Education in developing countries and reducing maternal mortality: a forgotten piece of the puzzle?

Despite substantial improvement in reducing maternal mortality during the recent decades, we constantly face tragic fact that maternal mortality (especially preventable deaths) is still unacceptably too high, particularly in the developing countries, where 99% of all maternal deaths worldwide occur. Poverty, lack of proper statistics, gender inequality, beliefs and corruption-associated poor governmental policies are just few of the reasons why decline in maternal mortality has not been as sharp as it was wished and expected. Education has not yet been fully recognized as the way out of poverty, improvement of women's role in the society and consequent better perinatal care and consequent lower maternal mortality. Education should be improved on all levels including girls, women and their partners, medical providers, religious and governmental authorities. Teaching the teachers should be also an essential part of global strategy to lower maternal mortality. This paper is mostly a commentary, not a systematic review nor a meta-analysis with the aim to rise attention (again) to the role of different aspects of education in lowering maternal mortality. The International Academy of Perinatal Medicine should play a crucial role in pushing the efforts on this issue as the influential instance that promotes reflection and dialog in perinatal medicine, especially in aspects such as bioethics, the appropriate use of technological advances, and the sociological and humanistic dimensions of this specific problem of huge magnitude. The five concrete steps to achieve these goals are listed and discussed.

What do malaria program officers want to learn? A survey of perspectives on a proposed malaria short course in Nigeria

BACKGROUND

In disease control, the program officers are vital to the successful implementation of control strategies. However, poor knowledge of the disease and its control, staff attrition, and lack of intentional training for new staff can lead to under-performance and ineffectiveness of interventions. Thus, the Nigeria Field Epidemiology and Laboratory Training Program, in collaboration with National Malaria Elimination Program, planned a malaria short course (MSC) to strengthen the capacity of current program managers and incoming staff. To guide the development of the curriculum for the MSC, we conducted a needs assessment survey to ascertain the perceived usefulness of the MSC, the priority rating of MSC thematic domains and associated factors.

METHODS

Overall, 384 purposively selected respondents across ten states and the Federal Capital Territory in Nigeria were interviewed. These comprised malaria and non-malaria control program staff at state, local government area (LGA) and ward levels. We administered a structured questionnaire to elicit information on socio-demographics, training needs, priority malaria thematic domains, perceived course usefulness and willingness of ministries/organizations to release staff to attend the MSC. Data were analyzed using descriptive and inferential statistics at p<0.05.

RESULTS

Mean age was 43.9 (standard deviation: 7.6 years), 172 (44.8%) were females. Of the 384 respondents, 181 (47.1%), 144 (37.5%) and 59 (15.4%) were at the ward, LGA and state levels, respectively. Seventy-two (18.8%) had never worked in malaria control program. Majority (98.7%, n = 379) reported the need for further training, 382 (99.5%) opined that the course would be useful, and all affirmed their employers' willingness towards their participation at the training. Respondents rated high the domains of basic malariology, malaria treatment, malaria prevention, surveillance/data management, use of computers, leadership skills, program management and basic statistics. Predictors of malaria topical domains' high rating were gender (odds ratio (OR) = 6.77; 95% CI:3.55-12.93) and educational qualifications (OR = 0.48; 95% CI:0.26-0.89).

CONCLUSIONS

A malaria short course is a necessity and appropriate for program officers at different levels of health administration in Nigeria to achieve malaria elimination, taking into consideration the challenges of human resource retention. The outcome of this study should inform the curriculum and the delivery of the MSC.

Needs Based Assessment of Trauma Systems 2, is it ready for primetime? A natural experiment testing its reliability

INTRODUCTION

Needs Based Assessment of Trauma Systems 2 (NBATS-2) attempts to predict the impact on patient volume and travel time for patients when a new trauma center (TC) is added to the system. The purpose of this study was to examine NBATS-2 predictive accuracy regarding expected volume and travel times of trauma patients at a newly designated TC and nearby legacy TCs when compared with actual data.

METHODS

Needs Based Assessment of Trauma Systems predictive model for volume of trauma patients at the new TC was run based on 25th, 50th, and 75th percentiles of both state and National Trauma Data Bank (NTDB) patients per 100 TC beds. This was compared with the actual number of trauma patients from the State Discharge Data set before (2011-2012) and after (2016-2017) designation of the TC. Analysis was then augmented using the geographic information system (ArcGIS) spatial modeling to characterize median travel times for actual trauma patients, before and after designation of the TC.

RESULTS

Both state and NTDB 25th, 50th, and 75th percentiles resulted in significant overestimation of volume at the new TC in 2016. After another year of TC maturation (2017), overestimation decreased but was still present. The 25th percentile from state and NTDB data sets provided the most accurate predictions. For the legacy TCs, the model switched from under to overestimation as the state and NTDB percentiles increased. The geographic information system accurately showed patients traveling <40 minutes to a TC nearly doubled.

CONCLUSION

Needs Based Assessment of Trauma Systems 2 provides an excellent template for state strategic planning; however, it overestimates new TC volume and under/overestimates volumes for legacy TCs depending on the state and NTDB percentiles used. This study shows that population density of the county in which the new or legacy TC is located should be considered when choosing the appropriate state or NTDB percentile. The geographic information system appropriately showed a decrease in trauma patient travel times after TC designation.

LEVEL OF EVIDENCE

Care Management, level V.

A painful lesson from the COVID-19 pandemic: the need for broad-spectrum, host-directed antivirals

While the COVID-19 pandemic has spurred intense research and collaborative discovery worldwide, the development of a safe, effective, and targeted antiviral from the ground up is time intensive. Therefore, most antiviral discovery efforts are focused on the re-purposing of clinical stage or approved drugs. While emerging data on drugs undergoing COVID-19 repurpose are intriguing, there is an undeniable need to develop broad-spectrum antivirals to prevent future viral pandemics of unknown origin. The ideal drug to curtail rapid viral spread would be a broad-acting agent with activity against a wide range of viruses. Such a drug would work by modulating host-proteins that are often shared by multiple virus families thereby enabling preemptive drug development and therefore rapid deployment at the onset of an outbreak. Targeting host-pathways and cellular proteins that are hijacked by viruses can potentially offer broad-spectrum targets for the development of future antiviral drugs. Such host-directed antivirals are also likely to offer a higher barrier to the development and selection of drug resistant mutations. Given that most approved antivirals do not target host-proteins, we reinforce the need for the development of such antivirals that can be used in pre- and post-exposure populations.

Health needs of indigenous Mayan older adults in Mexico and health services available

Current data indicate that inequitable health service access is one of the major problems faced by indigenous people in Mexico and around the world. The aim of this study was to analyse the perceived health needs of indigenous older adults in a Mayan region of Mexico and the health services provided to address these needs. It used a qualitative design which explored health needs, perceptions of well-being, experiences with public health services and obstacles in accessing services through semi-structured interviews with 20 older adults, nine traditional healers and seven public healthcare providers from Mayan municipalities in southeastern Mexico during 2013-2014. We identified that cultural differences related to the language, values, beliefs and worldview of indigenous populations are ignored or incorporated only minimally by health services. The provision of services does not correspond to the health needs of indigenous Mayan older adults, and wide gaps still undermine their human rights and health status; despite the establishment of favourable regulations, healthcare services are organised for the non-indigenous population. The conditions of social vulnerability affecting indigenous older adults require that healthcare institutions incorporate an intercultural approach in order to improve the quality of care according to the necessities of the population.

