BMC Health Services Research最新文献

Background: Heart failure is a major global health challenge incurring a high rate of mortality, morbidity and hospitalisation. Effective medicines management at the time of hospital discharge into the community could reduce poor outcomes for people with heart failure. Within the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) programme, the Medicines at Transitions Intervention (MaTI) was co-designed to improve such transitions, with a cluster randomised controlled trial to test effectiveness. The MaTI includes a patient toolkit and transfer of discharge medicines information to community pharmacy. This paper aims to determine the degree to which the intervention was delivered, and identify barriers and facilitators experienced by staff for the successful implementation of the intervention.

Methods: The study was conducted in six purposively selected intervention sites. A mixed-methods design was employed using hospital staff interviews, structured and unstructured ward observations, and routine trial data about adherence to the MaTI. A parallel mixed analysis was applied. Qualitative data were analysed thematically using the Framework method. Data were synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research (CFIR).

Results: With limited routines of communication between ward staff and community pharmacy, hospital staff found implementing community pharmacy-related steps of the intervention challenging. Staff time was depleted by attempts to bridge system barriers, sometimes leading to steps not being delivered. Whilst the introduction of the patient toolkit was often completed and valued as important patient education and a helpful way to explain medicines, the medicines discharge log within it was not, as this was seen as a duplication of existing systems. Within the CFIR the most applicable constructs were identified as 'intervention complexity' and 'cosmopolitanism' based on how well hospitals were networked with community pharmacies, and the availability of hospital resources to facilitate this.

Conclusion: The MaTI was generally successfully implemented, particularly the introduction of the toolkit. However, implementation involving community pharmacy was more challenging and more effective communication systems are needed to support wider implementation.

Trial registration: 11/04/2018 ISRCTN66212970. https://www.isrctn.com/ISRCTN66212970 .

Background: Sustainable supply chain management encompasses the strategic coordination and control of material, information, and financial flows, as well as the collaborative efforts among the entities engaged in the medicinal supply chain. This research proposes a dynamic and sustainable supply chain management model tailored explicitly for the inpatient pharmacies of Medical Centers and Hospitals affiliated with Iran University of Medical Sciences.

Methods: This is a quantitative study in terms of research objective and a qualitative study based on the stages in the conceptual development of the model. Therefore, the current study can be considered a mixed-methods approach. After identifying the key factors influencing the sustainability of the medicine supply chain, we conducted a dynamic analysis of the problem using system dynamics methodology. In order to simulate the system's behavior over 24 months, we utilized a combination of existing documentary information and expert opinions. The developed model was implemented using Vensim PLE software, allowing us to simulate and analyze the impact of various policies on the system.

Results: Medicine disposal exhibited an upward trend, particularly during the second 12-month period. Conversely, the trend of medicine expirations remained relatively stable in the initial months but showed an upward trajectory after that. The cost associated with disposed medicine experienced a consistent increase, with a higher rate observed during the second 12-month period. In contrast, sales of low-consumable medicine experienced a significant initial surge followed by a slower growth rate. Finally, the pharmacy's profit demonstrated an overall increasing trend, although the rate of increase was higher during the first 12 months.

Conclusion: Among the various scenarios considered, namely "increasing the adequacy of human resources," "increasing the speed of response," and "utilizing pharmacists in the drug prescribing team," it was found that these interventions had a substantial effect on both enhancing the pharmacy's profit and reducing medication waste. Therefore, these scenarios were identified as having the most significant impact. The proposed model can serve as a valuable tool for forecasting and informing policy-making, providing insights into addressing the challenges associated with the sustainable drug supply chain in hospital pharmacies.

Background: The considered shift from individual blame and sanctions towards a commitment to system-wide learning from incidents in healthcare has led to increased understanding of both the moral and epistemic importance of involving those affected. It is important to understand whether and how local policy describes and prompts involvement with a view to understanding the policy landscape for serious incident investigations in healthcare. This study aimed to explore the way in which involvement of those affected by serious incidents is represented in incident investigation policy documents across acute and mental health services in the English NHS, and to identify guidance for more effective construction of policy for meaningful involvement.

Methods: We conducted a documentary analysis of 43 local serious incident investigation policies to explore the way in which involvement in serious incident investigations is represented in policy documents across acute and mental health services in the NHS in England.

Results: Three headline findings were generated. First, we identified involvement as a concept was conspicuous by its absence in policy documents. Direct reference to support or involvement of those affected by serious incidents was lacking. Even where involvement and support were recognised as important, this was described as a passive process rather than there being moral or epistemic justification for more active contribution to learning. Second, learning from serious incidents was typically described as a high priority but the language used was unclear and 'learning' was more often positioned as construction of an arbitrary set of recommendations rather than a participatory process of deconstruction and reconstruction of specific systems and processes. Third, there was an emphasis placed on a just and open culture but paradoxically this was reinforced by expected compliance, positioning investigations as a tool through which action is governed rather than an opportunity to learn from and with the experiences and expertise of those affected.

