Nursing home patients and Emergency Department attendance in a single urban Irish catchment area: an observational study surrounding the introduction of a community medicine for older person service.

BACKGROUND: Nursing home (NH) patients are at a high risk of Emergency Department (ED) attendance, and adverse events in the ED. With an increasing NH population, monitoring trends in ED utilization is important to aid service planning, and attention to potentially preventable attendances should be paid, to identify areas that may benefit from specialist support. AIMS: This 12-year (2008-2019) study aimed to observe trends in ED utilization of NH patients in a single urban Irish catchment area, surrounding the introduction of a Community Medicine for the Older Person (CMOP) outreach program. METHOD: A retrospective review of all NH attendances within the catchment area was performed based upon NH address. Attendance, admission, discharge, and died in department (DID) were adjusted per annual NH bed numbers (PBC). Trends were observed and compared pre and post the CMOP activation. Comparisons of continuous variables were performed using an unpaired parametric Student's t test. RESULTS: There were 6877 attendances, with 58% (n = 3989) admitted, 40% (n = 2785) discharged, and 2% (n = 123) DID. There was a statistically significant difference in mean discharge rate PBC pre and post the CMOP introduction (0.22 vs 0.16, P = 0.04). There was no statistically significant difference in attendance, admission, or DID. CONCLUSION: This is the first Irish study of NH ED utilization over an extended period. ED attendances PBC have not decreased since the introduction of the CMOP. Discharges PBC, however, have decreased and may represent a decrease in potentially preventable attendance/improvement in appropriateness of ED transfers, following the introduction of this intervention.

Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta.

CONTEXT.­: Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings. OBJECTIVE.­: To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes. DESIGN.­: Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents. RESULTS.­: Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record. CONCLUSIONS.­: A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.

Cost-effectiveness of community mobilization (Camino Verde) for dengue prevention in Nicaragua and Mexico: A cluster randomized controlled trial.

BACKGROUND: We assessed the cost-effectiveness of Camino Verde, a community-based mobilization strategy to prevent and control dengue and other mosquito-borne diseases. A cluster-randomized controlled trial in Managua, Nicaragua, and in three coastal regions in Guerrero, Mexico (75 intervention and 75 control clusters), Camino Verde used non-governmental community health workers, called brigadistas, to support community mobilization. This donor-funded trial demonstrated reductions of 29.5% (95% confidence interval, CI: 3.8%-55.3%) on dengue infections and 24.7% (CI: 1.8%-51.2%) on self-reported cases. METHODS: We estimated program costs through a micro-costing approach and semi-structured questionnaires. We show results as incremental cost-effectiveness ratios (ICERs) for costs per disability-adjusted life-year (DALYs) averted and conducted probabilistic sensitivity analyses. FINDINGS: The Camino Verde trial spent US$16.72 in Mexico and $7.47 in Nicaragua per person annually. We found an average of 910 (CI: 487-1 353) and 500 (CI: 250-760) dengue cases averted annually per million population in Mexico and Nicaragua, respectively, compared to control communities. The ICER in Mexico was US$29 618 (CI: 13 869-66 898) per DALY averted, or 3.0 times per capita GDP. For Nicaragua, the ICER was US$29 196 (CI: 14294-72181) per DALY averted, or 16.9 times per capita GDP. INTERPRETATION: Camino Verde, as implemented in the research context, was marginally cost-effective in Mexico, and not cost-effective in Nicaragua, from a healthcare sector perspective. Nicaragua's low per capita GDP and the use of grant-funded management personnel weakened the cost-effectiveness results. Achieving efficiencies by incorporating Camino Verde activities into existing public health programs would make Camino Verde cost-effective.

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City.

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

Impact of the COVID-19 pandemic on mental health and well-being of communities: an exploratory qualitative study protocol.

INTRODUCTION: The COVID-19 pandemic has certainly resulted in an increased level of anxiety and fear in communities in terms of disease management and infection spread. Due to fear and social stigma linked with COVID-19, many individuals in the community hide their disease and do not access healthcare facilities in a timely manner. In addition, with the widespread use of social media, rumours, myths and inaccurate information about the virus are spreading rapidly, leading to intensified irritability, fearfulness, insomnia, oppositional behaviours and somatic complaints. Considering the relevance of all these factors, we aim to explore the perceptions and attitudes of community members towards COVID-19 and its impact on their daily lives and mental well-being. METHODS AND ANALYSIS: This formative research will employ an exploratory qualitative research design using semistructured interviews and a purposive sampling approach. The data collection methods for this formative research will include indepth interviews with community members. The study will be conducted in the Karimabad Federal B Area and in the Garden (East and West) community settings in Karachi, Pakistan. The community members of these areas have been selected purposively for the interview. Study data will be analysed thematically using NVivo V.12 Plus software. ETHICS AND DISSEMINATION: Ethical approval for this study has been obtained from the Aga Khan University Ethical Review Committee (2020-4825-10599). The results of the study will be disseminated to the scientific community and to the research subjects participating in the study. The findings will help us explore the perceptions and attitudes of different community members towards the COVID-19 pandemic and its impact on their daily lives and mental well-being.

