Fragmented Care Research Articles

Midwifery continuity of care for women with perinatal mental health conditions: A cohort study from Australia.

Perinatal mental health (PMH) conditions are associated with adverse outcomes such as maternal suicide, preterm birth and longer-term childhood sequelae. Midwifery continuity of care (one midwife or a small group of midwives) has demonstrated benefits for women and newborns, including a reduction in preterm birth and improvements in maternal anxiety/worry and depression. To determine if midwifery care provided through a Midwifery Group Caseload Practice model is associated with improved perinatal outcomes for women who have anxiety and depression and/or other perinatal mental health conditions. An EPDS ≥ 13, and/or answered the thought of harming myself has occurred to me and/or women who self-reported a history compared to standard models of care (mixed midwife/obstetric fragmented care). A retrospective cohort study using data routinely collected via an electronic database between 1 January 2018 31st of January 2021. The population were women with current/history of PMH, who received Midwifery Caseload Group Practice (MCP), or standard care (SC). Data were analysed using descriptive statistics for maternal characteristics and logistic regression for birth outcomes. One-to-one matching of the MCP group with the SC group was based on propensity scores. 7,359 births were included MCP 12% and SC 88%. Anxiety was the most common PMH with the same proportion affected in MCP and SC. Adjusted odds of preterm birth and adverse perinatal outcomes were lower in the MCP group than the SC group (aOR (95%CI): 0.77 (0.55, 1.08) and 0.81 (0.68, 0.97), respectively) and higher for vaginal birth and full breastfeeding (aOR (95% CI): 1.87 (1.60, 2.18) and 2.06 (1.61, 2.63), respectively). In the matched sample the estimate of a relationship between MCP and preterm birth (aOR (95% CI): 0.88 (0.56, 1.42), adverse perinatal outcomes (aOR (95% CI): 0.83 (0.67, 1.05)) and breastfeeding at discharge (aOR (95% CI): 1.82 (1.30, 2.51)), stronger for vaginal birth (aOR (95% CI): 2.22 (1.77, 2.71)). This study supports positive associations between MCP and breastfeeding and vaginal birth. MCP was also associated with lower risk of adverse perinatal outcomes, though in the matched sample with a smaller sample size, the confidence interval included 1. The direction of the association MCP and preterm birth was negative (protective). However, in the matched sample analysis, the confidence interval was wide, and the finding was also consistent with no benefit from MCP. Randomised controlled trials are required to answer questions around preterm birth and adverse perinatal outcomes and further research is being planned.

Community Hospital Interventions Addressing the Medical and Social Needs of Patients : Patient Perspectives From the CHART Investment Program.

High utilizers of acute care in nonurban settings are at risk for poor health outcomes. Much of Massachusetts is nonurban, with many residents experiencing limited access to health care providers, fragmented health care services, inadequate housing, and low health literacy. This study examines patient perspectives on the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program, a state-based grant program focused on advancing community hospitals toward value-based care. We found that CHART staff engaged patients in care coordination and patient advocacy, promoted patient agency and health literacy, and provided socioemotional support. These findings may help inform future program development around meeting the medical and social needs of high utilizers of health care services.

Frontline perspectives on barriers to care for patients with California Medicaid: a qualitative study.

While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions. To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal. Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation. Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

Living with an artificial eye: qualitative insights into patient and family member experiences.

