Health Care Delivery Models Research Articles

Persistent unmet need for surgical care in Western Uganda.

Treatable surgical diseases account for a significant proportion of the global burden of disease, particularly in low- and middle-income communities. The number of deaths owing to poor surgical care or its non-availability has been reported to exceed those from HIV/AIDS, tuberculosis and malaria combined. The Ugandan government and its development partners aim to put in place measures to achieve universal health coverage for all communities. These include construction and equipping health facilities, training of health workers, opening up road networks, and poverty alleviation programmes. However, these efforts have, as yet, fallen short as evidenced by external hernias remaining the leading cause of intestinal obstruction for more than 40 years. We recommend establishment of global surgery collaborations with rural-based medical training schools and other health facilities, essential surgical skills training for medical students, task shifting in surgical care and integration of regular surgical camps in the Uganda's healthcare delivery model.

Centering marginalized voices in advocacy for equitable policy change in kidney disease.

Inequities in kidney disease are a result of differences in healthcare access and inequitable structural policies that lead to downstream social challenges. An individual with kidney disease sits at the intersection of a variety of governmental and institutional policies that directly affect their access to kidney healthcare and different care delivery models. However, their voice in policy change is often neglected by stakeholders with more structural power. Marginalized individuals with kidney disease are disproportionately affected by kidney disease and inequitable policies can further these health disparities. The review aims to describe how marginalized individuals can be centered in research and lead in advocacy efforts to promote equitable policy change. The marginalized patient voice is critical in advocacy to promote equitable policy change. We discuss examples illustrating research and advocacy methods which center and partner with marginalized communities to catalyze effective policy interventions. Centralizing the patient voice when engaging in advocacy can identify and contextualize the effects of inequitable public policy and improve advocacy efforts.

Equity in Mental Health Care Receipt among Youth Who Use School-Based Health Centers

Youth experience significant mental health (MH) needs, and gender- and racially/ethnically-diverse youth are less likely than peers to receive care. School-based health centers (SBHCs) are a healthcare delivery model that may decrease disparities. This study examined the role of SBHCs in reducing disparities in MH care receipt among SBHC clients. Data from electronic health records of 5,396 youth ages 12 to 21 years who visited 14 SBHCs in one California county from 2021-2023 were analyzed in 2023-2024 using multiple logistic regression to assess disparities in MH care receipt and depression screenings. Receipt of MH care from SBHCs varied significantly by gender but not age, sexual orientation, or race/ethnicity. Compared to female clients, males had reduced odds (AOR: 0.50) and gender-diverse clients had higher odds (AOR: 2.70) of receiving MH care. For receipt of depression screenings, male clients had reduced odds (AOR: 0.86); Latino clients had higher odds than white clients (AOR: 1.80); and older adolescents and young adults had higher odds than younger adolescents (AORs: 1.44 and 1.45, respectively). Receipt of follow-up MH care after a positive depression result varied only by gender, with male clients having reduced odds (AOR: 0.63). SBHCs may reach youth who are traditionally less likely to seek care in other settings, including racially/ethnically- and gender-diverse youth. As in other settings, engaging males in healthcare is an area for improvement. These findings help to demonstrate the potential of SBHCs for decreasing disparities in mental health care.

Nephrology nurse practitioner model of care for chronic kidney disease: Lessons learned and informing future healthcare delivery

