Comprehensive care programmes for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) represent a small, but growing, proportion of all children. Regardless of their underlying diagnosis, by definition, all CMC have similar functional limitations and high healthcare needs. It has been suggested that improving aspects of healthcare delivery for CMC improves health- and quality of life-related outcomes for children and their families and reduces healthcare-related expenditure. As a result, dedicated comprehensive care programmes have been established at many hospitals to meet the needs of CMC; however, it is unclear if such programmes are effective.

OBJECTIVES

Our main objective was to assess the effectiveness of comprehensive care programmes that aim to improve care coordination and other aspects of health care for CMC and to assess whether the effectiveness of such programmes differs according to the programme setting and structure. We aimed to assess their effectiveness in relation to child and parent health, functioning, and quality of life, quality of care, number of healthcare encounters, unmet healthcare needs, and total healthcare-related costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and CINAHL in May 2023. We also searched reference lists, trial registries, and the grey literature.

SELECTION CRITERIA

Randomised and non-randomised trials, controlled before-after studies, and interrupted time series studies were included. Studies that compared enrolment in a comprehensive care programme with non-enrolment in such a programme/treatment as usual were included. Participants were children that met the criteria for the definition of CMC, which is: having (i) a chronic condition, (ii) functional limitations, (iii) increased health and other service needs, and (iv) increased healthcare costs. Studies that included the following types of outcomes were included: health; quality of care; utilisation, coverage and access; resource use and costs; equity; and adverse outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, assessed the risk of bias in each included study, and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled. We were unable to undertake a meta-analysis for comparisons and outcomes, so we used a structured synthesis approach.

MAIN RESULTS

We included four studies with a total of 912 CMC as participants. All included studies were randomised controlled trials conducted in hospitals in the USA or Canada. Participants varied across the included studies; however, all four studies included children with complex and chronic illness and high healthcare needs. While the primary aim of the intervention was similar across all four studies, the components of the interventions differed: in the four studies, the intervention involved some element of care coordination; in two of the studies, it involved the child receiving care from a multidisciplinary team, while in one study, the intervention was primarily centred on access to an advanced practice nurse care coordinator and another study involved nurse a practitioner-paediatrician dyad partnering with families. The risk of bias in the four studies varied across domains, with issues primarily relating to the lack of blinding of participants, personnel, and outcome assessors, inadequate allocation concealment, and incomplete outcome data. Comprehensive care for CMC compared to usual care may make little to no difference to child health, functioning, and quality of life at 12 or 24 months (three studies with 404 participants) and we assessed the evidence for the outcomes in this category (child health-related quality of life and functional status) as being of low certainty. For CMC, comprehensive care probably makes little or no difference to parent health, functioning, and quality of life compared to usual care at 12 months (one study with 117 participants) and we assessed the evidence for this outcome as being of moderate certainty. Comprehensive care for CMC compared to usual care may slightly improve child and family satisfaction with, and perceptions of, care and service delivery at 12 months (three studies with 453 participants); however, we assessed the evidence for these outcomes as being of low certainty. For CMC, comprehensive care probably makes little or no difference to the number of healthcare encounters (emergency department visits) and the number of hospitalised days (hospital admissions) compared to usual care at 12 months (three studies with 668 participants), and we assessed the evidence for these outcomes as being of moderate certainty. Three of the included studies (668 participants) reported cost outcomes and had conflicting results, with one study reporting significantly lower healthcare costs at 12 months in the intervention group compared to the control group, one reporting no differences between groups, and the other study reporting a greater increase in total healthcare costs in the intervention group compared to the control group. Overall, comprehensive care may make little or no difference to overall healthcare costs in CMC; however, the methods used to measure total healthcare costs varied across studies and the certainty of the evidence relating to this outcome is low. No studies assessed the costs to the family.

AUTHORS' CONCLUSIONS

The findings of this review should be treated with caution due to the limited amount and quality of the published research that was available to be included. Overall, the certainty of the evidence for the effectiveness of comprehensive care for CMC ranged from low to moderate across outcomes and there is currently insufficient evidence on which to draw strong conclusions. There is a need for more high-quality randomised trials with consistency of the target population and intervention components, methods of reporting outcomes, and follow-up periods, as well as full cost analyses, taking into account both costs to the family and costs to the healthcare system.

