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In observational health services research, researchers often use clustered data to estimate the independent association between individual outcomes and several cluster‐level covariates after adjusting for individual‐level characteristics. Generalized estimating equations are a popular method for estimating generalized linear models using clustered data. The conventional Liang–Zeger variance estimator is known to result in estimated standard errors that are biased low when the number of clusters in small. Alternative variance estimators have been proposed for use when the number of clusters is low. Previous studies focused on these alternative variance estimators in the context of cluster randomized trials, which are often characterized by a small number of clusters and by an outcomes regression model that often consists of a single cluster‐level variable (the treatment/exposure variable). We addressed the following questions: (i) which estimator is preferred for estimating the standard errors of cluster‐level covariates for logistic regression models with multiple binary and continuous cluster‐level variables in addition to subject‐level variables; (ii) in such settings, how many clusters are required for the Liang–Zeger variance estimator to have acceptable performance for estimating the standard errors of cluster‐level covariates. We suggest that when estimating standard errors: (i) when the number of clusters is < 15 use the Kauermann–Carroll estimator; (ii) when the number of clusters is between 15 and 40 use the Fay–Graubard estimator; (iii) when the number of clusters exceeds 40, use the Liang–Zeger estimator or the Fay–Graubard estimator. When estimating confidence intervals, we suggest using the Mancl–DeRouen estimator with a t‐distribution. [ABSTRACT FROM AUTHOR]

Background: People with "Differences of Sex Development" (DSD) require comprehensive, specialised, and individualised medical and psychological care. This is often perceived as inadequate by those affected. Therefore, the German Federal Ministry of Health funded the project DSDCare which aimed to improve the quality of care for people with DSD over the lifespan in Germany. Method: Indicators of structural, process, and outcome quality were defined, which are used to evaluate the quality of care. The indicators of structural quality are collected once a year from ten participating centres. Based on the "Open Source Registry System for Rare Diseases (OSSE)", a DSD-specific registry (DSDReg) was developed, in which patient-related care data are recorded in order to be able to assess the process and outcome quality. Furthermore, patient-reported outcomes are collected directly from the patients by means of questionnaires. The data are reported back to the participating centres in an annual benchmarking. Results: Twenty-five indicators of structural quality were defined, twelve indicators of process quality and ten of outcome quality. A total of 477 patients were registered in DSDReg in the period from May 2021 till October 2022. The mean age is 16 years; the most common diagnosis groups are 46,XY DSD (34.8%), followed by 46,XX DSD (33.3%) and chromosomal DSD (27.5%). Patient numbers vary across centres from N = 10 to N = 131. Questionnaires are available from 316 (66.2%) affected individuals, including 122 from adults, 120 from children or adolescents with DSD, and 191 from parents. Preliminary results show heterogeneity between centres in both data quality and quality of care. Conclusions: The DSDReg is well established in the DSDCare project as a quality assurance tool with continuously increasing recruitment figures. The implemented quality indicators are applicable, enable a comparison between the participating centres and will foreseeably lead to an improvement of the care of patients with DSD. A long-term continuation of the registry after the end of the initial study period is therefore indicated. [ABSTRACT FROM AUTHOR]

Maternity care is a core service provision of any healthcare system, delivering care for women and birthing people, and their wider family units. During the SARS-CoV-2 pandemic, much of maternity care service provision was reconfigured with the aim of continuing care provision which could not otherwise be re-scheduled or delayed, but in-line with infection control measures instituted through social and physical distancing. The RESILIENT Study was designed to investigate the impact of the COVID-19 pandemic and pandemic-related reconfigurations to maternity care service delivery. It is particularly concerned with the experiences of minority ethnic groups and those with social or medical complexity. One of our specific objectives was to investigate the experiences of maternity care during the pandemic from the perspective of women and birthing people; fathers, partners, and non-gestational parents; healthcare professionals; and policy makers through the use of in-depth interviews. We will analyse data on virtual care, self-monitoring, and vaccination (each using thematic framework analysis); care-seeking and care experience (using template analysis); and on building an ethical future of maternity care (using grounded theory analysis). This is the focus of this protocol. Our findings about the experiences of care receipt, provision, and planning during the pandemic will complement existing literature and our impact will be broad, on: individual patients, NHS maternity providers, NHS policies, and wider society. [ABSTRACT FROM AUTHOR]

Objective: To describe the barriers to and facilitators of implementing and delivering virtual hospital (VH) services, and evidence and practice gaps where further research and policy changes are needed to drive continuous improvement. Study design: Qualitative descriptive study. Setting, participants: Online semi‐structured interviews and a focus group were conducted between July 2022 and April 2023 with doctors, nurses and leadership staff involved in VH services at three sites in New South Wales, Australia. Main outcome measures: Barriers to and facilitators of implementing and delivering VH services in sites with differing operating structures and levels of maturity, and evidence and practice gaps relating to VH services. Results: A total of 22 individuals took part in the study. Barriers, facilitators, and evidence and practice gaps emerged within five major themes: scope and structure of VH services; development and implementation of VH models of care; delivery of VH models of care; evaluation of VHs and VH models of care; and sustainment and scalability of VH services. Facilitators of VH success included hybrid approaches to care, partnerships with external services, and skills of the VH workforce. Barriers and gaps in evidence and practice included technical challenges, the need to define the role of VH services, the need to evaluate the tangible impact of VH care models and technologies, and the need to develop funding models that support VH care delivery. Participants also highlighted the perceived impacts and benefits of VH services on the workforce (within and beyond the VH setting), consumers, and the health care system. Conclusions: Our findings can help inform the development of new VH services and the improvement of existing VH services. As VH services become more mainstream, gaps in evidence and practice must be addressed by future research and policy changes to maximise the benefits. [ABSTRACT FROM AUTHOR]

Objectives: To explore the experiences of clinicians delivering, facilitating, and potentially affected by a hybrid virtual medical model servicing rural and remote hospitals in western New South Wales. Design, setting, participants: Qualitative study using semi‐structured focus groups and individual interviews, conducted between 7 April 2022 and 16 March 2023, with rural generalist doctors delivering the Virtual Rural Generalist Service (VRGS) within the Western NSW Local Health District, local site staff, and local general practitioner visiting medical officers (GP VMOs). Main outcome measures: Key themes in clinician experience of the model and recommendations for improved experience, based on qualitative content analysis. Results: We interviewed 12 VRGS doctors, 25 site nursing staff and nine GP VMOs. Clinicians were overwhelmingly positive about the VRGS, seeing it as providing good quality care and being an innovative and translatable solution to rural workforce challenges. In‐person site visits by VRGS doctors were highly valued, especially by local site staff, for team building, skill building and increasing VRGS doctors' understanding of the local context. The VRGS model relies on nursing availability and skill, and creates additional workload for nurses. Nurses in isolated sites valued the clinical support provided by the VRGS. Overall, most GP VMOs valued the fatigue relief offered by the VRGS; however, some viewed the VRGS as diminishing local doctors' autonomy and the viability of their positions. Conclusions: The hybrid VRGS model is widely accepted by clinicians as providing good quality care for patients and high job satisfaction for providers. The service supports the local health workforce and makes rural medical positions more attractive and sustainable. The in‐person shift requirement is central to the model's effectiveness and acceptability. Further investment is needed to train and resource local nurses who play an integral role in providing virtual medical care. [ABSTRACT FROM AUTHOR]

