A population-based approach to integrated healthcare delivery: a scoping review of clinical care and public health collaboration

Continuity and sustainability of care in family medicine: Assessing its association with quality of life and health outcomes in older populations-A systematic review

BACKGROUND

Continuity of care is a core principle of family medicine associated with improved outcomes. However, fragmentation challenges sustaining continuous relationships. This review aimed to provide timely and critical insights into the benefits of continuity and sustainability of care for older adults.

METHODS

PubMed, EMBASE, CINAHL, Cochrane Library were systematically searched for studies on continuity/sustainability models in family medicine and effects on older adults. 14 studies met inclusion criteria for final synthesis. Quality was assessed using ROBINS-I. Outcomes were narratively and thematically synthesized.

RESULTS

Greater continuity of care was consistently associated with reduced healthcare utilization including lower emergency department visits and hospitalizations. Continuity also correlated with improved chronic disease management, care coordination, patient-reported experiences, and quality of life. Patient-centered medical homes and care coordination models showed potential to strengthen continuity and sustainability. Thoughtful telehealth integration and technology tools augmented continuity.

CONCLUSION

Continuous healing relationships are vital for patient-centered care of older adults. While current fragmentation challenges sustainability, innovations in primary care teaming, coordination, telehealth, and health information technology can extend continuity's benefits. Realizing improvements requires system-wide reorientation toward relationships and whole-person care.

A 25-Year Retrospective of Health IT Infrastructure Building: The Example of the Catalonia Region

Over the past decades, health care systems have significantly evolved due to aging populations, chronic diseases, and higher-quality care expectations. Concurrently with the added health care needs, information and communications technology advancements have transformed health care delivery. Technologies such as telemedicine, electronic health records, and mobile health apps promise enhanced accessibility, efficiency, and patient outcomes, leading to more personalized, data-driven care. However, organizational, political, and cultural barriers and the fragmented approach to health information management are challenging the integration of these technologies to effectively support health care delivery. This fragmentation collides with the need for integrated care pathways that focus on holistic health and wellness. Catalonia (northeast Spain), a region of 8 million people with universal health care coverage and a single public health insurer but highly heterogeneous health care service providers, has experienced outstanding digitalization and integration of health information over the past 25 years, when the first transition from paper to digital support occurred. This Viewpoint describes the implementation of health ITs at a system level, discusses the hits and misses encountered in this journey, and frames this regional implementation within the global context. We present the architectures and use trends of the health information platforms over time. This provides insightful information that can be used by other systems worldwide in the never-ending transformation of health care structure and services.

The role of pharmacy in promoting public health: Pharmacy and public health in 2050

From 2000 to 2025, the profession of pharmacy expanded into vaccinations, point-of-care testing, and chronic disease prevention and management. In the next 25 years, pharmacy will continue to advance in new ways. This paper focuses on expanded roles of community and ambulatory care pharmacy to more directly improve public health. Built around the ten essential services of public health, this paper calls upon the profession of pharmacy to stretch beyond traditional roles to assume roles that would strengthen the public health workforce and make seminal contributions to improved population health. Barriers to be overcome in pursuit of that future are also addressed. The paper will conclude with a public health-focused call to pharmacy.

The integration of human and non-human actors to advance healthcare delivery: unpacking the role of actor-network theory, a systematic literature review

BACKGROUND

There is an increasing public, societal and policy imperative for effective integration of healthcare delivery systems. Central to integration in healthcare is a focus on people-centred health, access, patient empowerment, interprofessional teamwork and collaboration between all healthcare stakeholders - difficult to achieve in current silo-driven bureaucratic health organisations. Therefore, actor-network theory (ANT) offers a theoretical approach to understanding the complexities of healthcare delivery by unpacking the type of actor's interplay between social elements and immaterial objects, their interactions, interdependencies and power dynamics.

AIMS

The first of its type, this systematic review aims to identify, synthesise, and appraise extant literature on the use and application of ANT in healthcare contexts.

METHODS

This systematic review was conducted in accordance with PRISMA guidelines and registered with PROSPERO. The authors generated a search strategy utilising 31 Boolean terms, conducting electronic searches of MEDLINE, CINAHL Complete, SCOPUS, PubMed, APA PsycINFO, Business Source Complete and Academic Search Complete. The studies obtained were evaluated for inclusion based on their alignment with the specified inclusion and exclusion criteria. Studies were independently evaluated by the authors, with all data synthesised using a thematic analysis.

RESULTS

From an initial 2,533 studies, the systematic review included 103 studies which utilised ANT within a healthcare context. The analysis of the studies identified trends in the application of ANT across healthcare which we categorised into four themes: healthcare delivery systems, technology and data, integrated care, and innovation management. The findings demonstrated variability and fragmentation in the application of ANT, often diverging from its fundamental principles.

CONCLUSIONS

Decluttering the literature suggests three dimensions for understanding the relationships of actors, unidimensional ANT - based on single actors, bi-dimensional ANT, the relationship between two actors and multi-dimensional ANT, where human and non-human actors interact to impact healthcare outcomes. The limited number of studies on the use of ANT for integrated healthcare research highlights both its importance to the topic and the considerable research gap that must be addressed.

'I am more stressed if my infection affects others': development of a COVID-19-related stress scale in older people and examination of its validity and associations with mental health risks

BACKGROUND

COVID-19 was a collective traumatic event; however, different individuals may have perceived it differently.

AIMS

This study investigated what older people in a collective culture perceived as stressful during COVID-19 and examined how different stressors related to COVID-19 infection and mental health risks.

METHOD

Thirty-six participants from diverse backgrounds engaged in a three-round Delphi study to generate items for a COVID-19-related stress scale for older adults (CSS-OA). Subsequently, 4674 people (aged ≥60 years) participated in a cross-sectional telephone survey; interviewers collected their responses to CSS-OA and information about COVID-19 infection, depressive symptoms, anxiety, loneliness and demographics. Exploratory factor analysis and confirmatory factor analysis were conducted on CSS-OA. A multiple indicator multiple cause (MIMIC) model was used to examine associations between CSS-OA and other measures.

