The Journey toward the Patient-Centered Medical Home: A Grounded, Dynamic Theory of Primary Care Transformation

Introduction: This dissertation develops a grounded and dynamic theory of primary care transformation (PCT) in a health service delivery organization (HSDO) implementing the Patient-Centered Medical Home model, in the United States of America. The focus of this theory is on the structural facilitators and challenges to achieving and sustaining high quality primary care. Methodology: Fieldwork performed included semi-structured interviews conducted across the HSDO (n=82), direct observations (n=10 clinics) and archival review. This dissertation utilizes newly-developed methods for theory development and validation, in concert with existing system dynamics methods; with an improved potential to integrate findings across quantitative and qualitative research directions. Results: My theory illuminates how the actions of various stakeholders (medical assistants, managers, clinicians and patients) interact with each other and with the fundamental characteristics of primary care service delivery to create diverse transformation trajectories. Two types of leverage points are identified: policies and preferences. The latter are more difficult to modify as they require changing stakeholders’ mental models. It is the combination of policies and preferences interacting within the system structure that produces hoped-for and feared transformation trajectories. There is no policy that induces success regardless of stakeholder preferences. There are some preferences that induce success or failure regardless of the policies being implemented. Conclusion: Sustaining success requires understanding the system structure within which policies and preferences operate – how decisions are made, their consequences, and the delays involved. Otherwise, transformation risks being overwhelmed by unintended consequences, misunderstood system behavior or impatience. This work presents an improved understanding of what PCT involves, and of how operational and cognitive aspects intersect. Overall, this work is more than a study of transformation. It presents theory, methods and a case for the development of an integrative methodology and paradigm

Osteosynthesis development with collagenic nanobiostructures

Universitatea de Medicină şi Farmacie ”Iuliu Haţieganu”, Clinica de Ortopedie şi Traumatologie Cluj-Napoca, Secţia a II-a, Conferinţa a XI-a Naţională a ortopezilor-traumatologi din Republica Moldova “POLITRAUMATISME – CONCEPŢII CONTEMPORANE DE DIAGNOSTIC ŞI TRATAMENT”Cercetările în sfera biomaterialelor şi a biomecanicii reprezintă puncte cheie ale progresului în nanomedicină. Nanobiostructurile sunt de mare interes în chirurgia ortopedică în tratamentul unor variate leziuni osteoarticulare: fracturi, pseudartroze, fracturi pe teren patologic (tumori osoase sau osteoporoză), infecţii osoase, artroze etc. Nanobiostructurile conţin colagen, cu sau fără alt polimer, hidroxiapatită nanostructurată, unele peptide (factori de creştere), fosfat de calciu, bisfosfonaţi şi alţi ingredienţi auxiliari. Aplicarea nanobiostructurilor pe diferite suporturi (plăci, tije) favorizează procesele biologice ale consolidării osoase, osteogeneza şi remodelarea osoasă, în condiţiile unei stabilităţi mecanice asigurate prin fixarea internă a fracturii. Aplicabilitatea clinica a tehnologiilor poate contribui in mod semnificativ la dezvoltarea tratamentelor multor boli musculoscheletale. The research in the field of biomaterials and biomechanics represents the key-point of progress in nanomedicine. Nanobiostructures are at high interest in the surgical treatment of various orthopedic conditions: fractures, non-unions, pathologic fractures (bone tumors or osteoporosis), bone infections, osteoarthritis etc. Nanobiostructures are made of collagen, with or without other polymer, nanostructured hydroxyapatite, some peptides (growth factors), calcium phosphate, bisphosphonates and other ingredients. The addition of nanobiostructures to various implants (plates, rods) enhances the biological processes of bone healing, bone growth and remodeling, being protected by the mechanical stability of the internal fixation of fractures. Clinical applicability of the technologies can significantly contribute to improvement of the treatment of several muscular and skeletal diseases

