Changes In Care Policy Research Articles

ThP6.10 - Overview of Necrotising Soft Tissue Infections' Risks and Outcomes

Abstract Introduction Necrotising Soft Tissue Infections (NSTI) are severe life-threatening conditions, which are increasing in incidence. Associated with high mortality and morbidity, NSTI’s are a significant burden to health care services globally. Identifying themes, risk factors and underlying causation is therefore of interest. Methods A retrospective data cohort study examining clinical data for all histologically confirmed NSTI cases in a single centre between 2012 to 2022 was conducted. Results 73 confirmed NSTI cases were identified. Patient co-morbidities included the following:CasesDiabetic34Smoker16Post-op12IVDU8Trauma7Immunosuppressed6Bowel Perf5Cancer5 68 patients underwent urgent surgical debridement, with an average of 3.59 (Range 1-11) further surgical interventions required. Patients spent an average of 8.24 days (Range 1-42 days) in ICU, with a hospital stay of 44.02 days. (Range 7-180 days) 6(8%) patients died (5 within first week of presentation). Defunctioning stomas were performed in 24 patients during the admission and 32 patients underwent reconstructive surgery after recovery from the acute phase. An array of causative organisms were identified with no clear delineating trends.NumberAnaerobes36Streptococcus35Staphylococcus20E Coli + Coliforms20Enterococcus15 Conclusion NSTIs continue to increase in incidence and prevalence. The old surgical adage ‘You will see one NSTI in your lifetime is no longer true. Associated morbidity and mortality is significant and a focus on early recognition and prevention is vital. Further larger data sets are required to delineate clear trends and associated risk factors that can effect meaningful health care policy change.

Changes in maternity care policies and practices that support breastfeeding as measured by the Ten Steps to Successful Breastfeeding — United States, 2018–2022

BackgroundExperiences during the birth hospitalization affect a family’s ability to establish and maintain breastfeeding. The Ten Steps to Successful Breastfeeding (Ten Steps) describe evidence-based hospital policies and practices shown to improve breastfeeding outcomes. We aim to describe hospitals’ implementation of the Ten Steps, changes over time, and hospitals’ implementation of a majority (≥ 6) of the Ten Steps by hospital characteristics and state.MethodsThe biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey assesses all hospitals in the United States (including the District of Columbia and territories) that routinely provide maternity care services. We analyzed data from 2018, 2020, and 2022 survey cycles to describe trends in the prevalence of hospitals implementing maternity care policies and practices that are consistent with the Ten Steps. Differences were calculated using the absolute difference in percentage-points between 2018 and 2022.ResultsBetween 2018 and 2022, the percentage of hospitals that implemented Step 2: Staff Competency and Step 5: Support Mothers with Breastfeeding increased 12 and 8 percentage points, respectively. The percentage of hospitals that implemented Step 6: Exclusive Breastfeeding Among Breastfed Infants was 7 percentage points lower in 2022 than 2018. Implementation of the remaining seven steps did not change by more than 5 percentage points in either direction between 2018 and 2022. Nationally, the percentage of hospitals that implemented ≥ 6 of the Ten Steps increased from 44.0% in 2018 to 51.1% in 2022. Differences were seen when comparing implementation of ≥ 6 of the Ten Steps by hospital characteristics including state, hospital size, and highest level of neonatal care offered.ConclusionsNationally, maternity care policies and practices supportive of breastfeeding continued to improve; however, certain practices lost progress. Differences in implementation of the Ten Steps were observed across states and by certain hospital characteristics, suggesting more work is needed to ensure all people receive optimal breastfeeding support during their delivery hospitalization.

신규위탁 원장의 국공립어린이집 운영에서의 공공성 저해 요인 탐색

Objectives The purpose of this study is to find out the motivation and background for consignment support of new entrusted public child care center to support consignment, and to exploration of disturbance factors of publicness in the new entrusteded directors’s public child care centers management. Methods The participants in this study were three directors who entrusted a new public child care center in H-si, Gyeonggi-do. Data were collected through a total of three sessions of in-depth interviews, data on the experi-ences of in the new entrusteded directors’s were transcribed, read repeatedly, extracted with meaningful key-words, and analyzed qualitatively to derive research results. Results The results of this study are as follows. First, the motivation and background of the director of the new entrusted public child care center for fostering support was found to be support for entrustment to a stable public child care center due to changes in child care policy and anxiety about operating private daycare centers. Second, the directors of a newly entrusted public child care center found that the factors disturbance the publicness of run-ning the child care center after being appointed include concerns about systematic management of the newly en-trusted public child care center, recruiting and managing teachers, difficulties for parents trying to resolve com-plaints, found that the factors disturbance the and difficulties responding to related organizations. Conclusions In order to ensure the publicness of the management of public child care centers, it is necessary to continuously investigate the factors disturbance that the director of a newly entrusted public child care centers finds difficult, establish a system and training course to provide systematic support from new entrustment. A edu-cation program for new directors should be developed to overcome the difficulties that new directors face when running a public child care center for the first time and to solve the problems that directors face.

