What Patients Want: A Qualitative Study of Patients' Perspectives on Optimizing the Hospital Discharge Process.

Background: Poor discharge planning can lead to increases in adverse drug events, hospital readmissions, and costs. Prior research has identified the pharmacist as an integral part of the discharge process. Objectives: To gain patients' perspectives on the discharge process and what they would like pharmacists to do to ensure a successful discharge. Methods: Twenty patients discharged from tertiary care hospitals were interviewed after discharge. A phenomenological approach was used to conduct this qualitative study. Results: Five main themes were identified from the patient interviews: interactions with health care professionals, importance of discharge documentation, importance of seamless care, comprehensive and patient-specific medication counselling, and patients' preference for involvement and communication at all stages of hospital stay. Conclusions: Although participants generally reported positive interactions with health care providers at discharge, several areas for improvement were identified, particularly in terms of communication, discharge documentation, and continuity of care. A list of recommendations aligning with patient preferences is provided for clinicians.

Contexte: Une mauvaise planification du congé hospitalier peut entraîner une augmentation des événements indésirables liés aux médicaments, des réadmissions et des coûts. Des recherches antérieures ont reconnu le pharmacien comme faisant partie intégrante du processus associé au congé de l'hôpital. Objectifs: Recueillir le point de vue des patients sur le processus relatif au congé et sur ce qu'ils aimeraient que les pharmaciens fassent pour assurer la réussite de celui-ci. Méthodologie: Vingt patients d'hôpitaux de soins tertiaires ont été interrogés après leur congé. Cette étude qualitative a été menée en adoptant une approche phénoménologique. Résultats: Cinq thèmes principaux ont émergé à partir des entretiens avec les patients: les interactions avec les professionnels de la santé, l'importance de la documentation au moment du congé, l'importance de soins continus, des conseils complets et spécifiques au patient en matière de médication, et la préférence des patients pour l'implication et la communication à toutes les étapes de leur séjour à l'hôpital. Conclusions: Bien que les participants aient généralement signalé des interactions positives avec les prestataires de soins de santé au moment de leur congé, plusieurs domaines d'amélioration ont été dépistés, notamment sur les plans de la communication, de la documentation au moment du congé et de la continuité des soins. Une liste de recommandations alignées sur les préférences des patients est fournie aux cliniciens.

An Update to the Malthus Model for Radiotherapy Utilisation in England.

AIMS: The Malthus Programme predicts national and local radiotherapy demand by combining cancer incidence data with decision trees detailing the indications, and appropriate dose fractionation, for radiotherapy. Since the last model update in 2017, technological advancements and the COVID-19 pandemic have led to increasing hypofractionation of radiotherapy schedules. Indications for radiotherapy have also evolved, particularly in the context of oligometastatic disease. Here we present a brief update on the model for 2021. We have updated the decision trees for breast, prostate, lung and head and neck cancers, and incorporated recent cancer incidence data into our model, generating a current estimate of fraction demand for these four cancer sites across England. MATERIALS AND METHODS: The decision tree update was based on evidence from practice-changing randomised controlled trials, published guidelines, audit data and expert opinion. Site- and stage-specific incidence data were taken from the National Disease Registration Service. We used the updated model to estimate the proportion of patients who would receive radiotherapy (appropriate rate of radiotherapy) and the fraction demand per million population at a national and Clinical Commissioning Group level in 2021. RESULTS: The total predicted fraction demand has decreased by 11.4% across all four cancer sites in our new model, compared with the 2017 version. This reduction can be explained primarily by greater use of hypofractionated treatments (including stereotactic ablative radiotherapy) and a shift towards earlier stage presentation. The only large change in appropriate rate of radiotherapy was an absolute decrease of 3% for lung cancer. CONCLUSIONS: Compared with our previous model, the current version predicts a reduction in fraction demand across England. This is driven principally by hypofractionation of radiotherapy regimens, using technology that requires increasingly complex planning. Treatment complexity and local service factors need to be taken into account when translating fraction burden into linear accelerator demand or throughput.

Produção do cuidado no contexto das pessoas com artrite reumatoide / Production of care in the context of people with rheumatoid arthritis

O modo de produzir o cuidado ocorre na relação entre trabalhador da saúde e a pessoa a ser cuidada, por meio de instrumentos, saberes ou pelas relações estabelecidas no próprio encontro. Nesse processo as distintas formas de produção do cuidado são entendidas à luz da concepção de saúde dos envolvidos na prática cuidativa. No contexto da pessoa com artrite reumatoide a falta de intervenção em momento oportuno pode acarretar em dores, processos inflamatórios, deformidades e incapacidades. Com o objetivo de analisar a produção do cuidado no contexto das pessoas com artrite reumatoide, por meio de uma abordagem qualitativa, foi possível o deslocamento do pesquisador in-mundo para construção de uma pesquisa interferência, apoiado em alguns conceitos da análise institucional. Nesse processo, acompanhado pelo diário de pesquisa, foi possível caminhar pela produção de itinerários terapêuticos de seis mulheres com artrite reumatoide; construir fluxogramas analisadores com trabalhadores dos diferentes serviços, equipes da atenção primária à saúde e do centro de especialidades e apoio diagnóstico do município de Rondonópolis-MT, e experimentar momentos de reflexão com grupos de trabalhadores e gestores do Sistema Único de Saúde. Como resultado a constatação coletiva de um cuidado médico centrado, com todos os seus elementos instituídos (medicalização, fracionamento do individuo, foco na doença), produtor de esperas, filas, restrições no acesso - que não viabiliza a produção de cuidados e sim a produção de atos burocráticos. É urgente, a necessidade de fomentar forças instituintes que permitam o desenvolvimento de intervenções pautadas nas necessidades de saúde, para viabilizar uma produção do cuidado com base no alcance de boas condições de vida; acesso irrestrito às ações e serviços, vínculos com trabalhadores que se responsabilizem pelo cuidado e disparem estímulos de autonomia e autocuidado. Além disso, fomentar a possibilidade de autoanalise e autogestão para que, grupos de gestores e trabalhadores, imergidos em processos reflexivos consigam repensar as ações e desenvolver estratégias instituintes para reorganizar a centralidade do cuidado para pessoa a ser cuidada. Como pistas para novas interferências: a queixa de dor não pode ser banalizada, é necessário resgatar as ações de matriciamento e investir em protocolos que definam as responsabilidades, em especial, na garantia do acesso e do cuidado longitudinal.

