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The Proactive Community Case Management (ProCCM) trial in Mali reinforced the health system across both arms with user fee removal, professional Community Health Workers (CHWs), and upgraded primary health centres (PHCs)-and randomized village-clusters to receive proactive home visits by CHWs (intervention) or fixed site-based services by passive CHWs (control). Across both arms, sick children's 24-hour treatment and pregnant women's four or more antenatal visits doubled, and under-five mortality halved, over three years compared to baseline. In the intervention arm, proactive CHW home visits had modest effects on children's curative and women's antenatal care utilization, but no effect on under-five mortality, compared to the control arm. We aimed to explain these results by examining implementation, mechanisms, and context in both arms. We conducted a process evaluation with a mixed method convergent design that included 79 in-depth interviews with providers and participants over two time-points, surveys with 195 providers, and secondary analyses of clinical data. We embedded realist approaches in novel ways to test, refine, and consolidate theories about how ProCCM worked, generating three context-intervention-actor-mechanism-outcome nodes that unfolded in a cascade. First, removing user fees and deploying professional CHWs in every cluster enabled participants to seek health sector care promptly and created a context of facilitated access. Second, health systems support to all CHWs and PHCs enabled equitable, respectful, quality healthcare, which motivated increased, rapid utilization. Third, proactive CHW home visits facilitated CHWs and participants to deliver and seek care, and build relationships, trust, and expectations, but these mechanisms were also activated in both arms. Addressing multiple structural barriers to care, user fee removal, professional CHWs, and upgraded clinics interacted with providers' and patients' agency to achieve rapid care and child survival in both arms. Proactive home visits expedited or compounded mechanisms that were activated and changed the context across arms.

We aimed to explore the differences in immune checkpoint inhibitor (ICI) immunotherapy utilization for advanced melanoma by examining patient and neighborhood characteristics. We performed a retrospective cohort study using a deidentified, random sample of SEER-Medicare beneficiaries aged ≥65 years with stage III or stage IV melanoma (2011-2017). Our primary outcome was initiation of ICI immunotherapy (ipilimumab, pembrolizumab, nivolumab, or atezolizumab) after stage III or stage IV melanoma diagnosis. We analyzed ICI usage with multivariable logistic regression. After analyzing the entire 2011-2017 cohort, we conducted a secondary analysis in which we separately analyzed the 2011-2014 and 2015-2017 cohorts to assess possible differences over time. We included 3531 beneficiaries, with mean follow-up of 2.1 (SD = 2.0) years. Higher likelihood of ICI usage was associated with male sex (OR = 1.21, 95% confidence interval = 1.04-1.42) and higher density of medical oncologists (OR = 1.02, 95% confidence interval = 1.01-1.04). Lower likelihood of ICI usage was associated with older age group and Charlson comorbidity score (score ≥2; OR = 0.72, 95% confidence interval = 0.60-0.86). These associations were diminished in more recent years (no association with sex, medical oncologist density, Charlson comorbidity score, and association with only the oldest age group in years 2015-2017). We found significant sex- and age-related differences in initiation among SEER-Medicare beneficiaries with stage III or stage IV melanoma, which appear to be improving over time.

PURPOSE: To examine changes in rural and urban Veterans utilization of acute inpatient care in Veterans Health Administration (VHA) and non-VHA hospitals following access expansion from the Veterans Choice Act, which expanded eligibility for VHA-paid community hospitalization. METHODS: Using repeated cross-sectional data of VHA enrollees hospitalizations in 9 states (AZ, CA, CT, FL, LA, MA, NY, PA, and SC) between 2012 and 2017, we compared rural and urban Veterans probability of admission in VHA and non-VHA hospitals by payer over time for elective and nonelective hospitalizations using multinomial logistic regression to adjust for patient-level sociodemographic features. We also used generalized linear models to compare rural and urban Veterans travel distances to hospitals. FINDINGS: Over time, the probability of VHA-paid community hospitalization increased more for rural Veterans than urban Veterans. For elective inpatient care, rural Veterans probability of VHA-paid admission increased from 2.9% (95% CI 2.6%-3.2%) in 2012 to 6.5% (95% CI 5.8%-7.1%) in 2017. These changes were associated with a temporal trend that preceded and continued after the implementation of the Veterans Choice Act. Overall travel distances to hospitalizations were similar over time; however, the mean distance traveled decreased from 39.2 miles (95% CI 35.1-43.3) in 2012 to 32.3 miles (95% CI 30.2-34.4) in 2017 for rural Veterans receiving elective inpatient care in VHA-paid hospitals. CONCLUSIONS: Despite limited access to rural hospitals, these data demonstrate an increase in rural Veterans use of non-VHA hospitals for acute inpatient care and a small reduction in distance traveled to elective inpatient services.

Some antihypertensive medications are photosensitizing. The implications for skin cancer risk remain unclear because results from prior studies are inconsistent and as new evidence is published. We performed a systematic review and meta-analysis to evaluate the association between antihypertensives and common skin cancers (cutaneous squamous cell carcinoma, basal cell carcinoma, and melanoma) and to evaluate dose-response relationships. Forty-four articles met inclusion criteria, and 42 could be meta analyzed. Increased risks were seen for basal cell carcinoma with calcium channel blockers (relative risk [RR] = 1.17, 95% confidence interval [CI] = 1.11-1.22), diuretics (RR = 1.06, 95% CI = 1.03-1.10), and thiazides (RR = 1.10, 95% CI = 1.04-1.16); for squamous cell carcinoma with calcium channel blockers (RR = 1.08, 95% CI = 1.01-1.14), diuretics (RR = 1.29, 95% CI = 1.17-1.43), and thiazides (RR = 1.36, 95% CI = 1.15-1.61); and for melanoma in angiotensin-converting enzyme inhibitors (RR = 1.09, 95% CI = 1.03-1.14), calcium channel blockers (RR = 1.08, 95% CI = 1.03-1.12), and thiazides (RR = 1.09, 95% CI = 1.02-1.17). The quality of evidence was low or very low. We observed evidence for dose-response for thiazides with basal cell carcinoma; angiotensin-converting enzyme inhibitors, diuretics, and thiazides with squamous cell carcinoma; and angiotensin-converting enzyme inhibitors, diuretics, and thiazides with melanoma. Our meta-analysis supports a potential causal association between some antihypertensives, particularly diuretics, and skin cancer risk.

ObjectivesTo explore the relevance of pregnancy intention as a screen for contraceptive needs among postpartum individuals.Study designWe surveyed 234 postpartum individuals to assess the alignment between pregnancy intentions in the next year and current desire to prevent pregnancy.ResultsMost individuals (87%) desired pregnancy prevention now, including 73% of individuals who desired or were ambivalent about pregnancy in the next year.ConclusionA majority of individuals considering pregnancy in the next year desired pregnancy prevention now. Directly assessing current desire to prevent pregnancy may be more specific for contraceptive needs in postpartum individuals.ImplicationsOur ability to ensure that all individuals who want to prevent pregnancy have access to contraception depends on the use of effective screening questions. These findings prompt consideration of broader clinical implementation of screening for desire to prevent pregnancy in lieu of questions about pregnancy intention in the next year.

INTRODUCTION: Non-Hispanic Black (NHB) Americans have a higher incidence of colorectal cancer (CRC) and worse survival than non-Hispanic white (NHW) Americans, but the relative contributions of biological versus access to care remain poorly characterized. This study used two nationwide cohorts in different healthcare contexts to study health system effects on this disparity. METHODS: We used data from the Surveillance, Epidemiology, and End Results (SEER) registry as well as the United States Veterans Health Administration (VA) to identify adults diagnosed with colorectal cancer between 2010 and 2020 who identified as non-Hispanic Black (NHB) or non-Hispanic white (NHW). Stratified survival analyses were performed using a primary endpoint of overall survival, and sensitivity analyses were performed using cancer-specific survival. RESULTS: We identified 263,893 CRC patients in the SEER registry (36,662 (14%) NHB; 226,271 (86%) NHW) and 24,375 VA patients (4,860 (20%) NHB; 19,515 (80%) NHW). In the SEER registry, NHB patients had worse OS than NHW patients: median OS of 57 months (95% confidence interval (CI) 55-58) versus 72 months (95% CI 71-73) (hazard ratio (HR) 1.14, 95% CI 1.12-1.15, p = 0.001). In contrast, VA NHB median OS was 65 months (95% CI 62-69) versus NHW 69 months (95% CI 97-71) (HR 1.02, 95% CI 0.98-1.07, p = 0.375). There was significant interaction in the SEER registry between race and Medicare age eligibility (p

