Delivery Of Medical Care Research Articles

Crammer’s Corner

Managing clinical risk is integral to safe delivery of medical care. This is especially true in general practice where a significant amount of clinical management is based purely on history and examination findings. Invariably, AiTs in general practice are likely to find this aspect of patient care quite daunting in contrast to their peers in secondary care who have much easier access to investigations. In this article, GP trainer, Dr Kunal Chawathey provides useful tips for AiTs to safely manage clinical risk in a primary care setting.

Quality audit of diagnostic colonoscopy protocols in the colorectal cancer screening program

AIM: to analyze the quality of primary colonoscopy protocols in patients included in the colorectal cancer screening program.PATIENTS AND METHODS: out of the 86 patients admitted for the removal of colon polyps detected during primary screening of colorectal cancer at medical institutions of various levels, 67 (77.9%) had colonoscopy protocols, which were analyzed in accordance with the study objectives.RESULTS: the informative value of colonoscopy protocols at the endoscopic stage of colorectal cancer screening in clinic institution of the 3rd level was significantly higher than in the 2nd and 1st levels (5 criteria out of 8).Comparison of protocols quality of two last medical institutions showed no significant differences. The optimal and acceptable quality of colonoscopy protocols, studied in accordance with the same criteria, was achieved by 3 (37.5%) at clinics of the 3rd level and by 1 (12.5%) at medical institutions of the 2nd and 1st levels.CONCLUSION: the quality of colonoscopy protocols at clinics of the 3rd level is significantly higher than at hospitals of the 1st and 2nd levels of medical care delivery. The audit of the diagnostic colonoscopy protocols for colorectal cancer screening of the entire cohort showed the loss of information compared to the standard protocol and in most of them there is a low quality of content.

Respect for conscientious judgement in health care.

Respect for conscientious judgement in health care.

원격의료의 쟁점과 지역사회보건의료를 위한 활용 방안

The paradigm of the medical care delivery system must be shifted from the existing hospital visit and hospitalization to community. This is the establishment of the community health care system, and for this, the role of the local clinic must be changed. Primary care clinics should provide visiting medical services to patients with impaired mobility. In addition, it is necessary to continuously treat and manage registered chronically ill patients in the community. In this process, it is necessary to systematically introduce and utilize telemedicine. In this paper, we present specific plans and logic for local clinics to introduce and utilize telemedicine for the development of community health care. In addition, it is argued that telemedicine used in the institutionalization of community health care and primary care clinics has nothing to do with the medical privatization that civil society was concerned about, but rather corresponds to measures to strengthen the publicness of health care.

Management of acne in transgender and gender diverse youth Part 2: Unique considerations and strategies in medical treatment

Acne vulgaris is among the most common skin disorders afflicting adolescents worldwide, and though well-established guidelines of care exist for acne management, these guidelines do not uniformly consider or address the unique psychosocial and medical needs of transgender and gender diverse (TGD) youth. Part 2 of this two-part review provides guidance on a stepwise approach to the medical treatment of acne in TGD youth, with an emphasis on safety, efficacy, and the delivery of medical care in a culturally humble, thoughtful, and gender-affirming manner.

American health workforce policy and PAs: A brief history.

Health workforce policy in the United States from the mid-1970s has been strongly influenced by perceptions of the adequacy of the physician supply and its relationship to physician assistants/associates (PAs) and NPs. During the 1980s, a series of inaccurate reports by the federal government mistakenly warned of an impending physician surplus and shaped policy decisions for decades. In spite of perceptions of a physician surplus, the PA profession expanded rapidly in the 1990s. Projections of the adequacy of the physician supply changed to a shortage in the first decade of this century and the PA component of the healthcare workforce continued to expand. During the past decade, the Association of American Medical Colleges has employed microsimulation modeling expertise to project the extent of physician shortages, an effort that initially failed to incorporate the contributions of PAs and NPs in the workforce. Although current projection models include the contributions of PAs and NPs, the substitution ratios used are notably low. Specifically, PA and NP productivity effort was set roughly at one-quarter to one-half that of the physician. PAs and NPs make up a substantial contingent within the US healthcare workforce and should be included fully in future workforce projection estimates. This article provides policy recommendations for the advancement of PA contributions to the delivery of medical care.

Telemedicine solutions for clinical care delivery during COVID-19 pandemic: A scoping review.