Artificial eye users (AEUs) can experience a negative impact on psychological and emotional wellbeing, including reduced social functioning, which may be a consequence of living with one eye removed, and/or of having a prosthetic eye. This may have wider consequences for their families. We aimed to explore what it means to live with a prosthetic eye, for both AEUs and their families-and how any quality of life (QoL) issues impact on their day-to-day functioning. A subset of AEUs and their family members taking part in a feasibility randomised controlled trial comparing hand-painted to digitally printed artificial eyes were invited for semi-structured interviews. Transcripts were analysed using reflexive thematic analysis. Qualitative results related to trial participation are covered elsewhere. Here, we focus on QoL and day-to-day functioning. Twelve AEUs (eight males) and five spouses (one male) who had worn artificial eyes for 2-65years took part, and four themes were identified. (1) Impact on day-to-day life: AEUs and their spouses have to adapt to (partial) sight loss, reduced levels of confidence, and social withdrawal. (2) Impact on psychological and emotional wellbeing: distress among AEUs and their spouses can be severe and prolonged, highlight unmet support needs. (3) Challenges with treatment experiences: AEUs experienced negative impact of fragmentation of care and long waiting times. (4) Worries about the future: AEUs mentioned fragility of remaining sight, and concerns around potential need for further treatment. Patients and their family members experience negative impact of being an AEU on their everyday lives and quality of life. There is a potential role for psychosocial support services in supporting AEUs and their families even long after eye loss.

Defining geriatric care in a developing country: A Multidisciplinary model empowering clinical pharmacists

BackgroundThe elderly population often has complex health needs due to multimorbidity, polypharmacy, and inappropriate prescriptions. Clinical pharmacists play an important role in optimizing pharmacotherapy as a part of a multidisciplinary geriatric care team. However, there is a lack of integrated models in developing countries. AimTo develop a standardized framework for the provision of clinical pharmacy services in geriatric care – A Comprehensive Geriatric Care Model. MethodsA systematic service design process was used to develop an innovative geriatric care model in a tertiary hospital in southern India. The roles of stakeholders were captured through interviews and observations. Evidence-based clinical pharmacy services were developed focusing on medication reconciliation, medication review, patient counselling, and transitions of care. ResultsThe Comprehensive Geriatric Care Model integrates the pharmacist into coordinated care. The responsibilities of physicians, nurses, patients, caregivers, and pharmacists throughout the inpatient stay are shown in swim-lane diagrams. Pharmacy services address inappropriate prescriptions, poor adherence, adverse drug reactions, and fragmented care. ConclusionsThe systematic development of an interprofessional geriatric care model embedded with evidence-based clinical pharmacy services was made possible using a patient-centered service design methodology. The implementation and evaluation of this collaborative approach could significantly improve the quality of care and outcomes for older adults.

Care fragmentation and readmission mortality and length of stay before and during the COVID-19 pandemic: data from the National Readmissions Database, 2018–2020

ImportanceA quarter of all 30-day readmissions involve fragmented care, where patients return to a different hospital than their original admission; these readmissions are associated with increased in-hospital mortality and longer lengths-of-stay (LOS). The stress on healthcare systems at the beginning of the COVID-19 pandemic could worsen care fragmentation and related outcomes.ObjectiveTo compare fragmented readmissions in 2020 versus 2018–2019 and assess whether mortality and LOS in fragmented readmissions differed in the two time periods.DesignObservational studySettingNational Readmissions Database (NRD), 2018–2020ParticipantsAll adults (> 18 y/o) with 30-day readmissionsMain outcomes and measuresWe examined the percentage of fragmented readmissions over 2018–2020. Using unadjusted and adjusted logistic and linear regressions, we estimated the associations between fragmented readmissions and in-hospital mortality and LOS.Results24.0–25.7% of readmissions in 2018–2020 and 27.3%-31.0% of readmissions for COVID-19 were fragmented. 2018–2019 fragmented readmissions were associated with 18–20% higher odds of in-hospital mortality compared to nonfragmented readmissions. Fragmented readmissions for COVID-19 were associated with an 18% increase in in-hospital mortality (AOR 1.18, 95% CI 1.12, 1.24). The LOS of fragmented readmissions in March-November 2018–2019 were on average 0.81 days longer, while fragmented readmissions between March-November of 2020 were associated with a 0.88–1.03 day longer LOS.Conclusions and relevanceA key limitation is that the NRD does not contain information on several patient/hospital-level factors that may be associated with the outcomes of interest. We observed increased fragmentation during COVID-19, but its impact on in-hospital mortality and LOS remained consistent with previous years.