With the proliferation of cancer research based on large databases, misalignment of research questions and data set capabilities is inevitable. Nationally maintained databases are appealing to cancer researchers because of the ease of access to large amounts of patient data available for analysis and risk estimation. Data sets that are commonly used in cancer research include the National Cancer Database, the SEER (Surveillance, Epidemiology, and End Results) program of the National Cancer Institute, the SEER–Medicare database, the American College of Surgeons National Surgical Quality Improvement Program, and the Healthcare Cost and Utilization Project databases, among others. Each data set has pros and cons with respect to variable availability and the ability to analyze cancer‐specific outcomes. It is critical for researchers to understand the strengths and limitations of each database. Changing variable definitions, the length of postoperative data collection, and the availability of patient‐reported outcomes or social determinants of health data are examples of factors that researchers must consider when selecting a data set for research purposes. For the current review, the authors summarized the advantages and disadvantages of various national data sets for cohort studies in cancer populations. The authors summarize the strengths and weaknesses of commonly used national databases in population‐based cancer research. The recommendations they offer for appropriate database use are based on cancer type and research question. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusions To test whether an audit and feedback‐based intervention improved HbA1c 12 months after transfer to type 1 diabetes adult care.Multi‐centre, quasi‐experimental pre‐post study of an AF‐based intervention targeting paediatric diabetes teams, which encouraged the implementation of an evidence‐informed structured transition process at five paediatric diabetes centres in Ontario, Canada. Participants entered the study at their final paediatric visit. A parallel control cohort was ascertained using population‐based administrative datasets. The primary outcome was HbA1c 12 months after transfer. The main exposure was the study period: pre‐implementation (June 2018–May 2019); early‐implementation (June 2019–September 2020); and late‐implementation (October 2020–September 2021). Multivariable linear regression models were fit separately in each cohort.There were 449 and 2844 individuals in the intervention and control cohorts, respectively. Twelve months after transfer, participants in the late‐implementation intervention cohort had an HbA1c that was, on average, 0.41% lower than participants in the pre‐implementation period (p = 0.016). Among the control cohort, there was no significant difference in the HbA1c 12 months after transfer between study periods.We found an effect of the intervention on glycaemic management one year following transfer to adult care. Future work will focus on refining and testing the effectiveness of the intervention in an expanded number of study sites and in collaboration with adult diabetes care providers. [ABSTRACT FROM AUTHOR]

ABSTRACT Aim Design Methods Results Conclusion Impact Patient or Public Contribution To explore collaboration and social dynamics within paediatric Morbidity and Mortality meetings.Qualitative Exploratory Case Study Methodology incorporating semi‐structured interviews and qualitative observations.Data were collected in a large quaternary paediatric hospital in Melbourne, Australia. Semi‐structured interviews with meeting attendees were conducted after observing and documenting meeting conduct. Reflexive thematic analysis was used to interpret data and generate a thematic map of findings.Forty‐four interviews and 32 meeting observations were conducted between July 2019 and January 2020. Participants valued collaboration between attendees in Morbidity and Mortality meetings, however there were barriers to this. They included differing views about roles and negative impacts of hierarchies and authority. Senior doctors dominated discussion, and participants described this occasionally signalling reverence and respect, but sometimes signified intimidation and feeling unsure about how to contribute. Because of this complexity, successfully achieving positive social dynamics in a meeting required active promotion and management.Morbidity and Mortality meetings mirror the complexity and richness of the clinical environment. Descriptions of how meeting conduct can shape positive workplace culture and address hierarchical obstructions to safe clinical care highlight their far‐reaching potential. Effective collaboration is an intrinsic part of realising this value.This paper addresses a paucity in the literature in understanding how social dynamics and collaboration in Morbidity and Mortality meetings are interpreted and experienced. These findings illuminate challenges and obstacles to achieving a productive and equitable social dynamic in meetings. They also illustrate positive discrimination strategies that may improve participation and widespread engagement of nurses, junior doctors, and allied health professionals. Importantly, fostering constructive social dynamics in the Morbidity and Mortality meeting could positively impact patient safety culture and therefore patient care.No patient or public contribution. [ABSTRACT FROM AUTHOR]

Background Method Results Conclusion Elderly population is increasing in high‐income countries. For instance, by 2050, 21.4% of the United States population is expected to be 65+, thus making advance care planning (ACP) increasingly important. We aim to identify predictors of ACP completion in 11 high‐income countries and explore relationships between ACP and utilization factors.Using the 2021 International Health Policy (IHP) survey data, we assessed the relationship between sociodemographic factors, healthcare utilization, and ACP. The primary outcome variable was a composite of three ACP activities. A generalized linear mixed model (GLMM) was used to identify predictors of ACP completion.Analyses included 18,677 older adults who answered at least one ACP question. Only 5126 (27.4%) reported completion of three ACP activities. Germany (64.7%) showed the highest completion rates, while Sweden (5.0%) and France (5.0%) showed the lowest completion rates. Predictors of ACP completion identified in the GLMM were: increasing age (incidence rate ratio [IRR] range between 1.2 and 1.5), completion of high school education or more (IRR: 1.1, 95% CI: 1.1–1.1), higher income (IRR: 1.1, 95% CI: 1.1–1.2), presence of two or more health conditions (IRR: 1.1, 95% CI: 1.0–1.1), hospital stay in the past 2 years (IRR: 1.1, 95% CI: 1.1–1.1), and access to quality primary care (IRR: 1.0, 95% CI: 1.0–1.1). Male gender (IRR: 0.9, 95% CI: 0.8–0.9) had a negative association with ACP activity completion.Several patient‐specific and health system utilization factors were identified as predictors of ACP activity completion, which clinicians and policymakers could use to enhance ACP completion. [ABSTRACT FROM AUTHOR]

ABSTRACT Background/Objective Methods Results Conclusions The demand for pediatric dermatology services in the U.S. is high, especially at large academic healthcare centers. eConsultation programs provide a solution to poor in‐person access by offering diagnostic and management support to primary care providers (PCPs). To determine the real‐world utility of eConsultation in pediatric dermatology within a closed system at a major academic center, we assessed the outcomes, diagnostic and management concordance, and predictors of eConsult completion of an asynchronous provider‐to‐provider pediatric dermatology eConsult program.Retrospective cohort study of 900 consecutive outpatient pediatric dermatology eConsult referrals from PCPs at a tertiary academic center from 2017 to 2021.Of 900 eConsult referrals, 621 (69%) were completed without the need for in‐person dermatology follow‐up. 46 (5%) were completed but required follow‐up. 233 eConsult referrals (26%) were declined, primarily due to medical complexity. Thirty referrals (3%) were declined because of inadequate clinical photos. The PCP communicated eConsult recommendations to the patient/family on an average of 1.6 days (SD 3) after receiving the completed eConsult. eConsults for adolescents were less likely to be completed compared to infants (p = 0.03). Diagnostic and management concordance between PCP and dermatologist was 78% and 67%, respectively.Provider‐to‐provider eConsultation provides rapid speciality guidance to PCPs managing low‐complexity skin conditions in pediatric outpatients. The lower rate of management plan concordance compared to diagnostic concordance suggests that eConsultation improves outpatient skin management by PCPs. [ABSTRACT FROM AUTHOR]

Objectives Data supporting routine infectious diseases (ID) consultation in gram-negative bloodstream infection (GN-BSI) are limited. We evaluated the association between ID consultation and mortality in patients with GN-BSI in a retrospective population-wide cohort study in Ontario using linked health administrative databases. Methods Hospitalized adult patients with GN-BSI between April 2017 and December 2021 were included. The primary outcome was time to all-cause mortality censored at 30 days, analyzed using a mixed effects Cox proportional hazards model with hospital as a random effect. ID consultation 1–10 days after the first positive blood culture was treated as a time-varying exposure. Results Of 30 159 patients with GN-BSI across 53 hospitals, 11 013 (36.5%) received ID consultation. Median prevalence of ID consultation for patients with GN-BSI across hospitals was 35.0% with wide variability (range 2.7%–76.1%, interquartile range 19.6%–41.1%). In total, 1041 (9.5%) patients who received ID consultation died within 30 days, compared to 1797 (9.4%) patients without ID consultation. In the fully adjusted multivariable model, ID consultation was associated with mortality benefit (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI].77–.88, P <.0001; translating to absolute risk reduction of −3.8% or number needed to treat [NNT] of 27). Exploratory subgroup analyses of the primary outcome showed that ID consultation could have greater benefit in patients with high-risk features (nosocomial infection, polymicrobial or non-Enterobacterales infection, antimicrobial resistance, or non-urinary tract source). Conclusions Early ID consultation was associated with reduced mortality in patients with GN-BSI. If resources permit, routine ID consultation for this patient population should be considered to improve patient outcomes. [ABSTRACT FROM AUTHOR]

