ResearchPad - 1704 https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Low-value injury care in the adult orthopaedic trauma population: a protocol for a rapid review]]> https://www.researchpad.co/article/elastic_article_9143 Orthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the frequency of such practices could reduce adverse events, improve clinical outcomes and free up resources. The aim of this study is to synthesise the evidence on intra-hospital practices for orthopaedic injuries, previously identified as potentially of low value.Methods and analysisWe will search Medline, Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials and Epistemonikos to identify systematic reviews, randomised controlled trials (RCTs), quasi-RCTs, cohort studies and case–control studies that evaluate selected practices according to a priori PICOS statements (Population–Intervention–Comparator–Outcome–Study design). We will evaluate the methodological quality for systematic reviews using the Measurement Tool to Assess Systematic Reviews version 2 (AMSTAR-2). Risk of bias in original studies will be evaluated with the Cochrane revised tool for RCTs (RoB2) and with the risk of bias in non-randomised studies of interventions (ROBINS-I) tool. If for a given practice, more than two original studies on our primary outcome are identified, we will conduct meta-analysis using a random effects model and assess heterogeneity using the I2 index. We will assess credibility of evidence (I–IV) based on statistical significance, sample size, heterogeneity and bias as per published criteria.Ethics and disseminationEthics approval is not required as original data will not be collected. Knowledge users from three level I trauma centres are involved in the design and conduct of the study in accordance with an integrated knowledge translation approach. Findings related to the rapid review will be available in May 2020. They will be presented to key stakeholders to inform discussions and raise awareness on low-value injury care. In addition, results will be disseminated in a peer-reviewed journal, at national and international scientific meetings and to healthcare associations. ]]> <![CDATA[Use of healthcare services and assistive devices among centenarians: results of the cross-sectional, international 5-COOP study]]> https://www.researchpad.co/article/elastic_article_9108 To measure the use of healthcare services and assistive devices by centenarians in five countries.DesignCross-sectional study using a survey questionnaire.SettingCommunity-dwelling and institutionalised centenarians living in Japan, France, Switzerland, Sweden and Denmark.Participants1253 participants aged 100 or in their 100th year of life, of whom 1004 (80.1%) were female and 596 (47.6%) lived in institutions.Main outcome measuresRecent use of medical visits, nursing care at home, home-delivered meals, acute care hospital stays overnight, professional assessments such as sight tests, mobility aids and other assistive devices. A set of national healthcare system indicators was collected to help interpret differences between countries.ResultsThere was considerable variability in the healthcare services and assistive devices used by centenarians depending on their country and whether they were community-dwelling or institutionalised. In contrast to the relatively homogeneous rates of hospitalisation in the past year (around 20%), community-dwelling centenarians reported widely ranging rates of medical visits in the past 3 months (at least one visit, from 32.2% in Japan to 86.6% in France). The proportion of community-dwellers using a mobility device to get around indoors (either a walking aid or a wheelchair) ranged from 48.3% in Japan to 79.2% in Sweden. Participants living in institutions and reporting the use of a mobility device ranged from 78.6% in Japan to 98.2% in Denmark.ConclusionsOur findings suggest major differences in care received by centenarians across countries. Some may result from the characteristics of national healthcare systems, especially types of healthcare insurance coverage and the amounts of specific resources available. However, unexplored factors also seem to be at stake and may be partly related to personal health and cultural differences. ]]> <![CDATA[Evidence-based quality indicators for primary healthcare in association with the risk of hospitalisation: a population-based cohort study in Switzerland]]> https://www.researchpad.co/article/N4917e3c8-9c39-466d-bf8f-75f07991f7ff The quality of ambulatory care in Switzerland is widely unknown. Therefore, this study aimed to evaluate the recently proposed quality indicators (QIs) based on a nationwide healthcare claims database and determine their association with the risk of subsequent hospitalisation at patient-level.DesignRetrospective cohort study.SettingInpatient and outpatient claims data of a large health insurance in Switzerland covering all regions and population strata.Participants520 693 patients continuously insured during 2015 and 2016.MeasuresA total of 24 QIs were obtained by adapting the existing instruments to the Swiss national context and measuring at patient-level. The association between each QI and hospitalisation in the subsequent year was assessed using multiple logistic regression models.ResultsThe proportion of patients with good adherence to QIs was high for the secondary prevention of diabetes and myocardial infarction (glycated haemoglobin (HbA1c) control, 89%; aspirin use, 94%) but relatively low for polypharmacy (53%) or using potentially inappropriate medications (PIMs) in the elderly (PIM, 33%). Diabetes-related indicators such as the HbA1c control were significantly associated with a lower risk of hospitalisation (OR, 0.87; 95% CI, 0.80 to 0.95), whereas the occurrence of polypharmacy and PIM increased the risk of hospitalisation in the following year (OR, 1.57/1.08; 95% CI, 1.51 to 1.64/1.05 to 1.12).ConclusionsThis is the first study to evaluate the recently presented QIs in Switzerland using nationwide real-life