Poor Continuity Of Care Research Articles

Barriers and system improvements for physical activity promotion after gestational diabetes: A qualitative exploration of the views of healthcare professionals.

Physical activity is an important behaviour for managing the ten times increased risk of type 2 diabetes after gestational diabetes. Previous studies exploring physical activity promotion in healthcare focus on general practitioners but have not explored the gestational diabetes pathway. Therefore, this paper explores the barriers to and suggestions for, activity promotion along the gestational diabetes healthcare pathway. The paper was written in accordance with the Standards for Reporting Qualitative Research. Patient and Public Involvement with women who had lived experiences of gestational diabetes informed purposeful sampling by identifying which healthcare professional roles should be targeted in participant recruitment. Participants were recruited through word-of-mouth, that is, email and connections with local healthcare service leads. Twelve participants took part in semi-structured one-to-one interviews, analysed using reflexive thematic analysis. Participants included a Public Health Midwife (n = 1), Diabetes Midwifes (n = 3), Diabetes Dietitian (n = 1), Diabetes Consultants (n = 2), Diabetes Specialist Nurse (n = 1), general practitioners (n = 2), Practice nurse (n = 1) and a Dietitian from the UK National Diabetes Prevention Program (n = 1). Six themes were generated: 'management of gestational diabetes takes precedent', 'poor continuity of care', 'lack of capacity to promote PA', 'beliefs about the acceptability of PA promotion', 'resources to support conversations about PA' and 'adapting healthcare services for women post-gestational diabetes'. During pregnancy messaging around physical activity is consistent, yet this is specific for managing gestational diabetes and is not followed through postnatally. Improvements in continuity of care are necessary, in addition to ensuring the availability and links with wider exercise and activity schemes.

Shared Decision-Making at the Intersection of Disability, Culture, and Language Accessibility: An Educational Session for Medical Students.

People with disabilities and those with non-English language preferences have worse health outcomes than their counterparts due to barriers to communication and poor continuity of care. As members of both groups, people who are Deaf users of American Sign Language have compounded health disparities. Provider discomfort with these specific demographics is a contributing factor, often stemming from insufficient training in medical programs. To help address these health disparities, we created a session on disability, language, and communication for undergraduate medical students. This 2-hour session was developed as a part of a 2020 curriculum shift for a total of 404 second-year medical student participants. We utilized a retrospective postsession survey to analyze learning objective achievement through a comparison of medians using the Wilcoxon signed rank test (α = .05) for the first 2 years of course implementation. When assessing 158 students' self-perceived abilities to perform each of the learning objectives, students reported significantly higher confidence after the session compared to their retrospective presession confidence for all four learning objectives (ps < .001, respectively). Responses signifying learning objective achievement (scores of 4, probably yes, or 5, definitely yes), when averaged across the first 2 years of implementation, increased from 73% before the session to 98% after the session. Our evaluation suggests medical students could benefit from increased educational initiatives on disability culture and health disparities caused by barriers to communication, to strengthen cultural humility, the delivery of health care, and, ultimately, health equity.

Factors influencing speech pathology practice in dysphagia after stroke: A qualitative focus group study.

