BACKGROUND: Fragmentation of care (that is, the use of multiple ambulatory providers without a dominant provider) may increase the risk of gaps in communication among providers. However, it is unclear whether people with fragmented care (as measured in claims) perceive more gaps in communication among their providers. It is also unclear whether people who perceive gaps in communication experience them as clinically significant (that is, whether they experience adverse events that they attribute to poor coordination).
METHODS: We conducted a longitudinal study using data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, including a survey on perceptions of healthcare (2017-2018) and linked fee-for-service Medicare claims (for the 12 months prior to the survey) (N = 4,296). We estimated correlation coefficients to determine associations between claims-based and self-reported numbers of ambulatory visits and ambulatory providers. We then used logistic regression to determine associations between claims-based fragmentation (measured with the reversed Bice-Boxerman Index [rBBI]) and self-reported gaps in care coordination and, separately, between claims-based fragmentation and self-reported adverse events that the respondent attributed to poor coordination.
RESULTS: The correlation coefficient between claims-based and self-report was 0.37 for the number of visits and 0.38 for the number of providers (p < 0.0001 for each). Individuals with high fragmentation by claims (rBBI ≥ 0.85) had a 23% increased adjusted odds of reporting any gap in care coordination (95% CI 3%, 48%) and, separately, a 61% increased adjusted odds of reporting an adverse event that they attributed to poor coordination (95% CI 11%, 134%).
CONCLUSIONS: Medicare beneficiaries with claims-based fragmentation also report gaps in communication among their providers. Moreover, these gaps appear to be clinically significant, with beneficiaries reporting adverse events that they attribute to poor coordination.

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BACKGROUND: Despite calls for regionalizing pancreatic cancer (PC) care to high-volume centers (HVCs), many patients with PC elect to receive therapy closer to their home or at multiple institutions. In the context of cross-institutional PC care, the challenges associated with coordinating care are poorly understood.
METHODS: In this qualitative study we conducted semi-structured interviews with oncology clinicians from a HVC (n = 9) and community-based hospitals (n = 11) to assess their perspectives related to coordinating the care of and treating PC patients across their respective institutions. Interviews were transcribed, coded, and analyzed using deductive and inductive approaches to identify themes related to cross-institutional coordination challenges and to note improvement opportunities.
RESULTS: Clinicians identified challenges associated with closed-loop communication due, in part, to not having access to a shared electronic health record. Challenges with patient co-management were attributed to patients receiving inconsistent recommendations from different clinicians. To address these challenges, participants suggested several improvement opportunities such as building rapport with clinicians across institutions and updating tumor board processes. The opportunity to update tumor board processes was reportedly multi-dimensional and could involve: (1) designating a tumor board coordinator; (2) documenting and disseminating tumor board recommendations; and (3) using teleconferencing to facilitate community-based clinician engagement during tumor board meetings.
CONCLUSIONS: In light of communication barriers and challenges associated with patient co-management, enabling the development of relationships among PC clinicians and improving the practices of multidisciplinary tumor boards could potentially foster cross-institutional coordination. Research examining how multidisciplinary tumor board coordinators and teleconferencing platforms could enhance cross-institutional communication and thereby improve patient outcomes is warranted.

BACKGROUND: Geriatric assessment (GA) is a multidimensional process that disrupts the primary health care (PHC) referral system. Accessing consistent data is central to the provision of integrated geriatric care across multiple healthcare settings. However, due to poor-quality data and documentation of GA, developing an agreed minimum data set (MDS) is required. Therefore, this study aimed to develop a GA-MDS in the PHC referral system to improve data quality, data exchange, and continuum of care to address the multifaceted necessities of older people.
METHODS: In our study, the items to be included within GA-MDS were determined in a three-stepwise process. First, an exploratory literature search was done to determine the related items. Then, we used a two-round Delphi survey to obtain an agreement view on items to be contained within GA-MDS. Finally, the validity of the GA-MDS content was evaluated.
RESULTS: Sixty specialists from different health geriatric care disciplines scored data items. After, the Delphi phase from the 230 selected items, 35 items were removed by calculating the content validity index (CVI), content validity ratio (CVR), and other statistical measures. Finally, GA-MDS was prepared with 195 items and four sections including administrative data, clinical, physiological, and psychological assessments.
CONCLUSIONS: The development of GA-MDS can serve as a platform to inform the geriatric referral system, standardize the GA process, and streamline their referral to specialized levels of care. We hope GA-MDS supports clinicians, researchers, and policymakers by providing aggregated data to inform medical practice and enhance patient-centered outcomes.

