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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: 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]

Aim Methods Results Conclusions To test whether an audit and feedback‐based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.Multi‐centre, quasi‐experimental pre‐post study of an AF‐based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence‐informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population‐based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre‐implementation (June 2018–May 2019); early‐implementation (June 2019–September 2020); and late‐implementation (October 2020–September 2021). Multivariable linear regression models were fit separately in each cohort.There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late‐implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre‐implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Design Methods Results Conclusion Impact Patient or Public Contribution To explore collaboration and social dynamics within paediatric Morbidity and Mortality meetings.Qualitative Exploratory Case Study Methodology incorporating semi‐structured interviews and qualitative observations.Data were collected in a large quaternary paediatric hospital in Melbourne, Australia. Semi‐structured interviews with meeting attendees were conducted after observing and documenting meeting conduct. Reflexive thematic analysis was used to interpret data and generate a thematic map of findings.Forty‐four interviews and 32 meeting observations were conducted between July 2019 and January 2020. Participants valued collaboration between attendees in Morbidity and Mortality meetings, however there were barriers to this. They included differing views about roles and negative impacts of hierarchies and authority. Senior doctors dominated discussion, and participants described this occasionally signalling reverence and respect, but sometimes signified intimidation and feeling unsure about how to contribute. Because of this complexity, successfully achieving positive social dynamics in a meeting required active promotion and management.Morbidity and Mortality meetings mirror the complexity and richness of the clinical environment. Descriptions of how meeting conduct can shape positive workplace culture and address hierarchical obstructions to safe clinical care highlight their far‐reaching potential. Effective collaboration is an intrinsic part of realising this value.This paper addresses a paucity in the literature in understanding how social dynamics and collaboration in Morbidity and Mortality meetings are interpreted and experienced. These findings illuminate challenges and obstacles to achieving a productive and equitable social dynamic in meetings. They also illustrate positive discrimination strategies that may improve participation and widespread engagement of nurses, junior doctors, and allied health professionals. Importantly, fostering constructive social dynamics in the Morbidity and Mortality meeting could positively impact patient safety culture and therefore patient care.No patient or public contribution. [ABSTRACT FROM AUTHOR]

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]

Background Method Results Conclusion Elderly population is increasing in high‐income countries. For instance, by 2050, 21.4% of the United States population is expected to be 65+, thus making advance care planning (ACP) increasingly important. We aim to identify predictors of ACP completion in 11 high‐income countries and explore relationships between ACP and utilization factors.Using the 2021 International Health Policy (IHP) survey data, we assessed the relationship between sociodemographic factors, healthcare utilization, and ACP. The primary outcome variable was a composite of three ACP activities. A generalized linear mixed model (GLMM) was used to identify predictors of ACP completion.Analyses included 18,677 older adults who answered at least one ACP question. Only 5126 (27.4%) reported completion of three ACP activities. Germany (64.7%) showed the highest completion rates, while Sweden (5.0%) and France (5.0%) showed the lowest completion rates. Predictors of ACP completion identified in the GLMM were: increasing age (incidence rate ratio [IRR] range between 1.2 and 1.5), completion of high school education or more (IRR: 1.1, 95% CI: 1.1–1.1), higher income (IRR: 1.1, 95% CI: 1.1–1.2), presence of two or more health conditions (IRR: 1.1, 95% CI: 1.0–1.1), hospital stay in the past 2 years (IRR: 1.1, 95% CI: 1.1–1.1), and access to quality primary care (IRR: 1.0, 95% CI: 1.0–1.1). Male gender (IRR: 0.9, 95% CI: 0.8–0.9) had a negative association with ACP activity completion.Several patient‐specific and health system utilization factors were identified as predictors of ACP activity completion, which clinicians and policymakers could use to enhance ACP completion. [ABSTRACT FROM AUTHOR]

ABSTRACT Background/Objective Methods Results Conclusions The demand for pediatric dermatology services in the U.S. is high, especially at large academic healthcare centers. eConsultation programs provide a solution to poor in‐person access by offering diagnostic and management support to primary care providers (PCPs). To determine the real‐world utility of eConsultation in pediatric dermatology within a closed system at a major academic center, we assessed the outcomes, diagnostic and management concordance, and predictors of eConsult completion of an asynchronous provider‐to‐provider pediatric dermatology eConsult program.Retrospective cohort study of 900 consecutive outpatient pediatric dermatology eConsult referrals from PCPs at a tertiary academic center from 2017 to 2021.Of 900 eConsult referrals, 621 (69%) were completed without the need for in‐person dermatology follow‐up. 46 (5%) were completed but required follow‐up. 233 eConsult referrals (26%) were declined, primarily due to medical complexity. Thirty referrals (3%) were declined because of inadequate clinical photos. The PCP communicated eConsult recommendations to the patient/family on an average of 1.6 days (SD 3) after receiving the completed eConsult. eConsults for adolescents were less likely to be completed compared to infants (p = 0.03). Diagnostic and management concordance between PCP and dermatologist was 78% and 67%, respectively.Provider‐to‐provider eConsultation provides rapid speciality guidance to PCPs managing low‐complexity skin conditions in pediatric outpatients. The lower rate of management plan concordance compared to diagnostic concordance suggests that eConsultation improves outpatient skin management by PCPs. [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]

