Fragmented Health Care System Research Articles

Integrating Syrian refugees into Lebanon’s healthcare system 2011–2022: a mixed-method study

IntroductionThe Lebanese government estimates the number of Syrian refugees to be 1.5 million, representing 25% of the population. Refugee healthcare services have been integrated into the existing Lebanese health system. This study aims to describe the integration of Syrian refugee health services into the Lebanese national health system from 2011 to 2022, amid an ongoing economic crisis since 2019 and the COVID-19 pandemic.MethodsThis paper employs a mixed-methods approach drawing upon different data sources including: 1- document review (policies, legislation, laws, etc.); 2- semi-structured interviews with policymakers, stakeholders, and health workers; 3- focus group discussions with patients from both host and refugee populations; and 4- health systems and care seeking indicators.ResultsAlthough the demand for primary health care increased due to the Syrian refugee crisis, the provision of primary health care services was maintained. The infusion of international funding over time allowed primary health care centers to expand their resources to accommodate increased demand. The oversupply of physicians in Lebanon allowed the system to maintain a relatively high density of physicians even after the massive influx of refugees. The highly privatized, fragmented and expensive healthcare system has impeded Syrian refugees’ access to secondary and tertiary healthcare services. The economic crisis further exacerbated limits on access for both the host and refugee populations and caused tension between the two populations. Our findings showed that the funds are not channeled through the government, fragmentation across multiple financing sources and reliance on international funding. Common medications and vaccines were available in the public system for both refugee and host communities and were reported to be affordable. The economic crisis hindered both communities’ access to medications due to shortages and dramatic price increases.ConclusionIntegrating refugees in national health systems is essential to achieve sustainable development goals, in particular universal health coverage. Although it can strengthen the capacity of national health systems, the integration of refugees in low-resource settings can be challenging due to existing health system arrangements (e.g., heavily privatized care, curative-oriented, high out-of-pocket, fragmentation across multiple financing sources, and system vulnerability to economic shocks).

Abstract PO4-10-09: MBC Community Barriers and Patient Navigation Training Needs

Abstract Background Komen’s mission is to save lives by meeting the most critical needs in our communities and investing in breakthrough research to prevent and cure breast cancer. One method to achieve our mission is through patient navigation. Evidence supports the role of patient navigation in improving breast health outcomes. Patient navigators identify and address barriers to equitable cancer care delivery in a fragmented healthcare system and work to ease the burdens that patients diagnosed with breast cancer experience. As a valued member of a patient’s health care team, patient navigators contribute to improving the quality of cancer care and eliminating barriers throughout the continuum of care. However, not all breast cancer patients experience the same barriers. Metastatic breast cancer (MBC) is the most advanced stage of breast cancer, and there is some evidence that suggests those diagnosed with MBC have unique experiences and needs that often determine and/or contribute to their disease trajectory. Despite this, little in-depth systematic work has been done to understand the unique challenges faced by those diagnosed with MBC or to explore strategies to address those challenges, and there have been no known efforts to equip patient navigators to specifically address the unique barriers of those diagnosed with MBC. Methods Susan G. Komen®’s Center for Applied Research (CfAR) designed the MBC Patient Navigation Training research study to improve the health outcomes of those diagnosed with MBC through patient navigation. The study design includes 4 phases of qualitative methodology with MBC and patient navigator communities to accomplish the following objectives: Examine the needs and barriers of MBC patients (Phase 1) Identify what needs and barriers MBC patients face that can be addressed through patient navigation (Phase 2) Assess the gaps in Komen's Patient Navigation Training Programs' ability to prepare navigators across the United States to address the identified needs/barriers of MBC patients (Phase 3) Design a new module to fill the gaps in Komen's Patient Navigation Training Program to support patient navigators serving MBC communities across the U.S. (Phase 4) Participants were recruited through a grassroots approach to community engagement, with members of the study team, Komen staff, and other breast health advocates contacting individuals and organizations across the U.S. Individuals were invited to attend a virtual introductory call to meet study staff and each other before consenting to participate in the virtual focus groups. Results Participants diagnosed with MBC (n=17) attended one of four virtual focus groups held May 2023 to share their lived experiences. The focus groups were recorded, the recordings were transcribed and checked for accuracy, and study staff analyzed data using a constant comparison approach to qualitative data analysis with NVivo data management software. Those diagnosed with MBC identified challenges of their diagnosis, barriers within the healthcare system, financial toxicity, lack of support, and health inequities as factors limiting their access to care. These participants also identified the role patient navigators could serve to help address these challenges. Next Steps In Phase 2, the study team will examine to what extent patient navigators feel prepared to address the barriers of MBC communities. Based on the findings from this study, the team will identify areas where more training is needed (Phase 3) and design a training module for Komen’s Patient Navigation Training Program (Phase 4) to better prepare patient navigators across the U.S. to meet the needs of MBC communities and improve health outcomes and cancer care delivery. Citation Format: Stephanie McCoy, Kyandra Fox, Kasey Volpe, Toni Lee, Janet Okamoto, Julie McMahon, Kari Wojtanik. MBC Community Barriers and Patient Navigation Training Needs [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-10-09.

