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1.  Integrating complementary and alternative medicine into academic medical centers: Experience and perceptions of nine leading centers in North America 
Background
Patients across North America are using complementary and alternative medicine (CAM) with increasing frequency as part of their management of many different health conditions. The objective of this study was to develop a guide for academic health sciences centers that may wish to consider starting an integrative medicine program.
Methods
We queried North American leaders in the field of integrative medicine to identify initial sites. Key stakeholders at each of the initial sites visited were then asked to identify additional potential study sites (snowball sampling), until no new sites were identified. We conducted structured interviews to identify critical factors associated with success and failure in each of four domains: research, education, clinical care, and administration. During the interviews, field notes were recorded independently by at least two investigators. Team meetings were held after each visit to reach consensus on the information recorded and to ensure that it was as complete as possible. Content analysis techniques were used to identify key themes that emerged from the field notes.
Results
We identified ten leading North American integrative medical centers, and visited nine during 2002–2003. The centers visited suggested that the initiation of an integrative medicine program requires a significant initial outlay of funding and a motivated "champion". The centers had important information to share regarding credentialing, medico-legal issues and billing for clinical programs; identifying researchers and research projects for a successful research program; and strategies for implementing flexible educational initiatives and establishing a functional administrative structure.
Conclusion
Important lessons can be learned from academic integrative programs already in existence. Such initiatives are timely and feasible in a variety of different ways and in a variety of settings.
doi:10.1186/1472-6963-5-78
PMCID: PMC1343546  PMID: 16368000
2.  Adult cancer survivorship care: experiences from the LIVESTRONG centers of excellence network 
Background
The objectives of this study were to characterize survivorship models of care across eight LIVESTRONG Survivorship Center of Excellence (COE) Network sites and to identify barriers and facilitators influencing survivorship care.
Methods
Using the framework of the Chronic Care Model (CCM), quantitative and qualitative methods of inquiry were conducted with the COEs. Methods included document reviews, key informant telephone interviews with 39 participants, online Assessment of Chronic Illness Care (ACIC) surveys with 40 participants, and three site visits.
Results
Several overarching themes emerged in qualitative interviews and were substantiated by quantitative methods. Health system factors supporting survivorship care include organization and leadership commitment and program champions at various levels of the health care team. System barriers include reimbursement issues, lack of space, and the need for leadership commitment to support changes in clinical practices as well as having program “champions” among clinical staff. Multiple models of care include separate survivorship clinics and integrated models as well as consultative models. COEs' scores on the ACIC survey showed overall “reasonable support” for survivorship care; however, the clinical information system domain was least developed. Although the ACIC findings indicated “reasonable support” for self-management, the qualitative analysis revealed that self-management support was largely limited to health promotion provided in clinic-based education and counseling sessions, with few COEs providing patients with self-management tools and interventions.
Conclusions
The CCM framework captured experiences and challenges of these COEs and provided insight into the current state of survivorship care in the context of National Cancer Institute-designated comprehensive cancer centers. Findings showed that cancer patients and providers could benefit from clinical information systems that would better identify candidates for survivorship care and provide timely information. In addition, a crucial area for development is self-management support outside of clinical care.
Implications for cancer survivors
Cancer survivors may benefit from learning about the experience and challenges faced by the eight LIVESTRONG Centers of Excellence in developing programs and models for cancer survivorship care, and these findings may inform patient and caregiver efforts to seek, evaluate, and advocate for quality survivorship programs designed to meet their needs.
doi:10.1007/s11764-011-0180-z
PMCID: PMC3739450  PMID: 21553353
Cancer; Cancer survivorship; Chronic care model; Health care
3.  Joy and Challenges in Improving Chronic Illness Care: Capturing Daily Experiences of Academic Primary Care Teams 
Journal of General Internal Medicine  2010;25(Suppl 4):581-585.
BACKGROUND
Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.
OBJECTIVE
We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.
DESIGN
The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.
PARTICIPANTS
Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.
APPROACH
Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).
KEY RESULTS
At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.
CONCLUSIONS
The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.
doi:10.1007/s11606-010-1408-8
PMCID: PMC2940446  PMID: 20737233
chronic illness; team; joy in work; graduate medical education; ambulatory training; interprofessional training
4.  Adherence to HAART: A Systematic Review of Developed and Developing Nation Patient-Reported Barriers and Facilitators 
PLoS Medicine  2006;3(11):e438.
Background
Adherence to highly active antiretroviral therapy (HAART) medication is the greatest patient-enabled predictor of treatment success and mortality for those who have access to drugs. We systematically reviewed the literature to determine patient-reported barriers and facilitators to adhering to antiretroviral therapy.
Methods and Findings
We examined both developed and developing nations. We searched the following databases: AMED (inception to June 2005), Campbell Collaboration (inception to June 2005), CinAhl (inception to June 2005), Cochrane Library (inception to June 2005), Embase (inception to June 2005), ERIC (inception to June 2005), MedLine (inception to June 2005), and NHS EED (inception to June 2005). We retrieved studies conducted in both developed and developing nation settings that examined barriers and facilitators addressing adherence. Both qualitative and quantitative studies were included. We independently, in duplicate, extracted data reported in qualitative studies addressing adherence. We then examined all quantitative studies addressing barriers and facilitators noted from the qualitative studies. In order to place the findings of the qualitative studies in a generalizable context, we meta-analyzed the surveys to determine a best estimate of the overall prevalence of issues. We included 37 qualitative studies and 47 studies using a quantitative methodology (surveys). Seventy-two studies (35 qualitative) were conducted in developed nations, while the remaining 12 (two qualitative) were conducted in developing nations. Important barriers reported in both economic settings included fear of disclosure, concomitant substance abuse, forgetfulness, suspicions of treatment, regimens that are too complicated, number of pills required, decreased quality of life, work and family responsibilities, falling asleep, and access to medication. Important facilitators reported by patients in developed nation settings included having a sense of self-worth, seeing positive effects of antiretrovirals, accepting their seropositivity, understanding the need for strict adherence, making use of reminder tools, and having a simple regimen. Among 37 separate meta-analyses examining the generalizability of these findings, we found large heterogeneity.
Conclusions
We found that important barriers to adherence are consistent across multiple settings and countries. Research is urgently needed to determine patient-important factors for adherence in developing world settings. Clinicians should use this information to engage in open discussion with patients to promote adherence and identify barriers and facilitators within their own populations.
An analysis of qualitative and quantitative studies found consistent barriers to adherence to HIV therapy across multiple settings and countries, ranging from access to medication to problems with complicated regimens.
Editors' Summary
Background.