The way of producing care occurs in the relationship between the health worker and the person to be cared for, through instruments, knowledge or the relationships established in the meeting itself. In this process, the different forms of care production are understood in the light of the health concept of those involved in the care practice. In the context of the person with rheumatoid arthritis, the lack of timely intervention can lead to pain, inflammatory processes, deformities and disabilities. With the objective of analyzing the production of care in the context of people with rheumatoid arthritis, through a qualitative approach, it was possible for the researcher to move in-world to build an interference research, supported by some concepts of institutional analysis. In this process, accompanied by the research diary, it was possible to walk through the production of therapeutic itineraries of six women with rheumatoid arthritis; build analyzer flowcharts with workers from different services, primary health care teams and the specialty center and diagnostic support in the municipality of Rondonópolis-MT, and experience moments of reflection with groups of workers and managers of the Unified Health System. As a result, the collective realization of a centered medical care, with all its instituted elements (medicalization, individual fractionation, focus on the disease), producer of waits, queues, access restrictions - which does not enable the production of care, but the production of bureaucratic acts. There is an urgent need to foster instituting forces that allow the development of interventions based on health needs, to enable the production of care based on the achievement of good living conditions; unrestricted access to actions and services, links with workers who are responsible for care and trigger autonomy and self-care stimuli. In addition, promoting the possibility of self-analysis and self-management so that groups of managers and workers, immersed in reflective processes, are able to rethink actions and develop instituting strategies to reorganize the centrality of care for the person to be cared for. As clues for new interferences: the complaint of pain cannot be trivialized, it is necessary to rescue matrix actions and invest in protocols that define responsibilities, in particular, in guaranteeing access and longitudinal care.

Design of the Maternal Website EMAeHealth That Supports Decision-Making During Pregnancy and in the Postpartum Period: Collaborative Action Research Study.

BACKGROUND: Despite the benefit maternal education has for women, it needs new tools to increase its effectiveness and scope, in tune with the needs of current users. OBJECTIVE: We attempted to develop a multifunctional personalized eHealth platform aimed at the self-management of health in relation to maternity, which can be considered a flexible and adaptable maternal education tool. METHODS: The International Patient Decision Aid Standards (IPDAS) were applied. A website prototype was developed for implementation in the public health system using a collaborative action research process, in which experts and patients participate, with qualitative research techniques, as well as focus groups, prioritization, and consensus techniques. RESULTS: We have proposed a website that includes (1) systematically updated information related to clinical practice guidelines, (2) interaction between peers and users/professionals, (3) instruments for self-assessment of health needs as a basis for working on counseling, agreement on actions, help in the search for resources, support in decision-making, and monitoring and evaluation of results, and (4) access for women to their clinical data and the option of sharing the data with other health agents. These components, with different access requirements, would be reviewed through iterative cycles depending on the frequency and effectiveness resulting from their use and would be accessible from any digital device. CONCLUSIONS: A website that supports maternal education should contain not only information, but also resources for individual attention and social support. Its usefulness for the health and satisfaction of women should be evaluated in various different environments.

Gestão participativa na Estratégia Saúde da Família: reorientação da demanda à luz do Método Paideia / Participatory management in the Family Health Strategy: reorientation of demand in the light of the Paideia Method

RESUMO Objetivou-se descrever a construção de um plano de ação de corresponsabilização entre gestores, profissionais e usuários, para a reorientação da demanda espontânea em uma Unidade de Saúde da Família, por meio de ferramentas de gestão participativa. Tratou-se de um estudo intervencionista do tipo pesquisa-ação, realizado com uma equipe de Estratégia Saúde da Família do município de Petrolina (PE). Participaram do estudo 11 sujeitos, selecionados pela técnica de amostragem da representatividade qualitativa, sendo 3 gestores da atenção básica do município, 4 profissionais de saúde da Estratégia Saúde da Família envolvida no estudo e 4 líderes comunitários, representantes dos usuários. O referencial teórico adotado para a análise da intervenção foi o método de análise e cogestão de coletivos, o Método Paideia. O estudo evidenciou o despreparo dos coletivos para atuarem na gestão participativa, ao tempo que revelou que as possibilidades de reestruturação dos serviços são otimizadas quando pensadas de maneira democrática e corresponsável. Considerou-se que as principais contribuições deste estudo foram a sensibilização e a mobilização dos sujeitos para atuarem de maneira participante no planejamento e na gestão dos problemas de saúde.

ABSTRACT The objective was to describe the construction of a co-responsibility action plan involving managers, professionals and users, aimed at reorienting spontaneous demand in a Family Health Unity, by means of participatory management tools. This was an interventional research study, the action-research type, carried out with a Family Health Strategy team in the municipality of Petrolina (PE). The study involved eleven participants, who were selected using the qualitative representativeness sampling technique, and included three primary care managers in the municipality, four health professionals from the Family Health Strategy involved in the study and four community leaders, representatives of users. The theoretical framework adopted for the analysis of the intervention was the method of analysis and co-management of collectives - the Paideia method. The study revealed the unpreparedness of collectives to act in participatory management, while showing that possibilities of restructuring services are optimized when thought of in a democratic and co-responsible way. It was considered that the main contributions of this research were the awareness and the mobilization of the subjects to act in a participatory way in the planning and management of health problems.

Planning the oral health workforce: Time for innovation.

The levels and types of oral health problems occurring in populations change over time, while advances in technology change the way oral health problems are addressed and the ways care is delivered. These rapid changes have major implications for the size and mix of the oral health workforce, yet the methods used to plan the oral health workforce have remained rigid and isolated from planning of oral healthcare services and healthcare expenditures. In this paper, we argue that the innovation culture that has driven major developments in content and delivery of oral health care must also be applied to planning the oral health workforce if we are to develop 'fit for purpose' healthcare systems that meet the needs of populations in the 21st century. An innovative framework for workforce planning is presented focussed on responding to changes in population needs, service developments for meeting those needs and optimal models of care delivery.

