General Medical Services Research Articles

Exploring the role of primary care pharmacists in NHS Lanarkshire following the implementation of the pharmacotherapy hub: a service evaluation

Abstract Introduction The General Medical Service (GMS) contract was produced in Scotland in an attempt to tackle General Practitioner (GP) workforce issues. The pharmacotherapy work stream is part of this and provides a framework for pharmacy teams, dividing services into level 1 (core), level 2 (advanced) and level 3 (specialist).1 A statement by the Royal Pharmaceutical Society (RPS) and the British Medical Association (BMA) discussed the introduction of pharmacotherapy hubs to complete level 1 work for multiple practices, centralising the medicines reconciliation process. Theoretically, this would release pharmacists to carry out clinical and more advanced/specialist services.2 There are currently 8 pharmacotherapy hubs within NHS Lanarkshire (NHSL), incorporating level 2 and 3 services into job plans for General Practice Clinical Pharmacists (GPCPs). No work has been undertaken to explore changes in practice since the implementation of these hubs. The qualitative study explored drivers and motivators for pharmacists in practice, shaping future pharmacotherapy services in NHSL and Scotland. Aim To explore the views and attitudes of primary care pharmacists towards their practice role in NHSL following the implementation of the pharmacotherapy hub. Methods Ethical approval was granted from the School of Pharmacy and Life Sciences Ethics Committee (Robert Gordon University). Pharmacists working within the 8 hub localities were invited to participate via email correspondence if they had over 6 months experience in practice pre-hub implementation and then 6 months post-hub implementation. Participants attended a one-to-one interview to share their views towards their practice role since the hub was implemented. Interviews were recorded, transcribed verbatim and thematically analysed. Results Twelve pharmacists across six localities participated. The five key themes identified were job role, managing time, professional development, professional belonging and patient care. The implementation of the hub was an enabler for pharmacists to partake in advanced pharmacotherapy tasks. Pharmacists negatively perceived level 1 core pharmacotherapy tasks in comparison to level 3 clinical patient-facing time. Participants linked the hubs impact on practice with role development, an increase in autonomy, confidence and job satisfaction. Discussion/Conclusion The hub has enabled in-practice pharmacists to move to a more sustainable balance between core and advanced/specialist tasks. Collaboration is required between pharmacy teams and practices to understand the pharmacist role in pharmacotherapy. Further recommendations include continuing the roll-out of pharmacotherapy hubs, standardisation of pharmacist clinical time balanced with core tasks and implementation of protected learning time for pharmacy teams. The study was open to response bias but this was addressed by using semi-structure interview guides in the one-to-one interviews. Researcher bias was minimised by two researchers analysing the data and practicing reflexivity. The study was open to recall bias due to participant’s retrospective thinking. In NHSL prioritising the hub roll-out and collaboration with stakeholders are essential. This will ensure the balance between efficient pharmacotherapy services and maintaining attractive roles, contributing to a sustainable workforce.

Research Progress of Shared Decision-Making in Schizophrenia with Anxiety.

Shared decision-making (SDM) has been practiced fairly frequently in general medicine, but less so in mental disorders, especially in closed psychiatric wards, and its positive predictor has recently been recognized in the field of mental health. Studies have shown that patients with severe mental disorders want a say in their care and their desire to participate in clinical decision-making is even higher than those treated by general medical services. This review aims to explore the research progress of SDM for patients with schizophrenia with anxiety in a collectivist culture (such as Chinese culture) and to provide a reference for the implementation of SDM in closed psychiatric wards.

