Results From a National Mixed-Methods Study Exploring Community Health Improvement Implementation: An Opportunity to Strengthen Public Health Systems Through Collective Action.

CONTEXT: There are multiple calls for public health agency role and workforce transformation to increase capacity to orchestrate cross-sectoral partnerships that set and implement strategies addressing the structural and social determinants of health. Mobilizing for Action through Planning and Partnerships (MAPP) may be one tool for collective action to improve population health and equity. However, little is known about the Action Cycle in MAPP and implementation of resulting community health improvement plans. OBJECTIVE: To explore the characteristics of MAPP users who completed the MAPP Action Cycle and factors that facilitated or inhibited implementation activities during this phase. METHODS: We used a sequential participatory mixed-methods design involving 2 phases of data collection. The first data collection phase included a Web-based survey using Qualtrics. The second data collection phase included qualitative key-informant interviews and focus groups. A national public health and health care advisory group informed the evaluation throughout the entire process to ground the process in practice and experience. RESULTS: This study showed that some MAPP participants do not conduct implementation activities as defined by the MAPP Action Cycle and of those who do, implementation activity varies by participant experiences conducting MAPP and accreditation status. The MAPP users who completed 3 or more rounds of MAPP were more likely to align and integrate MAPP within their agencies as well as organize a collaborative implementation process with partners. More resources and skills in planning that facilitate long-range partnerships were noted as key to implementation. CONCLUSIONS: Opportunity remains to improve implementation in MAPP. National leaders should explore and build capacity and infrastructure within public health agencies and with their partners to create a system of readiness and an infrastructure that support implementation over time.

Spatial equity in the layout of urban public sports facilities in Hangzhou.

This paper proposes a framework for a layout evaluation of urban public sports facilities. First, the buffer analysis method is used to measure the service level of public sports facilities. The study findings indicate that the overall service level of public sports facilities presents the spatial characteristics of a central agglomeration, and the value of the service level diffuses outward from high to low. There is evident spatial heterogeneity in the layout of public sports facilities in Hangzhou. Second, the Gini coefficient, Lorenz curve, and location entropy are employed to measure the equity of the distribution among spatial units and the intradistrict disparity. The results show a mismatch between the spatial distribution of the facilities and the distribution of the permanent population. The patterns of distribution of the location entropy classes of Hangzhou can be divided into three types: balanced, alternating, and divergent districts. The method in this paper is effective in measuring spatial equity and visualizing it. it has a certain degree of systemicity, universality and operability. At the same time, this method can compare the diachronic characteristics of the same city and the synchronic characteristics of different cities, which has universal application value.

Assessment of diabetes knowledge, screening and uptake of community diabetes programs in a peri-urban region in Australia.

AIMS: The Wollondilly Diabetes Program (WDP) is testing ways to improve uptake of diabetes prevention services. This project evaluated the reach of WDP in diabetes promotion while assessing diabetes knowledge and risk among residents. METHODS: A WDP member travelled in the DW weekly to community events including outreach programs between October 2016 and June 2019. Data from diabetes knowledge questionnaire (DKQ), the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK), HbA1c and Random Blood Glucose (RBG) measurements obtained from participants who attended community events and road shows. RESULTS: Over the 32 months period, WDP attended 32 community events reaching 1415 people (∼3% of the Wollondilly adult population). DKQ was completed by 154 people (52.9% females, 78% Australian born, median age 69 years), 39% had diabetes and their mean score (25.0 ± 3.1, maximum possible score = 31) was similar to those without diabetes (24.0 ± 4.6, p = 0.093). AUSDRISK assessment was completed by 166 people with 85% at intermediate or high risk of diabetes. There were 65% results above range for RBG (≥5.5 mmol/l) and/or HbA1c (≥5.7%,39 mmol/mol). CONCLUSION: A community outreach team set up in partnership with local stakeholders that offers opportunistic diabetes screening, is an effective way of engaging with the community to increase diabetes awareness and knowledge.

Prevalence of winter migration to warmer destinations among Ontarians ("snowbirds") and patterns of their use of health care services: a population-based analysis.

