Can Integrated Care Help in Meeting the Challenges Posed on Our Health Care Systems by COVID-19? Some Preliminary Lessons Learned from the European VIGOUR Project

Improving Antibiotic Use in Nursing Homes by Infection Prevention and Control and Antibiotic Stewardship (IMAGINE): Protocol for a Before-and-After Intervention and Implementation Study

BACKGROUND

Despite the extensive use of antibiotics and the growing challenge of antimicrobial resistance, there has been a lack of substantial initiatives aimed at diminishing the prevalence of infections in nursing homes and enhancing the detection of urinary tract infections (UTIs).

OBJECTIVE

This study aims to systematize and enhance efforts to prevent health care-associated infections, mainly UTIs and reduce antibiotic inappropriateness by implementing a multifaceted intervention targeting health care professionals in nursing homes.

METHODS

A before-and-after intervention study carried out in a minimum of 10 nursing homes in each of the 8 European participating countries (Denmark, Greece, Hungary, Lithuania, Poland, Slovakia, Slovenia, and Spain). A team of 4 professionals consisting of nurses, doctors, health care assistants, or health care helpers are actively involved in each nursing home. Over the initial 3-month period, professionals in each nursing home are registering information on UTIs as well as infection and prevention control measures by means of the Audit Project Odense method. The audit will be repeated after implementing a multifaceted intervention. The intervention will consist of feedback and discussion of the results from the first registration, training on the implementation of infection and prevention control techniques provided by experts, appropriateness of the diagnostic approach and antibiotic prescribing for UTIs, and provision of information materials on infection control and antimicrobial stewardship targeted to staff, residents, and relatives. We will compare the pre- and postintervention audit results using chi-square test for prescription appropriateness and Student t test for implemented hygiene elements.

RESULTS

A total of 109 nursing homes have participated in the pilot study and the first registration audit. The results of the first audit registration are expected to be published in autumn of 2024. The final results will be published by the end of 2025.

CONCLUSIONS

This is a European Union-funded project aimed at contributing to the battle against antimicrobial resistance through improvement of the quality of management of common infections based on evidence-based interventions tailored to the nursing home setting and a diverse range of professionals. We expect the intervention to result in a significant increase in the number of hygiene activities implemented by health care providers and residents. Additionally, we anticipate a marked reduction in the number of inappropriately managed UTIs, as well as a substantial decrease in the overall incidence of infections following the intervention.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/60099.

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

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

Impact of COVID-19 on cancer care pathways in a comprehensive cancer center in northern Italy

The COVID-19 pandemic burdened health care systems worldwide. Health services were reorganized with the dual purpose of ensuring the most adequate continuity of care and, simultaneously, the safety of patients and health professionals. The provision of care to patients within cancer care pathways (cCPs) was not touched by such reorganization. We investigated whether the quality of care provided by a local comprehensive cancer center has been maintained using cCP indicators. A retrospective single-cancer center study was conducted on eleven cCPs from 2019 to 2021 by comparing three timeliness indicators, five care indicators and three outcome indicators yearly calculated on incident cases. Comparisons of indicators between 2019 and 2020, and 2019 and 2021, were performed to assess the performance of cCP function during the pandemic. Indicators displayed heterogeneous significant changes attributed to all cCPs over the study period, affecting eight (72%), seven (63%) and ten (91%) out of eleven cCPs in the comparison between 2019 and 2020, 2020 and 2021, and 2019 and 2021, respectively. The most relevant changes were attributed to a negative increase in time-to-treatment surgery-related indicators and to a positive increase in the number of cases discussed by cCP team members. No variations were found attributed to outcome indicators. Significant changes did not account for clinical relevance once discussed by cCP managers and team members. Our experience demonstrated that the CP model constitutes an appropriate tool for providing high levels of quality care, even in the most critical health situations.

Exploratory Factor Analysis (EFA) of the Short Functional Geriatric Evaluation (SFGE) to Assess the Multidimensionality of Frailty in Community-Dwelling Older Adults

The Short Functional Geriatric Evaluation (SFGE) is a multidimensional and short questionnaire to assess biopsychosocial frailty in older adults. This paper aims to clarify the latent factors of SFGE. Data were collected from January 2016 to December 2020 from 8800 community-dwelling older adults participating in the "Long Live the Elderly!" program. Social operators administered the questionnaire through phone calls. Exploratory factor analysis (EFA) was carried out to identify the quality of the structure of the SFGE. Principal component analysis was also performed. According to the SFGE score, 37.7% of our sample comprised robust, 24.0% prefrail, 29.3% frail, and 9.0% very frail individuals. Using the EFA, we identified three main factors: psychophysical frailty, the need for social and economic support, and the lack of social relationships. The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.792, and Bartlett's test of sphericity had a statistically significant result (p-value < 0.001). The three constructs that emerged explain the multidimensionality of biopsychosocial frailty. The SFGE score, 40% of which is social questions, underlines the crucial relevance of the social domain in determining the risk of adverse health outcomes in community-dwelling older adults.

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'.

Background

COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities.

