Indicators and measurement tools for health system integration: a knowledge synthesis protocol

DiScO: novel rapid systems mapping to inform digital transformation of health systems

Background

Global health systems are confronting challenges that intersect climate change with evolving communicable and non-communicable public health risks. Addressing these challenges requires systems integration via citizen big data that exist outside health systems. However, systems integration across jurisdictions is a complex challenge that requires stakeholder input. This study's purpose was to conduct rapid systems mapping with international health system stakeholders to inform the development and implementation of a global digital citizen science observatory (DiScO), which aims to catalyze digital transformation of health systems across jurisdictions.

Methods

A rapid qualitative systems mapping study was conducted during the International Society for Behavioral Nutrition and Physical Activity Annual Global Summit in Uppsala, Sweden, in June 2023. The choice of the venue and approach was informed by three key criteria: (1) Established evidence linking physical activity and nutrition with non-communicable diseases; (2) Concrete existing methods of obtaining citizen big data by physical activity and nutrition researchers; (3) Precedence of physical activity and nutrition researchers conducting citizen science as well behavioral/clinical big data collection. The design of this study was an innovative pre-post systems map development, which consisted of (1) real-time rapid systems mapping (pre/initial map) by engaging with international stakeholders and (2) adjustment of the real-time systems map (post/final map) after analyzing stakeholder discussion data.

Results

Rapid systems mapping resulted in a complex network that included key themes to successfully develop and implement DiScO: priorities, opportunities, risks, challenges, partnerships, and resources. Additionally, a new theme emerged organically through stakeholder group discussions - mitigation strategies. The adapted rapid systems map (i.e., after data analyses) depicts 23 key nodes of intervention across the seven key themes.

Conclusion

Rapid systems mapping at international symposia is a novel methodological approach to capture stakeholder input, particularly to understand complexity across international jurisdictions - an approach that can be replicated across disciplines and sectors to inform digital transformation of health systems. The development and implementation of DiScO, a platform for decentralization and democratization of technology, will take into consideration all the key nodes of intervention identified in the rapid systems map to promote digital health for equity across global jurisdictions.

Effect of Tuberculosis (TB) and Diabetes mellitus (DM) integrated healthcare on bidirectional screening and treatment outcomes among TB patients and people living with DM in developing countries: a systematic review

A systematic review (Prospero CRD42017075562) including articles published between 1 January 1990 and 31 October 2021 was performed to synthesize evidence on the effect of integrating tuberculosis (TB) and diabetes mellitus (DM) healthcare on screening coverage and treatment loss to follow-up as compared to non-integrated care services for TB and DM in low- to middle-income countries (LMICs). Searches were performed in PubMed, Web of Science, WHO Global Index Medicus, and Cochrane Central Library. This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and we adopted Cochrane data collection form for Randomized Controlled Trials (RCTs) and non-RCTs. Due to heterogeneity and limited data of studies included, meta-analysis was not performed. Of 6902 abstracts, 10 studies from South America, Asia, and Africa were included. One study from Zimbabwe showed 57% increase in DM screening among TB patients in integrated care as compared to non-integrated care; 95% CI: 54.1, 59.8. Seven studies with before-after comparison groups reported increased screening coverage during implementation of integrated healthcare that ranged from 10.1% in Mexico to 99.1% in China. Three studies reported reduction in loss to follow-up among TB patients in integrated care; two in China showed 9.2%, 95% CI: -16.7, -1.7, and -9.5%, 95% CI: -18.4, -0.7 differences, while a study from Mexico showed -5.3% reduction, 95% CI: -9.8, -0.9.With few and heterogenous included studies, the synthesized evidence is weak to establish effect of TB/DM integrated care. Therefore, further robust studies such as randomized clinical trials and well-designed observational studies are needed.

Influence of Selected Indicators of Healthcare System Functioning Evaluation on the Health Result

BACKGROUND

According to the World Health Organization's statistics, 7 of the 10 main causes of death in 2019 were noncommunicable diseases. Health indicators are measures used to evaluate public health system effectiveness and functioning. Monitoring mortality rates from leading causes, life expectancy and other health indicators is essential to address their causes and adapt health systems to react adequately. The aim of this study is to present the dependencies of selected health care indicators and health outcomes.

METHODS

Based on the literature review conducted, selected health indicators, along with healthcare system data, were analyzed using Pearson's r correlation. The analyses included data from the Organization for Economic Cooperation and Development (OECD) presented in statistics and the Health at a Glance 2021 report and data collected as part of the preparation of the Financing Global Health 2020 report by the Institute for Health Metrics and Evaluation.

RESULTS

Health system resources are linked to health outcomes. The number of medical consultations, the number of nurses per patient or the level of financing of services under general health insurance are related to life expectancy and deaths due to causes that could have been avoided or treated.

CONCLUSIONS

Life expectancy is positively correlated with access to general health insurance and public expenditure on healthcare. There is a need for all countries to provide their citizens with broad access to healthcare services.