Dysphagia affects over half of adults after stroke. Dysphagia rehabilitation aims to improve swallowing and reduce negative outcomes for these adults. However, significant variability exists in dysphagia rehabilitation. Research is needed to explore the underlying clinician-specific and workplace factors that contribute to variability in dysphagia rehabilitation after stroke. To explore factors influencing speech pathology practice in dysphagia rehabilitation after stroke. We used a phenomenological approach with an interpretivist perspective. Twenty speech pathologists working in dysphagia rehabilitation participated from different workplace settings around Australia. Five semi-structured focus groups were conducted online. Data were inductively analysed using thematic analysis with a coding reliability method. Four themes were discussed within focus groups: (1) relationship between experienced and less experienced clinicians: 'Following what other people have done', (2) need for collaborative learning: 'A safe space to share and train', (3) variation between settings impacts on continuity of care: 'There's a difference between community and acute', and (4) working effectively with multidisciplinary teams (MDT): 'An MDT which can listen to the voice of speech pathology'. Relationships between senior and junior speech pathologists, within speech pathology and MDT, and across inpatient and community settings influenced speech pathology practice. Flattened hierarchies in speech pathology, collaborative learning in workplaces, mutual respect within teams and connection across inpatient and community settings could improve the quality and consistency of dysphagia rehabilitation after stroke. What is already known on this subject Dysphagia rehabilitation can improve swallowing after a stroke. However, dysphagia rehabilitation is characterised by variability in clinical practice. Clinician-specific and workplace factors influence clinical practice and may contribute to variability in dysphagia rehabilitation. What this study adds Professional relationships influence speech pathologists' clinical practice, including relationships between senior and junior clinicians, between inpatient and community settings and with peers and multidisciplinary teams. Workplace norms and hierarchies, poor continuity of care between settings and competing priorities from other disciplines can hinder dysphagia rehabilitation. However, collaborative learning, positive workplace cultures and respectful transdisciplinary care can improve the quality and consistency of clinical practice. What are the clinical implications of this work? Flattening hierarchies in the workplace can foster a safe learning space. Further, questioning workplace norms and seeking out peer learning within and across settings can build clinical skills and confidence. Developing positive workplace cultures that support continuous development may be key for empowering speech pathologists to provide high-quality and consistent dysphagia rehabilitation.

Experiences and challenges of people living with multiple long-term conditions in managing their care in primary care settings in Kerala, India: A qualitative study.

Multimorbidity or multiple long-term conditions (MLTCs), the coexistence of two or more chronic conditions within an individual, presents a growing concern for healthcare systems and individuals' well-being. However, we know little about the experiences of those living with MLTCs in low- and middle-income countries (LMICs) such as India. We explore how people living with MLTCs describe their illness, their engagements with healthcare services, and challenges they face within primary care settings in Kerala, India. We designed a qualitative descriptive study and conducted in-depth, semi-structured interviews with 31 people (16 males and 15 females) from family health centres (FHCs) in Kerala. Interview data were recorded, transcribed, and thematic analysis using the Framework Method was undertaken. Two main themes and three sub-themes each were identified; (1) Illness impacts on life (a)physical issues (b) psychological difficulties (c) challenges of self-management and (2) Care-coordination maze (a)fragmentation and poor continuity of care (b) medication management; an uphill battle and (c) primary care falling short. All participants reported physical and psychological challenges associated with their MLTCs. Younger participants reported difficulties in their professional lives, while older participants found household activities challenging. Emotional struggles encompassed feelings of hopelessness and fear rooted in concerns about chronic illness and physical limitations. Older participants, adhering to Kerala's familial support norms, often found themselves emotionally distressed by the notion of burdening their children. Challenges in self-management, such as dietary restrictions, medication adherence, and physical activity engagement, were common. The study highlighted difficulties in coordinating care, primarily related to traveling to multiple healthcare facilities, and patients' perceptions of FHCs as fit for diabetes and hypertension management rather than their multiple conditions. Additionally, participants struggled to manage the task of remembering and consistently taking multiple medications, which was compounded by confusion and memory-related issues. This study offers an in-depth view of the experiences of individuals living with MLTCs from Kerala, India. It emphasizes the need for tailored and patient-centred approaches that enhance continuity and coordination of care to manage complex MLTCs in India and similar LMICs.

Mental health and psychosocial support for children with upper limb musculoskeletal conditions.

This study describes mental health and psychosocial screening processes, access to care and interventions provided to children with upper limb musculoskeletal conditions. A cross-sectional e-survey study was conducted of 107 healthcare professionals who work with children with congenital hand and upper limb differences and brachial plexus birth injuries. Of them, 41 (38%) reported that they routinely screen for mental health and psychosocial concerns. Few (12%) reported the use of standardized outcome measures. In total, 51 (48%) healthcare professionals reported that there was a waiting list for mental health services at their institution. Collectively, healthcare professionals were unsatisfied with the staffing, access to care and types of interventions available. Reported barriers to care included the growing need for mental health support, lack of resources and poor continuity of care after referrals. Future research should focus on identifying and validating a mental health screening tool and investigating the processes affecting access to mental health care.Level of evidence: IV.