AbstractPurpose:Materials and methods:Results:Conclusions:\nIMPLICATIONS FOR REHABILITATIONBoth demand and need for assistive technology (AT) are growing worldwide. However, ensuring an optimal fit between the person and AT is complex. With health professionals often being the “gatekeeper” to AT, it is imperative to understand their experiences of AT. This study was positioned within a sociotechnical space known as “HabITec”, which aims to bring together potential AT users with health professionals and technology developers to enhance the technology-person fit. The current paper reports on health professionals’ experiences of the HabITec Lab (THL), the physical manifestation of HabITec that was piloted in a tertiary hospital for 12-months.The study used a qualitative descriptive approach to explore the experiences of nine health professionals who referred patients to the lab. Four major themes were identified together with suggestions for the future of THL and HabITec. The themes focused on 1) Balancing service and independence; 2) Capitalising on possibilities and connections; 3) Negotiating multiple mismatches; and 4) Fitting it all together in a coherent service.It was clear that health professionals who referred patients to THL identified a range of benefits associated with it, but barriers to its effectiveness were identified and concerns were raised over health professionals becoming too reliant on the lab. For THL to be sustainably implemented, it appears that a policy-level shift is needed to enable its appropriate resourcing.A sociotechnical space with the capacity to bring together assistive technology users with health professionals and technology developers has shown potential to enhance the technology-person fit.A policy-level shift is needed to ensure future successful and sustainable implementation of such a space; however, further comparison with standard assistive technology practice is needed to warrant investment.Such a space should be conscious of equipping health professionals with assistive technology knowledge and skills.Attention must be paid to adequate promotion of services to ensure appropriate uptake.A sociotechnical space with the capacity to bring together assistive technology users with health professionals and technology developers has shown potential to enhance the technology-person fit.A policy-level shift is needed to ensure future successful and sustainable implementation of such a space; however, further comparison with standard assistive technology practice is needed to warrant investment.Such a space should be conscious of equipping health professionals with assistive technology knowledge and skills.Attention must be paid to adequate promotion of services to ensure appropriate uptake. [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]

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: General practitioners (GPs) are the first point of contact for patients with unexplained symptoms of long/post-COVID (L/PC), whereby patients report suffering from a wide range of systemic, nonspecific persistent symptoms after recovery from acute SARS-CoV‑2 infection. This study explores L/PC care from the GP perspective and describes experiences, challenges and information needs. Methods: An anonymous nationwide survey open to all GPs in ambulatory care in Germany was conducted in September 2022. Data were collected using a self-designed online questionnaire. Analyses were carried out using descriptive statistics. Results are weighted by age, sex and region. Results: Overall, the surveys response rate reached 2.1% of all GPs practicing in Germany; 93% (n = 819) stated that they had provided care for L/PC patients. Therapeutic measures most often recommended by GPs were nondrug therapy, follow-ups, and long-term sick leave prescriptions (doctor's notes). Barriers were encountered in all areas of care, including diagnosis, treatment, continuity of care and coordination. The greatest need for information related to L/PC was seen in the areas of therapy (including medication), pathophysiology and rehabilitation. Conclusion: GPs providing care to L/PC patients in Germany report barriers in care coordination and information needs. Establishing regional networks of GPs in cooperation with special outpatient and rehabilitation facilities and fostering information exchange between research and practice may help to improve the provision of need-based care for these patients. [ABSTRACT FROM AUTHOR]

Background: Studies have shown insufficient utilization of care for patients with erectile dysfunction (ED) after radical prostatectomy (RP). Aim: The aim of this study was to evaluate variables associated with barriers to seeking and receiving ED treatment. Methods: In this multicenter prospective cross-sectional study, the functional outcomes of 936 patients were assessed 10 to 15 years after RP. A total of 525 patients with ED or incontinence were asked about their treatment experiences or lack thereof. The data were analyzed using the chi-square test, t test, and multivariate logistic analyses. Outcomes: Patients answered validated questionnaires regarding information sources, communication with their partner and urologist, and barriers to ED treatment. Results: Of the 525 patients, 80 were not available to survey. A total of 304 patients answered the survey (response: 68.0%). A total of 246 patients had ED and were included in this study. The mean age at surgery was 64.4 ± 6.1 years, and the mean age at the time of this survey was 77.1 ± 6.2 years. The mean follow-up duration was 12.7 ± 1.5 years. Forty-six percent (n = 114 of 246) of the patients had never received ED treatment. The most important conversation partners regarding the ED were the partner (69% [n = 169 of 246]) and the urologist (48% [n = 118 of 246]). Patients who never received ED treatment were less likely to have conversations with their urologist (34% vs 60%; P <.001), had less support (51% vs 68%; P =.01), and had less interest in sex from their partner (20% vs 40%; P =.001). Communication with other groups (general practitioners, other physicians, family, friends, and the Internet) had no influence on ED treatment utilization. The most relevant barrier to receiving ED treatment was the belief that treatment would not help (65%). No interest in sex from their partner (odds ratio, 3.9) and no conversation with their urologist about ED (odds ratio, 2.9) were found to be independent predictors of not receiving ED treatment. Clinical Implications: Urologists should have enhanced awareness of how to approach patients directly about their ED and actively offer them treatment options. Strengths and Limitations: These results should be further validated in a multicenter, prospective study. Response bias may have affected the results. Furthermore, the current cohort was relatively old. Conclusion: This study revealed that no interest in sex from one's partner and insufficient communication with a urologist were relevant barriers to insufficient utilization of ED treatment after RP. [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 While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment. Objective To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention. Methods Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway : Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months. Results While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n  = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n  = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms. Conclusion Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI. [ABSTRACT FROM AUTHOR]

