Developing a national trauma research action plan: Results from the Burn Research Gap Delphi Survey.

BACKGROUND: The 2016 National Academies of Science, Engineering and Medicine call for a national integrated, military-civilian trauma action plan to achieve zero preventable deaths and disability after injury included a proposal to establish a National Trauma Research Action Plan to "strengthen trauma research and ensure that the resources available for this research are commensurate with the importance of injury and the potential for improvement in patient outcomes." The Department of Defense funded the Coalition for National Trauma Research to generate a comprehensive research agenda spanning the continuum of trauma/burn care from prehospital to rehabilitation. The Burn/Reconstructive Surgery group represents one focus area for this research agenda development. METHODS: Experts in burn and reconstructive surgery research identified gaps in knowledge, generated research questions and prioritized questions using a consensus driven Delphi survey approach. Participants were identified using established Delphi recruitment guidelines to ensure heterogeneity and generalizability with military and civilian representatives. Literature reviews informed the panel. Panelists were encouraged to use a PICO format to generate research questions: Patient/Population; Intervention; Compare/Control; Outcome. Participants ranked the priority of each question on a nine-point Likert scale, which was categorized to represent low, medium, and high priority items. Consensus was defined based on ≥60% panelist agreement. RESULTS: Subject matter experts generated 949 research questions in 29 Burn & 26 Reconstruction topics. Five hundred ninety-seven questions reached consensus. Of these, 338 (57%) were high-priority, 180 (30%), medium-priority, and 78 (13%) low-priority questions. CONCLUSION: Many high-priority questions translate to complex wound management and outcomes. Panel recognition that significant gaps in knowledge exist in understanding functional outcomes after injury underscores the importance of long-term recovery metrics even when studying acute injury or interventions such as resuscitation or inhalation injury. Funding agencies and burn/reconstructive surgery researchers should consider these gaps when they prioritize future research. LEVEL OF EVIDENCE: Expert consensus, Level IV.

Building the foundation for a practice-based research network: supporting primary care research across Canada.

Context: The Strategy for Patient Oriented Research (SPOR) was designed to engage previously passive stakeholders in the research process to ensure that the most urgent health challenges are addressed with evidence-based solutions that are feasible and scalable. The Primary and Integrated Health Care Innovations Network (PIHCIN), one of multiple SPOR entities, is rooted in community-based primary health care and meant to support transformation of primary and integrated care to improve patient experiences and health. Objective: To describe key components of building the foundation for a cross-jurisdictional, practice-based research network. Design: Cross-sectional survey and PIHCI network documentation review. Setting: SPOR PIHCI networks within British Columbia; Alberta; Saskatchewan; Manitoba; Ontario; Quebec; New Brunswick; Nova Scotia; Prince Edward Island; Newfoundland and Labrador; and the Northwest Territories. Participants: Responses were received from 11 networks who completed a template asking about their governance, capacity building, stakeholder engagement and patient partners. Responses were also received from the SPOR PIHCIN Pan-Canadian Patient Council. Outcome Measures: Thematic analysis across responses and documents for key components foundational to PIHCIN: types of stakeholders engaged, types of capacity building activities, knowledge translation and exchange activities. Results: Tripartite (clinician, scientist, decision-maker) leadership was used to align more closely with provincial and territorial needs in bringing practice and research closer together. PIHCIN enabled a unique pan-Canadian forum for government staff responsible for primary care. Individual networks and the PIHCIN patient-partners were actively engaged in research and governance on all levels including leading their own research. PIHCIN built research capacity by partnering with the Transdisciplinary Understanding and Training on Research Primary Health Care (TUTOR-PHC) and embedding fellows within the network. The PIHCI network undertook two separate learning series featuring patients, policy makers and scientists that were open to the public and demonstrated clear impact. Conclusion: Foundational components of embedded patients-partners, tripartite leadership, capacity building and knowledge translation and exchange have led to the formation of the PIHCI network providing an excellent base to build a pan-Canadian practice-based research and learning platform.

Establishing information needs and research priorities in response to the Covid-19 pandemic in the local maternity setting.

The purpose of this project was to identify gaps in the current evidence base and to identify research priorities in the local context during the Covid-19 pandemic. This paper reports on the application and adaptation of the CHNRI methodology which follows a series of criteria setting, filtering and scoring exercises. The views of maternity care professionals, midwifery managers and leaders, women and families were continually sought throughout the project stages. We found the CHNRI methodology to be a useful framework to highlight topics with greater or smaller consensus within a relatively short time frame and with minimal burden to participants. The criteria were defined to focus on research topics where no existing or on-going studies were identified and topics likely to lead to improvements in care with relevance beyond the Covid-19 pandemic.