Evaluation of a community-based dental screening program prior to radiotherapy for head and neck cancer: a single-center experience.

PURPOSE: Oral toxicities following radiation therapy (RT) for head and neck (HN) cancer can be profound and are associated with poor health outcomes. The Division of Oral Medicine and Dentistry at Brigham and Women's Hospital and Dana-Farber Cancer Institute therefore implemented a dental evaluation program designed for community-based (CB) dentists to evaluate and treat patients scheduled for HN RT. The aim of this retrospective single-center cohort study was to assess the compliance of CB dentists with this pre-RT dental evaluation program. METHODS: A retrospective analysis of dental evaluations completed by CB dentists from December 2013 to December 2015 was performed. Descriptive statistics were used to determine compliance. RESULTS: A total of 186 dental evaluations were received. Compliance with completion of dental treatment was as follows: scaling and prophylaxis: 94.5% (172/182); dental restorations: 78.7% (48/61); endodontic therapy: 76.9% (10/13); and dental extractions: 76.9% (30/39). Compliance of CB dentists with all requested components of the pre-RT evaluation and treatment was 77.4% (144/186). The median distance traveled by patients to the CB dentist and to the hospital was 5.2 miles (range 0.03-66.0) and 46.5 miles (range 0.8-1457; p < 0.01), respectively. CONCLUSION: In this study, the majority of patients completed their necessary dental treatment in a timely manner by their CB dentist in collaboration with an oral medicine specialist. Given the high compliance of CB dentists, this program could serve as a model for other cancer centers to optimize oral and dental health prior to RT.

Community-based mass treatment with azithromycin for the elimination of yaws in Ghana-Results of a pilot study.

INTRODUCTION: The WHO yaws eradication strategy consists of one round of total community treatment (TCT) of single-dose azithromycin with coverage of > 90%.The efficacy of the strategy to reduce the levels on infection has been demonstrated previously in isolated island communities in the Pacific region. We aimed to determine the efficacy of a single round of TCT with azithromycin to achieve a decrease in yaws prevalence in communities that are endemic for yaws and surrounded by other yaws-endemic areas. METHODS: Surveys for yaws seroprevalence and prevalence of skin lesions were conducted among schoolchildren aged 5-15 years before and one year after the TCT intervention in the Abamkrom sub-district of Ghana. We used a cluster design with the schools as the primary sampling unit. Among 20 eligible primary schools in the sub district, 10 were assigned to the baseline survey and 10 to the post-TCT survey. The field teams conducted a physical examination for skin lesions and a dual point-of-care immunoassay for non-treponemal and treponemal antibodies of all children present at the time of the visit. We also undertook surveys with non-probabilistic sampling to collect lesion swabs for etiology and macrolide resistance assessment. RESULTS: At baseline 14,548 (89%) of 16,287 population in the sub-district received treatment during TCT. Following one round of TCT, the prevalence of dual seropositivity among all children decreased from 10.9% (103/943) pre-TCT to 2.2% (27/1211) post-TCT (OR 0.19; 95%CI 0.09-0.37). The prevalence of serologically confirmed skin lesions consistent with active yaws was reduced from 5.7% (54/943) pre-TCT to 0.6% (7/1211) post-TCT (OR 0.10; 95% CI 0.25-0.35). No evidence of resistance to macrolides against Treponema pallidum subsp. pertenue was seen. DISCUSSION: A single round of high coverage TCT with azithromycin in a yaws affected sub-district adjoining other endemic areas is effective in reducing the prevalence of seropositive children and the prevalence of early skin lesions consistent with yaws one year following the intervention. These results suggest that national yaws eradication programmes may plan the gradual expansion of mass treatment interventions without high short-term risk of reintroduction of infection from contiguous untreated endemic areas.

Design and implementation of observational studies to measure disease burden with a focus on stroke.

Observational epidemiological studies have the dual goals of measuring disease burden and assessing the association between exposures and outcomes. This report focuses on the first of these goals and provides an overview of design considerations of commonly used approaches, specifically community surveillance studies, cross-sectional studies, and longitudinal cohort studies. Each of these designs has strengths and weaknesses, with no study design being superior in all cases. Rather, these designs are complementary to achieve a better understanding of the burden of stroke.

Hemoglobin concentration is associated with self-reported disability and reduced physical performance in a community dwelling population of nonagenarians: the Mugello Study.