Conclusions: More effective representation in policy of the moral and epistemic reasons for stakeholder involvement in serious incident investigations may lead to better understanding of its importance, thus increasing potential for organisational learning and reducing the potential for compounded harm. Moreover, understanding how structural elements of policy documents were central to the way in which the document is framed and received is significant for both local and national policy makers to enable more effective construction of healthcare policy documents to prompt meaningful action.

Background: To investigate awareness, use, and perceptions of the patient guidelines (PGs) of the German Guideline Program in Oncology (GGPO) and to explore general preferences regarding cancer information among patients and healthcare providers (HCPs).

Methods: Two cross-sectional surveys among patients with cancer (November 2020-May 2021) and among HCPs (April -June 2021) were set up as anonymised, self-administered, semi-structured online surveys, including open-ended questions. Data were analysed with descriptive statistics and qualitative thematic analysis. Patients were recruited from national self-help organisations and certified cancer centres located all over Germany. HCPs were recruited from cancer centres, scientific medical societies and guideline groups.

Results: Of 816 participating patients, 45% were aware of the GGPO-PGs, while 55% of the 455 participating HCPs were aware of them. Of those aware of the GGPO-PGs, 65% of patients and 86% of HCPs perceived them as helpful, while 95% in both groups saw them as comprehensive. Seventy-five percent of patients and 85% of HCPs were satisfied with the GGPO-PGs, 22%/13% were partially satisfied, and 3%/2% were rather/not at all satisfied. In addition to self-help organisations, physicians and hospitals were perceived as central in distributing the GGPO-PGs. More patients (78%) than HCPs (56%) stated a preference for detailed information, although the wish for concise information - e.g. decision aids - was concurrently expressed by the majority of all participants. Thematic analysis showed that up-to-dateness, trustworthiness, and supportive messaging are important properties for PGs.

Conclusions: HCPs found the GGPO-PGs helpful, but awareness was low, which suggests that dissemination should be improved. This is also true for patients; however, further research needs to be done to increase the helpfulness of PGs for patients. Oncological PGs seem to be needed in different formats according to patients' situational needs. Theory-driven research should investigate how to best frame patient information in a supportive way.

Background: Multiple state and national health care organizations have invested in activities to screen for and address the health-related social needs (HRSNs) of their patients. However, patient perspectives concerning HRSN screening discussions and facilitated referrals to supports are largely unexplored. The main objectives of this study were to explore the ways in which Massachusetts Medicaid (MassHealth) members engage with their health care clinicians to discuss HRSNs, to identify common needs discussed, and to describe whether members feel these needs are being addressed by health care clinicians and staff.

Methods: The study team performed a cross-sectional, qualitative research study that included in-depth, open-ended interviews with 44 adult MassHealth members. Interviews were conducted between June and October 2022. Interviews were recorded, transcribed, and systematically coded for analysis, and common themes were reported. The data collected for this study were part of a larger independent evaluation of MassHealth's 2017-2022 Section 1115 Demonstration that granted authority from CMS to implement health care delivery system reforms in Massachusetts.

Results: In this qualitative study of Medicaid members, some reportedly felt comfortable freely discussing all of their clinical and social needs with their health care clinicians, while others noted feelings of apprehension. Several members recalled being asked about their HRSNs in various clinical or community settings, while others did not. The majority of members endorsed having an unmet HRSN, including housing, nutrition, financial, or transportation issues, and many barriers to addressing these HRSNs were discussed. Finally, many members cited a preference for discussing HRSNs with community-based care coordinators and social workers at the community partner organizations rather than with their health care clinicians. Community-based care coordinators were lauded as essential facilitators in making the connection to necessary resources to help address HRSNs.

Conclusions: Study results highlight an opportunity to increase the effectiveness of HRSN screening and referral practices within the health care setting through relationship building between Medicaid members and diverse interdisciplinary care teams that include staff such as community health workers. Continued investment in cross-sector partnerships, screening workflows, and patient-clinician relationships may contribute to establishing an environment in which members can comfortably discuss HRSNs and connect with needed services to improve their health.

Background: Obesity is a chronic disease characterized by excess body fat and is a risk factor for other chronic non-communicable diseases. Its multifactorial and complex nature makes its management a challenge for health services. This manuscript presents an investigation protocol that aims to analyze the effectiveness of collective nutritional interventions for obesity management applicable to primary health care.

Methods: Randomized Controlled Community Trial (RCCT) in a representative sample of users of the Programa Academia de Saúde (PAS), in Belo Horizonte, Minas Gerais, Brazil, with obesity. The research consists of four phases: (1) Screening to identify the participants eligible for the nutritional interventions (individuals with obesity, readiness for change to lose body weight, and willingness and interest to participate in a group activity for six months or more); (2) Baseline to characterize the participants; (3) Implementation of collective nutritional interventions; (4) Reassessment of the participants. Participants in the control group (CG) will receive the usual health service care, and participants in the intervention group (IG) will participate in collective nutritional interventions based on Therapeutic Group 1 (TG1) or Therapeutic Group 2 (TG2) of the "Instructive of Collective Approach for the obesity management in SUS".