Reform and reverberation: Australian aged care policy changes and the unintended consequences for allied health.

Allied health has a valuable role in providing services to people living in residential aged care. The recent Royal Commission into Aged Care Quality and Safety included several important recommendations relating to the nursing, personal care, and allied health workforce and the care that they provide. The purpose of this paper is to review these recommendations and the Australian Government's policy responses and explore the emerging changes in allied health service provision in residential aged care. Data from the four available Quarterly Financial Reports from the 2022-2023 financial year were extracted and analysed in relation to staff costs and time per person per day across personal care, nursing, and allied health workers. Supplementary data sources including the 2020 Aged Care Workforce Census were accessed to provide contextual data relating to individual allied health professions, including occupational therapy. The analysis shows a modest increase in median registered nurse minutes per person per day, and cost per person per day, from the first to second quarter, and again in the third and fourth. By contrast, median time and cost for allied health declined. From 5.6minutes per person per day in the first quarter, reported allied health minutes fell to 4.6minutes per person per day in the second quarter, an 18% decrease, and by the fourth quarter was 4.3minutes per person per day. This is just over half the Australian average of 8minutes reported to the RCACQS in 2019. Under recent residential aged care reforms, aged care providers have regulatory incentives to concentrate their financial resources on meeting the mandated care hours for registered nurses, enrolled nurses, personal care workers, and assistants in nursing. These same reforms do not mandate minutes of allied health services. Although providers of residential aged care in Australia continue to employ and value allied health, we argue that mandating care minutes for personal and nursing care without mandating the provision of allied health creates a perverse incentive whereby access to allied health services is unintentionally reduced.

Midwives' stress and burnout during the Omicron wave in Italy: An observational survey.

To evaluate midwives' level of stress and burnout during the COVID-19 Omicron phase in Italy. Secondary aims were to explore the impact of the pandemic on midwives' personal dimensions and professional activities and potential supporting strategies. A mixed-methods study was undertaken from July to December 2022. Data were collected using a national online observational survey. Descriptive and inferential analyses were performed to evaluate stress, burnout and the impact of the pandemic on personal and professional dimensions. A deductive qualitative approach was used to analyse open-ended responses, that were merged with quantitative data following a convergent mixed-methods approach. A total of 1944 midwives participated in the survey. The stress summary score mean was 10.34, and 562 midwives (28.91%) experienced burnout. The intention to reduce working hours was reported by 202 midwives (10.39%), with 60.40% (n = 122) of them experiencing burnout. The intention to leave clinical practice within the following 2 years was reported by 239 (12.29%), with 68.20% (n = 163) of them experiencing burnout. All the personal dimensions and professional activities considered were defined by more than half of midwives as being impacted 'Moderately' or 'To a great extent' by pandemic. Stress and burnout frequencies increased when the midwives' perception of the pandemic effects was higher. Potential supporting strategies described by midwives as the most important in increasing their ability to cope with the pandemic were 'Women's awareness of the midwives' role' (n = 1072; 55.14%) and 'Family and friends' emotional support' (n = 746; 38.38%). Our findings suggested strategies to support a positive and safe working environment for midwives during a pandemic emergency, with potential transferability to similar contexts when human resources are lacking. It is recommended that maternity services provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. Studies conducted during the first COVID-19 pandemic wave showed an increased level of stress, anxiety, burnout, post-traumatic stress disorder and depression experienced by healthcare professionals; moreover, midwives experienced drastic changes in care pathways and policies with struggles identified when providing high-quality woman-centred care following pandemic restrictions. Although it is recommended, there is lack of knowledge about long-term psychological effects of COVID-19 for midwives. Our study highlights that during the Omicron wave midwives experienced a high level of stress and burnout with an impact on individual dimensions and professional activities. Their stress and burnout were influenced by several factors, including restrictions in place, lack of organizational acknowledgement, work overload and need for extra childcare cover. Maternity services should provide the necessary resources for a safe and supportive working environment to prevent high stress levels and chronic burnout. Recommendations on how to facilitate this are suggested. During the writing process, we referred to 'The Strengthening the Reporting of Observational Studies Epidemiology Statement', the guidelines for reporting observational studies from the Equator network. No patient or public contribution. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Work overload conditions negatively impacted on the quality of maternity services. Improving organizational aspects, reducing working hours, promoting family and friends' emotional support and improving women's awareness of midwife's role were the main strategies reported by midwives. These suggestions for ensuring a positive and safe working environment for midwives during a pandemic emergency could potentially be applied to similar situations where human resources are lacking.