Objectives: To identify research and development priorities for virtual care following the coronavirus disease 2019 pandemic from the perspective of key stakeholders (patients, clinicians, informaticians and academics). Design: Qualitative study using a modified nominal group technique. Setting: Online semi‐structured interviews and workshops held in November 2022 and February 2023. Participants: Health workers involved in delivering virtual care in two metropolitan local health districts and one specialty statewide network, and people who had received care from these sites, were recruited using passive snowball sampling. Research and academic staff from a tertiary institution were also invited to participate. Main outcome measures: Priorities to support a translational research agenda for virtual care. Results: Twenty‐five individuals participated including 18 innovation deliverers, two innovation recipients and five implementation facilitators. Stakeholders identified several key priorities for developing virtual care models and for sustaining and scaling virtual care services. These included demonstrating the economic and societal value of virtual care, developing a common framework to support evaluation and comparison of virtual care services, ensuring virtual care services integrate acute and primary care, and defining which models of care are most appropriate for virtual care delivery. Conclusion: As the health system recalibrates with the return of in‐person care, there is a growing need to demonstrate the value of virtual care models to patients, the health system, and society at large. Demonstrating this value while also demonstrating improvements to health outcomes will future‐proof virtual care, enabling it to be used to address broader challenges of health care delivery. In addition, sustaining virtual care will depend on robust operational structures and workforce training and education. As services evolve, research and development priorities must be revisited to ensure that translational research aligns with stakeholder interests. [ABSTRACT FROM AUTHOR]

Background: Norwegian Municipal Inpatient Acute Care (MIPAC) services were established as part of the 2012 Coordination Reform. The intention was to prevent unnecessary hospital admissions by redirecting and maintaining less urgent patients at the primary care level, which provides inpatient acute healthcare services closer to patients' home. However, the role MIPAC plays in the patient trajectory and how trajectories vary across different units and settings is less clear. Objective: Therefore, this study aimed to (1) describe the general patient transfer trajectories for MIPAC patients and (2) examine facility and regional variations in MIPAC patients' sources of admission and discharge destinations. Design: A cross-sectional study using aggregated register data. Methods: The study involved 36 662 admissions across 185 MIPAC units in 2019. Descriptive statistics were used to describe patient transfer trajectories, and a random-effects multinomial logistic model was applied to assess the association between facility and regional factors and patients' admission sources and discharge destinations. Results: The findings revealed distinct admission and discharge patterns based on facility and regional factors. Notably, intermunicipal units with 5 and more municipalities collaborating had higher relative risk ratios (RRR) for discharging to hospital (RRR = 1.50, 95%CI: 1.30-1.72) compared with independent MIPAC units. Large MIPAC units with more than 5 beds had increased relative risk ratios of patients admitted from the hospital than from home (RRR = 4.29, 95%CI: 1.56-11.78). Additionally, regional disparities existed, with units in the Central (RRR = 2.29, 95%CI: 1.56-3.38) and Western Norway health authorities (RRR:1.58, 95%CI: 1.22-2.06) displaying higher nursing home discharge rates than units in the South-Eastern Norway health authority. Conclusions and implications: This study confirms the Norwegian MIPAC services' adherence to admission avoidance policies and identifies significant variations in service delivery across regions and facilities. The Norwegian MIPAC model also has potential to inspire other countries in developing admission avoidance services in the primary care setting. [ABSTRACT FROM AUTHOR]

Copyright of Die Urologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background Little is known about how variation in the scheduled length of primary care visits can impact patients' patterns of health care utilization. Objective To evaluate how the scheduled length of in-person visits with primary care physicians (PCPs) was associated with PCP and patient characteristics, outpatient utilization, and preventive care receipt. Methods This retrospective cohort study examined data from a large American academic health system. PCP visit length template was defined as either 15- and 30-min scheduled appointments (i.e. 15/30), or 20- and 40-min scheduled appointments (i.e. 20/40). Results Of 222 included PCPs, 85 (38.3%) used the 15/30 template and 137 (61.7%) used the 20/40 template. The 15/30 group had higher proportions of male (49.4%, vs. 35.8% in the 20/40 group) and family medicine (37.6% vs. 21.2%) physicians. In adjusted patient-level analysis (N = 238,806), having a 15/30 PCP was associated with 9% more primary care visits (incidence rate ratio [IRR], 1.09; 95% confidence interval [CI], 1.03–1.14), and 8% fewer specialty care visits (IRR, 0.92; 95% CI, 0.86–0.98). PCP visit length template was not associated with significant differences in obstetrics/gynaecology visits, continuity of care, or preventive care receipt. In interaction analyses, having a 15/30 PCP was associated with additional primary care visits among non-Hispanic White patients (IRR, 1.10; 95% CI, 1.04–1.16) but not among non-Hispanic Black patients. Conclusion PCPs' choices about the scheduled length of in-person visits may impact their patients' specialty care use, and have varying impacts across different racial/ethnic groups. [ABSTRACT FROM AUTHOR]

Copyright of Die Unfallchirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Purpose: The use of narration in healthcare has been accentuated as a response to the requested shift towards person-centred care. The notion of narrative relations refers to a process of involving several people in mutual and ongoing narrative exchange. This study aimed to explore how and where narrative relations may be adopted and enacted in everyday healthcare practice. Methods: The study has a qualitative, explorative design. Seven interprofessional focus group discussions with healthcare staff were prompted by vignettes. A multidisciplinary team of healthcare staff (n = 31) were recruited on a geriatric ward. Data were analysed using a constant comparative method. Results: A core theme shows how narrative relations are adopted and enacted both as part of an approved practice—the work procedures commonly approved as part of healthcare, and as a disregarded practice where covert but important narrative relations take place to support fundamental qualities of healthcare. Moreover, the findings consider arenas of healthcare practice where approved or disregarded practices are enacted in the clinic frontstage and the clinic backstage. Conclusions: Narrative relations may take place in different arenas of healthcare practice yet simultaneously become a cohesive force interconnecting those arenas and uphold continuity. Impeded narrative relations in one arena may have unintended consequences in another. [ABSTRACT FROM AUTHOR]

This cross-sectional study evaluated whether children with special health care needs (CSHCN) were more likely to use the emergency department (ED) for nontraumatic dental conditions (NTDCs) than children without special health care needs (SHCN). The study also examined whether the likelihood of receiving an opioid prescription after an NTDC-ED visit differed between children with and without SHCN. This analysis was based on 2017 Oregon Medicaid enrollment, claims, and pharmacy data (N = 225,614 children aged 3-17 years). To assess associations between SHCN, NTDC-ED use, and receipt of opioid prescriptions, confounding variable–adjusted odds ratios and 95% CIs were generated from logistic regression models. Approximately 14% (n = 31,867) of children had an SHCN. The prevalence of NTDC-ED use was 0.36% (n = 807) for all children. In the confounding variable–adjusted model, the odds of NTDC-ED use were 1.6 times greater for CSHCN than children without SHCN (95% CI, 1.3 to 1.9; P <.001). Among children with an NTDC-ED visit, 8.3% received an opioid prescription. In the confounding variable–adjusted model, CSHCN were at lower odds of receiving an opioid prescription after an NTDC-ED visit than children without SHCN, but this difference was not statistically significant (odds ratio, 0.84; 95% CI, 0.4 to 1.6; P =.57). CSHCN enrolled in Medicaid had significantly higher odds of having NTDC-ED visits than children without SHCN, but there was no significant difference between the 2 groups in the odds of receiving an opioid prescription after an NTDC-ED visit. All children, especially those with SHCN, should have adequate access to office-based oral health care through a dental home to reduce use of the ED for NTDC. [ABSTRACT FROM AUTHOR]

Purpose: To describe the volume, timing and provider of mental health services provided to workers with accepted low back pain (LBP) claims, and to identify determinants of service volume and time to first mental health service. Methods: Using claim and service-level workers' compensation data from four Australian states (Queensland, South Australia, Western Australia, Victoria) for LBP claims with at least one mental health service lodged between 1 July 2011 and 30 June 2015. Mental health services occurring 30 days prior to 730 days following claim acceptance were examined. Outcomes were number of mental health services and time (weeks) from claim acceptance to first service, calculated overall, by provider and interaction type, and by independent variables (age group, sex, time loss duration, financial year of lodgement, jurisdiction, socioeconomic status, remoteness). Negative binomial and Cox regression models examined differences between service volume and time to first service by independent variables, respectively. Results: Of workers with LBP claims who accessed mental health services, psychologist services were most common (used by 91.2% of workers) and 16% of workers saw multiple provider types. Number of services increased with time loss duration, as did time to first service. Victorian workers had the most services, yet accessed them latest. Conclusions: Psychologist services were most common, longer duration claims used more mental health services but accessed them later, and there were a number of jurisdictional differences. Results suggest opportunities for workers' compensation authorities to provide, to those who may benefit, greater and earlier access to mental health care. [ABSTRACT FROM AUTHOR]

