Bridging the gap to meet complex needs: an intersectoral action well supported by appropriate policies and governance.

Many people face problems about physical, mental, and social dimensions of health, and may have complex needs. They often experience a mismatch between their needs and the ability of the healthcare system to meet them, resulting in under- or overutilization of the healthcare system. On one hand, improving access to community-based primary healthcare for hard-to-reach populations should bring all healthcare and social services to one point of contact, near the community. On the other hand, better addressing the unmet needs of people who overuse healthcare services calls for integrated care among providers across all settings and sectors. In either case, intersectoral action between healthcare and social professionals and resources remains central to bringing care closer to the people and the community, enhancing equitable access, and improving health status. However, efforts to implement integrated care are unevenly weighted toward clinical and professional strategies (micro level), which could jeopardize our ability to implement and sustain integrated care. The development of appropriate policies and governance mechanisms (macro level) is essential to break down silos, promote a coherent intersectoral action, and improve health equity.

What is known about the role of external facilitators during the implementation of complex interventions in healthcare settings? A scoping review.

OBJECTIVE: To synthesise current knowledge about the role of external facilitators as an individual role during the implementation of complex interventions in healthcare settings. DESIGN: A scoping review was conducted. We reviewed original studies (between 2000 and 2023) about implementing an evidence-based complex intervention in a healthcare setting using external facilitators to support the implementation process. An information specialist used the following databases for the search strategy: MEDLINE, CINAHL, APA PsycINFO, Academic Search Complete, EMBASE (Scopus), Business Source Complete and SocINDEX. RESULTS: 36 reports were included for analysis, including 34 different complex interventions. We performed a mixed thematic analysis to synthesise the data. We identified two primary external facilitator roles: lead facilitator and process expert facilitator. Process expert external facilitators have specific responsibilities according to their role and expertise in supporting three main processes: clinical, change management and knowledge/research management. CONCLUSIONS: Future research should study processes supported by external facilitators and their relationship with facilitation strategies and implementation outcomes. Future systematic or realist reviews may also focus on outcomes and the effectiveness of external facilitation.

Profiles of healthcare use of persons living with dementia: A population-based cohort study.

AIM: Persons living with dementia are a heterogeneous population with complex needs whose healthcare use varies widely. This study aimed to identify the healthcare use profiles in a cohort of persons with incident dementia, and to describe their characteristics. METHODS: This is a retrospective cohort study of health administrative data in Quebec (Canada). The study population included persons who: (i) had an incident dementia diagnosis between 1 April 2015 and 31 March 2016; (ii) were aged ≥65 years and living in the community at the time of diagnosis. We carried out a latent class analysis to identify subgroups of healthcare users. The final number of groups was chosen based on clinical interpretation and statistical indicators. RESULTS: The study cohort consisted of 15 584 individuals with incident dementia. Four profiles of healthcare users were identified: (i) Low Users (36.4%), composed of individuals with minimal healthcare use and fewer comorbidities; (ii) Ambulatory Care-Centric Users (27.5%), mainly composed of men with the highest probability of visiting cognition specialists; (iii) High Acute Hospital Users (23.6%), comprised of individuals mainly diagnosed during hospitalization, with higher comorbidities and mortality rate; and (iv) Long-Term Care Destined Users (12.5%), who showed the highest proportion of antipsychotics prescriptions and delayed hospitalization discharge. CONCLUSIONS: We identified four distinct subgroups of healthcare users within a population of persons living with dementia, providing a valuable context for the development of interventions tailored to specific needs within this diverse population. Geriatr Gerontol Int 2024; ••: ••-••.

Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a qualitative study.