Factors that affect the implementation of an integrated care programme for older people with different frailty levels: a qualitative study of commissioners and provider stakeholders

IntroductionThe NHS has made it mandatory for General Practices in England to proactively identify and manage older people with moderate and severe frailty since the GMS contract of 2017/2018. In Luton, stakeholders developed the Luton Framework of Frailty (LFF) to implement this national policy. The aim of this study was to explore the factors that affect the implementation of this national policy at a local level.MethodsIn-depth interviews were conducted with 18 commissioners and service providers, all of whom were involved in providing services for older people with different frailty levels (OPDFL). Purposive and snowball sampling methods were used, with thematic analysis used for data analysis.ResultsTwo main themes with several sub-themes were found. The first theme was the tension within existing national policy initiatives to provide integrated care services for OPDFL, which illuminated their strengths and limitations. Participants felt that new initiatives, such as the development of Primary Care Networks and Enhanced Health in Care Homes, have improved primary care coordination. However, the traditional reactive approach for managing older people who are frail was thought to be counterproductive, when an approach that focused on prevention and early intervention would have been better. The second theme concerned the contextual factors that affect implementation of integrated care. These included having key leaders at a local level, the requirement for more funding, as well as the need for good working relationships among service providers. However, the lack of awareness about the care pathways among GPs was thought to be a reason for the variation in the implementation of the LFF. The COVID-19 pandemic was perceived as a challenge for the implementation of the LFF. Finally, polices were thought to succeed only if more resources are provided, while the term frailty should be used with caution due to the negative connotations of OPDFL towards this term.ConclusionThe implementation of an integrated care programme for OPDFL can be affected by several factors. Having proactive national policies that facilitate coordination and, having key leaders locally, the need for more funding, and good working relationships, are some of the contextual factors that could facilitate a successful implementation. In contrast, the lack of awareness of the care pathways that have been introduced locally, insufficient resources to deliver the programmes efficiently and a lack of careful consideration of how the term frailty is used could hinder this being put into practice.

EVALUATION OF THE ROLE OF THE ACUTE MEDICAL REGISTRAR IN ORTHOPAEDICS

This project hoped to evaluate a new role, encompassing an in-hours registrar physician being based on the orthopaedic wards for advice, patient reviews, and patient journey optimisation. This service aimed to provide input for all patients who required them outwith the already established ortho-geriatric service.The success of this role was assessed through feedback questionnaires, as well as through the auditing of functional indicators such as the burden on the on-call orthopaedic registrar and other departments for advice from junior doctors, plus the number of medical emergencies.The survey received a total of 42 responses from various staff roles. All respondents thought the role had improved patient care or the functioning of the department. Respondents thought the role primarily enhanced patient care and safety and led to increased support for junior doctors and nursing staff. Data showed a 44% reduction in medical emergency calls since the role began. Total calls outwith the department for medical support reduced by 100% in hours and 50% out of hours when analysed over 22 days. Over a 14 day period, calls to the on-call orthopaedic registrar also reduced by 100% in hours, with no significant difference out of hours.This role has improved patient care and safety and allowed faster medical support with reduced impact on orthopaedic and general medical services. Feedback has been very positive from all staff. The major limitation is lack of 24 hour support. Next steps will include expanding the role, as well as introduction of framework for professional development.

Exploring the equity of distribution of general medical services funding allocations in Wales: a time-series analysis.

Good access to quality primary care in high-income countries can improve population health. Access to primary care is however often not equal among socioeconomic groups; our analysis sought to explore whether funding, a determinant of service supply, is equitably distributed among GP practices in Wales. We sought to explore the relationship between funding and deprivation among GP practices in Wales, to understand the equity of current funding policies. We obtained funding data for general practices in Wales between 2014 and 2022 and explored the equity of distribution using the percentage of practice patients living in the 20% most deprived small areas in Wales. We generated a linear regression model exploring the relationship between practice funding and deprivation, with an interaction term with time in years. Practice funding rose for all practices between 2014 and 2022. Practice deprivation and time in years were both associated with practice funding, with increases in practice deprivation associated with reduced funding allocations, and time being associated with a small increase in funding over the study period. Over the period of analysis of 2004-2022, for every 10% increase in patients living in the most deprived LSOAs, funding per patient decreases on average by 1%. Primary cares in Wales in more deprived areas receive discernibly less funding per patient than those in less deprived areas. Given the potential and likelihood primary care can affect population health outcomes, this underinvestment may be contributing to existing health inequalities and requires urgent further analysis and action.

Content and timing of the 6-8 week maternal postnatal check: a mixed methods study.