BACKGROUND: Older Canadians frequently migrate to warmer destinations for the winter season (snowbirds). Our aim was to examine the prevalence of migration to warmer destinations among Ontarians, and to compare the characteristics and use of health care services of snowbirds to those of older Ontarians who did not migrate for the winter. METHODS: We conducted a population-based analysis using health administrative databases from Ontario. We compiled 10 seasonal cohorts (2009/10 to 2018/19) of adults aged 65 or more who filled a travel supply of medications under the Ontario Drug Benefits program (snowbirds) between September and January (snowbird season). We calculated the seasonal prevalence of snowbirds per 100 Ontarians aged 65 or more. We matched each snowbird in the 2018/19 season to 2 nonsnowbirds on age and sex, and compared their characteristics and patterns of use of government-funded health care services. RESULTS: Over the 10-year period, 53 431 to 70 863 Ontarians aged 65 or more were identified as snowbirds (seasonal prevalence 2.6%-3.3%). Compared to nonsnowbirds, snowbirds were more likely to be recent migrants, live in higher-income neighbourhoods, have fewer comorbidities and make more visits to primary care physicians. From January to March 2019, snowbirds accessed government-funded health care services for a median of 0 days (interquartile range [IQR] 0-1 d), compared to 4 days (IQR 2-8 d) among nonsnowbirds. INTERPRETATION: About 3% of older Ontarians migrate to warmer destinations for the winter each season. Since few access health care services in Ontario from January to March, researchers are encouraged to consider the snowbird population and the impact of their absence on evaluations that assume continuous observation.

Low incidence of ABL-class and JAK-STAT signaling pathway alterations in uniformly treated pediatric and adult B-cell acute lymphoblastic leukemia patients using MRD risk-directed approach - a population-based study.

BACKGROUND: ABL-class and JAK-STAT signaling pathway activating alterations have been associated with both a poor post-induction minimal residual disease (MRD) response and an inferior outcome in B-cell acute lymphoblastic leukemia (B-ALL). However, in most of the studies patients received non-uniform treatment. METHODS: We performed a population-based analysis of 160 (122 pediatric and 38 adult) Lithuanian BCR-ABL1-negative B-ALL patients who had been uniformly treated according to MRD-directed NOPHO ALL-2008 protocol. Targeted RNA sequencing and FISH analysis were performed in cases without canonical B-ALL genomic alterations (high hyperdiploids and low hypodiploids included). RESULTS: We identified ABL-class fusions in 3/160 (1.9%) B-ALL patients, and exclusively in adults (p = 0.003). JAK-STAT pathway fusions were present in 4/160 (2.5%) cases. Of note, P2RY8-CRLF2 fusion was absent in both pediatric and adult B-ALL cases. Patients with ABL-class or JAK-STAT pathway fusions had a poor MRD response and were assigned to the higher risk groups, and had an inferior event-free survival (EFS) / overall survival (OS) compared to patients without these fusions. In a multivariate analysis, positivity for ABL-class and JAK-STAT fusions was a risk factor for worse EFS (p = 0.046) but not for OS (p = 0.278) in adults. CONCLUSIONS: We report a low overall frequency of ABL-class and JAK-STAT fusions and the absence of P2RY8-CRLF2 gene fusion in the Lithuanian BCR-ABL1 negative B-ALL cohort. Future (larger) studies are warranted to confirm an inferior event-free survival of ABL-class/JAK-STAT fusion-positive adult patients in MRD-directed protocols.

Wheelchair Seated Posture and Health Outcomes of Older Veterans in Community Living Centers.

PURPOSE: Nursing home residents sit in wheelchairs (WCs) for extended periods, often with slumped posture. They often experience pneumonia, pressure ulcers, and pain. This study described WC seated posture with its selected predictors and outcomes in the nursing home environment, throughout the daytime hours of 1 day. DESIGN AND METHODS: This observational study (n = 45) in two Veterans Administration Community Living Centers introduced a new measure of WC fit and described WC seated posture of older Veterans, with selected predictors and outcomes. FINDINGS: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting, but not by level of sitting ability. Poor posture measured by the Seated Posture Scale was associated with pain. Highest interface pressures measurable were seen in peak pressure index (PPI = 200 mm Hg), indicating risk of pressure injury. Veterans often denied discomfort, possibly lowering overall pain scores, while reporting severe pain in specific body parts. CONCLUSIONS: Wheelchair seated posture was predicted by cognitive status, WC fit, WC skills, and duration of sitting. Poor posture was associated with pain, and poor posture was an outcome of poor WC fit. Poor WC fit in this study supported earlier findings in non-Veterans Administration nursing homes.

