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Value-based healthcare in Latin America: a survey of 70 healthcare provider organisations from Argentina, Brazil, Chile, Colombia and Mexico

Por: Makdisse · M. · Ramos · P. · Malheiro · D. · Katz · M. · Novoa · L. · Cendoroglo Neto · M. · Ferreira · J. H. G. · Klajner · S.
Objectives

Value-based healthcare (VBHC) is a health system reform gradually being implemented in health systems worldwide. A previous national-level survey has shown that Latin American countries were in the early stages of alignment with VBHC. Data at the healthcare provider organisations (HPOs) level are lacking. This study aim was to investigate how HPOs in five Latin American countries are implementing VBHC.

Design

Mixed-methods research was conducted using online questionnaire, semistructured interviews based on selected elements of the value agenda (from December 2018 to June 2020), analyses of aggregated data and documents. Qualitative analysis was performed using NVivo QSR International, 1.6.1 (4830). Quantitative analysis used Fisher’s exact test. Univariate analysis was used to compare organisations in relation to the implementation of VBHC initiatives. A p≤0.05 was considered significant.

Participants

Top and middle-level executives from 70 HPOs from Argentina, Brazil, Chile, Colombia and Mexico.

Results

The definition of VBHC varied across participating organisations. Although the value equation had been cited by 24% of participants, its composition differed in most case from the original Equation. Most VBHC initiatives were related to care delivery organisation (56.9%) and outcomes measurement (22.4%) but in most cases, integrated practice unit features had not been fully developed and outcome data was not used to guide improvement. Information, stakeholders buy-in, compensation and fragmented care delivery were the most cited challenges to VBHC implementation. Fee-for-service predominated, although one-third of organisations were experimenting with alternative payment models.

Conclusions

A wide variation in the definition and level of VBHC implementation existed across organisations. Our finding suggests investments in information systems and on education of key stakeholders will be key to foster VBHC implementation in the region. Further research is needed to identify successful implementation cases that may serve as regional benchmark for other Latin American organisations advancing with VBHC.

Impact of leadership behaviour on physician well-being, burnout, professional fulfilment and intent to leave: a multicentre cross-sectional survey study

Por: Mete · M. · Goldman · C. · Shanafelt · T. · Marchalik · D.
Objective

To examine how perceived leadership behaviours affect burnout, professional fulfilment and intent to leave the organisation among physicians.

Design

Anonymous cross-sectional survey study from November 2016 to October 2018.

Setting

12 036 attending and resident physicians at 11 healthcare organisations participating in the Physician Wellness Academic Consortium (PWAC) were surveyed to assess burnout and professional fulfilment and their drivers.

Participants

A sample of 5416 attending physicians with complete data on gender, specialty, leadership, burnout and professional fulfilment.

Main outcomes and measures

The leadership behaviour of each physician’s supervisor was assessed using the Mayo Clinic Participatory Management Leadership Index and categorised in tertiles. Multivariable logistic regression analyses examined the effect of leadership behaviour rating of each physician’s supervisor on burnout, professional fulfilment and intent to leave controlling for gender and specialty.

Results

The response rate was 45% across 11 institutions. Half of the respondents were female. Professional fulfilment increased with increasing tertiles of leadership behaviour rating (19%, 34%, 47%, p

Conclusion

Perceived leadership behaviours have a strong relationship with burnout, professional fulfilment and intent to leave among physicians. Organisations should consider leadership development as a potential vehicle to improve physician wellness and prevent costly physician departures.

Development and validation of a social vulnerabilities survey for medical inpatients

Por: Tang · K. L. · Sajobi · T. · Santana · M.-J. · Lawal · O. · Tesorero · L. · Ghali · W. A.
Objectives

Our objective was to validate a Social Vulnerabilities Survey that was developed to identify patient barriers in the following domains: (1) salience or priority of health; (2) social support; (3) transportation; and (4) finances.

Design

Cross-sectional psychometric study.

Questions for one domain (health salience) were developed de novo while questions for the other domains were derived from national surveys and/or previously validated questionnaires. We tested construct (ie, convergent and discriminative) validity for these new questions through hypothesis testing of correlations between question responses and patient characteristics. Exploratory factor analysis was conducted to determine structural validity of the survey as a whole.

Setting

Patients admitted to the inpatient internal medicine service at a tertiary care hospital in Calgary, Canada.

Participants

A total of 406 patients were included in the study.

Results

The mean age of respondents was 55.5 (SD 18.6) years, with the majority being men (55.4%). In feasibility testing of the first 107 patients, the Social Vulnerabilities Survey was felt to be acceptable, comprehensive and met face validity. Hypothesis testing of the health salience questions revealed that the majority of observed correlations were exactly as predicted. Exploratory factor analysis of the global survey revealed the presence of five factors (eigenvalue >1): social support, health salience, drug insurance, transportation barriers and drug costs. All but four questions loaded to these five factors.