Marco de referencia de la Red Integrada de Servicios de Salud a la respuesta de COVID-19 / Reference framework of the Integrated Health Services Network to the COVID-19 response

En el marco de la emergencia producida por el nuevo Coronavirus, COVID-19, surgido en la ciudad de Wuhan, provincia de Hubei en la República Popular de China en el mes de diciembre del 2019 y declaración oficial de Pandemia el 11 de marzo de 2020 por el Director General de la Organización Mundial de la Salud (OMS), la Directora de la Organización Panamericana de la Salud (OPS), Dra. Carissa Etienne ha solicitado elevar el nivel de preparación de los servicios de salud. Ante este nuevo escenario el Centro de Operaciones de Emergencias (COE), activado desde enero, ha pasado a una fase en la cual es prioritario orientar esfuerzos a que los servicios de salud de los países en la región de las Américas puedan estar preparados para la respuesta a una trasmisión comunitaria sostenida. En respuesta a estas orientaciones el departamento de sistemas y servicios de salud (HSS), ha definido como lineamiento general responder a la emergencia del COVID-19 a través de las redes de servicios de salud y el enfoque estratégico de Atención Primaria en Salud en los países.

Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil. / Carteira de Serviços da Atenção Primária à Saúde: garantia de integralidade nas Equipes de Saúde da Família e Saúde Bucal no Brasil.

More than 30 years into the anniversary of the Unified Health System (SUS), 40 years after Alma-Ata, and soon after the Astana Conference, the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS). This paper presents the process of developing the national PHC service portfolio, one of the strategies developed by SAPS to strengthen the PHC clinic, and the challenges for the expansion of comprehensive care in the actions developed by the Family Health and Oral Health teams. After the public consultation, from a total of 209 initially listed actions and procedures, including incorporations and exclusions, 210 items were defined, including the actions planned for the integration between primary care and health surveillance. We emphasize that the national portfolio model can be adapted to the reality and municipal context in each of the federation units, including considering the availability of the local care network.

Ao ultrapassarmos os 30 anos do Sistema Único de Saúde (SUS), após 40 anos de Alma-Ata e logo após a Conferência de Astana, o Ministério da Saúde do Brasil propõe diversas estratégias de fortalecimento da APS com a criação da Secretaria de Atenção Primária à Saúde (SAPS). Este artigo apresenta o processo de desenvolvimento da carteira nacional de serviços para a APS, uma das estratégias desenvolvidas pela SAPS para fortalecimento da clínica na APS, e os desafios para a ampliação da integralidade do cuidado nas ações desenvolvidas pelas equipes de Saúde da Família e Saúde Bucal. Após a consulta pública, de um total de 209 ações e procedimentos inicialmente listados, entre incorporações e exclusões, foram definidos 210 itens, incluindo as ações previstas para a integração entre atenção primária e vigilância em saúde. Ressaltamos que o modelo da carteira nacional pode ser adaptado à realidade e contexto municipal em cada uma das unidades da federação, inclusive considerando a disponibilidade da rede de atenção local.

Carteira de Serviços da Atenção Primária à Saúde: garantia de integralidade nas Equipes de Saúde da Família e Saúde Bucal no Brasil / Primary Health Care Portfolio: Assuring of integrality in the Family Health and Oral Health Teams in Brazil

Resumo Ao ultrapassarmos os 30 anos do Sistema Único de Saúde (SUS), após 40 anos de Alma-Ata e logo após a Conferência de Astana, o Ministério da Saúde do Brasil propõe diversas estratégias de fortalecimento da APS com a criação da Secretaria de Atenção Primária à Saúde (SAPS). Este artigo apresenta o processo de desenvolvimento da carteira nacional de serviços para a APS, uma das estratégias desenvolvidas pela SAPS para fortalecimento da clínica na APS, e os desafios para a ampliação da integralidade do cuidado nas ações desenvolvidas pelas equipes de Saúde da Família e Saúde Bucal. Após a consulta pública, de um total de 209 ações e procedimentos inicialmente listados, entre incorporações e exclusões, foram definidos 210 itens, incluindo as ações previstas para a integração entre atenção primária e vigilância em saúde. Ressaltamos que o modelo da carteira nacional pode ser adaptado à realidade e contexto municipal em cada uma das unidades da federação, inclusive considerando a disponibilidade da rede de atenção local.

