Internalizing and externalizing symptoms in children during the COVID-19 pandemic: a systematic mixed studies review.

Introduction: Given the vulnerability of children during the COVID-19 pandemic, paying close attention to their wellbeing at the time is warranted. The present protocol-based systematic mixed-studies review examines papers published during 2020-2022, focusing on the impact of the COVID-19 pandemic on children's internalizing/externalizing symptoms and the determinants thereof. Method: PROSPERO: CRD42022385284. Five databases were searched and the PRISMA diagram was applied. The inclusion criteria were: papers published in English in peer-reviewed journals; papers published between January 2020 and October 2022 involving children aged 5-13 years; qualitative, quantitative, and mixed studies. The standardized Mixed Method Appraisal Tool protocol was used to appraise the quality of the studies. Results: Thirty-four studies involving 40,976 participants in total were analyzed. Their principal characteristics were tabulated. The results showed that children's internalizing/externalizing symptoms increased during the pandemic, largely as a result of disengagement from play activities and excessive use of the internet. Girls showed more internalizing symptoms and boys more externalizing symptoms. Distress was the strongest parental factor mediating children's internalizing/externalizing symptoms. The quality of the studies was appraised as low (n = 12), medium (n = 12), and high (n = 10). Conclusion: Gender-based interventions should be designed for children and parents. The studies reviewed were cross-sectional, so long-term patterns and outcomes could not be predicted. Future researchers might consider a longitudinal approach to determine the long-term effects of the pandemic on children's internalizing and externalizing symptoms. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022385284, identifier: CRD42022385284.

Case-based learning interventions for undergraduate nursing students in a theoretical course: A review of design, implementation, and outcomes.

BACKGROUND: Case-based learning (CBL) is a contextualized learning and teaching method that can facilitate active and reflective learning to develop critical thinking and problem-solving skills. However, nursing educators have some difficulty in creating a CBL environment that matches the diverse professional nursing curriculum and students' needs, including developing relevant cases and appropriate CBL implementation processes. OBJECTIVE: To summarize the case design, implementation process, and their relationship with CBL effectiveness. METHODS: Electronic databases of PubMed, Embase, Web of Science, CINAHL, China National Knowledge Infrastructure (CNKI) and Wanfang Data (a Chinese database) were searched from inception until January 2022. Study quality was assessed using the Mixed Methods Appraisal Tool. A qualitative synthesis was then conducted to summarize the study findings. RESULTS: The systematic mixed studies review included twenty-one quantitative studies, five qualitative studies and two mixed methods studies. The case design and implementation process were indispensable parts of each study, but the application process of CBL in each study was slightly different, basically including case design, preparation, small-group interaction and exploration, collaborative efforts, teacher summary, assignment and teacher feedback. There were three themes in this review that indicate the effect of CBL on students, namely, knowledge, competence and attitude. CONCLUSION: The present review analyzes the available literature and suggests that there is no common format for the case design and CBL implementation process, but demonstrates that they are an indispensable part of each study. This review provides conceptual procedures for nurse educators to design and implement CBL in nursing theoretical courses to improve the effectiveness of CBL.

Telehealth in palliative care during the COVID-19 pandemic: A systematic mixed studies review.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented disruption to healthcare delivery worldwide. The use of telehealth practices rapidly expanded during the pandemic, while its application in palliative care remains a conflicted issue. AIMS: The aims of this study were to evaluate users' reports of their satisfaction with telehealth palliative care during COVID-19 and to identify facilitators and barriers to telehealth implementation in palliative care during COVID-19. METHODS: A systematic search of the literature, including studies between January 2020 and June 2022, was conducted using PubMed, MEDLINE, CINAHL Plus, Embase, and Google Scholar. Empirical studies of telehealth in palliative care during COVID-19 were included. RESULTS: A total of 18 studies were included in the review, of which nine were outpatient consultations, four were family meetings, two were remote volunteering programs, two were inpatient care, and one was a residential care home needs assessment. The satisfaction rates were high (66%-99%) among patients and family members who participated in telehealth consultations, but the satisfaction with family meetings was mixed. Compared with their clients, healthcare professionals were less likely to assess telehealth as satisfactory. The authors identified four barriers and four facilitators. The barriers were technological challenges, lack of nonverbal communication, ethical concerns, and limitations for clinical practice. The facilitators were accessibility and convenience, visual cues, facilitation and training, and family engagement. LINKING EVIDENCE TO ACTION: This systematic mixed studies review suggests that current evidence supports the feasibility of telehealth implementation in palliative care for outpatient consultations and routine follow-up appointments. This review also identified facilitators and barriers to telehealth in palliative care, and the findings can inform the implementation of future palliative care services. Future attention should be paid to the effectiveness of telehealth implementation in palliative care patients.

