Provision Of Comprehensive Care Research Articles

Early career family physician perspectives on their residency experience and practice choices in Canada: a qualitative study

Background: Though there are more family physicians in Canada than ever before, and residency programs are expanding, gaps in access to comprehensive care remain. This study aimed to describe and understand the role residency training experiences played in shaping practice choices, including the provision of comprehensive community-based care, among early career family physicians. Methods: A secondary analysis of sixty-three (63) qualitative interviews was conducted on data from a larger mixed method study on practice patterns and choices of early career Canadian family physicians. We utilized Braun and Clarke’s six phases of reflexive thematic analysis on portions of transcripts concerning residency training experiences. Results: Participants described positive residency training experiences that shaped practice choice with respect to preceptors and mentorship, experiences of longitudinal care, breadth of exposure, and preparedness for comprehensive clinical practice. Woven through these four domains were “points of tension” and “hidden truths”. Points of tension included: i) the promotion of an idealized professional identity and practice that was difficult to uphold, ii) lack of representation among faculty/preceptors with respect to age and gender, at some sites, and iii) frustration about the lack of opportunities for interprofessional collaborative practices that reflected training experiences. Hidden truths included: i) lack of preparation to run a business, ii) high administrative workload, iii) realities of payment models, and iv) the range of roles available for family physicians beyond the provision of comprehensive care. Conclusions: Findings highlight opportunities for educational reform supporting the transition from residency to practice alongside the importance of addressing systemic factors beyond training which impact physicians’ choices regarding comprehensive care.

Early career family physician perspectives on their residency experience and practice choices in Canada: a qualitative study

Background: Though there are more family physicians in Canada than ever before, and residency programs are expanding, gaps in access to comprehensive care remain. This study aimed to describe and understand the role residency training experiences played in shaping practice choices, including the provision of comprehensive community-based care, among early career family physicians. Methods: A secondary analysis of sixty-three (63) qualitative interviews was conducted on data from a larger mixed method study on practice patterns and choices of early career Canadian family physicians. We utilized Braun and Clarke’s six phases of reflexive thematic analysis on portions of transcripts concerning residency training experiences. Results: Participants described positive residency training experiences that shaped practice choice with respect to preceptors and mentorship, experiences of longitudinal care, breadth of exposure, and preparedness for comprehensive clinical practice. Woven through these four domains were “points of tension” and “hidden truths”. Points of tension included: i) the promotion of an idealized professional identity and practice that was difficult to uphold, ii) lack of representation among faculty/preceptors with respect to age and gender, at some sites, and iii) frustration about the lack of opportunities for interprofessional collaborative practices that reflected training experiences. Hidden truths included: i) lack of preparation to run a business, ii) high administrative workload, iii) realities of payment models, and iv) the range of roles available for family physicians beyond the provision of comprehensive care. Conclusions: Findings highlight opportunities for educational reform supporting the transition from residency to practice alongside the importance of addressing systemic factors beyond training which impact physicians’ choices regarding comprehensive care.

Introduction: A Practical Guide to Central Nervous System Malformations—From Genetics, to Diagnosis and Treatment

AbstractCentral nervous system (CNS) malformations encompass diverse congenital anomalies impacting brain and spinal cord development, profoundly affecting neurological function. They arise from disruptions in embryonic neural tube formation, neuronal migration, and cortical organization. This abstract provides a comprehensive overview of CNS malformations, covering classification, etiology, clinical manifestations, and diagnostic challenges. CNS malformations fall into distinct groups: neural tube defects (e.g., anencephaly, spina bifida), resulting from incomplete neural tube closure; malformations of cortical development (e.g., lissencephaly, polymicrogyria), featuring irregularities in cortical folding; and anomalies affecting structures like the corpus callosum, cerebellum, and CNS vasculature, alongside conditions such as hydrocephalus and Chiari malformations. Genetic factors, including mutations in LIS1, DCX, and RELN, contribute significantly, while environmental factors like maternal folic acid deficiency also play a role. Some malformations occur in genetic syndromes (e.g., tuberous sclerosis, neurofibromatosis). Clinical presentations vary, with neural tube defects typically presenting severe deficits at birth, while cortical malformations manifest as intellectual disabilities, seizures, and motor deficits. Hydrocephalus elevates intracranial pressure, and Chiari malformations cause headaches and neurological symptoms. Diagnosis necessitates a multidisciplinary approach involving clinical evaluation, neuroimaging, genetic testing, and histopathological analysis. Prenatal diagnosis via ultrasound and magnetic resonance imaging is crucial for planning interventions, while postnatal diagnosis relies on clinical and imaging findings.Understanding CNS malformations is vital for early detection, intervention, and comprehensive care provision. Advances in genetics and neuroimaging offer hope for improved outcomes and better quality of life for affected individuals.

