Care Facilities Research Articles

Exploration of Iron deficiency Anemia and its associated factors among pregnant women seeking antenatal care in public health facilities of southwestern Ethiopia. A mixed study.

Background: Anemia is a major problem in Ethiopia, affecting a large part of the population. Despite the importance of the problem, the causes of anemia, especially iron deficiency anemia, among pregnant women attending antenatal care (ANC) in the study area have been little studied. Therefore, the aim of this study was to investigate iron deficiency anemia and its associated factors in pregnant women seeking antenatal care in public health facilities in Southwest Ethiopia in 2023. Methods and Materialsa mixed facility-based cross-sectional study was conducted involving 364 pregnant women from selected health facilities in Ilubabor and Buno Bedele zones. Backward multiple logistic regression was used to analyze the relationship between dependent and independent variables, with statistical significance set at a P value less than 0.05. ResultsIn this study, the prevalence of iron deficiency anemia was found to be 21.4%. Several factors have been significantly associated with iron deficiency anemia including; presence of malaria parasite [AOR= 15.8, CI = 5.1–48.4], presence of Helminthes [AOR= 8.1, CI=2.8–23.9], consumption of leafy vegetables less than once a day [AOR = 3.4, CI = 1.5-13.3] and not taking iron supplements/consumption [AOR= 2.2, CI = 1.1 to 4.4]. Conclusion and RecommendationsThe overall prevalence of iron deficiency anemia in the study area suggests that, it is a moderate public health problem. In order to improve the nutritional status of women, routine and consistent nutritional advice, the establishment of regular preventive systems and the implementation of feedback mechanisms are recommended.

Analgesic regimens administered to older adults receiving skilled nursing facility care following hip fracture: a proof-of-concept federated analysis

BackgroundAlthough a majority of patients in the U.S. receive post-acute care in skilled nursing facilities (SNFs) following hip fracture, large-sample observational studies of analgesic prescribing and use in SNFs have not been possible due to limitations in available data sources. We conducted a proof-of-concept federated analysis of electronic health records (EHRs) from 11 SNF chains to describe analgesic use during hip fracture post-acute care.MethodsWe included residents with a diagnosis of hip fracture between January 1, 2018 and June 30, 2021 who had at least one administration of an analgesic. Use of analgesics was ascertained from EHR medication orders and medication administration records. We quantified the proportion of residents receiving analgesic regimens based on the medications that were administered up to 100 days after hip fracture diagnosis. Plots visualizing trends in analgesic use were stratified by multiple resident characteristics including age and Alzheimer’s Disease and Related Dementias (ADRD) diagnosis.ResultsThe study included 23,706 residents (mean age 80.5 years, 68.6% female, 87.7% White). Most (~ 60%) residents received opioids + APAP. Monotherapy with APAP or opioids was also common. The most prevalent regimens were oxycodone + APAP (20.1%), hydrocodone + APAP (15.8%), APAP only (15.1%), tramadol + APAP (10.4%), and oxycodone only (4.3%). During the study period, use of APAP-only increased, opioids-only decreased, and opioids + APAP remained stable. Use of APAP-only appeared to be more prevalent among individuals aged > 75 years (versus ≤ 75 years) and those with ADRD (versus without).ConclusionsWe successfully leveraged federated SNF EHR data to describe analgesic use among residents receiving hip fracture post-acute care.

Midwives' experiences regarding recordkeeping during intrapartum care in Limpopo Province healthcare facilities.

South Africa has experienced an increase in litigations because of poor recordkeeping. The quality of maternal healthcare necessitates quality recordkeeping. All midwives' interventions should be documented in the maternity case record as an instrument to highlight the quality of intrapartum care offered. The purpose of the study was to determine and describe the experiences of midwives regarding recordkeeping during intrapartum care in Limpopo province and to make recommendations to improve recordkeeping. A qualitative, explorative and descriptive design was adopted. Midwives were selected purposively to participate in focus group discussions. Data were thematically analysed with the help of the independent transcriptionist and coder. The findings revealed the themes: perceptions of midwives regarding recordkeeping and the challenges and enablers that influence recordkeeping during intrapartum care. Quality recordkeeping requires timely, detailed, comprehensive and accurate recording. The study recommended the availability of updated guidelines, in-service training, monitoring and evaluation of recordkeeping, peer review, record auditing, proper time management among midwives and appointment of staff in line with the staffing needs of the unit to enhance recordkeeping.Contribution:Quality recordkeeping has a positive impact on the provision of quality healthcare to mothers during intrapartum care and reduces litigations related to maternity cases.