Abstract PO3-11-02: Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer

Abstract Introduction Fragmented cancer care is defined as receiving care across multiple institutions. The National Academy of Medicine has identified cancer care fragmentation as a priority area for cost reduction. However, little is known about the role of fragmented care on receipt of guideline-recommended care patient-reported outcomes, particularly among populations affected by health inequities like Black women. The objective of this study was to characterize breast cancer care fragmentation among a population-based cohort of young Black women with breast cancer. Methods Study participants were a population-based sample of self-identified Black women diagnosed with invasive breast cancer at or below age 50, recruited since 2017 through the Florida and Tennessee state cancer registries. As part of the study, participants completed baseline questionnaires about their cancer care delivery experiences. Participants were eligible if they self-reported the locations where they received their cancer treatment (i.e., diagnosis, surgery, chemotherapy, and radiation). Indicator variables for care fragmentation were created to identify participants who received their diagnosis, surgery, chemotherapy, and radiation within the same health system and those who received their cancer care across multiple health systems. Chi-squared tests were used to assess the relationship between care fragmentation, receipt of guideline-recommended genetic testing, and self-rated health. Self-rated health was dichotomized into Excellent/Very Good/Good and Fair/Poor. Results A total of 183 Black women diagnosed breast cancer ≤ age 50 were included in the analysis. Among the included participants, 11% (n=20) only had surgery, 15% (n=27) had surgery and radiation, 17% (n=31) had surgery and chemotherapy, and 57% (n=105) had surgery, chemotherapy, and radiation. Among the 105 women who had surgery, chemotherapy, and radiation, 17% (n=17) received all cancer treatment within the same health system of diagnosis, 21% (n=21) received all cancer treatment within the same health system but were diagnosed within a different health system, and the remaining 62% of participants received their cancer treatment across different health systems, representing care fragmentation. In chi-squared analyses, fragmented care was not associated with lower receipt of genetic testing(p=0.33) or self-rated health (p=0.28). Conclusion In this population-based study, most participants had fragmented breast cancer care, however fragmentation was not associated with lower self-rated health or receipt of guideline-recommended germline genetic testing. Current approaches for assessing care fragmentation are often too coarse to capture the complexity of breast cancer care delivery and service availability. Patient-centered conceptual models of what drives cancer care fragmentation and the specific aspects of fragmentation that have the potential to drive adverse outcomes are critical. Citation Format: Mya Roberson, Jordyn Brown, Brianna Taffe, Anne Weidner, Lindsay Venton, Sonya Reid, Tuya Pal. Characterizing Breast Cancer Care Fragmentation Among Young Black Women Diagnosed with Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-11-02.

Abstract PO4-23-03: The Influence of Reconstruction Type on Outcomes in Women Undergoing Mastectomy with Immediate Reconstruction: A Nationwide Study