"I'm on the Right Path": Exploring 1-Month Retention in a Homeless-Tailored Outpatient-Based Opioid Treatment Program.

Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program's OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants' 1-month retention status to explore facilitators of and barriers to retention in OBOT care. The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic's surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.

HIV/AIDS Care and Support Services Satisfaction for Orphan and Vulnerable Children in Northwest Ethiopia: Mixed Method Study

Background: The provision of comprehensive care and support services to orphans and disadvantaged children that are individualized and tailored through the use of child- and family-centered information is critical but little if any information is available on satisfaction with HIV/AIDS care among orphans and vulnerable children in Gondar. Therefore, this study aimed to assess the satisfaction of HIV/AIDS care and support service delivered to caregivers of Orphans and Vulnerable Children, Gondar City, 2023. Methods: A facility-based cross-sectional study design with explanatory concurrent mixed methods was applied. A total of 424 Orphans and Vulnerable Children’s caregivers for interviewer-administered questionaries, 5 key informant interviews, and 385 Orphans and Vulnerable Children’s document reviews were conducted. The data were entered into the Kobo toolbox software and exported to STATA version 16 for analysis. A binary logistic regression analysis was performed to identify significant variables. The qualitative data were transcribed, translated, coded, and analyzed using thematic analysis. Results: In this study, the Orphans and Vulnerable Children’s/ caregivers satisfaction of HIV/AIDS C&S services was 68.20% with (95%CI=63.20%,71.10%). In multivariable logistic regression analysis, separate waiting rooms (AOR=0.05, 95% CI: 0.005, 0.52), materials for Orphans and Vulnerable Children to take home (AOR=1.76, 95%CI: 1.67, 7.59), and provisions of attractive and friendly services to Orphans and Vulnerable Children (AOR=2.24, 95%CI: 1.08, 4.64) were significant variables. Conclusion: Orphan and vulnerable children caregiver satisfaction to HIV/AIDS C&S service was 68.20% with (95%CI=63.20%,71.10%). Separate waiting rooms, attractive and friendly service, and materials to take home were factors that affected Orphans and Vulnerable Children’s caregiver satisfaction to the HIV/AIDS C&S service. Rigorous efforts to build systems that apply the policy and principles of HIV C&S services are recommended. Therefore, the government, partners, programmers, and implementers should give attention to improving the HIV C&S services.