Understanding and Managing Fragmented Transitions in Care: Learning from and Guided by Patient, Family, Health Care Provider and System-Level Experiences Before, During and Follow-up to COVID-19

One ongoing challenge in health care is ensuring patients/families and also health care providers have clear direction and implementation guidance around transitions in care across all care and community settings that includes integration, continuity and coordination. Clearly understanding patient, family, care provider and system-level experiences including what works and where improvements are needed with care transitions across acute and community settings has been an ongoing challenge for most health care systems before and during COVID-19. However, although efforts to identify and use experience measures were complicated and impacted during COVID-19 because of rapidly enforced restrictions and emergent safety protocols, learning to adapt to change was also essential.
 Our study explored the experiences of patients/clients, families, care providers and system leaders regarding their care transitions between acute and community-based care settings prior to and during COVID-19, along with changes in care outcomes, practices, policies and services became the focus of a two-year pilot study in one Canadian provincial health system. We co-designed relevant acute to community care transition process and outcome/impact experience indicators/measures with patients/clients, families and care providers; and explored the feasibility for transferring measures and lessons learned for practice, policy and service changes as part of follow-up and post COVID new ‘norm’ transformation of care transitions. 
 The study involved the Provincial Seniors and Continuing Care Advisory Council, Continuing Care Quality Committee, Transition Services, primary care and eight pilot care settings involving patients/clients transitioning from acute to community settings. Each care setting involved patient/family advisors co-designing and implementing the initiative with care providers and transition leaders. This included survey development, and gathering, analyzing and interpreting client/patient and care provider experiences. Findings in each and across settings included identifying common core patient/family and care provider experience indicators/measures regarding acute to community care transitions, before and during COVID. System-level factors and experiences were also gathered. Themes for what makes transitions in care successful before, during and follow-up to COVID were also confirmed – e.g. clear communication, navigation and information/direction for all stakeholders. The aggregated findings targeted health outcomes and guided changes in transition practices from across acute points of care as well as Emergency, to various community-based care settings including Home Care, Long-term or other interim programs utilized while patients waited for final transition decisions – e.g. CHOICE programs.
 Essential learnings include having a clear understanding of the experiences of patients/clients, families, care providers and system-level regarding care transitions, and how well integrated, coordinated and continuity-aligned this care is. This includes understanding what works well and where there are gaps in the system. Managing the gaps helps mitigate failed or unsatisfactory patient transitions across care settings. Such findings also guide or inform quality and safety improvement. 
 Identified transition core measures continue to be studied beyond the pilots for transferability across acute, emergency, primary and community care settings. As well, COVID-19 impacts on practice, policy and service changes involving coordinated and integrated transitions need to be monitored for how well care settings adapt to “new norms” and meet patient/client needs. This work continues.

Addressing the National Crisis Facing Black and Latina Women, Birthing People, and Infants: The Maternal and Child Health Equity Summit.

To address the national crisis of maternal and infant health disparities, especially outcomes experienced by Black and Latina women and birthing people, The New York Academy of Medicine, the Icahn School of Medicine at Mount Sinai, the Blavatnik Family Women's Health Research Institute, and the University of Pennsylvania Health System and Perelman School of Medicine hosted the Maternal and Child Health Equity Summit. The primary purpose of the summit was to disseminate findings to a national audience of two National Institutes of Health-funded mixed-methods studies that investigated the contribution of hospital quality to disparities in maternal and infant Health in New York City (R01MD007651 and R01HD078565). In addition, the summit showcased factors in maternal and infant health inequity from leading diverse experts in both fields and identified outstanding challenges to reducing maternal and infant morbidity and mortality disparities and strategies to address them. Summit presenters and participants identified five primary areas of focus in proposed clinical actions and approaches for maternal and neonatal health care based on discussions during the summit: 1) quality and standardization of care; 2) adjustment of care strategy based on patient-reported experience; 3) health care professional and institutional accountability to patients; 4) commitment to building trust; and 5) anti-racism practices in education, training, and hiring. Recommendations from this conference should inform hospital care and public policy changes and frame a national agenda to address perinatal health disparities for Black, Indigenous, and other women and birthing people of color.