Technologies to Optimize the Care of Severe COVID-19 Patients for Health Care Providers Challenged by Limited Resources

Health care systems are belligerently responding to the new coronavirus disease 2019 (COVID-19). The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a specific condition, whose distinctive features are severe hypoxemia associated with (>50% of cases) normal respiratory system compliance. When a patient requires intubation and invasive ventilation, the outcome is poor, and the length of stay in the intensive care unit (ICU) is usually 2 or 3 weeks. In this article, the authors review several technological devices, which could support health care providers at the bedside to optimize the care for COVID-19 patients who are sedated, paralyzed, and ventilated. Particular attention is provided to the use of videolaryngoscopes (VL) because these can assist anesthetists to perform a successful intubation outside the ICU while protecting health care providers from this viral infection. Authors will also review processed electroencephalographic (EEG) monitors which are used to better titrate sedation and the train-of-four monitors which are utilized to better administer neuromuscular blocking agents in the view of sparing limited pharmacological resources. COVID-19 can rapidly exhaust human and technological resources too within the ICU. This review features a series of technological advancements that can significantly improve the care of patients requiring isolation. The working conditions in isolation could cause gaps or barriers in communication, fatigue, and poor documentation of provided care. The available technology has several advantages including (a) facilitating appropriate paperless documentation and communication between all health care givers working in isolation rooms or large isolation areas; (b) testing patients and staff at the bedside using smart point-of-care diagnostics (SPOCD) to confirm COVID-19 infection; (c) allowing diagnostics and treatment at the bedside through point-of-care ultrasound (POCUS) and thromboelastography (TEG); (d) adapting the use of anesthetic machines and the use of volatile anesthetics. Implementing technologies for safeguarding health care providers as well as monitoring the limited pharmacological resources are paramount. Only by leveraging new technologies, it will be possible to sustain and support health care systems during the expected long course of this pandemic.

[Contingency plan for the intensive care services for the COVID-19 pandemic]

In January 2020, the Chinese authorities identified a new virus of the Coronaviridae family as the cause of several cases of pneumonia of unknown aetiology. The outbreak was initially confined to Wuhan City, but then spread outside Chinese borders. On 31 January 2020, the first case was declared in Spain. On 11 March 2020, The World Health Organization (WHO) declared the coronavirus outbreak a pandemic. On 16 March 2020, there were 139 countries affected. In this situation, the Scientific Societies SEMICYUC and SEEIUC have decided to draw up this Contingency Plan to guide the response of the Intensive Care Services. The objectives of this plan are to estimate the magnitude of the problem and identify the necessary human and material resources. This is to provide the Spanish Intensive Medicine Services with a tool to programme optimal response strategies.

A Stroke Care Model at an Academic, Comprehensive Stroke Center During the 2020 COVID-19 Pandemic

BACKGROUND AND PURPOSE

The COVID-19 pandemic has required the adaptation of hyperacute stroke care (including stroke code pathways) and hospital stroke management. There remains a need to provide rapid and comprehensive assessment to acute stroke patients while reducing the risk of COVID-19 exposure, protecting healthcare providers, and preserving personal protective equipment (PPE) supplies. While the COVID infection is typically not a primary cerebrovascular condition, the downstream effects of this pandemic force adjustments to stroke care pathways to maintain optimal stroke patient outcomes.

METHODS

The University of California San Diego (UCSD) Health System encompasses two academic, Comprehensive Stroke Centers (CSCs). The UCSD Stroke Center reviewed the national COVID-19 crisis and implications on stroke care. All current resources for stroke care were identified and adapted to include COVID-19 screening. The adjusted model focused on comprehensive and rapid acute stroke treatment, reduction of exposure to the healthcare team, and preservation of PPE.

AIMS

The adjusted pathways implement telestroke assessments as a specific option for all inpatient and outpatient encounters and accounts for when telemedicine systems are not available or functional. COVID screening is done on all stroke patients. We outline a model of hyperacute stroke evaluation in an adapted stroke code protocol and novel methods of stroke patient management.

CONCLUSIONS

The overall goal of the model is to preserve patient access and outcomes while decreasing potential COVID-19 exposure to patients and healthcare providers. This model also serves to reduce the use of vital PPE. It is critical that stroke providers share best practices via academic and vetted social media platforms for rapid dissemination of tools and care models during the COVID-19 crisis.

'Your country needs you': the ethics of allocating staff to high-risk clinical roles in the management of patients with COVID-19

As the COVID-19 pandemic impacts on health service delivery, health providers are modifying care pathways and staffing models in ways that require health professionals to be reallocated to work in critical care settings. Many of the roles that staff are being allocated to in the intensive care unit and emergency department pose additional risks to themselves, and new policies for staff reallocation are causing distress and uncertainty to the professionals concerned. In this paper, we analyse a range of ethical issues associated with changes to staff allocation processes in the face of COVID-19. In line with a dominant view in the medical ethics literature, we claim, first, that no individual health professional has a specific, positive obligation to treat a patient when doing so places that professional at risk of harm, and so there is a clear ethical tension in any reallocation process in this context. Next, we argue that the changing asymmetries of health needs in hospitals means that careful consideration needs to be given to a stepwise process for deallocating staff from their usual duties. We conclude by considering how a justifiable process of reallocating professionals to high-risk clinical roles should be configured once those who are 'fit for reallocation' have been identified. We claim that this process needs to attend to three questions that we consider in detail: (1) how the choice to make reallocation decisions is made, (2) what justifiable models for reallocation might look like and (3) what is owed to those who are reallocated.

Translating evidence-based parenting programs for primary care: Stakeholder recommendations for sustainable implementation

AIMS

To translate evidence-based programs (EBP) for a new setting, attention must be given to the characteristics of the intervention and the local setting, as well as evidence that is compelling to decision-makers. This paper describes the history of a partnership and stakeholder recommendations to inform the adaptation of an EBP for primary care.

METHODS

We established a community advisory board (CAB) consisting of stakeholders with expertize in primary care delivery. A thematic analysis was conducted with fieldnotes and transcriptions from CAB meetings and regular meetings with participating clinics.

RESULTS

We found that (a) parenting programs with a focus on behavioral and physical health are appropriate for this setting, (b) variability in the structure of primary care means implementation must be tailorable, and (c) financial and organizational outcomes are compelling for decision-makers.

CONCLUSION

Factors related to the content and structure of evidence-based programs are uniquely related to distinct implementation outcomes of interest to key stakeholders.