Abstract More than 30 years into the anniversary of the Unified Health System (SUS), 40 years after Alma-Ata, and soon after the Astana Conference, the Brazilian Ministry of Health proposes several strategies to strengthen PHC with the creation of the Primary Health Care Secretariat (SAPS). This paper presents the process of developing the national PHC service portfolio, one of the strategies developed by SAPS to strengthen the PHC clinic, and the challenges for the expansion of comprehensive care in the actions developed by the Family Health and Oral Health teams. After the public consultation, from a total of 209 initially listed actions and procedures, including incorporations and exclusions, 210 items were defined, including the actions planned for the integration between primary care and health surveillance. We emphasize that the national portfolio model can be adapted to the reality and municipal context in each of the federation units, including considering the availability of the local care network.

A mixed-methods approach to understanding partnership experiences and outcomes of projects from an integrated knowledge translation funding model in rehabilitation.

BACKGROUND: Integrated knowledge translation (IKT) can optimize the uptake of research evidence into clinical practice by incorporating knowledge users as equal partners in the entire research process. Although several studies have investigated stakeholder involvement in research, the literature on partnerships between researchers and clinicians in rehabilitation and their impact on clinical practice is scarce. This study described the individual research projects, the outcomes of these projects on clinical practice and the partnership experiences of an initiative that funds IKT projects co-led by a rehabilitation clinician and a researcher. METHODS: This was a sequential explanatory mixed methods study where quantitative data (document reviews and surveys) informed the qualitative phase (focus groups with researchers and interviews with clinicians). Descriptive analysis was completed for the quantitative data and thematic analysis was used for the qualitative data. RESULTS: 53 projects were classified within multiple steps of the KTA framework. Descriptive information on the projects and outcomes were obtained through the survey for 37 of the 53 funded projects (70%). Half of the respondents (n = 18) were very satisfied or satisfied with their project's impact. Only two (6%) projects reported having measured sustainability of their projects and four (11%) measured long-term impact. A focus group with six researchers and individual interviews with nine clinicians highlighted the benefits (e.g. acquired collaborative skills, stronger networks between clinicians and academia) and challenges (e.g. measuring KT outcomes, lack of planning for sustainability, barriers related to clinician involvement in research) of participating in this initiative. Considerations when partnering on IKT projects included: the importance of having a supportive organization culture and physical proximity between collaborators, sharing motives for participating, leveraging everyone's expertise, grounding projects in KT models, discussing feasibility of projects on a restricted timeline, and incorporating the necessary knowledge users. Clinicians discussed the main outputs (scientific contribution, training and development, increased awareness of best practice, step in a larger effort) as project outcomes, but highlighted the complexity of measuring outcomes on clinical practice. CONCLUSION: The study provides a portrait of an IKT funding model, sheds light on past IKT projects' strengths and weaknesses and provides strategies for promoting positive partnership experiences between researchers and rehabilitation clinicians.

The conduct of Australian Indigenous primary health care research focusing on social and emotional wellbeing: a systematic review.

Objectives and importance of study: Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research (Values and ethics) describes key values that should underpin Aboriginal and Torres Strait Islander (Indigenous)-focused health research. It is unclear how research teams address this document in primary health care research. We systematically review the primary health care literature focusing on Indigenous social and emotional wellbeing (SEWB) to identify how Values and ethics and community preferences for standards of behaviour (local protocols) are addressed during research. STUDY TYPE: Systematic review in accordance with PRISMA Guidelines and MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. METHODS: We searched four databases and one Indigenous-specific website for qualitative, quantitative and mixed-method studies published since Values and ethics was implemented (2003). Included studies were conducted in primary health care services, focused on Indigenous SEWB and were conducted by research teams. Using standard data extraction forms, we identified actions taken (reported by authors or identified by us) relating to Values and ethics and local protocols. RESULTS: A total of 25 studies were included. Authors of two studies explicitly mentioned the Values and ethics document, but neither reported how their actions related to the document's values. In more than half the studies, we identified at least three actions relating to the values. Some actions related to multiple values, including use of culturally sensitive research processes and involving Indigenous representatives in the research team. Local protocols were rarely reported. CONCLUSION: Addressing Values and ethics appears to improve research projects. The academic community should focus on culturally sensitive research processes, relationship building and developing the Indigenous research workforce, to facilitate acceptable research that affects health outcomes. For Values and ethics to achieve its full impact and to improve learning between research teams, authors should be encouraged to report how the principles are addressed during research, including barriers and enablers that are encountered.