Background: Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care. Objective: The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain. Methods: A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores. Results: Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p <.0001] and pain [t(82) = -8.15, p <.0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p <.0001). Conclusion: This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy. [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]

Rationale: Healthcare systems remain disease oriented despite growing sustainability concerns caused by inadequate management of patients with multimorbidity. Comprehensive care programmes (CCPs) can play an important role in streamlining care delivery, but large differences in setup and results hinder firm conclusions on their effectiveness. Many elements for successful implementation of CCPs are identified, but strategies to overcome barriers and embed programmes within health systems remain unknown. Aims and Objectives: To address this knowledge gap through a detailed study of implementing a CCP in a Dutch hospital setting, including patient experiences, facilitators, barriers and ways to overcome those barriers. Additionally, this study aims to explore effects on patient satisfaction and healthcare use. Methods: A qualitative study design with 39 semistructured interviews and focus groups between July 2020 and February 2023 with 16 patients and 17 involved professionals. Additionally, effects on quantitative outcomes for patient satisfaction (PACIC‐20) and healthcare use were explored. Results: Professionals expressed a wide range of topics related to implementation and ways to overcome barriers at hospital and system level. Alterations in the design to accommodate varying care demands, focus on inclusions through referrals, and lack of long‐term support and appropriate financing were key topics. Patients expressed varying experiences, stated a strong desire for comprehensive information, and emphasised the importance of trust in caregivers. Patient satisfaction showed no effects, while healthcare use showed slight decreases in trends, but patient numbers were limited. Conclusion: The introduction of a CCP is feasible, and exploratory analysis on effectiveness shows lower hospital care use without decreasing patient satisfaction. However, this is accompanied by several challenges that show current fragmented systems still do not support implementation of integrated care initiatives. Overcoming those comes with substantial costs and may require a strong bottom‐up implementation within a motivated team and actions on all levels of healthcare systems. [ABSTRACT FROM AUTHOR]

Rationale: Though it is crucial to contribute to patient recovery through access, diversity, continuity and regularity of outpatient care, still today most of these are deemed nonoptimal. Identifying patient profiles based on outpatient service use and quality of care indicators might help formulate more personalized interventions and reduce adverse outcomes. Aims and Objectives: This study aimed to identify profiles of individuals with mental disorders (MDs) patterned after their outpatient care use and quality of care received, and to link those profiles to individual characteristics and subsequent outcomes. Methods: A cohort of 5669 individuals with MDs was considered based on data from the 2013–2014 and 2015–2016 Canadian Community Health Survey, which were linked to administrative data from the Quebec health insurance registry. Latent class analysis generated profiles based on service use over the 12 months preceding each respondent's interview, and comparative analyses were used to associate profiles with sociodemographic and clinical characteristics, and health outcomes over the three following months. Results: Four profiles were identified. Profile 1 (P‐1) was labelled 'Low service use'; P‐2 'Moderate general practitioner (GP) care and continuity and regularity of care'; P‐3 'High GP care, continuity and regularity of care, and low psychiatrist care'; and P‐4 'High psychiatrist care and regularity of care, and low GP care'. Profiles 3 and 4 (~50% of the cohort) were provided with better care, but showed worse outcomes, mainly acute care use due to more complex conditions and unmet needs. Profiles 1 and 2 had better outcomes as they showed fewer risk factors such as being younger and having better social conditions. Conclusion: Intensity, diversity and regularity of care were higher in profiles with more complex MDs, chronic physical illnesses, and worse perceived health conditions. Adapting specific interventions for each profile, such as assertive community treatment or intensive case management for Profile 4, is recommended. [ABSTRACT FROM AUTHOR]

Purpose: Clinical registries have great potential for quality control of medical procedures regarding the indications, therapeutic processes and results, including their possible complications. This is particularly true when providing patients with severe hearing loss or deafness with a cochlear implant (CI). This treatment represents a lifelong care process that requires continuous quality control over time. On the initiative of the Executive Committee of the German Society of Otorhinolaryngology (Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V., DGHNO-KHC), a national German CI registry (Deutsches Cochlear Implant Register, DCIR) was established in January 2022. This article focuses on the first demographic and baseline data of the DCIR. Methods: The DCIR covers the complete therapeutic process from indication, surgery, fitting and lifelong aftercare in CI therapy. By the end of 2022, 75 hospitals in Germany had agreed to contribute to the DCIR. Results: During the year 2022, 63 hospitals actively contributed data to the DCIR. Pseudonymized data from 2,292 CI implantations (2,176 primary implantations, 99 explantations with immediate re-implantations and 17 re-implantations following an earlier explantation) in 2,108 patients were documented. Cochlear implantation was accomplished in 1,807 adults (≥ 18 years) and 301 children (< 18 years). Fourty patients (1,9%) were children < 1 year of age and 55 (2,6%) were patients > 85 years. From the total of 2,292 implantations, 226 (9.9%) were performed as simultaneous bilateral implantations (CI implantation in both ears of 113 patients on the same day of surgery) and 412 implantations (19.1% of 2,162 implantations with data provided on the contralateral ear's hearing status) were in patients with single sided deafness (normal hearing in the contralateral ear). In addition, the reported complications in 2022 were also evaluated. Seven reports (0.4%) of mild to moderate severe facial nerve dysfunctions were documented. No reports of severe or total facial nerve dysfunction (House-Brackmann grade V/VI), meningitis or death related to CI therapy were documented. Conclusion: Although still in the start-up phase, these initial DCIR data already provide an interesting first insight into the demographic structure and baseline data of CI therapy in Germany. The successful implementation of the DCIR represents an important step towards continuous quality control of CI care. [ABSTRACT FROM AUTHOR]