Background:The unexpected emergence of coronavirus disease 2019 (COVID-19) has changed mindsets about the healthcare system and medical practice in many fields, forcing physicians to reconsider their approaches to healthcare provision. It is necessary to add new, unique, and efficient solutions to traditional methods to overcome this critical challenge. In this regard, telemedicine offers a solution to this problem. Remote medical activities could diminish unnecessary visits and provide prompt medical services in a timely manner.ObjectiveThis scoping review aimed to provide a map of the existing evidence on the use of telemedicine during the COVID-19 pandemic by focusing on delineation functions and technologies, analyzing settings, and identifying related outcomes.MethodsThis review was conducted following the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. PubMed and Scopus databases were systematically searched based on specific eligibility criteria. The English publications included in this study focused on telemedicine systems implemented during the COVID-19 pandemic to provide clinical care services. Two independent reviewers screened the articles based on predefined inclusion and exclusion criteria. The relevant features of telemedicine systems were summarized and presented into the following four domains and their subcategories, including functionality, technology, context, and outcomes.ResultsOut of a total of 1,602 retrieved papers, 66 studies met the inclusion criteria. The most common function implemented was counseling, and telemedicine was used for diagnosis in seven studies. In addition, in 12 studies, tele-monitoring of patients was performed by phone, designed platforms, social media, Bluetooth, and video calls. Telemedicine systems were predominantly implemented synchronously (50 studies). Moreover, 10 studies used both synchronous and asynchronous technologies. Although most studies were performed in outpatient clinics or centers, three studies implemented a system for hospitalized patients, and four studies applied telemedicine for emergency care. Telemedicine was effective in improving 87.5% of health resource utilization outcomes, 85% of patient outcomes, and 100% of provider outcomes.ConclusionThe benefits of using telemedicine in medical care delivery systems in pandemic conditions have been well–documented, especially for outpatient care. It could potentially improve patient, provider, and healthcare outcomes. This review suggests that telemedicine could support outpatient and emergency care in pandemic situations. However, further studies using interventional methods are required to increase the generalizability of the findings.

Disaster-related deaths after the Fukushima Daiichi nuclear power plant accident - Definition of the term and lessons learned

There are two types of disaster deaths: direct and indirect. Direct deaths are caused by the direct physical effects of disasters, such as earthquakes, tsunamis, and radiation exposure, whereas indirect deaths are caused by secondary health effects such as emergency evacuation, relocation, evacuation environment, medical care delivery system, and psychosocial effects. In Japan, the term “disaster-related deaths” is used to refer to indirect deaths; they are defined by the Cabinet Office as follows: “Deaths because of aggravation of injuries caused by the disaster or illnesses caused by the physical burden of living in evacuation shelters, etc., which are recognized as being caused by the disaster based on the Law Concerning Provision of Disaster Condolence Grants (1973 Law No. 82) (actually, disaster condolence payments) (Including those for which no payment has been made, but excluding those whose whereabouts are unknown as a result of the relevant disaster).” This study aims to provide an account of disaster-related deaths in Fukushima Prefecture, the primary affected area of the Fukushima Daiichi Nuclear Power Plant (FDNPP) accident. An observational study was conducted on disaster-related deaths published by the Japanese government and local governments from March 2011 to July 2021. The total number of deaths in the Great East Japan Earthquake (GEJE) was 19,617, of which 3,691 were disaster-related deaths. Fukushima Prefecture had the largest percentage of disaster-related deaths at 59.1%. The status of certification of disaster-related death was different among municipalities in Fukushima Prefecture (range of certification rates: 40%–75.9%). This is the first study on disaster-related deaths in Fukushima in the 10 years after the FDNPP accident. It is possible that further analysis in the future will be useful for disaster countermeasures.

Racial Justice Beyond the Curriculum: Aligning Systems of Care With Anti-Racist Instruction in Graduate Medical Education.

Racial Justice Beyond the Curriculum: Aligning Systems of Care With Anti-Racist Instruction in Graduate Medical Education.

Employing comics for strengthening the delivery of medical education and patient care

The medical knowledge is extremely vast and continues to advance with each day making it extremely challenging for medical students. One of the innovative teaching-learning methods has been the use of comics in the field of delivering medical education and for improving patient care. The utility of comics in the delivery of medical education can be explained in different ways, namely mediation of varied emotional states upon errors made while diagnosis, highlighting illustrations about the good and bad practice of medicine, etc. Like any intervention, even the use of comics in medical education and clinical practice has its own challenges. To conclude, the integration of comics in medical education and patient care is an innovative approach to strengthen the overall process of curriculum delivery. The need of the hour is to understand its scope and then use in relevant settings to make it more effective and beneficial to different stakeholders.

