Task shifting in primary care to tackle healthcare worker shortages: An umbrella review

Task shifting from general practitioners to other health professionals in out-of-hours primary care - a systematic literature review on content and quality of task shifting

BACKGROUND

Task shifting from general practitioners (GPs) to other health professionals could solve the increased workload, but an overview of the evidence is lacking for out-of-hours primary care (OOH-PC).

OBJECTIVES

To evaluate the content and quality of task shifting from GPs to other health professionals in clinic consultations and home visits in OOH-PC.

METHODS

Four database literature searches were performed on 13 December 2021, and updated in August 2023. We included articles that studied content (patient characteristics, reason for encounter) and/or quality (patient satisfaction, safety, efficiency) of task shifting in face-to-face contacts at OOH-PC. Two authors independently screened articles for inclusion and assessed the methodological quality of included articles using the JBI critical appraisal checklist. Data was extracted and results were synthesised in a narrative summary.

RESULTS

The search identified 1,829 articles, resulting in the final inclusion of seven articles conducted in the UK or the Netherlands. Studies compared GPs with other health professionals (mainly nurses). These other health professionals saw patients with less urgent health problems, younger patients, and patients with less complex health problems than GPs. Most studies concluded that other health professionals provided safe and vastly efficient care corresponding to the level of GPs but findings about productivity were inconclusive.

CONCLUSION

The level of safety and efficiency of care provided by other health professionals in OOH-PC seems like that of GPs, although they mainly see patients presenting with less urgent and less complex health problems.

Assessing metabolic risk factors for psychiatric patients: An IT-supported task shift from physician to pharmacist

BACKGROUND

Psychiatric medication can have adverse effects such as weight gain, which is a metabolic risk factor for the development of cardiovascular disease and diabetes. This study aimed to assess whether an IT-supported task shift from physicians to pharmacists could improve clinical guideline compliance in assessing metabolic risk factors for psychiatric patients.

METHOD

An IT tool was designed and implemented in the electronic health record to enable pharmacists to efficiently screen patients for metabolic risk factors. The tool provided a risk score for each patient based on criteria from the cross-regional guideline. All admitted patients with a score were assessed by the pharmacists, who referred and discussed the patients with a physician when deemed relevant. We measured guideline compliance during baseline (manual screening) and intervention (automated screening) after implementing the IT tool and pharmacist assessment. After the intervention period, we conducted follow-up interviews with all participating pharmacists.

RESULTS

Guideline compliance increased significantly from 26 % (baseline) to 63 % (intervention) (Fisher's exact test p < .001, N = 98). The task shift from physicians to pharmacists was also significant (Fisher's exact test, p < .001, N = 40). Interviews revealed that the pharmacists found the task shift meaningful and received positive feedback from the physicians. The facilitators of the task shift included interprofessional collaboration, physician shortage, provider empowerment, and the manageable nature of the task. The barriers included a need for further competence development and lack of pharmacist authorization. The IT tool was considered useful and suggestions for improvements emerged.

CONCLUSION

The IT-supported task shift from physician to pharmacist significantly improved guideline compliance in the assessment of metabolic risk factors in psychiatric patients. The findings support increasing the pharmacist's role in psychiatric care to improve patient outcomes.

A Goffmanian analysis of impact of unclear professional identity and role negotiation of pharmacists in primary care: A multiple case study

BACKGROUND

Professional identity and its development is a focus of research, education, and practice. But, there is a lack of how professional identity impacts changes in pharmacists' roles in practice, which are particularly prevalent in primary care teams.

OBJECTIVES

This research uses Goffmanian theory, micro-sociologic interactional theory, to describe the outcomes of role negotiation in integrated primary care teams.

METHODS

This is a multiple case study done per Yin, which used interviews and documents to collect data. Interviews used a storytelling format to gather information on the pharmacist's role and negotiation with their team. Four to six interviews were done in each case. Data was analyzed in an iterative manner using the Qualitative approach by Leuven including narrative reports being created for each case.

RESULTS

Five cases were recruited but three cases were completed. In each case, the pharmacist was passive in role negotiation and allowed other actors to decide what tasks were of value. Likely this passivity was due to their professional identities: supportive and "not a physician". These identities led to a focus on the pharmacists' need to develop. This multi-case study demonstrated that pharmacists' professional identity led to passivity being valued and expected. Whether pharmacists self-limited, which has been previously seen, needs to be better defined. But unclear archetypes reduced tasks identified as unique to the pharmacist.

CONCLUSION

Goffmanian theory highlighted a key success for future pharmacist role negotiation, a clear professional identity by both pharmacists and society, including team members. Until that occurs, there is a risk of underuse in primary care team settings.

Potential for pharmacist prescribing in primary care: A Dutch citizen perspective

Background

Medication prescribing by pharmacists is a task shifting approach to help ensure quality and accessibility of healthcare. In many countries, like the Netherlands, pharmacist prescribing is not legally ensured, and it is unknown what citizens think of its potential introduction.

Objective

To investigate citizen perspectives on the potential role of pharmacists in prescribing in primary care.

Methods

A Citizen Platform with citizens (>18 years) from the Netherlands was conducted in October 2022. This consisted of a one-day program in which the participants were engaged in interactive assignments and received expert presentations to foster the development of informed opinions. In the final assignment, 3 participant groups designed their ideal future scenario including preconditions regarding the role of the pharmacist in prescribing in primary care. All assignments were recorded, and notes were taken. The researchers then consolidated the 3 scenarios into one version and categorized the preconditions. The Citizen Platform results were summarized and subsequently discussed in 2 online focus groups with other citizens in February 2023 to investigate the perspectives of less informed citizens. Focus group discussions were audio-recorded, transcribed, and thematically analyzed.

Results

The Citizen Platform (n = 10) resulted in a shared scenario involving a primary care center where general practitioners (GPs) pharmacists and other healthcare professionals collaborate as a team. In this scenario, pharmacists can modify treatment in certain chronic diseases, manage minor ailments and support GPs with the care for patients with complex needs. Preconditions needed to realize this scenario include having shared medical records, the GP retaining the overview of the care for the patient and additional training for pharmacists. The focus groups (n = 6, in total) yielded 5 themes which acknowledge potential pharmacist prescribing but depict a more skeptical view towards pharmacist prescribing and include several concerns, for example pharmacists' potential conflict of interest.

Conclusions

Citizens that are informed about opportunities for pharmacy prescribing are capable of sketching potential scenarios for pharmacist prescribing in a collaborative primary care context. Less informed citizens seem more skeptical towards pharmacist prescribing.

Capacity building and community of practice for women community health workers in low-resource settings: long-term evaluation of the Mobile University For Health (MUH)

Background

Lebanon has been facing a series of crises, significantly increasing health challenges, and straining its healthcare infrastructure. This caused deficiencies in the system's ability to attend to population health needs, and it profoundly impacted vulnerable and refugee communities who face additional challenges accessing healthcare services. In response, the Global Health Institute at the American University of Beirut designed and implemented the Mobile University for Health (MUH), which promotes task-shifting through capacity building complemented by communities of practice (CoP). The program aimed to prepare vulnerable women to assume the role of community health workers (CHW) within their communities, and to promote positive health knowledge and behaviours.

Methods

A mixed-methods approach was used to evaluate MUHs' three certificates (women's health, mental health and psychosocial support, and non-communicable diseases). Implementation took place between 2019 and 2022, with 83 CHWs graduating from the program. Short-term data including knowledge assessments, course evaluations, and community member feedback surveys were collected. 93 semi-structured interviews with CHWs and 14 focus group discussions with community members were conducted to evaluate the long-term impact of the capacity building and CoP components.

