Facility-Based Maternal Quality of Care Frameworks: A Systematic Review and Best Fit Framework Analysis.

OBJECTIVES: The World Health Organization has adopted two main strategies to improve the quality of maternal health: increasing the number of deliveries by skilled birth attendants and increasing access to emergency obstetric care. Despite increased access to care, there continue to be high rates of maternal morbidity and mortality in part due to quality of care. This study aims to identify and summarize existing frameworks for measuring quality of maternal care at a facility-level. METHODS: PubMed, Health Systems Evidence, Embase, Global Health, OVID Healthstar, OVID Medline, PsycINFO, and Web of Science were searched for frameworks, tools, theories, or components of frameworks relevant to maternal quality of care in facility-level settings. Title/abstract and full-text screening were completed by two independent reviewers and conflicts resolved through consensus or a third reviewer. RESULTS: An initial search resulted in 3182 studies. Fifty-four studies were included in the qualitative analysis. A best fit framework analysis was done using the updated Hulton framework as the conceptual framework. A facility-based maternal quality of care framework is proposed including the following components, separated into provision and experience of care: (1) human resources; (2) infrastructure; (3) equipment, supplies and medicine; (4) evidence and information; (5) referral and networks of care; (6) cultural competence; (7) clinical practice; (8) financing; (9) leadership and governance; (10) cognition; and 11) respect, dignity, equity, and emotional support.

Despite increased institutional access to care, there continue to be high rates of maternal morbidity and mortality in some low- and middle-income countries. This is in part due to the quality of maternal care once care has been accessed. Several frameworks have been proposed for understanding the complexities surrounding quality of care in maternal health but there has not been a single framework consistently used in the literature for facility-based quality of maternal care. This paper identifies and summarizes existing frameworks and tools, and uses a best fit framework analysis to propose a comprehensive framework for assessing facility-based maternal quality of care.

Limitations of COVID-19 testing and case data for evidence-informed health policy and practice.

BACKGROUND: Coronavirus disease 2019 (COVID-19) became a pandemic within a matter of months. Analysing the first year of the pandemic, data and surveillance gaps have subsequently surfaced. Yet, policy decisions and public trust in their country's strategies in combating COVID-19 rely on case numbers, death numbers and other unfamiliar metrics. There are many limitations on COVID-19 case counts internationally, which make cross-country comparisons of raw data and policy responses difficult. PURPOSE AND CONCLUSIONS: This paper presents and describes steps in the testing and reporting process, with examples from a number of countries of barriers encountered in each step, all of which create an undercount of COVID-19 cases. This work raises factors to consider in COVID-19 data and provides recommendations to inform the current situation with COVID-19 as well as issues to be aware of in future pandemics.

Varenicline for Tobacco-Dependent Adults Who Are Not Ready to Discontinue Use: A Systematic Review and Meta-Analysis.

Rationale: Not all individuals with tobacco dependence are ready to give up smoking. Research reveals behavioral differences between adults ready to discontinue tobacco use and those who are not. Thus, the interventions applied to these populations might differ. However, the evidence of using varenicline in individuals who are not ready to discontinue tobacco use is uncertain. Objectives: To determine if, in tobacco-dependent adults who report not being ready to discontinue tobacco use, clinicians should begin treatment with varenicline or wait until subjects are ready to discontinue tobacco use. Methods: We conducted a systematic review to assess the effectiveness and safety of treatment with varenicline in tobacco-dependent adults who are not ready to discontinue tobacco use. We systematically searched the Cumulative Index to Nursing and Allied Health Literature, Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials comparing varenicline versus placebo for individuals who were not ready to discontinue tobacco use. Outcomes of interest include point prevalence abstinence during treatment or at six months or longer, smoking reduction, motivation to quit, adverse events, and withdrawal symptoms. Two authors independently extracted data and assessed eligibility and risk of bias using a standardized data collection form. We followed the Grading of Recommendations, Assessment, Development and Evaluations approach to assess the certainty of evidence. Results: Five trials met our inclusion criteria. All 2,616 participants were adults who were not ready to discontinue tobacco use at study entry. For 7-day point prevalence abstinence at six months or longer, high-certainty evidence suggested that varenicline increased abstinence compared with placebo (relative risk, 2.00 [95% confidence interval (CI), 1.70-2.35]; absolute risk reduction, 173 more per 1,000 [95% CI, 121 more to 234 more]). We identified moderate-certainty evidence suggesting that varenicline increased serious adverse events (relative risk, 1.75 [95% CI, 0.98-3.13]; absolute risk reduction, 12 more per 1,000 [95% CI, 0 fewer to 35 more]). For withdrawal, low-certainty evidence suggested that varenicline treatment was associated with a lower symptom score (mean difference, 1.54 points lower; 95% CI, 2.15-0.93 points lower; low certainty) assessed using the Brief Questionnaire of Smoking Urges. Conclusions: In tobacco-dependent adults who are not ready to discontinue tobacco use, initiating varenicline treatment results in a large increase in abstinence and likely results in a slight increase in serious adverse events.