Association of inappropriate polypharmacy with emergency department visits in older patients receiving anti-neoplastic therapy: a population-based study.

PURPOSE: We aimed to investigate the prevalence and predicting factors of inappropriate polypharmacy including potentially inappropriate medications (PIMs) and drug-drug interactions (DDIs) and their associations with emergency department (ED) visits in older Korean patients receiving anti-neoplastic therapy. METHODS: We identified older patients receiving anti-neoplastic therapy in 2016 from the National Health Claims database. We investigated the prevalence of inappropriate polypharmacy comprising PIMs and DDIs in geriatric patients according to the 2019 American Geriatrics Society Beers Criteria® and chemotherapeutic DDIs using Lexicomp OnlineTM and Micromedex®. A nested case-control study was conducted to evaluate the associations between inappropriate polypharmacy and ED visits during anti-neoplastic therapy. Multivariate logistic regressions were performed after adjusting for age, sex, cancer diagnosis, prior ED visits, Charlson Comorbidity Index, and type of anti-neoplastic therapy. RESULTS: Inappropriate polypharmacy, its subtype PIMs, geriatric, and chemotherapeutic DDIs were observed in 85.4%, 80.4%, 17.3%, and 37.9% of the 21,956 patients receiving anti-neoplastic therapy, respectively. After adjusting for confounding factors, the presence of inappropriate polypharmacy (adjusted odds ratio (aOR) 2.15, 95% confidence interval (CI) 1.97-2.35), 2 or more PIMs (aOR 1.85, 95% CI 1.68-2.02), 2 or more chemotherapeutic DDIs (aOR 2.88, 95% CI 2.54-3.28), and geriatric DDIs (aOR 1.61, 95% CI 1.43-1.80) increased the likelihood of ED visits during anti-neoplastic therapy. CONCLUSION: This nationwide study showed that inappropriate polypharmacy was prevalent and increased the risk of ED visits in older patients receiving anti-neoplastic therapy. Study findings suggested a need to implement deprescribing strategies in this population.

Increasing Engagement for Breast Cancer Screening and Treatment: The "ICANTREAT" Community of Expertise Initiative.

BACKGROUND: Incidence of breast cancer and associated mortality are on the rise globally. Breast cancer incidence in India is on the rise and also accounts for a staggering 50% mortality rate among women. Health illiteracy, socio-economic and cultural barriers in addition to lack of an organized nationwide screening and prevention programme contribute to poor patient outcomes. Thus, it is imperative to strengthen the existing screening and treatment facilities to address the increasing cancer burden. In this regard, we conducted a workshop to investigate the scope of a multi- stakeholder engagement in breast cancer screening and treatment. METHODS: A stakeholder workshop grounded in an established co-design methodology  was convened in a semi-urban coastal district in South India with active participation of physicians, surgeons, occupational therapists, community leaders, programme officers, public health professionals and breast cancer survivors. Shiffman and Smith's framework was adapted to highlight barriers to screening and role of stakeholders in the co-design of solutions. RESULTS: Deliberate and active discussions marked the workshop proceedings resulting in the identification of   individual and systems level barriers, facilitators and implementation strategies. Social stigma and non-existent standard protocols for screening and referral were recognised as critical barriers, while community engagement and a dedicated patient advocate were the proposed facilitators. CONCLUSION: This workshop was an important step in bringing together key stakeholders and marked the beginning of the ICANTREAT initiative and a Community of Expertise. The outcomes highlight the importance of stakeholder involvement in the cancer- care pathway for breast cancer screening, diagnosis and treatment.

Developing the Active Communities Tool to Implement the Community Guide's Built Environment Recommendation for Increasing Physical Activity.