Geographic inequities in hemodialysis access: a call to reassess dialysis facility locations in Brazil.

Patients who travel more than 60 min to undergo hemodialysis may experience higher mortality and lower quality of life. The primary aim of this study was to calculate the travel distance between patient city areas and dialysis facility care locations in Brazil, to highlight barriers and need to optimize access to chronic dialysis. We conducted a retrospective cohort study using claims data from the Brazilian Public Health System's database, focusing on kidney replacement therapy (KRT) by hemodialysis. Our study population comprised all patients undergoing hemodialysis in Brazil between January 2023 and December 2023. For patients from different city areas, we calculated the Haversine distance between the patient city area and the dialysis facility. We evaluated 154,788 patients who received hemodialysis funded by the Brazilian Public Health System. Fifty-nine percent of the patients underwent dialysis in the same city area. Overall, patients traveled a median (IQR) distance of 35.9 [19.5 - 64.2] kilometers to the facilities, 48% traveled more than 40 km, with a maximum traveling distance of 353 km. Notably, the median distance traveled was shortest in the Southeast (27.6 km) and longest in the North (84.3 km). The number of patients that traveled more than 40 km was lower in the Southeast (32%) and higher in the North region (77%). The travel distance to the dialysis facility is an important inequity to KRT access in Brazil. In the South and Southeast, where there is a higher dialysis unit density, patients have greater regional availability of dialysis centers, and shorter traveling distances than in the North, Midwest, and Northeast regions.

System opieki nad małym dzieckiem w Danii z perspektywy osób rozważających emigrację

The purpose of this article is to present the Danish childcare system before starting school, to analyze the types of care available and its provision in the context of children’s developmental needs. The text describes types and terms of care and the care facilities. It also indicates the principles of the pedagogical plan, what values it reflects and what aspects of care and upbringing are paid attention to in Denmark. The system is described in the context of the assumptions of developmental psychology, and so the basis of the assumptions for caring for children and supporting their development is defi- ned. The developmental effects of implementing the pedagogical plan are analyzed.

Facilitators and Barriers in Palliative and End-of-Life Care in Prisons.

With an aging prison population facing various chronic diseases, the importance of palliative and end-of-life care (EOLC) in correctional facilities is heightened. This systematic review aimed to identify facilitators and barriers to palliative and EOLC in prisons. PubMed, Web of Science, Scopus, and Cochrane databases were searched for primary qualitative studies (January 2014 to December 2022) in English. Eligible studies focused on people in prison, health care professionals, administrators, and governors regarding palliative or EOLC provision within prison settings. Five studies were included, from Australia, France, the United Kingdom, and the United States, whose overall quality was moderate to high. Key facilitators included access to family, support from prison staff, specialized care availability, and cultural/spiritual support. Barriers encompassed discomfort, patient-clinician relationship constraints, time limitations, protocol uncertainty, restricted patient agency, negative attitudes, inequality, conflicting priorities, and lack of grief support. Addressing these barriers and leveraging facilitators will be crucial in ensuring equitable access to compassionate EOLC for individuals experiencing incarceration. Policymakers, health care providers, and correctional authorities must prioritize the enhancement of palliative care services within prisons, supported by further research and targeted interventions to address disparities and optimize care provision.

Enhancing Clinical Data Quality to Improve Patient Care in Rural Health Facilities