Advantages and Challenges of Using Telehealth for Home-Based Palliative Care: Systematic Mixed Studies Review.

BACKGROUND: Owing to the increasing number of people with palliative care needs and the current shortage of health care professionals (HCPs), providing quality palliative care has become challenging. Telehealth could enable patients to spend as much time as possible at home. However, no previous systematic mixed studies reviews have synthesized evidence on patients' experiences of the advantages and challenges of telehealth in home-based palliative care. OBJECTIVE: In this systematic mixed studies review, we aimed to critically appraise and synthesize the findings from studies that investigated patients' use of telehealth in home-based palliative care, focusing on the advantages and challenges experienced by patients. METHODS: This is a systematic mixed studies review with a convergent design. The review is reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A systematic search was performed in the following databases: Allied and Complementary Medicine Database, CINAHL, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, MEDLINE, PsycInfo, and Web of Science. The inclusion criteria were as follows: studies using quantitative, qualitative, or mixed methods; studies that investigated the experience of using telehealth with follow-up from HCPs of home-based patients aged ≥18; studies published between January 2010 and June 2022; and studies published in Norwegian, Danish, Swedish, English, Portuguese, or Spanish in peer-reviewed journals. Five pairs of authors independently assessed eligibility of the studies, appraised methodological quality, and extracted data. The data were synthesized using thematic synthesis. RESULTS: This systematic mixed studies review included 41 reports from 40 studies. The following 4 analytical themes were synthesized: potential for a support system and self-governance at home; visibility supports interpersonal relationships and a joint understanding of care needs; optimized information flow facilitates tailoring of remote caring practices; and technology, relationships, and complexity as perpetual obstacles in telehealth. CONCLUSIONS: The advantages of telehealth were that patients experience a potential support system that could enable them to remain at home, and the visual features of telehealth enable them to build interpersonal relationships with HCPs over time. Self-reporting provides HCPs with information about symptoms and circumstances that facilitates tailoring care to specific patients. Challenges with the use of telehealth were related to barriers to technology use and inflexible reporting of complex and fluctuating symptoms and circumstances using electronic questionnaires. Few studies have included the self-reporting of existential or spiritual concerns, emotions, and well-being. Some patients perceived telehealth as intrusive and a threat to their privacy at home. To optimize the advantages and minimize the challenges with the use of telehealth in home-based palliative care, future research should include users in the design and development process.

The Violence of Non-Violence: A Systematic Mixed-Studies Review on the Health Effects of Sanctions.

The use of sanctions as a policy tool to affect change in the political behavior of target states has increased over the past 30 years, along with a concern about their impact on civilian health. Some researchers have proposed that targeting sanctions can avoid their moral costs, yet others have challenged this claim. This systematic mixed-studies review explored the debate about targeted sanctions by appraising their health effects as reported in the medical and public health literature, with a global focus and through the COVID-19 era.We searched three electronic databases without temporal or geographical restrictions and identified 50 studies spanning three decades (1992-2021) meeting our inclusion criteria. Using a piloted form, we extracted quotations addressing our research questions and identified themes that we grouped according to the effects of sanctions on health or its determinants, generating frequency distributions to assess the strength of support for each theme. While no study posited a causal relationship between sanctions and health, or engaged the morality of sanctions, most implied that when sanctions were present, health was inevitably impacted, even for sanctions ostensibly targeted to minimize civilian harm. Our findings suggest that given the integrated nature of the global economy, it is all but impossible to design sanctions that will achieve their stated goals without inflicting significant harm on civilians. We conclude that the use of sanctions as a policy tool threatens global health and human rights, especially in times of crises.

Critiquing the evolution of maternity care preferences research: A systematic mixed studies review.