People aged 90 and older represent a fast-growing population segment who deserve specific attention and research. Aging is associated with a progressive decrease in hemoglobin concentration, which predicts adverse outcome, such as mortality, morbidity, frailty and disability. Whether this association is independent from increased prevalence of comorbidity, causing both anemia and reduced physical function is yet under debate. The aim of this study is to explore the relationship between hemoglobin concentration and self-reported disability and reduced physical performance in a community dwelling population of nonagenarians. Data presented were collected in the framework of the Mugello Study, a clinical epidemiologic survey of nonagenarians living in the Mugello area (Tuscany, Italy). 251 persons (177 women, age 93.2 ± 3.3 years; 74 men, age 92.2 ± 2.5 years) underwent a blood draw. Along with hemoglobin concentration, self-reported disability (basic and instrumental activities of daily living), physical performance (Short Physical Performance Battery), self-reported physical activity and muscular strength (handgrip measurement) were assessed. Covariates, inherent sociodemographic and health indicators and comorbidities were also included in the analysis. This study confirms that anemia is very common in the oldest old, with a significantly higher prevalence in males (50% in men vs 24% in women). Multiple linear regression analysis, including all the comorbid conditions as confounding factors, shows that hemoglobin concentration is independently associated with handgrip strength, self-reported physical activity and disability in dressing, and taking a shower/bath. In conclusion, results from this study confirm that in the oldest old, low hemoglobin concentration is strongly associated with self-reported disability and decline of physical performance independent of comorbidity.

Grant writing: Moving from generating ideas to applying to grants that matter.

There is an extraordinary burden placed upon the healthcare system and people as a result of health disparities that exist within the United States. If there is going to be a concerted effort to develop innovative strategies to reduce health disparities, input from the community and behavioral scientists can and should be included in this approach and narrative. Grant writing provides one vehicle to express the narrative and to provide a means to fund research and programs within clinic-based and community settings. This paper describes a four-step inquiry process to guide healthcare professionals with varying degrees of clinical and scholarship interests through the grant writing process. They include: (1) Why write grants (motivations), (2) what is the area of focus? (Interests), (3) whom should be on the project? (partnerships), and (4) what needs to happen next to move the idea forward? (actions) The complexity of psychosocial issues means that behavioral science is well suited to develop both hypotheses-driven and phenomenological research to understand bio-psycho-social health issues. Grant writing does not need to be mysterious or daunting. It can provide a means to an end, not only to fund research but also as a means to an end of health disparities.

Urban general practice and medical education: Academic outcomes from a unique urban, longitudinal integrated community-based program.

BACKGROUND: In 2009, Flinders University established an urban, community-based, longitudinal integrated program providing medical students extended placements that offered continuities of patient care, clinical supervision and peer group. OBJECTIVE: The aim of this research was to analyse academic outcomes of the new placement program. METHODS: The results of all students undertaking Year 3 exams from 2011 to 2014 were collected and analysed. The Years 1 and 2 exam results for students in the new program were also analysed. RESULTS: Students in the new placement program achieved significantly higher grades than those who undertook the traditional rotations program, with aver-age scores of 69.05, compared with 66.45 (P = 0.03). Analysis of average class ranking for students who undertook the new program showed a statistically significant improvement from 59th in class to 48th in class (P = 0.03). DISCUSSION: This evaluation shows that an urban, community-based, longitudinal integrated clerkship centred in general practice provides at least academically equivalent outcomes to traditional rotations-based programs.

Ivermectin Treatment and Sanitation Effectively Reduce Strongyloides stercoralis Infection Risk in Rural Communities in Cambodia.

BACKGROUND: Strongyloides stercoralis is the only soil-transmitted helminth with the ability to replicate within its host, leading to long-lasting and potentially fatal infections. It is ubiquitous and its worldwide prevalence has recently been estimated to be at least half that of hookworm. Information on the epidemiology of S. stercoralis remains scarce and modalities for its large-scale control are yet to be determined. METHODOLOGY/PRINCIPAL FINDINGS: A community-based two-year cohort study was conducted among the general population in a rural province in North Cambodia. At each survey, participants infected with S. stercoralis were treated with a single oral dose of ivermectin (200µg/kg BW). Diagnosis was performed using a combination of the Baermann method and Koga agar plate culture on two stool samples. The cohort included participants from eight villages who were either positive or negative for S. stercoralis at baseline. Mixed logistic regression models were employed to assess risk factors for S. stercoralis infection at baseline and re-infection at follow-up. A total of 3,096 participants were examined at baseline, revealing a S. stercoralis prevalence of 33.1%. Of these participants, 1,269 were followed-up over two years. Re-infection and infection rates among positive and negative participants at baseline were 14.4% and 9.6% at the first and 11.0% and 11.5% at the second follow-up, respectively. At follow-up, all age groups were at similar risk of acquiring an infection, while infection risk significantly decreased with increasing village sanitation coverage. CONCLUSIONS/SIGNIFICANCE: Chemotherapy-based control of S. stercoralis is feasible and highly beneficial, particularly in combination with improved sanitation. The impact of community-based ivermectin treatment on S. stercoralis was high, with over 85% of villagers remaining negative one year after treatment. The integration of S. stercoralis into existing STH control programs should be considered without further delay.