Methods to refine and extend a Pregnancy Register in the UK Clinical Practice Research Datalink primary care databases.

Real-world data represents a valuable tool for pregnancy research. However, an algorithmic approach is needed to ascertain pregnancy timings from this complex data. The Clinical Practice Research Datalink (CPRD) GOLD Pregnancy Register, based on UK Primary care data, has therefore proven to be a valuable research tool. The same algorithmic approach was applied to the CPRD Aurum data to generate an equivalent register in the larger database. Records of female patients registered with a CPRD Aurum contributing practice between the 1st of January 1987 and the 30th of April 2021 were searched for evidence of pregnancy. The algorithm used to generate the CPRD GOLD Pregnancy Register was redeveloped and applied first to CPRD GOLD and then to CPRD Aurum. The resulting CPRD Aurum Pregnancy Register was validated against the CPRD GOLD register, linked Hospital Episode Statistics (HES) and the Office of National Statistics (ONS) live birth data. There are 16 833 427 pregnancy episodes in the CPRD Aurum Pregnancy Register from 6724 615 women, more than double the number in CPRD GOLD. The distribution of pregnancy outcome types was comparable between the registers. Across the whole register, there was good concordance between pregnancy episodes found in CPRD Aurum and linked HES. However, both CPRD registers saw a declining number of pregnancy episodes from 2007 onwards, steeper than in HES or the ONS birth data. A pregnancy register has been created in CPRD Aurum. Changes in antenatal care policies in the UK have led to declining numbers of pregnancies in EHR primary care data. However, the creation of this pregnancy register has tripled the number of patients in the CPRD Pregnancy Registers and will increase the capacity to study pregnancy in CPRD data, particularly rare or emerging exposures, and outcomes.

Changes in the primary care policy and the (un)sustainability of the Family Health Strategy

RESUMO A Atenção Primária à Saúde é um nível de atenção estratégico para a conformação de um sistema de saúde sustentável e capaz de responder a necessidades diversas. Este artigo teve como objetivo analisar a normatização federal e suas implicações para a organização das equipes de atenção primária no Brasil. Pesquisa exploratória de métodos mistos, envolvendo a análise de 25 portarias federais e de dados secundários de abrangência nacional referentes às equipes homologadas no Cadastro Nacional de Estabelecimentos de Saúde, no período de 2017 a 2021. Os resultados indicam mudanças na direcionalidade da política quanto à configuração, ao financiamento e ao credenciamento das equipes. Verificaram-se expansão das equipes de atenção primária, redução de Agentes Comunitários de Saúde e enfraquecimento do Núcleo de Apoio à Saúde da Família. Os resultados sugerem que os estímulos a outros arranjos de equipes e a flexibilização da cobertura do agente comunitário e da atuação multiprofissional comprometem a sustentabilidade do modelo de Saúde da Família no Sistema Único Saúde.

Patient concerns about accessing sexual and reproductive health services outside of primary care: A survey in rural and urban settings in the Pacific Northwest

ObjectivesWhile primary care providers are a major source of sexual and reproductive health (SRH) services in the United States, particularly in rural areas, not all primary care settings offer a full range of SRH services. We aimed to understand primary care patient concerns regarding accessing SRH services, including abortion care, outside of their primary care clinic and if those concerns differed by urban or rural setting. Study designAn anonymous survey was distributed over a 2-week period between December 2019 to March 2020 to all adult patients in four primary care clinics in Idaho, Washington, and Wyoming. The survey assessed patient concerns regarding accessing SRH services outside of their primary care clinic and their willingness to travel to access SRH services. ResultsThe overall response rate was 69% (745/1086). Over 85% of respondents identified at least one concern to seeking SRH services outside of a primary care setting, with cost, insurance coverage, length of wait time, and lack of an established relationship being the most frequently reported concerns. A majority of respondents were willing to travel a maximum of 1 hour for most SRH services. Respondents from rural-serving clinics were significantly more likely to be willing to travel longer amounts of time for medication abortion, aspiration abortion, and intrauterine device placement. ConclusionOur findings highlight that a majority of both urban and rural primary care patients have concerns regarding accessing SRH services outside of their primary care clinic and are unwilling to travel more than 1 hour to access most SRH services. ImplicationsA majority of primary care patients have concerns regarding accessing SRH services outside of primary care settings. Health care policy changes should aim to strengthen the SRH services available in primary care settings to alleviate the burdens primary care patients face in accessing SRH services outside of their primary care clinic, particularly for rural populations.