The Quality of Life of Sickle Cell Disease Patients in Saudi Arabia 2023

The quality of life of sickle cell disease patients in Saudi Arabia 2023. Sickle cell disease (SCD) is a genetic blood disorder that affects millions of people around the world. It is caused by a mutation in the hemoglobin gene that results in the production of abnormal hemoglobin, which is the protein responsible for carrying oxygen in the blood. SCD is relatively common in Saudi Arabia, with a prevalence of around 2.3%, while the carrier state for SCD, sickle cell trait (SCT), is estimated to be 3.1%. The southern region of the country has the highest prevalence of both SCD and SCT, followed by the eastern region, with lower rates in the central and northern regions. The high prevalence of SCD and SCT in Saudi Arabia poses significant challenges to the healthcare system, with individuals experiencing complications such as pain crises, infections, and stroke, leading to increased hospitalizations and costly treatments. The government has taken steps to address this issue through newborn screening programs and comprehensive care provision, but further efforts are required to ensure equitable access to healthcare for all affected individuals. The disease can have a significant impact on the quality of life of patients due to its chronic nature, pain, and complications. In this study, we aimed to comprehensively investigate various aspects of SCD patients' experiences in Saudi Arabia. We explored the experiences of SCD patients, focusing on their encounters with pain, hospitalizations, and interactions with healthcare providers, the impact of SCD on the social lives and relationships of patients and the educational and support needs of both SCD patients and their families By addressing these research objectives, we gain a comprehensive understanding of the challenges and needs of SCD patients in Saudi Arabia, ultimately contributing to the development of more patient-centered and effective care strategies. Data Collection methods, instruments used, measurements: Patients were recruited through treating doctors during routine consultations utilizing an online based comprehensive survey. Result: The recruitment period for this study was from March 1, 2023, to the end of June of the same year. A total of 75 patients participated in the survey. However, only 50 responses were included in the analysis due to missing or conflicting data found in the excluded answers. The median age of the surveyed patients was 28 years, indicating an improvement in the care provided compared to previous published articles. Among the participants, 66.7% were males, and all the responses came from individuals affected by the disease. The majority of the patients (83.3%) resided in the southern region of the kingdom, followed by (16.7%) from the eastern region. Regarding patient support, all included participants stated that their support came solely from their families, as they declined any support from other patients, religious groups, or healthcare professionals. The main sources of support were the parents, followed by life partners and siblings. Although the patients expressed satisfaction with their family support, (50%) were unsure if support from outside the family was necessary. Regarding pain status, 50% of the patients reported experiencing pain more than three times in the last six months. Medical attention was sought in 50% of these cases, and 33.3% of the attacks required admission. In managing their crises, all patients used opioid-based analgesics. However, only (66.7%) used hydration in addition to home remedies, hot compressions, and local treatments, while (16.7%) used non-opioid-based medications. Despite experiencing emotional distress due to the disease symptoms, anxiety, and feelings of being dismissed, none of the patients sought emotional support from certified professional personnel. The disease had a notable impact on the professional lives of the patients, with 50% being unemployed, and others considering quitting their jobs, refusing promotions, or needing job assistance. The treatment goals from the patients' perspective were to reduce disease complications, improve their quality of life, and decrease pain crises and hospital admissions. Unfortunately, less than 49% of the patients achieved these treatment goals with the provided medications.

Patient perception of attributes of primary care: a study of Aam Aadmi Mohalla Clinics in Delhi, India.

Aam Aadmi Mohalla Clinics (AAMC) are the community level public primary care facilities recently introduced to strengthen primary care in Delhi, India by bringing affordable healthcare close to home. This study looks at the primary care attributes of AAMC from a patient perspective, to assess their features, strengths and weaknesses. Using a primary care survey tool, a cross-sectional survey of 360 users was conducted at 18 facilities across 9 districts of Delhi to gather information on six dimensions of primary care delivery. Thematic analysis of responses to quantitative, multiple-choice and Likert scale questions using percentage of respondents in each category; and a strengths, weaknesses, opportunities and suggestions (SWOS) framework, was used to examine the primary care attributes. AAMCs have done well in improving proximity, availability, physical and financial access to primary care with respondents reporting their residence within 1 kilometre of AAMCs (95%), physician being available (100%), free drugs in stock (99%). Service delivery is however not comprehensive with missing preventive care. Respondents reported missing gatekeeping, weak referral mechanism (6-19%), and low physician's familiarity with their overall health (2%). AAMCs have brought affordable healthcare with free medicines and diagnostics to neighbourhood. There is an opportunity for attaining universal healthcare that is responsive to user needs through provision of comprehensive care. Compulsory enrolment of neighbourhood population with an electronic database of patients has an immense potential to improve longitudinality and coordination of care.

Edukasi Kesehatan Sebagai Intervensi Masalah Kesiapan Peningkatan Manajemen Kesehatan Lansia Dengan Riwayat Penyakit Kronis Menuju Kualitas Hidup Lansia Yang Optimal

