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Background: Affiliations between community and academic hospitals are increasing. However, their impact on transfer practices remains under-characterized.

Objectives: To understand the impacts of hospital affiliation on transfer practices and hospital resource utilization.

Design: Retrospective cohort study.

Methods: We included patients ⩾18 years who were transferred from a 178-bed community hospital to a tertiary academic hospital between January 2015 to December 2019. Interrupted time series analysis was used to evaluate changes in outcomes after the affiliation in January 2017. Our primary outcome was the change in quarterly rate of early discharge (discharge within 48 hours post-transfer). Secondary outcomes included change in quarterly proportions of low-income patients, patients residing at a far distance from the hospital, and ICU admissions. We performed a sub-analysis in patients transferred to a surgical specialty that evaluated the tri-annual rate of operative management (surgical or interventional radiology procedure performed <72 hours after admission).

Results: Among 144 included patients, 93 (64.6%) were transferred post-affiliation and 63 (43.1%) were transferred to a surgical specialty. No significant trends were seen across outcomes in the pre-affiliation period. Relative to the former period, there was a quarterly decrease in early discharge rates (P = .027) and a quarterly increase in the percentage of patients residing at a long distance from the transferring hospital (P = .027) after affiliation. There was also a relative tri-annual decrease in the rate of operative management (P = .039).

Conclusion: Post-affiliation, the volume of transfers and utilization of resources at the receiving hospital increased. The percentage of transfer patients residing farther from the transferring hospital also increased.

Background: Exercise-based interventions, particularly dual-task training (DT), have been increasingly recognized as effective strategies for improving cognitive, motor, and functional capacities in individuals with Parkinson's disease (PD). This study presented a protocol for a randomized controlled trial (RCT) designed to evaluate and compare the effects of land and aquatic-based single-task (ST) and dual-task (DT) training on physical and cognitive outcomes in individuals with PD. The present study aims to describe the protocol of 4 different physical exercise programs, including single-task and dual-task exercises on land and in the aquatic environment, and their potential impact on the cognitive, motor, functional, and quality of life capacities of people with Parkinson's disease.

Methods: This randomized controlled trial (RCT) involved individuals with PD who were randomly assigned to 1 of 4 intervention groups: (i) Land Single-Task (LST), (ii) Land Dual-Task (LDT), (iii) Aquatic Single-Task (AST), and (iv) Aquatic Dual-Task (ADT). Participants in each group underwent a 12-week exercise program with standardized volume, frequency, and intensity. The interventions focused on improving cognitive and motor functions, balance, dynamic gait, fear of falling, and quality of life (QoL). A battery of validated assessments was used, including the MoCA, SCOPA-COG, TUG, FTSST, Mini-BEST, DGI, ABC, and PDQ-39, administered at baseline, post-intervention, and at a 12-week follow-up.

Objectives: This study aimed to investigate whether dual-task training, particularly in the aquatic environment, offered superior benefits over single-task training in improving cognitive, motor, and functional abilities in individuals with PD. Additionally, the study explored the potential of the aquatic environment to provide unique stimuli that enhance neuroplasticity, balance, and overall mobility.

Conclusions: This protocol outlined a structured approach to evaluating the effectiveness of land and aquatic-based exercise interventions in individuals with PD. The findings from this study will contribute to the development of evidence-based guidelines for exercise prescription in PD, emphasizing the role of aquatic environments in therapeutic interventions.

Background: The COVID-19 pandemic posed unprecedented challenges to healthcare systems worldwide, prompting governments to rapidly expand hospital bed capacity to meet the surge in demand for medical care. This study focuses on evaluating Colombia's healthcare system response by examining the expansion of hospital beds during the health crisis.

Methods: In an observational study, we used a national census of all healthcare facilities in Colombia, compiled by the Ministry of Health and Social Protection (MPSP), to analyze changes in hospital bed allocation from 2010 to 2022. Our analysis accounted for the size of each provider, its public or private ownership, and the types of services it was authorized to deliver. We applied interrupted time series models to assess changes at both the hospital and municipal levels over time.

