Examining the Relationship Between Screening for Postpartum Depression and Associated Child Health Service Utilization and Costs: A Study Using the All Our Families Cohort and Administrative Data.

INTRODUCTION: Despite a recognized association between maternal postpartum depression (PPD) and adverse child health outcomes, evidence examining the relationship between PPD symptoms and associated child health service utilization and costs remains unclear. In addition, there is a paucity of evidence describing the relationship between early identification of maternal PPD and associated health service utilization and costs for children. This study aims to address this gap by describing the secondary associations of screening for maternal PPD and annual health service utilization and costs for children over their first five years of life. METHODS: Mothers and children enrolled in the prospective All Our Families cohort were linked to provincial administrative data in Alberta, Canada. Multivariable generalized linear models were used to estimate the average annual inpatient, outpatient, physician, and total health service utilization and costs from a public health system perspective for children of mothers screened high risk for PPD, low/moderate risk for PPD, or unscreened. RESULTS: Total mean costs were greatest for children during their first year of life than other years. Those whose mothers were not screened had significantly lower costs compared to those whose mothers were screened low/moderate risk, despite equivalent health service utilization. DISCUSSION: Findings from this study describe the secondary associations of screening for maternal PPD using a public health system perspective. More research is required to fully understand variations in health costs for children across maternal PPD screening categories.

This study describes the relationship between maternal PPD screening status and annual child health service utilization and costs over the first five years of age. Findings from this administrative data study will support decision-makers in understanding the secondary effects associated with maternal PPD screening and inform future cost-effectiveness analyses of PPD screening interventions using a maternal-child health perspective.

Implementing paediatric patient-reported outcome measures in outpatient asthma clinics: a feasibility assessment study.

OBJECTIVE: Implementation of patient-reported outcome measures (PROMs) is limited in paediatric routine clinical care. The KidsPRO programme has been codesigned to facilitate the implementation of PROMs in paediatric healthcare settings. Therefore, this study (1) describes the development of innovative KidsPRO programme and (2) reports on the feasibility of implementing PedsQL (Pediatric Quality of Life Inventory) PROM in asthma clinics using the KidsPRO programme. DESIGN: Feasibility assessment study. SETTING: Outpatient paediatric asthma clinics in the city of Calgary, Canada. PARTICIPANTS: Five paediatric patients, four family caregivers and three healthcare providers were recruited to pilot the implementation of PedsQL PROM using KidsPRO. Then, a survey was used to assess its feasibility among these study participants. MAIN OUTCOME MEASURES: Participants' understanding of using PROMs, the adequacy of support provided to them, the utility of using PROMs as part of their appointment, and their satisfaction with using PROMs. ANALYSES: The quantitative data generated through closed-ended questions was analysed and represented in the form of bar charts for each category of study participants (ie, patients, their family caregivers and healthcare providers). The qualitative data generated through the open-ended questions were content analysed and categorised into themes. RESULTS: The experience of using PROMs was overwhelmingly positive among patients and their family caregivers, results were mixed among healthcare providers. Qualitative data collected through open-ended questions also complemented the quantitative findings. CONCLUSION: The evidence from this study reveals that the implementation of PROMs in routine paediatric clinical care asthma clinics in Alberta is seems to be feasible.

Study protocol for Attachment & Child Health (ATTACHTM) program: promoting vulnerable Children's health at scale.

BACKGROUND: Children's exposure to toxic stress (e.g., parental depression, violence, poverty) predicts developmental and physical health problems resulting in health care system burden. Supporting parents to develop parenting skills can buffer the effects of toxic stress, leading to healthier outcomes for those children. Parenting interventions that focus on promoting parental reflective function (RF), i.e., parents' capacity for insight into their child's and their own thoughts, feelings, and mental states, may understand help reduce societal health inequities stemming from childhood stress exposures. The Attachment and Child Health (ATTACHTM) program has been implemented and tested in seven rapid-cycling pilot studies (n = 64) and found to significantly improve parents' RF in the domains of attachment, parenting quality, immune function, and children's cognitive and motor development. The purpose of the study is to conduct an effectiveness-implementation hybrid (EIH) Type II study of ATTACHTM to assess its impacts in naturalistic, real-world settings delivered by community agencies rather than researchers under more controlled conditions. METHODS: The study is comprised of a quantitative pre/post-test quasi-experimental evaluation of the ATTACHTM program, and a qualitative examination of implementation feasibility using thematic analysis via Normalization Process Theory (NPT). We will work with 100 families and their children (birth to 36-months-old). Study outcomes include: the Parent Child Interaction Teaching Scale to assess parent-child interaction; the Parental Reflective Function and Reflective Function Questionnaires to assess RF; and the Ages and Stages Questionnaire - 3rd edition to examine child development, all administered pre-, post-, and 3-month-delayed post-assessment. Blood samples will be collected pre- and post- assessment to assess immune biomarkers. Further, we will conduct one-on-one interviews with study participants, health and social service providers, and administrators (total n = 60) from each collaborating agency, using NPT to explore perceptions and experiences of intervention uptake, the fidelity assessment tool and e-learning training as well as the benefits, barriers, and challenges to ATTACHTM implementation. DISCUSSION: The proposed study will assess effectiveness and implementation to help understand the delivery of ATTACHTM in community agencies. TRIAL REGISTRATION: Name of registry: https://clinicaltrials.gov/. REGISTRATION NUMBER: NCT04853888 . Date of registration: April 22, 2021.