Conclusions

The Social Vulnerabilities Survey has face, construct and structural validity. It can be used to measure modifiable social vulnerabilities, such that their effects on health outcomes can be explored and understood.

Protocol for a scoping review of the use of information and communication technology platforms for the delivery and utilisation of transgender healthcare

Por: Cui · J. · Prankumar · S. K. · Wong · H. T. · Addo · I. Y. · Tumwine · C. · Noor · M. N.
Introduction

In recent years, there has been strong interest in making digital health and social tools more accessible, particularly among vulnerable and stigmatised groups such as transgender people. While transgender people experience unique physical, mental and sexual health needs, not much is currently known about the extent to which they use information and communication technologies such as short messaging service and videoconferencing to access health services. In this paper, we discuss our protocol for a scoping review of the literature about the delivery and utilisation of digitally mediated health services for transgender populations.

Methods and analysis

This scoping review of the provision and experience of telemedicine among transgender people will follow the methodological framework developed by Arksey and O’Malley. The search will be conducted using three online databases, namely PubMed, CINAHL and Scopus, with additional literature explored using Google Scholar to identify grey literature. Relevant English-language studies will be shortlisted after completing a title and abstract review based on defined inclusion criteria. Following that, a final list of included studies will be compiled after a full-text review of the shortlisted articles has been completed. To enable the screening process, a team of researchers will be assigned refereed publications explicitly referring to the provision and experience of transgender healthcare through telemedicine. Screening performed independently will then collaboratively be reviewed to maintain consistency.

Ethics and dissemination

The research is exempt from ethics approval since our analysis is based on extant research into the use of digital technologies in providing healthcare to transgender people. The results of this study will be disseminated through peer-reviewed academic publications and presentations. Our analysis will guide the design of further research and practice relating to the use of digital communication technologies to deliver healthcare services to transgender people.

Trend in CT utilisation and its impact on length of stay, readmission and hospital mortality in Western Australia tertiary hospitals: an analysis of linked administrative data 2003-2015

Por: Ha · T. N. · Kamarova · S. · Youens · D. · Wright · C. · McRobbie · D. · Doust · J. · Slavotinek · J. · Bulsara · M. K. · Moorin · R.
Objective

High use of CT scanning has raised concern due to the potential ionising radiation exposure. This study examined trends of CT during admission to tertiary hospitals and its associations with length of stay (LOS), readmission and mortality.

Design

Retrospective observational study from 2003 to 2015.

Setting

West Australian linked administrative records at individual level.

Participants

2 375 787 episodes of tertiary hospital admission in adults aged 18+ years.

Main outcome measures

LOS, 30-day readmissions and mortality stratified by CT use status (any, multiple (CTs to multiple areas during episode), and repeat (repeated CT to the same area)).

Methods

Multivariable regression models were used to calculate adjusted rate of CT use status. The significance of changes since 2003 in the outcomes (LOS, 30-day readmission and mortality) was compared among patients with specific CT imaging status relative to those without.

Results

Between 2003 and 2015, while the rate of CT increased 3.4% annually, the rate of repeat CTs significantly decreased –1.8% annually and multiple CT showed no change. Compared with 2003 while LOS had a greater decrease in those with any CT, 30-day readmissions had a greater increase among those with any CT, while the probability of mortality remained unchanged between the any CT/no CT groups. A similar result was observed in patients with multiple and repeat CT scanning, except for a significant increase in mortality in the recent years in the repeat CT group.

Conclusion

The observed pattern of increase in CT utilisation is likely to be activity-based funding policy-driven based on the discordance between LOS and readmissions. Meanwhile, the repeat CT reduction aligns with a more selective strategy of use based on clinical severity. Future research should incorporate in-hospital and out-of-hospital CT to better understand overall CT trends and potential shifts between settings over time.

Vocational and psychosocial predictors of medical negligence claims among Australian doctors: a prospective cohort analysis of the MABEL survey

Por: Bradfield · O. M. · Bismark · M. · Scott · A. · Spittal · M.
Objective

To understand the association between medical negligence claims and doctors’ sex, age, specialty, working hours, work location, personality, social supports, family circumstances, self-rated health, self-rated life satisfaction and presence of recent injury or illness.

Design and setting

Prospective cohort study of Australian doctors.

Participants

12 134 doctors who completed the Medicine in Australia: Balancing Employment and Life survey between 2013 and 2019.

Primary outcome measure

Doctors named as a defendant in a medical negligence claim in the preceding 12 months.