OBJECTIVE: Whether women's preferences for maternity care are informed remains unclear, suggesting that maternal preferences may not accurately represent what women truly want. The aim of this study was to understand and critique research on women's maternity care preferences published since 2010. DESIGN: Systematic mixed studies review. CINHAL, EMBASE, MEDLINE, and ProQuest Nursing and Allied Health electronic databases were searched from January 2010 to April 2022. FINDINGS: Thirty-five articles were included. Models of care and mode of birth were the most frequently investigated preference topics. Roughly three-quarters of included studies employed a quantitative design. Few studies assessed women's baseline knowledge regarding the aspects of maternity care investigated, and three provided information to help inform women's maternity care preferences. Over 85% of studies involved women who were either pregnant at the time of investigation or had previously given birth, and 71% employed study designs where women were required to select from pre-determined response options to describe their preferences. Two studies asked women about their preferences in the face of unlimited access and availability to specific maternity care services. KEY CONCLUSIONS: Limited provision of supporting information, the predominant inclusion of women with experience using maternity care services, and limited use of mixed methods may have hindered the collection of accurate information from women about their preferences. IMPLICATIONS FOR PRACTICE: Women's maternity care preferences research since 2010 may only present a limited version of what they want.

Nurses' competency in electrocardiogram interpretation in acute care settings: A systematic review.

AIMS: Identify and synthesize evidence of nurses' competency in electrocardiogram interpretation in acute care settings. DESIGN: Systematic mixed studies review. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature, Medline, Scopus and Cochrane were searched in April 2021. REVIEW METHODS: Data were selected using the updated Preferred Reporting Items for Systematic Reviews and Meta-Analysis framework. A data-based convergent synthesis design using qualitative content analysis was adopted. Quality appraisal was undertaken using validated tools appropriate to study designs of the included papers. RESULTS: Forty-three papers were included in this review. Skills and attitudes were not commonly assessed, as most studies referred to 'competency' in the context of nurses' knowledge in electrocardiogram interpretation. Nurses' knowledge levels in this important nursing role varied notably, which could be partly due to a range of assessment tools being used. Several factors were found to influence nurses' competency in electrocardiogram interpretation across the included studies from individual, professional and organizational perspectives. CONCLUSION: The definition of 'competency' was inconsistent, and nurses' competency in electrocardiogram interpretation varied from low to high. Nurses identified a lack of regular training and insufficient exposure in electrocardiogram interpretation. Hence, regular, standard training and education are recommended. Also, more research is needed to develop a standardized and comprehensive electrocardiogram interpretation tool, thereby allowing educators to safely assess nurses' competency. IMPACT: This review addressed questions related to nurses' competency in electrocardiogram interpretation. The findings highlight varying competency levels and assessment methods. Nurses reported a lack of knowledge and confidence in interpreting electrocardiograms. There is an urgent need to explore opportunities to promote and maintain nurses' competency in electrocardiogram interpretation.

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review.

Migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable levels of engagement with HIV care and treatment when compared to native-born populations. A systematic mixed studies review was conducted to generate a multilevel understanding of the barriers and facilitators affecting HIV Care Cascade steps for migrant people living with HIV (MLWH) in OECD countries. Medline, Embase, Scopus, CINAHL, and the Cochrane Library were searched on March 25, 2020. Screening, critical appraisal, and analysis were conducted independently by two authors. We used qualitative content analysis and the five-level Socio-Ecological Model (i.e., individual, interpersonal, organizational, community, and policy) to categorize barriers and facilitators. Fifty-nine studies from 17 OECD countries were included. MLWH faced similar barriers and facilitators regardless of their host country, ethnic and geographic origins, or legal status. Most barriers and facilitators were associated with the individual and organizational levels and centered around retention in HIV care and treatment. Adapting clinical environments to better address MLWH's competing needs via multidisciplinary models would address retention issues across OECD countries.

Advantages and Challenges in Using Telehealth for Home-Based Palliative Care: Protocol for a Systematic Mixed Studies Review.

BACKGROUND: Given the increasing number of people in need of palliative care services and the current health care professional workforce strain, providing equitable, quality palliative care has become a challenge. Telehealth could be an innovative approach to palliative care delivery, enabling patients to spend more time or even remain at home, if they wish, throughout the illness trajectory. However, no previous systematic mixed studies reviews have synthesized evidence on patients' experiences of the advantages and challenges of telehealth for home-based palliative care. OBJECTIVE: The aim of this systematic mixed studies review is to critically appraise and synthesize findings from studies that investigated patients' use of telehealth in home-based palliative care with a focus on the advantages and challenges experienced by the patients. METHODS: This article describes the protocol for a systematic mixed studies review with a convergent design. The reporting will be guided by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A systematic search was performed in eight databases for studies published from January 2010 to June 2020. The search will be updated in 2021. Pairs of authors will independently assess eligibility, extract data, and assess methodological quality. The data will then be analyzed using thematic synthesis. RESULTS: We describe the rationale and design of a systematic mixed studies review. The database searches were performed on June 25, 2020. Assessment of eligibility and further steps have not yet been performed. Results are anticipated by August 2021. CONCLUSIONS: Following the ethos of patient-centered palliative care, this systematic mixed studies review could lead to recommendations for practice and policy, enabling the development and implementation of telehealth applications and services that align with patients' preferences and needs at home. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/22626.