Aims and objectives

This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation.

Methods

The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context.

Findings

A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.

Responding to Covid-19: an analysis of position statements of gerontological societies worldwide

The Covid-19 pandemic, with its adverse implications for older adults, has generated unprecedented public interest in issues around age and ageing globally. We systematically investigated the responses of national gerontological and geriatric societies (NGGS) to emerging challenges during the first wave of the pandemic. Framed within traditional research topics in gerontology, the aim was to identify the spectrum of focal points and positions directed towards governments, policy makers, researchers and society. A comprehensive, two-phased data collection strategy generated N = 22 position statements of NGGS affiliated to the International Association of Gerontology and Geriatrics. Using Ayalon et al. (J Gerontol Ser B, 2020. https://doi.org/10.1093/geronb/gbaa066 ) thematic categorisation of gerontological research, we applied quantitative and qualitative content analysis to analyse "calls for action" within the statements. The content of NGGS' position statements show a high level of agreement on the salient topics during the first wave of the pandemic and reveal shared values such as equality, diversity and inclusion of older adults and the discipline of gerontology to be an applied one with relevance to policy and practice. The results can support future interdisciplinary research in gerontology post Covid-19 based on a vision to contribute to a society of all ages.

Chefs in Future Integrated Healthcare - Current State and Innovation Needs: A First Overview of the NECTAR Project (aN Eu Curriculum for Chef gasTro-Engineering in Primary Food Care)

People in need of care, chronic or acute, often present problematic food intake and special nutritional needs. Integrated, person-centred and pro-active food and nutritional care delivery has been proven effective for people in health care. However, skills mismatches have been reported in different professions involved, which also applies to the role of chefs in healthcare. The EU funded project NECTAR aims at closing this gap by creating a new job profile, called Chef Gastro-Engineering (CGE). The current publication summarizes the status quo in hospitals and gives a perspective on the future role of chefs in integrated healthcare delivery.

Integrated care in Western Europe: a wise solution for the future?

INTRODUCTION

IC is a term commonly adopted across the world underpinning a positive attitude against fragmentation of healthcare service provision. While the principles supporting IC are simple, their implementation is more controversial.

AREAS COVERED

The growing number of IC definitions is related to the increasing domains of applications, which reflect the increasing demand induced by aging multi-morbid patients. A comprehensive definition of IC should now include the coordination of health and social services useful to deliver continuous care across organizational boundaries. The recent debate on IC is largely influenced by the mismatch between the increasing burden of health and social needs for chronic conditions from the demand side, and the design of health-care systems still focused on acute care from the supply side.

EXPERT OPINION

The major reasons of persisting IC weakness in European countries stem from arguable choices of health policy taken in the recent past. The political creed in 'market competition' is probably the most emblematic. All initiatives encouraging health-care providers to compete with each other are likely to discourage IC. Since most European GPs are still self-employed professionals working in their own cabinets, the anachronistic professional status of GPs is another historically rooted reason of IC weakness.

Integrated People-Centred Care in Canada - Policies, Standards, and Implementation Tools to Improve Outcomes

INTRODUCTION

Despite the national and international policy commitment to implement integrated health systems, there is an absence of national standards that support evidence-based design, implementation, and monitoring for improvement. Health Standards Organization (HSO)'s CAN/HSO 76000:2021 - Integrated People-Centred Health Systems (IPCHS) National Standard of Canada (NSC) has been developed to help close this gap. This manuscript outlines the policy context and the process taken to develop the IPCHS standard.

DESCRIPTION

The IPCHS standard is built around 10 design principles with detailed, action-oriented criteria and guidance for policy makers and health system partners. The IPCHS standard was co-designed with a technical committee that included balanced representation of policy makers, health system decision-makers, Indigenous leaders, providers, patients, caregivers, and academics. Additional feedback was received from a diverse audience during two public review periods and targeted consultation via interviews. This qualitative feedback, combined with the evidence reviews completed by the technical committee, informed the final content of the IPCHS standard.

DISCUSSION

The IPCHS standard was developed through a co-design process and complements existing frameworks by providing 66 detailed, action-oriented criteria, with specific guidance. The co-design process and consultations resulted in increased awareness and capacity among policy makers and health system partners. Supplementary tools are also in development to facilitate implementation and monitoring of progress and outcomes. This manuscript was developed in collaboration with technical committee members and HSO staff who led the targeted consultation and adoption of the IPCHS standard in six integrated care networks.

CONCLUSION

Implementing integration strategies requires that we create and sustain a culture of continuous improvement and learning. Key lessons from the development process focused on the importance of co-design, embedding people-centred practices throughout the standard, formal yet iterative methodology inclusive of broad consultation, clear accountability for both policy makers and system partners, tools that support action and can be adapted to local context and level of integrated system maturity.

