Changes In Practice Research Articles

Integrating Maternity Care Through Bundled Payments In The Netherlands: Early Results And Policy Lessons.

Bundled payments are increasingly used globally to move health care delivery in a value-based direction. However, evidence remains scant in key clinical areas. We evaluated bundled payments for maternity care in the Netherlands during the period 2016-18. We used a quasi-experimental difference-in-differences design to measure the association between the bundled payment model and changes in key clinical and economic outcomes. Bundled payments were associated with an increase in outpatient, midwife-led births and a reduction in in-hospital, obstetrician-led births, along with changes in the use of labor inductions and planned versus emergency cesarean deliveries. Total spending on maternity care decreased by US$328 (5percent) per pregnancy. No changes in maternal or neonatal health outcomes were observed. Several policy lessons emerged. First, bundled payments appeared to help affect providers' behavior in the maternity care setting. Second, bundled payments seemed to exert heterogeneous effects across participating maternity care networks, as the same financial incentive translated into different changes in clinical practices and outcomes. Third, alternative payment models should be designed with clear goals and definitions of success to guide evaluation and implementation.

Training Dental Teams to Address Community Health: Necessary Partnerships and Evaluation of an Evidence-Based Curriculum

Abstract: Background: Annually, 27 million Americans visit a dental professional but not a physician. Dental professionals must recognize that they are members of their patients’ primary care teams. Continuing education must then prepare them to appropriately serve their specific communities. Objectives: The objective of this paper was to describe the implementation of an evidence-based model to train dental professionals on how to respond to community-level health needs. The paper details crucial partnerships and provides evidence and key considerations for replicating the curriculum to improve population health. Methods: The Extension for Community Healthcare Outcomes (ECHO) model was used in one state where dental health care use is challenging for persons living rural, eligible for Medicaid, aging, and those who are American Indian. This formative evaluation knowledge assessments, data on participants’ changes in clinical care practice, web analytics, and artifact review to assess effective implementation strategies and necessary community partnerships. Conclusions: Successful implementation of the curriculum required active participation and partnership with state provider associations, the office of Medicaid, the state Board of Dental Licensure, and others. Without engaged partners, the curriculum would not have been community relevant, nor would it have had case presentation from local providers. In a state with only 427 practicing dentists, live attendance ranged between 9 and 22 dental team members, with between 11 and 91 views of the recorded sessions. Using the evidence-based ECHO model, which requires community health partnerships, is a cost-effective, and accessible, method to offering community specific education for dental providers across a large geographic region.

Structural Modeling of Food Safety Knowledge, Attitude, and Practices of Food Handlers in Highway Tourist Stop-Over Food Service Establishments in Uganda

The study examines the socio-demographic characteristics, food safety knowledge, attitudes, and practices of food handlers in highway tourist stop-over food service establishments in Uganda. The study further explores the relationship between the above factors using the Structural Equation Model (SEM). Understanding food safety knowledge, attitudes, and practices of food handlers can inform future interventions toward food safety assurance in food service establishments. The study used a cross-sectional design and data was collected using a self-administered structured questionnaire. Data was analyzed using Statistical Package for Social Sciences (SPSS) Version 22 and Analysis of Moment Structures (AMOS). Approximately half of the respondents had adequate knowledge of food safety and good practices. The results from SEM confirmed that food safety knowledge significantly affected practices (β= 0.37 p<0.05), attitude insignificantly, and negatively affected practices (β= -0.04 p>0.05). Only 13.3% of the changes in practices were explained by the knowledge and attitudes of the respondents (R-squared 0.133). The majority of the food handlers were males, had experience of more than 2 years, attended food safety training, and had limited knowledge about Hazard Analysis Critical Control Points (HACCP). The study is the first of its kind in Uganda. The findings suggest that future interventions should look beyond food safety knowledge and attitudes of the food handlers in food safety assurance efforts.

Bioethics and the value of disagreement

What does it mean to be a bioethicist? How should the role(s) of bioethics be understood in the context of a world of intense value conflict and polarisation? Bioethics is—in...

