Artificial intelligence in healthcare: why not apply the medico-legal method starting with the Collingridge dilemma?

Technology has greatly influenced and radically changed human life, from communication to creativity and from productivity to entertainment. The authors, starting from considerations concerning the implementation of new technologies with a strong impact on people's everyday lives, take up Collingridge's dilemma and relate it to the application of AI in healthcare. Collingridge's dilemma is an ethical and epistemological problem concerning the relationship between technology and society which involves two approaches. The proactive approach and socio-technological experimentation taken into account in the dilemma are discussed, the former taking health technology assessment (HTA) processes as a reference and the latter the AI studies conducted so far. As a possible prevention of the critical issues raised, the use of the medico-legal method is proposed, which classically lies between the prevention of possible adverse events and the reconstruction of how these occurred.The authors believe that this methodology, adopted as a European guideline in the medico-legal field for the assessment of medical liability, can be adapted to AI applied to the healthcare scenario and used for the assessment of liability issues. The topic deserves further investigation and will certainly be taken into consideration as a possible key to future scenarios.

Conceptualising relational care from an Indigenous Maori perspective: A scoping review.

OBJECTIVE: To identify and describe the attributes of relational care from an Indigenous Maori healthcare consumer perspective. DATA SOURCES: CINAHL Plus, Ovid MEDLINE, ProQuest Nursing & Allied Health, Scopus, New Zealand Index, the Ministry of Health Library, New Zealand Research and Google Scholar were searched between 23 and 30 May 2022. METHODS: This scoping review used the Joanna Briggs Institute methodology for scoping reviews, thematic analysis and the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework for the synthesis of the findings. RESULTS: A total of 1449 records were identified, and 10 sources were selected for final review. We identified five relational attributes that were most important to Maori: (1) the expressive behaviours and characteristics of healthcare professionals (HCPs), (2) communication to facilitate the healthcare partnership, (3) appreciating differing worldviews, (4) the context in which healthcare is delivered and (5) whanaungatanga (meaningful relationships). CONCLUSION: The relational attributes identified are inextricably linked. Connecting with HCPs and developing a therapeutic relationship is fundamental to improving consumer experience and engagement with mainstream healthcare services. Whanaungatanga is fundamental to meaningful engagements with HCPs. Future research should explore how relational care is practiced in acute care settings when clinician-consumer interactions are time-limited, examine how the health system influences the capacity for relational care and how Indigenous and Western paradigms can co-exist in healthcare. IMPLICATIONS: This scoping review can inform future projects addressing health equity for Indigenous communities by creating environments that prioritise culturally safe relational care and value Indigenous knowledge systems. REPORTING METHOD: We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. NO PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Provision of injectable contraceptives by community health workers in sub-Saharan Africa: a systematic review of safety, acceptability and effectiveness.

BACKGROUND: Injectable contraceptives are the most popular method of contraception in sub-Saharan Africa (SSA), but their availability in clinical settings has been severely limited, despite the scarcity of health care providers and limited access to health facilities. WHO and USAID have endorsed the community-based distribution of injectable contraceptives as a promising option for improving access to family planning services and expanding the method mix for women who want to limit the number of births. Studies have shown that community health workers (CHWs) can provide women with injectable contraceptives that meet acceptable quality standards. The goal of this study is to identify, evaluate and synthesize evidence supporting the use of community-based administration of injectable contraceptives in SSA. METHODS: This review's guidance was based on a previously developed protocol. Nine international electronic databases and the websites of organizations known to support community-based reproductive health initiatives in SSA were searched systemically. Experts in this area were also contacted for the identification of unpublished literature and ongoing studies. The reference lists of eligible studies were reviewed. The Effective Public Practice Project tool was used to assess the quality and risk of bias in eligible studies. Data were extracted and analysed using a custom data extraction form and a narrative synthesis. RESULTS: The search strategy identified a total of 1358 studies with 12 studies meeting the inclusion criteria. One unpublished study was provided by an expert making a total of 13 studies. The results showed that irrespective of the study designs, well-trained CHWs can competently administer injectable contraceptives safely and community-based delivery of injectable contraceptives is acceptable in SSA. Also, the use of community health workers in the provision of depot-medroxyprogesterone acetate expanded access to inhabitants of hard-to-reach areas and led to an overall uptake of injectable contraceptives as well as family planning. Studies that compared CHWs to clinic-based providers revealed equivalent or higher levels of performance in favour of CHWs. CONCLUSIONS: The CHWs can competently provide injectable contraceptives within SSA communities if appropriately trained and supervised. Hence, SSA policymakers should give this initiative due consideration as a way of improving access to family planning services.