Readiness to improve health management is one of the nursing problems in the behavioral category and a subcategory of counseling and learning regarding the pattern of regulation and integration of health programs into daily life that is sufficient to meet health goals. Health achievement in the elderly with chronic diseases can be improved by health education. Readiness of health management in the elderly group with chronic or degenerative diseases can occur, provided that the elderly are willing to take part in the treatment program and are curious about their own care. The purpose of providing health education has an influence on the readiness of better health management towards optimal health. The implementation method is carried out by health education including health counseling, providing alternative sources of information, as well as teaching a healthy lifestyle, and nursing therapy therapy according to problems and fulfillment of psychological health. The results of the activity show that most of the elderly have nursing problems in the prosperous category as evidenced by the level of good knowledge about their illness as much as 83% and where the elderly have understood their own care for chronic diseases. Health education is given to support the achievement of optimal health and the provision of comprehensive care. the conclusion of the activity is that all groups, both groups of nursing problems in the categories of disorders, risks and prosperity, still require health education to support health. Health workers who are around the community always provide health education

A Win-Win for Sport and Exercise Medicine and Primary Care: A Qualitative Case Study of the Added Competence Model in Canada.

To understand the unique impacts of the College of Family Physicians of Canada's (CFPC) Certificate of Added Competence (CAC) in Sport and Exercise Medicine (SEM) on the delivery of comprehensive care in Canada. Secondary analysis of qualitative interview data collected during a multiple case study of the impacts of the CAC program in Canada. Six cases purposively sampled from across Canada. Each case was bound by a collective of healthcare providers who work with a defined group of patients. Across the cases, 48 individuals participated, including SEM and other enhanced skill family physicians, generalist family physicians, residents, specialists, and administrative staff. Qualitative descriptions of the impacts of the SEM certificate on comprehensive care provision in Canada. SEM certificate holders experience enhanced well-being and professional satisfaction while also benefitting comprehensive care in communities in numerous ways. That SEM certificate holders may prioritize professional interests over community healthcare needs was identified as a potential drawback. Athletes and physically active individuals have specific healthcare needs, and may constitute a significant critical mass to be considered a community unto themselves. The SEM certificates impact healthcare positively when holders work in collaborative models that are well aligned with local community needs. Expanding the awareness of the scope of SEM and advocacy for adequate remuneration for these services have the potential to enhance SEM contributions to comprehensive family medicine in Canada.

2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility.

A guideline that both evaluates current practice and provides recommendations to address sedation, pain, and delirium management with regard for neuromuscular blockade and withdrawal is not currently available. To develop comprehensive clinical practice guidelines for critically ill infants and children, with specific attention to seven domains of care including pain, sedation/agitation, iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment, and early mobility. The Society of Critical Care Medicine Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility Guideline Taskforce was comprised of 29 national experts who collaborated from 2009 to 2021 via teleconference and/or e-mail at least monthly for planning, literature review, and guideline development, revision, and approval. The full taskforce gathered annually in-person during the Society of Critical Care Medicine Congress for progress reports and further strategizing with the final face-to-face meeting occurring in February 2020. Throughout this process, the Society of Critical Care Medicine standard operating procedures Manual for Guidelines development was adhered to. Taskforce content experts separated into subgroups addressing pain/analgesia, sedation, tolerance/iatrogenic withdrawal, neuromuscular blockade, delirium, PICU environment (family presence and sleep hygiene), and early mobility. Subgroups created descriptive and actionable Population, Intervention, Comparison, and Outcome questions. An experienced medical information specialist developed search strategies to identify relevant literature between January 1990 and January 2020. Subgroups reviewed literature, determined quality of evidence, and formulated recommendations classified as "strong" with "we recommend" or "conditional" with "we suggest." Good practice statements were used when indirect evidence supported benefit with no or minimal risk. Evidence gaps were noted. Initial recommendations were reviewed by each subgroup and revised as deemed necessary prior to being disseminated for voting by the full taskforce. Individuals who had an overt or potential conflict of interest abstained from relevant votes. Expert opinion alone was not used in substitution for a lack of evidence. The Pediatric Pain, Agitation, Neuromuscular Blockade, and Delirium in critically ill pediatric patients with consideration of the PICU Environment and Early Mobility taskforce issued 44 recommendations (14 strong and 30 conditional) and five good practice statements. The current guidelines represent a comprehensive list of practical clinical recommendations for the assessment, prevention, and management of key aspects for the comprehensive critical care of infants and children. Main areas of focus included 1) need for the routine monitoring of pain, agitation, withdrawal, and delirium using validated tools, 2) enhanced use of protocolized sedation and analgesia, and 3) recognition of the importance of nonpharmacologic interventions for enhancing patient comfort and comprehensive care provision.

