Alleviating the burden of depression: a simulation study on the impact of mental health services

AIMS

Depressive disorders are ranked as the single leading cause of disability worldwide. Despite immense efforts, there is no evidence of a global reduction in the disease burden in recent decades. The aim of the study was to determine the public health impact of the current service system (status quo), to quantify its effects on the depression-related disease burden and to identify the most promising strategies for improving healthcare for depression on the population level.

METHODS

A Markov model was developed to quantify the impact of current services for depression (including prevention, treatment and aftercare interventions) on the total disease burden and to investigate the potential of alternative scenarios (e.g., improved reach or improved treatment effectiveness). Parameter settings were derived from epidemiological information and treatment data from the literature. Based on the model parameters, 10,000,000 individual lives were simulated for each of the models, based on monthly transition rates between dichotomous health states (healthy vs. diseased). Outcome (depression-related disease burden) was operationalized as the proportion of months spent in depression.

RESULTS

The current healthcare system alleviates about 9.5% (95% confidence interval [CI]: 9.2%-9.7%) of the total disease burden related to depression. Chronic cases cause the majority (83.2%) of depression-related burden. From a public health perspective, improving the reach of services holds the largest potential: Maximum dissemination of prevention (26.9%; CI: 26.7%-27.1%) and treatment (26.5%; CI: 26.3%-26.7%) would result in significant improvements on the population level.

CONCLUSIONS

The results confirm an urgent need for action in healthcare for depression. Extending the reach of services is not only more promising but also probably more achievable than increasing their effectiveness. Currently, the system fails to address the prevention and treatment of chronic cases. The large proportion of the disease burden associated with chronic courses highlights the need for improved treatment policies and clinical strategies for this group (e.g., disease management and adaptive or personalized interventions). The model complements the existing literature by providing a new perspective on the depression-related disease burden and the complex interactions between healthcare services and the lifetime course.

The effect of psychiatric decision unit services on inpatient admissions and mental health presentations in emergency departments: an interrupted time series analysis from two cities and one rural area in England

AIMS

High-quality evidence is lacking for the impact on healthcare utilisation of short-stay alternatives to psychiatric inpatient services for people experiencing acute and/or complex mental health crises (known in England as psychiatric decision units [PDUs]). We assessed the extent to which changes in psychiatric hospital and emergency department (ED) activity were explained by implementation of PDUs in England using a quasi-experimental approach.

METHODS

We conducted an interrupted time series (ITS) analysis of weekly aggregated data pre- and post-PDU implementation in one rural and two urban sites using segmented regression, adjusting for temporal and seasonal trends. Primary outcomes were changes in the number of voluntary inpatient admissions to (acute) adult psychiatric wards and number of ED adult mental health-related attendances in the 24 months post-PDU implementation compared to that in the 24 months pre-PDU implementation.

RESULTS

The two PDUs (one urban and one rural) with longer (average) stays and high staff-to-patient ratios observed post-PDU decreases in the pattern of weekly voluntary psychiatric admissions relative to pre-PDU trend (Rural: -0.45%/week, 95% confidence interval [CI] = -0.78%, -0.12%; Urban: -0.49%/week, 95% CI = -0.73%, -0.25%); PDU implementation in each was associated with an estimated 35-38% reduction in total voluntary admissions in the post-PDU period. The (urban) PDU with the highest throughput, lowest staff-to-patient ratio and shortest average stay observed a 20% (-20.4%, CI = -29.7%, -10.0%) level reduction in mental health-related ED attendances post-PDU, although there was little impact on long-term trend. Pooled analyses across sites indicated a significant reduction in the number of voluntary admissions following PDU implementation (-16.6%, 95% CI = -23.9%, -8.5%) but no significant (long-term) trend change (-0.20%/week, 95% CI = -0.74%, 0.34%) and no short- (-2.8%, 95% CI = -19.3%, 17.0%) or long-term (0.08%/week, 95% CI = -0.13, 0.28%) effects on mental health-related ED attendances. Findings were largely unchanged in secondary (ITS) analyses that considered the introduction of other service initiatives in the study period.

CONCLUSIONS

The introduction of PDUs was associated with an immediate reduction of voluntary psychiatric inpatient admissions. The extent to which PDUs change long-term trends of voluntary psychiatric admissions or impact on psychiatric presentations at ED may be linked to their configuration. PDUs with a large capacity, short length of stay and low staff-to-patient ratio can positively impact ED mental health presentations, while PDUs with longer length of stay and higher staff-to-patient ratios have potential to reduce voluntary psychiatric admissions over an extended period. Taken as a whole, our analyses suggest that when establishing a PDU, consideration of the primary crisis-care need that underlies the creation of the unit is key.

Greater need but reduced access: a population study of planned and elective surgery rates in adult mental health service users

AIMS

Timely access to surgery is an essential part of healthcare. People living with mental health (MH) conditions may have higher rates of chronic illness requiring surgical care but also face barriers to care. There is limited evidence about whether unequal surgical access contributes to health inequalities in this group.

METHODS

We examined 1.22 million surgical procedures in public and private hospitals in New South Wales (NSW), Australia, in 2019. In a cross-sectional study of 76,320 MH service users aged 18 and over, surgical procedure rates per 1,000 population were compared to rates for 6.23 million other NSW residents after direct standardisation for age, sex and socio-economic disadvantage. Rates were calculated for planned and emergency surgery, for major specialty groups, for the top 10 procedure blocks in each specialty group and for 13 access-sensitive procedures. Subgroup analyses were conducted for hospital and insurance type and for people with severe or persistent MH conditions.

RESULTS

MH service users had higher rates of surgical procedures (adjusted incidence rate ratio [aIRR]: 1.53, 95% CI: 1.51-1.56), due to slightly higher planned procedure rates (aIRR: 1.22, 95% CI: 1.19-1.24) and substantially higher emergency procedure rates (aIRR: 3.60, 95% CI: 3.51-3.70). Emergency procedure rates were increased in all block groups with sufficient numbers for standardisation. MH service users had very high rates (aIRR > 4.5) of emergency cardiovascular, skin and plastics and respiratory procedures, higher rates of planned coronary artery bypass grafting, coronary angiography and cholecystectomy but lower rates of planned ophthalmic surgery, cataract repair, shoulder reconstruction, knee replacement and some plastic surgery procedures.

CONCLUSIONS

Higher rates of surgery in MH service users may reflect a higher prevalence of conditions requiring surgical care, including cardiac, metabolic, alcohol-related or smoking-related conditions. The striking increase in emergency surgery rates suggests that this need may not be being met, particularly for chronic and disabling conditions which are often treated by planned surgery in private hospital settings in the Australian health system. A higher proportion of emergency surgery may have serious personal and health system consequences.

Health Service Use Among Migrants in the German National Cohort-The Role of Birth Region and Language Skills

Objective: To compare health service use (HSU) between migrants and non-migrants in Germany. Methods: Using data from the population-based German National Cohort (NAKO), we compared the HSU of general practitioners, medical specialists, and psychologists/psychiatrists between six migrant groups of different origins with the utilization of non-migrants. A latent profile analysis (LPA) with a subsequent multinomial regression analysis was conducted to characterize the HSU of different groups. Additionally, separate regression models were calculated. Both analyses aimed to estimate the direct effect of migration background on HSU. Results: In the LPA, the migrant groups showed no relevant differences compared to non-migrants regarding HSU. In separate analyses, general practitioners and medical specialists were used comparably to slightly more often by first-generation migrants from Eastern Europe, Turkey, and resettlers. In contrast, the use of psychologists/psychiatrists was substantially lower among those groups. Second-generation migrants and migrants from Western countries showed no differences in their HSU compared to non-migrants. Conclusion: We observed a low mental HSU among specific migrant groups in Germany. This indicates the existence of barriers among those groups that need to be addressed.

Patient-reported outcomes in integrated health and social care: A scoping review

Background

Patient-reported outcomes (PROs) have potential to support integrated health and social care research and practice; however, evidence of their utilisation has not been synthesised.

Objective

To identify PRO measures utilised in integrated care and adult social care research and practice and to chart the evidence of implementation factors influencing their uptake.

Design

Scoping review of peer-reviewed literature.

Data sources

Six databases (01 January 2010 to 19 May 2023).

Study selection

Articles reporting PRO use with adults (18+ years) in integrated care or social care settings.

Review methods

We screened articles against pre-specified eligibility criteria; 36 studies (23%) were extracted in duplicate for verification. We summarised the data using thematic analysis and descriptive statistics.

Results

We identified 159 articles reporting on 216 PRO measures deployed in a social care or integrated care setting. Most articles used PRO measures as research tools. Eight (5.0%) articles used PRO measures as an intervention. Articles focused on community-dwelling participants (35.8%) or long-term care home residents (23.9%), with three articles (1.9%) focussing on integrated care settings. Stakeholders viewed PROs as feasible and acceptable, with benefits for care planning, health and wellbeing monitoring as well as quality assurance. Patient-reported outcome measure selection, administration and PRO data management were perceived implementation barriers.