Effect of Continuity of Care on Chronic Diseases

Chronic diseases are quite prevalent and are associated with grave repercussions and considerable target organ dysfunction. Providing such patients with high-quality care can significantly lower their morbidity and mortality risk. Early disease detection, frequently when the patients are generally asymptomatic, is necessary for the provision of proper care that could reduce the chances of hazardous consequences and complications. The arrangement of care delivery with continuity of care has been shown to provide many health benefits. Numerous beneficial health outcomes have been linked to the continuity of care way of structuring the delivery of care. Continuity of care is defined as the process by which the patient and his or her physician care team work together to manage their ongoing medical care in order to achieve the shared purpose of high-quality, affordable healthcare. Additionally, continuity of care is associated with increased follow-up appointment compliance, more frequent cancer screenings, prevention programs usage, fewer emergency room visits, less hospital admissions, among various others. The continuity of care is influenced by a variety of factors, including equity and effectiveness as well as the quality of care throughout time. Research studies have shown that greater treatment continuity is associated with better mental health, a greater sense of satisfaction, and a higher quality of life. Although, the overuse of medical resources, especially through the provision of unnecessary services, is associated with poor continuity of care. The purpose of this research is to review the available information about the effect of continuity of care on chronic diseases.

Determining the Association Between Continuity of Primary Care and Acute Care Use in Chronic Kidney Disease: A Retrospective Cohort Study.

Acute care use is high among individuals with chronic kidney disease (CKD). It is unclear how relational continuity of primary care influences downstream acute care use. We aimed to determine if poor continuity of care is associated with greater rates of acute care use and decreased prescriptions for guideline-recommended drugs. We conducted a population-based retrospective cohort study of adults with stage 3-4 CKD and ≥3 visits to a primary care clinician during the period April 1, 2011 to March 31, 2014 in Alberta, Canada. Continuity was calculated using the Usual Provider Continuity index. Descriptive statistics were used to summarize patient and acute care encounter characteristics. Adjusted rates and incidence rate ratios for all-cause and CKD-related ambulatory care-sensitive condition (ACSC) hospitalizations and emergency department (ED) visits were estimated using negative binomial regression. Adjusted odds ratios for prescription use were estimated by multivariable logistic regression. Among 86,475 patients with CKD, 51.3%, 30.0%, and 18.7% had high, moderate, and poor continuity of care, respectively. There were 77,988 all-cause hospitalizations, 6,489 ACSC-related hospitalizations, 204,615 all-cause ED visits, and 8,461 ACSC-related ED visits during a median follow-up of 2.3 years. Rates of all-cause and ACSC hospitalization and ED use increased with poorer continuity of care in a stepwise fashion across CKD stages. Patients with poor continuity were less likely to be prescribed a statin. Poor continuity of care is associated with increased acute care use among patients with CKD. Targeted strategies that strengthen patient-physician relationships and guide physicians regarding guideline-recommended prescribing are needed.

Risk of suicide death in psychiatric patients according to the level of continuity of care and area deprivation: A population-based nested case-control study