Infectious diseases, comorbidities and outcomes in hospitalized people who inject drugs (PWID) infections in persons who inject drugs.

Injection drug use poses a public health challenge. Clinical experience indicates that people who inject drugs (PWID) are hospitalized frequently for infectious diseases, but little is known about outcomes when admitted. Charts were identified from local hospitals between 2013-2018 using consultation lists and hospital record searches. Included individuals injected drugs in the past six months and presented with infection. Charts were accessed using the hospital information system, undergoing primary and secondary reviews using Research Electronic Data Capture (REDCap). The Wilcoxon rank-sum test was used for comparisons between outcome categories. Categorical data were summarized as count and frequency, and compared using Fisher's exact test. Of 240 individuals, 33% were admitted to the intensive care unit, 36% underwent surgery, 12% left against medical advice (AMA), and 9% died. Infectious diagnoses included bacteremia (31%), abscess (29%), endocarditis (29%), cellulitis (20%), sepsis (10%), osteomyelitis (9%), septic arthritis (8%), pneumonia (7%), discitis (2%), meningitis/encephalitis (2%), or other (7%). Sixty-six percent had stable housing and 60% had a family physician. Fifty-four percent of patient-initiated discharges were seen in the emergency department within 30 days and 29% were readmitted. PWID are at risk for infections. Understanding their healthcare trajectory is essential to improve their care.

Extended Duration Treatment of Tobacco Dependence: A Systematic Review and Meta-Analysis.

Rationale: The American Thoracic Society (ATS) developed a clinical practice guideline on initiating pharmacologic treatment in tobacco-dependent adults. Controller pharmacotherapies treat tobacco dependence effectively when taken as prescribed, but relapse after pharmacologic discontinuation is common. Objectives: To evaluate the effectiveness and safety of initiating controller for an extended (>12 wk) versus a standard duration (6-12 wk) in tobacco-dependent adults. Methods: We systematically searched PubMed, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials from database inception to December 2021 to identify randomized controlled trials comparing extended versus standard duration of controllers for tobacco-dependent adults. We conducted meta-analyses using the Mantel-Haenszel method with random effects model. Outcomes of interest include point-prevalent abstinence at 1-year follow-up or longer, relapse, adverse events, quality of life, and withdrawal symptoms. Subgroup analyses were conducted according to types of treatment and duration of extended therapy when feasible. We assessed the certainty of the estimate following the grading of recommendations, assessment, development and evaluation methodology. Results: We included 13 randomized controlled trials including 8,695 participants that directly compared extended- (>12 wk) versus standard-duration controller therapy with varenicline, bupropion, or nicotine replacement therapy. Compared with standard-duration controller therapy, extended-duration controller therapy probably increased abstinence at 1-year follow-up, measured as 7-day point-prevalence abstinence (relative risk, 1.18; 95% confidence interval [CI], 1.05-1.33; moderate certainty). Extended-duration controller therapy probably reduced relapse compared with standard-duration controller therapy, assessed at 12-18 months after initiation of therapy (hazard ratio, 0.43; 95% CI, 0.29-0.64; moderate certainty). Moderate certainty evidence also suggested that extended-duration controller therapy probably did not increase risk of serious adverse events (relative risk, 1.37; 95% CI, 0.79-2.36). Conclusions: This systematic review supported the recommendation for extended-duration therapy with controllers. Further studies on optimal extended duration are warranted.