Abstract PO5-06-10: Evaluating Disparities in Access to Quality Cancer Care for Black Women with Triple Negative Breast Cancer in the US: A Provider Perspective

Abstract Introduction: Triple-negative breast cancer (TNBC) presents unique challenges due to its aggressive nature and limited treatment options. Black women are disproportionately affected by TNBC, experiencing higher incidence rates and poorer outcomes compared to other racial/ethnic groups. This study aims to evaluate disparities in access to quality cancer care for Black women with TNBC from the perspective of oncology healthcare providers. Methods: From December 2022 to February 2023, the Association of Community Cancer Centers conducted a survey of 84 multidisciplinary care team members who provided care to Black patients with TNBC. The online survey captured quantitative and qualitative data on challenges related to accessing timely TNBC diagnosis and treatment services, care coordination for work-up and biomarker testing, confidence in TNBC treatment, clinical trial enrollment, supportive care services, and related referrals. Additionally, a follow-up focus group was conducted in May 2023 to further interpret select survey data, with a focus on shared decision-making, patient-provider communication, and ways to support cancer programs in improving screening, biomarker testing, and care coordination for individuals with TNBC. Results: Respondents reported several barriers to accessing timely diagnosis and treatment services for Black women with TNBC, including challenges in coordinating care for work-up and biomarker testing, providers' confidence in providing guideline-concordant comprehensive cancer care services for this patient population, enrolling patients in clinical trials, and making referrals for supportive care services. The survey revealed that community cancer programs treated an average of 21-50 patients with TNBC annually, with 31% of them being Black. Perceived patient-level factors contributing to challenges in accessing TNBC diagnosis and treatment included geographic distance to care facilities (14%), health literacy (18%), and insurance-related factors (21%). Practice-level barriers included limited accessibility of practice location (19%), capacity to accommodate new patients (27%), and insurance-related factors (34%). Additional findings highlighted slightly lower provider confidence in areas such as tobacco cessation (only 54% very confident), breast reconstruction (59% very confident), fertility counseling (52% very confident), and coordinating care across a fragmented healthcare system (52% very confident). Respondents identified the most commonly offered comprehensive cancer care services as palliative care (82%), nutrition support (77%), telemedicine (68%), psychological counseling (68%), and financial advocacy (68%). Less commonly offered services include recreational therapy (21%), legal aid (17%), and childcare (16%). Conclusion: This study highlighted the barriers faced by providers in delivering quality cancer care to Black women with TNBC. The findings underscore the importance of addressing challenges related to timely diagnosis and treatment services, care coordination, confidence in treatment options, clinical trial enrollment, and referrals for supportive care services. Insights from the focus group discussions further highlight the need for shared decision-making, improved patient-provider communication, and identification of opportunities to support cancer programs in addressing the specific needs of Black women with TNBC. To advance equity in cancer care, targeted interventions should focus on enhancing provider education, improving care coordination systems, and promoting cultural sensitivity. Efforts should also be made to overcome barriers related to limited accessibility of practice location, and insurance-related factors. By addressing these gaps, providers can play a crucial role in reducing disparities and improving outcomes for Black women with TNBC. Citation Format: Doreen Effange, Niharika Dixit, Ruth O'Regan, Ogori Kalu, Ryann Norcereto, Richard Simonds, Elizabeth Valencia, LaToya Bolds-Johnson, Aubrey Van Kirk Villalobos, Christie Mangir, Elana Plotkin, Karen Tacka, Leigh Boehmer. Evaluating Disparities in Access to Quality Cancer Care for Black Women with Triple Negative Breast Cancer in the US: A Provider Perspective [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-06-10.