The average number of times a person will have surgery in their lifetime, and the amount of surgical healthcare resources they use, is unknown. Lifetime risk is a measure of the risk of an average person having a specific event within their lifetime. We report the lifetime risk of surgery and the change observed during the first year of the COVID-19 pandemic. We conducted a population cohort study using hospital episode statistics to identify all patients undergoing surgery between January 1, 2016, and December 31, 2020, in England. We calculated age- and sex-specific incidence rates of surgery and combined these with routinely available population and mortality data from the Office for National Statistics. We computed the probability of requiring surgery stratified by 5-yr epochs (age 0–4 to ≥90 yr). Our primary analysis calculated lifetime risk for all surgery using the life table method. We assessed the impact of the COVID-19 pandemic, comparing a pre-pandemic and a pandemic period. Between 2016 and 2020, 23 427 531 patients underwent surgery, of which 11 937 062 were first surgeries. The average denominator population for England was 55.9 million. The lifetime risk of first surgery was 60.2% (95% confidence interval 55.1–65.4%) for women and 59.1% (95% confidence interval 54.2–64.1%) for men. The COVID-19 pandemic decreased the lifetime risk of first surgery by 32.3% for women and by 31.7% for men. This estimated lifetime risk should only be applied to the English population. This population epidemiological analysis suggests that approximately 60% of people in England will undergo surgery in their lifetime. [ABSTRACT FROM AUTHOR]

Purpose: We aimed at identifying prevalence, clinical outcomes and prognostic factors in cancer patients with intravenous chemotherapy-induced severe neutropenia (ICISN). Methods: In this multicenter retrospective cohort study on the clinical data warehouse of Greater Paris University Hospitals (AP-HP), we included all adult patients with solid cancer hospitalized between 2016 and 2021 with intravenous chemotherapy within 30 days prior to severe neutropenia (D70 or D611 ICD-10 codes AND a neutrophil count < 500/mm3). The primary endpoint was referral to intensive care unit (ICU) or death within 30 days. We collected cancer, patient, and treatment characteristics. Results: Among 141,586 cancer inpatients, 40,660 received chemotherapy among whom 661 (1.6%) had ICISN. Median age was 63 years (interquartile range (IQR), 54–70) and 330 patients (49%) were female. The median Charlson score was 10 (IQR, 8–11). Main primary cancers were lung (n = 204, 31%) and breast (n = 87, 13%). Advanced cancers were found in 551 patients (83%), 331 (50%) were in 1st line of chemotherapy, 284 (42%) in the 1st cycle of the current line and 149 (22%) had primary G-CSF. Documented bacterial (mostly gram-negative bacilli) and fungal infections were observed in 113 (17%) and 19 (3%) patients; 58 (9%) were transferred to ICU and 82 (12%) died within 30 days, 372 (56%) patients received subsequent chemotherapy. Independent prognostic factors were the level of monocyte, lymphocyte counts or albuminemia and a documented bacterial infection, while Charlson index and primary prophylactic G-CSF were not associated with patient clinical outcomes. Conclusion: Despite the use of primary G-CSF, ICISN remains a frequent event, which leads to ICU death in one on five cases Some prognostic factors of severity have been highlighted and could help clinicians to prevent severe complications. [ABSTRACT FROM AUTHOR]