The World Health Organization has estimated that in 2005, about 38 million people worldwide were living with HIV/AIDS; the mortality caused by HIV/AIDS is very high. Antiretroviral drugs are effective at controlling the disease and extending life span. However, it is important for people to stick to the drug regimens exactly in order to keep levels of HIV low, prevent it from becoming resistant to drugs, and stop the illness from progressing. However, many people find it very difficult to take antiretroviral drugs precisely as they should. There is already some evidence from research studies on the reasons why this is the case. There are two different research approaches taken by these studies: “qualitative” methods, which try to find out about attitudes and behaviors using focus groups, interviews, or other techniques; and “quantitative” methods, which try to find out about peoples' opinions and experience using surveys with set questions for the participants to answer, and then count the different responses.
Why Was This Study Done?
The investigators wanted to put together all of the available evidence from published research studies (called doing a “systematic review”) on which factors affected people's adherence to antiretroviral drugs. They wanted to do a systematic review because it is thought to be a very rigorous way of appraising all the available evidence (although there is considerable debate about the value of using such a method to analyze the results of qualitative research).
What Did the Researchers Do and Find?
The study team searched biomedical literature databases as well as conference abstracts and research registries using a defined set of search queries. They screened all the scientific papers they found; those reporting results of original research into factors affecting antiretroviral adherence were then analyzed in more detail. 84 relevant studies were identified, of which 37 used “qualitative” methods (focus groups, interviews, open-ended questioning) and 47 used “quantitative” methods (surveys). Most of these studies had been carried out in the developed world. Then, the researchers extracted the factors affecting adherence from the original studies, which could be either “positive” factors (helping adherence) or “negative” ones (making adherence more difficult). They classified the factors into four key themes: “patient related” (e.g., seeing positive results, fear of disclosure, being depressed); “beliefs about medication” (e.g., faith in how well the drugs worked, side effects); “daily schedules” (e.g., using reminder tools, disruptions to routine); and “interpersonal relationships” (e.g., trusting relations with health-care provider; social isolation).
  Many barriers to adherence were common to both developed and developing settings. Some factors were unique to the studies conducted in the developing world, such as financial constraints and problems with traveling to get access to treatment. Fear of disclosure was an important barrier identified in many of the studies.
What Do These Findings Mean?
The researchers combined the results of many different studies and identified factors that help or obstruct adherence to antiretroviral treatment. By identifying influences common to the different settings, greater weight can be placed on the factors that were identified. Only 12 of the studies included in this research were from the developing world, where the majority of HIV/AIDS patients live; hence more work is needed to examine and address the factors influencing antiretroviral adherence in these parts of the world. This study provides researchers and health policy makers with a starting point for changes that might help to ensure greater adherence to antiretroviral treatment.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030438.
Medline Plus information on AIDS medicines (Medline Plus is a service of the US National Library of Medicine and the National Institutes of Health)
Joint United Nations Programme on HIV/AIDS has information about the state of the HIV/AIDS epidemic worldwide
The World Health Organization has an HIV/AIDS program site providing comprehensive information on the HIV/AIDS epidemic worldwide
The World Health Organization pages on antiretroviral therapy
doi:10.1371/journal.pmed.0030438
PMCID: PMC1637123  PMID: 17121449
5.  Longitudinal Evaluation of the Impact of Placement Development Teams on Student Support in Clinical Practice 
The Open Nursing Journal  2011;5:14-23.
Aims:
To investigate the impact of a new structure for supporting healthcare students and mentors in practice placements (Placement Development Teams).
Introduction:
The English Model National Partnership Agreement for healthcare education required Strategic Health Authorities, Higher Education Institutions and National Health Service Trusts to redesign strategies for student support. Placement Development Teams are one English University’s response to this.
Materials and Methodology:
This study was phase 2 of a longitudinal qualitative evaluation of Placement Development Teams. Data were collected after establishment of Placement Development Teams, and compared and contrasted with those collected prior to their implementation.
Telephone interviews were conducted with key educational stakeholders in Trusts and Strategic Health Authorities. Focus groups were conducted with third year non-medical healthcare students and first year paramedics working in 16 NHS Trusts in the south west peninsula of England.
Results:
Pre-Placement Development Teams, themes from the students’ data were: Supportive and unsupportive behaviour of staff; Mentor allocation; Placement allocation; Benefits of students to the placement area and Perceived control over the learning experience. Post-Placement Development Teams, the themes were Communication; Supportive and unsupportive behaviour of staff; The effect of peers on the placement experience; Knowledge and perceptions of the work of the PDTs.
Form the staff data, pre-Placement Development Teams the themes were: Vision for improving student support. Post-Placement Development Teams themes from the staff data were how they provided a central point of contact for student and mentor support; and how they supported students and mentors.
Conclusion:
Support of students and mentors is particularly important following the introduction of The English Model National Partnership Agreement for healthcare education. Placement Development Teams can facilitate partnership working between higher education institutions and placement providers for student support.
doi:10.2174/1874434601105010014
PMCID: PMC3109856  PMID: 21660180
Healthcare education; supporting students in practice; placement learning.
6.  Multiple Intravenous Infusions Phase 1b 
Background
Minimal research has been conducted into the potential patient safety issues related to administering multiple intravenous (IV) infusions to a single patient. Previous research has highlighted that there are a number of related safety risks. In Phase 1a of this study, an analysis of 2 national incident-reporting databases (Institute for Safe Medical Practices Canada and United States Food and Drug Administration MAUDE) found that a high percentage of incidents associated with the administration of multiple IV infusions resulted in patient harm.
Objectives
The primary objectives of Phase 1b of this study were to identify safety issues with the potential to cause patient harm stemming from the administration of multiple IV infusions; and to identify how nurses are being educated on key principles required to safely administer multiple IV infusions.
Data Sources and Review Methods
A field study was conducted at 12 hospital clinical units (sites) across Ontario, and telephone interviews were conducted with program coordinators or instructors from both the Ontario baccalaureate nursing degree programs and the Ontario postgraduate Critical Care Nursing Certificate programs. Data were analyzed using Rasmussen’s 1997 Risk Management Framework and a Health Care Failure Modes and Effects Analysis.
Results
Twenty-two primary patient safety issues were identified with the potential to directly cause patient harm. Seventeen of these (critical issues) were categorized into 6 themes. A cause-consequence tree was established to outline all possible contributing factors for each critical issue. Clinical recommendations were identified for immediate distribution to, and implementation by, Ontario hospitals. Future investigation efforts were planned for Phase 2 of the study.
