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BackgroundDespite the implementation of a set of social and health policies, Brazil has experienced a slowdown in the decline of infant mortality, regional disparities and persistent high death levels, raising questions about the determinants of infant mortality after the implementation of these policies. The objective of this article is to propose a methodological approach aiming at identifying the determinants of infant mortality in Brazil after the implementation of those policies.MethodA series of multilevel panel data with fixed effect nested within-clusters were conducted supported by the concept of health capabilities based on data from 26 Brazilian states between 2004 and 2015. The dependent variables were the neonatal, the infant and the under-five mortality rates. The independent variables were the employment rate, per capita income,Bolsa FamíliaProgram coverage, the fertility rate, educational attainment, the number of live births by prenatal visits, the number of health professionals per thousand inhabitants, and the access to water supply and sewage services. We also used different time lags of employment rate to identify the impact of employment on the infant mortality rates over time, and household income stratified by minimum wages to analyze their effects on these rates.ResultsThe results showed that in addition to variables associated with infant mortality in previous studies, such asBolsa FamíliaProgram, per capita income and fertility rate, other factors affect child mortality. Educational attainment, quality of prenatal care and access to health professionals are also elements impacting infant deaths. The results also identified an association between employment rate and different infant mortality rates, with employment impacting neonatal mortality up to 3 years and that a family income below 2 minimum wages increases the odds of infant deaths.ConclusionThe results proved that the methodology proposed allowed the use of variables based on aggregated data that could hardly be used by other methodologies.

En France, le champ organisationnel des soins primaires connait des transformations significatives depuis une vingtaine d’annees, avec l’emergence de nouvelles formes de regulation et de nouveaux modeles organisationnels. Parmi ces derniers, les maisons de sante pluriprofessionnelles ont beneficie du soutien des pouvoirs publics depuis le milieu des annees 2000.A travers l’etude retrospective de documents d’archive sur les politiques de developpement des maisons de sante en France, nous proposons une analyse logique de ces politiques publiques et de ce modele organisationnel. Nous caracterisons ensuite, en nous appuyant sur les theories neo-institutionnelles, les logiques qui sous-tendent la diffusion de ces nouvelles organisations formelles et discutons l’utilite de ce cadre d’analyse pour apprehender les transformations associees aux reformes de l’organisation des soins primaires.

Background As the uptake of health information technologies increased, most healthcare organizations have become producers of big data. A growing number of hospitals are investing in the development of big data analytics (BDA) capabilities. If the promises associated with these capabilities are high, how hospitals create value from it remains unclear. The present study undertakes a scoping review of existing research on BDA use in hospitals to describe the path from BDA capabilities (BDAC) to value and its associated challenges. Methods This scoping review was conducted following Arksey and O’Malley’s 5 stages framework. A systematic search strategy was adopted to identify relevant articles in Scopus and Web of Science. Data charting and extraction were performed following an analytical framework that builds on the resource-based view of the firm to describe the path from BDA capabilities to value in hospitals. Results Of 1,478 articles identified, 94 were included. Most of them are experimental research (n=69) published in medical (n=66) or computer science journals (n=28). The main value targets associated with the use of BDA are improving the quality of decision-making (n=56) and driving innovation (n=52) which apply mainly to care (n=67) and administrative (n=48) activities. To reach these targets, hospitals need to adequately combine BDA capabilities and value creation mechanisms (VCM) to enable knowledge generation and drive its assimilation. Benefits are endpoints of the value creation process. They are expected in all articles but realized in a few instances only (n=19). Conclusions This review confirms the value creation potential of BDA solutions in hospitals. It also shows the organizational challenges that prevent hospitals from generating actual benefits from BDAC-building efforts. The configuring of strategies, technologies and organizational capabilities underlying the development of value-creating BDA solutions should become a priority area for research, with focus on the mechanisms that can drive the alignment of BDA and organizational strategies, and the development of organizational capabilities to support knowledge generation and assimilation.

Despite the implementation of social and health policies that positively affected the health of the populations in Brazil, since 2009 the country has experienced a slower decline of infant mortality. After an economic and political crisis, Brazil witnessed increases in infant mortality that raised questions about what are the determinants of infant mortality after the implementation of such policies. We conducted a scoping review to identify and summarize those determinants with searches in three databases: LILACS, MEDLINE, and SCIELO. We included studies published between 2010 and 2020. We selected 23 papers: 83% associated infant mortality with public policies; 78% related infant mortality with the use of the health system and socioeconomic and living conditions; and 27% related to individual characteristics to infant mortality. Inequalities in the access to healthcare seem to have important implications in reducing infant mortality. Socioeconomic conditions and health-related factors such as income, education, fertility, housing, and the Bolsa Família. Program coverage was pointed out as the main determinants of infant mortality. Likewise, recent changes in infant mortality in Brazil are likely related to these factors. We also identified a gap in terms of studies on a possible association between employment and infant mortality.