Toward a New Epistemology for Medical Science.

The use of race remains common at all levels of medical science and practice, including education, research, and care delivery. There are ongoing vigorous debates about the validity of the manner in which race is used. Unfortunately, when one looks closely at the manner in which race is used, what one often finds is in fact racism. This article explores some of the ways in which the development of the concept of race as a biological construct, was used to justify racism, and shaped the early development of scientific thought. This historical perspective is used to elaborate the ways in which those seminal ideas continue to distort medical research, education, and care delivery, and perpetuate health disparities.

Vertical integration of GP practices with acute hospitals in England and Wales: rapid evaluation

Background Vertical integration refers to merging organisations that operate at different stages along the patient pathway. An organisation running an acute hospital and also operating primary care medical practices (i.e. general medical practitioner practices, also known as ‘general practices’) is an example of vertical integration. Evidence is limited concerning the advantages and disadvantages of different arrangements for implementing vertical integration, their rationale and their impact. Objectives Our aim was to (1) understand the rationale for, and early impact of, vertical integration in the NHS in England and Wales and (2) develop a theory of change for vertical integration. Design We carried out a rapid qualitative cross-comparative case study evaluation at three sites in England (n = 2) and Wales (n = 1), which comprised three work packages: (1) a rapid review of literature, telephone scoping interviews and a stakeholder workshop; (2) interviews with stakeholders across case study sites, alongside observations of strategic meetings and analysis of key documents from the sites; and (3) development of a theory of change for each site and for vertical integration overall. Results We interviewed 52 stakeholders across the three case study sites; however, gaining access to and arranging and completing non-participant observations proved difficult. The single most important driver of vertical integration proved to be the maintenance of primary care local to where patients live. Vertical integration of general practices with organisations running acute hospitals has been adopted in some locations in England and Wales to address the staffing, workload and financial difficulties faced by some general practices. The opportunities created by vertical integration’s successful continuation of primary care, namely to develop patient services in primary care settings and better integrate them with secondary care, were exploited to differing degrees across the three sites. There were notable differences between the sites in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial. Limitations Across all three case study sites, the study team was unable to complete the desired number of non-participant observations. The pace of data collection during early interviews and documentary analysis varied. Owing to the circumstances of the COVID-19 pandemic during project write-up, the team was unable to undertake site-specific workshops during data analysis and an overall workshop with policy experts. Conclusions The main impact of vertical integration was to sustain primary medical care delivery to local populations in the face of difficulties with recruiting and retaining staff, and in the context of rising demand for care. This was reported to enable continued patient access to local primary care and associated improvements in the management of patient demand. Future work The patient experience of vertical integration, effectiveness of vertical integration in terms of impact on secondary care service utilisation (e.g. accident and emergency attendances, emergency admissions and length of stay) and patient access (e.g. general practitioner and practice nurse appointments) to primary care requires further evaluation. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 17. See the NIHR Journals Library website for further project information.

Structural changes in the Russian health care system: do they match European trends?

ВackgroundIn the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS.MethodsWe address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system.ResultsThe main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery.ConclusionThe structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.

Health professionals' perspectives of integrating meditation into cardiovascular care: A descriptive qualitative study.

Preliminary research suggests that meditation may provide benefits in psychological health and well-being in people with cardiovascular disease (CVD). However, little is known about health professionals' perceptions of the barriers and facilitators to integrating meditation into CVD. A descriptive qualitative study design with semi-structured interviews was used to explore the acceptability of integrating meditation into outpatient CVD programs and the organisational factors that may affect its integration. Clinicians were recruited through purposive and snowball sampling. E-mail addresses were obtained from publicly listed profiles of cardiovascular and relevant health organisations. Interview questions included perspectives of organising or delivering meditation within a health setting, format of meditation delivery, organisational or other factors that facilitate or present barriers to integrating meditation into clinical practice, and perceived risks associated with integrating meditation in clinical settings. Verbatim transcripts were thematically analysed using an inductive approach and the Braun and Clarke (2006) method to identify themes within barriers and facilitators to implementation. Eighteen predominately female (61%) senior nursing and medical professionals (61%), as well as health managers (17%), psychologists (11%) and allied health professionals (11%), aged 40-60 years were interviewed between 18 May 2017 and 29 March 2018 in Australia via telephone, or face-to-face at a university or the participants' workplace. Three key themes were identified including: enhancing awareness of meditation within a biomedical model of care, building the evidence for meditation in CVD and finding an organisational fit for meditation in cardiovascular care. Meditation was perceived to sit outside the existing health service structure, which prioritised the delivery of medical care. Health professionals perceived that some physicians did not recognise the potential for meditation to improve cardiovascular outcomes while others acknowledged meditation's positive benefits as a safe, low-cost strategy. The benefits of meditation were perceived as subjective, based on preliminary evidence. Health professionals perceived that aligning meditation with health organisational objectives and integrating meditation into outpatient cardiac rehabilitation and community-based secondary prevention pathways is needed. A fully powered clinical trial is required to strengthen the evidence regarding the role of meditation for psychological health in CVD. Generating clinician engagement and support is necessary to enhance awareness of meditation's use in cardiovascular secondary prevention.