Background: In Norway, municipal acute wards (MAWs) were implemented as alternatives to hospitalisation. Evaluations of the quality of MAW services are lacking. The primary objective of this study was to compare patient experiences after admission to a MAW versus to a hospital. The secondary objective was to compare 'readmissions', 'length of stay', 'self-assessed health-related quality of life' as measured by the EuroQol 5 items 5 level (EQ-5D-5L) index, and 'health status' measured by the RAND-12, in patients admitted to a MAW versus a hospital. Methods: A multicentre randomised controlled trial (RCT), randomising patients to either MAW or hospital. Results: In total, 164 patients were enrolled in the study; 115 were randomised to MAW and 49 to hospital. There were no significant differences between the MAW and hospital groups regarding patient experience, which was rated positively in both groups. Patients in the MAW group reported significantly better physical health status as measured by the RAND-12 four to six weeks after admittance than those randomised to hospital (physical component summary score, 31.7 versus 27.1, p = 0.04). The change in EQ-5D index score from baseline to four to six weeks after admittance was significantly greater among patients randomised to MAWs versus hospitals (0.20 versus 0.02, p = 0.03). There were no other significant differences between the MAW and hospital groups. Conclusions: In this study, patient experiences and readmissions were similar, whether patients were admitted to a MAW or a hospital. The significant differences in health status and quality of life favouring the MAWs suggest that these healthcare services may be better for elderly patients. However, unfortunately we did not reach the planned sample size due to challenges in the data collection posed by the Covid-19 pandemic. KEY POINTS: Municipal acute wards have been implemented in Norway as alternatives to hospitalisation. However, the quality of these wards remains unexplored. Results in this study indicates that patient experiences after stays in municipal acute wards are equally positive to experiences after stays in hospital there are no significant differences in length-of-stay, readmission rates or mortality between municipal acute wards and hospital patients have slightly more positive self-rated health and health status 4–6 weeks after staying in a municipal acute ward [ABSTRACT FROM AUTHOR]

Purpose: The management of inferior vena cava (IVC) tumor thrombus in patients with renal cell carcinoma (RCC) is among the most challenging surgical procedures. We aimed to define a minimum annual caseload for sufficient expertise. Methods: We identified all cases with RCC, nephrectomy, and IVC procedures in the Federal Statistical Office billing database (2006–2020). We defined annual hospital caseload categories as low (< 4 cases), medium (4–9 cases) and high (> 9 cases) volume. Logistic multivariate models identified mortality-related factors. In addition, we analyzed data on tumor stage distribution from German cancer registries. Results: We recorded 3,700 nephrectomies with IVC-tumor resection with stable annual case number of 247 mean. This correlated with a stable incidence of T3b/c RCC. Patient age was 66 ± 14 years. Of all cases, 56% occurred in low, 30% in medium, and 14% in high volume clinics without a significant trend towards centralization. The overall in-hospital mortality rate was 5.8% and the transfusion rate 72%. An annual caseload of 8 showed to be a significant cut-off for mortality with 6.2% at < 8 cases and 2.8% for > = 8 cases annually (p < 0.001). Multivariate analysis revealed patient age (OR 6.4 for octogenerians) ventilation time (OR 14.3 for > 24 h) and hospital caseload (OR 2.6) as the most important risk factors for in-hospital mortality. Conclusion: Our results show a negative correlation of annual caseload and mortality for this procedure. A minimum number of 8 procedures per year seems reasonable for the successful management of IVC tumor thrombus with significantly lower mortality. [ABSTRACT FROM AUTHOR]

Introduction: The experiences of patients receiving health care constitute an important aspect of health-care quality assessments. One of the purposes of the national program of patient-experience surveys in Norway is to support institutional and departmental improvements to the quality of local health-care services. This program includes national surveys of patients receiving interdisciplinary treatment for substance dependence performed four times between 2013 and 2017. The aims of this study were twofold: (i) to determine the attitudes of employees towards these surveys and their use of the survey results, and (ii) to identify changes in patient experiences at the national level from 2013 to 2017. Material and methods: Employees were surveyed one week prior to conducting cross-sectional patient experience surveys. One-way ANOVA and chi-square tests were used to assess differences between years, and content analysis was applied to the open-ended comments. Results: Around 400 employees were recruited in each of the four survey years, and the response rate varied from 61% to 79%. The employees generally reported a positive attitude towards patient-experience surveys, and 40%–50% of them had implemented quality initiatives based on the results of the patient surveys. The mean score for the question on usefulness was higher than 3 (on a Likert scale from 1 to 5 points) for all four surveys. Many employees provided details about the changes that had been made in open-ended comments. The results from the patient-experience surveys demonstrated positive changes over time. Discussion: The employees had positive viewpoints towards patient-experience surveys, and around half of them had implemented quality initiatives. This implies that employees find such surveys important, and that patient-experience surveys are regarded as useful and actionable. The surveys of patients showed positive changes in their experiences over time. The most-common target areas reported by employees showed clear improvements in patient experiences at the national level. [ABSTRACT FROM AUTHOR]

Background: Non-life-threatening cases treated by emergency services have been increasing in recent years, especially in older people. In a region in Germany with approximately 600,000 inhabitants, the role of a specially trained community paramedic (Gemeindenotfallsanitäter, G-NFS) was introduced in 2019. The G-NFS is dispatched to low-acuity requests, attends the assignment alone and is allowed to treat patients at home. Aim: The aim of this study was to analyse the assignments attended by the G-NFS relating to the suspected diagnoses, with a focus on older people (≥ 65 years) according to their care setting. Methods: In this descriptive, retrospective study, we analysed the anonymous assignment report forms 07/2023–12/2023 of cases where patients were aged ≥ 65 years. The suspected diagnoses (free text field) were categorised according to the International Classification of Primary Care 2nd Edition (ICPC-2) scheme. Furthermore, baseline characteristics, urgency of the assignment, provided measures, transport and further treatment were analysed, stratified by care setting. Results: Of the 1,643 included anonymous assignment report forms, 52.9% (n = 869) related to patients aged ≥ 65 years. In this population, the mean age was 80.7 years (SD 8.2), 49.6% were female and most were in long-term care, whether as home care recipients (34.8%) or as nursing home residents (26.9%). The most frequent diagnoses were categorised as urological (24.9%), general and unspecified (13.7%), circulatory (13.6%), digestive (12.8%), musculoskeletal (11.5%) and respiratory (10.3%). In 52.7% of the cases no transport was necessary, while 73.7% of urological cases did not need to be transported. Conclusion: The G-NFS was dispatched mainly to older people. Most of them were in long-term care and were not transported. The most common suspected diagnoses were categorised as urological, followed by general and unspecified, and circulatory, and differed by care setting. There is a strong need to strengthen outpatient healthcare structures for low-acuity health issues in older and immobile patients. [ABSTRACT FROM AUTHOR]

Background: Health care staff should be given the opportunity to participate in research, but recruiting clinicians via their employing organisation is not always straightforward or quick in the UK. Unlike many countries outside the UK, very low-risk survey, interview or focus group studies can be subject to some of the same governance approval procedures as interventional studies. An exemplar study carried out by the NIHR funded Palliative Care Research Partnership North West Coast is used to highlight the challenges still faced by researchers and health care organisations when setting up a low-risk staff study across multiple NHS and non-NHS sites. Methods: A study database was created and information was collected on the first point of contact with the clinical site, Health Research Authority (HRA) and local organisational approval times, time from trust or hospice agreement to the first survey participant recruited and overall site survey recruitment numbers. Descriptive statistics (median, range) were used to analyse these data. Results: Across participating NHS trusts, it took a median of 147.5 days (range 99–195) from initial contact with the local collaborator to recruitment of the first survey participant and hospice sites mirrored these lengthy timescales (median 142 days, range 110–202). The lengthiest delays in the HRA approval process were the period between asking NHS trusts to assess whether they had capacity and capability to support the research and them granting local agreement. Local approval times varied between trusts and settings which may indicate organisations are applying national complex guidance differently. Conclusions: There is the potential for HRA processes to use more NHS resources than the research study itself when recruiting to a low-risk staff study across multiple organisations. There is a need to reduce unnecessary administrative burden and bureaucracy to give clinicians and research staff more opportunities to participate in research, and to free up NHS R&D departments, research nurses and clinicians to focus on more demanding and patient focused research studies. Hospices need standardised guidance on how to assess the risk of being involved in low-risk research without adopting the unnecessarily complex systems that are currently used within the NHS. [ABSTRACT FROM AUTHOR]

