation knowledge translation (KT) resource to explain the purpose, use and importance of evidence synthesis to the public regarding healthcare decision-making.

Methods

We drew on a user-centred design approach to develop a spoken animated video (SAV) by conducting two cycles of idea generation, prototyping, user testing, analysis, and refinement. Six researchers identified the initial key messages of the SAV and informed the first draft of the storyboard and script. Seven members of the public provided input on this draft and the key messages through think-aloud interviews, which we used to develop an SAV prototype. Seven additional members of the public participated in think-aloud interviews while watching the video prototype. All members of the public also completed a questionnaire on perceived usefulness, desirability, clarity and credibility. We subsequently synthesised all data to develop the final SAV.

Results

Researchers identified the initial key messages as 1) the importance of evidence synthesis, 2) what an evidence synthesis is and 3) how evidence synthesis can impact healthcare decision-making. Members of the public rated the initial video prototype as 9/10 for usefulness, 8/10 for desirability, 8/10 for clarity and 9/10 for credibility. Using their guidance and feedback, we produced a three-and-a-half-minute video animation. The video was uploaded on YouTube, has since been translated into two languages, and viewed over 12,000 times to date.

Conclusions

Drawing on user-centred design methods provided a structured and transparent approach to the development of our SAV. Involving members of the public enhanced the credibility and usefulness of the resource. Future work could explore involving the public from the outset to identify key messages in developing KT resources explaining methodological topics. This study describes the systematic development of a KT resource with limited resources and provides transferrable learnings for others wishing to do similar.

Collecting Patient Feedback as a Means of Monitoring Patient Experience and Hospital Service Quality - Learning from a Government-led Initiative

PURPOSE

Patient feedback plays a significant role in hospital service improvement. However, how to encourage patient feedback that can guide hospital service improvement is still being explored. By examining patient feedback data related to a tertiary hospital in China that was collected from the "12345" Government Service Convenience Hotline (GSCH), the paper discusses the learnings from GSCH in encouraging patient feedback and how quality improvement initiatives have effected the number and types of complaints made by patients and their families via GSCH.

METHODS

The study retrospectively collected and analyzed complaints on a Tertiary General University-affiliated hospital made via GSCH between 2016 and 2020. Patient care process-related complaints were coded using the health care complaint analysis tool (HCAT) and other complaint data were categorized based on the nature of the complaints. The autoregressive integrated moving average (ARIMA) models and mosaic plots were used to observe complaints trends and different complaint variables, respectively. The relationship between various quality improvement initiatives introduced since 2018 and patient complaints was also tested.

RESULTS

Close to 67% (n=2688) of calls made to the GSCH hotlines about the hospital were classified as a complaint including 60.6% vs 39.4% related to patient care process and nonpatient care process, respectively. For patient care process-related complaints, specifically against departments and personnel, 57.72% (n=961) were on clinical departments and 55.87% (n=471) were on doctors. Comparing the proportion of the complaint data in different categories in the two-year period of 2017-2018 and 2019-2020, an increase in management problems (47.73% vs 58.50%, P<0.001) and decrease in relationship problems (33.65% vs 25.69%, P=0.002) were recorded.

CONCLUSION

A unified, transparent, and impartial GSCH platform greatly encourages feedback from patients and families. Feedbacks provide evidence to guide health care organizations in improving the overall experience of patients and the quality of services that they provide.

Effect of standardised surgical assessment and shared decision-making on morbidity and patient satisfaction after breast conserving therapy: A cross-sectional study

BACKGROUND

The role of oncoplastic breast conserving therapy (OPBCT) on physical function, morbidity and patient satisfaction has yet to be defined. Additionally, technique selection should be individualised and incorporate patient preference. The study aim was to investigate differences between "standard" (sBCT) and oncoplastic breast conservation (OPBCT) in patient-reported outcomes (PROs) when patients have been assessed in a standardised manner and technique selection has been reached through shared decision-making (SDM).

METHODS

This is a cross-sectional study of 215 women treated at a tertiary referral centre. Standardised surgical assessment included breast and lesion volumetry, definition of resection ratio, patient-related risk factors and patient preference. Postoperative morbidity and patient satisfaction were assessed by validated PROs tools (Diseases of the Arm, Shoulder and Hand-DASH and Breast-Q). Patient experience was assessed by semi-structured interviews.

