Continuity of care for children with anorexia nervosa in the Netherlands: a modular perspective

Care provision for children with anorexia nervosa is provided by outpatient care teams in hospitals, but the way these teams are organized differs per hospital and hampers the continuity of care. The aim of this study is to explore the organization and continuity of care for children with anorexia nervosa in the Netherlands by using a modular perspective.We conducted a qualitative, exploratory case study and took the healthcare provision for children with anorexia nervosa, provided by outpatient care teams, as our case. We conducted nine interviews with healthcare professionals involved in outpatient care teams from six hospitals. A thematic analysis was used to analyze the data.The modular perspective offered insights into the work practices and working methods of outpatient care teams. We were able to identify modules (i.e. the separate consultations with the various professionals), and components (i.e. elements of these consultations). In addition, communication mechanisms (interfaces) were identified to facilitate information flow and coordination among healthcare professionals. Our modular perspective revealed gaps and overlap in outpatient care provision, consequently providing opportunities to deal with unnecessary duplications and blind spots.   Conclusion: A modular perspective can be applied to explore the organization of outpatient care provision for children with anorexia nervosa. We specifically highlight gaps and overlap in healthcare provision, which in turn leads to recommendations on how to support the three essential parts of continuity of care: informational continuity, relational continuity, and management continuity. What is Known: • Care provision for children with anorexia nervosa requires a network of health care professionals from different organizations, as a result the organization and provision of care faces challenges. What is New: • Modular care provision sheds light on the complexity and organization of outpatient care provision and supports the three dimensions of continuity of care as experienced by children with anorexia nervosa and their parents/caregivers.

[Concordance of medication prescription records in the hospitalised surgical patient]

INTRODUCTION

Electronic prescription is the prescription system that allows healthcare professionals to send medication prescriptions directly to community pharmacies and the outpatient unit of Hospital Pharmacy Services for dispensing. However, there is difficulty in obtaining a reliable pharmacotherapeutic history in chronic patients through electronic prescription upon hospital admission as a critical point for adequate treatment adaptation. Therefore, the pharmacist as a member of the multidisciplinary team must ensure, through medication conciliation, an adequate transition of care through the correct management of the treatment that the chronic patient requires during their hospitalization.

OBJECTIVES

To evaluate the quality of electronic prescription records for routine chronic treatment by analyzing the concordance of the electronic prescription.

MATERIAL AND METHODS

Observational, cross-sectional and retrospective study at the General University Hospital of Elche. Hospitalized patients in charge of the Orthopedic Surgery and Traumatology, Urology and Neurosurgery Services in which the responsible doctor requested medication reconciliation by the Pharmacy Service between January 2022 - December 2022 were included.

RESULTS

378 patients, 209 (55.3%) women and 169 (44.7%) men, with a mean age±standard deviation of 71.0±11.6 years and 69.0±11.8 years, respectively. The total percentage of patients with discrepancies in the electronic prescription with respect to the usual chronic treatment was 60.6%, reflecting that only 39.4% of the patients had non-discordant electronic prescriptions.

CONCLUSIONS

More than half of hospitalized surgical patients present discrepancies in the medications prescribed in the home electronic prescription, which justifies the importance of treatment reconciliation upon admission carried out by hospital pharmacists.

Improving maternal and neonatal outcomes for women with gestational diabetes through continuity of midwifery care: A cross-sectional study

PROBLEM

Gestational Diabetes Mellitus (GDM) is a complication of pregnancy which may exclude women from midwife-led models of care.

BACKGROUND

There is a paucity of research evaluating the safety and feasibility of continuity of midwifery care (CoMC) for women with GDM.

AIM

To investigate the impact of CoMC on maternal and neonatal outcomes, for otherwise low-risk women with GDM.

METHODS

This exploratory cross-sectional study observed maternal and neonatal outcomes including onset of labour, augmentation, labour analgesia, mode of birth, perineal trauma, gestation at birth, shoulder dystocia, infant birth weight, neonatal feeding at discharge.

FINDINGS

Participants were 287 otherwise low-risk pregnant women, who developed GDM, and either received CoMC (n=36) or standard hospital maternity care (non-CoMC) (n=251). Women with GDM who received CoMC were significantly more likely to experience an spontaneous onset of labour (OR 6.3; 95% CI 2.7-14.5; p<.001), labour without an epidural (OR 4.2; 95% CI 2.0 - 9.2,<0.001) and exclusively breastfeed (OR 4.3; 95% CI 1.26 - 14.32; p=0.02).

DISCUSSION

Receiving CoMC may be a public health initiative which not only improves maternal and neonatal outcomes, but also long-term morbidity associated with GDM.

CONCLUSION

Findings provide preliminary evidence suggesting CoMC improves maternal and neonatal outcomes and is likely a safe and viable option for otherwise low-risk women with GDM. Larger studies are recommended to confirm findings and explore the full impact of CoMC for women with GDM.

Women- and clinician- important outcomes and priorities regarding vasa praevia: An international qualitative study to inform development of a core outcome set

BACKGROUND

Many studies have reported interventions for women with vasa praevia to improve perinatal outcomes. However, which outcomes are important for women remains unclear.

AIM

To explore what outcomes are important for women with lived experience of vasa praevia and why, in order to inform the development of a core outcome set for studies on vasa praevia.

METHODS

An international qualitative study was conducted with women and clinicians. Semi-structured interviews were audio-recorded, transcribed, and analysed taking an inductive approach.

FINDINGS

Eighteen women and six clinicians (four obstetricians, two midwives) from the United States, United Kingdom, Canada, and Australia were interviewed. Participants identified 47 patient-important outcomes and experience measures, which were grouped under five themes: baby's survival and health, mother's physical health, mother's mental and emotional health, quality of health care delivery, and resource use and cost. While survival of the baby without short- and long-term morbidity remained the main priority, other important considerations included the physical, mental, social and financial wellbeing of families, future access to antenatal screening and diagnosis, information on management options and consequences, continuity of care, clear and effective communication, peer support and the appreciation of individual variations to risk tolerance, values and resource availability.

CONCLUSION

We have identified patient-important outcomes and experience measures that have been directly fed into the development of a core outcome set on vasa previa. Incorporating these considerations into both clinical practice and future research studies has the potential to improve outcomes and experiences for women with vasa praevia.

Designing a tool ensuring older patients the right medication at the right time after discharge from hospital- the first step in a participatory design process

BACKGROUND

On average, older patients use five or more medications daily, increasing the risk of adverse drug reactions, interactions, or medication errors. Healthcare sector transitions increase the risk of information loss, misunderstandings, unclear treatment responsibilities, and medication errors. Therefore, it is crucial to identify possible solutions to decrease these risks. Patients, relatives, and healthcare professionals were asked to design the solution they need.

METHODS

We conducted a participatory design approach to collect information from patients, relatives, and healthcare professionals. The informants were asked to design their take on a tool ensuring that patients received the correct medication after discharge from the hospital. We included two patients using five or more medications daily, one relative, three general practitioners, four nurses from different healthcare sectors, two hospital physicians, and three pharmacists.

RESULTS

The patients' solution was a physical location providing a medication overview, including side effects and interactions. Healthcare professionals suggested different solutions, including targeted and timely information that provided an overview of the patient's diagnoses, treatment and medication. The common themes identified across all sub-groups were: (1) Overview of medications, side effects, and diagnoses, (2) Sharing knowledge among healthcare professionals, (3) Timely discharge letters, (4) Does the shared medication record and existing communication platforms provide relevant information to the patient or healthcare professional?

CONCLUSION

All study participants describe the need for a more concise, relevant overview of information. This study describes elements for further elaboration in future participatory design processes aimed at creating a tool to ensure older patients receive the correct medication at the correct time.

Women's views and experiences of a new Midwifery Group Practice model in rural Australia

BACKGROUND

Women in rural Australia often have limited maternity care options available, and in Victoria, like many Australian states, numerous small hospitals no longer offer birthing services.

AIM

To evaluate women's views and experiences of maternity care at a local rural hospital that re-established birthing services with a Midwifery Group Practice (MGP) model of maternity care.

METHODS

Women who booked into the new MGP model from May 2021 to June 2022 were invited to complete an anonymous online survey and participate in an optional additional semi-structured interview to explore their views and experiences. Descriptive statistics were used for quantitative data, and open-ended survey and interview responses were analysed using a general inductive approach.

FINDINGS

Sixty-seven percent (44/66) of women completed the survey and five also completed an interview. Women were highly satisfied with the care they received. They felt respected, empowered, and had a sense of agency throughout their pregnancies, labour and birth, and post-birth. They reported low levels of anxiety during labour and birth, and felt that they coped physically and emotionally better than they anticipated. They felt well supported by midwives and highly valued the continuity of care within the MGP model.

CONCLUSION

Women's voices play a critical role in informing maternity care provision, particularly for those in rural communities who may have limited access to care options. The findings support and expand on existing research regarding the value of midwifery continuity of care models, and can inform other rural maternity services in introducing similar models.