Conclusion

This scoping review showed increasing utilisation of PROs in adult social care and integrated care. Further research is needed to optimise PROs for care planning, design effective training resources and develop policies and service delivery models that prioritise secure, ethical management of PRO data.

Prevalence of multiple long-term conditions (multimorbidity) in England: a whole population study of over 60 million people

OBJECTIVES

To determine the prevalence of multiple long-term conditions (MLTC) at whole English population level, stratifying by age, sex, socioeconomic status and ethnicity.

DESIGN

A whole population study.

SETTING

Individuals registered with a general practice in England and alive on 31 March 2020.

PARTICIPANTS

60,004,883 individuals.

MAIN OUTCOME MEASURES

MLTC prevalence, defined as two or more of 35 conditions derived from a number of national patient-level datasets. Multivariable logistic regression was used to assess the independent associations of age, sex, ethnicity and deprivation decile with odds of MLTC.

RESULTS

The overall prevalence of MLTC was 14.8% (8,878,231), varying from 0.9% (125,159) in those aged 0-19 years to 68.2% (1,905,979) in those aged 80 years and over. In multivariable regression analyses, compared with the 50-59 reference group, the odds ratio was 0.04 (95% confidence interval (CI): 0.04-0.04; p < 0.001) for those aged 0-19 years and 10.21 (10.18-10.24; p < 0.001) for those aged 80 years and over. Odds were higher for men compared with women, 1.02 (1.02-1.02; p < 0.001), for the most deprived decile compared with the least deprived, 2.26 (2.25-2.27; p < 0.001), and for Asian ethnicity compared with those of white ethnicity, 1.05 (1.04-1.05; p < 0.001). Odds were lower for black, mixed and other ethnicities (0.94 (0.94-0.95) p < 0.001, 0.87 (0.87-0.88) p < 0.001 and 0.57 (0.56-0.57) p < 0.001, respectively). MLTC for persons aged 0-19 years were dominated by asthma, autism and epilepsy, for persons aged 20-49 years by depression and asthma, for persons aged 50-59 years by hypertension and depression and for those aged 60 years and older, by cardiometabolic factors and osteoarthritis. There were large numbers of combinations of conditions in each age group ranging from 5936 in those aged 0-19 years to 205,534 in those aged 80 years and over.

CONCLUSIONS

While this study provides useful insight into the burden across the English population to assist health service delivery planning, the heterogeneity of MLTC presents challenges for delivery optimisation.

Retrospective observational study analysing the trends in ventilation tube insertion in children in Scotland between 2001 and 2018

OBJECTIVES

Otitis media with effusion (OME) is common, affecting up to 90% of children. Around 25% will have a persistent effusion with conductive hearing loss which can impact their development. Ventilation tubes (VTs) can improve their hearing in the short term. This study aims to analyse the trends in VT insertion rates across Scotland.

DESIGN

Retrospective observational study.

SETTING

All mainland Scottish health boards.

PARTICIPANTS

All children aged 0-16 who underwent a VT insertion procedure from 2001 to 2018 were included.

MAIN OUTCOME MEASURES

Data were provided by the Scottish Public Health Observatory, using Scottish Morbidity Records. Mid-year population estimates were obtained from the National Records Office of Scotland. Socioeconomic deprivation was estimated based on area of residence using the Scottish Index of Multiple Deprivation. VT insertion rates were calculated and trends analysed.

RESULTS

A total of 35 878 VT procedures were performed in total with a mean rate of 2.02 per 1000 children per year. The highest insertion rates were observed in children aged 4-6. VT insertion rates reduced during the study period (R = -0.729, p = .001). Variability in VT insertion rates between health boards reduced. There was a significant association between socioeconomic deprivation and VT insertion rate, with the most deprived children having the highest rate (p < .001).

CONCLUSIONS

VT insertion rates and the variability between Scottish health boards have reduced over the past two decades, suggesting a more equitable system. Our data intimates that the decision to perform VT insertion is based upon disease prevalence rather than clinician preference.

Effects of Telephone Consultation on Safety, Service Use, Patient Satisfaction, and Workload: Systematic Review and Meta-Analysis of Randomized Trials

Objective: Telephone consultation (TC) is widely used for its easy access and convenience. This review aimed to assess the effects of TC including triage on safety, service use, patient satisfaction, and health professionals' workload to inform directions for future health service practice. Methods: CENTRAL, MEDLINE, Embase, CINAHL, ProQuest Dissertation & Theses (Health & Medicine), ClinincalTrials.gov, and International Clinical Trial Registry Platform were searched on April 7, 2022. The included were randomized controlled trials that compared TC with standard (face-to-face [F2F]) management or that by another group of call advisers. Cochrane methods were used to select eligible studies, assess the risk of bias, estimate summary effect measure, and grade evidence certainty. Meta-analysis was performed on important outcomes with moderate- or high-quality evidence. Results: Eight studies were included involving 40,002 participants. TC could increase call resolution-proportion of callers' concerns being addressed by telephone advice alone (two studies; high certainty) and reduce F2F contacts with doctors for the first consultation (two studies, moderate certainty) compared with standard management or TC by doctors. None of included studies reported increases in adverse events, including all-cause mortality, acute and emergency department visit, and hospitalization. There was inadequate evidence regarding the effects of TC on patient satisfaction and length of consultation. Conclusion: The findings support the benefits of TC on improving call resolution and reducing F2F contacts with doctors on the day of first management for regular day service; and TC by nurses can provide better effects than that by doctors for out-of-hours service.

Regional variations in inpatient decompensated cirrhosis mortality may be associated with access to specialist care: results from a multicentre retrospective study

Introduction

Specialist centres have been developed to deliver high-quality Hepatology care. However, there is geographical inequity in accessing these centres in the United Kingdom (UK). We aimed to assess the impact of these centres on decompensated cirrhosis patient outcomes and understand which patients transfer to specialist centres.

Methods

A UK multicentred retrospective observational study was performed including emergency admissions for patients with decompensated cirrhosis in November 2019. Admissions were grouped by specialist/non-specialist centre designation, National Health Service region and whether a transfer to a more specialist centre occurred or not. Univariable and multivariable comparisons were made.

Results

1224 admissions (1168 patients) from 104 acute hospitals were included in this analysis. Patients at specialist centres were more likely to be managed by a Consultant Gastroenterologist/Hepatologist on a Gastroenterology/Hepatology ward. Only 24 patients were transferred to a more specialist centre. These patients were more likely to be admitted for gastrointestinal bleeding and were not using alcohol. Specialist centres eliminated regional variations in mortality which were present at non-specialist centres. Low specialist Consultant staffing numbers impacted mortality at non-specialist centres (aOR 2.15 (95% CI 1.18 to 4.07)) but not at specialist centres. Hospitals within areas of high prevalence of deprivation were more likely to have lower specialist Consultant staffing numbers.

Conclusions

Specialist Hepatology centres improve patient care and standardise outcomes for patients with decompensated cirrhosis. There is a need to support service development and care delivery at non-specialist centres. Formal referral pathways are required to ensure all patients receive access to specialist interventions.

The effects of community interventions on unplanned healthcare use in patients with multimorbidity: a systematic review

OBJECTIVES

To summarise the impact of community-based interventions for multimorbid patients on unplanned healthcare use. The prevalence of multimorbidity (co-existence of multiple chronic conditions) is rapidly increasing and affects one-third of the global population. Patients with multimorbidity have complex healthcare needs and greater unplanned healthcare usage. Community-based interventions allow for continued care of patients outside hospitals, but few studies have explored the effects of these interventions on unplanned healthcare usage.

DESIGN

A systematic review was conducted. MEDLINE, EMBASE, PsychINFO and Cochrane Library online databases were searched. Studies were screened and underwent risk of bias assessment. Data were synthesised using narrative synthesis.

SETTING

Community-based interventions.

PARTICIPANTS

Patients with multimorbidity.

MAIN OUTCOME MEASURES

Unplanned healthcare usage.

RESULTS

Thirteen studies, including a total of 6148 participants, were included. All included studies came from high-income settings and had elderly populations. All studies measured emergency department attendances as their primary outcome. Risk of bias was generally low. Most community interventions were multifaceted with emphasis on education, self-monitoring of symptoms and regular follow-ups. Four studies looked at improved care coordination, advance care planning and palliative care. All 13 studies found a decrease in emergency department visits post-intervention with risk reduction ranging from 0 (95% confidencec interval [CI]: -0.37 to 0.37) to 0.735 (95% CI: 0.688-0.785).

CONCLUSIONS

Community-based interventions have potential to reduce emergency department visits in patients with multimorbidity. Identification of specific successful components of interventions was challenging given the overlaps between interventions. Policymakers should recognise the importance of community interventions and aim to integrate aspects of these into existing healthcare structures. Future research should investigate the impact of such interventions with broader participant characteristics.