Physical activity is higher in communities that include supportive features for walking and bicycling. In 2016, the Community Preventive Services Task Force released a systematic review of built environment approaches to increase physical activity. The results of the review recommended approaches that combine interventions to improve pedestrian and bicycle transportation systems with land use and environmental design strategies. Because the recommendation was multifaceted, the Centers for Disease Control and Prevention determined that communities could benefit from an assessment tool to address the breadth of the Task Force recommendations. The purpose of this article is to describe the systematic approach used to develop the Active Communities Tool. First, we created and refined a logic model and community theory of change for tool development. Second, we reviewed existing community-based tools and abstracted key elements (item domains, advantages, disadvantages, updates, costs, permissions to use, and psychometrics) from 42 tools. The review indicated that no tool encompassed the breadth of the Community Guide recommendations for communities. Third, we developed a new tool and pilot tested its use with 9 diverse teams with public health and planning expertise. Final revisions followed from pilot team and expert input. The Active Communities Tool comprises 6 modules addressing all 8 interventions recommended by the Task Force. The tool is designed to help cross-sector teams create an action plan for improving community built environments that promote physical activity and may help to monitor progress toward achieving community conditions known to promote physical activity.

Electricity use is associated with residents' vital data and lifestyles: observational study using an IT health support system in Japan.

Motivated by developments in information technology, recording personal parameters with health devices is effective in health promotion. Today's indoor individual lifestyles often involve using electrical appliances. We developed a health support system combined with wireless electricity monitoring and investigated whether electricity use is associated with residents' vital data and lifestyles. We recruited 116 participants in February 2013. Their vital and electricity use data were collected daily. They completed a self-administered questionnaire. Among participants living alone, electricity from 20 February to 11 March 2013 was negatively associated with high-density lipoprotein (HDL) (P = 0.008) and positively associated with low-density lipoprotein (LDL) (P = 0.007) and neutral fat (P = 0.020) levels. Among all participants, electricity use was negatively associated with vegetable intake (P = 0.044) and step count (P = 0.040). Temperature sensitivity in winter was negatively associated with the LDL/HDL ratio for both men and women. For men, temperature sensitivity in winter was negatively related with alcohol intake; for women, it was positively related to body fat percentage and abdominal circumference and negatively correlated to vegetable intake. Temperature sensitivity in summer was positively associated with vegetable intake for men and women. In conclusion, electricity use was related to vital data and lifestyles and influenced by temperature.

The unintended consequences of client-centred flexible planning in home-based postpartum care: a shift in care workers' tasks and responsibilities.

OBJECTIVE: To explore care workers' experiences with a flexible planning of home-based postpartum care as an innovative instrument to facilitate more client-centred care. DESIGN: A mixed-methods design with a primarily qualitative approach followed by a quantitative follow-up, according to the Priority-Sequence model. SETTING: This study is part of a larger research project researching the health effects of a flexible planning in postpartum care. The new planning enables clients and care workers to spread and/or pause the care over 14 days postpartum instead of the standard planning of eight to ten consecutive days. PARTICIPANTS: Maternity home care workers who provide care according the flexible planning. Eight care workers were interviewed, another eight care workers participated in the focus group discussion, and 59 care workers filled in the survey. FINDINGS: Two main unintended consequences of the flexible planning were found: 1. care workers experienced an undesirable 'shift in their tasks' along the course of the postpartum period and 2. were heavily worried about 'making enough contracted hours'. Consequently, care workers unwillingly performed much more domiciliary activities compared to the standard planning, especially during the final days of care. KEY CONCLUSIONS: The predominant nursing tasks and responsibilities of care workers appeared insufficient to respond to clients' altering needs. In addition, shorter working days and on-call duties caused an undesired excessive high-level of flexibility among care workers. Consequently, care was paradoxically determined by organisational structures rather than clients' individual needs. IMPLICATIONS FOR PRACTICE: Our study elucidated that co-creation together with health professionals is a prerequisite for successfully implementing innovations as their way of working and personal lives are profoundly affected.

Population segments as a tool for health care performance reporting: an exploratory study in the Canadian province of British Columbia.