data. Our study suggests that the quality of healthcare, as measured by these QIs, varied. The majority of QIs, in particular QIs reflecting chronic care and medication use, are considered beneficial markers of healthcare quality as they were associated with reduced risk of hospitalisation in the subsequent year. Results from this large practical test on real-life data show the feasibility of these QIs and are beneficial in selecting the appropriate QIs for healthcare implementation in general practice. ]]> <![CDATA[Factors influencing the early initiation of breast feeding in public primary healthcare facilities in Northeast Nigeria: a mixed-method study]]> https://www.researchpad.co/article/N13703f35-a47e-4c25-bf44-e216d0ce3c68 The early initiation of breast feeding is a high-impact intervention that gives newborns a better chance of survival. We assess the barriers and facilitators influencing the practice of early breast feeding of newborns in public primary healthcare facilities (PHCs) in Northeast Nigeria, to influence the planning of programmes targeted at improving newborn care in the region.MethodWe used an explanatory mixed-method approach. We conducted case observation of childbirths and newborn care for the quantitative arm, and interviewed mothers and birth attendants 1 hour after childbirth for the qualitative arm. The analysis for the quantitative arm was done with SPSS V.23. For the qualitative arm, we transcribed the audio files, coded the texts and categorised them using thematic analysis.ResultWe observed 393 and 27 mothers for the quantitative and qualitative arms of the study, respectively. The quantitative arm shows that 39% of mothers did not breastfeed their newborns within 1 hour of birth. The qualitative arm shows that 37% of mothers did not breastfeed within 1 hour of birth. Themes that describe the barriers to early breast feeding in public PHCs are: birth attendants’ unwillingness or inability to accommodate mothers’ safe traditional practices, ineffective rooming-in practices, staff shortages, lack of privacy in the lying-in ward and poor implementation of visiting-hour policy in public PHCs. The pregnant women denied safe traditional birth practices like chanting, praying or reading religious books during delivery are five times more likely not to breastfeed newborns within the first hour of birth (relative risk=4.5, 95% CI 1.2–17.1) compared with pregnant women allowed these practices.ConclusionStakeholders must increase their focus on improving breastfeeding practices in public PHCs. Instituting policies that protect mothers’ privacy and finding innovative ways to accommodate and promote safe traditional practices in the intrapartum and postpartum period in PHCs will improve the early breast feeding of newborns in these PHCs. ]]> <![CDATA[Collaborating with healthcare providers to understand their perspectives on a hospital-to-home warning signs intervention for rural transitional care: protocol of a multimethod descriptive study]]> https://www.researchpad.co/article/Nff0e00d0-ffa9-4ecd-947e-e0f3473c73ec This study builds on our prior research, which identified that older rural patients and families (1) view preparation for detecting and responding to worsening health conditions as their most pressing unmet transitional care (TC) need and (2) perceive an evidence-based intervention, preparing them to detect and respond to warning signs of worsening health conditions, as highly likely to meet this need. Yet, what healthcare providers need to implement a warning signs intervention in rural TC is unclear. The objectives of this study are (1) to examine healthcare providers’ perspectives on the acceptability of a warning signs intervention and (2) to identify barriers and facilitators to healthcare providers’ provision of the intervention in rural communities.Methods and analysisThis multimethod descriptive study uses a community-based, participatory research approach. We will examine healthcare providers’ perspectives on a warning signs intervention. A purposive, criterion-based sample of healthcare providers stratified by professional designation (three strata: nurses, physicians and allied healthcare professionals) in two regions (Southwestern and Northeastern Ontario, Canada) will (1) rate the acceptability of the intervention and (2) participate in small (n=4–6 healthcare providers), semistructured telephone focus group discussions on barriers and facilitators to delivering the intervention in rural communities. Two to three focus groups per stratum will be held in each region for a total of 12–18 focus groups. Data will be analysed using conventional qualitative content analysis and descriptive statistics.Ethics and disseminationEthics approval was obtained from the Office of Research Ethics at York University and the Health Sciences North Research Ethics Board. Findings will be communicated through plain language summary and policy briefs, press releases, manuscripts and conferences. ]]> <![CDATA[Dyadic approach to supervised community rehabilitation participation in an Asian setting post-stroke: exploring the role of caregiver and patient characteristics in a prospective cohort study]]> https://www.researchpad.co/article/Nba258c82-2fe5-4a5c-8d62-6112f907c1fd Objective
To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting.
Design
Prospective cohort study.
Setting
Community setting.
Participants
We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke.
Outcome measures
SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke
Results
251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor’s disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver’s positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068).
Conclusion
We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community.
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<![CDATA[Psychometric validation of a Patient-Centred Quality of Cancer Care Questionnaire in Mexico]]> https://www.researchpad.co/article/Nd7bbebc1-9486-458c-9ff0-ff5e55d5e6d1