In the footstep of the old patient from hospital to home: A qualitative field observation study.

Older people often have multiple health conditions and therefore extended care needs. The transition from the hospital back to their home requires careful planning. The fragmented healthcare system and rapid discharge from the hospital can result in limited involvement of the older patient in the discharge planning process. We aimed to explore how older hospitalised patients experienced the transition from hospital to home and how possibilities and constraints in interactions with relevant parties in the transition affected their everyday lives. An ethnographic participant observation study including interviews was conducted with 10 older hospitalised patients. The theoretical perspective in the study is critical psychology and data were analysed using the condition-, meaning- and reasoning analysis. Three themes were identified: (1) Lost in transition - the person's ability to act is limited, (2) In transition - the relatives become important, (3) At home - the home transforms into a workplace. Lack of involvement becomes a condition for older patients as some struggle to create meaning in their transition, affecting their everyday lives. The patients experienced their relatives as important as they ensured that the HCPs got to know their values and wishes. This knowledge is important for HCPs working closely with older people both at the hospital and at home ensuring active involvement of the older person with respect and acknowledgement of the older person's wishes, needs, resources and vulnerability.

Gluing Together a Fragmented Healthcare System for Geriatrics Will Be Hard. It's Time for United Action

“Gluing” together integrated Geriatric Clinical Service lines (GCSL) within the US healthcare system is a significant challenge. Reasons encompass health professional workforce shortages, inconsistent requirements for geriatric educational competencies among the health professional disciplines, preconceived ageist attitudes about older adults with complex illnesses, and a US healthcare system infrastructure that is not aligned with longitudinal and interdisciplinary care needs for older adults. This review focuses on three major characteristics of the US healthcare system that have impeded widespread dissemination of GCSLs: 1) the US's historical fee for service (FFS) reimbursement system; 2) increasing reliance upon disease specific specialty care services for older patients that have resulted from advances in medicine; and 3) rising consolidation of US healthcare systems over the last 30 years. Three specific options are also provided that might help change the current and future trajectories of GCSLs: 1) local political advocacy to implement health policy legislation; 2) expand geriatric physician and health professional workforce by nontraditional means; and 3) reprioritize expansionist healthcare systems corporate behavior. Each of these interventions will be hard to achieve, but it is time to unite if GCSLs are to thrive as pathways to improve care outcomes for older adults with complex medical, cognitive and neuropsychiatric disorders.

Designing and Implementation of a Digitalized Intersectoral Discharge Management System and Its Effect on Readmissions: Mixed Methods Approach.

Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital. This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate. A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group. Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20). This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

Leveling Up PrEP: Implementation Strategies at System and Structural Levels to Expand PrEP Use in the United States.

Despite highly effective biomedical HIV pre-exposure prophylaxis (PrEP) options, suboptimal PrEP uptake impedes progress towards ending the epidemic in the United States of America (USA). Implementation science bridges what we know works in controlled clinical trial settings to the context and environment in which efficacious tools are intended to be deployed. In this review, we focus on strategies that target PrEP use barriers at the system or structural level, exploring the implications and opportunities in the context of the fragmented USA healthcare system. Task shifting could increase PrEP prescribers, but effectiveness evidence is scarce in the USA, and generally focused in urban settings. Integration of PrEP within existing healthcare infrastructure concentrates related resources, but demonstration projects rarely present the resource implications of redirecting staff. Changing the site of service via expanded telehealth could improve access to more rural populations, though internet connectivity, technology access, and challenges associated with determining biomedical eligibility remain logistical barriers for some of the highest burden communities in the USA. Finally, a tailored care navigation and coordination approach has emerged as a highly effective component of PrEP service provision, attempting to directly modify the system-level determinants of PrEP use experienced by the individual. We highlight recent advances and evidence surrounding task shifting, integration, service delivery, and tailoring. With the exception of tailored care navigation, evidence is mixed, and the downstream impact and sustainability of task shifting and care integration require further attention. To maximize PrEP outcomes, research will need to continue to examine the interplay between individuals, clinics, and the healthcare system and associated policies within which they operate.