RESULTS

The Delphi process generated eight items, all secondary or tertiary stressors related to infection. Exploratory factor analysis revealed a three-factor model, and confirmatory factor analysis confirmed an excellent fit (comparative fit index = 0.99, root mean square error of approximation = 0.06). Pre-existing mental health conditions, having family members/friends infected with COVID-19, loneliness, anxiety and depressive symptoms were associated with higher stress. Conversely, self-infection with COVID-19, older age, being female and living alone were negatively associated with some domains of CSS-OA (all P < 0.05).

CONCLUSIONS

The Delphi process enhanced our understanding of what older people perceived as stressful, much of which resulted from certain healthcare strategies and reflected cultural influences. These and the MIMIC results highlight the need to balance public health policies with respect to infectious diseases and older people's mental health and quality of life.

How Primary Healthcare Sector is Organized at the Territorial Level in France? A Typology of Territorial Structuring

BACKGROUND

Most the Organization for Economic Co-operation and Development (OECD) countries are currently facing the challenges of the health transition, the aging of their populations and the increase in chronic diseases. Effective and comprehensive primary healthcare (PHC) services are considered essential for establishing an equitable, and cost-effective healthcare system. Developing care coordination and, on a broader scale, care integration, is a guarantee of quality healthcare delivery. The development of healthcare systems at the meso-level supports this ambition and results in a process of territorial structuring of PHC. In France, the Health Territorial and Professional Communities (HTPC) constitute meso-level organizations in which healthcare professionals (HCPs) from the same territory gather. We conducted a study to determine, in a qualitative step, the key elements of the territorial structuring of PHC in France and, then, to develop, in a quantitative step, a typology of this structuring.

METHODS

A sequential-exploratory mixed-method study with a qualitative step using a multiple case approach and a quantitative step as a hierarchical clustering on principal components (HCPC) from a multiple correspondence analysis (MCA).

RESULTS

A total of 7 territories were qualitatively explored. Territorial structuring appears to depend on: past collaborations at the micro-level, meso-level coordination among HCPs and multiprofessional structures, diversity of independent professionals, demographic dynamics attracting young professionals, and public health investment through local health contracts (LHCs). The typology identifies 4 clusters of mainland French territories based on their level of structuring: under or unstructured (38.6%), with potential for structuring (34.7%), in the way for structuring (25.3%) and already structured territories (1.4%).

CONCLUSION

Interest in territorial structuring aligns with challenges in meso-level healthcare organization and the need for integrated care. Typologies of territorial structuring should be used to understand its impact on access, care quality, and medical resources.

Strategies and indicators to integrate health equity in health service and delivery systems in high-income countries: a scoping review

OBJECTIVE

The objective of this review was to describe how health service and delivery systems in high-income countries define and operationalize health equity. A secondary objective was to identify implementation strategies and indicators being used to integrate and measure health equity.

INTRODUCTION

To improve the health of populations, a population health and health equity approach is needed. To date, most work on health equity integration has focused on reducing health inequities within public health, health care delivery, or providers within a health system, but less is known about integration across the health service and delivery system.

INCLUSION CRITERIA

This review included academic and gray literature sources that described the definitions, frameworks, level of integration, strategies, and indicators that health service and delivery systems in high-income countries have used to describe, integrate, and/or measure health equity. Sources were excluded if they were not available in English (or a translation was not available), were published before 1986, focused on strategies that were not implemented, did not provide health equity indicators, or featured strategies that were implemented outside the health service or delivery systems (eg, community-based strategies).

METHODS

This review was conducted in accordance with the JBI methodology for scoping reviews. Titles and abstracts were screened for eligibility followed by a full-text review to determine inclusion. The information extracted from the included studies consisted of study design and key findings, such as health equity definitions, strategies, frameworks, level of integration, and indicators. Most data were quantitatively tabulated and presented according to 5 secondary review questions. Some findings (eg, definitions and indicators) were summarized using qualitative methods. Most findings were visually presented in charts and diagrams or presented in tabular format.

RESULTS

Following review of 16,297 titles and abstracts and 824 full-text sources, we included 122 sources (108 scholarly and 14 gray literature) in this scoping review. We found that health equity was inconsistently defined and operationalized. Only 17 sources included definitions of health equity, and we found that both indicators and strategies lacked adequate descriptions. The use of health equity frameworks was limited and, where present, there was little consistency or agreement in their use. We found that strategies were often specific to programs, services, or clinics, rather than broadly applied across health service and delivery systems.

CONCLUSIONS

Our findings suggest that strategies to advance health equity work are siloed within health service and delivery systems, and are not currently being implemented system-wide (ie, across all health settings). Healthy equity definitions and frameworks are varied in the included sources, and indicators for health equity are variable and inconsistently measured. Health equity integration needs to be prioritized within and across health service and delivery systems. There is also a need for system-wide strategies to promote health equity, alongside robust accountability mechanisms for measuring health equity. This is necessary to ensure that an integrated, whole-system approach can be consistently applied in health service and delivery systems internationally.

REVIEW REGISTRATION

DalSpace dalspace.library.dal.ca/handle/10222/80835.

Impact of no publicly accessible prenatal education programming on patients and their care providers: a descriptive qualitative study in Nova Scotia, Canada

OBJECTIVE

Patients in Nova Scotia do not have access to public prenatal education programming. This study aimed to explore whether care providers find patients are uninformed or misinformed, and the impact of that on patients and their care providers with a focus on clinical outcomes, time, resources and informed decision-making.

METHODS

Semistructured interviews were conducted with 13 care providers around Halifax and Cape Breton. An interview guide (supplemental) of open-ended questions was used for consistency. A descriptive qualitative approach was employed to describe the contents of the interviews. Each interview was audio-taped and transcribed verbatim by an interdependent transcriber. Transcripts were analysed using established techniques in qualitative descriptive research including coding, grouping, detailing and comparing the data using NVivo V.12 software. A co-coder (SS) independently coded two interviews for inter-rater reliability.