Research priorities in health communication and participation: international survey of consumers and other stakeholders.

OBJECTIVE: To identify research priorities of consumers and other stakeholders to inform Cochrane Reviews in 'health communication and participation' (including such concepts as patient experience, shared decision-making and health literacy). SETTING: International. PARTICIPANTS: We included anyone with an interest in health communication and participation. Up to 151 participants (18-80 years; 117 female) across 12 countries took part, including 48 consumers (patients, carers, consumer representatives) and 75 professionals (health professionals, policymakers, researchers) (plus 25 people who identified as both). DESIGN: Survey. METHODS: We invited people to submit their research ideas via an online survey open for 4 weeks. Using inductive thematic analysis, we generated priority research topics, then classified these into broader themes. RESULTS: Participants submitted 200 research ideas, which we grouped into 21 priority topics. Key research priorities included: insufficient consumer involvement in research (19 responses), 'official' health information is contradictory and hard to understand (18 responses), communication/coordination breakdowns in health services (15 responses), health information provision a low priority for health professionals (15 responses), insufficient eliciting of patient preferences (14 responses), health services poorly understand/implement patient-centred care (14 responses), lack of holistic care impacting healthcare quality and safety (13 responses) and inadequate consumer involvement in service design (11 responses). These priorities encompassed acute and community health settings, with implications for policy and research. Priority populations of interest included people from diverse cultural and linguistic backgrounds, carers, and people with low educational attainment, or mental illness. Most frequently suggested interventions focused on training and cultural change activities for health services and health professionals. CONCLUSIONS: Consumers and other stakeholders want research addressing structural and cultural challenges in health services (eg, lack of holistic, patient-centred, culturally safe care) and building health professionals' communication skills. Solutions should be devised in partnership with consumers, and focus on the needs of vulnerable groups.

Quality of Sick Child-Care Delivered by Community Health Workers in Tanzania.

BACKGROUND: Community health worker (CHW) interventions to manage childhood illness is a strategy promoted by the global health community which involves training and supporting CHW to assess, classify and treat sick children at home, using an algorithm adapted from the Integrated Management of Childhood Illness (IMCI). To inform CHW policy, the Government of Tanzania launched a program in 2011 to determine if community case management (CCM) of malaria, pneumonia and diarrhea could be implemented by CHW in that country. METHODS: This paper reports the results of an observational study on the CCM service delivery quality of a trial cohort of CHW in Tanzania, called WAJA. In 2014, teams of data collectors, employees of the Ministry of Health and Social Welfare trained in IMCI, assessed the IMCI skills rendered by a sample of WAJA on sick children who presented to WAJA with illness signs and symptoms in their communities. The assessment included direct observations of WAJA IMCI episodes and expert re-assessment of the same children seen by WAJA to assess the congruence between the assessment, classification and treatment outcomes of WAJA cases and those from cases conducted by expert re-assessors. RESULTS: In the majority of cases, WAJA correctly assess sick children for CCM-treatable illnesses (malaria, pneumonia, and diarrhea) and general danger signs (90% and 89%, respectively), but too few correctly assess for physical danger signs (39%); on classification in the majority of cases (73%) WAJA correctly classified illness, though more for CCM-treatable illnesses (83%). In majority of cases (78%) WAJA treated children correctly (84% of malaria, 74% pneumonia, and 71% diarrhea cases). Errors were often associated with lapses in health systems support, mainly supervision and logistics. CONCLUSION: CCM is a feasible strategy for CHW in Tanzania, who, in the majority of cases, implemented the approach as well as IMCI expert re-assessors. Nevertheless, for CCM to be effective, in Tanzania, a strategy to implement it must be coordinated with efforts to strengthen local health systems.

Primary Care Behavioral Health (PCBH) Model Research: Current State of the Science and a Call to Action.

The Primary Care Behavioral Health (PCBH) model of service delivery is being used increasingly as an effective way to integrate behavioral health services into primary care. Despite its growing popularity, scientifically robust research on the model is lacking. In this article, we provide a qualitative review of published PCBH model research on patient and implementation outcomes. We review common barriers and potential solutions for improving the quantity and quality of PCBH model research, the vital data that need to be collected over the next 10 years, and how to collect those data.