A single-center retrospective review of laparoscopic totally extraperitoneal versus robotic transabdominal preperitoneal inguinal hernia repair

Background With the increased use of robotic surgery, robotic transabdominal preperitoneal repair (R-TAPP) has become a commonly used approach for inguinal hernia repair. The laparoscopic totally extraperitoneal repair (L-TEP) has the advantage of not entering the peritoneal cavity; however, it has greater technical difficulty. Robotic surgery has demonstrated superiority over laparoscopy in many surgical settings, but there is limited evidence comparing L-TEP and R-TAPP. Methods This was a retrospective review of patients who underwent L-TEP and R-TAPP at Baylor University Medical Center between December 2011 and January 2022. Information on patient demographic characteristics, comorbidities, postoperative complications, hospital length of stay, and postoperative complications requiring a procedure was collected. Results A total of 298 patients were analyzed; 245 underwent R-TAPP and 53 underwent L-TEP. Hernia recurrence was significantly decreased in those who underwent R-TAPP (1.2%) compared to L-TEP (9.4%) (P = 0.01). Postoperative pain was also significantly decreased in the R-TAPP group (5.3%) as compared to the L-TEP group (13.2%) (P = 0.01). Conclusions With the transition from L-TEP to R-TAPP over recent years, there is limited evidence supporting this change in practice. Our single-center retrospective review demonstrates that R-TAPP is noninferior to L-TEP and has significantly decreased hernia recurrence.

Improving outcomes for uncomplicated gastroschisis: clinical practice guidelines from the American Pediatric Surgical Association Outcomes and Evidence-based Practice Committee.

The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B-D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.

Cultural Transformation through Digitalization: A Bibliometric Approach in Responding to Changes in Social Values, Norms, and Cultural Practices in Society

This study employs VOSviewer to conduct a bibliometric analysis and visualize the intricate research landscape surrounding the themes of digitalization, cultural transformation, organizational practices, and the impact of global crises like the COVID-19 pandemic. Through a series of network density maps, the research identifies key thematic concentrations and academic collaborations over recent years. It reveals how digitalization intersects with various societal dimensions, influencing education, cultural heritage, sustainability, and business practices. The analysis emphasizes the role of digital technologies in facilitating significant social and organizational changes, advocating for policies that enhance digital literacy and inclusivity. Additionally, the examination of authorship networks sheds light on influential scholars and collaborative dynamics, providing insights that can guide future research directions. The study underscores the necessity for adaptive business models that integrate sustainability and resilience, crucial for navigating contemporary and future challenges.

Environmental impacts of genetically modified crops.

Genetically modified (GM) crops have been adopted by some of the world's leading agricultural nations, but the full extent of their environmental impact remains largely unknown. Although concerns regarding the direct environmental effects of GM crops have declined, GM crops have led to indirect changes in agricultural practices, including pesticide use, agricultural expansion, and cropping patterns, with profound environmental implications. Recent studies paint a nuanced picture of these environmental impacts, with mixed effects of GM crop adoption on biodiversity, deforestation, and human health that vary with the GM trait and geographic scale. New GM or gene-edited crops with different traits would likely have different environmental and human health impacts.

Solutions and insights for agricultural monitoring, reporting, and verification (MRV) from three consecutive issuances of soil carbon credits

Regenerative agricultural practice adoption on conventionally managed fields has gained momentum as a climate mitigation strategy, given the ability of these practices to sequester carbon or reduce greenhouse gas emissions. However, the geospatial and temporal variability of the impact of specific practices, such as cover cropping or no-till, pose challenges for scalable quantification of emissions reduction and deploying incentives to drive increased adoption. To quantify impact while accounting for variability and uncertainty at scale, Indigo Ag created a monitoring, reporting, and verification (MRV) pipeline to produce agricultural soil carbon credits produced at large scales (hundreds of thousands of hectares). The pipeline ingests field data from enrolled farmers, checks data quality, uses hybrid soil sampling and biogeochemical modeling to produce estimates of emissions reduction and uncertainty, and then applies deductions based on calculated uncertainty and leakage to quantify total project-wide carbon credits and monitor for durability of carbon. The implementation of a carbon project (CAR1459) from 2018 to 2022 on 553,743 ha of U.S. cropland utilizing the pipeline is estimated to have reduced emissions by 398,408.5 tCO2e, amounting to 296,662 tCO2e of soil carbon credits after uncertainty deductions. This paper explores the effect sizes associated with specific regenerative practice changes across the project domain. Cover cropping consistently resulted in a net positive climate impact and reduced emissions by 1.29 tCO2e per hectare per year, on average. Introduction of no-till was more common in the project, but it had a lower average emissions reduction of 0.38 tCO2e per hectare per year. Effect sizes for no-till vary spatiotemporally and are typically low in the first several years after adoption but increase in subsequent years. Agricultural carbon programs that capture and incentivize the nuance of outcomes of practices rather than the implementation of practices, can promote adoption of the right management practice to be deployed on the right field for maximum environmental benefit.