Maintaining cultural identity: A systematic mixed studies review of cultural influences on the self-care of African immigrants living with non-communicable disease.

AIM: To understand and identify cultural factors influencing the self-care practices of African immigrants living with chronic illness in countries outside Africa. BACKGROUND: The influence of cultural factors on self-care is relatively unexplored in African immigrants with non-communicable diseases (NCDs). DESIGN: Systematic Mixed Studies review. DATA SOURCES: PubMed, Psych Info, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Anthropology Plus and Sociological Abstract computerized databases. No limit was placed on publication date. REVIEW METHODS: Results-based convergent design was used. The Mixed Method Appraisal Tool was used to evaluate the studies. Quantitative studies were synthesized narratively while qualitative studies were synthesized using thematic synthesis. RESULTS: We identified 251 articles and nine fulfilled our inclusion criteria. The studies were published between 2006 and 2019, with six qualitative and three quantitative studies. Studies were conducted in the United States, Australia, Sweden, the Netherlands and the United Kingdom. Most studies examined the influence of culture on self-care of diabetes (n = 6), while the rest focused on hypertension (n = 3). Findings highlight that cultural norms and practices, non-Western approaches to interpreting and managing illness, cultural connotations of health behaviours and structural challenges influencing self-care. Cultural food preferences made adherence to prescribed diets challenging. Family support facilitated self-care. Maintaining cultural identity was both a driver and constraint to engaging in self-care. CONCLUSION: The complex interplay of cultural and structural factors influences the willingness of Africans who have immigrated to a developed country to follow recommended self-care practices. Considering these cultural norms and structural barriers can help to explain the self-care behaviours of African immigrant populations. IMPACT: Clinicians and policymakers who account for structural factors and integrate cultural factors into care facilities, treatment protocols and policy can be influential in promoting self-care in African immigrant populations.

Leveraging the opportunities of mixed methods in research synthesis: Key decisions in systematic mixed studies review methodology.

This article identifies and unpacks three key decision points in a systematic mixed research synthesis, a mixed methods approach to research synthesis. The research community has increasingly recognized the value of synthesis studies in expanding our understanding of phenomena. Mixed-methodology broadly has also gained ground as a pragmatic approach to research investigations. By leveraging mixed methods approaches in a synthesis review, systematic mixed studies review (SMSR) enables a broad and integrated summary of existing research on the topic. Yet SMSRs can be challenging to undertake given the complexity of working with research synthesis and mixed methods requirements. This methods guidance article presents information to assist novice researchers in navigating these critical decisions in SMSRs, and provides examples of how these were addressed by researchers in the two case studies provided. Implications of the SMSRs for the research community and future research directions are also discussed.

The Role of Spirituality in Patients Undergoing Hematopoietic Stem Cell Transplantation: a Systematic Mixed Studies Review.

BACKGROUND: Hematopoietic stem cell transplantation (HSCT) has become the standard treatment for many diseases, but it is an intense and distinctive experience for patients. HSCT-related mortality is present throughout the whole process of transplantation, from pretransplantation to recovery. Long-term rehabilitation and the uncertain risk of death evoke feelings of vulnerability, helplessness, and intense fear. Zimmermann et al. proposed that spiritual well-being is an important dimension of quality of life and that patients at the end stage of life require spiritual support in addition to physical care, psychological care, and social support. Therefore, the purpose of this review is to examine the role of spirituality in the process of HSCT. METHOD: A systematic mixed studies review (SMSR) was based on Pluye and Hong's framework to understand the role of spirituality in patients' experiences while undergoing HSCT. We use the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement to report the results of integration. RESULTS: Fifteen original qualitative studies, 19 quantitative studies, and one mixed method study were included in the systematic mixed studies review. The evidence from the review revealed the following three themes: the spiritual experiences of HSCT patients, the spiritual coping styles of HSCT patients, and the spiritual need changes brought about by HSCT. DISCUSSION: Few medical institutions currently offer spiritual healing, although HSCT patients with different cultural backgrounds may have different spiritual experiences and spiritual coping styles. Psychotherapists or nurses should be considered to provide spiritual care for patients undergoing HSCT, to help patients cope with disease pressures, promote HSCT patients' comfort, and improve their quality of life.