AbstractPurpose:Materials and methods:Results:Conclusions:\nIMPLICATIONS FOR REHABILITATIONBoth demand and need for assistive technology (AT) are growing worldwide. However, ensuring an optimal fit between the person and AT is complex. With health professionals often being the “gatekeeper” to AT, it is imperative to understand their experiences of AT. This study was positioned within a sociotechnical space known as “HabITec”, which aims to bring together potential AT users with health professionals and technology developers to enhance the technology-person fit. The current paper reports on health professionals’ experiences of the HabITec Lab (THL), the physical manifestation of HabITec that was piloted in a tertiary hospital for 12-months.The study used a qualitative descriptive approach to explore the experiences of nine health professionals who referred patients to the lab. Four major themes were identified together with suggestions for the future of THL and HabITec. The themes focused on 1) Balancing service and independence; 2) Capitalising on possibilities and connections; 3) Negotiating multiple mismatches; and 4) Fitting it all together in a coherent service.It was clear that health professionals who referred patients to THL identified a range of benefits associated with it, but barriers to its effectiveness were identified and concerns were raised over health professionals becoming too reliant on the lab. For THL to be sustainably implemented, it appears that a policy-level shift is needed to enable its appropriate resourcing.A sociotechnical space with the capacity to bring together assistive technology users with health professionals and technology developers has shown potential to enhance the technology-person fit.A policy-level shift is needed to ensure future successful and sustainable implementation of such a space; however, further comparison with standard assistive technology practice is needed to warrant investment.Such a space should be conscious of equipping health professionals with assistive technology knowledge and skills.Attention must be paid to adequate promotion of services to ensure appropriate uptake.A sociotechnical space with the capacity to bring together assistive technology users with health professionals and technology developers has shown potential to enhance the technology-person fit.A policy-level shift is needed to ensure future successful and sustainable implementation of such a space; however, further comparison with standard assistive technology practice is needed to warrant investment.Such a space should be conscious of equipping health professionals with assistive technology knowledge and skills.Attention must be paid to adequate promotion of services to ensure appropriate uptake. [ABSTRACT FROM AUTHOR]

Background: Five decades into the era of mass incarceration, a growing number of older adults have experienced criminal legal involvement (CLI) in their lifetime. Studies have shown that prior incarceration is associated with substantial disease burden, but little is known about the distinct needs and utilization patterns of middle-aged and older adults with lifetime CLI compared to those without. Using a nationally representative data set, we tested the association between lifetime CLI exposure and use of acute care services among middle-aged and older adults. Methods: Our sample included 44,007 US adults (25,074 middle-aged-50-64 years; 18,709 older- ≥65 years) who participated in the National Survey of Drug Use and Health (2015–2019). The data is publicly available. Our independent variable was lifetime CLI. Using separate negative binomial regression models for middle-aged and older adults, we tested the association between lifetime CLI and acute healthcare utilization (ED visits and nights spent inpatient) controlling for relevant sociodemographic covariates. Results: For middle-aged respondents, 19.1% reported lifetime CLI; for older adults, the rate of exposure was 9.6%. In multivariate models, CLI was associated with increased ED visits in middle-aged adults (IRR 1.18, 95% CI 1.06–1.31) but not older adults (IRR 0.99, 95% CI 0.85–1.16). CLI was associated with increased nights hospitalized in both groups (middle-aged: IRR 1.33, 95% CI 1.08–1.62; older adults: IRR 1.26, 95% CI 1.01, 1.57). Conclusion: Middle-aged and older adults with lifetime CLI experience higher rates of acute care utilization than their peers with no lifetime CLI, even after adjustment for confounders. As the cohort of adults from the era of mass incarceration ages, understanding the mechanisms by which lifetime CLI impacts health outcomes is crucial in designing interventions to improve outcomes and reduce unnecessary acute healthcare utilization. [ABSTRACT FROM AUTHOR]

Introduction: The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services experience implementation of fall prevention interventions and how they perceive their roles. Methods: We conducted 14 semi-structured individual interviews with managers from different levels of homecare services in five city districts. The interviews were transcribed verbatim and reflexive thematic analysis was used to analyze the material. Results: The analysis resulted in three main themes: (1) understanding organizational mechanisms to facilitate new practices, (2) practicing positive leadership behavior to facilitate implementation, and (3) demonstrating persistence to sustain implementation. Our results showed the importance of clear leadership across all levels of the organization and the value of devoting time and utilizing existing systems. Managers described using recognition and positive attitudes to motivate employees in the implementation process. They emphasized listening to and involving employees, providing trust, and being flexible. However, the implementation process could be challenging, highlighting the need for managers to be persistent. Conclusion: Managers at all levels play an important role in the implementation of fall prevention, but there is a need to define and align their specific roles in the process. Understanding how to use existing systems and influence through positive leadership behavior seem to be vital for success. Recognizing the demanding nature of implementation, managers emphasized the importance of systems for long term support. The study findings may influence how managers in clinical practice engage in the implementation process and inform future researchers about managers' roles in implementation in homecare services. [ABSTRACT FROM AUTHOR]

Background: Studies have shown insufficient utilization of care for patients with erectile dysfunction (ED) after radical prostatectomy (RP). Aim: The aim of this study was to evaluate variables associated with barriers to seeking and receiving ED treatment. Methods: In this multicenter prospective cross-sectional study, the functional outcomes of 936 patients were assessed 10 to 15 years after RP. A total of 525 patients with ED or incontinence were asked about their treatment experiences or lack thereof. The data were analyzed using the chi-square test, t test, and multivariate logistic analyses. Outcomes: Patients answered validated questionnaires regarding information sources, communication with their partner and urologist, and barriers to ED treatment. Results: Of the 525 patients, 80 were not available to survey. A total of 304 patients answered the survey (response: 68.0%). A total of 246 patients had ED and were included in this study. The mean age at surgery was 64.4 ± 6.1 years, and the mean age at the time of this survey was 77.1 ± 6.2 years. The mean follow-up duration was 12.7 ± 1.5 years. Forty-six percent (n = 114 of 246) of the patients had never received ED treatment. The most important conversation partners regarding the ED were the partner (69% [n = 169 of 246]) and the urologist (48% [n = 118 of 246]). Patients who never received ED treatment were less likely to have conversations with their urologist (34% vs 60%; P <.001), had less support (51% vs 68%; P =.01), and had less interest in sex from their partner (20% vs 40%; P =.001). Communication with other groups (general practitioners, other physicians, family, friends, and the Internet) had no influence on ED treatment utilization. The most relevant barrier to receiving ED treatment was the belief that treatment would not help (65%). No interest in sex from their partner (odds ratio, 3.9) and no conversation with their urologist about ED (odds ratio, 2.9) were found to be independent predictors of not receiving ED treatment. Clinical Implications: Urologists should have enhanced awareness of how to approach patients directly about their ED and actively offer them treatment options. Strengths and Limitations: These results should be further validated in a multicenter, prospective study. Response bias may have affected the results. Furthermore, the current cohort was relatively old. Conclusion: This study revealed that no interest in sex from one's partner and insufficient communication with a urologist were relevant barriers to insufficient utilization of ED treatment after RP. [ABSTRACT FROM AUTHOR]

Introduction: Mental disorders during young adulthood can significantly impair functioning in daily activities. Non‐clinical support services aim to improve functioning by helping people to build social and life skills, participate in education and employment and improve physical health. This study aims to examine and synthesise the evidence for non‐clinical services on improving functional outcomes for young adults with mental disorders. Methods: A systematic search was undertaken to identify quantitative and qualitative studies reporting on a non‐clinical service component (vocational support, peer support, youth development, lifestyle interventions, family and network support) and examining functional outcomes (e.g., outcomes focussed on work and education, life skills, relationships and healthy behaviours). Results: Seventeen studies met inclusion criteria. Identified studies focussed on vocational support services (n = 9), lifestyle interventions (n = 6) and family and network support services (n = 2). No studies on peer‐support services or youth development services were found. More than half of the vocational support service studies reported increased employment rates among young adults (n = 6). Studies focussing on lifestyle interventions included a combination of physical activity, nutrition education, health coaching and motivation and behaviour change. However, the measures of functioning used across studies were too varied to determine whether lifestyle interventions may be useful in improving functional outcomes for young adults. Conclusion: Further research is needed to understand the impact of non‐clinical services on functioning. This evidence will provide pragmatic guidance for service planners to invest in supports and interventions that make a meaningful difference to the lives of young adults living with mental disorders. [ABSTRACT FROM AUTHOR]

Background While nearly 50% of adult women report at least one episode of urinary incontinence (UI), most never receive treatment. Objective To better integrate primary and specialty UI care, we conducted (i) an environmental scan to assess the availability of key pathway resources in primary care, (ii) interviews with primary care providers to understand barriers to care, and (iii) a pilot UI care pathway intervention. Methods Environmental scan: Clinic managers from all primary care clinics within a Midwestern healthcare system were invited to participate in an interview covering the availability of clinic resources. Provider interviews: Primary care providers were invited to participate in an interview covering current practices and perceived barriers to UI care. Pilot UI care pathway : Patients who screened positive for UI were provided resources for first-line behavioral management. Pilot patients completed questionnaires at baseline, 8 weeks, and 6 months. Results While many clinics had point-of-care urinalysis (17/21, 81%), most did not have a working bladder ultrasound (14/21, 67%) or on-site pelvic floor physical therapy (18/21, 86%). Providers (n  = 5) described barriers to completing almost every step of diagnosis and treatment for UI. The most persistent barrier was lack of time. Patients (n  = 15) reported several self-treatment strategies including avoiding bladder irritants (7/15, 47%) and performing Kegel exercises (4/15, 27%). Five patients (33%) requested follow-up care. At 6 months, patients reported small improvements in UI symptoms. Conclusion Promising results from a novel UI care pathway pilot indicate that streamlining UI care may assist primary care providers in the first-line treatment of UI. [ABSTRACT FROM AUTHOR]