How to analyze and link patient experience surveys with administrative data to drive health service improvement - examples from Alberta, Canada.

The ability of hospitals and health systems to learn from those who use its services (i.e., patients and families) is crucial for quality improvement and the delivery of high-quality patient-centered care. To this end, many hospitals and health systems regularly collect survey data from patients and their families, and are engaged in activities to publicly report the results. Despite this, there has been limited research into the experiences of patients and families, and how to improve them. Since 2015, our research team has conducted a variety of studies which have explored patient experience survey data, in isolation, and in linkages with routinely-captured administrative data sets across Alberta; a Canadian province of 4.4 million residents. Via secondary analyses, these studies have shed light upon the drivers of inpatient experience, the specific aspects of care which are most correlated with one's overall experiences, and the association of elements of the patient experience with other measures, such as patient safety indicators and unplanned hospital readmissions. The aim of this paper is to provide an overview of the methods we have used, including further details about the data sets and linkage protocol. The main findings from these papers have been presented for readers and those who wish to conduct their own work in this area.

Codesigning person-centred quality indicators with diverse communities: A qualitative patient engagement study.

INTRODUCTION: Effective engagement of underrepresented communities in health research and policy remains a challenge due to barriers that hinder participation. Our study had two objectives: (1) identify themes of person-centred care (PCC) from perspectives of diverse patients/caregivers that would inform the development of person-centred quality indicators (PC-QIs) for evaluating the quality of PCC and initiatives to improve PCC and (2) explore innovative participatory approaches to engage ethnocultural communities in qualitative research. METHODS: Drawing on participatory action research methods, we partnered with a community-based organization to train six 'Community Brokers' from the Chinese, Filipino, South Asian, Latino-Hispanic, East African and Syrian communities, who were engaged throughout the study. We also partnered with the provincial health organization to engage their Patient and Family Advisory, who represented further aspects of diversity. We conducted focus group discussions with patients/caregivers to obtain their perspectives on their values, preferences and needs regarding PCC. We identified themes through our study and engaged provincial stakeholders to prioritize these themes for informing the development of PC-QIs and codesign initiatives for improving PCC. RESULTS: Eight focus groups were conducted with 66 diverse participants. Ethnocultural communities highlighted themes related to access and cost of care, language barriers and culture, while the Patient and Family Advisory emphasized patient and caregiver engagement. Together with provincial stakeholders, initiatives were identified to improve PCC, such as codesigning innovative models of training and evaluation of healthcare providers. CONCLUSION: Incorporating patient and community voices requires addressing issues related to equity and understanding barriers to effective and meaningful engagement. PATIENT OR PUBLIC CONTRIBUTION: Patient and public engagement was central to our research study. This included partnership with a community-based organization, with a broad network of ethnocultural communities, as well as the provincial health service delivery organization, who both facilitated the ongoing engagement of diverse patients/caregiver communities throughout our study including designing the study, recruiting participants, collecting and organizing data, interpreting findings and mobilizing knowledge. Drawing from participatory action research methods, patients and the public were involved in the codesign of the PC-QIs and initiatives to improve PCC in the province based on the findings from our study.

Technological Ecological Momentary Assessment Tools to Study Type 1 Diabetes in Youth: Viewpoint of Methodologies.