Background: Chronic kidney disease (CKD) affects more than 10% of the Australian adult population. It is a progressive disease that involves multiple physiological systems and is associated with several comorbid conditions, making it particularly burdensome on patients and the healthcare system. Alternative models of healthcare delivery are required to slow the progression to kidney failure. Aim: To describe the characteristics, patient profiles, and health outcomes of patients with CKD attending a nephrology nurse practitioner-led clinic. Design: Longitudinal health-service exploratory design. Methods: Following ethics approval, data were extracted from a chronic kidney disease registry for all consenting patients who attended a nephrology nurse practitioner-led clinic. Data were analysed descriptively. Results: Over the study period, 253 patients (122 male and 131 female) attended the clinic. The mean age was 70.27 ± 10.48 years, and at baseline most had either chronic kidney disease grade 3A (32.8%) or 3B (41.5%). For the majority of those who remained in the clinic, kidney function remained stable or slightly improved. A large proportion were within recommended target ranges for systolic (85.6%) and diastolic (98%) blood pressure although many had high BMI (mean 31.99 ± 6.47) and HbA1c (57.1%). Conclusion: The nephrology nurse practitioner-led clinic demonstrated effectiveness in addressing CKD targets for patients and provides an opportunity to transform traditional primary and specialist healthcare delivery. What is already known about the topic? Early intervention in chronic kidney disease (CKD) can slow or halt the progression of the disease, reducing long-term burden and healthcare costs. An integrated model of care including primary and specialist providers is considered optimal for the early detection and treatment of CKD. An integrated nephrology nurse practitioner model is an emerging model of care for CKD patients. However, studies investigating the cost-effectiveness, efficacy, and characteristics of this model compared to specialist or primary care in Australia are lacking. What this paper adds: This paper describes the characteristics and outcomes of a nephrology nurse practitioner-led outpatient clinic embedded within a multidisciplinary model of care. The majority of patients who remained in nephrology nurse practitioner care maintained recommended CKD targets. The findings provide evidence that nephrology nurse practitioners are able to manage patients with less advanced CKD grades who have comorbid conditions and other health risk-factors.

Academic Service Partnerships: A 21st Century Business Strategy to Integrate Physician Assistant Learners Into a Value-Based Health Care Delivery Model.

Although there has been a surge in physician assistant (PA) programs in the United States, PA programs have concurrently experienced challenges with partnering with a sufficient pool of clinical training sites. During the long-lived fee-for-service era, many programs have relied on transactional relationships with individual clinicians, hospitals, community health centers, private practices, and other entities to provide the required clinical experiences for PA learners. These arrangements often involved bargaining a supervised clinical experience in exchange for continuing medical education credit or other incentives included in a clinician's benefits package. However, with the recent transformation of the US health care delivery system into a value-based care model, academic service partnerships have emerged as valuable solutions. Academic service partnerships uniquely integrate health professions learners into health systems by providing more sustainable, results-driven clinical experiences that benefit the program, the clinical training site, and the patients.

Neurology nursing numbers: where are our nurses?

The publication of our NHS Long Term Workforce Plan ( NHS England, 2023 ) is perhaps one of the most seminal moments in the 75-year history of the NHS. This is the first time the government has asked the NHS to come up with a comprehensive workforce plan; a once-in-a-generation opportunity to put staffing on a sustainable footing and improve patient care. The future outlook for the nursing workforce holds both promise and challenges as the healthcare landscape continues to evolve. With ongoing shifts in demographics, technology, and healthcare delivery models, nurses play a crucial role in providing quality patient care. But does the NHS know how many nurses are currently working in neurology? Are there enough to manage the care that is required? Sue Thomas highlights the current challenges facing the neurology and nursing workforce, trends in nursing employment, the impact of technology and highlights the lack of information about our current neurology nursing numbers and suggests that strategies are needed to address neurology nursing shortages.

Integrating Palliative Care and Hematologic Malignancies: Bridging the Gaps for Our Patients and Their Caregivers.

Patients with hematologic malignancies (HMs) struggle with immense physical and psychological symptom burden, which negatively affect their quality of life (QOL) throughout the continuum of illness. These patients are often faced with substantial prognostic uncertainty as they navigate their illness course, which further complicates their medical decision making, especially at the end of life (EOL). Consequently, patients with HM often endure intensive medical care at the EOL, including frequent hospitalization and intensive care unit admissions, and they often die in the hospital. Our EOL health care delivery models are not well suited to meet the unique needs of patients with HMs. Although studies have established the role of specialty palliative care for improving QOL and EOL outcomes in patients with solid tumors, numerous disease-, clinician-, and system-based barriers prevail, limiting the integration of palliative care for patients with HMs. Nonetheless, multiple studies have emerged over the past decade identifying the role of palliative care integration in patients with various HMs, resulting in improvements in patient-reported QOL, symptom burden, and psychological distress, as well as EOL care. Importantly, these studies have also identified active components of specialty palliative care interventions, including strategies to promote adaptive coping especially in the face of prognostic uncertainty. Future work can leverage the knowledge gained from specialty palliative care integration to develop and test primary palliative care interventions by training clinicians caring for patients with HMs to incorporate these strategies into their clinical practice.