Multiprofessional assessment of patients with chronic pain in primary healthcare

Background and aims Chronic pain is a common reason to seek health care. Multimodal rehabilitation is frequently used to rehabilitate patients with complex pain conditions. The multiprofessional assessment that patients go through before entering multimodal rehabilitation may, in itself, have a positive impact on patient outcome but little is known regarding patients own view. Therefore, the purpose of this study was to discover how patients experienced this multiprofessional assessment project. Methods Ten patients participating in a multiprofessional assessment at a primary healthcare centre in Western Finland were interviewed using a semi-structured interview. Qualitative content analysis was used to analyse the interviews. Results The analysis resulted in six categories of participant description of their multiprofessional assessment experiences and the rehabilitation plan they received. Feeling chosen or not quite fitting in was a category describing participant feelings upon starting the assessment. They expressed their thoughts on the examinations in the category more than just an examination. Being affirmed described participant desire to be taken seriously and treated well. Receiving support described the perceived roles of the team members. Participant negative experiences of the assessment were described in confusion and disappointment. Finally, in taking and receiving responsibilities, participants described their own role in the team. Conclusions Experiences of patients in a multiprofessional assessment were mostly positive. This highlights the value of a team assessment that takes several aspects of chronic pain into account when assessing complex patients.

COVID-19 guidance for triage of operations for thoracic malignancies: A consensus statement from Thoracic Surgery Outcomes Research Network

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study

BACKGROUND

The United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).

METHODS AND FINDINGS

Data were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p < 0.001), share-the-care (25% increase, p < 0.001), and facilitating patient engagement in HIV primary care (13% increase, p < 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p < 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p < 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p < 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.

CONCLUSIONS

In this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes.

Stakeholder Engagement in Planning the Design of a National Needs Assessment for Cardiovascular Disease Prevention and Management in Nepal

BACKGROUND

There is growing support for stakeholder engagement in health research, but the actual impact of such engagement has not been well established.

OBJECTIVES

This paper describes the stakeholder engagement process and evaluation during the planning of the national needs assessment for cardiovascular disease in Nepal.

METHODS

We used personal and professional networks to identify relevant stakeholders within the 7Ps framework (Patients and the Public, Providers, Purchasers, Payers, Public Policy Makers and Policy Advocates, Product Makers and the Principal Investigators) to develop a plan for assessing cardiovascular health needs in Nepal. We consulted 40 stakeholders through 2 meetings in small groups and a workshop in a large group to develop the study methods, conceptual framework, and stakeholder engagement process. We interviewed 33 stakeholders to receive feedback on the stakeholder engagement process.

RESULTS

We engaged 80% of the targeted stakeholders through small group discussions and a workshop. Three of 5 recommendations from the small group discussion were aimed at improving the stakeholder engagement process and 2 were aimed to improve the research methods. Eleven of 27 recommendations from the workshop aimed to improve the research methods, 4 aimed to improve stakeholder engagement, and 2 helped to expand the scope of dissemination. Ten were irrelevant or could not be incorporated due to resource limitation. Most stakeholders noted that the workshop provided an open platform for a multisectoral group to colearn from one another and share ideas. Others highlighted that the discussion generated insights to enhance research by incorporating expertise and ideas from different perspectives. The major challenges discussed were about committing the time for engagement.

CONCLUSIONS

The stakeholder engagement process positively affected the design of our research. This study provides important insights for future researchers that aim to engage stakeholders in national-level assessment programs in the health care system in the context of Nepal.

The Choice and Partnership Approach to community mental health and addictions services: a realist-informed scoping review protocol

INTRODUCTION

Early identification and appropriate treatment of child and adolescent mental health disorders can often be hampered by patchwork services with poorly planned or unclear pathways. The Choice and Partnership Approach (CAPA) is an evidence-based transformational model of community (community-based or outpatient) mental health and addictions services for children and adolescents that aims to better match services to needs and to improve timely access to care. CAPA has been variably implemented across jurisdictions but has not been comprehensively evaluated for its impact on system and client outcomes. Our research question is, 'To what degree does CAPA work, for whom and under what circumstances?'. The purpose of this review is twofold: (1) to gain an understanding of the extent and outcomes of the implementation of CAPA in community mental health and addictions services; and (2) to identify the role of context as it influences the implementation of CAPA and resulting client and system outcomes.

METHODS AND ANALYSIS

We will conduct a realist-informed scoping review of the literature related to CAPA in either child and adolescent or adult community mental health and addictions services. Relevant studies, reports and documentation will be identified by searching the following online databases: MEDLINE, Embase, CINAHL, PsycINFO, Academic Search Premier, ERIC, Web of Science, Cochrane, Dissertations Abstracts, NCBI Bookshelf, PubMed Central and the Canadian Health Research Collection. The search strategy was developed by a health sciences library scientist and informed by a multidisciplinary team comprising methodological and content knowledge experts. The search will gather evidence from multiple online databases of peer-reviewed literature and grey literature repositories. All articles will be independently assessed for inclusion by pairs of reviewers. The key themes derived from a thematic analysis of extracted data will be presented in a narrative overview.

ETHICS AND DISSEMINATION

Research ethics review is not required for this scoping review. The results will be disseminated through meetings with stakeholders (including clients and families, clinicians and decision-makers), conference presentations and peer-reviewed publication. The results of this review will inform an overarching programme of research, policy and quality indicator development to ultimately improve mental health and addictions care and subsequent mental health outcomes for children and adolescents.

Health Care Needs in School-Age Refugee Children

Most European countries have systematic health assessments of refugees with a main focus on infectious diseases. The aim of this study was to describe the broader health care needs identified in newly settled refugee children in a school health setting. The study population consisted of all 609 recently settled Non-European refugee and asylum-seeking children in the age range 6-15 years who were enrolled in the schools of Malmö, Sweden during the autumn semester of 2015, of which 265 had arrived in Sweden unaccompanied. The data were collected in a structured routine intake interview by an experienced school nurse. Almost half of the children had obvious untreated caries. For the unaccompanied children, prominent mental health needs were present in almost one in three. Previously unidentified vision and/or hearing problems were identified in one in ten and around 5% had a daily medication, and 4.5% of the unaccompanied children and 1.2% of the accompanied children were judged to be in need of immediate care and were referred accordingly. Newly settled refugee children in northern Europe have considerable health care needs apart from communicable diseases. School health services have a unique platform to identify and initiate this care.

Needs-based provision of medical care to nursing home residents: protocol for a mixed-methods study

INTRODUCTION

Nursing home residents typically have greater needs for medical care than community-dwelling elderly. However, restricted cognitive abilities and limited mobility may impede their access to general practitioners and medical specialists. The provision of medical care in nursing homes may therefore be inappropriate in some areas of medical care. The purpose of this mixed-methods study is to systematically assess, evaluate and explain met and unmet medical care needs in German nursing homes and to develop solutions where medical care is found to be inappropriate.

METHODS AND ANALYSIS

First, statutory health insurance claims data are analysed to identify differences in the utilisation of medical care between nursing home residents and community-dwelling elderly with and without need for long-term care. Second, the health status and medical care of 500 nursing home residents are assessed and evaluated to quantify met and unmet medical care needs. Third, qualitative expert interviews and case conferences and, fourth, quantitative analyses of linked data are used to provide structural, case-specific and generalisable explanations of inappropriate medical care among nursing home residents. Fifth, a modified Delphi study is employed to develop pilot projects aiming to improve medical care in nursing homes.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the University of Bremen on 23 November 2017. Research findings are disseminated through presentations at national and international conferences and publications in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

DRKS00012383.