Developing a Tabletop Exercise to Test Community Resilience: Lessons from the Los Angeles County Community Disaster Resilience Project.

OBJECTIVE: We aimed to develop and test a community resilience tabletop exercise to assess progress in community resilience and to provide an opportunity for quality improvement and capacity building. METHODS: A tabletop exercise was developed for the Los Angeles County Community Disaster Resilience (LACCDR) project by using an extended heat wave scenario with health and infrastructure consequences. The tabletop was administered to preparedness only (control) and resilience (intervention) coalitions during the summer of 2014. Each exercise lasted approximately 2 hours. The coalitions and LACCDR study team members independently rated each exercise to assess 4 resilience levers (partnership, engagement, self-sufficiency, and education). Resilience coalitions received more detailed feedback in the form of recommendations for improvement. RESULTS: The resilience coalitions performed the same or better than the preparedness coalitions on the partnership and self-sufficiency levers. Most coalitions did not have enough (both quantity and type) of the partner organizations needed for an escalating heat wave or changing conditions or enough engagement of organizations representing at-risk populations. Coalitions also lacked educational materials to cover topics as far ranging as heat to power outages to psychological impacts of disaster. CONCLUSION: A tabletop exercise can be used to stress and test resilience-based capacities, with particular attention to a community's ability to leverage a range of partnerships and other assets to confront a slowly evolving but multifactorial emergency.

Reducing avoidable pressure ulcers in the community.

The elimination of avoidable pressure ulcers remains a challenge in healthcare provision, represents an increasing financial burden on resources and continues to affect patients' quality of life. Many pressure ulcers are deemed to be avoidable and there are several factors that can influence this, including the development of a care delivery system and a service delivery strategy that incorporate a comprehensive structure, a meticulous process and measurable outcomes. Nottingham CityCare developed a strategy to reduce avoidable pressure ulcers. The implementation of the strategy in an inner city community setting is discussed. The importance of eliminating pressure ulcers is explored, and the barriers to care delivery are reviewed, demonstrating how a new culture in clinical practice can ensure the elimination of avoidable pressure ulcers. The challenges within the implementation process are reflected on and the implementation of the SSKIN (Surface, Skin inspection, Keep your patient moving, Incontinence and moisture, Nutrition and hydration) phenomenon is reviewed in relation to care delivery, record-keeping and evaluation.

The nurse's role in preventive care in the field of community nursing.

OBJECTIVES: According to published reports from the WHO, health care is undergoing a transformation that reflects the increasing importance of community care based on social, group, and individual needs. Community health care is provided by multidisciplinary teams, with nurses occupying irreplaceable positions. Nurse competencies constitute significant potential in the area of community based preventive care as well as the more traditional roles in treatment and recovery. METHODS: Data was obtained from health care professionals and the public through a structured interview. The study population included 1,007 physicians, 1,005 nurses and 2,022 laypersons. Respondents were selected randomly with the aid of quotas. The parameters for the selection of health care workers (nurses and physicians) were constructed based on registration data from the Institute of Health Information and Statistics. Layperson selection was based on data from the Czech Statistical Office. The Statistical Analysis of Social Data program (version 1.4.4) was used to process the data, which was in the form of 1st and 2nd degree contingency tables. The dependence level was determined based on χ2 and other testing criteria (according to the character of the signs). RESULTS: The results show that respondents perceive the concept of a "community nurse" as a nurse working independently in local neighborhoods and communities. Results also showed that work in senior care, followed by home care, and care for chronically ill patients were the most preferred. A role for nurses in health care education centers was only supported by 13.1% of physicians, 13.8% of nurses, and 6.8% of laypersons. The results also reveal that community nursing is perceived by both health care professionals and laypersons as fieldwork (i.e. work not based in a hospital or clinic environment), yet, at the same time, it was perceived as work that dealt with people needing health care. The results also reflect the opinion that the establishment of an independent nurse in the workplace (in the form of preventive care) could lead to an increase in the quality of care for employees (65.7% of physicians and 70.8% of nurses), an improvement in workplace health education (33% of physicians and 34.7% of nurses) and would provide support for healthy work environments (31.4% of physicians and 30.4% of nurses). CONCLUSION: Our results lead us to conclude that the health care system in the Czech Republic needs to better utilize the potential of trained nurses in the field of community health care. Additionally, steps need to be taken to increase job opportunities and staffing for nurses wanting to work in community health and preventive care.