Impact of Comprehensive Primary Care in Patients With Complex Chronic Diseases: Nationwide Cohort Database Analysis in Korea

BACKGROUND

More comprehensive healthcare services should be provided to patients with complex chronic diseases to better manage their complex care needs. This study examined the effectiveness of comprehensive primary care in patients with complex chronic diseases.

METHODS

We obtained 2002-2019 data from the National Health Insurance Sample Cohort Database. Participants were individuals aged ≥ 30 years with at least two of the following diseases: hypertension, diabetes mellitus, and hyperlipidemia. Doctors' offices were classified into specialized, functional, and gray-zone based on patient composition and major diagnostic categories. The Cox proportional hazard model was used to examine the association between office type and hospital admission due to all-causes, severe cardiovascular or cerebrovascular diseases (CVDs), hypertension, diabetes mellitus, or hyperlipidemia.

RESULTS

The mean patient age was 60.3 years; 55.8% were females. Among the 24,906 patients, 12.8%, 38.3%, and 49.0% visited specialized, functional, and gray-zone offices, respectively. Patients visiting functional offices had a lower risk of all-cause admission (hazard ratio [HR], 0.935; 95% confidence interval [CI], 0.895-0.976) and CVD-related admission (HR, 0.908; 95% CI, 0.844-0.977) than those visiting specialized offices. However, the admission risks for hypertension, diabetes mellitus, and hyperlipidemia were not significantly different among office types.

CONCLUSION

This study provides evidence of the effectiveness of primary care in functional doctors' offices for patients with complex chronic diseases beyond a single chronic disease and suggests the need for policies to strengthen functional offices providing comprehensive care.

HIV Psychiatry: The Missing Link to HIV Prevention and Comprehensive Care

HIV psychiatry may be the missing link to HIV prevention and care. Although HIV has been transformed from a fatal illness to a chronic and manageable illness, morbidity and mortality from HIV and AIDS continue to persist despite advances in prevention and care. In the 42 years since the HIV pandemic began in 1981, >84 million people were infected with HIV and 40 million people with HIV have died. In 2021, 1.5 million were newly infected and as of 2022, >38 million people were living with HIV.

The role of the specialist nurse in comprehensive care for bleeding disorders in Europe: An integrative review

INTRODUCTION

Managing bleeding disorders (BDs) is complex, requiring a comprehensive approach coordinated by a multidisciplinary team (MDT). Haemophilia nurses (HNs) play a central role in the MDT, frequently coordinating care. As novel treatments bring change to the treatment landscape, ongoing education and development is key. However, understanding of the roles and tasks of HNs is lacking.

AIM

The EAHAD Nurses Committee sought to identify and describe the roles and tasks of the European HN.

METHODS

A five-step integrative review was undertaken, including problem identification, literature search, data evaluation, data synthesis and presentation. Relevant literature published from 2000 to 2022 was identified through database, hand and ancestry searching. Data were captured using extraction forms and thematically analysed.

RESULTS

Seven hundred and seventy-seven articles were identified; 43 were included. Five main roles were identified, with varied and overlapping associated tasks: Educator, Coordinator, Supporter, Treater and Researcher. Tasks related to education, coordination and support were most frequently described. Patient education was often 'nurse-led', though education and coordination roles concerned both patients and health care practitioners (HCPs), within and beyond the MDT. The HN coordinates care and facilitates communication. Long-term patient care relationships place HNs in a unique position to provide support. Guidelines for HN core competencies have been developed in some countries, but autonomy and practice vary.

CONCLUSION

As the treatment landscape changes, all five main HN roles will be impacted. Despite national variations, this review provides a baseline to anticipate educational needs to enable HNs to continue to fulfil their role.

Summary of evidence on comprehensive healthcare for chemotherapy-induced peripheral neuropathy in cancer patients

OBJECTIVE

This paper aims to provide an evidence-based summary of the most effective strategies for comprehensive healthcare of chemotherapy-induced peripheral neuropathy (CIPN) in cancer patients.

METHOD

Following the "6S" model, relevant evidence on CIPN management was collected from reputable evidence-based resource websites and databases nationally and internationally. The included articles were evaluated for methodological quality, and evidence was extracted using the Australian JBI Evidence-based Health Care Center's literature evaluation standard (2016 edition).