RESULTS

The study revealed six themes: (1) concern for a significant population of Nova Scotians experiencing pregnancy, birth and postpartum uninformed and misinformed, (2) consequences for patients who are uninformed and misinformed, (3) more time and resources spent on care for patients who are uninformed or misinformed, (4) patients and their care providers need a publicly available education programme, particularly vulnerable populations, (5) emphasis on programme quality and disappointment with the programme previously been in place and (6) recommendations for an effective prenatal education programme for Nova Scotians.

CONCLUSIONS

This study shows care providers believe a public prenatal education programme could improve health literacy in Nova Scotia. Patients are seeking health education, but it is not accessible to all and being uninformed or misinformed negatively impacts patients' experiences and outcomes. This study revealed excess time and resources are being spent on individualised prenatal education by care providers with high individual and system-wide cost and explored the complicated process of providing patient-centred care for people who are uninformed or misinformed.

A Framework for Interpretability in Machine Learning for Medical Imaging

Interpretability for machine learning models in medical imaging (MLMI) is an important direction of research. However, there is a general sense of murkiness in what interpretability means. Why does the need for interpretability in MLMI arise? What goals does one actually seek to address when interpretability is needed? To answer these questions, we identify a need to formalize the goals and elements of interpretability in MLMI. By reasoning about real-world tasks and goals common in both medical image analysis and its intersection with machine learning, we identify five core elements of interpretability: localization, visual recognizability, physical attribution, model transparency, and actionability. From this, we arrive at a framework for interpretability in MLMI, which serves as a step-by-step guide to approaching interpretability in this context. Overall, this paper formalizes interpretability needs in the context of medical imaging, and our applied perspective clarifies concrete MLMI-specific goals and considerations in order to guide method design and improve real-world usage. Our goal is to provide practical and didactic information for model designers and practitioners, inspire developers of models in the medical imaging field to reason more deeply about what interpretability is achieving, and suggest future directions of interpretability research.

Exploring cross-boundary collaboration for youth mental health in Sweden - a qualitative study using the integrative framework for collaborative governance

BACKGROUND

Youth mental health is a major health concern in almost every country. Mental health accounts for about 13% of the global burden of disease in the 10-to-19-year age group. Still there are significant gaps between the mental health needs of young people and the quality and accessibility of available services. Collaboration between health and social service actors is a recognized way of reducing gaps in quality and access. Yet there is little scientific evidence on how these collaborations are applied, or on the challenges of cross-boundary collaboration in the youth mental health space. This study aims to explore how collaboration is understood and practiced by professionals working in the Swedish youth mental health system.

METHODS

We conducted 42 interviews (November 2020 to March 2022) with health and social care professionals and managers in the youth mental health system in Sweden. Interviews explored participants' experience and understanding of the purpose, realization, and challenges of collaboration. Data were analysed under an emergent study design using reflexive thematic analysis.

RESULTS

The analysis produced three themes. The first shows that collaboration is considered as essential and important, and that it serves diverse purposes and holds multiple meanings in relation to professionals' roles and responsibilities. The second addresses the different layers of collaboration, in relation to activities, relationships, and target levels, and the third captures the challenges and criticisms in collaborating across the youth mental health landscape, but also in growing possibilities for future development.

CONCLUSION

We conclude that collaboration serves multiple purposes and takes many shapes in the Swedish youth mental health system. Despite the many challenges, participants saw potential in further building collaboration. Interestingly our participants also raised concerns about too much collaboration. There was scepticism about collaboration directing attention away from young people to the professionals, thereby risking the trust and confidentiality of their young clients. Collaboration is not a panacea and will not compensate for an under-resourced youth mental health system.

The Coproduction of Health Framework: Seeking Instructive Management Models and Theories

At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.

Barriers and enablers of integrated care in the UK: a rapid evidence review of review articles and grey literature 2018-2022

Integrated care refers to person-centered and coordinated, health and social care, and community services. Integrated care systems are partnerships of organizations that deliver health and care services which were placed on a statutory footing in England, April 2022. Due to the need for fast, accessible, and relevant evidence, a rapid review was conducted according to World Health Organization methods to determine barriers and enablers of integrated care across the United Kingdom, 2018-2022. Nine databases were searched for review articles reporting evaluation of integrated care interventions involving medical (clinical and diagnostic) and nonmedical (public health services and community-based or social care/person-centred care) approaches, quality checked with the Critical Appraisal Skills Program qualitative checklist. OpenGrey and hand searches were used to identify grey literature, quality checked with the Authority, Accuracy, Coverage, Objectivity, Date, and Significance checklist. Thirty-four reviews and 21 grey literature reports fitted inclusion criteria of adult physical/mental health outcomes/multiple morbidities. Thematic analysis revealed six themes (collaborative approach; costs; evidence and evaluation; integration of care; professional roles; service user factors) with 20 subthemes including key barriers (cost effectiveness; effectiveness of integrated care; evaluation methods; focus of evidence; future research; impact of integration) and enablers (accessing care; collaboration and partnership; concept of integration; inter-professional relationships; person-centered ethos). Findings indicated a paucity of robust research to evaluate such interventions and lack of standardized methodology to assess cost effectiveness, although there is growing interest in co-production that has engendered information sharing and reduced duplication, and inter-professional collaborations that have bridged task-related gaps and overlaps. The importance of identifying elements of integrated care associated with successful outcomes and determining sustainability of interventions meeting joined-up care and preventive population health objectives was highlighted.

An Evaluation of Primary Care Clinician Referrals for Behavioral Weight Loss Counseling

INTRODUCTION/OBJECTIVES

In the context of enrolling patients from primary care practices into a weight loss research study, this study describes the percentage of patients primary care clinicians (PCCs) considered appropriate for referral and study participation rates among those referred.

METHODS

An electronic health record review identified 5322 patients aged 18 to 75 years with BMI ≥ 30 kg/m2 as eligible for review by community, attending, and resident PCCs for referral to a weight loss study. Referrals and patient interest in participating in the study are reported overall and by PCC type.