Efficacy of e-Health Interventions in Patients with Chronic Low-Back Pain: A Systematic Review with Meta-Analysis.

Introduction: Low-back pain (LBP) is the leading cause of disability worldwide. Around 75-84% of the world's population will experience LBP at some point, establishing it as a major global health problem. e-Health is the remote delivery of therapeutic services, clinical information, and medical care, and may prove a very useful approach to tackle this pathology. Objectives: To evaluate the efficacy of e-health-based interventions in improving the symptoms of chronic LBP. Methods: A systematic review with meta-analysis was performed in PubMed, Web of Science, and PEDro until January 2022 through the assessment of methodological quality of systematic reviews (AMSTAR). Studies were included in which e-health interventions were used as experimental treatment compared to physical therapy to determine changes in back-specific functional status and pain in patients with chronic LBP. Two reviewers examined the sources individually, calculated the risk of bias, and extracted the data (PROSPERO number CRD42022306130). The effect size was calculated using the standardized mean difference (SMD) and its confidence interval (95% CI). Results: A total of 9 randomized controlled trials with 3,180 participants were included. The results of the findings showed an effect of e-health compared to other physical therapy on short-term (SMD = -0.59, 95% CI: -1.77 to 0.59) and intermediate short-term (SMD = -0.40, 95% CI: -0.91 to 0.11) pain intensity and back-specific functional status in the short term (SMD = -0.20, 95% CI: -0.81 to 0.41) and intermediate short term (SMD = -0.30, 95% CI: -0.74 to 0.14). The effect of e-health compared to minimal intervention on short-term intermediate pain intensity (SMD = -0.64, 95% CI: -1.72 to 0.45) and short-term intermediate back-specific functional status (SMD = -0.39, 95% CI: -0.87 to 0.09). Conclusions: e-Health interventions based on self-maintenance and education are as effective on pain and back-specific functional status as other face-to-face or home-based interventions in patients with chronic LBP, with moderate scientific evidence.

Perceptions and Understanding of Patients with Cardiovascular Disease and Non-Licensed Caregivers about Patient-Centered Care: An Exploratory Study in Central Appalachia.

This study explored knowledge, understanding, and perceptions of patient-centered care (PCC) among patients with cardiovascular diseases and their non-licensed caregivers (NLCs) in Central Appalachia, a medically underserved rural environment. Seven focus group discussions (FGDs) involving 78 patients/NLCS were conducted across the six states of the region. Focus group discussions were audio-recorded, transcribed, and thematically coded. Major themes were: 1) access to quality health care providers (HCPs) and 2) patientprovider interactions. Subthemes for access to quality HCPs included a) long-term relationships with providers, b) high turnover of cardiovascular specialists, c) lack of traditional family physicians, and d) physician assistants/nurse practitioners versus physicians as primary providers. Subthemes for patient-provider interactions included a) reciprocal communication, b) individualized care, and c) meaningful voice in care decisions. These results underscore the importance of interpersonal relationships with providers in the delivery of medical care in the region.