Continuity of care and area deprivation have been implicated as possible risk factors of suicide in psychiatric patients. This nested case-control study aimed to examine the association between continuity of care and area deprivation and suicide death in patients with psychiatric disorders. Data were collected from the Korean National Health Insurance Service National Sample Cohort, 2003–2013. The subjects were 974 patients with psychiatric disorders who completed suicides. Each case was compared to three control cases with propensity score matching by gender, age, and follow-up period with incidence density sampling, comprising the final control group of 2,922 living patients. Hazard ratios (HR) for suicide risk considering continuity of care and area deprivation were analysed using a multiple conditional logistic regression. The average follow-up periods between the case and control groups were not statistically different (case: 277.6 weeks, control: 271.4 weeks, p = .245). Both poor continuity of care and higher area deprivation proved to be associated with increased risk of suicide (poor continuity of care; adjusted HR [AHR]: 3.38, 95% confidence intervals [CI]: 2.58–4.43, highest area deprivation; AHR: 1.93, 95% CI: 1.53–2.44). Poor continuity of care combined with highest area deprivation showed a negative synergistic effect on a highly increased risk of suicide (AHR: 2.88, 95% CI: 1.45–5.74). Age was effect modified between suicide risk and poor continuity of care as well as suicide risk and higher area deprivation. A strong patient-provider relationship with good continuity of care may lead to a lower possibility of suicide in psychiatric patients. Moreover, improving community capacity for suicide prevention as well as appropriate postvention should be addressed.

Models and Interventions to Promote and Support Engagement of First Nations Women with Maternal and Child Health Services: An Integrative Literature Review.

Background: Studies show that participation in maternal and child health (MCH) services improves health outcomes for First Nations families. However, accessing MCH services can be associated with fear, anxiety, and low attendance at subsequent appointments. Objective: To identify the existing knowledge of models/interventions that support engagement of First Nations women with MCH services in the child’s first five years. Methods: An integrative review was undertaken of full-text, peer-reviewed journal articles and grey literature, which were analysed to identify barriers and enabling factors that influenced the engagement of First Nations families with MCH services. Results: Enabling factors that influenced the engagement with MCH services included service models/interventions that are timely and appropriate, and effective integrated community-based services that are flexible, holistic, culturally strong, and encourage earlier identification of risk and further assessment, intervention, referral, and support from the antenatal period to the child’s fifth birthday. Barriers to engagement included inefficient communication, lack of understanding, cultural differences between the client and the provider, poor continuity of care, limited flexibility of service delivery to meet individual needs, and a health care model that does not recognise the importance of the social determinants of health and wellbeing. Discussion: Timely, effective, holistic engagement with First Nations women during their child’s first 2000 days, which respects their culture and facilitates genuine partnerships built on co-design and shared decision making with the indigenous community, needs to be an essential part of the MCH service model if health care providers seek to practice within First Nations communities. Conclusion: Improving engagement with MCH services is important for First Nations families, nursing practice, and public health.

Health and social care services for people with dementia at home at the end of life: A qualitative study of bereaved informal caregivers’ experiences

Background: More people are dying at home with dementia and Alzheimer’s disease. While informal caregivers are the main providers of care for people with dementia dying at home, they require support from health and social care services. However, little is known about how they experience these services. Aim: To explore informal caregivers’ views and experiences of health and social care services when looking after a person with dementia at home at the end-of-life. Design: A qualitative interview study. Data were analysed using thematic analysis. Setting/Participants: Twenty-nine bereaved informal caregivers who had looked after a person with dementia at home during the last 6 months of life. Results: Specialist palliative care for people with dementia dying at home is rare and care is mostly managed by General Practitioners and domiciliary care workers. Four overarching themes were identified: Poor continuity of care; Lack of expertise; Limited advance care planning; and Loss of autonomy. Conclusions: End-of-life care at home for people with dementia must be proactively planned with an emphasis on advance care planning. Policy makers should recognise the critical role of domiciliary care services in end-of-life care and ensure that they are adequately qualified and trained.

A cross-sectional survey of moral distress and ethical climate - Situations in paediatric oncology care that involve children's voices.