Transforming tuberculosis (TB) service delivery model in China: issues and challenges for health workforce.

BACKGROUND: China's TB control system has been transforming its service delivery model from CDC (Centers for Disease Control and Prevention)-led model to the designated hospital-led model to combat the high disease burden of TB. The implications of the new service model on TB health workforce development remained unclear. This study aims to identify implications of the new service model on TB health workforce development and to analyze whether the new service model has been well equipped with appropriate health workforce. METHODS: The study applied mixed methods in Zhejiang, Jilin, and Ningxia provinces of China. Institutional survey on designated hospitals and CDC was conducted to measure the number of TB health workers. Individual questionnaire survey was conducted to measure the composition, income, and knowledge of health workers. Key informant interviews and focus group discussions were organized to explore policies in terms of recruitment, training, and motivation. RESULTS: Zhejiang, Jilin, and Ningxia provinces had 0.33, 0.95, and 0.47 TB health professionals per 10 000 population respectively. They met the national staffing standard at the provincial level but with great variety at the county level. County-designated hospitals recruited TB health professionals from other departments of the same hospital, existing TB health professionals who used to work in CDC, and from township health centers. County-designated hospitals recruited new TB health professionals from three different sources: other departments of the same hospital, CDC, and township health centers. Most newly recruited professionals had limited competence and put on fixed posts to only provide outpatient services. TB doctors got 67/100 scores from a TB knowledge test, while public health doctors got 77/100. TB professionals had an average monthly income of 4587 RMB (667 USD). Although the designated hospital had special financial incentives to support, they still had lower income than other health professionals due to their limited capacity to generate revenue through service provision. CONCLUSIONS: The financing mechanism in designated hospitals and the job design need to be improved to provide sufficient incentive to attract qualified health professionals and motivate them to provide high-quality TB services.

Analysis of strategies to attract and retain rural health workers in Cambodia, China, and Vietnam and context influencing their outcomes.

BACKGROUND: Many Asia-Pacific countries are experiencing rapid changes in socio-economic and health system development. This study aims to describe the strategies supporting rural health worker attraction and retention in Cambodia, China, and Vietnam and explore the context influencing their outcomes. METHODS: This paper is a policy analysis based on key informant interviews with stakeholders about a rural province of Cambodia, China, and Vietnam, coupled with a broad review of the literature. RESULTS: Cambodia, China, and Vietnam have implemented medical education, provided financial incentives, and provided personal and professional support to attract and retain rural health workers. More socio-economic development was related to a wider range of interventions and their scope. The health system context influenced the outcomes. Increased autonomy of public hospitals attracted more health workers from rural primary health facilities in China and Vietnam. Health financing policies for universal health coverage in China and Vietnam have increased the utilization of health services. Subsidies for poor people to access health services in Cambodia have provided financial incentives to retain rural health workers. However, the dismantling of the referral system in China and Vietnam has resulted in a high rate of health workers moving from primary health facilities to higher-level hospitals while clear definition of primary healthcare package in Cambodia guided its planning of primary health workforce. The prosperous private health sector in Cambodia and Vietnam attracted more health workers from rural primary health facilities, impeded implementation and determined effectiveness of financial incentives. CONCLUSIONS: Socio-economic and health system reforms including health financing, public hospital autonomy, abolition of referral system and prosperous private sector have both positive and negative impacts on the design, implementation, and effectiveness of interventions to attract and retain rural health workers. Interventions to attract and retain health workers in rural and remote areas need to be considered within overall health system reform.

A systematic review of nurse-led interventions with populations experiencing homelessness.

