Background and AimCritically ill survivors may have functional impairments even five years after hospital discharge. To date there are four systematic reviews suggesting a beneficial impact for mobilisation in mechanically ventilated and intensive care unit (ICU) patients, however there is limited information about the influence of timing, frequency and duration of sessions. Earlier mobilisation during ICU stay may lead to greater benefits. This study aims to determine the effect of early rehabilitation for functional status in ICU/high-dependency unit (HDU) patients.DesignSystematic review and meta-analysis. MEDLINE, EMBASE, CINALH, PEDro, Cochrane Library, AMED, ISI web of science, Scielo, LILACS and several clinical trial registries were searched for randomised and non-randomised clinical trials of rehabilitation compared to usual care in adult patients admitted to an ICU/HDU. Results were screened by two independent reviewers. Primary outcome was functional status. Secondary outcomes were walking ability, muscle strength, quality of life, and healthcare utilisation. Data extraction and methodological quality assessment using the PEDro scale was performed by primary reviewer and checked by two other reviewers. The authors of relevant studies were contacted to obtain missing data.Results5733 records were screened. Seven articles were included in the narrative synthesis and six in the meta-analysis. Early rehabilitation had no significant effect on functional status, muscle strength, quality of life, or healthcare utilisation. However, early rehabilitation led to significantly more patients walking without assistance at hospital discharge (risk ratio 1.42; 95% CI 1.17-1.72). There was a non-significant effect favouring intervention for walking distance and incidence of ICU-acquired weakness.ConclusionsEarly rehabilitation during ICU stay was not associated with improvements in functional status, muscle strength, quality of life or healthcare utilisation outcomes, although it seems to improve walking ability compared to usual care. Results from ongoing studies may provide more data on the potential benefits of early rehabilitation in critically ill patients.

Background: Doctors’ organisations in the UK have reported worrying levels of work-related stress and burnout in the general practitioner (GP) workforce for some time, and the COVID-19 pandemic has presented clear new challenges. Aims: To synthesise international evidence exploring the impact of COVID-19 on primary care doctors’ mental health and wellbeing and identify risk factors associated with their psychological wellbeing during this time. Design and setting: Mixed-methods systematic review. Method: We searched six bibliographic databases, Google Scholar and MedRxiv and conducted reference checking to identify studies of GP psychological wellbeing during the pandemic. Two reviewers selected studies, extracted data and assessed the quality of studies using standardised tools. Heterogeneity in outcomes, setting and design prohibited statistical pooling; we combined the studies using a convergent integrated thematic synthesis. Results: Thirty-one studies were included. Multiple sources of stress were identified, including changed working practices, risk, exposure and inadequate PPE, information overload, pandemic preparedness and cohesion across sectors. Studies demonstrated an impact on psychological wellbeing, with some GPs experiencing stress, burnout, anxiety, depression, fear of COVID, lower job satisfaction and physical symptoms. Studies described gender and age differences: women report poorer psychological outcomes across all domains and older GPs reported greater stress and burnout. Use of outcome measures and reporting practice varied greatly. Conclusion: Our review of international evidence demonstrates that the COVID-19 pandemic has adversely affected GPs’ wellbeing around the world. Further research could explore gender and age differences, identifying interventions targeted to these groups.

Resumo As internações por condições sensíveis à atenção primária têm sido utilizadas como indicador de efetividade desse nível de atenção. O artigo explora a associação entre variáveis selecionadas e a proporção dessas internações no Brasil. A pesquisa envolveu a análise descritiva da evolução de indicadores nacionais de 1998-2012 e a realização de estudo transversal dos municípios brasileiros com população acima de 50 mil habitantes, por região do país, para o ano de 2012, utilizando-se técnicas estatísticas de correlação e regressão linear. Os resultados mostraram discreto declínio na proporção de internações por condições sensíveis à atenção primária no Brasil. Condições socioeconômicas, demográficas e de oferta de médicos no sistema de saúde nos municípios mostraram associação com a proporção de internações por condições sensíveis à atenção primária, com expressão distinta nas cinco regiões do país. Apesar de avanços relacionados à expansão da Estratégia Saúde da Família, permanecem desafios, como a distribuição adequada de médicos e outros profissionais no território nacional e a efetiva mudança do modelo de atenção à saúde.