RESULTS

A total of 60 articles were included in this study, comprising 2 guidelines, 5 expert consensus statements, and 53 systematic reviews. The findings of these articles were summarized across 7 dimensions, including risk factor screening, assessment, diagnosis, prevention, treatment, management, and health education, resulting in the identification of 42 relevant pieces of evidence.

CONCLUSIONS

This study provides a comprehensive synthesis of evidence-based recommendations for managing CIPN in cancer patients, offering guidance for healthcare professionals engaged in clinical practice. However, when implementing these recommendations, it is crucial to consider the individual patient's clinical circumstances, preferences, and expert judgment, ensuring feasibility and applicability in real-world clinical settings.

Access to Mental Health and Substance Use Treatment in Comprehensive Primary Care Plus

Importance

To meet increasing demand for mental health and substance use services, the Centers for Medicare & Medicaid Services launched the 5-year Comprehensive Primary Care Plus (CPC+) demonstration in 2017, requiring primary care practices to integrate behavioral health services.

Objective

To examine the association of CPC+ with access to mental health and substance use treatment before and during the COVID-19 pandemic.

Design, Setting, and Participants

Using difference-in-differences analyses, this retrospective cohort study compared adults attributed to CPC+ and non-CPC+ practices, from January 1, 2018, to June 30, 2022. The study included adults aged 19 to 64 years who had depression, anxiety, or opioid use disorder (OUD) and were enrolled with a private health insurer in Pennsylvania. Data were analyzed from January to June 2023.

Exposure

Receipt of care at a practice participating in CPC+.

Main Outcomes and Measures

Total cost of care and the number of primary care visits for evaluation and management, community mental health center visits, psychiatric hospitalizations, substance use treatment visits (residential and nonresidential), and prescriptions filled for antidepressants, anxiolytics, buprenorphine, naltrexone, or methadone.

Results

The 188 770 individuals in the sample included 102 733 adults (mean [SD] age, 49.5 [5.6] years; 57 531 women [56.4%]) attributed to 152 CPC+ practices and 86 037 adults (mean [SD] age, 51.6 [6.6] years; 47 321 women [54.9%]) attributed to 317 non-CPC+ practices. Among patients diagnosed with OUD, compared with patients attributed to non-CPC+ practices, attribution to a CPC+ practice was associated with filling more prescriptions for buprenorphine (0.117 [95% CI, 0.037 to 0.196] prescriptions per patient per quarter) and anxiolytics (0.162 [95% CI, 0.005 to 0.319] prescriptions per patient per quarter). Among patients diagnosed with depression or anxiety, attribution to a CPC+ practice was associated with more prescriptions for buprenorphine (0.024 [95% CI, 0.006 to 0.041] prescriptions per patient per quarter).

Conclusions and Relevance

Findings of this cohort study suggest that individuals with an OUD who received care at a CPC+ practice filled more buprenorphine and anxiolytics prescriptions compared with patients who received care at a non-CPC+ practice. As the Centers for Medicare & Medicaid Innovation invests in advanced primary care demonstrations, it is critical to understand whether these models are associated with indicators of high-quality primary care.

Àgô Sankofa: an overview of the progression of sickle cell disease in Brazil in the past two decades

Sickle cell disease (SCD) is an emblematic case of historical health neglect in Brazil and reflects how institutional racism produces health inequalities. This article engaged in a historical journey of this disease, showing the delayed implementation of health policies for people with sickle cell disease, often concealed in Public Power's (in)actions and omissions. The lack of commitment to implement the recommendations of the Brazilian Ministry of Health, such as neonatal screening, and the difficulty in incorporating technologies for health care result from this modus operandi. The advances and setbacks in programmatic actions and the constant pressure on several governmental entities have characterized the reported saga in the last twenty years. The present text discusses the policies for people with SCD, appropriating the Sankofa symbol, meaning that building the present is only possible by remembering past mistakes. Thus, we recognize this trajectory and this historical moment in which there is a concrete possibility of moving forward and achieving the longed-for comprehensive care for people with SCD. There is an invitation to glance at a new perspective, one in which hope is the trigger for the movements needed to guarantee the rights of people with SCD.

