Learning from the universal, proactive outreach of the Brazilian Community Health Worker model: impact of a Community Health and Wellbeing Worker initiative on vaccination, cancer screening and NHS health check uptake in a deprived community in the UK.

BACKGROUND: Delays in preventative service uptake are increasing in the UK. Universal, comprehensive monthly outreach by Community Health and Wellbeing Workers (CHW), who are integrated at the GP practice and local authority, offer a promising alternative to general public health campaigns as it personalises health promotion and prevention of disease holistically at the household level. We sought to test the ability of this model, which is based on the Brazilian Family Health Strategy, to increase prevention uptake in the UK. METHODS: Analysis of primary care patient records for 662 households that were allocated to five CHWWs from July 2021. Primary outcome was the Composite Referral Completion Indicator (CRCI), a measure of how many health promotion activities were received by members of a household relative to the ones that they were eligible for during the period July 2021-April 2022. The CRCI was compared between the intervention group (those who had received at least one visit) and the control group (allocated households that were yet to receive a visit). A secondary outcome was the number of GP visits in the intervention and control groups during the study period and compared to a year prior. RESULTS: Intervention and control groups were largely comparable in terms of household occupancy and service eligibilities. A total of 2251 patients in 662 corresponding households were allocated to 5 CHWs and 160 households had received at least one visit during the intervention period. The remaining households were included in the control group. Overall service uptake was 40% higher in the intervention group compared to control group (CRCI: 0.21 ± 0.15 and 0.15 ± 0.19 respectively). Likelihood of immunisation uptake specifically was 47% higher and cancer screening and NHS Health Checks was 82% higher. The average number of GP consultations per household decreased by 7.4% in the intervention group over the first 10 months of the pilot compared to the 10 months preceding its start, compared with a 0.6% decrease in the control group. CONCLUSIONS: Despite the short study period these are promising findings in this deprived, traditionally hard to reach community and demonstrates potential for the Brazilian community health worker model to be impactful in the UK. Further analysis is needed to examine if this approach can reduce health inequalities and increase cost effectiveness of health promotion approaches.

Perinatal Health in Amazon Triple Border Region: Cross-Sectional Analysis Comparing Outcomes in the Brazilian, Peruvian and Colombian Population.

OBJECTIVE: To investigate the perinatal outcomes in Brazilian, Peruvian, and Colombian women in a Brazilian reference maternity hospital based at Amazon triple border region. METHOD: A cross-sectional case study of data from 3242 live birth certificates issued at the Tabatinga public maternity hospital, in the countryside of Amazonas, in the period between January 2015 and December 2017. Maternal and perinatal independent variables were analysed based on central tendency and variability, and frequency distribution for categorical variables. The Pearson's Chi-Square test and univariate analyses were performed to estimate probability ratios (Odds Ratio-OR). RESULTS: Significant differences were found in the education level in the three population groups, as well as in the number of previous pregnancies, antenatal consultations, month of initial prenatal care, and type of delivery. Brazilian pregnant women had more prenatal consultations, caesarean sections, and premature births. Peruvian and Colombian women started antenatal care later, and those with high-risk pregnancies tended to deliver in their home country. CONCLUSION FOR PRACTICE: Our findings show some singularities in the care of women and infants in the Amazonian triple border region. The Brazilian Unified Health Care System performs an important role in the guarantee of free access to health services, and ensures comprehensive care for women and infants, promoting human rights in border regions regardless of nationality.

Effects of Combined Inorganic Nitrate and Nitrite Supplementation on Cardiorespiratory Fitness and Skeletal Muscle Oxidative Capacity in Type 2 Diabetes: A Pilot Randomized Controlled Trial.

