A multi-step approach to developing a health system evaluation framework for community-based health care.

BACKGROUND: Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada. METHODS: A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation. RESULTS: Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts-Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. 'Indicator narratives' depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach. CONCLUSIONS: This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC.

Primary Healthcare Policy Research: Including Variables Associated With the Social Determinants of Health Matters Comment on "Universal Health Coverage for Non-communicable Diseases and Health Equity: Lessons From Australian Primary Healthcare".

Fisher et al have provided a solid addition to health policy literature in their finding that universal health coverage supports equitable access to Australian primary healthcare (PHC), despite factors such as episodic care and poor distribution of services. Their definition of PHC was comprehensive, extending beyond medical care to include social determinants of health and public policy. However, they limited their operational definition for purposes of the study to general practice, community health and allied health. Applying a narrower definition risks lost opportunities to identify policy implications for equity beyond financial accessibility. The populations most at risk of non-communicable diseases also face significant language, culture, and individual and systemic discrimination barriers to access. Future policy research should consider using a comprehensive PHC definition in determining variables of interest and designing research methodologies, to avoid missing important knowledge that allows existing biases within primary care to continue.

Facilitating Integration Through Team-Based Primary Healthcare: A Cross-Case Policy Analysis of Four Canadian Provinces.

INTRODUCTION: Team-based care can improve integrated health services by increasing comprehensiveness and continuity of care in primary healthcare (PHC) settings. Collaborative models involving providers from different professions can help to achieve coordinated, high-quality person-centred care. In Canada, there has been variation in both the timing/pace of adoption and approach to interprofessional PHC (IPHC) policy. Provinces are at different stages in the development, implementation, and evaluation of team-based PHC models. This paper describes how different policies, contexts, and innovations across four Canadian provinces (British Columbia, Alberta, Ontario, Quebec) facilitate or limit integrated health services through IPHC teams. METHODS: Systematic searches identified 100 policy documents across the four provinces. Analysis was informed by Walt and Gilson's Policy Triangle (2008) and Suter et al.'s (2009) health system integration principles. Provincial policy case studies were constructed and used to complete a cross-case comparison. RESULTS: Each province implemented variations of an IPHC based model. Five key components were found that influenced IPHC and integrated health services: patient-centred care; team structures; information systems; financial management; and performance measurement. CONCLUSION: Heterogeneity of the implementation of PHC teams across Canadian provinces provides an opportunity to learn and improve interprofessional care and integrated health services across jurisdictions.

The Experience of Family Physicians and Home Health Staff Involved in an Intervention to Increase Patient-Related Collaboration.

Les médecins de famille (MF) et le personnel de soins de santé à domicile (PSD) canadiens rencontrent d'importants obstacles lorsqu'ils doivent collaborer pour la prestation de soins aux patients qu'ils ont en commun. Cette étude à méthodologie mixte visait à évaluer la qualité et la viabilité de l'utilisation de l'audioconférence sécurisée dans une optique d'amélioration de la planification des soins pour ces patients. Les données primaires incluaient les résultats d'un sondage réalisé avant et après l'intervention, ainsi que des entretiens semi-structurés et des groupes de discussion post-intervention. Des méthodes statistiques non paramétriques ont été utilisées pour analyser les résultats du sondage, et les données qualitatives ont fait l'objet d'une analyse thématique de contenu. Les résultats des analyses quantitatives et qualitatives ont ensuite été intégrés afin de faire ressortir les inférences reflétant les approches des MF et du PSD relatives aux obstacles et aux avantages de la planification interdisciplinaire des soins. Les MF et le PSD ont montré que des obstacles structurels limitent leur capacité à collaborer. Le PSD et les MF ont également convenu que les rencontres entre les intervenants des deux services étaient bénéfiques pour les patients et que l'utilisation de l'audioconférence constituait une méthode efficiente de planification collaborative des soins. Les limites comprenaient la petite taille de l'échantillon et la courte période d'intervention, compte tenu de l'ampleur des changements attendus.Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to patient-related collaboration about patients they share. This mixed-methods study sought to determine the quality and sustainability of secure audio conferencing as a way to increase care planning about shared patients. Primary data sources included pre-and post-study administration of a published survey and post-study semi-structured interviews and focus groups. Non-parametric statistical procedures were used to analyze survey results and thematic content analysis was undertaken for qualitative data. Results from both quantitative and qualitative analysis were integrated into the overall analysis, in order to draw inferences reflecting both approaches to barriers and benefits of collaborative care planning for FPs and HHS. Both FPs and HHS provided evidence that structural barriers impede their ability to collaborate. HHS and FPs also agreed that joint conferences were beneficial for patients, and that the use of audio conferencing provided an efficient method of collaborative care planning. Limitations included a small sample size and short timeline for the intervention period, given the magnitude of the expected change.

