Determinants of Performance of Health Systems Concerning Maternal and Child Health: A Global Approach Is the public healthcare sector a more strenuous working environment than the private sector for a physician? The effects of expanded mental health benefits on treatment costs. Unravelling the quality of HIV counselling and testing services in the private and public sectors in Zambia Perceptions and utilization of primary health care services in Iraq: findings from a national household survey Organisation of asthma care: what difference does it make? A systematic review of the literature. Emtonjeni—A Structural Intervention to Integrate Sexual and Reproductive Health into Public Sector HIV Care in Cape Town, South Africa: Results of a Phase II Study [Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. Assessing the evidence for the use of chiropractic manipulation in paediatric health conditions: A systematic review. Transcutaneous electrical nerve stimulation (TENS) for chronic pain - an overview of Cochrane Reviews. Helping patients help themselves: A systematic review of self-management support strategies in primary health care practice Early detection strategies for untreated first-episode psychosis How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Protocol for an overview of systematic reviews of interventions to reduce unscheduled hospital admissions among adults National Institutes of Health State-of-the-Science Conference Statement: Tobacco Use: Prevention, Cessation, and Control Organisation of a proposed Cochrane Diet and Nutrition Field How has the impact of 'care pathway technologies' on service integration in stroke care been measured and what is the strength of the evidence to support their effectiveness in this respect? Factors influencing patient satisfaction in primary healthcare clinics in Kuwait. Risk of bias in randomised controlled trials of health behaviour change interventions: Evidence, practices and challenges Mental Health Disorders in Elderly People Receiving Home Care: Prevalence and Correlates in the National U.S. Population Effects of home visits by home nurses to elderly people with health problems: design of a randomised clinical trial in the Netherlands [ISRCTN92017183] Systematic reviews in public health: old chestnuts and new challenges. Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews.
Aims To assess the association of social determinants on the performance of health systems around the world . Methods A transnational ecological study was conducted with an observation level focused on the country . In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants :  corruption , democratization , income ine quality and cultural fragmentation , we used a mixed linear regression model for repeated measures with r and om intercepts and a conglomerate-based geographical analysis , between 2000 and 2010 . Results Health determinants with a significant association on child mortality(<1year ) : higher access to water ( βa Quartile 4(Q4 ) vs Quartile 1(Q1 ) = -6,14 ; 95%CI : -11,63 to -0,73 ) , sanitation systems , ( Q4 vs Q1 = -25,58 ; 95%CI : -31,91 to -19,25 ) , % measles vaccination coverage ( Q4 vs Q1 = -7.35 ; 95%CI : -10,18 to -4,52 ) , % of births attended by a healthcare professional ( Q4 vs Q1 = -7,91 ; 95%CI : -11,36 to -4,52 ) and a % of the total health expenditure ( Q3 vs Q1 = -2,85 ; 95%CI : -4,93 to -0,7 ) . Ethnic fragmentation ( Q4 vs Q1 = 9,93 ; 95%CI : -0.03 to 19.89 ) had a marginal effect . For child mortality<5 years , an association was found for these variables and democratization ( not free vs free = 11,23 ; 95%CI : -0,82 to 23,29 ) , out-of-pocket expenditure ( Q1 vs Q4 = 17,71 ; 95%CI : 5,86 to 29,56 ) . For MMR ( Maternal mortality ratio ) , % of access to water for all the quartiles , % of access to sanitation systems , ( Q3 vs Q1 = -171,15 ; 95%CI : -281,29 to -61 ) , birth attention by a healthcare professional ( Q4 vs Q1 = -231,23 ; 95%CI : -349,32 to -113,15 ) , and having corrupt government ( Q3 vs Q1 = 83,05 ; 95%CI : 33,10 to 133 ) . Conclusions Improving access to water and sanitation systems , decreasing corruption in the health sector must become priorities in health systems . The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results Aims : The present study examined the differences between physicians working in public and private health care in strenuous working environments ( presence of occupational hazards , physical violence , and presenteeism ) and health behaviours ( alcohol consumption , body mass index , and physical activity ) . In addition , we examined whether gender or age moderated these potential differences . Methods : Cross-sectional survey data were compiled on 1422 female and 948 male r and omly selected physicians aged 25–65 years from The Finnish Health Care Professionals Study .  Logistic regression and linear regression analyses were used with adjustment for gender , age , specialisation status , working time , managerial position , and on-call duty . Results : Occupational hazards , physical violence , and presenteeism were more commonly reported by physicians working in the public sector than by their counterparts in the private sector . Among physicians aged 50 years or younger , those who worked in the public sector consumed more alcohol than those who worked in the private sector , whereas in those aged 50 or more the reverse was true . In addition , working in the private sector was most strongly associated with lower levels of physical violence in those who were older than 50 years , and with lower levels of presenteeism among those aged 40–50 years . Conclusions : The present study found evidence for the public sector being a more strenuous work environment for physicians than the private sector . Our results suggest that public healthcare organisations should pay more attention to the working conditions of their employees BACKGROUND Mental health disorders represent one of the most common problems facing adults in the labor force . It is estimated that within a 12-month period nearly 30 % of the US population experiences some diagnosable mental health or addictive disorder . This study examines the impact that corporate benefit policies can have on mental health treatment costs . AIMS To measure the effects of a change in mental health benefit design on treatment expenditures for employees of a large US-based company . METHODS Data came from mental health treatment administrative cl aims and eligibility information provided by the company and a comparable set of cl aims for a r and omly selected control group for the years 1995 - 1998 . We measure the effect of a change in mental health benefits consisting of three major elements : a company-wide effort to destigmatize mental illness ; reduced cost-sharing for mental health treatment ; and the implementation of a provider network that emphasized access to non-physician mental health specialists . We use a two-part regression model within a difference in differences framework to examine outpatient , pharmaceutical , and combined outpatient and pharmaceutical expenditures between the treatment company and the control group . RESULTS We find that the program led to a statistically significant dollar 17 increase in outpatient costs ( excluding pharmaceutical costs ) per employee . Similar to outpatient care we find that the benefit change was associated with a statistically significant increase in pharmaceutical costs of about dollar 15 . DISCUSSION The results reveal that the mental health benefit expansion at the company led to a significant increase in aggregate mental health expenditures among employees . However , the aggregate increase in cost masks a number of interesting underlying trends in mental health utilization . First , conditional upon any mental health treatment , mental health costs were virtually unchanged before and after the benefit change . Conditional on any use , outpatient and pharmaceutical expenditures went in opposite directions , with outpatient expenditures falling and pharmaceutical expenditures increasing . IMPLICATION S FOR HEALTH CARE PROVISION AND USE Private sector initiatives can increase use of mental health care treatment through decreased cost-sharing , improved access to specialty providers , and destigmatization of mental disorders . IMPLICATION S FOR HEALTH CARE POLICY FORMULATION : Given that the vast majority of people in the US get their health insurance through employer-sponsored health insurance , efforts on the part of the private sector to recognize and treat serious chronic illnesses such as mental disorder in a proactive manner should be encouraged . IMPLICATION S FOR FUTURE RESEARCH While the aggregate cost of corporate initiatives to improve access to quality mental health care is frequently examined , it is also important to decompose the aggregate cost changes into effects from a change in the rate of initiation and changes in utilization conditional upon initiation Background Despite the substantial investment for providing  HIV counselling and testing ( VCT ) services in Zambia , there has been little effort to systematic ally evaluate the quality of  VCT services provided by various types of health providers . This study , conducted in 2009 , examines  VCT in the public and private sectors including private for-profit and NGO/faith-based sectors in Copperbelt and Luapula . Methods The study used five primary data collection methods to gauge quality of  VCT services  : closed-ended client interviews with clients exiting  VCT sites ; open-ended client interviews ; interviews with facility managers ; review of service statistics ; and an observation of the physical environment for VCT by site .  