The relationship between relational continuity and family physician follow-up after an antidepressant prescription in older adults: a retrospective cohort study

BACKGROUND

Side effects can occur within hours to days of starting antidepressant medications, whereas full therapeutic benefit for mood typically takes up to four weeks. This mismatch between time to harm and lag to benefit often leads to premature discontinuation of antidepressants, a phenomenon that can be partially reversed through early doctor-patient communication and follow-up. We investigated the relationship between relational continuity of care - the number of years family physicians have cared for older adult patients - and early follow-up care for patients prescribed antidepressants.

METHODS

A retrospective cohort study was conducted on residents of Ontario, Canada aged 66 years or older who were dispensed their first antidepressant prescription through the provincial drug insurance program between April 1, 2016, and March 31, 2019. The study utilized multivariable regression to estimate the relationship between relational continuity and 30-day follow-up with the prescribing family physician. Separate estimates were generated for older adults living in urban, non-major urban, and rural communities.

RESULTS

The study found a small positive relationship between relational continuity of care and follow-up care by the prescribing family physician for patients dispensed a first antidepressant prescription (RRR = 1.005; 95% CI = 1.004, 1.006). The relationship was moderated by the patients' location of dwelling, where the effect was stronger for older adults residing in non-major urban (RRR = 1.009; 95% CI = 1.007, 1.012) and rural communities (RRR = 1.006; 95% CI = 1.002, 1.011).

CONCLUSIONS

Our findings do not provide strong evidence of a relationship between relational continuity of care and higher quality management of antidepressant prescriptions. However, the relationship is slightly more pronounced in rural communities where access to continuous primary care and specialized mental health services is more limited. This may support the ongoing need for the recruitment and retention of primary care providers in rural communities.

Impact of continuity of care on older adults diagnosed with mental and behavioural disorders at risk of death due to intentional self-harm: a retrospective Korean cohort study

OBJECTIVES

The aim of this study was to evaluate the impact of continuity of care on older adults diagnosed with mental and behavioural disorders who are at risk of death due to intentional self-harm.

STUDY DESIGN

This was a retrospective cohort study.

METHODS

Data from the Korean National Health Insurance Service-Elderly Cohort Database (2002-2013) were used. A total of 53,980 patients who had visited the outpatient clinic three or more times within the year following the initial diagnosis of mental and behavioural disorders were included. A generalised estimating equation model was generated to examine the impact of continuity of care (CoC) on the risk of death due to intentional self-harm among older adults with mental illnesses.

RESULTS

The risk of death due to intentional self-harm was significantly higher in those with poor CoC for mental and behavioural disorders than in those with good CoC. The risk ratio, adjusting for all covariates, was larger for the Usual Provider of Care index (adjusted risk ratio [aRR]: 1.63, 95% confidence interval [CI]: 1.25-2.12) than for the CoC index (aRR: 1.50, 95% CI: 1.18-1.90), indicating a stronger association with the concentration of contact with the most frequently visited provider.

CONCLUSIONS

Poor CoC among Korean older adults diagnosed with mental and behavioural disorders was identified as a significant risk factor for death due to intentional self-harm. The results of this study highlight the need for interventions that can prevent suicidal behaviour in older adults, such as institutionalising the usual providers of mental health care for older adults.

The effect of a midwifery continuity of care program on clinical competence of midwifery students and delivery outcomes: a mixed-methods protocol

BACKGROUND

The midwifery continuity of care model is one of the care models that have not been evaluated well in some countries including Iran. We aimed to assess the effect of a program based on this model on the clinical competence of midwifery students and delivery outcomes in Ahvaz, Iran.

METHODS

This sequential embedded mixed-methods study will include a quantitative and a qualitative phase. In the first stage, based on the Iranian midwifery curriculum and review of seminal midwifery texts, a questionnaire will be developed to assess midwifery students' clinical competence. Then, in the second stage, the quantitative phase (randomized clinical trial) will be conducted to see the effect of continuity of care provided by students on maternal and neonatal outcomes. In the third stage, a qualitative study (conventional content analysis) will be carried out to investigate the students' and mothers' perception of continuity of care. Finally, the results of the quantitative and qualitative phases will be integrated.

DISCUSSION

According to the nature of the study, the findings of this research can be effectively used in providing conventional midwifery services in public centers and in midwifery education.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1401.460). Also, the study protocol was registered in the Iranian Registry for Randomized Controlled Trials (IRCT20221227056938N1).

Importance of continuity of care from a patient perspective - a cross-sectional study in Swedish health care

OBJECTIVE

The primary objective of this study was to evaluate the patients' view on continuity of care (CoC), including preference for a certain general practitioner (GP) and importance and access to a regular general practitioner (RGP).

DESIGN

Cross-sectional study.

SETTING

Primary care center in Halland County, in the western part of Sweden.

SUBJECTS

Patients ≥18 years old and having at least one appointment at the primary care center during October-December 2022.

MAIN OUTCOME MEASURES

Preference for a certain GP and importance of and accessibility for an RGP.

RESULTS

The study included 404 patients. Importance of having an RGP was considered by 86% of the patients. Preference for a certain GP was thought by 73% of the patients, and when asked as a bivariate question, 69% considered having an RGP. Both the importance of an RGP and preference for a certain GP were more often considered by patients ≥65 years (p < .0001). Regarding accessibility, 67% of the patients reported having access to their RGP 'always/most of the time or a lot of the time' and 62% reported seeing their RGP at last visit.

CONCLUSIONS

In conclusion, this study showed that the majority of patients value CoC in terms of importance of having an RGP. Older patients were more likely to have a preference for a certain GP. Two-third of the patients succeeded in seeing their RGP always or a lot of the time. The results in this study provide evidence that CoC is important for most patients, regardless of age and gender.Key pointsPrevious studies have showed that continuity of care (CoC) is important regarding mortality and morbidity. In primary care, there is a current debate regarding CoC, accessibility and the strive for CoC. This study showed that the majority of patients, regardless of age and gender, value CoC and consider it being important. However, there was a statistically significant difference regarding age, where patients above 65 years old thought it was more important to have a regular general practitioner and more often had a preference for a certain GP.

Follow-up cancer care in Danish general practice - a questionnaire study

BACKGROUND

Increasing longevity and improved cancer treatment have increased the prevalence of cancer survivors substantially and reinforced the need for effective strategies for follow-up cancer care in general practice.

AIM

To investigate the organisation of follow-up cancer care in Danish general practice and to analyse the General Practitioners' (GPs) self-assessment of competences regarding cancer survivors and late effects.

DESIGN & SETTING

A total of 500 Danish GPs were invited to a web-based survey.

METHOD

Questions comprised organisation of follow-up cancer care, and the GPs' self-assessment of their competences in follow-up care and evaluation of late effects. Covariates considered included gender, age, seniority, and practice type. Analyses were conducted using descriptive statistics and multivariable logistic regression models.

RESULTS

Some 29% of the GPs reported systematic organisation of follow-up cancer care in their clinic. Over half of the GPs assessed themselves as competent in evaluating mental sequelae, existential considerations, and the impact on co-morbidities. In contrast, only 19% and 33% of GPs reported competences in sexual and physical sequelae, respectively. Female GPs were less likely to report competences regarding physical and mental sequelae as well as sexual disturbances, and GPs from partnership practices were more likely to report competence in assessing mental sequelae.

CONCLUSION

Less than one of three general practices have organised systematic follow-up cancer care and GPs assess their competence as low with respect to physical sequelae and sexual challenges. This emphasises the need for more systematic organisation and focus on knowledge of late effects in general practice.

A scoping review

One of the most relevant challenges for healthcare providers during the COVID- 19 pandemic has been assuring the continuity of care to patients with complex health needs such as people living with rare diseases (RDs). The COVID-19 pandemic accelerated the healthcare sector's digital transformation agenda. The delivery of telemedicine services instead of many face-to-face procedures has been expanded and, many healthcare services not directly related to COVID-19 treatments shifted online remotely. Many hospitals, specialist centres, patients and families started to use telemedicine because they were forced to. This trend could directly represent a good practice on how care services could be organized and continuity of care could be ensured for patients. If done properly, it could boast improved patient outcomes and become a post COVID-19 major shift in the care paradigm. There is a fragmented stakeholders spectrum, as many questions arise on: how is e-health interacting with 'traditional' healthcare providers; about the role of the European Reference Networks (ERNs); if remote care can retain a human touch and stay patient centric. The manuscript is one of the results of the European Brain Council (EBC) Value of Treatment research project on rare brain disorders focusing on progressive ataxias, dystonia and phenylketonuria with the support of Academic Partners and in collaboration with European Reference Networks (ERNs) experts, applying empirical evidence from different European countries. The main purpose of this work is to investigate the impact of the COVID-19 pandemic on the continuity of care for ataxias, dystonia and phenylketonuria (PKU) in Europe. The analysis carried out makes it possible to highlight the critical points encountered and to learn from the best experiences. Here, we propose a scoping review that investigates this topic, focusing on continuity of care and novel methods (e.g., digital approaches) used to reduce the care disruption. This scoping review was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) standards. This work showed that the implementation of telemedicine services was the main measure that healthcare providers (HCPs) put in place and adopted for mitigating the effects of disruption or discontinuity of the healthcare services of people with rare neurological diseases and with neurometabolic disorders in Europe.