RESULTS

The mean (SD) age was 53.1 (13.9) years, mean BMI 36.5 (6.2) kg/m2, 41.5% were male, and 30.9% were African American. PCCs reviewed 3882 patients and referred 2762 (71.1%) to the study. Of 1120 not referred, 260 (23.2%) were not known well enough by PCCs to assess for referral. The most common reasons for not referring included too much comorbidity (171, 15.3%), psychological reasons (170, 15.2%), and non-English speaking (125, 11.2%). Among 1897 patients invited to participate, 676 (35.6%) expressed interest and 360 (19.0%) were enrolled.

CONCLUSIONS

PCCs referred 71.1% of their eligible patients. Among those referred, interest in participation was modest and enrollment was low.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04302727.

Influencing Factor Analysis of First-Choice Medical Institutions for Aging People in China

Purpose

This study aimed to analyze first-choice medical institutions for middle-aged and older adults in Fujian Province to promote the development of hierarchical diagnosis and treatment for them.

Patients and Methods

Single factor analysis, disordered multi-classification logistic regression, and multiple correspondence classification were used to analyze the influencing factors of first-choice medical institutions for middle-aged and older adults. A total of 486 valid questionnaires were obtained. The questionnaire was based on Health Service Integration Theory and the behavioral model of Andersen.

Results

Age, education level, living area, monthly income, nearest medical institution to home, and integrated health service system understanding significantly influenced respondents' preference of first medical institution. Middle-aged and older adults were more inclined to visit county and municipal hospitals first. The treatment center's proximity was also an important determinant of their first-choice selection of medical care.

Conclusion

To realize high-quality hierarchical diagnosis and treatment and integrated health service system construction, it is important to improve the service capacity of primary medical institutions, increase the training of family doctors, implement the contract coverage of family doctors, optimize the allocation and geographical layout of primary medical institutions, ensure adequate income levels, and promote township hospital staff.

A Mobile Health Application Using Geolocation for Behavioral Activity Tracking

The increasing popularity of mHealth presents an opportunity for collecting rich datasets using mobile phone applications (apps). Our health-monitoring mobile application uses motion detection to track an individual's physical activity and location. The data collected are used to improve health outcomes, such as reducing the risk of chronic diseases and promoting healthier lifestyles through analyzing physical activity patterns. Using smartphone motion detection sensors and GPS receivers, we implemented an energy-efficient tracking algorithm that captures user locations whenever they are in motion. To ensure security and efficiency in data collection and storage, encryption algorithms are used with serverless and scalable cloud storage design. The database schema is designed around Mobile Advertising ID (MAID) as a unique identifier for each device, allowing for accurate tracking and high data quality. Our application uses Google's Activity Recognition Application Programming Interface (API) on Android OS or geofencing and motion sensors on iOS to track most smartphones available. In addition, our app leverages blockchain and traditional payments to streamline the compensations and has an intuitive user interface to encourage participation in research. The mobile tracking app was tested for 20 days on an iPhone 14 Pro Max, finding that it accurately captured location during movement and promptly resumed tracking after inactivity periods, while consuming a low percentage of battery life while running in the background.

Addressing health inequity during the COVID-19 pandemic through primary health care and public health collaboration: a multiple case study analysis in eight high-income countries

BACKGROUND

The COVID-19 pandemic substantially magnified the inequity gaps among vulnerable populations. Both public health (PH) and primary health care (PHC) have been crucial in addressing the challenges posed by the pandemic, especially in the area of vulnerable populations. However, little is known about the intersection between PH and PHC as a strategy to mitigate the inequity gap. This study aims to assess the collaboration between PHC and PH with a focus on addressing the health needs of vulnerable populations during the COVID-19 pandemic across jurisdictions.

METHODS

We analyzed and compared data from jurisdictional reports of COVID-19 pandemic responses in PHC and PH in Belgium, Canada (Ontario), Germany, Italy, Japan, the Netherlands, Norway, and Spain from 2020 to 2021.

RESULTS

Four themes emerge from the analysis: (1) the majority of the countries implemented outreach strategies targeting vulnerable groups as a means to ensure continued access to PHC; (2) digital assessment in PHC was found to be present across all the countries; (3) PHC was insufficiently represented at the decision-making level; (4) there is a lack of clear communication channels between PH and PHC in all the countries.

CONCLUSIONS

This study identified opportunities for collaboration between PHC and PH to reduce inequity gaps and to improve population health, focusing on vulnerable populations. The COVID-19 response in these eight countries has demonstrated the importance of an integrated PHC system. Consequently, the development of effective strategies for responding to and planning for pandemics should take into account the social determinants of health in order to mitigate the unequal impact of COVID-19. Careful, intentional coordination between PH and PHC should be established in normal times as a basis for effective response during future public health emergencies. The pandemic has provided significant insights on how to strengthen health systems and provide universal access to healthcare by fostering stronger connections between PH and PHC.

Perceptions and attitudes of users and non-users of mental health services concerning mental illness and services in Japan

Objectives

There is a global movement to develop and implement community-based integrated mental health systems. The present study attempted to clarify the perceptions and attitudes of users and non-users of mental health services concerning mental illness and services in Japan.

Methods

A new questionnaire was developed for this internet survey. Data from 500 outpatients with depression and 500 healthy subjects were sampled according to the demographics of the Japanese population.

Results

Over 90% of healthy subjects and over 70% of patients were unaware of the common age of onset or lifetime prevalence of mental illness. Over 90% of the healthy subjects and about 70% of the patients could not describe any services where they would feel comfortable discussing mental health problems. In both groups, "adolescents and young adults" were ranked first as a target population for mental health and illness policies. The top requirement for the integrated care systems was the promotion and awareness of correct knowledge of mental illness in both the healthy subjects and patients.

Conclusion

Societal requirements could include disseminating correct knowledge, awareness-raising actions for society, and implementing services where people, especially young people, can easily consult and receive support in the community.

Exploration of understanding of integrated care from a public health perspective: A scoping review

Background

Many health care systems attempt to develop an integrated care approach that is a whole population health-oriented system. However, knowledge of strategies to support this effort are scarce and fragmented. The aim of the current paper is to investigate existing concepts of integrated care and their elements from a public health perspective and to propose an elaborated approach that could be applied to explore the public health orientation of integrated care.

