Validation of the RIM Score-COVID in the Spanish SEMI-COVID-19 Registry

The significant impact of COVID-19 worldwide has made it necessary to develop tools to identify patients at high risk of severe disease and death. This work aims to validate the RIM Score-COVID in the SEMI-COVID-19 Registry. The RIM Score-COVID is a simple nomogram with high predictive capacity for in-hospital death due to COVID-19 designed using clinical and analytical parameters of patients diagnosed in the first wave of the pandemic. The nomogram uses five variables measured on arrival to the emergency department (ED): age, sex, oxygen saturation, C-reactive protein level, and neutrophil-to-platelet ratio. Validation was performed in the Spanish SEMI-COVID-19 Registry, which included consecutive patients hospitalized with confirmed COVID-19 in Spain. The cohort was divided into three time periods: T1 from February 1 to June 10, 2020 (first wave), T2 from June 11 to December 31, 2020 (second wave, pre-vaccination period), and T3 from January 1 to December 5, 2021 (vaccination period). The model's accuracy in predicting in-hospital COVID-19 mortality was assessed using the area under the receiver operating characteristics curve (AUROC). Clinical and laboratory data from 22,566 patients were analyzed: 15,976 (70.7%) from T1, 4,233 (18.7%) from T2, and 2,357 from T3 (10.4%). AUROC of the RIM Score-COVID in the entire SEMI-COVID-19 Registry was 0.823 (95%CI 0.819-0.827) and was 0.834 (95%CI 0.830-0.839) in T1, 0.792 (95%CI 0.781-0.803) in T2, and 0.799 (95%CI 0.785-0.813) in T3. The RIM Score-COVID is a simple, easy-to-use method for predicting in-hospital COVID-19 mortality that uses parameters measured in most EDs. This tool showed good predictive ability in successive disease waves.

A questionnaire to measure the impact of ICT-based coordination mechanisms on clinical coordination

Background

In national health systems based on primary care, cross-level clinical coordination (CC) is a priority, as it may improve quality of care. Evidence on the impact of information and communication technology (ICT)-based coordination mechanisms on CC is inconclusive. The implementation of those mechanisms increased during the pandemic. The aim is to adapt the validated COORDENA-CAT questionnaire, for measuring CC, to analyse the implementation of ICT-based coordination mechanisms and its impact on CC in three regions of Spain.

Methods

The COORDENA-CAT questionnaire underwent a two-stage adaptation process:1) contents revision based on literature review, expert discussions, and pretest to adapt the contents and language and produce a version for each region; and 2) piloting the adapted version by self-administration of the questionnaire to primary and secondary care doctors in the health systems of two of the participating regions.

Results

The adapted version (COORDENA-TICs) kept most of the original contents. Main changes were on coordination mechanisms section. Pretest showed an adequate level of comprehensiveness, comprehension, sequence of themes and questions, and length. A low non-response rate was observed, with little variability or unexpected responses. The question on any difficulties encountered in answering the questionnaire revealed no relevant difficulties. The Shared Electronic Medical Record of each region was the most frequently used ICT-based coordination mechanism. Limited access to information and technical issues related to its use were the most common difficulties encountered. Suggestions for improving its use were receiving specific training on its use.

Conclusions

COORDENA-TICs questionnaire is a useful tool to assess utilization of ICT-based coordination mechanisms and its impact on CC from the perspective of primary and secondary care doctors. It will allow comparisons across areas, regions and to evaluate changes over time

Key messages

Access to health services for non-Covid-19 causes during the pandemic. A literature review

Background

Negative effects of the Covid-19 pandemic on access to care for other diseases are currently at debate.

Aim

To review existing literature on care access for non-Covid-19 conditions since the pandemic onset.

Methods

Scoping review using various databases (Medline, VHL, Web of Science, 2020/21). Terms used: ‘access', ‘health services', ‘Covid-19'. Out of 4,060 identified articles, 37 were selected after reviewing and assessing titles, abstracts and full text. Aday and Andersen's framework guided the analysis.