Over 400 clients and 87 facility managers were interviewed from almost 90 facilities . Sites were r and omly selected and results are generalizable at the provincial level . Results The study shows concerning levels of underperformance in VCT services  across the sectors . It reveals serious underperformance in counselling about key risk-reduction methods . Less than one-third of clients received counselling on reducing number of sexual partners and only approximately 5 % of clients received counselling about disclosing test results to partners . In terms of client profiles , the NGO sector attracts the most educated clients and less educated Zambians seek  VCT  services at very low rates ( 7 % ) . The private for-profit performs equally or sometimes better than other sectors even though this sector is not adequately integrated into the Zambian national response to HIV . Conclusion The private for-profit sector provides  VCT services  on par in quality with the other sectors . Most clients did not receive counselling on partner reduction or disclosure of HIV test results to partners . In a generalized HIV epidemic where multiple concurrent sexual partners are a significant problem for transmitting the disease , risk-reduction methods and discussion should be a main focus of pre-test and post-test counselling Background After many years of sanctions and conflict , Iraq is rebuilding its health system , with a strong emphasis on the traditional hospital-based services . A network exists of public sector hospitals and clinics , as well as private clinics and a few private hospitals . Little data are available about the approximately 1400 Primary Health Care clinics ( PHCCs ) staffed with doctors . How do Iraqis utilize primary health care services ? What are their preferences and perceptions of public primary health care clinics and private primary care services in general ? How does household wealth affect choice of services ? Methods A 1256 household national survey was conducted in the catchment areas of r and omly selected PHCCs in Iraq . A cluster of 10 households , beginning with a r and omly selected start household , were interviewed in the service areas of seven public sector PHCC facilities in each of 17 of Iraq 's 18 governorates . A question naire was developed using key informants . Teams of interviewers , including both males and females , were recruited and provided a week of training which included field practice . Teams then gathered data from households in the service areas of r and omly selected clinics . Results Iraqi participants are generally satisfied with the quality of primary care services available both in the public and private sector . Private clinics are generally the most popular source of primary care , however the PHCCs are utilized more by poorer households . In spite of free services available at PHCCs many households expressed difficulty in affording health care , especially in the purchase of medications . There is no evidence of informal payments to secure health services in the public sector . Conclusions There is widespread satisfaction reported with primary health care services , and levels did not differ appreciably between public and private sectors . The public sector PHCCs are preferentially used by poorer population s where they are important providers . PHCC services are indeed free , with little evidence of informal payments to providers OBJECTIVES : To evaluate the effectiveness of different forms of organisation ( delivery ) of asthma care . METHODS : A systematic review of the published evidence of effectiveness organisational methods of asthma management . Search es on computerised data bases including Medline , CINAHL , and HELMIS , and relevant citations and letters to experts were used to identify relevant studies . RESULTS : 27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors , such as shared care , general practice asthma clinics , outpatient programmes , inpatient admissions policies , and the use of specialists . Only one third of the studies used a r and omised controlled trial and many had small sample sizes . No conclusive evidence was found to favour any particular organisational form , although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care . CONCLUSIONS : There is little good published research evaluating different ways of organising the delivery of asthma care . There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers , in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes Integration of sexual and reproductive health within HIV care services is a promising strategy for increasing access to family planning and STI services and reducing unwanted pregnancies , perinatal HIV transmission and maternal and infant mortality among people living with HIV and their partners . We conducted a Phase II r and omized futility trial of a multi-level intervention to increase adherence to safer sex guidelines  among those wishing to avoid pregnancy and  adherence to safer conception guidelines  among those seeking conception in newly-diagnosed HIV-positive persons in four public-sector HIV clinics in Cape Town . Clinics were pair-matched and the two clinics within each pair were r and omized to either a three-session provider-delivered enhanced intervention ( EI ) ( onsite contraceptive services and brief milieu intervention for staff ) or st and ard-of-care ( SOC ) provider-delivered intervention . The futility analysis showed that we can not rule out the possibility that the  EI intervention has a 10 % point or greater success rate in improving adherence to safer sex/safer conception guidelines than does SOC ( p = 0.573 ) , indicating that the intervention holds merit , and a larger-scale confirmatory study showing whether the EI is superior to SOC has merit UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment OBJECTIVE To review the biomedical literature up to and including 2003 , and determine the extent of the evidence related to the therapeutic application of chiropractic manipulation for paediatric health conditions . No critical appraisal of the evidence is undertaken . DATA SOURCES The indexed manual therapy sector including medical , chiropractic , physiotherapy , naturopathic and osteopathic literature was search ed . This included PubMed ; the Manual , Alternative , and Natural Therapy Index System ; the Cumulative Index to Nursing and Allied Health Literature ; the Index to Chiropractic Literature ; the Paediatric Economic Data base Evaluation Project ; the Cochrane Library ; the Canadian Coordinating Office for Health Technology Assessment data base ; and the Agency for Healthcare Research and Quality data base . Other re sources included research conference and symposium proceedings , and the references of identified studies . RESULT The search identified 1731 articles , of which 166 met the eligibility criteria . Two review ers determined by consensus each citation 's appropriate level on the strength of evidence scale . There was one systematic review , nine r and omized controlled trials , one observational study , 141 descriptive case studies and 14 conference abstract s. SUMMARY Health cl aims made by practitioners regarding the application of chiropractic manipulation as a health care intervention for paediatric health conditions are , for the most part , supported by low levels of scientific evidence . Chiropractors , in particular , employ manipulation for the treatment of a wide variety of paediatric health conditions . The evidence rests primarily with clinical experience , descriptive case studies and a few r and omized controlled trials . There is a need for more rigorous scientific inquiry to examine the value of manipulative therapy in the treatment of paediatric conditions . To advance the health interests of paediatric patients , health care decisions made on the basis of expert opinion or clinical experience must integrate the best research evidence available from high- quality , scientific studies BACKGROUND Chronic pain , considered to be pain lasting more than three months , is a common and often difficult to treat condition that can significantly impact upon function and quality of life . Treatment typically includes pharmacological and non-pharmacological approaches . Transcutaneous electrical nerve stimulation ( TENS ) is an adjunct non-pharmacological treatment commonly recommended by clinicians and often used by people with pain . OBJECTIVES To provide an overview of evidence from Cochrane Review s of the effectiveness of TENS to reduce pain in adults with chronic pain ( excluding headache or migraine).To provide an overview of evidence from Cochrane Review s of the safety of TENS when used to reduce pain in adults with chronic pain ( excluding headache or migraine).To identify possible sources of inconsistency in the approaches taken to evaluating the evidence related to TENS for chronic pain ( excluding