Co-designing solutions to enhance access and engagement in pediatric telerehabilitation

Introduction

Prior to the COVID-19 pandemic, children's therapy appointments provided by Ontario's publicly-funded Children's Treatment Centre (CTCs) primarily occurred in-person. With COVID-19 restrictions, CTCs offered services via telerehabilitation (e.g., video, phone), which remains a part of service delivery. CTC data shows that families experience barriers in attending telerehabilitation appointments and may need supports in place to ensure service accessibility. Our study aimed to co-design innovative solutions to enhance access and engagement in ambulatory pediatric telerehabilitation services. This manuscript reports the co-design process and findings related to solution development.

Methods

This research project used an experience based co-design (EBCD) approach, where caregivers, clinicians and CTC management worked together to improve experience with telerehabilitation services. Interview data were collected from 27 caregivers and 27 clinicians to gain an in-depth understanding of their barriers and successes with telerehabilitation. Next, 4 interactive co-design meetings were held with caregivers, clinicians and CTC management to address priorities identified during the interviews. Using qualitative content analysis, data from the interviews and co-design meetings were analyzed and findings related to the solutions developed are presented.

Findings

Four topics were identified from the interview data that were selected as focii for the co-design meetings. Findings from the co-design meetings emphasized the importance of communication, consistency and connection (the 3C's) in experiences with telerehabilitation. The 3C's are represented in the co-designed solutions aimed at changing organizational processes and generating tools and resources for telerehabilitation services.

Discussion

The 3C's influence experiences with telerehabilitation services. By enhancing the experience with telerehabilitation, families will encounter fewer barriers to accessing and engaging in this service delivery model.

Violence against healthcare workers during the COVID-19 pandemic: a cross-sectional survey at Cairo University Hospital

Introduction

Healthcare workers have a significant chance of experiencing violence, with physical violence impacting anywhere from 8 to 38% of healthcare professionals throughout their careers. Besides physical abuse, many healthcare workers are subject to verbal aggression or threats, with patients and visitors being the most frequent sources of such incidents.

Methods

This research examines the work atmosphere of healthcare professionals at Kasr Al-Aini University Hospital in Cairo, Egypt, during the pandemic. The study aims to evaluate the frequency of violence toward healthcare workers and health professionals training through a cross-sectional survey conducted among them. The research was conducted on Egyptian healthcare workers over 6 months, from November 2020 until the end of January 2021, using convenience sampling in a cross-sectional study. Over half of the respondents reported experiencing violence.

Results

Among those who experienced violence, 93% reported verbal aggression, 43% reported physical and verbal abuse, and 59% claimed that violence increased during the pandemic. Additionally, 97% of those who experienced violence reported it occurring within the 4 months following the survey. About 42.5% of the respondents were female, and nearly 65% were over 30. 82% of the respondents did not receive training on handling violence while performing their job.

Conclusion

This study highlights the high prevalence of verbal assaults in healthcare settings, primarily by patients' families or acquaintances. Despite reporting such incidents, most respondents did not see any significant government action. Furthermore, the COVID-19 pandemic did not significantly change the frequency of violent incidents, indicating that the root causes of violence are systemic and extend beyond the pandemic. These findings underscore the need for systemic changes in healthcare organizations to address and prevent violence against healthcare workers.

Gestational diabetes mellitus care re-imagined - A cost-minimisation analysis: Cost savings from a tertiary hospital, using a novel, digital-based gestational diabetes management model

BACKGROUND

Diagnosis of gestational diabetes mellitus (GDM) in a pregnancy has a significant impact on health service resources and represents a substantial financial and time impost on women.

AIM

To describe a cost-minimisation analysis conducted following the demonstration of clinically equivalent care of women using a novel, digital model for GDM management, compared with conventional care.

MATERIALS AND METHODS

A pre-implementation model of care was compared with the post-implementation model of care which included systematic development and delivery of education videos, use of the Commonwealth Scientific and Industrial Research Organisation 'M♡THer' smart phone app/portal and a dramatically reduced schedule of visits. The Mater Mothers' Hospital Brisbane cares for approximately 1200 women with GDM per annum, on which the cost estimates were based. Service costs were estimated using the resource method, where resource volumes and costs were gathered from experts within the health service. Patient costs were estimated using results from a short survey completed by a cohort of the study population.

RESULTS

Health service costs showed a modest saving of AU$17 441.78 (US$12 158.92) in the intervention group over a 12-month period. Cost savings for the woman were estimated at $566.56 (US$394.96) per patient after accounting for lost wages, childcare expenses, and travel expenses avoided. This reduction led to an overall saving of $679 872 (US$473 948.82) for the cohort of 1200 women, primarily due to the reduction in face-to-face visits.

CONCLUSION

Re-imagining GDM patient care by introducing a novel, digital-based GDM model of care has substantial positive cost implications for patients.

GDM care re-imagined: Maternal and neonatal outcomes following a major model of care change for gestational diabetes mellitus at a large metropolitan hospital

BACKGROUND

The rapidly rising prevalence of gestational diabetes mellitus (GDM) poses major challenges to the efficient, timely and sustainable provision of diabetes care.

AIM

To assess whether the implementation of a novel, digital model of care would provide improved efficiency without compromising clinical outcomes in a cohort of women with GDM.

METHODS

A digital model of care was developed, implemented and evaluated using a prospective pre-post study design in 2020-21 at a quaternary centre. We introduced six culturally and linguistically tailored educational videos, home delivery of equipment and prescriptions, and a smartphone app-to-clinician portal for glycaemic review and management. Outcomes were prospectively recorded by an electronic medical record. Associations between model of care and maternal and neonatal characteristics and birth outcomes were examined for all women and separately by treatment received (diet, metformin, insulin).

RESULTS

Comparing pre-implementation (n = 598) and post-implementation (n = 337) groups, maternal (onset, mode of birth) and neonatal (birthweight, large for gestational age (LGA), nursery admission) clinical outcomes confirmed that the novel model of care was similar to standard, traditional care. Minor birthweight variation was noted when separated by treatment type (diet, metformin, insulin).

CONCLUSION

This pragmatic service redesign demonstrates reassuring clinical outcomes in a culturally diverse GDM cohort. Despite the lack of randomisation, this intervention has potential generalisability for GDM care and important key learnings for service redesign in the digital era.

Improving stroke clinical guideline adherence in an Australian hospital using a clinician-led implementation process

BACKGROUND

Private hospitals in Australia manage 11% of acute and 48% of rehabilitation stroke admissions, yet little is known about implementation of stroke clinical guidelines in this setting. Clinical guidelines recommend that acute stroke patients be co-located in a stroke unit in a geographically defined area, rather than dispersed across the hospital.

OBJECTIVE

To investigate post-intervention adherence to clinical guidelines for stroke management, and to explore staff barriers and facilitators to guideline implementation.

METHODS

Observational study before-and-after local implementation of Australian stroke clinical guidelines. The primary outcome was a change in the proportion of patients who were physically co-located in an acute stroke unit. Secondary outcomes included changes in adherence to additional acute and rehabilitation guideline criteria, and staff identification of barriers and facilitators to guide implementation. Data were collected from medical record audits, health service information and staff surveys.

RESULTS

Co-location in an acute stroke unit did not change significantly after guideline implementation (49% adherence pre-intervention and 54% post-intervention). Across acute and rehabilitation wards, 15% (11/72) of guideline criteria improved (p < .05). These related to assessments of swallowing and neglect, presence of a stroke care co-ordinator and occupational therapist, post-discharge care plan, provision of patient education and return to driving. Facilitators to guideline implementation included staff education, collaboration, and dissemination of user-friendly stroke policies.

CONCLUSION

Stroke clinical guideline implementation led to a favorable uptake of some criteria, yet not all. Implementation was assisted by staff education, user-friendly stroke policies and multidisciplinary team collaboration.

TRIAL REGISTRATION

ANZCTR: registration number ACTRN12616000646448 (http://www.ANZCTR.org.au/ACTRN12616000646448.aspx).

Comparison of diagnostic routines for suspected Alzheimer's disease patients in US-American and German primary care

Aim: Thorough diagnostics are a prerequisite for the optimal treatment of Alzheimer's disease (AD). Biomarker-based diagnostics are standard in academia, data on practitioners' diagnostic workups is scarce. Materials & methods: Surveys in German and US healthcare providers (HCP) were conducted regarding diagnostics in presumed AD patients. A subsample of 153 German and 88 US professionals was analyzed in detail. Results: Fewer German physicians conduct AD diagnostics themselves compared with US colleagues (67% vs 99%; p < 0.0001). German doctors more often order diagnostics at other institutions (65% vs 45%; p < 0.005). No significant differences were found regarding the type of diagnostics ordered at other institutions. Conclusion: Diagnostic routines for suspected AD patients differ between German and US-American healthcare providers.