With the proliferation of cancer research based on large databases, misalignment of research questions and data set capabilities is inevitable. Nationally maintained databases are appealing to cancer researchers because of the ease of access to large amounts of patient data available for analysis and risk estimation. Data sets that are commonly used in cancer research include the National Cancer Database, the SEER (Surveillance, Epidemiology, and End Results) program of the National Cancer Institute, the SEER–Medicare database, the American College of Surgeons National Surgical Quality Improvement Program, and the Healthcare Cost and Utilization Project databases, among others. Each data set has pros and cons with respect to variable availability and the ability to analyze cancer‐specific outcomes. It is critical for researchers to understand the strengths and limitations of each database. Changing variable definitions, the length of postoperative data collection, and the availability of patient‐reported outcomes or social determinants of health data are examples of factors that researchers must consider when selecting a data set for research purposes. For the current review, the authors summarized the advantages and disadvantages of various national data sets for cohort studies in cancer populations. The authors summarize the strengths and weaknesses of commonly used national databases in population‐based cancer research. The recommendations they offer for appropriate database use are based on cancer type and research question. [ABSTRACT FROM AUTHOR]

Background : New treatment approaches are urgently needed to improve the prognosis of children and adolescents with anorexia nervosa (AN). Recently, the feasibility of multidisciplinary home treatment that strongly involves the patients' parents/caregivers has been investigated. However, no RCT has yet been performed to test the efficacy and safety of this approach compared to standard treatment approaches, such as inpatient treatment. Methods: In this multicenter randomized-controlled trial, home treatment for children and adolescents with AN aged 12 to 18 years is established at 5 major treatment centers for AN in Germany. Approximately 240 patients who are admitted to the hospital for AN will be included in the trial. After a short inpatient somatic stabilization phase (5–8 weeks), patients are randomized to receive either treatment as usual (TAU), in the form of continued inpatient or day patient treatment, or the newly developed home treatment (HoT) (n = 82/arm, n = 164 in total). There are three assessments throughout treatment (admission, randomization, and discharge), as well as follow-up assessments at 9 and 12 months after admission. The BMI at 12 months after admission (primary outcome) is compared between groups (adjusted for premorbid BMI and admission BMI); secondary outcomes include eating disorder and general psychopathology, the number and duration of psychiatric rehospitalizations, quality of life, motivation for treatment and treatment satisfaction. Other secondary outcomes include the primary caregivers' burden and skills in handling the child's illness and direct treatment costs. Statistical analysis will be based on intention-to-treat principles, using mixed models for repeated measures. (Serious) adverse events are assessed throughout treatment. In addition, the feasibility and implementation of HoT as well as the satisfaction and workload of the members of the multidisciplinary treatment teams in both arms will be assessed. Discussion: In the case of a positive evaluation, HoT can be considered an effective treatment method to replace or complete established treatment methods, such as IP, for treating AN in children and adolescents. The home treatment setting might shorten inpatient stays in this patient group, increase treatment satisfaction, and help to reduce the risk of rehospitalization, which is associated with a better outcome in this vulnerable patient group. Trial registration: The trial was registered with the German Clinical Trial Register (DRKS) under the ID DRKS00025925 on November 26, 2021 (prospectively registered): https://drks.de/search/de/trial/DRKS00025925. [ABSTRACT FROM AUTHOR]

Social work in the German rehabilitation sector is practiced with great variation and its interventions lack research evidence. The SWIMMER project aims to develop a program theory of social work in rehabilitation to explain this variation and to discuss possible conditions. The dealing with ethical dilemmas by social workers is one possible influence and the focus of this paper. The social workers' practice was analyzed using the triple mandate, a German-Swiss concept that describes three possible, sometimes simultaneous directives without a concrete call to action from society, the client or the profession. This qualitative, case-comparative research project collected data from interviews with social workers and managers, participant observation and counseling sessions in ten German rehabilitation facilities. Social workers were confronted with all three mandates. They prioritized either the societal mandate or the client mandate. A consequence for social work practice was the limitation of options under social law (mandate by society). Social workers relied on their professional experience to reflect on the mandates. They used a variety of strategies when faced with conflicting mandates. The research project has succeeded in systematizing the orientations of social workers in goal conflicts. Further investigation on this topic on a broader basis would be beneficial. [ABSTRACT FROM AUTHOR]

Background: To address the societal burden of low back pain (LBP), several health systems have adopted Models of Care (MoCs). These evidence-informed models aim for consistent care and outcomes. However, real-world applications vary, with each setting presenting unique challenges and nuances in the primary healthcare landscape. This scoping review aims to synthesize the available evidence regarding the use of implementation theories, models or frameworks, context-specific factors, implementation strategies and outcomes reported in MoCs targeting LBP in primary healthcare. Methods: MEDLINE(Pubmed), EMBASE, Cochrane Central Register of Controlled Trials, PEDro, Scopus, Web of Science and grey literature databases were searched. Eligible records included MoCs for adults with LBP in primary healthcare. Two reviewers independently extracted data concerning patient-related, system-related and implementation-related outcomes. The implementation processes, including guiding theories, models or frameworks, barriers and facilitators to implementation and implementation strategies were also extracted. The data were analysed through a descriptive qualitative content analysis and synthesized via both quantitative and qualitative approaches. Results: Eleven MoCs (n = 29 studies) were included. Implementation outcomes were assessed in 6 MoCs through quantitative, qualitative, and mixed methods approaches. Acceptability and appropriateness were the most reported outcomes. Only 5 MoCs reported underlying theories, models, or frameworks. Context-specific factors influencing implementation were identified in 3 MoCs. Common strategies included training providers, developing educational materials, and changing record systems. Notably, only one MoC included a structured multifaceted implementation strategy aligned with the evaluation of patient, organizational and implementation outcomes. Conclusions: The implementation processes and outcomes of the MoCs were not adequately reported and lacked sufficient theoretical support. As a result, conclusions about the success of implementation cannot be drawn, as the strategies employed were not aligned with the outcomes. This study highlights the need for theoretical guidance in the development and implementation of MoCs for the management of LBP in primary healthcare. Registration: Open Science Framework Registries (). [ABSTRACT FROM AUTHOR]

Background: Trastuzumab (Herceptin) can be administered intravenously (IV Herceptin) and subcutaneously, with similar efficacy and safety, but with differences in dosage and costs. Previous studies have evaluated the costs of both treatment approaches in the outpatient settings, but no study has compared the costs of IV Herceptin administered in outpatients with subcutaneous Herceptin administered at patients' homes (Homecare SC Herceptin). Objectives: This study aimed to compare the per-patient costs of Homecare SC Herceptin versus IV Herceptin administered in a healthcare institution's outpatient setting in Singapore. Designs: We performed a model-based cost-minimization analysis to estimate and compare the per-patient annual costs associated with each treatment modality from a societal perspective. Methods: Direct cost comprised healthcare resources utilization: drug, consumables, manpower, facility and cardiac assessment. Indirect cost was valued using a human capital approach to account for productivity lost by patients. Monte Carlo simulations with 1000 iterations were performed to account for parameter uncertainties. Costs were reported in 2023 Singapore dollars. Results: The annual societal cost per patient receiving IV Herceptin ranged from S$64,194 to S$65,135, while for Homecare SC Herceptin, it ranged from S$25,865 to S$26,807. Homecare SC Herceptin reduced the annual cost burden by 58.8% and 59.7%, per non-metastatic and metastatic breast cancer patient, respectively. The primary cost contributor was drug therapy, comprising more than 90% of the total cost. Even when excluding the cost of drugs, Homecare SC Herceptin remained cheaper by S$1912 annually. The cost reduction is approximately 60% compared to IV Herceptin regardless of disease status, with a 100% probability that the decision to adopt Homecare SC Herceptin leads to cost savings in Singapore. Conclusion: Treatment of breast cancer with Homecare SC Herceptin is a cost-saving option compared to IV Herceptin. [ABSTRACT FROM AUTHOR]