WHO recognizes that high-quality research is not just a scientific pursuit but a crucial factor in achieving global health, health equity, and economic development. It is not just about the numbers but about the lives we can save and improve. In this context, four research priority areas have been identified: prioritizing health needs, building research capacity, ensuring good research practice, and ensuring good evidence is translated into practice. Local health research tailored to local needs remains an important global health goal, with the potential to revolutionize patient care in rural health facilities. Researchers and policymakers in low- and middle-income countries have expressed serious concerns about the limited access to high-quality data, a fundamental requirement for reliable and valid research. The assessment of data quality is typically categorized into five key areas: availability, usability, dependability, relevance, and presentation quality. This concept is further clarified by demonstrating how a robust healthcare data environment can enhance patient management through research efforts. The term ‘health data environment' encompasses the entire process of gathering, storing, managing, analysing, and utilizing health-related data to improve patient care and healthcare policies through informed decision-making. In this context, we present the challenges that undermine the quality of research data and propose solutions. Specifically, we identify the lack of adequate human resources, reliance on paper-based records systems, and the high costs of internet connectivity as the primary barriers to collecting and sharing high-quality data for research in low-resource settings. To tackle these challenges, we advocate for governments and funding institutions to invest in data management and communication systems, recruit and train data management staff to support clinicians, and reduce connectivity costs. Furthermore, we propose the deployment of a decentralized system as a cost-effective and less labor-intensive solution that only requires data entry staff at health facilities in resource-limited settings. This article explores current data collection, storage, and interpretation challenges and proposes innovative improvement solutions. It emphasizes the transformative potential of digitization, standardization, and staff training to enhance data quality. It further addresses the impact of quality data on evidence-based practice, ultimately leading to improved health outcomes. Focusing on rural healthcare facilities sheds light on the unique barriers these settings face, proposing tailored strategies that can bridge the gap between urban and rural health service delivery. These insights offer valuable guidance for policymakers, healthcare administrators, and practitioners striving to improve patient care in rural areas through data-driven strategies.

Challenges in Diagnosis and Management of SLE in Africa: An Online Survey.

We surveyed African physicians about challenges in diagnosis and management of systemic lupus erythematosus (SLE). We used a cross-sectional, online questionnaire-based survey of African specialist physicians on availability of laboratory tests, medications, and specialized services for the diagnosis of SLE. Our 226 respondents from 31 countries were dermatologists (38%), rheumatologists (28%), and nephrologists (23%), the majority practicing at university/state-funded hospitals (80.8%), but over half of patients (59.6%) were self-funded for laboratory tests and medications. Antinuclear antibody (ANA), antiphospholipid antibody, and complement tests were available to 79.4%, 67.6%, and 62.3% of respondents, respectively, but fewer in the East and West African regions. Median turnaround time for the ANA test was within two weeks but more than four weeks for 5.6% of respondents, and longer in West Africa compared with other regions (P = 0.0002). Availability of urine protein-to-creatinine test, skin and renal histopathology was 82%, 82.5%, and 76.2%, respectively. Median turnaround times were within one to two weeks, but more than four weeks for 13.8% of respondents for skin histology results and usually within four weeks but more than four weeks for 24.5% of respondents for renal histology. Glucocorticoids and antimalarials were readily available across all regions, with variable availability of immunosuppressants from 93.7% for methotrexate to 65% for calcineurin inhibitors and only 58.4% for the biologic rituximab. Intensive care units/high care facilities, hemodialysis, and renal transplantation were available to 69.8%, 91.9%, and 56.5% of respondents, respectively. Variable availability of laboratory tests, medications, and supportive services coupled with cost constraints are major impediments to early diagnosis and optimal management of SLE in most of Africa and are likely factors contributing to underreporting and poor prognosis of SLE in Africa.

(Digital) Mind-Body Intervention for Residents in Care Facilities: Mixed Format of On-Site and App Intervention to Combine Benefits

(Digital) Mind-Body Intervention for Residents in Care Facilities: Mixed Format of On-Site and App Intervention to Combine Benefits

Health Insurance Type and Access to the Indian Health Service Before, During, and After Childbirth Among American Indian and Alaska Native People in the United States

BackgroundAmerican Indian and Alaska Native (AI/AN) people in the United States face elevated childbirth-related risks when compared with non-Hispanic white people. Access to health care is a treaty right of many AI/AN people, often facilitated through the Indian Health Service (IHS), but many AI/AN people do not qualify for or cannot access IHS care and rely on health insurance coverage to access care in other facilities. Our goal was to describe health insurance coverage and access to IHS care before, during, and after childbirth for AI/AN birthing people in the United States. MethodsWe analyzed 2016 ton 2020 Pregnancy Risk Assessment Monitoring System data (44 states and 2 other jurisdictions) for 102,860 postpartum individuals (12,920 AI/AN and 89,940 non-Hispanic white). We calculated weighted percentages, adjusted predicted probabilities, and percentage point differences for health care coverage (insurance type and IHS care) before, during, and after childbirth. ResultsApproximately 75% of AI/AN birthing people did not have IHS care around the time of childbirth. AI/AN people had greater variability in insurance coverage and more insurance churn (changes in type of insurance, including between coverage and no coverage) during the perinatal period, compared with non-Hispanic white people. Health care coverage differed for rural and urban AI/AN people, with rural AI/AN residents having the lowest prevalence of continuous insurance (60%). ConclusionAI/AN birthing people experience insurance churning and limited access to IHS care during the perinatal period. Efforts to improve care for AI/AN birthing people should engage federal, state, and tribal entities to ensure fulfillment of the trust responsibility of the United States and to address health inequities.

