How Generalizable Are Findings from a Community-Based Prospective Cohort Study? Extending Estimates from the Adult Changes in Thought Study to Its Source Population.

Background: The Adult Changes in Thought (ACT) study is a cohort of Kaiser Permanente Washington members ages 65+ that began in 1994. Objective: We wanted to know how well ACT participants represented all older adults in the region, and how well ACT findings on eye disease and its relationship with Alzheimer's disease generalized to all older adults in the Seattle Metropolitan Region. Methods: We used participation weights derived from pooling ACT and Behavioral Risk Factor Surveillance System (BRFSS) data to estimate prevalences of common eye diseases and their associations with Alzheimer's disease incidence. Cox proportional hazards models accounted for age, education, smoking, sex, and APOE genotype. Confidence intervals for weighted analyses were bootstrapped to account for error in estimating the weights. Results: ACT participants were fairly similar to older adults in the region. The largest differences were more self-reported current cholesterol medication use in BRFSS and higher proportions with low education in ACT. Incorporating the weights had little impact on prevalence estimates for age-related macular degeneration or glaucoma. Weighted estimates were slightly higher for diabetic retinopathy (weighted 5.7% (95% Confidence Interval 4.3, 7.1); unweighted 4.1% (3.6, 4.6)) and cataract history (weighted 51.8% (49.6, 54.3); unweighted 48.6% (47.3, 49.9)). The weighted hazard ratio for recent diabetic retinopathy diagnosis and Alzheimer's disease was 1.84 (0.34, 4.29), versus 1.32 (0.87, 2.00) in unweighted ACT. Conclusions: Most, but not all, associations were similar after participation weighting. Even in community-based cohorts, extending inferences to broader populations may benefit from evaluation with participation weights.

Virtual urgent care is here to stay: driving toward safe, equitable, and sustainable integration within emergency medicine.

BACKGROUND: Virtual care in Canada rapidly expanded during the COVID-19 pandemic in a low-rules environment in response to pressing needs for ongoing access to care amid public health restrictions. Emergency medicine specialists now face the challenge of advising on which virtual urgent care services ought to remain as part of comprehensive emergency care. Consideration must be given to safe, quality, and appropriate care as well as issues of equitable access, public demand, and sustainability (financial and otherwise). The aim of this project was to summarize current literature and expert opinion and formulate recommendations on the path forward for virtual care in emergency medicine. METHODS: We formed a working group of emergency medicine physicians from across Canada working in a variety of practice settings. The virtual care working group conducted a scoping review of the literature and met monthly to discuss themes and develop recommendations. The final recommendations were circulated to stakeholders for input and subsequently presented at the 2023 Canadian Association of Emergency Physicians (CAEP) Academic Symposium for discussion, feedback, and refinement. RESULTS: The working group developed and reached unanimity on nine recommendations addressing the themes of system design, equity and accessibility, quality and patient safety, education and curriculum, financial models, and sustainability of virtual urgent care services in Canada. CONCLUSION: Virtual urgent care has become an established service in the Canadian health care system. Emergency medicine specialists are uniquely suited to provide leadership and guidance on the optimal delivery of these services to enhance and complement emergency care in Canada.