BackgroundInfant mortality as a relevant indicator of population's health, social inequalities and living conditions has been fairly documented in the literature as it still represents a major challenge for emerging countries such as Brazil. While infant mortality rates have decreased in the last 30 years, some macro-regions of the country present great variability of infant mortality rates. These disparities, together with a rise in infant mortality and under-five mortality rates, and after the country experienced a political-economic crisis, draw attention to social determinants of health. MethodWe conducted a descriptive analysis of the determinants of infant mortality in Brazil between 2004 and 2015, based on the World Health Organization’s Commission on Social Determinants of Health conceptual framework aiming at analyzing the evolution of these determinants to understand the behavior of the infant mortality rate observed in recent years in the country.ResultsResults suggested that there is a correlation between infant mortality and structural determinants such as income, the Bolsa Família Program, education and employment, and intermediary determinants such as the number of livebirths by prenatal visits, the number of physicians and nurses per thousand inhabitants, fertility rate, safe water, and sewage service coverage rates.ConclusionResults suggest that inequalities in infant mortality observed among macro-regions in Brazil are related to disparities in the distribution of Social Determinants of Health such as income, Bolsa Família Program coverage, education attainment, employment, fertility rate and of health-related determinants such as quality of and accessibility to healthcare and water supply, as well as sewage services. These disparities impose different dynamics between the structural and intermediary determinants of health that likely limit further reductions in infant mortality, which would probably explain both the slowdown in the reduction and the tendency of IMR to remain at a relatively high level. Results also suggest that the increase of infant mortality rate in 2016 is attributable to the deterioration in one or more of those determinants, such as a fall in employment rate due to the economic crisis, may be pointed out as one of the causes of interruption on the trend of decline in infant mortality.

This research aimed to better understand how institutions are maintained, and the role of materiality in this institutional work. More specifically, the present qualitative case study analyzed how different actors in a large academic hospital in Canada worked together (i.e. accomplished institutional work) to maintain the institution of medical record keeping as a new clinical information system (computerized physician order entry-the material entity) was enacted. The study reveals that, to maintain the institution at stake, the intertwinement of processes of creating and maintaining institutions took place. In fact, different forms of institutional work interact Results also strongly suggest that the design of computerized physician order entry and its implementation (i.e. the materiality involved in this institutional change) played an important role in the maintenance of the institution of medical record keeping: on the one hand, it was particularly present in three types of institutional work, namely enabling, policing, and deterring; on the other hand, it appeared to be an essential component of the routinization of work by allowing a better fit between the new technology and the organization of work

OBJECTIVES To evaluate the impact of synchronous telemedicine models on the clinical outcomes in pediatric acute care settings. DATA SOURCES Citations from EBM Reviews, MEDLINE, EMBASE, Global Health, PubMed, and CINAHL. STUDY SELECTION We identified studies that evaluated the impact of synchronous telemedicine on clinical outcomes between January 2000 and April 2018. All studies involving acutely ill children in PICUs, pediatric cardiac ICUs, neonatal ICUs, and pediatric emergency departments were included. Publication inclusion criteria were study design, participants characteristics, technology type, interventions, settings, outcome measures, and languages. DATA EXTRACTION Two authors independently screened each article for inclusion and extracted information, including telecommunication method, intervention characteristics, sample characteristics and size, outcomes, and settings. DATA SYNTHESIS Out of the 789 studies initially identified, 24 were included. The six main outcomes of interest published were quality of care, hospital and standardized mortality rate, transfer rate, complications and illness severity, change in medical management, and length of stay. The use of synchronous telemedicine results improved quality of care and resulted in a decrease in the transfer rate (31-87.5%) (four studies), a shorter length of stay (8.2 vs 15.1 d) (six studies), a change or reinforcement of the medical care plan, a reduction in complications and illness severity, and a low hospital and standardized mortality rate. Overall, the quality of the included studies was weak. CONCLUSIONS Despite the broad recommendations found for using telemedicine in pediatric acute care settings, high-quality evidence of its impacts is still lacking. Further robust studies are needed to better determine the clinical effectiveness and the associated impacts of telemedicine in pediatric acute care settings.