O acadêmico de Medicina frente à população em situação de rua: Trabalho Colaborativo como ferramenta

ABSTRACT This is the experience report of a medical academic from Federal University Fluminense, intern of the Education Program for Work for Health/Interprofessionality, working as part of the Street Clinic of Niterói/RJ, Brazil between April 2019 and March 2020. Aiming at the recognition of challenges, limits and potential of Interprofessional Education and Collaborative Work, the narrative constructed through 44 reports sent to the Program’s preceptors and tutors was used as a methodological tool, being shared not only what the practical field as a physical space brought to light, but also what came to life through intersubjectivity in the encounter with different characters. The opportunity to follow the strategy allowed the student to know more about this essential service to ensure equity in the health of the homeless population, leading to the improvement/development of skills/tools that will compose a work centered on the formation of positive bonds with service users, in the provision of comprehensive care and collabora- tive health practices. It was concluded that, despite the numerous barriers, Interprofessional Education and Collaborative Work are important instruments in academic training, standing out in the production of high quality health services, especially in offering comprehensive care to people in vulnerability.

Challenges facing the More Doctors program (Programa Mais M\xe9dicos) in vulnerable and peri-urban areas in Greater Brasilia, Brazil

BackgroundA shortage of physicians, especially in vulnerable and peri-urban areas, is a global phenomenon that has serious implications for health systems, demanding policies to assure the provision and retention of health workers. The aim of this study was to analyze the strategies employed by the More Doctors Program (Programa Mais Médicos) to provide primary care physicians in vulnerable and peri-urban parts of Greater Brasilia.MethodsThe study used a qualitative approach based on the precepts of social constructivism. Forty-nine semi-structured interviews were conducted: 24 with physicians employed as part of the More Doctors program, five with program medical supervisors, seven with secondary care physicians, twelve with primary care coordinators, and one federal administrator. The interviews occurred between March and September 2019. The transcripts of the interviews were submitted to thematic content analysis.ResultsThe partnership between the Ministry of Health and local authorities was essential for the provision of doctors—especially foreign doctors, most from Cuba, to assist vulnerable population groups previously without access to the health system. There was a notable presence of doctors with experience working with socioeconomically disadvantaged populations, which was important for gaining a better understanding of the effects of the endemic urban violence in the region. The incentives and other institutional support, such as enhanced salaries, training, and housing, transportation, and food allowances, were factors that helped provide a satisfactory working environment. However, the poor state of the infrastructure at some of the primary care units and limitations of the health service as a whole were factors that hampered the provision of comprehensive care, constituting a cause of dissatisfaction.ConclusionsMore Doctors introduced a range of novel strategies that helped ensure a supply of primary care doctors in vulnerable and peri-urban parts of Greater Brasilia. The inclusion of foreign doctors, most from Cuba, was crucial for the success of the health services provided for the local communities, who subsist in violent and socioeconomically deprived urban areas. However, it became clear that barriers from within the health service itself hampered the physicians’ capacity to provide a satisfactory service. As such, what is needed for primary care to be effective is not just the recruitment, training, and deployment of doctors, but also investment in the organization of the whole health system.

Impacts of the Certificates of Added Competence credentialling program: a qualitative case study of enhanced-skill family medicine practice across Canada.