Collaborating with the Community: Improving Patient Access to Palliative Radiation Therapy

PURPOSE

Palliative radiation therapy (PRT) has an essential role in cancer symptom control but is underutilized in Ontario. This initiative aimed to implement an educational outreach intervention to improve knowledge of and access to PRT among interprofessional palliative health care teams across an Ontario Local Health Integration Network.

METHODS AND MATERIALS

A needs assessment was completed from June to September 2018 with interprofessional palliative health care teams. Participants completed a survey to identify perceived opportunities, barriers, and enablers to recommending or referring patients for PRT. Thematic analysis informed content of the educational outreach intervention and included how to access PRT, common indications, case studies, and side-effect management after completing PRT. The educational outreach intervention was completed from October 2018 to January 2019. Participants completed a survey, and results were analyzed using descriptive statistics. The number of patients who received PRT was determined by cross-referencing the regional database with the radiation oncology information system.

RESULTS

Although 22.9% of participants had previously recommended or referred patients, 96.2% of participants agreed or strongly agreed that they are likely to recommend or refer patients for PRT after the educational outreach intervention (n = 131). An increase was observed in the number of patients receiving PRT from the community during the intervention period.

CONCLUSIONS

The educational outreach intervention improved knowledge and the likelihood of interprofessional palliative health care teams providing access to PRT for patients in the community. More patients now receive PRT, conveying improved symptom control and quality of life.

Prevalence of celiac disease in primary care: the need for its own code

BACKGROUND

Celiac disease (CD) is an autoimmune chronic enteropathy of the small intestine caused by exposure to gluten in genetically predisposed individuals. CD is not easy to diagnose due to its unspecific symptomatology, especially in adults, a diagnosed/undiagnosed ratio of 1:7 is estimated. CD does not have its own code in the International Classification of Primary Care (ICPC) but it is coded under code D99 "Disease digestive system, other", which hinders diagnosis, intervention and research. The aim of this study is to investigate the prevalence of CD in Aragón, Spain, using the information available from Primary Care, as well as to discuss the difficulties involved in determining prevalence of CD from data collected at this level of medical intervention.

METHODS

We designed an epidemiological cross-sectional study and analysed 26,964 electronic clinical records from the Aragonese Health Service under code ICPC D99 collected up to December 31st, 2016. The clinical records were classified by their editable field "descriptor" according to their probability of being related to CD. Analyses of gender, age, age at diagnosis, province and health sector were carried out.

RESULTS

We found 4534 clinical records under 293 different descriptors with a high probability of referring to CD. Prevalence in Aragón was estimated to be 0.35% ranging from 0.24 to 0.81% with important differences among health sectors.

CONCLUSIONS

The prevalence of 0.35% is a long way from the generally accepted 1% but within the usually considered ratio 1:7 of diagnosed:undiagnosed cases. Differences among sectors should be carefully analysed. Lacking its own ICPC code, diagnosis of CD in Primary Care Services is not included in a single category, but it is distributed under several descriptors, which makes it difficult to offer any firm diagnosis for treatment and hinders research. Finally, the high prevalence of CD justifies its own ICPC code and the need to withdraw CD from the generic D99 code "Disease digestive system other".

Identification of service development needs for incarcerated adults with autism spectrum disorders in an Australian prison system

PURPOSE

The purpose of this paper is to identify and deliberate the service development needs required for the improvement of service provision for incarcerated adults with autism spectrum disorder (ASD) in NSW, Australia.

DESIGN/METHODOLOGY/APPROACH

Consultation groups were conducted to bring together n=5 key stakeholders from heath and correctional-based services in the prison system. A facilitated asynchronous e-mail-based discussion occurred amongst group members between consultation group meetings.

FINDINGS

Two main themes were identified: detecting persons with ASD and providing appropriate care. Participants discussed current service gaps with regard to the identification of people with ASD at the point of contact with the prison service, and the difficulties associated with diagnosing prisoners with ASD. The need for effective alert systems to detect persons with ASD in custody was identified. The current absence of ASD-specific support services in prison was highlighted, and recommendations for improvement suggested.

PRACTICAL IMPLICATIONS

Current health and correctional-based service provision failed to adequately support incarcerated adults with ASD. Improvements in prison-entry screening processes, alert systems and diagnostic practices are required. Multidisciplinary collaboration between prison-based and external service providers is required for the development of a model of care based on individualised case management to adequately support incarcerated adults with ASD in prison.

ORIGINALITY/VALUE

Given the lack of reported service provision for incarcerated adults with ASD internationally, other prison-based services are likely to experience similar service development needs and see the relevance of the recommendations made directly from the study findings.

"What program directors think IV": Results of the 2017 Annual Survey of the Association of Program Directors in Radiology

RATIONALE AND OBJECTIVES

The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country.

MATERIALS AND METHODS

This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members.

RESULTS

Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%.

CONCLUSION

Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.

Pilot study to build capacity for family medicine with abbreviated, low-cost training programme with minimal impact on patient care for a cohort of 84 general practitioners caring for Palestinian refugees in Jordan

PURPOSE

Studies document that primary care improves health outcomes and controls costs. In regions of the world where primary care is underdeveloped, building capacity is essential. Most capacity building programmes are expensive and take physicians away from their clinical settings. We describe a programme created, delivered and evaluated from 2013 to 2014 in Jordan.

DESIGN

Cohort study.

SETTING

Physicians providing primary care in the United Nations Relief and Works Agency for Palestine Refugees clinics in Jordan.

PARTICIPANTS

Eighty-four general practitioners (GPs) were invited to participate and completed the training and evaluation. GPs are physicians who have a license to practice medicine after completing medical school and a 1 year hospital-based rotating internship. Although GPs provide care in the ambulatory setting, their hospital-based education provides little preparation for delivering ambulatory primary care.

INTERVENTION/PROGRAMME

This three-stage programme included needs assessment, didactics and on-the-job coaching. First, the learning needs and baseline knowledge of the trainees were assessed and the findings guided curriculum development. During the second stage, 48 hours of didactics covered topics such as communications skills and disease management. The third stage was delivered one on one in the trainee's clinical setting for a 4 to 6-hour block. The first, middle and final patient interactions were evaluated.

PRIMARY AND SECONDARY OUTCOME MEASURES

Preknowledge and postknowledge assessments were compared. The clinical checklist, developed for the programme, assessed eight domains of clinical skills such as communication and history taking on a five-point Likert scale during the patient interaction.

RESULTS

Preknowledge and postknowledge assessments demonstrated significantly improved scores, 46% to 81% (p<0.0001). Trainee's clinical checklist scores improved over the assessment intervals. Satisfaction with the training was high.

CONCLUSION

This programme is a potential model for building primary care capacity at low cost and with little impact on patient care that addresses both knowledge and clinical skills on the job.

Barriers to accessing cancer services for adults with physical disabilities in England and Wales: an interview-based study

OBJECTIVES

The aim of this study was to explore the barriers to accessing cancer services faced by adults with pre-existing physical disabilities.

DESIGN

Cross-sectional, exploratory qualitative study. Data were collected by semistructured interviews and analysed thematically.

SETTING

Participants were recruited through statutory and third sector organisations in England and Wales between October 2017 and October 2018.