BACKGROUND: More and more people suffer from concomitant chronic physical diseases and common mental disorders, calling for integrated self-management support in primary care. However, self-management support of chronic physical diseases and common mental disorders is not clearly operationalized by guidelines and is still conducted in silos by primary care nurses, especially in favour of chronic diseases. This study aims to better understand primary care nurses' experience of integrated self-management support for people with physical chronic diseases and common mental disorders. METHODS: An interpretive descriptive qualitative approach was conducted with 23 primary care nurses from family medicine groups in Quebec (Canada). They were selected through purposive and snowball sampling methods to participate in an individual interview. Data were analysed using an iterative inductive and deductive analysis (Rainbow Model of Integrated Care and the Practical Reviews in Self-Management Support (PRISMS) taxonomy). RESULTS: Nurses' experience of integrated self-management support for people with CD and CMD was structured around: (1) elements of the approach; (2) clinical integration through prevention and health promotion; and (3) operationalization of integrated self-management support. Several elements deemed essential to integrated self-management support were identified. Nurses offered integrated self-management support through prevention of risk factors and promotion of a healthy lifestyle for physical chronic diseases and common mental disorders. Nurses' self-management support activities included education, action plans, monitoring, and many practical, psychological, and social support strategies. A model of integrated self-management support for primary care nursing is proposed to better understand its clinical integration. CONCLUSION: This study presents clinical integration of self-management support and activities for people with physical chronic diseases and common mental disorders in primary care settings. Understanding integrated self-management support will help implement future interventions.

Cannabis use, mental health, and problematic Internet use in Quebec: A study protocol.

BACKGROUND: Problematic Internet use is characterized by excessive use of online platforms that can result in social isolation, family problems, psychological distress, and even suicide. Problematic Internet use has been associated with cannabis use disorder, however knowledge on the adult population remains limited. In Quebec, cannabis use has significatively increased since 2018, and it is associated with various risks in public safety, public health, and mental health. This study aims to identify factors associated with problematic Internet use among adult cannabis users and to better understand their experiences. METHOD: This project is a mixed explanatory sequential study consisting of two phases. Phase 1 (n = 1500) will be a cross-sectional correlational study using probability sampling to examine variables that predispose individuals to problematic Internet use, characteristics associated with cannabis use, Internet use, and the mental health profile of adult cannabis users in Quebec. Descriptive analyses and regression models will be used to determine the relationship between cannabis use and Internet use. Phase 2 (n = 45) will be a descriptive qualitative study in the form of semi-structured interviews aimed at better understanding the experience and background of cannabis users with probable problematic Internet use. DISCUSSION: The results of this study will support the development of public policies and interventions for the targeted population, by formulating courses of action that contribute to the prevention and reduction of harms associated with cannabis use and problematic Internet use. Furthermore, an integrated knowledge mobilization plan will aid in the large-scale dissemination of information that can result useful to decision-makers, practitioners, members of the scientific community, and the general population regarding the use of cannabis and the Internet.

Fostering collective leadership to improve integrated primary care: lessons learned from the PriCARE program.

Case management (CM) is an intervention for improving integrated care for patients with complex care needs. The implementation of this complex intervention often raises opportunities for change and collective leadership has the potential to optimize the implementation. However, the application of collective leadership in real-world is not often described in the literature. This commentary highlights challenges faced during the implantation of a CM intervention in primary care for people with complex care needs, including stakeholders' buy-in and providers' willingness to change their practice, selection of the best person for the case manager position and staff turnover. Based on lessons learned from PriCARE research program, this paper encourages researchers to adopt collective leadership strategies for the implementation of complex interventions, including promoting a collaborative approach, fostering stakeholders' engagement in a trusting and fair environment, providing a high level of communication, and enhancing collective leadership attitudes and skills. The learnings from the PriCARE program may help guide researchers for implementing complex healthcare interventions.

Comparing the implementation of advanced access strategies among primary health care providers.

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

Functional and phenotypic consequences of an unusual inversion in MSH2.

Lynch syndrome is an autosomal dominant disorder that usually results from a pathogenic germline variant in one of four genes (MSH2, MSH6, MLH1, PMS2) involved in DNA mismatch repair. Carriers of such variants are at risk of developing numerous cancers during adulthood. Here we report on a family suspected of having Lynch syndrome due to a history of endometrial adenocarcinoma, ovarian clear cell carcinoma, and adenocarcinoma of the duodenum in whom we identified a germline 29 nucleotide in-frame inversion in exon 3 of MSH2. We further show that this variant is almost completely absent at the protein level, and that the associated cancers have complete loss of MSH2 and MSH6 expression by immunohistochemistry. Functional investigation of this inversion in a laboratory setting revealed a resultant abnormal protein function. Thus, we have identified an unusual, small germline inversion in a mismatch repair gene that does not lead to a premature stop codon yet appears likely to be causal for the observed cancers.