TASC (Telehealth After Stroke Care): a study protocol for a randomized controlled feasibility trial of telehealth-enabled multidisciplinary stroke care in an underserved urban setting

Background

Hypertension is the most important modifiable risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, hypertension remains poorly controlled in many stroke survivors. Black and Hispanic patients have a higher prevalence of uncontrolled BP and higher rates of stroke. Limited access to care contributes to challenges in post-stroke care. Telehealth After Stroke Care (TASC) is a telehealth intervention that integrates remote BP monitoring (RBPM) including nursing telephone support, tailored BP infographics and telehealth video visits with a multidisciplinary team approach including pharmacy to improve post-stroke care and reduce stroke disparities.

Methods

In this pilot trial, 50 acute stroke patients with hypertension will be screened for inclusion prior to hospital discharge and randomized to usual care or TASC. Usual care patients will be seen by a primary care nurse practitioner at 1–2 weeks and a stroke neurologist at 1 and 3 months. In addition to these usual care visits, TASC intervention patients will see a pharmacist at 4 and 8 weeks and will be enrolled in RBPM consisting of home BP monitoring with interval calls by a centralized team of telehealth nurses. As part of RBPM, TASC patients will be provided with a home BP monitoring device and electronic tablet that wirelessly transmits home BP data to the electronic health record. They will also receive tailored BP infographics that help explain their BP readings. The primary outcome will be feasibility including recruitment, adherence to at least one video visit and retention rates. The clinical outcome for consideration in a subsequent trial will be within-patient change in BP from baseline to 3 months after discharge. Secondary outcomes will be medication adherence self-efficacy and satisfaction with post-stroke telehealth, both measured at 3 months. Additional patient reported outcomes will include depression, cognitive function, and socioeconomic determinants. Multidisciplinary team competency and fidelity measures will also be assessed.

Conclusions

Integrated team-based interventions may improve BP control and reduce racial/ethnic disparities in post-stroke care. TASC is a post-acute stroke care model that is novel in providing RBPM with tailored infographics, and a multidisciplinary team approach including pharmacy. Our pilot will determine if such an approach is feasible and effective in enhancing post-stroke BP control and promoting self-efficacy.

Trial registration

ClinicalTrials.gov NCT04640519

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01025-z.

Improve Healthcare Quality Through Mortality Committee: Retrospective Analysis of Bambino Gesù Children Hospital's Ten Years' Experience 2008-2017

BACKGROUND

Healthcare quality improvements are one of the most important goals to reach a better and safer healthcare system. Reviewing in-hospital mortality data is useful to identify areas for improvement, and to monitor the impact of actions taken to avoid preventable cases, such as those related to healthcare associated infections (HAI).

METHODS

In this paper, we present the experience of the Mortality Committee of Bambino Gesù Children Hospital (OPBG). OPBG has instituted a process of systematic revision of all in-hospital deaths conducted by a multidisciplinary team. The goal is to identify system-wide issues that could be improved to reduce in-hospital preventable deaths. In this way, the mortality review goes alongside all the other risk management activities for the continuous quality improvement and patient safety.

RESULTS

In years 2008-2017, we performed a systematic analysis of 1148 inpatient deaths. In this time period, the overall mortality rate was 0.4%. Forty-seven deaths were caused due to infections, 10 of which involved patients with HAI transferred to OPBG from other facilities or patients with community- acquired infections. Six deaths related to HAI were followed by claims compensations. All these cases were not followed by compensation because the onset of HAI was considered an inevitable consequence of the underlying disease.

CONCLUSION

Introduction of the mortality review committee has proved to be a valid instrument to improve the quality of the care provided in a hospital, allowing early identification of care gaps that could lead to an increase in mortality rates. Article Highlights Box: Reduction of preventable deaths is one of the most important goals to be achieved for any health-care system and to improve the quality of care. • Several studies have shown that analysis of morbidity and mortality rate helps to detect any factors that can lead to an increase in in-hospital mortality rates. • The review of in-hospital deaths allows to learn how to improve the quality and safety of care through identification of critical issues that lead to an increase in mortality ratio. • In some medical areas, such as intensive care units or surgery, the implementation of the conference on mortality and morbidity is more useful for assessing procedures at high risk of errors. • The implementation of existing databases with data deriving from the systematic review of medical records and in-hospital deaths appears to be desirable. • Mortality Review Committees can represent a very useful tool for all the health facilities for the reduction of preventable deaths, such as those related to HAI.

An integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A feasibility study

BACKGROUND

Stroke is the leading cause of death and adult disability in Canada. Eighty percent of older adults (≥65 years) who have suffered a stroke will return to their homes, and 60% will require ongoing rehabilitation. The transition between hospital and home is often fragmented, leading to adverse health outcomes, hospital readmissions, and increased health-care costs. This study examined the feasibility of a 6-month integrated transitional care stroke intervention (TCSI), and explored its effects on health outcomes, patient and provider experience, and cost in 30 community-living older adults (≥55 years) with stroke and multimorbidity (≥2 chronic conditions) using outpatient stroke rehabilitation services.