Telehealth-Based Information Retrieval and Extraction for Analysis of Clinical Characteristics and Symptom Patterns in Mild COVID-19 Patients

Clinical characteristics of COVID-19 patients have been mostly described in hospitalised patients, yet most are managed in an outpatient setting. The COVID-19 pandemic transformed healthcare delivery models and accelerated the implementation and adoption of telemedicine solutions. We employed a modular remote monitoring system with multi-modal data collection, aggregation, and analytics features to monitor mild COVID-19 patients and report their characteristics and symptoms. At enrolment, the patients were equipped with wearables, which were associated with their accounts, provided the respective in-system consents, and, in parallel, reported the demographics and patient characteristics. The patients monitored their vitals and symptoms daily during a 14-day monitoring period. Vital signs were entered either manually or automatically through wearables. We enrolled 162 patients from February to May 2022. The median age was 51 (42–60) years; 44% were male, 22% had at least one comorbidity, and 73.5% were fully vaccinated. The vitals of the patients were within normal range throughout the monitoring period. Thirteen patients were asymptomatic, while the rest had at least one symptom for a median of 11 (7–16) days. Fatigue was the most common symptom, followed by fever and cough. Loss of taste and smell was the longest-lasting symptom. Age positively correlated with the duration of fatigue, anorexia, and low-grade fever. Comorbidities, the number of administered doses, the days since the last dose, and the days since the positive test did not seem to affect the number of sick days or symptomatology. The i-COVID platform allowed us to provide remote monitoring and reporting of COVID-19 outpatients. We were able to report their clinical characteristics while simultaneously helping reduce the spread of the virus through hospitals by minimising hospital visits. The monitoring platform also offered advanced knowledge extraction and analytic capabilities to detect health condition deterioration and automatically trigger personalised support workflows.

Impact of medical innovations on quality of care in low income settings

Access to high-quality healthcare remains a challenge in low-income settings, primarily due to resource constraints and limited access to medical innovations. This systematic review examines the impact of medical innovations on the quality of care in low-income settings. Through a comprehensive analysis of relevant literature, this paper highlights the various medical innovations that have been implemented in low-income settings and evaluates their effectiveness in improving healthcare outcomes and patient satisfaction. The review identifies three broad categories of medical innovations: technological innovations, innovative healthcare delivery models, and novel treatment modalities. Technological innovations encompass a wide range of advancements, including telemedicine, mobile health (mHealth) applications, and point-of-care diagnostics. These innovations have shown promise in improving access to healthcare services, enhancing diagnostic accuracy, and facilitating remote monitoring and follow-up care in low-resource settings. Innovative healthcare delivery models, such as community health worker programs, task shifting, and mobile clinics, have also been implemented to overcome barriers to healthcare access in low-income settings. These models prioritize community engagement, decentralization of services, and task delegation to non-physician healthcare providers to expand coverage and reach underserved populations. Furthermore, novel treatment modalities, including affordable and portable medical devices, point-of-care testing kits, and low-cost medications, have been developed to address the specific healthcare needs of low-income populations. These innovations aim to improve treatment efficacy, reduce treatment costs, and minimize the burden of disease in resource-limited settings. The review synthesizes evidence from a diverse range of studies to assess the impact of these medical innovations on healthcare outcomes and patient satisfaction. Key findings suggest that while medical innovations hold promise in enhancing quality of care, several challenges including limited resources, infrastructure constraints, and training requirements need to be addressed to maximize their impact. The paper concludes by emphasizing the importance of tailored approaches and sustainable strategies for implementing medical innovations in low-income settings. By fostering partnerships, leveraging existing infrastructure, and investing in capacity building initiatives, stakeholders can effectively integrate medical innovations into healthcare delivery systems and improve access to high-quality care for underserved populations. This systematic review contributes to the growing body of literature on healthcare innovation and provides valuable insights for policymakers, healthcare providers, and researchers seeking to address the healthcare needs of low-income populations and achieve health equity on a global scale.

