BMC Health Services Research最新文献

Background: Suicide is the fourth leading cause of death among young people aged 15-29 worldwide. Young people often present to emergency departments (EDs) with self-harm and suicide-related behaviors. The period following discharge from the ED is recognized as one of elevated risk for both repeated self-harm and suicide. During this critical time, suicide prevention aftercare services are recommended. Despite their increased popularity, evidence demonstrating the effectiveness of these models is very limited.

Methods: Using a hybrid effectiveness-implementation type I design, this evaluation will assess the effectiveness and implementation of a suicide prevention aftercare (Hospital Outreach Post-suicidal Engagement; HOPE) service designed to reduce risk of self-harm and suicide in young people aged 12-25 who are referred to the service following an ED presentation for self-harm or suicide attempt. Two complementing theoretical frameworks will guide this evaluation, specifically the design, data collection, analysis, and interpretation of results. The RE-AIM evaluation framework will be used to assess Reach, Effectiveness (including cost-effectiveness), Adoption, Implementation and Maintenance of the HOPE aftercare service. The PRISM implementation framework will be used to assess multi-level contextual factors hypothesized to affect the RE-AIM outcomes. Several data sources will be used to assess the changes in primary and secondary outcomes from baseline to post-intervention, and at follow-up, including user and provider self-report surveys, semi-structured interviews, and routinely collected hospital data. An historical control study will also be conducted using data from the Self-Harm Monitoring System for Victoria to examine the impact of the service on rates of self-harm and suicide-related presentations to ED, and compare trends prior to and following commencement of the HOPE aftercare service. In addition, dynamic systems modelling will be used to assess the future scalability of the service.

Discussion: Findings from this evaluation will determine the effectiveness, including cost-effectiveness, of the HOPE aftercare service and describe the implementation context. They will inform the future development and sustainability of this and other similar services across Australia and internationally.

Trial registration: This trial was prospectively registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) on the 19th December 2023 (Registration number ACTRN12623001332617). We do not foresee any amendments to this protocol however, if any unforeseen modifications are required, they will be submitted to ANZCTR.

Trial sponsor: Orygen, 35 Poplar Road, Parkville, VIC, 3052, Australia.

Health and care information technologies can improve service delivery, but unfortunately many fail to realise their potential. This is because tools fail to effectively integrate with user and organisational practices. We here draw on two decades and an extensive body of practical and theoretical experience of conducting formative evaluations in health service settings to extract seven essential principles for planning and developing digital tools. Firstly, it is important to determine if digitalisation is the right approach for the desired change and to view these tools as complex interventions needing careful planning. The development process should embrace varying levels of co-creation and adapt to different needs and contexts. Ensuring that tools integrate well with existing information infrastructures and striking a balance between being widely applicable and locally relevant is essential. Furthermore, planning for how these interventions will fit into broader health and care pathways is vital. By considering these factors, decision-makers can significantly improve the chances of successful implementation, adoption and scaling of health and care technologies.

Introduction: Clinical practice guidelines are essential tools for standardizing medical practices and improving healthcare quality. However, current guideline implementation is unsatisfactory. Barriers to guideline implementation include external environmental factors (e.g., medical personnel, medical institutions, local policies) and intrinsic characteristics (e.g., context, format, language etc.), with the latter being addressable by optimizing the guidelines themselves. This study aims to develop an appraisal tool to promote effective guideline implementation. Existing guideline implementability appraisal tools lack a clear theoretical basis, evidence of reliability and validity, and/or empirically-based guidance for effective implementation, all of which will be addressed in this study.