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes.

BACKGROUND: Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members. OBJECTIVE: The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps. METHODS: We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future. RESULTS: We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions. CONCLUSIONS: The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

[Patients, players in healthcare research]. / Les patients, acteurs de la recherche en soins.

Healthcare research is developing in France, notably through hospital nursing and paramedical research programmes. Few research projects involve the patients as investigators as part of collaborative studies. These approaches favour the involvement of all the players concerned. Thereby, healthcare research, due to its holistic dimension, encourages the development of collaborative practices between researchers, patients and caregivers.

[Integration and utilization of physiotherapy in hospice and palliative care : A survey on clinical practice in Germany]. / Die Einbindung und Anwendung der Physiotherapie in der Hospiz- und Palliativversorgung : Ein Survey zur Praxis in Deutschland.

BACKGROUND: Palliative care is an approach that improves the quality of life of patients with incurable and progressive illnesses; therefore, in these situations physiotherapy can play an important role. AIM: This study was carried out to examine the integration and utilization of physiotherapy in palliative and hospice care services in Germany. METHODS: A cross-sectional survey including all palliative care units, specialized outpatient palliative care teams and hospices in Germany (n = 680) in 2013 was carried out. RESULTS: The response rate was 43.5 % (n = 296). Physiotherapy is predominantly applied in palliative care units (79 %) but rarely in hospices (38 %) and outpatient palliative care teams (30 %). A structured physiotherapeutic assessment is rarely carried out even on palliative care units (26 %). Positive effects of physiotherapy are especially described for symptoms, such as edema, pain, constipation and dyspnea. CONCLUSION: Despite its significant potential to relieve symptoms, physiotherapy is not systematically integrated into palliative care practice in Germany.

Repercussões da avaliação PMAQ-AB no processo de trabalho das equipes de Saúde da Família / Repercussions of the PMAQ-AB evaluation in the work process of the Family Health teams

O objetivo deste estudo foi analisar as repercussões da avaliação PMAQ-AB no processo de trabalho das equipes de saúde da família avaliadas. Para abordar esse objeto, utilizou-se como referencial teórico o processo de trabalho em saúde e a avaliação dos serviços de saúde no contexto da Atenção Primária à Saúde (APS), situando o Programa de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB). Trata-se de pesquisa qualitativa, na forma de estudo de caso, realizado no Departamento Regional de Saúde V - Barretos (DRS-V), cuja amostra foi constituída por dez profissionais. As entrevistas foram semiestruturadas e realizadas no local de trabalho. A análise das entrevistas seguiu a análise de conteúdo temática de Bardin. Tomou-se como referência o trabalho e o processo de trabalho, segundo Marx e Gonçalves, e os três elementos que o compõe: objeto, meio e finalidade. O PMAQ-AB apresentou-se como um instrumento capaz de induzir modificações, principalmente, relacionadas ao meio e às tecnologias duras e leve duras como: melhorias na infraestrutura, ampliação da oferta e redistribuição de área. Identificou-se o fortalecimento do trabalho vivo e das tecnologias leves no trabalho da equipe. Os resultados permitiram concluir que ele foi considerado em sua maioria; como uma ferramenta essencial para identificar lacunas no processo de trabalho, induzir reflexões críticas a partir da realidade vivenciada pelas equipes, e contribuiu para melhor organização do processo de trabalho. Os desafios encontrados pelas equipes foram a dificuldade de implantação das Práticas Integrativas e Complementares (PICs), a rotatividade dos profissionais, a falta de apoio institucional, a falta de apoio dos gestores e a carência em ações de educação permanente. Comprova-se neste estudo, algumas fragilidades do PMAQ-AB, como a forte relação entre o instrumento e o repasse de recursos financeiros, a falta de espaços para devolutiva dos dados, e a possibilidade de mascaramento das ações nas equipes. Considera-se que este estudo, pode contribuir para um novo olhar e para o desenvolvimento de novos trabalhos a partir da institucionalização da avaliação nos serviços de saúde, na visão dos avaliados que compõem este processo, e também para validar o instrumento de avaliação PMAQ-AB