• Retrospective descriptive study of the MarketScan database on non-intravenous rescue benzodiazepines (non-IV-rBZDs) after febrile seizures. • Among 82,835 patients with at least one febrile seizure, only 9737 (11.8 %) filled at least one non-IV-rBZD prescription. • Complex febrile seizure and initial hospitalization for febrile seizure were strongly associated with filling a non-IV-rBZD prescription. • New febrile seizures and eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. To describe the prescription patterns of home, non-intravenous rescue benzodiazepines (non-IV-rBZDs) for febrile seizures and the factors associated with their prescription. Retrospective descriptive study using the MarketScan Commercial Database, a large database of employer-sponsored privately insured patients in the United States. We used data from January 1st 2006 to December 31st 2022. We studied patients with febrile seizures as the main code for the healthcare encounter (identified with International Classification of Diseases codes) with age from 6 months to 5 years of age and with at least 1 month of follow-up. There were a total of 82,835 patients [median (p 25 -p 75) age 1.0 (1.0–2.0) years, 56.7 % males] with at least one febrile seizure, of whom 9,737 (11.8 %) filled at least one non-IV-rBZD prescription. Among the 9,737 patients who filled at least one prescription, the median (p 25 -p 75) time from first febrile seizure to non-IV-rBZD prescription was 27 (2–186) days. Among the factors known at the time of the first febrile seizure, complex febrile seizure (OR: 3.51, 95 % CI: 3.24–3.79), and an initial inpatient hospitalization for febrile seizure (OR: 3.53, 95 % CI: 3.29–3.79) were the factors most strongly associated with filling a non-IV-rBZD prescription. In contrast, sex, rural patient's residence, and salary employment (versus other employment class) were not independently associated with filling a non-IV-rBZD prescription. Among the factors known at the end of follow-up, complex febrile seizures, type of initial encounter, and an eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. Only approximately 12 % of children with a febrile seizure filled a prescription for a home non-IV-rBZD. The major factors independently associated with prescription were complex febrile seizure, hospital admission, recurrent febrile seizures, and an eventual diagnosis of epilepsy. [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]

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]

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]

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]

Objective: Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use. Study Design: A retrospective study of the 2004 to 2020 National Cancer Database.gg Methods: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life. Results: Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76‐0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07‐1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53‐0.77) and high‐income (aOR, 078; 95% CI, 0.71‐0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11‐2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42‐1.75). High‐income (aOR, 0.78; 95% CI, 0.71‐0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52). Conclusion: Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service. [ABSTRACT FROM AUTHOR]

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Background and objective: With advancement in technology, it has been possible to use minimally invasive surgical approaches for performing pyeloplasty for the treatment of ureteral strictures. This study aims to investigate the current trends of pyeloplasty and reconstructive ureteral procedures. Methods: We analyzed the nationwide German hospital billing database (Destatis) from 2006 to 2022. Linear regression models were utilized for the identification of trends over time. Key findings and limitations: A total of 34 975 pyeloplasties and 37 470 cases with ureteral reconstruction procedures were analyzed. The total number of pyeloplasties increased from 1990 procedures in 2006 to 2251 in 2019, before declining again down to 1916 procedures in 2022 (p = 0.783). Open pyeloplasty cases decreased from 79.5% in 2006 to 17.6% in 2022, while those using the robotic approach increased from 0.3% in 2006 to 35.9% in 2022 (p

Background: The frequent occurrence of pressure injuries despite their preventability raises important questions about our understanding of the barriers to care. This study explores the lived experience of nurses and caregivers in Singapore to establish a conceptual framework for better understanding of pressure injuries arising in the community. Methods: A multicenter qualitative study was conducted utilizing semistructured interviews and focused group discussions of nurses and caregivers of patients with pressure injuries. Data were collected with a narrative inquiry approach and analyzed with grounded theory. An iterative cycle of interviewing, coding, discussion, and reflection was conducted until theoretical saturation. Results: Ten inpatient nurses and 10 caregivers from the community were recruited. Analysis identified cognitive (awareness and caregiver training), emotional (motivation and empowerment), resource (human and infrastructural), and biomedical factors which collectively impacted the effectiveness of prevention. Additionally, constructs of learning and sustainability of caregiving played a crucial role in long term prevention. Limitation: The derived framework requires further validation with quantitative data and may not be generalizable to other cultural and economic populations. Conclusion: Multiple constructs have been identified to have a synergistic effect in prevention. Targeted measures should be implemented by healthcare institutions to better equip caregivers in prevention.

Abstract Background Making Every Contact Count (MECC) is a public health strategy which strives to enable brief interventions to be implemented through opportunistic healthy lifestyle conversations. In a mental health inpatient setting a bespoke MECC training package has been developed to encourage cascade training through a train the trainer model and to incorporate an additional regional health strategy A Weight Off Your Mind into Core MECC training to provide a focus on healthy weight management. This study evaluated the fidelity of design of MECC in the mental health inpatient setting and fidelity of the training package currently being cascaded across the region. Methods Initially a documentary analysis of six documents shared through the mental health inpatient setting including MECC implementation guide, logic model, checklist and evaluation framework. Documents were analysed using the Template for Intervention Description and Replication (TIDieR) checklist and coded using the Behaviour Change Technique (BCT) Taxonomy version one (BCTTv1) and the Expert Recommendations for Implementing Change (ERIC) Taxonomy. Coding was compared against MECC guidance documents to complete the fidelity assessment. A training delivery guide, training slides and two recordings of both train the trainer and Core MECC + A Weight Off Your Mind training were analysed for behaviour change techniques (BCTs) and compared to conduct a fidelity training assessment. Results Overall the implementation of MECC in the mental health inpatient setting had moderate fidelity to the MECC guidance, with a total of 31 BCTs identified across guidance and provider documents and a 77% adherence of provider documents to guidance. The highest level of fidelity applied to the MECC implementation guide where 86% of identified BCTs were also present. The training package showed high fidelity that both training programmes were being delivered as intended with 100% of BCT matched from training materials to training transcripts. Potential loss of fidelity through additional BCTs was present across provider documents and training transcripts. Conclusion The implementation of MECC across the mental health inpatient setting and the training package appear to be delivered as intended therefore demonstrating good fidelity and potential benefits to public health. Future research would benefit from assessing cascade training sessions from those who have completed train the trainer to evaluate ongoing fidelity of training across the trust.