A stepwise approach to the adult immunodeficiency evaluation for the rhinologist

PURPOSE OF REVIEW

Patients with an immunodeficiency may present to their Rhinologist with a history of recurrent, severe, and chronic infections. Therefore, it is essential for the Rhinologist to have a basic understanding of clinically relevant immune deficiencies.

RECENT FINDINGS

After describing different types of immunodeficiencies, their presentations, and management strategies, an evaluation algorithm is described.

SUMMARY

Through a collaborative approach, Rhinologists and Clinical Immunologists can provide comprehensive medical care to patients with immunodeficiencies.

[Sleep Strategies for Shift Work Nurses]

To meet the demands of a 24/7 society, shift work is necessary. Shift work is outside the traditional regular 9-to-5 work schedule, is characterized by irregular working hours, and exists in various industries. However, this abnormal working time can disrupt the natural day and night rhythm, and if poorly adjusted, it can lead to shift work sleep disorder (SWSD). SWSD is associated with multiple health risks, including impaired cognitive function, increased risk of accidents, and various metabolic and cardiovascular diseases. The frontline nurses typically work shifts to provide comprehensive patient care. This article aims to discuss sleep physiology, apply existing literature to discuss the impact on nurses resulting from shift work, and further offer strategies to regulate sleep to promote physical and mental health. These strategies range from organizational interventions (e.g., optimizing shift schedules) to individual interventions (e.g., lifestyle changes) and the use of chronobiological techniques (e.g., light therapy) to promote the adjustment of circadian rhythms, etc.

Healthcare provider perspectives on integrating a comprehensive spine care model in an academic health system: a cross-sectional survey

BACKGROUND

Healthcare systems (HCS) are challenged in adopting and sustaining comprehensive approaches to spine care that require coordination and collaboration among multiple service units. The integration of clinicians who provide first line, evidence-based, non-pharmacological therapies further complicates adoption of these care pathways. This cross-sectional study explored clinician perceptions about the integration of guideline-concordant care and optimal spine care workforce requirements within an academic HCS.

METHODS

Spine care clinicians from Duke University Health System (DUHS) completed a 26-item online survey via Qualtrics on barriers and facilitators to delivering guideline concordant care for low back pain patients. Data analysis included descriptive statistics and qualitative content analysis.

RESULTS

A total of 27 clinicians (57% response) responded to one or more items on the questionnaire, with 23 completing the majority of questions. Respondents reported that guidelines were implementable within DUHS, but no spine care guideline was used consistently across provider types. Guideline access and integration with electronic records were barriers to use. Respondents (81%) agreed most patients would benefit from non-pharmacological therapies such as physical therapy or chiropractic before receiving specialty referrals. Providers perceived spine patients expected diagnostic imaging (81%) and medication (70%) over non-pharmacological therapies. Providers agreed that receiving imaging (63%) and opioids (59%) benchmarks could be helpful but might not change their ordering practice, even if nudged by best practice advisories. Participants felt that an optimal spine care workforce would require more chiropractors and primary care providers and fewer neurosurgeons and orthopedists. In qualitative responses, respondents emphasized the following barriers to guideline-concordant care implementation: patient expectations, provider confidence with referral pathways, timely access, and the appropriate role of spine surgery.

CONCLUSIONS

Spine care clinicians had positive support for current tenets of guideline-concordant spine care for low back pain patients. However, significant barriers to implementation were identified, including mixed opinions about integration of non-pharmacological therapies, referral pathways, and best practices for imaging and opioid use.

Models of Care in Providing Comprehensive Healthcare on Cancer Survivors: A Scoping Review with a TIDieR Checklist Analysis

BACKGROUND

The study's aim is to identify the models of care used to provide survivorship care plans (SCPs) to cancer survivors in healthcare services, describing what kind of professionals are involved, in which settings and timings, and their feasibility.

METHODS

The Joanna Briggs Institute methodology for scoping reviews is followed. Studies that considered the SCPs applying different models of care, in any healthcare setting on any adult cancer survivors who completed oncological treatments, have been included. Pubmed, Embase, Cochrane Library, Scopus, and Cinahal were searched from 2013 to 2023 with these keywords: "Survivorship Care Plan", "Oncology", and "Program". The study selection process was reported with the PRISMA-ScR. A total of 325 records were identified, 42 were screened, and, ultimately, 23 articles were included.