Mixed studies review of factors influencing receipt of pain treatment by injured black patients.

AIM: To explore the factors that influence provider pain treatment decision-making and the receipt of pain management by injured Black patients in the United States. DESIGN: We completed a systematic mixed studies review using a results-based convergent synthesis design. DATA SOURCES: PubMed, SCOPUS and CINAHL were searched for articles published between 2007-2017 using the search terms 'African American', 'Black American', 'race', 'pain treatment', 'pain management' and 'analgesia'. Twenty studies were included in this review. REVIEW METHOD: A search of databases and hand-searching identified peer-reviewed published papers. The Mixed Method Appraisal Tool was used to appraise the studies. RESULTS: The results indicate that healthcare provider characteristics, racial myths about pain sensitization and assumed criminality all impact provider treatment decision-making and the receipt of pain treatment by injured Black patients. IMPACT: This review addresses racial disparities in pain management by focusing on the factors that impact the receipt of pain treatment by injured Black patients. The findings will have an impact on providers who prescribe pain treatment and on the patients they treat. These findings suggest that assumed criminality of certain patients can negatively impact care, which is a type of bias not frequently explored or discussed in health disparities research. This review will help inform further research in healthcare disparities and prompt providers to examine their assumptions about the patients for whom they care. CONCLUSION: These results provide important areas for further study, including how assumed criminality of certain patients can have a negative impact on care.

Positive Changes Experienced After a First Episode of Psychosis: A Systematic Review.

OBJECTIVE: Although the negative consequences associated with first-episode psychosis (FEP) have been well investigated, relatively less is known about positive changes that people may experience after FEP. Existing literature is disparate and in need of synthesis. Such a synthesis can inform the design of mental health services that foster strengths, hope, and optimism. The objective of this study was to synthesize the literature on how positive change is experienced after FEP by affected persons and their families and friends and to delineate the individual, social, and structural factors facilitating positive change. METHODS: A librarian-assisted systematic review of quantitative, qualitative, and mixed-methods studies published in English between 1970 and 2015 was conducted. Articles identified from three databases (PubMed, PsycINFO, and Embase) and through additional search strategies were screened. Results sections were open coded and analyzed by using thematic synthesis. RESULTS: Of the 2,777 studies identified, 40 were retained. The synthesis of findings showed that after FEP, service users and their families and friends experienced positive changes at the individual (for example, more insight and clarity), interpersonal (for example, improved relationships), and spiritual levels (for example, greater religiosity). In addition to being facilitated by mental health services, these positive changes were enabled by personal (for example, motivation), social (for example, family support), and spiritual (for example, prayer) factors. CONCLUSIONS: Suffering is a core experience of FEP from which a range of positive changes can follow among service users and their families and friends. It may be beneficial for mental health services to specifically strive to promote these positive changes.

The use of life stories and its influence on persons with dementia, their relatives and staff - a systematic mixed studies review.

BACKGROUND: Dementia is an important predictor of nursing home admissions. Due to progressive dementia symptoms, over time it becomes difficult for persons with dementia to communicate their wishes and participate in decisions concerning their everyday lives. Their well-being, sense of dignity, integrity and personhood are at risk. The persons' life stories have been highlighted as particularly important in dementia care and are referred to as seeing the person beyond the dementia. The aim of this study was to explore and describe the use of life stories and its influence on persons with dementia living in nursing homes, their relatives and staff. METHODS: A systematic mixed studies review was conducted. The literature searches were performed in the following databases: CINAHL, PubMed and PsycINFO and the Cochrane library, as well as by hand searching references in the studies included. An updated search was performed eight months after the first search. Data was synthesised inspired by integrative analysis. RESULTS: Three studies using quantitative design and two studies (presented in three papers) using qualitative design representing research from 2006 to 2015 were included in the review. Life stories generally had a positive influence on the persons with dementia, their relatives, and staff. The use of life stories might contribute to 'Maintenance of the person with dementia as a whole person rather than a demented patient'. On the other hand, enabling persons with dementia to tell their own story could be a challenge. For the staff it could be challenging when sensitive information emerged uninvited. Involving relatives could also be difficult as to whose story were uncovered. CONCLUSIONS: The use of person's life story might be of significance, but there is not enough evidence to make any statement about its importance as the research is scarce. Studies, including randomised controlled trials, are needed to measure the impact of life story work on the physiological and psychological aspects of persons with dementia, and also how it influences their relatives and staff.