Background: Telehealth direct access physical therapy is becoming more prevalent in the management of outpatient musculoskeletal pain. This innovative model affords more opportunity to reach potential patients who otherwise would not be able to access services due to geographical isolation, travel barriers, and timely access to quality care. Objective: The purpose of the study was to investigate if pain, function, and ability to perform jobs improved after direct access telehealth physical therapy in patients with musculoskeletal pain. Methods: A single cohort retrospective design was implemented to offer telehealth physical therapy to patients with musculoskeletal pain from March to November 2021. Eligible patients were at least 18 years old, located in California, and had a history of peripartum pelvic dysfunction, muscle pain, joint pain, or neural symptoms. Paired-samples t-tests and the Wilcoxon signed-rank test were used to analyze normally distributed and non-parametric data (α = 0.05), respectively, to compare pretest and post scores. Results: Based on 89 participants, paired-samples t-tests showed statistically significant differences in function [t(87) = 20.71, p <.0001] and pain [t(82) = -8.15, p <.0001]. Wilcoxon's signed-rank test showed statistically significant differences in ability to perform job (Z = -7.345, p <.0001). Conclusion: This study demonstrated that in a cohort of individuals with multiregional musculoskeletal pain, there was a decrease in pain and improvements in function and ability to perform job after direct access telehealth physical therapy. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to develop the Remote Health Value Framework to evaluate the models of healthcare provision for workers in the oil and gas sector, predominantly situated in rural and remote areas. Methods: The framework was co-designed with the leadership team in one global oil and gas company using a multi-criteria decision analysis approach with a conjoint analysis component. This was used to elicit and understand preferences and trade-offs among different value domains that were important to the stakeholders with respect to the provision of healthcare for its workers. Preference elicitation and interviews were conducted with a mix of health, safety, and environment (HSE) team and non-HSE managers and leaders. Results: Out of five presented value domains, participants considered the attribute 'Improving health outcomes of employees' the most important aspect for the model of healthcare which accounted for 37.3% of the total utility score. Alternatively, the 'Program cost' attribute was least important to the participants, accounting for only 11.0% of the total utility score. The marginal willingness-to-pay analysis found that participants would be willing to pay A$9090 per utile for an improvement in a particular value attribute. Conclusions: This is the first value framework for healthcare delivery in the oil and gas industry, contextualised by its delivery within rural and remote locations. It provides a systematic and transparent method for creating value-based healthcare models. This approach facilitates the evaluation of healthcare investments, ensuring they align with value domains prioritised by the HSE and leadership teams. What is known about the topic? It has been challenging for oil and gas companies to deliver and evaluate value-based healthcare services to improve workers' wellbeing, supplementing essential emergency services and occupational health. What does this paper add? The Remote Health Value Framework (RHVF), developed and tested in this work, offers a blueprint for designing and evaluating models of care considering the companies' and workers' priorities. What are the implications for practitioners? The RHVF's application has the potential to improve industry standards, enabling a data-driven approach to healthcare investments that closely align with both corporate objectives and employee wellbeing. [ABSTRACT FROM AUTHOR]

Rationale: Healthcare systems remain disease oriented despite growing sustainability concerns caused by inadequate management of patients with multimorbidity. Comprehensive care programmes (CCPs) can play an important role in streamlining care delivery, but large differences in setup and results hinder firm conclusions on their effectiveness. Many elements for successful implementation of CCPs are identified, but strategies to overcome barriers and embed programmes within health systems remain unknown. Aims and Objectives: To address this knowledge gap through a detailed study of implementing a CCP in a Dutch hospital setting, including patient experiences, facilitators, barriers and ways to overcome those barriers. Additionally, this study aims to explore effects on patient satisfaction and healthcare use. Methods: A qualitative study design with 39 semistructured interviews and focus groups between July 2020 and February 2023 with 16 patients and 17 involved professionals. Additionally, effects on quantitative outcomes for patient satisfaction (PACIC‐20) and healthcare use were explored. Results: Professionals expressed a wide range of topics related to implementation and ways to overcome barriers at hospital and system level. Alterations in the design to accommodate varying care demands, focus on inclusions through referrals, and lack of long‐term support and appropriate financing were key topics. Patients expressed varying experiences, stated a strong desire for comprehensive information, and emphasised the importance of trust in caregivers. Patient satisfaction showed no effects, while healthcare use showed slight decreases in trends, but patient numbers were limited. Conclusion: The introduction of a CCP is feasible, and exploratory analysis on effectiveness shows lower hospital care use without decreasing patient satisfaction. However, this is accompanied by several challenges that show current fragmented systems still do not support implementation of integrated care initiatives. Overcoming those comes with substantial costs and may require a strong bottom‐up implementation within a motivated team and actions on all levels of healthcare systems. [ABSTRACT FROM AUTHOR]

Rationale: Though it is crucial to contribute to patient recovery through access, diversity, continuity and regularity of outpatient care, still today most of these are deemed nonoptimal. Identifying patient profiles based on outpatient service use and quality of care indicators might help formulate more personalized interventions and reduce adverse outcomes. Aims and Objectives: This study aimed to identify profiles of individuals with mental disorders (MDs) patterned after their outpatient care use and quality of care received, and to link those profiles to individual characteristics and subsequent outcomes. Methods: A cohort of 5669 individuals with MDs was considered based on data from the 2013–2014 and 2015–2016 Canadian Community Health Survey, which were linked to administrative data from the Quebec health insurance registry. Latent class analysis generated profiles based on service use over the 12 months preceding each respondent's interview, and comparative analyses were used to associate profiles with sociodemographic and clinical characteristics, and health outcomes over the three following months. Results: Four profiles were identified. Profile 1 (P‐1) was labelled 'Low service use'; P‐2 'Moderate general practitioner (GP) care and continuity and regularity of care'; P‐3 'High GP care, continuity and regularity of care, and low psychiatrist care'; and P‐4 'High psychiatrist care and regularity of care, and low GP care'. Profiles 3 and 4 (~50% of the cohort) were provided with better care, but showed worse outcomes, mainly acute care use due to more complex conditions and unmet needs. Profiles 1 and 2 had better outcomes as they showed fewer risk factors such as being younger and having better social conditions. Conclusion: Intensity, diversity and regularity of care were higher in profiles with more complex MDs, chronic physical illnesses, and worse perceived health conditions. Adapting specific interventions for each profile, such as assertive community treatment or intensive case management for Profile 4, is recommended. [ABSTRACT FROM AUTHOR]

Purpose: Clinical registries have great potential for quality control of medical procedures regarding the indications, therapeutic processes and results, including their possible complications. This is particularly true when providing patients with severe hearing loss or deafness with a cochlear implant (CI). This treatment represents a lifelong care process that requires continuous quality control over time. On the initiative of the Executive Committee of the German Society of Otorhinolaryngology (Deutsche Gesellschaft für Hals-Nasen-Ohren-Heilkunde, Kopf- und Hals-Chirurgie e.V., DGHNO-KHC), a national German CI registry (Deutsches Cochlear Implant Register, DCIR) was established in January 2022. This article focuses on the first demographic and baseline data of the DCIR. Methods: The DCIR covers the complete therapeutic process from indication, surgery, fitting and lifelong aftercare in CI therapy. By the end of 2022, 75 hospitals in Germany had agreed to contribute to the DCIR. Results: During the year 2022, 63 hospitals actively contributed data to the DCIR. Pseudonymized data from 2,292 CI implantations (2,176 primary implantations, 99 explantations with immediate re-implantations and 17 re-implantations following an earlier explantation) in 2,108 patients were documented. Cochlear implantation was accomplished in 1,807 adults (≥ 18 years) and 301 children (< 18 years). Fourty patients (1,9%) were children < 1 year of age and 55 (2,6%) were patients > 85 years. From the total of 2,292 implantations, 226 (9.9%) were performed as simultaneous bilateral implantations (CI implantation in both ears of 113 patients on the same day of surgery) and 412 implantations (19.1% of 2,162 implantations with data provided on the contralateral ear's hearing status) were in patients with single sided deafness (normal hearing in the contralateral ear). In addition, the reported complications in 2022 were also evaluated. Seven reports (0.4%) of mild to moderate severe facial nerve dysfunctions were documented. No reports of severe or total facial nerve dysfunction (House-Brackmann grade V/VI), meningitis or death related to CI therapy were documented. Conclusion: Although still in the start-up phase, these initial DCIR data already provide an interesting first insight into the demographic structure and baseline data of CI therapy in Germany. The successful implementation of the DCIR represents an important step towards continuous quality control of CI care. [ABSTRACT FROM AUTHOR]