Invisible cancers: Seeing, knowing, enacting and proving cancers in Haiti

In Haiti, pathological confirmation of a cancer diagnosis is often delayed or impossible, imaging is expensive and imperfect, and many tests are unavailable. Physicians frequently struggle to establish cancers at a level of certainty required by “evidence based” standards, delaying definitive diagnosis and rendering some cancers permanently “suspected.” I use 22 months of participant observation at the two largest cancer treatment programs in Haiti, as well as throughout Haiti's fragmented healthcare system, to look closely at processes of diagnosis and management of suspected ‘cancers’ which may never fully come to be. I argue that as global oncology becomes increasingly standardized, local practices are forced into alignment with a global knowledge basis that governs the knowability/unknowability of cancer. Using three case studies drawn from this work, I examine relationships among visibility, power, expertise and the replication of inequity through the governance of knowledge production. Finally, I examine the implications of these processes for cancer care in the global south.

The Coproduction of Health Framework: Seeking Instructive Management Models and Theories.

At the beginning of the 21st century, multiple and diverse social entities, including the public (consumers), private and nonprofit healthcare institutions, government (public health) and other industry sectors, began to recognize the limitations of the current fragmented healthcare system paradigm. Primary stakeholders, including employers, insurance companies, and healthcare professional organizations, also voiced dissatisfaction with unacceptable health outcomes and rising costs. Grand challenges and wicked problems threatened the viability of the health sector. American health systems responded with innovations and advances in healthcare delivery frameworks that encouraged shifts from intra- and inter-sector arrangements to multi-sector, lasting relationships that emphasized patient centrality along with long-term commitments to sustainability and accountability. This pathway, leading to a population health approach, also generated the need for transformative business models. The coproduction of health framework, with its emphasis on cross-sector alignments, nontraditional partner relationships, sustainable missions, and accountability capable of yielding return on investments, has emerged as a unique strategy for facing disruptive threats and challenges from nonhealth sector corporations. This chapter presents a coproduction of health framework, goals and criteria, examples of boundary spanning network alliance models, and operational (integrator, convener, aggregator) strategies. A comparison of important organizational science theories, including institutional theory, network/network analysis theory, and resource dependency theory, provides suggestions for future research directions necessary to validate the utility of the coproduction of health framework as a precursor for paradigm change.

Healthcare provision for Swedish persons with intellectual and developmental disabilities

AbstractThis paper aims to give a short description of Swedish healthcare provision for persons with intellectual and developmental disabilities (IDD). Swedish persons with IDD should have access to the general healthcare system on the same terms as the general population, and thereby enjoy equal opportunities for healthcare of good quality. Reports from government agencies and interest groups, however, describe a decentralised and fragmented healthcare system that requires significant coordination; a lack of adjustments; a lack of specialised healthcare professionals; and gaps in healthcare provision. Research in recent years has reported unequal access to planned healthcare; excess mortality and premature deaths; and insufficient or inadequate support in end‐of‐life care. We conclude that health inequalities and healthcare challenges faced by Swedish persons with IDD might be caused by obstacles at several structural levels. Allowing persons with IDD to access timely and adequate healthcare requires the development of better opportunities for coordination of healthcare and social services, as well as training for healthcare professionals and direct support staff.

Cytotoxicity of water supply in a Palestinian refugee camp and a Syrian informal tented settlement in Lebanon.