Results

649 (5.35%) doctors reported being named in a medical negligence claim during the study period. In addition to previously identified demographic factors (sex, age and specialty), we identified the following vocational and psychosocial risk factors for claims: working full time (OR=1.48, 95% CI 1.13 to 1.94) or overtime hours (OR 1.70, 95% CI 1.29 to 2.23), working in a regional centre (OR 1.69, 95% CI 1.37 to 2.08), increasing job demands (OR 1.16, 95% CI 1.04 to 1.30), low self-rated life satisfaction (OR 1.43, 95% CI 1.08 to 1.91) and recent serious personal injury or illness (OR 1.40, 95% CI 1.13 to 1.72). Having an agreeable personality was mildly protective (OR 0.91, 95% CI 0.83 to 1.00). When stratified according to sex, we found that working in a regional area, low self-rated life satisfaction and not achieving work–life balance predicted medical negligence claims in male, but not female, doctors. However, working more than part-time hours and having a recent personal injury or illness predicted medical negligence claims in female, but not male, doctors. Increasing age predicted claims more strongly in male doctors. Personality type predicted claims in both male and female doctors.

Conclusions

Modifiable risk factors contribute to an increased risk of medical negligence claims among doctors in Australia. Creating more supportive work environments and targeting interventions that improve doctors’ health and well-being could reduce the risk of medical negligence claims and contribute to improved patient safety.

Assessing patient experience with patient safety in primary care: development and validation of the ASK-ME-questionnaire

Por: Stahl · K. · Reisinger · A. · Groene · O.
Objective

To develop and test the validity and reliability of a tool measuring patient experiences with patient safety in ambulatory care that is suitable for routine use in general practitioner and specialist practices.

Design

Instrument development was based on a literature review, a 3-round Delphi survey with a multidisciplinary expert panel and cognitive interviews with patients. The instrument was piloted in 22 practices using a cross-sectional survey. Exploratory (EFA) and confirmatory factor analysis (CFA) were performed to test construct validity. Internal consistency and the ability of the questionnaire to differentiate between selected subgroups and at the level of individual practices was examined.

Setting

General practitioner and specialist practices.

Participants

Patients aged >18 years seeking care in ambulatory care practices between February and June 2020.

Results

The final ASK-ME-questionnaire consisted of 22 items covering 5 theoretical dimensions. A total of 3042 patients (71.1%) completed the questionnaire. Median item non-response rate was 4.2% (IQR 3.4%–4.7%). EFA yielded 3 factors comprising 14 items explaining 64.8% of the variance representing contributing factors to patient safety incidents. CFA confirmed the factorial structure suggested by EFA. The model fit the data satisfactorily (comparative fit index=0.92, root mean square error of approximation=0.08, standardised root mean square residual=0.08). Internal consistency values ranged from 0.7 to 0.9. Discriminant validity was supported by significant differences between patients of different age and differences in self-reported health status. The factors distinguished well between practices.

Conclusion

The ASK-ME-questionnaire showed good psychometric properties. It is suitable for routine use in patient safety measurement and improvement systems in ambulatory care. Further research is required to adequately assess number and type of experienced events in routine measurements.

Qualitative study informing the development and content validity of the HAND-Q: a modular patient-reported outcome measure for hand conditions

Por: Sierakowski · K. · Kaur · M. N. · Sanchez · K. · Bain · G. · Cano · S. J. · Griffin · P. · Klassen · A. · Pusic · A. L. · Lalonde · D. · Dean · N. R.
Objectives

The purpose of this study was to identify and understand the issues that are relevant to patients with hand conditions. The data were used to develop a patient-reported outcome measure (PROM) for adults with hand conditions (HAND-Q) and refine it with input from patients and clinician experts.

Design

Semistructured qualitative interviews were used to understand what matters to patients. Cognitive debriefing was used to refine preliminary HAND-Q scales.

Setting

Hand clinics in tertiary healthcare centres in Canada, Australia and USA.

Participants

Eligible participants were English-speaking adults who had experienced hand surgery in the preceding 12 months and were at least 4 weeks post-hand surgery A total of 62 in-depth interviews (females, n=34; mean age=65 years) were conducted to develop an item pool and draft the HAND-Q scales. The preliminary scales were refined through cognitive debriefing interviews with 20 participants and feedback from 25 clinician experts. All interviews were audiorecorded, transcribed verbatim and coded using a line-by-line approach.

Results

Qualitative data were organised into two top-level domains of health-related quality of life and satisfaction with treatment outcomes. The scales were refined iteratively, and the field-test version included 319 unique items and 20 independently functioning scales.