The average number of times a person will have surgery in their lifetime, and the amount of surgical healthcare resources they use, is unknown. Lifetime risk is a measure of the risk of an average person having a specific event within their lifetime. We report the lifetime risk of surgery and the change observed during the first year of the COVID-19 pandemic. We conducted a population cohort study using hospital episode statistics to identify all patients undergoing surgery between January 1, 2016, and December 31, 2020, in England. We calculated age- and sex-specific incidence rates of surgery and combined these with routinely available population and mortality data from the Office for National Statistics. We computed the probability of requiring surgery stratified by 5-yr epochs (age 0–4 to ≥90 yr). Our primary analysis calculated lifetime risk for all surgery using the life table method. We assessed the impact of the COVID-19 pandemic, comparing a pre-pandemic and a pandemic period. Between 2016 and 2020, 23 427 531 patients underwent surgery, of which 11 937 062 were first surgeries. The average denominator population for England was 55.9 million. The lifetime risk of first surgery was 60.2% (95% confidence interval 55.1–65.4%) for women and 59.1% (95% confidence interval 54.2–64.1%) for men. The COVID-19 pandemic decreased the lifetime risk of first surgery by 32.3% for women and by 31.7% for men. This estimated lifetime risk should only be applied to the English population. This population epidemiological analysis suggests that approximately 60% of people in England will undergo surgery in their lifetime. [ABSTRACT FROM AUTHOR]

Purpose: We aimed at identifying prevalence, clinical outcomes and prognostic factors in cancer patients with intravenous chemotherapy-induced severe neutropenia (ICISN). Methods: In this multicenter retrospective cohort study on the clinical data warehouse of Greater Paris University Hospitals (AP-HP), we included all adult patients with solid cancer hospitalized between 2016 and 2021 with intravenous chemotherapy within 30 days prior to severe neutropenia (D70 or D611 ICD-10 codes AND a neutrophil count < 500/mm3). The primary endpoint was referral to intensive care unit (ICU) or death within 30 days. We collected cancer, patient, and treatment characteristics. Results: Among 141,586 cancer inpatients, 40,660 received chemotherapy among whom 661 (1.6%) had ICISN. Median age was 63 years (interquartile range (IQR), 54–70) and 330 patients (49%) were female. The median Charlson score was 10 (IQR, 8–11). Main primary cancers were lung (n = 204, 31%) and breast (n = 87, 13%). Advanced cancers were found in 551 patients (83%), 331 (50%) were in 1st line of chemotherapy, 284 (42%) in the 1st cycle of the current line and 149 (22%) had primary G-CSF. Documented bacterial (mostly gram-negative bacilli) and fungal infections were observed in 113 (17%) and 19 (3%) patients; 58 (9%) were transferred to ICU and 82 (12%) died within 30 days, 372 (56%) patients received subsequent chemotherapy. Independent prognostic factors were the level of monocyte, lymphocyte counts or albuminemia and a documented bacterial infection, while Charlson index and primary prophylactic G-CSF were not associated with patient clinical outcomes. Conclusion: Despite the use of primary G-CSF, ICISN remains a frequent event, which leads to ICU death in one on five cases Some prognostic factors of severity have been highlighted and could help clinicians to prevent severe complications. [ABSTRACT FROM AUTHOR]

• Retrospective descriptive study of the MarketScan database on non-intravenous rescue benzodiazepines (non-IV-rBZDs) after febrile seizures. • Among 82,835 patients with at least one febrile seizure, only 9737 (11.8 %) filled at least one non-IV-rBZD prescription. • Complex febrile seizure and initial hospitalization for febrile seizure were strongly associated with filling a non-IV-rBZD prescription. • New febrile seizures and eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. To describe the prescription patterns of home, non-intravenous rescue benzodiazepines (non-IV-rBZDs) for febrile seizures and the factors associated with their prescription. Retrospective descriptive study using the MarketScan Commercial Database, a large database of employer-sponsored privately insured patients in the United States. We used data from January 1st 2006 to December 31st 2022. We studied patients with febrile seizures as the main code for the healthcare encounter (identified with International Classification of Diseases codes) with age from 6 months to 5 years of age and with at least 1 month of follow-up. There were a total of 82,835 patients [median (p 25 -p 75) age 1.0 (1.0–2.0) years, 56.7 % males] with at least one febrile seizure, of whom 9,737 (11.8 %) filled at least one non-IV-rBZD prescription. Among the 9,737 patients who filled at least one prescription, the median (p 25 -p 75) time from first febrile seizure to non-IV-rBZD prescription was 27 (2–186) days. Among the factors known at the time of the first febrile seizure, complex febrile seizure (OR: 3.51, 95 % CI: 3.24–3.79), and an initial inpatient hospitalization for febrile seizure (OR: 3.53, 95 % CI: 3.29–3.79) were the factors most strongly associated with filling a non-IV-rBZD prescription. In contrast, sex, rural patient's residence, and salary employment (versus other employment class) were not independently associated with filling a non-IV-rBZD prescription. Among the factors known at the end of follow-up, complex febrile seizures, type of initial encounter, and an eventual diagnosis of epilepsy were major independent factors associated with filling a non-IV-rBZD prescription. Only approximately 12 % of children with a febrile seizure filled a prescription for a home non-IV-rBZD. The major factors independently associated with prescription were complex febrile seizure, hospital admission, recurrent febrile seizures, and an eventual diagnosis of epilepsy. [ABSTRACT FROM AUTHOR]

Objective: Characterizing factors associated with palliative care (PC) use in patients with stage III and VI head and neck cancer using Anderson's behavioral model of health service use. Study Design: A retrospective study of the 2004 to 2020 National Cancer Database.gg Methods: We used multivariate logistic regression to assess the association of predisposing, enabling, and need factors with PC use. We also investigated the association of these factors with interventional PC type (chemotherapy, radiotherapy, surgery) and refusal of curative treatment in the last 6 months of life. Results: Five percent of patients received PC. "Predisposing factors" associated with less PC use include Hispanic ethnicity (adjusted odds ratio [aOR], 086; 95% confidence interval [CI], 0.76‐0.97) and white and black race (vs white: aOR, 1.14; 95% CI, 1.07‐1.22). "Enabling factors" associated with lower PC include private insurance (vs uninsured: aOR, 064; 95% CI, 0.53‐0.77) and high‐income (aOR, 078; 95% CI, 0.71‐0.85). "Need factors" associated with higher PC use include stage IV (vs stage III cancer: aOR, 2.25; 95% CI, 2.11‐2.40) and higher comorbidity index (vs Index 1: aOR, 1.58; 95% CI, 1.42‐1.75). High‐income (aOR, 0.78; 95% CI, 0.71‐0.85) and private insurance (aOR, 0.6; 95% CI, 0.53, 0.77) were associated with higher interventional PC use and lower curative treatment refusal (insurance: aOR, 0.82; 95% CI, 0.55, 0.67; income aOR, 0.48; 95% CI, 0.44, 0.52). Conclusion: Low PC uptake is attributed to patients' race/culture, financial capabilities, and disease severity. Culturally informed counseling, clear guidelines on PC indication, and increasing financial accessibility of PC may increase timely and appropriate use of this service. [ABSTRACT FROM AUTHOR]

Background Real-world research on cancer care in the community should address social determinants of health (SDOH) to advance health equity in cancer diagnosis, treatment, and survivorship. We sought patient and stakeholder perspectives to co-develop research principles to guide researchers when using patient record data to address health equity in their research protocols. Materials and methods Key informant interviews with 13 individuals elicited perspectives and insights related to health equity and SDOH when conducting research using data from community-based oncology care. Interviews included a brief overview of a prior scoping review and related questions in the interview guide. Key informants included experts in health equity and SDOH, and patient and community advisory board members. Rapid qualitative analysis was used to identify key themes, patterns, and insights from the interview data. Principles were developed based on the results of the analysis. Results Three overarching categories for promoting health equity were (1) education; (2) community engagement; and (3) research design and implementation. Education principles highlight the necessity of training in relevant skills to address health equity. Community engagement principles highlight various actions that researchers can take to conduct research inclusive of community concerns regarding health equity. The research design and implementation category provides practical guidelines for researchers in planning, conducting, and disseminating community-based oncology research to address health equity. Conclusion Our principles guide oncology real-world research protocols to address SDOH in community settings and promote health equity. These principles should be tailored to specific cancer topics and communities. [ABSTRACT FROM AUTHOR]

