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Background: Health care systems are increasingly challenged by demographic shifts, rising chronic illnesses, human resource constraints, and growing efficiency demands. Improving both occupational safety and health (OSH) and patient safety (PS) management has been identified as a pivotal strategy to address these challenges. However, there is a paucity of evidence-based methods that support systematic and integrated OSH and PS. In response, the Systematic and Integrated Occupational Safety and Health and Patient Safety Management Systems (SIOHPS) intervention was developed, guided by the Safer Culture Framework and the Medical Research Council (MRC) framework for complex interventions.

Objective: This paper outlines the study protocol for a process evaluation embedded in the SIOHPS trial.

Methods: The process evaluation will use a convergent parallel mixed methods design. The SIOHPS trial is conducted in 13 Swedish hospital settings. Guided by the Consolidated Framework for Implementation Research (CFIR), quantitative and qualitative data will be collected before, during, and after the trial through questionnaires, telephone interviews, focus group interviews (FGIs), observations, the SIOHPS digital tool, and other relevant documentation. In line with the convergent parallel mixed methods study design, the quantitative and qualitative data will be analyzed in a stepwise manner, initially independently from each other, followed by iterative triangulation.

Results: Funding began in January 2023. The development phase was completed in early 2024, and the evaluation phase started in June 2024, with completion planned in early February 2026. Quantitative data collection for two of three clusters (baseline, 4-and 8-month follow-up) is complete, and data cleaning is underway. All qualitative data collected to date have been transcribed. Final data collection forcluster III, including the 8-month survey and FGIs, is scheduled for the end of January and early February 2026. Data analysis will begin in early 2026, with results to be disseminated through publications and conference presentations later in 2026.

Conclusions: The process evaluation will integrate quantitative and qualitative data sources to elucidate the mechanisms through which the SIOHPS intervention influences safety culture, health care worker (HCW) health, PS, and quality of care. This comprehensive approach unpacks the"black box" of the implementationprocess, which will provideanin-depthnuancedpicture of the intervention's effectiveness and valuable insights into scalability and transferability across diverse health care contexts.

Ensuring high vaccination coverage is vital, particularly during a pandemic. While pre-booked appointment letters have shown promise in vaccination campaigns, their effectiveness in specific sociodemographic groups remains to be explored. Our study evaluated the effect of pre-booked appointment letters on COVID-19 vaccine uptake within different sociodemographic groups using a quasi-experimental methodology. In Uppsala County, Sweden, residents born between 1962 and 1971 received pre-booked COVID-19 vaccination letters starting 24 May 2021, while younger residents received SMS prompts for self-booking starting 7 June 2021. Through a regression discontinuity design, we used the intervention cut-off at birth year 1971 to assess the effectiveness of the letters to increase vaccine uptake compared to the SMS campaign. Our analysis included 96 194 individuals born between 1962 and 1981, examining vaccination within 90 days post-eligibility as primary outcome. We investigated effects within sociodemographic groups, assessed household spillover effects, and performed negative control analyses using neighbouring counties. Adults just above the cut-off had an odds ratio of 1.3 (95% CI 1.10-1.53) of being vaccinated than those just below, with a 1.97 percentage point increase (95% CI: 0.45-3.50) from a baseline of 91.95%. The intervention showed effectiveness within most sociodemographic strata. No effects were found in negative control counties, nor were there household spillover effects. Pre-booked appointment letters are effective at boosting vaccination uptake, even in diverse sociodemographic groups. While our findings come from COVID-19 vaccination, they align with evidence from various immunization programs, suggesting that personalized communications can achieve equitable vaccine coverage across different healthcare settings.

Background

Integrated occupational safety and health and patient safety management are essential for addressing the challenges faced by healthcare services today. Developing and evaluating tools that support this work is crucial. This project aims to assess the effectiveness of a structured method for systematic and integrated occupational safety and health and patient safety management systems (SIOHPS). Additionally, the project includes embedded economic and process evaluation. This article presents the overall design of the SIOHPS-project, with a specific focus on the design and evaluation of the (cost-)effectiveness study.