Objectives

To develop and validate a Patient-Centred Quality of Cancer Care Questionnaire in Spanish (PCQCCQ-S) appropriate to the Mexican context.

Design

Psychometric validation of a questionnaire.

Setting

Two public oncology hospitals in Mexico City.

Participants

1809 patients with cancer aged ≥18 years.

Source of information

Cross-sectional survey.

Methods

The validation procedures comprised (1) content validity through a group of experts and patients; (2) item reduction and evaluation of the factor structure, through an exploratory factor analysis based on the polychoric correlation matrix; (3) internal consistency using Cronbach’s alpha; (4) convergent validity between the PCQCCQ-S and supportive care needs scale; (5) correlation analysis between the PCQCCQ-S and quality of life scale by calculating Spearman’s rank-correlation coefficient; and (6) differentiation by ‘known groups’ through the Wilcoxon rank-sum test.

Results

The PCQCCQ-S has 30 items with the following five factors accounting for 96.5% of the total variance: (1) timely care; (2) clarity of the information; (3) information for treatment decision-making; (4) activities to address biopsychosocial needs; and (5) respectful and coordinated care. Cronbach’s alpha values ranged from 0.73 to 0.90 among the factors. PCQCCQ-S has moderate convergent validity with supportive care needs scale, revealing that higher quality is correlated with lower patient needs. PCQCCQ-S has acceptable ability to differentiate by ‘known groups’, showing that older patients and those with low levels of education perceived lower total quality of care as compared with their counterparts.

Conclusion

PCQCCQ-S has acceptable psychometric properties and can be used to measure quality of patient-centred cancer care in Mexico and serve as a reference to develop PCQCCQ-S in other Spanish-speaking countries.

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<![CDATA[Association of intrinsic and extrinsic motivating factors with physician burnout and job satisfaction: a nationwide cross-sectional survey in Taiwan]]> https://www.researchpad.co/article/N240d6718-b8ab-4be5-b875-85e2b3927641

Objective

The aim of this study was to systematically and simultaneously examine the association of intrinsic and extrinsic motivating factors with physician burnout and job dissatisfaction.

Design

A nationally representative survey was fielded from September to November 2017.

Setting

Hospitals and clinics throughout Taiwan.

Participants

A total of 6674 physicians.

Main exposure measure

The main exposure measures were intrinsic motivators (sense of calling, personally rewarding hours per day and meaningful, long-term relationships with patients) and extrinsic motivators (income, work hours, autonomy, and pay-for-performance (P4P) and bundled payment initiatives).

Main outcome measures

The main outcome measures were physician burnout and job dissatisfaction.