Limitations
This exploratory field study identifies the potential for errors, but does not describe the direct observation of such errors, except in a few cases where errors were observed. Not all issues are known in advance, and the frequency of errors is too low to be observed in the time allotted and with the limited sample of observations.
Conclusions
The administration of multiple IV infusions to a single patient is a complex task with many potential associated patient safety risks. Improvements to infusion and infusion-related technology, education standards, clinical best practice guidelines, hospital policies, and unit work practices are required to reduce the risk potential. This report makes several recommendations to Ontario hospitals so that they can develop an awareness of the issues highlighted in this report and minimize some of the risks. Further investigation of mitigating strategies is required and will be undertaken in Phase 2 of this research.
Plain Language Summary
Patients, particularly in critical care environments, often require multiple intravenous (IV) medications via large volumetric or syringe infusion pumps. The infusion of multiple IV medications is not without risk; unintended errors during these complex procedures have resulted in patient harm. However, the range of associated risks and the factors contributing to these risks are not well understood.
Health Quality Ontario’s Ontario Health Technology Advisory Committee commissioned the Health Technology Safety Research Team at the University Health Network to conduct a multi-phase study to identify and mitigate the risks associated with multiple IV infusions. Some of the questions addressed by the team were as follows: What is needed to reduce the risk of errors for individuals who are receiving a lot of medications? What strategies work best?
The initial report, Multiple Intravenous Infusions Phase 1a: Situation Scan Summary Report, summarizes the interim findings based on a literature review, an incident database review, and a technology scan.
The Health Technology Safety Research Team worked in close collaboration with the Institute for Safe Medication Practices Canada on an exploratory study to understand the risks associated with multiple IV infusions and the degree to which nurses are educated to help mitigate them. The current report, Multiple Intravenous Infusions Phase 1b: Practice and Training Scan, presents the findings of a field study of 12 hospital clinical units across Ontario, as well as 13 interviews with educators from baccalaureate-level nursing degree programs and postgraduate Critical Care Nursing Certificate programs. It makes 9 recommendations that emphasize best practices for the administration of multiple IV infusions and pertain to secondary infusions, line identification, line set-up and removal, and administering IV bolus medications.
The Health Technology Safety Research Team has also produced an associated report for hospitals entitled Mitigating the Risks Associated With Multiple IV Infusions: Recommendations Based on a Field Study of Twelve Ontario Hospitals, which highlights the 9 interim recommendations and provides a brief rationale for each one.
PMCID: PMC3377572  PMID: 23074426
7.  Primary Care Research Team Assessment (PCRTA): development and evaluation. 
BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.
PMCID: PMC2560501  PMID: 12049028
8.  Integrating community children’s nursing in urgent and emergency care: a qualitative comparison of two teams in North West England 
BMC Pediatrics  2012;12:101.
Background
Despite the policy principle that “children are best cared for at home whenever possible” children continue to have high rates of emergency department (ED) attendance and emergency hospital admission. Community Children’s Nursing Teams (CCNTs) can care for acutely ill children at home but their potential to provide an alternative to ED attendance and hospitalisation depends on effective integration with other services in the urgent care system, such as EDs and Observation and Assessment Units (OAUs). Although challenges of integrating CCNTs have been identified, there has been no comparative assessment of the factors that facilitate or hinder integration of care of acutely ill children by CCNTs with the urgent care system. The aim of this study was to identify enablers and barriers to integration of CCNTs with urgent and emergency care.
Methods
Comparative case studies were conducted of two CCNTs serving Primary Care Trusts in North West England. Twenty-two health professionals including CCNT managers and staff; paediatricians; nurses; children’s ward, ED and OAU staff; commissioners of children’s services; GPs and primary care staff were interviewed between June 2009 and February 2010. Qualitative data were analysed thematically using the Framework approach.
Results
Barriers to integration included paediatricians’ perceived lack of ownership of the CCNT, poor communication between consultants and community children’s nurses (CCNs), and weak personal relationships. This prevented early referral to the CCNT as an alternative to hospital care. Enablers of integration included co-location and rotation of CCNs through urgent care settings including OAUs and EDs. This enabled nurses to develop skills, make decisions about referral to home care and gain the confidence of referring clinicians.
Conclusions
Integration of CCNTs at multiple points in the urgent care system is required in order to provide an alternative to inappropriate ED attendances and emergency admission. The principal enablers and barriers are both aspects of normative integration, which involves shared understanding of the contribution of CCNTs and trusting relationships between practitioners. Co-location and rotation of CCNs through acute services can promote integration and appropriate referrals to CCNTs to support families to care for children at home.
doi:10.1186/1471-2431-12-101
PMCID: PMC3505145  PMID: 22799532
9.  Educating Health Care Professionals to Provide Institutional Changes in Cancer Survivorship Care 
The Institute of Medicine (IOM) 2006 report, From Cancer Patient to Cancer Survivor: Lost in Transition (In M. Hewitt, S. Greenfield and E. Stovall (Eds.), (pp. 9–186). Washington DC: The National Academies Press, 2006) identifies the key components of care that contribute to quality of life for the cancer survivor. As cancer survivorship care becomes an important part of quality cancer care oncology professionals need education to prepare themselves to provide this care. Survivorship care requires a varied approach depending on the survivor population, treatment regimens and care settings. The goal of this program was to encourage institutional changes that would integrate survivorship care into participating centers. An NCI-funded educational program: Survivorship Education for Quality Cancer Care provided multidiscipline two-person teams an opportunity to gain this important knowledge using a goal-directed, team approach. Educational programs were funded for yearly courses from 2006 to 2009. Survivorship care curriculum was developed using the Quality of Life Model as the core around the IOM recommendations. Baseline data was collected for all participants. Teams were followed-up at 6, 12 and 18 months postcourse for goal achievement and institutional evaluations. Comparison data from baseline to 18 months provided information on the 204 multidiscipline teams that participated over 4 years. Teams attended including administrators, social workers, nurse practitioners, registered nurses, physicians and others. Participating centers included primarily community cancer centers and academic centers followed by pediatric centers, ambulatory/physician offices and free standing cancer centers. Statistically significant changes at p=<0.05 levels were seen by 12 months postcourse related to the effectiveness, receptiveness and comfort of survivorship care in participant settings. Institutional assessments found improvement in seven domains of care that related to institutional change. This course provided education to participants that led to significant changes in survivorship care in their settings.
doi:10.1007/s13187-012-0314-7
PMCID: PMC3724461  PMID: 22271583
Cancer survivorship education; Institutional change; Quality of life; Institutional survey; Institutional assessment
10.  Design of a medication management program for Medicare beneficiaries: Qualitative findings from patients and physicians 
Background
The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals.