METHODS

The TCSI is a 6-month intervention delivered by an interprofessional (IP) team (occupational therapist, physiotherapist, speech language pathologist, registered nurse, social worker). It involved care coordination, home visiting, and IP case conferences, supported by a web-based application. A qualitative descriptive approach was used to explore the feasibility of implementing the intervention. A prospective one-group pretest/posttest was used to evaluate the effects of the intervention on health outcomes and use and costs of health services, from baseline to 6 months.

RESULTS

Participants had an average of eight comorbid conditions. The intervention was feasible and acceptable to both older adults and providers. From baseline to 6 months, there was no statistically significant difference in health outcomes. However, there was a significant reduction in the total per person use and costs of health services.

CONCLUSIONS

This study established the feasibility of conducting a larger randomized controlled trial of this intervention.

Integrated Knowledge Translation with Public Health Policy Makers: A Scoping Review

Integrated knowledge translation (iKT) refers to the engagement of knowledge users (e.g., policy makers, clinicians, patients) as active participants in the research process. Theoretically, this involvement enhances research relevancy and usefulness, thereby supporting health system change. However, evidence to support best practices for iKT is lacking, particularly in a public health context and with non-clinical decision-makers. The objectives of this research were to report how decision-maker involvement in public health iKT research has been described and operationalized and whether the process was evaluated. We conducted a scoping review of published literature from January 2005 to December 2017 and extracted information related to iKT involvement, barriers and facilitators and outcomes. Studies typically did not distinguish between different kinds of knowledge users, making it impossible to comment specifically on decision-makers' involvement. Authors believed knowledge user involvement was beneficial to the quality and potential impact of research activities, although corroborating evaluation data were unavailable. Broad research-knowledge user partnerships spanning multiple projects, as well as flexible involvement of knowledge users, enhanced engagement and supported the iKT process.

Feasibility and preliminary effects of an integrated hospital-to-home transitional care intervention for older adults with stroke and multimorbidity: A study protocol

BACKGROUND

Stroke is a major life-altering event and the leading cause of death and disability in Canada. Most older adults who have suffered a stroke will return home and require ongoing rehabilitation in the community. Transitioning from hospital to home is reportedly very stressful and challenging, particularly if stroke survivors have multiple chronic conditions. New interventions are needed to improve the quality of transitions from hospital to home for this vulnerable population.

OBJECTIVES

The primary objective of this study is to examine the feasibility of implementing a new 6-month transitional care intervention supported by a web-based app. The secondary objective is to explore its preliminary effects.

DESIGN

A single arm, pre/post, pragmatic feasibility study of 20-40 participants in Ontario, Canada. Participants will be community-dwelling older adults (≥55 years) with a confirmed stroke diagnosis, ≥2 co-morbid conditions, and referred to a hospital-based outpatient stroke rehabilitation centre. The 6-month transitional care intervention will be delivered by an interprofessional (IP) team and involve care coordination/system navigation, self-management education and support, home visits, telephone contacts, IP team meetings and a web-based app. Primary evaluation of the intervention will be based on feasibility outcomes (e.g. acceptability, fidelity). Preliminary intervention effects will be based on 6-month changes in health outcomes, patient experience, provider experience and cost.

CONCLUSIONS

Information on the feasibility and preliminary effects of this newly-developed intervention will be used to optimize the design and methods for a future pragmatic trial to test the effectiveness and implementation of the intervention in other contexts and settings.

Measuring interdisciplinarity in clinical practice with IPC59, a modified and improved version of IPC65

RATIONALE

Interdisciplinarity is considered a key concept in the management of complex cases in healthcare. However, working in interdisciplinary teams requires the integration of many concepts and a large amount of effort. To help healthcare managers and professionals identify the strengths and weaknesses of their interdisciplinary team and to ensure its continuous improvement, we developed a tool called the IPC65.

OBJECTIVE

The purpose of this study was to test the reliability and validity of the IPC65.

METHODS

Based on a comprehensive review of the literature and qualitative and quantitative assessments, the IPC65 was developed. In this study, the analysis was based on 392 healthcare professionals and managers from short-term care settings who provided valid responses throughout the province of Quebec in Canada. Descriptive statistics, Cronbach's alpha values, and inter-item correlations were measured, and a principal component analysis (PCA) was conducted. Item discrimination was used to provide an improved version of the IPC65.

RESULTS

The IPC65 showed good statistical results. The discriminant procedure provided the basis for shortening and improving the IPC65 to form the IPC59. Cronbach's alpha values ranged from 0.857 to 0.967 in IPC59, demonstrating very good reliability for all four dimensions. The PCA showed good validity.

CONCLUSION

The IPC59 can be used to assess the degree of integration of key concepts leading to interdisciplinarity.

Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review

ABSTRACTIntegrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.