Background: While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied. Aim: The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings. Design: We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924). Data sources: We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018. Results: Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization. Conclusion: Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.
Background: Depression affects an individual’s physical health and mental well-being, and in pregnant and postpartum women, has specific adverse short- and long-term effects on maternal, child, and family health. The aim of these two systematic reviews is to identify evidence on the benefits and harms of screening for depression compared to no screening in the general adult and pregnant and postpartum populations in primary care or non-mental health clinic settings. These reviews will inform recommendations by the Canadian Task Force on Preventive Health Care.Methods: We searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library using a randomized controlled trial filter, where applicable, October 4, 2018 and updated to May 11, 2020. We also searched for grey literature (e.g., websites of organizations of health professionals and patients). Study selection for depression screening trials was performed first on title and abstract, followed by full-text screening. Data extraction, assessment of the risk of bias using the Cochrane risk of bias tool, and application of Grading of Recommendations Assessment, Development and Evaluation were performed by one reviewer and validated by a second reviewer. Results: A total of three trials were included. All three trials were included in the general adult review, while one of the three trials was included in the pregnant and postpartum review. We did not pool results due to substantial differences between studies and high risk of bias. In the general adult review, the first trial (n=1001) evaluated whether screening for depression in adults with acute coronary syndrome compared to usual care improves health-related quality of life, depression symptoms, or the harms of screening at six, 12, and 18 months. There were little to no differences between the groups at 18 months for the outcomes. The second trial included adults (n=1412) undergoing initial consultation for osteoarthritis, evaluated for depression and general health (mental and physical) after initial consultation, and at three, six, and 12 months. The physical component score was statistically significantly lower (worse health) in the screened group at six months; however, this difference was not significant at three or at 12 months. There were no clinically important or statistically significant differences for other outcomes between groups at any time. The third trial (included in both reviews) reported on 462 postpartum women. At six months postpartum, fewer women in the screening group were identified as possibly depressed compared to the control group (RR 0.59, 95% confidence interval (CI) 0.39 to 0.89) and mean EPDS scores were also statistically significantly lower in the screened group (standardized mean difference 0.34 lower (95%CI 0.15 to 0.52 lower)). All other outcomes did not differ between groups at follow-up. There were serious concerns about the cut-offs used for the questionnaire used to screen, diagnostic confirmation, selective outcome reporting, and the reported magnitude of effects.Discussion: There are limitations of the evidence included in the reviews. There was moderate certainty in the evidence from one trial that screening for depression in the general adult population in primary care or non-mental health clinic settings likely results in little to no difference on reported outcomes, however, the evidence was uncertain from the other two included trials. The evidence is very uncertain about the effect of screening for depression in pregnant or postpartum women in primary care or non-mental health clinic settings. Well-conducted and better-reported trials are needed that meet the screening trial criteria used in this review.Systematic review registration: Both protocols have been registered in the International Prospective Registry of Systematic Reviews (PROSPERO) [Adult: CRD42018099690; Pregnancy and postpartum: CRD42018099689] and published (https://systematicreviewsjournal.biomedcentral.com/track/pdf/10.1186/s13643-018-0930-3).