Abstract INTRODUCTION: Outcomes after mastectomy with immediate reconstruction may vary depending on the type of reconstruction, but the evidence is limited and inconsistent. The purpose of this study was to compare the most common reconstruction techniques in a large national cohort of women undergoing these procedures. METHODS: The Nationwide Readmissions Database for 2016-2020 was queried for all women aged 18 years or older undergoing mastectomy for breast cancer with immediate reconstruction. The primary outcome was prolonged length of stay (LOS) greater than 7 days. The secondary outcomes were readmission within 30 days and readmission to a different hospital. The types of reconstruction were compared along with all other relevant variables from the database. Univariable comparison was performed using chi-squared tests for each outcome. Multivariable logistic regression was performed using all significant confounders. RESULTS: During the study period, 35,430 patients were identified undergoing mastectomy for breast cancer with immediate reconstruction. The rate of prolonged (LOS) was 2.4% (n= 840) and the readmission rate was 5.4% (n=1,919). From the readmitted patients, the rate of readmission to a different hospital was 14.2% (n=273). Controlling for confounders with multivariable logistic regression revealed the strongest risk factors for prolonged LOS were latissimus dorsi flap (OR 5.4 [4.0-7.4] p< 0.001) and an investor-owned hospital (OR 4.3 [3.5-5.2] p< 0.001). The highest risk of readmission was a transverse rectus abdominis flap (OR 1.3 [1.1-1.6] p< 0.001) and the highest risk of readmission to a different hospital was a small hospital (OR 2.2 [1.6-3.1] p< 0.001). CONCLUSION: Reconstruction type influences outcomes in women undergoing mastectomy. These outcomes have significant implications for surgical decision-making and fragmentation of care. Further research to identify ways to reduce adverse outcomes and improve patient satisfaction is warranted. Citation Format: Lucia Castro Hernandez, Joshua Parreco. The Influence of Reconstruction Type on Outcomes in Women Undergoing Mastectomy with Immediate Reconstruction: A Nationwide Study [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-23-03.

Defragmentation of care in complex patients with ESKD improves clinical outcomes.

Given the problematic fragmentation of care for patients with end-stage kidney disease (ESKD), a kidney care organization and an integrated health system within a large accountable care organization partnered to best utilize their individual capabilities to collaborate around their shared patients in a coordinated care approach. Ultimately, the goal of the program is to allow care teams to achieve the triple aim of improving the patient experience, improving clinical outcomes, and reducing the total cost of health care. This is a retrospective examination of the first year of the Shared Patient Care Coordination (SPCC)program. The analysis consisted of 2 parts. First, rates of hospitalizations and emergency department visits were compared between the SPCC patients and other patients of the integrated health system who had ESKD but did not participate in SPCC. Second, rates of clinical indicators-central venous catheter (CVC) use, home dialysis, advance care planning, and missed dialysis treatments-were benchmarked vs normative data taken by bootstrap sampling of the kidney care organization's patient population. Overall, dialysis patients participating in the SPCC program had a 15% lower rate of hospital admissions than those not participating ( P = .02). Additionally, the bootstrap analysis showed that by the second year, dialysis patients in the program had favorable rates (above the 95th percentile) of CVC use, dialysis treatment absenteeism, and completion of advance care plans. Enhanced and structured communication between dialysis providers and patient care teams provides a unique opportunity to coordinate patient-centered care and improve patient outcomes.

Informational continuity by midwives during birth at primary care settings in the Western Cape.

Informational continuity ensures that all health and psychosocial information of the pregnant women is available at all encounters with healthcare providers. The World Health Organization recognised that ineffective informational continuity during birth contributed to fragmented care and duplication of services, which ultimately influenced the morbidity and mortality rates of the pregnant women. The aim of this study was to delve into the midwives' experiences on informational continuity approaches that enable effective care coordination during birth within the primary health care setting. The study setting was two maternity obstetric units (MOUs) in the Western Cape, South Africa. A qualitative descriptive phenomenological design was used. Participants were recruited by using purposive sampling. Interviews were audiorecorded, transcribed verbatim and analysed. Three themes emerged from the findings. Theme one: adequate sharing of information with women during the intrapartum period. Theme two: efficient transition of information among midwives and other healthcare providers during the intrapartum period. Theme three: challenges to informational continuity during the intrapartum period. Communication with the women as well as with other healthcare providers during birth was effective. However, with minimal challenges, informational continuity was effectuated through communication among the midwives, the pregnant women and other healthcare providers. Informational continuity approaches among the midwives, with the women and between healthcare facilities are a prerequisite to ensure continuity of care and care coordination during birth.