A-182 Applications of artificial intelligence optical character recognition in laboratory clerical functions offsetting staffing shortages and error reduction

Abstract Background The clinical laboratory profession has been dealing with a decade long, and now critical retention and staffing problem. The average national turnover rate for laboratory technicians is 17%, and the highest turnover rate exhibited for phlebotomists is 36%. While turnover rates have an impact on a laboratory, or hospitals budget, more importantly they have a substantial impact on quality and error rates, particularly in the pre-analytical stage of testing; with studies showing up to 65.09% of errors impacting the pre-analytical phase. Methods In an effort to remedy this high error rate, a meta-analysis was performed on paper order entry and clerical pre-analytical error, in parallel with performance and accuracy data of advanced optical character recognition driven by artificial intelligence and machine learning (AI OCR). Results AI OCR studies demonstrated an untrained accuracy percentage, to include handwriting of 91.08%, and when trained utilizing both relational and hierarchal logic data bases accuracy increased to 98.4%. The rate at which AI OCR processed and classified medical information was 3-4 pages per second. It is estimated that 99.9%-100% accuracy can be achieved with additional form field training and mapping. The level of accuracy and efficiency for laboratory paper order-entry utilizing AI OCR can also be increased with the addition of natural language processing and data recognition algorithms when combined with logic databases containing information such as medical record numbers, ICD-10 codes, and laboratory test compendiums. Conclusions The performance of this technology demonstrates a strong application to reduce the burden of clerical paper order entry, while addressing the 30.8% dissatisfaction rate regarding manual entry processes among lab professionals surveyed. Moreover, AI OCR clerical data classification, extraction and entry processes augmented with human verification steps examined, demonstrated overall accuracy of 99.99%. The application of AI OCR in laboratory pre-analytical processes has the potential to improve test order accuracy and efficiency, ultimately impacting the quality of patient care and operational costs for healthcare facilities. When examined through the lens of staff retention, studies show that 80% of laboratory employees feel that a workplace with the necessary tools and technology positively impacts their job satisfaction. While organizations investing in technologies that drive both job efficiency and satisfaction see a 125% return on investment through productivity. Demonstrating that the application of sophisticated technologies that both increase productivity and decrease error rates have a substantial impact on job satisfaction and ultimately retention. Although laboratory clerical data and order entry processes were examined for this meta-analysis, the aggregate data compiled showed that the application of AI OCR in clerical processes could also have a substantial impact on the 25.9% annual turnover rate for hospitals as a whole in the United States.

Interactive hygiene training using free open source software.

Regular hygiene trainings are an important way to refresh and improve knowledge about hygiene measures and the prevention of healthcare-associated infections. We aimed to develop an e-learning course to allow healthcare workers (HCWs) to learn these contents through a self-paced online format. We developed an interactive hygiene training for HCWs of a tertiary care hospital using different content types of the HTML-5 package (H5P) plugin embedded into a Moodle-based learning management system. We evaluated the course using a short online questionnaire. We present various suitable topics for online hygiene trainings as well as their implementation in an e-learning course. Examples include content on hand hygiene indications and techniques, information on multidrug-resistant organisms and other current topics in infection control. HCWs reported high overall satisfaction, perceived increase in knowledge, practical relevance as well as good usability and comprehensibility. Currently available commercial and non-commercial hygiene trainings present a number of specific advantages but also drawbacks. The presented approach combines the advantages of both approaches. The majority of the presented content can be readily adapted to suit various hospitals and care facilities or serve as inspiration for creating similar courses while remaining cost-effective. H5P course presentations are a low-threshold, cost-effective way to implement digital hygiene trainings in a wide variety of clinical settings.