RESULTS

The models of care include: SCP standardization in hospitals; self-support oriented; consultation-based; primary or specialist direct referral; shared care; a multimodal approach. Multidisciplinary teams were involved in the SCP models of care. The settings were private clinics or cancer centers. One-hour SCP interventions were most frequently delivered through in-person visits, by telephone, or online.

CONCLUSIONS

Implementing SCPs is feasible in healthcare contexts, but with challenges, like time and resource management. Patient-centered programs promoting coordinated care are promising models of care.

Standard of Care for Psychological Assessment of Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

Comprehensive care prior to allogeneic hematopoietic stem cell transplantation (alloHSCT) can improve patient outcomes, yet psychological assessment prior to transplantation has been overlooked as a standard of care.

OBJECTIVES

This review summarizes the evidence on psychological assessment for patients undergoing alloHSCT and explores the impact of psychological distress and/or psychological disorders on clinical outcomes and overall survival.

METHODS

A literature search was conducted using PubMed®, CINAHL®, Embase®, and PsycINFO® for studies focused on psychological screening of patients in the alloHSCT population.

FINDINGS

alloHSCT is associated with patient psychological distress and disorders, which can result in negative outcomes such as poorer quality of life and overall survival. Future studies implementing a validated instrument for psychological assessment may allow for early identification of vulnerable patients undergoing alloHSCT and interventions, which may improve overall outcomes.

Evaluation of the Impact of Oral Health on the Daily Activities of Users of the National Health System

BACKGROUND

the integration of dentistry services in the Unified Health System in Brazil (SUS) is essential in primary care assistance.

OBJECTIVE

we aimed to develop a tool for improving demand flowby evaluating the impact of oral health on the daily activities of users of the Family Health Unitusing the Oral Impacts of Daily Performance (OIDP)tool.

METHODS

In Barretos, Brazil, a cross-sectional study was conducted at a Family Health Unit (FHU)including patients over 12 years old. Oral health impact was assessed using the Oral Impacts of Daily Performance (OIDP) tool, and family risk was measured with the Coelho-Savassi scale.

RESULTS

430 participants, including 411 adults and 19 young people, were recruited. Of the adults, 31% had an average OIDP score of 16.61. For young people, 53% reported an impact (average OIDP score: 28.61). Family risk (R1) was prevalent in 57.9% of young people and 53.3% of adults. Among adults, different activities were affected by risk: smiling without embarrassment (risk level 2), enjoying contact with people (risk level 3), and performing one's job or social role (risk level 1). Emotional state (R3) had the lowest OIDP score (p = 0.029).

CONCLUSION

implementation of the OIDP scale in clinical practice enhances healthcare planning and ensures better-quality and equitable services, thus emphasizing comprehensive oral healthcare within the SUS.

The Comprehensive Primary Care Plus Model and Health Care Spending, Service Use, and Quality

Importance

Implemented in 18 regions, Comprehensive Primary Care Plus (CPC+) was the largest US primary care delivery model ever tested. Understanding its association with health outcomes is critical in designing future transformation models.

Objective

To test whether CPC+ was associated with lower health care spending and utilization and improved quality of care.

Design, Setting, and Participants

Difference-in-differences regression models compared changes in outcomes between the year before CPC+ and 5 intervention years for Medicare fee-for-service beneficiaries attributed to CPC+ and comparison practices. Participants included 1373 track 1 (1 549 585 beneficiaries) and 1515 track 2 (5 347 499 beneficiaries) primary care practices that applied to start CPC+ in 2017 and met minimum care delivery and other eligibility requirements. Comparison groups included 5243 track 1 (5 347 499 beneficiaries) and 3783 track 2 (4 507 499 beneficiaries) practices, matched, and weighted to have similar beneficiary-, practice-, and market-level characteristics as CPC+ practices.

Interventions

Two-track design involving enhanced (higher for track 2) and alternative payments (track 2 only), care delivery requirements (greater for track 2), data feedback, learning, and health information technology support.

Main Outcomes and Measures

The prespecified primary outcome was annualized Medicare Part A and B expenditures per beneficiary per month (PBPM). Secondary outcomes included expenditure categories, utilization (eg, hospitalizations), and claims-based quality-of-care process and outcome measures (eg, recommended tests for patients with diabetes and unplanned readmissions).