Barriers and Enablers to Evaluating Outcomes From Public Involvement in Health Service Design: An Interpretive Description

While health services are expected to have public involvement in service (re)design, there is a dearth of evaluation of outcomes to inform policy and practice. There are major gaps in understanding why outcome evaluation is under-utilised. The aims of this interpretive descriptive study were to explore researcher participants' experiences of and/or attitudes towards evaluating health service outcomes from public involvement in health service design in high-income countries. Additionally, the aims were to explore barriers and enablers of evaluation, and reasons for the use of evaluation tools or frameworks. Semi-structured interviews (n = 13) were conducted with researchers of published studies where the public was involved in designing health services. Using framework analysis, four themes were developed that captured participants' experiences: Public involvement is hard - evaluation is harder; power, a diversity of agendas, and the invisible public; practical and methodological challenges; and genuineness and authenticity matter. Evaluation is driven by stakeholder requirements, including decision-makers, funding bodies, researchers, and academics, and evaluation tools are rarely used. The public is largely absent from the outcome evaluation agenda. There is a lack of commitment and clarity of purpose of public involvement and its evaluation. Outcome evaluation must be multi-layered and localised and reflect the purpose of public involvement, what constitutes success (and to whom), and use the most appropriate methods. Multi-level supports should include increased resources, such as funding, time, and expertise. Without improved evaluation, outcomes of investment in public involvement in health service design/redesign remain unknown.

Ten years of a geriatric oncology service at a public university cancer centre in Brazil

The implementation of a geriatric oncology service is challenging in both high-income and low-and-middle-income countries. The Octavio Frias de Oliveira Institute of Cancer of Sao Paulo (ICESP) is a tertiary healthcare complex of the Clinics Hospital of the University of Sao Paulo Medical School and is considered a model of excellence in oncology in Latin America. The objective of this manuscript is to describe 10 years of the geriatric oncology service at ICESP and the challenges for its implementation. We performed a narrative description of the ICESP's geriatric oncology service and a general retrospective descriptive analysis of data collected from routine structured medical records of patients referred to the service from 2011 to 2021. This article highlights the different settings in which the service operates (outpatient, pre-operative and hospital follow-up). In this period, 1,700 patients were assessed for preoperative evaluation (median age 83.9, SD 4.95), 468 patients were evaluated for therapeutic decision (median age 79.4, SD 7.38), 968 in general geriatric oncology care outpatient clinics from 2012 to 2021 (median age 78.7, SD 7.91) and 1,391 inpatient evaluations. In the past 10 years, our geriatric oncology team has grown exponentially and changed its characteristics in order to adjust them to the hospital demands, raising awareness among the oncology teams about the benefit of using geriatric assessment and promoting multidisciplinary discussions.

Health Services Research in Brachytherapy: Current Understanding and Future Challenges

Brachytherapy is an integral component of cancer care. Widespread concerns have been expressed though about the need for greater brachytherapy availability across many jurisdictions. Yet, health services research in brachytherapy has lagged behind that in external beam radiotherapy. Optimal brachytherapy utilisation, to help inform expected demand, have not been defined beyond the New South Wales region in Australia, with few studies having reported observed brachytherapy utilisation. There is also a relative lack of robust cost and cost-effectiveness studies, making investment decisions in brachytherapy even more uncertain and challenging to justify, despite its key role in cancer control. As the range of indications for brachytherapy expands, providing organ/function preservation for a wider range of diagnoses, there is an urgent need to redress this balance. By outlining the work undertaken in this area to date, we highlight its importance and explore where further study is required.

Is Fragmented Cancer Care Associated With Medical Expenditure? Nationwide Evidence From Patients With Lung Cancer Using National Insurance Claim Data

Objectives: We aimed to investigate the association between fragmented cancer care in the early phase after cancer diagnosis and patient outcomes using national insurance claim data. Methods: We identified National Health Insurance beneficiaries diagnosed with lung cancer in South Korea from 2010 to 2014. We included 1,364 lung cancer patients with reduced immortal time bias and heterogeneity. We performed multiple regression analysis using a generalized estimate equation with a gamma distribution for medical expenditures. Results: Among the 1,364 patients with lung cancer, 12.8% had fragmented cancer care. Healthcare costs were higher in fragmented cancer care for both during diagnosis to 365 days and diagnosis to 1,825 days. Linear regression results showed that fragmented cancer care was associated with 1.162 times higher costs during the period from diagnosis to 365 days and 1.163 times the cost for the period from diagnosis to 1,825 days. Conclusion: We found fragmented cancer care is associated with higher medical expenditure. Future health policy should consider the limitation of patients' free will when opting for fragmented cancer care, as there are currently no control mechanisms.

Declining Geographic Access to High-Volume Revision Total Hip Arthroplasty Surgeons: A National Medicare Analysis

BACKGROUND

While trends in the economics of revision THA (revTHA) procedures have been well-described from the standpoint of both hospitals and surgeons, their population-level effects of these trends on patient access are not well-understood.

METHODS

The Medicare fee-for-service provider utilization and payment public use files were used to extract data for primary and revTHA for beneficiaries between 2013 and 2019. Primary and revTHA procedures were identified using the Healthcare Common Procedure Coding System code; 27130 for primaries and 27132, 27134, 27137, or 27138 for revisions. Geospatial analyses were performed by aggregating surgeon practice locations at the level of individual counties, hospital service areas, and hospital referral regions.

RESULTS

The number of high-volume primary THA surgeons within the Medicare population increased by 17.6% over the study period (3,838 in 2013 to 4,515 in 2019). Conversely, the number of high-volume revTHA surgeons decreased by 36.1% (178 in 2013 to 129 in 2019). Linear regression revealed a significant increase and decrease in high-volume primary (β = 109.07, P ≤ .001) and revision (β = -13.04, P = .011) THA surgeons, respectively. Over the study period, the number of counties with at least 1 high-volume primary THA surgeon increased by 6.1% (1,194 to 1,267), while the number of counties with at least 1 high-volume revTHA surgeon decreased by 30.2% (159 to 111).

CONCLUSION

The present findings of declining geographic access may represent a consequence of shifting economic incentives and declining reimbursements for the care of complicated revTHA patients.

Effects of anti-osteoporosis therapy on the risk of secondary fractures and surgical complications following surgical fixation of proximal humerus fracture in older people

BACKGROUND

age-related fragility fractures cause significant burden of disease. Within an ageing society, fracture and complication prevention will be essential to balance health expenditure growth.

OBJECTIVE

to assess the effect of anti-osteoporotic therapy on surgical complications and secondary fractures after treatment of fragility fractures.

PATIENTS AND METHODS

retrospective health insurance data from January 2008 to December 2019 of patients ≥65 years with proximal humeral fracture (PHF) treated using locked plate fixation (LPF) or reverse total shoulder arthroplasty were analysed. Cumulative incidences were calculated by Aalen-Johansen estimates. The influence of osteoporosis and pharmaceutical therapy on secondary fractures and surgical complications were analysed using multivariable Fine and Gray Cox regression models.

RESULTS

a total of 43,310 patients (median age 79 years, 84.4% female) with a median follow-up of 40.9 months were included. Five years after PHF, 33.4% of the patients were newly diagnosed with osteoporosis and only 19.8% received anti-osteoporotic therapy. A total of 20.6% (20.1-21.1%) of the patients had at least one secondary fracture with a significant reduction of secondary fracture risk by anti-osteoporotic therapy (P < 0.001). An increased risk for surgical complications (hazard ratio: 1.35, 95% confidence interval: 1.25-1.47, P < 0.001) after LPF could be reversed by anti-osteoporotic therapy. While anti-osteoporotic therapy was more often used in female patients (35.3 vs 19.1%), male patients showed significantly stronger effects reducing the secondary fracture and surgical complication risk.

CONCLUSIONS

a significant number of secondary fractures and surgical complications could be prevented by consequent osteoporosis diagnosis and treatment particularly in male patients. Health-politics and legislation must enforce guideline-based anti-osteoporotic therapy to mitigate burden of disease.

Cancer care patterns in South Korea: Types of hospital where patients receive care and outcomes using national health insurance claims data

BACKGROUND

Although strengthening coverage has improved cancer care, there are concerns related to medical distortion. Previous studies have only examined whether patients visit a specific hospital, and not the continuum of patients with cancer, resulting in a lack of evidence in South Korea. This study aimed to investigate the patterns in hospital type for cancer care and analyze their association with outcomes.

METHODS

The data for this study were obtained from the National Health Insurance Services Sampled Cohort database. This study included patients with four types of cancer (top four cancer incidence in 2020): gastric (3353), colorectal (2915), lung (1351), and thyroid (5158) cancer. The latent class mixed model was used to investigate cancer care patterns, and multiple regression or survival analysis was performed to examine medical cost, length of stay (LOS), and mortality.

RESULTS

The patterns in each cancer type were classified into two to four classes, namely, mainly visited clinics or hospitals, mainly visited general hospitals, mainly visited tertiary hospitals (MT), and tertiary to general hospitals through trajectory modeling based on the utilization of cancer care. Compared to the MT pattern, other patterns were generally associated with higher cost, LOS, and mortality.