O artigo analisa a condução federal da política de atenção primária à saúde no Brasil de 2003 a 2008, considerando as funções de Estado na saúde de planejamento, regulação, financiamento e execução direta de serviços. A pesquisa compreendeu revisão bibliográfica, realização de entrevistas semi-estruturadas com atores-chave da política, análise documental, orçamentária e de bases de dados secundários. Observou-se redução na execução federal direta das ações e fragilidades no que diz respeito ao planejamento. A atuação federal se caracterizou principalmente pela regulação, baseada na emissão de portarias atreladas a mecanismos financeiros. No que concerne ao financiamento, houve discreto aumento da participação da atenção básica no orçamento federal, reajustes e criação de novos incentivos, alguns visando à eqüidade. Embora tenham ocorrido avanços no período, permanece o desafio de reconuração do modelo regulatório federal e a garantia de um aporte maior de recursos para este nível de atenção, a fim de que ocorra o efetivo fortalecimento da atenção primária no país.

Objectives To evaluate the effect of Care Quality Commission external inspections of acute trusts on adverse event rates in the English National Health Service. Methods Interrupted time-series analysis including all acute NHS trusts in England ( n = 155) using two control groups (new versus historical inspection regime and trusts not inspected). Multilevel random-coefficient modelling of (1) rates of falls with harm and (2) pressure ulcers, from April 2012 to June 2016, was undertaken using the new, resource-intensive regime of Care Quality Commission inspections as an intervention. Data used in the model included dates and type of inspection, patient safety indicators, demographic characteristics and financial risk of hospitals. Results In one year, Care Quality Commission inspected 66 acute trusts (42% of all English trusts) using their new regime and 46 (30%) using their previous one. Prior to inspections being announced, rates of falls with harm and pressure ulcers were improving in both intervention and control hospitals. The announcement of an inspection did not affect either indicator. After inspections, rates of falls with harm improved more slowly, and pressure ulcer rates no longer improved for trusts inspected using both regimes. Conclusions Neither form of external inspection was associated with positive, clinically significant effects on adverse event rates. Any improvement happening before the announced Care Quality Commission inspections slowed after the inspection.

ObjectivesTo identify follow-up services planned for patients with COVID-19 discharged from intensive care unit (ICU) and to explore the views of ICU staff and general practitioners (GPs) regarding these patients’ future needs and care coordination.DesignThis is a sequential mixed-methods study using online surveys and semistructured interviews. Interview data were inductively coded and thematically analysed. Survey data were descriptively analysed.SettingGP surgeries and acute National Health Service Trusts in the UK.ParticipantsGPs and clinicians leading care for patients discharged from ICU.Primary and secondary outcomesUsual follow-up practice after ICU discharge, changes in follow-up during the pandemic, and GP awareness of follow-up and support needs of patients discharged from ICU.ResultsWe obtained 170 survey responses and conducted 23 interviews. Over 60% of GPs were unaware of the follow-up services generally provided by their local hospitals and whether or not these were functioning during the pandemic. Eighty per cent of ICUs reported some form of follow-up services, with 25% of these suspending provision during the peak of the pandemic and over half modifying their provision (usually to provide the service remotely). Common themes relating to barriers to provision of follow-up were funding complexities, remit and expertise, and communication between ICU and community services. Discharge documentation was described as poor and lacking key information. Both groups mentioned difficulties accessing services in the community and lack of clarity about who was responsible for referrals and follow-up.ConclusionsThe pandemic has highlighted long-standing issues of continuity of care and complex funding streams for post-ICU follow-up care. The large cohort of ICU patients admitted due to COVID-19 highlights the need for improved follow-up services and communication between specialists and GPs, not only for patients with COVID-19, but for all those discharged from ICU.