Deficient water, sanitation, and hygiene (WASH) significantly account for a high burden of disease across the globe. Lebanon, an Eastern Mediterranean lower-middle-income country with a polluted environment, a fragmented healthcare system, and an ongoing severe economic crisis, faces serious challenges in sustaining safe water supplies, especially in vulnerable communities, while also hosting the world highest refugee population per capita. This study aimed to examine the mutagenicity, and the estrogenic and androgenic activities of water supplies, across both a Palestinian refugee camp and a Syrian informal settlement. Water samples were collected from two targeted camps in Dbayeh and Choueifat, North and South of the Capital City Beirut, respectively, between the months of September and October 2022. Microbial and physicochemical properties of samples were determined, including fecal contamination, total dissolved solids, and various minerals and salts. Organic pollutants were extracted using pre-packed solid phase extraction (SPE) columns, and then mutagenicity of extracts was examined using the Ames test in two Salmonella typhi bacterial strains. The estrogenic and androgenic activities of extracts were assessed using the yeast estrogen and androgen screen tests assays (YES/YAS). Results show excessive levels of total coliforms and total dissolved solids (TDS) in samples from both sites. In addition, the water supply from the Dbayeh Palestinian refugee camp is mutagenic, while the water supply from the Choueifat Syrian informal settlement shows anti-androgen activity. Our findings provide valuable WASH baseline data in two major vulnerable communities in Lebanon, and highlight the importance of a water toxicity testing approach concomitant with a water safety plan, based on a holistic strategy that covers all stages of the water supply chain.

Mapping the Common Barriers to Optimal COPD Care in High and Middle-Income Countries: Qualitative Perspectives from Clinicians.

Chronic obstructive pulmonary disease (COPD) poses a significant global health burden despite being largely preventable and treatable. Despite the availability of guidelines, COPD care remains suboptimal in many settings, including high-income countries (HICs) and upper-middle-income countries (UMICs), with varied approaches to diagnosis and management. This study aimed to identify common and unique barriers to COPD care across six countries (Australia, Spain, Taiwan, Argentina, Mexico, and Russia) to inform global policy initiatives for improved care. COPD care pathways were mapped for each country and supplemented with epidemiological, health-economic, and clinical data from a targeted literature review. Semi-structured interviews with 17 respiratory care clinicians were used to further validate the pathways and identify key barriers. Thematic content analysis was used to generate the themes. Six themes were common in most HICs and UMICs: "Challenges in COPD diagnosis", "Strengthening the role of primary care", "Fragmented healthcare systems and coordination challenges", "Inadequate management of COPD exacerbations", "Limited access to specialized care" and, "Impact of underfinanced and overloaded healthcare systems". One theme, "Insurance coverage and reimbursement challenges", was more relevant for UMICs. HICs and UMICs differ in patient and healthcare provider awareness, primary care involvement, spirometry access, and availability of specialized care. Both face issues with healthcare fragmentation, guideline adherence, and COPD exacerbation management. In addition, UMICs also grapple with resource limitations and healthcare infrastructure challenges. Many challenges to COPD care are the same in both HICs and UMICs, underscoring the pervasive nature of these issues. While country-specific issues require customized solutions, there are untapped possibilities for implementing global respiratory strategies that support countries to manage COPD effectively. In addition to healthcare system-level initiatives, there is a crucial need for political prioritization of COPD to allocate the essential resources it requires.

Technology-Enabled Collaborative Care for Diabetes and Mental Health (TECC-D): Feasibility and Satisfaction of a Co-Re-Designed Integrated Virtual Care Model

Objective: For individuals living with Type-2 Diabetes (T2D), mental health issues such as distress, anxiety, and depression are common. However, current models of care require those living with T2D and mental health issues to navigate a fragmented healthcare system to receive physical and mental health services. This is especially true in rural areas where there are additional barriers at the individual and provider level. To address these gaps, we co-re-designed a person-centred Technology-Enabled Collaborative Care for Diabetes and Mental Health (TECC-D) model through iterative input. 
 Co-Re-Design: To meet the complex needs of those living with T2D and mental health issues, a co-re-design process was utilized. This involved building on existing assets, including a previously co-designed collaborative care model that was re-designed for this population with input from three people with lived experience of diabetes, diabetes and mental health care providers, and community stakeholders. This team supported the design and implementation of the model throughout the study duration.
 Methods: In this explanatory sequential feasibility trial, the TECC-D model leveraged existing assets including widely available technology (telephone, web-conferencing) to integrate T2D and mental health support through weekly, virtual health coaching sessions with a Certified Diabetes Educator, supported by a multidisciplinary virtual care team for 8 weeks. Primary outcomes included the feasibility and acceptability of the TECC-D model with exploratory outcomes including changes in mental health, substance use, and physical health behaviours collected at baseline, 4, 8, and 12 weeks. Provider and partner experience and satisfaction were also explored through a qualitative descriptive study.
 Results: 31 participants were recruited and completed the program between June 2021 and June 2022. Study findings demonstrate that the TECC-D model is a feasible and scalable care solution that empowers individuals living with T2D and mental health issues to take an active role in improving their physical and mental health. Participants and providers described program components (e.g., health coaching, virtual care team) and program delivery (e.g., frequency and duration of the program) positively. This included: 1) seeing virtual care as practical and effective for managing routine care needs; 2) feeling that having an expert care coach supported by a virtual care team was “over and above” the care that participants had previously experienced; 3) building expertise and capacity within the care team specific to diabetes and mental health; and 4) recognizing that integrated care is “missing from diabetes care” and that in offering clinical integration, participants felt “much more than just the sum of my parts”. 
 Conclusions: Utilizing widely available technology in the current health system and engaging existing primary and community-based care assets, this model of care was found to be both feasible and acceptable by participants, providers, and patient partners and may improve the lives of individuals living with T2D and mental health issues.