Methods

The project is guided by the Medical Research Council (MRC) framework for complex interventions and is coproduced with key stakeholders. The intervention is designed to support systematic occupational health and patient safety management systems, incorporating both Safety I and Safety II perspectives. It is grounded in safety culture theory and knowledge about team debriefing for learning. The intervention consists of several core components, including targeted education, end-of-shift team debriefings, and support for systematic management. The intervention is supported by a digital tool. A program theory guides the evaluation. A pragmatic stepped-wedge cluster-controlled design (p-SWD) is used, with hospital healthcare units as clusters. The p-SWD includes three steps, with at least four clusters transitioning from the control to the intervention group at each step. A minimum of twelve healthcare units from two different regions in Sweden will participate. The intervention effect will be evaluated using sick leave and quality of care as primary outcomes. Secondary outcomes include safety climate, work environment factors, healthcare worker health, performance, patient safety and quality of nursing care. Primary and secondary analyses are conducted based on intention-to-treat approach. Cost-effectiveness will be assessed using cost-benefit and cost-consequence analyses.

Discussion

The need of methods that integrate systematic occupational safety and health and patient safety management has been emphasized by different stakeholders worldwide. The SIOHPS study has strong potential for nationwide implementation in Sweden to help healthcare organizations address current challenges. Additionally, the project will contribute to existing safety culture theory by exploring the integration of these domains.Trial registrationClinicalTrials.gov Identifier: NCT06398860. Registration date: 2024-04-30.

Introduction: Health and social care systems are constantly undergoing major reforms to meet the rising demands of an increasing proportion of older patients, with many such reforms aiming to improve integration and coordination. The aim of this systematic review was to synthesize the evidence on inter-organizational coordination interventions between hospitals and outpatient (health- and social care) providers for older patients with complex needs during- and after hospital discharge.

Methods: A systematic search of four databases was performed to identify interventions of inter-organizational coordination at hospital discharge for older patients with complex needs. The retrieved literature was analyzed using a narrative synthesis.

Results: Twelve studies were included (seven randomized controlled trials and five non-randomized intervention studies). The most common intervention components were; needs assessments, dedicated care coordinators and multi-professional teams. Findings show that inter-organizational coordination could decrease- or even increase readmission rates, with similar findings for hospital length of stay and mortality. Furthermore, inter-organizational coordination seemed to have a positive impact on quality of life and activities of daily living.

Conclusion: Inter-organizational coordination could potentially reduce health-care utilization and improve quality of life for older patients with complex needs. However, the findings remain uncertain and further research is warranted.

Heart failure poses a significant challenge in healthcare, contributing substantially to morbidity and mortality. The overall aim of the thesis was to investigate how collaboration between different health and social care providers affects hospital readmissions within 30 days among older adults with multimorbidity, with a particular focus on those with heart failure. It investigates the impacts of local and national reforms, and post-discharge care options. Study I explored the effect of heart failure nurses in a Swedish primary care setting on readmission outcomes. Contrary to expectations, the presence of heart failure nurses did not significantly reduce readmission rates. It seems that it might be the role assigned to specific heart failure nurses, rather than simply having this resource that could improve outcomes. Study II evaluated effects of the Swedish Care Coordination Act on persons >65 years with multimorbidity and heart failure. The study found no significant impact on readmission or mortality rates following the implementation of the Care Coordination Act. This suggests that the Care Coordination Act 's structured mandates alone may be insufficient to cater to older persons with more complex care needs, such as those with heart failure. Study III investigated the effect of discharge to a nursing home for older patients with multimorbidity. Discharges to nursing homes resulted in a marked reduction in short-term readmissions and mortality compared to home-based care. The study highlights the central role of monitoring when it comes to older persons with multimorbidity following a hospital admission which may explain why nursing homes offer short time benefits. In the longer term decision-making requires consideration of patient preferences and clinical assessments. Study IV examined healthcare leaders' perspectives on the 30-day readmission indicator. Leaders recognized its widespread use but emphasized the need for more integrated system-level analysis and patient-centered care to achieve meaningful reductions in readmission. They advocated for top-level leadership to set clear goals and ensure system-wide accountability.

Taken together, this thesis identified no positive effects of the local or national interventions, highlighting the difficulty of developing effective policy and interventions to improve post-discharge outcomes for heart failure patients.  Future success may depend on better implementation of coordinated individual plans and concerted efforts across the healthcare system. Patients with the most complex care needs may for instance benefit from dedicated care coordinators responsible for managing and integrating their care.