Theorizing demand by Family Health Strategy professionals and users: spontaneous, scheduled, suppressed / Teorización de la demanda por profesionales y usuarios de la Estrategia de Salud Familiar: espontáneo, programado, reprimido / Teorização da demanda por profissionais e usuários da Estratégia Saúde da Família: espontânea, programada, reprimida

ABSTRACT Objective: to understand spontaneous, scheduled and suppressed demands in the face of health needs and accessibility, from the perspective of Family Health Strategy professionals and users. Method: a qualitative study using Grounded Theory and Symbolic Interactionism, with 34 participants, 16 of whom are health professionals and 18 are users. The sources of evidence were open, intensive and individual interviews and memos. Data collection occurred between October/2016 to May/2017. Data analysis took place in interdependent steps: open, axial, selective coding, for the process. Results: thirty-two in vivo codes were indicated that represent the statement and meanings of the research participants regarding demand at Family Health Strategy, compiled in three theoretical codes that originated the central category "The Theory of Demand at Family Health Strategy: spontaneous, scheduled or suppressed?". Spontaneous demand turns to complaints and illness, in daily appointments without previous scheduling, with restricted hours and as a means of accessing the health service. Scheduled demand is established in scheduling medical appointments for specific groups. Suppressed demand, more and more frequent in the daily routine of health services, is associated with the lack of access and resolution. Conclusion: health demands are configured in a space of lack of access and accessibility, denoting the main problem experienced by FHS users and professionals.

RESUMEN Objetivo: comprender las demandas espontáneas, programadas y reprimidas ante las necesidades de salud y accesibilidad, desde la perspectiva de los profesionales y usuarios de la Estrategia de Salud Familiar. Método: estudio cualitativo, utilizando el método de la Teoría Fundamentada y el marco teórico Interaccionismo Simbólico, con 34 participantes, entre ellos 16 profesionales de la salud y 18 usuarios. Las fuentes de evidencia fueron entrevistas y memorandos abiertos, intensivos e individuales. La recolección de datos ocurrió entre octubre/2016 y mayo/2017. El análisis de datos se llevó a cabo en pasos interdependientes: codificación abierta, axial, selectiva, para el proceso. Resultados: indicó 32 códigos in vivo que representan el discurso y los significados de los participantes de la investigación sobre la demanda en la Estrategia de Salud Familiar, recopilados en tres códigos teóricos que dieron origen a la categoría central "La teoría de la demanda en la Estrategia Salud de la Familia: ¿espontánea, programada o reprimida?". La demanda espontánea se convierte en quejas y enfermedades, en citas diarias sin programación previa, con horario restringido y como vía de acceso al servicio de salud. La demanda programada se establece en la programación de citas médicas para grupos específicos. La demanda reprimida, cada vez más frecuente en la vida cotidiana de los servicios de salud, se asocia a la falta de acceso y resolución. Conclusión: las demandas de salud se configuran en un espacio de falta de acceso y accesibilidad, denotando el principal problema que viven los usuarios y profesionales de la ESF.

RESUMO Objetivo: compreender as demandas espontânea, programada e reprimida frente às necessidades de saúde e à acessibilidade, sob a ótica de profissionais e usuários da Estratégia Saúde da Família. Método: estudo qualitativo, sob o método da Teoria Fundamentada nos Dados e do referencial teórico Interacionismo Simbólico, com 34 participantes, sendo 16 profissionais de saúde e 18 usuários. As fontes de evidências foram entrevistas aberta, intensiva e individual e memorandos. A coleta de dados ocorreu entre outubro/2016 a maio/2017. A análise dos dados se deu em etapas interdependentes: codificação aberta, axial, seletiva, para o processo. Resultados: indicaram 32 códigos in vivo que representam a alocução e os significados dos participantes da pesquisa frente à demanda na Estratégia Saúde da Família, compilados em três códigos teóricos que originaram a categoria central "A teoria da demanda na Estratégia Saúde da Família: espontânea, programada ou reprimida?". A demanda espontânea se volta à queixa e ao adoecimento, em atendimentos diários sem agendamento prévio, com restrição de horários e como meio de acesso ao serviço de saúde. A demanda programada se estabelece no agendamento de consultas médicas para grupos específicos. A demanda reprimida, cada vez mais frequente no cotidiano dos serviços de saúde, está associada à falta de acesso e de resolutividade. Conclusão: as demandas em saúde se configuram em um espaço de falta de acesso e acessibilidade, denotando o principal problema vivenciado pelos usuários e profissionais da ESF.

Which disease-related factors influence patients' and physicians' willingness to consider joint replacement in hip and knee OA? Results of a questionnaire survey linked to claims data.

BACKGROUND: A great heterogeneity in total joint replacement (TJR) rates has been reported for osteoarthritis (OA), most likely arising from a gap between patients' and physicians' views on the need for TJR. The purpose of this study therefore was to analyze potential cofactors which might influence the desire of patients to undergo TJR and physicians' willingness to discuss surgery with their patients. METHODS: A total of 8995 patients in Germany with a claims data diagnosis of hip or knee OA or polyarthrosis were asked to complete a questionnaire for this cross-sectional study of sociodemographic factors, indicators of current joint function (WOMAC score), willingness to undergo TJR and whether they had already discussed TJR with a physician. The overall response rate was 40%. Responders with polyarthrosis and individuals without current or chronic symptoms in the corresponding joints, pain in already replaced joints or simultaneous symptomatic hip and knee OA were excluded. We linked the survey results to claims data. Separate logistic regression models were used to assess which parameters were associated with patients' willingness to undergo TJR and physicians' discussion of surgery. RESULTS: We analyzed 478 hip OA and 932 knee OA patients. Just 17% with hip OA and 14% with knee OA were willing to undergo TJR, although 44 and 45% had already discussed surgery with their physicians. Patients' willingness was associated with higher WOMAC scores, a deterioration of symptoms over the last 2 years, and previous TJR for another joint. The discussion with a physician was influenced by the impact on personal life and previous arthroplasty. Older age (odds Ratio (OR) 1.2 per 10 years), male sex (OR 0.69 vs female), longer symptom duration (OR 1.08 per 5 years), deterioration of symptoms (OR 2.0 vs no change/improvement), a higher WOMAC score (OR 1.3 per 10% deterioration) and reduced well-being (OR 1.1 per 10% deterioration) were associated with physician discussion in knee OA patients. CONCLUSIONS: The proportion of patients willing to undergo TJR is lower than the proportion in whom physicians discuss surgery. While previous TJR seems to enhance patients' and surgeons' willingness, the influence of other cofactors is heterogeneous.