Design and methods

We applied a scoping review approach. A literature search was conducted in Embase, Medline, CINAHL, Scopus and Web of Science for the period 2000-2020 yielding 16 studies for inclusion.

Results

Across the papers, 14 frameworks were identified. Nine of these referred to the Chronic Care Model (CCM). Service delivery, person-centeredness, IT systems design and utilization and decision support were identified as the core elements of most of the included frameworks. The descriptions of these elements were mainly clinical-oriented focusing particularly on clinical care processes and treatment of diseases instead of wider determinants of population health.

Conclusions

A synthesized model is proposed that emphasizes the importance of mapping the unique needs and characteristics of the population it aims to serve, leans on the social determinants approach with a commitment to individual and community empowerment, health literacy and suggests reorienting services to meet the expressed needs of the population.

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.

Leveraging Responsible, Explainable, and Local Artificial Intelligence Solutions for Clinical Public Health in the Global South

In the present paper, we will explore how artificial intelligence (AI) and big data analytics (BDA) can help address clinical public and global health needs in the Global South, leveraging and capitalizing on our experience with the "Africa-Canada Artificial Intelligence and Data Innovation Consortium" (ACADIC) Project in the Global South, and focusing on the ethical and regulatory challenges we had to face. "Clinical public health" can be defined as an interdisciplinary field, at the intersection of clinical medicine and public health, whilst "clinical global health" is the practice of clinical public health with a special focus on health issue management in resource-limited settings and contexts, including the Global South. As such, clinical public and global health represent vital approaches, instrumental in (i) applying a community/population perspective to clinical practice as well as a clinical lens to community/population health, (ii) identifying health needs both at the individual and community/population levels, (iii) systematically addressing the determinants of health, including the social and structural ones, (iv) reaching the goals of population's health and well-being, especially of socially vulnerable, underserved communities, (v) better coordinating and integrating the delivery of healthcare provisions, (vi) strengthening health promotion, health protection, and health equity, and (vii) closing gender inequality and other (ethnic and socio-economic) disparities and gaps. Clinical public and global health are called to respond to the more pressing healthcare needs and challenges of our contemporary society, for which AI and BDA can help unlock new options and perspectives. In the aftermath of the still ongoing COVID-19 pandemic, the future trend of AI and BDA in the healthcare field will be devoted to building a more healthy, resilient society, able to face several challenges arising from globally networked hyper-risks, including ageing, multimorbidity, chronic disease accumulation, and climate change.

Unveiling the Significance and Challenges of Integrating Prevention Levels in Healthcare Practice

In recent years, there has been a global increase in human life expectancy, but preventable morbidity and mortality remain significant concerns. To address these issues, preventive healthcare practice has gained importance in various healthcare disciplines. Its goal is to maintain and promote health, reduce risk factors, diagnose illnesses early, and prevent complications. This approach encompasses different stages of disease progression, including primordial prevention, primary prevention, secondary prevention, tertiary prevention, and quaternary prevention. Primordial prevention focuses on addressing root causes and social determinants of diseases to prevent the emergence and development of risk factors. Primary prevention aims to prevent diseases before they occur by implementing interventions such as vaccinations and health education. Secondary prevention focuses on early detection and prompt intervention to prevent the progression of diseases. Tertiary prevention manages the consequences of diseases by restoring health and providing rehabilitation. Lastly, quaternary prevention aims to protect patients from unnecessary medical interventions and harm caused by excessive medicalization. Despite the recognition of the cost-effectiveness of preventive measures, a significant portion of healthcare resources and attention is still allocated to disease management, and only a small percentage of individuals receive all recommended preventive services. Healthcare providers need to prioritize the implementation of preventive care services, even when clinical interventions are necessary, and overcome barriers to preventive care. By investing in preventive care and implementing these strategies, healthcare practitioners can play a crucial role in disease prevention and contribute to the well-being of individuals, families, communities, and countries.

General practitioners' experiences of being involved in local public health work in Norway. A qualitative study

AIM

The aim was to explore how general practitioners experienced being involved in local public health work and how they worked with prevention and health promotion clinically after the introduction of the Public Health Act in 2012.

DESIGN, SETTING AND SUBJECTS

Qualitative study with focus groups interviews with 18 GPs from different municipalities in Norway.

RESULTS

The GPs said that they either had not at all or only to a limited extent been involved in local public health work in their municipalities. They reported finding it hard to prioritize individual disease prevention and health promotion in their clinical work. GPs thought of health promotion as something that mainly concerned healthy people at a group level.

CONCLUSIONS

Based on the experiences of the GPs in this study, there is a gap between governmental expectations to the role of GPs in public health, and how it works in practice.KEY POINTSWith the Norwegian Public Health Act launched in 2012, GPs were expected to contribute to better population health in their clinical work and as data providers to local public health surveillance.The GPs interviewed in this study said they had not been involved in local public health work, and they found it hard to give disease prevention and health promotion priority in their clinical work.GPs expressed various perceptions of what prevention and health promotion entails.

Can the organization of health resource integration be analyzed in terms of the current state of unmet demand for health services? take the health needs of the elderly in a place in zhejiang province, china, as an example

BACKGROUND

The aging of the population has made the health problems of the elderly increasingly prominent, and their health needs are increasing. Existing studies on health resource integration approaches are mostly incomplete in assessing the health service capacity from the perspective of the health service provider.

OBJECTIVE

The unmet health needs of the elderly were sampled and analyzed from the perspective of health service demanders. To explore how to build an integrated medical organization structure to better meet the health needs of the elderly.

METHODS

A whole-group sampling method was used to conduct a questionnaire survey of 1527 older adults in N district of H city, Zhejiang province, China, to cross-sectionally analyze their current status of unmet health needs.

RESULTS

The survey and analysis found that the needs of the elderly in this community to obtain disease-related knowledge, rational exercise, a healthy diet, and access to health information were not met. There were more patients with chronic diseases, and the top three chronic disease prevalence rates were hypertension (40.2%), dyslipidemia (8.4), and diabetes (7%). Chronic disease co-morbidities accounted for 13.3%.