Background: Having a primary care provider is associated with better care experiences and lower care costs. In 2021, INSPIRE-PHC released Primary Care Data Reports - publicly available summaries of administrative billing data about how populations in each of Ontario's 60 health teams use primary care services. Given the characterization of Canadian primary care systems as 'in crisis', publicly available data about primary care at the regional level presented a significant opportunity for knowledge mobilization. An understandable resource could ground the public conversation about primary care access in data. Recognizing the role that lived experience plays in ensuring the public understands research findings, a partnership between patient advisors, Ontario Health Team representatives, researchers, and trainees was established to co-produce public-facing infographics based on primary care data. Methods: Evidence-based guidelines for public health infographic creation and elements of transformative action research guided a six-meeting process to engage up to 14 patient advisors, three Ontario Health Team staff and two primary care trainees. Patient advisors were affiliated with a provincial patient-oriented primary health care research group or a Hamilton-based Ontario Health Team. Ninety-minute meetings were conducted virtually, and notes were shared with attendees to ensure they accurately reflected the conversation. Two consultations with Ontario Health Team-affiliated primary care providers provided direction and ensured project outputs aligned with local priorities. Results: Project partners shared feedback on draft infographics, audience identification, priority elements from Primary Care Data Reports to include in the infographics, and aesthetic features (e.g., headings, colour scheme, charts). Project partners felt the most important metrics to convey to the public were those that simultaneously reinforced the benefits of primary care on individual health outcomes and health system costs. Conclusions: Patient engagement in research is becoming widespread, but co-developing knowledge products with patient and health system partners is less common. Our approach to engaging patients prevented both oversimplification and unnecessary complexity in a public-facing visual about attachment to primary care. Plain English summary: Primary care is the first point of contact for patients accessing the health care system. Primary care providers (i.e., family doctors and nurse practitioners – working individually or in teams of nurses, dieticians, pharmacists, social workers and others) – help patients and families manage health concerns over time by working to prevent, diagnose, and treat illnesses and link patients with specialist care when needed. Having a primary care provider is associated with better healthcare experiences and lower costs of care. In 2021, the Primary Care Data Reports were released to the public. The reports contain administrative data about how patients engage with primary care in each of the 58 Ontario Health Teams. Patient advisors, Ontario Health Team representatives, researchers, and trainees created an infographic to share this data in a way that can be understood by everyone. Infographics use images to help people process information faster, which can make health-related topics easier to understand. By understanding the value of primary care, people can participate in conversations about how to ensure primary care is accessible to everyone. Engaging patients is becoming common in research, but collaborating with patient advisors and health system partners to create visual summaries is less common. We had six virtual meetings that were 90 min each with up to 14 patient advisors, Ontario Health Team representatives, researchers and trainees. Patient advisors helped decide who the audience would be, which information from the Primary Care Data Reports to include, and how the infographic would look. Patient advisors felt it was most important to highlight the benefits patients can get from primary care, and the impact primary care can have to reduce health system costs. We consulted with primary care clinicians to ensure the infographic reflected local priorities. Working with patient advisors and Ontario Health Team representatives helped to create an infographic about Primary Care Data Reports data that is easy to understand by the public. [ABSTRACT FROM AUTHOR]

Background: Trends in phototherapy utilization in the context of new therapeutics have not been evaluated. Objective: This study aimed to evaluate phototherapy utilization, payments, and geographic distribution for Medicare beneficiaries from 2000 to 2021. Patients/Methods: A longitudinal analysis of the Medicare Part B National Summary Data Files was conducted to obtain phototherapy utilization and payment amounts. Medicare Physician & Other Practitioners by Provider and Service datasets were used to determine provider type and geographic distribution. Results: Between 2000 and 2021, total Medicare phototherapy volume increased from 335,152 to 621,850, correlating with a 3.0% annual growth rate (5.0% between 2000 and 2015, −3.1% between 2016 and 2021). Ultraviolet B phototherapy represented the majority of use, rising from 68.1% in 2000 to 78.0% in 2021. Psoralens plus ultraviolet A decreased by 11.3% annually, while laser treatments increased by 17.3%. Between 2013 and 2021, the number of clinics offering phototherapy declined; facilities were available in only 9.9% of counties, mainly clustered along both coasts and east of the Mississippi. Conclusions: Overall, phototherapy continues to be an important therapeutic option. Limited access in non‐urban areas remains a significant challenge, and further work is necessary to both evaluate this impact and reduce disparities. [ABSTRACT FROM AUTHOR]

Objective: Children in families with parental cancer may experience emotional, social or physical problems. The aims are to analyze child, parent and family‐based determinants of children's health‐related quality of life (HRQoL) and their experiences of parental cancer. Methods: As part of a mixed‐methods, multicenter, prospective, interventional non‐randomized study "Family‐SCOUT," a family‐centered intervention in the form of care and case management was developed. Children's HRQoL (KIDSCREEN‐10) was assessed at baseline (study inclusion). Descriptive analyses and family cluster‐adjusted linear mixed models were performed. Qualitative coding of children's experiences reported in an open‐ended text field of the questionnaire was performed. Results: Four hundred and seventy‐two families with 472 parents with cancer and 649 children were included in the study of which N = 346 were analyzed. The average age of the children was 12.8 years. 48% of the children were female. Family cluster‐adjusted mixed linear model showed significant associations between children's HRQoL (dependent variable) and children's age (−0.44, p = 0.023, 95%‐CI = −0.82 to −0.06) and between families (ICCnull model = 0.377, Pseudo‐R2 = 0.443). Children experienced changes in the family situation, such as daily routines and communication among all family members, death of a parent, COVID‐19‐related difficulties, and supportive social relationships. Conclusions: Child, parent and family‐based factors appear to be related to children's HRQoL. Research on children's HRQoL and experiences in the context of parental cancer underscores the need for a multidimensional and family‐based approach to support these children. [ABSTRACT FROM AUTHOR]

Summary: The use of uncrewed aerial vehicles (drones) has increased over the last decade. However, their application in healthcare has not been fully examined, in part, due to regulations preventing flight beyond the visual line of sight. This prospective randomised controlled laboratory study aimed to determine whether the in vitro quality of packed red blood cell components is maintained when transported by drone, beyond visual line of sight. Ten identical pairs of packed red blood cell units were randomly allocated to transport by drone or by ground vehicle (1:1, allocation concealment) 68 km between two hospitals in Northumbria, UK. Markers of blood component quality were compared at 8, 14, 28 and 35 days following blood unit manufacture. There was no statistical difference in haemolysis, potassium concentration, total haemoglobin, glucose and lactate, haematocrit and mean cell volume, between the two groups, up to the date of unit expiry. The temperature of the packed red blood cell units did not deviate outside the recommended 2–10°C for transportation, regardless of the allocated group. Blood component transport was faster by drone, but did not reach statistical significance. This study demonstrates the feasibility and safety of flying blood components by drone between hospitals in the United Kingdom. [ABSTRACT FROM AUTHOR]