Care trajectories of individuals with anxiety disorders: A retrospective cohort study.

BACKGROUND: Anxiety disorders (ADs) are associated with increased healthcare use (HCU), and individuals may seek healthcare through various pathways according to clinical and individual characteristics. This study aimed to characterize care trajectories (CTs) of individuals with ADs. METHODS: This is a retrospective cohort study using the Care Trajectories - Enriched Data cohort, a linkage between the Canadian Community Health Surveys (CCHS), and health administrative data from Quebec. The cohort included 5143 respondents reporting ADs to the CCHS between 2009 and 2016. We measured CTs over 5 years before CCHS using a state sequence analysis. RESULTS: The cohort was categorized into five types of CTs. Type 1 (52.7 %) was the lowest care-seeking group, with fewer comorbidities. Type 2 (24.0 %) had higher levels of physical and mental health comorbidities and moderate HCU, mainly ambulatory visits to general practitioners. Type 3 (13.1 %) represented older patients with the highest level of physical illnesses and high HCU, predominantly ambulatory consultation of specialists other than psychiatrists. Types 4 and 5 combined young and middle-aged patients suffering from severe psychological distress. HCU of type 4 (6.7 %) was high, mainly consultations of ambulatory psychiatrists, and HCU of type 5 (3.5 %), was the highest and mostly in acute care. LIMITATIONS: Administrative and survey data may have coding errors, missing data and self-report biases. CONCLUSION: Five types of CTs showed distinct patterns of HCU often modulated by physical and mental health comorbidities, which emphasizes the importance of considering ADs when individuals seek care for other mental health conditions or physical illness.

Taxonomy of advanced access practice profiles among family physicians, nurse practitioners and nurses in university-affiliated team-based primary healthcare clinics in Quebec.

OBJECTIVES: The advanced access model is highly recommended to improve timely access to primary healthcare (PHC). However, its adoption varies among PHC providers. We aim to identify the advanced access profiles of PHC providers. DESIGN: A cross-sectional study was conducted between October 2019 and March 2020. Latent class analysis (LCA) measures were used to identify PHC provider profiles based on 14 variables, 2 organisational context characteristics (clinical size and geographical area) and 12 advanced access strategies. SETTING AND PARTICIPANTS: All family physicians, nurse practitioners and nurses working in the 49 university-affiliated team-based PHC clinics in Quebec, Canada, were invited, of which 35 participated. PRIMARY OUTCOME MEASURE: The LCA was based on 335 respondents. We determined the optimal number of profiles using statistical criteria (Akaike information criterion, Bayesian information criterion) and qualitatively named each of the six advanced access profiles. RESULTS: (1) Low supply and demand planification (25%) was characterised by the smallest proportion of strategies used to balance supply and demand. (2) Reactive interprofessional collaboration (25%) was characterised by high collaboration and long opening periods for appointment scheduling. (3) Structured interprofessional collaboration (19%) was characterised by high use of interprofessional team meetings. (4) Small urban delegating practices (13%) was exclusively composed of family physicians and characterised by task delegation to other PHC providers on the team. (5) Comprehensive practices in urban settings (13%) was characterised by including as many services as possible on each visit. (6) Rural agility (4%) was characterised by the highest uptake of advanced access strategies based on flexibility, including adjusting the schedule to demand and having a large number of open-slot appointments available in the next 48 hours. CONCLUSION: The different patterns of advanced access strategy adoption confirm the need for training to be tailored to individuals, categories of PHC providers and contexts.

How is the COVID-19 pandemic impacting our life, mental health, and well-being? Design and preliminary findings of the pan-Canadian longitudinal COHESION study.