AimTo assess experiences of morally distressing situations and perceptions of ethical climate in paediatric oncology care, with a focus on situations that involve children's voices.DesignCross‐sectional survey.MethodsRegistered Nurses at all four paediatric oncology centres in Denmark were asked to complete a web‐based questionnaire with Danish translations of the Swedish Moral Distress Scale‐Revised (MDS‐R) and the Swedish Hospital Ethical Climate Survey‐Shortened (HECS‐S). Data analysis included descriptive statistics and non‐parametric correlation tests.ResultsNurses (n = 65) perceived morally distressing situations as rather uncommon, except for those that involved shortage of time, poor continuity of care and unsafe staffing levels. Most nurses (83%) found it disturbing to perform procedures on school‐aged children against their will, and 20% reported that they do this often. Perceptions of ethical climate were positive and healthcare professionals were perceived to be attentive to children's wishes.

Universal coverage of the first antenatal care visit but poor continuity of care across the maternal and newborn health continuum among Nepalese women: analysis of levels and correlates

BackgroundRoutine maternity care visits (MCVs) such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) visits are crucial to utilisation of maternal and newborn health (MNH) interventions during pregnancy-postnatal period. In Nepal, however, not all women complete these routine MCVs. Therefore, this study examined the levels and correlates of (dis)continuity of MCVs across the antenatal-postnatal period.MethodsWe conducted further analysis of the 2016 Nepal Demographic and Health Survey. A total of 1,978 women aged 15–49 years, who had live birth two years preceding the survey, were included in the analysis. The outcome variable was (dis)continuity of routine MCVs (at least four ANC visits, institutional delivery, and PNC visit) across the pathway of antennal through to postnatal period. Independent variables included several social determinants of health under structural, intermediary, and health system domains. Multinomial logistic regression was conducted to identify the correlates of routine MCVs. Relative risk ratios (RR) were reported with 95% confidence intervals at a significance level of p<0.05.ResultsApproximately 41% of women completed all routine MCVs with a high proportion of discontinuation around childbirth. Women of disadvantaged ethnicities, from low wealth status, who were illiterate had higher RR of discontinuation of MCVs (compared to completion of all MCVs). Similarly, women who speak Bhojpuri, from remote provinces (Karnali and Sudurpaschim), who had a high birth order (≥4), who were involved in the agricultural sector, and who had unwanted last birth had a higher RR of discontinuation of MCVs. Women discontinued routine MCVs if they had poor awareness of health mother-groups and perceived the problem of not having female providers.ConclusionsRoutine monitoring using composite coverage indicators is required to track the levels of (dis)continuity of routine MCVs at the maternity care continuum. Strategies such as raising awareness on the importance of maternity care, care provision from female health workers could potentially improve the completion of MCVs. In addition, policy and programmes for continuity of maternity care are needed to focus on women with socioeconomic and ethnic disadvantages and from remote provinces.

988 A Quality Improvement Project; Improving the Quality and Safety of Handover During COVID-19

AimThe World Health Organisation (WHO) positions effective handover, in its top five patient safety solutions. During our District Hospital Trust’s COVID-19 response, an unprecedented reorganisation of all teams occurred. All surgical and medical speciality junior doctors were re-deployed and split into 4 zones to cover the hospital. In this quality improvement project (QIP), we sought to understand our trainees’ thoughts on this new multi-zonal handover process and aimed to identify risk-reduction measures to aid better patient care.MethodThe opinions of trainees on the new handover system were obtained using an online Likert scale survey. Following the responses, a new morning and night handover proforma was developed. This was used trust-wide and a post-intervention repeat survey was conducted to assess the new changes.ResultsThe primary survey received 31 responses with feedback illustrating mixed effectiveness of the existing handover process. Free text comments highlighted issues surrounding “safety”, “poor organisation”, “poor continuity of care” with one serious incident reported. Post-intervention of a new handover proforma, a repeat online survey received 25 responses. Results were significantly more positive with >84% of responses being in the “strongly agree to agree” category, including for “continuity of care”, “organisation”, and “safety”.ConclusionsThis QIP illustrates a good example of a low-cost intervention to create a better handover system and aid hospitals during time of crises. For us, it managed to reform the handover process and ultimately improved our patient care. Forthcoming, we would like to create a national best practice guide for effective handover.

Home-based rehabilitation programs on postural balance, walking, and quality of life in patients with stroke: A single-blind, randomized controlled trial.