Nitric oxide (NO) stimulates mitochondrial biogenesis in skeletal muscle. However, NO metabolism is disrupted in individuals with type 2 diabetes mellitus (T2DM) potentially contributing to their decreased cardiorespiratory fitness (i.e., VO2max) and skeletal muscle oxidative capacity. We used a randomized, double-blind, placebo-controlled, 8-week trial with beetroot juice containing nitrate (NO3−) and nitrite (NO2−) (250 mg and 20 mg/day) to test potential benefits on VO2max and skeletal muscle oxidative capacity in T2DM. T2DM (N = 36, Age = 59 ± 9 years; BMI = 31.9 ± 5.0 kg/m2) and age- and BMI-matched non-diabetic controls (N = 15, Age = 60 ± 9 years; BMI = 29.5 ± 4.6 kg/m2) were studied. Mitochondrial respiratory capacity was assessed in muscle biopsies from a subgroup of T2DM and controls (N = 19 and N = 10, respectively). At baseline, T2DM had higher plasma NO3− (100%; p < 0.001) and lower plasma NO2− levels (−46.8%; p < 0.0001) than controls. VO2max was lower in T2DM (−26.4%; p < 0.001), as was maximal carbohydrate- and fatty acid-supported oxygen consumption in permeabilized muscle fibers (−26.1% and −25.5%, respectively; p < 0.05). NO3−/NO2− supplementation increased VO2max (5.3%; p < 0.01). Further, circulating NO2−, but not NO3−, positively correlated with VO2max after supplementation (R2= 0.40; p < 0.05). Within the NO3−/NO2− group, 42% of subjects presented improvements in both carbohydrate- and fatty acid-supported oxygen consumption in skeletal muscle (vs. 0% in placebo; p < 0.05). VO2max improvements in these individuals tended to be larger than in the rest of the NO3−/NO2− group (1.21 ± 0.51 mL/(kg*min) vs. 0.31 ± 0.10 mL/(kg*min); p = 0.09). NO3−/NO2− supplementation increases VO2max in T2DM individuals and improvements in skeletal muscle oxidative capacity appear to occur in those with more pronounced increases in VO2max.

The NCI library of traditional Chinese medicinal plant extracts - Preliminary assessment of the NCI-60 activity and chemical profiling of selected species.

Botanical-based natural products are an important resource for medicinal drug discovery and continue to provide diverse pharmacophores with therapeutic potential against cancer and other human diseases. A prototype Traditional Chinese Medicine (TCM) plant extract library has been established at the US National Cancer Institute, which contains both the organic and aqueous extracts of 132 authenticated medicinal plant species that collectively represent the potential therapeutic contents of most commonly used TCM herbal prescriptions. This library is publicly available in 96- and 384- well plates for high throughput screening across a broad array of biological targets, as well as in larger quantities for isolation of active chemical ingredients. Herein, we present the methodology used to generate the library and the preliminary assessment of the anti-proliferative activity of this crude extract library in NCI-60 human cancer cell lines screen. Particularly, we report the chemical profiling and metabolome comparison analysis of four commonly used TCM plants, namely Brucea javanica, Dioscorea nipponica, Cynanchum atratum, and Salvia miltiorrhiza. Bioassay-guided isolation resulted in the identification of the active compounds, and different extraction methods were compared for their abilities to extract cytotoxic compounds and to concentrate biologically active natural products.

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study.

OBJECTIVE: To model cost and benefit of a national community health worker workforce. DESIGN: Modelling exercise based on all general practices in England. SETTING: United Kingdom National Health Service Primary Care. PARTICIPANTS: Not applicable. DATA SOURCES: Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. MAIN OUTCOME MEASURES: We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. RESULTS: Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. CONCLUSION: A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care.

Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study.

BACKGROUND: Person-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient's world. Patient-centeredness has been commonly defined through physician's behaviors aimed at delivering patient-centered care. Yet, it is unclear how 'person-centeredness' is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context. METHODS: We conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison. RESULTS: We identified six themes representing core 'ingredients' of person-centeredness in the integrated care context: "Holism", "Naming", "Heed", "Compassion", "Continuity of care", and "Agency and Empowerment", all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt 'unseen' by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional 'Space' to be 'seen' and heard vs. feeling 'translucent', 'unseen', and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a 'dyad', the meanings patients attributed to 'care', and the theoretical correspondence between 'person-centeredness' and 'integrated care'. CONCLUSIONS: Person-centeredness is a crucial issue for patients in integrated care, yet it was variably achieved in the current pilot. Patients in the context of integrated care, as in other contexts, strive to have their own unique physical and emotional 'space' to be 'seen' and heard. Integrated care models can benefit from incorporating person-centeredness as a core element.