Health programmes and services addressing the prevention and management of infectious diseases in people who inject drugs in Canada: a systematic integrative review.

OBJECTIVES: People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID. DESIGN: This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada. RESULTS: This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction. CONCLUSIONS: These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care. PROSPERO REGISTRATION NUMBER: CRD42020142947.

Variations in reported outcomes in studies on vasa previa: a systematic review.

OBJECTIVE: To evaluate reported outcomes of published studies on the diagnosis and management of vasa previa in pregnancy. MATERIALS AND METHODS: Databases such as MEDLINE, Embase, Cochrane, PubMed, and ClinicalTrials.gov were searched up to March 2018 for all published studies on vasa previa using combinations of the following medical subject headings and key words: vasa previa, placenta previa, low-lying placenta, succenturiate lobe or placenta, bilobed or bilobate placenta, and velamentous insertion. All original human research that described maternal, obstetric, placental, fetal or neonatal outcomes relating to pregnancies with vasa previa were included for analysis. Title and abstract screening and data extraction was conducted independently and in duplicate by 2 reviewers for all studies until total agreement for eligibility was achieved. Data extraction was also conducted in duplicate in approximately 50% of studies reviewed. RESULTS: A total of 160 published studies (1004 pregnancies) were included. There was a wide range of reported outcomes, many of which were sparingly reported. The most commonly reported maternal outcomes included mode of delivery, presence of antepartum hemorrhage, time of diagnosis, and rupture of membranes. The presence of known risk factors for vasa previa such as a low-lying placenta, succenturiate or bilobed placenta, and (velamentous) cord insertion was incorrectly reported as "outcomes" in many studies. The most commonly reported fetal/neonatal outcomes included fetal heart rate, gestational age at delivery, birthweight, Apgar score, presence of neonatal anemia, cord blood gas measurements, need for blood transfusion, and death. Of note, only 3 studies reported outcomes related to life impact, maternal social and emotional functioning, perceived delivery of care, or resource utilization. CONCLUSION: Despite the profound effect the diagnosis of vasa previa has on pregnant women, families, and healthcare systems, studies on vasa previa seldom report outcomes related to life impact and resource utilization. There is a need for the development of a core outcome set-a minimum standard set of outcomes deemed important by pregnant women and other stakeholders involved in their care-to standardize outcome reporting in future studies on vasa previa.

Vasa previa and associated risk factors: a systematic review and meta-analysis.

OBJECTIVE: To systematically review published literature and calculate the prevalence of vasa previa and its known risk factors. MATERIALS AND METHODS: MEDLINE, Embase, the Cochrane Library, PubMed (non-MEDLINE and in process), and www.clinicaltrials.gov were searched from inception to March 2018 using indexing terms "vasa previa," "placenta previa," "low lying placenta," "succenturiate lobe," "bilobate placenta," "bilobed placenta," and "velamentous insertion." All original research studies reporting on 5 or more pregnancies with vasa previa were included. The search was limited to studies on human data and those published in the English language. Two reviewers independently screened titles and abstracts, completed data extraction, and assessed reporting quality using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. Disagreements were discussed and resolved at each step of the process. RESULTS: We included 21 studies that reported 428 pregnancies with vasa previa of 1,027,918 deliveries (0.46 cases of vasa previa per 1000 deliveries). These studies fared well on risk of bias assessment using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. The prevalence and 95% confidence intervals of known risk factors for vasa previa included a low-lying placenta (61.5%, 53.0%-70.0%), velamentous cord insertion (52.2%, 39.6%-64.7%), bilobed or succenturiate lobed placenta (33.3%, 20.9%-45.7%), use of in vitro fertilization (26.4%, 16.0%-36.8%), and multiple gestation (8.92%, 5.33%-12.5%). CONCLUSION: Vasa previa affects 0.46 cases per 1000 pregnancies. Given the high prevalence of prenatally detectable risk factors in affected pregnancies, the cost-effectiveness of screening strategies for vasa previa either in isolation, using a risk factor-based approach, or universally, in tandem with cervical-length screening using transvaginal ultrasound, should be revisited.