Since 2020, the General Medical Services contract requires GP practices in England to offer women a GP appointment 6-8 weeks after birth: the '6-8 week postnatal check' or 'consultation'. Historically, provision of checks was variable, and women still frequently report poor experiences. To explore GPs' and women's perspectives of the 6-8 week postnatal check, including key components and timing. Mixed methods study: focus groups of GPs and women, and an online survey of GPs in England. Focus groups explored GPs' and women's experiences of postnatal consultations. An online survey explored GPs' clinical approach, organisation, and improvement potential. Quantitative analysis examined associations between demographics and clinical approach. Thematic framework analysis was used for qualitative data. 18 women and 14 GPs participated in focus groups. 671 GPs completed the survey. Mental wellbeing and contraception were reported as important topics, although some women were not asked about mental health. GP survey responses indicated most recommendations from national guidance were 'always' or 'very often' covered by most, but not all GPs. Clinical coverage was higher for GPs who used clinical templates, had awareness of guidance, were female or a parent. Many GPs (n=326, 49%) needed more time than was allocated for the consultation: (n=524, 78% allocated<15 minutes; n=351, 52% completed in<15 minutes). This study suggests GPs are allocated insufficient time for postnatal consultations, with substantial variation in practice. Specifying consultation duration and consideration of template usage in policy may improve care and outcomes for women.

Research on Big Data Capability and Medical Service Performance

With the rapid development of information technology, Big data technology has been widely applied in various fields.In the field of medical services, Big data capabilities not only help improve the efficiency and quality of medical services, but also promote the innovative development of the medical industry.This article deeply analyzes the connotation of Big data capabilities and their application in improving medical service performance, and combines the practical work of large-scale general hospitals and community medical service institutions to analyze the specific value and application effect of Big data in medical service practice. At the same time, based on medical reform, it summarizes the challenges, coping strategies, and development trends of Big data in medical service performance practice, with the ultimate goal of providing reference and guidance for practical work.

Meeting the Needs of Emerging Adults With Type 1 Diabetes Living in a Rural Area With Mobile Health Interventions: Focus Group Study.

Emerging adults (EAs; age 18-30 years) with type 1 diabetes (T1D) have more challenges with diabetes management and glycemic control than other age groups. Living in a rural community introduces additional unique diabetes care challenges due to limited access to specialty care and ancillary support services. Yet, few interventions have been developed to improve diabetes management in rural-dwelling EAs with T1D. This study aimed to understand the diabetes management experiences of older adolescents and EAs (age 16-25 years) with T1D living in a rural area and to assess their perceptions of the acceptability of 4 fully automated mobile health (mHealth) interventions to support diabetes management. EAs were identified by clinical staff through convenience sampling. In total, 8 EAs participated in 1 focus group and 1 EA completed an individual interview; all data were collected over Zoom. Facilitators explored EAs' experiences living in a rural community with T1D and discussed EAs' impressions of, feedback on, and recommendations for improving 4 mHealth interventions to meet the specific needs of EAs with T1D living in rural communities. Discussions were transcribed and analyzed using conventional content analysis. In total, 9 EAs (aged 18.8, SD 2.7 years; 5, 56% men; 8, 89% White) with a duration of diabetes of 8.6 (SD 4.3) years participated. They described experiences with diabetes stigma (attributing diabetes to poor lifestyle choices) and feelings of self-consciousness (hyperawareness) in their rural communities. They attributed these experiences to the small size of their communities ("everyone knows") and community members' lack of knowledge about diabetes (unable to differentiate between type 1 and type 2 diabetes). In contrast, EAs reported high levels of social support for diabetes and diabetes care from family, friends, and other community members, but low support for medical needs. The location of their diabetes care providers and the limited accessibility of diabetes-specific and general medical care services in their local community created a challenging medical care context. Overall, EAs found mHealth interventions appealing due to their digital delivery and highlighted features that increased accessibility (voiceovers and simple, jargon-free language), individualization (ability to tailor intervention content and delivery), and applicability to their own lives and other EAs with T1D (relatability of vignettes and other content). EAs suggestions for improving the interventions included more opportunities to tailor the interventions to their preferences (greater frequency and duration, ability to adapt content to emerging needs), increasing opportunities for peer support within the interventions (friend and significant other as identified support person, connecting with peers beyond their local community), and making the tone of intervention components more casual and engaging. mHealth interventions aligned with EAs' needs and preferences are a promising strategy to support EAs in communities where social support and resources might be limited. N/A, not a clinical trial.