CONCLUSION

The relatively independently set up health service system at the present stage in China can no longer fully meet the health needs of the elderly, and the health service providers should provide integrated and continuous health services to meet the needs of whole-cycle health management. Therefore, we believe that effectively integrating various health service providers in the region and building an integrated health service organization with general practitioners as the core may be a solution to the current situation of unmet health needs of the elderly.

Framing Disparities in Access to Medical Speech-Language Pathology Care in Rural Alabama

PURPOSE

Rural-living residents of Alabama depend on rural hospitals and clinics staffed with physicians and allied health professionals including speech-language pathologists (SLPs). The purpose of the exploratory study was to examine the speech-language pathology workforce in health care facilities in nonmetropolitan Alabama counties to determine potential disparities in access and identify medical SLP deserts for rural Alabamians.

METHOD

The hospitals, rural health clinics, nursing homes, and rehabilitation centers for each of the 37 nonmetropolitan counties were identified through the 2020 Alabama Department of Public Health directories, and phone surveys were completed to determine medical SLP staffing at each facility. Descriptive statistics and regression analysis were conducted.

RESULTS

The initial review yielded 229 rural health care facilities with 223 ultimately included in the analysis and 176 facilities completing a phone inquiry (76.68%). Sixty-one (35.88%) reported employing at least one SLP and no facility stated staffing SLP assistants. Linear regression indicated a positive, yet moderate effect size between the reported number of SLPs staffed within each county and specific population of the county (r ² = .519). Anecdotally, facilities reported difficulty in hiring and retaining SLPs due to rural geographical location.

CONCLUSIONS

The exploratory findings suggest disparities in access to behavioral communication and swallowing care for rural residents in the state. The methodology employed for data collection and analysis may be applied to other states and U.S. territories, in an effort to frame the issue nationally and support rural health care policy across the United States. Further investigation regarding the cost effectiveness of telepractice, the availability of broadband Internet access, the efficacy of community-based service delivery, and the effectiveness of incentivized rural SLP graduate programs is warranted to mitigate the disparities in access.

Clinical public health: harnessing the best of both worlds in sickness and in health

INTRODUCTION

Effective, sustained collaboration between clinical and public health professionals can lead to improved individual and population health. The concept of clinical public health promotes collaboration between clinical medicine and public health to address complex, real-world health challenges. In this commentary, we describe the concept of clinical public health, the types of complex problems that require collaboration between individual and population health, and the barriers towards and applications of clinical public health that have become evident during the COVID-19 pandemic.

RATIONALE

The focus of clinical medicine on the health of individuals and the aims of public health to promote and protect the health of populations are complementary. Interdisciplinary collaborations at both levels of health interventions are needed to address complex health problems. However, there is a need to address the disciplinary, cultural and financial barriers to achieving greater and sustained collaboration. Recent successes, particularly during the COVID-19 pandemic, provide a model for such collaboration between clinicians and public health practitioners.

CONCLUSION

A public health approach that fosters ongoing collaboration between clinical and public health professionals in the face of complex health threats will have greater impact than the sum of the parts.

Improving oral health care accessibility for homeless and vulnerably housed pet-owning populations

Individuals experiencing homelessness face unique barriers to oral health care. In collaboration with local universities in Ottawa, Canada, research was conducted to explore the experiences of Community Veterinary Outreach (CVO) clients in accessing oral health care. CVO utilizes a One Health approach, providing preventive veterinary care alongside human health care services to promote health service uptake among pet owners experiencing homelessness. Based on the results of 4 research projects, this short communication proposes recommendations for promoting accessible oral health care and increasing service uptake at One Health clinics by CVO clients experiencing homelessness. Relevant themes leading to the recommendations were 1) barriers to care, including financial and individual circumstances, and discrimination by service providers; and 2) facilitators of care, including the presence of pets, compassionate care, and care received in community settings. Recommendations to improve accessibility of oral health services for CVO clients are 1) continuation of pet-friendly services; 2) delivery of oral health care in alternative settings; and 3) reduction of discrimination through continuing education for oral health professionals. It is hypothesized that the implementation of these recommendations will improve oral health care service accessibility and uptake among clients at CVO clinics and in the community.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

The Health-Seeking Behavior among Malaysian Adults in Urban and Rural Areas Who Reported Sickness: Findings from the National Health and Morbidity Survey (NHMS) 2019

Understanding care-seeking behavior among urban and rural populations can help to support the planning and implementation of appropriate measures to improve health in the community. This study aims to determine the factors associated with the health-seeking behavior among Malaysian adults in urban and rural areas who reported sickness. This study used data of Malaysian adults aged 18 years and over from the National Health and Morbidity Survey 2019; a cross-sectional, national household survey that targeted all non-institutionalized residents in Malaysia. Respondent’s characteristics and health-seeking behavior were described using complex sample descriptive statistics. Multivariable logistic regression analysis was conducted to examine the association between potential factors (sociodemographic characteristics, enabling, and health need) and health-seeking behaviors (seeking treatment from healthcare practitioners and self-medication). A total of 10,484 respondents, estimated to represent 18.9 million Malaysian adults aged 18 years and over, were included in the analysis. Prevalence of seeking treatment from healthcare practitioners and self-medication among Malaysian adults with self-reported sickness were 57.3% and 23.3%, respectively. Self-reported sickness among both the urban and rural populations who rated their health as poor to very poor was more likely to seek treatment than those who rated good to excellent. However, among the urban population, those who rated their health as poor to very poor were less likely to self-medicate. Among the urban population, government employees were more likely to seek treatment, and being without formal education significantly increased the likelihood to self-medicate. Among the rural population, those with at least one long-term condition were more likely to seek treatment than those with none. Understanding the factors which influence health-seeking behavior among the urban and rural population could close the gaps in healthcare utilization among the population in Malaysia.