Conclusions

The HAND-Q is a comprehensive PROM developed using extensive patient and clinician expert input, following established guidelines for PROM development and validation. In the next phase, the psychometric properties of the HAND-Q will be established in an international field test, following which the HAND-Q will be available for use in clinical research and practice .

FAST-IT: Find A Simple Test -- In TIA (transient ischaemic attack): a prospective cohort study to develop a multivariable prediction model for diagnosis of TIA through proteomic discovery and candidate lipid mass spectrometry, neuroimaging and machine lea

Por: Milton · A. G. · Lau · S. · Kremer · K. L. · Rao · S. R. · Mas · E. · Snel · M. F. · Trim · P. J. · Sharma · D. · Edwards · S. · Jenkinson · M. · Kleinig · T. · Noschka · E. · Hamilton-Bruce · M. A. · Koblar · S. A.
Introduction

Transient ischaemic attack (TIA) may be a warning sign of stroke and difficult to differentiate from minor stroke and TIA-mimics. Urgent evaluation and diagnosis is important as treating TIA early can prevent subsequent strokes. Recent improvements in mass spectrometer technology allow quantification of hundreds of plasma proteins and lipids, yielding large datasets that would benefit from different approaches including machine learning. Using plasma protein, lipid and radiological biomarkers, our study will develop predictive algorithms to distinguish TIA from minor stroke (positive control) and TIA-mimics (negative control). Analysis including machine learning employs more sophisticated modelling, allowing non-linear interactions, adapting to datasets and enabling development of multiple specialised test-panels for identification and differentiation.

Methods and analysis

Patients attending the Emergency Department, Stroke Ward or TIA Clinic at the Royal Adelaide Hospital with TIA, minor stroke or TIA-like symptoms will be recruited consecutively by staff-alert for this prospective cohort study. Advanced neuroimaging will be performed for each participant, with images assessed independently by up to three expert neurologists. Venous blood samples will be collected within 48 hours of symptom onset. Plasma proteomic and lipid analysis will use advanced mass spectrometry (MS) techniques. Principal component analysis and hierarchical cluster analysis will be performed using MS software. Output files will be analysed for relative biomarker quantitative differences between the three groups. Differences will be assessed by linear regression, one-way analysis of variance, Kruskal-Wallis H-test, 2 test or Fisher’s exact test. Machine learning methods will also be applied including deep learning using neural networks.

Ethics and dissemination

Patients will provide written informed consent to participate in this grant-funded study. The Central Adelaide Local Health Network Human Research Ethics Committee approved this study (HREC/18/CALHN/384; R20180618). Findings will be disseminated through peer-reviewed publication and conferences; data will be managed according to our Data Management Plan (DMP2020-00062).

Body mass index and all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus in South Korea: a retrospective cohort study

Por: Hong · J.-S. · Kang · H.-C.
Objectives

The lower risk of death in overweight or obese patients, compared with normal-weight individuals, has caused confusion for patients with diabetes and healthcare providers. This study investigated the relationship between body mass index (BMI) and mortality in patients with type 2 diabetes.

Design

A retrospective cohort study.

Setting

We established a national population database by merging the Korea National Health Insurance (KNHI) claims database, the National Health Check-ups Database and the KNHI Qualification Database of South Korea.

Participants

A total of 53 988 patients who were newly diagnosed with type 2 diabetes (E11 in International Classification of Diseases, 10th Edition) in 2007, had available BMI data, lacked a history of any serious comorbidity, received diabetes medication and did not die during the first 2 years were followed up for a median of 8.6 years.

Primary outcome measures

All-cause mortality.

Results

The mean BMI was 25.2 (SD 3.24) kg/m2, and the largest proportion of patients (29.4%) had a BMI of 25–27.4 kg/m2. Compared with a BMI of 27.5–29.9 kg/m2 (the reference), mortality risk continuously increased as BMI decreased while the BMI score was under 25 (BMI 2: adjusted HR (aHR) 2.71, 95% CI 2.24 to 3.27; BMI 18.5–20.9 kg/m2: aHR 1.94, 95% CI 1.70 to 2.22; BMI 21–22.9 kg/m2: aHR 1.51, 95% CI 1.34 to 1.70; and BMI 23–24.9 kg/m2: aHR 1.14, 95% CI 1.01 to 1.28). For patients aged ≥65 years, the inverse association was connected up to a BMI ≥30 kg/m2 group (aHR 0.76, 95% CI 0.59 to 0.98). However, the associations for men, patients aged 2.

Conclusions

This study suggests that, for patients with type 2 diabetes at a normal weight, distinct approaches are needed in terms of promoting muscle mass improvement or cardiorespiratory fitness, rather than maintaining weight status. Improved early diagnosis considering the inverse association between BMI and mortality is also needed.