PARTICIPANTS

18 people with a diagnosis of cancer and a pre-existing physical disability.

RESULTS

The findings illustrate that people with physical disabilities in England and Wales face a variety of barriers to accessing cancer services. The overall theme that emerged was that participants experienced a lack of attitudinal and institutional preparation both from healthcare professionals and healthcare facilities. This overall theme is illustrated through three subthemes: lack of acknowledgment of disability, unseeing disability and physical inaccessibility.

CONCLUSIONS

As the population ages and increasing numbers of people live with cancer and disability, it is important to develop knowledge to respond to the needs of this population. The mere existence of services does not guarantee their usability. Services need to be relevant, flexible, and accessible and offered in a respectful manner. It is important that healthcare professionals work towards inclusive healthcare provision, enabling the utilisation of services by all. Necessary steps to be taken include better communication between the various professionals and across the different teams involved in patients' care, raising awareness of how physical disability can affect or interact with cancer-related treatment and creating more accessible physical environments.

Making Connections: Understanding How Screening, Triage, and Referral Processes Can Promote Veteran Housing Stability

To improve understanding of the screening, triage, and referral processes within social determinant of health-Electronic Medical Record (EMR) integration, we explored how Veterans connect with needed resources following screening for housing instability using three data sources: administrative Homelessness Screening Clinical Reminder (HSCR) data, administrative Supportive Services for Veterans Families (SSVF) data, and chart review data. The cohort included Veterans who had responded to the HSCR in the 90 days prior to presenting for SSVF services between October 2012 and 2015 (N = 134); chart reviews were abstracted for a sample (n = 53). Most Veterans who presented for SSVF services had screened negative for housing instability (68.7%) on the HSCR, yet chart abstractions demonstrated that more than half connected to triage assistance prior to seeking services irrespective of their screening outcome. Future screening efforts should consider the role of the person administering the screening instrument and critical areas for assessment.

A case study exploring the effectiveness of an innovative "5Q Care Test" to determine whether patients with complex needs require health or social care

A case study was conducted in 2016 to evaluate the effectiveness of an innovation to enable people with "complex" care requirements to be discharged from hospital to an appropriate service for their care, without using the NHS England Continuing Health Care (CHC) assessment. The setting was a rural district general hospital in England, where the quality outcomes and cost-effectiveness of the CHC assessment being conducted in hospital were giving cause for concern. The NHS CHC Framework advocates conducting these assessments in the community where a more accurate indication of long-term care can be determined. The "5Q Care Test" was collaboratively developed with health and social care partners, care providers, and CHC interest groups, including users of the services. It was implemented as a tool to support moving the CHC assessment into the community, as it enabled practitioners to swiftly determine patients' appropriate initial care pathway out of hospital. A full economic impact analysis was conducted 7 months after the tool was introduced. The results showed significant improvement in the quality and cost-effectiveness of the "5Q Care Test," with a reduction in the hospital length of stay, which is known to be associated with improved outcomes for patients and financial savings.

Bridging antimicrobial resistance knowledge gaps: The East African perspective on a global problem

Background

There is worldwide concern of rapidly increasing antimicrobial resistance (AMR). However, there is paucity of resistance surveillance data and updated antibiograms in Africa in general. This study was undertaken in Kenyatta National Hospital (KNH) -the largest public tertiary referral centre in East & Central Africa—to help bridge existing AMR knowledge and practice gaps.

Methods

A retrospective review of VITEK 2 (bioMérieux) records capturing antimicrobial susceptibility data for the year 2015 was done and analysed using WHONET and SPSS.

Results

Analysis of 624 isolates revealed AMR rates higher than most recent local and international reports. 88% of isolates tested were multi-drug resistant (MDR) whereas 26% were extensively-drug resistant (XDR). E. coli and K. pneumoniae had poor susceptibility to penicillins (8–48%), cephalosporins (16–43%), monobactams (17–29%), fluoroquinolones (22–44%) and trimethoprim-sulfamethoxazole (7%). Pseudomonas aeruginosa and Acinetobacter baumanii were resistant to penicillins and cephalosporins, with reduced susceptibility to carbapenems (70% and 27% respectively). S aureus had poor susceptibility to penicillins (3%) and trimethoprim-sulfamethoxazole (29%) but showed excellent susceptibility to imipenem (90%), vancomycin (97%) and linezolid (99%).

Conclusions

The overwhelming resistance to commonly used antibiotics heralds a clarion call towards strengthening antimicrobial stewardship programmes and regular AMR regional surveillance.

The development and implementation of a 12-month simulation-based learning curriculum for pediatric emergency medicine fellows utilizing debriefing with good judgment and rapid cycle deliberate practice

BACKGROUND

There are currently training gaps, primarily procedural and teamwork skills, for pediatric emergency medicine (PEM) fellows. Simulation-based learning (SBL) has been suggested as an educational modality to help fill those gaps. However, there is little evidence suggesting how to do so. The objective of this project is to develop and implement an SBL curriculum for PEM fellows with established curriculum development processes and instructional design strategies to improve PEM fellowship training.

METHODS

We developed a 12-month longitudinal SBL curriculum focused on needs assessment, instructional strategies, and evaluation. The curriculum development process led us to combine the instructional strategies of debriefing with good judgment, rapid cycle deliberate practice, and task-training to improve core PEM skills such as procedural competence, crisis resource management, and managing complex medical and traumatic emergencies. Using multiple approaches, we measured outcomes related to learners (attendance, performance, critical procedure opportunities), instructor performance, and program structure.

RESULTS

Eight/Eight (100%) PEM fellows participated in this curriculum from July 2015 to June 2017 with an overall attendance rate of 68%. Learners self-reported high satisfaction (4.4/5, SD = 0.5) and perceived educational value (4.9/5, SD = 0.38) with the curriculum and overall program structure. Learners had numerous opportunities to practice critical procedures such as airway management (20 opportunities), defibrillator use (ten opportunities), and others (ten opportunities). Learner Debriefing Assessment for Simulation in Healthcare (short version) scores had mean scores greater than 5.8/7 (SD = 0.89) across all six elements.

CONCLUSIONS

This longitudinal SBL curriculum combining debriefing with good judgment and rapid cycle deliberate practice can be a feasible method of reducing current training gaps (specifically with critical procedure opportunities) in PEM fellowship training. More work is needed to quantify the training gap reduction and to refine the curriculum.

Which client characteristics predict home-care needs? Results of a survey study among Dutch home-care nurses

Fee-for-service, funding care on an hourly rate basis, creates an incentive for home-care providers to deliver high amounts of care. Under casemix funding, in contrast, clients are allocated-based on their characteristics-to homogenous, hierarchical groups, which are subsequently funded to promote more effective and efficient care. The first step in developing a casemix model is to understand which client characteristics are potential predictors of home-care needs. Nurses working in home care (i.e. home-care nurses) have a good insight into clients' home-care needs. This study was conducted in co-operation with the Dutch Nurses' Association and the Dutch Healthcare Authority. Based on international literature, 35 client characteristics were identified as potential predictors of home-care needs. In an online survey (May, 2017), Dutch home-care nurses were asked to score these characteristics on relevance, using a 9-point Likert scale. They were subsequently asked to identify the top five client characteristics. Data were analysed using descriptive statistics. The survey was completed by 1,007 home-care nurses. Consensus on relevance was achieved for 15 client characteristics, with "terminal phase" being scored most relevant, and "sex" being scored as the least relevant. Relevance of the remaining 20 characteristics was uncertain. Additionally, based on the ranking, "ADL functioning" was ranked as most relevant. According to home-care nurses, both biomedical and psychosocial client characteristics need to be taken into account when predicting home-care needs. Collaboration between clinical practice, policy development, and science is necessary to realise a funding model, to work towards the Triple Aim (improved health, better care experience, and lower costs).