Results

Among the CPC+ patients, 5% were Black, 3% were Hispanic, 87% were White, and 5% were of other races (including Asian/Other Pacific Islander and American Indian); 85% of CPC+ patients were older than 65 years and 58% were female. CPC+ was associated with no discernible changes in the total expenditures (track 1: $1.1 PBPM [90% CI, -$4.3 to $6.6], P = .74; track 2: $1.3 [90% CI, -$5 to $7.7], P = .73), and with increases in expenditures including enhanced payments (track 1: $13 [90% CI, $7 to $18], P < .001; track 2: $24 [90% CI, $18 to $31], P < .001). Among secondary outcomes, CPC+ was associated with decreases in emergency department visits starting in year 1, and in acute hospitalizations and acute inpatient expenditures in later years. Associations were more favorable for practices also participating in the Medicare Shared Savings Program and independent practices. CPC+ was not associated with meaningful changes in claims-based quality-of-care measures.

Conclusions and Relevance

Although the timing of the associations of CPC+ with reduced utilization and acute inpatient expenditures was consistent with the theory of change and early focus on episodic care management of CPC+, CPC+ was not associated with a reduction in total expenditures over 5 years. Positive interaction between CPC+ and the Shared Savings Program suggests transformation models might be more successful when provider cost-reduction incentives are aligned across specialties. Further adaptations and testing of primary care transformation models, as well as consideration of the larger context in which they operate, are needed.

General practice staff and patient experiences of a multicomponent intervention for people at high risk of poor health outcomes: a qualitative study

BACKGROUND

This study reports the experiences of general practice staff and patients at high risk of poor health outcomes who took part in a clustered randomised controlled trial of a multicomponent general practice intervention. The intervention comprised patient enrolment to a preferred General Practitioner (GP) to promote continuity of care, access to longer GP appointments, and timely general practice follow-up after hospital care episodes. The aims of the study were to better understand participant's (practice staff and patients) perspectives of the intervention, their views on whether the intervention had improved general practice services, reduced hospital admissions and finally whether they believed the intervention would be sustainable after the trial had completed.

METHODS

A qualitative study design with semi-structured interviews was employed. The practice staff sample was drawn from both the control and intervention groups. The patient sample was drawn from those who had expressed an interest in taking part in an interview during the trial and who had also experienced a recent hospital care episode.

RESULTS

Interviews were conducted with 41 practice staff and 45 patients. Practice staff and patients expressed support for the value of appointments with a regular GP and having sufficient time in appointments for the provision of comprehensive care. There were mixed views with respect to the extent to which the intervention had improved services. The positive changes reported were related to services being provided in a more proactive, thorough, and systematic manner with a greater emphasis on team based care involving the Practice Nurse. Patients nominated after hours care and financial considerations as the key reasons for seeking hospital care. Practice staff noted that the intervention would be difficult to sustain financially in the absence of additional funding.

CONCLUSIONS

The multicomponent intervention was supported by practice staff and patients and some patients perceived that it had led to improvements in care.

Nursing care for the Warao people: an experience report based on transcultural theory

OBJECTIVE

To report on the experience of nurses from the Street Clinic in caring for the Indigenous Venezuelan population of the Warao ethnic group in Maceió/AL based on Madeleine Leininger's Transcultural Theory.

METODOLOGY

A descriptive study, of the experience report type, based on the care of the Warao Indigenous population in the light of Madeleine Leininger's Transcultural Theory, carried out during the year 2022.

RESULTS

Light technologies were used to form bonds and understand the cultural universe of the Warao people. The concepts of preservation, accommodation and cultural restructuring of care from Leininger's transcultural theory helped to elucidate the practice. Comprehensive care was offered in accordance with the programs recommended by the Ministry of Health, with transcultural care, including respect for refusal of care. The language barrier and health beliefs represented challenges in the context of singular care.

FINAL CONSIDERATIONS

The experience of nurses from the Street Clinic in caring for the Indigenous population favored significant social interaction and expanded the possibilities for achieving comprehensive health care. The application of Transcultural Theory proved to be an effective and congruent device for health care.