Objectives
We conducted focus groups with older adults and primary care physicians to explore: (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from both patient and provider perspectives.
Methods
Five focus groups (4 with older adults, 1 with primary care physicians) were conducted by a trained moderator using a semi-structured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification.
Results
Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist's access to the medical record, and a mutually-trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM.
Conclusions
This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include one that is comprehensive, addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with both patients and providers is essential.
doi:10.1016/j.amjopharm.2012.01.002
PMCID: PMC3322273  PMID: 22284582
older adults; medication management; focus groups; collaborative practice; pharmacists
11.  Potentials and barriers in cooperation between conventional and complementary practitioners at a Danish Multiple Sclerosis Hospital 
Introduction
More than 50% of the People with Multiple Sclerosis (PwMS) in Denmark have used complementary and alternative medicine (CAM). The majority of these combine CAM and conventional treatment, and from 2004 to 2010 the Danish Multiple Sclerosis Society conducted a research project with the purpose of investigating and testing models for cooperation between conventional and complementary practitioners.
Theory
Five health care providers and five CAM practitioners were set up to work together from 2004 to 2010 in developing and offering integrated treatment to 200 PwMS at a Danish MS Hospital. The investigation of the collaborative process between practitioners has been based on theories of epistemic cultures as well as learning theories, focusing on interdisciplinary development.
Methods
Empirical material consists of individual interviews with practitioners, a group interview with practitioners, a group interview with professional staff at the Danish MS Hospital, interviews with patients as well as written responses from the practitioners.
Results and conclusions
The six-year cooperation among the practitioners documented mutual inspiration and learning within the team, as well as numerous basic challenges involved in developing interdisciplinary treatment for PwMS. Cooperation between researchers and the treatment team resulted in the development of four interdisciplinary models, which describe the potentials and barriers in relation to various types of collaboration.
Discussions
In many cases, integrating CAM and conventional treatment providers is seen as an ideal. This paper points out the importance of not overlooking the opportunities, values and the potential inherent in a pluralistic ideal in terms of the patients’ own active efforts and the dynamism that can arise when the patient becomes a co-informant, co-coordinator and/or co-integrator.
PMCID: PMC3225281
multiple sclerosis; integrative treatment; integrative care; teambased treatment; complementary medicine; CAM
12.  The implementation evaluation of primary care groups of practice: a focus on organizational identity 
BMC Family Practice  2010;11:15.
Background
Since 2002 the Health Ministry of Québec (Canada) has been implementing a primary care organizational innovation called 'family medicine groups'. This is occurring in a political context in which the reorganization of primary care is considered necessary to improve health care system performance. More specifically, the purpose of this reform has been to overcome systemic deficiencies in terms of accessibility and continuity of care. This paper examines the first years of implementation of the family medicine group program, with a focus on the emergence of the organizational identity of one of the pilot groups located in the urban area of Montreal.
Methods
An in-depth longitudinal case study was conducted over two and a half years. Face to face individual interviews with key informants from the family medicine group under study were conducted over the research period considered. Data was gathered throuhg observations and documentary analysis. The data was analyzed using temporal bracketing and Fairclough's three-dimensional critical discourse analytical techniques.
Results
Three different phases were identified over the period under study. During the first phase, which corresponded to the official start-up of the family medicine group program, new resources and staff were only available at the end of the period, and no changes occurred in medical practices. Power struggles between physicians and nurses characterized the second phase, resulting in a very difficult integration of advanced nurse practitioners into the group. Indeed, the last phase was portrayed by initial collaborative practices associated with a sensegiving process prompted by a new family medicine group director.
Conclusions
The creation of a primary care team is a very challenging process that goes beyond the normative policy definitions of who is on the team or what the team has to do. To fulfil expectations of quality improvement through team-based care, health care professionals who are required to work together need shared time/space contexts to communicate; to overcome interprofessional and interpersonal conflicts; and to make sense of and define who they collectively are and what they do as a clinical team.
doi:10.1186/1471-2296-11-15
PMCID: PMC2841653  PMID: 20175911
13.  Facilitators and Challenges to Start-Up of the Colorectal Cancer Screening Demonstration Program 
Preventing Chronic Disease  2008;5(2):A39.
Introduction
The Centers for Disease Control and Prevention (CDC) funded the Colorectal Cancer Screening Demonstration Program in 2005. To assess the feasibility of providing community-based colorectal cancer screening, CDC is conducting a multiple-case study as part of a larger evaluation effort. This article highlights key facilitators and challenges common to the five programs studied during the start-up period.
Methods
The multiple-case study that includes all five program sites is being conducted during the 3-year program as part of process evaluation efforts. Data collection for program start-up occurred during August 2005 through September 2006. Data include approximately 70 interviews with program staff and stakeholders, document review, and observations. Both case-specific and cross-case analyses were conducted.
Results
On the basis of the cross-case analysis, we identified four factors that facilitated program start-up and four factors that challenged program start-up. Facilitating factors included 1) pre-existing program infrastructure, 2) partnerships, 3) clinical expertise, and 4) program champions. Factors challenging program start-up included 1) contracts with endoscopists, 2) resources for treating medical complications of screening and for cancer treatment, 3) administrative barriers, and 4) resource limitations. Additionally, preplanning was critical, allowing programs to efficiently initiate activities once funds became available.
Conclusion
The most important facilitator identified was the ability to build on pre-existing infrastructure, which provided experienced staff, partnerships, and provider relationships, as well as aided program integration with other chronic disease programs. Results also suggest that substantial planning and partnership development can begin before funds are secured to implement a colorectal cancer screening program.
PMCID: PMC2396997  PMID: 18341775
14.  Implementing a Complex Intervention to Support Personal Recovery: A Qualitative Study Nested within a Cluster Randomised Controlled Trial 
PLoS ONE  2014;9(5):e97091.
Objective
To investigate staff and trainer perspectives on the barriers and facilitators to implementing a complex intervention to help staff support the recovery of service users with a primary diagnosis of psychosis in community mental health teams.
Design
Process evaluation nested within a cluster randomised controlled trial (RCT).
Participants
28 interviews with mental health care staff, 3 interviews with trainers, 4 focus groups with intervention teams and 28 written trainer reports.
Setting
14 community-based mental health teams in two UK sites (one urban, one semi-rural) who received the intervention.
Results
The factors influencing the implementation of the intervention can be organised under two over-arching themes: Organisational readiness for change and Training effectiveness. Organisational readiness for change comprised three sub-themes: NHS Trust readiness; Team readiness; and Practitioner readiness. Training effectiveness comprised three sub-themes: Engagement strategies; Delivery style and Modelling recovery principles.