Achieving provider engagement: providers' perceptions of implementing and delivering integrated care.

The literature on integrated care is limited with respect to practical learning and experience. Although some attention has been paid to organizational processes and structures, not enough is paid to people, relationships, and the importance of these in bringing about integration. Little is known, for example, about provider engagement in the organizational change process, how to obtain and maintain it, and how it is demonstrated in the delivery of integrated care. Based on qualitative data from the evaluation of a large-scale integrated care initiative in London, United Kingdom, we explored the role of provider engagement in effective integration of services. Using thematic analysis, we identified an evolving engagement narrative with three distinct phases: enthusiasm, antipathy, and ambivalence, and argue that health care managers need to be aware of the impact of professional engagement to succeed in advancing the integrated care agenda.

Integrated care pilot in north-west London: a mixed methods evaluation.

INTRODUCTION: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. METHODS: The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). RESULTS: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. CONCLUSION: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time.

The commissioning reforms in the English National Health Service and their potential impact on primary care.

Reform of the National Health Service in England will increase power and responsibility for family doctors. They will have a larger role in planning and buying health care including control of substantial budgets. This article examines the likely implications of the proposed reforms for primary care, and in particularly for family doctors. This article considers the effect of the new clinical role in commissioning health care, changes to the accountability structures, and the effect on competition and integration within health services. It also considers the effect of new financial incentives and the possibility of creating conflicts of interest.

The North West London Integrated Care Pilot: innovative strategies to improve care coordination for older adults and people with diabetes.

The North West London Integrated Care Pilot (ICP) was launched in June 2011 and brings together more than 100 general practices, 2 acute care trusts, 5 primary care trusts, 2 mental health care trusts, 3 community health trusts, 5 local authorities, and 2 voluntary sector organizations (Age UK and Diabetes UK) to improve the coordination of care for a pilot population of 550 000 people. Specifically, the ICP serves people older than 75 years and those with diabetes. Although still in the early stages of implementation, the ICP has already received national awards for its innovations in design and delivery. This article critically describes the ICP objectives, facilitating processes, and planned impact as well as the organizational and financial challenges that policy makers are facing in the implementation of the pilot program.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework / Pagamento para desempenho no Programa Saúde da Família: lições do Quality and Outcomes Framework da Inglaterra

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

OBJETIVO: Esquemas de pagamento para desempenho recompensam o médico baseado na qualidade e no resultado do tratamento dos seus pacientes. O Ministério da Saúde brasileiro analisa seu uso em hospitais públicos e alguns municípios estão desenvolvendo estratégias de pagamento por desempenho para o Programa de Saúde da Família. No artigo discute-se o Quality and Outcomes Framework - esquema de pagamento para desempenho usado no Reino Unido desde 2004, bem como sua experiência para elaborar algumas lições importantes que os municípios brasileiros devem considerar antes de empreender o esquema de pagamento por desempenho na atenção primária.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework.

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

Enhancing the efficiency of N-ethyl-N-nitrosourea-induced mutagenesis in the zebrafish.

N-Ethyl-N-nitrosourea (ENU) treatment is the standard experimental method used for chemical mutagenesis of many vertebrate organisms commonly used in the laboratory. In zebrafish and medaka, the use of a repetitive, sublethal dose of 3-3.5 mM ENU has been shown to give the best balance between mutagenicity and toxicity. However, even at this concentration, a significant proportion of fish die during the treatment. Therefore, large numbers of fish are required to obtain a sufficient number of mutagenized founders at the end of the procedure. Additionally, it is quite common to have high levels of mortality in any particular dosing cycle. This may cause a mutagenesis experiment to suddenly fail after several weeks of work. Here we provide a very simple method for ENU mutagenesis of zebrafish using a subparalytic dose of clove oil as a sedative that drastically reduces the lethality of ENU treatment in fish. This facilitates ENU mutagenesis protocols considerably, facilitates higher dosing, and allows for sensitive strains of fish such as homozygous mutants to be mutagenized for use in genetic studies.