Comparison of US Hospital Charity Care Policies Before vs After Onset of the COVID-19 Pandemic

Tax-exempt hospitals are required to provide charity care to maintain their tax-exempt status; charity care policies must be published online with clear eligibility criteria. Prior research has shown wide variability in charity care policy content; it is unknown how hospitals change their charity care policies over time. To examine changes to tax-exempt hospital charity care policies before vs after the COVID-19 pandemic. This cohort study used downloaded charity care policies from a geographically representative sample of 170 tax-exempt hospitals from December 1 to 31, 2019, and December 1 to 31, 2021, and categorized the policy changes made as more restrictive, more generous, indeterminate, minimal, or not updated. Onset of the COVID-19 pandemic. The primary outcome was charity care policy content changes from 2019 to 2021. Also examined were the effects of hospital ownership type, state Medicaid expansion status, and hospital consolidation on policy changes. In this sample of 170 hospitals, 151 published documents available for comparison. Among these hospitals, 127 (84.1%) updated their charity care policies and 77 (51.0%) made substantial changes, with 242 distinct policy changes to categories such as income eligibility cutoffs, asset limitations, and service exclusions. Although the majority of hospitals expanded charity care (47 [31.1%]), a sizable minority restricted charity care (12 [7.9%]). Medicaid expansion during the study period and hospital consolidations were not associated with expansion of charity care; the largest merger in this sample led to reduced charity care at all 4 hospitals involved. Tax-exempt hospitals appear to have updated their policies with mostly positive changes during and after the onset of the COVID-19 pandemic; however, some hospitals restricted charity care in 2021 documents. Unpublicized or vague eligibility criteria may limit patients' understanding of charity care policies and conceal the full extent of charity care policy changes over time. Policy makers should consider requiring greater transparency and simplification for hospital charity care policies to ensure adequate access to care for uninsured and underinsured patients.

Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review.

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions. Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays). Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis. Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Mental health and parenting demands among grandparent caregivers of young U.S. children

Substance abuse epidemics and changes in incarceration and foster care policies have recently placed more young children in grandparent custody. Grandmothers bear much of this caregiving responsibility. Our objective was to compare grandparent caregivers of preschool-aged children (grandparent(s) only or in multigenerational households) to parent caregivers, by caregiver sex, in their mental health, available emotional support, and capacity to manage parenting demands. Using U.S. National Survey of Children’s Health data (2016–2019), we used survey-weighted logistic regression models adjusted for socio-demographic confounders and conducted sub-group analyses by caregiver sex. Among 30,046 families with a child aged 1–5 years, 776 (4.1%) were grandparent-only, 817 (3.3%) multigenerational, 28,453 (92.7) parent-headed (weighted percentages). Most caregivers (78.7%) were in Excellent/Very Good mental health, but grandfathers in grandparent-only households were less so. Despite being more likely to parent alone, caregivers in grandparent-only households had about twice the odds of having a source of emotional support (adjusted prevalence odds ratio [aPOR] = 2.07; 95% confidence interval [CI] 1.12, 3.83). Grandmothers, in particular, had greater odds of handling day-to-day parenting demands (aPOR = 2.40, 95% CI 1.35, 4.27) and of reporting rarely/never feeling angry with the child in their care (aPOR = 2.77, 95% CI 1.53, 5.01), compared to mothers in parent households. Caregivers in multigenerational households displayed no differences as compared to parents except for grandfathers in multigenerational households who were more likely often bothered by the child. Despite increasing demands on grandparents, they generally reported faring as well as or better than parent caregivers, especially grandmothers. Their prior experience and social support may make them resilient.