Homelessness is associated with poorer health status, and affects men, women, children, and veterans alike across the United States. With over half a million-people suffering from homelessness on any given night, it is imperative that the health care delivery system step in to help this vulnerable group. Registered nurses encounter people experiencing homelessness in hospitals, clinics, shelters, and across the public health sector. They have the necessary skills to help make positive health-related changes for homeless populations and improve their overall quality of life. Therefore, the purpose of this systematic review was to (a) assess existing nurse-led interventional studies with homeless populations, (b) highlight effective methods that nurses used to impact care, and (c) make recommendations about future research needed. PRISMA guidelines were used and multiple databases were searched for nurse-led interventional research with those experiencing homelessness. Recommendations include using a holistic nursing approach when working to improve outcomes for homeless populations to ensure optimal treatment for their complex physical, mental, and social health problems.

Realities and experiences of community health volunteers as agents for behaviour change: evidence from an informal urban settlement in Kisumu, Kenya.

BACKGROUND: Community health workers play an important role in health service delivery and are increasingly involved in behaviour change interventions, including for hygiene-related behaviour change. However, their role and capacity to deliver behaviour change interventions, particularly in high-density urban settlements, remain under-researched. This study examines the behaviour change-related activities of community health volunteers (CHVs)-community health workers affiliated with the Kenyan Ministry of Health-in a peri-urban settlement in Kenya, in order to assess their capabilities, opportunities to work effectively, and sources of motivation. METHODS: This mixed-methods study included a census of 16 CHVs who work in the study area. All CHVs participated in structured observations of their daily duties, structured questionnaires, in-depth interviews, and two focus group discussions. Structured data were analysed descriptively. Thematic content analysis was followed for qualitative data. Results were synthesized and interpreted using the capability, opportunity, motivation for behaviour change framework, COM-B. RESULTS: In addition to their responsibilities with the Ministry of Health, CHVs partnered with a range of non-governmental organizations engaged in health and development programming, often receiving small stipends from these organizations. CHVs reported employing a limited number of behaviour change techniques when interacting with community members at the household level. Capability: While supervision and support from the MOH was robust, CHV training was inconsistent and inadequate with regard to behaviour change and CHVs often lacked material resources necessary for their work. Opportunity: CHVs spent very little time with the households in their allocated catchment area. The number of households contacted per day was insufficient to reach all assigned households within a given month as required and the brief time spent with households limited the quality of engagement. MOTIVATION: Lack of compensation was noted as a demotivating factor for CHVs. This was compounded by the challenging social environment and CHVs' low motivation to encourage behaviour change in local communities. CONCLUSIONS: In a complex urban environment, CHVs faced challenges that limited their capacity to be involved in behaviour change interventions. More resources, better coordination, and additional training in modern behaviour change approaches are needed to ensure their optimal performance in implementing health programmes.

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali.

BACKGROUND: The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS: Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS: In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS: This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Strengthening Public Health Management Capacity in Vietnam: Preparing Local Public Health Workers for New Roles in a Decentralized Health System.

Health sector decentralization has created an urgent need to strengthen public health management capacity in many countries throughout the developing world. This article describes the establishment of a national management training network in Vietnam that used Project-Based Learning to strengthen management competencies of HIV program workers and linked training to measurable improvement in HIV/AIDS public health program outcomes. Skills were taught using a combination of classroom learning and mentored fieldwork. From 2005 to 2015, 827 HIV/AIDS program managers were trained with this method throughout Vietnam by trainers in 3 regional training centers. A total of 218 applied learning projects were carried out by trainees during this period; 132 resulted in measurable improvements in HIV/AIDS program outputs, and 86 produced well-organized plans for implementing, monitoring, and evaluating HIV/AIDS intervention strategies. Vietnam's management training network represents an important advancement in public health workforce development that helps prepare workers for new roles and responsibilities in a decentralized health system.

Practical Quality Improvement Implementation in Orthopaedic Clinical Practice.

The passage of the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015 (HR 2) helps ensure patient access to care and stable physician reimbursement for the near future. HR 2's underlying theme is the improvement of value to address the unsustainable rise in national healthcare spending. Quality improvement and performance improvement, which affect outcomes and costs as well as address variation, are the keys to improve the value of orthopaedic healthcare delivery. Orthopaedic surgeons should examine quality and performance strategies as well as several examples before they begin to implement these processes to improve quality and performance in their practices.