Clinical evaluation of targeted sedation nursing combined with comprehensive nursing in children with severe pneumonia

The severity of severe pneumonia in children depends on the degree of local inflammation, spread of lung inflammation and systemic inflammatory response. Appropriate care can effectively reduce the mortality of children with severe pneumonia. This study was designed to explore the nursing effect of targeted sedation nursing and comprehensive nursing intervention in children with severe pneumonia. Eighty children with severe pneumonia who complained of the main complaint were selected, and they were evenly distributed to receive comprehensive care (control group) and targeted sedation care and comprehensive care (observation group). In each group, different degrees of sedation, pain scores, and changes in adverse reactions were evaluated. Before nursing, the sedation and pain scores of the 2 groups of children were not statistically significant; after nursing, the sedation and pain scores of the 2 groups of children improved with time, and the sedation effect of the observation group was significantly lower than that of the control. In the group, the pain score was lower than that of the control group, indicating improvement. The SAS and SDS of the observation group were lower than those of the control group, while the social support score was significantly higher than that of the control group. The difference was statistically significant (P < .05). The accidental extubation, delirium, respiratory depression, and laryngospasm of the 2 groups of children were significantly improved, and the observation group was significantly less than the control group. This difference was statistically significant (P < .05). Targeted sedation nursing and comprehensive nursing intervention can effectively reduce the incidence of adverse reactions in children with severe pneumonia, reduce the pain and discomfort of children with severe pneumonia, and significantly improve the degree of sedation, which has certain reference value for the care of children with severe pneumonia.

Characteristics and counseling strategies for physical activity used by primary health care professionals

This study aim to describe the characteristics and strategies of counseling for physical activity used by Primary Health Care (PHC) professionals. A survey was carried out with 587 (85.4% women) health professionals who work in PHC in Florianopolis, in the state of Santa Catarina, southern Brazil. Counseling carried out in the last 12 months was considered. Operational aspects related to counseling practices and strategies used for counseling were evaluated. The frequency of physical activity guidance was 86.2% (95%CI = 83.2-88.8%). Counseling was characterized as a brief practice, carried out in individual consultations, aimed at adults and the older adults and people with morbidities. The most used strategy was to guide users to participate in physical activity groups at the Health Center (89.5%) and in relation to the 5As method, giving some "advice" was the most used strategy (99.0%) and the least used. used was to follow strategies (22.6%). Counseling for physical activity has been based on a brief practice, carried out in individual consultations and focused on people with morbidities and on adults and the elderly. The strategies used do not seem to cover the full care of the advised users.

Incorporating health IT into primary care transformation

OBJECTIVES

To understand the role of health information technology (IT) vendors and health IT functionality in supporting advanced primary care.

STUDY DESIGN

We synthesized multiple rounds of surveys and interviews (2017-2022) from a mixed-methods evaluation of Comprehensive Primary Care Plus (CPC+), a multipayer model developed by CMS. CPC+ was the first federal advanced primary care reform effort that formalized health IT vendors' roles in supporting health IT implementation and specified detailed health IT requirements for practices.

METHODS

We conducted content analysis to identify cross-cutting themes related to health IT for both practices and vendors, comparing similarities and differences across participants and (when possible) over time.

RESULTS

Vendors and practices reported advances in registries and dashboards for improved information management within the practice as well as strengthened relationships between vendors and practices that supported health IT implementation. However, CPC+ practices noted several gaps or challenges using existing functionalities, and both vendors and practices reported broader challenges for more transformative health IT change, particularly the lack of interoperable health information exchange needed to support care management and care coordination. Key factors constraining vendors' investment in further advances included long product development schedules, making it difficult to respond to rapidly evolving model requirements. Vendors also shared that CPC+ practices represented a small fraction of their client base, so investing in developing new functionality was not strategic unless it was more broadly relevant outside CPC+.

CONCLUSIONS

Continued collaboration among health IT vendors, practices, policy makers, and payers could support continued technological improvements, particularly related to information exchange and communication. Aligning requirements more closely with other federal and private models could also help mitigate the risk for vendors.

Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada

OBJECTIVES

Population ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce's capacity to absorb these patients.

DESIGN

A serial cross-sectional population-based analysis using health administrative data.

SETTING

Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance.

PARTICIPANTS

All insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054).