RESULTS

There was no difference of the median values between OPBCT and sBCT in postoperative morbidity of the upper extremity (DASH 3.3 vs 5, p = 0.656) or the function of the chest wall (Breast-Q 82 vs 82, p = 0.758). Postoperative satisfaction with breasts did not differ either (Breast-Q 65 vs 61, p = 0.702). On the individual level, women that opted for OPBCT after SDM had improved satisfaction when compared to baseline (+3 vs -1, p = 0.001). Shared decision-making changed patient attitude in 69.8% of patients, leading most often to de-escalation from mastectomy.

CONCLUSIONS

These findings support that a combination of standardised surgical assessment and SDM allows for tailored treatment and de-escalation of oncoplastic surgery without negatively affecting patient satisfaction and morbidity.

Level of Professionalism and Associated Factors Among Nurses Working in South Wollo Zone Public Hospitals, Northeastern Ethiopia, 2022

Introduction

Nurses are the frontline force for patient care, and nursing professionalism is a key tool for quality of care. Nursing professionalism and its characteristics should be defined in accordance with the current system.

Objective

To determine the level of professionalism in nursing and its associated factors in the South Wollo Public Hospital, Northeast Ethiopia.

Methods

A multicenter hospital-based cross-sectional study design was used in South Wollo Zone Public Hospitals from March to April 2022, with 357 nurses selected using a simple random sampling method. Data were collected using a pretested questionnaire, then entered and analyzed using EpiData 4.7 and SPSS 26. Finally, predictors of nursing professionalism were identified using a multivariate logistic regression.

Result

Of the 350 respondents, 179 (51.1%) were women and 171 (48.9%) were men, with 68.6% displaying high levels of professionalism. Being women (adjusted odds ratio [AOR] = 2.93, 95% CI [1.718, 5.000]), having a positive self-image (AOR = 2.96, 95% CI [1.421, 6.205]), having a good organizational culture (AOR = 3.16, 95% CI [1.587, 6.302]), being a member of the nursing association (AOR = 1.95, 95% CI [1.137, 3.367]), and nurses who were satisfied with their job were significantly associated with nursing professionalism.

Conclusion

In this study, the level of nursing professionalism was encouraging but needed more effort. Furthermore, sex, self-image, organizational culture, nursing association membership, and job satisfaction were positive predictors of nursing professionalism. As a result, hospital administrations consider factors that maintain a pleasant institutional working environment to foster a positive self-image and increase job satisfaction.

Value-based health care in Western countries: a scoping review on the implementation of patient-reported-outcomes sets for hospital-based interventions

INTRODUCTION

For implementation of the value-based health-care (VBHC) concept, use of patient-reported outcome measures (PROMs), patient-reported experience measures (PREMs), and clinical outcomes is crucial. The aim of this study was to summarize published studies on implemented PROMs, PREMs, and clinical-outcomes sets in health-care practice.

AREAS COVERED

A scoping review was conducted by using PubMed and Embase. Our study focused on implementation examples of patient-reported outcome sets in Western countries' hospitals. Included papers were analyzed on content, in particular concerning PROMs, PREMs, and clinical outcomes. We also assessed differences between diseases, categorized as patient-reported outcomes in curative, chronic, and palliative treatments in the hospital.

EXPERT OPINION

A total of 20 studies were found that presented VBHC implementation examples. Results illustrate the disconnection between the development of PROMs and PREMs and the implementation phase, with implementation still in infancy. Hospital organizations should enhance organization for the implementation of VBHC. It is crucial that leading examples of successful VBHC serve as blueprints for implementation, with the participation of all relevant stakeholders. Affordability and sustainability of health care can be enhanced by scaling up successful VBHC-interventions on population levels.

Influence of the COVID-19 pandemic on self-reported urinary incontinence during pregnancy and postpartum: A prospective study

OBJECTIVE

To explore how the COVID-19 pandemic influenced self-reported occurrence and severity of pregnancy-related urinary incontinence (UI) in the maternity pathways of Tuscany, Italy.

METHODS

In this prospective pre-post cohort study, we selected a pre-pandemic (n = 1018) and a post-pandemic (n = 3911) cohorts of women that completed, from the first trimester until 3 months postpartum, three surveys including validated patient-reported outcome measures for UI. Data were obtained from systematic surveys on the maternity pathways of Tuscany from March 2019 to June 2021. We performed panel regression models to explore how UI risk differed between COVID-19 groups.

RESULTS

UI occurred less frequently and less severely in post-pandemic patients-especially stress/mixed UI in women never performing pelvic floor muscle training (PFMT)-whereas no difference emerged in women performing during-pregnancy PFMT. During COVID-19, obese women had higher risk of UI, whereas women undergoing operative delivery had lower risk. The post-pandemic group reported more severe UI symptoms at the third trimester, but less severe UI postpartum in women suffering from UI during pregnancy.