Results: Findings reveal a significant reduction in hospital beds in 2020, with adult beds decreasing by 1049 units and pediatric beds by 0.709 units compared to 2019. However, there was an increase in ICU beds for adults across all years, which persisted after the end of the crisis. The expansion mainly targeted small hospitals and the public network of providers. Most of the expansion was restricted to areas of the country that already had a supply of ICU and hospitalization beds.

Conclusion: Colombia's healthcare system responded dynamically to the COVID-19 pandemic by reallocating resources and expanding hospital bed capacity, despite the complex command and control configuration of its health system. Yet, it shows that the country needs to modify its financial and organizational structures to ensure better preparedness for future health crises.

Background: Chronic pain is a complex condition affecting patients' health-related quality of life (HRQoL). Pharmacogenetic (PGx) testing offers an approach to personalize pain management by optimizing medication regimens. However, the impact of this approach on measurable patient reported outcomes (PROs) remains unexplored.

Objectives: This study evaluated the association of PGx testing on PROs in chronic pain patients and investigated differences between those who received PGx-guided therapy and those who did not, focusing on changes in HRQoL and pain intensity from pre-to-post PGx.

Design: An exploratory pre-post analysis was conducted as part of an observational case series assessing the influence of PGx testing and subsequent PGx-guided therapy on PROs in chronic pain patients with drug-related problems under their analgesic regimen.

Methods: PROs were assessed in 29 patients pre-PGx (baseline) and post-PGx (follow-up, 4-6 weeks later). HRQoL was measured using the EQ-5D-5L. The EQ index was calculated using the German value set. Pain intensity was determined with the Numeric Rating Scale (NRS). Minimal important difference (MID) threshold was applied for both outcomes. Statistical analyses included Wilcoxon signed-rank tests, chi-square tests, and effect size calculations.

Results: The mean EQ index score improved from pre-to-post PGx (0.379 ± 0.420-0.697 ± 0.307, P < .001, d = -0.84). Stratification revealed that the PGx-guided therapy group showed significantly greater improvements in HRQoL and NRS compared to the non-PGx guided therapy group (P < .01). Among 19 patients who met the MID for the EQ index, 18 had undergone PGx-guided therapy. For NRS, MID was reached in 3 pain intensity categories in the PGx-guided therapy group.

Conclusions: HRQoL and pain intensity significantly improved after PGx testing, with potentially clinically relevant results in the PGx-guided therapy group. Due to the observational nature of the study, further controlled studies are required to assess the clinical impact and economic feasibility of PGx-guided therapy.

Background: This exploratory study investigates the code of silence in healthcare, exploring its origins and outlining its negative impact on healthcare quality and patient safety. Drawing parallels with other professions where similar codes exist, the research delves into the reasons healthcare professionals may choose not to report inappropriate practices.

Objective: This article outlines the reasons for the existence of the code of silence in healthcare, assesses its prevalence, and suggests strategies to address it.

Design and methods: This is a qualitative study which uses in-depth interviews with 88 licensed healthcare providers (physicians, nurses, administrators, and pharmacists) to identify common types of inappropriate practices, the actions taken to address them, and the reasons why observers chose to remain silent.

Results: We find that the majority of healthcare providers in the sample (nearly 70%) either witnessed or were made aware of incidents of inappropriate practices. In a substantial proportion (about 40%) of the cases, no action was taken after reporting the inappropriate practice. The findings are discussed in the context of existing codes of professional ethics and the organizational cultures that either encourage or discourage transparency. The study highlights the tension healthcare professionals face between their personal values, institutional goals, and fear of retribution.

Conclusion: Breaking the code of silence is both a personal and organizational responsibility. The paper concludes with actionable recommendations to break the code of silence, such as fostering a supportive reporting culture, improving anonymous reporting mechanisms, and encouraging leadership to prioritize accountability.