Background:In 2015, the College of Family Physicians of Canada (CFPC) expanded its Certificates of Added Competence (CAC) program to include enhanced-skill certification in Care of Elderly, Family Practice Anesthesia, Palliative Care, and Sports and Exercise Medicine. We aimed to describe the impact of these 4 CACs on the provision of comprehensive care in Canada, while also identifying the factors of influence that foster these impacts.Methods:Between September 2018 and June 2019, we conducted qualitative case studies of 6 family medicine practices across Canada, sampled to represent geographic, population and practice arrangement diversity. We developed a framework of relevant factors and their relations to CAC-mediated comprehensive care delivery. We took an exploratory approach to the first 4 case studies, guided by theoretical propositions based on a literature review, and the CFPC’s 4 principles of family medicine and goals for practice. The emerging theory was confirmed and adapted through the final 2 explanatory case studies. Data were obtained through semistructured qualitative interviews with enhanced-skill and generalist physicians, specialists, trainees and administrators associated with these cases. We performed a descriptive content analysis, within and across cases.Results:Interviews with 48 participants showed considerable variation in the way CACs are operationalized related to the specific domain of care, the community, relationships among practitioners, motivations of the practitioner and needs of the patient population. The presence of CAC holders in communities expands the scope of available services, reduces the need for patients to travel and encourages continuity of care; however, comprehensive care may be negatively affected when CAC holders develop enhanced-skill practices according to clinical interests rather than community needs. Factors associated with collaborative care models, practice requirements, remuneration structure, community culture and individual aspirations interact to reinforce or undermine the effectiveness of enhanced-skill practices.Interpretation:Holders of CACs have a positive impact when they work in collaborative models that align with the needs of communities and that support local generalist family physicians. Health care policies should incentivize CAC activities that contribute to planned care delivery at the practice and community levels.

Initial experience of Emicizumab prophylaxis in children with inhibitor positive severe hemophilia A from a single center in India

BackgroundAlthough improvement in the access to clotting factor concentrates and provision of comprehensive care has dramatically improved the quality of life of patients with severe hemophilia, inhibitor-positive patients still develop significant morbidity in terms of joint involvement, progression to disability and life threatening bleeds due to poor access to bypassing agents and immune tolerance induction. ObjectiveTo analyze the response of patients with severe hemophilia A and high-titer inhibitors started on Emicizumab prophylaxis. MethodsPatients with inhibitor-positive severe Hemophilia A were followed up for bleed frequency, joint involvement and health-related quality-of-life assessment (HR-QOL) using PedHAL questionnaire. The data from 1 year prior to start of Emicizumab or from diagnosis of inhibitor status (if shorter period) was compared to that 4 weeks after start of the drug. Emicizumab was administered as per standard guidelines. Results4 patients were initiated on Emicizumab prophylaxis and followed for a median period of 34 weeks (19–57 weeks). The average bleed frequency reduced from 2 to 3.5 per month to 0 after initiation of prophylaxis. No significant adverse events were reported. Improvement in raw and normalized data for all 7 domains of PedHAL which measures activities of daily living was observed. Functional improvement was noted as early as 4 weeks into treatment. ConclusionEmicizumab is a promising agent for prophylaxis of patients with severe hemophilia A and high titre inhibitors.

Objective difficulties in differential diagnosis of pneumocystis pneumonia on the background of human immunodeficiency virus infection

Аbstract. The results of two clinical observations with a description of the examination and treatment of patients with infection caused by human immunodeficiency virus, with pneumocystic lung lesions at various stages of the provision of comprehensive care are presented. Since not a single combination of symptoms, clinical signs, and radiological findings is a diagnostic criterion for pneumocystis pneumonia, its diagnosis is currently mainly based on microscopic visualization of characteristic forms on stained airway preparations. The problem of treating pneumocystis pneumonia is determined by a very narrow range of active drugs available on the market, despite the fact that there is practically no data on the growth of resistance of clinically significant pneumocysts. Defects in the provision of medical care in both cases were a violation of the order and timing of the dispensary, in particular, and the lack of medical monitoring of the structures that monitor the health of patients, in general. Therefore, in the context of an increase in the total number of patients with infection caused by human immunodeficiency virus, and the manifestation of secondary diseases in them, the leading of which is tuberculosis, it is necessary to develop and implement additional professional programs for the early detection, in particular, lung lesions, as part of a continuing medical education for general practitioners, general practitioners and doctors of other specialties providing assistance in organizations of primary health care.

Abortion care pathways and service provision for adolescents in high-income countries: A qualitative synthesis of the evidence.