Health programmes and services addressing the prevention and management of infectious diseases in persons who inject drugs in Canada: a systematic integrative review protocol.

INTRODUCTION: Injection drug use (IDU) and intravenous drug use (IVDU) are of concern to the people using drugs, their families and health systems. One of the complications of IDU/IVDU is the risk of infection. Clinical experience has shown that persons who inject drugs (PWID) are hospitalised and re-hospitalised frequently. In Canada there are sparse data about the reasons for which PWID are admitted to hospital and their health trajectories, especially for infectious diseases. There are special concerns regarding PWID with infections who leave the hospital against medical advice and those who leave with a peripherally inserted central catheter line in place for administration of long-term antibiotics or other therapies. Improving our understanding of current programmes and services addressing the prevention and management of infectious diseases and their complications in PWID could lead to focused interventions to enhance care in this population. METHODS AND ANALYSIS: An integrative systematic review allows for inclusion of a variety of methodologies to understand a health issue from different viewpoints. PubMed, CINAHL, Web of Science Databases and websites of the Public Health Agency of Canada, Canadian Institute for Substance Use Research, and Canadian Centre on Substance Use and Addiction will be searched using terms for infectious diseases, drug use and geography (Canada) and limited to the last 10 years (2009-2019). The Quality Appraisal Tool in Studies with Diverse Designs will be used to appraise the quality of identified studies and documents. Quantitative, qualitative or mixed methods data synthesis will be used as needed. ETHICS AND DISSEMINATION: This study is a secondary analysis of publicly available documents; therefore, no ethics approval is required. This information will inform a research agenda to further investigate interventions that aim to address these issues. PROSPERO REGISTRATION NUMBER: CRD42020142947.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline.

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Transforming our relationship with the social determinants of health: a scoping review of social justice interventions in Canadian Medical Schools.

This article was migrated. The article was marked as recommended. Background/Purpose: Physicians are in a powerful position to improve the health status of communities through mitigating disparities rooted in social inequities. However, it is uncertain whether medical schools are preparing future physicians with the skills needed to care for diverse populations. The current scoping review aimed to describe how Canadian medical schools teach social justice, comparing pedagogical strategies. Methods: A search was performed using OVID to identify published studies of implemented and evaluated social justice-based interventions within Canadian medical school curricula. Results: Six studies were included. Common themes included increased content knowledge, greater understanding of SDoH, acknowledgement of power and privilege imbalances, identification of physicians' roles as advocates, emphasis on the importance of interdisciplinary care, and increased capacity for self-reflection and personal growth. Experiential interventions were associated with greater personal transformation, but had limited accessibility. Conclusion: Despite the widespread recognition of physicians' roles as health advocates, there is a lack of consensus about an effective strategy for teaching social justice in medical education in Canada. While additional research focusing on the relative merits of didactic versus experiential learning is needed, these preliminary results suggest that experiential learning emphasizing self-reflection and personal growth may be optimal when approaching transformative learning.

Maternal body mass index and pregnancy outcomes: a systematic review and metaanalysis.