Background: English primary care faces a reduction in GP supply and increased demand. Aim: To explore trends in GP working time and supply, accounting for factors influencing demand for services. Design and setting: Retrospective observational study in English primary care between 2015 and 2022. Method: Trends in median GP contracted time commitment were calculated using annual workforce datasets. Three measures of demand were calculated at practice-level: numbers of patients; numbers of older patients (≥65 years); and numbers of chronic conditions using 21 Quality and Outcomes Framework disease registers. Multi-level Poisson models were used to assess associations between GP supply and practice demand, adjusted for deprivation, region, and year. Results: Between 2015 and 2022, the median full-time equivalent (FTE) of a fully qualified GP decreased from 0.80 to 0.69. There was a 9% increase in registered population per GP FTE (incidence rate ratio [IRR] = 1.09; 95% confidence interval [CI] = 1.05 to 1.14). This increase was steeper using numbers of chronic conditions (32%, IRR = 1.32; 95% CI = 1.26 to 1.38). Practices in the most deprived decile had 17% more patients (IRR = 1.17; 95% CI = 1.08 to 1.27) and 19% more chronic conditions (IRR = 1.19; 95% CI = 1.06 to 1.33) per GP FTE, compared with the least deprived decile. These disparities persisted over time. All regions reported more chronic conditions per GP FTE than London. Conclusion: Population demand per GP has increased, particularly in terms of chronic conditions. This increase is driven by several factors, including a reduction in GP contracted time commitments. Persistent deprivation gradients in GP supply highlight the need to recruit and retain GPs more equitably. [ABSTRACT FROM AUTHOR]

The professional experiences of school nurses who work outside of urban areas are not often described. We used data from a 2019 statewide survey of school nurses to describe differences between the urban and non-urban (urban cluster and rural) school nurse workforce in New Mexico. Non-urban school nurses were twice as likely as urban nurses to provide clinical services to multiple school campuses (P <.001) and more likely to serve both elementary and secondary school settings (P =.002). They were less likely than urban school nurses to be bachelor's prepared, or to have received recent continuing education on diabetes (P <.001), reproductive health (P = 0.02), LGBQ+ and transgender student health (P <.001, for each), and suicide risk assessment and screening (P =.012). Our findings underscore concerns about geographic differences in the school nursing workforce in terms of educational preparation and student access that could potentially limit the school nurse role in advancing child health equity. [ABSTRACT FROM AUTHOR]

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Objective Materials and Methods Results Conclusion(s) This study aimed to evaluate the costs and consequences of a new midwife‐navigator‐facilitated care pathway for reduced fetal movements.This study was conducted at a tertiary obstetric centre in Queensland, Australia and modelling occurred for this and smaller services. Two months of data from pre (n = 112 in 2019) and post (n = 141 in 2020) implementation of the care pathway were analysed with T‐tests and logistic regression models to evaluate maternal and neonatal outcomes. A Markov model was built to estimate the costs and consequences of the intervention. Sensitivity analysis was conducted to test various scenarios including modelling for smaller centres.There were no statistically significant differences in clinical outcome between the intervention and usual care groups. Intervention patients spent one hour and eight minutes less time in hospital (P < 0.001). This resulted in a saving to the centre of AU$135 per patient (AU$159 083 annually). One‐way sensitivity analysis suggested that cost savings would be found in all scenarios except for smaller units providing services for less than 1900 births per annum.To our knowledge, no other care pathway involving acute obstetric care has been economically evaluated to date. Our model based on real‐world presentations for reduced fetal movements confirms that midwife‐navigators may be an economically beneficial implementation strategy for dealing with common obstetric conditions. [ABSTRACT FROM AUTHOR]

Background: Supporting individuals in managing their suicidality can prevent suicidal behavior. This study evaluated the suicide prevention project SERO, which was launched in Central Switzerland in 2021. SERO comprises four components: the suicide risk assessment technique PRISM-S, a personal safety plan, mental health first aid courses for relatives, and a self-management app. We assessed the mental health of individuals at increased suicide risk after hospital discharge and evaluated the usage and usefulness of SERO components. Methods: A cross-sectional study targeted former patients of Lucerne Psychiatry with an increased suicide risk. Between March 2023 and March 2024, we collected data from 24 individuals through a questionnaire administered six months post-discharge. Descriptive statistics characterized sociodemographics, assessed self-efficacy, self-management, and health literacy, and analyzed the usage and usefulness of SERO components. Associations between the usage of SERO components and mental health outcomes were investigated using Wilcoxon rank sum tests. Results: Mental health assessments indicated, on average, low to moderate levels of self-efficacy, self-management, and health literacy, with substantial variations across individuals. Participants' exposure to SERO components varied: 83% used PRISM-S for suicide risk assessment, 67% developed a personal safety plan, 38% used the SERO app, and 8% reported that their relatives participated in a mental health first aid course. 50% of safety plan users and 44% of SERO app users found the tools helpful before or during a suicidal crisis. 78% of SERO app users would recommend the app to others. Conclusion: Low to moderate levels of self-efficacy, self-management, and health literacy underscore the need for targeted interventions to support individuals at suicide risk. Positive feedback on the personal safety plan and the SERO app suggests their potential effectiveness in helping individuals manage their suicidality. Therefore, integrating structured measures for promoting self-management into standard care protocols in psychiatric hospitals and into patients' lives may contribute to preventing suicides. The main limitation of our study is its small sample size. Future larger-scale studies should investigate user experiences in detail, assess the causal effects of SERO components on specific mental health and suicideoutcomes, and evaluate the cost-effectiveness of each component separately and in combination. [ABSTRACT FROM AUTHOR]

Background: It is well known that individuals recently discharged from psychiatric inpatient care face a high risk of suicide. Severe physical health conditions have also been linked to suicide risk. The risk of suicide following discharge from somatic hospitals is not known for individuals admitted due to acute physical health conditions. Methods: A Cohort study using data from the entire Norwegian population aged 12 years and older from 2008 to 2022 linked with information on health service use and cause of death. We used Cox regression with age as time axis to estimate sex-adjusted hazard ratios of suicide following discharge for ages 12 to 64 years and 65 years and older. We also performed analyses after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. To assess individual risk, we performed an adapted case-crossover analysis among discharged patients who died from suicide. Results: A total of 4 632,980 individuals aged 12 to 64 years and 1,469,265 individuals aged 65 years and older were included. Compared to unexposed individuals at similar ages, we found an increased risk of suicide in the first 4 weeks after discharge, with a hazard ratio (HR) of 7.0 (95% confidence interval (CI) 5.9 to 8.3) among those aged 12 to 64 years and 6.8 (95% CI 5.4 to 8.6) among those 65 years and older. In the younger age group, the risk was attenuated, with a HR of 2.4 (95% CI 1.7 to 3.2) after excluding hospitalizations with indications of concurrent mental disorders, self-harm, or suicide attempts. The corresponding HR was 4.8 (95% CI 3.5 to 6.4) among those 65 years and older, declining to 1.9, (1.2 to 3.1) in weeks 5 to 8 and 1.2 (0.7 to 2.2) in weeks 21 to 24. The case-crossover analysis confirmed that individuals 65 years and older were particularly vulnerable. Conclusions: The heightened risk of suicide following discharge from acute somatic hospitalization, even in the absence of concurrent mental disorders, self-harm, or prior suicide attempts, underscores the critical need for comprehensive mental health and existential support for patients post-discharge. [ABSTRACT FROM AUTHOR]

Purpose: The European health data space promises an efficient environment for research and policy-making. However, this data space is dependent on high data quality. The implementation of electronic medical record systems has a positive impact on data quality, but improvements are not consistent across empirical studies. This study aims to analyze differences in the changes of data quality and to discuss these against distinct stages of the electronic medical record's adoption process. Methods: Paper-based and electronic medical records from three surgical departments were compared, assessing changes in data quality after the implementation of an electronic medical record system. Data quality was operationalized as completeness of documentation. Ten information that must be documented in both record types (e.g. vital signs) were coded as 1 if they were documented, otherwise as 0. Chi-Square-Tests were used to compare percentage completeness of these ten information and t-tests to compare mean completeness per record type. Results: A total of N = 659 records were analyzed. Overall, the average completeness improved in the electronic medical record, with a change from 6.02 (SD = 1.88) to 7.2 (SD = 1.77). At the information level, eight information improved, one deteriorated and one remained unchanged. At the level of departments, changes in data quality show expected differences. Conclusion: The study provides evidence that improvements in data quality could depend on the process how the electronic medical record is adopted in the affected department. Research is needed to further improve data quality through implementing new electronical medical record systems or updating existing ones. [ABSTRACT FROM AUTHOR]

Purpose Methods Results Conclusion To delineate the current trends regarding gender‐affirming surgeries (GAS) in Germany.Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5‐646.0 for masculinizing‐ and 5‐646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends.A total of 19,632 gender‐affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p < 0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p < 0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p < 0.001).This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high‐caseload centers across Germany. [ABSTRACT FROM AUTHOR]