Results

Data revealed multiple strengths of the initiative, including increased access to education for the community, effectiveness of blended learning modality, successful planning and delivery of CoP sessions, and improved knowledge, skills, and health behaviours over time. The supplementary CoP sessions fostered trust in CHWs, increased community empowerment, and increased leadership skills among CHWs. However, some challenges persisted, including limited access to healthcare services, implementation logistical issues, difficulties with some aspects of the learning modality, and some resistance within the communities.

Conclusion

MUH promoted and improved positive health knowledge and behaviours within targeted vulnerable populations in Lebanon. The supplementary CoP component proved instrumental in empowering CHWs and enhancing their impact within their communities. The study highlights the need for ongoing training and support for CHWs and underscores the importance of continued investment and adaptation of such initiatives through a gendered lens. This evaluation provides evidence on the successes of a capacity building model that has strong potential for scale and replication across health topics in conflict-affected contexts.

Trends in the mobility of primary healthcare human resources in underdeveloped regions of western China from 2000 to 2021: Evidence from Nanning

OBJECTIVE

This research aimed to identify the fundamental and geographic characteristics of the primary healthcare personnel mobility in Nanning from 2000 to 2021 and clarify the determinants that affect their transition to non-primary healthcare institutions.

METHODS

Through utilizing the Primary Healthcare Personnel Database (PHPD) for 2000-2021, the study conducts descriptive statistical analysis on demographic, economic, and professional aspects of healthcare personnel mobility across healthcare reform phases. Geographic Information Systems (QGIS) were used to map mobility patterns, and R software was employed to calculate spatial autocorrelation (Moran's I). Logistic regression identified factors that influenced the transition to non-primary institutions.

RESULTS

Primary healthcare personnel mobility is divided into four phases: initial (2000-2008), turning point (2009-2011), rapid development (2012-2020), and decline (2021). The rapid development stage saw increased mobility with no spatial clustering in inflow and outflow. From 2016 to 2020, primary healthcare worker mobility reached its peak, in which the most significant movement occurred between township health centers and other institutions. Aside from their transition to primary medical institutions, the primary movement of grassroots health personnel predominantly directs towards secondary general hospitals, tertiary general hospitals, and secondary specialized hospitals. Since 2012, the number and mobility distance of primary healthcare workers have become noticeably larger and remained at a higher level from 2016 to 2020. The main migration of primary healthcare personnel occurred in their districts (counties). Key transition factors include gender, education, ethnicity, professional category, general practice registration, and administrative division.

CONCLUSIONS

This study provides evidence of the features of primary healthcare personnel mobility in the less developed western regions of China, in which Nanning was taken as a case study. It uncovers the factors that impact the flow of primary healthcare personnel to non-primary healthcare institutions. These findings are helpful to policy refinement and support the retention of primary healthcare workers.

The accessibility of pharmacist prescribing and impacts on medicines access: A systematic review

BACKGROUND

Pharmacist prescribing has been introduced in several countries as a strategy to improve access to health care and medicines. However, the direct impacts of pharmacist prescribing on medicines access, and the overall accessibility of pharmacist prescribing services, are not well known.

OBJECTIVES

This systematic review aimed to assess the direct impacts of pharmacist prescribing on medicines access, and the accessibility of pharmacist prescribing services, in community and primary care settings.

METHODS

PubMed, Embase, and CINAHL were searched for studies published in English between 01 January 2003 to 15 June 2023. Both quantitative and qualitative primary studies were included if they described pharmacist prescribing in a primary care setting. Outcomes included findings related to access to medicines as a result of pharmacist prescribing (primary outcome), and access to pharmacist prescribing services overall (secondary outcome). Narrative synthesis of outcomes was undertaken.

RESULTS

A total of 47 studies were included from four countries (United States, United Kingdom, Canada, New Zealand). Thirteen studies provided evidence that pharmacist prescribing may improve medicines access in several ways, including: increasing the proportion of eligible people receiving medicines, increasing the number of overall dispensed prescriptions, or reducing time to receipt of treatment. The remainder of the included studies reported on the accessibility of pharmacist prescribing services. Published studies highlight that pharmacist prescribers practicing in community settings are generally accessible, with pharmacist prescribers viewed by patients as easy and convenient to consult. There was limited evidence about the affordability of pharmacy prescribing services, and a number of potential equity issues were observed, including reduced access to pharmacist prescribers in more socioeconomically disadvantaged areas and those with greater proportions of populations at risk of health inequities, such as culturally and linguistically diverse communities.

CONCLUSIONS

This systematic review found that pharmacist prescribing services were both highly accessible and beneficial in improving access to medicines. However, measures of medicines access varied, and few studies included direct measures of medicines access as an outcome of pharmacist prescribing, highlighting a need for future studies to incorporate direct measures of medicines access when assessing the impact of pharmacist prescribing services.

The process of nurses' role negotiation in general practice: A grounded theory study

AIM

To explain the process by which nurses' roles are negotiated in general practice.

BACKGROUND

Primary care nurses do important work within a social model of health to meet the needs of the populations they serve. Latterly, in the face of increased demand and workforce shortages, they are also taking on more medical responsibilities through task-shifting. Despite the increased complexity of their professional role, little is known about the processes by which it is negotiated.

DESIGN

Constructivist grounded theory.

METHODS

Semi-structured interviews were conducted with 22 participants from 17 New Zealand general practices between December 2020 and January 2022. Due to COVID-19, 11 interviews were via Zoom™. Concurrent data generation and analysis, using the constant comparative method and common grounded theory methods, identified the participants' main concern and led to the construction of a substantive explanatory theory around a core category.

RESULTS

The substantive explanatory theory of creating place proposes that the negotiation of nurse roles within New Zealand general practice is a three-stage process involving occupying space, positioning to do differently and leveraging opportunity. Nurses and others act and interact in these stages, in accordance with their conceptualizations of need-responsive nursing practice, towards the outcome defining place. Defining place conceptualizes an accommodation between the values beliefs and expectations of individuals and pre-existing organizational norms, in which individual and group-normative concepts of need-responsive nursing practice are themselves developed.

CONCLUSION

The theory of creating place provides new insights into the process of nurses' role negotiation in general practice. Findings support strategies to enable nurses, employers and health system managers to better negotiate professional roles to meet the needs of the populations they serve, while making optimum use of nursing skills and competencies.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Findings can inform nurses to better negotiate the complexities of the primary care environment, balancing systemic exigencies with the health needs of populations.

IMPACT

What Problem Did the Study Address? In the face of health inequity, general practice nurses in New Zealand, as elsewhere, are key to meeting complex primary health needs. There is an evidence gap regarding the processes by which nurses' roles are negotiated within provider organizations. A deeper understanding of such processes may enable better use of nursing skills to address unmet health need. What Were the Main Findings? Nurses' roles in New Zealand general practice are determined through goal-driven negotiation in accordance with individual concepts of need-responsive nursing practice. Individuals progress from occupying workspaces defined by the care-philosophies of others to defining workplaces that incorporate their own professional beliefs, values and expectations. Negotiation is conditional upon access to role models, scheduled dialogue with mentors and decision-makers, and support for safe practice. Strong clinical and organizational governance and individuals' own positive personal self-efficacy are enablers of effective negotiation. Where and on Whom Will the Research Have Impact? The theory of Creating Space can inform organizational and individual efforts to advance the roles of general practice nurses to meet the health needs of their communities. General practice organizations can provide safe, supported environments for effective negotiation; primary care leaders can promote strong governance and develop individuals' sense of self-efficacy by involving them in key decisions. Nurses themselves can use the theory as a framework to support critical reflection on how to engage in active negotiation of their professional roles.