OBJECTIVE DATA: The purpose of this study was to determine the effect of body mass index category on pregnancy outcomes. STUDY: Five databases (Medline, Embase, PubMed, www.clinicaltrials.gov, and Cochrane) were searched from inception until February 2019 for English or French publications that reported on pregnancy outcomes in women with body mass index ≥30 kg/m2. Reference lists of included articles were searched, and authors were contacted for missing data where necessary. Because no randomized trials were identified, we included single-center and population-based cohort studies that stratified pregnancy outcomes under the following body mass index categories: underweight, standard weight, overweight, and obese classes I-III, based on the World Health Organization international classification system. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was appraised with the use of the Newcastle-Ottawa Scale Quality Assessment Scale for cohort studies. Because significant heterogeneity was anticipated among studies, we used random-effects metaanalysis to arrive at pooled estimates and 95% confidence intervals for pregnancy outcomes in each body mass index category and relative risks in relation to women with a standard body mass index. RESULTS: We identified 10,258 studies, of which 13 studies with a low risk-of-bias that described 3,722,477 pregnancies that were included in the metaanalysis. Most adverse pregnancy outcomes increased steadily with increasing body mass index category. Compared with women with body mass index 18.5-24.9 kg/m2, women with body mass index >40 kg/m2 were at increased risk for gestational diabetes mellitus [17% vs 3.9%; relative risk, 4.6 [95% confidence interval, 3.6-5.9]), hypertensive disorders of pregnancy (15.9% vs 3.5%; relative risk, 4.6 [95% confidence interval, 3.4-6.0]), and cesarean delivery (47.7% vs 26.0%; relative risk, 1.86 [95% confidence interval, 1.75-1.97]). Babies were at increased risk for hypoglycemia (4.1% vs 1.4%; relative risk, 3.3 [95% confidence interval, 2.8-3.8]), macrosomia (12.9% vs 6.2%; relative risk, 2.6 [95% confidence interval, 1.4-4.7]), infection (2.8% vs 1.3%; relative risk, 2.3 [95% confidence interval, 1.6-3.3]), birth trauma (1.3% vs 0.9%; relative risk, 2.1 [95% confidence interval, 1.2-3.8]), respiratory distress (5.1% vs 2.7%; relative risk, 2.0 [95% confidence interval, 1.8-2.2]), death (1.4% vs 0.9%; relative risk, 1.8 [95% confidence interval, 1.2-2.9]), and neonatal intensive care unit admission (13.5% vs 9.5%; relative risk, 1.6 [95% confidence interval, 1.4-1.9]). CONCLUSION: There is a linear association between maternal body mass index and almost all adverse pregnancy outcomes. These risks, stratified by body mass index category as presented in this article, would facilitate counselling and encourage appropriate interventions to improve outcomes for mothers and babies.

Patient Values and Preferences Regarding Opioids for Chronic Noncancer Pain: A Systematic Review.

Objective: Shared-care decision-making between patients and clinicians involves making trade-offs between desirable and undesirable consequences of management strategies. Although patient values and preferences should provide the basis for these trade-offs, few guidelines consider the relevant evidence when formulating recommendations. To inform a guideline for use of opioids in patients with chronic noncancer pain, we conducted a systematic review of studies exploring values and preferences of affected patients toward opioid therapy. Methods: We searched MEDLINE, CINAHL, EMBASE, and PsycINFO from the inception of each database through October 2016. We included studies examining patient preferences for alternative approaches to managing chronic noncancer pain and studies that assessed how opioid-using chronic noncancer pain patients value alternative health states and their experiences with treatment. We compiled structured summaries of the results. Results: Pain relief and nausea and vomiting were ranked as highly significant outcomes across studies. When considered, the adverse effect of personality changes was rated as equally important. Constipation was assessed in most studies and was an important outcome, secondary to pain relief and nausea and vomiting. Of only two studies that evaluated addiction, both found it less important to patients than pain relief. No studies examined opioid overdose, death, or diversion. Conclusion: Our findings suggest that the adverse effects of opioids, especially nausea and vomiting, may reduce or eliminate any net benefit of opioid therapy unless pain relief is significant (>2 points on a 10-point scale). Further research should investigate patient values and preferences regarding opioid overdose, diversion, and death.