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases, and its prevalence is rapidly increasing. The management of glucose in T1D is challenging, as youth must consider a myriad of factors when making diabetes care decisions. This task often leads to significant hyperglycemia, hypoglycemia, and glucose variability throughout the day, which have been associated with short- and long-term medical complications. At present, most of what is known about each of these complications and the health behaviors that may lead to them have been uncovered in the clinical setting or in laboratory-based research. However, the tools often used in these settings are limited in their ability to capture the dynamic behaviors, feelings, and physiological changes associated with T1D that fluctuate from moment to moment throughout the day. A better understanding of T1D in daily life could potentially aid in the development of interventions to improve diabetes care and mitigate the negative medical consequences associated with it. Therefore, there is a need to measure repeated, real-time, and real-world features of this disease in youth. This approach is known as ecological momentary assessment (EMA), and it has considerable advantages to in-lab research. Thus, this viewpoint aims to describe EMA tools that have been used to collect data in the daily lives of youth with T1D and discuss studies that explored the nuances of T1D in daily life using these methods. This viewpoint focuses on the following EMA methods: continuous glucose monitoring, actigraphy, ambulatory blood pressure monitoring, personal digital assistants, smartphones, and phone-based systems. The viewpoint also discusses the benefits of using EMA methods to collect important data that might not otherwise be collected in the laboratory and the limitations of each tool, future directions of the field, and possible clinical implications for their use.

Developing a Canadian evaluation framework for patient and public engagement in research: study protocol.

BACKGROUND: Patient and public engagement (PPE) in research is growing internationally, and with it, the interest for its evaluation. In Canada, the Strategy for Patient-Oriented Research has generated national momentum and opportunities for greater PPE in research and health-system transformation. As is the case with most countries, the Canadian research community lacks a common evaluation framework for PPE, thus limiting our capacity to ensure integrity between principles and practices, learn across projects, identify common areas for improvement, and assess the impacts of engagement. OBJECTIVE: This project aims to build a national adaptable framework for the evaluation of PPE in research, by: 1. Building consensus on common evaluation criteria and indicators for PPE in research; 2. Defining recommendations to implement and adapt the framework to specific populations. METHODS: Using a collaborative action-research approach, a national coalition of patient-oriented research leaders, (patient and community partners, engagement practitioners, researchers and health system leaders) will co-design the evaluation framework. We will develop core evaluation domains of the logic model by conducting a series of virtual consensus meetings using a nominal group technique with 50 patient partners and engagement practitioners, identified through 18 national research organizations. We will then conduct two Delphi rounds to prioritize process and impact indicators with 200 participants purposely recruited to include respondents from seldom-heard groups. Six expert working groups will define recommendations to implement and adapt the framework to research with specific populations, including Indigenous communities, immigrants, people with intellectual and physical disabilities, caregivers, and people with low literacy. Each step of framework development will be guided by an equity, diversity and inclusion approach in an effort to ensure that the participants engaged, the content produced, and the adaptation strategies proposed are relevant to diverse PPE. DISCUSSION: The potential contributions of this project are threefold: 1) support a national learning environment for engagement by offering a common blueprint for collaborative evaluation to the Canadian research community; 2) inform the international research community on potential (virtual) methodologies to build national consensus on common engagement evaluation frameworks; and 3) illustrate a shared attempt to engage patients and researchers in a strategic national initiative to strengthen evaluation capacity for PPE.

Patient-Reported Experiences in Accessing Primary Healthcare among Immigrant Population in Canada: A Rapid Literature Review.

(1) Background: Immigrants represent around 21.9% of the total population in Canada and encounter multifaceted obstacles in accessing and receiving primary healthcare. This literature review explores patient experiences in primary care from the perspective of immigrants and identifies areas for further research and improvement. (2) Methods: A comprehensive search was performed on PubMed, MEDLINE, Embase, SCOPUS, and Google scholar to identify studies published from 2010 to July 2020. Relevant articles were peer-reviewed, in English language, and reported patient experiences in primary healthcare in Canada. (3) Results: Of the 1566 searched articles, 19 articles were included in this review. Overall, the finding from articles were summarized into four major themes: cultural and linguistic differences; socioeconomic challenges; health system factors; patient-provider relationship. (4) Conclusion: Understanding the gaps to accessing and receiving appropriate healthcare is important to shape policies, enhance the quality of services, and deliver more equitable healthcare services. It is therefore pertinent that primary healthcare providers play an active role in bridging these gaps with strong support from policymakers. Understanding and respecting diversity in culture, language, experiences, and systems is crucial in reducing health inequalities and improving access to quality care in a respectful and responsive manner.

A Randomized Controlled Trial of an Alternative Care Provider Clinic for Severe Sleep-disordered Breathing.