Background: Having traditionally received limited attention in empirical research and safety improvement agendas, issues of patient safety in mental healthcare increasingly feature in healthcare quality improvement discourses. Dominant approaches to safety stem from narrow clinical risk management perspectives, yet existing evidence points to the limitations of this characterisation. Although mental healthcare is increasingly delivered in community-based settings, narratives of safety pertain primarily to hospital-based mental healthcare. Therefore, through exploratory qualitative interviews and one focus group, we aimed to examine how service users, carers, and healthcare providers conceptualise 'patient safety' in community-based mental healthcare. Methods: Semi-structured interviews and a single focus group were conducted with users of UK community-based mental healthcare provision for adults (n = 13), their carers (n = 12), and providers (n = 18), who were diverse in characteristics and experiences. Study data were analysed in accordance with a reflexive approach to thematic analysis. Findings: Four key themes were developed, reflecting contrasting conceptualisations of safety in this care context, where participant thinking evolved throughout discussions. 'Systemic inertia: threats to safety' characterises the entrenched, systemic challenges which rendered participants powerless to advocate for or deliver safe care. 'Managing the risks service users present' equates 'safe care' to the mitigation of risks service users may pose to themselves or others when unwell, or risks from those around them. 'More than responding to risks: everyone plays a role in creating safety' recognises providers' agency in causing or proactively preventing patient harm. Finally, 'The goals of 'safety': our destination is not yet in sight' positions safety as a work in progress, calling for ambitious safety agendas, giving primacy to goals which meaningfully improve service users' lives. Conclusions: Our findings have implications for the understanding and improvement of patient safety in community-based mental healthcare settings, where improvement objectives should transcend beyond management of risks and preventing deterioration to address patient and carer-centred concerns, including practices that make people feel unsafe. [ABSTRACT FROM AUTHOR]

Opioids are commonly used to provide analgesia during and after congenital heart surgery. The effects of exposure to opioids on neurodevelopment in neonates and infants are not well understood. This study sought to evaluate the associations between cumulative opioid exposure (measured in morphine mg equivalent) over the first year of life and 2-year neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development-Third/Fourth Edition [Bayley-III/IV] cognitive, language, and motor scores). A single-center retrospective cohort study of infants undergoing congenital heart surgery was performed. Adjustment for measurable confounders was performed through multivariable linear regression. A total of 526 subjects were studied, of whom 32% underwent Society for Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category 4 or 5 operations. In unadjusted analyses, higher total exposure to opioids was associated with worse scores across all 3 Bayley-III/IV domain scores (all P < 0.05). After adjustment for measured confounders, greater opioid exposure was associated with lower Bayley-III/IV scores (cognitive: β = −1.0 per log-transformed morphine mg equivalents, P = 0.04; language: β = −1.2, P = 0.04; and motor: β = −1.1, P = 0.02). Total hospital length of stay, prematurity, genetic syndromes, and worse neighborhood socioeconomic status (represented either by Social Vulnerability Index or Childhood Opportunity Index) were all associated with worse Bayley-III/IV scores across all domains (all P < 0.05). Greater postnatal exposure to opioids was associated with worse neurodevelopmental outcomes across cognitive, language, and motor domains, independent of other less modifiable factors. This finding should motivate research and efforts to explore reduction in opioid exposure while preserving quality cardiac intensive care. [ABSTRACT FROM AUTHOR]

Social work in the German rehabilitation sector is practiced with great variation and its interventions lack research evidence. The SWIMMER project aims to develop a program theory of social work in rehabilitation to explain this variation and to discuss possible conditions. The dealing with ethical dilemmas by social workers is one possible influence and the focus of this paper. The social workers' practice was analyzed using the triple mandate, a German-Swiss concept that describes three possible, sometimes simultaneous directives without a concrete call to action from society, the client or the profession. This qualitative, case-comparative research project collected data from interviews with social workers and managers, participant observation and counseling sessions in ten German rehabilitation facilities. Social workers were confronted with all three mandates. They prioritized either the societal mandate or the client mandate. A consequence for social work practice was the limitation of options under social law (mandate by society). Social workers relied on their professional experience to reflect on the mandates. They used a variety of strategies when faced with conflicting mandates. The research project has succeeded in systematizing the orientations of social workers in goal conflicts. Further investigation on this topic on a broader basis would be beneficial. [ABSTRACT FROM AUTHOR]

Background: A healthy nursing workforce is vital to ensuring that patients are provided quality care. Assessing nurses' well-being and related factors requires routine evaluations fromhealth systemleaders that leverage brief psychometrically soundmeasures. To date, measures used to assess nurses' well-being have primarily been psychometrically tested among other clinicians or nurses working in specific clinical practice settings rather than in large, representative, heterogeneous samples of nurses. Objectives: This study aimed to psychometrically testmeasures frequently used to evaluate factors linked to nurse well-being in a heterogeneous sample of nurses within a large academic health system. Methods: This cross-sectional, survey-based study used a convenience sample of nurses working across acute care practice settings. A total of 177 nurses completed measures, which included the Professional Quality of Life, the short form of the Professional Quality of Life measure, the two-item Connor-Davidson Resilience Scale, the five-item WorldHealth OrganizationWell-Being Index, the Secondary Traumatic Stress Scale, and the single-item Mini-Z. Internal reliability and convergent validity were assessed for each measure. Results: All the measures were found to be reliable. Brief measures used to assess domains of well-being demonstrated validity with longer measures, as evident by significant correlation coefficients. Discussion: This study provides support for the reliability and validity of measures commonly used to assess well-being in a diverse sample of nurses working across acute care settings. Data from routine assessments of the nursing workforce hold the potential to guide the implementation and evaluation of interventions capable of promoting workplace well-being. Assessments should include psychometrically sound, low-burden measures, such as those evaluated in this study. [ABSTRACT FROM AUTHOR]

Objectives To evaluate the effectiveness of a novel digital patient education (PE) programme in improving self-management in patients newly diagnosed with rheumatoid arthritis (RA). Methods This was a parallel, open-label, two-armed, randomized controlled trial with superiority design. Patients from five rheumatology clinics were randomized into digital PE (intervention) or face-to-face PE (control). The primary outcome was self-efficacy, measured by average difference in the Rheumatoid Arthritis Self‐Efficacy (RASE) score from baseline to month 12. Secondary outcomes were RA knowledge, health literacy, adherence and quality of life. Healthcare utilization data and digital PE programme usage were recorded. Self-efficacy, knowledge and health literacy data were analysed using mixed-effects repeated measures modelling; adherence using logistic regression, and quality of life and healthcare utilization using descriptive statistics with the Wilcoxon rank-sum test. Results Of the 180 patients randomized (digital PE, n  = 89; face-to-face PE, n  = 91), 175 had data available for analysis. Median age was 59.0 years and 61% were women. The average difference in self-efficacy between groups from baseline to month 12 was significant by a −4.34 difference in RASE score, favouring the intervention group (95% CI: −8.17 to −0.51; P  = 0.026). RA knowledge, health literacy and quality of life showed minor improvements over time but no difference between groups, except out-patient clinic contacts, which were fewer in the intervention group. Conclusion The findings suggest that digital PE is effective in improving self-efficacy and therefore self-management in patients with early RA. This intervention has potential to lower healthcare costs by decreasing out-patient clinic contacts. Trial registration number clinicaltrials.gov , NCT04669340. [ABSTRACT FROM AUTHOR]

Introduction: Testicular tumors are the most common malignancies in young adults and their incidence is growing. The implantation of a testicular prosthesis, for example, during orchiectomy is a standard procedure but its frequency in Germany is unknown. This study aims to analyze trends of testicular prosthesis implantation in recent years in Germany. Material and methods: The nationwide German hospital billing database and the German hospital quality reports from 2006 to 2021 were studied. Results: A total of 12,753 surgical procedures with implantation of testicular prosthesis and 1,244 procedures with testicular prosthesis explantation were included. Testicular prosthesis implantation increased in total from 699 cases in 2006 to 870 cases in 2020 (+11.4 cases/year; p < 0.001). The share of implantation of testicular prosthesis due to testicular tumor decreased from 72.6% in 2006 to 67.5% in 2020 (p < 0.001). The share of implantation due to gender affirming surgery increased from 6.8% in 2006 to 23.3% in 2020 (p < 0.001). The share of implantation due to testicular atrophy decreased from 11.4% in 2006 to 3.4% in 2020 (p < 0.001). Simultaneous implantation of testicular prosthesis during orchiectomy for testicular cancer increased from 7.8% in 2006 to 11.4% in 2020 (p < 0.001). In 2006, 146 hospitals (85%) performed < 5 testicular prosthesis implantation, while 20 hospitals (12%) performed 5–15 implantation procedures and 6 hospitals (3%) performed > 15 testicular implantation surgeries. In 2021, 115 hospitals (72%) performed < 5 testicular prosthesis implantation, while 39 hospitals (25%) performed 5–15 implantation procedures and 5 hospitals (3%) performed > 15 testicular implantation surgeries. Conclusion: This study shows that implantation of testicular prostheses is steadily increasing. Explantation rates are low. Besides testicular cancer transgender surgeries were the main driver for increasing case numbers in recent years. [ABSTRACT FROM AUTHOR]

Background: Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. Methods: We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. Results: Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. Discussion: Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population. [ABSTRACT FROM AUTHOR]

Objectives: Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement. Methods: A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses. Results: Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth. Conclusions for Practice: Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced. Significance: What is Already Known on this Subject?: There is no detailed national guidance about the content or quantity of antenatal education that should be delivered by the NHS to patients and, how coping strategies are developed within these sessions is unknown. What this Study Adds?: Antenatal educators believe that quality of antenatal education needs to be improved. Access to coping strategies for labour and birth is hindered by the type of class, the educator's approach and socioeconomic status. This study can be used to support an argument for addressing the inequality in access to antenatal preparation, whilst better preparing all women through higher quality of antenatal education provision in the NHS. [ABSTRACT FROM AUTHOR]