Results

Of selected articles, 21 analyse impact on health services use; 8 on performance; 8 on access barriers. Most analyse specific services during early pandemic stages through register review, showing an initial decline in use with inconsistent results on recovery. Some indicate increased complexity of treated patients and treatment delays. Studies surveying professionals analyse the impact on services performance or clinical practice, reporting a decrease in consultations/interventions for diverse pathologies and response implementation (e.g. telemedicine), but not how they affected access. Few studies focus on social inequalities in use, showing a greater reduction in low-income or ethnic minority users. Studies on unmet needs, access or barriers based on user surveys or qualitative methods are scarce, focused on a pathology or clinical area. Particularly in Spain, studies analyse impact on use of emergency, primary care and cancer diagnosis, and on emergency and cardiology services functioning. Studies based on user surveys are lacking: only a qualitative study analysed access difficulties for chronic patients in confinement. Methodological weaknesses are identified.

Conclusions

Although currently emerging, studies analysing the pandemic impact on equal access to care for non-Covid-19 conditions are scarce, limited in focus and methodology, especially in Spain. Comprehensive medium/long-term impact assessments, including analysis of causes, are needed.

Key messages

Research is lacking on the impact of the COVID-19 pandemic on healthcare access, particularly for vulnerable groups. Further evidence is needed to improve health systems resilience in the future.

Understanding how to improve the use of clinical coordination mechanisms between levels of care

Background

Clinical coordination mechanisms (CCM) can play an important role in improving clinical coordination between primary (PC) and secondary care (SC) doctors, being necessary to understand the reasons hindering their use. The aim is to analyse the level of use of CCM, and the difficulties and factors associated to it.

Methods

Cross-sectional study based on an online survey using the COORDENA-CAT questionnaire (October-December 2017). Sample: 3308 doctors of the Catalan national health system. Outcome variables: frequent use of six CCM and difficulties in their use. Explanatory variables: sociodemographic, labour characteristics, organizational and interactional factors. Stratification variable: level of care. Analysis: descriptive bivariate and multivariate by logistic regression.

Results

The level of use differed according to the CCM and level of care, being lower for the different cross-level consultations (via electronic medical record -EMR: 52.36%, email: 26.11% and phone: 21.73%). Shared EMR of the organisation (81.27%) and of the region (65.89%), and joint clinical case conferences (63.28%) were the most frequently used, especially by PC doctors, and the ones presenting more difficulties in use. While the difficulties pointed to organizational problems, mostly related to computer and schedule problems, the analysis of factors pointed also to some individual factors. Working in integrated areas or with local hospitals were factors positively associated with the use of CCM. Interactional factors, such as personally knowing the other level doctor, were associated among SC doctors.

Conclusions

The use of CCM differed across mechanisms and level of care, and was clearly improvable. Difficulties and factors affecting their use were mostly organizational, so managerial support is required to create the appropriate conditions for their use. It is also important to strengthen interaction between doctors of different care levels to improve the use of CCM.

Key messages

The level of use of CCM differed according to the mechanism and level of care, and was clearly improvable. This study identifies difficulties and factors affecting their use, mainly organizational. These results are useful for managers promoting strategies to improve clinical coordination by the effective implementation of CCM, which require managerial support and interaction between doctors.

Factors influencing participatory intervention implementation to improve care coordination

Background

Problems related to care coordination are identified as challenges to the organization of health systems. In order to improve coordination, it is necessary to invest in interventions that promote collaboration between levels of care. The study analyzes factors influencing the implementation of the intervention joint meetings between levels of care, guided by participatory action research to improve clinical coordination from the perspective of actors involved in a public health care network in Brazil.

Methods

Qualitative descriptive-interpretative study carried out in the health network of a municipality in the northeast of Brazil. Ten interviews were conducted to managers and health professionals, members of local steering committee and focus group with primary care physicians and specialists participating in the intervention. Thematic content analysis was used; it generated categories from theoretical and emerging frameworks.