Methods and analysis: The research is divided into four phases: (1) Generating a theoretical framework for guideline implementability (i.e., scoping review and concept analysis method); (2) Conducting a factorial experiment (i.e., guideline users simulate the use of different guideline versions to examine the relationship between constructs in the framework and implementability), and removing constructs with weak relationships to form the final implementability theoretical framework; (3) Generating dimensions and items for the guideline implementability appraisal tool based on the constructs in the theoretical framework, conducting comprehensive reliability and validity testing, usability testing, and iterative optimization according to the COSMIN guidelines; (4) Integrating the validated tool with the STAR guideline rating system for guideline appraisal and feedback to promote guideline implementability. STRENGTHS AND LIMITATIONS: (1) Our research will follow a standardized and rigorous process for developing measurement scales, ensuring that the resulting evaluation scale for the implementability of CPGs is theoretically grounded, internally consistent between theory and practice, and reliable and valid. (2) The theoretical framework developed in our study will strengthen the validity and rationality of constructs in the real world. (3) In the confirmatory factor analysis, this study will determine the dimensions and items' weight through factor loadings, allowing for the quantification of the implementability of CPGs and providing users of the guidelines with objective evaluative results. In addition, the clinical practice guideline implementability evaluation tool developed in this study can assist guideline developers in enhancing implementability before, during, and after guideline formulation.

Background: Language barriers in healthcare lead to miscommunication between professionals and patients, thereby reducing the quality of and equitable access to healthcare. In African countries, the recognition and formal study of these barriers is severely limited despite Africa having more languages than any other continent. Our study investigates language barriers in healthcare facilities in Zomba district in Malawi, where three major local languages are spoken.

Methods: We employed a mixed methods approach and conducted a questionnaire-led study. Data were gathered at 22 health facilities, from 79 healthcare professionals and 312 outpatients using a semi-structured questionnaire. Findings were corroborated using document analysis to review legislation and policies, curriculum documents and patient notes.

Results: Language discordance emerged as a problem for professionals and patients. Both faced challenges due to vocabulary limitations for medical terms in English and Chichewa. Professionals did not receive training on how to effectively communicate medical concepts in local languages. Most patients did not speak English, which was used for all written records. Patient understanding of the information given to them verbally during consultations or in written health notes was very low, and this diminished their confidence in the diagnosis or treatment they received. Social factors including gender, age or patient experience, as well as patient literacy or perceived low literacy, poor rapport between healthcare professionals and patients, and a lack of privacy during consultations all exacerbated communication issues. Consequences of language barriers included unsatisfactory care experiences and compromised exchanges of health information. Strategies used by professionals to cope with these challenges were flexibility in the choice of language, reliance on physical checks and non-verbal communication indicators and the occasional use of ad-hoc interpretations.

Conclusion: Language barriers in healthcare facilities in Malawi have serious implications on the quality of healthcare provided. We propose solutions such as the development of dictionaries with phrases for symptoms and conditions, sensitisation courses that incorporate language considerations for both professionals and patients. Policies such as the provision of interpreters and staff allocation are discussed. We recognise that coordinated efforts at national and international levels are key to securing significant funding for effective interventions.

Background: The rate of 30-day all-cause hospital readmissions can affect the funding a hospital receives. An accurate and reliable readmission prediction model could save money and increase quality-of-care. Few projects have explored formulating this task as a survival prediction problem, where models can exploit a real-valued time-to-readmission target. This paper demonstrates the effectiveness of a survival-inspired readmission model, especially when paired with a longitudinal patient representation that is agnostic to disease-cohort and predictive task.

Methods: We forecast readmissions for a population-level cohort of 421,088 patients discharged in 2015 and 2016 from hospitals in Alberta, Canada. Clinical features and sequences of historical medical codes (calculated from at least four full years prior to discharge) from linked administrative sources serve as model inputs. We trained binary 30-day readmission models (XGBoost and a Deep Neural Network) and time-to-event readmission models (CoxPH and N-MTLR) with and without machine-learned medical knowledge at initialization, then compared against the popular LACE-based model using the AUROC score at 30 days (AUROC@30). Survival models are additionally evaluated using concordance, Integrated Brier, and L1-loss scores.