Limited research in high-income countries (HICs) examines adolescent abortion care-seeking pathways. This review aims to examine the pathways and experiences of adolescents when seeking abortion care, and service delivery processes in provision of such care. We undertook a systematic search of the literature to identify relevant studies in HICs (2000–2020). A directed content analysis of qualitative and quantitative studies was conducted. Findings were organised to one or more of three domains of an a priori conceptual framework: context, components of abortion care and access pathway. Thirty-five studies were included. Themes classified to the Context domain included adolescent-specific and restrictive abortion legislation, mostly focused on the United States. Components of abortion care themes included confidentiality, comprehensive care, and abortion procedure. Access pathway themes included delays to access, abortion procedure information, decision-making, clinic operation and environments, and financial and transportation barriers. This review highlights issues affecting access to abortion that are particularly salient for adolescents, including additional legal barriers and challenges receiving care due to their age. Opportunities to enhance abortion access include removing legal barriers, provision of comprehensive care, enhancing the quality of information, and harnessing innovative delivery approaches offered by medical abortion.

The Effect of the Comprehensive Midwifery Care Model with the One Student One Client (OSOC) Approach to Birth Outcomes in North Aceh Regency

Maternal and Newborn Health is a priority as the main indicator in health. During the pregnancy period until the puerperium it is estimated that as many as 15% can experience life-threatening complications of the mother and baby. However, this death is considered to be prevented through the provision of comprehensive care that can be done with the One Student One Client (OSOC) approach, which is an activity that exists between low-risk pregnant women and midwife students during pregnancy up to 6 weeks post delivery. Objective: This study aims to assess the relationship of comprehensive midwifery care with the One Student One Client (OSOC) approach to birth outcomes (gestational age at delivery, prolonged labor and asphyxia) Method: This study is a retrospective cohort study, using secondary data from medical record documentation Results: Comprehensive midwifery care with the OSOC approach was associated with the occurrence of prolonged labor p value 0.046 (RR 95% CI; 3.2 (1.08-9.74), asphyxia with p value 0.037 (RR 95% CI; 2.57 1.12-6.50) Conclusion: The OSOC method can be used in comprehensive midwifery care for all mothers and babies from pregnancy up to 6 weeks post delivery in an effort to improve birth outcomes.

Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage

BackgroundDespite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage.MethodsWe use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician’s gender.ResultsWe observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce.ConclusionsWhile P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician’s gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

Integrated models of care for diabetes and hypertension in low- and middle-income countries (LMICs)\xa0: Protocol for a systematic review

BackgroundIn low- and middle-income countries (LMICs), the burden of non-communicable diseases (NCDs) is growing against an existing burden of other diseases such as HIV/AIDS. Integrated models of care can help address the rising burden of multi-morbidity. Although integration of care can occur at various levels and has been defined in numerous ways, our aim is to assess the effects of integration of service delivery at primary healthcare level in LMICs.MethodsWe will consider randomised controlled trials (RCTs), cluster RCTs, non-randomised trials, controlled before-after studies and interrupted time series that examine integrated models of care among people with multi-morbidities, of which diabetes or hypertension is one, living in LMICs. We will compare fully integrated models of care to stand-alone care, partially integrated models of care to stand-alone care and fully integrated models to partially integrated models of care. Primary outcomes include all-cause mortality, disease-specific morbidity, HbA1c, systolic blood pressure and cholesterol levels. Secondary outcomes include access to care, retention in care, adherence, continuity of care, quality of care and cost of care. We will conduct a comprehensive search in the following databases: MEDLINE, EMBASE, the Cochrane Central Register of Control Trials, LILACS, Africa-Wide Information, CINAHL and Web of Science. In addition, we will search trial registries, relevant conference abstracts and check references lists of included studies. Selection of studies, data extraction and assessment of risk of bias will be performed independently by two review authors. We will resolve discrepancies through discussion with a third author. We will contact study authors in case of missing data. If included studies are sufficiently homogenous, we will pool results in a meta-analysis. Clinical heterogeneity related to the population, intervention, outcomes and context will be documented in table format and explored through subgroup analysis. We will assess χ2and I2 tests for statistical heterogeneity. We will use GRADE to make judgements about the certainty of evidence and present findings in a summary of findings table.DiscussionIn light of limited evidence on the provision of comprehensive care for diabetes and hypertension, and its comorbidity in LMCIs, we believe that the findings of this systematic review will provide a synthesis of evidence on effective models of integrated care for diabetes and hypertension and their comorbidities at primary healthcare level. This will enable policy-makers to device policies and programs that are evidence informed.Systematic review registrationPROSPERO CRD42018099314.