Literature Collection

BACKGROUND: Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS: Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS: The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS: Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

In a deinstitutionalised mental health care system, those with mental illness require complex, multidisciplinary and intersectoral care at the primary or community service setting. This paper describes an Evidence Map of different strategies to strengthen the provision of mental health care at the primary health care (PHC) setting, the quality of the evidence, and knowledge gaps. Electronic and reference searching yielded 2666 articles of which 306 qualified for data extraction. A systematic review methodology identified nine different strategies that strengthen the provision of mental healthcare and these strategies are mapped in line with the outcomes they affect. The top three strategies that were reported the most, included strategies to empower families, carers and patients; integration of care or collaborative interventions; and e-health interventions. The least reported strategy was task shifting. The Evidence Map further shows the amount and quality of evidence supporting each of the listed strategies, and this helps to inform policy design and research priorities around mental health. This is the first systematic Evidence Map to show the different strategies that strengthen the provision of mental healthcare at PHC setting and the impact these strategies have on patient, hospital and societal level indicators.

BACKGROUND: Older adults with multimorbidity experience fragmentation of care. Ensuring optimal use of healthcare services requires stratifying their need for integrated care. We aimed to map existing stratification tools for assessing older adults with multimorbidity in an integrated care context. METHODS: We searched MEDLINE, Embase, PsycINFO, Cochrane Library, and CINAHL, and extracted definitions of population, concept, and context following the JBI Framework for Scoping Reviews. RESULTS: We identified 17,689 articles of which 11 articles were included. Few stratification tools for this population exist and differ on scoring methods, domains and settings of use. Stratification is used for identifying older adults with multimorbidity to multidisciplinary teams or to case managers. Future research should develop stratification tools across sectors focused on the common risk factors of multimorbidity in older adults.

OBJECTIVE: Postpartum depression (PPD) is a major contributor to postpartum morbidity and mortality. Beyond efforts at routine screening, risk stratification models could enable more targeted interventions in settings with limited resources. The authors sought to develop and estimate the performance of a generalizable risk stratification model for PPD in patients without a history of depression, using information collected as part of routine clinical care. METHODS: The authors conducted a retrospective cohort study of all individuals who delivered between 2017 and 2022 in one of two large academic medical centers and six community hospitals. An elastic net model was constructed and externally validated to predict PPD, defined as having a mood disorder, an antidepressant prescription, or a positive screen on the postpartum Edinburgh Postnatal Depression Scale. Predictors used included sociodemographic factors, medical history, and prenatal depression screening information, all of which were known before discharge from the delivery hospitalization. RESULTS: The cohort included 29,168 individuals; 2,696 (9.2%) met at least one criterion for postpartum depression in the 6 months following delivery. In the external validation data, the model had good discrimination and remained well calibrated: the area under the receiver operating characteristic curve was 0.721 (95% CI=0.709, 0.736), and the Brier calibration score was 0.087 (95% CI=0.083, 0.091). At a specificity of 90%, the positive predictive value was 28.8% (95% CI=26.7, 30.8), and the negative predictive value was 92.2% (95% CI=91.8, 92.7). CONCLUSIONS: These findings demonstrate that a simple machine-learning model can be used to stratify the risk for PPD before delivery hospitalization discharge. This tool could help identify patients within a practice at the highest risk and facilitate individualized postpartum care planning for the prevention of, screening for, and management of PPD at the start of the postpartum period and potentially the onset of symptoms.

OBJECTIVES: To assess the effectiveness of Strengthening Care for Children (SC4C) for reducing the number of referrals by general practitioners of patients under 18 years of age to hospital services. STUDY DESIGN: Stepped-wedge cluster randomised trial; data collected for up to 16 months after the intervention. SETTING: General practices in North Western Melbourne and Central and Eastern Sydney primary health networks, 1 May 2021-30 September 2023. PARTICIPANTS: General practitioners who worked at least two clinical sessions each week, saw patients under 18 years of age, and for whom at least 1 month of referrals data during the control period were available; families of people under 18 years attending these practices. INTERVENTION: Weekly (6 months) then fortnightly (6 months) general practitioner-paediatrician co-consultations; monthly paediatrician-led case discussions; weekday phone and email support by paediatricians. MAIN OUTCOME MEASURES: Proportion of general practitioner visits in which patients were referred to publicly funded hospital outpatient clinics or emergency departments (patient level), overall and by baseline referral rate. SECONDARY OUTCOMES: Referrals after completion of the intervention; general practitioner confidence regarding child health care; low value care for frequent childhood conditions; family preference for general practitioner or paediatrician care. RESULTS: One hundred and thirty participating general practitioners from 22 general practices conducted 50,101 consultations during the control period; 125 general practitioners from 21 general practices received the intervention and undertook 96,804 consultations. Patients were referred to hospitals in 2.3% of control period consultations and 1.9% of intervention period consultations (risk difference, -0.34 [95% confidence interval {CI}, -0.69 to 0.004] percentage points). Among general practitioners with high referral rates at baseline (5% or higher), patients were referred to hospital outpatient or emergency department in 7.3% of control period consultations and in 3.0% of intervention period consultations (risk difference, -4.28 [95% CI, -6.59 to -1.97] percentage points); the referral rate was also lower after the intervention period (sustainability vs. control periods: 2.9% vs. 5.8%; risk difference, -2.92 [95% CI, -5.36 to -0.48] percentage points). The proportions of general practitioners confident about their knowledge and skills regarding child health care were larger during the intervention than the control period. Quality of care and family preference for general practitioner-led care for their children remained high across the study. No adverse events were recorded. CONCLUSION: Strengthening primary care for children reduces the frequency of hospital referrals of children by general practitioners with high referral rates, increases rates of general practitioner confidence about caring for children and maintains family preference for general practitioner-led care. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12620001299998 (prospective).; THE KNOWN: The demand for hospital outpatient and emergency services for children is rising in high income countries. Integrated care models in which paediatricians support care by general practitioners could reduce the number of hospital referrals. THE NEW: An integrated general practitioner–paediatrician model did not reduce hospital referrals overall, but sustainably reduced referrals of children by general practitioners who had previously referred 5% or more of patients under 18 years of age. THE IMPLICATIONS: To relieve pressure on hospitals and improve equitable access to specialist care, this care model could be expanded to include general practices in areas with high numbers of children and general practitioners with high referral rates.; eng