BACKGROUND: The newborn and infant continuum of care such as essential newborn care, early initiation and exclusive breastfeeding, and immunisation are highly recommended for improving the quality of life and survival of infants. However, newborn and infant mortality remains high across Sub-Saharan African countries. While unintended pregnancies are associated with adverse newborn and infant health outcomes, there is inconclusive evidence on whether pregnancy intention influences newborn and infant continuum of care completion. Therefore, this review aimed to pool findings reported in the literature on the association between pregnancy intention and newborn and infant health care across the continuum of care in Sub-Saharan Africa.
METHODS: We searched MEDLINE Complete, EMBASE, CINAHL Complete, and Global Health databases for studies potentially eligible for this systematic review and meta-analysis. Two researchers independently screened the identified articles by abstract and title, and then full-text using Covidence. We used the Newcastle-Ottawa Scale to assess the quality of the included studies. The Cochran\'s Q test and I2 were executed to detect and quantify the presence of statistical heterogeneity in the studies. Meta-analysis was done for each outcome when more than one original study reported relevant data, using Stata statistical software version 18.
RESULTS: Eleven studies were included from a total of 235 articles identified by the search. The odds of completing essential newborn care (pooled odds ratio: 3.04, 95% CI: 1.56, 5.90), early initiation of breastfeeding (pooled odds ratio: 1.30, 95% CI: 1.13, 1.52), exclusive breastfeeding (pooled odds ratio: 2.21, 95% CI: 1.68, 2.89), and being fully immunised (pooled odds ratio: 2.73, 95% CI: 1.16, 6.40) were higher among infants born to women with intended pregnancies as compared to women with unintended pregnancies.
CONCLUSIONS: Intended pregnancy was positively associated with essential newborn care completion, early initiation and exclusive breastfeeding, and full immunisation of infants in SSA countries. Thus, policy-makers and stakeholders should strengthen the provision of quality family planning services to prevent unintended pregnancy. Furthermore, follow-up of women with unintended pregnancies is needed to increase women\'s opportunity to access essential newborn health care services that further reduce the risk of newborn and infant morbidity and mortality.
BACKGROUND: PROSPERO registration number CRD42023409148.

BACKGROUND: Patients with head and neck cancers (HNC) experience many transitions in care (TiC), occurring when patients are transferred between healthcare providers and/or settings. TiC can compromise patient safety, decrease patient satisfaction, and increase healthcare costs. The evidence around TiC among patients with HNC is sparse. The objective of this study was to improve our understanding of TiC among patients with HNC to identify ways to improve care.
METHODS: This multimethod study consisted of two phases: Phase I (retrospective population-based cohort study) characterized the number and type of TiC that patients with HNC experienced using deterministically linked, population-based administrative health data in Alberta, Canada (January 1, 2012, to September 1, 2020), and Phase II (qualitative descriptive study) used semi-structured interviews to explore the lived experiences of patients with HNC and their healthcare providers during TiC.
RESULTS: There were 3,752 patients with HNC; most were male (70.8%) with a mean age at diagnosis of 63.3 years (SD 13.1). Patients underwent an average of 1.6 (SD 0.7) treatments, commonly transitioning from surgery to radiotherapy (21.2%). Many patients with HNC were admitted to the hospital during the study period, averaging 3.3 (SD 3.0) hospital admissions and 7.8 (SD 12.6) emergency department visits per patient over the study period. Visits to healthcare providers were also frequent, with the highest number of physician visits being to general practitioners (average = 70.51 per patient). Analysis of sixteen semi-structured interviews (ten patients with HNC and six healthcare providers) revealed three themes: (1) Navigating the healthcare system including challenges with the complexity of HNC care amongst healthcare system pressures, (2) Relational head and neck cancer care which encompasses patient expectations and relationships, and (3) System and individual impact of transitions in care.
CONCLUSIONS: This study identified challenges faced by both patients with HNC and their healthcare providers amidst the frequent TiC within cancer care, which was perceived to have an impact on quality of care. These findings provide crucial insights that can inform and guide future research or the development of health interventions aiming to improve the quality of TiC within this patient population.