Development of an Interprofessional Home Healthcare Management Service: Within an Urban Housing Development

In response to the need for increased access to primary care services for a low-income, at-risk community, two local universities partnered with a nonprofit Housing and Urban Development affiliated provider of affordable housing to launch a primary care clinic within an urban public housing community. Although the establishment of this clinic represented progress in meeting many healthcare needs of the target population, an interprofessional team also identified a need for the initiation of a new home-based service line. The goal of this project was to establish an innovative, sustainable, and cost-effective healthcare delivery method that would improve the health of this population. The project focused on a literature review, needs-assessment, and development of a comprehensive medical home visit program to serve the homebound, frail elderly, and other at-risk adults with complex medical conditions who reside in this community. The medical needs of potential recipients were assessed by conducting interviews with key support staff including a health service coordinator, health advocates, and housing provider service coordinators. Residents were also interviewed using a newly developed health perception and information survey. The data derived from the needs-assessment and pertinent literature were used to draft an initial program guideline. Because the needs-assessment indicated this population would not derive maximum benefit from a traditional house calls program, the project team developed a Home Healthcare Management service with an expanded scope to provide enhanced care coordination, house visits (medical and nonmedical), and community outreach.

Strategies for Promoting the Medical Device Industry in Korea: An Analytical Hierarchy Process Analysis

This study examines the medical device industry in the context of the Fourth Industrial Revolution and identifies the key strategies and general directions for promoting this industry through analytical hierarchy process (AHP). It is based on discussions of the key issues with specialists such as doctors, medical device companies, hospital staff, professors, and government agencies in the medical device industry. A total of 18 responses were obtained from the survey, and an analysis was conducted on the results. Among the medical device strategies identified by the surveyed specialists, clarifying the application of regulations (access strategy), increasing R&D investment for the technological development of medical devices (expansion strategy), and increasing support for global market expansion (infrastructure expansion strategy) were found to have the highest priority. Based on the above, we suggest key strategies and directions for promoting the medical device industry.

"You've got to look after yourself, to be able to look after them" a qualitative study of the unmet needs of caregivers of community based primary health care patients

BACKGROUND

There is growing reliance on unpaid caregivers to provide support to people with care needs. Integrated care approaches that aim to coordinate primary care with community care known as community based primary health care (CBPHC) has been a key policy initiative across health systems; however most attention has been paid to the needs of patients and not caregivers. The objective of this paper was to explore the unmet needs of caregivers of older adults with complex care needs receiving CBPHC.

METHODS

This qualitative descriptive study entailed one-to-one interviews with 80 caregivers from Canada and New Zealand where roles, experiences and needs were explored. Interview text related to unmet need was reviewed inductively and core themes identified.

RESULTS

Three themes were identified across CBPHC sites: unrecognized role; lack of personal resources; and no breaks even when services are in place.

CONCLUSIONS

To support caregivers, models of care such as CBPHC need to look beyond the patient to meaningfully engage caregivers, address their needs and recognize the insight they hold. This knowledge needs to be valued as a key source of evidence to inform developments in health and social care.

Hospital postdischarge intervention trialled with family caregivers of older people in Western Australia: potential translation into practice

There is lack of a suitable assessment tool that can be used routinely and systematically by hospital staff to address family caregivers' (FCs') support needs. This paper describes a novel approach to identifying and addressing FCs' needs following hospital discharge of the older person receiving care.

SETTING AND PARTICIPANTS

FC recruitment occurred on the patient's discharge from a tertiary hospital in Western Australia; 64 completed the study; 80% were female; mean age 63.2 years.

INTERVENTION

The Further Enabling Care at Home (FECH) programme was delivered over the telephone by a specially trained nurse and included: support to facilitate understanding of the patient's discharge letter; caregiver support needs assessment and prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports.

RESULTS

Sixty-four FCs completed the FECH programme. The top three support needs identified by the FCs were: knowing what to expect in the future (52%), knowing who to contact if they were concerned (52%) and practical help in the home (36%). The telephone-based outreach service worked well and was convenient for the nurse and the FCs, and saved on transport, time and money. Most of the FCs appreciated the systematic approach to identify and articulate their needs and were satisfied with the support they received, mainly navigation through the systems, problem solving, self-care strategies, explanation of illness, symptoms and medication and access to after-hours services.

CONCLUSIONS

In order to guide services which may consider adopting this systematic approach to supporting FCs and integrating it into their routine practice, this evaluation of the FECH programme has described the processes implemented and highlighted the factors that hindered or facilitated these processes to engage caregivers with appropriate services in a timely manner. Positive feedback indicated that the programme was a useful addition to hospital discharge planning.

TRIAL REGISTRATION NUMBER

ACTRN12614001174673; Results.

Creation of an Integrated Knowledge Translation Process to Improve Pediatric Emergency Care in Canada

TREKK (Translating Emergency Knowledge for Kids) was established to address knowledge needs to support care of children in general emergency departments. To achieve this goal, we developed an integrated knowledge translation (KT) process based on identified priorities to create the TREKK Evidence Repository, containing "knowledge pyramids" and Bottom Line Recommendations (summary documents) on the diagnosis and treatment of emergency pediatric conditions. The objective of this article is to describe our methods for developing and disseminating the TREKK Evidence Repository to improve pediatric emergency care in Canada. Our work was guided by the research question: Can an integrated KT process address an information gap in healthcare practice? We utilized a pyramid-shaped framework, built upon the "4S" hierarchy of evidence model, to provide detailed evidence appropriate to stakeholders' needs. For each priority condition (asthma, bronchiolitis, croup, etc.), clinical advisors and KT experts collaborated to create a Bottom Line Recommendation and to select guidelines, reviews, and key studies for that condition's topic area in the Evidence Repository on the TREKK website (trekk.ca). Targeted promotion, including a social media campaign, communicated the availability of new topics in the Evidence Repository and available knowledge tools. Feedback from 35 end-users on pilot versions of the Evidence Repository was positive with 91% indicating that they would use the resource in the emergency department. Using an integrated KT process, we responded to end-users' requests for varying level of information on priority pediatric conditions through the creation of knowledge tools and development of a process to identify and vet high quality evidence-based resources.