This document summarizes a study on ICU utilization and outcomes in the United States from 2008 to 2019. The study found that while the number of hospitalizations decreased, the proportion of hospitalizations using ICU resources remained stable. The authors also noted a decline in hospital length of stay and mortality among ICU hospitalizations, suggesting improved care or potential over-utilization of ICU care. The study emphasizes the need for standardized definitions and metrics to accurately assess ICU utilization and calls for further research to optimize its use. [Extracted from the article]

OBJECTIVES: To compare outcomes for 2 weeks vs. 1 week of maximal patientintensivist continuity in the ICU. DESIGN: Retrospective cohort study. SETTING: Two U.S. urban, teaching, medical ICUs where intensivists were scheduled for 2-week service blocks: site A was in the Midwest and site B was in the Northeast. PATIENTS: Patients 18 years old or older admitted to a study ICU between March 1, 2017, and February 28, 2020. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We applied target trial emulation to compare admission during an intensivist's first week (as a proxy for 2 wk of maximal continuity) vs. admission during their second week (as a proxy for 1 wk of maximal continuity). Outcomes included hospital mortality, ICU length of stay, and, for mechanically ventilated patients, duration of ventilation. Exploratory outcomes included imaging, echocardiogram, and consultation orders. We used inverse probability weighting to adjust for baseline differences and random-effects meta-analysis to calculate overall effect estimates. Among 2571 patients, 1254 were admitted during an intensivist's first week and 1317 were admitted during a second week. At sites A and B, hospital mortality rates were 25.8% and 24.2%, median ICU length of stay were 4 and 2 days, and median mechanical ventilation durations were 3 and 3 days, respectively. There were no differences in adjusted mortality (odds ratio [OR], 1.01 [95% CI, 0.96-1.06]) or ICU length of stay (-0.25 d [-0.82 d to +0.32 d]) for 2 weeks vs. 1 week of maximal continuity. Among mechanically ventilated patients, there were no differences in adjusted mortality (OR, 1.00 [0.87-1.16]), ICU length of stay (+0.06 d [-0.78 d to +0.91 d]), or duration of mechanical ventilation (+0.37 d [-0.46 d to +1.21 d]) for 2 weeks vs. 1 week of maximal continuity. CONCLUSIONS: Two weeks of maximal patient-intensivist continuity was not associated with differences in clinical outcomes compared with 1 week in two medical ICUs. [ABSTRACT FROM AUTHOR]

Some emergency department (ED) visits by persons with rheumatoid arthritis (RA) may be avoidable. This study aims to describe ED use by persons with RA in Alberta, Canada over a 10-year period. Using linked population-based administrative datasets, the annual frequency of ED visits, timing of visits, acuity at presentation assessed (Canadian Triage Acuity Scale (CTAS)), return visits within 72 h, and final disposition were assessed. Most responsible diagnoses assessed by the ED provider were categorized. Between 2008 and 2017, a total of 48,633 persons with RA had 416,964 unique ED visits. There was a 41% relative increase in visits over the study period and within a fiscal year 37% of persons with RA on average attended an ED. Half of the visits were assessed as CTAS 4 'Less Urgent' (31%) and CTAS 5 'Non-Urgent' (19%). No specific diagnosis could be assigned in 36% of visits and RA was listed as the most responsible diagnosis in 2.5% of all visits. Hospital admissions, occurring on average for 14% of ED visits, increased by 15% over the 10 years, and were rare for CTAS 4 (6.4%) and CTAS 5 (1.4%) presentations. Male patients (difference to female 1.2%, 95%CI 0.6, 1.7) and urban patients (difference to rural 8.4%, 95%CI 7.7, 9.2) were more frequently admitted to hospital. Persons with RA have increased ED utilization over time, with a significant volume of less urgent and non-urgent visits. Opportunities for appropriate ambulatory care provision to reduce acute care use should be identified. [ABSTRACT FROM AUTHOR]

Background: Autogenic training (AT) is a structured meditative‐style practice, consisting of a sequence of simple mental exercises intended to induce a relaxed state in patients. There is some emerging evidence to suggest that AT can be effective in treating certain chronic conditions, however, further evidence is required. A service evaluation of AT services at the Royal London Hospital for Integrated Medicine was conducted to evaluate the impact of AT on patients with chronic conditions. Methods: The service evaluation consisted of the completion of validated quantitative outcome measures pre and posttreatment to explore the impact of AT. AT patients were asked to complete the Measure Yourself Medical Outcomes Profile (MYMOP) and Perceived Stress Scale (PSS) at their first hospital appointment (baseline) and then again 8 weeks later following completion of their AT sessions. Pre‐ and posttreatment scores for each outcome measure were analysed in SPSS using the Wilcoxon signed‐rank test. Results: One hundred ninety‐nine patients completed both initial and follow‐up MYMOP forms and were included in the evaluation. The most common presenting complaints for MYMOP symptom 1 were prolonged anxiety/stress and depression (n = 70, 35.2%), chronic pain and migraine headache (n = 44, 22.1%), chronic insomnia and sleep problems (n = 42, 21.1%) and, long‐term exhaustion and fatigue (n = 18, 9%). The change in median score pre‐ and posttreatment for all MYMOP categories (symptoms, activity and well‐being) were statistically highly significant p < 0.001. Anxiety, stress, depression, pain and insomnia were the symptoms that had the largest statistically significant difference between the median score pre‐ and posttreatment. Fifty‐five patients completed the PSS questionnaire at two time points (pre‐ and posttreatment). It showed a highly statistically significant change in PSS median score in patients experiencing stress (p < 0.001). Discussion: The findings of the evaluation indicate that 8 weeks of AT appears to be effective in improving symptoms of concern to patients and enhancing patients' overall well‐being. In particular, AT was found to be beneficial for patients with symptoms of anxiety, stress, depression, pain and insomnia. [ABSTRACT FROM AUTHOR]

Introduction: Patient involvement is a critical component of dementia research priority-setting exercises to ensure that research benefits are relevant and acceptable to those who need the most. This systematic review synthesises research priorities and preferences identified by people living with dementia and their caregivers. Methods: Guided by Joanna Briggs Institute methodology, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, we conducted a systematic search in five electronic databases: CINAHL, Medline, PsycINFO, Web of Science and Scopus. The reference lists of the included studies were also manually searched. We combined quantitative and qualitative data for synthesis and descriptive thematic analysis. Results: Eleven studies were included in this review. Findings are grouped into four main categories: Increase in knowledge, education, and awareness; Determining the cause; Sustainability of care; and Cure of dementia and related conditions. Conclusion: There is a need to respond to the stigma associated with dementia, which limits access to care and the quality of life for both people living with dementia and their caregivers. We need to work on changing public, private and workplace attitudes about dementia and encourage supporting and participating in dementia research. Future research should involve people living with dementia and their primary caregivers from culturally and linguistically diverse communities in priority-setting exercises. [ABSTRACT FROM AUTHOR]

Objective: The objectives of this study were to characterize and identify correlates of healthy days at home (HDaH) before and after TBI requiring inpatient rehabilitation. Setting: Inpatient hospital, nursing home, and home health services. Participants: Average of n = 631 community-dwelling fee-for-service age 66+ Medicare beneficiaries across 30 replicate samples who were hospitalized for traumatic brain injury (TBI) between 2012 and 2014 and admitted to an inpatient rehabilitation facility (IRF) within 72 hours of hospital discharge. Design: Retrospective study using data from Medicare claims supplemented with data from the National Trauma Databank. Main measures: The primary outcome, HDaH, was calculated as time alive not using inpatient hospital, nursing home, and home health services in the year before TBI hospitalization and after IRF discharge. Results: We found HDaH declined from 93.2% in the year before TBI hospitalization to 65.3% in the year after IRF discharge (73.6% among survivors only). Most variability in HDaH was: (1) in the first 3 months after discharge and (2) by discharge disposition, with persons discharged from IRF to another acute hospital having the worst prognosis for utilization and death. In negative binomial regression models, the strongest predictors of HDaH in the year after discharge were rehabilitation Functional Independence Measure mobility score (β = 0.03; 95% CI, 0.002-0.06) and inpatient Charlson Comorbidity Index score (β = − 0.06; 95% CI, −0.13 to 0.001). Dual Medicaid eligible was associated with less HDaH among survivors (β = − 0.37; 95% CI, −0.66 to −0.07). Conclusion: In this study, among community- dwelling older adults with TBI, we found a notable decrease in the proportion of time spent alive at home without higher-level care after IRF discharge compared to before TBI. The finding that physical disability and comorbidities were the biggest drivers of healthy days alive in this population suggests that a chronic disease management model is required for older adults with TBI to manage their complex health care needs. [ABSTRACT FROM AUTHOR]