The status of oral health research in the World Health Organization (WHO) African region is unclear, yet the need for such information is central to moving an oral health agenda forward. Such an agenda is essential for effectively translating research into actionable practices and supporting regional strategies. The aim of this scoping review was to provide data on the scope and output of oral health research in the WHO African region to be used as a starting point for establishing a research agenda that can affect oral health in the region. We conducted a systematic search in PubMed; EMBASE; Epistemonikos; Scopus; the International Association for Dental, Oral, and Craniofacial Research General and Regional Sessions; ProQUEST; PROSPERO; and African regional databases such as Regional African Index Medicus and the African Journal Online. We included primary and secondary studies published in English, French, or Portuguese between January 1, 2011, and December 31, 2022, addressing oral health–related research having individuals, groups, or populations as units of analysis. These reports either addressed a topic relevant to the WHO African region assessed using the title and study objective or were conducted in a country in the region. We excluded in vitro and in vivo studies focusing on cells, biomarkers, or animals. We assessed 24,014 records, and 1,379 proved eligible. Our findings indicate a preference for particular research designs less suitable for evidence-informed practice guidelines and oral policies, a limited scope of oral health research topics, and important regional differences in research capacity. Furthermore, publications by researchers in the WHO African region tend to be published in journals with a limited readership. A discussion of our findings among oral health researchers at academic institutions in the WHO African region on how to create within- and across-country collaborations could potentially improve both health and oral health in the region. [ABSTRACT FROM AUTHOR]

In 2017, British Columbia (BC) transferred responsibility for healthcare services in provincial correctional facilities from the Ministry of Public Safety and Solicitor General to the Ministry of Health. This study explored how healthcare leadership perceived the impact of the transfer on services, work-life, and job satisfaction. We conducted one-on-one interviews (n = 8) with healthcare managers and medical and administrative leadership within Correctional Health Services. Using the Two-Factor theory of job satisfaction as a framework, we applied Interpretive Description methodology to analyse interview data. Participants identified changes to four areas of the working environment: (1) staffing, equipment, and resources (2) systems of supervision and support (3) standards, policies, and quality improvement and (4) culture and orientation. These changes predominantly affected motivational factors of job satisfaction and were described as enriching the roles of managers and staff. Participants described improved autonomy and recognition of providers, increased quality of services delivered, and a shift toward patient-centred care. The perspectives of healthcare leaders provide new insight into the potential impact of transferring healthcare services in custody to a public healthcare system. Discussion of changes and their affects also provide practical learning for jurisdictions seeking to improve healthcare under a variety of governance and service-delivery models. [ABSTRACT FROM AUTHOR]

Background: This study assessed feasibility constructs of adolescent contraceptive care in the pediatric emergency department (PED), including contraception initiation. Methods: We conducted a randomized trial in two PEDs with pregnancy‐capable adolescents aged 15–18 years who were assigned to enhanced usual care (usual) or same‐day initiation (same day). All received counseling and clinic referral, but same‐day participants could also receive contraception in the PED. We trained PED clinicians in counseling and prescribing. Adolescents and clinicians rated feasibility using five Likert‐type items (1 = strongly disagree to 5 = strongly agree) after the session. We assessed PED medication initiation and appropriateness via medical record review and contraception use and side effects at 30 days via adolescent survey. To further explore feasibility, we conducted clinician interviews at study completion; these were audio‐recorded, transcribed, and analyzed. We hypothesized contraceptive care would be feasible (defined as average score ≥ 4 across five survey items). Results: We enrolled 37 adolescents (12 in usual and 25 in same‐day), mean age was 16.6 years, 73% were Black, and 19% were Hispanic. We trained 27 clinicians. Average feasibility scores were 4.6 ± 0.4 (adolescents) and 4.1 ± 0.8 (clinicians). Eleven (44%) same‐day participants initiated contraception in the PED. One adolescent with migraines initially received estrogen‐containing pills; this was corrected after discharge. At 30 days, same‐day participants were more likely to report contraception use (78% vs. 13%; p = 0.007). One adolescent reported bloating as a side effect. Clinicians enjoyed delivering contraceptive care, found study resource materials useful, and identified staffing shortages as a barrier to care delivery. Conclusions: We are among the first to report on PED‐based adolescent contraception initiation to prevent unintended pregnancy. Adolescents and clinicians reported that contraceptive care was feasible. Initiation was common and medications were largely appropriate and tolerated. Future efforts should explore integrating contraceptive care into routine PED care. [ABSTRACT FROM AUTHOR]

Background: Palliative care improves the quality of life for people with life‐limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters). Methods: This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010–2017) to describe veteran demographics, socioeconomic status, life‐limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241–99245). Results: Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64). Conclusions: This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one‐third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults. [ABSTRACT FROM AUTHOR]

Background: Long-term health conditions are major challenges for care systems. Social prescribing link workers have been introduced via primary care networks (PCNs) across England since 2019 to address the wider determinants of health by connecting individuals to activities, groups, or services within their local community. Aim: To assess whether the rollout of social prescribing link workers was in areas with the highest need. Design and setting: A retrospective study of social prescribing link workers in England from 2019 to 2023. Method: Workforce, population, survey, and area-level data at the PCN-level from April 2020 to October 2023 were combined. Population need before the rollout of link workers was measured using reported lack of support from local services in the 2019 General Practice Patient Survey. To assess if rollout reflected need, linear regression was used to relate provision of link workers (measured by full-time equivalent [FTE] per 10 000 patients) in each quarter to population need for support. Results: Populations in urban, more deprived areas and with higher proportions of people from minority ethnic groups had the highest reported lack of support. Geographically these were in the North West and London. Initially, there was no association between need and provision; then from July 2022, this became negative and significant. By October 2023, a 10-percentage point higher need for support was associated with a 0.035 (95% confidence interval = −0.634 to −0.066) lower FTE per 10 000 patients. Conclusion: Rollout of link workers has not been sufficiently targeted at areas with the highest need. Future deployments should be targeted at those areas. [ABSTRACT FROM AUTHOR]

BACKGROUND Remote patient monitoring (RPM), which includes out-of-office blood pressure (BP) measurement, coupled with interventions including telehealth and team-based care, is recommended for hypertension (HTN) management. We aimed to assess participant experience with RPM for HTN (RPM-HTN) to understand barriers and facilitators to implementing RPM-HTN in a primary care population where health disparities and social inequities are prevalent. METHODS This is a qualitative implementation study of participants' experiences with an RPM-HTN program for primary care patients with uncontrolled HTN at an academic health system. We recruited participants with high and low levels of engagement (≥16 or <16 days of transmitted BP readings per month). Semi-structured interviews were conducted, and descriptive statistics and rapid qualitative analysis were used to identify factors affecting the implementation of RPM-HTN, specifically adoption, acceptability, appropriateness, and feasibility. RESULTS Multiple themes emerged from interviews with 14 participants. A doctor's recommendation and wanting help with BP management were facilitators for engagement, while work conflicts and forgetfulness were barriers to engagement. Participants enjoyed the format and content of nurse and clinical pharmacist phone calls and forming a relationship with the team; expressed improved understanding of HTN and BP management; and appreciated the convenience of remote monitoring. CONCLUSIONS Participants found RPM-HTN acceptable and appropriate, highlighting the team-based and out-of-office approach to care. This study provides actionable targets to overcome feasibility barriers to implementation. In order to increase engagement, RPM policies and procedures should take into account barriers including the quantity of required BP measurements and mechanisms of telehealth communication. [ABSTRACT FROM AUTHOR]