Barriers and Facilitators to Treatment Engagement Among Clients in Inpatient Substance Abuse Treatment

There is a call for drawing on client voice to provide a rich, nuanced understanding of factors influencing substance treatment engagement as to maximizing treatment benefits. We interviewed 60 clients in a short-term inpatient substance treatment program and examined facilitators and barriers to treatment engagement. Thematic analysis yielded four themes, including perceived treatment needs, trust and counselor rapport, peer inspiration, and organizational factors. Perceived treatment needs serve as both a facilitator and a barrier wherein the acknowledgment of needs led to greater treatment engagement whereas a lack of perceived needs hindered treatment engagement. The establishment of trust and counselor rapport and peer inspiration facilitated treatment engagement. Clients rated several organizational factors including a lack of treatment provision, gender-responsive treatment and infrastructure, and ineffective communication with nonclinical staff as barriers to treatment engagement. Clinical implications include enhancing treatment motivation and counselor rapport, establishing gender-responsive treatment programs, and providing trainings for staff.

Bullying: What the PNP Needs to Know

Despite generations of doubt about the true impact of bullying, it is now clear that childhood bullying can have significant lifelong consequences for victims and bullies alike. Recent school shootings and suicides by students who have been victims of bullying have helped to solidify public awareness of the gravity of the problem of childhood bullying. Adults who were frequently bullied in childhood have an increased frequency of psychiatric disorders, including anxiety, depression, and suicidality, extending into middle age (Arseneault, 2017). In fact, frequent bullying in childhood may impact victims similar to experiencing multiple adverse childhood experiences (Takizawa, Maughan, & Arseneault, 2014). Bullying also has a detrimental effect on young perpetrators (Zuckerman, 2016). Bullying is clearly a pediatric health care problem. This continuing education article will explore bullying in terms of definitions, epidemiology, types, risk factors, resilience factors, consequences, and implications for practice.

Aligning an undergraduate psychological medicine subject with the mental health needs of the local region

BACKGROUND

The James Cook University (JCU) medical school recently revised its Year 2 human development and behaviour module to be more relevant and practical for students, and more aligned with the mental health priorities of the local region (north Queensland). This study reports medical students' level of preparedness conferred by the re-designed 'Psychological Medicine and Human Development' (PMHD) subject for their later 4-week, rural clinical placement in Year 2.

METHODS

Non-randomized, controlled 'naturalistic' study with pre- and post-intervention surveys. The patient mental health experiences of Year 2 students who went on clinical placement after undertaking the PMHD subject were compared to those who went on placement before undertaking PMHD.

RESULTS

A total of 209 JCU Year 2 medical students completed surveys from a possible 217 (response rate = 96%). Compared to students whom had not taken PMHD before going on placement, students going on placement after undertaking PMHD were significantly more likely to report: feeling comfortable discussing mental health issues with patients (p = 0.001); being prepared for mental health discussions with patients (p < 0.001); having an actual mental health discussion with a patient (p < 0.001); and, volunteering an opinion on the appropriateness of their supervising doctor's response (p < 0.001). Students reported subject content involving information and classroom instruction on assessing and interviewing patients for mental illness to be of most use.

CONCLUSIONS

Providing medical students with psychological medicine information on locally prevalent mental health conditions plus practical classroom experiences in conducting mental state exams better prepares them for interacting with patients experiencing psychological distress. This novel methodology - aligning formal teaching in a subject with an evaluation utilizing a proximate student placement to provide useful feedback on the curriculum content and assess the relevance of the material taught - could be used to revise other content areas of a medical course to be more locally relevant and practically focused, and then to evaluate the success of this revision.

Patient value: its nature, measurement, and role in real world evidence studies and outcomes-based reimbursement

The assessment of "patient value" is fundamental to clinical trials, real world evidence studies, and outcomes-based reimbursement schemes. Measures of health-related quality-of-life (HRQoL) are widely used in health research. Such measures are effective in determining the presence or absence of symptoms and functional ability. However, HRQoL measures were not intended, nor designed, to determine the value to patients of alternative health states. Functions have no intrinsic value-they are a means to fulfil human needs. However, needs can be met in a variety of ways, for example by adopting different functions or by the provision of social services. It is possible to analyze all functions in terms of the needs they satisfy. A needs model has been applied in health research since the 1990s. It is concerned with the extent to which human needs are fulfilled in the presence of disease and its treatment. It is argued that this is the major concern of the patient. Needs-based measures are patient-centric and produce a valid unidimensional index of outcome. Consequently, they provide a direct means of measuring patient value. This approach provides the possibility of evaluating health services in terms of the value they provide to consumers and payers. It also has a role to play in real-world evidence studies and outcomes-based reimbursement. It is recommended that greater attention is given in future to the development of patient-reported outcome measures that provide direct assessments of patient value.

Fracture liaison services for osteoporosis in the Asia-Pacific region: current unmet needs and systematic literature review

The analysis aimed to identify the treatment gaps in current fracture liaison services (FLS) and to provide recommendations for best practice establishment of future FLS across the Asia-Pacific region. The findings emphasize the unmet need for the implementation of new programs and provide recommendations for the refinement of existing ones. The study's objectives were to evaluate fracture liaison service (FLS) programs in the Asia-Pacific region and provide recommendations for establishment of future FLS programs. A systematic literature review (SLR) of Medline, PubMed, EMBASE, and Cochrane Library (2000-2017 inclusive) was performed using the following keywords: osteoporosis, fractures, liaison, and service. Inclusion criteria included the following: patients ≥ 50 years with osteoporosis-related fractures; randomized controlled trials or observational studies with control groups (prospective or retrospective), pre-post, cross-sectional and economic evaluation studies. Success of direct or indirect interventions was assessed based on patients' understanding of risk, bone mineral density assessment, calcium intake, osteoporosis treatment, re-fracture rates, adherence, and mortality, in addition to cost-effectiveness. Overall, 5663 unique citations were identified and the SLR identified 159 publications, reporting 37 studies in Asia-Pacific. These studies revealed the unmet need for public health education, adequate funding, and staff resourcing, along with greater cooperation between departments and physicians. These actions can help to overcome therapeutic inertia with sufficient follow-up to ensure adherence to recommendations and compliance with treatment. The findings also emphasize the importance of primary care physicians continuing to prescribe treatment and ensure service remains convenient. These findings highlight the limited evidence supporting FLS across the Asia-Pacific region, emphasizing the unmet need for new programs and/or refinement of existing ones to improve outcomes. With the continued increase in burden of fractures in Asia-Pacific, establishment of new FLS and assessment of existing services are warranted to determine the impact of FLS for healthcare professionals, patients, family/caregivers, and society.

Using the transformative paradigm to conduct a mixed methods needs assessment of a marginalized community: Methodological lessons and implications

We explore opportunities as well as challenges associated with conducting a mixed methods needs assessment using a transformative paradigm. The transformative paradigm is a research framework that centers the experiences of marginalized communities, includes analysis of power differentials that have led to marginalization, and links research findings to actions intended to mitigate disparities. We argue that a community needs assessment is a natural fit for the use of a transformative framework, serving as an entry-point for the development of responsive programmatic and funding decisions. Based on a case study of efforts initiated by a local community health foundation to document disparities in their city, we show how an evaluation team used principles aligned with the transformative framework to guide the design and implementation of a community needs assessment. The needs assessment provided a better understanding of the power of community relationships, demonstrated how lack of trust can continue to constrain community voices, and revealed why agencies must actively support a social justice framework beyond the end of an assessment to ensure transformative change.