Understanding the mental health and intention to leave of the public health workforce in Canada during the COVID-19 pandemic: A cross-sectional study

BackgroundThere is limited evidence about the mental health and intention to leave of the public health workforce in Canada during the COVID-19 pandemic. The objectives of this study were to determine the prevalence of burnout, symptoms of anxiety and depression, and intention to leave among the Canadian public health workforce, and associations with individual and workplace factors.MethodsA cross-sectional study was conducted using data collected by a Canada-wide survey from November 2022 to January 2023, where participants reported sociodemographic and workplace factors. Mental health outcomes were measured using validated tools including the Oldenburg Burnout Inventory, the 7-item Generalized Anxiety Disorder scale, and the 2-item Patient Health Questionnaire to measure symptoms of depression. Participants were asked to report if they intended to leave their position in public health. Logistic regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for the associations between explanatory variables such as sociodemographic, workplace factors, and outcomes of mental health, and intention to leave public health.ResultsAmong the 671 participants, the prevalence of burnout, and symptoms of depression and anxiety in the two weeks prior were 64%, 26%, and 22% respectively. 33% of participants reported they were intending to leave their public health position in the coming year. Across all outcomes, sociodemographic factors were largely not associated with mental health and intention to leave. However, an exception to this was that those with 16–20 years of work experience had higher odds of burnout (aOR = 2.16; 95% CI = 1.12–4.18) compared to those with ≤ 5 years of work experience. Many workplace factors were associated with mental health outcomes and intention to leave public health. Those who felt bullied, threatened, or harassed because of work had increased odds of depressive symptoms (aOR = 1.85; 95% CI = 1.28–2.68), burnout (aOR = 1.61; 95% CI = 1.16–2.23), and intention to leave (aOR = 1.64; 95% CI = 1.13–2.37).ConclusionsDuring the COVID-19 pandemic, some of the public health workforce experienced negative impacts on their mental health. 33% of the sample indicated an intention to leave their role, which has the potential to exacerbate pre-existing challenges in workforce retention. Study findings create an impetus for policy and practice changes to mitigate risks to mental health and attrition to create safe and healthy working environments for public health workers during public health crises.

EDUCAÇÃO SEXUAL PARA PESSOAS COM DEFICIÊNCIA INTELECTUAL

Intellectual disability can be understood as a set of limitations in adaptive behavioral and intellectual functioning, presented by practical, social and conceptual behavioral changes. All people go through sexual development, and people with intellectual disabilities are no exception because, like most people, they also have emotional problems, feelings, needs and sexual experiences. The relationship between inclusive education and sexuality has been the subject of much debate in the fields of psychology and education. The vast myths surrounding the sexuality of people with intellectual disabilities reinforce inequalities related to the sexuality of others. In this way, we intend to reflect and recognize the relevance of legitimate and effective sexual education for people with intellectual disabilities. Therefore, this study uses a literature review to organize the thinking of different authors and scholars on related topics, divided into three themes. In the first topic, we will briefly review the epidemiology, etiology and risk factors for people with intellectual disabilities. In the second part we will discuss aspects related to sexuality in people with intellectual disabilities. In the third point we will present the possibilities and strategies of sexual education for people with intellectual disabilities.

Nursing Research Contributes to Changes in Clinical Practice

Through my experience visiting Hazanuddin University and touring the hospitals in Makassar, I reconsidered the role of nursing research in the development of nursing technology. It will be increasingly important to train professionals to provide quality care, develop new nursing techniques through interdisciplinary research and industry-academia collaboration, and establish evidence regarding insurance reimbursement.

Justification regimes and crisis practices: International educational collaboration amidst pandemic and war

This research investigates how international educational collaboration (IEC) as a social activity adapts to global crises: COVID-19 and the Russian’s invasion in Ukraine. We focus on Finnish higher education institutions (HEIs) and non-governmental organisations (NGOs) that actively provide IEC activities, such as student exchange, education export and educational capacity building abroad. Drawing from the sociology of conventions (SC) and the concept of social practices, we formulate a multidimensional framework that connects regimes of justification, and social practices that emerge in crises. Considering crises as a critical test, we analyse how IEC cope with unexpected situations that require establishing new justifications of public accountability and morality, and practices that fit the crises situation. Our empirical data collected through a two-stage open-ended questionnaire in 2021 and 2022 enables us to consider the recent trends and potential future(s) of IEC. Empirically, we conclude that coping with global crises requires IEC actors to make changes in IEC practices. Analytically, we theorise that regimes of justification and social practices that emerge during crises (crisis practices) are interconnected. Thus, this study contributes to practice-oriented frame by considering accountability of practices in the unexpected circumstances, enhancing the understanding of how different organisations adapt to turbulent times.