Manganese and neurobehavioral impairment. A preliminary risk assessment.

Similar patterns of cognitive and motor deficits have been widely reported from manganese exposures in welding, metallurgical and chemical industry workers. A risk assessment was performed based on studies reported in the literature, extending some earlier work, and deriving new estimates of exposure response and excess risk. Many investigations of manganese neurological effects in humans have insufficient information to derive an exposure response; however, findings from a chemical manufacturer, two smelter and two welder populations permitted application of the benchmark dose procedure for continuous end-points. Small particles and aggregates of condensation fume (condensing vaporized metal, <0.1µm in diameter) appear to have a higher potency per unit mass than larger particles from dusts (>1.0µm). Consideration was given to long-term effects of continuous low exposures that instead of producing increasing toxicity attain a steady-state condition. Impairment was defined as excursions beyond the 5th percentile in a normal population and the concentrations of manganese predicted to result in 1% excess prevalence of impairment over different time periods were calculated. Over five years, exposures resulting in 1% excess prevalence of impairment (for purposes of discussion) were in the vicinity of 10µg/m3 for manganese fume and 25µg/m3 for larger particle dusts. These levels are below current recommendations for occupational limits on manganese exposure in the United States.

How's Your Health at Home: Frail Homebound Patients Reported Health Experience and Outcomes.

We used a web-based mixed methods survey (HowsYourHealth - Frail) to explore the health of frail older (78% age 80 or older) adults enrolled in a home-based primary care program in Vancouver, Canada. Sixty per cent of eligible respondents participated, representing over one quarter (92/350, 26.2%) of all individuals receiving the service. Despite high levels of co-morbidity and functional dependence, 50 per cent rated their health as good, very good, or excellent. Adjusted odds ratios for positive self-rated health were 7.50, 95 per cent CI [1.09, 51.81] and 4.85, 95 per cent CI [1.02, 22.95] for absence of bothersome symptoms and being able to talk to family or friends respectively. Narrative responses to questions about end of life and living with illness are also described. Results suggest that greater focus on symptom management, and supporting social contact, may improve frail seniors' health.

A survey of nursing home organizational characteristics associated with potentially avoidable hospital transfers and care quality in one large British Columbia health region.

Hospitalization of nursing home residents can be futile as well as costly, and now evidence indicates that treating nursing home residents in place produces better outcomes for some conditions. We examined facility organizational characteristics that previous research showed are associated with potentially avoidable hospital transfers and with better care quality. Accordingly, we conducted a cross-sectional survey of nursing home directors of care in Vancouver Coastal Health, a large health region in British Columbia. The survey addressed staffing levels and organization, physician access, end-of-life care, and factors influencing facility-to-hospital transfers. Many of the modifiable organizational characteristics associated in the literature with potentially avoidable hospital transfers and better care quality are present in nursing homes in British Columbia. However, their presence is not universal, and some features, especially the organization of physician care and end-of-life planning and services, are particularly lacking.

Drop-casted self-assembling graphene oxide membranes for scanning electron microscopy on wet and dense gaseous samples.

Graphene oxide sheets dispersed in water and many other solvents can spontaneously assemble into a surface film covering an evaporating droplet due to their amphiphilicity. Thus, graphene oxide membranes with controllable thickness suspended over an orifice have been directly fabricated using a simple drop-cast approach. Mechanical properties and electron transparency tests of these membranes show their use as electron transparent, but molecularly impenetrable, windows for environmental electron microscopy in liquids and dense gaseous media. The foreseeable, broader application of this drop-cast window methodology is the creation of access spots for electron probes to study isolated microsamples in their natural, undisrupted state within the interior of prefabricated devices (such as microfluidic chips or sealed containers of biological, chemically reactive, toxic, or forensic materials).