Results

The willingness of professionals and management support to participate of the intervention process emerge as fundamental factors. However, they are influenced by factors of the system, such as electoral period and management change and these reflected on the slowdown and instability in implementation process. In the health network, turnover of professionals and low trust between primary and specialized care were evidenced as challenges. However, the proactive role of local steering committee, driven by participatory strategy for development of the intervention, promoted reflections and decisions agreed between professionals and managers. This rebounded on adjustments to strengthen the intervention and improvements on knowledge and collaboration between levels.

Conclusions

analysis of factors contributes to reflection on changes in the context, adaptation of intervention over time and importance of the role of professionals. Such understanding becomes essential for sustainability and improvement of care coordination.

Key messages

Knowledge about factors that influence implementation of an intervention guided by participatory action research contributes to the development of strategies aimed at its sustainability. Contextual factors that hamper improvements implementation to coordination of care can be overcome through participatory strategies mobilizing health professionals and managers.

Effectiveness of interventions related to continuity of health care in five Latin America countries

Background

Evaluation of interventions to improve continuity of care across care levels is scarce in Latin America. The

Aim

to analyse the impact of implemented interventions on the perception of continuity of care of chronic patients in public health care networks of five LA countries (Brazil, Chile, Colombia, Mexico, and Uruguay).

Methods

Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN) were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying CCAENA questionnaire® to a sample of patients with chronic conditions (392/network; 784/country/year). Result variables: information continuity (exchange of clinical information) and clinical management continuity (repetition of exams, accessibility of primary care (PC) and secondary care (SC), perception of agreement between PC and SC doctors and of collaboration between PC and SC doctors. Descriptive analysis were conducted, and chi-square test was calculated to determine significant changes.

Results

An increase in the perception of continuity of information between care levels was observed in the IN of all countries, but Colombia. Clinical management continuity: decrease in the repetition of exams and increase in accessibility of consultation with the specialist in all countries but Mexico. The accessibility of PC doctor decreased in the IN in all countries. No differences in the perception of agreement between PC and SC doctors regarding diagnosis, treatment and recommendations were found. The perception of collaboration between PC and SC doctors increased in the five countries.

Conclusions

Consistent with expected results, the level of perceived information continuity and clinical management continuity increased in the IN, with differences between countries. Further multivariate analyses will be conducted to explore the differences between the IN and CN.

Key messages

Provides a cross-country comparison of the perception of continuity of care in patients with chronic conditions. Contributes to fill the knowledge gap on the effectiveness of participatory interventions improving continuity of care.

Outcomes and conditions for sustaining changes of Participatory Action Research interventions

Background

Finding new strategies for care integration has become a priority for many health systems in Latin America. Although the implementation of interventions through a participatory action research (PAR) approach is considered effective, its application in health services is scarce.

Aim

to analyse impact of PAR interventions on care coordination, and aspects for sustainability and transferability in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

A qualitative, descriptive-interpretative study was conducted in each healthcare network. Focus groups and individual semi-structured interviews were conducted to a criteria sample of Local Steering Committee (29), Platform of professionals (28), professionals (49) y managers (28). A thematic content analysis was conducted, segmented by country and themes. Different interventions were designed and implemented through a PAR process: joint meetings to discuss clinical cases and/or training; shared care guidelines; offline virtual consultations; a (back) referral form; and an induction program.

Results

Informants highlighted that joint meetings based on reflexive methods contributed substantially to improving contextually relevant elements of clinical coordination - communication in patient follow-up, clinical agreement, appropriateness of referrals - and administrative coordination. The meetings, alongside the PAR process, helped to improve interaction between professionals, fostering willingness to collaborate. No significant contributions were identified in the remaining interventions due to the low uptake. A necessary condition for the sustainability and replicability of the interventions was that the PAR process had to be used appropriately in a favorable context.

Conclusions

Evidence is provided on the significant contribution of interventions to improving locally relevant clinical coordination elements and professional interaction when implemented through an adequate PAR process.

Key messages

It contributes to fill the gap regarding the impact of PAR interventions on care coordination. A key aspect for impact and sustainability is an adequate use of PAR approach in a favourable context.