International audience; Over-rationality is addressed in this article in terms of excessive standardization of the process of care delivered to patients. In this specific case, standardization can be observed in the definition and implementation of operational procedures, in the definition of best practices based on evidence-based medicine, and in the introduction of performance standards (e.g. an optimal delay). A deep analysis of the organization of work required by the process of care reveals that the goal of this organization is to determine a balance between standardization and adaptation, depending of the occurrence of unforeseen situations to face in the daily activity. Then, an excessive standardization can limit the flexibility required in the organization of work. We illustrate this phenomenon of over-rationality through two cases: the use of operational procedures, often named “protocol”, and the implementation of information systems. Last, we identify reasons of this trend, and, in return, affirm the need to acknowledge an autonomous actor able to assess the best attitude to adopt for managing the variety of working situations to face during the delivery of care.; Le phénomène de sur-rationalité est traité dans cet article sous l’angle de la standardisation excessive qui peut s’observer dans la gestion de la prise en charge des malades. Dans ce cas précis, la standardisation peut s’appliquer au travail d’exécution en fixant des procédures et règles opératoires qui permettent d’engager l’action d’une manière reproductible, à la définition de bonnes pratiques (ce que les anglo-saxons nomment l’« evidence based medicine »), et à l’introduction de standards de performance (comme un délai optimal). Une analyse minutieuse de l’organisation de la prise en charge des malades montre que cette dernière se conçoit comme une alternance de standardisation et d’adaptation lorsque des situations de travail imprévisibles ou spécifiques l’obligent. En conséquence, une sur-rationalité se comprend comme une standardisation excessive qui peut empêcher le recours au registre de l’adaptation. Nous illustrons ce phénomène de sur-rationalité à travers deux exemples : l’application de la procédure opératoire standardisée ou « protocole », et le recours aux technologies de l’information. Nous identifions ensuite les raisons de cet excès, et proposons en réponse d’affirmer la reconnaissance d’un acteur autonome apte à juger le recours pertinent au registre de la standardisation, et les modalités de son application.

Multimorbidity increases care needs among people with chronic diseases. In order to support communication between patients, their informal caregivers and their healthcare teams, we developed CONCERTO+, a patient portal for chronic disease management in primary care. A user-centered design comprising 3 iterations with patients and informal caregivers was performed. Clinicians were also invited to provide feedback on the feasibility of the solution. Several improvements were brought to CONCERTO+, and it is now ready to be implemented in real-life setting.

Background Remote Patient Monitoring Systems (RPMS) based on e-health, Nurse Navigators (NNs) and patient engagement can improve patient follow-up and have a positive impact on quality of care (by limiting adverse events) and costs (by reducing readmissions). However, the extent of this impact depends on effective implementation which is often restricted. This is partly due to the lack of attention paid to the RPMS design phase prior to implementation. The content of the RPMS can be carefully designed at this stage and various obstacles anticipated. Our aim was to report on an RPMS design case to provide insights into the methodology required in order to manage this phase. Methods This study was carried out at Gustave Roussy, a comprehensive cancer centre, in France. A multidisciplinary team coordinated the CAPRI RPMS design process (2013–2015) that later produced positive outcomes. Data were collected during eight studies conducted according to the Medical Research Council (MRC) framework. This project was approved by the French National Data Protection Authorities. Results Based on the study results, the multidisciplinary team defined strategies for resolving obstacles prior to the implementation of CAPRI. Consequently, the final CAPRI design includes a web app with two interfaces (patient and health care professionals) and two NNs. The NNs provide regular follow-up via telephone or email to manage patients’ symptoms and toxicity, treatment compliance and care packages. Patients contact the NNs via a secure messaging system. Eighty clinical decision support tools enable NNs to prioritise and decide on the course of action to be taken. Conclusion In our experience, the RPMS design process and, more generally, that of any complex intervention programme, is an important phase that requires a sound methodological basis. This study is also consistent with the notion that an RPMS is more than a technological innovation. This is indeed an organizational innovation, and principles identified during the design phase can help in the effective use of a RPMS (e.g. locating NNs if possible within the care organization; recruiting NNs with clinical and managerial skills; defining algorithms for clinical decision support tools for assessment, but also for patient decision and orientation).