CONCLUSION

The patterns found in this study may be a more realistic way of defining patients with cancer in South Korea compared to previous studies, and its association-related outcomes may be used as a basis to address problems in the healthcare system and prepare alternatives for patients with cancer. Future studies should review cancer care patterns related to other factors such as regional distribution.

Mobile Health Interventions to Improve Health Behaviors and Healthcare Services among Vietnamese Individuals: A Systematic Review

The purpose of this review is to summarize the feasibility, acceptability, and efficacy of interventions that utilize mobile health (mHealth) technology to promote health behavior changes or improve healthcare services among the Vietnamese population. Ovid MEDLINE, CINAHL, EMBASE, Scopus, and Web of Science were used to identify studies published from 2011-2022. Studies utilizing mHealth to promote behavior change and/or improve healthcare services among Vietnamese were included. Studies that included Vietnamese people among other Asians but did not analyze the Vietnamese group separately were excluded. Three independent researchers extracted data using Covidence following PRISMA guidelines. Measures of feasibility, acceptability, and efficacy were synthesized. The ROBINS-I and RoB2 tools were used to evaluate methodological quality. Fourteen articles met inclusion criteria and included 5660 participants. Participants rated high satisfaction, usefulness, and efficacy of mHealth interventions. Short message service was most frequently used to provide health education, support smoking cessation, monitor chronic diseases, provide follow-up, and manage vaccination. Measures of feasibility, acceptability, and efficacy varied across studies; overall findings indicated that mHealth is promising for promoting lifestyle behavior change and improving healthcare services. Cost effectiveness and long-term outcomes of mHealth interventions among the Vietnamese population are unknown and merit further research. Recommendations to integrate mHealth interventions are provided to promote the health of Vietnamese people.

Effect of COVID-19 pandemic on utilisation of community-based mental health care in North-East of Italy: A psychiatric case register study

AIMS

WHO declared that mental health care should be considered one essential health service to be maintained during the coronavirus disease 2019 (COVID-19) pandemic. This study aims to describe the effect of lockdown and restrictions due to the COVID-19 pandemic in Italy on mental health services' utilisation, by considering psychiatric diagnoses and type of mental health contacts.

METHODS

The study was conducted in the Verona catchment area, located in the Veneto region (northeastern Italy). For each patient, mental health contacts were grouped into: (1) outpatient care, (2) social and supportive interventions, (3) rehabilitation interventions, (4) multi-professional assessments, (5) day care. A 'difference in differences' approach was used: difference in the number of contacts between 2019 and 2020 on the weeks of lockdown and intermediate restrictions was compared with the same difference in weeks of no or reduced restrictions, and such difference was interpreted as the effect of restrictions. Both a global regression on all contacts and separate regressions for each type of service were performed and Incidence Rate Ratios (IRRs) were calculated.

RESULTS

In 2020, a significant reduction in the number of patients who had mental health contacts was found, both overall and for most of the patients' characteristics considered (except for people aged 18-24 years for foreign-born population and for those with a diagnosis of schizophrenia. Moreover, in 2020 mental health contacts had a reduction of 57 096 (-33.9%) with respect to 2019; such difference remained significant across the various type of contacts considered, with rehabilitation interventions and day care showing the greatest reduction. Negative Binomial regressions displayed a statistically significant effect of lockdown, but not of intermediate restrictions, in terms of reduction in the number of contacts. The lockdown period was responsible of a 32.7% reduction (IRR 0.673; p-value <0.001) in the overall number of contacts. All type of mental health contacts showed a reduction ascribable to the lockdown, except social and supportive interventions.

CONCLUSIONS

Despite the access to community mental health care during the pandemic was overall reduced, the mental health system in the Verona catchment area was able to maintain support for more vulnerable and severely ill patients, by providing continuity of care and day-by-day support through social and supportive interventions.

Patient care, integration and collaboration of physician associates in multiprofessional teams: A mixed methods study

AIMS

The aim of the study was to explore the physician associate role in patient care, integration and collaboration with team members, within the hospital setting.

DESIGN

Convergent mixed methods case study design.

METHODS

Questionnaires with some open-ended questions and semi-structured interviews were analysed with descriptive statistics and thematic analysis.

RESULTS

Participants included 12 physician associates, 31 health professionals and 14 patients/relatives. Physician associates provide effective, safe and, importantly, continuity of care and patients received patient-centred care. Integration into teams was variable, and there was a lack of knowledge about the physician associate role amongst staff and patients. Views towards physician associates were mostly positive, but support for physician associates differed across the three hospitals.

CONCLUSION

This study further consolidates the role of physician associates to multiprofessional teams and patient care and emphasises the importance of providing support to individuals and teams when integrating new professions. Interprofessional learning throughout healthcare careers can develop interprofessional working within multiprofessional teams.

IMPACT

Leaders in healthcare will see that clarity about the role of physician associates must be given to staff members and patients. Employers and team members will see the need to properly integrate new professions and team members within the workplace and to enhance professional identities. The research will also impact on educational establishments to provide more interprofessional training.

PATIENT AND PUBLIC INVOLVEMENT

There is no patient and public involvement.

Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey

INTRODUCTION

Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations.

METHODS

With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark.

RESULTS

Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall.

CONCLUSIONS

This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.

Increased complication rates for salvage RTSA after failed locked plate fixation compared to primary RTSA in the treatment of proximal humeral fractures in elderly patients

HYPOTHESIS

Common surgical treatment options for proximal humeral fractures in the elderly include locked plate fixation (LPF) and reverse total shoulder arthroplasty (RTSA). It was hypothesized that secondary RTSA after LPF was associated with higher complication rates and costs compared to primary RTSA.

METHODS

Health insurance data of patients ≥65 years of age that received a RTSA due to a proximal humeral fracture between 01/2013 and 09/2019 with a pre-study phase of five years were analyzed. Multivariable Cox, logistic and linear regression models were used to evaluate the association between treatment group, complications, length of hospital stay (LOS), charges and mortality during 34 months follow-up.

RESULTS

14,220 patients received a primary and 1.282 a secondary RTSA after prior surgery using LPF for treatment of a proximal humeral fracture. After adjustment to patient's characteristics, more surgical complications were observed after secondary RTSA during index hospitalization (OR 4.62, 95% CI 4.00 - 5.34, p<0.001) and long-term follow-up (HR 1.52, 95% CI 1.27 - 1.81, p<0.001). Moreover, secondary RTSA was associated with an increased cumulative total cost of 6638.1€ (95% CI 6229.9 - 7046.5€, p<0.001). If conversion from LPF to secondary RTSA occurred during index hospitalization more major adverse, thromboembolic events as well as a higher mortality was found during short and long-term (all p<0.05).

CONCLUSION

Secondary RTSA is associated with higher total costs and more complications. Hence, if surgical treatment of a proximal humeral fracture in the elderly is needed, prognostic factors for LPF need to be evaluated carefully. In doubt, patients will profit from primary RTSA in long term.

Satellite liver transplant centres significantly improve transplant assessment outcomes for patients with chronic liver disease but not hepatocellular carcinoma: a retrospective cohort study

Introduction

Liver transplantation (LT) remains integral to the management of end-stage chronic liver disease (CLD). However, referral thresholds and assessment pathways remain poorly defined. Distance from LT centre has been demonstrated to impact negatively on patient outcomes resulting in the development of satellite LT centres (SLTCs). We aimed to evaluate the impact of SLTCs on LT assessment in patients with CLD and hepatocellular carcinoma (HCC).

Methods

A retrospective cohort study was undertaken including all patients with CLD or HCC assessed for LT at King's College Hospital (KCH) between October 2014 and October 2019. Referral location, social, demographic, clinical and laboratory data were collected. Univariable and multivariable analyses (MVA) were performed to assess the impact of SLTCs on patients being accepted as LT candidates and contraindications being identified.

Results

1102 and 240 LT assessments were included for patients with CLD and HCC, respectively. MVA demonstrated significant associations with; patients living greater than 60 min from KCH/SLTCs and LT candidacy acceptance in CLD, and less deprived patients and LT candidacy acceptance in HCC. However, neither variable was associated with identification of LT contraindications. MVA demonstrated that referrals from SLTCs were more likely to result in acceptance of LT candidacy and less likely to result in a contraindication being identified in CLD. However, such associations were not demonstrated in HCC.

Conclusion

SLTCs improve LT assessment outcomes in CLD but not HCC reflecting the standardised HCC referral pathway. Developing a formal regional LT assessment pathway across the UK would improve equity of access to transplantation.