Impact of the first lockdown related to the COVID-19 pandemic on ophthalmic emergencies in a French University Hospital

IntroductionAt the beginning of the COVID-19 pandemic, the French government implemented its first national lockdown between March and May 2020 in order to limit the dissemination of the virus. This historic measure affected patients’ daily lives and transportation, resulting in changes in the delivery of medical care, particularly emergency care. This study aimed to assess the impact of this restriction policy on the number and severity of ophthalmic emergencies seen in an ophthalmology emergency department.MethodsThis retrospective study conducted at the regional university Hospital of Tours included all patients presenting to the ophthalmology emergency department over four periods: lockdown (03/16/2020 to 05/10/2020), post-lockdown (05/11/2020 to 06/12/2020) and the two corresponding periods in 2019. The following data were recorded: sex, age, time of visit, reason for visit, diagnosis, severity of emergency graded on the BaSe SCOrE, time from first symptoms until visit, existence of a work-related injury, and referral source (ophthalmologist or other).ResultsA total of 1186 and 1905 patients were respectively included during the 2020 lockdown period and the corresponding period in 2019. The study populations for the 2019 and 2020 post-lockdown periods consisted of 1242 and 1086 patients respectively. During the lockdown, the number of consultations decreased significantly (−37.7%), affecting mild and severe emergencies similarly. During the post-lockdown period, the number of emergencies gradually increased but did not reach the level of the corresponding period in 2019 (−12.6%).ConclusionThe first French lockdown resulted in a significant decrease in ophthalmic emergency visits, similar for all levels of severity. All age groups were impacted similarly, without the expected exaggerated decrease for patients over 50 years of age, who are considered to be at greater risk for developing a severe form of COVID-19. The post-lockdown period showed a gradual increase in ophthalmic emergency visits, although these remained fewer than the previous year.

In pursuit of a community-informed group prenatal care model for telehealth use

Group prenatal care is increasingly being used to improve maternal and infant physical and mental health outcomes. We assessed COVID-19–related changes in prenatal care, economic circumstances, and social needs of low-income pregnant and parenting persons to inform adapting a group prenatal care program enhanced with education, care coordination, and other support for use with telehealth. This study offers tangible ways to design and enhance telehealth group prenatal care to address the priorities identified by low-income families while incorporating limitations and requirements of medical care delivery systems. Telehealth group prenatal care programs can be implemented to increase access to health care, resources, and social connection during and after the pandemic.

COVID-19 in Prisons: State Health Care Contracting and the Pandemic Behind Bars

The COVID-19 pandemic has had far-reaching consequences, resulting in millions of infections and deaths worldwide. Given the vast impact of the virus and how it has highlighted health care access/treatment concerns within the general public, this study examined how these issues specifically impacted COVID-19 cases and deaths among incarcerated individuals. In particular, we examined how the method of medical care delivery (i.e., provided by correctional versus contracted practitioners) impacted the reported rates of COVID-19 cases/deaths within correctional institutions. Findings indicated that COVID-19 diagnosis and mortality rates were significantly lower in states where at least some health care for incarcerated individuals was directly provided by correctional employees. We offer various explanations for these findings while also highlighting potential key reporting differences between these two forms of correctional health care delivery.

Delayed medical care and its perceived health impact among US older adults during the COVID-19 pandemic.

Medical care delivery has been substantially disrupted during the coronavirus disease 2019 (COVID-19) pandemic, leading to delays in medical care, particularly among older adults. Less is known about how these delays have affected different segments of this population. Understanding the negative health consequences older adults face from delayed care will provide critical insights into the longer-term population health needs following the pandemic. We used data from a COVID-19 substudy embedded in a nationally representative longitudinal study of older adults, the National Social Life, Health, and Aging Project. Data were collected between September 14, 2020, and January 27, 2021. Two thousand six hundred seventy-two individuals responded to the survey. Using logistic and multinomial logistic regressions, we determined respondent-level characteristics associated with delayed medical care, experiencing a negative impact on physical health from delayed care, and with reporting worsening physical health during the pandemic. Nearly, one-third (32.8%) of older adults reported delayed medical care during the pandemic. Female sex, higher levels of education, greater concerns about the pandemic, and poorer self-rated physical health were associated with delayed medical care. Blacks and those who are 70 and older were less likely to report delayed care. Among those whose care was delayed, 76.5% reported having already recovered delayed care. Nearly one in five (17.6%) reported that delayed care negatively affected their health. Older adults with worse self-rated physical and mental health or who had not fully recovered delayed care were more likely to report perceived negative health impacts from the delay. Regardless of delayed medical care, 10.2% reported worse physical health during the pandemic. One-third of older adults experienced care delays during the pandemic. Despite high rates of care recovery, nearly one in five older adults who experienced delayed care reported being negatively affected. Strategies must be developed to reach these vulnerable patients to increase their healthcare utilization.