Background: The health issues experienced by older people can often be severe and complex, and an increasing number are using residential aged care services to meet their care needs. High-quality nursing care is fundamental to the health and safety of aged care residents and is contingent on nurses' accurate assessment, informed decision-making, and delivery of timely interventions. However, the role of the aged care nurse is often challenging, impeded by factors such as understaffing, high workloads, and a lack of access to clinical infrastructure and resources. When these challenges mount, residents are put at greater risk of adverse outcomes, such as avoidable clinical deterioration and hospital transfers. This study describes the adaptation and implementation of the emergency nursing framework, HIRAID® (History including Infection risk, Red Flags, Assessment, Interventions, Diagnostics, reassessment, communication and plan)—a tool to assist nurses' assessment, decision-making and care in residential aged care. Methods: The HIRAID® framework will be adapted for residential aged care using a real-time Delphi and panel of aged care and nursing experts. The co-designed HIRAID® Aged Care framework will be trialled in 23 residential aged care homes in Sydney, Australia, in a modified stepped-wedge cluster randomised controlled trial design. All homes will be randomised into one of four clusters. Outcomes of interest include the rate of clinical deterioration events resulting from nurses' actions, the rate of hospital transfers determined to be inappropriate, performance against the national mandatory aged care quality indicators, resident satisfaction with care, nurse and medical staff satisfaction with communication, and the quality of nursing documentation. These outcomes will be evaluated using a combination of qualitative and quantitative analysis of routinely collected resident data, expert assessments of facility documentation events against validated criteria, and pre- and post-intervention surveys of residents, family carers, nurses, and medical staff. Discussion: This protocol describes a pragmatic trial that aims to translate an evidence-based framework from the emergency care context into residential aged care. The adapted HIRAID® Aged Care framework will be the first of its kind to standardise and guide holistic nursing assessment, decision-making, and documentation in residential aged care in Australia. Ethics and dissemination: This research has been approved by the Western Sydney Local Health District Human Research Ethics Committee: 2023/ETH00523. A waiver of consent has been approved to access resident health data and nursing documentation at each participating site. Trial registration: Australian and New Zealand Clinical Trial Registry, ACTRN12623000481673. Registered 12 May 2023. Protocol version: Version 1.0 6 February 2024. [ABSTRACT FROM AUTHOR]

Background: Health systems are fundamental to the promotion and protection of breastfeeding. Health professionals have a pivotal influence on families' infant feeding decisions and may act as facilitators or barriers to adequate breastfeeding practices. Research Aim: To explore factors influencing health professionals' decisions regarding the indication of infant formula in Montevideo, the capital of Uruguay, an emerging Latin American country. Method: This was a qualitative study based on semi-structured interviews with 30 health professionals (neonatologists, pediatricians, family doctors, and nurses) working in primary and secondary care in both private and public health institutions. The interviews were audio-recorded, transcribed, and analyzed using content analysis based on deductive-inductive coding. Results: The narratives of the participants identified maternity wards as the healthcare sites where the indication of infant formula occurs most frequently. Motives underlying the indication of infant formula by health professionals were diverse. The type of birth and the conditions of the child and the mother were the most relevant in secondary care, whereas maternal work was the main determining factor in primary care. A wide range of factors encouraging and discouraging the indication of infant formula were identified by health professionals in primary and secondary healthcare locations, which were related to all the levels of influence of the socioecological model. Conclusions: Strategies to reduce the use of infant formula in Uruguay should include improving the support and guidance provided to families in the maternity ward, strengthening the implementation and monitoring of the Baby-Friendly Hospital Initiative, and improving the current maternity leave regulations. [ABSTRACT FROM AUTHOR]

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Background: In aging societies, emergency departments (ED) face an increasing number of older, geriatric patients. Research shows that older emergency patients have a greater burden of comorbidities and a higher risk of adverse events. It has been questioned whether contemporary ED structures can meet the specific needs and characteristics of older patients. Little is known about how professional health care providers perceive and experience ED care for older patients. This study aimed to get insight into the perspective of healthcare providers working with older ED patients and to explore the challenges they experience in their daily work. Methods: The study used a qualitative research design with a social-constructivist perspective and a Grounded Theory based methodology. Data were collected through qualitative interviews with N = 25 healthcare providers from different urban EDs in Berlin, Germany, and adjacent healthcare institutions. Following the Ground Theory approach, categories and central themes were identified, analyzed, and interpreted to gain a comprehensive understanding of the healthcare provider perspective. Results: The interviews revealed a significant and increasing relevance of geriatric ED patients for healthcare providers. However, there was no shared definition of 'the geriatric patient'. Most interviewees found ED structures to be inadequate for older patients. They described specific challenges, such as information gathering and safety risks in the ED, as well as an increased use of resources (both time and personnel) when caring for older patients. In addition, specific problems in the collaboration with other professions and institutions were addressed, namely nursing homes, hospital wards, consultations, and the hospital social service. Conclusion: Healthcare providers experience a structural mismatch between contemporary EDs and the specific needs of geriatric patients. They are aware of the vulnerabilities of geriatric patients and try to compensate for inherent structural shortcomings. Such structures and limited resources often cause practical, organizational, and ethical problems. There is a great need to develop, implement, and evaluate systematic approaches and care concepts that address the specifics of ED care for geriatric patients. [ABSTRACT FROM AUTHOR]

Objectives Data supporting routine infectious diseases (ID) consultation in gram-negative bloodstream infection (GN-BSI) are limited. We evaluated the association between ID consultation and mortality in patients with GN-BSI in a retrospective population-wide cohort study in Ontario using linked health administrative databases. Methods Hospitalized adult patients with GN-BSI between April 2017 and December 2021 were included. The primary outcome was time to all-cause mortality censored at 30 days, analyzed using a mixed effects Cox proportional hazards model with hospital as a random effect. ID consultation 1–10 days after the first positive blood culture was treated as a time-varying exposure. Results Of 30 159 patients with GN-BSI across 53 hospitals, 11 013 (36.5%) received ID consultation. Median prevalence of ID consultation for patients with GN-BSI across hospitals was 35.0% with wide variability (range 2.7%–76.1%, interquartile range 19.6%–41.1%). In total, 1041 (9.5%) patients who received ID consultation died within 30 days, compared to 1797 (9.4%) patients without ID consultation. In the fully adjusted multivariable model, ID consultation was associated with mortality benefit (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI].77–.88, P <.0001; translating to absolute risk reduction of −3.8% or number needed to treat [NNT] of 27). Exploratory subgroup analyses of the primary outcome showed that ID consultation could have greater benefit in patients with high-risk features (nosocomial infection, polymicrobial or non-Enterobacterales infection, antimicrobial resistance, or non-urinary tract source). Conclusions Early ID consultation was associated with reduced mortality in patients with GN-BSI. If resources permit, routine ID consultation for this patient population should be considered to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services experience implementation of fall prevention interventions and how they perceive their roles. Methods: We conducted 14 semi-structured individual interviews with managers from different levels of homecare services in five city districts. The interviews were transcribed verbatim and reflexive thematic analysis was used to analyze the material. Results: The analysis resulted in three main themes: (1) understanding organizational mechanisms to facilitate new practices, (2) practicing positive leadership behavior to facilitate implementation, and (3) demonstrating persistence to sustain implementation. Our results showed the importance of clear leadership across all levels of the organization and the value of devoting time and utilizing existing systems. Managers described using recognition and positive attitudes to motivate employees in the implementation process. They emphasized listening to and involving employees, providing trust, and being flexible. However, the implementation process could be challenging, highlighting the need for managers to be persistent. Conclusion: Managers at all levels play an important role in the implementation of fall prevention, but there is a need to define and align their specific roles in the process. Understanding how to use existing systems and influence through positive leadership behavior seem to be vital for success. Recognizing the demanding nature of implementation, managers emphasized the importance of systems for long term support. The study findings may influence how managers in clinical practice engage in the implementation process and inform future researchers about managers' roles in implementation in homecare services. [ABSTRACT FROM AUTHOR]

Background: Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Methods: Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015–2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. Results: For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06–1.31) but not older adults (IRR 0.99, 95% CI 0.85–1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08–1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Conclusion: Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization. [ABSTRACT FROM AUTHOR]

Background: Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Methods: Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015–2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. Results: For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06–1.31) but not older adults (IRR 0.99, 95% CI 0.85–1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08–1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Conclusion: Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization. [ABSTRACT FROM AUTHOR]