Expanding access to genetic testing for pancreatic cancer.

Among individuals with pancreatic ductal adenocarcinoma (PDAC) 5-10% have a pathogenic germline variant (PGV) in a PDAC susceptibility gene. Guidelines recommend genetic testing among all individuals with PDAC. Additionally, at-risk relatives of PDAC patients benefit from their own genetic education, risk assessment, and testing. Multigene panel testing (MGPT) can identify individuals with inherited cancer risk who can benefit from early cancer surveillance and risk reduction strategies. This manuscript discusses various healthcare delivery models for MGPT including traditional in-person genetic counseling, novel integrated in-person infrastructures, telemedicine genetics care via telephone- or video-visits and direct-to-consumer testing. Barriers and facilitators to care on the individual, provider, and system level are also outlined including specific considerations for historically marginalized communities.

Unmet needs in people with high-grade glioma: defining criteria for stepped care intervention.

We aimed to define levels of unmet supportive care needs in people with primary brain tumor and to reach expert consensus on feasibility of addressing patients' needs in clinical practice. We conducted secondary analysis of a prospective cohort study of people diagnosed with high-grade glioma (n = 116) who completed the Supportive Care Needs Survey-Short Form during adjuvant chemoradiation therapy. Participants were allocated to 1 of 3 categories: no need ("no need" for help on all items), low need ("low need" for help on at least 1 item, but no "moderate" or "high" need), or moderate/high need (at least 1 "moderate" or "high" need indicated). Clinical capacity to respond to the proportion of patients needing to be prioritized was assessed. Overall, 13% (n = 5) were categorized as no need, 23% (n = 27) low need, and 64% (n = 74) moderate/high need. At least 1 moderate/high need was reported in the physical and daily living domain (42%) and the psychological (34%) domain. In recognition of health system capacity, the moderate/high need category was modified to distinguish between moderate need ("moderate" need indicated for at least 1 item but "high" need was not selected for any item) and high need (at least 1 "high" need indicated). Results revealed 24% (n = 28) moderate need and 40% (n = 46) high need. Those categorized as high need indicated needing assistance navigating the health system and information. Using four step allocations resulted in 40% of patients indicating high need. Categories may facilitate appropriate triaging and guide stepped models of healthcare delivery.

Use of UK faith Centre as a COVID-19 community vaccination clinic: exploring a potential model for community-based health care delivery.

Effective and safe vaccines against COVID-19 are essential to achieve global control of the coronavirus (SARS-CoV-2). Using faith centres may offer a promising route for promoting higher vaccine uptake from certain minority ethnic groups known to be more likely to be vaccine hesitant. This cross-sectional study explored attendees' perceptions, experiences of being offered, and receiving COVID-19 vaccination in a local mosque in Woking, Surrey, UK. About 199 attendees completed a brief questionnaire on experiences, views, motivations about attending the mosque and vaccination on site. The most common ethnic groups reported were White British (39.2%) and Pakistani (22.6%); 36.2% identified as Christian, 23.6% as Muslim, 5.5% as Hindu, and 17.1% had no religion. Genders was relatively equal with 90 men (45.2%) and 98 women (49.2%), and 35-44-year-olds represented the most common age group (28.1%). Views and experiences around receiving vaccinations at the mosque were predominantly positive. Primary reasons for getting vaccinated at the mosque included convenience, accessibility, positive aspects of the venue's intercultural relations, and intentions to protect oneself against COVID-19, regardless of venue type. Negative views and experiences in regards to receiving the vaccination at the mosque were less common (7% expressed no intention of recommending the centre to others), and disliked aspects mostly referred to the travel distance and long waiting times. Offering COVID-19 vaccination in faith centres appears acceptable for different faith groups, ensuring convenient access for communities from all religions and ethnic backgrounds.