Results

A total of 1152 physicians returned the surveys. More sense of calling and personally rewarding hours per day were associated with less physician burnout (OR 0.16, 95% CI 0.10 to 0.26 and OR 0.25, 95% CI 0.13 to 0.47, respectively) and job dissatisfaction (OR 0.35, 95% CI 0.21 to 0.57 and OR 0.46, 95% CI 0.26 to 0.83, respectively). Longer work hours were associated with more physician burnout (OR 2.67, 95% CI 1.54 to 4.63) and job dissatisfaction (OR 1.71, 95% CI 1.05 to 2.79). Not receiving P4P bonuses from their organisations was associated with more physician burnout (OR 1.56, 95% CI 1.02 to 2.38). Not sharing the losses from caring for patients included in the bundled payment system was associated with less physician burnout (OR 0.59, 95% CI 0.36 to 0.97).

Conclusions

Fostering a healthcare work environment that supports intrinsic motivation and improves work hours may reduce physician burnout and job dissatisfaction. Rewarding physicians fairly and equitably may prevent them from feeling burned out. Value-based care delivery and payment model innovations, such as bundled payments, may encourage healthcare professionals to coordinate care through the standardisation of care to decrease burnout.

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<![CDATA[Evaluation of a complex integrated, cross-sectoral psycho-oncological care program (isPO): a mixed-methods study protocol]]> https://www.researchpad.co/article/Na1aa9aa3-7148-47f7-9d43-12813c50f821

Introduction

International standards of care require the complete integration of psycho-oncological care into biomedical cancer treatment. The structured integrated, cross-sectoral psycho-oncological programme ‘isPO’ is aiming to ensure a provision of care in inpatient and outpatient settings according to a stepped-care approach. Up to now, psycho-oncological care is missing regulated and standardised processes to demonstrate the effectiveness. This study protocol describes the process and outcome evaluation that is conducted, along with the isPO study. The programme evaluation is aiming to proof effectiveness, explain potential discrepancies between expected and observed outcomes. Additionally, provide insight into the implementation process, as well as contextual factors that might promote or inhibit the dissemination and implementation of the stepped care programme will be gained. In addition to these measures, a cost–consequence analysis will provide further evidence aimed at integrating psycho-oncological care into primary healthcare.

Methods and analysis

The evaluation concept is based on a tripartite strategy consisting of a prospective, formative and summative evaluation. To capture all determinants, a concurrent mixed-method design is applied comprising qualitative (interviews and focus groups) and quantitative (standardised questionnaires) surveys of patients and healthcare providers. In addition, analysis of the psycho-oncological care data (isPO care data) and statutory health insurance claims data will be conducted. Primary and secondary data will complement one another (data linkage) to obtain a more comprehensive picture of the effectiveness and implementation of the complex intervention within the isPO study.

Ethics and dissemination

The study has been approved by the ethics committee of the Medical Faculty of the University of Cologne. For all collected data, the relevant national and European data protection regulations will be considered. All personal identifiers (eg, name, date of birth) will be pseudonymised. Dissemination strategies include annual reports as well as quality workshops for the organisations, the presentation of results in publications and on conferences, and public relations.

Trial registration number

DRKS00015326; Pre-results.

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<![CDATA[Assessment of staffing needs for physicians and nurses at Upazila health complexes in Bangladesh using WHO workload indicators of staffing need (WISN) method]]> https://www.researchpad.co/article/N2a0c9e6c-1d4c-4db7-b2f9-78824bf40bcf

Objective

This study aimed to assess the current workload and staffing need of physicians and nurses for delivering optimum healthcare services at the Upazila Health Complexes (UpHCs) in Bangladesh.

Design

Mixed-methods, combining qualitative (eg, document reviews, key informant interviews, in-depth interviews, observations) and quantitative methods (time-motion survey).

Setting

Study was conducted in 24 health facilities of Bangladesh. However, UpHCs being the nucleus of primary healthcare in Bangladesh, this manuscript limits itself to reporting the findings from the providers at four UpHCs under this project.

Participants

18 physicians and 51 nurses, males and females.

Primary outcome measures

Workload components were defined based on inputs from five experts, refined by nine service providers. Using WHO Workload Indicator of Staffing Need (WISN) software, standard workload, category allowance factor, individual allowance factor, total required number of staff, WISN difference and WISN ratio were calculated.