Conclusions
Three findings can inform future implementation and evaluation of complex interventions. First, the underlying intervention model predicted that three areas would be important for changing practice: staff skill development; intention to implement; and actual implementation behaviour. This study highlighted the importance of targeting the transition from practitioners' intent to implement to actual implementation behaviour, using experiential learning and target setting. Second, practitioners make inferences about organisational commitment by observing the allocation of resources, Knowledge Performance Indicators and service evaluation outcome measures. These need to be aligned with recovery values, principles and practice. Finally, we recommend the use of organisational readiness tools as an inclusion criteria for selecting both organisations and teams in cluster RCTs. We believe this would maximise the likelihood of adequate implementation and hence reduce waste in research expenditure.
Trial Registration
Controlled-Trials.com ISRCTN02507940
doi:10.1371/journal.pone.0097091
PMCID: PMC4038471  PMID: 24875748
15.  A systematic exploration of differences in contextual factors related to implementing the MOVE! weight management program in VA: A mixed methods study 
Background
In January 2006, Veterans Affairs (VA) disseminated the MOVE!® Weight Management Program to VA medical centers to address the high prevalence of overweight/obesity. In its second year, MOVE! implementation varied widely across facilities. The objective of this study was to understand contextual factors that facilitated or impeded implementation of MOVE! in VA medical centers in the second year after its dissemination.
Methods
We used an embedded mixed methods cross-sectional study design. Qualitative and quantitative data were collected simultaneously with the primary purpose to explore contextual factors most likely to influence MOVE! implementation effectiveness at five purposively selected facilities. Facilities were selected to maximize variation with respect to participation in MOVE! by candidate Veterans. Semi-structured phone interviews were conducted with 24 staff across the five facilities. Quantitative responses were elicited followed by open-ended questions. The quantitative measures were adapted from a published implementation model. Qualitative analysis was conducted using rigorous content analysis methods.
Results
Qualitative and quantitative data converged to strengthen findings that point to several recommendations. Management support can help increase visibility of the program, commit needed resources, and communicate the importance of implementation efforts. Establishing a receptive implementation climate can be accomplished by emphasizing the important role that weight management may have in reducing incidence and severity of obesity-related chronic conditions. Coalescing highly functioning multi-disciplinary teams was an essential step for more effective implementation of MOVE!. In some situations, local champions can overcome challenging barriers in facilities that lack sufficient management support.
Conclusions
Key organizational factors at local VA medical centers were strongly associated with MOVE! implementation. Results pointed to recommendations that can help accelerate large-scale dissemination of complex weight management programs.
doi:10.1186/1472-6963-11-248
PMCID: PMC3206421  PMID: 21961925
16.  Identifying the barriers to conducting outcomes research in integrative health care clinic settings - a qualitative study 
Background
Integrative health care (IHC) is an interdisciplinary blending of conventional medicine and complementary and alternative medicine (CAM) with the purpose of enhancing patients' health. In 2006, we designed a study to assess outcomes that are relevant to people using such care. However, we faced major challenges in conducting this study and hypothesized that this might be due to the lack of a research climate in these clinics. To investigate these challenges, we initiated a further study in 2008, to explore the reasons why IHC clinics are not conducting outcomes research and to identify strategies for conducting successful in-house outcomes research programs. The results of the latter study are reported here.
Methods
A total of 25 qualitative interviews were conducted with key participants from 19 IHC clinics across Canada. Basic content analysis was used to identify key themes from the transcribed interviews.
Results
Barriers identified by participants fell into four categories: organizational culture, organizational resources, organizational environment and logistical challenges. Cultural challenges relate to the philosophy of IHC, organizational leadership and practitioner attitudes and beliefs. Participants also identified significant issues relating to their organization's lack of resources such as funding, compensation, infrastructure and partnerships/linkages. Environmental challenges such as the nature of a clinic's patient population and logistical issues such as the actual implementation of a research program and the applicability of research data also posed challenges to the conduct of research. Embedded research leadership, integration of personal and professional values about research, alignment of research activities and clinical workflow processes are some of the factors identified by participants that support IHC clinics' ability to conduct outcomes research.
Conclusions
Assessing and enhancing the broader evaluation culture of IHC clinics prior to implementing outcomes research may be a critical step towards ensuring productive and cost-effective research programs. However, as IHC clinics are often complex systems, a whole systems approach to research should be used taking into account the multidimensional and complex nature of such treatment systems so that the results are useful and reflect real life.
doi:10.1186/1472-6963-10-14
PMCID: PMC2826302  PMID: 20074354
17.  Analysis and development of multiprofessional teams in medical rehabilitation 
Team analysis and team development are important instruments of organizational development and quality management. They contribute to team optimization in medical rehabilitation. Team analysis allows assessment of strengths and weaknesses of teams, resulting in possible recommendations for team development. So far there are only a few empirical studies and little practical experience analyzing multiprofessional teams in the health care field and inpatient medical rehabilitation in particular. This article presents team analyses performed on twelve multiprofessional medical rehabilitation teams in Germany and corresponding recommendations for team development.
A heuristic model of team analysis and team development was designed for this purpose. The model comprises the following parameters: input (team structure), process (teamwork) and output (team success). Variables to measure these parameters were derived from team performance models and known weaknesses of teams in medical care. Team analyses were conducted by administering a semi-standardized interview form and a short questionnaire to the head physicians of participating clinics while a survey was administered to all members of the rehabilitation team.
The results of the team analyses suggested the use of team development measures on each team. The teams were classified into three categories by their need for team development (low, medium and high). Furthermore five modules of team development could be generated from the results of the team analyses: (1) executive coaching, (2) communication training, (3) changing attitude towards teamwork, (4) task-oriented team development, and (5) training on socio-integrative aspects of teamwork. Some of these modules are important constituents of quality management programs. Team development can facilitate quality management programs, particularly with regard to process and output relating to leadership and staff. The study shows, that there is a basic, yet variable need of team analysis and team development in the medical rehabilitation facilities.
PMCID: PMC2736513  PMID: 19742278
team analysis; team development; medical rehabilitation
18.  The integration of occupational therapy into primary care: a multiple case study design 
BMC Family Practice  2013;14:60.
Background
For over two decades occupational therapists have been encouraged to enhance their roles within primary care and focus on health promotion and prevention activities. While there is a clear fit between occupational therapy and primary care, there have been few practice examples, despite a growing body of evidence to support the role. In 2010, the province of Ontario, Canada provided funding to include occupational therapists as members of Family Health Teams, an interprofessional model of primary care. The integration of occupational therapists into this model of primary care is one of the first large scale initiatives of its kind in North America. The objective of the study was to examine how occupational therapy services are being integrated into primary care teams and understand the structures supporting the integration.