Concierge Medicine: A Viable Business Model for (Some) Physicians of the Future?

Concierge medicine is a medical management structure that has been in existence since the 1990s. Essentially, a typical concierge medical practice limits its number of patients and provides highly personalized attention that includes comprehensive annual physicals, same-day appointments, preventive and wellness care, and fast, 24/7 response time. Concierge medicine has become popular among both physicians and patients/consumers who are frustrated by the limitations imposed by managed care organizations. From many physicians' perspectives, concierge medicine offers greater autonomy, the opportunity to return to a more manageable patient load, and the chance to improve their incomes that have declined because of increasingly lowered reimbursements for their services. From many patients'/consumers' perspectives, concierge medicine provides more immediate, convenient, and caring access to their primary care physicians and, regardless of their physician's annual retainer fee, the elimination of third-party insurance coverage costs and hassles. The major criticisms of the concierge medicine model come from some health care policy makers and experts, who believe that concierge medicine is elitist and its widespread implementation will increase the shortage of primary care physicians, which is already projected to become worse because of the Affordable Care Act's individual mandate, which requires everyone to have health insurance.Utilizing these topics as its framework, this article explains why concierge medicine's form of medical management is gaining ground, cites its advantages and disadvantages for stakeholders, and examines some of the issues that will affect its growth.

Health workers' experiences, barriers, preferences and motivating factors in using mHealth forms in Ethiopia.

BACKGROUND: Mobile health (mHealth) applications, such as innovative electronic forms on smartphones, could potentially improve the performance of health care workers and health systems in developing countries. However, contextual evidence on health workers' barriers and motivating factors that may influence large-scale implementation of such interfaces for health care delivery is scarce. METHODS: A pretested semistructured questionnaire was used to assess health workers' experiences, barriers, preferences, and motivating factors in using mobile health forms on smartphones in the context of maternal health care in Ethiopia. Twenty-five health extension workers (HEWs) and midwives, working in 13 primary health care facilities in Tigray region, Ethiopia, participated in this study. RESULTS: Over a 6-month period, a total of 2,893 electronic health records of 1,122 women were submitted to a central computer through the Internet. Sixteen (69.6%) workers believed the forms were good reminders on what to do and what questions needed to be asked. Twelve (52.2%) workers said electronic forms were comprehensive and 9 (39.1%) workers saw electronic forms as learning tools. All workers preferred unrestricted use of the smartphones and believed it helped them adapt to the smartphones and electronic forms for work purposes. With regards to language preference, 18 (78.3%) preferred using the local language (Tigrinya) version of the forms to English. Indentified barriers for not using electronic forms consistently include challenges related to electronic forms (for example, problem with username and password setting as reported by 5 (21.7%), smartphones (for example, smartphone froze or locked up as reported by 9 (39.1%) and health system (for example, frequent movement of health workers as reported by 19 (82.6%)). CONCLUSIONS: Both HEWs and midwives found the electronic forms on smartphones useful for their day-to-day maternal health care services delivery. However, sustainable use and implementation of such work tools at scale would be daunting without providing technical support to health workers, securing mobile network airtime and improving key functions of the larger health system.

[Quaternary prevention: is acting always justified in family medicine?]. / Prévention quaternaire: agir est-il toujours justifié en médecine de famille?

Quaternary prevention aims to protect the patient or population against overmedicalisation. Quaternary prevention influences all the activities of family medicine by questioning the utility of primary prevention and early diagnosis, identifying the risks of creating new pathological entities and practicing a maximalist medicine. Family doctors can support quaternary prevention by focusing on their patients' priorities and the local resources of an efficient health system.

How pharmacist-led health services are tailored to minoritized populations, their acceptability and effectiveness: A scoping literature review.