headache or migraine ) in the Cochrane Library with a view to recommending strategies to improve consistency in methodology and reporting . To highlight areas of remaining uncertainty regarding the effectiveness of TENS for chronic pain ( excluding headache or migraine ) with a view to recommending strategies to reduce any uncertainty . METHODS Search methods We search ed the Cochrane Data base of Systematic Review s ( CDSR ) , in the Cochrane Library , across all years up to Issue 11 of 12 , 2018 . Selection of review sTwo authors independently screened the results of the electronic search by title and abstract against inclusion /exclusion criteria . We included all Cochrane Review s of r and omised controlled trials ( RCTs ) assessing the effectiveness of TENS in people with chronic pain . We included review s if they investigated the following : TENS versus sham ; TENS versus usual care or no treatment/waiting list control ; TENS plus active intervention versus active intervention alone ; comparisons between different types of TENS ; or TENS delivered using different stimulation parameters . Data extraction and analysis Two authors independently extracted relevant data , assessed review quality using the AMSTAR checklist and applied GRADE judgements where required to individual review s. Our primary outcomes included pain intensity and nature/incidence of adverse effects ; our secondary outcomes included disability , health-related quality of life , analgesic medication use and participant global impression of change . MAIN RESULTS We included nine review s investigating TENS use in people with defined chronic pain or in people with chronic conditions associated with ongoing pain . One review investigating TENS for phantom or stump-associated pain in people following amputation did not have any included studies . We therefore extracted data from eight review s which represented 51 TENS-related RCTs representing 2895 TENS-comparison participants entered into the studies .The included review s followed consistent methods and achieved overall high scores on the AMSTAR checklist . The evidence reported within each review was consistently rated as very low quality . Using review authors ' assessment of risk of bias , there were significant method ological limitations in included studies ; and for all review s , sample sizes were consistently small ( the majority of studies included fewer than 50 participants per group).Six of the eight review s presented a narrative synthesis of included studies . Two review s reported a pooled analysis . Primary and secondary outcomes One review reported a beneficial effect of TENS versus sham therapy at reducing pain intensity on a 0 to 10 scale ( MD -1.58 , 95 % CI -2.08 to -1.09 , P < 0.001 , I² = 29 % , P = 0.22 , 5 studies , 207 participants ) . However the quality of the evidence was very low due to significant method ological limitations and imprecision . A second review investigating pain intensity performed a pooled analysis by combining studies that compared TENS to sham with studies that compared TENS to no intervention ( SMD -0.85 , 95 % CI -1.36 to -0.34 , P = 0.001 , I² = 83 % , P < 0.001 ) . This pooled analysis was judged as offering very low quality evidence due to significant method ological limitations , large between-trial heterogeneity and imprecision . We considered the approach of combining sham and no intervention data to be problematic since we would predict these different comparisons may be estimating different true effects . All remaining review s also reported pain intensity as an outcome measure ; however the data were presented in narrative review form only . Due to method ological limitation and lack of useable data , we were unable to offer any meaningful report on the remaining primary outcome regarding nature/incidence of adverse effects , nor for the remaining secondary outcomes : disability , health-related quality of life , analgesic medication use and participant global impression of change for any comparisons . We found the included review s had a number of inconsistencies when evaluating the evidence from TENS studies . Approaches to assessing risk of bias around the participant , personnel and outcome -assessor blinding were perhaps the most obvious area of difference across included review s. We also found wide variability in terms of primary and secondary outcome measures , and inclusion /exclusion criteria for studies varied with respect to including studies which assessed immediate effects of single interventions . AUTHORS ' CONCLUSIONS We found the method ological quality of the review s was good , but quality of the evidence within them was very low . We were therefore unable to conclude with any confidence that , in people with chronic pain , TENS is harmful , or beneficial for pain control , disability , health-related quality of life , use of pain relieving medicines , or global impression of change . We make recommendations with respect to future TENS study design s which may meaningfully reduce the uncertainty relating to the effectiveness of this treatment in people with chronic pain Background Primary health professionals are well positioned to support the delivery of patient self-management in an evidence -based , structured capacity . A need exists to better underst and the active components required for effective self-management support , how these might be delivered within primary care , and the training and system changes that would subsequently be needed . Objectives ( 1 ) To examine self-management support interventions in primary care on health outcomes for a wide range of diseases compared to usual st and ard of care ; and ( 2 ) To identify the effective strategies that facilitate positive clinical and humanistic outcomes in this setting . Method A systematic review of r and omized controlled trials evaluating self-management support interventions was conducted following the Cochrane h and book & PRISMA guidelines . Published literature was systematic ally search ed from inception to June 2019 in PubMed , Scopus and Web of Science . Eligible studies assessed the effectiveness of individualized interventions with follow-up , delivered face-to-face to adult patients with any condition in primary care , compared with usual st and ard of care . Matrices were developed that mapped the evidence and components for each intervention . The method ological quality of included studies were appraised . Results 6,510 records were retrieved . 58 studies were included in the final qualitative synthesis . Findings reveal a structured patient-provider exchange is required in primary care ( including a one-on-one patient-provider consultation , ongoing follow up and provision of self-help material s ) . Interventions should be tailored to patient needs and may include combinations of strategies to improve a patient ’s disease or treatment knowledge ; independent monitoring of symptoms , encouraging self-treatment through a personalized action plan in response worsening symptoms or exacerbations , psychological coping and stress management strategies , and enhancing responsibility in medication adherence and lifestyle choices . Follow-up may include tailored feedback , monitoring of progress with respect to patient set healthcare goals , or honing problem-solving and decision-making skills . Theoretical models provided a strong base for effective SMS interventions . Positive outcomes for effective SMS included improvements in clinical indicators , health-related quality of life , self-efficacy ( confidence to self-manage ) , disease knowledge or control . An SMS model has been developed which sets the foundation for the design and evaluation of practical strategies for the construct of self-management support interventions in primary healthcare practice . Conclusions These findings provide primary care professionals with evidence -based strategies and structure to deliver SMS in practice . For this collaborative partnership approach to be more widely applied , future research should build on these findings for optimal SMS service design and upskilling healthcare providers to effectively support patients in this collaborative process Some studies in first-episode schizophrenia correlate shorter duration of untreated psychosis ( DUP )  with better prognosis , suggesting that timing of treatment may be important . A three-site prospect i ve clinical trial in Norway and Denmark is underway to investigate the effect of the timing of treatment in first-episode psychosis . One health care sector ( Rogal and , Norway ) is experimental and has developed an early detection ( ED ) system to reduce DUP . Two other sectors ( Ullevål , Norway , and Roskilde , Denmark ) are comparison sectors and rely on existing detection and referral systems for first-episode cases . The study ultimately will compare early detected with usual detected patients . This paper describes the study 's major independent intervention variable , i.e. a comprehensive education and detection system to change DUP in first onset psychosis . System variables and first results from the four-year inclusion period ( 1997 - 2000 ) are described . It includes targeted information towards the general public , health professionals and schools , and ED teams to recruit appropriate patients into treatment as soon as possible . This plus easy access to psychiatric services via ED teams systematic ally changed referral patterns of first-episode schizophrenia . DUP was reduced by 1.5 years ( mean ) from before the time the ED system was instituted ( to 0.5 years ) . The ED strategies appear to be effective and to influence directly the community 's help-seeking behaviour Background Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . Objectives To systematic ally review all high‐ quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care To examine how elements of service integration are defined in such studies To examine the type of evidence utilised to measure service integration To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration To produce recommendations for ICP developers , users and evaluators . Inclusion criteria Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services ‐ acute care , rehabilitation and long‐term support ‐ in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' . Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi‐experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English‐ language abstract , where available . These were included only if an English translation was available . Exclusion criteria This review excluded studies that : focused only on a single aspect of stroke care ( e.g. dysphasia ) evaluated ICPs as part of a wider program of service development did not make an explicit link between ICPs and service integration did not meet the definition of ICP utilised for the purpose s of the review focused exclusively on the outcomes of variance analysis Search strategy In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three‐stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . Data collection Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single‐ appraisal checklist and data ‐ extraction tool which could be applied to all research design s.32 The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.31 in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . Data synthesis Given the heterogeneity of the included studies , meta‐ analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . Results ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow‐up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . Early studies of  ICP‐managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher‐level functioning and carer needs influencing perceptions of quality of life . ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.20 None of the studies assessed the balance of costs and benefits of ICP use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . Conclusions Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay . ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter‐professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP‐managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . As none of the studies review ed included an economic evaluation , moreover , it remains unclear whether the benefits of ICPs Introduction Unscheduled hospital admissions are an increasing burden on health systems worldwide . To date , initiatives to reduce admissions have had limited success as it is unclear which strategies effectively reduce admissions and are supported by a strong evidence -base . Therefore , we will conduct an overview to find , assess and summarise all published peer- review ed systematic review s of r and omised controlled trials that examine the effect of an intervention on  unplanned admissions among adults . Methods and analysis This is a protocol for a systematic overview of review s. We will search four data bases : Ovid MEDLINE , PubMed , Cochrane Data base of Systematic Review s and the Cochrane Data base of Abstract s of Review s of Effects . We will consider systematic review s and meta-analyses of r and omised controlled trials in adults ( ≥16 years old ) evaluating the effect of any intervention on unscheduled hospital admissions including those to treat , monitor , diagnose or prevent a health problem . We will only include review s that identified unscheduled hospitalisations as a prespecified outcome . Two authors will independently screen articles for inclusion using a priori criteria . We will assess the quality of included review s and extract ratings of the quality of evidence from within each review . We will create a hierarchical list of interventions based on estimates of absolute admission reductions and the quality of the evidence . Presentation of results will align with guidelines in the Cochrane H and book of Systematic Review s of Interventions and the Preferred Reporting Items for Systematic Review s and Meta- Analysis statement . Ethics and dissemination Ethics approval is not required . We will su bmi t the results of this study for peer- review publication . The results will inform future research and could be used by healthcare managers , administrators and policymakers to guide re source allocation decisions and inform local implementation and optimisation of interventions to reduce unscheduled hospital admissions National Institutes of Health ( NIH ) consensus and state-of-the-science statements are prepared by independent panels of health professionals and public representatives on the basis of 1 ) the results of a systematic literature review prepared under contract with the Agency for Healthcare Research and Quality ( AHRQ ) , 2 ) presentations by investigators working in areas relevant to the conference questions during a 2-day public session , 3 ) questions and statements from conference attendees during open discussion periods that are part of the public session , and 4 ) closed deliberations by the panel during the remainder of the second day and the morning of the third . This statement is an independent report of the panel and is not a policy statement of the NIH or the federal government . The statement reflects the panel 's assessment of medical knowledge available at the time the statement was written . Thus , it provides a snapshot in time of the state of knowledge on the conference topic . When reading the statement , keep in mind that new knowledge is inevitably accumulating through medical research . Tobacco use is the leading preventable cause of premature death in the United States . Each year , more than 440000 Americans die of tobacco-related disease , accounting for 1 in every 5 deaths . Cigarette smoking is responsible for more than 30 % of cancer deaths annually in the United States . Smoking also contributes substantially to deaths from heart disease , stroke , and chronic obstructive pulmonary disease . According to current estimates , 21 % of American adults ( 44.5 million individuals ) and 22 % of American high school students ( 3.75 million individuals ) smoke . Cigarettes are the predominant form of tobacco that Americans consume , but tobacco consumption also includes smokeless tobacco , cigars , and pipes . In addition to the toll in human lives , tobacco use is an enormous economic burden on society . From 1995 to 1999 , estimated annual smoking-attributable economic costs in the United States were $ 75.5 billion for direct medical care for adults and $ 81.9 billion for lost productivity . Tobacco use per capita has decreased from about 14 pounds per year in the 1950s to about 5 pounds per year in 2000 , suggesting that public health interventions have been effective . Yet it is unlikely that the United States will reach the Healthy People 2010 objectives of reducing smoking prevalence to 12 % or less in adults and 16 % or less in youth . Further progress in reducing tobacco use is an important challenge facing the public health , medical , and political communities . For these reasons , the National Cancer Institute and the NIH 's Office of Medical Applications of Research sponsored a State-of-the-Science Conference on Tobacco Use : Prevention , Cessation , and Control on 12 - 14 June 2006 in Bethesda , Maryl and . The key questions to be addressed at the State-of-the-Science Conference were : 1 ) What are the effective population - and community-based interventions to prevent tobacco  use in adolescents and young adults , including among diverse population s ? 2 ) What are the effective strategies for increasing consumer dem and for and use of proven , individually oriented cessation treatments , including among diverse population s ? 3 ) What are the effective strategies for increasing the implementation of proven , population -level , tobacco-use cessation strategies , particularly by health care systems and communities ? 4 ) What is the effect of smokeless tobacco product marketing and use on overall harm to the population from tobacco use ? 5 ) What is the effectiveness of prevention and of cessation interventions in population s with co-occurring morbidities and risk behaviors ? 6 ) What research is needed to make the most progress and greatest public health gains nationally and internationally ? At the conference , invited experts presented information pertinent to these questions , and a systematic literature review prepared under contract with AHRQ was summarized . The evidence report ( www.ahrq.gov/clinic/epcix.htm ) emphasized r and omized , controlled trials ; systematic review s ; and other experimental or observational studies with more than 100 participants . During the conference , attendees provided both oral and written statements in response to the key questions . The panel members weighed this evidence as they addressed the key conference questions . 