Pregnancy, obstetrical and neonatal outcomes in women exposed to physician-related occupational hazards: a scoping review.

OBJECTIVE: Evidence is needed to guide organisational decision making about workplace accommodations for pregnant physicians. Our objective was to characterise the strengths and limitations of current research examining the association between physician-related occupational hazards with pregnancy, obstetrical and neonatal outcomes. DESIGN: Scoping review. DATA SOURCES: MEDLINE/PubMed, EMBASE, CINAHL/ EBSCO, SciVerse Scopus and Web of Science/Knowledge were searched from inception to 2 April 2020. A grey literature search was performed on 5 April 2020. The references of all included articles were hand searched for additional citations. ELIGIBILITY CRITERIA: English language citations that studied employed pregnant people and any 'physician-related occupational hazards', meaning any relevant physical, infectious, chemical or psychological hazard, were included. Outcomes included any pregnancy, obstetrical or neonatal complication. DATA EXTRACTION AND SYNTHESIS: Physician-related occupational hazards included physician work, healthcare work, long work hours, 'demanding' work, disordered sleep, night shifts and exposure to radiation, chemotherapy, anaesthetic gases or infectious disease. Data were extracted independently in duplicate and reconciled through discussion. RESULTS: Of the 316 included citations, 189 were original research studies. Most were retrospective, observational and included women in any occupation rather than healthcare workers. Methods for exposure and outcome ascertainment varied across studies and most studies had a high risk of bias in data ascertainment. Most exposures and outcomes were defined categorically and results from different studies could not be combined in a meta-analysis due to heterogeneity in how these categories were defined. Overall, some data suggested that healthcare workers may have an increased risk of miscarriage compared with other employed women. Long work hours may be associated with miscarriage and preterm birth. CONCLUSIONS: There are important limitations in the current evidence examining physician-related occupational hazards and adverse pregnancy, obstetrical and neonatal outcomes. It is not clear how the medical workplace should be accommodated to improve outcomes for pregnant physicians. High-quality studies are needed and likely feasible.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs. OBJECTIVE: Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications. DESIGN: We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs. SETTING: Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1). PATIENTS: Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2. MEASUREMENTS: We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care. METHODS: We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded. RESULTS: Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo). LIMITATIONS: These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model. CONCLUSIONS: Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment. TRIAL REGISTRATION: Not applicable.

CONTEXTE: Environ 78 % des patients atteints d'insuffisance rénale chronique (IRC) habitent un pays à revenu faible ou intermédiaire (PRFI). On en sait toutefois peu sur les modèles de prise en charge pour l'IRC dans les PRFI. OBJECTIFS: Nous souhaitions faire la mise à jour d'une revue systématique antérieure qui portait sur les modèles de prise en charge pour l'IRC dans les PRFI. Nous voulions également synthétiser l'information concernant les soins multidisciplinaires en IRC et la prise en charge des complications. CONCEPTION DE L'ÉTUDE: En septembre 2020, les bases de données MEDLINE, EMBASE et Global Health ont été consultées à la recherche d'articles publiés entre le 1er janvier 2017 et le 14 septembre 2020. Nous avons utilisé une combinaison de termes de recherche, incluant différentes itérations d'IRC, de modèles de prise en charge et de PRFI. La définition de la Banque mondiale (2019) a été utilisée pour identifier les PRFI. CADRE: Nous avons inclus des études publiées dans des PRFI de quatre continents : Afrique, Asie, Amérique du Nord (Mexique) et Europe (Ukraine). Les études avaient été réalisées dans des hôpitaux tertiaires (N = 6), une clinique multidisciplinaire, des centres de soins primaires (N = 2), des centres d'aiguillage (N = 2), un hôpital communautaire, un hôpital universitaire, un hôpital régional et un centre médical urbain. SUJETS: Les 18 études répondant aux critères d'inclusion portaient sur un total de 4 679 patients, dont 4 665 adultes. Neuf études seulement rapportaient un DFGe moyen, lequel s'étendait de 7 à 45,90 ml/min/1,73 m2. MESURES: Les informations suivantes sur les soins en IRC ont été extraites : financement, établissement urbain ou rural, catégories de personnel soignant et type de soins fournis, définis par les recommandations de KDIGO (Kidney Disease Improving Global Outcomes) pour la prise en charge d'IRC. MÉTHODOLOGIE: Nous avons inclus les études qui répondaient aux critères suivants : (1) la population étudiée était principalement constituée d'adultes (18 ans et plus); (2) la majorité de la population étudiée était atteinte d'IRC et non d'insuffisance rénale terminale (IRT); (3) la population étudiée habitait un PRFI selon la définition de la Banque mondiale; (4) le manuscrit décrivait avec suffisamment de détails un modèle de soins cliniques pour l'IRC; (5) le manuscrit était rédigé en anglais ou en français. Les études sur les animaux, les rapports de cas, les commentaires et les éditoriaux ont été exclus. RÉSULTATS: 18 études (24 modèles de soins, 4 665 patients) répondaient aux critères d'inclusion. Sur 24 modèles de soins, 20 avaient impliqué des équipes de soins interdisciplinaires. Les recommandations internationales pour la prise en charge de l'IRC avaient été intégrées à 20 modèles de soins. La prise en charge conservatrice de l'IRC (sans dialyse ni greffe rénale) n'était cependant rapportée que dans une minorité de modèles (11/24). Bien que nous ayons noté des similitudes entre tous les modèles de soins cliniques, des variations ont été observées dans les services fournis et dans les modalités de financement; ces dernières allant du financement public complet (p. ex. : Sri Lanka, Thaïlande) aux versements directs par les patients (p. ex. : Bénin, Togo). LIMITES: Les limites comprennent notamment: (1) le manque de détails sur les soins en IRC dans plusieurs études; (2) le faible nombre d'études incluses; (3) l'utilisation d'un modèle de soins dont la définition différait de l'originale présentée par Stanifer et coll.; et (4) l'utilisation des recommandations de KDIGO comme norme pour définir un modèle de soins pour l'IRC. CONCLUSION: La plupart des modèles de soins intégraient les éléments clés des soins recommandés pour l'IRC. L'accès à ces soins dépendait toutefois du mécanisme de financement en place. Cependant, peu de modèles intégraient la prise en charge conservatrice de l'IRC, laquelle devrait être une priorité pour de futurs investissements.