BACKGROUND: Worldwide, minoritized populations experience inequitable health risks and outcomes. The importance of offering tailored services to meet the specific needs of target populations should be addressed during service development. Within healthcare systems, pharmacists play a crucial role in supporting patients to manage their medicines and health conditions. OBJECTIVES: This scoping review aims to identify, collate and analyse literature describing pharmacist-led services tailored for minoritized populations in order to strengthen the knowledge base and support for achieving health equity. METHODS: A scoping review was guided by the PRISMA-ScR checklist and the five-stage process outlined by Arksey and O'Malley. Medline, EMBASE, Scopus, CINAHL Plus, International Pharmaceutical Abstracts, and Google Scholar databases, plus grey literature were searched to identify relevant studies published up to October 2022. Texts were included if they reported on a pharmacist-led health service tailored to meet the needs of a minoritized population. The review protocol was registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/E8B7D). RESULTS: Of the 566 records initially identified, 16 full-text articles were assessed for eligibility and 9 articles describing 6 unique services met the criteria and were included in the review. Three services were non-health-condition-specific, 2 targeted type two diabetes and 1 focussed on opioid dependency disorders. Service acceptability was consistently explored, and all services ensured that pharmacists' views were considered. However, only 4 consulted with the people from the group that the service targeted. Where reported, the effectiveness was not comprehensively evaluated. CONCLUSION: There is limited literature in this area and a critical need for more evidence on the effectiveness of pharmacist-led services for minoritized populations. We need a better understanding of how pharmacists contribute to health equity pathways and how to expand this. Doing so will inform future services and contribute towards achieving equitable health outcomes.

Facilitating improvement in primary care: the promise of practice coaching.

Practice coaching, also called practice facilitation, assists physician practices with the desire to improve in such areas as patient access, chronic and preventive care, electronic medical record use, patient-centeredness, cultural competence, and team-building. This issue brief clarifies the essential features of practice coaching and offers guidance for health system leaders, public and private insurers, and federal and state policymakers on how best to structure and design these programs in primary care settings. Good-quality evidence demonstrates that practice coaching is effective. The authors argue that primary care delivery in the United States would benefit from a more systematic approach to the training and deployment of primary care practice coaches.

Reflexive Practice as an Approach to Improve Healthcare Delivery for Indigenous Peoples: A Systematic Critical Synthesis and Exploration of the Cultural Safety Education Literature.

Cultural safety is increasingly being taught in tertiary programmes of study for health professionals. Reflexivity is a key skill required to engage in culturally safe practice, however, there is currently limited literature examining how reflexivity is taught or assessed within cultural safety curricula. A systematic review of the literature up until November 2021 was conducted, examining educational interventions which aimed to produce culturally safe learners. Studies were limited to those with a focus on Indigenous health and delivered in Australia, Aotearoa New Zealand, Canada, and the United States. A total of 46 documents describing 43 different educational interventions were identified. We found that definitions and conceptualisations of reflexivity varied considerably, resulting in a lack of conceptual clarity. Reflexive catalysts were the primary pedagogical approaches used, where objects, people, or Indigenous pedagogies provided a counterpoint to learners' knowledges and experiences. Information regarding assessment methods was limited but indicates that the focus of existing programmes has been on changes in learner knowledge and attitudes rather than the ability to engage in reflexivity. The results demonstrate a need for greater conceptual clarity regarding reflexivity as it relates to cultural safety, and to develop methods of assessment that focus on process rather than outcomes.

Primary care for refugees.

Over the past decade, at least 600,000 refugees from more than 60 different countries have been resettled in the United States. The personal history of a refugee is often marked by physical and emotional trauma. Although refugees come from many different countries and cultures, their shared pattern of experiences allows for some generalizations to be made about their health care needs and challenges. Before being accepted for resettlement in the United States, all refugees must pass an overseas medical screening examination, the purpose of which is to identify conditions that could result in ineligibility for admission to the United States. Primary care physicians have the opportunity to care for members of this unique population once they resettle. Refugees present to primary care physicians with a variety of health problems, including musculoskeletal and pain issues, mental and social health problems, infectious diseases, and longstanding undiagnosed chronic illnesses. Important infectious diseases to consider in the symptomatic patient include tuberculosis, parasites, and malaria. Health maintenance and immunizations should also be addressed. Language barriers, cross-cultural medicine issues, and low levels of health literacy provide additional challenges to caring for this population. The purpose of this article is to provide primary care physicians with a guide to some of the common issues that arise when caring for refugee patients.