Hip arthroplasty complete revision

Universitatea de Medicină şi Farmacie ”Iuliu Haţieganu”, Clinica de Ortopedie şi Traumatologie Cluj-Napoca, Secţia a II-a, Conferinţa a XI-a Naţională a ortopezilor-tramatologi din Republica Moldova “Politraumatisme – concepţii contemporane de diagnostic şi tratament”, 21 mai 2009, Chișinău, Republica MoldovaArtroplastia totală de şold este descrisă ca una dintre cele mai importante realizări în asigurarea stării de sănătate. Durata medie de viaţă a crescut, tot mai mulţi pacienţi dezvoltând leziuni degenerative ale articulaţiei şoldului care impun o intervenţie de artroplastie. În prezent un număr tot mai mare de pacienţi beneficiază de o artroplastie primară de şold, mulţi dintre ei sperând în continuare la menţinerea unui nivel ridicat de activitate. Din aceste motive chiar şi cu o rată de succes foarte mare a intervenţiilor chirurgicale primare, numărul reviziilor este în continuă creştere. Acest studiu face o analiză a cauzelor insuccesului artroplastiei primare şi ia în calcul şi posibilitatea efectuării artroplastiei şoldului cu o proteză de revizie şi în alte afecţiuni în afara coxartrozei, cum ar fi fracturile trohanteriene după eşecul fixării interne, cu pierdere mare de masă osoasă.Total hip arthroplasty is considered one of the most important achievements in healthcare. Life span has extended and thus more and more patients develop degenerative osteoarthritis lesions of the hip that require arthroplasty intervention. Nowadays a growing number of patients benefit from primary total hip replacement, many of them expecting to maintain an increased level of activity. Even with a high rate of success of the primary surgery, due to this reason the number of revisions is still growing. The present study analyses the causes of primary arthroplasty failure and discusses the possibility of using revision hip arthroplasty in other affections, for example in trochanteric fractures after failure of internal fixation with great bone mass loss

Resilience in childhood vaccination: analysing delivery system responses to shocks in Lebanon.

From Europe PMC via Jisc Publications RouterHistory: ppub 2023-11-01Publication status: PublishedFunder: Wellcome Trust; Grant(s): 215654/Z/19/ZIntroductionDespite rapidly growing academic and policy interest in health system resilience, the empirical literature on this topic remains small and focused on macrolevel effects arising from single shocks. To better understand health system responses to multiple shocks, we conducted an in-depth case study using qualitative system dynamics. We focused on routine childhood vaccination delivery in Lebanon in the context of at least three shocks overlapping to varying degrees in space and time: large-scale refugee arrivals from neighbouring Syria; COVID-19; and an economic crisis.MethodsSemistructured interviews were performed with 38 stakeholders working at different levels in the system. Interview transcripts were analysed using purposive text analysis to generate individual stakeholder causal loop diagrams (CLDs) mapping out relationships between system variables contributing to changes in coverage for routine antigens over time. These were then combined using a stepwise process to produce an aggregated CLD. The aggregated CLD was validated using a reserve set of interview transcripts.ResultsVarious system responses to shocks were identified, including demand promotion measures such as scaling-up community engagement activities and policy changes to reduce the cost of vaccination to service users, and supply side responses including donor funding mobilisation, diversification of service delivery models and cold chain strengthening. Some systemic changes were introduced-particularly in response to refugee arrivals-including task-shifting to nurse-led vaccine administration. Potentially transformative change was seen in the integration of private sector clinics to support vaccination delivery and depended on both demand side and supply side changes. Some resilience-promoting measures introduced following earlier shocks paradoxically increased vulnerability to later ones.ConclusionFlexibility in financing and human resource allocation appear key for system resilience regardless of the shock. System dynamics offers a promising method for ex ante modelling of ostensibly resilience-strengthening interventions under different shock scenarios, to identify-and safeguard against-unintended consequences.pubpu

In Vitro Sensitivity Research Concerning Some Microorganisms at Hydroxyquinoline and Cupric Derivatives Deposited onto Hydroxyapatite