Informing Hospital Change Processes through Visualization and Simulation: A Case Study at a Children's Emergency Clinic

OBJECTIVE

To demonstrate the use of visualization and simulation tools in order to involve stakeholders and inform the process in hospital change processes, illustrated by an empirical study from a children's emergency clinic.

BACKGROUND

Reorganization and redevelopment of a hospital is a complex activity that involves many stakeholders and demands. Visualization and simulation tools have proven useful for involving practitioners and eliciting relevant knowledge. More knowledge is desired about how these tools can be implemented in practice for hospital planning processes.

METHODS

A participatory planning process including practitioners and researchers was executed over a 3-year period to evaluate a combination of visualization and simulation tools to involve stakeholders in the planning process and to elicit knowledge about needs and requirements.

RESULTS

The initial clinic proposal from the architect was discarded as a result of the empirical study. Much general knowledge about the needs of the organization was extracted by means of the adopted tools. Some of the tools proved to be more accessible than others for the practitioners participating in the study. The combination of tools added value to the process by presenting information in alternative ways and eliciting questions from different angles.

CONCLUSIONS

Visualization and simulation tools inform a planning process (or other types of change processes) by providing the means to see beyond present demands and current work structures. Long-term involvement in combination with accessible tools is central for creating a participatory setting where the practitioners' knowledge guides the process.

Family planning services for incarcerated women: models for filling an unmet need

Purpose Incarcerated women around the globe are predominantly of reproductive age. Most of these women have been pregnant before, and many want to be sexually active and avoid pregnancy upon release. Yet few of these women are on a regular method of contraception. Providing contraceptive services for women in custody benefits individual and public health goals of reducing unintended pregnancy. This policy briefing reviews evidence for an unmet need for family planning in the correctional setting, and policy implications for expanding services. The paper aims to discuss these issues. Design/methodology/approach The authors describe four model programs in the USA with established contraceptive services on site, highlighting practical steps other facilities can implement. Findings Correctional facilities health administrators, providers, advocates, and legislators should advance policies which should counsel women on family planning and should make a range of contraceptive methods available before release, while remaining sensitive to the potential pressure these women may feel to use birth control in this unique environment. Practical implications Family planning services for incarcerated women benefits individuals, facilities, and the community. Social implications Policies which enable correctional facilities to provide comprehensive family planning to incarcerated women - including reproductive life goals counseling and contraceptive method provision - promote equity in access to critical reproductive health services and also provide broad scale population level benefits in preventing unintended pregnancy or enabling counseling for healthy pregnancies for a group of women who often have limited access to such services. Originality/value This policy briefing highlights an area of health care in prisons and jails which gets little attention in research and in policy circles: family planning services for incarcerated women. In addition to reviewing the importance of such services for this population, the authors also highlight model family planning programs in correctional facilities. These provide actionable insights for other administrators and providers.

Mapping displaced populations with reference to social vulnerabilities for post-disaster public health management

Millions of people are currently displaced from their homes because of local and international conflicts. In the last two decades, a substantial increase in the number of displaced people has been recorded. We measured the social vulnerabilities of displaced populations using a mathematical approach in combination with application of geographical information systems (GIS) tools and techniques to visualise movement and draw attention to the location of significant concentration of vulnerabilities. A retrospective study approach based on datasets collected from governmental and non-governmental organisations working with refugees and internally displaced persons in Pakistan was used. We applied simple mathematical formulas to calculate and map various types of vulnerability, such as refugee population, absorption capacity, unmet needs and overall vulnerability. This approach displays risks and vulnerabilities of displaced populations in an easily understood and straightforward manner that can be replicated in other parts of the world.

Cancer Prevention During Early Adulthood: Highlights From a Meeting of Experts

Using a life course approach, the Centers for Disease Control and Prevention's Division of Cancer Prevention and Control and the National Association of Chronic Disease Directors co-hosted a 2-day meeting with 15 multidisciplinary experts to consider evidence linking factors in early adulthood to subsequent cancer risk and strategies for putting that evidence into practice to reduce cancer incidence. This paper provides an overview of key themes from those meeting discussions, drawing attention to the influence that early adulthood can have on lifetime cancer risk and potential strategies for intervention during this phase of life. A number of social, behavioral, and environmental factors during early adulthood influence cancer risk, including dietary patterns, physical inactivity, medical conditions (e.g., obesity, diabetes, viral infections), circadian rhythm disruption, chronic stress, and targeted marketing of cancer-causing products (e.g., tobacco, alcohol). Suggestions for translating research into practice are framed in the context of the four strategic directions of the National Prevention Strategy: building healthy and safe community environments; expanding quality preventive services in clinical and community settings; empowering people to make healthy choices; and eliminating health disparities. Promising strategies for prevention among young adults include collaborating with a variety of community sectors as well as mobilizing young adults to serve as advocates for change. Young adults are a heterogeneous demographic group, and targeted efforts are needed to address the unique needs of population subgroups that are often underserved and under-represented in research studies.

Speech pathology as the MasterChef: Getting the right ingredients and stirring the pot

The purpose of this paper is to consider the many influences that have an impact on appropriate speech-language pathology service delivery. The competitive cooking and entertainment television program, MasterChef, is used as an analogy to consider the ingredients, blend and approach required to improve speech-language pathology services. Speech-language pathologists (SLPs) enter the profession with the aim of assisting those with communication and swallowing disorders to have a better quality of life. Thus, we should be restless to continue to improve our services in order to achieve the best influence and outcomes by changing our recipes and ingredients. However, having good technical skills as a SLP is not sufficient in ensuring that the services are the best they can be. We have to consider available resources, customers and service users, who it is that judges our services, whether we are as good as we could or should be, what can help us improve our services, what the appetite is for our services, and how we incorporate evidence-based practice. This paper considers the value of understanding and using information on incidence and prevalence, evidence-based practice and outcome measurement. Blending technical, clinical and academic abilities with personal skills will result in an award-winning menu.

Strategies to Address Unmet Needs and Facilitate Return to Learn Guideline Adoption Following Concussion

BACKGROUND

Many students do not receive return to learn (RTL) services upon return to academics following a concussion.

METHODS

Using a mixed-methods approach, we conducted a survey of RTL practices and experiences in Washington State schools between January 2015 and June 2015. We then held a statewide summit of RTL stakeholders and used a modified Delphi process to develop a consensus-based RTL implementation model and process.

RESULTS

Survey participants included 83 educators, 57 school nurses, 14 administrators, and 30 parents, representing 144 schools in rural and urban areas. Unmet need domains and recommendations identified were (1) a current lack of school policies; (2) barriers to providing or receiving accommodations; (3) wide variability in communication patterns; and (4) recommendations shared by all stakeholder groups (including desire for readily available best practices, development of a formal school RTL policy for easy adoption and more training). Using stakeholder input from RTL summit participants and survey responses, we developed an RTL implementation model and checklist for RTL guideline adoption.

CONCLUSIONS

Washington State children have unmet needs upon returning to public schools after concussion. The student-centered RTL model and checklist for implementing RTL guidelines can help schools provide timely RTL services following concussion.