Results

Physicians have very high (WISN ratio 0.43) and nurse high (WISN ratio 0.69) workload pressure. 50% of nurses’ time are occupied with support activities, instead of nursing care. There are different workloads among the same staff category in different health facilities. If only the vacant posts are filled, the workload is reduced. In fact, sanctioned number of physicians and nurses is more than actual need.

Conclusions

It is evident that high workload pressures prevail for physicians and nurses at the UpHCs. This reveals high demand for these health workforces in the respective subdistricts. WISN method can aid the policy-makers in optimising utilisation of existing human resources. Therefore, the government should adopt flexible health workforce planning and recruitment policy to manage the patient load and disease burden. WISN should, thus, be incorporated as a planning tool for health managers. There should be a regular review of health workforce management decisions, and these should be amended based on periodic reviews.

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<![CDATA[Secondary care consultant clinicians’ experiences of conducting emergency care and treatment planning conversations in England: an interview-based analysis]]> https://www.researchpad.co/article/N1d23d9b3-67f0-4932-b90a-bf2a63a674b7

Objective

To examine secondary care consultant clinicians’ experiences of conducting conversations about treatment escalation with patients and their relatives, using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process.

Design

Semi-structured interviews following ward round observations.

Setting

Two National Health Service hospitals in England.

Participants

Fifteen medical and surgical consultants from 10 specialties, observed in 14 wards.

Analysis

Interview transcripts were analysed using thematic analysis.

Results

Three themes were developed: (1) determining when and with whom to conduct a ReSPECT conversation; (2) framing the ReSPECT conversation to manage emotions and relationships and (3) reaching ReSPECT decisions. The results showed that when timing ReSPECT conversations, consultant clinicians rely on their predictions of a patient’s short-term prognosis; when framing ReSPECT conversations, consultant clinicians seek to minimise distress and maximise rapport and when involving a patient or a patient’s relatives in decision-making discussions, consultant clinicians are guided by their level of certainty about the patient’s illness trajectory.

Conclusions

The management of uncertainty about prognoses and about patients’ emotional reactions is central to secondary care consultant clinicians’ experiences of timing and conducting ReSPECT conversations.

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<![CDATA[Verbal Autopsy with Participatory Action Research (VAPAR) programme in Mpumalanga, South Africa: protocol for evaluation]]> https://www.researchpad.co/article/N3e9d5a34-9d3f-4599-a3b9-c59cf97b2879

Introduction

There is a growing recognition of the importance of developing learning health systems which can engage all stakeholders in cycles of evidence generation, reflection, action and learning from action to deal with adaptive problems. There is however limited evaluative evidence of approaches to developing or strengthening such systems, particularly in low-income and middle-income settings. In this protocol, we aim to contribute to developing and sharing knowledge on models of building collaborative learning platforms through our evaluation of the Verbal Autopsy with Participatory Action Research (VAPAR) programme.

Methods and analysis

The evaluation takes a participatory approach, focussed on joint learning on whether and how VAPAR contributes to its aims, and what can be learnt for this and similar settings. A realist-informed theory of change was developed by the research team as part of a broader collaboration with other stakeholders. The evaluation will draw on a wide variety of perspectives and data, including programme data and secondary data. This will be supplemented by in-depth interviews and workshops at the end of each cycle to probe the different domains, understand changes to the positions of different actors within the local health system and feedback into improved learning and action in the next cycle. Quantitative data such as verbal autopsy will be analysed for significant trends in health indicators for different population groups. However, the bulk of the data will be qualitative and will be analysed thematically.

Ethics and dissemination

Ethics in participatory approaches include a careful focus on the power relationships within the group, such that all groups are given voice and influence, in addition to the usual considerations of informed participation. Within the programme, we will focus on reflexivity, relationship building, two-way learning and learning from failure to reduce power imbalances and mitigate against a blame culture. Local engagement and change will be prioritised in dissemination.

