Conectar
To identify implementation strategies that effectively facilitate the adoption of social needs care coordination activities using enabling technologies among care management teams serving patients in community-based health centres.
Modified Delphi process.
Discrete, feasible implementation strategies were identified through literature review and semi-structured interviews with care management staff and subject matter experts in clinical informatics, workflow redesign, and product engineering. A modified Delphi was conducted with eight subject matter experts and nine health centre care management staff. Iterative rounds of online surveys were used to achieve consensus on the most relevant implementation strategies and their delivery methods.
The modified Delphi process achieved consensus on nine discrete implementation strategies needed to advance care management teams' ability to screen, refer and track social needs. Prioritised strategies included developing champions, enhancing quality improvement capacity, training staff on using enabling technologies and providing tailored technical assistance for workflow refinement. Consensus was also reached on a monthly cadence for most of the implementation strategies.
Consensus was reached on strategies to enhance care management teams' implementation of social needs screening, referrals and tracking using enabling technologies. These strategies will comprise an intervention to be pilot tested, refined and assessed in a cluster randomised clinical trial.
Findings from this study will inform the development of strategies to further the adoption of enabling technologies to support social needs care coordination.
This work is key to the design of a type 2 hybrid implementation-effectiveness trial that will assess whether user-informed, evidence-based implementation strategies can improve care management teams' adoption of enabling technologies to facilitate social needs care coordination for patients.
The research team includes a patient advisor with community-based nursing expertise and a nurse practitioner-clinical informaticist leader who was involved in data collection and interpretation of findings.
Trial registration: Clinicaltrials.gov registration # NCT06489002. Registered July 5, 2024, https://clinicaltrials.gov/study/NCT06489002?term=NCT06489002&rank=1.
To identify outcome domains of importance to adults undergoing prosthetic rehabilitation following lower limb amputation in low- and middle-income countries (LMICs), based on their lived experiences described in qualitative literature.
Systematic review and qualitative synthesis informed by a critical realist perspective and reported according to ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines.
CINAHL, PsycInfo, Web of Science and Trip databases were searched from inception to April 2024.
We included qualitative studies exploring the views and experiences of adults (≥18 years) using lower limb prosthesis in LMICs (World Bank definition). Studies including upper limb amputees, non-prosthetic users, mixed samples that could not be disaggregated or not reporting first-person accounts were excluded.
Two reviewers independently screened studies using predefined criteria. Data were extracted from results sections, including participant quotations and author interpretations. Reflexive thematic analysis was conducted to identify outcome domains across studies. Study quality was appraised using the CASP (Critical Appraisal Skills Programme) qualitative checklist; no studies were excluded based on quality.
Five studies involving 55 participants from Nepal, Kenya, Cambodia, Bangladesh and Kiribati met the inclusion criteria. Four outcome domains were identified: (1) The importance of a prosthesis: highlighting access, socket comfort, durability and functional suitability; (2) valued activities: particularly the importance of work and participation in daily living tasks; (3) acceptance following limb loss: encompassing community participation and self and social acceptance; and (4) independence: including reduced reliance on family and greater control over daily life. Across settings, participants emphasised prosthesis durability, work participation and culturally relevant function.
Evidence on meaningful outcomes of prosthetic rehabilitation in LMICs is extremely limited. Findings indicate that access to a comfortable and durable prosthesis enabling work and daily living is central to recovery, alongside social acceptance and independence. These domains may provide initial insights into outcome measurement and development in low-resource settings. Further primary research across diverse LMIC contexts is urgently needed.
Practice guidelines recommend addressing patient non-medical drivers of health such as access to nutritious food and transportation as part of whole-person care. Emergent electronic health record (EHR)-based tools can enable non-medical needs care coordination, but adoption commonly faces workflow and infrastructure barriers. Targeted implementation support strategies (eg, training, practice facilitation) can enhance technology adoption in healthcare settings, but no prior research has assessed if implementation strategies can improve how care managers use enabling technologies for non-medical needs care coordination. This study will test whether providing implementation support to primary care health centre care management teams improves the adoption of EHR-based enabling technologies to address patients’ non-medical needs.