Clinical coordination across care levels according to medical specialty in the Catalan health system

Background

In primary care-based national health systems, cross-level clinical coordination is a priority, as it contributes to quality of care and efficiency. Studies show that clinical coordination may vary depending on doctoŕs specialty. The study's aim was to determine the differences in experience and perception of clinical coordination and their related factors according to the doctor's specialty in the Catalan health system

Methods

Cross-sectional study, based on an on-line survey applying the COORDENA-CAT questionnaire to 1666 secondary care doctors. Descriptive and multivariate analysis were used to compare five groups of specialties (potentially decentralised, hospital-based, internal-medicine/geriatrics, gynaecology, and paediatrics), for experience, perception and factors related to clinical coordination.

Results

Clinical coordination experience was relatively high in all groups, with differences when comparing with decentralised specialties; hospital-based specialties and internal medicine/geriatrics presented lower care consistency and follow up across levels, while gynaecology and paediatrics showed higher accessibility. General perception of coordination was low, being worse in hospital-based specialties (PR:0.80,95%CI0.72-0.89) and better in gynaecology (PR:1.36,95%CI1.18-1.56). Moreover, hospital-based specialties reported lower use of coordination mechanisms and less interaction with doctors from the other level (PR:0.42,95%CI0.23-0.72), than gynaecology (PR:2.04, 95%CI1.22-3.45).

Conclusions

Doctors' experience and perception of clinical coordination was lower among hospital-based specialties and internal medicine/geriatrics and higher in gynaecology and paediatrics. These differences may be explained by complexity, coordination needs, level of specialty decentralisation or related factors. Further research is needed to understand such differences and consider the coordination needs of each specialty to improve cross-level clinical coordination.

Key messages

Differences between specialities might be explain by the complexity, level of specialty decentralisation or factors related to clinical coordination. Clinical coordination needs of each specialty should be deeply explored to improve cross-level clinical coordination.

Does management integration improve cross-level clinical coordination? Experience of Catalonia

Background

Cross-level clinical coordination is a priority for health systems. Evidence suggests that management integration may improve clinical coordination. This study aims to evaluate clinical coordination according to the type of management integration of the area in the Catalan health system.

Methods

Cross-sectional study based on the online questionnaire COORDENA-CAT (October-December 2017). Study population: primary and secondary care (acute and long term) doctors of the public Catalan health system. Sample: 3.308 doctors. Outcome variables: experience and perception of clinical coordination across care levels, knowledge and use of coordination mechanisms and related factors. Explanatory variables: area according to type of management (integrated, semi-integrated and non-integrated), demographic, employment characteristics and attitude towards work. Descriptive and multivariate analysis by robust Poisson regression.

Results

Better clinical coordination was observed in integrated areas compared to those semi-integrated, mostly in information transfer (PR 0.80 (95%CI 0.74-0.87)) and adequate follow-up of the patient (PR 0.89 (95%IC 0.82-0.97)). No differences were observed between integrated and non-integrated areas. General perception of coordination was higher in integrated areas than in semi-integrated and non-integrated areas (PR 0.73 (95%CI 0.63-0.84) and PR 0.85 (95%CI 0.75-0.97) respectively). Some organizational and interactional factors and the knowledge and use of coordination mechanisms showed also better results in integrated areas. There were common fields for improvement like accessibility between care levels.

Conclusions

No differences between integrated and non-integrated areas reveal that management integration is not enough condition to improve clinical coordination. Differences with semi-integrated areas suggest that coordination efforts should be equitable among all the providers of the territory to avoid inequalities in quality of care.

Key messages

Management integration does not determine clinical coordination. Cooperation formulas are needed between all territory providers that allow to fix common strategies to improve clinical coordination.

0152 Insomnia Severity and Daytime Complaints: What is to be Learned When These Domains are Discordant?

Introduction

If illness severity and daytime dysfunction are construed as categorical entities, it is possible to conceptualize the relationship between these variables in terms of a 2x2 matrix where the resultant cells represent a concordant dimension (quadrants 2 & 4 [high-high and low-low]) and a discordant dimension (quadrants 1 & 3 [high-low and low-high]). The question for the present analysis was, what percentage of subjects populate each quadrant and is it the case that the discordant dimension contains only a small percentage of subjects?