Background Depression affects an individual’s physical health and mental well-being and, in pregnant and postpartum women, has specific adverse short- and long-term effects on maternal, child, and family health. The aim of these two systematic reviews is to identify evidence on the benefits and harms of screening for depression compared to no screening in the general adult and pregnant and postpartum populations in primary care or non-mental health clinic settings. These reviews will inform recommendations by the Canadian Task Force on Preventive Health Care. Methods We searched MEDLINE, Embase, PsycINFO, CINAHL, and the Cochrane Library using a randomized controlled trial filter, where applicable, October 4, 2018, and updated to May 11, 2020. We also searched for gray literature (e.g., websites of organizations of health professionals and patients). Study selection for depression screening trials was performed first on title and abstract, followed by full-text screening. Data extraction, assessment of the risk of bias using the Cochrane risk of bias tool, and application of Grading of Recommendations Assessment, Development and Evaluation were performed by one reviewer and validated by a second reviewer. Results A total of three trials were included. All three trials were included in the general adult review, while one of the three trials was included in the pregnant and postpartum review. We did not pool results due to substantial differences between studies and high risk of bias. In the general adult review, the first trial (n = 1001) evaluated whether screening for depression in adults with acute coronary syndrome compared to usual care improves health-related quality of life, depression symptoms, or harms of screening at 6, 12, and 18 months. There were little to no differences between the groups at 18 months for the outcomes. The second trial included adults (n = 1412) undergoing initial consultation for osteoarthritis, evaluated for depression and general health (mental and physical) after initial consultation and at 3, 6, and 12 months. The physical component score was statistically significantly lower (worse health) in the screened group at 6 months; however, this difference was not significant at 3 or at 12 months. There were no clinically important or statistically significant differences for other outcomes between groups at any time. The third trial (included in both reviews) reported on 462 postpartum women. At 6 months postpartum, fewer women in the screening group were identified as possibly depressed compared to the control group (RR 0.59, 95% confidence interval (CI) 0.39 to 0.89) and mean EPDS scores were also statistically significantly lower in the screened group (standardized mean difference 0.34 lower (95% CI 0.15 to 0.52 lower)). All other outcomes did not differ between groups at follow-up. There were serious concerns about the cut-offs used for the questionnaire used to screen, diagnostic confirmation, selective outcome reporting, and the reported magnitude of effects. Discussion There are limitations of the evidence included in the reviews. There was moderate certainty in the evidence from one trial that screening for depression in the general adult population in primary care or non-mental health clinic settings likely results in little to no difference on reported outcomes; however, the evidence was uncertain from the other two included trials. The evidence is very uncertain about the effect of screening for depression in pregnant or postpartum women in primary care or non-mental health clinic settings. Well-conducted and better-reported trials are needed that meet the screening trial criteria used in this review. Systematic review registration Both protocols have been registered in the International Prospective Registry of Systematic Reviews (PROSPERO) [adult: CRD42018099690; pregnancy and postpartum: CRD42018099689] and published (https://systematicreviewsjournal.biomedcentral.com/track/pdf/10.1186/s13643-018-0930-3).
This retrospective cohort study describes the rates, location, and determinants of specialist physician visits among 257,216 long-term care (LTC) residents across 648 LTC homes in Ontario, Canada, between 2007 and 2016. Visit rates in the last year of life were calculated for a sub-cohort of residents who died in LTC between 2013 and 2016. Visits were measured per resident-year using physician billings. Over 10 years, the rate of visits to specialists outside the LTC home was consistently higher than within LTC (2.99 vs. 1.55 visits/resident-year). Residents were less likely to receive specialist care if they were older, had dementia, or lived in urban LTC homes. From 12 months before death to the last week of life, rates of specialist visits increased by 246% and 56% inside and outside of LTC, respectively. Improving access to physician specialist care in LTC homes may reduce burdensome transitions and improve resident quality of life.
Spiritual health is established as an important protective health asset in child populations. Measurement and assessment of this elusive concept are, however, challenging. Brief and age-appropriate instruments are required for surveys and related population health research. One longstanding model describing child spirituality suggests that scales and measures consider four standard domains describing connections to self, others, nature, and the transcendent. In this validation study, we tested the structural validity and internal consistency of a brief, literacy-level appropriate instrument for adolescents that was based on prior adaptations of this model. The 2018 cross-national study population included 47,180 children aged 11–15 years from 9 countries. Based upon theory, factor pattern matrices, and Scree plots, the exploratory factor analysis best supported the four-factor model, with items organized according to the original four domains. Internal consistency of the items was acceptable (alpha>.7) to good (alpha>.8) within domains, again within each of the 9 countries. The confirmatory factor analysis again supported the four-factor model (by country, SRMR: 0.020 to 0.042; and AGFI and NFI fit: >0.98). Model fit indices for the four-factor model were improved compared with its unidimensional version. Moving forward, our analysis establishes the structural validity and internal consistency of this adapted brief spiritual health instrument to be used in surveys of adolescents.
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