Rationale: Lack of timely access to diagnosis and treatment of sleep-disordered breathing (SDB) has sparked interest in using nonphysician providers. Previous studies of these alternative care providers (ACPs) excluded patients with more complicated forms of SDB and did not directly explore the impacts of a model incorporating ACPs on healthcare system performance, such as wait times.Objectives: To evaluate the use of ACPs in the management of patients with severe SDB from a clinical and system perspective.Methods: In this noninferiority study, patients with severe SDB (N = 156) were enrolled from October 2014 to July 2016 and randomized to either sleep physician management or management by ACP with same-day sleep physician review. Severe SDB was defined as one of 1) respiratory event index greater than 30/h, 2) mean nocturnal oxygen saturation less than 85%, and 3) arterial carbon dioxide greater than 45 mm Hg with respiratory event index greater than 15/h. The primary outcome was nightly positive airway pressure adherence at 3 months, using a noninferiority margin of 1 hour. Secondary outcomes included sleepiness, quality of life, patient satisfaction, wait times for diagnosis and treatment initiation, and demand for further testing and clinical assessment. Outcomes were evaluated using modified intention-to-treat and per-protocol analyses.Results: Care delivery using ACPs was indeterminate compared with sleep physician care with respect to treatment adherence, because the 95% confidence interval included the noninferiority margin of 1 hour (mean difference, -0.5 [-1.49 to 0.49] h). Patients in the ACP arm reported greater improvements in sleepiness and quality of life; wait times were shorter for initial assessment (28%) and treatment initiation (18%). There was no difference in demand for sleep testing or clinical follow-up. Per-protocol analysis revealed similar results.Conclusions: Management of severe SDB using ACPs was indeterminate compared with sleep physician care. The small decrease in adherence in the ACP arm was balanced by benefits in patient-reported outcomes and reduction in wait times. In systems with unacceptably long wait times for SDB diagnosis and treatment, a small decrease in treatment adherence, as was observed in this study, may be an acceptable trade-off to improve access to care for patients with severe SDB.Clinical trial registered with www.clinicaltrials.gov (NCT02191085).

Avaliação por TCFC do Transporte do Canal Radicular após o Uso de Diferentes Sistemas Rotatórios de NiTi / CBCT Assessment of the Root Canal Transportation After the Use of Different NiTi Rotary Systems

Objetivo: o objetivo do estudo foi avaliar a ocorrência de transporte do canal radicular após o preparo com instrumentos de níquel-titânio (NiTi) de rotação contínua, por meio do exame de tomografia computadorizada de feixe cônico (TCFC). Material e método: Canais mesiovestibulares e mesiolinguais de vinte molares inferiores humanos foram distribuídos aleatoriamente em dois grupos experimentais (n=10), de acordo com o sistema rotatório de NiTi: Grupo 1 ­ BioRace; e Grupo 2 - ProTaper Next. Imagens de TCFC foram obtidas antes do preparo do canal radicular (TCFC 1) e após o uso dos instrumentos BR2 (#25/.04) e X2 (#25/.06) (TCFC 2) e BR5 (#40/.04) e X4 (#40/.06) (TCFC 3). Dois examinadores avaliaram todas as imagens determinando a ocorrência ou não de transporte do canal radicular. Foram estabelecidos 3 níveis para a mensuração nas imagens: 1-2 mm aquém do vértice radicular (terço apical); 3-4 mm aquém do vértice radicular (terço médio); 4- 2 mm abaixo da furca (terço cervical). Os dados foram analisados utilizando o teste de Kruskal-Wallis com pós-teste de Dunn para comparações múltiplas. O nível de significância foi de 5%. Resultados: Os canais radiculares preparados com o sistema BioRace não apresentaram transporte (P<0,05). Foi observado transporte apenas no terço apical do canal mesiovestibular após o uso do instrumento ProTaper Next X4 (#40/.06) (P<0,05). Conclusão: O sistema BioRace permitiu a ampliação dos canais mesiovestibular e mesiolingual de molares inferiores até o diâmetro cirúrgico 40 sem resultar em transporte do canal.