Background

Heart failure patients tend to experience higher rates of hospital readmissions compared to other ambulatory care-sensitive conditions. In Sweden, the nationwide Care Coordination Act (CCA) was introduced in January 2018 with the goal of improving care coordination resulting in a reduction of readmissions and length of stay. There is insufficient knowledge regarding the effect of this reform on heart failure patients.

Methods

We studied the association of implementing CCA on all cause 30-day readmissions and length of stay for patients over 65 years of age with ICD-50 heart failure. The dataset included all admissions with a primary diagnosis of heart failure among elderly, multimorbid patients between 2015 and 2019. An interrupted time series analysis using hierarchical mixed models with random effects clustered at the hospital ward level was conducted.

Results

A total of 111 414 admissions were included. The average readmission rate for heart failure patients was 26.8 % before and 26.7 % after the CCA. The average length of stay (LOS) was 8.4 days before the CCA and 8.1 days after. Mortality within 30 days was 7.3 % before the CCA and 7.5 % after. There were no significant differences between the periods before and after. In an analysis assessing the overall linear time trend 2 of 21 regions showed a reduction in readmissions and 10 in length of stay.

Conclusions

After the introducing the CCA, no detectable impact was found on readmissions or mortality for heart failure patients, which is in line with previous studies such as those studying the US Hospital Readmission Reduction Program. While no overall association on length of stay could be identified, it was reduced in a number of the Swedish regions. The heterogeneity between regions could be used to understand the specific components needed to achieve reduction of readmissions in future studies.

Objectives The majority of patients with respiratory illness are seen in primary care settings. Given COVID-19 is predominantly a respiratory illness, the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID), assessed the pandemic impact on primary care visits for respiratory illnesses.Design Definitions for respiratory illness types were agreed on collectively. Monthly visit counts with diagnosis were shared centrally for analysis.Setting Primary care settings in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden and the United States.Participants Over 38 million patients seen in primary care settings in INTRePID countries before and during the pandemic, from January 1st, 2018, to December 31st, 2021.Main outcome measures Relative change in the monthly mean number of visits before and after the onset of the pandemic for acute infectious respiratory disease visits including influenza, upper and lower respiratory tract infections and chronic respiratory disease visits including asthma, chronic obstructive pulmonary disease, respiratory allergies, and other respiratory diseases.Results INTRePID countries reported a marked decrease in the average monthly visits for respiratory illness. Changes in visits varied from -10.9% [95% confidence interval (CI): -33.1 to +11.3%] in Norway to -79.9% (95% CI: -86.4% to -73.4%) in China for acute infectious respiratory disease visits and - 2.1% (95% CI: -12.1 to +7.8%) in Peru to -59.9% (95% CI: -68.6% to -51.3%) in China for chronic respiratory illness visits. While seasonal variation in allergic respiratory illness continued during the pandemic, there was essentially no spike in influenza illness during the first 2 years of the pandemic.Conclusion The COVID-19 pandemic had a major impact on primary care visits for respiratory presentations. Primary care continued to provide services for respiratory illness, although there was a decrease in infectious illness during the COVID pandemic. Understanding the role of primary care may provide valuable information for COVID-19 recovery efforts and planning for future global emergencies.

Background

The COVID-19 pandemic has reshaped healthcare delivery worldwide.

Objective

To explore potential changes in the reasons for visits and modality of care in primary care settings through the International Consortium of Primary Care Big Data Researchers (INTRePID).

Methods

We conducted a cross-sectional, retrospective study from 2018–2021. We examined visit volume, modality, and reasons for visits to primary care in Argentina, Australia, Canada, China, Peru, Norway, Singapore, Sweden, and the USA. The analysis involved a comparison between the pre-pandemic and pandemic periods.