Corrigendum to "Tonelli M, Nkunu V, Varghese C, et al. Framework for establishing integrated kidney care programs in low- and middle-income countries" Kidney Int Suppl. 2020;10:e19-e23.

[This corrects the article DOI: 10.1016/j.kisu.2019.11.002.].

Framework for establishing integrated kidney care programs in low- and middle-income countries.

Secular increases in the burden of kidney failure is a major challenge for health systems worldwide, especially in low- and middle-income countries (LMICs) due to growing demand for expensive kidney replacement therapies. In LMICs with limited resources, the priority of providing kidney replacement therapies must be weighed against the prevention and treatment of chronic kidney disease, other kidney disorders such as acute kidney injury, and other noncommunicable diseases, as well as other urgent public health needs. Kidney failure is potentially preventable-not just through primary prevention of risk factors for kidney disease such as hypertension and diabetes, but also by timely management of established chronic kidney disease. Among people with established or incipient kidney failure, there are 3 key treatment strategies-conservative care, kidney transplantation, and dialysis-each of which has its own benefits. Joining up preventive care for people with or at risk for milder forms of chronic kidney disease with all 3 therapies for kidney failure (and developing synergistic links between the different treatment options) is termed "integrated kidney care" and has potential benefits for patients, families, and providers. In addition, because integrated kidney care implicitly considers resource use, it should facilitate a more sustainable approach to managing kidney failure than providing one or more of its components separately. There is currently no agreed framework that LMIC governments can use to establish and/or scale up programs to prevent and treat kidney failure or join up these programs to provide integrated kidney care. This review presents a suggested framework for establishing integrated kidney care programs, focusing on the anticipated needs of policy makers in LMICs.

Why do some physicians choose to tackle inequities in healthcare?

BACKGROUND: Despite the reputation of Canada's healthcare system as being accessible to all Canadians, certain populations continue to face inequities within our healthcare system. In addition to promoting fairness, addressing healthcare inequities has the potential to reduce healthcare costs, which is increasingly important as healthcare costs continue to rise. Intentionally or otherwise, physicians are often leaders in healthcare teams, but there is a paucity of literature on physicians' perceptions of the problem of healthcare inequities and their potential role in addressing inequities. In this pilot study, we use a grounded theory approach to explore contextual factors and mechanisms that associate with an individual physician's involvement (or otherwise) in initiatives to reduce healthcare inequity. METHODS: Using purposeful sampling and a set of a priori questions, we interviewed ten physicians - five of whom self-identified as being actively involved and five not actively involved in addressing healthcare inequities - to explore potential reasons for physicians choosing to address the causes of healthcare inequities. RESULTS: We identified contextual barriers (e.g., lack of knowledge and time) and facilitators (prior experience, protected time, mentorship and system supports) that we interpreted as interacting with the underlying mechanism (motivation to address inequities) to influence a physician's decision on whether or not to address healthcare inequities. CONCLUSION: Based upon our findings we propose further studies to understand and/or overcome barriers to physicians being involved in addressing healthcare inequities.