The public and patient involvement imperative in Ireland: Building on policy drivers

What can we learn from the history of Public and Patient Involvement (PPI) in healthcare and research across global jurisdictions? Depending on region and context, the terminology and heritage of involvement in research vary. In this paper, we draw on global traditions to explore dominant themes and key considerations and critiques pertaining to PPI in order to inform a PPI culture shift in Ireland. We then describe the heritage of PPI in Ireland and present the case for combining methodological imperatives with policy drivers to support and encourage meaningful involvement. Specifically, we propose that PPI can be enriched by the theory and processes of participatory health research (PHR); and that implementation requires concurrent capacity building. We conclude with a call for Irish researchers (authors of this paper included) to consider the conceptual complexities and nuances of a participatory approach to build on the policy imperatives driving PPI and to contribute to the international evidence base and research culture. Specifically, we call for Irish health researchers and funders to consider and reflect on: (1) the rich literature of PHR as a resource for enacting meaningful PPI; (2) the roots and origins of varying participatory health research methods; (3) how community/patient groups can lead health research; and (4) co-learning and partnership synergy to create space for both academic and community expertise; and (5) the importance of using standardized reporting tools.

Exploring health and social services in Denmark, Norway, Spain and the United Kingdom for the development of Parkinson's care pathways. A document analysis

People with Parkinson's disease (PD) may find it difficult to identify and access the wide number of services they need and are entitled to along their complex PD journey. As part of the project OPTIM-PARK - Optimisation of community resources and systems of support to enhance the process of living with Parkinson's Disease, document analysis was developed to create overviews of existing resources and systems of support in Denmark, Norway, Spain and the United Kingdom. Documents on community resources, policies, guidelines and professional recommendations were the main sources of information. They were sought systematically at official websites of the public sector (national and regional levels) and websites of non-governmental organisations and scientific societies; searches were performed in October 2020 and updated in September 2021. A higher-level cross-national content analysis integrated all the country-specific information. Data- and concept-driven coding frames were developed; trial coding and peer review strengthened face validity and reliability. The analysis led to overviews of: (1) Key aims at patient and societal levels. (2) Key elements in form of professional approaches. (3) Community resources. (4) Legally anchored services. In general, clear descriptions of how to implement care pathways and tools to facilitate delivery were missing in the included documents, and pathways and guidelines did not include referral to general social support, social security support or labour and employment support. The results shed light on the complex support systems and resources and can inspire the planning of more comprehensive care pathways for people with PD and other long-term conditions.

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits

BACKGROUND

Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs).

OBJECTIVE

To understand if there is an association between parent preventive care and their children's well-child visits.

METHODS

We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents.

RESULTS

We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care.

CONCLUSIONS

These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Gaps in the screening process for women diagnosed with cervical cancer in four diverse US health care settings

BACKGROUND

Potential care gaps in the cervical cancer screening process among women diagnosed with cervical cancer in an era with increased human papillomavirus (HPV) testing have not been extensively evaluated.

METHODS

Women diagnosed with cervical cancer between ages 21 and 65 at four study sites between 2010 and 2014 were included. Screening histories were ascertained from 0.5 to 4 years prior to cervical cancer diagnosis. We identified potential care gaps in the screening history for each woman and classified them into one of three mutually exclusive types: lack of a screening test, screening test failure, and diagnostic/treatment care gap. Distributions of care gaps were tabulated by stage, histology, and study site. Multivariable nominal logistic regression was used to examine the associations between demographic and cancer characteristics and type of care gap.

RESULTS

Of 499 women evaluated, 46% lacked a screening test in the time window examined, 31% experienced a screening test failure, and 22% experienced a diagnostic/treatment care gap. More than half of the women with advanced cancer and squamous cell carcinoma lacked a screening test compared to 31% and 24% of women with localized cancer and adenocarcinoma, respectively. Women aged 21-29 at diagnosis were more likely to experience screening test failure and diagnostic/treatment care gap, while those aged 50-65 were more likely to lack a screening test, compared to women aged 30-39.

CONCLUSIONS

Our findings demonstrate a continuing need to develop interventions targeting unscreened and under-screened women and improve detection and diagnosis of adenocarcinoma in women undergoing cervical cancer screening and diagnostic follow-up.

Influences of COVID-19 pandemic on hospital-at-home functions in Finland - a questionnaire survey

OBJECTIVE

To investigate functions of Finnish hospital-at-home (HAH) during the first year of COVID19-pandemic 2020 compared with the previous year 2019.

DESIGN

Retrospective questionnaire survey.

SETTING

Finnish HAHs from Northern, Eastern, Southern, Western and Central parts of Finland participated in a questionnaire web-based questionnaire survey. The numbers of patients, activities and staff in 2019 and 2020, participation in the care of COVID19 patients, availability of protective clothing, attitudes of patients towards home care and development of new practices in the corona era were asked using both predefined and free questions.

SUBJECTS

questionnaire was sent to the nurses and physicians in charge of the HAHs (N = 13), 77% responded. The HAHs provided services to a total of 1,196,783 inhabitants in their municipalities.

RESULTS

There were no significant changes in the numbers of patients, staff or activities between the years 2019 and 2020. Although nurses did viral tests, COVID19 patients were cared only in 40% of HAHs. Protective clothing was well available. New instructions for infection management were created.

CONCLUSIONS

The COVID-19 pandemic did not largely influence the functions of the examined Finnish HAHs in 2020. Most activities and patients' characteristics remained unchanged from 2019. The role of HAHs should be further developed in Scandinavian countries, particularly during pandemics.Key PointsHospital-at-home (HAH) is a cost-effective model to provide hospital-like services.Data about the role of HAHs during COVID19 pandemics is lacking in the Nordic countries.This study shows that, the large Finnish municipal HAHs have been not influenced by pandemics.

Coproduced resources to support parents caring for children with gastrostomies

Objective

To describe and disseminate a package of support for parents who care for children with gastrostomies, consisting of a library of videos and resources to support families from referral for gastrostomy surgery, to long-term support at home.

Methods

The resources were systematically developed and evaluated by parents, hospital and community-based nurses, paediatricians, a surgeon and researchers.

Results

The videos empower families, reduce their anxiety and increase their confidence, providing support throughout the families' journey. Surveys and feedback from parents and clinicians show that the video library is seen as providing clear and comprehensive guidance and is suitable for integration into routine practice. To effectively disseminate these resources across a region, the videos need to be shared widely with relevant community and hospital-based teams, and shared through parent networks. The videos should be viewed as one part of a wider package of training and support, in combination with hands-on-practice and clinical support.

Conclusions

The resources described have been developed with and for families. Critically the videos are founded in the lived-experience of families, as well as the expertise of clinicians from community and hospital services. Similar resources are needed to support families performing other types of specialist care. The resources are freely available to any parent or clinical team.

UK endoscopy workload and workforce patterns: is there potential to increase capacity? A BSG analysis of the National Endoscopy Database

Background

The lack of comprehensive national data on endoscopy activity and workforce hampers strategic planning. The National Endoscopy Database (NED) provides a unique opportunity to address this in the UK. We evaluated NED to inform service planning, exploring opportunities to expand capacity to meet service demands.

Design

Data on all procedures between 1 March 2019 and 29 February 2020 were extracted from NED. Endoscopy activity and endoscopist workforce were analysed.

Results

1 639 640 procedures were analysed (oesophagogastroduodenoscopy (OGD) 693 663, colonoscopy 586 464, flexible sigmoidoscopy 335 439 and endoscopic retrograde cholangiopancreatography 23 074) from 407 sites by 4990 endoscopists. 89% of procedures were performed in NHS sites. 17% took place each weekday, 10% on Saturdays and 6% on Sundays. Training procedures accounted for 6% of total activity, over 99% of which took place in NHS sites. Median patient age was younger in the independent sector (IS) (51 vs 60 years, p<0.001). 74% of endoscopists were male. Gastroenterologists and surgeons each comprised one-third of the endoscopist workforce; non-medical endoscopists (NMEs) comprised 12% yet undertook 23% of procedures. Approximately half of endoscopists performing OGD (52%) or colonoscopies (48%) did not meet minimum annual procedure numbers.

Conclusion

This comprehensive analysis reveals endoscopy workload and workforce patterns for the first time across both the NHS and the IS in all four UK nations. Half of all endoscopists perform fewer than the recommended minimum annual procedure numbers: a national strategy to address this, along with expansion of the NME workforce, would increase endoscopy capacity, which could be used to exploit latent weekend capacity.

The effect of the COVID-19 lockdown on mental health care use in South Africa: an interrupted time-series analysis

AIMS

The coronavirus disease 2019 (COVID-19) pandemic and ensuing restrictions have negatively affected the mental health and well-being of the general population, and there is increasing evidence suggesting that lockdowns have led to a disruption of health services. In March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on mental health care utilisation rates in private-sector care in South Africa.

METHODS

We conducted an interrupted time-series analysis using insurance claims from 1 January 2017 to 1 June 2020 of beneficiaries 18 years or older from a large private sector medical insurance scheme. We calculated weekly outpatient consultation and hospital admission rates for organic mental disorders, substance use disorders, serious mental disorders, depression, anxiety, other mental disorders, any mental disorder and alcohol withdrawal syndrome. We calculated adjusted odds ratios (OR) for the effect of the lockdown on weekly outpatient consultation and hospital admission rates and the weekly change in rates during the lockdown until 1 June 2020.