Research-related knowledge, understanding and practice in public mental health: the voices of social workers and occupational therapists

IntroductionPrevious studies have explored facilitators and barriers to research conducted by allied health professionals in general medical settings. Since the mental health system is acknowledged to be significantly under-funded and more poorly functioning than general medical services, it is unclear whether the published facilitators and barriers also apply to mental health settings. This study sought to explore the research-related knowledge, understanding and practices of allied mental health clinicians based in a large public mental health service.MethodsA mixed methods study recruited 59 occupational therapists and social workers working in a dedicated metropolitan public mental health service in Melbourne, Australia. Quantitative survey results are reported elsewhere. Semi-structured interviews were conducted with 16 survey responder volunteers. Thematic analysis was conducted on the qualitative survey and interview data.ResultsFour main themes were identified: research must connect with clinical practice; fragments of knowledge; research in practice; and research is not part of my professional identity. The third theme, research in practice, comprised four subthemes: no time for research in clinical roles, missing communication, lack of ownership, and what I need to do research.ConclusionsThis study found that research and research-related activities were not considered part of the mental health social workers and occupational therapists’ professional identities. Dealing with this issue may be instrumental to the realization of these clinicians’ professional peak-body associations’ code of practice and to government mandated practice standards. We provided several strategies to encourage both clinicians and services to view research-related activities as an everyday part of clinical roles. This is especially important if we think of allied health evidence-based practice requiring a reasonable level of research-related skills and/or competencies to appraise, practice, evaluate and adapt their evidence-based practice.

Problems of Detecting Tuberculosis by Sputum Microscopy in General Medical Services in the Republic of Karelia

The objective: to determine the effectiveness of detection of patients with pulmonary tuberculosis and prevention of its spread by sputum microscopy in clinical diagnostic laboratories of general medical services of the Republic of Karelia.Results. A reduction in the number of sputum microscopy tests in clinical laboratories of GMS and decrease in the positivity rate to 0.66% was revealed. Among new tuberculosis patients with rifampicin resistance, 51% had abundant bacterial excretion (AFB 2+ and 3+); according to sputum microscopy, tuberculous mycobacteria susceptible to rifampicin were isolated in 38%. In the Republic of Karelia, 31.7% of tuberculosis patients were detected in in-patient units of GMS: 60% of them had cavities, and 28.8% had abundant bacterial excretion (AFB 2+ and 3+). The poor quality of sputum microscopy is the cause of late detection of tuberculosis in the Republic of Karelia and promotes the spread of MDR tuberculosis strains among the population, including nosocomial infection.

The Impact of the Covid-19 Pandemic on an Integrated Care Programme for Older People with Different Frailty Levels (OPDFL): A Qualitative Study with Service Providers in the East of England.

While populations of all ages were affected by the pandemic, older people with frailty had much worse outcomes. The NHS England has mandated identifying and proactively managing older people with moderate and severe frailty in the General medical services (GMS) contract 2017/18. As a result of this policy, an integrated care programme for older people with different frailty levels (OPDFL) was introduced in Luton in 2018 (known as, Luton Framework for Frailty - LFF). This study was conducted to explore the views of service providers in Luton regarding the impact of the COVID-19 pandemic on the implementation of LFF. Semi-structured interviews were conducted with service providers in Luton between April 2021 to July 2021. The data were analysed using thematic analysis. Eighteen service providers took part in the study. Three main themes were identified, the first of which was that proactive and frailty-related health promotion services were halted. Secondly, existing relationships due to the LFF facilitated the implementation of services for care home residents during the pandemic. Finally, participants identified that some of the challenges impacting the delivery of health promotion services were those that affected the health system in general, such as healthcare staff feeling stressed and the centralised decision-making by the government. The lessons learnt from this study could be useful in managing services for older people with frailty in times of emergencies or epidemics.