Methods
A multiple case study design was used to provide an in-depth description of the integration of occupational therapy. Four Family Health Teams with occupational therapists as part of the team were identified. Data collection included in-depth interviews, document analyses, and questionnaires.
Results
Each Family Health Team had a unique organizational structure that contributed to the integration of occupational therapy. Communication, trust and understanding of occupational therapy were key elements in the integration of occupational therapy into Family Health Teams, and were supported by a number of strategies including co-location, electronic medical records and team meetings. An understanding of occupational therapy was critical for integration into the team and physicians were less likely to understand the occupational therapy role than other health providers.
Conclusion
With an increased emphasis on interprofessional primary care, new professions will be integrated into primary healthcare teams. The study found that explicit strategies and structures are required to facilitate the integration of a new professional group. An understanding of professional roles, trust and communication are foundations for interprofessional collaborative practice.
doi:10.1186/1471-2296-14-60
PMCID: PMC3663696  PMID: 23679667
Inteprofessional primary care; Collaboration; Family health teams; Multiple case study design; Occupational therapy; Integration
19.  Exploring the impact of common assessment instrumentation on communication and collaboration in inpatient and community-based mental health settings: a focus group study 
Background
Recognition that integrated services can lead to more efficient and effective care has made the principle of integration a priority for health systems worldwide for the last decade. However, actually bringing fully integrated services to life has eluded most health care organizations. Mental health has followed the rule, rather than the exception, when it comes integrating services. The lack of effective mechanisms to evaluate the needs of persons across mental health care services has been an important barrier to communication between professionals involved in care. This study sought to understand communication among inpatient and community-based mental health staff during transfers of care, before and after implementation of compatible assessment instrumentation.
Methods
Two focus groups were held with staff from inpatient (n = 10) and community (n = 10) settings in an urban, specialized psychiatric hospital in Ontario (Canada) – prior to and one year after implementation of compatible instrumentation in the community program. Transcripts were coded and aggregated into themes.
Results
Very different views of current communication patterns during transfers of care emerged. Inpatient mental health staff described a predictable, well-known process, whereas community-based staff emphasized unpredictability. Staff also discussed issues related to trust and the circle of care. All agreed that compatible assessments in inpatient and community mental health settings would facilitate communication through use of a common assessment language. However, no change in communication patterns was reported one year post implementation of compatible instrumentation.
Conclusions
Though all participants agreed on the potential for compatible instrumentation to improve communication during transfers of care, this cannot happen overnight. A number of issues related to trust, evidence-based practice, and organizational factors act as barriers to communication. In particular, staff noted the need for the results of comprehensive mental health assessments to be transformed into meaningful, user-friendly clinical summaries to facilitate uptake of assessment information, and consequently use of a common assessment language across mental health settings.
doi:10.1186/1472-6963-14-457
PMCID: PMC4282495  PMID: 25277136
Integrated care; Communication; Collaboration; Assessment; Mental health; interRAI; RAI mental health; interRAI community mental health
20.  P02.01. Bending Towards Integration: A Multiple Case Study Assessing the Progressive Landscape of Interprofessional Collaborative Care Within US Integrative Healthcare Centers 
Focus Area: Sustainable Business Practices
A paradigm shift is underway in our healthcare system whereby traditionally allopathic medical centers are beginning to adopt non-allopathic modalities of healing into their practices. This phenomenon has influenced the widespread emergence of integrative healthcare centers throughout the country whereby multiple disciplines are housed under one institutional roof. There is much to be learned from these pioneering centers of collaborative practice, as their seasoned experience in assimilating systems of healing provides valuable insight into the intricacies of interprofessional team care and contributes to the prospect of new and improved healthcare models.
This session presents key findings from a multiple case study whereby the following three US integrative centers serve as research participants to explore the inner dynamics of interprofessional collaborative care: Center for Continuum Health and Healing (CCHH) at Beth Israel Medical Center in New York, New YorkIntegrative Medicine Center (IMC) at Yale-affiliated Griffin Hospital in Derby, ConnecticutNorthern Hawaii Community Hospital (NHCH) in Waimea, Hawaii
Data for this study were collected over a total period of 6 months, and in-depth interviews served as the primary source of qualitative information. Drawing from practitioner and staff perspectives within each center, the analysis illuminates perceived value factors and core challenges of interprofessional collaborative care, as well as underscores standout facilitators and best practices supporting the sustainability of integrative practices with an emphasis on communication forums, internal culture, and architectural design. Although the meta-findings address key barriers to multidisciplinary collaboration, the merits of converging healing paradigms in clinical practice is highlighted and a fundamental “bending” towards successful integration is celebrated. The conclusion of the study fuels optimism that the collective effort unique to the integrative model might serve as a successful blueprint to replace our ailing approach to medicine.
doi:10.7453/gahmj.2013.097CP.P02.01
PMCID: PMC3875044
21.  Can a GP be a generalist and a specialist? Stakeholders views on a respiratory General Practitioner with a special interest service in the UK 
Background
Primary care practitioners have a potentially important role in the delivery of specialist care for people with long-term respiratory diseases. Within the UK the development of a General Practitioner with Special Interests (GPwSI) service delivered within Primary Care Trusts (PCTs) involves a process of 'transitional change' which impacts on the professional roles of clinicians who may embrace or resist change. In addition, the perspective of patients on the new roles is important. The objective of the current study is to explore the attitudes and views of stakeholders to the provision of a respiratory GPwSI service within the six PCTs in Leicester, UK.
Methods
Using a qualitative design, GPs, nurses, secondary care doctors, nurse specialists, physiotherapists, a healthcare manager and patients with respiratory disease took part in focus groups and in-depth interviews.
Results
The 25 participants expressed diverse opinions about the challenge of integrating specialist services with generalist care and the specific contribution that GPs might make to the care of people with chronic respiratory disease. A range of potential roles for a respiratory GPwSI, working as part of a multi-disciplinary team, were suggested, and a number of practical issues were highlighted. Success of the GPwSI role is deemed to be dependant on having the trust of their primary and secondary care colleagues as well as patients, credibility as a practitioner, and being politically astute thereby enabling them to act as a champion supporting the transition process within the local health service.
Conclusion
The introduction of a respiratory GPwSI service represents a challenge to traditional roles which, whilst broadly acceptable, raised a number of important issues for the stakeholders in our study. These perspectives need to be taken into account if workforce change is to be successfully negotiated and implemented.
doi:10.1186/1472-6963-6-62
PMCID: PMC1524758  PMID: 16734893
22.  Two Strategies for the Delivery of IPTc in an Area of Seasonal Malaria Transmission in The Gambia: A Randomised Controlled Trial 
PLoS Medicine  2011;8(2):e1000409.