Impact of the Hospital Frailty Risk Score on Outcomes following Primary Total Elbow Arthroplasty

The Hospital Frailty Risk Score (HFRS) has demonstrated strong correlation with adverse outcomes in various joint replacement surgeries, yet its applicability in total elbow arthroplasty (TEA) remains unexplored. The purpose of this study is to assess the association between HFRS and postoperative complications following elective primary TEA. The Nationwide Readmissions Database was queried to identify patients undergoing primary TEA from 2016 to 2020. The HFRS was used to compare medical, surgical, and clinical outcomes of frail vs. non-frail patients. Mean and relative costs, total hospital length of stay (LOS), and discharge disposition for frail and non-frail patients were also compared. We identified 2,049 primary TEA in frail patients and 3,693 in non-frail patients. Frail patients had increased complication rates including acute respiratory failure (13.6% vs. 1.1%; p < 0.001), urinary tract infections (12.3% vs. 0.0%; p < 0.001), transfusions (3.9% vs. 1.1%; p < 0.001), pneumonia (1.1% vs. 0.2%; p < 0.001), acute respiratory distress syndrome (3.2% vs 0.6%; p < 0.001), sepsis (0.7% vs. 0.1%; p < 0.001), and hardware failure (1.2% vs 0.1%; p < 0.001). Frail patients also experienced higher rates of readmission (37% vs. 25%; p < 0.001) and death (1.7% vs. 0.2%; p < 0.001), while being less likely to undergo revision (6.5% vs. 17%; p < 0.001). Frail patients incurred higher healthcare costs ($28,497 vs. $23,377; p < 0.001) and longer LOS (5.3 days vs. 2.6 days; p < 0.001), with reduced likelihood of routine hospital stays (36% vs. 71%; p < 0.001) and increased utilization of short-term hospitalization (p < 0.001), care facilities (p < 0.001), and home health care services (p < 0.001). HFRS is a validated indicator of frailty and is strongly associated with increased rates of complications in patients undergoing elective primary TEA. These findings should be considered by orthopedic surgeons when assessing surgical candidacy and discussing treatment options in this at-risk patient population.

Оказание хирургической помощи пострадавшим от применения огнестрельного оружия ограниченного поражения в Арктической зоне Архангельской области

Summary. The aim of the study was to estimate the surgical care provided to the victims of traumatic weapons in the Arctic zone of the Arkhangelsk region. Materials and methods of research. We conducted a document-based statistical study using the records from 248 case histories (statistical form # 003/u) filled in for the victims of traumatic weapons, who received medical care in medical facilities of Arkhangelsk and Severodvinsk cities, located the Arctic Zone of Russia in 2005-2022. The research methods are analytical and mathematical-statistical. Categorical variables presented as percentages and frequencies were used for the analysis. The values of all relative quantities were calculated using the WinPepi program. The severity of the injuries was assessed using the VPKh-P(OR) scale, developed under the supervision of Major General of the Medical Service, Professor E.K.Gumanenko (1990) at the S.M.Kirov Military Medical Academy. The results of the study and their analysis. Every third victim of limited-damage firearms in the Arctic zone of the Arkhangelsk region required inpatient surgical care with the involvement of surgeons of various specialties. In case of multiple and combined wounds, it was necessary to involve two or more surgeons of various profiles. In case of minor wounds from limited-damage firearms during primary surgical treatment, the severity of the wound is underestimated by surgeons and, as a result, the bullet is not initially detected and remains in the wound, which, in turn, complicates the condition of the victim and requires repeated surgical intervention. In 39% of cases of wounds from limited-damage firearms to the head, every fifth case (21.9%) of wounds to the chest, every tenth case of wounds to the abdomen – specialized surgical care is required, the availability of which in the Arctic zone can be very problematic.

Patient’s willingness to pay for improved community health insurance in Tanzania

Globally, achieving universal health coverage remains significant challenge. Health insurance coverage in low- and middle-income countries is still low with only a few African countries managed to reach 50% coverage. This study aimed to investigate the factors influencing patients’ willingness to pay (WTP) for medication and various versions of the improved Community Health Insurance Fund (iCHF) in Tanzania. A facility-based cross-sectional study was conducted in all hospitals, health centres, and eight randomly sampled dispensaries, sampling participant from the queue, one out of every three patient based on their order of entry into consultation room, and interviewed 1,748 patients in Kilombero and Same districts in Tanzania. We used multi-stage Contingent Valuation Methods exploring data collected during client exit interviews. We employed a random utility model and estimated WTP through an ordered logit model. The independent variables were; patient’s gender, age, marital status, education, employment status, Non-Communicable Disease (NCD) status, health insurance status, and the type of healthcare facility level. Our findings revealed that most patients exhibited a WTP of an amount equivalent to the current iCHF premiums and would also be willing to pay for an augmented iCHF premium inclusive of additional medication coverage. Upon adjusting for demographic characteristics, we observed that patients enrolled in an insurance program or benefiting from user fee waivers demonstrated a lower WTP for medication, while those with non-communicable diseases (NCDs) and seeking care in private facilities exhibited a higher WTP. Furthermore, patients with a secondary education level or above generally displayed higher WTP for premiums. Conversely, patients enrolled in private insurance and availing user fee waivers, along with those accessing care in public facilities, demonstrated a lowered WTP for iCHF premiums. These results highlight the need for targeted interventions to address systemic deficiencies and improve access to medicines. Our conclusions is that policies considering NCD status, education levels and income status are important when designing health insurance schemes for the informal sector in Tanzania, with the goal of increasing uptake of CHF.