1 . What Are the Effective  Population - and Community-Based Interventions  to Prevent Tobacco Use in Adolescents and Young Adults , Including among Diverse population s ? Never starting to use tobacco is a much better strategy than having to stop . Tobacco use usually begins primarily during adolescence . Almost 25 % of 12th grade rs have smoked in the previous 30 days , and almost all adult daily smokers tried cigarettes before age 18 years . Research reports suggest a flattening of the past decade 's downward trend in adolescent smoking .  Adolescents ( 13 to 18 years of age ) and young adults ( 18 to 24 years of age ) are susceptible to cultural influences , including family , friends , peers , media , community , and tobacco marketing influence . Gender , racial/ethnic background , socioeconomic status , geography , and sexual orientation all influence tobacco use and the effectiveness of strategies to prevent it , which means that many preventive strategies are needed . What We Know Previous review s have identified 3 effective general population approaches to preventing tobacco use in adolescents and young adults : 1 ) increased prices through taxes on tobacco products ; 2 ) laws and regulations that prevent young people from gaining access to tobacco products , reduce their exposure to tobacco smoke , and restrict tobacco industry advertising ; and 3 ) mass media campaigns . Previous review s show that school-based intervention programs aim ed at preventing tobacco use in adolescents are effective in the short term . Comprehensive statewide programs have also reduced overall tobacco use in young adults . What We Need to Learn Although previous evidence shows that clean indoor air and youth access policies reduce adolescent smoking rates , we need to know more about the effectiveness of these policies in specific population s. The evidence that culturally sensitive programs are more effective in reducing smoking among adolescents and young adults is not adequate to support a firm conclusion . We need to develop school-based strategies that lead to sustained reduction in starting tobacco use . 2 . What Are the Effective Strategies for Increasing Consumer Dem and for and Use of Proven , Individually Oriented Cessation Treatments , Including among Diverse Population s ? About 70 % of the 44.5 million adult smokers in the United States want to quit , but of those who try to quit in a given year , fewer than 5 % succeed . Effective treatments can double or triple quit rates , but too few smokers try these interventions and too few physicians offer them . What We Know Previous systematic review s identified effective strategies for increasing use of the following proven individually oriented cessation treatments . A mass media education campaign uses brief , recurring messages to inform and to motivate tobacco users to quit . It is effective in increasing tobacco use cessation when combined with other interventions . For example , media messages that direct viewers to call for further information or support increase use of telephone-based tobacco cessation information or support services . Proactive telephone smoking cessation support occurs when the health care provider initiates contact with the smoker . Advice to stop smoking is effective , especially when combined with other interventions , such as educational approaches or pharmacologic therapies . Increasing the unit price for tobacco products increases tobacco use cessation and reduces consumption regardless of the smoker 's ethnicity , gender , and socioeconomic status . Reducing out-of-pocket costs for effective cessation therapiesfor example , because health insurance pays for the serviceincreases their use . Making smokers aware of their health insurance 's coverage policy can increase use of smoking cessation treatments . Culturally tailored , gender-specific , and language -appropriate programs show promise . What We Need to Learn Generic interventions may be less effective than interventions tailored to specific population s , so we need to underst and how best to tailor interventions . To increase dem and for treatments , smokers must want them , expect them , and ask for them . We need to learn how to make treatments more attractive to tobacco users . We need to create a sustained dem and for effective treatments . 3 . What Are the Effective Strategies for Increasing the Implementation of Proven , Population -Level Tobacco Use Cessation Strategies , Particularly by Health Care Systems and Communities ? Despite strong evidence that a variety of pharmacologic and behavioral interventions increase tobacco cessation , only a small proportion of tobacco users ever try them . Strategies that target individual tobacco users may be effective but fail to reach most smokers . Community-level strategies target broad geographic population s ( for example , cities ) or smaller , more localized groups of people ( for example , military bases , colleges ) . Clinical setting s in which to implement community-level strategies range in scope from individual practice s to large integrated organizations . What We Know Community-based interventions aim to increase dem and for cessation interventions ( media campaigns , higher prices , smoke-free environments ) or facilitate access to cessation services ( community-level quit lines , offering cessation services in community setting s ) . Evidence suggests that media campaigns , telephone-counseling programs ( quit lines ) , and increases in tobacco prices and taxes are effective . Providing cessation services in non clinical community setting s shows some promise , but the literature lacks good evidence of community setting interventions in the United States . The Cochrane Collaboration helps people make well-informed decisions about health care by preparing , maintaining and promoting the accessibility of systematic review s of the effects of healthcare interventions . In all , 51 Cochrane Review Groups are responsible for preparing and maintaining the review s. Most of these Review Groups are problem-based . However , there are a number of areas or dimensions of health care , such as the setting of care ( eg primary care ) or the type of patient/consumer ( eg older persons ) , that can not be usefully conceptualised as ‘ health problems ’ . In order to reflect the interests of these dimensions , or ‘ fields ’ , of health care more effectively , the Cochrane Collaboration created another type of entity : Cochrane Fields or Networks . The core functions of these Fields are described . It is proposed that a new Cochrane Subfield for Diet and Nutrition should be set up to attract a cadre of new review ers in order to ensure the proper representation of diet and nutrition expertise in the relevant Collaborative Review Groups . The method ological pitfalls of the use of nonr and omised studies will be a key issue for the new Subfield , since the focus of the Cochrane Collaboration 's programme of search ing data bases , journals and conference proceedings has been on the identification of reports of r and omised controlled trials ( RCTs ) . Some of these sources will be need to be search ed again for non- RCT studies . The financial considerations of establishing of a Cochrane Subfield for Diet and Nutrition are discussed UNLABELLED EXECUTIVE SUMMARY : BACKGROUND Across the developed world , we are witnessing an increasing emphasis on the need for more closely coordinated forms of health and social care provision . Integrated care pathways ( ICPs ) have emerged as a response to this aspiration and are believed by many to address the factors which contribute to service integration . ICPs map out a patient 's journey , providing coordination of services for users . They aim to have : ' the right people , doing the right things , in the right order , at the right time , in the right place , with the right outcome ' . The value for ICPs in supporting the delivery of care across organisational boundaries , providing greater consistency in practice , improving service continuity and increasing collaboration has been advocated by many . However , there is little evidence to support their use , and the need for systematic evaluations in order to measure their effectiveness has been widely identified . A recent Cochrane review assessed the effects of ICPs on functional outcome , process of care , quality of life and hospitalisation costs of in patients with acute stroke , but did not specifically focus on service integration or its derivatives . To the best of our knowledge , no such systematic review of the literature exists . OBJECTIVES • To systematic ally review all high- quality studies which have evaluated the impact of care pathway technologies on ' service integration ' and its derivatives in stroke care • To examine how elements of service integration are defined in such studies • To examine the type of evidence utilised to measure service integration • To analyse the weight of evidence used to support cl aims about the effectiveness of ICPs on improving service integration • To produce recommendations for ICP developers , users and