International audience; Background - A regional hospital group located in northeastern Brittany (France) won a national call for improving the care provided to children at risk.Objective - Our work analyzed and compared the health paths of children at risk in this administrative territory of the French healthcare system. This work, thanks to its territorial approach, can help to better understand and identify mechanisms for improving the quality of care as well as the mechanisms that contribute to disruptions and inequalities in the access to a Child protection system.Methods - This qualitative study was based on a field analysis where 28 people were interviewed. The inclusion criteria were being: in one of the four domains of child protection (justice, health, social services and education), in one of the five target service areas (n = 21) and an expert in the field of children at risk (n = 7).Results - The results showed that the health pathway of abused children was unequal and followed a silo trajectory, with multiple breaks in the support provided. We found many barriers to multi-professional collaboration: institutional, professional, individual and regional.Conclusion - In terms of recommendations, we underline the relevance of models that promote greater integration. The article ends with a discussion of evidence to this effect.

Objectives Multimorbidity increases care needs and primary care use among people with chronic diseases. The Concerto Health Program (CHP) has been developed to optimise chronic disease management in primary care services. However, in its current version, the CHP primarily targets clinicians and does not aim to answer directly the needs of individual patients and their informal caregivers. This study aims to develop, implement and evaluate a user-centered, multifunctional and personalised eHealth platform (CONCERTO+) to promote a more active patient role in chronic disease management and decision-making. Method This ongoing project uses a collaborative research approach and has 3 major phases: 1) the development of a multi-module eHealth platform combining scientific evidence and user-centered design; 2) a feasibility study of the CONCERTO+ solution through a pilot cluster randomised controlled trial where patients with multiple chronic diseases from a primary healthcare practice will receive CONCERTO+ during 6 months and be compared to patients from a control practice receiving usual care; and 3) an analysis of CONCERTO+ potential for scaling up. Results The first phase of the project was the development of the user-centered solution. A first prototype was developed in Fall 2018 and tested with 10 patients and caregivers. Their comments led us to develop a second prototype that was tested with 10 patients and caregivers in Spring 2019. Following these 2 iterations, a final version of CONCERTO+ was developed and integrated to a large eHealth portal that enables information exchange and communication between health care providers and patients. The next phase, which consists of a pilot trial with diabetic patients followed in primary care practices, is ongoing. Conclusions Digital health solutions such as patient portals have been found to improve self-management for chronic care conditions. By fostering a more active role of patients, it is hypothesised that a solution like CONCERTO+ could optimise the use of health care services and decrease emergency visits.

International audience; La quête de rationalité: Le cas de la standardisation de la prise en charge des malades The quest of rationality: Standardization in the delivery of care Etienne Minvielle, EHESP-MOS, et Gustave Roussy Claude Sicotte, EHESP-MOS, Chaire de recherche EHESP /MNH-BFM: Prospective en Santé 2 Résumé Le phénomène de sur-rationalité est traité dans cet article sous l'angle de la standardisation excessive qui peut s'observer dans la gestion de la prise en charge des malades. Dans ce cas précis, la standardisation peut s'appliquer au travail d'exécution en fixant des procédures et règles opératoires qui permettent d'engager l'action d'une manière reproductible, à la définition de bonnes pratiques (ce que les anglo-saxons nomment l'« evidence based medicine »), et à l'introduction de standards de performance (comme un délai optimal). Une analyse minutieuse de l'organisation de la prise en charge des malades montre que cette dernière se conçoit comme une alternance de standardisation et d'adaptation lorsque des situations de travail imprévisibles ou spécifiques l'obligent. En conséquence, une sur-rationalité se comprend comme une standardisation excessive qui peut empêcher le recours au registre de l'adaptation. Nous illustrons ce phénomène de sur-rationalité à travers deux exemples : l'application de la procédure opératoire standardisée ou « protocole », et le recours aux technologies de l'information. Nous identifions ensuite les raisons de cet excès, et proposons en réponse d'affirmer la reconnaissance d'un acteur autonome apte à juger le recours pertinent au registre de la standardisation, et les modalités de son application. Summary Over-rationality is addressed in this article in terms of excessive standardization of the process of care delivered to patients. In this specific case, standardization can be observed in the definition and implementation of operational procedures, in the definition of best practices based on evidence-based medicine, and in the introduction of performance standards (e.g. an optimal delay). A deep analysis of the organization of work required by the process of care reveals that the goal of this organization is to determine a balance between standardization and adaptation, depending of the occurrence of unforeseen situations to face in the daily activity. Then, an excessive standardization can limit the flexibility required in the organization of work. We illustrate this phenomenon of over-rationality through two cases: the use of operational procedures, often named "protocol", and the implementation of information systems. Last, we identify reasons of this trend, and, in return, affirm the need to acknowledge an autonomous actor able to assess the best attitude to adopt for managing the variety of working situations to face during the delivery of care.