REPORTING METHOD

The authors adhered to relevant EQUATOR guidelines using the COREQ reporting method.

PATIENT OR PUBLIC CONTRIBUTION

Researchers and participants currently working in general practice were involved in the development of this study. By the process of theoretical sampling and constant comparison, participants' comments helped to shape the study design. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: An understanding of the processes by which health professionals negotiate their roles is important to support them to meet the challenges of increased complexity across all health sectors globally.

Experiences and attitudes of task-shifting and task-sharing of physicians, nurses, and nursing assistants in hospitals: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore the experiences and attitudes of physicians, nurses, and nursing assistants regarding task-shifting and task-sharing in hospitals.

INTRODUCTION

Despite multiple health care professionals performing overlapping tasks, the need for effective task-shifting and task-sharing remains a concern. Understanding task-shifting and task-sharing experiences, as well as the attitudes of health care providers in hospitals, is essential for providing safe and patient-appropriate care with limited human resources.

INCLUSION CRITERIA

Qualitative studies that examine the experiences and attitudes of physicians, nurses, and nursing assistants in hospitals regarding task-shifting and task-sharing will be included. The review will include physicians, advanced practice nurses who are nurse practitioners or clinical nurse specialists, registered nurses, and nursing assistants. Midwives, pharmacists, occupational therapists, physical therapists, and students will be excluded.

METHODS

PubMed, MEDLINE, CINAHL, PsycINFO, Cochrane Database, and Web of Science will be searched as part of a 3-step search strategy. We will search for unpublished research and gray literature using Google Scholar and ProQuest Dissertations and Theses. Studies published in English or Japanese from the time each database was established to the present will be considered for inclusion. The methodological quality of all studies will be evaluated by screening against the inclusion criteria and by at least 2 critical evaluations using the standardized JBI checklist. Synthesized results will be pooled by meta-aggregation and published as a ConQual Summary of Findings.

REVIEW REGISTRATION

PROSPERO CRD42023409612.

HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

PURPOSE OF REVIEW

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

RECENT FINDINGS

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

Estimation of the lost productivity to the GDP and the national cost of correcting visual impairment from refractive error in Kenya

BACKGROUND

In developing countries such as Kenya, minimal attention has been directed towards population based studies on uncorrected refractive error (URE). However, the absence of population based studies, warrants utilization of other avenues to showcase to the stakeholders in eye health the worth of addressing URE. Hence this study estimated the lost productivity to the Gross Domestic Product (GDP) as a result of URE and the national cost required to address visual impairment from URE in Kenya.

METHODS

The lost productivity to the GDP for the population aged 16-60 years was calculated. Thereafter the productivity loss of the caregivers of severe visual impaired individuals was computed as a product of the average annual productivity for each caregiver and a 5% productivity loss due to visual impairment. The productivity benefit of correcting refractive error was estimated based on the minimum wage for individuals aged between 16-60 years with URE. Estimation of the national cost of addressing URE was based on spectacle provision cost, cost of training functional clinical refractionists and the cost of establishing vision centres. A cost benefit analysis was undertaken based on the national cost estimates and a factor of 3.5 times.

RESULTS

The estimated lost productivity to the GDP due to URE in in Kenya is approximately US$ 671,455,575 -US$ 1,044,486,450 annually for population aged between 16-60 years. The productivity loss of caregivers for the severe visually impaired is approximately US$ 13,882,899 annually. Approximately US$ 246,750,000 is required to provide corrective devices, US$ 413,280- US$ 108,262,300 to train clinical refractionists and US$ 39,800,000 to establish vision centres. The productivity benefit of correcting visual impairment is approximately US$ 41,126,400 annually. Finally, a cost benefit analysis showed a return of US$ 378,918,050 for human resources, US$ 863,625,000 for corrective devices and US$ 139,300,000 for establishment of vision centres.

CONCLUSION

The magnitude of productivity loss due to URE in Kenya is significant warranting prioritization of refractive error services by the government and all stakeholders since any investment directed towards addressing URE has the potential to contribute a positive return.

Nurse and midwife involvement in task-sharing and telehealth service delivery models in primary care: A scoping review

AIM

To synthesise and map current evidence on nurse and midwife involvement in task-sharing service delivery, including both face-to-face and telehealth models, in primary care.

DESIGN

This scoping review was informed by the Joanna Briggs Institute (JBI) Methodology for Scoping Reviews.

DATA SOURCE/REVIEW METHODS

Five databases (Ovid MEDLINE, Embase, PubMed, CINAHL and Cochrane Library) were searched from inception to 16 January 2024, and articles were screened for inclusion in Covidence by three authors. Findings were mapped according to the research questions and review outcomes such as characteristics of models, health and economic outcomes, and the feasibility and acceptability of nurse-led models.

RESULTS

One hundred peer-reviewed articles (as 99 studies) were deemed eligible for inclusion. Task-sharing models existed for a range of conditions, particularly diabetes and hypertension. Nurse-led models allowed nurses to work to the extent of their practice scope, were acceptable to patients and providers, and improved health outcomes. Models can be cost-effective, and increase system efficiencies with supportive training, clinical set-up and regulatory systems. Some limitations to telehealth models are described, including technological issues, time burden and concerns around accessibility for patients with lower technological literacy.

CONCLUSION

Nurse-led models can improve health, economic and service delivery outcomes in primary care and are acceptable to patients and providers. Appropriate training, funding and regulatory systems are essential for task-sharing models with nurses to be feasible and effective.

IMPACT

Nurse-led models are one strategy to improve health equity and access; however, there is a scarcity of literature on what these models look like and how they work in the primary care setting. Evidence suggests these models can also improve health outcomes, are perceived to be feasible and acceptable, and can be cost-effective. Increased utilisation of nurse-led models should be considered to address health system challenges and improve access to essential primary healthcare services globally.

REPORTING METHOD

This review is reported against the PRISMA-ScR criteria.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

PROTOCOL REGISTRATION

The study protocol is published in BJGP Open (Moulton et al., 2022).

[HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]

Purpose of review

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

Recent findings

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation.

Summary

Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

Effects of task shifting from primary care physicians to nurses: a protocol for an overview of systematic reviews

INTRODUCTION

Task-shifting from primary care physicians (PCPs) to nurses is one option to better and more efficiently meet the needs of the population in primary care and to overcome PCP shortages. This protocol outlines an overview of systematic reviews to assess the effects of delegation or substitution by nurses of PCPs' activities regarding clinical, patient-relevant, professional and health services-related outcomes.

METHODS AND ANALYSIS

We will conduct a systematic literature search for secondary literature in PubMed/MEDLINE, EMBASE, CINAHL and Cochrane databases. Systematic reviews, meta-analyses and Health Technology Assessments in German and English comprising randomised controlled trials and prospective controlled trials will be considered for inclusion. Search terms will include Medical Subject Headings combined with free text words. At least one-third of abstracts and full-text articles are reviewed by two independent reviewers. Methodological quality will be assessed using the Overview Quality Assessment Questionnaire. We will only consider reviews if they include controlled trials, if the profession that substituted or delegated tasks was a nurse, if the profession of the control was a PCP, if the assessed intervention was the same in the intervention and control group and if the Overview Quality Assessment Questionnaire score is ≥5. The corrected covered area will be calculated to describe the degree of overlap of studies in the reviews included in the study. We will report the overview according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

ETHICS AND DISSEMINATION

The overview of secondary literature does not require the approval of an Ethics Committee and will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42020183327.