Abstract Background Hip fracture is common in older people and has significant health and care implications. This study aimed to examine the impact of household characteristics (living alone or living with someone who is themselves ill) on adverse outcomes following hip fracture. Methods A cohort study of hip fracture patients aged ≥ 50 years living alone or with one co-resident using Welsh nationwide data between January 2013 and December 2018. Outcomes were emergency hospital admission within 30 days and care-home admission and mortality within one year of hospital discharge. Analysis used cause-specific Cox proportional hazards models to examine associations with living alone and with co-resident chronic disease status. Results Of the 12,089 hip fracture patients discharged, 56.0% lived alone. Compared to hip fracture patients living with a co-resident, those living alone were more commonly women (78.4% versus 65.2%), older (mean 83.1 versus 78.5 years), and had more long-term conditions (mean 5.7 versus 5.3). In unadjusted analyses, compared to living with a co-resident with 0–1 long-term condition and no dementia, living alone (hazard ratio [HR] 1.44, 95%CI 1.23–1.68), living with someone with dementia (HR 1.57, 95%CI 1.07–2.30), and living with someone with 4 + physical long-term conditions (HR 1.24, 95%CI 1.03–1.49) were associated with an increase in mortality, but no significant association was found in adjusted analysis. Adjusted for age, sex, socioeconomic position, and long-term condition count of the hip fracture patient, living alone (adjusted HR [aHR] 2.26, 95%CI 1.81–2.81) and living with a co-resident with dementia (aHR 2.38, 95%CI 1.59–3.57) were both associated with more than double the risk of care home admission. There were no significant associations with 30-day hospital admission. Conclusions Hip fracture patients who live alone have higher one-year mortality, but associations are explained by the demographic and clinical characteristics of those living alone. However, living alone or living with a co-resident with dementia was independently associated with an additional doubling of the risk of care home admission. Household-based approaches to research and health policy may help target risk groups following hip fracture community discharge and further research is needed to understand the mechanisms by which these associations act.

Abstract 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 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 Background Raising the quality of health services is key to continued progress in improving child health, however, data on service quality are limited and difficult to interpret. The relationship between facility readiness and the quality of care is complex. Methods Using publicly available data sets from five low- and middle-income countries (LMICs), we assessed the relationship between structural factors and the clinical quality of care for managing sick children. We developed indices for readiness and quality accounting for available indicators, expert opinion, and alignment with integrated management of childhood illness (IMCI) guidelines. In each country, we assessed the association between readiness and quality, with and without adjusting for other factors. We considered associations overall, by domain, and by provider type, explored non-linear associations, and compared associations at the individual and facility-level. Results The analysis included data from 3,149 health facilities and 11,159 sick child observations. In four of the five countries included in the analysis, we observed for every 10%-point increase in readiness, quality increased by about 1% point after adjusting for facility type and managing authority. There was little evidence of a non-linear relationship or a threshold effect altering the relationship between readiness and quality of care. Beyond readiness, younger child age, higher cost of care, and having a respiratory, digestive, or febrile diagnosis were most often associated with a higher quality of care. Higher “human resources” readiness domain scores were most consistently associated with better quality of care, while the quality of care domain of “treatment” was the least influenced by readiness. Facility-level associations did not vary greatly from individual-level associations. Conclusions The weak correlation observed suggests readiness plays an important role in quality but as currently measured cannot be used to characterize clinical quality of care. Data for assessing quality of health services are limited, presenting challenges for understanding impediments, assessing interventions, and gauging changes in the quality of care over time. We need better data to assess the quality of care being delivered in LMICs to understand what factors drive quality, with the goal of improving the management of sick children.

Abstract 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 .

Background Primary care is integral to healthcare systems extending beyond traditional illness management to include preventive care, chronic disease management, and health promotion. Practice-based research networks (PBRNs) have emerged as essential infrastructures for conducting clinical research in primary care. This study explores the establishment of the ‘Research-Practices Halle-Leipzig’ (RaPHaeL) PBRN in Germany, evaluating the characteristics and research readiness of participating practices.Methods A cross-sectional survey (MORNING II) was conducted among all general practitioners (GPs) joining the RaPHaeL PBRN, assessing socio-demographic characteristics, practice infrastructure, and research readiness. After a descriptive analysis, we compared data with a previous study (MORNING) to examine potential differences between PBRN participants and non-participants. We developed a research readiness score (RRS) to quantify practices’ ability to perform clinical research subtasks.Results The response rate was 97.1% and our participants were often male, involved in undergraduate education, generally interested in research or had previous research experiences. However, they differed widely in age and size, staff structure, and patient demographics of their practices. Initially, around two-thirds of the practices were not sufficiently prepared to conduct clinical trials (self-assessed feasibility of relevant subtasks). If further research and documentation tasks are required, patient recruitment estimations are lower than for patient identification and information.Conclusion This study highlights the variability in research readiness among GP practices and shows the need for targeted training. By systematically assessing and enhancing research capabilities of participating GPs, PBRNs can facilitate high-quality clinical research in primary care to improve patient outcomes and healthcare delivery.