BackgroundThe most challenging aspect of rehabilitation is the high costs of in-patient rehabilitation programs and poor continuity of care while patients are transferred to home. In this regard, numerous home-based rehabilitation programs have been developed. The purpose of this study was to investigate the effects of home-based rehabilitative programs on postural balance, walking, and quality of life in individuals with chronic hemiparetic stroke.DesignA CONSORT-compliant randomized controlled trial.MethodsSeventeen community-dwelling people diagnosed with a first stroke participated in this study. They randomly divided the home-based rehabilitative program (HBP) group (n = 9) and control group (n = 8). The HBP group received coordination exercises at home and the control group received clinic-based exercises. This study measured postural balance, walking, and quality of life using four outcome measures: 10-meter walk test, figure of 8 walk test, four-square step test, and 36 item short-form survey.ResultsAfter analysis, it was found that the HBP improved postural balance, comfortable speed, and fast speed walking, and straight and curved walking for chronic stroke. Second, clinic-based rehabilitation services improved postural balance, comfortable speed, and fast speed walking abilities in patients with chronic stroke.ConclusionThe results of this study suggest that the HBP group received positive benefits with regard to the postural balance and walking abilities of chronic hemiparetic stroke patients compared to the clinical setting exercise program.

Reconceptualizing Care Transitions Research From the Patient Perspective.

Reconceptualizing Care Transitions Research From the Patient Perspective.

Supporting Patient-centered Communication on Adolescent Sexual and Reproductive Health-Perspectives to Build an Appointment Planning Tool.

Input from adolescents and healthcare providers is needed to develop electronic tools that can support patient-centered sexual and reproductive (SRH) care. This study explores facilitators and barriers to patient-centered communication in the context of developing an electronic appointment planning tool to promote SRH communication in clinic settings. In-depth interviews were conducted to explore what constitutes adolescent-friendly SRH care and communication, as well as on the design of the appointment planning tool. Interviews were coded iteratively, and analyzed using the software Atlas.TI v8. An adolescent primary care clinic, and a pediatric and adolescent gynecology clinic. Adolescent girls (N=32; ages 14-18) and providers who care for adolescent girls (N=10). Thematic analyses explored facilitators/barriers to SRH communication and care and preferences for the tool. Facilitators identified by adolescents and providers included: direct patient/provider communication; adolescent-driven decision-making regarding care and contraceptive choice; supplementing clinic visits with electronic resources; and holistic care addressing physical, mental, and social needs. Barriers identified by participants included: limited time for appointments; limited adolescent autonomy in appointments; and poor continuity of care when adolescents cannot see the same provider. Given the complexity of issues raised, adolescents and providers were interested in developing an appointment planning tool to guide communication during appointments, and contributed input on its design. The resulting Appointment Planning Tool app pilot is in progress. Qualitative interviews with adolescents and providers offer critical insights for the development and implementation of mobile health (mHealth) tools that can foster patient-centered care.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study.

BackgroundPeople with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.AimTo identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.Design & settingThirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).MethodFactors precipitating admissions were examined using framework analysis.ResultsThree aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services — in time and proximity — and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.ConclusionDedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales

IntroductionThere is a paucity of knowledge and understanding of medical error in opioid substitution treatment programmes.ObjectivesTo characterise patient safety incidents involving opioid-substitution treatment with methadone or buprenorphine in community-based care to identify the sources and nature of harm, describe and interpret themes and use this qualitative analysis to identify priorities to focus future improvement work.MethodsWe undertook a mixed-methods study examining incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care submitted between 2005 and 2015 from the National Reporting and Learning System, a repository of incident reports from England and Wales. We analysed each report using four frameworks to identify incident type, contributory factors, incident outcome and severity of harm. Analysis involved detailed data coding and iterative generation of data summaries using descriptive statistical and thematic analysis.Results2,284 reports were identified. We found that most risks of harm came from failure in one of four processes of care delivery: prescribing opiate-substitution (n=151); supervised dispensing errors (n=248); non-supervised dispensing errors (n=318); and monitoring and communication activities (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91/127, 72%). Staff- (e.g. mistakes, not following protocols) and organisation-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were present for over half of incidents.ConclusionsWe have identified four processes of care delivery and associated contributory factors, which represent potential target areas for healthcare systems worldwide to develop interventions to improve the safe delivery of opioid substitution treatment.