This hybrid implementation-effectiveness type 2 pragmatic trial has a mixed methods design. The primary outcomes include: (1) Whether patients enrolled in care management programmes have been screened for unmet non-medical health-related needs and (2) Whether patients with identified unmet non-medical health-related needs received a referral to a community organisation to address their need. The secondary outcomes include: (1) Whether referrals for financial-related non-medical needs had a documented outcome in the EHR, such as successful connection to services, service unavailability or other disposition statuses, (2) Whether the referral outcomes indicated ‘successful connection to services’ and (3) Clinical markers including hypertension and diabetes control. Formative evaluation of barriers and facilitators to using EHR tools to conduct non-medical needs screening, referrals and tracking of receipt of services will include semi-structured interviews and a ‘guided tour’ of enabling technology used by care managers. A modified Delphi process will then inform the development of a set of implementation strategies for inclusion in the intervention. The intervention will be piloted in three health centres, refined, then tested in a stepped-wedge cluster-randomised trial in 20 health centres.
We obtained ethics approval for all study activities from Advarra Institutional Review Board (registration number #00000971). Results will be disseminated to Health Centres and Health Centre network nationally at meetings and we will disseminate to researchers via manuscripts in peer-reviewed journals and scientific meetings.
Previous studies have shown the COVID-19 pandemic was associated with reductions in volume across a spectrum of non-SARS-CoV-2 hospitalizations. In the present study, we examine the impact of the pandemic on patient safety and quality of care.
This is a retrospective population-based study of discharge abstracts.
We applied a set of nationally validated indicators for measuring the quality of inpatient care to hospitalizations in Ontario, Canada between January 2010 and December 2022. We measured 90-day mortality after selected types of higher risk admissions (such as cancer surgery and cardiovascular emergency) and the rate of patient harm events (such as delirium, pressure injuries and hospital-acquired infections) occurring during the hospital stay.
A total 13,876,377 hospitalization episodes were captured. Compared with the pre-pandemic period, and independent of SARS-CoV-2 infection, the pandemic period was associated with higher rates of mortality after bladder cancer resection (adjusted risk ratio [aRR] 1.20 (1.07–1.34)) and open repair for abdominal aortic aneurysm (aRR 1.45 (1.06–1.99)). The pandemic was also associated with higher rates of delirium (adjusted odds ratio [aOR] 1.04 (1.02–1.06)), venous thromboembolism (aOR 1.10 (1.06–1.13)), pressure injuries (aOR 1.28 (1.24–1.33)), aspiration pneumonitis (aOR 1.15 (1.12–1.18)), urinary tract infections (aOR 1.02 (1.01–1.04)), Clostridiodes difficile infection (aOR 1.05 (1.02–1.09)), pneumothorax (aOR 1.08 (1.03–1.13)), and use of restraints (aOR 1.12 (1.10–1.14)), but was associated with lower rates of viral gastroenteritis (aOR 0.22 (0.18–0.28)). During the pandemic, SARS-CoV-2-positive admissions were associated with a higher likelihood of various harm events.
The COVID-19 pandemic was associated with higher rates of patient harm for a wide range of non-SARS-CoV-2 inpatient populations.
Understanding which quality measures are improving or deteriorating can help health systems prioritize quality improvement initiatives.
No patient or public contribution.
Difficulty with walking can lead to reduced quality of life for people with Parkinson’s disease (pwPD); improving walking is considered a treatment priority. Drug therapies can control PD symptoms; however, pwPD often still experience mobility problems.
Functional electrical stimulation (FES) induces movement in weak muscles via external electrical stimulation. FES is used in stroke and multiple sclerosis patients to correct dropped foot by stimulating the common peroneal nerve and is associated with improved quality of life and mobility. The randomised feasibility study preceding this definitive study showed that daily FES can produce a clinically meaningful improvement in walking speed in pwPD; this was sustained 4 weeks after FES was withdrawn. STEPS II is the first definitive randomised controlled trial, with blinded outcome assessment, aiming to determine the efficacy of FES in pwPD.
STEPS II is a two-group, parallel, assessor-blinded, superiority randomised controlled trial with an internal pilot, designed to compare FES plus usual care versus usual care alone. 234 participants will be randomised across eight UK sites. Telephone pre-screening and face-to-face screening will determine eligibility. The intervention group will attend four unblinded FES visits to receive the device and assess walking with and without FES. All participants have blinded assessments at baseline and weeks 2, 6, 18 and 22. The primary objective is to compare whole body bradykinesia at 18 weeks post-baseline via changes in 10m walking speed. Secondary objectives will assess the wider effects of FES on Parkinsonian gait and quality of life. An embedded qualitative component will explore wider experiences of FES.
This study received ethical approval from the Yorkshire and The Humber-Sheffield Research Ethics Committee (reference 23/YH/0193). A Data Monitoring Committee and Trial Steering Committee will provide independent oversight. Dissemination will be via publications, conferences and social media. FES intervention and training materials will be made open access.