Neighborhood-Level Disadvantage and Delayed Adjuvant Therapy in Head and Neck Cancer

For patients with head and neck squamous cell carcinoma (HNSCC), initiation of postoperative radiation therapy (PORT) within 6 weeks of surgery is recommended by the National Comprehensive Cancer Network Guidelines and the Commission on Cancer. Although individual-level measures of socioeconomic status are associated with receipt of timely, guideline-adherent PORT, the role of neighborhood-level disadvantage has not been examined. To characterize the association of neighborhood-level disadvantage with delays in receiving PORT. This retrospective cohort study included 681 adult patients with HNSCC undergoing curative-intent surgery and PORT from 2018 to 2020 at 4 US academic medical centers. The data were analyzed between June 21, 2023, and March 5, 2024. The primary outcome was delay in initiating guideline-adherent PORT (ie, >6 weeks after surgery). Time-to-PORT (TTP) was a secondary outcome. Census block-level Area Deprivation Index (ADI) scores were calculated and reported as national percentiles (0-100); higher scores indicate greater deprivation. The association of ADI scores with PORT delay was assessed using multivariable logistic regression adjusted for demographic, clinical, and institutional characteristics. PORT initiation across ADI score population quartiles was evaluated with cumulative incidence plots and Cox models. Among 681 patients with HNSCC undergoing surgery and PORT (mean [SD] age, 61.5 [11.2] years; 487 [71.5%] men, 194 [29.5%] women) the PORT delay rate was 60.8% (414/681) and median (IQR) TTP was 46 (40-56) days. The median (IQR) ADI score was 62.0 (44.0-83.0). Each 25-point increase in ADI score was associated with a corresponding 32% increase in the adjusted odds ratio (aOR) of PORT delay (aOR, 1.32; 95% CI, 1.07-1.63) on multivariable regression adjusted for institution, age, race and ethnicity, insurance, comorbidity, cancer subsite, stage, postoperative complications, care fragmentation, travel distance, and rurality. Increasing ADI score population quartiles were associated with increasing TTP (hazard ratio of PORT initiation, 0.71; 95% CI, 0.53-0.96; 0.59; 95% CI, 0.44-0.77; and 0.54; 95% CI, 0.41-0.72; for ADI quartiles 2, 3, and 4 vs ADI quartile 1, respectively). Increasing neighborhood-level disadvantage was independently associated with a greater likelihood of PORT delay and longer TTP in a dose-dependent manner. These findings indicate a critical need for the development of multilevel strategies to improve the equitable delivery of timely, guideline-adherent PORT.

Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy.

Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF. All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]). Of 68,185 patients readmitted non-electively within 30days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (β+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF). Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.

Association of polydoctoring and mortality among persons over 85 years with multimorbidity: a prospective cohort study in Japan.

Polydoctoring can increase the risk of care fragmentation among patients with multimorbidity, but its impact on health outcomes remains unclear. To determine the effects of polydoctoring, as measured by the regularly visited facilities (RVF) indicator, on patient outcomes among older individuals with multimorbidity. Data from the ongoing prospective cohort study, Kawasaki Aging and Wellbeing Project (KAWP), was utilised in this study. Among the 1026 KAWP participants aged 85-89 years, those with two or more chronic conditions were enrolled in this study. Care fragmentation and polydoctoring was evaluated using the RVF, which is a new indicator that measures the number of medical facilities consistently involved in a patient's care. Based on RVF, mortality was analysed using the Cox proportional hazards model, with adjustments for age, sex, frailty, and number of comorbidities. A significant reduction in mortality rates was observed in participants with an RVF of ≥3 and 2-4 comorbidities (hazard ratio [HR] 0.43, 95% confidence interval [CI] = 0.18 to 0.99, P value = 0.048). However, no significant difference in mortality based on RVF was observed for those with ≥5 comorbidities. Notably, individuals with ≥5 comorbidities and an RVF of 0 had a significantly higher HR for death (HR 2.68, 95% CI = 1.05 to 6.84, P value = 0.039). In older patients with multimorbidity, polydoctoring may reduce mortality in patients with ≤4 coexisting conditions, but it does not significantly impact mortality in those with ≥5 conditions. These findings provide insights for healthcare decision making in managing older patients with multimorbidity.