BACKGROUND: With the advent of the COVID-19 pandemic, in-person social interactions and opportunities for accessing resources that sustain health and well-being have drastically reduced. We therefore designed the pan-Canadian prospective COVID-19: HEalth and Social Inequities across Neighbourhoods (COHESION) cohort to provide a deeper understanding of how the COVID-19 pandemic context affects mental health and well-being, key determinants of health, and health inequities. METHODS: This paper presents the design of the two-phase COHESION Study, and descriptive results from the first phase conducted between May 2020 and September 2021. During that period, the COHESION research platform collected monthly data linked to COVID-19 such as infection and vaccination status, perceptions and attitudes regarding pandemic-related measures, and information on participants' physical and mental health, well-being, sleep, loneliness, resilience, substances use, living conditions, social interactions, activities, and mobility. RESULTS: The 1,268 people enrolled in the Phase 1 COHESION Study are for the most part from Ontario (47%) and Quebec (33%), aged 48 ± 16 years [mean ± standard deviation (SD)], and mainly women (78%), White (85%), with a university degree (63%), and living in large urban centers (70%). According to the 298 ± 68 (mean ± SD) prospective questionnaires completed each month on average, the first year of follow-up reveals significant temporal variations in standardized indexes of well-being, loneliness, anxiety, depression, and psychological distress. CONCLUSIONS: The COHESION Study will allow identifying trajectories of mental health and well-being while investigating their determinants and how these may vary by subgroup, over time, and across different provinces in Canada, in varying context including the pandemic recovery period. Our findings will contribute valuable insights to the urban health field and inform future public health interventions.

Stakeholders' perceptions of a nurse-led telehealth case management intervention in primary care for patients with complex care needs: a qualitative descriptive study.

OBJECTIVE: With the onset of the COVID-19 pandemic, telehealth case management (TCM) was introduced in primary care for patients requiring care by distance. While not all healthcare needs can be addressed via telehealth, the use of information and communication technology to support healthcare delivery has the potential to contribute to the management of patients with chronic conditions and associated complex care needs. However, few qualitative studies have documented stakeholders' perceptions of TCM. This study aimed to describe patients', primary care providers' and clinic managers' perceptions of the use of a nurse-led TCM intervention for primary care patients with complex care needs. DESIGN: Qualitative descriptive study. SETTING: Three primary care clinics in three Canadian provinces. PARTICIPANTS: Patients with complex care needs (n=30), primary care providers (n=11) and clinic managers (n=2) participated in qualitative individual interviews and focus groups. INTERVENTION: TCM intervention was delivered by nurse case managers over a 6-month period. RESULTS: Participants' perceptions of the TCM intervention were summarised in three themes: (1) improved patient access, comfort and sense of reassurance; (2) trusting relationships and skilled nurse case managers; (3) activities more suitable for TCM. TCM was a generally accepted mode of primary care delivery, had many benefits for patients and providers and worked well for most activities that do not require physical assessment or treatment. Participants found TCM to be useful and a viable alternative to in-person care. CONCLUSIONS: TCM improves access to care and is successful when a relationship of trust between the nurse case manager and patient can develop over time. Healthcare policymakers and primary care providers should consider the benefits of TCM and promote this mode of delivery as a complement to in-person care for patients with complex care needs.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review.

BACKGROUND: Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation. OBJECTIVE: We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies. METHODS: We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis. RESULTS: This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022. CONCLUSIONS: Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48155.

Patient engagement in health implementation research: A logic model.