OUTCOME MEASURES

The number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time.

SECONDARY OUTCOME MEASURES

The characteristics of patients and their early-career and mid-career comprehensive FPs.

RESULTS

Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients.

CONCLUSIONS

The primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.

Participation in a Medicare advanced primary care model and the delivery of high-value services

OBJECTIVE

To evaluate whether primary care providers' participation in the Comprehensive Primary Care Plus Initiative (CPC+) was associated with changes in their delivery of high-value services.

DATA SOURCES

Medicare Physician & Other Practitioners public use files from 2013 to 2019, 2017 to 2019 Medicare Part B claims for a 5% random sample of Medicare Fee-for-Service (FFS) beneficiaries, the Area Health Resources File, the National Plan & Provider Enumeration System files, and public use datasets from the Centers for Medicare & Medicaid Services Physician Compare.

STUDY DESIGN

We used a difference-in-difference approach with a propensity score-matched comparison group to estimate the association of CPC+ participation with the delivery of annual wellness visits (AWVs), advance care planning (ACP), flu shots, counseling to prevent tobacco use, and depression screening. These services are prominent examples of high-value services, providing benefits to patients at a reasonable cost. We examined both the likelihood of delivering these services within a year and the count of services delivered per 1000 Medicare FFS beneficiaries per year.

DATA COLLECTION/EXTRACTION METHODS

Secondary data are linked at the provider level.

PRINCIPAL FINDINGS

We find that CPC+ participation was associated with increases in the likelihood of delivering AWVs (13.03 percentage points by CPC+'s third year, p < 0.001) and the number of AWVs per 1000 Medicare FFS beneficiaries (44 more AWVs by CPC+'s third year, p < 0.001). We also find that CPC+ participation was associated with more flu shots per 1000 beneficiaries (52 more shots by CPC+'s third year, p < 0.001) but not with the likelihood of delivering flu shots. We did not find consistent evidence for the association between CPC+ participation and ACP services, counseling to prevent tobacco use, or depression screening.

CONCLUSIONS

CPC+ participation was associated with increases in the delivery of AWVs and flu shots, but not other high-value services.

Racial-Ethnic Composition of Primary Care Practices and Comprehensive Primary Care Plus Initiative Participation

BACKGROUND

It remains unclear whether the racial-ethnic composition or the socioeconomic profiles of eligible primary care practices better explain practice participation in the Centers for Medicare and Medicaid Services' (CMS) Comprehensive Primary Care Plus (CPC+) program.

OBJECTIVE

To examine whether practices serving high proportions of Black or Latino Medicare fee-for-service (FFS) beneficiaries were less likely to participate in CPC+ in 2021 compared to practices serving lower proportions of these populations.

DESIGN

2019 IQVIA OneKey data on practice characteristics was linked with 2018 CMS claims data and 2021 CMS CPC+ participation data. Medicare FFS beneficiaries were attributed to practices using CMS's primary care attribution method.

PARTICIPANTS

11,718 primary care practices and 7,264,812 attributed Medicare FFS beneficiaries across 18 eligible regions.

METHODS

Multivariable logistic regression models examined whether eligible practices with relatively high shares of Black or Latino Medicare FFS beneficiaries were less likely to participate in CPC+ in 2021, controlling for the clinical and socioeconomic profiles of practices.

MAIN MEASURES

Proportion of Medicare FFS beneficiaries attributed to each practice that are (1) Latino and (2) Black.

KEY RESULTS

Of the eligible practices, 26.9% were CPC+ participants. In adjusted analyses, practices with relatively high shares of Black (adjusted odds ratio, aOR = 0.62, p < 0.05) and Latino (aOR = 0.32, p < 0.01) beneficiaries were less likely to participate in CPC+ compared to practices with lower shares of these beneficiary groups. State differences in CPC+ participation rates partially explained participation disparities for practices with relatively high shares of Black beneficiaries, but did not explain participation disparities for practices with relatively high shares of Latino beneficiaries.

CONCLUSIONS

The racial-ethnic composition of eligible primary care practices is more strongly associated with CPC+ participation than census tract-level poverty. Practice eligibility requirements for CMS-sponsored initiatives should be reconsidered so that Black and Latino beneficiaries are not left out of the benefits of practice transformation.