Results

There were more than 215 million visits from over 38 million patients during the study period in INTRePID primary care settings. Most INTRePID countries experienced a decline in monthly visit rates during the first year of the pandemic, with rate ratios (RR) and 95% confidence intervals (CI) ranging from RR:0.57 (95%CI:0.49–0.66) to RR:0.90 (95%CI:0.83–0.98), except for in Canada (RR:0.99, 95%CI:0.94–1.05) and Norway (RR:1.00, 95%CI:0.92–1.10), where rates remained stable and in Australia where rates increased (RR:1.19, 95%CI:1.11–1.28). Argentina, China, and Singapore had limited or no adoption of virtual care, whereas the remaining INTRePID countries varied in the extent of virtual care utilization. In Peru, virtual visits accounted for 7.34% (95%CI:7.33%-7.35%) of all interactions in the initial year of the pandemic, dipping to 5.22% (95%CI:5.21%-5.23%) in the subsequent year. However, in Canada 75.30% (95%CI:75.20%-75.40%) of the visits in the first year were virtual, decreasing to 62.77% (95%CI:62.66%-62.88%) in the second year. Diabetes, hypertension and/or hyperlipidemia and general health exams were in the top 10 reasons for visits in 2019 for all countries. Anxiety, depression and/or other mental health related reasons were among the top 10 reasons for virtual visits in all countries that had virtual care.

Conclusions

The pandemic resulted in changes in reasons for visits to primary care, with virtual care mitigating visit volume disruptions in many countries.

Background: The COVID-19 pandemic impacted mental health disorders, affecting both individuals with pre-existing conditions and those with no prior history. However, there is limited evidence regarding the pandemic ' s impact on mental health visits to primary care physicians. The International Consortium of Primary Care Big Data Researchers (INTRePID) explored primary care visit trends related to mental health conditions in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden, and the USA.

Methods: We conducted an interrupted time series analysis in nine countries to examine changes in rates of monthly mental health visits to primary care settings from January 1st, 2018, to December 31st, 2021. Sub -group analysis considered service type (in-person/virtual) and six categories of mental health conditions (anxiety/depression, bipolar/ schizophrenia/other psychotic disorders, sleep disorders, dementia, ADHD/eating disorders, and substance use disorder).

Findings: Mental health visit rates increased after the onset of the pandemic in most countries. In Argentina, Canada, China, Norway, Peru, and Singapore, this increase was immediate ranged from an incidence rate ratio of 1·118 [95% CI 1.053 - 1.187] to 2.240 [95% CI 2.057 - 2.439] when comparing the fi rst month of pandemic with the pre-pandemic trend. Increases in the following months varied across countries. Anxiety/depression was the leading reason for mental health visits in most countries. Virtual visits were reported in Australia, Canada, Norway, Peru, Sweden, and the USA, accounting for up to 40% of the total mental health visits.

Interpretation: Findings suggest an overall increase in mental health visits, driven largely by anxiety/depression. During the COVID-19 pandemic, many of the studied countries adopted virtual care in particular for mental health visits. Primary care plays a crucial role in addressing mental ill-health in times of crisis.

Objective: To understand how the COVID-19 pandemic has impacted sexual and reproductive health (SRH) visits.Design: An ecological study comparing SRH services volume in different countries before and after the onset of the COVID-19 pandemic.Setting: Seven countries from the INTernational ConsoRtium of Primary Care BIg Data Researchers (INTRePID) across four continents.Population: Over 3.8 million SRH visits to primary care physicians in Australia, China, Canada, Norway, Singapore, Sweden and the USA.Methods: Difference in average SRH monthly visits before and during the pandemic, with negative binomial regression modelling to compare predicted and observed number of visits during the pandemic for SRH visits.Main outcome measures: Monthly number of visits to primary care physicians from 2018 to 2021.Results: During the pandemic, the average volume of monthly SRH visits increased in Canada (15.6%, 99% CI 8.1-23.0%) where virtual care was pronounced. China, Singapore, Sweden and the USA experienced a decline (-56.5%, 99% CI -74.5 to -38.5%; -22.7%, 99% CI -38.8 to -6.5%; -19.4%, 99% CI -28.3 to -10.6%; and -22.7%, 99% CI -38.8 to -6.5%, respectively); while Australia and Norway showed insignificant changes (6.5%, 99% CI -0.7 to -13.8% and 1.7%, 99% CI -6.4 to -9.8%). The countries that maintained (Australia, Norway) or surpassed (Canada) pre-pandemic visit rates had the greatest use of virtual care.Conclusions: In-person SRH visits to primary care decreased during the pandemic. Virtual care seemed to counterbalance that decline. Although cervical cancer screening appeared insensitive to virtual care, strategies such as incorporating self-collected samples for HPV testing may provide a solution in a future pandemic.