A quality improvement study on the effect of electronic transmission of a basic discharge medication report on medication discrepancies in patients discharged from the hospital

BACKGROUND

Medication discrepancies can occur in transitions of care because of a lack of communication between hospitals and community pharmacies. These discrepancies can lead to preventable adverse drug events (ADEs).

AIM

To investigate the effect of electronic transmission of the basic discharge medication report on unintentional medication discrepancies observed between this report and the 28-day post-discharge status in the community pharmacy.

METHOD

The study took place in a Dutch teaching hospital and 8 community pharmacies. A quality improvement study with a nonrandomized, historically controlled intervention design was performed. The intervention consisted of the electronic transmission of a basic discharge medication report to the community pharmacies. Unintentional medication discrepancies were identified by comparing the basic discharge medication report to the 28-day post-discharge medication record in community pharmacies. The main outcome measure was the proportion of drugs with one or more unintentional discrepancies compared between the historical control group and intervention group, using the chi-square test. Secondary outcome measure was the proportion of patients with one or more unintentional discrepancies.

RESULTS

The participants used a total of 1078 drugs in the control group and 862 in the intervention group. The intervention significantly reduced the proportion of drugs with an unintentional discrepancy from 230 out of 1078 in the control group (21.3%) to 149 out of 862 drugs in the intervention group (17.3%; p = 0.025). At patient level, a non-significant increase was seen (62.4-78.8%; p = 0.41).

CONCLUSION

The electronic transmission of the basic discharge medication report reduced the proportion of drugs with an unintentional discrepancy after discharge, but not the proportion of patients.

Impact of the Russian invasion on opioid agonist therapy programs in Ukraine: A qualitative study

BACKGROUND

Opioid Agonist Treatment (OAT) combines opioid agonist medications with counseling and therapy for a whole-patient approach to treating opioid use disorder. The war in Ukraine threatened the continuity of care and well-being of individuals receiving OAT. This study aimed to capture patients' experiences accessing OAT during the war in Ukraine to provide insights that can inform and improve the programs that serve them.

METHODS

In October - November 2022, we conducted semi-structured interviews with 17 OAT patients who are peer advocates in the Ukrainian Patient Network VOLNA. All interviews were conducted virtually via Zoom, recorded, and transcribed. Through thematic analysis, we generated codes from the transcripts, iteratively using both inductive and deductive approaches.

RESULTS

The qualitative interviews revealed four themes: 1) 'medication,' focusing on concerns about availability, dosage, and quality of OAT; 2) 'patient barriers,' discussing access challenges for specific patient groups, such as refugees or patients living under the occupation; 3) 'clinic-level challenges,' involving dosing adequacy, treatment continuity, patient volume, and clinician stigma, and 4) 'regulatory inflexibility,' describing uneven implementation of regulations and increased policing to receive OAT during the war.

CONCLUSION

Our study emphasizes the importance of adapting OAT programs in Ukraine to better serve vulnerable patients affected by the war. The Russian invasion has severely disrupted OAT provision, increasing the risks of opioid withdrawal, overdose, and diversion. By understanding patients' experiences, treatment preferences, and barriers to care, OAT programs can provide continuity of care to those in need.

What about the fundamentals of nursing-its interventions and its continuity among older people in need of home- or facility-based care: a scoping review

AIM

This scoping review investigated and descriptively summarised previous research about fundamental nursing, its focus (what care needs are described, how is it described and by whom is it described), continuity of care (is it described in relation to fundamental nursing) and possible nursing interventions or activities targeting older people's fundamentals of care needs in home- or facility-based care.

METHODS

This scoping review was carried out following the steps of Arksey and O'Malley's methodology and PRISMA-ScR reporting guidelines. Searches were conducted in PubMed via NIH, CINAHL via EBSCO and PsycInfo via ProQuest for the time period between January 2002 and May 2023.

RESULTS

Forty-two studies were included where the majority had been conducted in a facility-based care context. Nutrition-or rather nutritional care activities targeting eating and drinking-was the most frequently described fundamental care needs addressed. After this came personal care such as cleansing, dressing, oral care, skin, and foot care. Few studies addressed more than one fundamental care need at the time. The nursing staff described fundamental nursing as complex, comprehensive, and demanding. Older people and relatives described a gap between the fundamental nursing provided and their perceived need for support. Less attention was given to older peoples relational and psychosocial needs. Identified nursing interventions mainly targeted physical care needs. Our findings also implied that interventions focusing on fundamental nursing were described as feasible in practice with favourable or moderate results, while long-term effects were difficult to detect. No studies were identified focusing on fundamental nursing in relation to outcomes such as continuity of care.

CONCLUSION

Fundamental nursing was mainly described in relation to physical care needs, which were essentially conducted within facility-based care contexts. Interventions and activities primarily focused on one fundamental need at the time, mainly within the physical domain. No nursing interventions were identified focusing on relational and psychosocial needs where continuity of care can be viewed as a relevant outcome. Such limited focus are especially concerning as research has highlighted the importance of that older people with complex care needs can benefit from a holistic and person-centred approach i.e. fundamental nursing.

TRIAL REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/XJ39E Protocol: http://dx.doi.org/10.1136/bmjopen-2022-069798.

Effectiveness of continuity of care after robot-assisted laparoscopic adrenalectomy under ambulatory mode: a single-center intervention study

To investigate the effectiveness of continuity of care after robot-assisted adrenal tumor resection under ambulatory mode. Patients who underwent robot-assisted laparoscopic adrenalectomy (RALA) in the ambulatory surgery department and urology department of our hospital from January 2022 to January 2023 were selected as study subjects. Among them, 50 patients in the Department of Urology as the control group were given routine care. The 50 patients in the ambulatory surgery department as the observation group were given continuity of care on the basis of routine care. Observation indexes include: wound healing, blood pressure, blood potassium, renal function impairment, self-care ability in daily life, medication compliance, follow-up rate, and patient satisfaction. There were no remarkable discrepancies between the two groups in terms of demographic data and basic preoperative conditions of the patients. Compared with the control group, the observation group significantly improved the patients' wound healing, postoperative blood pressure and blood potassium and kidney function (P value all < 0.05). Compared with the control group, the observation group significantly improved postoperative patients' ADL scores, follow-up rates within three months after surgery, and patient satisfaction scores (P value all < 0.05). For patients receiving ambulatory mode robot-assisted laparoscopic adrenalectomy, continuity of care can effectively reduce postoperative complications, improve patients' postoperative self-care ability in daily life, medication compliance and follow-up rate, and improve patient satisfaction, which is worthy of promotion and application by nursing workers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effectiveness of continuity of care in patients with inflammatory bowel disease: a systematic review

AIM

To investigate the effectiveness of continuity of care in patients with inflammatory bowel disease.

BACKGROUND

The prevalence of inflammatory bowel disease(IBD) is increasing by years, especially in China. Moreover, IBD is prolonged and difficult to heal, which seriously impairs the quality of life of patients. Some studies have identified that continuity of care could contribute to the improvement of the quality of life, but the results remains inconclusive in patients with IBD.

METHODS

PRISMA guidelines was the outline of this study. Review Manager Software (version 5.3) was used to carry out the data analysis. Outcome assessments included quality of life (QoL), remission rates, number of outpatient clinic visits, and medication adherence.

RESULTS

Ultimately, 12 studies involving 2415 patients were brought into this meta-analysis. The results indicated there was no significant difference for continuity of care to improve the QoL in intervention group (SMD = 0.02, 95% CI: -0.08, 0.12). Besides, the remission rates of disease had no difference with those patients in the two groups (OR = 1.07, 95% CI: 0.72, 1.60). However, continued care could contribute to the number of outpatient clinic visits (MD = -0.84, 95% CI: -1.19, -0.49) and patients' adherence to medication significantly (OR = 2.40, 95% CI: 1.16, 4.95).

CONCLUSIONS

IBD patients could benefited from continuity of care with reducing their number of clinic visits and improving medication adherence. Nonetheless, there was no evidence of continuity of care contribute to QoL and remission of disease for these patients.

A flexible approach to measure care coordination based on patient-sharing networks

BACKGROUND

Effective care coordination may increase clinical efficiency, but its measurement remains difficult. The established metric "care density" (CD) measures care coordination based on patient-sharing among physicians, but it may be too rigid to generalize across disorders and countries. Therefore, we propose an extension called fragmented care density (FCD), which allows varying weights for connections between different types of providers. We compare both metrics in their ability to predict hospitalizations due to schizophrenia.