What, how, when and who of trial results summaries for trial participants: stakeholder-informed guidance from the RECAP project

Por: Bruhn · H. · Campbell · M. · Entwistle · V. · Humphreys · R. · Jayacodi · S. · Knapp · P. · Tizzard · J. · Gillies · K.
Objective

To generate stakeholder informed evidence to support recommendations for trialists to implement the dissemination of results summaries to participants.

Design

A multiphase mixed-methods triangulation design involving Q-methodology, content analysis, focus groups and a coproduction workshop (the REporting Clinical trial results Appropriately to Participants project).

Setting

Phase III effectiveness trials.

Participants

A range of participants were included from ongoing and recently completed trials, public contributors, trialists, sponsors, research funders, regulators, ethics committee members.

Results

Fewer than half of the existing trial result summaries contained information on the clinical implications of the study results, an item deemed to be of high importance to participants in the Q-methodology study. Priority of inclusion of a thank you message varied depending on whether considering results for individuals or populations. The need for personally responsive modes of sharing trial result summaries was highlighted as important. Ideally, participants should be the first to know of the results with regard to the timing of sharing results summaries but given this can be challenging it is therefore important to manage expectations. In addition to patients, it was identified that it is important to engage with a range of stakeholders when developing trial results summaries.

Conclusions

Results summaries for trial participants should cover four core questions: (1) What question the trial set out to answer?; (2) What did the trial find?; (3) What effect have the trial results had and how will they change National Health Service/treatment?; and (4) How can I find out more? Trial teams should develop appropriately resourced plans and consult patient partners and trial participants on how ‘best’ to share key messages with regard to content, mode, and timing. The study findings provide trial teams with clear guidance on the core considerations of the ‘what, how, when and who’ with regard to sharing results summaries.

Hospital nurse staffing and sepsis protocol compliance and outcomes among patients with sepsis in the USA: a multistate cross-sectional analysis

Por: Dierkes · A. M. · Aiken · L. H. · Sloane · D. M. · Cimiotti · J. P. · Riman · K. A. · McHugh · M. D.
Objectives

Sepsis is a serious inflammatory response to infection with a high death rate. Timely and effective treatment may improve sepsis outcomes resulting in mandatory sepsis care protocol adherence reporting. How the impact of patient-to-nurse staffing compares to sepsis protocol compliance and patient outcomes is not well understood. This study aimed to determine the association between hospital sepsis protocol compliance, patient-to-nurse staffing ratios and patient outcomes.

Design

A cross-sectional study examining hospital nurse staffing, sepsis protocol compliance and sepsis patient outcomes, using linked data from nurse (2015–2016, 2020) and hospital (2017) surveys, and Centers for Medicare and Medicaid Services Hospital Compare (2017) and corresponding MedPAR patient claims.

Setting

537 hospitals across six US states (California, Florida, Pennsylvania, New York, Illinois and New Jersey).

Participants

252 699 Medicare inpatients with sepsis present on admission.

Measures

The explanatory variables are nurse staffing and SEP-1 compliance. Outcomes are mortality (within 30 and 60 days of index admission), readmissions (within 7, 30, and 60 days of discharge), admission to the intensive care unit (ICU) and lengths of stay (LOS).

Results

Sepsis protocol compliance and nurse staffing vary widely across hospitals. Each additional patient per nurse was associated with increased odds of 30-day and 60-day mortality (9% (OR 1.09, 95% CI 1.05 to 1.13) and 10% (1.10, 95% CI 1.07 to 1.14)), 7-day, 30-day and 60-day readmission (8% (OR 1.08, 95% CI 1.05 to 1.11, p

Conclusions

Outcomes are more strongly associated with improved nurse staffing than with increased compliance with sepsis protocols.

Development of the Homeless Health Access to Care Tool to identify health-related vulnerability among people experiencing homelessness: Delphi study, Australia

Por: Currie · J. · Grech · E. · Longbottom · E. · Yee · J. · Hastings · R. · Aitkenhead · A. · Larkin · M. · Jones · L. · Cason · A. · Obrecht · K.
Objectives

In this paper, we report the development of the Homeless Health Access to Care Tool. This tool aims to improve the gap in assessing health need and capacity to access healthcare of people experiencing homelessness. Tools exist that prioritise people experiencing homelessness for housing, but none specifically designed to prioritise for healthcare, or that are succinct enough to be easily implemented to emergency department or primary healthcare settings.

Design and setting

The Homeless Health Access to Care Tool has been adapted from an existing tool, the Vulnerability Index Service Prioritisation Decision Assistance Tool through a five-step process: (1) domain identification, (2) literature review, (3) analysis of hospital admission data, (4) expert judges, and (5) Delphi study.