Where I am from matters: factors influencing behavioral and emotional changes in autistic individuals during COVID-19 in Latin America.

The COVID-19 pandemic brought an increased incidence of disease and mortality in the world at large, making it a particularly salient and stressful life event. For those individuals residing in Latin America, the pandemic was met with fragmented healthcare systems, economic downturn, and sociopolitical crisis which puts autistic individuals at risk for more detrimental outcomes. Behavioral and emotional challenges experienced by autistic individuals at the beginning of the pandemic could later develop into more severe symptomatology as the pandemic progresses. The present study aimed to explore changes in dysregulated (overt and internalizing) behaviors and preoccupation with getting sick during the COVID-19 pandemic among autistic children in 7 Latin American countries. Sample consisted of 1,743 caregivers, residing in: Argentina (n = 677, 38.8%) Brazil (n = 156, 9%), Chile (n = 251, 14.4%), Dominican Republic (n = 171, 9.8%), Mexico (n = 126, 7.2%), Uruguay (n = 259, 14.9%) and Venezuela (n = 103, 5.9%). The majority of caregivers who completed the questionnaire were mothers (85.1%), and most had a male autistic child (81.6%). A series of independent sample t-tests were conducted to assess country differences in dysregulated behaviors and preoccupation with getting sick. Linear regressions were conducted to identify which demographic characteristics and micro-level contextual factors predicted dysregulated overt behaviors and psychological changes. Contextual factors, such as country of residence, were related to preoccupation with getting sick and dysregulated behavior. Particularly, residing in Mexico and Brazil were related to changes in preoccupation with getting sick and mental health concerns. Coexistence predicted dysregulated internalizing behaviors, while being older significantly predicted preoccupation with getting sick. Increased screen time only predicted anxiety. Our findings highlight differences and predictions of behavioral challenges and psychological changes based on certain contextual factors and individual characteristics while experiencing severe life stressors such as a worldwide pandemic. This knowledge could help inform policies and decrees aimed at protecting those most vulnerable due to their increased difficulty adapting to change.

The economic impact of a local, collaborative, stepped, and personalized care management for older people with chronic diseases: results from the randomized comparative effectiveness LoChro-trial

BackgroundWithin the ageing population of Western societies, an increasing number of older people have multiple chronic conditions. Because multiple health problems require the involvement of several health professionals, multimorbid older people often face a fragmented health care system. To address these challenges, in a two-group parallel randomized controlled trial, a newly developed care management approach (LoChro-Care) was compared with usual care.MethodsLoChro-Care consists of individualized care provided by chronic care managers with 7 to 16 contacts over 12 months. Patients aged 65 + with chronic conditions were recruited from inpatient and outpatient departments. Healthcare utilization costs are calculated by using an adapted version of the generic, self-reporting FIMA©-questionnaire with the application of standardized unit costs. Questionnaires were given at 3 time points (T0 baseline, T1 after 12 months, T2 after 18 months). The primary outcome was overall 3-month costs of healthcare utilization at T1 and T2. The data were analyzed using generalized linear models with log-link and gamma distribution and adjustment for age, sex, level of care as well as the 3-month costs of care at T0.ResultsThree hundred thirty patients were analyzed. The results showed no significant difference in the costs of healthcare utilization between participants who received LoChro-Care and those who received usual care, regardless of whether the costs were evaluated 12 (adjusted mean difference € 130.99, 95%CI €-1477.73 to €1739.71, p = 0.873) or 18 (adjusted mean difference €192.99, 95%CI €-1894.66 to €2280.65, p = 0.856) months after the start of the intervention.ConclusionThis study revealed no differences in costs between older people receiving LoChro-Care or usual care. Before implementing the intervention, further studies with larger sample sizes are needed to provide robust evidence on the cost effects of LoChro-Care.Trial registrationGerman Clinical Trials Register (DRKS): DRKS00013904, https://drks.de/search/de/trial/DRKS00013904; date of first registration 02/02/2018.