Methods

Illness severity and daytime dysfunction data was collected from individuals with sleep continuity complaints in archival/community-based sample (N = 4680; 60% female; Ages 18–89) (www.sleeplessinphilly.com). Illness severity was operationalized as Total Wake Time (TWT; [SL+WASO+EMA=TWT]) and daytime dysfunction was operationalized as the composite score of six daytime symptoms items. Median splits were calculated for each variable and subjects were typed accordingly (HH, LL, HL, & LH).

Results

Surprisingly, the sample was relatively equally distributed into the two dimensions; 38% and 23% for the concordant dimension and 13% and 26% for discordant dimension.

Conclusion

The 39% of subjects in the discordant groups might be thought of as complaining good sleepers (LH) and noncomplaining poor sleepers (HL). Other investigators have identified the LH subjects as individuals with “insomnia identity”. Alternatively, it is possible to characterize the whole dimension as being related to a mismatch between the individual’s sleep need and sleep ability. Those who need a lot, may suffer a lot, in the face of only a little (LH) whereas those who need a little, may suffer only a little, in the face of a lot (HL).

Support

 

0456 Natural History of Insomnia: Sleep Reactivity Predicts New-Onset Acute Insomnia

Introduction

Greater vulnerability to stress-related sleep disturbance (i.e., sleep reactivity) is a risk factor for chronic insomnia (CI). What has not been investigated is whether greater sleep reactivity, as assessed by the Ford Insomnia Response to Stress Test (FIRST), predicts the onset of acute insomnia (AI), and more, whether greater sleep reactivity predicts the transition from AI to CI.

Methods

A national cohort of 1,222 good sleeper subjects (68% female; mean age=53.2 years) were prospectively assessed to estimate the incidence of AI and CI. The FIRST was completed at baseline and sleep diaries were completed on a daily basis for a period of one year. Subjects were categorized based on their FIRST scores (high, FIRST>16; low, FIRST≤16). Subjects were also grouped based on whether they developed AI (two consecutive weeks with a frequency of ≥ 3 nights per week of sleep initiation or maintenance problems) or maintained good sleep (GS; n=896). For those subjects that transitioned to AI (n=326), they were also grouped based on whether or not they developed CI (insomnia ≥ 3 nights/week for at least three months; n=23). Chi-square analyses were performed to determine if higher FIRST scores at baseline predicted the incidence of AI or CI.

Results

32.5% of subjects in the high FIRST group met criteria for AI at some point during the one-year interval, whereas 22.5% of subjects in the low FIRST group experienced AI (χ 2=15.2, p<.001). In contrast, FIRST did not predict CI status (low FIRST, 8.5% CI, high FIRST, 5.6% CI; χ 2=1.1, p=.30).

Conclusion

Greater sleep reactivity predicted incident AI but not the onset of CI. While these findings suggest that sleep reactivity may be a predisposing factor for AI, data are not consistent with previous findings showing FIRST scores are predictive of the development of CI. It’s possible that the present study was underpowered to detect these differences, given that the incidence of CI was low (less than 2% of the total sample). Additional analyses are ongoing to evaluate the temporal association between stressful life events and AI in subjects with high and low FIRST scores.

Support

Perlis: NIH R01AG041783, K24AG055602

0351 Sleep Continuity, Sleep-Related Daytime Dysfunction, and Problem Endorsement: Do These Vary Concordantly by Age?

Introduction

It is well documented that sleep continuity (i.e., SC [ability to initiate and/or maintain sleep]) worsens with age. It is unclear whether problem endorsement and/or daytime dysfunction show similar age-related trends. Accordingly, an analysis was undertaken to assess whether initial, middle, and/or late insomnia all exhibit age related change and whether problem endorsement and/or daytime dysfunction show comparable age-related changes.