METHODS

We conducted a longitudinal cohort study based on German claims data from 2014 through 2017 to predict quarterly hospital admissions. 21,016 patients with schizophrenia from the federal state Baden-Württemberg were included. CD and FCD were calculated based on patient-sharing networks. The weights of FCD were optimized to predict hospital admissions during the first year of a 24-month follow-up. Subsequently, we employed likelihood ratio tests to assess whether adding either CD or FCD improved a baseline model with control variables for the second follow-up year.

RESULTS

The inclusion of FCD significantly improved the baseline model, Χ2(1) = 53.30, p < 0.001. We found that patients with lower percentiles in FCD had an up to 21% lower hospitalization risk than those with median or higher values, whereas CD did not affect the risk.

CONCLUSIONS

FCD is an adaptive metric that can weight provider relationships based on their relevance for predicting any outcome. We used it to better understand which medical specialties need to be involved to reduce hospitalization risk for patients with schizophrenia. As FCD can be modified for different health conditions and systems, it is broadly applicable and might help to identify barriers and promoting factors for effective collaboration.

Continuity of primary care for type 2 diabetes and hypertension and its association with health outcomes and disease control: insights from Central Vietnam

BACKGROUND

Vietnam is undergoing a rapid epidemiological transition with a considerable burden of non-communicable diseases (NCDs), especially hypertension and diabetes (T2DM). Continuity of care (COC) is widely acknowledged as a benchmark for an efficient health system. This study aimed to determine the COC level for hypertension and T2DM within and across care levels and to investigate its associations with health outcomes and disease control.

METHODS

A cross-sectional study was conducted on 602 people with T2DM and/or hypertension managed in primary care settings. We utilized both the Nijmegen continuity of care questionnaire (NCQ) and the Bice - Boxerman continuity of care index (COCI) to comprehensively measure three domains of COC: interpersonal, informational, and management continuity. ANOVA, paired-sample t-test, and bivariate and multivariable logistic regression analysis were performed to examine the predictors of COC.

RESULTS

Mean values of COC indices were: NCQ: 3.59 and COCI: 0.77. The proportion of people with low NCQ levels was 68.8%, and that with low COCI levels was 47.3%. Primary care offered higher informational continuity than specialists (p < 0.01); management continuity was higher within the primary care team than between primary and specialist care (p < 0.001). Gender, living areas, hospital admission and emergency department encounters, frequency of health visits, disease duration, blood pressure and blood glucose levels, and disease control were demonstrated to be statistically associated with higher levels of COC.

CONCLUSIONS

Continuity of primary care is not sufficiently achieved for hypertension and diabetes mellitus in Vietnam. Strengthening robust primary care services, improving the collaboration between healthcare providers through multidisciplinary team-based care and integrated care approach, and promoting patient education programs and shared decision-making interventions are priorities to improve COC for chronic care.

The meaning of continuity of care from the perspective of older people with complex care needs-A scoping review

People aged 65 years or older with complex care needs are at risk of fragmented care. This may jeopardise patient safety. Complex care needs are defined as care needs that require the performance of time-consuming processes such as reviewing medical history, providing counselling, and prescribing medications. A scoping review was conducted with the aim of mapping the literature regarding continuity of care from the perspective of older people with complex care needs. Search results from seven databases (PubMed, Cinahl, PsycInfo, ASSIA, Web of Science, Google Scholar, Scopus, DOAJ), grey literature (BASE), and a hand-search search of key journals were used. A deductive analysis based on aspects of continuity of care was performed. The search resulted in 5704 records. After a title and abstract screening, 93 records remained. In total, 18 articles met the inclusion criteria and were included in the scoping review. Older people´s sense of continuity of care increases when fewer healthcare workers are involved in their care but help from skilled professionals is more important than meeting the same person. It is vital for older people's feeling of continuity of care that discharge planning involves them, their families, and care providers in an organised way.

Impact of an emergency department nursing intervention on continuity of care, self-care, and psychological symptoms

BACKGROUND

The emergency department plays a crucial role in providing acute care to patients. Nursing interventions in this setting are essential for improving the continuity of care, enhancing patients' self-care abilities, and reducing psychological symp-toms.

AIM

To evaluate the effect of nursing interventions in the emergency department on these indicators in an emergency department.

METHODS

A retrospective analysis was conducted on 120 patients admitted to the emergency department between January 2022 and May 2023. The patients were divided into two groups: The control group (conventional nursing intervention) and the observation group (conventional nursing intervention + emergency department nursing intervention). The two groups were compared regarding continuity of care, self-care ability, psychological symptoms, and satisfaction with care.

RESULTS

The emergency department nursing interventions significantly improved the continuity of care, enhanced patients' self-care abilities, and reduced psychological symptoms such as anxiety and depression.

CONCLUSION

Nursing interventions in the emergency department positively impact continuity of care, self-care, and psychological symptoms. However, it is important to acknowledge the limitations of this study, including the small number of studies, variable methodological quality, and the heterogeneity of the study population. Future research should address these limitations and further explore the effects of different types of nursing interventions in the emergency department. Additionally, efforts should be made to enhance the application and evaluation of these interventions in clinical practice.

Relational continuity may give better clinical outcomes in patients with serious mental illness - a systematic review

BACKGROUND

Continuity of care is considered important for results of treatment of serious mental illness (SMI). Yet, evidence of associations between relational continuity and different medical and social outcomes is sparse. Research approaches differ considerably regarding how to best assess continuity as well as which outcome to study. It has hitherto been difficult to evaluate the importance of relational continuity of care. The aim of this systematic review was to investigate treatment outcomes, including effects on resource use and costs associated with receiving higher relational continuity of care for patients with SMI.

METHODS

Eleven databases were searched between January 2000 and February 2021 for studies investigating associations between some measure of relational continuity and health outcomes and costs. All eligible studies were assessed for study relevance and risk of bias by at least two independent reviewers. Only studies with acceptable risk of bias were included. Due to study heterogeneity the synthesis was made narratively, without meta-analysis. The certainty of the summarized result was assessed using GRADE. Study registration number in PROSPERO: CRD42020196518.

RESULTS

We identified 8 916 unique references and included 17 studies comprising around 300 000 patients in the review. The results were described with regard to seven outcomes. The results indicated that higher relational continuity of care for patients with serious mental illness may prevent premature deaths and suicide, may lower the number of emergency department (ED) visits and may contribute to a better quality of life compared to patients receiving lower levels of relational continuity of care. The certainty of the evidence was assessed as low or very low for all outcomes. The certainty of results for the outcomes hospitalization, costs, symptoms and functioning, and adherence to drug treatment was very low with the result that no reliable conclusions could be drawn in these areas.

CONCLUSIONS

The results of this systematic review indicate that having higher relational continuity of care may have beneficial effects for patients with severe mental illness, and no results have indicated the opposite relationship. There is a need for better studies using clear and distinctive measures of exposure for relational continuity of care.

A content analysis of women's experiences of different models of maternity care: the Birth Experience Study (BESt)

BACKGROUND

Pregnancy, birth, and early parenthood are significant life experiences impacting women and their families. Growing evidence suggests models of maternity care impact clinical outcomes and birth experiences. The aim of this study was to explore the strengths and limitations of different maternity models of care accessed by women in Australia who had given birth in the past 5 years.

METHODS

The data analysed and presented in this paper is from the Australian Birth Experience Study (BESt), an online national survey of 133 questions that received 8,804 completed responses. There were 2,909 open-ended comments in response to the question on health care provider/s. The data was analysed using content analysis and descriptive statistics.

RESULTS

In models of fragmented care, including standard public hospital care (SC), high-risk care (HRC), and GP Shared care (GPS), women reported feelings of frustration in being unknown and unheard by their health care providers (HCP) that included themes of exhaustion in having to repeat personal history and the difficulty in navigating conflicting medical advice. Women in continuity of care (CoC) models, including Midwifery Group Practice (MGP), Private Obstetric (POB), and Privately Practising Midwifery (PPM), reported positive experiences of healing past birth trauma and care extending for multiple births. Compared across models of care in private and public settings, comments in HRC contained the lowest percentage of strengths (11.94%) and the highest percentage of limitations (88.06%) while comments in PPM revealed the highest percentage of strengths (95.93%) and the lowest percentage of limitations (4.07%).

CONCLUSIONS

Women across models of care in public and private settings desire relational maternity care founded on their unique needs, wishes, and values. The strengths of continuity of care, specifically private midwifery, should be recognised and the limitations for women in high risk maternity care investigated and prioritised by policy makers and managers in health services.

TRIAL REGISTRATION

The study is part of a larger project that has been retrospectively registered with OSF Registries Registration DOI https://doi.org/10.17605/OSF.IO/4KQXP .

How midwives facilitate informed decisions in the third stage of labour - an exploration through portraiture

PROBLEM

Midwifery philosophy promotes informed decision-making. Despite this, midwives report a lack of informed decision-making in standard maternity care systems.

BACKGROUND

Previous research has shown a woman's ability to make informed decisions within her maternity care significantly impacts her childbearing experience. When informed decision-making is facilitated, women report positive experiences, whereas when lacking, there is an increased potential for birth trauma.