evaluators . INCLUSION CRITERIA Types of participants The review focused on the care of adult patients who had suffered a stroke . It included the full spectrum of services - acute care , rehabilitation and long-term support - in hospital and community setting s. Types of intervention(s)/phenomena of interest Integrated care pathways were the intervention of interest , defined for the purpose of this review as ' a multidisciplinary tool to improve the quality and efficiency of evidence based care and is used as a communication tool between professionals to manage and st and ardise the outcome orientated care ' Here ' multidisciplinary ' is taken to refer to the involvement of two or more disciplines . Types of outcomes ' Service integration ' was the outcome of interest however , this was defined and measured in the selected studies . Types of studies This review was concerned with how ' service integration ' was defined in evaluations of ICPs ; the type of evidence utilised in measuring the impact of the intervention and the weight of evidence to support the effectiveness of care pathway technologies on ' service integration ' . Studies that made an explicit link between ICPs and service integration were included in the review . Evidence generated from r and omised controlled trials , quasi-experimental , qualitative and health economics research was sought . The search was limited to publications after 1980 , coinciding with the emergence of ICPs in the healthcare context . Assessment for inclusion of foreign papers was based on the English- language abstract , where available . These were included only if an English translation was available . EXCLUSION CRITERIA This review excluded studies that : • focused only on a single aspect of stroke care ( e.g. dysphasia ) • evaluated ICPs as part of a wider program of service development • did not make an explicit link between ICPs and service integration • did not meet the definition of ICP utilised for the purpose s of the review • focused exclusively on the outcomes of variance analysis SEARCH STRATEGY In order to avoid replication , the Joanna Briggs Institute for Evidence Based Nursing and Midwifery Data base and the Cochrane Library were search ed to establish that no systematic review s existed and none were in progress . A three-stage search strategy was then used to identify both published and unpublished studies ( see Appendix III ) . DATA COLLECTION Our search strategy located 2123 papers , of which 39 were retrieved for further evaluation . We critically appraised seven papers , representing five studies . These were all evaluation studies and , as is typical in this field , comprised a range of study design s and data collection methods . Owing to the diversity of the study types included in the review , we developed a single- appraisal checklist and data - extraction tool which could be applied to all research design s.(32 ) The tool drew on the Joanna Briggs Institute ( JBI ) appraisal checklists for experimental studies and interpretive and critical research , and also incorporated specific information and issues which were relevant for our purpose s ( see Appendix VI ) . This extends the thinking outlined in Lyne et al.(31 ) in which , drawing on Campbell and Stanley 's classic paper , the case is made for developing an appraisal tool which is applicable to all types of evaluation , irrespective of study design . In assessing the quality of the papers , we were sympathetic to the method ological challenges of evaluating complex interventions such as ICPs . We were also cognisant of the very real constraints in which service evaluations are frequently undertaken in healthcare context s. In accordance with the aims of this particular review , we have included studies , which are method ologically weaker than is typical of many systematic review s because , in our view , in the absence of stronger evidence , they yield useful information . DATA SYNTHESIS Given the heterogeneity of the included studies , meta- analysis and /or qualitative synthesis was not possible . A narrative summary of the study findings is presented . RESULTS 1 ICPs can be effective in ensuring that patients receive relevant clinical interventions and /or assessment s in a timely manner , although these improvements may reflect better documentation rather than actual changes in practice . 2 ICPs can be effective in improving the documentation of rehabilitation goals , documentation of communication with patients , carers ( diagnosis , prognosis and follow-up arrangements ) and documentation of notification of primary care physicians of discharge . However , this can create additional burdens of work for staff . 3 Early studies of ICP-managed care in the acute stroke context have demonstrated reduced length of stay without any associated adverse effects on discharge destination , morbidity or mortality . These effects do not reach statistical significance , however , and may reflect wider changes in service provision and a general trend towards reduced length of hospital stay . While later studies in the acute and rehabilitation context s do not reveal any significant reduction in length of stay , they do report greater documented use of certain clinical interventions and assessment s , suggesting that ICPs can be effective in mobilising hospital re sources around the patient . 4 ICPs implemented in the context of acute stroke care can be effective in reducing the occurrence of urinary tract infections , although we do not know whether this can be attributed to improved service integration . 5 ICP management in stroke rehabilitation may not be flexible enough to meet diverse patient needs and can result in insufficient attention to higher-level functioning and carer needs influencing perceptions of quality of life . 6 ICP management may assist in clarifying role boundaries and a shared underst and ing of the work , but this can result in some members of the disciplinary team perceiving that their contribution is not appropriately reflected in the documentation . 7 There is some evidence that ICPs may be effective in changing professional behaviours in the desired direction where there is scope for improvement , but in situations in which multidisciplinary working is effective , their positive effects may be limited . Furthermore , it is far from clear what the active ingredients of ICPs actually are . Kwan et al. suggest that it was the process of ICP development that had most impact on behaviours rather than the use of the artefact per se.(20 ) 8 None of the studies assessed the balance of costs and benefits of ICP  use . Therefore , we do not know whether the costs of ICP development and implementation are justified by any of the reported benefits . CONCLUSIONS Implication s for practice There is some evidence that ICPs may support certain elements of service integration in the context of stroke care . This seems to be as a result of their ability to support the timely implementation of clinical interventions and the mobilisation of re sources around the patient without incurring additional increases in length of stay .  ICPs appear to be most successful in improving service coordination in the acute stroke context where patient care trajectories are predictable . Their value in the context of rehabilitation setting s in which recovery pathways are more variable is less clear . There is some evidence that ICPs may be effective in bringing about behavioural changes in context s where deficiencies in service provision have been identified . Their value in context s where inter-professional working is well established is less clear . While earlier before and after studies show a reduction in length of stay in ICP-managed care , this may reflect wider healthcare trends , and the failure of later studies to demonstrate further reductions suggests that there may be limits as to how far this can continue to be reduced . There is some evidence to suggest that ICPs bring about improvements in documentation , but we do not know how far documented practice reflects actual practice . It is unclear how ICPs have their effects and the relative importance of the process of development and the artefact in use . ( ABSTRACT TRUNCATED PURPOSE To measure the quality of health care services patient satisfaction is used as one of the most important indicators . The study aims to identify factors affecting patient 's satisfaction at primary health care clinics . DESIGN / METHODOLOGY /APPROACH The data was collected during January 2007 and May 2007 through a r and omly-distributed question naire . The question naires were distributed in primary healthcare clinics that represent all heath care regions in Kuwait . A total of 426 completed question naires , out of 500 , were returned result ing in a response rate of 85.2 percent . FINDINGS The majority ( 87 percent ) of the patients responded that the time for communication between physician and patient was not enough . Seventy-nine-percent of the surveyed patients said they would go to the emergency room of the hospital in future if needed instead of going to the primary care clinic . Regarding the quality of the communication relationship between physician and patients most of the patients responded negatively . Exploratory factor analysis identified six factors