Using a participatory design to develop an implementation framework for integrating falls prevention for older people within the Chinese primary health care system

BACKGROUND

Chinese National Essential Public Health Service Package (NEPHSP) has mandated primary health care providers to provide falls prevention for community-dwelling older people. But no implementation framework is available to guide better integration of falls prevention for older people within the primary health care system.

METHODS

This is a two-stage online participatory design study consisting of eight workshops with stakeholders from three purposively selected cities. First, two workshops were organised at each study site to jointly develop the framework prototype. Second, to refine, optimise and finalise the prototype via two workshops with all study participants. Data analysis and synthesis occurred concurrently with data collection, supported by Tencent Cloud Meeting software.

RESULTS

All participants confirmed that the integration of falls prevention for older people within the NEPHSP was weak and reached a consensus on five opportunities to better integrate falls prevention, including workforce training, community health promotion, health check-ups, health education and scheduled follow-up, during the delivery of NEPHSP. Three regional-tailored prototypes were then jointly developed and further synthesised into a generic implementation framework by researchers and end-users. Guided by this framework, 11 implementation strategies were co-developed under five themes.

CONCLUSIONS

The current integration of falls prevention in the NEPHSP is weak. Five opportunities for integrating falls prevention in the NEPHSP and a five-themed implementation framework with strategies are co-identified and developed, using a participatory design approach. These findings may also provide other regions or countries, facing similar challenges, with insights for promoting falls prevention for older people.

Nurse-led lifestyle counseling in Polish primary care: the effect of current health status and perceived barriers

Introduction

Our study included counseling on diet and physical activity, smoking, e-cigarette use, and alcohol consumption. The aim was to examine the correlates of counseling provided by primary care nurses with the health status/health behaviors of nurses and the barriers in the advice provided.

Materials and methods

In 2022, we conducted a cross-sectional survey among 331 nurses employed in the primary care sector in Lodz. The questionnaire consisted of three sections: characteristics of the patient population receiving treatment and provided with healthy lifestyle counseling by nurses, barriers to the process of assessing, controlling, and guiding patients, and health status/health behaviors of nurses.

Results

Eighty percent of the nurses in our study provided advice on diet and physical activity to primary care patients. Over 70% of the survey participants performed minimal anti-smoking interventions forsmokers, 67.7% for alcohol drinkers, and 56.8% for e-cigarette users. The correlates of counseling in the field of diet and physical activity turned out to be the knowledge and skills, which enabled nurses to provide advice (OR = 2.57, p < 0.01). The correlates of the conducted minimal anti-smoking interventions in smoking patients were: subjective assessment of overweight and obesity in nurses, knowledge and skills in conducting counseling (OR = 1.92, p < 0.05), and measuring body weight, height and BMI (OR = 2.18, p < 0.01). Among the three most common barriers identified by the nurses in the process of assessing, monitoring, and guiding patients were the opinion that patients are not interested in improving their diet, physical activity, and weight loss (60.7%), lack of time (51.4%), as well as the belief that patients find it too difficult to change their current habits (54.1%).

Conclusion

The results of our survey indicate that nurses' participation in healthy lifestyle counseling in adult patients is unsatisfactory. Interventions in primary care should be designed considering the specific obstacles nurses may face in leading healthy lifestyles. Further training of nursing staff is required to increase their knowledge on healthy lifestyles.

Effectiveness of Doctor Clerks Supporting Physicians' Work in Japan: A Systematic Review

The burgeoning administrative workload on physicians in Japan's healthcare system has necessitated innovative approaches to optimize clinical care. Integrating doctor clerks, tasked with administrative and clerical duties, has emerged as a potential solution to alleviate this burden. This systematic review aims to evaluate the effectiveness of doctor clerks in improving physicians' working conditions and patient care quality. A comprehensive literature search was conducted using Ichushi Web and Google Scholar from January 2000 to September 2023. Data were extracted on publication year, study setting, department focus, work scope, and outcomes of doctor clerk implementation. The search identified 3570 studies, with 17 meeting the inclusion criteria. Most studies were performed in general hospitals with 76.5% (13/17). The studies regarding university hospitals were 17.6% (3/17). Only one study was performed in a community hospital with 5.9% (1/17). More than half of doctor clerks worked not explicitly allocated to one department and did their work not specific to one department with 52.9% (9/17). Three studies report that doctor clerks collaborate with orthopedic surgeons. Two studies report that doctor clerks collaborate with emergency medicine physicians. Each study reports that doctor clerks collaborate with respiratory or general medicine. The most frequent is document support, with 94.1% (16/17). The second most frequent working content is consultation support, with 47.1% (8/17). The third most frequently working content is ordering support, with 23.5% (4/17). Call response, secretary work, education support, research support, conference support, and other professional support are included, each with 5.9% (1/17). Regarding clinical outcomes, five studies assessed a reduction in physician paperwork time (29.4%). Four studies assessed the frequency of the contents of doctor clerks' work (23.5%). Four studies assessed the positive perception of physicians (23.5%). Four studies assessed the amount of the reduction in physicians' overtime work (23.5%). Three studies assess the amount of the reduction in hospital costs (17.6%). One study assessed part-time physicians' fatigue reduction (5.9%). Each study assessed the quality of patient care, such as doctor's clerk education for standardization, increase in the number of patients accepted, reduction in medical incidents, decrease in patient waiting time, and primary to tertiary prevention. Introducing doctor clerks in Japan's healthcare system shows promise in enhancing physicians' working conditions and potentially improving patient care. However, conclusive evidence on the impact on patient care quality necessitates further investigation, serving as a foundation for future policy and healthcare system optimization.

Vaccination against emerging and reemerging infectious diseases in places of detention: a global multistage scoping review

Background

Despite the elevated risks of infection transmission, people in prisons frequently encounter significant barriers in accessing essential healthcare services in many countries. The present scoping review aimed to evaluate the state of availability and model of delivery of vaccination services within correctional facilities across the globe.

Methods

Following the methodological framework for scoping reviews and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews criteria, we conducted a systematic search across four peer-reviewed literature databases (Medline via PubMed, Web of Science, the Cochrane Library, Science Direct, and EBSCO), as well as 14 sources of grey literature. Two researchers meticulously examined the identified papers independently to extract pertinent data published between 2012 and 2022. The quality of the selected publications was assessed using established quality assessment tools.

Results

Of the 11,281 identified papers 52 met the inclusion criteria. With the exception of one, all the included publications presented data from high-income countries, predominantly originating from the United States. Across the world, the most prevalent vaccines available in prison settings were COVID-19 and HBV vaccines, typically distributed in response to health crises such as pandemics, epidemics, and local outbreaks. Vaccine coverage and uptake rates within correctional facilities displayed noteworthy disparities among various countries and regions. Besides, individual and organizational barriers and facilitating factors of vaccination in prison settings emerged and discussed in the text.

Discussion

The lack of vaccination services combined with low rates of vaccination coverage and uptake among people living and working in correctional facilities represents a cause for concern. Prisons are not isolated from the broader community, therefore, efforts to increase vaccine uptake among people who live and work in prisons will yield broader public health benefits.

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective.

METHODS

This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes.

RESULTS

The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received.