AIM

To explore midwives' experiences of facilitating informed decision-making, using third-stage management as context.

METHODS

Five midwives from Victoria, Australia, were interviewed about their experiences with informed decision-making. These interviews were guided by portraiture methodology whereby individual narrative portraits were created. This paper explores the shared themes among these five portraits.

FINDINGS

Five individual narrative portraits tell the stories of each midwife, providing rich insight into their philosophies, practices, barriers and enablers of informed decision-making. These are then examined as a whole dataset to explore shared themes, and include; 'informed decision-making is fundamental to midwifery practice' 'the system', and 'navigating the system'. The system contained the sub-themes; hierarchy in hospitals, the medicalisation of birth, and the impact on midwifery practice, and 'navigating the system' - contained; safety of the woman and safety of the midwife, and the gold-standard of midwifery.

DISCUSSION AND CONCLUSION

Midwives in this study valued informed decision-making as fundamental to their philosophy but also faced barriers in their ability to facilitate it. Barriers to informed decision-making included: power-imbalances; de-skilling in physiological birth; fear of blame, and interdisciplinary disparities. Conversely enablers included continuity models of midwifery care, quality antenatal education, respectful interdisciplinary collaboration and an aim toward a resurgence of fundamental midwifery skills.

Organizational structures influencing timely recognition and acknowledgment of end-of-life in hospitals - A qualitative study of nurses' and doctors' experiences

PURPOSE

Healthcare personnel's timely recognition and acknowledgment of end-of-life (EOL) is fundamental for reducing futile treatment, enabling informed decisions regarding the last days or weeks of life, and focusing on high-quality palliative care. The aim of this study is to explore and describe nurses' and doctors' experiences of how organizational structures in hospitals influence timely recognition and acknowledgment of EOL.

METHODS

A qualitative explorative design was applied, with data collected through 12 individual in-depth interviews using a semi-structured interview guide. A total of 6 nurses and 6 doctors were strategically recruited from medical and surgical wards in a Norwegian hospital. Qualitative content analysis was used.

RESULTS

The analysis revealed the theme The importance of hospital organizational structures in timely recognition and acknowledgment of EOL and a subtheme comprising three areas of organizational structures influencing timely recognition and acknowledgment of EOL; Challenges to and demands of continuity, collaboration, and time.

CONCLUSIONS

The study's results show challenges in identifying when cancer patients approach the last weeks and days of life within hospital wards. For nurses and doctors to be able to recognize and acknowledge EOL, continuity of care, collaboration, and time is needed. A fragmented healthcare system, with a predominant focus on treatment and cure, may prevent cancer patients from receiving timely palliative, care causing unnecessary suffering.

Association between initial continuity of care status and diabetes-related health outcomes in older patients with type 2 diabetes mellitus: A nationwide retrospective cohort study in South Korea

BACKGROUND AND AIM

Timely and continuous care is necessary for patients with diabetes to prevent hospitalization and complications. This study investigated the association between initial Continuity of Care Index (COCI) status after diagnosis of type 2 diabetes mellitus (T2DM) and short- and long-term diabetes-related health outcomes.

METHODS

It targeted elderly patients aged 60 years and above diagnosed with T2DM and used the National Health Insurance Service Senior cohort data from 2008 to 2019. The outcome measures were diabetic avoidable hospitalization and diabetic complication incidence for a five-year period. The main independent variable was the first-year COCI status after T2DM diagnosis. Survival analyses were performed using the Cox proportional hazards model.

RESULTS

Participants with a good COCI status within the first year of being diagnosed with T2DM experienced a reduced risk of diabetes-induced avoidable hospitalization (five years: Hazard ratio (HR) 0.39, 95 % Confidence interval (CI) 0.27-0.57; overall period: HR 0.56, 95 % CI 0.43-0.72) and diabetic complications (five years: HR 0.74, 95 % CI 0.68-0.80; overall period: HR 0.77, 95 % CI 0.71-0.82).

CONCLUSIONS

In the short- and long-term, there is a need for early management and improved healthcare accessibility of diabetes to prevent diabetes-avoidable hospitalization and diabetes-related complications.

Primary care utilisation, adherence to guideline-based pharmacotherapy and continuity of care in primary care patients with chronic diseases and multimorbidity - a cross-sectional study

BACKGROUND

To understand how to improve care for patients with chronic diseases and multimorbidity we wanted to describe the prevalence of different chronic diseases and the pattern of multimorbidity and to analyse the associations between occurrence of diseases and primary care utilization, adherence to guideline-based pharmacotherapy, and continuity of care.

METHODS

Retrospective cross-sectional study of routine care data of the general population in region Jönköping in Sweden (345 916 inhabitants using primary care services) covering 4.3 years.

PARTICIPANTS

Patients fulfilling the inclusion criteria of having ≥ 1 of 10 common chronic diseases and ≥ 3 visits to primary care between 2011 and 2015.

PRIMARY OUTCOME MEASURES

In order to determine diseases and multimorbidity, primary care utilisation, adherence to guideline-based pharmacotherapy, frequencies and percentages, interval and ratio scaled variables were described using means, standard deviations, and various percentiles in the population. Two continuity indices were used (MMCI, COC) to describe continuity.

RESULTS

Of the general population, 25 829 patients fulfilled the inclusion criteria (7.5% of the population). Number of diseases increased with increasing age, and multimorbidity was much more common than single diseases (mean 2.0 per patient). There was a slight positive correlation (0.29) between number of diseases and visits, but visits did not increase proportionally to the number of diseases. Patients with physical diseases combined with anxiety and/or depression made more visits than others. The number of diseases per patient was negatively associated with the adherence to pharmacotherapy guidelines. There was no association between continuity and healthcare utilisation or adherence to pharmacotherapy guidelines.

CONCLUSIONS

Multimorbid patients are common in primary care and for many chronic diseases it is more common to have other simultaneous diseases than having only one disease. This can make adherence to pharmacotherapy guidelines a questionable measure for aged multimorbid patients. Existing continuity indices also revealed limitations. Holistic and patient-centred measures should be used for quality assessment of care for multimorbid patients in primary care.

Impact of women's feedback on midwifery student learning: A thematic analysis of students' reflections

PROBLEM

Little is known about the educational impact of providing routine, online feedback from women on midwifery student learning and clinical practice.

BACKGROUND

Feedback on students' clinical performance has historically been provided by lecturers and clinical supervisors. Women's feedback is not routinely collected or evaluated for impact on student learning.

AIM

To evaluate the impact of women's feedback about continuity of care experiences with a midwifery student on learning and practice.

DESIGN

Descriptive, exploratory qualitative study.

METHODS

All second-and third-year Bachelor of Midwifery students undertaking clinical placement between February and June 2022 at one Australian university, submitted formative, guided written reflections on de-identified women's feedback they received through their ePortfolio. Data were analysed using reflexive thematic analysis.

FINDINGS

Forty-four of the 69 eligible students (64%) submitted reflections on feedback received. Three themes emerged: 1) Confidence boosting, 2) Deeply integrating Midwifery Metavalues, and 3) Enhancing commitment to continuity. Three subthemes: connection, future practice and advocacy were identified. Women's feedback positively impacts student learning and places the woman in the educational feedback loop.

CONCLUSION

This study is an international first evaluating the impact of feedback from women on midwifery students' learning. Students reported greater confidence in their clinical practice, a deeper understanding of their midwifery philosophy, and an intention to advocate for, and work in, midwifery continuity models after graduation. Routine feedback about women's experiences should be embedded into midwifery education programs.

Continuity of care in primary healthcare settings among patients with chronic diseases in Saudi Arabia

Introduction

Maintaining continuity of care is one of the most critical components of providing great care in primary health care. This study aimed to explore continuity of care and its predictors in primary healthcare settings among patients with chronic diseases in Saudi Arabia.

Method

Face-to-face cross-sectional interviews were conducted with patients with chronic diseases who had at least four visits to primary care facilities in Riyadh, Saudi Arabia, between November 1, 2022 and March 3, 2023. We determined patients' continuity of care levels using the Bice-Boxerman continuity of care index. A Tobit regression model was used to determine the effects of several factors on the continuity of care index.

Results

The interviews were conducted with 193 respondents with chronic diseases of interest. The mean continuity of care index of the entire sample was 0.54. Those with asthma had the highest median continuity of care index at 0.75 (interquartile range, 0.62-0.75), whereas those diagnosed with thyroid disease had a much lower continuity of care index (0.47) (interquartile range, 0.3-0.62). Tobit regression model findings showed that employed respondents with poorer general health had a negative effect on continuity of care index levels. By contrast, a higher continuity of care index was significantly associated with elderly respondents, urban residents, and those diagnosed with dyslipidemia, diabetes, hypertension, or asthma.

Conclusions

According to our findings, the continuity of care level in Saudi Arabia's primary healthcare setting is low. The data demonstrate how continuity of care varies among study group characteristics and that improving continuity of care among chronic disease patients in Saudi Arabia is multifaceted and challenging, necessitating a coordinated and integrated healthcare delivery approach.