Results: All models that utilize sequence features markedly out-perform even the best models trained on only clinical features. Further, a time-to-event target improves predictive performance at 30 days, given the same model inputs and architecture. N-MTLR, using solely sequence inputs and initialized with pre-learned medical knowledge, achieves an average AUROC@30 of 0.8460 over five folds with a standard deviation of 0.003. All trained models match or out-perform the LACE baseline of 0.6587±0.003.

Conclusion: Sequences of administrative medical codes contain rich predictive information for forecasting readmissions, and embedding medical knowledge a priori using machine learning provides readmission models an advantageous foundation for training. When combined with a model that can leverage a time-to-event target, excellent performance is possible on the 30-day all-cause readmission task using only administrative data.

Background: The number of older adults with complex healthcare needs is growing alongside limited resources available in health services. To meet this challenge, it is urgent that healthcare staff are motivated and able to continuously translate new knowledge and working methods into daily practice. To facilitate such implementation, supportive measures responding to the healthcare personnel's needs seem essential. The present study aims to translate, contextualize and test a Swedish version of the Implementation Process Assessment Tool (IPAT) for measuring the facilitation needs among staff implementing a new working process in municipal elderly care.

Methods: A mixed-method design was used. First, the existing instrument was translated into Swedish. Thereafter, twelve staff members with different professions working in healthcare and at the municipal elderly care were interviewed using Think-aloud interviews to contextualize and test the face validity of the translated instrument. Lastly, the adjusted instrument (Swe-IPAT) was psychometrically evaluated through a cross-sectional survey among 305 staff members working in municipal elderly care.

Results: The psychometric evaluation of the Swe-IPAT revealed satisfying properties. Three factors, largely in line with the original IPAT, are suggested. Internal consistency assessed using Cronbach's alpha was 0.93 for the factor individual phases for behavioral change and perception of the intervention, 0.84 for the factor individual activities, and 0.95 for the factor collective readiness and support.

Conclusions: The 27-item Swe-IPAT, translated into Swedish and contextualized, demonstrated satisfactory psychometric properties when tested in an elderly care context. The instrument is suggested to be useful in providing feedback to managers in tailoring support and assessing implementation efforts among healthcare staff in elderly care. However, more research is needed to evaluate its properties throughout the entire implementation process and to test the usability of Swe-IPAT in other settings.

Background: The vaccine supply chain (VSC) integrates all activities from production to dispensing, characterized by complexity and low responsiveness. This study aims to define key performance indicators (KPIs) to evaluate the logistic and operational performance during the COVID-19 National Vaccination Plan in Colombia.

Methods: This study employed the design science research (DSR) methodology to develop a dashboard for monitoring COVID-19 vaccination progress. DSR is a problem-solving paradigm focused on conceiving, testing, and evaluating artifacts to tackle specific challenges. The dashboard integrated a set of Key Performance Indicators (KPIs) that incorporated three dimensions: epidemiological, humanitarian, and logistical. Both, the dashboard and the KPIs underwent validation through three iterative DSR cycles, in collaboration with both private and public health stakeholders.

Results: A set of 38 validated KPIs, grouped into eight categories, was consolidated into an online dashboard. This tool enabled real-time tracking of the National Vaccination Plan at both national and departmental levels, providing stakeholders with a comprehensive view of the vaccine supply chain. It also allowed for the assessment and comparison of the execution and effectiveness of public policies.

Conclusions: These KPIs supported decision-making from a logistical standpoint, enhancing the planning, preparation, and continuous improvement of mass vaccination processes, thereby increasing their potential impact even further.

Background: The German College of General Practitioners and Family Physicians (DEGAM) issued a COVID-19 guideline with eleven recommendations to support primary care services during the pandemic. Their use in general practices beyond the pandemic can contribute to pandemic preparedness. This study analysed general practitioners' (GPs) interest in applying recommended organisational changes in non-pandemic times.