CONCLUSIONS

During the COVID-19 pandemic, women reported fewer UI symptoms because they might have lacked chances to identify UI symptoms as a result of pandemic-related sedentarism and inactivity. The risk in women performing during-pregnancy PFMT was not increased, but just six of 26 health districts organized remote PFMT sessions, thus revealing limited resilience to the pandemic in Tuscany.

Regulating in the public interest: Lessons learned during the COVID-19 pandemic

This article has three aims. First, to reflect on how conceptualizations of the public interest may have shifted due to COVID-19. Second, to focus on the implications of regulatory responses for the health workforce and corresponding lessons as health leaders and systems transition from pandemic response to pandemic recovery. Third, to identify how these lessons lead to potential directions for future research, connecting regulation in a whole-of-systems approach to health system safety and health workforce capacity and sustainability. Pandemic regulatory responses highlighted both strengths and limitations of regulatory structures and frameworks. The COVID-19 pandemic may have introduced new considerations around regulating in the public interest, particularly as the impact of regulatory responses on the health workforce continues to be examined. Clearly articulating practitioner practice parameters, reducing barriers to practice, and working collaboratively with stakeholders were primary aspects of regulators' pandemic responses that impacted the health workforce.

Economic Evaluation of Telerobotic Ultrasound Technology to Remotely Provide Ultrasound Services in Rural and Remote Communities

INTRODUCTION

Telerobotic ultrasound technology allows radiologists and sonographers to remotely provide ultrasound services in underserved areas. This study aimed to compare costs associated with using telerobotic ultrasound to provide ultrasound services in rural and remote communities to costs associated with alternate models.

METHODS

A cost-minimization approach was used to compare four ultrasound service delivery models: telerobotic ultrasound (Model 1), telerobotic ultrasound and an itinerant sonographer (Model 2), itinerant sonographer without telerobotic ultrasound (Model 3), and travel to another community for all exams (Model 4). In Models 1-3, travel was assumed when exams could not be successfully performed telerobotically or by an itinerant sonographer. A publicly funded healthcare payer perspective was used for the reference case and a societal perspective was used for a secondary non-reference case. Costs were based on the literature and experience using telerobotic ultrasound in Saskatchewan, Canada. Costs were expressed in 2020 Canadian dollars.

RESULTS

Average cost per ultrasound exam was $342, $323, $368, and $478 for Models 1, 2, 3, and 4, respectively, from a publicly funded healthcare payer perspective, and $461, $355, $447, and $849, respectively, from a societal perspective. In one-way sensitivity analyses, Model 2 was the lowest cost from a payer perspective for communities with population >2075 people, distance >350 km from the nearest ultrasound facility, or >47% of the population eligible for publicly funded medical transportation.

CONCLUSION

Health systems may wish to consider solutions such as telerobotic ultrasound and itinerant sonographers to reduce healthcare costs and improve access to ultrasound in rural and remote communities.

Patterns of acceptance and use of digital health services among the persistent frequent attenders of outpatient care: A qualitatively driven multimethod analysis

Objective

Utilising digital health services in the treatment of patients who frequently attend outpatient care could be beneficial for patients' health and the sustainability of health systems but carries the risk of digital exclusion. This study aimed to explore the patterns of acceptance and use of digital health services among frequent attenders (FAs), which may help in the assessment of patients' digital suitability.

Methods

Persistent FAs (N = 30) were recruited by random sampling from one Finnish municipality. The semistructured interviews were conducted in February-May 2021. We analysed the data with qualitative content analysis using the Unified Theory of Acceptance and Use of Technology (UTAUT) model. Additionally, we quantified the data for two-step cluster analyses to create separate cluster models that grouped FAs based on acceptance and use of (a) digital services for self-management of health and (b) telemedicine services.

Results

Based on digital self-management, FAs were defined as Self-Managers, Supported Self-Managers, and Non-Self-Managers. Based on telemedicine use, they were grouped into Telemedicine Users, Doubtful Telemedicine Users, and Telemedicine Refusers. The clusters described different opportunities, awareness, and interest in using digital health services. Referral from professionals seemed to promote digital service use. For some, digital services were not accessible.

Conclusions

Our findings emphasise the importance of assessing the suitability of FAs to digital health services, as their readiness to use may vary. Professionals should recommend digital services that support individual health to suitable patients. More accessible digital services could promote digital suitability despite functional limitations.