The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.

BACKGROUND: The continuum of care (CoC) in maternal health refers to the continuity of individual reproductive health care across the antenatal, intrapartum, and postnatal periods. The CoC is an indicator of the quality of maternal and newborn health outcomes and women\'s empowerment is crucial to improving maternal and neonatal health service access and utilisation.
OBJECTIVE: To examine the spatial patterns of continuum of care use for maternal and neonatal health services and its correlation with women\'s empowerment.
METHODS: We analysed data from the Ethiopian Demographic and Health Surveys (EDHS) of 2011 and 2016. All women aged 15-49 who had live births in the preceding five years of the DHS surveys were included in the analysis. We measured the continuum of care using the modified co-coverage index (CoCI), which consisted of six indicators. Women\'s empowerment was assessed using a validated survey-based Women\'s Empowerment (SWPER) index. We used the Getis-Ord-Gi* spatial analysis tool to portray locations with clusters of CoC service use and spatial correlations between CoC use and women empowerment.
RESULTS: None of the newborn-mother pairs in the 2011 survey received the entire continuum of care and only 2.5% of newborn-mother pairs received the full range of continuum of care services in the 2016 survey. In 2016, 6.9% of mother-newborn pairs received the basic CoC services (four or more antenatal care [ANC] visits, skilled birth attendance [SBA], and postnatal care [PNC]), and no mother-newborn pair received all three services at the same time in 2011. The Amhara, Afar, and Somali regional states had the least CoC service use in both surveys. There was a positive spatial correlation between CoC use and women\'s empowerment domains.
CONCLUSIONS: Our analysis showed that the use of four or more ANC visits, SBS, newborn PNC, Bacillus Calmette-Guérin (BCG) vaccine uptake, and tetanus toxoid protection at birth were low in Ethiopia. Women empowerment domains were found to have a positive spatial correlation with CoC services use. To improve and preserve continuity of care, it is critical to leverage every maternal health facility encounter to encourage sustained service usage at each step of the continuum. Government policies should prioritise women\'s empowerment and raise public awareness of maternity services.

OBJECTIVE: To explore and describe the everyday practices (Work-As-Done) that hinder and facilitate patient care transitions from the intensive care unit (ICU) to the ward.
METHODS: Multiple qualitative case studies in the ICU and various specialized wards of three Dutch hospitals. Adult patients planned to be transferred were purposively sampled on a variety of characteristics along with their relative (if present), and the ICU and ward nurses who were involved in the transition process. Data were collected by using multiple sources (i.e., observations, semi-structured interviews and a qualitative survey) and then systematically analyzed using the thematic analysis approach until saturation was reached.
RESULTS: Twenty-six cases were studied. For each case, the actual transfer was observed. Sixteen patients, five relatives and 36 nurses were interviewed. Two patients completed the survey. Fifteen themes emerged from the data, showing that the quality of transitions is influenced by the extent to which nurses anticipate to patient-specific needs (e.g., providing timely and adequate information, orientation, mental support and aftercare) and to the needs of the counterpart to continue care (e.g., by preparing handovers) besides following standard procedures. Data also show that procedures sometimes interfere with what works best in practice (e.g., communication via a liaison service instead of direct communication between ICU and ward nurses).
CONCLUSIONS: Subtle, non-technical nursing skills play an important role in comforting patients and in the coordination of care when patients are transferred from the ICU to the ward.
CONCLUSIONS: These Work-As-Done findings and their underlying narratives, that are often overlooked when focusing on quality improvement, can be used as material to reflect on own practice and raise awareness for its impact on patients. They may stimulate healthcare staff in crafting interventions for optimizing the transition process.

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