Perceived knowledge, attitudes and practices regarding the medical consortium among medical staff in Sichuan, China: a cross-sectional survey

BackgroundIn China, fragmented and inefficient health care systems are common while quality resources are limited. To promote an organized, efficient system, the government launched a medical consortium policy to vertically integrate health care through the collaboration of different levels of medical care. Logically, medical staff’s knowledge, attitudes and practices (KAP) regarding the consortium are critical for its development. The objective of this study was to explore the KAP regarding the medical consortium among medical staff in a medical consortium in Sichuan Province, China.MethodsA cross-sectional survey was conducted. In total, 690 medical staff members in 3 cities of Sichuan Province, China, were interviewed from November 2018 to December 2018. The questionnaire consisted of 18 items, including 4 items related to perceived knowledge, 4 items related to attitudes and 2 items related to practices, and was rated on a 5-point Likert scale (one = strongly disagree/do not know, five = strongly agree/know).ResultsThe effective response sample was 640 copies of the questionnaire, and most medical staff members (92.50%) knew about the cooperation with other hospitals in the medical consortium. Medical staff scored differently on each item in the questionnaire, with the highest score being the item ‘agreeing with the ward rounds and clinical teaching and training organized by the leading hospital’ (4.54 ± 0.76), and the lowest score being the item ‘frequency in participating in ward rounds and clinical teaching organized by the leading hospital’ (2.83 ± 1.36). In addition, the effect of demographic characteristics on KAP was evaluated by stepwise multiple regression analysis, and a significant positive correlation was found between all the studied variables by Spearman’s correlation (p < 0.05).ConclusionsThis study showed that the attitudes toward and knowledge of the medical consortium significantly contribute to practices, satisfaction with the support work performed by the leading hospital and agreement of improvement after joining the medical consortium. Thus, to improve medical staff’s KAP and satisfaction, publicity and educational programs in medical consortia are necessary, and the leading hospital should attach importance to the informatization construction and demand of different medical staff members.Clinical trial registrationThere are no clinical trials in this study.

Lean and Safety Management: a Project to Improve the Continuity of Care for Chronic Patients

Enhancing the quality of care for chronic patients means guaranteeing the delivery of integrated care. Integrated health systems help overcome the fragmentation of care processes, by bridging the organisational, managerial, and informational gaps, with the final purpose of improving the access, quality, and continuity of services. Indeed, chronic patients require the assistance of multiple providers, referring to different levels of care (primary, secondary, or tertiary). However, hyper-specialised and fragmented healthcare systems hamper the achievement of these goals, resulting in suboptimal care, higher cost, and poor quality of care. The implementation of lean and safety management (L&amp;SM) within hospitals demonstrated its ability to improve efficiency, effectiveness, and patient satisfaction, through proactive identification and reduction of risks and wastes. The novelty lies in adopting this approach to act on integration and continuity between different levels of care. With this aim, a L&amp;SM project has been developed in a Spanish hospital. The project focuses on improving the discharge process from internal medicine to primary care, essential to prevent further patients’ readmissions. In fact, cooperation between the hospital and primary care is crucial to ensure continuity in chronic pathways, providing adequate assistance to patients’ healthcare and social needs. The first results show how this approach was instrumental to engage in the project all key actors involved in the pathways, overcoming departmental barriers, and enhancing continuity of care. Moreover, this approach facilitated the convergence of identified inefficiencies with the clinicians’ interests, focusing only on the aspects considered of primary importance, such as the communication between the hospital and primary care. The expected outcomes encompass the achievement of a better understanding of the process, the identification of the criticalities in terms of risks and waste, the proposal and implementation of improvement interventions. This project represents an innovative attempt to implement L&amp;SM outside of hospital boundaries to improve new performance dimensions, focusing on integration and continuity of care.