Application Design for Child Obesity Management Based on Users' Preferences and Needs.

This study aimed to investigate the constructive preferences and needs of children and guardians in a child obesity management application, and to suggest and visualize the key features of its design. To reflect users' preferences and needs, the questionnaires used in this study were developed in four stages: draft, validity test, review, and final version. The survey was conducted with fifth and sixth grade children who are overweight or obese and their guardians. Differences were observed by gender and between children and guardians with respect to children's perceived body shape, technology experience and preferences, preferred obesity management method, application design, exercise and diet-related features, preferred partner for obesity management, and preferred reward after mission completion. Our study suggests and visualizes the key features of a child obesity management application for both children and guardians based on their preferences and needs, which can be utilized by both application developers and researchers.

Sexualidade e saúde sexual de adolescentes: interseção de demandas para o cuidado / Adolescent sexuality and sexual health: intersecting demands for care / Sexualidad y salud sexual de adolescentes: intersección de demandas para el cuidado

Objetivo: conhecer as demandas para o cuidado no âmbito da sexualidade de adolescentes. Metodologia: estudo descritivo, abordagem qualitativa, tendo o gênero como categoria analítica. Realizado com 12 adolescentes de dois colégios públicos estaduais do interior da Bahia, em 2014. Foram utilizados oficinas de reflexão e questionário para coleta de dados e o tratamento se deu pela técnica de análise de discurso. Resultados: adolescentes consideram a sexualidade como dimensão humana que demanda atenção à saúde, com necessidade de orientações e cuidado direcionados a vulnerabilidades e conhecimento do corpo. É também processo afetivo-sexual, com prazer compartilhado, caminho para superação de desigualdades de gênero. Conclusão: as demandas apresentadas revelam um grupo que defende uma sexualidade saudável e prazerosa, livre de tabus e preconceitos, mas carente de orientações. As demandas extrapolam o que está posto como prioridade para atenção à saúde e urge a aproximação escola e serviços de saúde para implementar políticas de formação e cuidado de adolescentes.

Objective: to examine demands for care in the field of adolescent sexuality. Methodology: deploying gender as an analytical category, this qualitative, descriptive study was carried out in 2014 with 12 adolescents from two state public colleges in Bahia. Reflection workshops and a questionnaire were used for data collection and data were analysis by the discourse analysis technique. Results: adolescents consider sexuality to be a human dimension demanding health care, posing needs for guidance and care directed to vulnerabilities and body knowledge. It is also an affective and sexual process of shared pleasure, and a pathway to overcoming gender inequalities. Conclusion: the demands presented revealed a group that advocates healthy, pleasurable sexuality, free from taboos and prejudices, but lacking guidelines. The demands extend beyond what are considered health care priorities, and urge approximation between school and health services to implement adolescent education and care policies.

Objetivo: conocer las necesidades para el cuidado en el área de la sexualidad de adolescentes. Metodología: estudio descriptivo, de enfoque cualitativo, siendo el género la categoría de análisis. Fue realizado junto a 12 adolescentes de dos colegios públicos estatales del interior de Bahía, en 2014. Se han utilizado talleres de reflexión y cuestionarios para la recolección de datos y el análisis se basó en la técnica de análisis del discurso. Resultados: adolescentes consideran la sexualidad como dimensión humana que demanda atención a la salud, con necesidad de orientaciones y cuidado dirigidos a las vulnerabilidades y el conocimiento del cuerpo. Es también un proceso afectivo-sexual, con placer compartido, un camino para la superación de desigualdades de género. Conclusión: las demandas presentadas revelan un grupo que aboga por una sexualidad saludable y placentera, sin tabús y prejuicios, pero con pocas orientaciones. Las demandas extrapolan lo que se muestra como prioridad para la atención a la salud y urge el acercamiento escuela y servicios de salud para poner en marcha políticas de formación y cuidado de los adolescentes.

Demand forecast in the emergency department in Minas Gerais, Brazil / Previsão de demanda no departamento de emergência e Minas Gerais, Brasil

This study presents a mathematical model to carry out the demand forecasts in relation to patientes classified as green in the emergency department of a municipality in Minas Gerais, Brazil. In addition, another approach will investigate whether the green patients demand remains the same over the weekend, as compared to the weekdays, since there is no support from Primary Health Care units over the weekend. A retrospective study of the emergency service in the municipality of Monte Carmelo was carried out from January 2014 to December 2017.The time series of the patients classified as green during the host by the nurse, according to the Manchester Triage Scale, was analyzed in the temporal domain for the construction of a parametric model with the purpose of realizing the demand forecast. The Manchester Triage Scale has been adopted in most emergency department as a guiding instrument for risk classification, prioritizing the most serious cases. The data processing was fulfilled using Software R Version 3.4. The ARIMA model (1,1,1)presented a better fit for this forecast. The predictions of this model are values close to those observed for the number of patients seen that ranges from 1780.4 to 1796.6 patients per month. In relation to the demand of patients classified as green at the weekend, it has shown that it is slightly lower than the weekend, but it is still an expressive demand. The application of the models must be seen by the managers as a tool to aid decisions, thus it must support processes of planning, management and evaluation of public policies. In this context, mathematical models for demand forecasting are an instrument for management care and services.

Este estudo apresenta um modelo matemático para realizar as previsões de demanda em relação aos pacientes classificados como verdes no departamento de emergência de um município de Minas Gerais. Além disso, outra abordagem investigará se a demanda dos pacientes verdes permanece a mesma no final de semana, em relação aos dias da semana, uma vez que não há apoio das unidades de Atenção Primária de Saúde no final de semana. Um estudo retrospectivo do serviço de emergência no município de Monte Carmelo foi realizado no período de janeiro de 2014 a dezembro de 2017. A série temporal dos pacientes classificados como verdes durante o acolhimento pelo enfermeiro, segundo o Sistema de Triagem de Manchester, foi analisada no domínio temporal para a construção de um modelo paramétrico com a finalidade de realizar a previsão de demanda. O Sistema de Triagem de Manchester foi adotado na maioria dos serviços de emergência como instrumento orientador para a classificação de risco, priorizando os casos mais graves. O processamento de dados foi realizado usando o Software R Versão 3.4. O modelo ARIMA (1,1,1) apresentou melhor ajuste para essa previsão. As previsões deste modelo são valores próximos aos observados para o número de pacientes atendidos que variam de 1780.4 a 1796.6 pacientes por mês. Em relação à demanda de pacientes classificados como verdes no final de semana, constatou que é ligeiramente inferior a do fim de semana, mas ainda é uma demanda expressiva. A aplicação dos modelos deve ser vista pelos gestores como uma ferramenta para auxiliar as decisões, portanto, deve apoiar processos de planejamento, gestão e avaliação de políticas públicas. Nesse contexto, os modelos matemáticos para previsão de demanda são um instrumento de atendimento e serviços gerenciais.