Bojang and colleagues report a randomized trial showing that delivery of intermittent preventive treatment for malaria in children by village health workers is more effective than delivery by reproductive and child health trekking clinics.
Background
The Expanded Programme on Immunisation (EPI) provides an effective way of delivering intermittent preventive treatment for malaria (IPT) to infants. However, it is uncertain how IPT can be delivered most effectively to older children. Therefore, we have compared two approaches to the delivery of IPT to Gambian children: distribution by village health workers (VHWs) or through reproductive and child health (RCH) trekking teams. In rural areas, RCH trekking teams provide most of the health care to children under the age of 5 years in the Infant Welfare Clinic, and provide antenatal care for pregnant women.
Methods and Findings
During the 2006 malaria transmission season, the catchment populations of 26 RCH trekking clinics in The Gambia, each with 400–500 children 6 years of age and under, were randomly allocated to receive IPT from an RCH trekking team or from a VHW. Treatment with a single dose of sulfadoxine pyrimethamine (SP) plus three doses of amodiaquine (AQ) were given at monthly intervals during the malaria transmission season. Morbidity from malaria was monitored passively throughout the malaria transmission season in all children, and a random sample of study children from each cluster was examined at the end of the malaria transmission season. The primary study endpoint was the incidence of malaria. Secondary endpoints included coverage of IPTc, mean haemoglobin (Hb) concentration, and the prevalence of asexual malaria parasitaemia at the end of malaria transmission period. Financial and economic costs associated with the two delivery strategies were collected and incremental cost and effects were compared. A nested case-control study was used to estimate efficacy of IPT treatment courses.
Treatment with SP plus AQ was safe and well tolerated. There were 49 cases of malaria with parasitaemia above 5,000/µl in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT was delivered by VHWs, (incidence rates 2.8 and 1.2 per 1,000 child months, respectively, rate difference 1.6 [95% confidence interval (CI) −0.24 to 3.5]). Delivery through VHWs achieved a substantially higher coverage level of three courses of IPT than delivery by RCH trekking teams (74% versus 48%, a difference of 27% [95% CI 16%–38%]). For both methods of delivery, coverage was unrelated to indices of wealth, with similar coverage being achieved in the poorest and wealthiest groups. The prevalence of anaemia was low in both arms of the trial at the end of the transmission season. Efficacy of IPTc against malaria during the month after each treatment course was 87% (95% CI 54%–96%). Delivery of IPTc by VHWs was less costly in both economic and financial terms than delivery through RCH trekking teams, resulting in incremental savings of US$872 and US$1,244 respectively. The annual economic cost of delivering at least the first dose of each course of IPTc was US$3.47 and US$1.63 per child using trekking team and VHWs respectively.
Conclusions
In this setting in The Gambia, delivery of IPTc to children 6 years of age and under by VHWs is more effective and less costly than delivery through RCH trekking clinics.
Trial Registration
ClinicalTrials.gov NCT00376155
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In sub-Saharan Africa, malaria kills 800,000 people, the majority of whom are children, every year. Intermittent preventive treatment (IPT) of malaria is an effective malaria control strategy. IPT involves administration of antimalarial drugs at defined time intervals to individuals regardless of whether they are known to be infected with malaria to prevent morbidity and mortality from the infection. IPT was initially recommended for pregnant women (IPTp) who are given at least two doses of suphadoxine pyrimethamine (SP) during antenatal visits after the first trimester of pregnancy. IPT is also effective in infants (IPTi) and recently IPTi has been rolled out with the administration of three doses of an antimalarial drug during the expanded program of immunization visits. Clinical studies have also shown that IPT is effective at reducing malaria incidence in children (IPTc) by administering SP alone, or in combination with artesunate (AS) or amodiaquine (AQ,) over three intervals during the peak malarial season.
Why Was This Study Done?
The inclusion of IPTp in antenatal visits and IPTi in the expanded program of immunization has effectively scaled up these interventions to the population level. So far, IPTc has only been administered to children within the confines of clinical trials—there is currently no established system for delivery of IPTc. For the scale-up of IPTc to be successful, there needs to be an appropriate point of entry and the roll out of a delivery system that can be generalized to most settings in sub-Saharan Africa. In order to address this issue, the researchers conducted a randomized trial to compare the effectiveness of IPTc delivery to children up to 6 y of age by village health workers (VHW) or by reproductive and child health (RCH) trekking teams (run by the Ministry of Health) in rural areas of The Gambia.
What Did the Researchers Do and Find?
During the 2006 malaria transmission season, the researchers randomly allocated the catchment populations of 26 RCH clinics, each with 400–500 children 6 y of age and under, to receive IPT from an RCH trekking team or from a VHW. Before the trial started, the researchers, accompanied by the district health team, visited all villages in the study area to explain the purpose and methods of the study and to obtain consent from the elders of all participating villages. Eligible children were treated with a single dose of SP plus three doses of AQ given at monthly intervals during the malaria transmission season. The researchers passively monitored malaria incidence throughout the transmission season and at the end of the malaria season, examined a random sample of 40 children from each cluster to measure their temperature, height, and weight and to take a finger-prick blood sample to measure blood hemoglobin and parasite levels (by microscopy of thick blood smears). The researchers recorded the financial costs associated with each delivery strategy (mostly on the basis of staff pay and the financial incentives given to VHWs).
There were 49 cases of clinical malaria in the areas where IPT was delivered through RCH clinics and 21 cases in the areas where IPT was delivered by VHWs. In addition, VHW delivery of IPTc achieved a higher coverage level of three courses of IPT than delivery by RCH trekking teams (74% versus 48%). The prevalence of anemia was low in both arms at the end of the transmission season. Delivery of IPTc by VHWs was cheaper than delivery through RCH trekking teams, resulting in incremental savings of US$872 and US$1,244, respectively. The annual economic cost of delivering at least the first dose of each course of IPTc using the RCH trekking team was US$3.47 per child and with VHWs was US$1.63 per child.
What Do These Findings Mean?
The results of this study show that in rural areas of The Gambia, delivery of IPTc by VHWs is more effective and less costly than delivery by RCH trekking teams through RCH clinics. Delivering IPTc through community-based VHWs versus monthly visits by the RCH team has several advantages: VHWs are resident in the community, making drug administration easy and flexible (as children were able to receive their medication on any day of the month), and they can remind mothers/guardians to attend for treatment. Therefore, operationally, VHW delivery is less restrictive and more convenient for parents and guardians.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000409.