Aim: This study evaluated root canal transportation after root canal instrumentation with two nickel-titanium (NiTi) rotary systems, by using cone beam computed tomography (CBCT) imaging. Material and Methods: Mesiobuccal and mesiolingual root canals of twenty human mandibular molars were randomly divided into two experimental groups (n = 10), according to the NiTi rotary system: Group 1 ­ BioRace; and Group 2 ­ ProTaper Next. CBCT scans were obtained before the root canal instrumentation (CBCT 1) and after the use of BR2 (#25/.04) and X2 (#25/.06) instruments (CBCT 2) and after the use of BR5 (#40/.04) and X4 (#40/.06) instruments (CBCT 3). Two examiners evaluated the occurrence or not of transportation. Measurements were made at 3 different points: 1-2 mm from the apex (apical third); 3-4 mm from the apex (middle third); 4- 2 mm below furcation (cervical third). The Kruskal-Wallis and Dunn tests were used for statistical analysis. The level of significance was set at 5%. Results: Root canals instrumented with BioRace instruments showed no transportation (P<0.05). Transportation was observed only in the apical third of the mesiobuccal root canal after the use of ProTaper Next X4 instrument (#40/.06) (P<0.05). Conclusions: The BioRace system allowed the widening of mesiobuccal and mesiolingual root canals of mandibular molars up to apical diameter 40 without resulting in root canal transportation.

Patient-reported outcome measures within pediatric solid organ transplantation: A systematic review.

Subjective evaluation of medical care and disease outcomes from patients' perspectives has become increasingly important. Patient-reported outcome measures (PROMs) play a prominent role in engaging patients, capturing their experiences and improving patient care. This systematic review sought to identify PROMs that are used in the field of pediatric solid organ transplantation, with the aim to inform the implementation of PROMs into clinical practice for this population. A systematic review of English language, peer-reviewed articles was performed on key health science databases to identify publications using PROMs in pediatric solid organ transplantation. The search yielded 3670 articles, with a final data set of 62 articles that included 47 different PROMs. The three most frequently used PROMs included the following: (a) PedsQL™ Generic Core Scales (n = 25); (b) Children's Depression Inventory (n = 6); and (c) Child Health Questionnaire (n = 6). Of the 47 PROMs, 42 were generic and five were disease-specific; only six PROMS had a documented psychometric evaluation within a pediatric solid organ transplant population. This review outlines the attributes of the instruments (eg, domains captured), as well as the psychometric properties of those evaluated. PROMs are increasingly used in the field of pediatric transplantation; however, there are limited details in the current literature about their conceptual underpinnings and psychometric properties. This review highlights the need for additional psychometric evaluation of identified measures to establish the necessary foundation to inform the implementation of PROMs into clinical care for pediatric solid organ transplant patients.

Trends in psychiatric disorders prevalence and prescription patterns of children in Alberta, Canada.

PURPOSE: To describe the trends in the prevalence and incidence of children with psychiatric disorders, the types of medication prescribed, and the type of physician providing the prescriptions. METHOD: This retrospective study linked six population-based administrative databases (2008-2015) in Alberta, Canada. RESULTS: The prevalence of paediatric psychiatric disorders increased from 12.6 per 100 population in 2008 to 15.0 per 100 population in 2015, while the incidence rate increased from 2.0 per 100 population to 2.2 per 100 population in the same period. The proportion of patients dispensed any psychiatric medication increased from 21.4% in 2008 to 28.2% in 2015. Over the same period, dispensations for antidepressants increased from 7.0% to 11.2% and stimulants to treat ADHD, from 11.9% to 15.9%. For antidepressants, general practitioners (GPs) wrote the highest proportion of prescriptions (44.3% in 2011-48.1% in 2015), while paediatricians wrote the lowest proportion (8.7% in 2011-11.0% in 2015) and the proportion by psychiatrists decreased from 33.4% in 2011 to 27.2% in 2015. For stimulants to treat ADHD, paediatricians were the most frequent prescribers (36.9% in 2011-39.3% in 2015) followed by GPs as the second most frequent (33.1% in 2011-33.5% in 2015), while psychiatrists were the least likely to prescribe stimulants for ADHD. CONCLUSION: The increasing trend of psychiatric diagnoses and medication prescriptions in the paediatric population is evident using population-based administrative databases. The lack of safety and adverse consequences of medication use in this cohort warrants additional monitoring data.

How to measure cultural competence when evaluating patient-centred care: a scoping review.