Medical Radiation: Status and Availability in The Bahamas / Radiación Médica: Estatus y Disponibilidad en las Bahamas

ABSTRACT Introduction: The Bahamas became a member state of the International Atomic Energy Agency (IAEA) on January 7, 2014 (1). The purpose of this paper is to inform the reader on The Bahamas' ability to provide services that utilize radiation. Method: A study was conducted on various clinics across The Bahamas, New Providence in particular (primary sample area), Grand Bahama, Abaco and Exuma. Twenty per cent of the staff members of the respective locations were given questionnaires and the chief personnel were interviewed. Staff members were advised that their responses would remain anonymous and were welcomed to participate, thereafter. Microsoft Excel was used for data input and processing. Original surveys were checked against the dataset for potential errors. Results: Thirty-one clinics were approached to participate in the survey, of which 25 participated resulting in an 81% response rate. Fifty questionnaires were completed in total. Two clinics had multiple locations; therefore, 27 clinics (23 private, 4 public) participated in total. The included map illustrates the sample area of the survey, with New Providence being the primary sample area. The number of modalities, patients treated and frequency of quality assurance checks were also evaluated. Conclusion: Most of the examined clinics outsourced technicians and physicists to perform quality checks. This suggests that there is a need for qualified local technical support. Further studies are needed to understand the full extent of the country's needs regarding medical radiation and figuring out the steps necessary for approaching this subject.

RESUMEN Introducción: Las Bahamas se convirtieron en un Estado Miembro de la Agencia Internacional de Energía Atómica (AIEA) el 7 de enero de 2014 (1). El propósito de este trabajo es informar al lector sobre la capacidad de las Bahamas para prestar servicios que utilizan radiación. Método: Se realizó un estudio en varias clínicas a través de las Bahamas, Nueva Providencia en particular (área de muestra primaria), Gran Bahama, Abaco y Exuma. El veinte por ciento de los miembros del personal de las respectivas locaciones recibieron cuestionarios y el personal dirigente fueron entrevistados. A los miembros del personal se les informó que sus respuestas permanecerían anónimas, y se les dio la bienvenida por su participación. Para la entrada y el procesamiento de datos se usó Microsoft Excel. Las encuestas originales se chequearon contra el conjunto de datos para a fin de detectar posibles errores. Resultados: Treinta y una clínicas fueron abordadas para participar en la encuesta, de las cuales 25 participaron, para una tasa de respuesta de 81%. En total se completaron 50 cuestionarios. Dos clínicas tenían múltiples localidades. Por lo tanto, 27 clínicas (23 privadas, 4 públicas) participaron en total. El mapa incluido ilustra el área de la muestra de la encuesta, en la que Nueva Providencia es el área de la muestra primaria. El número de modalidades, los pacientes tratados, y la frecuencia de los controles de garantía de calidad, también fueron evaluados. Conclusión: La mayor parte de las clínicas examinadas subcontrataron técnicos y físicos para realizar chequeos de la calidad. Esto sugiere que hay necesidad de apoyo técnico local calificado. Se necesitan estudios adicionales para entender el alcance completo de las necesidades del país en relación con la radiación médica y los pasos necesarios para abordar este asunto.

Acesso à vacinação no cotidiano da atenção primária à saúde na região ampliada oeste de minas gerais, sob a ótica dos usuários / Acceso a la vacunación en el cotidiano de la atención primaria a la salud en la región ampliada oeste de minas generales, bajo la óptica usuarios / Access to daily vaccination in primary health care in the west region of minas gerais, under the optics of users

Este estudo teve por objetivo compreender o acesso à vacinação no cotidiano da Atenção Primária à Saúde na Região Ampliada Oeste do Estado de Minas Gerais, sob a ótica do usuário.Trata-se de estudo de casos múltiplos holístico-qualitativo, fundamentado na Sociologia Compreensiva do Cotidiano. Contém quatro casos que se constitui pelas microrregiões sanitárias e teve como unidade única de análise: “O acesso à vacinação na APS”. As fontes de evidências foram: a entrevista aberta com roteiro semiestruturado, a visita técnica às salas de vacinas e notas de campo. Para análise dos dados, utilizou-se da Análise de Conteúdo Temática,obedecendo à técnica analítica da síntese cruzada dos casos. Participaram do estudo 74 usuários de sete municípios representantes de quatro microrregiões da Região Ampliada de Saúde Oeste de Minas Gerais, Brasil. Resultados: Originaram três categorias: “Adequação funcional e uma agenda para o acesso à vacinação na APS sob a ótica do usuário”, “Acesso à vacinação na APS na voz do usuário: sentidos e sentimentos frente ao atendimento” e “Vacinação como demanda programada: um acesso que pode ser facilitado”. Os entraves relacionados aos aspectos organizacionais dos serviços, como o estabelecimento de dias específicos para a realização de determinadas vacinas, falta do imunobiológico e inadequado horário de funcionamento das salas de vacina foram descritos na primeira categoria. A segunda categoria traz as perspectivas dos usuários frente à realidade vivenciada do acesso vacinação na APS, por meio da manifestação dos sentidos e sentimentos atribuídos às dificuldades enfrentadas pelos aspectos geográficos, financeiros e sociais