Gestational diabetes is a common metabolic disorder in pregnancy which identifies a substantial increased risk of future diabetes. Despite this risk, many individuals are not screened for dysglycaemia in the postpartum period. Continuous glucose monitoring (CGM) is an evolving technology that provides details of an individual’s glucose levels throughout the day; however, it has not yet been evaluated as a screening tool for postpartum dysglycaemia. To address this gap, this prospective cohort study will examine the use of CGM in the early postpartum period to predict the risk of maternal dysglycaemia after delivery.
The Predicting Dysglycaemia in Individuals with Gestational Diabetes Immediately Postpartum using CGM (PREDISPOSE) study is a prospective cohort study designed to assess the ability of a CGM device (Freestyle Libre 2) worn in the postpartum period to detect persistent dysglycaemia in individuals with gestational diabetes. The study will recruit 240 individuals with gestational diabetes. Each participant will wear the CGM immediately postpartum and before attending routine postpartum diabetes screening, consisting of a 75-gram oral glucose tolerance test (OGTT) and related blood work (haemoglobin A1c (HbA1c), complete blood count and lipid profile). The primary outcome is the accuracy of the area under the curve for all glucose measurements from the first CGM wear to detect postpartum dysglycaemia. We will perform sensitivity and specificity analyses to determine optimal CGM cut-offs to diagnose diabetes or prediabetes. Secondary outcomes include the incidence of postpartum dysglycaemia (based on 75-gram OGTT and/or HbA1c), incidence of postpartum dyslipidaemia, patient acceptability of CGM testing, data variability from CGM and cardiometabolic health outcomes diagnosed in years one, two and five after delivery.
All participating sites have received ethics approval of the current protocol and have started recruitment of participants to the study. The ethics boards that approved this study are the Biomedical Research Ethics Board at the University of Manitoba, the Conjoint Health Research Ethics Board at the University of Calgary, the Mount Sinai Hospital Research Ethics Board at Mount Sinai Hospital and the Comité d'éthique de la Recherche at Université Laval. Study results will be disseminated through conference presentations and publication in a peer-reviewed journal, regardless of study findings.
NCT04972955. Registration date: 28 June 2021.
Variations in mental health and sexual and reproductive health (SRH) outcomes of girls/women (cisgender and transgender) and gender-diverse (nonbinary, Two-Spirit, gender fluid, agender, queer, gender neutral) youth with intersectional identities exist and have largely been ignored in the literature. There is a lack of information on how these health services meet the health needs of girls/women and gender-diverse youth with intersectional identities and the quality of such services. The objective of this global realist review is to identify how, why, for whom, in what contexts and to what extent mental health and SRH services meet the health needs of girls/women (cisgender and transgender) and gender-diverse youth (10–25 years) with intersectional identities.
The protocol has been registered with PROSPERO and will follow Realist and Meta-narrative Evidence Syntheses Quality Standards for Realist Reviews. We will identify the programme theory and implementation determinants of mental health and SRH services for girls/women (cisgender and transgender) and gender-diverse (nonbinary, Two-Spirit, fluid, agender, queer, gender neutral) youth (10–25 years). The scope of the review will be defined in the first stage and will include consultations with youth Advisory Group members and initial programme theory development. An iterative search of scholarly bibliographic databases (MEDLINE, Embase, APA PsycInfo, CINAHL, Web of Science, IBSS) in addition to a grey literature search will take place in the second stage. The third stage will include evidence extraction and synthesis. In the final stage, the narrative will be developed and refined in consultation with Youth Advisory Group members, and findings will be disseminated.
The study was approved by the Research Ethics Board at the Centre for Addiction and Mental Health (2023/153). Findings will be disseminated through peer-reviewed publications, youth-friendly materials and webinars and national and international conferences.
CRD42024532422.
Commentary on: Toledo-Chavarri A, Delgado J, Rodriguez-Martin B. Perspectives of women living with type one diabetes regarding preconception and antenatal care: A qualitative evidence synthesis. Health Expectations. 2023;27:e13876.
Enhanced peer support and coordinated care between health professionals are needed to address concerns of women with type 1 diabetes in pregnancy. The experiences and perceptions of diverse groups of women with type 1 diabetes need further exploration in order to ensure equitable care.
While guidelines provide evidence-based recommendations for women with type 1 diabetes in pregnancy, women’s perceptions of these recommendations are not well-known. Toledo-Chavarri and colleagues explore these perceptions and found that continuity of care, coordination between health professionals and services, and a more holistic approach are key aspects that are needed for more acceptable, feasible and equitable peripartum care.
Toledo-Chavarri and colleagues...
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