Evaluations of Continuing Health Provider Education Focused on Opioid Prescribing: A Scoping Review

PURPOSE

Continuing health provider education (HPE) is an important intervention supported by health policy to counter the opioid epidemic; knowledge regarding appropriate program design and evaluation is lacking. The authors aim to provide a comprehensive understanding of evaluations of opioid-related continuing HPE programs and their appropriateness as interventions to improve population health.

METHOD

In January 2020, the authors conducted a systematic search of 7 databases, seeking studies of HPE programs on opioid analgesic prescribing and overdose prevention. Reviewers independently screened the titles and abstracts of all studies and then assessed the full texts of all studies potentially eligible for inclusion. The authors extracted a range of data using categories for evaluating complex programs: the use of theory, program purpose, inputs, activities, outputs, outcomes, and industry involvement. Results were reported in a narrative synthesis.

RESULTS

Thirty-nine reports on 32 distinct HPE programs met inclusion criteria. Of these 32, 31 (97%) were U.S./Canadian programs and 28 (88%) were reported after 2010. Measurements of changes in knowledge and confidence were common. Performance outcomes were less common and typically self-reported. Most studies (n = 27 [84%]) used concerns of opioid-related harms at the population health level to justify the educational intervention, but only 5 (16%) measured patient- or population-level outcomes directly related to the educational programs. Six programs (19%) had direct or indirect opioid manufacturer involvement.

CONCLUSIONS

Continuing HPE has been promoted as an important means of addressing population-level opioid-related harms by policymakers and educators, yet published evaluations of HPE programs focusing on opioid analgesics inadequately evaluate patient- or population-level outcomes. Instead, they primarily focus on self-reported performance outcomes. Conceptual models are needed to guide the development and evaluation of continuing HPE programs intended to have population health benefits.

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

Organisations spanning social services, public health and healthcare have increasingly experimented with collaboration as a tool for improving population health and reducing health disparities. While there has been progress, the results have fallen short of expectations. Reflecting on these shortcomings, the Robert Wood Johnson Foundation (RWJF) recently proposed a new framework for cross-sector alignment intended to move the field towards improved outcomes. A central idea in this framework is that collaboratives will be more effective and sustainable if they develop collaborative systems in four core areas: shared purpose, governance, finance and shared data. The goal of this paper is to provide a foundation for research on the four core areas of the cross-sector alignment framework. Accordingly, this study is based on two guiding questions: (1) how are collaboratives currently implementing systems in the four core areas identified in the framework, and (2) what strategies does the literature offer for creating sustainable systems in these four areas? Given the emergent nature of research on health-oriented cross-sector collaboration and the broad research questions, we conducted a systematic scoping review including 179 relevant research papers and reports published internationally from the years 2010-2020. We identified the main contributions and coded each based on its relevance to the cross-sector alignment framework. We found that most papers focused on programme evaluations rather than theory testing, and while many strategies were offered, they tended to reflect a focus on short-term collaboration. The results also demonstrate that starting points and resource levels vary widely across individuals and organisations involved in collaborations. Accordingly, identifying and comparing distinct pathways by which different parties might pursue cross-sector alignment is an imperative for future work. More broadly, the literature is ripe with observations that could be assessed systematically to produce a firm foundation for research and practice.

The Interplay between Housing Environmental Attributes and Design Exposures and Psychoneuroimmunology Profile-An Exploratory Review and Analysis Paper in the Cancer Survivors' Mental Health Morbidity Context

Adult cancer survivors have an increased prevalence of mental health comorbidities and other adverse late-effects interdependent with mental illness outcomes compared with the general population. Coronavirus Disease 2019 (COVID-19) heralds an era of renewed call for actions to identify sustainable modalities to facilitate the constructs of cancer survivorship care and health care delivery through physiological supportive domestic spaces. Building on the concept of therapeutic architecture, psychoneuroimmunology (PNI) indicators-with the central role in low-grade systemic inflammation-are associated with major psychiatric disorders and late effects of post-cancer treatment. Immune disturbances might mediate the effects of environmental determinants on behaviour and mental disorders. Whilst attention is paid to the non-objective measurements for examining the home environmental domains and mental health outcomes, little is gathered about the multidimensional effects on physiological responses. This exploratory review presents a first analysis of how addressing the PNI outcomes serves as a catalyst for therapeutic housing research. We argue the crucial component of housing in supporting the sustainable primary care and public health-based cancer survivorship care model, particularly in the psychopathology context. Ultimately, we illustrate a series of interventions aiming at how housing environmental attributes can trigger PNI profile changes and discuss the potential implications in the non-pharmacological treatment of cancer survivors and patients with mental morbidities.

Exploring hospital compliance with the primary nursing care model: validating an inventory using the Delphi method

Background

The primary nursing care model is considered a personalized model of care delivery based on care continuity and on the relationship between the nurse and patient. Primary nursing checklists are not often mentioned in the literature; however, they represent a valid instrument to develop, implement, and evaluate primary nursing. The aim of this study was to create a structured checklist to explore hospital compliance in primary nursing.

Methods

The Delphi method was used to develop and validate a checklist. The preliminary version was created and sent to three experts for their opinions. Their comments were ultimately used in the first version, which included four components with 19 items regarding primary nursing characteristics. A two-round Delphi process was used to generate consensus items. The Delphi panel consisted of six experts working in primary nursing contexts and/or teaching or studying primary nursing. Data were collected using a structured questionnaire from July 2020 to January 2021. These experts were asked to rate each element for relevance using a 4-point Likert-type scale. Furthermore, the consensus among the panel of experts was set at ≥78%, with selected items being voted “quite relevant” and “highly relevant”. Content validity index (I-CVI) and modified kappa statistic were also calculated. Following expert evaluation, the first version of the checklist was modified, and the new version, constituting 17 items, was sent to the same experts.

Results

The first version of the checklist demonstrated a main relevance score of 3.34 (SD = 0.83; range = 1.3–4; mean I-CVI = 0.84; range: 0.83–1), but three items did not receive an adequate I-CVI score, that is, lower than 0.78. After the second round, the I-CVIs improved. The main score of relevance was 3.61 (SD: 0.35; range = 2.83–4; mean = I-CVI: 0.93). The S-CVI/UA was 0.58, and the S-CVI/Ave was 0.93.