INTRODUCTION: Growing evidence supports patient engagement (PE) in health implementation research to improve the quality, relevance and uptake of research. However, more guidance is needed to plan and operationalize PE before and throughout the research process. The aim of the study was to develop a logic model illustrating the causal links between context, resources, activities, outcomes and impact of PE in an implementation research programme. METHODS: The Patient Engagement in Health Implementation Research Logic Model (hereafter the Logic Model) was developed using a descriptive qualitative design with a participatory approach, in the context of the PriCARE programme. This programme aims to implement and evaluate case management for individuals who frequently use healthcare services in primary care clinics across five Canadian provinces. Participant observation of team meetings was performed by all team members involved in the programme and in-depth interviews were conducted by two external research assistants with team members (n = 22). A deductive thematic analysis using components of logic models as coding categories was conducted. Data were pooled in the first version of the Logic Model, which was refined in research team meetings with patient partners. The final version was validated by all team members. RESULTS: The Logic Model highlights the importance of integrating PE into the project before its commencement, with appropriate support in terms of funding and time allocation. The governance structure and leadership of both principal investigators and patient partners have significant effects on PE activities and outcomes. As an empirical and standardized illustration that facilitates a shared understanding, the Logic Model provides guidance for maximizing the impact of patient partnership in various contexts for research, patients, providers and health care. CONCLUSION: The Logic Model will help academic researchers, decision makers and patient partners plan, operationalize, and assess PE in implementation research for optimal outcomes. PATIENT OR PUBLIC CONTRIBUTION: Patient partners from the PriCARE research programme contributed to developing the research objectives and designing, developing and validating data collection tools, producing data, developing and validating the Logic Model and reviewing the manuscript.

Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces.

BACKGROUND: eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada. METHODS: We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework. RESULTS: The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes. CONCLUSIONS: Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

A call for qualitative and mixed-methods research on gambling and cannabis.

Gambling disorder and cannabis use disorder are both considered major public health issues. Despite the well-documented frequency of substance use disorders among people with gambling disorder, little is known about the experiences of those who both engage with gambling and cannabis. A scoping review was undertaken to investigate studies focusing on the experiences of people who gamble and use cannabis. Unexpectedly, no qualitative or mixed-methods studies that included an in-depth qualitative component to study the lived experiences of this population were found. This absence highlights the critical need to diversify research methods and fill the gap in knowledge of the lived experiences of people who both gamble and consume cannabis.

Integrated case management between primary care clinics and hospitals for people with complex needs who frequently use healthcare services in Canada: A multiple-case embedded study.

INTRODUCTION: Case management (CM) is recognized to improve care integration and outcomes of people with complex needs who frequently use healthcare services, but challenges remain regarding interaction between primary care clinics and hospitals. This study aimed to implement and evaluate an integrated CM program for this population where nurses in primary care clinics worked with a hospital case manager. METHODS: A multiple embedded case study was conducted in the Saguenay-Lac-Saint-Jean region (Québec, Canada), in four dyads including a clinic and a hospital. Mixed data collection included, at baseline and 6 months, interviews and focus groups with stakeholders, patient questionnaires (patient experience of integrated care and self-management), and emergency department (ED) visits in the previous 6 months. RESULTS: Integrated CM implementation was optimal when all stakeholders provided collective leadership, and were supportive of the program, particularly the physicians. The 6-month program enabled the observation of positive qualitative outcomes in most clinic-hospital dyads where implementation occurred. Full implementation was associated with improved care integration. DISCUSSION AND CONCLUSION: Integrated CM between primary care clinics and hospitals is a promising innovation to improve care integration for people with complex needs who frequently use healthcare services. Collective leadership and physicians' buy-in to integrated CM are important to foster the implementation.

Implementation analysis of a case management intervention for people with complex care needs in primary care: a multiple case study across Canada.

BACKGROUND: Case management is one of the most frequently performed interventions to mitigate the negative effects of high healthcare use on patients, primary care providers and the healthcare system. Reviews have addressed factors influencing case management interventions (CMI) implementation and reported common themes related to the case manager role and activities, collaboration with other primary care providers, CMI training and relationships with the patients. However, the heterogeneity of the settings in which CMI have been implemented may impair the transferability of the findings. Moreover, the underlying factors influencing the first steps of CMI implementation need to be further assessed. This study aimed to evaluate facilitators and barriers of the first implementation steps of a CMI by primary care nurses for people with complex care needs who frequently use healthcare services. METHODS: A qualitative multiple case study was conducted including six primary care clinics across four provinces in Canada. In-depth interviews and focus groups with nurse case managers, health services managers, and other primary care providers were conducted. Field notes also formed part of the data. A mixed thematic analysis, deductive and inductive, was carried out. RESULTS: Leadership of the primary care providers and managers facilitated the first steps of the of CMI implementation, as did the experience and skills of the nurse case managers and capacity development within the teams. The time required to establish CMI was a barrier at the beginning of the CMI implementation. Most nurse case managers expressed apprehension about developing an "individualized services plan" with multiple health professionals and the patient. Clinic team meetings and a nurse case managers community of practice created opportunities to address primary care providers' concerns. Participants generally perceived the CMI as a comprehensive, adaptable, and organized approach to care, providing more resources and support for patients and better coordination in primary care. CONCLUSION: Results of this study will be useful for decision makers, care providers, patients and researchers who are considering the implementation of CMI in primary care. Providing knowledge about first steps of CMI implementation will also help inform policies and best practices.