Abstract 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 ( https://osf.io/rsd8x ).

Abstract 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.

OBJECTIVE: To understand possible sociodemographic, economic and health differences between older rural and urban Brazilians participating in the 2013 National Health Survey (Pesquisa Nacional de Saúde). METHODS: A cross-sectional study was conducted with a secondary analysis of data from 11,177 elderly individuals. The dependent variable was place of residence (rural or urban), and the independent variables were sociodemographic characteristics (age group [age 60 to 79 or 80 years and older], gender, race, municipality and socioeconomic condition) and clinical characteristics: private health plan, enrollment in the Family Health Strategy program (Estratégia Saúde da Família) and self-perceived health. Associations between dependent and independent variables were assessed using the χ2 test, with p < 5% considered significant. RESULTS: Except for age group, all other sociodemographic and clinical characteristics were significantly associated with place of residence (p < 0.0001). Rural participants were more frequently: male, mixed race, married, illiterate, non-capital residents, with a lower socioeconomic level, better Family Health Strategy coverage, were less likely to have private health insurance. The self-perceived health of urban elderly was more frequently very good, good or very poor (p

Abstract 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.

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.

BACKGROUND: Prescribing non-opioid pain medications, such as non-steroidal anti-inflammatory (NSAIDs) medications, has been shown to reduce pain and decrease opioid use, but it is unclear how to effectively encourage multimodal pain medication prescribing for hospitalised patients. Therefore, the aim of this study is to evaluate the effect of prechecking non-opioid pain medication orders on clinician prescribing of NSAIDs among hospitalised adults. METHODS: This was a cluster randomised controlled trial of adult (≥18 years) hospitalised patients admitted to three hospital sites under one quaternary hospital system in the USA from 2 March 2022 to 3 March 2023. A multimodal pain order panel was embedded in the admission order set, with NSAIDs prechecked in the intervention group. The intervention group could uncheck the NSAID order. The control group had access to the same NSAID order. The primary outcome was an increase in NSAID ordering. Secondary outcomes include NSAID administration, inpatient pain scores and opioid use and prescribing and relevant clinical harms including acute kidney injury, new gastrointestinal bleed and in-hospital death. RESULTS: Overall, 1049 clinicians were randomised. The study included 6239 patients for a total of 9595 encounters. Both NSAID ordering (36 vs 43%, p

BACKGROUND: Quality improvement collaboratives (QIC) are an approach to accelerate the spread and impact of evidence-based interventions across health facilities, which are found to be particularly successful when combined with other interventions such as clinical skills training. We implemented a QIC as part of a quality improvement intervention package designed to improve newborn survival in Kenya and Uganda. We use a multi-method approach to describe how a QIC was used as part of an overall improvement effort and describe specific changes measured and participant perceptions of the QIC. METHODS: We examined QIC-aggregated run charts on three shared indicators related to uptake of evidence-based practices over time and conducted key informant interviews to understand participants perceptions of quality improvement practice. Run charts were evaluated for change from baseline medians. Interviews were analysed using framework analysis. RESULTS: Run charts for all indicators reflected an increase in evidence-based practices across both countries. In Uganda, pre-QIC median gestational age (GA) recording of 44% improved to 86%, while Kangaroo Mother Care (KMC) initiation went from 51% to 96% and appropriate antenatal corticosteroid (ACS) use increased from 17% to 74%. In Kenya, these indicators went from 82% to 96%, 4% to 74% and 4% to 57%, respectively. Qualitative results indicate that participants appreciated the experience of working with data, and the friendly competition of the QIC was motivating. The participants reported integration of the QIC with other interventions of the package as a benefit. CONCLUSIONS: In a QIC that demonstrated increased evidence-based practices, QIC participants point to data use, friendly competition and package integration as the drivers of success, despite challenges common to these settings such as health worker and resource shortages. TRIAL REGISTRATION NUMBER: NCT03112018.

OBJECTIVE: To describe health equity research priorities for health care delivery systems and delineate a research and action agenda that generates evidence-based solutions to persistent racial and ethnic inequities in health outcomes. DATA SOURCES AND STUDY SETTING: This project was conducted as a component of the Agency for Healthcare Research and Qualitys (AHRQ) stakeholder engaged process to develop an Equity Agenda and Action Plan to guide priority setting to advance health equity. Recommendations were developed and refined based on expert input, evidence review, and stakeholder engagement. Participating stakeholders included experts from academia, health care organizations, industry, and government. STUDY DESIGN: Expert group consensus, informed by stakeholder engagement and targeted evidence review. DATA COLLECTION/EXTRACTION METHODS: Priority themes were derived iteratively through (1) brainstorming and idea reduction, (2) targeted evidence review of candidate themes, (3) determination of preliminary themes; (4) input on preliminary themes from stakeholders attending AHRQs 2022 Health Equity Summit; and (5) and refinement of themes based on that input. The final set of research and action recommendations was determined by authors consensus. PRINCIPAL FINDINGS: Health care delivery systems have contributed to racial and ethnic disparities in health care. High quality research is needed to inform health care delivery systems approaches to undo systemic barriers and inequities. We identified six priority themes for research; (1) institutional leadership, culture, and workforce; (2) data-driven, culturally tailored care; (3) health equity targeted performance incentives; (4) health equity-informed approaches to health system consolidation and access; (5) whole person care; (6) and whole community investment. We also suggest cross-cutting themes regarding research workforce and research timelines. CONCLUSIONS: As the nations primary health services research agency, AHRQ can advance equitable delivery of health care by funding research and disseminating evidence to help transform the organization and delivery of health care.