Electronic Alert Systems for Patients With Acute Kidney Injury

The acute kidney injury (AKI) electronic alert (e-alert) system was hypothesized to improve the outcomes of AKI. However, its association with different patient outcomes and clinical practice patterns remains systematically unexplored. To assess the association of AKI e-alerts with patient outcomes (mortality, AKI progression, dialysis, and kidney recovery) and clinical practice patterns. A search of Embase and PubMed on March 18, 2024, and a search of the Cochrane Library on March 20, 2024, to identify all relevant studies. There were no limitations on language or article types. Studies evaluating the specified outcomes in adult patients with AKI comparing AKI e-alerts with standard care or no e-alerts were included. Studies were excluded if they were duplicate cohorts, had insufficient outcome data, or had no control group. Two investigators independently extracted data and assessed bias. The systematic review and meta-analysis followed the PRISMA guidelines. Random-effects model meta-analysis, with predefined subgroup analysis and trial sequential analyses, were conducted. Primary outcomes included mortality, AKI progression, dialysis, and kidney recovery. Secondary outcomes were nephrologist consultations, post-AKI exposure to nonsteroidal anti-inflammatory drugs (NSAID), post-AKI angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker (ACEI/ARB) prescription, hospital length of stay, costs, and AKI documentation. Thirteen unique studies with 41 837 unique patients were included (mean age range, 60.5-79.0 years]; 29.3%-48.5% female). The risk ratios (RRs) for the AKI e-alerts group compared with standard care were 0.96 for mortality (95% CI, 0.89-1.03), 0.91 for AKI stage progression (95% CI, 0.84-0.99), 1.16 for dialysis (95% CI, 1.05-1.28), and 1.13 for kidney recovery (95% CI, 0.86-1.49). The AKI e-alerts group had RRs of 1.45 (95% CI, 1.04-2.02) for nephrologist consultation, 0.75 (95% CI, 0.59-0.95) for post-AKI NSAID exposure. The pooled RR for post-AKI ACEI/ARB exposure in the AKI e-alerts group compared with the control group was 0.91 (95% CI, 0.78-1.06) and 1.28 (95% CI, 1.04-1.58) for AKI documentation. Use of AKI e-alerts was not associated with lower hospital length of stay (mean difference, -0.09 [95% CI, -0.47 to 0.30] days) or lower cost (mean difference, US $655.26 [95% CI, -$656.98 to $1967.5]) but was associated with greater AKI documentation (RR, 1.28 [95% CI, 1.04-1.58]). Trial sequential analysis confirmed true-positive results of AKI e-alerts on increased nephrologist consultations and reduced post-AKI NSAID exposure and its lack of association with mortality. In this systematic review and meta-analysis, AKI e-alerts were not associated with a lower risk for mortality but were associated with changes in clinical practices. They were associated with lower risk for AKI progression. Further research is needed to confirm these results and integrate early AKI markers or prediction models to improve outcomes.

Transcending attitudes: teacher responses to professional development in trauma-informed education

The adoption of trauma-informed practices in schools is a significant and growing area of school reform efforts. It has been assumed that professional development aimed at influencing teacher attitudes toward trauma-informed care in schools is an important first step in adopting trauma-informed practices and improving student and school outcomes. However, there are gaps in the literature assessing the impact of trauma-informed professional development on teacher attitudes toward trauma-informed care, and there is little evidence linking changes in teacher attitudes to changes in practices. This exploratory study assessed teacher responses to a year-long pilot program providing intensive professional development and consultation on trauma-informed practices in one urban elementary school in the U.S. Southwest. Findings raise questions about the impact of professional development on teacher attitudes and subsequent changes to practice.

Advancing computational thinking education: Insights from systems thinking applications

BACKGROUND: In today’s world, acquiring essential skills is crucial for empowering individuals, particularly children, to handle everyday challenges and tasks in a technologically advanced society. Among these skills, computational thinking (CT) plays a vital role in problem-solving and adapting to the complex and evolving demands of the 21st century. However, it is necessary to explore the role of other thinking skills alongside CT, considering that CT cannot be improved and applied in isolation. OBJECTIVE: This paper aims to address the gap in knowledge regarding the application of systems thinking to CT development and its integration into education settings. METHODS: Results from two studies, focusing on CT development using educational robotics and maker technologies, form the basis of this paper. The research findings are synthesized and consolidated using the systemic FMA (framework of ideas, methodology, and area of concern) model. RESULTS: The research findings illustrate that utilizing a diverse set of approaches, methods, and tools can improve CT skill development across different educational settings. CONCLUSIONS: The adapted FMA model promotes methodological pluralism and facilitates a critical examination of CT development boundaries, leading to both conceptual and practical changes. This approach enables the recognition of emergent properties, the design of interventions, and the incorporation of multiple perspectives.