OBJECTIVES: The purpose of this study was to identify patient-centred quality indicators (PC-QI) and measures for measuring cultural competence in healthcare. DESIGN: Scoping review. SETTING: All care settings. SEARCH STRATEGY: A search of CINAHL, EMBASE, MEDLINE, PsycINFO, Social Work Abstracts and SocINDEX, and the grey literature was conducted to identify relevant studies. Studies were included if they reported indicators or measures for cultural competence. We differentiated PC-QIs from measures: PC-QIs were identified as a unit of measurement of the performance of the healthcare system, which reflects what matters to patients and families, and to any individual that is in contact with healthcare services. In contrast, measures evaluate delivery of patient-centred care, in the form of a survey and/or checklist. Data collected included publication year and type, country, ethnocultural groups and mention of quality indicator and/or measures for cultural competence. RESULTS: The search yielded a total of 786 abstracts and sources, of which 16 were included in the review. Twelve out of 16 sources reported measures for cultural competence, for a total of 10 measures. Identified domains from the measures included: physical environment, staff awareness of attitudes and values, diversity training and communication. Two out of 16 sources reported PC-QIs for cultural competence (92 structure and process indicators, and 48 outcome indicators). There was greater representation of structure and process indicators and measures for cultural competence, compared with outcome indicators. CONCLUSION: Monitoring and evaluating patient-centred care for ethnocultural communities allows for improvements to be made in the delivery of culturally competent healthcare. Future research should include development of PC-QIs for measuring cultural competence that also reflect cultural humility, and the involvement of ethnocultural communities in the development and implementation of these indicators.

Monitoring and evaluation framework for hypertension programs. A collaboration between the Pan American Health Organization and World Hypertension League.

The Pan American Health Organization (PAHO)-World Hypertension League (WHL) Hypertension Monitoring and Evaluation Framework is summarized. Standardized indicators are provided for monitoring and evaluating national or subnational hypertension control programs. Five core indicators from the World Health Organization hearts initiative and a single PAHO-WHL core indicator are recommended to be used in all hypertension control programs. In addition, hypertension control programs are encouraged to select from 14 optional qualitative and 33 quantitative indicators to facilitate progress towards enhanced hypertension control. The intention is for hypertension programs to select quantitative indicators based on the current surveillance mechanisms that are available and what is feasible and to use the framework process indicators as a guide to program management. Programs may wish to increase or refine the number of indicators they use over time. With adaption the indicators can also be implemented at a community or clinic level. The standardized indicators are being pilot tested in Cuba, Colombia, Chile, and Barbados.

How to practice person-centred care: A conceptual framework.

BACKGROUND: Globally, health-care systems and organizations are looking to improve health system performance through the implementation of a person-centred care (PCC) model. While numerous conceptual frameworks for PCC exist, a gap remains in practical guidance on PCC implementation. METHODS: Based on a narrative review of the PCC literature, a generic conceptual framework was developed in collaboration with a patient partner, which synthesizes evidence, recommendations and best practice from existing frameworks and implementation case studies. The Donabedian model for health-care improvement was used to classify PCC domains into the categories of "Structure," "Process" and "Outcome" for health-care quality improvement. DISCUSSION: The framework emphasizes the structural domain, which relates to the health-care system or context in which care is delivered, providing the foundation for PCC, and influencing the processes and outcomes of care. Structural domains identified include: the creation of a PCC culture across the continuum of care; co-designing educational programs, as well as health promotion and prevention programs with patients; providing a supportive and accommodating environment; and developing and integrating structures to support health information technology and to measure and monitor PCC performance. Process domains describe the importance of cultivating communication and respectful and compassionate care; engaging patients in managing their care; and integration of care. Outcome domains identified include: access to care and Patient-Reported Outcomes. CONCLUSION: This conceptual framework provides a step-wise roadmap to guide health-care systems and organizations in the provision PCC across various health-care sectors.

Prospective economic evaluation of an electronic discharge communication tool: analysis of a randomised controlled trial.

OBJECTIVE: To complete an economic evaluation within a randomised controlled trial (RCT) comparing the use of an electronic discharge communication tool (eDCT) compared with usual care. SETTING: Patients being discharged from a single tertiary care centre's internal medicine Medical Teaching Units. PARTICIPANTS: Between January 2012 and December 2013, 1399 patients were randomised to a discharge mechanism. Forty-five patients were excluded from the economic evaluation as they did not have data for the index hospitalisation cost; 1354 patients contributed to the economic evaluation. INTERVENTION: eDCT generated at discharge containing structured content on reason for admission, details of the hospital stay, treatments received and follow-up care required. The control group was discharged via traditional dictation methods. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary economic outcome was the cost per quality-adjusted life year (QALY) gained. Secondary outcomes included the cost per death avoided and the cost per readmission avoided. RESULTS: The average transcription cost was $C22.28 per patient, whereas the estimated cost of the eDCT was $C13.33 per patient. The cost per QALY gained was $C239 933 in the eDCT arm compared with usual care due to the very small gains in effectiveness and approximately $C800difference in resource utilisation costs. The bootstrap analyses resulted in eDCT being more effective and more costly in 29.2% of samples, less costly and more effective in 29.2% of samples, less effective and more costly in 23.9% of samples and finally, less costly and less effective in 17.7% of samples. CONCLUSIONS: The eDCT reduced per patient costs of the generation of discharge summaries. The bootstrap estimates demonstrate considerable uncertainty supporting the finding of neutrality reported in the clinical component of the RCT. The immediate transcription cost savings and previously documented provider and patient satisfaction may increase the impetus for organisations to invest in such systems, provided they have a foundation of eHealth infrastructure and readiness. TRIAL REGISTRATION NUMBER: NCT01402609.