RESULTS

710 367 persons were followed up for a median of 153 weeks. Hospital admission rates (OR 0.38; 95% confidence interval (CI) 0.33-0.44) and outpatient consultation rates (OR 0.74; 95% CI 0.63-0.87) for any mental disorder decreased substantially after the introduction of the lockdown and did not recover to pre-lockdown levels by 1 June 2020. Health care utilisation rates for alcohol withdrawal syndrome doubled after the introduction of the lockdown, but the statistical uncertainty around the estimates was large (OR 2.24; 95% CI 0.69-7.24).

CONCLUSIONS

Mental health care utilisation rates for inpatient and outpatient services decreased substantially after the introduction of the lockdown. Hospital admissions and outpatient consultations for alcohol withdrawal syndrome increased after the introduction of the lockdown, but statistical uncertainty precludes strong conclusions about a potential unintended effect of the alcohol sales ban. Governments should integrate strategies for ensuring access and continuity of essential mental health services during lockdowns in pandemic preparedness planning.

Migrant GPs and patients: a cross-sectional study of practice characteristics, patient experiences and migration concordance

OBJECTIVE

To investigate practice type and location of native and immigrant general practitioners (GPs); effects of migration status concordance between GPs and patients on experiences of patients in key areas of primary care quality and discrimination.

DESIGN AND SETTING

Secondary analysis of GP and patient survey data from QUALICOPC (Quality and Costs of Primary Care), a cross-sectional study of GPs and their patients in 34 countries, performed between 2011 and 2013.

MAIN OUTCOME MEASURES

We explored practice type and location of native and immigrant GPs and the experiences of native patients and patients with a migration background of communication, continuity, comprehensiveness, accessibility, and discrimination, using multilevel analysis. Concordance was modelled as a cross-level interaction between migration status of GPs and patients.

RESULTS

Percentages of immigrant GPs varied widely. In Europe, this was highest in England and Luxemburg (40% of GPs born abroad) and lowest in Bulgaria and Romania (1%). The practice population of immigrant GPs more often included an above average proportion of people from ethnic minorities. There were no differences in main effects of patient experiences following a visit to an immigrant or native GP, in four core areas of primary care or in discrimination. However, people from first-generation migrant background more often experienced discrimination, in particular when visiting a native GP.

CONCLUSION

Patient experiences did not vary with GPs' migration status. Although experience of discrimination was uncommon, first-generation migrant patients experienced more discrimination. Primary care should provide non-discriminatory care, through GP awareness of unconscious bias and training to address this. Key messagesThere were large differences in percentage of migrant GPs between countries.Migrant GPs' practices had an above average proportion of people from ethnic minorities.In general, patients' experienced discrimination from GPs and practice staff was low, but first-generation migrant patients more often experienced discrimination.First-generation migrant patients more often experienced discrimination when they visited a native GP.

Assessment of Health Service Quality Through Electronic Health Record - A Scoping Review

The World Health Organization defines, that high quality health services should be effective, safe, people-centered, timely, equitable, integrated, and effective. This requires systematic quality assessment. The aim of this scoping review was to explore how electronic health records (EHRs) have been used to assess quality of health services using the WHO criteria. A total of 4247 records were obtained whereof 8 studies were included in the review. Research showed that EHRs were used to evaluate safety, performance and care processes. EHRs were regarded as an applicable real-world data source, highlighting the importance of consistency and standardised terminologies. Use of EHR data is limited to its representation of the real world and current evaluation systems have limited quality criteria, diverse definitions and they use only structured data. Future research should explore possibilities of natural language processing methods and include narrative EHR information for a more a comprehensive view of service quality assessment.

Association of Medicaid expansion under the Affordable Care Act with access to elective spine surgical care

OBJECTIVE

The Affordable Care Act expanded Medicaid eligibility in many states, improving access to some forms of elective healthcare in the United States. Whether this effort increased access to elective spine surgical care is unknown. This study's objective was to evaluate the impact of Medicaid expansion under the Affordable Care Act on the volume and payer mix of elective spine surgery in the United States.

METHODS

This study evaluated elective spine surgical procedures performed from 2011 to 2016 and included in the all-payer State Inpatient Databases of 10 states that expanded Medicaid access in 2014, as well as 4 states that did not expand Medicaid access. Adult patients aged 18-64 years who underwent elective spine surgery were included. The authors used a quasi-experimental difference-in-difference design to evaluate the impact of Medicaid expansion on hospital procedure volume and payer mix, independent of time-dependent trends. Subgroup analysis was conducted that stratified results according to cervical fusion, thoracolumbar fusion, and noninstrumented surgery.

RESULTS

The authors identified 218,648 surgical procedures performed in 10 Medicaid expansion states and 118,693 procedures performed in 4 nonexpansion states. Medicaid expansion was associated with a 17% (95% CI 2%-35%, p = 0.03) increase in mean hospital spine surgical volume and a 23% (95% CI -0.3% to 52%, p = 0.054) increase in Medicaid volume. Privately insured surgical volumes did not change significantly (incidence rate ratio 1.13, 95% CI -5% to 34%, p = 0.18). The increase in Medicaid volume led to a shift in payer mix, with the proportion of Medicaid patients increasing by 6.0 percentage points (95% CI 4.1-7.0, p < 0.001) and the proportion of private payers decreasing by 6.7 percentage points (95% CI 4.5-8.8, p < 0.001). Although the magnitude of effects varied, these trends were similar across procedure subgroups.

CONCLUSIONS

Medicaid expansion under the Affordable Care Act was associated with an economically and statistically significant increase in spine surgery volume and the proportion of surgical patients with Medicaid insurance, indicating improved access to care.

Flexible and Integrative Psychiatric Care Based on a Global Treatment Budget: Comparing the Implementation in Germany and Poland

Background: The past decade has witnessed the establishment of flexible and integrative treatment (FIT) models in 55 German and Polish psychiatric catchment areas. FIT is based on a global treatment budget (GTB), which integrates funding of all acute psychiatric hospital services for a regional population. Prior research has identified 11 specific program components of FIT in Germany. In this paper we aim at assessing the applicability of these components to the Polish context and at comparatively analysing FIT implementation in Poland and Germany. Methods: Qualitative interviews about the applicability of the 11 FIT-specific components were conducted with the program managers of the Polish FIT models (n = 19). Semi-quantitative data on the FIT-specific components were then collected in 19 Polish and 10 German FIT models. We assessed the grading of each component, their overall degree of implementation and compared them between the two countries. In all study hospitals, structural and statistical parameters of service delivery were collected and compared. Results: The qualitative results showed that the German FIT-specific components are in principle applicable to the polish context. This allowed the comparative assessment of components grading and degree of implementation, which showed only subtle discrepancies between German and Polish FIT models. The little discrepancies point to specific aspects of care such as home treatment, peer support, and cooperation with non-clinical and social welfare institutions that should be further integrated in the components' definition. Conclusions: The specific program components of FIT as first defined from the German experience, serves as a powerful tool to measure, and evaluate implementation of integrated psychiatric care both within and between health systems.

Power of big data to improve patient care in gastroenterology

Big data is defined as being large, varied or frequently updated, and usually generated from real-world interaction. With the unprecedented availability of big data, comes an obligation to maximise its potential for healthcare improvements in treatment effectiveness, disease prevention and healthcare delivery. We review the opportunities and challenges that big data brings to gastroenterology. We review its sources for healthcare improvement in gastroenterology, including electronic medical records, patient registries and patient-generated data. Big data can complement traditional research methods in hypothesis generation, supporting studies and disseminating findings; and in some cases holds distinct advantages where traditional trials are unfeasible. There is great potential power in patient-level linkage of datasets to help quantify inequalities, identify best practice and improve patient outcomes. We exemplify this with the UK colorectal cancer repository and the potential of linkage using the National Endoscopy Database, the inflammatory bowel disease registry and the National Health Service bowel cancer screening programme. Artificial intelligence and machine learning are increasingly being used to improve diagnostics in gastroenterology, with image analysis entering clinical practice, and the potential of machine learning to improve outcome prediction and diagnostics in other clinical areas. Big data brings issues with large sample sizes, real-world biases, data curation, keeping clinical context at analysis and General Data Protection Regulation compliance. There is a tension between our obligation to use data for the common good and protecting individual patient's data. We emphasise the importance of engaging with our patients to enable them to understand their data usage as fully as they wish.

Associations between depressive symptom clusters and care utilization and costs among community-dwelling older adults

OBJECTIVES

Whether and how symptom clusters are associated with care utilization remains understudied. This study aims to investigate the economic impact of symptom clusters.