Healthcare System Sustainability Challenges in Nepal and Opportunities Offered by Alternative Healthcare Delivery Arrangements.

The burden of chronic diseases in Nepal is increasing due to demographic and epidemiological transitions; alongside the persistent impact of communicable, maternal, newborn, and child health diseases, this critical situation acts as the precursor to rising healthcare costs. Nepal struggles to sustain its healthcare system amidst political instability, pandemics, natural disasters, and slow economic growth, particularly when healthcare funding is mainly dependent on out-of-pocket payments. Nepal requires lower-cost alternative healthcare delivery arrangements to provide high-value care while relieving economic sustainability pressures. Alternative healthcare delivery arrangements have a broad potential scope; they can involve strategic changes in how care is delivered and by whom, or they can also involve the application of information and communication technologies, e.g., telemedicine. This paper highlights the specific challenges to healthcare system sustainability in Nepal and the potential for high-value, lower-cost alternative healthcare delivery models to improve system performance in the longer term.

Ocular morbidity profiles of out-of-school children in a North Indian urban slum.

This study evaluates the recent trends in ocular morbidities and vision-related practices in "out-of-school" children in urban slums of Gurugram in North India. In this observational study, a validated questionnaire was administered to 161 students from two nonformal slum schools. Sociocultural, demographic data, vision-related practices, and visual acuity with subjective refraction of the children were recorded. A total of 80 boys and 81 girls (9.17 ± 2.58 years) participated in this study. About 40% of the children were from lower socioeconomic status. The visual acuity recorded for all the children, except three children, was 6/6 in both eyes. One child had a pre-phthisical eye with no light perception, following a childhood trauma, with the other eye having 6/6 vision. Two children had refractive errors (myopia and compound myopic astigmatism), with a best corrected visual acuity (BCVA) of 6/6. Thirteen children (8%) had Bitot's spots and 67 (35.4%) had allergic conjunctivitis. Eight (5%) children complained of dry eye-related symptoms like redness and watering of eyes, while 19 (11.8%) had diffuse headache. Average number of years spent in school for these children was less than 1.7 years (range: 1 month-6 years). Only 10.5% of the children gave the history of watching television more than 30 h/week. Significant association was found between the income of father and use of digital devices in children below 10 years ( P = 0.003) and children playing outdoors ( P = 0.001). There was a significant association noted for age and use of digital devices ( P = 0.037). The prevalence of refractive errors in "out-of-school" children of urban slum was much less than the national average. Almost one in three children suffered from eye allergies, while 8% children had Bitot's spots. The data about the prevalence of ocular comorbidities in underserved areas like urban slums can be used to update and strategize eye health-care delivery models for out-of-school children.

Institutions and institutionalisation: They're part of everyday life.

Institutions are established patterns of recurrent social relationships playing a fundamental part in all our lives. The family is the best-known institution, butother 'total' institutions serve as organisations directly affecting the lives of many individuals in the healthcare sector. This paper examines the sociological theory of institutionalisation as applied toindividuals admitted to aged-care facilities, where the complete life-rounds of inmates occur within clearly defined limits. The study provides a framework to enable general practitioners, nurses and healthcare professionals to better appreciate the processes involved asindividuals adapt to their new environment. Sociology provides valuable insights for healthcare providers in understanding how individuals adapt to their loss of independent living and find themselves subjected to intimate regulation in the total institution. The biopsychosocial model of healthcare delivery is better understood when we as health professionals have greater insights to appreciate the competing processes atwork.

Theoretical and methodological foundations of the problem of business planning in the healthcare system

Healthcare business planning is becoming a key tool needed to ensure quality, affordable healthcare while maintaining sustainable financial models. It allows you to adapt to changing conditions, strategically allocate resources, optimize budgetary costs, and improve the availability and qualit y of medical care. Target. Scientifically substantiate theoretical approaches and study the features of business planning in the healthcare system. Results. The theoretical and methodological foundations of the problem of business planning in the healthcare system have been studied; the directions of medical rehabilitation activities in the Khanty-Mansiysk Autonomous Region are described; measures were proposed to improve business planning within the medical rehabilitation system. Conclusion. Business planning for medical rehabilitation is becoming increasingly important in the context of pressures on government agencies, changing health care delivery models and the development of the private healthcare sector.