BACKGROUND: Primary care serves all age groups and individuals with health states ranging from those with no chronic conditions to those who are medically complex, or frail and approaching the end of life. For information to be actionable and guide planning, there must be some population disaggregation based on differences in expected needs for care. Promising approaches to segmentation in primary care reflect both the breadth and severity of health states, the types and amounts of health care utilization that are expected, and the roles of the primary care provider. The purpose of this study was to assess population segmentation as a tool to create distinct patient groups for use in primary care performance reporting. METHODS: This cross-sectional study used administrative data (patient characteristics, physician and hospital billings, prescription medicines data, emergency department visits) to classify the population of British Columbia (BC), Canada into one of four population segments: low need, multiple morbidities, medically complex, and frail. Each segment was further classified using socioeconomic status (SES) as a proxy for patient vulnerability. Regression analyses were used to examine predictors of health care use, costs and selected measures of primary care attributes (access, continuity, coordination) by segment. RESULTS: Average annual health care costs increased from the low need ($ 1460) to frail segment ($10,798). Differences in primary care cost by segment only emerged when attributes of primary care were included in regression models: accessing primary care outside business hours and discontinuous primary care (≥5 different GP's in a given year) were associated with higher health care costs across all segments and higher continuity of care was associated with lower costs in the frail segment (cost ratio = 0.61). Additionally, low SES was associated with higher costs across all segments, but the difference was largest in the medically complex group (cost ratio = 1.11). CONCLUSIONS: Population segments based on expected need for care can support primary care measurement and reporting by identifying nuances which may be lost when all patients are grouped together. Our findings demonstrate that variables such as SES and use of regression analyses can further enhance the usefulness of segments for performance measurement and reporting.

La teoría del cambio: una herramienta para la planificación y la evaluación participativa en salud comunitaria / Theory of change: a tool for participatory planning and evaluation in community health

Existe un creciente interés por encontrar respuestas innovadoras para evaluar intervenciones complejas en salud pública. En esta nota metodológica, se presenta la teoría del cambio como una herramienta útil para facilitar tanto la planificación como la evaluación de intervenciones en promoción de la salud comunitaria. Una teoría del cambio es una representación visual de cómo funciona un programa o una intervención, en la que se identifican sus diferentes componentes y cómo cada elemento se vincula con otro: cuáles son sus objetivos, los resultados esperados y a través de qué acciones se pretenden alcanzar. Es una herramienta de investigación aplicada a la práctica que se desarrolla mediante métodos participativos con las diferentes personas implicadas en la intervención, para identificar y decidir conjuntamente qué es lo que hay que evaluar y cómo evaluarlo

There is a growing interest in finding innovative approaches to the evaluation of complex interventions in public health. This methodological note presents the theory of change as a useful tool to facilitate both the planning and the evaluation of community health promotion interventions. A theory of change is a visual representation of how a programme or intervention works, in which its different components can be identified, together with how they relate to each other: what its objectives are, its expected results and through which actions they are expected to be achieved. It can be an applied research tool, developed using participatory approaches together with all relevant stakeholders, who can identify and jointly decide what to evaluate and how to

From natural disaster to pandemic: A health-system pharmacy rises to the challenge.

PURPOSE: This report describes a health-system pharmacy's response to a natural disaster while staff members simultaneously prepared for the coronavirus disease 2019 (COVID-19) pandemic. By detailing our experience, we hope to help other institutions that are current facing or could encounter similar crises. SUMMARY: In early March 2020, a tornado destroyed the health system's warehouse for storage of most clinical supplies, including personal protective equipment and fluids. The pharmacy purchasing team collaborated with suppliers and manufacturers to recover losses and establish alternative storage areas. Days later, the pharmacy department was forced to address the impending COVID-19 pandemic. Key elements of the COVID-19 response included reducing the potential for virus exposure for patients and staff; overcoming challenges in sourcing of staff, personal protective equipment, and medications; and changing care delivery practices to maintain high-quality patient care while maximizing social distancing. The pharmacy department also created distance learning opportunities for 70 pharmacy students on rotations. After an initial plan, ongoing needs include adjustment in patient care activities if significant staff losses occur, when and how to resume clinical activities, and how to best utilize the resources accumulated. Elements of practice changes implemented to reduce COVID-19 threats to patients and pharmacy personnel have proven beneficial and will be further evaluated for potential continuation. CONCLUSION: The pharmacy department's efforts to respond to a natural disaster and unprecedented pandemic have proven successful to this point and have illuminated several lessons, including the necessity of cohesive department communication, staff flexibility, prioritization of teamwork, and external collaboration.