The Entangled Emergencies of COVID-19

City of Chicago officials adopted a “racial equity” approach to mitigate the disproportionate racial impact of COVID-19, yet according to interviews with racially and socioeconomically marginalized Chicagoans, this approach failed to address core vulnerabilities associated with health, housing, mental health, and welfare. This article argues that COVID-19 represents and reifies the convergence of three sets of emergencies. First, federal and local governments governed through emergency, enacting temporally bounded governmental strategies that presumed scarcity, triaged care, and naturalized structural inequality by delinking the effects of racism from its causes. This response was spectacular and anticipatory—designed to safeguard the status quo until “normalcy” could be restored. This approach exacerbated two existing endemic emergencies: (1) the slow emergencies racially marginalized populations have faced for decades due to neoliberal restructuring and fragmented care infrastructure and (2) the sacrifice of lower-income frontline workers to premature death to safeguard the economy and protect the middle class.

‘Dissensus’ and the emergence of activist leadership in the baby room of UK early childhood settings

In the context of a chronically under-funded and fragmented Early Childhood Education and Care (ECEC) sector in England, there is an urgent need for models of leadership that emphasise action and advocacy. In the baby room, where pay, conditions and status are at their lowest, this is particularly the case. In this article, building on the model of activist leadership put forward by Woodrow and Busch, we consider ‘dissensus’ as a foundation for activist leadership among baby room leaders working in English nurseries. Dissensus is the willingness to express and explore differences, disagreements and tensions. In gathering the perspectives and experiences of 15 baby room leaders, we identified three threads of dissensus which we consider in this article: (1) the desire for baby room educators’ contributions to be recognised as more than ‘just care’, (2) feelings of resentment around being overlooked and undermined by ECEC colleagues outside of the baby room and (3) questions around pay and conditions in the baby room. We consider these threads of dissensus as a potential starting point for activist leadership in the baby room.

Perception of dental surgeons on multidisciplinary teamwork and preceptorship during the COVID-19 pandemic.

The objective of this work was to verify the perception of dental surgeons (DC) about their professional practice in the family health strategy (ESF), considering aspects related to multidisciplinary action, teamwork and preceptorship during the COVID-19 pandemic. 07 CDs from the Basic Health Units of a Health District (DS) in Recife participated, in the years 2020 to 2021. This was a qualitative study, using a semi-structured interview guide and sociodemographic questionnaire. The data were treated using Bardin's content analysis. The majority of CDs are women (71%), aged between 40 and 50 years old (57%), with more than 20 years of training (57%) and with good professional qualifications, including specialization in the field of activity and a master's degree. Three categories emerged from the qualitative analysis: Daily life before and after the Covid-19 pandemic and comprehensive care; Multidisciplinary teamwork and Influence of the exercise of Preceptorship on the Work Process of the CD in the ESF that recognize dentistry in the ESF is based on teamwork and multidisciplinary action to guarantee comprehensiveness, the pandemic changed the daily routine of services and fragmented care.

Factors associated with adjuvant treatment delays in patients treated surgically for head and neck cancer.

To determine the patient and treatment characteristics associated with delay in post-operative radiation therapy (PORT) for patients treated surgically for head and neck squamous cell cancer (HNSCC) at our institution. Single institution retrospective review. Tertiary care academic medical centre. Patients treated surgically for HNSCC who underwent PORT between 2013 and 2016. One hundred forty patients met inclusion criteria. A majority did not start radiotherapy within 6 weeks. Factors associated with a delayed initiation of PORT included length of stay >8 days, 30-day readmission, no adjuvant chemotherapy, post-operative complications and fragmented care. A majority of patients did not initiate PORT within the guideline-recommended 6 weeks. Modifiable risks factors that delay initiation of PORT were identified.