Isolation and characterization of griffithsin, a novel HIV-inactivating protein, from the red alga Griffithsia sp.

Griffithsin (GRFT), a novel anti-HIV protein, was isolated from an aqueous extract of the red alga Griffithsia sp. The 121-amino acid sequence of GRFT has been determined, and biologically active GRFT was subsequently produced by expression of a corresponding DNA sequence in Escherichia coli. Both native and recombinant GRFT displayed potent antiviral activity against laboratory strains and primary isolates of T- and M- tropic HIV-1 with EC50 values ranging from 0.043 to 0.63 nM. GRFT also aborted cell-to-cell fusion and transmission of HIV-1 infection at similar concentrations. High concentrations (e.g. 783 nM) of GRFT were not lethal to any tested host cell types. GRFT blocked CD4-dependent glycoprotein (gp) 120 binding to receptor-expressing cells and bound to viral coat glycoproteins (gp120, gp41, and gp160) in a glycosylation-dependent manner. GRFT preferentially inhibited gp120 binding of the monoclonal antibody (mAb) 2G12, which recognizes a carbohydrate-dependent motif, and the (mAb) 48d, which binds to CD4-induced epitope. In addition, GRFT moderately interfered with the binding of gp120 to sCD4. Further data showed that the binding of GRFT to soluble gp120 was inhibited by the monosaccharides glucose, mannose, and N-acetylglucosamine but not by galactose, xylose, fucose, N-acetylgalactosamine, or sialic acid-containing glycoproteins. Taken together these data suggest that GRFT is a new type of lectin that binds to various viral glycoproteins in a monosaccharide-dependent manner. GRFT could be a potential candidate microbicide to prevent the sexual transmission of HIV and AIDS.

Sequence variation within the dominant amino terminus epitope affects antibody binding and neutralization of human immunodeficiency virus type 1 Tat protein.

Tat is among the required regulatory genes of human immunodeficiency virus type 1 (HIV-1). Tat functions both within infected cells as a transcription factor and as an extracellular factor that binds and alters bystander cells. Some functions of extracellular Tat can be neutralized by immune serum or monoclonal antibodies. In order to understand the antibody response to Tat, we are defining antibody epitopes and the effects of natural Tat sequence variation on antibody recognition. The dominant Tat epitope in macaque sera is within the first 15 amino acids of the protein amino terminus. Together with a subdominant response to amino acids 57 to 60, these two regions account for most of the macaque response to linear Tat epitopes and both regions are also sites for the binding of neutralizing antibodies. However, the dominant and subdominant epitope sequences differ among virus strains, and this natural variation can preclude antibody binding and Tat neutralization. We also examined serum samples from 31 HIV-positive individuals that contained Tat binding antibodies; 23 of the 31 sera recognized the amino terminus peptide. Similar to binding in macaques, human antibody binding to the amino terminus was affected by variations at positions 7 and 12, sequences that are distinct for clade B compared to other viral clades. Tat-neutralizing antibodies to the dominant amino terminus epitope are affected by HIV clade variation.

Furin cleavage of the HIV-1 Tat protein.

Extracellular human immunodeficiency virus-1 (HIV-1) Tat protein and Tat-derived peptides are biologically active but mechanisms of Tat processing are not known. Within the highly conserved basic region of HIV-1 Tat protein (amino acids, a.a. 48-56), we identified two putative furin cleavage sites and showed that Tat protein was cleaved in vitro at the second site, RQRR\ (a.a. 53-56\). This in vitro cleavage was blocked by a monoclonal antibody that binds near the cleavage site or by the furin inhibitor alpha-1 PDX. Monocytoid cells rich in furin also degraded Tat and this process was slowed by the furin inhibitor or the specific monoclonal antibody. Furin processing did not affect the rates for Tat uptake and nuclear accumulation in HeLa or Jurkat cells, but the transactivation activity was greatly reduced. Furin processing is a likely mechanism for inactivating extracellular HIV-1 Tat protein.