This topic is further discussed in two PLoS Medicine research articles by Dicko et al. and Konat et al., and a PLoS Medicine Perspective by Beeson
WHO provides information about The Gambia
WHO also provides information about the health workforce, including the role of village health workers
Roll Back Malaria has information about malaria in children, including intervention strategies
Unicef also provides comprehensive information about malaria in children
doi:10.1371/journal.pmed.1000409
PMCID: PMC3032548  PMID: 21304921
23.  Tracking the evolution of hospice palliative care in Canada: A comparative case study analysis of seven provinces 
Background
An aging population, rise in chronic illnesses, increase in life expectancy and shift towards care being provided at the community level are trends that are collectively creating an urgency to advance hospice palliative care (HPC) planning and provision in Canada. The purpose of this study was to analyze the evolution of HPC in seven provinces in Canada so as to inform such planning and provision elsewhere. We have endeavoured to undertake this research out of awareness that good future planning for health and social care, such as HPC, typically requires us to first look backwards before moving forward.
Methods
To identify key policy and practice events in HPC in Canada, as well as describe facilitators of and barriers to progress, a qualitative comparative case study design was used. Specifically, the evolution and development of HCP in 7 strategically selected provinces is compared. After choosing the case study provinces, the grey literature was searched to create a preliminary timeline for each that described the evolution of HPC beginning in 1970. Key informants (n = 42) were then interviewed to verify the content of each provincial timeline and to discuss barriers and facilitators to the development of HPC. Upon completion of the primary data collection, a face-to-face meeting of the research team was then held so as to conduct a comparative study analysis that focused on provincial commonalities and differences.
Results
Findings point to the fact that HPC continues to remain at the margins of the health care system. The development of HPC has encountered structural inheritances that have both sped up progress as well as slowed it down. These structural inheritances are: (1) foundational health policies (e.g., the Canada Health Act); (2) service structures and planning (e.g., the dominance of urban-focused initiatives); and (3) health system decisions (e.g., regionalization). As a response to these inheritances, circumventions of the established system of care were taken, often out of necessity. Three kinds of circumventions were identified from the data: (1) interventions to shift the system (e.g., the role of advocacy); (2) service innovations (e.g., educational initiatives); and (3) new alternative structures (e.g., the establishment of independent hospice organizations). Overall, the evolution of HPC across the case study provinces has been markedly slow, but steady and continuous.
Conclusions
HPC in Canada remains at the margins of the health care system. Its integration into the primary health care system may ensure dedicated and ongoing funding, enhanced access, quality and service responsiveness. Though demographics are expected to influence HPC demand in Canada, our study confirms that concerned citizens, advocacy organizations and local champions will continue to be the agents of change that make the necessary and lasting impacts on HPC in Canada.
doi:10.1186/1472-6963-10-147
PMCID: PMC2898768  PMID: 20515491
24.  Resident and program director perspectives on third-year family medicine programs 
Canadian Family Physician  2009;55(9):904-905.e8.
ABSTRACT
OBJECTIVE
To determine the views of family medicine (FM) program directors, third-year program coordinators, and residents on the factors affecting demand and allocation of postgraduate year 3 (PGY3) positions and the effects of these programs on the professional activities of program graduates.
DESIGN
Cross-sectional surveys and key informant interviews.
SETTING
Ontario (FM residents) and across Canada (program directors) in 2006.
PARTICIPANTS
All FM residents in Ontario and all core program directors and PGY3 program coordinators nationally were eligible to participate in the surveys. Eighteen key informant interviews were conducted, all in Ontario. Interviewees included all FM program directors, selected PGY3 program coordinators, residents, and other community stakeholders.
METHODS
Resident surveys were Web-based; invitations to participate were delivered by FM programs via e-mail lists. The program director and coordinator surveys were postal surveys. Interviews were audiotaped and transcribed, and the authors coded the interviews for themes.
MAIN FINDINGS
Response rates for the surveys were 34% to 39% for residents and 78% for program directors and coordinators. Respondents agreed that programs should include flexible training options of varied duration. Demand for training is determined more by resident need than community or health system factors, and is either increasing or stable. Overall, respondents believed that approximately one-third of core program graduates should have the opportunity for PGY3 training. They thought re-entry from practice should be permitted, but mandatory return-of-service agreements were not desired. Program allocation and resident selection is a complex process with resident merit playing an important role. Respondents expected PGY3 graduates to practise differently than PGY2 graduates and to provide improved quality of care in their fields. They also thought that PGY3 graduates might play larger roles in leadership and teaching than core program graduates.
CONCLUSION
It is likely that PGY3 programs will continue to grow and form an increasingly important part of the FM training system in Canada. Flexible programs that can adapt to changing educational, health system, and community needs are essential. Training programs and national and provincial colleges of FM will also need to ensure that these physicians are provided with opportunities to maintain their links with the rest of the FM community.
PMCID: PMC2743591  PMID: 19752262
25.  Triggering change in diabetes care delivery in general practice: a qualitative evaluation approach using the clinical microsystem framework 
BMC Family Practice  2014;15:32.
Background
In 2008, the Sunshine Coast Division of General Practice (SCDGP) in Queensland, Australia initiated a highly successful Improved Diabetes Management (IDM) program with general practices in a regional area. The IDM program was evaluated against the 10 elements of a high functioning clinical microsystem framework as identified by Nelson et al. (2007) in order to determine key factors contributing to the successful adoption and uptake of the program in participating general practices.
Methods
The evaluation focussed on in-depth key informant interviews with 10 SCDGP staff and general practitioners (GPs) involved in the IDM program. A thematic analysis was undertaken and common emergent themes were reviewed against the 10 elements of high performing clinical microsystem.
Results
While all aspects of the clinical microsystem approach appeared effective in the design, implementation and adoption of the IDM program, several characteristics were crucial. The identification of champions of change in both the division and participating practices, the celebration of positive achievements and the use ‘real data’ from practices to demonstrate improved health outcomes for patients from the practice were instrumental in motivating participating GPs to both implement and sustain changes in their diabetes care delivery.
Conclusion
In designing and redesigning health care, the clinical microsystems approach offers a pathway for the effective uptake of innovation in Australian primary health care; a means of integrating structure, process and outcomes of a care framework for reviewing improvements in the health care delivery process and could lead to improvements in patient health outcomes.
doi:10.1186/1471-2296-15-32
PMCID: PMC3937026  PMID: 24520838
Clinical microsystems; Quality improvement; Diabetes mellitus, Chronic disease management; Health services research

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