Este artigo analisa a condução federal da política de atenção básica à saúde no Brasil nos anos 2000, buscando identificar elementos de continuidade e mudança com relação ao período anterior. A pesquisa se baseou no marco teórico do institucionalismo histórico e no conceito de path-dependence. A metodologia compreendeu uma diversidade de estratégias: revisão bibliográfica; análise documental; análise de bases de dados secundários; análise orçamentária e realização de entrevistas com atores-chave da política. Foi possível identificar continuidades e mudanças na condução federal da política nacional de atenção básica no período estudado. A predominância de continuidades, ressaltando-se a persistência do Programa de Saúde da Família como estratégia hegemônica para a reorientação da atenção básica no país, configura uma situação de path-dependence. Observaram-se também mudanças incrementais, a exemplo de iniciativas de fortalecimento da articulação intersetorial e inovações importantes, com destaque para a criação dos Núcleos de Apoio à Saúde da Família. Persistem, no entanto, problemas estruturais no âmbito da atenção básica, cuja superação é importante para viabilizar a efetiva mudança do modelo de atenção à saúde no país.

Background Deaths in the first year of the Coronavirus Disease 2019 (COVID-19) pandemic in England and Wales were unevenly distributed socioeconomically and geographically. However, the full scale of inequalities may have been underestimated to date, as most measures of excess mortality do not adequately account for varying age profiles of deaths between social groups. We measured years of life lost (YLL) attributable to the pandemic, directly or indirectly, comparing mortality across geographic and socioeconomic groups. Methods and findings We used national mortality registers in England and Wales, from 27 December 2014 until 25 December 2020, covering 3,265,937 deaths. YLLs (main outcome) were calculated using 2019 single year sex-specific life tables for England and Wales. Interrupted time-series analyses, with panel time-series models, were used to estimate expected YLL by sex, geographical region, and deprivation quintile between 7 March 2020 and 25 December 2020 by cause: direct deaths (COVID-19 and other respiratory diseases), cardiovascular disease and diabetes, cancer, and other indirect deaths (all other causes). Excess YLL during the pandemic period were calculated by subtracting observed from expected values. Additional analyses focused on excess deaths for region and deprivation strata, by age-group. Between 7 March 2020 and 25 December 2020, there were an estimated 763,550 (95% CI: 696,826 to 830,273) excess YLL in England and Wales, equivalent to a 15% (95% CI: 14 to 16) increase in YLL compared to the equivalent time period in 2019. There was a strong deprivation gradient in all-cause excess YLL, with rates per 100,000 population ranging from 916 (95% CI: 820 to 1,012) for the least deprived quintile to 1,645 (95% CI: 1,472 to 1,819) for the most deprived. The differences in excess YLL between deprivation quintiles were greatest in younger age groups; for all-cause deaths, a mean of 9.1 years per death (95% CI: 8.2 to 10.0) were lost in the least deprived quintile, compared to 10.8 (95% CI: 10.0 to 11.6) in the most deprived; for COVID-19 and other respiratory deaths, a mean of 8.9 years per death (95% CI: 8.7 to 9.1) were lost in the least deprived quintile, compared to 11.2 (95% CI: 11.0 to 11.5) in the most deprived. For all-cause mortality, estimated deaths in the most deprived compared to the most affluent areas were much higher in younger age groups, but similar for those aged 85 or over. There was marked variability in both all-cause and direct excess YLL by region, with the highest rates in the North West. Limitations include the quasi-experimental nature of the research design and the requirement for accurate and timely recording. Conclusions In this study, we observed strong socioeconomic and geographical health inequalities in YLL, during the first calendar year of the COVID-19 pandemic. These were in line with long-standing existing inequalities in England and Wales, with the most deprived areas reporting the largest numbers in potential YLL.