ABSTRACT Introduction: The preparations based on hydroxyquinoline, in various combinations, are used in medicine, being shown to have an inhibitory effect against bacteria, molds, fungi, parasites, and viruses, but also having other beneficial effects mentioned in other medical conditions (anti-cancer, anti-degenerative, anti-inflammatory). Aims: In vitro susceptibility testing of microorganisms: bacteria (Gram positive and Gram negative), yeast (Candida spp.,) and unicellular algae (Prototheca spp.) at the preparations based on hydroxyquinoline (HQ) and its cupric derivatives deposited on hydroxyapatite (HAP). Materials and methods: There were tested microbial strains of the following genera: Escherichia, Staphylococcus, Micrococcus, Bacillus, Candida, and Prototheca. The tested products (developed in the Laboratory for Nanobiomaterials Synthesis, Center of Physical Chemistry, Faculty of Chemistry and Chemical Engineering, UBB Cluj-Napoca) were developed in three versions: 1) HQ-Cu2+-HAP1; 2) HQ-Cu2+-HAP2; and 3) NHQ-Cu2+-HAP2, where NHQ stands for nitro hydroxyquinoline. Determination of the inhibitory effect was conducted by diffusion technique in nutrient agar, according to CLSI 2013 standards, with necessary adaptations for testing of products made in the form of suspensions. Results: Following interpretation, it was found that the inhibition zones, arising from the antimicrobial effect of the tested products showed variability in size, depending on the test product and the microbial strain: Escherichia coli (8-10 mm), Staphylococcus sp. (17.6 - 23.2 mm), Micrococcus spp. (24.4 - 27.6 mm), Bacillus spp. (14.0 - 16.0 mm), Candida spp. (20.4 - 25.2 mm), Prototheca spp. (20.8 - 30.0 mm). From the three tested products, the best efficacy was found at the product no. 3 (NHQ - Cu2+ - HAP2), followed by no. 1 (HQ- Cu2+-HAP1) and no. 2 (HQ-Cu2+-HAP2). Conclusions: The inhibitory effect was bactericidal, manifested more intensively against Gram-positive bacteria, yeasts, and prototheca. Such products, prepared in the form of suspensions, may have practical application in the prevention and treatment of skin or hooves disorders. No resistance phenomena are recorded. Keywords: copper, hydroxyapatite, hydroxyquinoline, microorganisms, sensitivity

Development and testing of the Stakeholder Quality Improvement Perspectives Survey (SQuIPS)

BACKGROUND: To create a theory-informed survey that quality improvement (QI) teams can use to understand stakeholder perceptions of an intervention. METHOD: We created the survey then performed a cross-sectional survey of QI stakeholders of three QI projects. The projects sought to: (1) reduce unplanned extubations in a neonatal intensive care unit; (2) maintain normothermia during colorectal surgery and (3) reduce specimen processing errors for ambulatory gastroenterology procedures. We report frequencies of responses to survey items, results of exploratory factor analysis, and how QI team leaders used the results. RESULTS: Overall we received surveys from 319 out of 386 eligible stakeholders (83% response rate, range for the three QI projects 57%-86%). The QI teams found that the survey results confirmed existing concerns (eg, the intervention would not make work easier) and revealed unforeseen concerns such as lack of consensus about the overall purpose of the intervention and its importance. The results of our factor analysis indicate that one 7-item scale (Cronbach\u27s alpha 0.9) can efficiently measure important aspects of stakeholder perceptions, and that two additional Likert-type items could add valuable information for leaders. Two QI team leaders made changes to their project based on survey responses that indicated the intervention made stakeholders\u27 jobs harder, and that there was no consensus about the purpose of the intervention. CONCLUSIONS: The Stakeholder Quality Improvement Perspectives Survey was feasible for QI teams to use, and identified stakeholder perspectives about QI interventions that leaders used to alter their QI interventions to potentially increase the likelihood of stakeholder acceptance of the intervention

Patient care experiences and perceptions of the patient-provider relationship: A mixed method study

Improving interpersonal continuity of care—the personal relationship forged between a patient and their primary care provider (PCP) over time—is often considered a goal of primary care. Continuity of care is frequently assessed in terms of longitudinal continuity, or the proportion of encounters with one practitioner, overlooking aspects of the patient-provider relationship that are key to interpersonal continuity of care. Further, few studies explore patients’ perspectives regarding which care experiences enhance or detract from the patient-provider relationship. This study, using focus group interviews, a patient experience CAHPS-PCMH survey, and electronic medical records, explored how patients’ experiences at 10 primary care clinics influenced their perceptions of their relationship with their PCPs. Focus group interviews with 63 participants indicated that patients’ experiences in the clinics, such as wait-times, influenced their perceptions of the patient-provider relationship. The relationship between patient experience and interpersonal continuity was empirically assessed using survey responses and medical records (n=645). We used patients’ perceptions that their provider knows them as a person as a measure of interpersonal continuity. Logistic regression results indicated that being seen within 15 minutes, receiving visit reminders, effective provider communication, and satisfaction, positively influenced patient perceptions of the patient-provider relationship. Furthermore, patients’ care experiences shaped their perceptions of the patient-provider relationship independent of their satisfaction with care. The mixed methods design adds depth to our understanding of patients’ care experiences, and illustrates that these experiences are critical for understanding the patient-provider relationship. Future research on interpersonal continuity should take patient experiences into account