and reliability of overall scale was found to be 0.61 . RESEARCH LIMITATIONS / IMPLICATION S One limitation to this study was the exclusion of the private sector . ORIGINALITY/VALUE The authors hope that this study identifies areas of dissatisfaction that can be quickly remedied and ensures enhancement in the areas of satisfaction with ongoing attention and emphasis The major strength of a r and omised controlled trial ( RCT ) is the degree to which it can establish a causal relationship between an experimental treatment and the outcome ( i.e. internal validity ) , as r and omisation should ensure that potential confounders are equally distributed over the treatment and control arms . Internal validity in RCTs can be threatened , however , by multiple sources of bias . For example , poor r and omisation procedures ( e.g. failure to conceal allocations until treatments have been assigned ) can lead to selection bias because more high-risk individuals are selected to receive the experimental treatment . There is a range of potential sources of bias in RCTs , and several well-known tools for assessing the risk of bias provide useful overviews of these sources and strategies for reducing them ( e.g. Guyatt et al. , 2011 ; Higgins , Altman , & Sterne , 2011 ) . These tools are also influential : trials scoring high on risk-of-bias assessment s should have a smaller chance on publication and – if published – to be included in ‘ best evidence ’ systematic review s ( Johnson , Low , & MacDonald , 2015 ) , and thus for their interventions to influence policy and practice . Systematic review s suggest that many health behaviour change ( HBC ) trials suffer from a moderate to high risk of bias ( e.g. Oberjé , de Kinderen , Evers , van Woerkum , & de Bruin , 2013 ; Poobalan , Aucott , Precious , Crombie , & Smith , 2009 ) ; more so than , for example , drug trials ( Crocetti , Amin , & Scherer , 2010 ) . Moreover , risk-of-bias scores have been found to explain heterogeneity in effect sizes , especially in trials with subjective outcome measures ( Savovic et al. , 2012 ; Wood et al. , 2008 ) . Since replication studies of HBC intervention evaluations are uncommon , invalid inferences due to bias may not be easily discovered and rectified . Despite these concerns , there has been little attention in the behaviour change intervention literature to the sources and consequences of bias in trials , and to strategies that may be effective in reducing the risk of bias . This paucity of research on risk of bias in HBC trial is in turn reflected in widely used instruments for assessing the risk of bias , such as the Cochrane risk-of-bias tool ( Higgins et al. , 2011 ) , which seems to be mostly based on evidence from non-behavioural trials . The objective of this special issue is to reflect on the evidence , practice s and challenges in relation to reducing the risk of bias in HBC trials . We hope that this special issue will both impact scientific practice ( i.e. enhancing the quality of HBC trial design , reporting and synthesis ) and have an agenda- setting effect ( i.e. inspire people to do empirical research into what sources of bias actually do affect HBC trials , what strategies are effective for mitigating these , and thus what criteria should be used for grading the quality of the evidence of HBC trials ) Background Current evidence on mental health disorders ( MHDs ) in the U.S. elderly home care population is highly varied and limited to the local level . Aim The objective of this study was to examine the prevalence and characteristics of U.S. elders with MHDs on the national level . Methods This is a primary analysis of secondary use data from a 5 % r and om sample of the 2010 National Outcome and Assessment Information Set ( OASIS ) data spanning a 60-day home care session . MHDs included depression , anxiety , substance abuse , psychotic disorders , aggression , and socially inappropriate behaviors and were identified by diagnosis , symptoms , or mental health service order in the plan of care . Logistic regression was used to identify correlates of MHD . Results The final analysis was conducted on records from 28,475 elderly patients with an average age of 79 ( range 65–110 ) . Patients were primarily female , White , Medicare beneficiaries , referred from short-stay acute hospitals , and living with others at home .  Prevalence of MHDs was approximately 40 % ; depression ( 28.0 % ) and anxiety ( 18.9 % ) were common . Factors associated with MHDs were younger age , female , smokers , frail , living alone , referred from psychiatric hospitals , cognitively or sensory impaired , poorer health status , recent history of falls or multiple hospitalizations , and insufficient social support . Only about one third of patients identified with MHD received mental health services during the 60-day home care episode , including psychiatric nursing services and depression interventions . Discussion MHDs are a national health concern in the older U.S. home care population and are common but largely undermanaged . Future research in the home care sector should be aim ed at developing targeted MHD screening and interventional protocol s and training the current workforce , as well as exp and ing the future workforce to improve psychiatric care for the homebound elderly Background Preventive home visits to elderly people by public health nurses aim to maintain or improve the functional status of elderly and reduce the use of institutional care services . A number of trials that investigated the effects of home visits show positive results , but others do not . The outcomes can depend on differences in characteristics of the intervention programme , but also on the selection of the target population . A risk group approach seems promising , but further evidence is needed . We decided to carry out a study to investigate the effects in a population of elderly with ( perceived ) poor health rather than the general population . Also , we test whether nurses who are qualified at a lower professional level ( home nurses instead of public health nurses ) are able to obtain convincing effects . The results of this study will contribute to the discussion on effective public health strategies for the aged . Methods / design The study is carried out as a parallel group r and omised trial . To screen eligible participants , we sent a postal question  naire to 4901 elderly people ( 70–84 years ) living at home in a town in the south of the Netherl and s. After applying inclusion criteria ( e.g. , self-reported poor health status ) and exclusion criteria ( e.g. , those who already receive home nursing care ) , we selected 330 participants . They entered the r and omisation procedure ; 160 were allocated to the intervention group and 170 to the control group .  The intervention consists of ( at least ) 8 systematic home visits over an 18 months period . Experienced home nurses from the local home care organisation carry out the visits . The control group receives usual care .  Effects on health status are measured by means of postal question naires after 12 months , 18 months ( the end of the intervention period ) and after 24 months ( the end of 6-months follow-up ) , and face-to-face interviews after 18 months . Data on mortality and service use are continuously registered during 24 months . A cost-benefit analysis is included . The design and setting of the study , the selection of eligible participants and the study interventions are described in this article . Other included items are : the primary and secondary outcome measures , the statistical analysis and the economic evaluation The Bulletin ’s editorial team has decided to encourage systematic review s. This is an important decision and is to be welcomed . However it is possible that it will not be received positively by all . Some may feel that systematic review s are not suitable for answering wider public health questions , and that the new section will simply result in the publication of systematic review s addressing narrowly focused , clinical questions with a focus on r and omized controlled trials alone.1 There is no reason why this should be so , and there are far too many examples of systematic review s of non- clinical interventions ( including government policies ) , which include non-r and omized studies , to list.2 Systematic review s of qualitative research are also becoming more common.3 Nonetheless misconceptions about the scope and flexibility of systematic review s still surface occasionally and it never fails to surprise me when I stumble across one of these hoary old chestnuts . If it really were true that systematic review s were only for simple , individual-level interventions , systematic review ers working in public health would be very concerned . After all , public health problems require us to draw on complex sets of qualitative as well as quantitative evidence ; and some policy interventions have never been subjected to r and omized controlled trials ( RCTs ) but have been evaluated using other approaches ; everything from controlled and uncontrolled before- and -after studies , to time series analyses , to qualitative methods . In such cases , systematic review s that focused on RCTs alone would have little to say and we would end up producing many “ empty review