METHODS

We conducted cross-sectional analyses of data collected from 3255 older adults aged 60 years and over in Hong Kong using the Patient Health Questionnaire-9 and the Client Service Receipt Inventory to measure depressive symptoms and service utilization to calculate 1-year care expenditure. Based on Research Domain Criteria framework, we categorized depressive symptoms into four clusters: Negative Valance Systems and Externalizing (NVSE; anhedonia and depression), Negative Valance Systems and Internalizing (guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue, and appetite), and Cognitive and Sensorimotor Systems (CSS; concentration and psychomotor). Two-part models were used with four symptom clusters to estimate economic impacts on care utilization.

RESULTS

Core affective symptoms had the largest economic impact on non-psychiatric care expenditure; a one-point increase in NVSE was associated with USD$ 571 additional non-psychiatric care expenditure. The economic impacts of CSS on non-psychiatric care expenditure was attenuated when the severity level of NVSE was higher.

CONCLUSIONS

Our findings highlight the importance of understanding economic impacts on care utilization based on symptom profiles with a particular emphasis on symptom combinations. Policymakers should optimize care allocation based on older adults' depressive symptom profiles rather than simply considering their depression sum-score or the severity defined by cut-off points.

Participating in Longitudinal Observational Research on Psychiatric Rehabilitation: Quantitative Results From a Patient Perspective Study

BACKGROUND

Longitudinal observational studies play on an important role for evidence-based research on health services and psychiatric rehabilitation. However, information is missing about the reasons, why patients participate in such studies, and how they evaluate their participation experience.

METHODS

Subsequently to their final assessment in a 2-year follow-up study on supported housing for persons with severe mental illness, n = 182 patients answered a short questionnaire on their study participation experience (prior experiences, participation reasons, burden due to study assessments, intention to participate in studies again). Basic respondent characteristics as well as symptom severity (SCL-K9) were also included in the descriptive and analytical statistics.

RESULTS

To help other people and curiosity were cited as the main initial reasons for study participation (>85%). Further motives were significantly associated with demographic and/or clinical variables. For instance, "relieve from boredom" was more frequently reported by men and patients with substance use disorders (compared to mood disorders), and participants 'motive" to talk about illness" was associated with higher symptom severity at study entry. Furthermore, only a small proportion of respondents indicated significant burdens by study participation and about 87% would also participate in future studies.

CONCLUSIONS

The respondents gave an overall positive evaluation regarding their participation experience in an observational study on psychiatric rehabilitation. The results additionally suggest that health and social care professionals should be responsive to the expectations and needs of patients with mental illness regarding participation in research.

From contact coverage to effective coverage of community care for patients with severe mental disorders: A real-world investigation from Italy

OBJECTIVES

To measure the gap between contact and effective coverage of mental healthcare (MHC).

MATERIALS AND METHODS

45,761 newly referred cases of depression, schizophrenia, bipolar disorder, and personality disorder from four Italian regions were included. A variant of the self-controlled case series method was adopted to estimate the incidence rate ratio (IRR) for the relationship between exposure (i.e., use of different types of MHC such as pharmacotherapy, generic contact with the outpatient services, psychosocial intervention, and psychotherapy) and relapse (emergency hospital admissions for mental illness).

RESULTS

11,500 relapses occurred. Relapse risk was reduced during periods covered by (i) psychotherapy for patients with depression (IRR 0.67; 95% CI: 0.49 to 0.91) and bipolar disorder (0.64; 0.29 to 0.99); (ii) psychosocial interventions for those with depression (0.74; 0.56 to 0.98), schizophrenia (0.83; 0.68 to 0.99), and bipolar disorder (0.55; 0.36 to 0.84), (iii) pharmacotherapy for patients with schizophrenia (0.58; 0.49 to 0.69), and bipolar disorder (0.59; 0.44 to 0.78). Coverage with generic care, in absence of psychosocial/psychotherapeutic interventions, did not affect risk of relapse.

CONCLUSION

This study ascertained the gap between contact and effective coverage of MHC and showed that administrative data can usefully contribute to assess the effectiveness of a mental health system.

Evaluation of a novel salaried medical officer position on service provision and performance at a rural health service: An exploratory mixed-methods study

OBJECTIVE

The objective of this study was to determine the impact of a new salaried medical officer position on health service provision and organisational performance.

DESIGN

Health service staff were invited to complete a survey to ascertain their overall satisfaction with the salaried medical officer position and impact on their workflow. Purposive sampling identified respondents for interviews to further explore the experiences of health service staff. Financial, administrative and quality information was extracted for analysis.

SETTING

Medium size rural health service in Victoria, Australia.

PARTICIPANTS

All general practitioner, nursing and allied health staff employed by, or who provide services to, the health service.

MAIN OUTCOME MEASURES

Satisfaction with the salaried medical officer position, ability to address patient concerns, themes from interviews, organisational performance data.

RESULTS

Forty surveys (general practitioner, nursing and allied health) were returned and 10 interviews completed. The mean rating for satisfaction with the salaried medical officer position was 8.4 out of 10. Addressing patient care concerns was rated significantly easier by nursing and allied health staff when the salaried medical officer was working. The interviews identified three broad themes: improved efficiency, increased accessibility and eliminated service gaps.

CONCLUSION

Health service staff reported that a salaried medical officer position at a rural health service improved work efficiency, increased accessibility to timely medical advice and improved quality of care, particularly patients at risk of sudden deterioration.

Capturing learning from public involvement with people experiencing homelessness to help shape new physiotherapy research: Utilizing a reflective model with an under-served, vulnerable population

Introduction

People experiencing homelessness (PEH) have poorer health than housed people but face barriers accessing care and being involved in research. As an often‐ignored group, their contribution to help shape research that is for and about them is essential, as it can strengthen the research proposal, in turn facilitating research and outcomes that are relevant to this vulnerable group.

Methods

Six people with experience of homelessness attended a PPI consultation aided by Pathway, a UK homeless peer advocacy charity, which coordinates an ‘Experts by Experience’ group. We present reflections on conducting PPI with PEH that informed the development of a physiotherapy research proposal. Kolb's Experiential Learning Cycle guided reflections across four stages: (1) describing the PPI experience; (2) reviewing and reflecting on the PPI experience; (3) learning from the PPI experience; and (4) planning and trying out learning.

Results

Reflections highlighted the importance of: working closely with an advocacy organisation and leader to reach under‐served people; the diversity of experiences; using familiar venues, contingency and budget planning; flexibility and ‘allowing time; talking less; listening more’; planning for early and ongoing PPI, and the potential of mobile ‘one‐off’ PPI outreach models to reach vulnerable groups.

Conclusion

Kolb's Experiential Learning Cycle aided team reflection on feedback from PEH, which helped refine and strengthen a physiotherapy research proposal. The project was unfunded. However, a reflective model helped maximize learning and impact including for future PPI and research. The novel application of Kolb's Experiential Learning Cycle provided structure, facilitated reflection and enhanced individual and collective learning and may benefit capturing learning from PPI with other vulnerable populations.

Patient or Public Contribution

We highlight how a PPI consultation with people with experience of homelessness helped shape a funding proposal. Additionally, the reflections of the experts by experience team leader are included.

Acute and Long-Term Outcomes of ST-Elevation Myocardial Infarction in Cancer Patients, a 'Real World' Analysis with 175,000 Patients

BACKGROUND

Acute myocardial infarction (AMI) and cancer are common and serious diseases. As the prognosis and treatment of both diseases has improved, more cancer patients will suffer an AMI. Unfortunately, data on these "double hit" patients is scarce.

METHODS

From the largest public German health insurance, anonymized data of all patients with pre-existing cancer who were hospitalized due to ST-elevation MI (STEMI) between 2010 and 2017 were analyzed and followed-up until 2018.

RESULTS

Of 175,262 STEMI patients, 27,213 had pre-existing cancer (15.5%). Most frequent were skin (24.9%), prostate (17.0%), colon (11.0%), breast (10.9%), urinary tract (10.6%), and lung cancer (5.2%). STEMI patients with malignancies were older and presented more often with coronary three-vessel disease, atrial arrhythmias, chronic kidney disease, chronic heart failure, cerebrovascular and peripheral artery disease (PAD, each p < 0.001). They showed more often previous AMI, percutaneous coronary interventions (PCI), cardiac surgery, and stroke (all p < 0.001). Acute PCIs were applied between 2 and 6% less frequently compared to those without cancer. In-hospital adverse events occurred more frequently in cancer. Eight-year survival was 57.3% (95% CI 57.0-57.7%) without cancer and ranged between 41.2% and 19.2% in distinct cancer types. Multivariable Cox regression for all-cause mortality found, e.g., lung cancer (HR 2.04), PAD stage 4-6 (HR 1.78), metastasis (HR 1.72), and previous stroke (HR 1.44) to have the strongest impact (all p < 0.001).

CONCLUSION

In this large "real world" data, prognosis after STEMI in cancer patients was markedly reduced but differed widely between cancer types. Of note, no withholding of interventional treatments in cancer patients could be observed.