Participants

The tool was adapted and developed by homeless health clinicians, academics and people with lived experience of homelessness. The Delphi study (n=9) comprised emergency department and homeless health clinicians.

Results

Consensus was gained on all but one item, five new items were added, and wording changes were made to six items based on expert feedback. Participants perceived the tool would take between 5 to 11 min to complete, the number of items were appropriate, and the majority agreed it would facilitate the assessment of health needs and capacity to access healthcare.

Conclusion

Robust development of the Homeless Health Access to Care Tool through the Delphi is the first phase of its development. The Homeless Health Access to Care Tool offers an opportunity to assess both health need and capacity to access healthcare with the aim to improve access to healthcare for people experiencing homelessness. This tool will facilitate standardised data collection to inform service design and data linkage regarding access to healthcare of people experiencing homelessness. The next stages of testing include construct validity, feasibility, usability and inter-rater reliability, and pilot implementation.

Using stakeholders experiences to redesign health services for persons living with heart failure: a case study protocol in a Swedish cardiac care setting

Por: Suutari · A.-M. · Nordin · A. · Kjellström · S. · Thor · J. · Areskoug Josefsson · K.
Introduction

Clinical guidelines promote recognising persons with heart failure (referred to as PWHF) as coproducers of their own care. Coproduction of healthcare—involving PWHF, families and professionals in care processes—aims to promote the best possible health. Still, it is unclear how to coproduce heart failure (HF) care. This study explores whether and how Experience-Based Co-Design (EBCD) involving PWHF, family members and professionals can be undertaken online, in a Swedish cardiac care setting, to codesign improved experiences of HF care.

Methods and analysis

In EBCD, stakeholders’ experiences are solicited to redesign healthcare services. First, we will undertake a thematic analysis of field notes from consultations and filmed/audio-recorded interviews with PWHF (n=10–12). This analysis will identify ‘touchpoints’ (emotionally positive/negative events that shape overall service experiences), edited into a ‘trigger film’. Next, a thematic analysis of family members’ (n=10–12) and professionals’ (n=10–12) interviews will identify key themes mirroring their experiences. Separate feedback events with each stakeholder group will confirm identified touchpoints and key themes and identify areas for HF care improvement. At a joint event, prompted by the ‘trigger film’, stakeholders will agree on one area for HF care improvement. A team including PWHF, family members and professionals, led by an improvement adviser, will then plan, design, implement and evaluate an improvement activity addressing the identified problem area. A deductive thematic analysis of field notes, project documentation and stakeholder focus group interviews, underpinned by MUSIQ, will identify how organisational conditions influence the process. Quantitative measurements, describing the results of the improvement activity, will be integrated with qualitative data to strengthen the case. To reduce resource intensity, we will use online tools during the process.

Ethics and dissemination

The Swedish Ethical Review Authority approved the study in May 2021. The results will be disseminated through seminars, conference presentations and publications.

Quality of refractive error care (Q.REC) in Cambodia, Malaysia and Pakistan: protocol for a cross-sectional unannounced standardised patient study

Por: Burnett · A. M. · Lee · L. · McGuinness · M. · Varga · B. · Perez Hazel · Y. · Ho · S. M.
Introduction

There are 161 million people living with vision impairment, due to uncorrected refractive errors. A further 510 million people are living with near-vision impairment. There is a need for clearly defined indicators that capture the quality of refractive error service outputs and outcomes and provide insights to shape, change and stimulate action. This study aims to evaluate the quality of refractive error care (Q.REC) in Cambodia, Malaysia and Pakistan, by using unannounced standardised patients (USPs) to identify the proportion of prescribed and dispensed spectacles appropriate for people’s refractive error needs and pinpoint/detail opportunities for quality improvement.

Method and analysis

A cross-sectional Q.REC study will be conducted in randomly selected optical services in Cambodia (180 services, 900 USP visits), the Klang Valley in Malaysia (66 services, 198 USP visits) and in Jhang, Sahiwal and Khanewal districts of Punjab region/state in Pakistan (64 services, 256 USP visits). USPs will receive baseline refractions by three skilled study optometrists/refractionists trained in the Q.REC protocol. USPs will then visit individual optical services, undergo a refraction, purchase spectacles or lenses (if recommended) and record observations about which elements of a refraction and dispensing were conducted. The study optometrist/refractionist will assess each pair of dispensed spectacles by examining the USP’s aided visual acuity and visual comfort at distance and/or near and compare the lens prescription to the averaged baseline refraction.