Patient satisfaction of specialist nurse-led renal cancer follow-up

BACKGROUND

For many patients with locally advanced renal cancer, management is surgery followed by surveillance imaging for several years. There is no concrete data regarding specialist nurse follow-up for patients after they have had surgery.

AIMS

The authors' aim was to assess patient satisfaction with specialist nurse follow-up for patients with renal cancer who have undergone surgery.

METHODS

A questionnaire was used to measure patient satisfaction of the specialist nurse consultation. There were 100 patients invited who had been followed up in the nurse-led clinic between January 2020 and May 2021. These patients were given a phone call to complete the questionnaire.

FINDINGS

The audit revealed that in terms of general satisfaction, 97.1% of patients felt totally satisfied with their visit/consultation at the specialist nurse clinic. Furthermore, 94.2% of patients felt that they had good continuity of care with specialist nurse follow-up.

CONCLUSION

Nurse-led follow-up was found to have high levels of patient satisfaction.

What do medical students and their clinical preceptors understand by primary health care in South Africa? A qualitative study

BACKGROUND

The definition of Primary Health Care (PHC) issued by the World Health Organisation in 1978 indicated that essential health care should be made accessible to individuals and their communities close to where they live and work. In 1992 Starfield articulated the four pillars of PHC: the patient's first contact with healthcare, comprehensive care, coordinated care and continuous care. Using this literature guidance, this study sought to explore what undergraduate medical students and their clinical preceptors understood by PHC in four South African medical schools.

METHODS

A qualitative study using the phenomenological design was conducted among undergraduate medical students and their clinical preceptors. The setting was four medical schools in South Africa (Sefako Makgatho Health Sciences University, Walter Sisulu University and the University of KwaZulu-Natal and the Witwatersrand University). A total of 27 in-depth interviews were conducted among the clinical preceptors and 16 focus group discussions among the students who were in their clinical years of training (MBChB 4-6). Interviews were digitally recorded and transcribed verbatim, followed by thematic data analysis using the MAXQDA 2020 (Analytics Pro) software.

RESULTS

Four themes were identified in which there were similarities between the students and their preceptors regarding their understanding of PHC: (1) PHC as the patient's first contact with the healthcare system; (2) comprehensive care; (3) coordination of care and (4) continuity of care. A further two themes were identified in which these two groups were not of similar understanding: (5) PHC as a level or an approach to healthcare and (6) the role of specialist clinical preceptors in PHC.

CONCLUSIONS

Medical students and their clinical preceptors displayed an understanding of PHC in line with four pillars articulated by Starfield and the WHO definition of PHC. However, there remains areas of divergence, on which the medical schools should follow the guidance provided by the WHO and Starfield for a holistic understanding of PHC.

Implementing and evaluating care and support planning: a qualitative study of health professionals' experiences in public polyclinics in Singapore

BACKGROUND

Two polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals' perspectives on CSP to inform future developments.

METHODS

Qualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them.

RESULTS

Both polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP 'going well' all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals' accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers' person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals' ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP.

CONCLUSION

Health professionals' interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Direct and indirect effects of COVID-19 on short-term mortality of breast cancer patients

We studied the COVID-19 impact in newly-diagnosed breast cancer (7,349 patients in 2019, and 5,563 in 2020). In 2020 there were two diagnostic drops: -37.2% (March-May), -15.8% (October-December). Early-stage at presentation (76.4% vs. 74.4%, p = 0.0013), conserving surgery (71.0% vs. 67.0%, p < 0.0001), chemotherapy (86.2% vs. 53.4%, p < 0.0001), and radiotherapy (65.7% vs. 42.1%, p < 0.0001) decreased in 2020 compared to 2019. COVID-19 occurred in 250 patients (4.49%). The time-dependent COVID-19 effect was associated with mortality (multivariable Cox analysis HR [95% CI] 2.26 [1.35-3.74]; p = 0.0018). Survival within the year of diagnosis was 97.6% in 2020 and 98.3% in 2019; 30-day mortality was 1.13% in 2020 (1.07 in uninfected patients), and 0.61% in 2019. The year of diagnosis lost its prognostic relevance after adjusting for stage and treatment. These findings emphasize the critical role of continuity of care, which was disrupted during the pandemic, and underscore the need for policies minimizing treatment initiation delay in newly diagnosed breast cancer patients.

Emergency department patient navigators successfully connect patients to care within a rapidly evolving healthcare system

In the United States, adherence to follow up medical appointments among patients discharged from the emergency department varies between 26% and 56%, depending on the population. It is well known that patients face significant barriers to care within an increasingly complicated system of care. In an effort to better support patients, in 2020, NewYork-Presbyterian Queens implemented a Patient Navigator Program with 7 bilingual Patient Navigators who were trained to deliver culturally sensitive education and support, and to schedule follow up appointments for patients experiencing barriers to care. Between February 2020 and December 2022, 30,164 patients were supported by the 7 Patient Navigators. Ninety-four percent of patients without a primary care provider had a new provider and appointment upon discharge, and 81% of patients attended the appointment scheduled by the Patient Navigator. This study demonstrates that Patient Navigators can work alongside clinical colleagues, and as members of emergency department health care teams, to support patients to connect to care and to attend follow up appointments. It also highlights that Patient Navigators are uniquely qualified to build trust and to support patients to achieve appropriate, continuous care within a rapidly evolving health care system.

[Concept-dependent and -independent care effects of site-specific care concepts using "pain" as an example]

BACKGROUND

Structures of palliative care, cross-sectoral transitions and care pathways of patients with palliative care needs were investigated at two sites. The systematic comparison of similarities and differences using the topic of 'pain' as an example is intended to provide information on the extent to which these are related to site-specific palliative care concepts (integrated and cooperative).

METHODS

The study follows a mixed-methods design. In addition to a document analysis of anonymised patient records (n = 774), expert interviews (n = 20), as well as interviews with patients, relatives (n = 60) and focus groups (n = 12), were conducted.

RESULTS

The systematic comparative analysis provides evidence for concept-independent commonalities (e.g. sociodemographic distribution, aggravated pain treatment) as well as concept-dependent differences (e.g. care pathways, facilitated continuous symptom control through integrated care structures) in the context of integrated or cooperative palliative care.

DISCUSSION

Commonalities and differences with regard to the topic of pain, as focused on here, and its organisational management become tangible as effects of the respective organisational structure (= concept-dependent) as well as concept-independent external influencing factors.

Pros and cons of quick returns-a cross-sectional survey among Swedish nurses and nurse assistants

Short rest (<11h) between evening and day shifts-known as quick returns (QRs)-impede recovery and may impair health. Nevertheless, QRs remain popular among some shift workers. This study explores nurses' and nurse assistants' perceptions of the merits and demerits of QRs from individual and organizational perspectives. Participants were recruited from eleven wards at two Swedish hospitals as part of a larger quasi-experimental intervention study. The majority (79%) had influence over their work schedules. Frequency distributions of responses are presented. Ninety six undertook a baseline survey regarding recovery, tolerance and work performance in relation to QRs. A majority experienced difficulties unwinding before bedtime (76%), insufficient sleep (80%), and daytime fatigue (72%). A third experienced an increased risk of errors and mistakes. However, QRs appeared to facilitate taking reports from patients and planning work, as this task was more often rated as 'very easy' following a QR compared to other shift combinations. Tolerance of QRs varied substantially. In conclusion, QRs seem to benefit continuity in work processes, but may do so at the expense of recovery and safety. Wards planning to reduce QRs-through participatory or fixed schedule models-should consider impacts on work processes.

Perception of transitional care quality associated with functional outcomes among patients with fractures and stroke in Taiwan

This study aimed to examine the relationship between self-perceived quality of transitional care and functional outcome among patients with stroke and fractures. The Care Transition Measure (CTM-15) was used to survey patient's self-perceived transitional care quality before discharge. General estimating equations were used to investigate the influences of transitional care quality on patient's functional outcomes at before, 1 week after, and 1 or 3 months after discharge. Among stroke patients, higher CTM-15 scores were positively associated with greater outcome in Instrumental Activities of Daily Living (IADL) following discharge. Higher scores for "reader-friendly written care plan," "consideration of patient's preferences," and "understanding of health management" had significantly positive effects on functional recovery in IADL among both patient groups following discharge. These findings suggest that heterogeneity in transitional care needs between medical and surgical patients shall not be overlooked. A one-size-fits-all strategy may be insufficient for ensuring patient care continuity following discharge.

Comparing the views of caseload midwives working with First Nations families in an all-risk, culturally responsive model with midwives working in standard caseload models, using a cross-sectional survey design

PROBLEM

Little is known about midwives' views and wellbeing when working in an all-risk caseload model.

BACKGROUND

Between March 2017 and December 2020 three maternity services in Victoria, Australia implemented culturally responsive caseload models for women having a First Nations baby.

AIM

Explore the views, experiences and wellbeing of midwives working in an all-risk culturally responsive model for First Nations families compared to midwives in standard caseload models in the same services.