s ” , which contain no studies at all . These would be undoubtedly quicker to do and quicker to read than the typical systematic review , but would be of limited use for making policy . However this is not the case . In public health we already have a wealth of review s that prioritize RCTs where they are available , but which draw upon a range of other evidence where they are appropriate to answering the review question .2 Take , as an example , transport policies , an important social determinant of health.4 Public health decision-makers have been interested in the effects on health of building new roads for decades , but there has never been a r and omized controlled trial , for obvious reasons . Yet it would make no sense to cl aim that there is no evidence to be review ed ; rather , there have been many controlled and uncontrolled studies that have examined the effects of new roads on respiratory symptoms , injuries , community severance , disturbance and a variety of other outcomes of public health importance . These studies have in fact been systematic ally review ed.5 Many other examples of review s of complex interventions that impact on public health could be given , which appear on the Cochrane Data base and elsewhere,6,7 and such review s are the main focus of the recently-established Cochrane Public Health Review Group . It is also worth noting that both the Cochrane and Campbell Collaboration include increasing numbers of review s that are relevant to low- and middle- income countries,8 though there is a particular need for more systematic review s that consider the effects on equity of the interventions that they include.9 Currently systematic review s have a “ utilitarian bias ” – they tend to be concerned more with the effects on population s and average effects than with distributional effects and impacts in disadvantaged subgroups . It is to be hoped that systematic review s su bmi tted to the Bulletin will routinely consider the effects of interventions on health inequities . The Cochrane Health Equity Field ( http://equity.cochrane.org/en/index.html ) was set up explicitly to further this agenda , to encourage systematic review authors to explicitly assess the effects of interventions not only on the whole population , but on the disadvantaged . So where does this leave non- systematic review s ? Should every review be a systematic review ? This is a difficult question to answer in a short editorial . My own view is that not all review s need to be systematic review s ; there is still a place for review papers that provide a broad overview , and that discuss a range of evidence and make a contribution to wider debates about what might work in particular setting s. However , while such discussion s help place evidence in context and suggest how it may be used , they should not be confused with the evidence -based conclusions of a transparent , scientific review , which systematic ally attempts to find all the relevant evidence , appraises its strengths and limitations in a transparent fashion , and draws that evidence together in such a way that the more robust studies are given greater weight . Finally , the challenges are many . Evidence on interventions to improve public health is in short supply , particularly evidence on social determinants . Systematic review ers therefore face a real challenge in making best use of the sometimes poor , often sparse and usually heterogeneous evidence available to them . It is easy to set narrow inclusion criteria for a review and then sift through the evidence before concluding that there is n’t enough – and what there is , is n’t very good anyway . Such “ evidential nihilism ” is probably not helpful to decision-makers , and public health systematic review ers need to continue to develop new methods and better frameworks within which different types of research evidence can be integrated to inform decision-making . Publishing systematic review s in the Bulletin should give an added impetus to this ongoing work . BACKGROUND Multiple sclerosis ( MS ) is a major cause of chronic , neurological disability , with a significant long-term disability burden , often requiring comprehensive rehabilitation . OBJECTIVES To systematic ally evaluate evidence from published Cochrane Review s of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS ( pwMS ) , to improve patient outcomes , and to highlight current gaps in knowledge . METHODS We search ed the Cochrane Data base of Systematic Review s up to December 2017 , to identify Cochrane Review s that assessed the effectiveness of organised rehabilitation interventions for pwMS . Two review ers independently assessed the quality of included review s , using the Revised Assessment of Multiple Systematic Review s ( R-AMSTAR ) tool , and the quality of the evidence for reported outcomes , using the GRADE framework . MAIN RESULTS Overall , we included 15 review s published in the Cochrane Library , comprising 164 r and omised controlled trials ( RCTs ) and four controlled clinical trials , with a total of 10,396 participants . The included review s evaluated a wide range of rehabilitation interventions , including : physical activity and exercise therapy , hyperbaric oxygen therapy ( HBOT ) , whole-body vibration , occupational therapy , cognitive and psychological interventions , nutritional and dietary supplements , vocational rehabilitation , information provision , telerehabilitation , and interventions for the management of spasticity . We assessed all review s to be of high to moderate method ological quality , based on R-AMSTAR criteria .Moderate- quality evidence suggested that physical therapeutic modalities ( exercise and physical activities ) improved functional outcomes ( mobility , muscular strength ) , reduced impairment ( fatigue ) , and improved participation ( quality of life ) . Moderate- quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation , and interventions that provided information improved patient knowledge . Low-qualitty evidence suggested that neuropsychological interventions , symptom-management programmes ( spasticity ) , whole body vibration , and telerehabilitation improved some patient outcomes . Evidence for other rehabilitation modalities was inconclusive , due to lack of robust studies . AUTHORS ' CONCLUSIONS The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit , although the certainty of evidence varies across the different types of interventions evaluated by the review s. Structured , multidisciplinary rehabilitation programmes and physical therapy ( exercise or physical activities ) can improve functional outcomes ( mobility , muscle strength , aerobic capacity ) , and quality of life . Overall , the evidence for many rehabilitation interventions should be interpreted cautiously , as the majority of included review s did not include data from current studies . More studies , with appropriate design , which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge
Authors ' conclusions There is a paucity of evidence regarding how best to reduce corruption .
Promising interventions include improvements in the  detection and punishment of corruption  , especially efforts that are coordinated by an independent agency .
Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry , internal control practice s in community health centres , and increased transparency and accountability for co-payments combined with reduced incentives for informal payments .
Key messages The review suggests that some strategies to fight corruption in the health sector can have an effect on corruption .
This study shows that these strategies may have led to fewer patients giving their doctors informal payments ( low certainty evidence ) . •
The study suggests that this may have changed doctors ' attitudes about the influence of pharmaceutical companies on their choice of medicines ( low certainty evidence ) . •
We do n't know what the effects of these strategies have on healthcare or people 's health , or if these strategies had any harmful effects .
Background Corruption is the abuse or complicity in abuse , of public or private position , power or authority to benefit oneself , a group , an organisation or others close to oneself ; where the benefits may be financial , material or non- material .
It is wide-spread in the health sector and represents a major problem .
Objectives Our primary objective was to systematic ally summarise empirical evidence of the effects of strategies to reduce corruption in the health sector .
Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence .
The extent to which increased transparency alone reduces corruption is uncertain .
Interventions to reduce corruption in the health sector What is the aim of this review ?
The aim of this Cochrane review is to assess the effectiveness of strategies to reduce corruption in the health sector .
Corruption can occur in any area of the health sector , and happens when people abuse their own position to benefit themselves , their organisation , or other people close to them .
It can take many forms , including bribes , theft , or giving incorrect or inaccurate information deliberately .
It can take money away from healthcare , lead to poorer quality care and make access to healthcare unfair , and often affects poor people the hardest .