Natural Language Processing Improves Detection of Nonsevere Hypoglycemia in Medical Records Versus Coding Alone in Patients With Type 2 Diabetes but Does Not Improve Prediction of Severe Hypoglycemia Events: An Analysis Using the Electronic Medical Record in a Large Health System.

OBJECTIVE: To determine if natural language processing (NLP) improves detection of nonsevere hypoglycemia (NSH) in patients with type 2 diabetes and no NSH documentation by diagnosis codes and to measure if NLP detection improves the prediction of future severe hypoglycemia (SH). RESEARCH DESIGN AND METHODS: From 2005 to 2017, we identified NSH events by diagnosis codes and NLP. We then built an SH prediction model. RESULTS: There were 204,517 patients with type 2 diabetes and no diagnosis codes for NSH. Evidence of NSH was found in 7,035 (3.4%) of patients using NLP. We reviewed 1,200 of the NLP-detected NSH notes and confirmed 93% to have NSH. The SH prediction model (C-statistic 0.806) showed increased risk with NSH (hazard ratio 4.44; P < 0.001). However, the model with NLP did not improve SH prediction compared with diagnosis code-only NSH. CONCLUSIONS: Detection of NSH improved with NLP in patients with type 2 diabetes without improving SH prediction.

Lessons learned about co-creation: developing a complex intervention in rural Peru.

Background: Co-creation is the process of involving stakeholders in the development of interventions. Although co-creation is becoming more widespread, reports of the process and lessons learned are scarce.Objective: To describe the process and lessons learned from using the COHESION manual, a co-creation methodology to develop interventions aimed at the improvement of diagnosis and/or management of chronic diseases at the primary healthcare level in a low-resource setting in Peru.Methods: Observational study to describe the use of the COHESION manual 'Moving from Research to Interventions: The COHESION Model' developed for a multi-country project in low- and middle-income countries for co-creation and the adaptations needed to customize it to the local context of rural communities in northern Peru.Results: The actual process of co-creation in Peru included co-creation-related questions in the formative research; an initial consultation with stakeholders at the micro, meso, and macro levels (e.g. community members, health workers, and policy-makers); the analysis of the collected data; a second consultation with each stakeholder group; the prioritization of intervention options; and finally the design of a theory of change for all activities included in the complex intervention. The complex intervention included: 1) offer training in specific diseases and soft skills to health workers, 2) create radio programs that promote chronic disease prevention and management plus empower patients to ask questions during their visits to primary health care (PHC) facilities, and 3) provide a small grant to the PHC for infrastructure improvement. Small adaptations to the COHESION manual were necessary for this co-creation process.Conclusion: This study provides a practical example of the process of co-creating complex interventions to increase access and quality of health care in a low-resource setting. The process, components, challenges and opportunities identified could be useful for other researchers who want to co-create interventions with beneficiaries in similar settings.

Pharmacist-led transitions-of-care program reduces 30-day readmission rates for Medicare patients in a large health system.

PURPOSE: This report describes the growth and development of the Pharmacy Transitions of Care (PTOC) program at a Florida health system and examines its impact on 30-day readmission rates for Medicare core-measure patients. SUMMARY: BayCare Health System is a large not-for-profit community health system with 15 hospitals in central Florida. In 2015, the PTOC program was developed to integrate 2 pharmacists into the transitions-of-care space to reduce readmissions, enhance patient care, and improve medication safety. The PTOC program focuses on traditional Medicare beneficiaries 65 years of age or older with the goal of preventing 30-day readmissions. The service model includes integration of a pharmacist into the discharge medication reconciliation process, as well as postacute care telephonic follow-up. Data and outcomes have been carefully tracked since program inception and consistently demonstrate a reduction in 30-day readmissions, with a 63% relative risk reduction during the beginning phases of the program and a ratio of observed to expected readmissions of 0.77. As a result, in less than 3 years the PTOC program has grown from 2 to 23 pharmacists and is a key component of BayCare Health System's patient care strategy. CONCLUSION: Medication reconciliation, clinical interventions, and patient education by pharmacists after hospital discharge reduced 30-day readmission rates for Medicare core-measure patients across a large health system. The adaptability of this program to other health systems and hospitals of varying size to achieve similar outcomes is valuable to share with the profession.