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<![CDATA[A study of the nature and level of trust between patients and healthcare providers, its dimensions and determinants: a scoping review protocol]]> https://www.researchpad.co/article/N8669f802-7e97-4d4b-96b5-7a1587cdca49

Introduction

The aim of this scoping review is to systematically search the literature to identify the nature and or level of trust between the patient, the users of health services (eg, clients seeking health promotion and preventive healthcare services) and the individual healthcare providers (doctors, nurses and physiotherapists/ occupational therapists), across public and private healthcare sectors, at all levels of care from primary through secondary to tertiary care. It also aims to identify the factors that influence trust between patients, users of health services (clients) and providers of healthcare at all levels of care from primary care to tertiary care, and across all health sectors (public and private). The study will also identify the tools used to measure trust in the healthcare provider.

Methods and analysis

The scoping review will be conducted based on the methodology developed by Arksey and O’Malley’s scoping review methodology, and Levac et al’s methodological enhancement. An experienced information specialist (HM) searched the following databases MEDLINE, EMBASE, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature. The search terms were both keywords in the title and/or abstract and subject headings (eg, MeSH, EMTREE) as appropriate. Search results were downloaded, imported and stored into a ‘Refworks’ folder specifically created for reference management. The preliminary search was conducted between 7 December 2017 and 14 December 2017. Quantitative methods using content analysis will be used to categorise study findings on factors associated with trust between patients, clients and healthcare providers. The collection of studies will be also examined for heterogeneity. Qualitative analysis on peer reviewed articles of qualitative interviews and focus group discussion will be conducted; it allows clear identification of themes arising from the data, facilitating prioritisation, higher order abstraction and theory development. A consultation exercise with stakeholders may be incorporated as a knowledge translation component of the scoping study methodology.

Ethics and dissemination

Ethical approval will be obtained for the research project from the Institutional Review Board. The International Medical University will use the findings of this scoping review research to improve the understanding of trust in healthcare, in its endeavour to improve health services delivery in its healthcare clinics and hospitals, and in its teaching and learning curriculum. The findings will also help faculty make evidence based decisions to focus resources and research as well as help to advance the science in this area. Dissemination of the results of the scoping review will be made through peer-reviewed publications, research reports and presentations at conferences and seminars.

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<![CDATA[Factors associated with positive user experience with primary healthcare providers in Mexico: a multilevel modelling approach using national cross-sectional data]]> https://www.researchpad.co/article/Ne8bbf4f4-81f7-4b3b-8bd3-08d3126473a3

Objective

This study aimed to investigate factors associated with patient experience with primary care in a large public health system in Mexico and determine the amount of variability in experience attributable to facility-level and state-level factors.

Methods

We analysed cross-sectional 2016 national satisfaction survey data from the Mexican Social Security Institute (IMSS). Patient-level data were merged with facility-level data and information on poverty by state. We assessed general contextual effects and examined the relationship of patient, facility and state factors with four patient experience measures using random effects logistic regression.

Results

25 745 patients’ responses from 319 facilities were analysed. The majority experienced good communication (78%), the opportunity to share health concerns (91%) and resolution of doubts (85%). 29% of visits were rated as excellent. Differences between facilities and states accounted for up to 12% and 6% of the variation in patient experience, respectively. Inclusion of facility-level contextual effects improved model predictions by 8%–12%; models with facility random effects and individual covariates correctly predicted 64%–71% of individual outcomes. In adjusted models, larger patient population was correlated with worse reported communication, less opportunity to share concerns and less resolution of doubts. Men reported more positive communication; older individuals reported more positive communication and experiences overall, but less opportunity to share concerns; and more educated individuals were less likely to report positive communication but more likely to report resolution of doubts and overall positive experiences. Preventive care visits were rated higher than curative visits for resolution of doubts, but lower for opportunity to share concerns, and specific conditions were associated with better or worse reported experiences in some cases.

Conclusion

Quality improvement efforts at IMSS facilities might bolster individual experiences with primary care, given that up to 12% of the variation in experience was attributable to facility-level differences. The relationship between individual characteristics and experience ratings reinforces the importance of patients’ expectations of care and the potential for differential treatment by providers to impact experience.

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<![CDATA[International phase 1 study protocol to develop a health state classification system for a preference-based measure for women with breast cancer: the BREAST-Q Utility module]]> https://www.researchpad.co/article/N9abdf34f-adc7-4159-861d-24d62b164d78

Introduction

Concerns unique to women with breast cancer can include impact of cancer on body image, sexual well-being and changes in breast appearance and sensation. These important issues are not captured by the existing generic preference-based measures (PBMs) and no breast cancer-specific PBM currently exists. This Phase 1 protocol describes a mixed-methods study to develop and validate the descriptive health state classification system for a breast cancer-specific PBM, called the BREAST-Q Utility module.