CONCLUSIONS

Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Healthcare and community stakeholders' perceptions of barriers and facilitators to implementing a behavioral activation intervention for people with dementia and depression: a qualitative study using Normalization Process Theory

BACKGROUND

Depression is commonly experienced by people with dementia, and associated with lower quality of life and functional decline. However, access to evidence-based psychological interventions for people with dementia and depression is limited. One potential solution is guided low-intensity behavioral activation. Following the new Medical Research Council Framework, considering factors such as potential barriers and facilitators to implementation is recommended during the development of new interventions. Aims of this study were to: (1) develop an understanding of existing healthcare and community support in the Swedish context for people with dementia and their informal caregivers; and (2) identify barriers and facilitators to intervention uptake informed by Normalization Process Theory.

METHODS

Semi-structured interviews and focus groups were held with healthcare (n = 18) and community (n = 7) stakeholders working with people with dementia and/or informal caregivers. Interview questions were informed by Normalization Process Theory. Data was analysed utilizing a two-step deductive analysis approach using the Normalization Process Theory coding manual, with inductive categories applied to data related to the main mechanisms of the theory, but not captured by its sub-constructs.

RESULTS

Twelve deductive and three inductive categories related to three Normalization Process Theory primary mechanisms (Coherence, Cognitive Participation, and Collective Action) were identified. Identified barriers to intervention uptake included: (1) additional burden for informal caregivers; (2) lack of appropriate workforce to provide guidance; (3) lack of time and financial resources; (4) people with dementia not recognising their diagnosis of dementia and/or a need for support; and (5) stigma. Identified facilitators to intervention uptake included: (1) intervention has potential to fill a large psychological treatment gap in Sweden; (2) objectives and potential benefits understood and agreed by most stakeholders; and (3) some healthcare professionals recognized their potential role in providing intervention guidance.

CONCLUSIONS

Several barriers and facilitators for future implementation, specific to the intervention, individuals and families, as well as professionals, were identified during intervention development. Barriers were mapped into evidence-based implementation strategies, which will be adopted to overcome identified barriers. A feasibility study further examining implementation potential, acceptability and feasibility, alongside clinical, methodological, and procedural uncertainties associated with the intervention will be conducted.

TRIAL REGISTRATION

Not applicable.

[Attitudes of general practitioners and medical practice assistants towards the delegation of medical services: Results of a survey in Berlin, Brandenburg and Thuringia]

INTRODUCTION

The delegation of tasks and responsibilities from general practitioners (GPs) to medical practice assistants (MPAs) can contribute to ensuring primary care in Germany. The aim of the study was to collect and analyze attitudes and procedures of GPs and MPAs regarding the delegation of physician-related tasks and activities.

METHODOLOGY

A self-designed, piloted questionnaire was sent to all GPs listed within the regional Associations of Statutory Health Insurance Physicians (KV) in Thuringia, Berlin, and Brandenburg (n=5,516) and their MPAs. Participants were asked to indicate which physician-related activities were already delegated and on which occasions further delegations could be considered.

RESULTS

890 GPs (response rate: 16.1%) and 566 MPAs participated in the written survey. The participants were predominantly female and most of them worked in urban areas. Numerous activities, such as medical history taking, triage, Disease Management Program (DMP) controls, vaccinations and home visits, have already been delegated. The willingness to delegate further tasks (e. g., follow-up prescriptions and referrals, independent takeover of simple consultations, assessing the necessity of physician consultation) was high.

CONCLUSION

The survey showed a high level of willingness of both occupational groups to delegate physician-related activities to MFAs. An expansion seems possible under certain conditions. Many activities have already been delegated to MPAs in primary care practices. Our survey provides suggestions regarding further tasks suitable for delegation, some of which go beyond the delegation agreement valid in Germany.

Cost-Effectiveness of Hydroxyurea for Sickle Cell Anemia in a Low-Income African Setting: A Model-Based Evaluation of Two Dosing Regimens

BACKGROUND AND OBJECTIVE

The disease burden of sickle cell anemia (SCA) in sub-Saharan African (SSA) countries is substantial, with many children dying without an established diagnosis or proper treatment. The global burden of SCA is increasing each year, making therapeutic intervention a high priority. Hydroxyurea is the only disease-modifying therapy with proven feasibility and efficacy suitable for SSA; however, no one has quantified the health economic implications of its use. Therefore, from the perspective of the health care provider, we estimated the incremental cost-effectiveness of hydroxyurea as a fixed-dose regimen or maximum tolerated dose (MTD) regimen, versus SCA care without hydroxyurea.

METHODS

We estimated the cost of providing outpatient treatment at a pediatric sickle cell clinic in Kampala, Uganda. These estimates were used in a discrete-event simulation model to project mean costs (2021 US$), disability-adjusted life years (DALYs), and consumption of blood products per patient (450 mL units), for patients between 9 months and 18 years of age. We calculated cost-effectiveness as the ratio of incremental costs over incremental DALYs averted, discounted at 3% annually. To test the robustness of our findings, and the impact of uncertainty, we conducted probabilistic and one-way sensitivity analyses, scenario analysis, and price threshold analyses.

RESULTS

Hydroxyurea treatment averted an expected 1.37 DALYs and saved US$ 191 per patient if administered at the MTD, compared with SCA care without hydroxyurea. In comparison, hydroxyurea at a fixed dose averted 0.80 DALYs per patient at an incremental cost of US$ 2. The MTD strategy saved 11.2 (95% CI 11.1-11.4) units of blood per patient, compared with 9.1 (95% CI 9.0-9.2) units of blood per patient at the fixed-dose alternative.

CONCLUSIONS

Hydroxyurea at MTD is likely to improve quality of life and reduce the consumption of blood products for children with SCA living in Uganda. Compared with a fixed dose regimen, treatment dosing at MTD is likely to be a cost-effective treatment for SCA, using realistic ranges of hydroxyurea costs that are relevant across SSA. Compared with no use of the drug, hydroxyurea could lead to substantial net savings per patient, while reducing the disease morbidity and mortality and increasing quality of life.

Patient perspective on task shifting from general practitioners to medical practice assistants - a quantitative survey in Germany

INTRODUCTION

Various developments result in increasing workloads in general practices. New models of care and a restructuring of the division of tasks could provide relief. One approach is to extend the delegation of medical tasks from general practitioners (GPs) to medical practice assistants (MPAs). So far, there has been a lack of information about specific situations in which patients are willing to be treated exclusively by MPAs.

METHODS

In three German federal states, patients who visited a general practice were surveyed exploratively and cross-sectionally with a self-designed, paper-based questionnaire. The data were analysed descriptively and multivariate. A mixed binary logistic regression model was calculated to account for cluster effects at practice level (random intercept model). The dependent variable was patients' acceptance of task delegation.

RESULTS

A total of 1861 questionnaires from 61 general practices were included in the analysis. Regarding the current problem/request, a total of 30% of respondents could imagine being treated only by MPAs. Regarding theoretical reasons for consultation, more than half of the patients agreed to be treated by MPAs. According to the regression model, MPAs were preferred when patients were younger (10-year OR = 0.84, 95%-CI [0.75, 0.93]) or had a less complicated issue (OR = 0.44, 95%-CI [0.26, 0.8]). For four current problems/requests ("acute complaints" OR = 0.27, 95%-CI [0.17, 0.45], "routine health check" OR = 0.48, 95%-CI [0.3, 0.79], "new problem" OR = 0.13, 95%-CI [0.06, 0.28], "known problem" OR = 0.16, 95%-CI [0.1, 0.27]) patients prefer to be treated by GPs instead of MPAs.