Vaccination access in Everyday Life of primary health care of the Western Extended HealthRegion of Minas Gerais, from the user’s standpointThis study was intended to understand the vaccination access in Everyday Life of primaryhealth care of the Western Extended Health Region of Minas Gerais, from the user’s standpoint.This is a holistic-qualitative and multiple-case study, which was underpinned on theComprehensive Sociology of Everyday Life. It contains four cases encompassing the sanitarymicro-regions and had as single analysis unit: “The access to vaccination in APS”. The sourcesof evidence were: the open interview with semi-structured script, the technical visit to thevaccination rooms, and field notes. In order to analyze the data, we used the Thematic ContentAnalysis, following the analytical technique of the cross-synthesis of cases. The study wasattended by 74 users from seven cities representing four micro-regions of the Western ExtendedHealth Region of Minas Gerais, Brazil. Results: The analysis gave rise to three categories:“Functional adequacy, and an agenda for access to vaccination from the user’s standpoint”,“Vaccination access in Everyday Life of primary health care from the user’s voice: senses andfeelings about health care” and “Vaccination as a programmed demand: an access that may beeased”. Barriers related to the organizational aspects of services, such as the establishment ofspecific days for administering certain vaccines, lack of immunobiological products andinappropriate hours of operation of vaccine rooms were shown in the first category. The secondcategory brings the users’ perspectives about the experienced reality of access to vaccination inAPS, through the manifestation of the senses and feelings assigned to the difficulties faced bythe geographic, financial and social dimensions

Acesso à vacinação no cotidiano da atenção primária à saúde na região ampliada oeste de minas gerais, sob a ótica dos usuários / Acceso a la vacunación en el cotidiano de la atención primaria a la salud en la región ampliada oeste de minas generales, bajo la óptica usuarios / Access to daily vaccination in primary health care in the west region of minas gerais, under the optics of users

Este estudo teve por objetivo compreender o acesso à vacinação no cotidiano da Atenção Primária à Saúde na Região Ampliada Oeste do Estado de Minas Gerais, sob a ótica do usuário. Trata-se de estudo de casos múltiplos holístico-qualitativo, fundamentado na Sociologia Compreensiva do Cotidiano. Contém quatro casos que se constitui pelas microrregiões sanitárias e teve como unidade única de análise: "O acesso à vacinação na APS". As fontes de evidências foram: a entrevista aberta com roteiro semiestruturado, a visita técnica às salas de vacinas e notas de campo. Para análise dos dados, utilizou-se da Análise de Conteúdo Temática, obedecendo à técnica analítica da síntese cruzada dos casos. Participaram do estudo 74 usuários de sete municípios representantes de quatro microrregiões da Região Ampliada de Saúde Oeste de Minas Gerais, Brasil. Resultados: Originaram três categorias: "Adequação funcional e uma agenda para o acesso à vacinação na APS sob a ótica do usuário", "Acesso à vacinação na APS na voz do usuário: sentidos e sentimentos frente ao atendimento" e "Vacinação como demanda programada: um acesso que pode ser facilitado". Os entraves relacionados aos aspectos organizacionais dos serviços, como o estabelecimento de dias específicos para a realização de determinadas vacinas, falta do imunobiológico e inadequado horário de funcionamento das salas de vacina foram descritos na primeira categoria. A segunda categoria traz as perspectivas dos usuários frente à realidade vivenciada do acesso vacinação na APS, por meio da manifestação dos sentidos e sentimentos atribuídos às dificuldades enfrentadas pelos aspectos geográficos, financeiros e sociais. A terceira categoria revela que os usuários conferem à vacinação o atributo de ser uma demanda programada em saúde, indicam que o uso de sistemas informatizados para registro dos dados de imunização e o envolvimento da equipe de saúde, com as atividades de imunização, favorecem o acesso oportuno à imunização e evitam situações de oportunidades perdidas de vacinação. Conclusão: Este estudo possibilitou conhecer aspectos intrinsecamente relacionadas ao acesso do usuário à imunização no âmbito da Atenção Primária à Saúde, considerando a subjetividade. Os entraves organizacionais, geográficos e socio demográficos identificados comprometem a prestação de um serviço de vacinação adequado, conforme estabelecido pelo Programa Nacional de Imunizações. O conhecimento desses fatores contribui para o planejamento da promoção vacinal e indica a necessidade de reforçar políticas mais equitativas. Uma agenda para o melhor acesso à vacinação na APS foi sugerida pelos usuários. O estudo apresenta contribuições para a área de Enfermagem e da Saúde, uma vez que a realidade apresenta entraves à incorporação da vacinação como demanda programada no cotidiano dos serviços, e que a programação dessa demanda pode promover o acesso a essa ação. Ressalta-se a importância de os serviços identificarem suas fragilidades e adotarem estratégias que viabilizem uma atenção usuário-centrada, promovendo o acesso aos serviços de saúde e, consequentemente, à imunização

Vaccination access in Everyday Life of primary health care of the Western Extended Health Region of Minas Gerais, from the user's standpoint This study was intended to understand the vaccination access in Everyday Life of primary health care of the Western Extended Health Region of Minas Gerais, from the user's standpoint. This is a holistic-qualitative and multiple-case study, which was underpinned on the Comprehensive Sociology of Everyday Life. It contains four cases encompassing the sanitary micro-regions and had as single analysis unit: "The access to vaccination in APS". The sources of evidence were: the open interview with semi-structured script, the technical visit to the vaccination rooms, and field notes. In order to analyze the data, we used the Thematic Content Analysis, following the analytical technique of the cross-synthesis of cases. The study was attended by 74 users from seven cities representing four micro-regions of the Western Extended Health Region of Minas Gerais, Brazil. Results: The analysis gave rise to three categories: "Functional adequacy, and an agenda for access to vaccination from the user's standpoint", "Vaccination access in Everyday Life of primary health care from the user's voice: senses and feelings about health care" and "Vaccination as a programmed demand: an access that may be eased". Barriers related to the organizational aspects of services, such as the establishment of specific days for administering certain vaccines, lack of immunobiological products and inappropriate hours of operation of vaccine rooms were shown in the first category. The second category brings the users' perspectives about the experienced reality of access to vaccination in APS, through the manifestation of the senses and feelings assigned to the difficulties faced by the geographic, financial and social dimensions. The third category shows that users endow vaccination with the assignment of being a programmed health demand, highlighting that the use of computerized systems to record immunization data and the involvement of the health team with immunization activities foster access to the vaccine room and prevent situations of, missed vaccination opportunities. Conclusion: This study has enabled us to know aspects intrinsically related to the user's access to immunization in the context of Primary Health Care, considering subjectivity. The identified organizational, geographic and sociodemographic barriers undermine the provision of an appropriate vaccination service, as established by the National Immunization Program. The knowledge of these factors contributes to the planning of vaccine promotion and signalizes the need to reinforce more equitable policies. An agenda for better access to the vaccine room has been suggested by users. The study presents contributions to the area of Nursing and Health, since the reality presents barriers to the incorporation of vaccination as a programmed demand in the daily services, and that the programming of this demand may promote access to this action. We should highlight the importance of services in identifying their weaknesses and adopting strategies that enable a user-centered health care, thereby promoting access to health services and, consequently, immunization