Discussion: The strengths of the study include its robust RCCT design, which allows for longitudinal analyses and is suitable for investigating causal hypotheses and applying strategies to improve adherence to interventions. Furthermore, the study included a representative sample of a public health service and aims to evaluate therapeutic proposals from the Brazilian Ministry of Health, which can contribute to implementation and extension in the national territory.

Trial registration: RBR-3vzsyqq and RBR-6pg682m.

Background: In light of the ongoing monkeypox (MPOX) epidemic, healthcare workers (HCWs) have been in contact with various diseases. Therefore, they should take appropriate preventive and control measures to maintain their health. This study assessed Egyptian HCWs' intentions to take MPOX vaccines.

Methods: A cross-sectional survey was conducted using social media platforms between September 27 and November 4, 2022. An anonymous online survey using the 5C scale was conducted using convenience and snowball sampling methods to assess the five psychological antecedents of vaccination (i.e., confidence, constraints, complacency, calculation, and collective responsibility).

Results: A total of 399 HCWs with a mean age of 32.6 ± 5.7 participated in this study. Of them, 89.7% were female. The five C psychological antecedents of vaccination were as follows: 55.9% were confident about vaccination, 50.6% were complacent, 56.6% experienced constraints, 60.7% calculated the risk and benefit, and 58.4% had collective responsibility. Multivariate analysis showed that high income level and having information about MPOX were significant predictors of confidence in the MPOX vaccines (adjusted odds ratio ((AOR) = 4.19, 95% CI (1.12- 15.59), P = 0.032). Participants aged 31-45 years and 19-30 years showed significant association (AOR = 2.46, 95% CI (0.85-7.15), P = 0.096) and (AOR = 4.19, 95% CI (1.39-12.64), P = 0.011), respectively. Having an idea about the MPOX vaccines significantly predicted the complacency domain (AOR = 3.77, 95%CI (1.47-9.65, P = 0.006). Moreover, precollege/undergraduate education and having an idea about MPOX vaccination were significant predictors of the constraint domain (AOR = 1.81.95% CI (1.09-2.99, P = 0.020), (AOR = 2.70, 95% CI (1.05-6.95, P = 0.038), respectively). Female sex, having a diploma, postgraduate studies, and having an idea about MPOX vaccine significantly predicted calculation domain (AOR = 2.06, 95% CI (1.05-4.04, P = 0.035), (AOR = 3.98,95% CI (1.33-11.87, P = 0.013), (AOR = 2.02, 95% CI (1.25-3.26, P = 0.004) & (AOR = 2.75. 95% CI (1.05-7.18, P = 0.039), respectively. The only significant predictor of collective responsibility was having a diploma and postgraduate studies (AOR = 3.44, 95% CI (1.21-9.78, P = 0.020), (AOR = 1.90,95% CI (1.17-3.09, P = 0.009).

Conclusions: Efforts to control MPOX should focus on promoting protective measures such as the vaccination of HCWs as well as raising their awareness about the updated information regarding the virus and the approved vaccines.

Background: Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians' use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers.

Methods: We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes.

Results: A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0-32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians' concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians' familiarity with the HIE software, clinicians' belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities.

Conclusions: This study is believed to be the first to qualitatively characterize clinicians' HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays.

Background: Intermediate care (IC) services bridge the transition for older patients from the hospital to the home. Despite the goal of involving individuals in their recovery process, these services often become standardised, leading to communication breakdowns. While evidence-based practices, such as the Four Habits Model (4HM), for effective communication are crucial for enhancing high-quality healthcare, research suggests their integration into routine practice remains limited. In this study, we aimed to investigate the implementation process of the 4HM through a two-day course that engaged healthcare professionals and managers in IC.

Methods: We conducted a process evaluation employing qualitative and quantitative methods: (i) individual interviews with three managers and two course participants pre-course, (ii) two focus group interviews with course participants (N = 11) and individual interviews with the same three managers post-course, and (iii) the NoMAD questionnaire (Normalisation MeAsure Development) administered four months later to assess the short- and long-term impact on course participants (N = 14). Reflexive thematic analyses were guided by Normalisation Process Theory (NPT), which offers insight into how new interventions become routine practices. The analysis of the NoMAD involved descriptive statistics.

Results: We identified four themes in the qualitative data: (i) Decoding Interactions: Making Sense of the 4HM in IC services, (ii) Fostering Change: Legitimising 4HM Through Staff Engagement, (iii) Harmonising Practice: Integrating 4HM into Complex Situations, and (iv) Embedding Value: Normalising the 4HM into Everyday Work. These themes illustrate the normalisation process of the 4HM course within IC, establishing standard practices. Healthcare professionals and managers highlighted the urgent need to integrate communication skills based on the 4HM into daily care. They noted positive changes in their communication habits following the course. The consistent findings from the NoMAD questionnaire underscore the sustainability of implementing the 4HM programme, as participants continue to utilise it in their clinical practice beyond the initial four-month period.

Conclusion: The 4HM course programme was deemed feasible for expansion within IC services. Both managers and staff found its focus on addressing communication breakdowns and readiness for change sensible. The study findings may benefit the stakeholders involved in IC service routines, potentially improving services for older patients and relatives.