DISCUSSION

For the first time, statements could be made on patients' acceptance of task delegation in relation to current and theoretical reasons for treatment in general practices in Germany. The discrepancy in response behaviour on a theoretical and individual level could be explained by different contexts of questions and differences at practice level. Overall, patients seem to be open to increased delegation of medical tasks, depending on the reason for treatment. Selection and response biases should be considered in the interpretation.

CONCLUSION

The results are not completely opposed to an extension of task delegation. Further interventional studies could provide information on the possible effects of expansion of delegable tasks.

Introducing a triage and Nurse on Call model in primary health care - a focus group study of health care staff's experiences

BACKGROUND

With the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff's experiences of introducing the triage and Nurse on Call model at the primary health care centre.

METHODS

Five focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.

RESULTS

The analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.

CONCLUSIONS

This study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

[Exploring facilitators and barriers to implementing expanded nursing roles in MexicoEstudo de facilitadores e barreiras para a implementação de funções ampliadas de enfermagem no México]

Objective

To explore the perceptions of nursing professionals regarding facilitators and barriers to the implementation of expanded nursing functions in a state in central Mexico.

Methods

Qualitative descriptive phenomenological study. During 2022, 18 semi-structured interviews were conducted with three types of informants: a) head nurses at state-level facilities; b) head nurses at local-level facilities; and c) heads of health units and operational nursing staff who have direct contact with patients.

Results

The following facilitators were identified: willingness to adopt the strategy (seen as favorable by managers and acceptable by nursing staff); reorganization of functions (simplification of processes and analysis of the situation of health units); access to training; and characteristics of nursing staff (professionalization, work experience, and favorable attitude). Barriers included: conditions at the first level of care (personnel shortages, too many administrative activities, lack of physical space, materials, supplies, and consumables), resistance to change (professional jealousy of other disciplines and duplication of tasks), staff salaries, lack of training, not trusted with expanded duties, and attitude of patients (resistance to nursing care).

Conclusions

By understanding the perceptions of nursing professionals, we can identify key elements for the successful expansion of nursing functions through expansion of the competencies of operational staff. Reorganization and proper management at different levels of decision-making will be necessary.

Identifying Implementation Factors for the Development, Operation, and Sustainment of Ambulatory Care Pharmacy Programs: a Qualitative Study

BACKGROUND

Pharmacist-led programs and clinics have been integrated into primary and specialty care clinics in a variety of ways, for example, to improve diabetes outcomes via patient education and counseling. However, factors important to the implementation of different outpatient pharmacy models have not been well elucidated.

OBJECTIVE

To identify provider- and health system-level drivers of implementation and sustainability of pharmacy-led programs in the outpatient setting.

DESIGN

Qualitative study of key informants using semi-structured interviews of individuals working in various roles throughout a large health system, including ambulatory clinical pharmacists, pharmacy managers, medical directors and physician leaders, and operations and quality managers.

PARTICIPANTS

Key informants (n=19) with leadership roles in pharmacy programs and front-line experience providing integrated pharmacy care were selected purposively and with snowball sampling.

APPROACH

We coded the interviews using a codebook derived from the 2022 Consolidated Framework for Implementation Research (CFIR), which details various internal and external factors important for implementation.

KEY RESULTS

We identified the following themes related to implementing ambulatory care pharmacy programs: (1) pharmacy programs varied in their level of embeddedness in the outpatient clinic, (2) establishing pharmacy program required leadership advocacy and coordination among stakeholders, (3) continued operations required integrated workflows and demonstrated value to the health system and clinicians, and (4) established revenue streams or added indirect value and continued improvement of integration sustained programs over time.

CONCLUSIONS

External policies and incentives such as new reimbursement codes and quality measurement programs that rely on pharmacy input play a significant role in shaping the design, implementation, and sustainability of health system outpatient pharmacy programs. Ensuring that quality metrics used in value-based contracts or programs demonstrate pharmacy benefits will be critical to supporting and growing pharmacy programs.

The training of midwives to perform obstetric ultrasound scan in Africa for task shifting and extension of scope of practice: a scoping review

INTRODUCTION

Ultrasound scan is one of the essential assessments that is crucial in the early identification of health risks during antenatal care. Its accessibility to women in low-and middle-income countries remains a serious challenge because ultrasound scans are not within the scope of practice for midwives. However, task shifting and extension of scope of practice aim to train midwives to assess pregnant women through an ultrasound scan. This paper aims to report the findings of a scoping review on the training of midwives to perform obstetric ultrasound scans in Africa.

METHODS

The 6-step iterative framework for scoping reviews by Arksey and O'Malley was used to determine the extent of qualitative and quantitative evidence available on the training of midwives on obstetric ultrasound scans, which includes specifying the research question, identifying relevant studies, selecting studies, extracting and charting data, collating, summarising, and synthesising and reporting findings.

RESULTS

A total of 12 articles from eight African countries were included in this scoping review. Three main themes and 13 sub-themes emerged and they are: obstetric ultrasound scan training, challenges experienced by midwives from task shifting and extension of scope of practice regarding obstetric ultrasound scan, and the value of task shifting and extension of scope of practice regarding obstetric ultrasound scan to midwives.

DISCUSSION

Despite the available evidence that the training of midwives on obstetric ultrasound scans is essential to ensure the accessibility of quality antenatal health services, the training of midwives on obstetric ultrasound scans in some African countries remains a serious challenge. It is evident from this scoping review results that there is a need for African countries to incorporate obstetric ultrasound scans as part of the scope of practice of midwives. Task shifting necessitates prioritising the training of midwives on the use of obstetric ultrasound scans as one of the steps towards the achievement of the United Nations Sustainable Development Goal number 3 targets by 2030.

Patterns of GP and nurse independent prescriber prescriptions for antibiotics dispensed in the community in England: a retrospective analysis

BACKGROUND

Physician-nurse task shifting, a process of delegation whereby tasks are moved to other specialized healthcare workers, is used in primary care in many countries to improve access, efficiency and quality of care. One such task is the prescription of medicines.

OBJECTIVES

To identify nurse independent prescriber (NIP) and GP numbers in England, the proportions and types of NIP and GP antibiotic prescriptions dispensed in the community, and the impact of COVID-19 on the volume, rate and types of antibiotic prescriptions dispensed.

METHODS

Descriptive population-based retrospective cohort study using routinely collected data on prescriptions for antibiotics dispensed in the community in England between January 2014 and October 2021.

RESULTS

Between 2014 and 2021, numbers (headcount) of NIPs whose prescriptions were dispensed in the community rose by 146% to 34 997. GP numbers (headcount) rose by 10% to 44 681. Of the 25.373 million antibiotic prescriptions dispensed between 2014 and 2021, NIPs were responsible for 8.6%. The rate of dispensed antibiotic prescriptions per prescriber per calendar year decreased (by 50% for NIPs and by 21% for GPs) between 2014 and 2020. This decreasing trend continued following the onset of the COVID-19 pandemic across both groups. Narrow-spectrum antibiotics (penicillins, macrolides, tetracyclines) were the most frequently dispensed across both NIPs and GPs.

CONCLUSIONS

NIPs are an increasing contributory influence on total antibiotic prescribing and should be included in antimicrobial stewardship efforts. Interventions for this group need to be tailored to the population and context in which they work.