Ethics and dissemination

This study has been approved by the University of New South Wales Human Research Ethics Committee (HC210102), the National Ethics Committee for Health Research in Cambodia (043 NECHR), National Medical Research Registry and the Medical Research and Ethics Committee (NMRR-21-689-59279) in Malaysia and the College of Ophthalmology & Allied Vision Sciences Ethical Review Board (COAVS 545/2021) in Pakistan. Written informed consent will be obtained from USPs. Service owners will have the opportunity to opt-out verbally or in writing. Results will be disseminated locally through workshops including the relevant local ministry of health personnel and stakeholders, published in peer-reviewed publications and presented at national and international conferences.

Impact of the implementation of the WHO Safe Childbirth Checklist on essential birth practices and adverse events in two Brazilian hospitals: a before and after study

Objective

The WHO Safe Childbirth Checklist (SCC) is a promising initiative for safety in childbirth care, but the evidence about its impact on clinical outcomes is limited. This study analysed the impact of SCC on essential birth practices (EBPs), obstetric complications and adverse events (AEs) in hospitals of different profiles.

Design

Quasi-experimental, time-series study and pre/post intervention.

Setting

Two hospitals in North-East Brazil, one at a tertiary level (H1) and another at a secondary level (H2).

Participants

1440 women and their newborns, excluding those with congenital malformations.

Interventions

The implementation of the SCC involved its cross-cultural adaptation, raising awareness with videos and posters, learning sessions about the SCC and auditing and feedback on adherence indicators.

Primary and secondary outcome measures

Simple and composite indicators related to seven EBPs, 3 complications and 10 AEs were monitored for 1 year, every 2 weeks, totalling 1440 observed deliveries.

Results

The checklist was adopted in 83.3% (n=300) of deliveries in H1 and in 33.6% (n=121) in H2. The hospital with the highest adoption rate for SCC (H1) showed greater adherence to EBPs (improvement of 50.9%;p

Conclusions

A multifaceted SCC-based intervention can be effective in improving adherence to EBPs and clinical outcomes in childbirth. The context and adherence to the SCC seem to modulate its impact, working better in a hospital of higher complexity.

Association between control status of blood pressure and frailty among middle-aged and older adults with hypertension in China: a longitudinal study

Por: Shen · F. · Chen · J. · Yang · R. · Yang · J. · Li · H.
Objective

To assess the association between blood pressure (BP) control and frailty among middle-aged and older populations with hypertension in China from 2013 to 2018.

Design

Prospective longitudinal study.

Setting

This study analysed data from the China Health and Retirement Longitudinal Study, a nationally representative survey administered in 28 provinces of China.

Participants

A total of 3254 participants diagnosed with hypertension previous to 2013 were taken into analysis. 1932 participants who were not frail in 2013 were enrolled to calculate relative risk.

Outcome measures

The frailty score was constructed following Rookwood’s Cumulative deficit frailty index, with a score >0.25 defined as frailty (outcome variable). The self-reported status of BP control (exposure variable) represented the general status of the participant’s BP level. A fixed-effects model was used to analyse the association between BP control and frailty. A Cox proportional hazard model was further used to further calculate the relative risk of frailty for different BP control levels.

Results

The fixed-effects model showed that compared with well-controlled BP, poorly controlled BP exhibited a positive association with frailty score (β=0.015; 95% CI 0.011 to 0.019; p

Conclusions

We provide new evidence of a negative association between BP control and frailty risk, but the findings differ among different age groups. Individualised strategies for BP management should be developed, especially for older hypertension patients.

Individual-level and community-level factors associated with eight or more antenatal care contacts in sub-Saharan Africa: evidence from 36 sub-Saharan African countries

Por: Tessema · Z. T. · Tesema · G. A. · Yazachew · L.
Objective

To reduce maternal mortality, the WHO has been introducing several antenatal care (ANC) measures. Pregnancy-related preventable morbidity and mortality, on the other hand, remain alarmingly high. This study was conducted to estimate the magnitude and the factors associated with eight or more ANC visits in sub-Saharan Africa.

Design

A population-based, cross-sectional investigation was conducted.

Setting

Sub-Saharan African countries.

Participants

A total of 300 575 women from recent Demographic and Health Surveys (DHS) conducted in 36 sub-Saharan African countries from 2006 to 2018 were included in this study.

Methods

The data were sourced from sub-Saharan African countries’ recent DHS data set from 2006 to 2018. A multilevel logistic regression model was fitted to identify factors associated with ANC use. Adjusted OR, with 95% CI and a p value of less than 0.05, was employed to determine parameters linked to ANC use.

Results

The pooled magnitude of eight or more ANC visits in sub-Saharan African countries was 6.8% (95% CI 6.7% to 6.9%). Residence, maternal education, husband’s education, maternal occupation, wealth index, media exposure, contraceptive use and desired pregnancy were all positively associated with eight or more ANC visits in the multilevel logistic regression analysis, whereas birth order was negatively associated with eight or more ANC visits.