Methods

The study utilized a cross-sectional group design in an archival/community dataset (www.sleeplessinphilly.com). This dataset (N=932) was comprised of adults between 18 and 89 years of age with self-reported sleep complaints. Participants were categorized as: Young Adults (18-29 years); Adults (30-44 years); Middle Age Adults (45-64 years); and Older Adults (65-89 years). Age groups were matched to the Older Adults group (n=233) by sex, race, and BMI. ANOVAs with Bonferroni corrections (alpha = .001), and contingency analyses were performed to assess for age group differences.

Results

It was found that, as expected, SC worsens with age but that this was limited to middle and late insomnia. Further, problem endorsement increased with age (except for SL) but sleep-related daytime dysfunction did not (except for concentration issues).

Conclusion

These results have several implications. Methodologically speaking, when evaluating the effects and/or correlates of SC, it may be wise to concomitantly assay “is this a problem for you” and “does this affect your daytime function”, as SC can occur without perceived daytime consequences, especially in older adults. Conceptually speaking, the observed discordance requires further exploration. In the past, it has been argued that sleep need is reduced in older adults. While this is a reasonable hypothesis (no need, no functional consequence), it remains to be demonstrated that older adults require less sleep.

Support

 

0153 Patient-Defined Insomnia Severity: How Much Wakefulness is Problematic?

Introduction

While Insomnia Disorder is formally defined in the ICSD-3 and DSM-5, neither diagnostic system adopts quantitative criteria for illness severity. Interestingly, quantitative criteria are provided for frequency and chronicity (i.e., ≥ 3 days / week for ≥ 3 months). For research purposes, illness severity has long been defined using the “30 minute rule” (SL and/or WASO and/or EMA of ≥ 30 minutes is the threshold for clinical relevance). In the present analysis, this threshold was assessed for its significance to patients.

Methods

Sleep continuity disturbance (SCD; SL, WASO, and EMA) and problem endorsement data were collected from an archival/community-based sample (N = 4680; 60% female; Ages 18–89 years; www.sleeplessinphilly.com). Problem endorsement was evaluated through questions that included, “Do you consider this a problem?” after participants reported length of SL, WASO, and EMA. Problem endorsement percentages were calculated for 5 minute bins for between 0 and 65 minutes, with one additional bin for > 65 minutes. The temporal bins were compared for significant deviations using absolute (percent of subjects at 0–5 and 5–10 minutes) and moving references (last significant percent).

Results

The first temporal bin to differ from the absolute reference for SL, WASO, and EMA was the 26–30 minute bin. At this threshold, 87%, 70%, and 94% of the subjects’ identifying SL, WASO and EMA as being problematic (and was deemed statistically different from “normal” [0–10 minute values]).

Conclusion

These data suggest that the “30 minute rule” (which is of unknown provenance) roughly corresponds to the level of illness severity (lowest common threshold) identified by patients as problematic. While the threshold for SL and EMA show a clear majority, the lower percentage of subjects for WASO suggests that people are more tolerant of middle of the night wakefulness.

Support

 

Associated factors to the perception of clinical coordination in the Catalan national health system

Background

Clinical coordination across levels of care is a priority for health systems. The aim is to analyse the factors associated to a high perception of clinical coordination of primary (PC) and secondary care (SC) doctors of the Catalan national health system (NHS).

Methods

Cross-sectional study based on the self-administered online questionnaire COORDENA-CAT. Data collection: October-December 2017. Study population: PC and SC (acute and long term) doctors of the public Catalan NHS that had been working for at least one year in the organization, had direct contact with patients and related with doctors of the other level of care. The participation rate was 20.5%, with a sample of 3308 doctors. Outcome variable: perception of clinical coordination across levels of care. Explanatory variables: socio-demographic, employment characteristics, attitude towards work, type of area (according to type of hospital and managing entity), interactional factors, organizational factors and knowledge of existing coordination mechanisms. Stratification variable: level of care. Descriptive and multivariate analysis by logistic regression.

Results

Only 32.13% of PC doctors and 35.72% of SC doctors found that patient care was coordinated across care levels within their area. In both levels of care, knowing the doctor of the other level; finding that their practice influences the other care level; finding that the organization’s management facilitates coordination; working in an area where the same entity manages SC and majority of PC and to hold joint clinical case conferences are factors positively associated to a high perception of clinical coordination. Besides, there are other positively associated factors exclusive for each level of care.