Estimating the prevalence of potential and actionable drug-gene interactions in Irish primary care: A cross-sectional study.

Pharmacogenetics (PGx) is increasingly recognized as a strategy for medicines optimisation and prevention of adverse drug reactions. According to guidelines produced by the Clinical Pharmacogenetics Implementation Consortium (CPIC) and the Dutch Pharmacogenetic Working Group (DPWG), most medicines with drug-gene interactions (DGIs) are prescribed in primary care. This study aimed to estimate the prevalence of potential and actionable DGIs involving all medicines dispensed in Irish primary care. Dispensings of 46 drugs to General Medical Services (GMS) patients in the Health Service Executive Primary Care Reimbursement Service Irish pharmacy claims database from 01 January 2021 to 31 December 2021 were analysed to estimate the national prevalence of total dispensings and incidence of first-time dispensings of drugs with potential DGIs according to the CPIC and/or DPWG guidelines. Phenotype frequency data from the UK Biobank and the CPIC were used to estimate the incidence of actionable DGIs. One in five dispensings (12 443 637 of 62 754 498, 19.8%) were medicines with potential DGIs, 1878 255 of these dispensed for the first time. On application of phenotype frequencies and linked guideline based therapeutic recommendations, 2349 055 potential DGIs (18.9%) required action, such as monitoring and guarding against maximum dose, drug or dose change. One in five (369 700, 19.7%) first-time dispensings required action, with 139 169 (7.4%) requiring a change in prescribing. Antidepressants, weak opioids and statins were most commonly identified as having actionable DGIs. This study estimated a high prevalence of DGIs in primary care in Ireland, identifying the need and opportunity to optimize drug therapy through PGx testing.

Total triage model in general practice: a systematic review of the opportunities and challenges.

Total triage (TT) has the potential to achieve more equitable access to primary care, to improve the overall quality of care, and enhance health outcomes. TT has gained increasing attention from the public, policymakers, and academics. To examine relevant scientific literature regarding the implementation of TT, the reported opportunities and challenges for patients and staff, and implications for practice. Medline, Embase, CINAHL, and Scopus were searched for articles and grey literature between 2013 and February 2023. Included documents described the implementation of TT during in-hours general practice and provided perspectives from patients/staff. Patients and stakeholders were involved throughout each stage of the review process. Findings were synthesised using a framework approach. In total, 23 documents were included at full-text screening. Analysis highlights a range of TT approaches, sometimes conflating remote and TT systems. TT was seen to both increase and reduce workload. Consistently, patient and staff views worsened with TT use. TT can increase barriers to care access with potential to exacerbate inverse care laws across the UK. Critical knowledge gaps included patient co-production in TT systems and the role of reception teams to adapt systems to meet patients' needs. TT can influence patient access, safety, and equity. The approach may also generate profoundly different working styles for general practice. This review adds to current debates surrounding patient access and TT, and consequences for staff/patients. The findings can be used to aid practices when navigating the new GP contract and the implementation of new TT approaches.

Changes in admission rates to an Aotearoa New Zealand hospital general medical service during COVID-19 lockdowns

aim: To better understand the reasons for reduced hospital admissions to a hospital general medicine service during COVID-19 lockdowns. methods: A statistical model for admission rates to the General Medicine Service at Wellington Hospital, Aotearoa New Zealand, since 2015 was constructed. This model was used to estimate changes in admission rates for transmissible and non-transmissible diagnoses during and following COVID-19 lockdowns for total admissions and various sub-groups. results: For the 2020 lockdown (n=734 admissions), the overall rate ratio of admissions was 0.71 compared to the pre-lockdown rate. Non-transmissible diagnoses, which constitute 87% of admissions, had an admission rate ratio of 0.77. Transmissible diagnoses, constituting 13% of admissions, had an admission rate ratio of 0.44. Reductions in admissions did not exacerbate existing ethnic disparities in access to health services. The lag in recovery of admission rates was more pronounced for transmissible than non-transmissible diagnoses. The 2021 lockdown (n=105 admissions) followed this pattern, but was of shorter duration with small numbers, and therefore measures were frequently not statistically significant. conclusions: The biggest relative reduction in hospital admission was due to a reduction in transmissible illness admissions, likely due to COVID-related public health measures. However, the biggest reduction in absolute terms was in non-transmissible illnesses, where hospital avoidance may be associated with increased morbidity or mortality.