Acolhimento a demanda espontânea nas perspectivas dos profissionais e usuários da atenção básica à saúde / Welcoming spontaneous demand in the perspectives of professionals and users of basic health care

Descrever o acolhimento à demanda espontânea, em unidades de Atenção Básica em Saúde - APS, na perspectiva dos profissionais de saúde e dos usuários. Métodos: estudo descritivo com dados de 56 municípios da Regional de Atenção à Saúde XIII do estado de São Paulo, que participaram da avaliação externa do Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica, em 2012. Foram analisadas 12 variáveis relacionadas aos profissionais e 11 aos usuários. Resultados: Segundo os profissionais, o acolhimento estava implantado em 96,7% das unidades, atendendo 98,9% das necessidades dos usuários, com tempo de espera para atendimento de até 15 minutos (89,5%), sendo os enfermeiros, agentes comunitários e médicos os mais envolvidos. Dois terços dos usuários afirmaram que suas necessidades foram atendidas, esperavam até uma hora para serem acolhidos (62%), elegendo médicos e vigilantes como os que mais acolhiam. Conclusão: Pôde-se perceber que há encontros nas perspectivas dos participantes do estudo relacionados à existência de acolhimento nas unidades de APS e à qualidade da atenção prestada e, em contrapartida, divergências de visões, principalmente, referentes ao conceito de acolhimento e aos operadores desta estratégia de saúde.

To describe the reception of spontaneous demand, in units of Basic Health Care - BHC, from the perspective of health professionals and users. METHODS: a descriptive study with data from 56 municipalities of the Region of Health Care XIII of the state of São Paulo, which participated in the external evaluation of the National Program for Improving Access and Quality of Basic Care in 2012. Twelve variables related to professionals and 11 users. Results: According to the professionals, the hospital was implanted in 96.7% of the units, meeting 98.9% of the users' needs, with a waiting time of up to 15 minutes (89.5%). community members and physicians. Two-thirds of users stated that their needs were met, waited up to one hour to be welcomed (62%), electing doctors and vigilantes as the most welcoming. Conclusion: It was possible to perceive that there are meetings in the perspectives of the participants of the study related to the existence of reception in the units of PHC and the quality of the attention given and, on the other hand, divergences of visions, mainly, referring to the concept of reception and to the operators of this one health strategy.

Demand and Signing of General Practitioner Contract Service among the Urban Elderly: A Population-Based Analysis in Zhejiang Province, China.

This study aims to examine whether the urban elderly in the Zhejiang Province of China signed contracts with their general practitioner (GP) based on their health service needs, and to further identify the determinants of their demand and signing decisions. A community-based cross-sectional study was conducted in 16 community health service (CHS) institutions in Zhejiang Province, China. The urban elderly over 60 years of age were enrolled when visiting the sampled CHS. Baseline characteristics were compared between participants using Chi-Square tests for categorical variables. Univariate and multivariable logistic regression analyses were used to identify determinants of the GP contract service demand and signing decisions, respectively. Among the 1440 urban elderly, 56.67% had signed contracts with their GP, and 55.35% had a demand of the GP contract service. The influencing factors of demand were a history of diabetes or cardiovascular disease (OR = 1.33, 95% CI, 1.05-1.68); urban resident basic medical insurance (URBMI) vs. urban employee basic medical insurance (UEBMI) (OR = 1.96, 95% CI, 1.46-2.61); and middle-income vs. low-income (OR = 0.67, 95% CI, 0.50-0.90 for RMB 1001-3000; OR = 0.59, 95% CI, 0.39-0.90 for RMB 3001-5000). Having a demand for the GP contract service was the strongest determinant of signing decisions (OR = 13.20, 95% CI, 10.09-17.27). Other factors also contributed to these decisions, including gender, caregiver, and income. The urban elderly who had signed contracts with GPs were mainly based on their health care needs. Elderly people with a history of diabetes or cardiovascular disease, as well as those with URBMI, were found to have stronger needs of a GP contract service. It is believed that the high-income elderly should be given equal priority to those of low-income.

Frequent users of emergency services: associated factors and reasons for seeking care / Usuários frequentes de serviço de emergência: fatores associados e motivos de busca por atendimento / Usuarios frecuentes de servicios de emergencia: factores asociados y motivos de la búsqueda de atención

Aim: to identify the profile of frequent users of emergency services, to verify the associated factors and to analyze the reasons for the frequent use of the services. METHOD: An explanatory sequential type mixed method was adopted. Quantitative data were collected from the electronic medical records, with a sample of 385 users attended four or more times in an emergency service, during the year 2011. Qualitative data were collected through semi-structured interviews with 18 users, intentionally selected from the results of the quantitative stage. Quantitative data were analyzed using descriptive and inferential statistics and qualitative data using thematic analysis. RESULTS: It was found that 42.9% were elderly, 84.9% had chronic diseases, 63.5% were classified as urgent, 42.1% stayed for more than 24 hours in the service and 46.5% were discharged. Scheduled follow-up appointment, risk classification, length of stay and outcome were factors associated with frequent use. The reasons for seeking the services were mainly related to the exacerbation of chronic diseases, to easier access and concentration of technology, to the bond, and to the scheduled appointments. CONCLUSIONS: The results contribute to comprehending the repeated use of emergency services and provide additional data to plan alternatives to reduce frequent use. .