The experience of pregnant women in contexts of vulnerability of prenatal primary nursing care: a descriptive interpretative qualitative study.

BACKGROUND: Prenatal primary nursing care contributes to improving the health outcomes of mothers and unborn babies. Some pregnant women in contexts of vulnerability experience prenatal nursing care in a positive way, while some do not. A better understanding of factors influencing this experience could help improve prenatal nursing care. The aim of this study was to describe factors influencing the prenatal primary nursing care experience of pregnant women in contexts of vulnerability. METHODS: Thorne's qualitative interpretative descriptive approach was used. Twenty-four pregnant women in contexts of vulnerability were recruited in local community service centers in Quebec, Canada, using purposive and snowball samplings, to carry out a semi-structured interview. Participants were 16 years old and over, in their second or third trimester, or had given birth in the previous year, and received prenatal nursing care through community health services. Data collection methods included a logbook, sociodemographic questionnaire and semi-structured interview on vulnerable pregnant women's experience with prenatal primary nursing care. The Qualitative Analysis Guide of Leuven guided the inductive thematic analysis, following a constant comparative iterative process. RESULTS: The women's experience was initially influenced by the fulfillment of their needs and expectations. These stem from their previous or current pregnancy experiences, their motivation to receive prenatal care, their family concerns as well as their contexts of vulnerability. From the pregnant women's perspective, the main factors that influenced their experience were the nurse's approach, characteristics and interventions that all impact on their relationship with nurses, as well as the prenatal primary care organization, including the modalities of prenatal care (i.e. schedule, setting, duration, number and frequency of meetings), the continuity and the program's prenatal care services, such as referral to a nutritionist, social worker or other services. CONCLUSIONS: A conceptual framework is proposed to describe relationships among the factors distributed in three dimensions that influence the experience of pregnant women in contexts of vulnerability and to guide nurses in the improvement of prenatal primary care. Considering the complexity of this experience, a person-centered approach is mandatory to promote a positive experience, equity and a better use of services.

Machine learning to improve frequent emergency department use prediction: a retrospective cohort study.

Frequent emergency department use is associated with many adverse events, such as increased risk for hospitalization and mortality. Frequent users have complex needs and associated factors are commonly evaluated using logistic regression. However, other machine learning models, especially those exploiting the potential of large databases, have been less explored. This study aims at comparing the performance of logistic regression to four machine learning models for predicting frequent emergency department use in an adult population with chronic diseases, in the province of Quebec (Canada). This is a retrospective population-based study using medical and administrative databases from the Régie de l'assurance maladie du Québec. Two definitions were used for frequent emergency department use (outcome to predict): having at least three and five visits during a year period. Independent variables included sociodemographic characteristics, healthcare service use, and chronic diseases. We compared the performance of logistic regression with gradient boosting machine, naïve Bayes, neural networks, and random forests (binary and continuous outcome) using Area under the ROC curve, sensibility, specificity, positive predictive value, and negative predictive value. Out of 451,775 ED users, 43,151 (9.5%) and 13,676 (3.0%) were frequent users with at least three and five visits per year, respectively. Random forests with a binary outcome had the lowest performances (ROC curve: 53.8 [95% confidence interval 53.5-54.0] and 51.4 [95% confidence interval 51.1-51.8] for frequent users 3 and 5, respectively) while the other models had superior and overall similar performance. The most important variable in prediction was the number of emergency department visits in the previous year. No model outperformed the others. Innovations in algorithms may slightly refine current predictions, but access to other variables may be more helpful in the case of frequent emergency department use prediction.