Trends in medication use after the onset of the COVID-19 pandemic in the Republic of Ireland: an interrupted time series study

Abstract Introduction The COVID-19 pandemic had a substantial impact on a range of health services, particularly in primary care. Research from Ireland suggests while community pharmacies remained open, restrictions for in-person healthcare appointments impacted patients.[1] Although there is evidence that the onset of the pandemic affected medicines utilisation internationally,[2] it is unclear how prescribing in Ireland changed following March 2020. Aim To evaluate how dispensing of medications in primary care in Ireland changed following the onset of the COVID-19 pandemic compared to expected trends. Methods This was an interrupted time series study, and the protocol was pre-registered (doi.org/10.17605/OSF.IO/WNQHR). It used publicly available data from the Health Service Executive Primary Care Reimbursement Services for each month between January 2016 and July 2022. Data covered dispensing on the General Medical Services (i.e. medical card) scheme for all medication therapeutic subgroups and commonly dispensed medications (based on the top 100 individual medications per month). Pre-pandemic data (January 2016-November 2019) was used to forecast expected trends from December 2019 onwards for each subgroup and medication with 99% prediction intervals. The Holt-Winters method was used, which decomposes time series data into seasonal, trend, and irregular components. Three months of observed data unaffected by the pandemic (December 2019-February 2020, validation period) were compared to the forecast to validate accuracy of predictions. Observed data were compared to forecasts in March 2020 (as the first month of pandemic restrictions in Ireland) and over the remainder of the study period from April 2020-July 2022. Statistical significance was defined as observed data outside the 99% prediction interval (p&amp;lt;0.01). Results The overall number of dispensings was 7.6% (99%CI 2.5% to 13.2%) higher than forecast in March 2020. Many (31/77) therapeutic subgroups had dispensing significantly different from forecast in March 2020. Drugs for obstructive airway disease had the largest difference, with dispensing 26.2% (99%CI 19.5%-33.6%) higher than forecasted. Other subgroups with dispensing significantly higher than forecasted included minerals, analgesics, thyroid therapy, serum lipid-reducing agents and diuretics. Dispensing was significantly lower than forecasted for other gynaecologicals (17.7% lower, 99%CI 6.3%-26.6%) and dressings (11.6%, 99%CI 9.4%-41.6%). Similarly, many individual medications had significantly higher dispensing in March 2020. Notably, dispensing of amoxicillin (with/without clavulanic acid) and oral prednisolone were lower than forecasted in the months following the onset of the pandemic, particularly during winter 2020/2021. Conclusion There was a peak in dispensing for many long-term medications in March 2020 suggesting patients obtained additional supplies of their regular medicines as pandemic restrictions were introduced. Exceptions were dispensing of two therapeutic subgroups (dressings/intrauterine devices) linked to in-person healthcare consultations, illustrating the disruption to service delivery. Lower than expected dispensing of antimicrobials and reduced seasonal peaks may be partly due to reduced infection transmission generally. Although we were limited by lacking data on the number of people dispensed each medication, this is the first study to examine changes in medication use during the COVID-19 pandemic in Ireland, considering all therapeutic areas. This study provides evidence to inform planning for medication demand and supply for future major health events.

Patients' views on primary care multidisciplinary teams in Scotland: a mixed-methods evaluation.