Methods and analysis

A heterogeneous sample of women aged 18 years and older diagnosed with breast cancer who are undergoing or have had treatment for breast cancer will be invited to participate in qualitative interviews. Participants will be asked to describe impact of their diagnosis and treatment(s) on their health-related quality of life (HRQOL). Interviews will be audio recorded, transcribed verbatim and coded using a line-by-line approach. At the end of each interview, based on each participant’s cancer treatment history, patients will complete the mastectomy, breast-conserving therapy or reconstruction module of BREAST-Q, with modified 5-point Likert scale to measure importance of the BREAST-Q concepts. Both sources of data will be analysed to identify the most important HRQOL concerns.

A conceptual framework and item pool will be developed from the qualitative dataset. Preliminary version of the BREAST-Q Utility module will be created and refined at an in-person meeting of multidisciplinary experts. Content validity of the Utility module will be examined (cognitive debriefing, expert feedback). Psychometric properties of Utility module will be evaluated in a large sample of women with breast cancer.

Ethics and dissemination

The study has been approved by Hamilton Integrated Research Ethics Board, Canada. Results of this study will be presented at international conferences and published in peer-reviewed journals.

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<![CDATA[Preferences for everyday living inventory (PELI): study protocol for piloting a culture-sensitive and setting-specific translated instrument in German care settings (PELI-D)]]> https://www.researchpad.co/article/Nb1d3040a-d03c-4c3d-8e12-c68a1f2d8a06

Introduction

Regardless of the healthcare setting, person-centred care and its implementation in caring for older people are a central issue for those who are responsible as professional caregivers and for those in need of care within the care process. Both aspects encompass the possibility of recognising personal preferences. To provide person-centred care, professional caregivers need to know about the individual preferences of the persons being cared for. Therefore, the PELI (an acronym for ‘Preferences for Everyday Living Inventory’) instrument was developed at the Polisher Research Institute (USA) for the systematic recording of individual preferences of older people in need of care. There is currently no comparable instrument available in the German language.

Methods

As part of the proposed project PELI-D, all versions of the original PELI instrument (nursing home version) were (1) culture-sensitively translated into German and will be (2) examined in a pilot study for their reliability, feasibility and practicability. For the project PELI-D, we worked together with our practice partners in Germany (Diaconia and Caritas in North Rhine-Westphalia) and collaborated with our partners in the USA who developed the PELI instrument. This study protocol focuses on the pilot study, which will be conducted by the German Center for Neurodegenerative Diseases (DZNE) (site Witten).

Ethics and dissemination

This study was approved by the internal quality control committee of the DZNE (ID number: WI029 PELI-D) and by the ethics committee of the German Society of Nursing Science Duisburg branch office (ID number: 18-010). All personal information will be deidentified with a specific identification code and stored in a secured location apart from the rest of the study data. Only qualified and study-related staff will be allowed access to the data. The results of the study will be distributed nationally and internationally through peer-reviewed journals, conferences and journals for nursing care practice.

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<![CDATA[Unravelling the role of leadership in motivation of health workers in a Moroccan public hospital: a realist evaluation]]> https://www.researchpad.co/article/Nc7ea63f3-1b43-4b6a-9a94-35d5ca804c5f

Objectives

This study aimed at opening the black box of the relationship between leadership and motivation of health workers by focusing on a high-performance hospital in Morocco.

Design

We adopted the realist evaluation approach and used the case study design to test the initial programme theory we formulated on the basis of a scoping review on complex leadership. We used the Intervention-Context-Actors-Mechanism-Outcome Configuration as a heuristic tool to identify plausible causal configurations.

Settings

Since 2000, the Ministry of Health in Morocco initiated many reforms in the frame of the governmental deconcentration process called ‘advanced regionalisation’. The implementation of these reforms is hampered by inadequate human resource management capacities of local health system managers. Yet, the National ‘Concours Qualité’, a national quality assurance programme implemented since 2007, demonstrated that there are many islands of excellence. We explore how leadership may play a role in explaining these islands of excellence.