Active and Healthy Aging After COVID-19 Pandemic in Portugal and Other European Countries: Time to Rethink Strategies and Foster Action

The population aging in Europe imposes challenges to societies that require adaptations and responses at various levels to minimize impacts and figuring out opportunities. Portugal has been committed to the World Health Organization and European Union's values and policy frameworks concerning active and healthy aging. In 2017, an inter-ministerial working group developed the National Strategy for Active and Healthy Aging. In the face of the COVID-19 pandemic that exposed the vulnerabilities of older populations, the launch of the Decade of Healthy Aging 2021-2030 and its baseline report and the 2018 Active Aging Index Analytical Report may constitute an opportunity to strategically think about the aging of the population as a national purpose in Portugal and in the other European countries that face similar challenges.

Integrated health service delivery during COVID-19: a scoping review of published evidence from low-income and lower-middle-income countries

BACKGROUND

Integrated health service delivery (IHSD) is a promising approach to improve health system resilience. However, there is a lack of evidence specific to the low/lower-middle-income country (L-LMIC) health systems on how IHSD is used during disease outbreaks. This scoping review aimed to synthesise the emerging evidence on IHSD approaches adopted in L-LMIC during the COVID-19 pandemic and systematically collate their operational features.

METHODS

A systematic scoping review of peer-reviewed literature, published in English between 1 December 2019 and 12 June 2020, from seven electronic databases was conducted to explore the evidence of IHSD implemented in L-LMICs during the COVID-19 pandemic. Data were systematically charted, and key features of IHSD systems were presented according to the postulated research questions of the review.

RESULTS

The literature search retrieved 1487 published articles from which 18 articles met the inclusion criteria and included in this review. Service delivery, health workforce, medicine and technologies were the three most frequently integrated health system building blocks during the COVID-19 pandemic. While responding to COVID-19, the L-LMICs principally implemented the IHSD system via systematic horizontal integration, led by specific policy measures. The government's stewardship, along with the decentralised decision-making capacity of local institutions and multisectoral collaboration, was the critical facilitator for IHSD. Simultaneously, fragmented service delivery structures, fragile supply chain, inadequate diagnostic capacity and insufficient workforce were key barriers towards integration.

CONCLUSION

A wide array of context-specific IHSD approaches were operationalised in L-LMICs during the early phase of the COVID-19 pandemic. Emerging recommendations emphasise the importance of coordination and integration across building blocks and levels of the health system, supported by a responsive governance structure and stakeholder engagement strategies. Future reviews can revisit this emerging evidence base at subsequent phases of COVID-19 response and recovery in L-LMICs to understand how the approaches highlighted here evolve.

Effect of COVID-19 on health system integration in the Netherlands: a mixed-methods study

OBJECTIVES

Overcrowding in acute care services gives rise to major problems, such as reduced accessibility and delay in treatment. In order to be able to continue providing high-quality health care, it is important that organizations are well integrated at all organizational levels. The objective of this study was to to gain an understanding in which extent cooperation within an urban acute care network in the Netherlands (The Hague) improved because of the COVID-19 crisis.

METHODS

Exploratory mixed-methods questionnaire and qualitative interview study. Semistructured interviews with stakeholders in the acute care network at micro (n = 10), meso (n = 9), and macro (n = 3) levels of organization. Thematic analysis took place along the lines of the 6 dimensions of the Rainbow Model of Integrated Care.

RESULTS

In this study we identified themes that may act as barriers or facilitators to cooperation: communication, interaction, trust, leadership, interests, distribution of care, and funding. During the crisis many facilitators were identified at clinical, professional, and system level such as clear agreements about work processes, trust in each other's work, and different stakeholders growing closer together. However, at an organizational and communicative level there were many barriers such as interference in each other's work and a lack of clear policies.

CONCLUSION

The driving force behind all changes in integration of acute care organizations in an urban context during the COVID-19 crisis seemed to be a great sense of urgency to cooperate in the shared interest of providing the best patient care. We recommend shifting the postcrisis focus from overcoming the crisis to overcoming cooperative challenges.

Big Data-Enabled Analysis of Factors Affecting Patient Waiting Time in the Nephrology Department of a Large Tertiary Hospital

The length of waiting time has become an important indicator of the efficiency of medical services and the quality of medical care. Lengthy waiting times for patients will inevitably affect their mood and reduce satisfaction. For patients who are in urgent need of hospitalization, delayed admission often leads to exacerbation of the patient's condition and may threaten the patient's life. We gathered patients' information about outpatient visits and hospital admissions in the Nephrology Department of a large tertiary hospital in western China from January 1st, 2014, to December 31st, 2016, and we used big data-enabled analysis methods, including univariate analysis and multivariate linear regression models, to explore the factors affecting waiting time. We found that gender (P=0.048), the day of issuing the admission card (Saturday, P=0.028), the applied period for admission (P < 0.001), and the registration interval (P < 0.001) were positive influencing factors of patients' waiting time. Disease type (after kidney transplantation, P < 0.001), number of diagnoses (P=0.037), and the day of issuing the admission card (Sunday, P=0.001) were negative factors. A linear regression model built using these data performed well in the identification of factors affecting the waiting time of patients in the Nephrology Department. These results can be extended to other departments and could be valuable for improving patient satisfaction and hospital service quality by identifying the factors affecting waiting time.