A technology-enhanced model of care for transitional palliative care versus attention control for adult family caregivers in rural or medically underserved areas: study protocol for a randomized controlled trial

BackgroundTransitioning care from hospital to home is associated with risks of adverse events and poor continuity of care. These transitions are even more challenging when new approaches to care, such as palliative care, are introduced before discharge. Family caregivers (FCGs) are expected to navigate these transitions while also managing care. In addition to extensive caregiving responsibilities, FCGs often have their own health needs that can inhibit their ability to provide care. Those living in rural areas have even fewer resources to meet their self-care and caregiving needs. The purpose of this study is to test the efficacy and cost-effectiveness of an intervention to improve FCGs’ health and well-being. The intervention uses video visits to teach, guide, and counsel FCGs in rural areas during hospital-to-home transitions. The intervention is based on evidence of transitional and palliative care principles, which are individualized to improve continuity of care, provide caregiver support, enhance knowledge and skills, and attend to caregivers’ health needs. It aims to test whether usual care practices are similar to this technology-enhanced intervention in (1) caregiving skills (e.g., caregiving preparedness, communication with clinicians, and satisfaction with care), (2) FCG health outcomes (e.g., quality of life, burden, coping skills, depression), and (3) cost. We describe the rationale for targeting rural caregivers, the methods for the study and intervention, and the analysis plan to test the intervention’s effect.MethodsThe study uses a randomized controlled trial design, with FCGs assigned to the control condition or the caregiver intervention by computer-generated lists. The intervention period continues for 8 weeks after care recipients are discharged from the hospital. Data are collected at baseline, 2 weeks, 8 weeks, and 6 months. Time and monetary costs from a societal perspective are captured monthly.DiscussionThis study addresses 2 independent yet interrelated health care foci—transitional care and palliative care—by testing an intervention to extend palliative care practice and improve transition management for caregivers of seriously ill patients in rural areas. The comprehensive cost assessment will quantify the commitment and financial burden of FCGs.Trial registrationClinicalTrials.gov NCT03339271. Registered on 13 November 2017.Protocol version: 11.

Racial and Ethnic Disparities in Severe Maternal Morbidity: A Qualitative Study of Women's Experiences of Peripartum Care.

Racial and ethnic disparities in rates of maternal morbidity and mortality in the United States are striking and persistent. Despite evidence that variation in the quality of care contributes substantially to these disparities, we do not sufficiently understand how experiences of perinatal care differ by race and ethnicity among women with severe maternal morbidity. We conducted focus groups with women who experienced a severe maternal morbidity event in a New York City hospital during their most recent pregnancy (n=20). We organized three focus groups by self-identified race/ethnicity ([1] Black, [2] Latina, and [3] White or Asian) to detect any within- and between-group differences. Discussions were audiotaped and transcribed. The research team coded the transcripts and used content analysis to identify key themes and to compare findings across racial and ethnic groups. Participants reported distressing experiences and lasting emotional consequences after having a severe childbirth complication. Many women appreciated the life-saving care they received. However, poor continuity of care, communication gaps, and a perceived lack of attentiveness to participants' physical and emotional needs led to substantial concern and disappointment in care. Black and Latina women in particular emphasized these themes. This study highlights missed opportunities for improved clinician communication and continuity of care to address emotional trauma when severe obstetric complications occur, particularly for Black and Latina women. Enhancing communication to ensure that women feel heard and informed throughout the birth process and addressing implicit bias, as a part of the more systemic issue of institutionalized racism, could both decrease disparities in obstetric care quality and improve the patient experience for women of all races and ethnicities.