Conclusions

Several common interactional and organizational factors are positively associated to a high perception of care coordination. Introducing policies to enhance such factors can foster care coordination in the Catalan NHS.

Key messages

This study found out factors associated to clinical coordination across care levels in each level. It helps to develop specific coordination policies by level of care to address those factors.

Can clinical coordination be improved through Participatory Action Research (PAR) interventions?

Background

Despite the effectiveness of Participatory Action Research (PAR) in reducing the gap between evidence and practice, its use to improve care integration is rare. The aim is to analyze the factors influencing the implementation of PAR interventions to improve clinical coordination in public health services networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

A qualitative, descriptive-interpretative study was conducted in participating healthcare networks of each country. Focus groups and individual semi-structured interviews were conducted to a criteria sample of participants: members of Local Steering Committee (LSC)(29), professionals’ platform (PP)(28), other professionals (49) and managers(28). Thematic content analysis was performed, segmented by country and themes.

Results

Findings reveal that contextual factors, the PAR process and interventions’ content were determinants in the implementation, interacting over time, and differing among experiences. On the one hand, institutional support (providing the necessary resources) together with the interest of professionals and managers in participating, emerged as influencing factors influenced by other factors related to: the system (alignment with policies; electoral cycle), networks (lack of time due to work overload; precarious employment conditions) and individuals (limited mutual knowledge and mistrust). On the other, some characteristics of the PAR process facilitated institutional support and motivation: professionals’ participation in all activities, design flexibility and shared decision-making - also present when interventions were based on mutual adjustment - the LSC’s leadership and the facilitating role of the research team.

Conclusions

Evidence is provided that when some contextual elements converge the implementation of interventions through PAR processes can turn into a factor of motivation and cohesion, determinant for the adoption of clinical coordination interventions.

Key messages

Contributes to fill the knowledge gap in factors influencing the implementation of PAR interventions in healthcare. Provides a framework for analysis and recommendations for their implementation.

Effectiveness of participatory interventions in improving clinical coordination in Latin America

Background

Evaluation of interventions to improve clinical coordination across care levels is scarce in Latin America.

Aim

to evaluate the effectiveness of interventions implemented through participatory action research in improving clinical coordination between care levels in public healthcare networks of Brazil, Chile, Colombia, Mexico and Uruguay.

Methods

Quasi-experimental study (controlled before and after design). Comparable networks, one intervention (IN) and one control (CN), were selected in each country. Baseline (2015) and evaluation (2017) surveys were conducted applying COORDENA® questionnaire to a sample of primary (PC) and secondary (SC) care doctors (174 doctors/network/year). Designed interventions promoted clinical agreement and communication across levels for patients’ follow-up. Outcome variables: a) intermediate: interactional and organizational factors; b) final: experience of clinical management coordination (care consistency and patients’ follow-up) and general perception of coordination between levels. Poisson regression models were estimated.

Results

Intermediate: interactional factors -personal knowledge and trust on the other care level-increased significantly in Brazil’ and Chile’ INs; and organizational factors -managers’ support- in the INs of Colombia and Mexico. Comparing to CN in 2017, INs of Brazil, Chile, Colombia and Mexico showed significant differences in some factors.

Final: care consistency items -agreement over the treatments- improved in the INs of Brazil, Colombia and Uruguay; and patients’ follow-up in the INs of Chile and Mexico. General perception of clinical coordination increased in the INs of Brazil, Colombia and Mexico. Compared to CN in 2017, only Brazil showed significant differences.

Conclusions

Improvements in intermediate and final care coordination results, consistent with expected results, were observed in all the INs. Reduced implementation time and some process and context factors may have limited their impact.

Key messages

First study assessing the effectiveness of participatory interventions in improving clinical coordination between care levels in public healthcare networks of Latin America. Results showed changes in the intermediate and final clinical coordination results in the intervention networks. Longer implementation and evaluation times are expected to achieve greater impact.