Temperature variations in pharmaceutical storage facilities and knowledge, attitudes, and practices of personnel on proper storage conditions for medicines in southern Malawi

Objective

We assessed the temperature variations in pharmacies and medicine storage areas in southern Malawi and conducted a knowledge, attitude and practices survey for personnel who manage medicine stores in various health facilities.

Methods

This was a longitudinal study design that used installed Tempmate® thermometers in 27 selected health facilities to record temperatures every 15 min for a period of 9 months. In addition, a questionnaire was used to assess the knowledge, attitude, and practices regarding good pharmaceutical storage. Observations were also made on the storage structures of the facilities and compared with the mean kinetic temperature.

Results

Storage temperature ranged from 13.8°C to 42°C with mean kinetic temperature (MKT) being 25.3°C (95% CI 24.4-26.2°C). Mean temperature for public facilities was lower (23.8°C) than the faith-based facilities (25.2°C) and private facilities (26.6°C). In terms of level of health care, lower temperatures were recorded in facilities offering tertiary level of care as compared to secondary and primary care facilities, p < 0.001. For the type of storage facilities, storage-in-a-box unit (SIAB) presented lower temperatures than ordinary storage areas (non-SIAB), p < 0.001. Majority of health workers (69%) had good knowledge on proper storage conditions. Air conditioners and thermometers were available in 88.4 and 76.9% of the facilities, respectively. However, few facilities utilized the air conditioners due to electricity problems. About 46.15% of the participants were able to correctly record temperatures (at least twice a day) for the storage facilities, 23.07% did not properly record while 30.77% of the personnel did not keep temperature records at all. Limited storage space was among the challenges that facilities encounter to maintain proper storage conditions.

Conclusion

Despite having the necessary knowledge on proper storage conditions, the pharmacy personnel failed to adhere to good pharmaceutical storage practices due to resource limitations. There is a need for stakeholder interventions such as increasing budget allocation to address the challenges faced by the health facilities.

Preliminary evaluation of dual-energy CT to quantitatively assess bone marrow edema in patients with diabetic foot ulcers and suspected osteomyelitis

OBJECTIVES

The purpose of this study is to evaluate the value of dual-energy CT (DECT) with virtual non-calcium (VNCa) in quantitatively assessing the presence of bone marrow edema (BME) in patients with diabetic foot ulcers and suspected osteomyelitis.

METHODS

Patients with a diabetic foot ulcer and suspected osteomyelitis that underwent DECT (80 kVp/Sn150 kVp) with VNCa were retrospectively included. Two observers independently measured CT values of the bone adjacent to the ulcer and a reference bone not related to the ulcer. The patients were divided into two clinical groups, osteomyelitis or no-osteomyelitis, based on the final diagnosis by the treating physicians.

RESULTS

A total of 56 foot ulcers were identified of which 23 were included in the osteomyelitis group. The mean CT value at the ulcer location was significantly higher in the osteomyelitis group (- 17.23 ± 34.96 HU) compared to the no-osteomyelitis group (- 69.34 ± 49.40 HU; p < 0.001). Within the osteomyelitis group, the difference between affected bone and reference bone was statistically significant (p < 0.001), which was not the case in the group without osteomyelitis (p = 0.052). The observer agreement was good for affected bone measurements (ICC = 0.858) and moderate for reference bone measurements (ICC = 0.675). With a cut-off value of - 40.1 HU, sensitivity was 87.0%, specificity was 72.7%, PPV was 69.0%, and NPV was 88.9%.

CONCLUSION

DECT with VNCa has a potential value for quantitatively assessing the presence of BME in patients with diabetic foot ulcers and suspected osteomyelitis.

KEY POINTS

• Dual-energy CT (DECT) with virtual non-calcium (VNCa) is promising for detecting bone marrow edema in the case of diabetic foot ulcers with suspected osteomyelitis. • DECT with VNCa has the potential to become a more practical alternative to MRI in assessing the presence of bone marrow edema in suspected osteomyelitis when radiographs are not sufficient to form a diagnosis.

The role of community health workers in primary healthcare in the WHO-EU region: a scoping review

BACKGROUND

Existing evidence on the role of community health workers (CHWs) in primary healthcare originates primarily from the United States, Canada and Australia, and from low- and middle-income countries. Little is known about the role of CHWs in primary healthcare in European countries. This scoping review aimed to contribute to filling this gap by providing an overview of literature reporting on the involvement of CHWs in primary healthcare in WHO-EU countries since 2001 with a focus on the role, training, recruitment and remuneration.

METHODS

This systematic scoping review followed the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, extension for Scoping Reviews. All published peer-reviewed literature indexed in PubMed, Web of Science, and Embase databases from Jan 2001 to Feb 2023 were reviewed for inclusion. Included studies were screened on title, abstract and full text according to predetermined eligibility criteria. Studies were included if they were conducted in the WHO-EU region and provided information regarding the role, training, recruitment or remuneration of CHWs.

RESULTS

Forty studies were included in this review, originating from eight countries. The involvement of CHWs in the WHO-EU regions was usually project-based, except in the United Kingdom. A substantial amount of literature with variability in the terminology used to describe CHWs, the areas of involvement, recruitment, training, and remuneration strategies was found. The included studies reported a trend towards recruitment from within the communities with some form of training and payment of CHWs. A salient finding was the social embeddedness of CHWs in the communities they served. Their roles can be classified into one or a combination of the following: educational; navigational and supportive.

CONCLUSION

Future research projects involving CHWs should detail their involvement and elaborate on CHWs' role, training and recruitment procedures. In addition, further research on CHW programmes in the WHO-EU region is necessary to prepare for their integration into the broader national health systems.

Advocacy for patients with headache disorders

Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.

The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

BACKGROUND

The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient.

OBJECTIVES

To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation.

METHOD

Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis.

RESULTS

In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained.

CONCLUSION

The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

Factors associated with the uptake of national essential public health service package for hypertension and type-2 diabetes management in China's primary health care system: a mixed-methods study

Background

China launched the primary health care (PHC) system oriented National Essential Public Health Service Package (NEPHSP) in 2009, to combat health challenges including the increasing burden from hypertension and type-2 diabetes (T2DM). In this study, the PHC system was assessed to understand factors influencing the uptake of the NEPHSP for hypertension and T2DM management.

Methods

A mixed-methods study was conducted in seven counties/districts from five provinces across the mainland of China. Data included a PHC facility level survey and interviews with policy makers, health administrators, PHC providers, and individuals with hypertension and/or T2DM. The facility survey used the World Health Organisation (WHO) service availability and readiness assessment questionnaire. Interviews were thematically analysed using the WHO health systems building blocks.

Findings

A total of 518 facility surveys were collected with over 90% in rural settings (n = 474). Forty-eight in-depth individual interviews and 19 focus-group discussions were conducted across all sites. Triangulating the quantitative and qualitative data found that China's continuous political commitment to strengthening the PHC system led to improvements in workforce and infrastructure. Despite this, many barriers were identified, including insufficient and under-qualified PHC personnel, remaining gaps in medicines and equipment, fragmented health information systems, residents' low trust and utilization of PHC, challenges in coordinated and continuous care, and lack of cross-sectorial collaborations.

Interpretation

The study findings provided recommendation for future PHC system strengthening, including improving the quality of NEPHSP delivery, facilitating resource-sharing across health facilities, establishing integrated care systems, and exploring mechanisms for better cross-sectorial engagement in health governance.

Funding

The study is supported by National Health and Medical Research Council (NHMRC) Global Alliance for Chronic Disease funding (APP1169757).