OBJETIVO: identificar o perfil de usuários frequentes de serviço de emergência, verificar fatores associados e analisar os motivos para utilização frequente do serviço. MÉTODO: adotou-se método misto, do tipo sequencial explanatório. Os dados quantitativos foram coletados em registros de prontuários eletrônicos, com amostra de 385 usuários, atendidos quatro vezes ou mais em um serviço de emergência, durante o ano de 2011. Os dados qualitativos foram obtidos por meio de entrevistas semiestruturadas, com 18 usuários, selecionados intencionalmente a partir dos resultados da etapa quantitativa. Os dados quantitativos foram analisados com estatística descritiva e inferencial e os qualitativos com análise temática. RESULTADOS: identificou-se que 42,9% eram idosos, 84,9% tinham doenças crônicas, 63,5% foram classificados como urgentes, 42,1% permaneceram mais de 24 horas no serviço e 46,5% tiveram alta. Os fatores associados à utilização frequente são retorno agendado, classificação de risco, tempo de permanência e desfecho. Os motivos da busca pelo serviço são relacionados, principalmente, à agudização de doenças crônicas, maior facilidade de acesso, concentração de tecnologia, vínculo e retornos agendados. CONCLUSÕES: os resultados contribuem para compreensão do uso repetido de serviços de emergência e oferecem subsídios para planejamento de alternativas para redução da utilização frequente. .

OBJETIVO: identificar el perfil de usuarios frecuentes de servicios de emergencia, verificar los factores asociados y analizar los motivos para utilización frecuente de ese servicio. MÉTODO: se adoptó un método mixto del tipo secuencial explicativo. Los datos cuantitativos fueron recolectados en registros de fichas electrónicas, con muestra de 385 usuarios atendidos cuatro veces o más, en un servicio de emergencia, durante el año de 2011. Los datos cualitativos fueron obtenidos por medio de entrevistas semiestructuradas con 18 usuarios, seleccionados intencionalmente a partir de los resultados de la etapa cuantitativa. Los datos cuantitativos fueron analizados con estadística descriptiva e inferencial y los cualitativos con análisis temático. RESULTADOS: se identificó que 42,9% eran ancianos, 84,9% tenían enfermedades crónicas, 63,5% fueron clasificados como urgentes, 42,1% permanecieron más de 24 horas en el servicio y 46,5% tuvieron alta para el domicilio. El retorno programado, la clasificación de riesgo, el tiempo de permanencia y el resultado, son factores asociados a la utilización frecuente. Los motivos de la búsqueda por el servicio son relacionados, principalmente a: la agudización de enfermedades crónicas, la mayor facilidad de acceso y concentración de tecnología, los vínculos, y a los retornos programados. CONCLUSIONES: los resultados contribuyen para la comprensión del uso repetido de servicios de emergencia y ofrecen informaciones para planificar alternativas para reducción de la utilización frecuente. .

Perfil de encaminhamentos a fisioterapia por um serviço de Atenção Primária à Saúde, 2012* / Profile of patients referred to physiotherapy by a Primary Health Care Service in 2012

Descrever a frequência de encaminhamentos e as características dos usuários da Atenção Primária à Saúde (APS) encaminhados aos serviços de fisioterapia, por Unidades de Saúde do Serviço de Saúde Comunitária do Grupo Hospitalar Conceição em Porto Alegre-RS, Brasil. Métodos: estudo transversal descritivo com dados primários e secundários, obtidos a partir de questionários e dos formulários de encaminhamento referentes ao período de julho a setembro de 2012. Resultados: do total de 258 formulários, a frequência de encaminhamentos a fisioterapia foi de 1,1 por cento; predominaram mulheres (70,5 por cento) não idosas (59,4 por cento); os diagnósticos clínicos mais prevalentes foram a osteoartrose (29,1 por cento) e as tendinopatias/lesões de tecidos moles (27,1 por cento); 87,1 por cento dos usuários referiram dor, estando 48,1 por cento destes, pelo menos, parcialmente impossibilitados de trabalhar. Conclusão: a frequência de encaminhamentos à fisioterapia pela APS foi baixa, embora a população esteja em um processo de adoecimento por problemas crônicos, com presença de dor e redução da capacidade laboral...

To describe the frequency of referrals and the characteristics of patients referred to physiotherapy services by Conceição Hospital Group Community Health Service Primary Health Care Units (PHCU). Methods: this is a cross-sectional and descriptive study using primary and secondary data obtained from questionnaires and referral forms for the period July to September 2012. Results: analyzing 258 forms, we found 1.1 per cent frequency of referral to physical therapy with higher prevalence of women (70.5 per cent) and non-elderly women (59.4 per cent). The two most prevalent clinical diagnoses were osteoarthrosis (29.1 per cent) and tendinosis/soft tissue injuries (27.1 per cent). 87.1 per cent of patients referred pain and at last 48.1 per cent of these were partially unable to work. Conclusion: prevalence of PHCU referrals to physiotherapy is low, although the population is subject to chronic illness problems, with pain as an aggravating factor and interference in work capacity...

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators.

BACKGROUND: Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD. METHOD: Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer-reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings. RESULTS: Twenty-seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified. CONCLUSION: This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence-based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.

Out-of-hours primary care services: demands and patient referral patterns in a Veneto region (Italy) Local Health Authority.

PURPOSE: The aim of this study was to describe the characteristics of patients admitted to an out-of-hours (OOH) service and to analyze the related outputs. SETTING: A retrospective population-based cohort study was conducted by analyzing an electronic database recording 23,980 OOH service contacts in 2011 at a Local Health Authority in the Veneto Region (North-East Italy). METHOD: A multinomial logistic regression was used to compare the characteristics of contacts handled by the OOH physicians with cases referred to other services. RESULTS: OOH service contact rates were higher for the oldest and youngest age groups and for females rather than males. More than half of the contacts concerned patients who were seen by a OOH physician. More than one in three contacts related problems managed over the phone; only ≈10% of the patients were referred to other services. Many factors, including demographic variables, process-logistic variables and clinical characteristics of the contact, were associated with the decision to visit the patient's home (rather than provide telephone advice alone), or to refer patients to an ED or to a specialist. Our study demonstrated, even after adjusting, certain OOH physicians were more likely than their colleagues to refer a patient to an ED. CONCLUSION: Our study shows that OOH services meet composite and variously expressed demands. The determining factors associated with cases referred to other health care services should be considered when designing clinical pathways in order to ensure a continuity of care. The unwarranted variability in OOH physicians' performance needs to be addressed.