Early childhood education and care policy change: comparing goals, governance and ideas in Nordic contexts

ABSTRACT Early childhood education and care (ECEC) is changing across Europe, reflecting multiple-policy intentions and assumptions about education in early years, and the role of the state in supporting, funding and regulating its institutions. In this article, we examine the evolution of ECEC comparatively in Finland and Sweden, and we explore the shifts in goals, governance mechanisms and policy ideas that have characterised reforms in the sector. We draw on an analysis of policy documents, and argue that the incremental changes achieved over the last 50 years have been in response to changing goals assigned to ECEC and ideas about its roles and functions as part of the welfare and education sectors. The power of ideas in effecting policy change is tempered by established institutional framings, yet is visible in the early dominance of child-centred ideas, and the later controversies over the emergent labour-market and education-driven rationales of the post-2010s.

Patient and provider experience and outcomes with synchronous teledermatology during the COVID-19 pandemic

To the Editor: Health care policy changes implemented during the COVID-19 pandemic significantly increased access to telehealth starting March 2020.1,2 Given the expanded acceptance of synchronous teledermatology, we collected data to inform the planning of dermatology access during and after the pandemic.

Multilevel factors associated with inequities in multidisciplinary cancer consultation.

To assess changes in the prevalence of multidisciplinary cancer consultations (MDCc) over the last decade and examine patient, surgeon, hospital, and neighborhood factors associated with receipt of MDCc among individuals diagnosed with cancer. Surveillance, Epidemiology and End Results (SEER)-Medicare data from 2006 to 2016. We used time-series analysis to assess change in MDCc prevalence from 2007 to 2015. We also conducted multilevel logistic regression with random surgeon- and hospital-level effects to assess associations between patient, surgeon, neighborhood, and health care organization-level factors and receipt of MDCc during the cancer treatment planning phase, defined as the 2months following cancer diagnosis. We identified Medicare beneficiaries >65 years of age with surgically resected breast, colorectal (CRC), or non-small cell lung cancer (NSCLC) stages I-III (n=103,250). From 2007 to 2015, the prevalence of MDCc increased from 35.0% to 61.2%. Overall, MDCc was most common among patients with breast cancer compared to CRC and NSCLC. Cancer patients who were Black, had comorbidities, had dual Medicare-Medicaid coverage, were residing in rural areas or in areas with higher Black and Hispanic neighborhood composition were significantly less likely to have received MDCc. Patients receiving surgery at disproportionate payment-sharing or rural-designated hospitals had 2% (95% CI: -3.55, 0.58) and 17.6% (95% CI: -21.45, 13.70), respectively, less probability of receiving MDCc. Surgeon- and hospital-level effects accounted for 15% of the variance in receipt of MDCc. The practice of MDCc has increased over the last decade, but significant geographical and health care organizational barriers continue to impede equitable access to and delivery of quality care across cancer patient populations. Multilevel and multicomponent interventions that target care coordination, health system, and policy changes may enhance equitable access to and receipt of MDCc.

Impact of COVID-19 on perinatal care: Perceptions of family physicians in the United States.

BackgroundPatient‐centered care is the best practice in the care of pregnant and postpartum patients. The COVID‐19 pandemic prompted changes in perinatal care policies, which were often reactive, resulting in unintended consequences, many of which made the delivery of patient‐centered care more difficult. This study aimed to understand the impact of the COVID‐19 pandemic on perinatal health care delivery from the perspective of family physicians in the United States.MethodsFrom October 5 to November 4, 2020, we surveyed mid‐ to late‐career family physicians who provide perinatal care. We conducted descriptive analyses to measure the impact of COVID‐19 on prenatal care, labor and delivery, postpartum care, patient experience, and patient volume. An immersion‐crystallization approach was used to analyze qualitative data provided as open‐text comments.ResultsOf the 1518 survey respondents, 1062 (69.8%) stated that they currently attend births; 595 of those elaborated about the impact of COVID‐19 on perinatal care in free‐text comments. Eight themes emerged related to the impact of COVID‐19 on perinatal care: visitation, patient decisions, testing, personal protective equipment, care continuity, changes in care delivery, reassignment, and volume. The greatest perceived impact of COVID‐19 was on patient experience.ConclusionsFamily physicians who provided perinatal care during the COVID‐19 pandemic noted a considerable impact on patient experience, which particularly affected the ability to deliver patient‐centered and family‐centered care. Continued research is needed to understand the long‐term impact of policies affecting the delivery of patient‐centered perinatal care and to inform more evidence‐based, proactive policies to be implemented in future pandemic or disaster situations.