METHODS

A survey was sent to all midwives in the culturally responsive (CR) model six-months and two years after commencement (or on exit), and to standard caseload (SC) midwives two years after the culturally responsive model commenced. Measures used included the Midwifery Process Questionnaire and Copenhagen Burnout Inventory (CBI).

FINDINGS

35 caseload midwives (19 CR, 16 SC) participated. Both groups reported positive attitudes towards their professional role, trending towards higher median levels of satisfaction for the culturally responsive midwives. Midwives valued building close relationships with women and providing continuity of care. Around half reported difficulty maintaining work-life balance, however almost all preferred the flexible hours to shift work. All agreed that a reduced caseload is needed for an all-risk model and that supports around the model (e.g. nominated social workers, obstetricians) are important. Mean CBI scores showed no burnout in either group, with small numbers of individuals having burnout in both groups.

DISCUSSION AND CONCLUSION

Midwives were highly satisfied working in both caseload models, but decreased caseloads and more organisational supports are needed in all-risk models.

Continuity of health care: measurement and application in two rural counties of Guangxi Province, China

BACKGROUND

Continuity of care (COC) is highly regarded in health promotion and health system strengthening. However, there is a lack of multidimensional quantitative assessment of continuity, making it challenging to evaluate and compare. Our objective was to create a novel measurement for COC and apply it in two rural counties in China to assess its validity and feasibility in evaluating health system reform.

METHOD

This study conducted a scoping literature review on COC, examining existing frameworks and indicators. Following an online expert poll, a composite indicator was developed using the analytical hierarchy process (AHP). The measurement tool was then applied to assess the current state of COC in two rural counties in China. In addition to descriptive analysis, demographic and economic characteristics were analyzed for their association with COC scores using t-tests and multiple linear regression models.

RESULTS

The final COC measurement encompasses three dimensions, six sub-dimensions, and ten individual indicators, which integrated and improved the current frameworks and indicators. Relational continuity, informational continuity, and management continuity were identified as the primary dimensions of COC measurement. The COC score is 0.49 in County A and 0.41 in County B, with information continuity being the highest-scoring dimension. Notably, the disparity in continuity scores is most pronounced among individuals with varying attitudes towards health, demonstrating a positive correlation.

CONCLUSION

The construction of the composite indicator in this study offers a scientific and effective metric for comprehensively measuring continuity of care. The empirical data analysis conducted in Western China serves as an illustrative application of the indicator, demonstrating its efficiency. The results obtained from this analysis provide a solid foundation and valuable reference for strengthening the health system.

Implementation and evaluation of a complex intervention to improve information availability at the interface between inpatient and outpatient care in older patients with multimorbidity and polypharmacy (HYPERION-TransCare) - study protocol for a pilot and feasibility cluster-randomized controlled trial in general practice in Germany

BACKGROUND

Despite attempts to improve the cross-sectoral flow of information, difficulties remain in routine healthcare. The resulting negative impact on continuity of care is often associated with poor health outcomes, especially in older patients. Our intervention aims to increase information availability with respect to medications and health conditions at the interface between inpatient and outpatient care and to contribute towards improving the quality of care in older patients. This pilot study focuses on feasibility and implementability.

METHODS

The idea of the complex intervention has been developed in a previous study. This intervention will be tested in a prospective, multicenter, cluster-randomized (via web tool), controlled pilot trial with two parallel study arms (intervention and control group). The pilot study will be conducted in 20 general practices in Hesse and Saxony (Germany) and include 200 patients (≥ 65 years of age with multimorbidity and polypharmacy) recruited by the practices. Practice staff and patients will be blinded. We will use qualitative and quantitative methods to assess the feasibility and implementability of the intervention and the study design in a process evaluation covering topics ranging from expectations to experiences. In addition, the feasibility of proposed outcome parameters for the future definitive trial will be explored. The composite endpoint will include health-related patient outcomes (hospitalization, falls, and mortality using, e.g., the FIMA questionnaire), and we will assess information on medications (SIMS questionnaire), symptoms and side effects of the medication (pro-CTCAE questionnaire), and health literacy (HLQ questionnaire). Data will be collected at study begin (baseline) and after 6 months. Furthermore, the study will include surveys and interviews with patients, general practitioners, and healthcare assistants.

DISCUSSION

The intervention was developed using a participatory approach involving stakeholders and patients. It aims to empower general practice teams as they provide patient-centered care and play a key role in the coordination and continuity of care. We aim to encourage patients to adopt an active role in their health care. Overall, we want to increase the availability of health-related information for patients and healthcare providers. The results of the pilot study will be used in the design and implementation of the future definitive trial.

TRIAL REGISTRATION

The study was registered in DRKS-German Clinical Trials Register: registration number DRKS00027649 (date: 19 January 2022). Date and version identifier 10.07.2023; Version 1.3.

Organisation and integrated healthcare approaches for people living with HIV, multimorbidity, or both: a systematic review

BACKGROUND

Universal recommendation for antiretroviral drugs and their effectiveness has put forward the challenge of assuring a chronic and continued care approach to PLHIV (People Living with HIV), pressured by aging and multimorbidity. Integrated approaches are emerging which are more responsive to that reality. Studying those approaches, and their relation to the what of delivery arrangements and the how of implementation processes, may support future strategies to attain more effective organizational responses.

METHODS

We reviewed empirical studies on either HIV, multimorbidity, or both. The studies were published between 2011 and 2020, describing integrated approaches, their design, implementation, and evaluation strategy. Quantitative, qualitative, or mixed methods were included. Electronic databases reviewed cover PubMed, SCOPUS, and Web of Science. A narrative analysis was conducted on each study, and data extraction was accomplished according to the Effective Practice and Organisation of Care taxonomy of health systems interventions.

RESULTS

A total of 30 studies, reporting 22 different interventions, were analysed. In general, interventions were grounded and guided by models and frameworks, and focused on specific subpopulations, or priority groups at increased risk of poorer outcomes. Interventions mixed multiple integrated components. Delivery arrangements targeted more frequently clinical integration (n = 13), and care in proximity, community or online-telephone based (n = 15). Interventions reported investments in the role of users, through self-management support (n = 16), and in coordination, through multidisciplinary teams (n = 9) and continuity of care (n = 8). Implementation strategies targeted educational and training activities (n = 12), and less often, mechanisms of iterative improvement (n = 3). At the level of organizational design and governance, interventions mobilised users and communities through representation, at boards and committees, and through consultancy, along different phases of the design process (n = 11).

CONCLUSION

The data advance important lessons and considerations to take steps forward from disease-focused care to integrated care at two critical levels: design and implementation. Multidisciplinary work, continuity of care, and meaningful engagement of users seem crucial to attain care that is comprehensive and more proximal, within or cross organizations, or sectors. Promising practices are advanced at the level of design, implementation, and evaluation, that set integration as a continued process of improvement and value professionals and users' knowledge as assets along those phases.

TRIAL REGISTRATION

PROSPERO number CRD42020194117.

Healthcare fragmentation, multimorbidity, potentially inappropriate medication, and mortality: a Danish nationwide cohort study

BACKGROUND

Patients with multimorbidity are frequent users of healthcare, but fragmented care may lead to suboptimal treatment. Yet, this has never been examined across healthcare sectors on a national scale. We aimed to quantify care fragmentation using various measures and to analyze the associations with patient outcomes.

METHODS

We conducted a register-based nationwide cohort study with 4.7 million Danish adult citizens. All healthcare contacts to primary care and hospitals during 2018 were recorded. Clinical fragmentation indicators included number of healthcare contacts, involved providers, provider transitions, and hospital trajectories. Formal fragmentation indices assessed care concentration, dispersion, and contact sequence. The patient outcomes were potentially inappropriate medication and all-cause mortality adjusted for demographics, socioeconomic factors, and morbidity level.

RESULTS

The number of involved healthcare providers, provider transitions, and hospital trajectories rose with increasing morbidity levels. Patients with 3 versus 6 conditions had a mean of 4.0 versus 6.9 involved providers and 6.6 versus 13.7 provider transitions. The proportion of contacts to the patient's own general practice remained stable across morbidity levels. High levels of care fragmentation were associated with higher rates of potentially inappropriate medication and increased mortality on all fragmentation measures after adjusting for demographic characteristics, socioeconomic factors, and morbidity. The strongest associations with potentially inappropriate medication and mortality were found for ≥ 20 contacts versus none (incidence rate ratio 2.83, 95% CI 2.77-2.90) and ≥ 20 hospital trajectories versus none (hazard ratio 10.8, 95% CI 9.48-12.4), respectively. Having less than 25% of contacts with your usual provider was associated with an incidence rate ratio of potentially inappropriate medication of 1.49 (95% CI 1.40-1.58) and a mortality hazard ratio of 2.59 (95% CI 2.36-2.84) compared with full continuity. For the associations between fragmentation measures and patient outcomes, there were no clear interactions with number of conditions.