The objective of this study was to analyze the repercussions of the PMAQ-AB evaluation in the work process of the family health teams evaluated. In order to approach this object, we use as theoretical reference, the work process in health and the evaluation of health services in the context of Primary Health Care (PHC), placing the Program of Improvement of Access and Quality of Primary Care (PMAQ-AB ). It is a qualitative research, in the form of a case study, carried out in the Regional Health Department V-Barretos (DRS-V), whose sample was constituted by ten professionals, the interviews were semi-structured and performed in the workplace. The analysis of the interviews followed the analysis of the thematic content of Bardin. According to Marx and Gonçalves, and the three elements that compose it: object, means and purpose, PMAQ-AB presented itself as an instrument capable of inducing changes mainly related to the environment and the hard and light technologies such as: infrastructure improvements, supply expansion and area redistribution. We identified the strengthening of living labor and light technologies in the work of the team. The results allowed us to conclude that it was considered mostly as an essential tool to identify gaps in the work process, to induce critical reflections based on the reality experienced by the teams, and to contribute to a better organization of the work process. The challenges encountered by the teams were the difficulty of implementing the Integrative and Complementary Practices (ICPs), the turnover of professionals, lack of institutional support, lack of support from managers and the lack of permanent education actions. In this study, we verified some weaknesses of PMAQ-AB, such as the strong relationship between the instrument and the transfer of financial resources, the lack of spaces for data retrieval, and the possibility of masking the actions in the teams. We believe that this study may contribute to a new look and to the development of new work from the institutionalization of evaluation in the health services, from the view of the evaluators that compose this process and also to validate the PMAQ-AB evaluation instrument

[Health services Research Faces New Challenges: Consequences for Definition and Concept]. / Versorgungsforschung vor neuen Herausforderungen: Konsequenzen für Definition und Konzept.

In Germany, Health Services Research (HSR) is undergoing rapid and impressive development. Starting from the translation of methods in individual health care (efficacy-effectiveness gap) and the social-scientific description as well as analysis of health care structures and processes, now it is the implementation of complex interventions on the organizational and system level that is the center of interest. This development is mainly triggered by the establishment of the so-called innovation funds by means of legislation in 2015, which has the task to evaluate structural changes and reforms in outpatient and integrated health care. Moreover, benefit and improvement at patient and population level is getting attention. Against this background, in this paper the current definition of HSR is modified so that the term "intervention" is extended to include organizational and system interventions, the focus on population is added to the patient perspective, and the orientation to appropriateness of care and improvement is integrated. Parallel to this, the theoretical throughput model as established by Pfaff in 2003 is updated, including 4 aspects: (1) the input factors of first order (resources of stakeholders) are expanded by complex interventions and active context as input factors of second order, (2) both undergoing modulation during the following throughput, (3) the final outcome is expanded by the population perspective, and (4) feedback loops from output and outcome to input and throughput are established. The "double complexity" of intervention and context as well as their interaction during throughput is the central and most important issue, because the interventions are highly context-sensitive and the complex context is most potent and poorly anticipated at the same time. Improvement science and implementation research represent fields of research from the perspective of improvement and the translation of knowledge and change of attitude, respectively, which are of great importance for HSR. Insofar as HSR is dealing with improvement and translation of complex interventions, the health care politics constitute an important transfer factor itself. Considering that, in the present situation, the political level represents both the main sponsor and the main demander of HSR results, improving methodological standards and further expansion of research structures of HSR are urgently needed.

Integrated and Gender-Affirming Transgender Clinical Care and Research.

Transgender (trans) communities worldwide, particularly those on the trans feminine spectrum, are disproportionately burdened by HIV infection and at risk for HIV acquisition/transmission. Trans individuals represent an underserved, highly stigmatized, and under-resourced population not only in HIV prevention efforts but also in delivery of general primary medical and clinical care that is gender affirming. We offer a model of gender-affirmative integrated clinical care and community research to address and intervene on disparities in HIV infection for transgender people. We define trans terminology, briefly review the social epidemiology of HIV infection among trans individuals, highlight gender affirmation as a key social determinant of health, describe exemplar models of gender-affirmative clinical care in Boston MA, New York, NY, and San Francisco, CA, and offer suggested "best practices" for how to integrate clinical care and research for the field of HIV prevention. Holistic and culturally responsive HIV prevention interventions must be grounded in the lived realities the trans community faces to reduce disparities in HIV infection. HIV prevention interventions will be most effective if they use a structural approach and integrate primary concerns of transgender people (eg, gender-affirmative care and management of gender transition) alongside delivery of HIV-related services (eg, biobehavioral prevention, HIV testing, linkage to care, and treatment).