Photovoice Exploration of Frontline Nurses' Experiences During the COVID-19 Pandemic.

The current COVID-19 global pandemic has had a profound impact on the health care system and on the physical and psychological well-being of nurses. Previous pandemics have led to nurses leaving the profession. Therefore, it is important that we hear the voices of nurses who experienced the pandemic on the frontlines to influence future planning and policy development. The purpose of this study was to explore frontline nurses' experiences during the COVID-19 pandemic through photos, narratives, and group discussions. Twelve nurses in two groups shared their lived experiences through Photovoice, a participatory action approach. Photos and narratives were collected over five weeks per group. One group at the beginning of the pandemic and the other group six months later. Focus group discussions were held following each group. Five themes emerged from the photovoice data: (1) The work of nursing; (2) Miscommunication; (3) Fatigue; (4) Resilience; and (5) Hope for the future. Various subthemes were noted within each theme to delineate the lived experience of frontlines nurses working in the COVID-19 pandemic. The voices of nurses and their experiences on the frontlines of the COVID-19 pandemic need to be considered in pandemic planning and integrated into health care policy, guidelines, and structural changes.

Use of Long-Term Care Decreased Over Time Among the Oldest-Old With and Without Dementia - A Register-Based Study

Care policies for older adults emphasize aging-in-place and home care over residential long-term care (LTC). We explore how the use of residential LTC in the last five years of life among people with and without dementia changed between those who died in 2001, 2007, 2013, and 2017 in Finland. Retrospective data drawn from the national health and social care registers include all those who died aged 70+ in 2007, 2013, and 2017, plus a 40% random sample from 2001 (N=128 050). Negative binomial regression analysis was used to estimate the association of dementia with LTC use during the last five years of life (1825 days). The independent variables included dementia, age, marital status, annual income, education, and chronic conditions. In the total study population, the proportion of LTC users and the mean number of days in LTC increased until 2013, after which it decreased. Changes in LTC use differed between different age groups and by dementia status. Over time, the decrease in round-the-clock LTC use was steep in those aged 90≤ with dementia and in people aged 80≤ without dementia. The individual factors related to morbidity and sociodemographic factors did not explain these results. The changes in LTC care policy may have contributed to the decrease in LTC use among the oldest. However, according to national statistics, the availability of formal home care has not increased. This development may suggest that the oldest-old and those with dementia – a highly vulnerable group – are left without proper care.

The effect of primary care policy changes on hospitalisation for ambulatory care sensitive conditions: notes from Brazil

Objectives: The aim of this study was to assess the effect of the Primary Health Care Reform and the impact of recent national policy changes on the trend in hospitalisation rates for Ambulatory Conditions Sensitive to Primary Care (ACSC) in the city of Rio de Janeiro, Brazil.Study design: Ecological study with data from the Brazilian National Health Information System.Methods: This study performed an interrupted time-series analysis, comparing three different time periods related to important changes in primary care policies in Brazil: Baseline (2008–2009); Primary Health Care Reform (RCAPS) (2010–2017); and National Primary Health Care Policy (PNAB) (2018–2019). Data included total monthly admissions for ACSC and rates for 19 groups of causes for hospitalisation.Results: There was a non-significant increasing trend in ACSC hospital admissions between January 2008 and December 2009 (β = 4.01, 95% confidence interval [CI] −12.14 to 20.15). The Primary Health Care Reform (RCAPS), which commenced in January 2010, resulted in a significant reduction in ACSC hospital admission trends during this time period (β = −7.97, 95% CI –9.78 to −6.16). Change in the PNAB did not change the declining ACSC hospital admission trend but it did reduce the rate of decline. In addition, the coefficient was no longer significant (β = −1.93, 95% CI –2.46 to 0.59), suggesting that monitoring of the historical series for a long time may show a reversal of the downward trend in some months. The most consistent change in ACSC hospital admission trend occurred between baseline and the RCAPS (β slope = −0.143, P < 0.001) and the level between the RCAPS period and the new PNAB (β step = 7.00, P = 0.008). Trends and differences in the time periods vary in the different ACSC hospitalisation-cause groups.Conclusion: Changes in public health policies impact ACSC hospitalisation rates, which can thus be used as an indicator for monitoring primary health care. We also recommend analysing admission rates by the individual ACSC hospitalisation-cause groups.