Gaining Ground.

Deon Bührs, Managing Director of Genie Health SA, on launching a hybrid healthcare delivery model in South Africa.

Funny things are everywhere: Combatting geographic disparities in aortic stenosis care.

Key points Only 25%–35% of geographic variation in the use of surgical and transcatheter aortic valve replacement can be attributed to differing patient and hospital characteristics. To address geographic disparities, the cardiovascular community must address modifiable cardiovascular risk factors, social determinants of health, and healthcare delivery models. Governmental and professional organizations must study and actively address geographic disparities in access to care for aortic valve disease.

The contextual interview: a cross-cutting patient-interviewing approach for social context

ABSTRACT Patient interviewing pedagogy in medical education has not evolved to comprehensively capture the biopsychosocial model of healthcare delivery. While gathering a patient’s social history targets important aspects of social context it does not adequately capture and account for the real-time reassessment required to understand evolving factors that influence exposure to drivers of health inequities, social determinants of health, and access to supports that promote health. The authors offer a patient interviewing approach called the Contextual Interview (CI) that specifically targets dynamic and ever-changing social context information. To substantiate the use of the CI in medical education, the authors conducted a qualitative review of the Accreditation Council for Graduate Medical Education Milestones for primary care specialties (Family Medicine, Internal Medicine, and Pediatrics). Milestones were coded to the extent to which they reflected the learner’s need to acknowledge, assess, synthesize and/or apply patient contextual data in real-time patient encounters. Approximately 1 in 5 milestones met the context-related and patient-facing criteria. This milestone review further highlights the need for more intentional training in eliciting meaningful social context data during patient interviewing. The CI as a cross-cutting, practical, time-conscious, and semi-structured patient interviewing approach that deliberately elicits information to improve the clinician’s sense and understanding of a patient’s social context. The authors reviewed future directions in researching adapted versions of the CI for undergraduate and graduate medical education.

A Randomized Trial of Two Remote Health Care Delivery Models on the Uptake of Genetic Testing and Impact on Patient-Reported Psychological Outcomes in Families With Pancreatic Cancer: The Genetic Education, Risk Assessment, and Testing (GENERATE) Study

Background and AimsGenetic testing uptake for cancer susceptibility in family members of cancer patients is suboptimal. Among relatives of pancreatic ductal adenocarcinoma (PDAC) patients, The GENetic Education, Risk Assessment, and TEsting (GENERATE) study evaluated two online genetic education/testing delivery models and their impact on patient-reported psychological outcomes (PRPOs). MethodsEligible participants had ≥1 first-degree relative with PDAC, or ≥1 first-/second-degree relative with PDAC with a known pathogenic germline variant in one of thirteen PDAC predisposition genes. Participants were randomized by family, between 5/8/2019-6/1/2021. Arm 1 participants underwent a remote interactive telemedicine session and online genetic education. Arm 2 participants were offered online genetic education only. All participants were offered germline testing. The primary outcome was genetic testing uptake, compared by permutation tests and mixed-effects logistic regression models. We hypothesized that Arm 1 participants would have a higher genetic testing uptake than Arm 2. Validated surveys were administered to assess patient-reported anxiety, depression, and cancer worry at baseline and 3-months post-intervention. Results424 families were randomized, including 601 participants (n=296 Arm 1; n=305 Arm 2), 90% of whom completed genetic testing (Arm 1 (87%); Arm 2 (93%), p=0.014). Arm 1 participants were significantly less likely to complete genetic testing compared to Arm 2 (adjusted ratio (Arm1/Arm2) 0.90, 95% confidence interval 0.78-0.98). Among participants who completed PRPO questionnaires (Arm 1 (n=194); Arm 2 (n=206)), the intervention did not impact mean anxiety, depression or cancer worry scores. ConclusionsRemote genetic education and testing can be a successful and complementary option for delivering genetics care.