Background: Scaling community-based health programs can contribute to efforts to achieve universal health coverage. Implementers of community-based health programs, such as community health workers (CHWs), hold valuable insights and experiences that can inform how these programs scale up and out.

Objectives: (1) To assess implementer experiences and perceptions of a community-based health program delivered by CHWs that underwent recent changes to broaden its programing and reach (ie, scaling up); and (2) to describe facilitators and barriers to the implementation of this community-based health program to inform subsequent scaling out.

Methods: In April 2023, an evaluation of an NGO-led CHW program was conducted with program implementers across 6 geographic regions in Negros Oriental, Philippines (n = 64 semi-structured interviews). Data were analyzed using a hybrid inductive-deductive analysis, informed by the Medical Research Council's framework for process evaluation of complex interventions. Ethics approval was provided by the University of Waterloo Research Ethics Board (Certificate #: 44828).

Results: CHWs perceived that the scaled up version of the program was more useful and impactful, given its expanded reach and provision of basic treatment; however, new program components also required significant time, effort, and strategy to implement which created new opportunity costs for CHWs. Implementation of the scaled up version of the program was facilitated via clear communication structures and supportive group training spaces. Pre-existing roles and social networks held by CHWs further facilitated the implementation of the scaled up version of the program. Overall, new individual-level and community-based strategies were leveraged by CHWs to implement the scaled up program, and participants described facilitators (eg, expanded reach) and barriers (eg, increased time and effort) that influenced program implementation.

Conclusion: This study contributes insights into how individuals involved in the scaling of a community-based health program may experience this process.

Aim: To provide a comprehensive scientometrics analysis of Six Sigma research in healthcare, a field gaining momentum due to its capacity to address missed improvement opportunities and inefficient cost-control strategies across global health systems.

Design: A cross-sectional mixed-methods study combining quantitative research and health metrics with thematic content analysis to explore trends and research patterns.

Methods: The study analyzed publications indexed in PubMed, Scopus, Web of Science, SciELO, and KCI, using thematic mapping techniques through term co-occurrence networks and cluster analysis. Also, correlation analysis with healthcare quality indicators and global health metrics were executed.

Results: A total of 883 publications were analyzed. (1) Geographical analysis showed 70.8% from high-income countries and 0.7% from low-income countries. (2) Thematic clusters were centered on hospital applications and patient safety. (3) Temporal trends revealed an increasing focus on "big data" and "health innovation." (4) Strong correlations were found between publication output and health/research expenditure (P < .01 for all cases); negative associations emerged with out-of-pocket expenditures and researcher density in low-income settings.

Conclusions: Findings provide a roadmap for aligning global research priorities and highlight the need for inclusive strategies that build research capacity and foster context-sensitive applications of Six Sigma in healthcare.

Background: The TeleTriageTeam (TTT) is a novel system for remote eyecare delivery.

Objectives: Explores the impact of TTT on costs by depicting program theory of care prioritization. Moreover, a quantification of longer-term effects of delay (and inversely earlier treatment) on costs is performed.

Design: Mixed-methods health economic evaluation.

Methods: First, we depicted the program theory of prioritization into a LOGIC-model using existing TTT-data and expert interviews outlining the causal pathways how and why a program is expected to work. Second, we identified the most relevant key diagnoses to be appraised based on incidence, severity, and presumed triage impact. Third, we estimated the impact of delay (or inversely earlier treatment) on societal costs and quality of life (QoL) based on literature searches. Cost data were updated to 2023. Results were reported per delayed patient per 6 months (the average TTT delay).

Results: Five key diagnoses were selected: cataract, diabetic retinopathy (DRP), age-related macular disease (AMD), glaucoma, and dry-eye-syndrome (DES). The LOGIC-model showed how the TTT actions could influence costs and QoL. Semi-structured interviews revealed delay results in adverse events, at the expense of shorter waiting times in prioritized patients, and overall decreases personnel burden. Reduced waiting times were also believed to decrease burden and costs in prioritized patients. Literature showed that a delay in glaucoma treatment results in savings (-€409), while the other diagnoses suggested higher societal costs (cataract €3298, DES €2156, AMD €1455, DRP €117). QoL reduction and increased costs due to delay were more apparent when delay results in longer duration of curable symptoms compared to delay in stable disease (up to 0.09 vs 0.003 QALYs and €3298 vs €1455, respectively).

