BMC Health Services Research最新文献

Background: Despite well-established recommendations for the treatment and secondary prevention of fragility fractures, implementation remains challenging. Understanding local practice realities and barriers is therefore essential for adapting global guidelines to national health systems. This study assessed the management of fragility hip fractures in elderly patients in Thailand, focusing on the perspectives of orthopaedic surgeons.

Method: We conducted a questionnaire-based survey of orthopaedic surgeons in Thailand who are actively involved in the care of patients with fragility fractures, focusing on acute management, secondary prevention, and overall perceptions of care. The survey was adapted and translated from the "Survey of Awareness and Attitudes to the Management of Fragility Fractures" developed by the Asia Pacific Orthopaedic Association. It was piloted with 10 volunteer orthopaedic surgeons and refined for clarity, comprehensiveness, and validity. The final questionnaire was distributed online in collaboration with the Royal College of Orthopaedic Surgeons of Thailand using registered membership contacts.

Results: Of 223 responses, 199 were eligible. Most participants practiced in tertiary public hospitals (36.2%), had < 5 years of experience, and managed 0-5 cases weekly. According to respondents, hip fracture fast-track protocols were available in 79.4% of hospitals, and 58.8% had fracture liaison services. Only 22.6% of respondents reported achieving surgery within 48 h in > 90% of their patients, and 46.7% prescribed osteoporosis treatment to ≥ 75% of patients. University-affiliated hospitals were more likely to prescribe osteoporosis medication (OR 4.68, 95% CI 1.87-11.67), while cost concerns reduced prescribing (OR 0.40, 95% CI 0.20-0.81). Private hospitals had the highest odds of surgery within 48 h (OR 104.43, 95% CI 7.21-1513.05). Implant unavailability was the main barrier to expedited surgery (OR 0.20, 95% CI 0.04-0.91).

Conclusions: Although hip fracture fast-track protocols and fracture liaison services are increasingly available, timely surgery and osteoporosis treatment remain suboptimal. Addressing cost barriers, improving implant logistics, and expanding diagnostic access are essential to strengthen fragility fracture care in Thailand.

Background: Primary care practices experience challenges to implementing team-based care, and these challenges may be more pronounced in small-to-medium-sized independent primary care practices (SIPs). Our objective is to provide a review of the literature on team-based care implemented within SIPs.

Methods: The literature was identified using keywords related to primary care and team-based care in PubMed/MEDLINE, CINAHL, Cochrane Library, and EMBASE. Studies on team-based care within small-primary care settings were extracted and organized according to the four domains of the Integrated (Health Care) Team Effectiveness Model (ITEM) framework.

Results: Twenty-five studies met our criteria for inclusion and were included in our review. Of those, only nine of the included studies solely focused on SIPs. Studies addressed some component of task design, including the composition of the team (i.e. MA and MD dyads) and the features of the task (i.e. role interdependence). Studies also discussed team processes, such as communication and coordination. Few studies discussed psychosocial traits during implementation, including trust and psychological safety. Lastly, studies described the organizational context of the practices, which includes their structure, resources or training environment. Identified barriers for team-based care implementation included financial constraints when hiring additional staff and issues with the current payment models that reward team-based care.

Conclusions: Studies solely focused on small primary care practices are limited. Of the four key domains, the biggest gap was identified around psychosocial traits and how mutual trust is fostered. Areas of future research include attention to how trust is built as practices implement team-based care and shift their mental model.

Background: The economic crisis in the Kurdistan Region of Iraq has severely affected public sector salaries and healthcare infrastructure. These disruptions have increased pressures on the healthcare workforce and exposed gaps in the region's institutional and workforce resilience. This study explored physicians' experiences and adaptive responses to the prolonged financial instability and its consequences for healthcare delivery.

Methods: A qualitative design was adopted using semi-structured interviews with 25 physicians from various specialties working in both public and private sectors across the Kurdistan Region. The study was conducted from March to August 2024 during a period of heightened financial instability. Data were analyzed thematically using a structured six-step qualitative analysis, using an inductive qualitative thematic analysis approach.

Results: Ten interrelated but analytically distinct themes emerged: workload-related operational stress, salary instability, psychological stress, burnout and hopelessness, coping mechanisms, institutional inaction, clinical decisions under constraints, proposed reforms, need for support, emerging innovations, and impact on patient care. Physicians described increased workloads, delayed or reduced salaries, emotional exhaustion, and a deep sense of hopelessness. Institutional inaction compounded these challenges, forcing doctors to ration care and delay procedures. Despite adversity, participants demonstrated moral resilience through volunteering, free care, and semi-private models. Limited innovations-such as telemedicine and community outreach-were also noted. Collectively, these findings reveal a fragile health system sustained primarily by physicians' ethical commitment rather than institutional stability.

Conclusion: The Kurdistan healthcare system endures economic hardship through the moral endurance and adaptability of its physicians. Sustaining healthcare quality requires transforming this individual resilience into institutional resilience through salary stabilization, leadership accountability, and structured psychosocial and professional support. Framing these findings through a resilience lens highlights the urgent need to strengthen both workforce resilience and system-level resilience to sustain healthcare delivery during prolonged crises.