Expanding primary care multidisciplinary teams (MDTs) was a key component of the 2018 Scottish GP contract, with more than 4700 MDT staff appointed since then. To explore patients' views on primary care MDT expansion in Scotland. A mixed-methods evaluation, which included a postal survey and semi-structured telephone interviews with patients in Scotland. A survey was undertaken of patients who had recently consulted a GP in deprived urban, affluent urban, and remote and rural areas, assessing awareness of five MDT roles and attitudes towards receptionist signposting. In addition, 30 individual interviews were conducted, exploring patients' MDT-care experiences. Of 1053 survey responders, most were unaware of the option of MDT rather than GP consultations for three out of five roles (69% unaware of link worker appointments; 69% mental health nurse; and 58% pharmacist). Reception signposting was less popular in deprived urban areas (34% unhappy versus 29% in remote and rural versus 21% affluent urban; P<0.001), and in patients with multimorbidity (31% unhappy versus 24% in non-multimorbid; P<0.05). Just over two-thirds of interviewees had multimorbidity and almost all reported positive MDT-care experiences. However, MDT care was generally seen as a supplement rather than a substitute for GP care. Around half of patients expressed concerns about reception signposting. These patients were more likely to also express concerns about GP access in general. Both of these concerns were more common in deprived urban areas than in remote and rural or affluent urban areas. MDT care has expanded in Scotland with limited patient awareness. Although patients understand its potential value, many are unhappy with reception signposting to first-contact MDT care, especially those in deprived urban areas living with multimorbidity. This represents a barrier to the aims of the new GP contract.

Greener healthcare operations during COVID-19 pandemic: A data envelopment analysis approach

This study examines internal greener operations in Indian healthcare during COVID-19 pandemic. Specifically, the research explores the interrelationships among three parallel healthcare lines: general care, emergency care, and biomedical waste (BMW) management to fulfill greener healthcare’s targeted sustainable development goals. We use the three parallel stage data envelopment analysis (DEA) approach model to assess efficiencies of the overall system and the individual parallel stages. We collected panel data for cities in the state of Maharashtra, India during the second wave of pandemic in 2021. We find that the effectiveness of general and emergency medical services depends on the requirements of healthcare resources such as beds and equipment in times of pandemics. By contrast, the capacity of individual BMW treatment processes such as incineration, autoclave, shredder, and deep burial would have a bearing on the efficiency of both BMW management and the total system for greener operations. In the second phase, we evaluated the impact of context-specific exogenous factors using a regression model. We found that literacy level was the most important factor at all three parallel stages separately. Additionally, the total population and number of female vaccinated persons were significant across the system while population density and number of male vaccinated persons were inconsequential factors. Interestingly, the Wilcoxon rank-sum hypothesis test offered no evidence to suggest that performance of general care and BMW management, and emergency care and BMW management were equivalent. Implications of these findings for academic theory, practitioners, and policy makers are offered.

Access to advanced healthcare services and its associated factors among patients with cervical cancer in Addis Ababa, Ethiopia.

This study aimed to assess the extent of access to healthcare services, perception and associated factors among patients with cervical cancer in Addis Ababa, Ethiopia. A facility-based cross-sectional study was conducted from 01 July through 30 August 2023 at two tertiary hospitals. Cases with histopathologic and clinical confirmation of cervical cancer were enrolled using a consecutive sampling technique. Data was collected through a validated questionnaire administered by interviewers using the KoboCollect application. Subsequently, the collected data underwent analysis using Statistical Sciences for Social Sciences (SPSS) version 26.0. Bivariable and multivariable regression models were performed at p ≤ 0.2 and p<0.05 statistical significance, respectively. A total of 391 patients were enrolled in the study. Health facilities were accessible for obtaining general medical services (56.5%), drugs (57.3%), laboratory diagnosis services (57.0%), imaging diagnosis services (56.8%), and radiotherapy services (55.8%) of the patients. Cost of services was affordable only in 11.5% of the cases. Essential anticancer medicines were out of stock for 229 (58.6%) of the patients during the past three months. About two-thirds of the patients have a good perception of access to healthcare services. In multivariable binary logistic regression, admission to the inpatient (AOR: 0.20, 95% CI: 0.06-0.67), joblessness (AOR: 0.19, 95% CI: 0.08-0.46), lower level of income to the extreme poverty line (3567ETB)(64.9 USD) (AOR: 0.19, 95% CI: 0.10-0.35), no CBHI coverage (AOR: 4.16, 95% CI: 1.76-9.85), having social support (AOR: 3.80; 95% CI: 1.96-7.41), and poor dietary practice (AOR: 2.36, 95% CI: 1.28-4.35) were found to have a statistically significant association with perceived good access to healthcare services. Only close to a half of the patients with cervical cancer, in Addis Ababa, have adequate access to healthcare services. Nearly two-thirds of the patients reported perceived good access to the services. Many factors were found to show a statistically significant association with patients' perceived access to healthcare services.