Conclusions

Compliance with the WHO guidelines on the minimum number of ANC contacts in sub-Saharan Africa is poor. We recommend that mother and child health programmes review existing policies and develop new policies to adopt, execute and address the obstacles to maintaining the WHO-recommended minimum of eight ANC interactions. Women’s education, economic position, media exposure and family planning uptake should be prioritised and improved. Urgent intervention is required to meet the minimum of eight ANC contacts in sub-Saharan Africa.

Quantifying the indirect impact of COVID-19 pandemic on utilisation of outpatient and immunisation services in Kenya: a longitudinal study using interrupted time series analysis

Por: Wambua · S. · Malla · L. · Mbevi · G. · Kandiah · J. · Nwosu · A.-P. · Tuti · T. · Paton · C. · Wambu · B. · English · M. · Okiro · E. A.
Objective

In this study, we assess the indirect impact of COVID-19 on utilisation of immunisation and outpatient services in Kenya.

Design

Longitudinal study.

Setting

Data were analysed from all healthcare facilities reporting to Kenya’s health information system from January 2018 to March 2021. Multiple imputation was used to address missing data, interrupted time series analysis was used to quantify the changes in utilisation of services and sensitivity analysis was carried out to assess robustness of estimates.

Exposure of interest

COVID-19 outbreak and associated interventions.

Outcome measures

Monthly attendance to health facilities. We assessed changes in immunisation and various outpatient services nationally.

Results

Before the first case of COVID-19 and pursuant intervention measures in March 2020, uptake of health services was consistent with historical levels. There was significant drops in attendance (level changes) in April 2020 for overall outpatient visits for under-fives (rate ratio, RR 0.50, 95% CI 0.44 to 0.57), under-fives with pneumonia (RR 0.43, 95% CI 0.38 to 0.47), overall over-five visits (RR 0.65, 95% CI 0.57 to 0.75), over-fives with pneumonia (RR 0.62, 95% CI 0.55 to 0.70), fourth antenatal care visit (RR 0.86, 95% CI 0.80 to 0.93), total hypertension (RR 0.89, 95% CI 0.82 to 0.96), diabetes cases (RR 0.95 95% CI, 0.93 to 0.97) and HIV testing (RR 0.97, 95% CI 0.94 to 0.99). Immunisation services, first antenatal care visits, new cases of hypertension and diabetes were not affected. The post-COVID-19 trend was increasing, with more recent data suggesting reversal of effects and health services reverting to expected levels as of March 2021.

Conclusion

COVID-19 pandemic has had varied indirect effects on utilisation of health services in Kenya. There is need for proactive and targeted interventions to reverse these effects as part of the pandemic’s response to avert non-COVID-19 indirect mortality.

Behavioural approaches to recruitment and retention in clinical trials: a systematic mapping review

Por: Coffey · T. · Duncan · E. M. · Morgan · H. · Lawrie · L. · Gillies · K.
Objectives

To identify studies that applied behavioural approaches to issues of recruitment and/or retention to trials; to describe these approaches; and to identify gaps for future research.

Design

Systematic mapping review of research undertaken in clinical trials within peer-reviewed sources. Review participants were individuals involved in clinical trials, including trial staff, participants, potential participants and former participants.

Data sources

MEDLINE, EMBASE, CINAHL, ERIC, PsycINFO, Web of Science and ASSIA from inception to 15 January 2020 with no date or language restrictions.

Eligibility criteria

Studies within the context of clinical trials reporting the barriers/facilitators to recruitment and retention, or developing/evaluating solutions to said barriers/facilitators, using a behavioural approach.

Results

31 articles were included. Recruitment-focused studies (n=22, 71%) represented the majority. Studies tended to focus on participant behaviours (n=22, 71%). Underserved populations (n=11, 35%) were a notable subset of studies. Most studies (n=23, 74%) were exploratory but those that evaluated interventions (n=8, 26%) often did so within underserved populations (n=6). A majority of studies (n=30, 97%) did not specify their behaviours consistent with guidelines from behavioural scientists. The most used approaches were social cognitive theory (n=8, 26%), the theory of planned behaviour (n=6, 19%) and the theoretical domains framework (n=5, 16%).

Conclusions

A range of behavioural approaches have been applied to recruitment and retention to trials. The multitude of recruitment research here is consistent with trials research generally and emphasises the need for research into retention. Authors report target behaviours minimally, which is not conducive to replication. Further research should build on lessons here, such as clearly specifying behaviours. Increased methodological rigour and transparency will lead to robust evidence bases and less research waste in poor recruitment and retention. Overall, trials informed by behavioural approaches promises to be efficient and more participant focused.

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