Conclusions: Eye care delay results reduced QoL and increased societal costs, yet this is compounded by gains attributable to justified prioritization of more urgent and more severe patients.

Background: Healthcare-seeking behaviour, and its associated factors, for obstetric complications are an important determinant of maternal deaths and adverse foetal outcomes. However, there is limited evidence on healthcare-seeking behaviours from health facilities in response to obstetric complications among Ethiopian women.

Objective: To investigate women's healthcare-seeking behaviour in response to obstetric complications, and its associated factors, in Ethiopia.

Methods: Data were sourced from the Performance Monitoring for Action (PMA-E) longitudinal survey national database. Andersen's health service use model was utilised to group individual and contextual factors. A multilevel mixed-effect logistic regression model was employed, with adjusted Odds Ratio (aOR) and 95% confidence intervals reported.

Results: Data were derived from a weighted sample of 1750 women who experienced obstetric complications during pregnancy, childbirth, and immediately postpartum. Overall healthcare-seeking at health facilities for obstetric complication symptoms during the maternity continuum was 62% (95%CI: 59.6-64.3), with 47.8% (95%CI: 45.0-50.5), 64.5% (95%CI: 61.3-67.5), and 52% (95%CI: 48.3-55.6) seeking healthcare from health facilities during pregnancy, childbirth, and the immediate post-partum period, respectively. Antenatal care attendance (aOR = 3.43, 95%CI: 2.4-5.0), nulliparity (aOR = 2.1; 95%CI: 1.0-4.4), household access to media (aOR = 1.5, 95%CI: 1.0-2.1), no intimate partner violence (IPV) during pregnancy (aOR = 1.8, 95%CI: 1.1-3.1), high community wealth status (aOR = 1.2, 95%CI: 1.1-2.4), community encouragement of facility childbirth (aOR = 2.2, 95%CI: 1.1-4.3), community non-acceptance of the traditional birth attendant (TBA; aOR = 2.4, 95%CI: 1.6-3.7), and high community participation in health developmental army (HDA; aOR = 2.1, 95%CI: 1.1-3.9) were significantly associated with healthcare seeking behaviour.

Conclusions: The healthcare-seeking behaviour of women from health facilities in response to obstetric complication symptoms was low and varied across the different stages of the maternity continuum. Key programme priority interventions should focus on reducing community reliance on TBA care, enhancing community encouragement of facility childbirth, and strengthening the HDA.

This study aims to identify factors influencing the continuity of follow-up care after hospital discharge from the perspectives of physicians and key healthcare stakeholders and map their interactions to facilitate understanding of dynamic relationships. We conducted audio-recorded semi-structured interviews with 17 participants (10 medical doctors, 3 state key informants, and 4 federal key informants) in Khartoum State, Sudan. Data analysis included thematic analysis to identify the factors and purposive text analysis to develop a causal loop diagram. We identified 39 factors affecting the continuity of follow-up care from hospital to home, categorized into 5 challenges: follow-up care adherence, quality of pre-discharge patient education, efficiency of the referral system, primary healthcare center accessibility, and quality improvement efforts. The study identified 2 balancing loops and 5 reinforcement feedback loops affecting follow-up care post-hospital discharge. The low adherence to follow-up care proposes quality improvement efforts as a solution, however, the high workload, resource depletion, referral system inefficiency, and quality improvement stagnation reinforcing loops impede progress in this direction. We recommend enhancing pre-discharge patient education and using multisectoral approaches to improve primary healthcare, optimize referrals with digital tools, and address staff turnover, to strengthen follow-up care.