Formative Perceptions of a Digital Pill System to Measure Adherence to Heart Failure Pharmacotherapy: Mixed Methods Study.

Heart failure (HF) affects 6.2 million Americans and is a leading cause of hospitalization. The mainstay of the management of HF is adherence to pharmacotherapy. Despite the effectiveness of HF pharmacotherapy, effectiveness is closely linked to adherence. Measuring adherence to HF pharmacotherapy is difficult; most clinical measures use indirect strategies such as calculating pharmacy refill data or using self-report. While helpful in guiding treatment adjustments, indirect measures of adherence may miss the detection of suboptimal adherence and co-occurring structural barriers associated with nonadherence. Digital pill systems (DPSs), which use an ingestible radiofrequency emitter to directly measure medication ingestions in real-time, represent a strategy for measuring and responding to nonadherence in the context of HF pharmacotherapy. Previous work has demonstrated the feasibility of using DPSs to measure adherence in other chronic diseases, but this strategy has yet to be leveraged for individuals with HF. We aim to explore through qualitative interviews the facilitators and barriers to using DPS technology to monitor pharmacotherapy adherence among patients with HF. We conducted individual, semistructured qualitative interviews and quantitative assessments between April and August 2022. A total of 20 patients with HF who were admitted to the general medical or cardiology service at an urban quaternary care hospital participated in this study. Participants completed a qualitative interview exploring the overall acceptability of and willingness to use DPS technology for adherence monitoring and perceived barriers to DPS use. Quantitative assessments evaluated HF history, existing medication adherence strategies, and attitudes toward technology. We analyzed qualitative data using applied thematic analysis and NVivo software (QSR International). Most participants (12/20, 60%) in qualitative interviews reported a willingness to use the DPS to measure HF medication adherence. Overall, the DPS was viewed as useful for increasing accountability and reinforcing adherence behaviors. Perceived barriers included technological issues, a lack of need, additional costs, and privacy concerns. Most were open to sharing adherence data with providers to bolster clinical care and decision-making. Reminder messages following detected nonadherence were perceived as a key feature, and customization was desired. Suggested improvements are primarily related to the design and usability of the Reader (a wearable device). Overall, individuals with HF perceived the DPS to be an acceptable and useful tool for measuring medication adherence. Accurate, real-time ingestion data can guide adherence counseling to optimize adherence management and inform tailored behavioral interventions to support adherence among patients with HF.

Using Linkage-enhancement Strategies to Bridge Treatment Gap among Inmates and Former Inmates in Correctional Settings with Inadequate Mental Health Care

Abstract: Service linkage and skill enhancement strategies were devised in Nigerian prisons with inadequate mental health resources to support the provision of psycho-legal services, including the assessments, identification, and care of inmates and former inmates with mental illness. Over the study period, 74 individuals, consisting of 64 (86.5%) males with a mean age of 33.25 (SD=11.2) years received care or psycho-legal services through these strategies. Clinically, 49% of the participants were diagnosed with schizophrenia (International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code: F20.0–9), 66.7% had first formal clinical diagnosis of mental illness, and as many as 56.1% of the participants endorsed using psychoactive substances. Most participants (73.0%) were assessed and treated within the prison's general medical services with support from a multidisciplinary team from a regional psychiatric hospital. Of the 50 psycho-legal assessments conducted, eight (10.8%) and 12 (16.2%) participants were not criminally responsible and unfit to stand trial, respectively. We included an action-plan to support the implementation of collaborative care, skill-enhancement, and linkage of services as viable strategies in correctional settings with inadequate mental health care.