In a Stranger’s House: Social Isolation of Internally Displaced People in Ukraine During Wartime

Abstract This article explores the impact of internal displacement during wartime in Ukraine on individuals’ social isolation. This study focused on understanding and comparing feelings of isolation in two different contexts: the native community in territories temporarily occupied by Russian troops since the full-scale war and the host community. The research reveals a consistent pattern of isolation characterized by feelings of loneliness, anxiety, and emotional exhaustion among internally displaced people (IDPs), irrespective of their location. Cultural disconnection emerges as a significant factor in both settings, with war-induced changes in social norms and practices leading to a sense of alienation in native communities, and the challenge of adapting to new cultural environments in host communities. Furthermore, it highlights IDPs’ increased vulnerability to bias, stigma, and anxiety in social interactions. Overall, this qualitative study advances the understanding of the effects of displacement on social isolation and provides insights that can inform effective recovery strategies and foster a resilient, cohesive national identity in post-war contexts in Ukraine.

Exploring the barriers to farmer participation in soil carbon projects under the Australian Carbon Credit Unit Scheme

ABSTRACT The Australian Carbon Credit Unit Scheme was established to incentivise reductions in emissions or carbon storage. However, there has been low participation by farmers in soil carbon projects since the first soil carbon method was established for agriculture in 2014, even though carbon prices are high and management changes to sequester carbon on farms should be complementary to other business outcomes. This study explores the barriers that might limit participation in soil carbon projects. A novel approach is that instead of interviewing landholders, we worked with agents, service providers and agencies in Australia to gain their insights about the participation challenges for farmers. The main barriers identified are information gaps, risk and uncertainty about returns, high upfront costs, poor knowledge, limited business cases and program complexity. Potential opportunities to overcome barriers include increasing awareness of and access to factual and science-based information, reducing risk and uncertainties, reducing measurement and practice change costs, increasing financial support and incentives, quantifying environmental benefits and complementary benefits of the practices, and simplifying the methods and program systems. This study also suggests better business models for carbon projects need to be developed, with adjustable scenarios, so that farmers can tailor them to their enterprise.

Increasing Fluroquinolone Susceptibility and Genetic Diversity of ESBL-Producing E. coli from the Lower Respiratory Tract during the COVID-19 Pandemic.

Lower respiratory tract infections (LRTIs) are the fourth leading cause of death worldwide, among which Escherichia coli (E. coli) pneumonia is considered a rare phenomenon. Treatment options for LRTIs have become limited, especially for extended-spectrum β-lactamase-producing E. coli (ESBL-EC), which are usually resistant to other groups of antimicrobials as well. The aim of our study was to compare the phenotypic resistance profiles and genotypes of ESBL-EC isolates associated with LRTIs before (pre-COVID-19) and during (COVID-19) the COVID-19 pandemic. All isolates were screened for antimicrobial resistance genes (ARGs) and virulence-associated genes (VAGs) and assigned to phylogenetic groups, sequence types and clonal groups by PCR. During the pandemic, a significantly lower proportion of ciprofloxacin-, levofloxacin- and trimethoprim-sulfamethoxazole-resistant ESBL-EC isolates was retrieved from lower respiratory tract (LRT) samples. PCR-based genotypization revealed greater clonal diversity and a significantly lower proportion of isolates with blaTEM, aac(6')-Ib-cr and qacEΔ1 genes. In addition, a higher proportion of isolates with the integrase gene int1 and virulence genes sat and tsh was confirmed. The lower prevalence of fluoroquinolone resistance and greater genetic diversity of ESBL-EC isolated during the COVID-19 period may have been due to the introduction of new bacterial strains into the hospital environment, along with changes in clinical establishment guidelines and practices.

Evaluation of Practice Change Following “Safer Anesthesia From Education” Obstetric Courses in Tanzania: A Prospective Cohort Study

Evaluation of Practice Change Following “Safer Anesthesia From Education” Obstetric Courses in Tanzania: A Prospective Cohort Study