Remote coaching for supporting the implementation of treatment for depression in primary care in Madhya Pradesh, India: protocol for a cluster randomized controlled trial.

Upwards of ninety percent of individuals living with depression in India do not have access to evidence-based treatments, especially in rural areas. Integrating these treatments into primary care is essential for bridging this care gap. This trial aims to evaluate whether a remote coaching implementation support strategy, referred to as Enhanced Implementation Support, is superior to routine support, referred to as Routine Implementation Support, in supporting the delivery of collaborative depression care in rural primary care centers. Employing a cluster-randomized hybrid type-III implementation trial design, 14 primary care facilities in Sehore district, Madhya Pradesh, will implement a collaborative depression care package based on the WHO's mhGAP program. Facilities will be randomized to either Enhanced Implementation Support or the Routine Implementation Support control condition. Enhanced Implementation Support consists of remote coaching and technical assistance, supplemented with in-person visits, and guided by the Plan-Do-Study-Act implementation cycles. The primary implementation outcome is the proportion of outpatients screened for depression by facility staff, with secondary outcomes including the proportions of outpatients who screen positive for depression, are referred to the medical officer, and initiate treatment. Secondary patient outcomes include proportion of patients who achieve reduction in depression symptom severity at 3-month follow up. Acceptability, feasibility, and fidelity of the depression care package will be assessed through routine observations collected during field visits, facility audits, and qualitative exit interviews with facility staff. Costs of delivering the Enhanced Implementation Support strategy will also be estimated. This trial can inform efforts to integrate depression care in rural primary care facilities in a low-resource setting, and illuminate whether external coaching support is superior relative to existing implementation support for achieving these goals. NCT05264792.

Role of Hospital Connectedness in Brain Metastasis Outcomes

Although patients with brain metastases receive interdisciplinary and multi-institutional care, the association between neuro-oncologic care networks and patient outcomes remains unknown. As patients often interact with multiple facilities, quantifying this association across a network of hospitals is critical to capture the complexity of the health care journey for patients with brain metastases. To evaluate how statewide health care network metrics are associated with inpatient mortality and hospital length of stay (LOS) for patients with brain metastases. This multicenter, statewide cohort study used data from the 2018 to 2019 Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases. Primary analyses were completed by August 2023. Participants included adults with a brain metastases receiving care in Massachusetts. All inpatient and emergency department visits mapped for patients following the first diagnosis of brain metastasis. Inpatient mortality and hospital LOS were the main outcomes assessed. Hospital interdependence in brain metastases care was calculated using a connectedness score (weighted degree: weighted sum of ties to other care facilities). The association between hospital connectedness and clinical outcomes was analyzed using mixed-effects logistic and linear regression models, adjusting for hospital-level features. In this cohort study, 4679 patients with brain metastases were identified with inpatient or ED encounters in Massachusetts (from 2018 to 2019). The median (IQR) age was 64 (57-73) years, and 2559 (55%) were female. There was interdependence in brain metastases care, with 993 patients (21%) visiting 2 or more unique hospitals. Highly connected hospitals were heterogeneous, with many being small and one-half lacking subspecialty neuro-oncologic care or teaching status. Increased hospital connectedness was significantly associated with improved inpatient mortality for patients with brain metastases, with the lowest connectedness quartile associated with more than double the risk of mortality compared with the highest quartile (odds ratio, 2.34; 95% CI, 1.33-4.11; P = .003). A stepwise increase in inpatient mortality risk was observed as hospital connectedness decreased, independently of hospital volume. Furthermore, intermediate hospital connectedness was associated with increased hospital LOS (coefficient, 1.08; 95% CI, 0.17-1.95; P = .006). This study found that hospital-to-hospital interconnectedness was significantly associated with improved clinical outcomes for patients with brain metastases. The salience of network metrics highlights their potential role alongside other patient-level and hospital-level variables to evaluate and improve oncology care delivery.