Methods: Data from the German egePan GP survey (n = 516 GPs) - a multi-level clustered randomised web-based survey - were analysed. GPs' interest in the future application of the eleven guideline recommendations was calculated. In addition, each recommendation was evaluated by the GPs using a Net-Promoter-Score (NPS range - 100 to 100). A linear regression model identified GP and practice characteristics associated with a higher interest in applying recommendations in non-pandemic times.

Results: 98.5% of the GPs indicated the intention to implement at least one guideline recommendation prospectively: disinfectant dispensers at the entrance (86%), optimised consultation scheduling to reduce waiting times (83%), and glass screens in the reception area (72%), which also received the highest NPS scores. In contrast, lower interest was observed for items such as insurance card readers handled by patients (48%), only selected staff treating infectious patients (44%), and video consultations for patients with infections (26%). A higher interest to implement recommendations in non-pandemic times was associated with a higher crisis leadership score (p < 0.001), using the Corona-Warn-App (p = 0.007), and being a female GP (p = 0.045). In addition, GPs from Western, Northern, and Southern, and those with a higher patient volume per three months, were more interested in future implementation.

Conclusions: Overall, GPs demonstrated the readiness to follow the DEGAM COVID-19 guideline outside pandemic periods, establishing them as key contributors to pandemic preparedness in Germany.

Background: In Ghana, nearly one in four (25%) of the population are sickle cell disease carriers. Furthermore, 2% of all babies born (20 for every 1000 live births) has sickle cell disease. However, little is known about how parents negotiate the financial challenges facing parents of a child with sickle cell disease. This study explores the financial difficulties of parents and children living with sickle cell disease.

Methods: The study adopted a qualitative approach. Twenty-seven parents were purposively selected from a sickle cell clinic in Accra, Ghana. Data collection was through an in-depth, face-to-face interview, using an interview guide based on the research objectives, and analyzed using thematic analysis.

Result: The findings showed that parents faced multiple financial difficulties (both direct and indirect) as they met the direct cost of medications, routine laboratory investigations, and hospital admissions. The National Health Insurance scheme does not wholly cover these costs. Families also describe more indirect costs, such as those associated with maintaining their child's well-being alongside those connected to their caring responsibilities, including the impact of giving up work and reducing working hours. Findings highlight the most pressing challenge, including the lack of access to financial support and a more general lack of understanding of the difficulties they faced on the part of policymakers.

Conclusion: Supporting sickle cell parents' financial needs would improve their emotional and social well-being, enabling them to be more effective family carers.

Background: Digital solutions in healthcare can facilitate and improve care. However, the experiences and the usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) The differences in patient experiences, having their foot examined supported by the Clinical Decision Support System as compared with having their foot examined in traditional practice, 2) How healthcare professionals, by using the digital tool, experienced the routine compared with performing the foot examination as in traditional practice.

Methods: Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by a healthcare professional using a digital tool (n = 47) or having their foot examined as in traditional practice (n = 53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey and the Orthotics and Prosthetics Users' Survey at study end. Two healthcare professionals, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the certified prosthetist and orthotist.

Results: Patients, aged 66 ± 13 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the National Patient Survey or by the Orthotics and Prosthetics Users' Survey, with scores of 67.17 ± 12.18 vs. 66.35 ± 16.52 (p = 0.78) for the intervention and control group respectively. For the same patient that healthcare professionals foot examined, the risk class was fully obtained when the risk to develop foot ulcers was assessed by using the digital tool, whereas only 2% of the patients were classified when foot assessed in traditional practice.

Conclusions: Regardless of the method used for the foot examination, patients perceived a high level of satisfaction with the services at the Department of Prosthetics and Orthotics. All the patients were risk classified in the intervention group. The healthcare professionals found that, by using the Clinical Decision Support System, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested.

Trial registration: Clinical Trials NCT03088566 , Registered 23 March 2017.