A Comparison of Factors Associated with Cessation of Exclusive Breastfeeding at 3 and 6 Months.

AIM: To analyze the association of labor and sociodemographic factors with cessation of exclusive breastfeeding (EBF) at 3 and 6 months of life. MATERIALS AND METHODS: A prospective cohort study (n = 529) was performed in a tertiary hospital with the Baby-Friendly Hospital Initiative (BFHI) award. Labor and sociodemographic factors were investigated. Single-term newborns were included. After 3 and 6 months, telephone calls were made to determine the type of lactation. Univariate analysis was performed with the chi-square test or Fisher's exact test. Multivariable logistic regression models were developed to determine risk factors associated with cessation of breastfeeding at 3 and 6 months. RESULTS: At 3 months, 523 participants (98.9%) were contacted, of whom 64.4% maintained EBF. Factors associated with cessation were pacifier use (odds ratio [OR] 3.49; 95% confidence interval [95% CI] 2.24-5.43), cesarean delivery (OR 4.49; 95% CI 2.96-6.83), no college degree (OR 2.01; 95% CI 1.35-3.01), and not attending breastfeeding support groups (OR 1.96; 95% CI 1.22-3.12). At 6 months, 512 participants (96.8%) were contacted, of whom 31.4% maintained EBF. Factors associated with cessation were reintegration into the workplace (OR 4.49; 95% CI 2.96-6.83), pacifier use (OR 3.49; 95% CI 2.24-5.43), and primiparity (OR 1.61; 95% CI 1.05-2.46). CONCLUSIONS: Several risk factors are associated with the premature cessation of EBF. There is a need to define strategies to correct modifiable factors and to promote protective factors with the aim of improving the success rate of EBF to reach the recommendations of the World Health Organization.

A systematic review of the cost and cost-effectiveness of electronic discharge communications.

BACKGROUND: The transition between acute care and community care can be a vulnerable period in a patients' treatment due to the potential for postdischarge adverse events. The vulnerability of this period has been attributed to factors related to the miscommunication between hospital-based and community-based physicians. Electronic discharge communication has been proposed as one solution to bridge this communication gap. Prior to widespread implementation of these tools, the costs and benefits should be considered. OBJECTIVE: To establish the cost and cost-effectiveness of electronic discharge communications compared with traditional discharge systems for individuals who have completed care with one provider and are transitioning care to a new provider. METHODS: We conducted a systematic review of the published literature, using best practices, to identify economic evaluations/cost analyses of electronic discharge communication tools. Inclusion criteria were: (1) economic analysis and (2) electronic discharge communication tool as the intervention. Quality of each article was assessed, and data were summarised using a component-based analysis. RESULTS: One thousand unique abstracts were identified, and 57 full-text articles were assessed for eligibility. Four studies met final inclusion criteria. These studies varied in their primary objectives, methodology, costs reported and outcomes. All of the studies were of low to good quality. Three of the studies reported a cost-effectiveness measure ranging from an incremental daily cost of decreasing average discharge note completion by 1 day of $0.331 (2003 Canadian), a cost per page per discharge letter of €9.51 and a dynamic net present value of €31.1 million for a 5-year implementation of the intervention. None of the identified studies considered clinically meaningful patient or quality outcomes. DISCUSSION: Economic analyses of electronic discharge communications are scarcely reported, and with inconsistent methodology and outcomes. Further studies are needed to understand the cost-effectiveness and value for patient care.