BACKGROUND: Australia's health care system is under pressure. Pediatric referrals to public hospital emergency and outpatient departments have increased recently, overburdening emergency services and resulting in extended waiting times for nonurgent pediatric care. Children living outside metropolitan areas are disproportionately affected. Integrated models of care with pediatricians collaborating with general practitioners (GPs) in their practices have been evaluated in the United Kingdom and Australia. Results are promising for quality of care improvement and reducing referrals to hospitals. GPs and pediatricians found the model feasible, knowledge- and confidence-boosting. In-person pediatric-GP support is resource-intensive, limiting scalability and sustainability. OBJECTIVE: The SUSTAIN trial is designed to evaluate a digitally delivered, integrated GP-pediatrician model of care. The primary objective is to determine whether the SUSTAIN model reduces GP referrals to hospital emergency departments for children <18 years. Secondary objectives include whether the model improves the delivery of guideline-concordant pediatric care by GPs, enhances GP confidence, and strengthens family trust in primary care. The trial also examines barriers and enablers to the implementation and includes a health economic evaluation comparing intervention costs with standard GP care. METHODS: SUSTAIN uses a stepped wedge cluster randomized controlled trial design to implement a GP-pediatrician integrated model of care delivered digitally. Participating GP practices across metropolitan and nonmetropolitan New South Wales are included and randomly assigned a start time. The intervention consists of 12 months' access to the shared GP-pediatrician consulting sessions with patients younger than 18 years conducted by telehealth, virtual pediatrician-led case discussions, phone/email pediatrician support, and complimentary access to the internationally renowned Sydney Child Health Program learning platform. GP and family surveys are collected at baseline and in the final month of intervention. An implementation evaluation using focus group discussions is conducted with each practice during the intervention and optional GP and family interviews at the end of the intervention. A health economic evaluation will explore the cost-effectiveness of this model of care. RESULTS: The trial is supported through a 2.5-year New South Wales Ministry of Health Translational Research Grants Scheme. Human Research Ethics Committee approval was obtained in November 2022, and practice recruitment began in March 2023. Data collection commenced for all participating practices from September 1, 2023, with anticipated completion on February 28, 2025. Data analysis will commence from March 2025, with results expected in the first quarter of 2026. CONCLUSIONS: Positive outcomes for the SUSTAIN trial, demonstrating that virtual pediatric support for GPs in both metropolitan and nonmetropolitan areas can strengthen pediatric primary care provision, have the potential to influence future health policy. This innovative approach to integrated care could be rolled out across Australia and other countries with primary care-led health care systems facing similar challenges.

BACKGROUND: Children living in regional and rural Australia have diminished health outcomes and are more likely to be developmentally vulnerable on one or more domains compared to urban peers. Despite this, children in regional and rural Australia often cannot access specialist care due to lack of availability, financial constraints, or waiting times of over 12 months. Strengthening Care for Rural Children (SC4RC) aims to evaluate an integrated general practitioner (GP)-paediatrician model of care in rural communities to enhance the quality of paediatric care by ensuring children receive timely, accessible care within their communities by reducing referrals to public and private paediatric services. METHODS: SC4RC is a stepped-wedge randomised controlled trial of 22 general practice clinics in regional and rural Victoria and New South Wales, Australia. Control data for each general practice clinic will be collected for a minimum of 1 month and each clinic will be randomly allocated a start month, with the intervention running for 11 months at each clinic. The intervention will consist of fortnightly GP-paediatrician co-consultation sessions, weekday phone and email paediatrician support for GPs, and access to a paediatric online community of practice via a Project ECHO™ series. The primary outcome is the proportion of paediatric (0 to <18 years) GP appointments that result in a referral to a paediatric service (hospital emergency departments, outpatient clinics, or private paediatricians) during the intervention period compared with the control period. Secondary outcomes include GP quality of care across 17 common childhood conditions, GP confidence in paediatric care, family confidence in GP care, and the sustainability of the SC4RC model. Integral to the project is our consumer engagement framework which will inform the translation and implementation of the project. An implementation evaluation will assess the acceptability, adaptability, and scalability of the model, whilst a health economic evaluation will measure the cost-effectiveness/benefit of the intervention. DISCUSSION: This protocol paper outlines how we will partner with primary care organisations and paediatric services to implement and evaluate SC4RC in some regional and rural communities in Victoria and NSW. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12623000550606. Registered on 23 May 2023.