Identifying Opportunities to Deliver High-Quality Cancer Care Across a Health System: A Clinical Responsibility.

We examined process-related quality metrics for oral squamous cell carcinoma (OSCC) depending on treating facility type across a health system and region. Retrospective in accordance with Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Single health system and region. Patients with OSCC diagnosed between 2012 and 2018 were identified from tumor registries of 6hospitals (1 academic and 5 community) within a single health system. Patients were categorized into 3care groups: (1) solely at the academic center, (2) solely at community facilities, and (3) combined care at academic and community facilities. Primary outcome measures were process-related quality metrics: positive surgical margin rate, lymph node yield (LNY), adjuvant treatment initiation≤6 weeks, National Comprehensive Cancer Network (NCCN)-guideline adherence. A total of 499 patients were included: 307 (61.5%) patients in the academic-only group, 101 (20.2%) in the community-only group, and 91 (18.2%) in the combined group. Surgery at community hospitals was associated with increased odds of positive surgical margins (11.9% vs2.5%, odds ratio [OR]: 47.73, 95% confidence interval [CI]: 11.2-275.86, P < .001) and lower odds of LNY ≥ 18 (52.8% vs85.9%, OR: 0.15, 95%CI: 0.07-0.33, P < .001) relative to the academic center. Compared with the academic-only group, odds of adjuvant treatment initiation ≤6 weeks were lower for the combined group (OR: 0.30, 95%CI: 0.13-0.64, P = .002) and odds of NCCN guideline-adherent treatment were lower in the community only group (OR: 0.35, 95%CI: 0.18-0.70, P = .003). Quality of oral cancer care across the health system and region is comparable to or better-than national standards, indicating good baseline quality of care. Differences by facility type and fragmentation of care present an opportunity for bringing best in-class cancer care across an entire region.

Exploring home rehabilitation therapists’ experiences of supporting older persons to physical exercise after acute hospitalization: a qualitative interview study

Key summary pointsAimThe aim of this study was to explore home rehabilitation therapists’ experiences of supporting physical exercise after acute hospitalization, including exercise programs initiated during hospital stay.FindingsThe participants experienced that they were striving for individualized support to physical exercise, although limited resources and a fragmented home care risk to direct support away from those who need it the most.Message Transitional care interventions need to be individualized, support motivation for exercise during hospitalization, and be adapted to the patient’s situation at home, as well as involve relevant stakeholder in the design and implementation.

Reviews for multimorbidity risk in people with inflammatory conditions: a qualitative study.

People with inflammatory rheumatological conditions (IRCs) are at high risk of developing other conditions including cardiovascular disease (CVD) and mood disorders. To explore perspectives of people with IRCs and healthcare practitioners (HCPs) on the content and delivery of a review consultation aimed at identification and management of multiple long-term conditions (mLTCs). Semi-structured interviews and focus groups with people with IRCs and HCPs in primary and secondary care. People with IRCs participated in individual semi-structured interviews by telephone or online platform. HCPs (including primary and secondary care clinicians) participated in online focus groups. Data were transcribed verbatim and analysed using inductive thematic analysis. Fifteen people with IRCs were interviewed; three focus groups with HCPs were conducted. The following two main themes were identified: reflecting on the value of review consultations; and what would a new review look like? Overall, people with IRCs and HCPs reflected that access to reviews is inequitable, leading to duplication of reviews and fragmentation in care. People with IRCs, at times, had difficulty conceptualising reviews, especially when discussing their future risk of conditions. People suggested that preparation before the healthcare review could align patient and HCP agendas as part of a flexible and person-centred discussion. Any review introduced for people with IRCs must move beyond a 'tick-box' exercise. To gain maximum value from a review, preparation from both patient and HCP may be required alongside a person-centred approach while ensuring they are targeted at people most likely to benefit.