Participants

We carried out a document review, 18 individual interviews and 3 group discussions (with doctors, administrators and nurses), and non-participant observations during a 2-week field visit in January–February 2018.

Results

We confirmed that effective leaders adopt an appropriate mix of transactional, transformational and distributed leadership styles that fits the mission, goals, organisational culture and nature of tasks of the organisation and the individual characteristics of the personnel when organisational culture is conducive. Leadership effectiveness is conditioned by the degree of responsiveness to the basic psychological needs of autonomy, competence and relatedness, perceived organisational support and perceived supervisor support. Transactional and overcontrolling leadership behaviour decreased the satisfaction of the need for autonomy and mutual respect. By distributing leadership responsibilities, complex leaders create an enabling environment for collective efficacy and creative problem solving.

Conclusions

We found indications that in the Moroccan context, well-performing hospitals could be characterised by a good fit between leadership styles, organisational characteristics and individual staff attributes.

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<![CDATA[Effectiveness of interventions targeting antibiotic use in long-term aged care facilities: a systematic review and meta-analysis]]> https://www.researchpad.co/article/N7ca1fe1b-62b2-4db2-9809-1b903517e120

Objectives

There are high levels of inappropriate antibiotic use in long-term care facilities (LTCFs). Our objective was to examine evidence of the effectiveness of interventions designed to reduce antibiotic use and/or inappropriate use in LTCFs.

Design

Systematic review and meta-analysis.

Data sources

MEDLINE, Embase and CINAHL from 1997 until November 2018.

Eligibility criteria

Controlled and uncontrolled studies in LTCFs measuring intervention effects on rates of overall antibiotic use and/or appropriateness of use were included. Secondary outcomes were intervention implementation barriers from process evaluations.

Data extraction and synthesis

Two reviewers independently applied the Cochrane Effective Practice and Organisation of Care group’s resources to classify interventions and assess risk of bias. Meta-analyses used random effects models to pool results.

Results

Of include studies (n=19), 10 had a control group and 17 had a high risk of bias. All interventions had multiple components. Eight studies (with high risk of bias) showed positive impacts on outcomes and included one of the following interventions: audit and feedback, introduction of care pathways or an infectious disease team. Meta-analyses on change in the percentage of residents on antibiotics (pooled relative risk (RR) (three studies, 6862 residents): 0.85, 95% CI: 0.61 to 1.18), appropriateness of decision to treat with antibiotics (pooled RR (three studies, 993 antibiotic orders): 1.10, 95% CI: 0.64 to 1.91) and appropriateness of antibiotic selection for respiratory tract infections (pooled RR (three studies, 292 orders): 1.15, 95% CI: 0.95 to 1.40), showed no significant intervention effects. However, meta-analyses only included results from intervention groups since most studies lacked a control group. Insufficient data prevented meta-analysis on other outcomes. Process evaluations (n=7) noted poor intervention adoption, low physician engagement and high staff turnover as barriers.

Conclusions

There is insufficient evidence that interventions employed to date are effective at improving antibiotic use in LTCFs. Future studies should use rigorous study designs and tailor intervention implementation to the setting.

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<![CDATA[Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia]]> https://www.researchpad.co/article/N875d0db3-2fd5-491a-8821-d83c8ad5c294

Objective

To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life.

Design

Retrospective multicentre cohort study.

Setting

Three large, metropolitan tertiary hospitals in Australia.

Participants

831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012.

Main outcome measures

Odds ratios (ORs) of NBT derived from logistic regression models.

Results

Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient’s family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect.

Conclusions

This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.

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<![CDATA[Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts]]> https://www.researchpad.co/article/N086b695a-badf-402e-96c2-94b9d65c7419

Objective

We aimed to compare patient’s and physician’s ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

Design

Baseline data from two prospective multicentre observational studies.

Setting

29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

Participants

395 patients (≥13 years old) with persistent asthma.

Measures

Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0–50; medium 51–80; high 81–100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients’ and physicians’ VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

Results

High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65–95) mm; 53% VAS>80) and by physicians (84 (68–95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV1 ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R2=44%).

Conclusion

Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

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