P702Anti-thrombin nanoparticles for reduce vascular damage and promote functional recovery in acute ischemic kidney injury well after reperfusion

Introduction

We have shown previously that pretreatment of acute ischemic kidney injury (AKI) in mice prior to reperfusion with anti-thrombin perfluorocarbon nanoparticles (PFC NP) limits damage to endothelium and hastens functional recovery. However, whether such treatments are effective after AKI is established is not known. We hypothesized that thrombin would continue to exert deleterious clotting and molecular signaling effects in AKI well after reperfusion that would respond to sustained local inhibition with long acting anti-thrombin nanoparticles.

Methods

23 C57Bl6 mice underwent bilateral kidney ischemia for 17 min, followed by 2 hours reperfusion and i.v. injection of anti-thrombin PPACK (D-phenylalanyl-L-prolyl-L-arginine chloromethyl ketone)-conjugated PFC NP (∼ 13,000 PPACK per PFC NP), or plain PFC NP (control: no drug). At 24 hours BUN was measured, and mice were euthanized for kidney histological assessment (H&E), protein expression (western blot) and eicosanoid mediators of inflammation (LC-MS/MS: AB SCIEX 5500 QTRAP).

Results

BUN at 24 hours after AKI was 63.29±9.09 vs 110.96±6.21 (P<0.002), for treated versus untreated mice, respectively, a 43% improvement. Western blots (Figure) indicated 40% reduction of canonical NF-kB signaling pathway protein p65 (p<0.01) and 2.2 fold increases in Bcl-xL: Bax ratio (P<0.01). Vascular damage, as indicated by glomerular and mesangial hemorrhage (Figure), was reduced, as was tubular cell swelling and edema. Levels of inflammatory procoagulant eicosanoids (e.g., PGE1, TBX2, PGA2, 15-HETE, 5-HETE, etc.) generally were higher in renal medulla than in cortex, and were suppressed by PPACK PFC NP.

Discussion

Continued inhibition of thrombin in AKI with locally-acting PPACK PFC NP preserved vascular integrity, limited renal hemorrhage, mitigated inflammation and tubular cell death, and accelerated functional recovery even when administered 2 hours after reperfusion. Because these PPACK PFC NP do not prolong bleeding times or coagulation parameters beyond ∼30–60 min after injection, yet maintain prolonged local surveillance against activated thrombin, they represent a potentially useful therapeutic strategy for established AKI after an ischemic insult.

Acknowledgement/Funding

DK102691

Metodología activa en el Estudio de Caso para desarrollo del pensamiento crítico y sentido ético

Introducción: Un modelo centrado en la enseñanza-aprendizaje supone un cambio en la docencia universitaria, esto implica el uso de metodologías activas con enfoque en el desarrollo de habilidades como el pensamiento crítico (PC) y sentido ético (SE). Objetivo: Evaluar el impacto de la implementación del estudio de caso (EC) en el desarrollo de habilidades de PC y SE en estudiantes de enfermería. Métodos: Se realizó una intervención longitudinal en una muestra de 103 estudiantes, se aplicó la prueba estadística ANOVA. Resultados: Se evaluó el desarrollo de PC al comparar los resultados obtenidos por los estudiantes en tres evaluaciones, se logró evidenciar un progreso en el desarrollo de las habilidades de PC, y SE. Con el análisis de varianza se estableció que el valor del estadístico F fue mayor al crítico (valor p < 0,05), para un nivel de confianza del 95%, se puede rechazar la hipótesis nula. Discusión: La implementación de la metodología contribuyó favorablemente en el desarrollo de las habilidades PC y SE en los estudiantes, lo que les permitió identificar y resolver problemas, al fundamentar sus decisiones. Además, fomentó el aprendizaje colaborativo y el respeto, entre pares. Conclusiones: La metodología EC promovió un aprendizaje activo y un cambio en la cultura del aula. Si bien, implementar la metodología de EC favoreció el desarrollo de habilidades de PC y SE en los estudiantes de enfermería, es necesario seguir investigando sobre factores que mejoren el proceso de enseñanza-aprendizaje con un enfoque activo.