Organizational structures influencing timely recognition and acknowledgment of end-of-life in hospitals – A qualitative study of nurses' and doctors’ experiences

PurposeHealthcare personnel's timely recognition and acknowledgment of end-of-life (EOL) is fundamental for reducing futile treatment, enabling informed decisions regarding the last days or weeks of life, and focusing on high-quality palliative care. The aim of this study is to explore and describe nurses' and doctors' experiences of how organizational structures in hospitals influence timely recognition and acknowledgment of EOL. MethodsA qualitative explorative design was applied, with data collected through 12 individual in-depth interviews using a semi-structured interview guide. A total of 6 nurses and 6 doctors were strategically recruited from medical and surgical wards in a Norwegian hospital. Qualitative content analysis was used. ResultsThe analysis revealed the theme The importance of hospital organizational structures in timely recognition and acknowledgment of EOL and a subtheme comprising three areas of organizational structures influencing timely recognition and acknowledgment of EOL; Challenges to and demands of continuity, collaboration, and time. ConclusionsThe study's results show challenges in identifying when cancer patients approach the last weeks and days of life within hospital wards. For nurses and doctors to be able to recognize and acknowledge EOL, continuity of care, collaboration, and time is needed. A fragmented healthcare system, with a predominant focus on treatment and cure, may prevent cancer patients from receiving timely palliative, care causing unnecessary suffering.

Drug Product and Drug Substance (CADIFA) Registration process in Brazil

There is a significant demand for improved healthcare and advanced pharmaceuticals in Brazil, presenting lucrative opportunities for foreign investors. However, engaging in business activities in Brazil can be challenging due to various factors. The process of registering pharmaceutical products in the country is time-consuming. Moreover, the highly regulated, complex, and fragmented Brazilian healthcare system, which is prone to corruption, can pose significant difficulties for small and medium-sized enterprises lacking the necessary financial resources and market knowledge. To comply with regulations, companies must provide detailed information about their drug products, including specifications, leaflets/labels, precautions, and other crucial details, all of which must be submitted in Portuguese in a comprehensive dossier. It typically takes close to a year to complete the medical registration process. In Latin America, specifically Brazil, Argentina, and Chile, there is a push to promote the registration of generic products by reducing the associated costs. Despite the obstacles and issues faced, Brazil's population of nearly 200 million people, its strategic position within Latin America, and its growing economy collectively present an appealing and promising market for various pharmaceutical sectors, offering potential for profitability.

National dengue surveillance, Cambodia 2002-2020.

Global dengue incidence has increased dramatically over the past few decades from approximately 500 000 reported cases in 2000 to over 5 million in 2019. This trend has been attributed to population growth in endemic areas, rapid unplanned urbanization, increasing global connectivity, and climate change expanding the geographic range of the Aedes spp. mosquito, among other factors. Reporting dengue surveillance data is key to understanding the scale of the problem, identifying important changes in the landscape of disease, and developing policies for clinical management, vector control and vaccine rollout. However, surveillance practices are not standardized, and data may be difficult to interpret particularly in low- and middle-income countries with fragmented health-care systems. The latest national dengue surveillance data for Cambodia was published in 2010. Since its publication, the country experienced marked changes in health policies, population demographics, climate and urbanization. How these changes affected dengue control remains unknown. In this article, we summarize two decades of policy changes, published literature, country statistics, and dengue case data collected by the Cambodia National Dengue Control Programme to: (i)identify important changes in the disease landscape; and (ii)derive lessons to inform future surveillance and disease control strategies. We report that while dengue case morbidity and mortality rates in Cambodia fell between 2002 and 2020, dengue incidence doubled and age at infection increased. Future national surveillance, disease prevention and treatment, and vector control policies will have to account for these changes to optimize disease control.