Global engagement of pharmacists in test and treat initiatives: Bringing care from clinics to communities

The coronavirus disease 2019 pandemic has placed substantial strain on the global health care workforce, disrupting essential and nonessential services. Task sharing of test and treat services to nontraditional prescribers, such as pharmacists, can facilitate more resilient health care systems by expanding access to health services while simultaneously decreasing the pressure on traditional health care providers. Expansion of pharmacists' scope of work has historically been hindered by sociopolitical, resourcing, and competency considerations; addressing these challenges will be key to including pharmacists in testing and treatment of priority diseases. Sociopolitical considerations include migrating to flexible national legislation and scope of practices as well as engagement with other health care providers and the public to increase the acceptance of pharmacists participating in test and treat services. Resourcing issues include health care financing for test and treat services to parallel established systems or use voucher systems and service competition. In addition, pharmacists can use their training in supply chain management to ease and prevent medication stockouts in test to treat initiatives. Investments in technologies that support disease surveillance, basic reporting, and interoperability with health management information systems can integrate these initiatives into health care systems. Competency considerations comprise test and treat specific education for the pharmacy profession to equip them with the knowledge and confidence to execute successfully. Monitoring and evaluating the outcomes of these services can facilitate the scalability of test and treat initiatives. Pharmacists are uniquely positioned to bring testing and treatment from the clinic to the community.

Has the COVID-19 Pandemic Led to Changes in the Tasks of the Primary Care Workforce? An International Survey among General Practices in 38 Countries (PRICOV-19)

The COVID-19 pandemic has had a large and varying impact on primary care. This paper studies changes in the tasks of general practitioners (GPs) and associated staff during the COVID-19 pandemic. Data from the PRICOV-19 study of 5093 GPs in 38 countries were used. We constructed a scale for task changes and performed multilevel analyses. The scale was reliable at both GP and country level. Clustering of task changes at country level was considerable (25%). During the pandemic, staff members were more involved in giving information and recommendations to patients contacting the practice by phone, and they were more involved in triage. GPs took on additional responsibilities and were more involved in reaching out to patients. Problems due to staff absence, when dealt with internally, were related to more task changes. Task changes were larger in practices employing a wider range of professional groups. Whilst GPs were happy with the task changes in practices with more changes, they also felt the need for further training. A higher-than-average proportion of elderly people and people with a chronic condition in the practice were related to task changes. The number of infections in a country during the first wave of the pandemic was related to task changes. Other characteristics at country level were not associated with task changes. Future research on the sustainability of task changes after the pandemic is needed.

Communication about medication management during patient-physician consultations in primary care: a participant observation study

OBJECTIVE

To explore communication about medication management during annual consultations in primary care.

DESIGN

passive participant observations of primary care consultations.

SETTING

Two primary care centres in southern Sweden.

PARTICIPANTS

Consultations between 18 patients (over the age of 60 years) with chronic diseases and 10 general practitioners (GPs) were observed, audio-recorded, transcribed and analysed using content analysis.

RESULTS

Four categories emerged: communication barriers, striving for a shared understanding of medication management, evaluation of the current medication treatment and the plan ahead and behavioural changes in relation to medication management. Misunderstandings in communication, failure to report changes in the medication treatment and use of generic substitutes complicated mutual understanding and agreement on continued treatment. The need for behavioural changes to reduce the need for medication treatment was recognised but should be explored further.

CONCLUSION

Several pitfalls, including miscommunication and inaccurate medication lists, for safe medication management were identified. The purpose of annual consultations should be clarified, individual treatment plans could be used more actively during primary care consultations and efforts are needed to improve verbal communication and information continuity.

Human resource needs and costs for HIV pre-exposure prophylaxis provision in nurse-led primary care in Eswatini and opportunities for task sharing

BACKGROUND

The global expansion of HIV pre-exposure prophylaxis (PrEP) includes health systems that face a shortage of skilled health care workers (HCWs). We estimated the human resource needs and costs for providing PrEP in nurse-led primary care clinics in Eswatini. Furthermore, we assessed potential cost savings from task sharing between nurses and other HCW cadres.

METHODS

We conducted a time-and-motion and costing study in a PrEP demonstration project between August 2017 and January 2019. A form for recording time and performed activities ("motion") was filled by HCWs of six primary care clinics. To estimate the human resource needs for specific PrEP activities, we allocated recorded times to performed PrEP activities using linear regression with and without adjusting for a workflow interruption, that is, if a client was seen by different HCWs or by the same HCW at different times. We assessed a base case in which a nurse provides all PrEP activities and five task shifting scenarios, of which four include workflow interruptions due to task sharing between different HCW cadres.

RESULTS

On average, PrEP initiation required 29 min (95% CI 25-32) of HCW time and PrEP follow-up 16 min (95% CI 14-18). The HCW time cost $4.55 (uncertainty interval [UI] 1.52-9.69) for PrEP initiation and $2.54 (UI 1.07-4.64) for PrEP follow-up when all activities were performed by a nurse. Time costs were $2.30-4.25 (UI 0.62-9.19) for PrEP initiation and $1.06-2.60 (UI 0.30-5.44) for PrEP follow-up when nurses shared tasks with HCWs from lower cadres. Interruptions of the workflow added, on average, 3.4 min (95% CI 0.69-6.0) to the time HCWs needed for a given number of PrEP activities. The cost of an interrupted workflow was estimated at $0.048-0.87 (UI 0.0098-1.63) depending on whose time need increased.

CONCLUSIONS

A global shortage of skilled HCWs could slow the expansion of PrEP. Task shifting to lower-cadre HCW in nurse-led PrEP provision can free up nurse time and reduce the cost of PrEP provision even if interruptions associated with task sharing increase the overall human resource need.

"Just give them a choice": Patients' perspectives on starting medications for opioid use disorder in the ED

OBJECTIVES

Medications for opioid use disorder (MOUD) prescribed in the emergency department (ED) have the potential to save lives and help people start and maintain recovery. We sought to explore patient perspectives regarding the initiation of buprenorphine and methadone in the ED with the goal of improving interactions and fostering shared decision making (SDM) around these important treatment options.

METHODS

We conducted semistructured interviews with a purposeful sample of people with opioid use disorder (OUD) regarding ED visits and their experiences with MOUD. The interview guide was based on the Ottawa Decision Support Framework, a framework for examining decisional needs and tailoring decisional support, and the research team's experience with MOUD and SDM. Interviews were recorded, transcribed, and analyzed in an iterative process using both the Ottawa Framework and a social-ecological framework. Themes were identified and organized and implications for clinical care were noted and discussed.

RESULTS

Twenty-six participants were interviewed, seven in person in the ED and 19 via video conferencing software. The majority had tried both buprenorphine and methadone, and almost all had been in an ED for an issue related to opioid use. Participants reported social, pharmacological, and emotional factors that played into their decision making. Regarding buprenorphine, they noted advantages such as its efficacy and logistical ease and disadvantages such as the need to wait to start it (risk of precipitated withdrawal) and that one could not use other opioids while taking it. Additionally, participants felt that: (1) both buprenorphine and methadone should be offered; (2) because "one person's pro is another person's con," clinicians will need to understand the facets of the options; (3) clinicians will need to have these conversations without appearing judgmental; and (4) many patients may not be "ready" for MOUD, but it should still be offered.

CONCLUSIONS

Although participants were supportive of offering buprenorphine in the ED, many felt that methadone should also be offered. They felt that treatment should be tailored to an individual's needs and circumstances and clarified what factors might be important considerations for people with OUD.