Patients' preferences in palliative care: A systematic mixed studies review.

BACKGROUND: It is necessary to develop palliative care to meet existing and future needs of patients and their families. It is important to include knowledge of patient preferences when developing high-quality palliative care services. Previous reviews have focused on patient preferences with regard to specific components of palliative care. There is a need to review research on patient's combined preferences for all elements that constitute palliative care. AIM: The aim of this study is to identify preferences for palliative care among patients in the palliative phase of their illness, by synthesizing existing research. DATA SOURCES: Studies were retrieved by searching databases - the Cochrane Library, Medline, CINAHL, PsycINFO, Scopus and Sociological Abstracts - from 1946 to 2014, and by hand searching references in the studies included. DESIGN: A systematic mixed studies review was conducted. Two reviewers independently selected studies for inclusion and extracted data according to the eligibility criteria. Data were synthesized using integrative thematic analysis. RESULTS: The 13 qualitative and 10 quantitative studies identified included participants with different illnesses in various settings. Four themes emerged representing patient preferences for care. The theme 'Living a meaningful life' illustrated what patients strived for. The opportunity to focus on living required the presence of 'Responsive healthcare personnel', a 'Responsive care environment' and 'Responsiveness in the organization of palliative care'. CONCLUSION: The four themes may be useful for guiding clinical practice and measurements of quality, with the overall goal of meeting future needs and improving quality in palliative care services to suit patients' preferences.

Barriers to implementation of case management for patients with dementia: a systematic mixed studies review.

PURPOSE: Results of case management designed for patients with dementia and their caregivers in community-based primary health care (CBPHC) were inconsistent. Our objective was to identify the relationships between key outcomes of case management and barriers to implementation. METHODS: We conducted a systematic mixed studies review (including quantitative and qualitative studies). Literature search was performed in MEDLINE, PsycINFO, Embase, and Cochrane Library (1995 up to August 2012). Case management intervention studies were used to assess clinical outcomes for patients, service use, caregiver outcomes, satisfaction, and cost-effectiveness. Qualitative studies were used to examine barriers to case management implementation. Patterns in the relationships between barriers to implementation and outcomes were identified using the configurational comparative method. The quality of studies was assessed using the Mixed Methods Appraisal Tool. RESULTS: Forty-three studies were selected (31 quantitative and 12 qualitative). Case management had a limited positive effect on behavioral symptoms of dementia and length of hospital stay for patients and on burden and depression for informal caregivers. Interventions that addressed a greater number of barriers to implementation resulted in increased number of positive outcomes. Results suggested that high-intensity case management was necessary and sufficient to produce positive clinical outcomes for patients and to optimize service use. Effective communication within the CBPHC team was necessary and sufficient for positive outcomes for caregivers. CONCLUSIONS: Clinicians and managers who implement case management in CBPHC should take into account high-intensity case management (small caseload, regular proactive patient follow-up, regular contact between case managers and family physicians) and effective communication between case managers and other CBPHC professionals and services.

Case management for dementia in primary health care: a systematic mixed studies review based on the diffusion of innovation model.

BACKGROUND: The purpose of this study was to examine factors associated with the implementation of case management (CM) interventions in primary health care (PHC) and to develop strategies to enhance its adoption by PHC practices. METHODS: This study was designed as a systematic mixed studies review (including quantitative and qualitative studies) with synthesis based on the diffusion of innovation model. A literature search was performed using MEDLINE, PsycInfo, EMBASE, and the Cochrane Database (1995 to August 2012) to identify quantitative (randomized controlled and nonrandomized) and qualitative studies describing the conditions limiting and facilitating successful CM implementation in PHC. The methodological quality of each included study was assessed using the validated Mixed Methods Appraisal Tool. RESULTS: Twenty-three studies (eleven quantitative and 12 qualitative) were included. The characteristics of CM that negatively influence implementation are low CM intensity (eg, infrequent follow-up), large caseload (more than 60 patients per full-time case manager), and approach, ie, reactive rather than proactive. Case managers need specific skills to perform their role (eg, good communication skills) and their responsibilities in PHC need to be clearly delineated. CONCLUSION: Our systematic review supports a better understanding of factors that can explain inconsistent evidence with regard to the outcomes of dementia CM in PHC. Lastly, strategies are proposed to enhance implementation of dementia CM in PHC.