BACKGROUND: Vulnerable older adults living with Alzheimers disease or Alzheimers disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care. METHODS: We used the Medical Expenditure Panel Survey (MEPS), years 2002-2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses). RESULTS: Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31-1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04-1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34-1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23-1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07-1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75-1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups. CONCLUSIONS: The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.

In qualitative research, photographs and other visual data have been used with oral narratives in ethnography, interviews, and focus groups to convey and understand the perceptions, attitudes, and lived experiences of participants. Visual methodologies that incorporate photographic data include photo elicitation, which has varied approaches with the inclusion of photographs generated by researchers or participants, and Photovoice, which is a form of photo elicitation focused on participatory action research. Current literature provides insufficient guidance on a systematic coding process of visual data elements that could maximize capturing of visual data for qualitative analysis. We describe our rationale and process for developing a two-step systematic process for coding visual data, specifically photographs. The two-step systematic process for coding photographs involves coding the foreground (focal point) and then the background of the photograph, using separate codebooks. Application of this two-step coding approach resulted in surfacing additional rich data on the health-related contexts and environments in which participants lived. Incorporation of this methodology could enhance understanding of the context of health and generate ideas and new directions of inquiry.

Abstract Background It is well known that individuals recently discharged from psychiatric inpatient care face a high risk of suicide. Severe physical health conditions have also been linked to suicide risk. The risk of suicide following discharge from somatic hospitals is not known for individuals admitted due to acute physical health conditions. Methods A Cohort study using data from the entire Norwegian population aged 12 years and older from 2008 to 2022 linked with information on health service use and cause of death. We used Cox regression with age as time axis to estimate sex-adjusted hazard ratios of suicide following discharge for ages 12 to 64 years and 65 years and older. We also performed analyses after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. To assess individual risk, we performed an adapted case-crossover analysis among discharged patients who died from suicide. Results A total of 4 632,980 individuals aged 12 to 64 years and 1,469,265 individuals aged 65 years and older were included. Compared to unexposed individuals at similar ages, we found an increased risk of suicide in the first 4 weeks after discharge, with a hazard ratio (HR) of 7.0 (95% confidence interval (CI) 5.9 to 8.3) among those aged 12 to 64 years and 6.8 (95% CI 5.4 to 8.6) among those 65 years and older. In the younger age group, the risk was attenuated, with a HR of 2.4 (95% CI 1.7 to 3.2) after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. The corresponding HR was 4.8 (95% CI 3.5 to 6.4) among those 65 years and older, declining to 1.9, (1.2 to 3.1) in weeks 5 to 8 and 1.2 (0.7 to 2.2) in weeks 21 to 24. The case-crossover analysis confirmed that individuals 65 years and older were particularly vulnerable. Conclusions The heightened risk of suicide following discharge from acute somatic hospitalization, even in the absence of concurrent mental disorders, self-harm, or prior suicide attempts, underscores the critical need for comprehensive mental health and existential support for patients post-discharge.

Abstract Background Having traditionally received limited attention in empirical research and safety improvement agendas, issues of patient safety in mental healthcare increasingly feature in healthcare quality improvement discourses. Dominant approaches to safety stem from narrow clinical risk management perspectives, yet existing evidence points to the limitations of this characterisation. Although mental healthcare is increasingly delivered in community-based settings, narratives of safety pertain primarily to hospital-based mental healthcare. Therefore, through exploratory qualitative interviews and one focus group, we aimed to examine how service users, carers, and healthcare providers conceptualise ‘patient safety’ in community-based mental healthcare. Methods Semi-structured interviews and a single focus group were conducted with users of UK community-based mental healthcare provision for adults (n = 13), their carers (n = 12), and providers (n = 18), who were diverse in characteristics and experiences. Study data were analysed in accordance with a reflexive approach to thematic analysis. Findings Four key themes were developed, reflecting contrasting conceptualisations of safety in this care context, where participant thinking evolved throughout discussions. ‘Systemic inertia: threats to safety’ characterises the entrenched, systemic challenges which rendered participants powerless to advocate for or deliver safe care. ‘Managing the risks service users present’ equates ‘safe care’ to the mitigation of risks service users may pose to themselves or others when unwell, or risks from those around them. ‘More than responding to risks: everyone plays a role in creating safety’ recognises providers’ agency in causing or proactively preventing patient harm. Finally, ‘The goals of ‘safety’: our destination is not yet in sight’ positions safety as a work in progress, calling for ambitious safety agendas, giving primacy to goals which meaningfully improve service users’ lives. Conclusions Our findings have implications for the understanding and improvement of patient safety in community-based mental healthcare settings, where improvement objectives should transcend beyond management of risks and preventing deterioration to address patient and carer-centred concerns, including practices that make people feel unsafe.