CONCLUSIONS

Several clinical indicators of care fragmentation were associated with morbidity level. Care fragmentation was associated with higher rates of potentially inappropriate medication and increased mortality even when adjusting for the most important confounders. Frequent contact to the usual provider, fewer transitions, and better coordination were associated with better patient outcomes regardless of morbidity level.

[Perception of barriers and facilitators in the continuity of care for precarious migrants in general practice]

INTRODUCTION

Continuity of care is essential for the diagnosis and treatment of somatic and mental conditions in precarious migrants. This study explored the barriers and facilitators in the continuity of care provided to precarious migrants in general practice.

METHODS

A qualitative study was carried out based on semi-directed interviews with twenty precarious migrants. The term “medical follow-up” was used in the interview grid to represent the concept of continuity of care. The verbatims were analyzed using the grounded theory approach, with data analysis triangulation.

RESULTS

Precarious migrants described the medical follow-up as repeated access to the same doctor for all their health problems. This follow-up was limited by difficulties in accessing health insurance and guidance in the health system, and by language and cultural barriers. Conversely, the physician’s clinical and interpersonal skills, the presence of a translator, the support from the migrants’ family circle and associations, and some organizations of the care structure facilitated their medical follow-up.

CONCLUSIONS

Relational, managerial, and informational continuities of care provided to precarious migrants should be optimized in a synergistic manner. To achieve this, it is necessary to improve doctors’ training in communication with migrants, medical information sharing and migrants’ education to the appropriate use of the healthcare system, in order to encourage their gradual empowerment in their care pathway.

Handling polypharmacy -a qualitative study using focus group interviews with older patients, their relatives, and healthcare professionals

BACKGROUND

On average, older patients use five or more medications daily. A consequence is an increased risk of adverse drug reactions, interactions, or medication errors. Therefore, it is important to understand the challenges experienced by the patients, relatives, and healthcare professionals pertinent to the concomitant use of many drugs.

METHODS

We conducted a qualitative study using focus group interviews to collect information from patients, relatives, and healthcare professionals regarding older patients' management of prescribed medicine. We interviewed seven patients using five or more medications daily, three relatives, three general practitioners, nine nurses from different healthcare sectors, one home care assistant, two hospital physicians, and four pharmacists.

RESULTS

The following themes were identified: (1) Unintentional non-adherence, (2) Intentional non-adherence, (3) Generic substitution, (4) Medication lists, (5) Timing and medication schedule, (6) Medication reviews and (7) Dose dispensing/pill organizers.

CONCLUSION

Medication is the subject of concern among patients and relatives. They become confused and insecure about information from different actors and the package leaflets. Therefore, patients often request a thorough medication review to provide an overview, knowledge of possible side effects and interactions, and a clarification of the medication's timing. In addition, patients, relatives and nurses all request an indication of when medicine should be taken, including allowable deviations from this timing. Therefore, prescribing physicians should prioritize communicating information regarding these matters when prescribing.

Care provided by midwives and the unmet needs of pregnant and postpartum women: A qualitative study of Japanese mothers

Objectives

We aimed to clarify the content of care provided by midwives working in hospitals and clinics in Japan and the unmet needs in midwifery care from mothers' perspectives.

Design

This study employed a qualitative approach through semi-structured interviews.

Setting

Fifteen Japanese women, whose youngest singleton children were aged 12-18 months, were asked to recall their experiences with midwives, from pregnancy through the first postpartum year. Verbatim records were analyzed using thematic analysis.

Results

Seven themes regarding the care provided by midwives were generated: confirmation of physical condition, maintenance and promotion of perinatal physiological process, support for better preparation for childbirth, assistance in labour and childbirth, support for a new life with a baby at home, support for the family, and care for comfort and confidence as a mother. Unmet needs were identified in all themes, except for 'confirmation of physical condition' and 'support for the family'. Ten subthemes, under the five themes of unmet needs, were integrated into three categories: midwives' responses to potential concerns, lack of continuity of care, and lack of personalised care.

Key conclusions and implications for practice

Midwives in hospitals and clinics in Japan mainly provided care from pregnancy to one-month postpartum, in line with global core competencies. However, they could respond more effectively to the potential concerns of women, and provide continuous, personalised care more sufficiently. Improving working environments for midwives and collaborating with postpartum public health services are key to addressing these unmet needs of women, leading to women-centred care.

Integrated growth assessment in the first 1000 d of life: an interdisciplinary conceptual framework

OBJECTIVES

Prenatal growth affects short- and long-term morbidity, mortality and growth, yet communication between prenatal and postnatal healthcare teams is often minimal. This paper aims to develop an integrated, interdisciplinary framework for foetal/infant growth assessment, contributing to the continuity of care across the first 1000 d of life.

DESIGN

A multidisciplinary think-tank met regularly over many months to share and debate their practice and research experience related to foetal/infant growth assessment. Participants’ personal practice and knowledge were verified against and supplemented by published research.

SETTING

Online and in-person brainstorming sessions of growth assessment practices that are feasible and valuable in resource-limited, low- and middle-income country (LMIC) settings.

PARTICIPANTS

A group of obstetricians, paediatricians, dietitians/nutritionists and a statistician.

RESULTS

Numerous measurements, indices and indicators were identified for growth assessment in the first 1000 d. Relationships between foetal, neonatal and infant measurements were elucidated and integrated into an interdisciplinary framework. Practices relevant to LMIC were then highlighted: antenatal Doppler screening, comprehensive and accurate birth anthropometry (including proportionality of weight, length and head circumference), placenta weighing and incorporation of length-for-age, weight-for-length and mid-upper arm circumference in routine growth monitoring. The need for appropriate, standardised clinical records and corresponding policies to guide clinical practice and facilitate interdisciplinary communication over time became apparent.

CONCLUSIONS

Clearer communication between prenatal, perinatal and postnatal health care providers, within the framework of a common understanding of growth assessment and a supportive policy environment, is a prerequisite to continuity of care and optimal health and development outcomes.

The Role of Nurses in the Quality of Cancer Care Management: Perceptions of Cancer Survivors and Oncology Teams

OBJECTIVES

This study aimed to explore the perceptions of cancer survivors and oncology professionals of quality in cancer care and the role of oncology nurses in prompting and maintaining quality across the cancer care continuum.

DATA SOURCES

Semistructured in-depth interviews were conducted with 16 cancer survivors and 22 healthcare professionals between August and October 2021. The interviews were transcribed and analyzed using ATLAS.ti v8 software according to a thematic analysis method based on grounded theory. The COnsolidated criteria for REporting Qualitative research (COREQ) was used to guide the report of the study.

CONCLUSION

Four main themes emerged from the interviews, which are outlined as follows. (1) Patient participation in the cancer care plan: shared information and decision-making; (2) emotional and support aspects in cancer care; (3) continuity in cancer care: from being a patient at the hospital to a survivor in the community; and (4) cancer care management. Cancer survivors pointed to elements that can increase the quality of cancer care, including the ongoing provision of information, support in decision-making, and continuity of care. Oncology staff interviewees mentioned the need for a single staff member to manage the cancer care plan and serve as a case manager for patients and survivors.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have a central role in achieving the highest possible quality of cancer care for the growing number of survivors and their families. It is recommended to expand the role of oncology nurses, providing them the training and competencies needed to formally declare them as care managers throughout the continuum of cancer care.

Continuity and care coordination of primary health care: a scoping review

BACKGROUND

Healthcare coordination and continuity of care conceptualize all care providers and organizations involved in health care to ensure the right care at the right time. However, systematic evidence synthesis is lacking in the care coordination of health services. This scoping review synthesizes evidence on different levels of care coordination of primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published evidence on healthcare coordination. PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science and Google Scholar were searched until 30 November 2022 for studies that describe care coordination/continuity of care in PHC and primary care. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines to select studies. We analysed data using a thematic analysis approach and explained themes adopting a multilevel (individual, organizational, and system) analytical framework.

RESULTS

A total of 56 studies were included in the review. Most studies were from upper-middle-income or high-income countries, primarily focusing on continuity/care coordination in primary care. Ten themes were identified in care coordination in PHC/primary care. Four themes under care coordination at the individual level were the continuity of services, linkage at different stages of health conditions (from health promotion to rehabilitation), health care from a life-course (conception to elderly), and care coordination of health services at places (family to hospitals). Five themes under organizational level care coordination included interprofessional, multidisciplinary services, community collaboration, integrated care, and information in care coordination. Finally, a theme under system-level care coordination was related to service management involving multisectoral coordination within and beyond health systems.

CONCLUSIONS

Continuity and coordination of care involve healthcare provisions from family to health facility throughout the life-course to provide a range of services. Several issues could influence multilevel care coordination, including at the individual (services or users), organizational (providers), and system (departments and sectors) levels. Health systems should focus on care coordination, ensuring types of care per the healthcare needs at different stages of health conditions by a multidisciplinary team. Coordinating multiple technical and supporting stakeholders and sectors within and beyond health sector is also vital for the continuity of care especially in resource-limited health systems and settings.