Addressing causality: participatory evaluation on improvisational drama workshops for people with dementia and their carers

ABSTRACT Despite advancements in arts and health research, the processes through which arts activities contribute to wellbeing and care remain ambiguous. This study aims to shed new light on causal links surrounding the impact of improvisational drama workshops on people with dementia and their carers at care facilities, using both participatory and goal-free evaluation. The article outlines challenges and strategies in addressing causality in the arts, followed by methodology and research context. Findings are discussed framed by key considerations for arts impact: negative impacts, uniqueness of the arts, artistic quality, and long-term outcomes. We conclude that a two-layered causal process, micro and macro, contributes to meaningful impact. This perspective emphasizes learning from negative impacts, integrating artistic elements with other relevant factors through trial and error, and reassessing shared goals during implementation. Sustained efforts in this endeavor can lead to significant long-term outcomes, extending beyond individual behavioral changes to community growth.

Analysis of Neoadjuvant Chemotherapy Utilization, Pathologic Response, and Overall Survival in Upper Tract Urothelial Carcinoma

IntroductionUpper tract urothelial carcinoma (UTUC) is a rare malignancy with poor prognosis. Radical nephroureterectomy (RNU) remains the standard treatment for high-risk UTUC. Considering the decline in renal function with RNU and results from prospective trials, NAC has emerged as a favored perioperative treatment for chemo-eligible patients with UTUC. However, strong evidence of the efficacy of NAC and predictors for its use are scarce. We aimed to assess trends in NAC utilization and pathologic outcomes and survival with NAC use. MethodsThe National Cancer Database was queried for patients with high-grade cTanyNanyM0 UTUC treated with RNU from 2004 to 2019. Outcomes included overall survival (OS), pathologic response (pR) and pathologic complete response (pCR), defined as ≤pT1pN0/X and pT0pN0/X, respectively. ResultsOf 6,645 patients treated with RNU, 209 received RNU NAC. Greater distance from treatment facility decreased the likelihood of receiving NAC. Higher cT stages (OR 1.72, P = .028), cN+ status (OR 7.40, P < .001) and treatment at an academic facility (OR 2.02, P < .001) predicted NAC treatment. NAC was associated with 34.0% pR and 5.3% pCR. In multivariable analysis, patients with pR and pCR had improved OS (HR = 0.176, P < .014). ConclusionWe report significant response rates with NAC and improved OS in patients who experienced pR or pCR. Over a 15-year study period, NAC was underutilized, especially in nonacademic settings and among patients living farther from care facilities, underscoring the need for improved regionalization and multidisciplinary approaches in UTUC management.

Inclusion of disability in primary healthcare facilities and socioeconomic inequity in Brazil.

To describe disability-related performance and inequality nationwide in Brazil, and the changes that took place between 2012 and 2019 after the introduction of Programme for Improving Primary Care Access and Quality (PMAQ). We derived scores for disability-related care and accessibility of primary healthcare facilities from PMAQ indicators collected in round 1 (2011-2013), and round 3 (2015-2019). We assessed how scores changed after the introduction of PMAQ. We used census data on per capita income of local areas to examine the disability-specific care and accessibility scores by income group. We undertook ordinary least squares regressions to examine the association between PMAQ scores and per capita income of each local area across implementation rounds. Disability-related care scores were low in round 1 (18.8, 95%CI 18.3-19.3, out of a possible 100) and improved slightly by round 3 (22.5, 95%CI 22.0-23.1). Accessibility of primary healthcare facilities was also poor in round 1 (30.3, 95%CI 29.8-30.8) but doubled by round 3 (60.8, 95%CI 60.3-61.3). There were large socioeconomic inequalities in round 1, with both scores approximately twice as high in the richest compared to the poorest group. Inequalities weakened somewhat for accessibility scores by round 3. These trends were confirmed through regression analyses, controlling for other area characteristics. Disability-related and accessibility scores also varied strongly between states in both rounds. People with disabilities are being left behind by the Brazilian healthcare system, particularly in poor areas, which will challenge the achievement of universal health coverage.