Exercitando o corpo e alegrando a alma: relato de experiência sobre incentivo à atividade física / Exercising the body and cheering the soul: experience report about the incentive to physical activity / Ejercitando el cuerpo y alegrando el alma: relato de experiencia sobre incentivo a la actividad física

A construção do Sistema Único de Saúde fomentou a reorganização de todo o sistema, sendo a implementação da Atenção Básica uma das principais estratégias para alcançar esse objetivo. Nesse contexto, a parceria entre Residências Multiprofissionais em Saúde e as equipes de Estratégia de Saúde da Família apresenta-se como uma alternativa para promover a mudança da prática assistencial em saúde. A Política Nacional de Promoção da Saúde aponta alguns eixos de atuação, entre eles, o incentivo a atividade física. Portanto, o objetivo deste trabalho foi descrever a experiência de residentes multiprofissionais em Saúde da Família, na condução de um grupo de atividade física com usuários de uma unidade básica de saúde. Para tanto, iniciou-se o grupo no mês de abril de 2015, realizando encontros semanais, com duração de uma hora e participação de duas agentes comunitárias de saúde. A faixa etária das participantes variou entre 35 a 70 anos. Percebeu-se que as atividades de educação em saúde, como as realizadas nesta pesquisa, possibilitaram a percepção da importância da inserção e colaboração da residência nas atividades desenvolvidas pela Estrategia de Saúde da Família. Assim, concluiu-se que a colaboração da residência fortalece o vínculo do profissional de saúde com a comunidade e possibilita que ele levante as demandas da comunidade e atue efetivamente sobre elas.

The construction of the Unified Health System has fostered the reorganization of the entire system, being the implementation of Primary Care one of the main strategies to achieve this goal. In this context, the partnership between Multiprofessional Residencies in Health and the Family Health Strategy teams presents itself as an alternative to promote the change in health care practice. The National Health Promotion Policy points to some areas of activity, among them, the incentive to physical activity. Therefore, the objective of this study was to describe the experience of multiprofessional residents in Family Health, in the conduction of a physical activity group with users of a basic health unit. For that purpose, the group started in April 2015, holding one-hour weekly meetings with the participation of two community health agents. The participants' age ranged from 35 to 70 years. It was noticed that Health education activities such as those carried out by this research enabled the perception of the importance of the insertion and collaboration of residency in the activities developed by the Family Health Strategy. Thus, it was possible to conclude that the collaboration of residency strengthens the bond between the health professional and the community and enables him to raise the demands of the community and act effectively on them.

La construcción del Sistema Único de Salud fomentó la reorganización de todo el sistema, siendo la implementación de la Atención Básica una de las principales estrategias para alcanzar ese objetivo. En ese contexto, la asociación entre Residencias Multiprofesionales en Salud y los equipos de Estrategia de Salud de la Familia presentase como una alternativa para promover el cambio de la práctica asistencial en salud. La política nacional de promoción de la salud apunta algunos ejes de actuación, entre ellos, el incentivo a la actividad física. Por lo tanto, el objetivo de este trabajo fue describir la experiencia de residentes multiprofesionales en Salud de la Familia, en la conducción de un grupo de actividad física con usuarios de una unidad básica de salud. Para ello, fue iniciado el grupo en el mes de abril de 2015, realizando encuentros semanales, con duración de una hora y participación de dos agentes comunitarias de salud. El grupo de edad de las participantes varió entre 35 y 70 años. Percibióse que las actividades de educación en salud, como las realizadas en esta investigación, posibilitaron la percepción de la importancia de la inserción y colaboración de la residencia en las actividades desarrolladas por la Estrategia de Salud de la Familia. Así, concluyóse que la colaboración de la residencia fortalece el vínculo del profesional de salud con la comunidad y posibilita que él levante las demandas de la comunidad y actúe efectivamente sobre ellas.

Montreal Accord on Patient-Reported Outcomes (PROs) use series - Paper 3: patient-reported outcomes can facilitate shared decision-making and guide self-management.

BACKGROUND: There is a shift toward making health care patient centered, whereby patients are part of medical decision-making and take responsibility for managing their health. Patient-reported outcomes (PROs) capture the patient voice and can be used to engage patients in medical decision-making. OBJECTIVE: The objective of this paper is to present important factors from patients', clinicians', researchers', and decision-makers' perspectives that influence successful adoption of PROs in clinical practice. Factors recommended in this paper were informed by a patient partner. DISCUSSION: Based on themes arising from the Montreal Accord proceedings, we describe factors that influence the adoption of PROs and how PROs can have a positive effect by enhancing communication and providing opportunities to engage patients, carers, and clinicians in care. Consideration of patient factors (e.g., health literacy), family support and networks (e.g., peer-support networks), technology (e.g., e-health), and health care system factors (e.g., resources to implement PROs) is necessary to ensure PROs are successfully adopted. PRO evaluation plans most likely to succeed over the long term are those incorporating PROs identified by patients as necessary for self-management and that coincide with providers' needs for collaboratively developing treatment plans with patients and families.