Objectives: This pilot hybrid study aimed to evaluate the implementation-effectiveness of a mindfulness-based retreat (MBR) for mothers of pediatric heart transplant (HTx) recipients. Method: The study used a convergent parallel mixed methods design. A purposive sample of 16 mothers was recruited from the Heart Transplant Program of a leading Canadian pediatric healthcare institution. A 2-day MBR was piloted at a local resort and mindfulness sessions were facilitated by two trained professionals with expertise working with families of children with chronic illness. Implementation outcomes assessed included feasibility, adoption, acceptability, appropriateness, and fidelity. Five standardized questionnaires were used to evaluate the effectiveness of the MBR on psychological wellbeing at baseline (T1), post-MBR (T2), and 3 months post-MBR (T3): Five Facet Mindfulness Questionnaire (FFMQ), Coping Health Inventory for Parents (CHIP), Distress Tolerance Scale, Multidimensional Scale of Perceived Social Support (MSPSS), and Pediatric Quality of Life Family Impact Module. Focus groups and individual interviews (n = 16) were completed. Results: The MBR was considered feasible, adoptable, acceptable, and appropriate by participants. Questionnaire scores were improved for the FFMQ (p = 0.022, d = 0.48), CHIP (family integration subscale; p = 0.033, d = 0.50), and MSPSS (family domain subscale; p = 0.025, d = 0.23) at T3 and were supported by qualitative findings. Significant changes were observed mostly between T1 and T3, reflecting that improvements have the potential to be sustained post-MBR. Measurements of fidelity suggest that the MBR was implemented as intended. Conclusions: A larger MBR trial with a control comparison to explore health outcomes, sustainability, and cost-effectiveness in parents of children with chronic illness is warranted. Preregistration: This study is not preregistered. [ABSTRACT FROM AUTHOR]

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The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional community health workers (CHWs) and upgraded primary health centres (PHCs)—and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-5 mortality halved, over 3 years compared with baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-5 mortality, compared with the control arm. We aimed to explain these results by examining implementation, mechanisms and context in both arms We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms. [ABSTRACT FROM AUTHOR]

Background Real-world research on cancer care in the community should address social determinants of health (SDOH) to advance health equity in cancer diagnosis, treatment, and survivorship. We sought patient and stakeholder perspectives to co-develop research principles to guide researchers when using patient record data to address health equity in their research protocols. Materials and methods Key informant interviews with 13 individuals elicited perspectives and insights related to health equity and SDOH when conducting research using data from community-based oncology care. Interviews included a brief overview of a prior scoping review and related questions in the interview guide. Key informants included experts in health equity and SDOH, and patient and community advisory board members. Rapid qualitative analysis was used to identify key themes, patterns, and insights from the interview data. Principles were developed based on the results of the analysis. Results Three overarching categories for promoting health equity were (1) education; (2) community engagement; and (3) research design and implementation. Education principles highlight the necessity of training in relevant skills to address health equity. Community engagement principles highlight various actions that researchers can take to conduct research inclusive of community concerns regarding health equity. The research design and implementation category provides practical guidelines for researchers in planning, conducting, and disseminating community-based oncology research to address health equity. Conclusion Our principles guide oncology real-world research protocols to address SDOH in community settings and promote health equity. These principles should be tailored to specific cancer topics and communities. [ABSTRACT FROM AUTHOR]

Introduction: Mental disorders during young adulthood can significantly impair functioning in daily activities. Non‐clinical support services aim to improve functioning by helping people to build social and life skills, participate in education and employment and improve physical health. This study aims to examine and synthesise the evidence for non‐clinical services on improving functional outcomes for young adults with mental disorders. Methods: A systematic search was undertaken to identify quantitative and qualitative studies reporting on a non‐clinical service component (vocational support, peer support, youth development, lifestyle interventions, family and network support) and examining functional outcomes (e.g., outcomes focussed on work and education, life skills, relationships and healthy behaviours). Results: Seventeen studies met inclusion criteria. Identified studies focussed on vocational support services (n = 9), lifestyle interventions (n = 6) and family and network support services (n = 2). No studies on peer‐support services or youth development services were found. More than half of the vocational support service studies reported increased employment rates among young adults (n = 6). Studies focussing on lifestyle interventions included a combination of physical activity, nutrition education, health coaching and motivation and behaviour change. However, the measures of functioning used across studies were too varied to determine whether lifestyle interventions may be useful in improving functional outcomes for young adults. Conclusion: Further research is needed to understand the impact of non‐clinical services on functioning. This evidence will provide pragmatic guidance for service planners to invest in supports and interventions that make a meaningful difference to the lives of young adults living with mental disorders. [ABSTRACT FROM AUTHOR]

Background: English primary care faces a reduction in GP supply and increased demand. Aim: To explore trends in GP working time and supply, accounting for factors influencing demand for services. Design and setting: Retrospective observational study in English primary care between 2015 and 2022. Method: Trends in median GP contracted time commitment were calculated using annual workforce datasets. Three measures of demand were calculated at practice-level: numbers of patients; numbers of older patients (≥65 years); and numbers of chronic conditions using 21 Quality and Outcomes Framework disease registers. Multi-level Poisson models were used to assess associations between GP supply and practice demand, adjusted for deprivation, region, and year. Results: Between 2015 and 2022, the median full-time equivalent (FTE) of a fully qualified GP decreased from 0.80 to 0.69. There was a 9% increase in registered population per GP FTE (incidence rate ratio [IRR] = 1.09; 95% confidence interval [CI] = 1.05 to 1.14). This increase was steeper using numbers of chronic conditions (32%, IRR = 1.32; 95% CI = 1.26 to 1.38). Practices in the most deprived decile had 17% more patients (IRR = 1.17; 95% CI = 1.08 to 1.27) and 19% more chronic conditions (IRR = 1.19; 95% CI = 1.06 to 1.33) per GP FTE, compared with the least deprived decile. These disparities persisted over time. All regions reported more chronic conditions per GP FTE than London. Conclusion: Population demand per GP has increased, particularly in terms of chronic conditions. This increase is driven by several factors, including a reduction in GP contracted time commitments. Persistent deprivation gradients in GP supply highlight the need to recruit and retain GPs more equitably. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to develop the Remote Health Value Framework to evaluate the models of healthcare provision for workers in the oil and gas sector, predominantly situated in rural and remote areas. Methods: The framework was co-designed with the leadership team in one global oil and gas company using a multi-criteria decision analysis approach with a conjoint analysis component. This was used to elicit and understand preferences and trade-offs among different value domains that were important to the stakeholders with respect to the provision of healthcare for its workers. Preference elicitation and interviews were conducted with a mix of health, safety, and environment (HSE) team and non-HSE managers and leaders. Results: Out of five presented value domains, participants considered the attribute 'Improving health outcomes of employees' the most important aspect for the model of healthcare which accounted for 37.3% of the total utility score. Alternatively, the 'Program cost' attribute was least important to the participants, accounting for only 11.0% of the total utility score. The marginal willingness-to-pay analysis found that participants would be willing to pay A$9090 per utile for an improvement in a particular value attribute. Conclusions: This is the first value framework for healthcare delivery in the oil and gas industry, contextualised by its delivery within rural and remote locations. It provides a systematic and transparent method for creating value-based healthcare models. This approach facilitates the evaluation of healthcare investments, ensuring they align with value domains prioritised by the HSE and leadership teams. What is known about the topic? It has been challenging for oil and gas companies to deliver and evaluate value-based healthcare services to improve workers' wellbeing, supplementing essential emergency services and occupational health. What does this paper add? The Remote Health Value Framework (RHVF), developed and tested in this work, offers a blueprint for designing and evaluating models of care considering the companies' and workers' priorities. What are the implications for practitioners? The RHVF's application has the potential to improve industry standards, enabling a data-driven approach to healthcare investments that closely align with both corporate objectives and employee wellbeing. [ABSTRACT FROM AUTHOR]

The professional experiences of school nurses who work outside of urban areas are not often described. We used data from a 2019 statewide survey of school nurses to describe differences between the urban and non-urban (urban cluster and rural) school nurse workforce in New Mexico. Non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses (P <.001) and more likely to serve both elementary and secondary school settings (P =.002). They were less likely than urban school nurses to be bachelor's prepared, or to have received recent continuing education on diabetes (P <.001), reproductive health (P = 0.02), LGBQ+ and transgender student health (P <.001, for each), and suicide risk assessment and screening (P =.012). Our findings underscore concerns about geographic differences in the school nursing workforce in terms of educational preparation and student access that could potentially limit the school nurse role in advancing child health equity. [ABSTRACT FROM AUTHOR]