Conclusion

Measuring primary nursing compliance should be implemented to provide continuous feedback to nurses. Moreover, utilizing valid checklists could permit comparing different results from others’ research. Future research should be conducted to compare the results from the checklist with nursing outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00712-1.

Working with communities: Meeting the health needs of those living in vulnerable communities when Primary Health Care and Universal Health Care are not available

RATIONALE, AIMS, AND OBJECTIVES

The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs.

METHODS

We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action.

RESULTS

From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training.

CONCLUSION

Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

Barriers to Dissemination of Local Health Data Faced by US State Agencies: Survey Study of Behavioral Risk Factor Surveillance System Coordinators

Background

Advances in information technology have paved the way to facilitate accessibility to population-level health data through web-based data query systems (WDQSs). Despite these advances in technology, US state agencies face many challenges related to the dissemination of their local health data. It is essential for the public to have access to high-quality data that are easy to interpret, reliable, and trusted. These challenges have been at the forefront throughout the COVID-19 pandemic.

Objective

The purpose of this study is to identify the most significant challenges faced by state agencies, from the perspective of the Behavioral Risk Factor Surveillance System (BRFSS) coordinator from each state, and to assess if the coordinators from states with a WDQS perceive these challenges differently.

Methods

We surveyed BRFSS coordinators (N=43) across all 50 US states and the District of Columbia. We surveyed the participants about contextual factors and asked them to rate system aspects and challenges they faced with their health data system on a Likert scale. We used two-sample t tests to compare the means of the ratings by participants from states with and without a WDQS.

Results

Overall, 41/43 states (95%) make health data available over the internet, while 65% (28/43) employ a WDQS. States with a WDQS reported greater challenges (P=.01) related to the cost of hardware and software (mean score 3.44/4, 95% CI 3.09-3.78) than states without a WDQS (mean score 2.63/4, 95% CI 2.25-3.00). The system aspect of standardization of vocabulary scored more favorably (P=.01) in states with a WDQS (mean score 3.32/5, 95% CI 2.94-3.69) than in states without a WDQS (mean score 2.85/5, 95% CI 2.47-3.22).

Conclusions

Securing of adequate resources and commitment to standardization are vital in the dissemination of local-level health data. Factors such as receiving data in a timely manner, privacy, and political opposition are less significant barriers than anticipated.

The impacts of health systems financing fragmentation in low- and middle-income countries: a systematic review protocol

BACKGROUND

Health systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs.

METHODS

Literature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies' objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies.

DISCUSSION

Evidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020201467.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Project ECHO COVID-19: Vulnerable Populations and Telehealth Early in the Pandemic

INTRODUCTION/OBJECTIVES

Project ECHO COVID-19 was launched nationwide on March 4, 2020 to disseminate guidance about COVID-19 in a timely and scalable manner to meet the urgent needs of primary care settings, the first line of defense in a pandemic.

METHODS

Data from post-session surveys were analyzed to assess participant satisfaction, knowledge gaps, change in knowledge, and anticipated changes in practice as a result of Project ECHO COVID-19. A content analysis was conducted of the 243 questions and concerns posted by over 2000 participants in the Question and Answer function of Zoom during the first 8 sessions (March 4-April 29, 2020).

RESULTS

Of 5243 registrants, 49% attended at least one session. Respondents agreed or strongly agreed that didactic sessions (97%) and case presentations (96%) met their learning needs; 93% reported gaining new knowledge, and 88% would implement that knowledge. Only 32% and 53% of respondents anticipated changing workflows and adapting to telehealth, respectively, despite the need for both as the pandemic continued. The content analysis identified 3 categories: clinical operations (eg, testing, triage, telehealth, billing); patient care (diagnosis and treatment of COVID-19, management of high-risk vulnerable populations); and epidemiology (viral spread, implications for public health).

CONCLUSIONS

Care of vulnerable populations and clinical operations should be addressed when planning education and clinical interventions for public health crises. Adapting the Project ECHO model to be more scalable was an effective means of creating a community of practice among health professionals when evidence-based guidance was not available to manage the implications of a pandemic.

Duration of sick leave after same-day discharge for lower extremity arterial disease and varicose vein interventions in active population of French patients, 2013-2016: observational study

OBJECTIVE

To assess whether disparities in rates of same-day discharge for lower extremities arterial disease (5%) and varicose vein interventions (90%) are associated with the burden of postprocedural rehabilitation process, measured through the duration of sick leave.

DESIGN

Retrospective observational study using French National Health Insurance data in 2012-2016.

SETTING

The French National Health Data System (Système National des Données de Santé), which covers 98.8% of the 66 million people in the French population.

PARTICIPANTS

French workforce population aged 18 to 65 years old who underwent a first angioplasty with stent placement for lower extremities arterial disease (LEAD, n=30 238) or a first varicose vein intervention (n=265 670) between 2013 and 2016.

MAIN OUTCOME MEASURES

Duration and renewals of sick leave within 180 days after endovascular intervention, continuity of care and prescription indices to assess coordination among healthcare professionals after intervention associated with specific intervention settings: conventional (inpatient) or same-day discharge (outpatient). Association was estimated by multivariate negative binomial regressions adjusting for age, gender and comorbidities.

RESULTS

Outpatient settings decrease the incidence rate ratio (IRR) of the number of cumulated days of sick leave by 14% in both interventions. The increasing variety of prescribers decreases the IRR of cumulated days of sick leave and prescription renewals for varicose interventions by 25% and 21%, respectively, but increases them for LEAD interventions by 240% and 106%. Less coordination between healthcare specialists increases the IRR of cumulative days of sick leave and renewals by 37% and 29% for varicose, and 11% and 9% for LEAD interventions.

CONCLUSIONS

Low rates of outpatients in LEAD angioplasty does not seem related to the duration of sick leave. Outpatient setting reduces the duration of sick leave and their renewals, whatever the intervention. Coordination of healthcare professionals is a key element of interventions follow-up with pathology specificities.