RéSUMé: CONTEXTE: Les soins virtuels au Canada ont rapidement pris de l'ampleur pendant la pandémie de COVID-19 dans un environnement où les règles sont peu strictes, en réponse aux besoins urgents d'accès continu aux soins dans un contexte de restrictions en santé publique. Les spécialistes de la médecine d'urgence sont maintenant confrontés au défi de conseiller sur les services de soins d'urgence virtuels qui devraient rester dans le cadre des soins d'urgence complets. Il faut tenir compte des soins sécuritaires, de qualité et appropriés, ainsi que des questions d'accès équitable, de la demande publique et de la durabilité (financière et autre). L'objectif de ce projet était de résumer la littérature actuelle et l'opinion d'experts et de formuler des recommandations sur la voie à suivre pour les soins virtuels en médecine d'urgence. MéTHODES: Nous avons formé un groupe de travail composé de médecins urgentistes de partout au Canada qui travaillent dans divers milieux de pratique. Le groupe de travail sur les soins virtuels a effectué un examen de la portée de la documentation et s'est réuni chaque mois pour discuter des thèmes et formuler des recommandations. Les recommandations finales ont été distribuées aux intervenants pour obtenir leurs commentaires, puis présentées au symposium universitaire 2023 de l'Association canadienne des médecins d'urgence (ACMU) pour discussion, rétroaction et perfectionnement. RéSULTATS: Le groupe de travail a élaboré et atteint l'unanimité sur neuf recommandations portant sur les thèmes de la conception du système, de l'équité et de l'accessibilité, de la qualité et de la sécurité des patients, de l'éducation et des programmes, des modèles financiers et de la viabilité des services virtuels de soins d'urgence au Canada. CONCLUSION : Les soins d'urgence virtuels sont devenus un service établi dans le système de santé canadien. Les spécialistes en médecine d'urgence sont particulièrement bien placés pour fournir un leadership et des conseils sur la prestation optimale de ces services afin d'améliorer et de compléter les soins d'urgence au Canada.

Clínicas Integradas em Odontologia, desafios, oportunidades e perspectivas: uma revisão de literatura

As clínicas integradas em Odontologia constituem em um desafio para o ensino superior na formação do profissional, que deverá aprender a tratar as condições orofaciais de seu paciente de forma diferenciada no futuro próximo, aliando cada vez mais a Odontologia e as novas tecnologias. Objetivou-se com este estudo de revisão discutida entender o conceito de clínica integrada e suas perspectivas em consonância com as Diretrizes Curriculares Nacionais. Foi realizado um levantamento bibliográfico sistematizado nos bancos de dados eletrônicos: Lilacs, PubMed e Scielo. Os termos em português e inglês "Educação em Odontologia" (Dental Education), "Clínicas Odontológicas" (Dental Clinics), "Graduação" (Undergraduate Program), "Prestação Integrada de Cuidados de Saúde" (delivery of health care, integrated) e "Currículo" (Curriculum) foram utilizados como palavras-chave. Foram eleitos 23 artigos para esta revisão e extraídas as ideias principais dos textos tendo como base as metodologias utilizadas e os principais resultados. Os autores foram unânimes em ressaltar que as clínicas integradas em Odontologia exercem influência na formação e no preparo do egresso generalista através do treinamento sobre um planejamento global, inter e multidisciplinar como pilar essencial para um currículo integrativo e inovador.

ntegrated clinics in Dentistry present a challenge for higher education in the training of professionals, who must adapt their approach to treating orofacial conditions in the near future, increasingly incorporating Dentistry and new technologies. This review study aimed to comprehend the concept of integrated clinics and its alignment with the National Curricular Guidelines. A systematic bibliographic survey was conducted in the following electronic databases: Lilacs, PubMed, and Scielo. The search employed keywords in both Portuguese and English, including "Education in Dentistry" (Dental Education), "Dental Clinics", "Graduation" (undergraduate program), "Integrated Provision of Health Care" (delivery of health care, integrated), and "Curriculum." Approximately 23 articles were selected for this review, and the primary ideas within the texts were extracted based on the employed methodologies and the principal results. The authors unanimously emphasized that integrated dentistry clinics significantly impact the training and preparation of generalist graduates. This influence stems from emphasizing global, inter, and multidisciplinary planning as an indispensable foundation for an integrative and innovative curriculum.

Integrative nursing in Europe - A competency profile for nursing students validated in a Delphi-study.

BACKGROUND: Integrative nursing is a framework for providing holistic care and includes complementary therapies and non-pharmacological interventions. There is no common European approach on how to educate healthcare professionals on complementary therapies and non-pharmacological interventions for symptom management. Nurses report a lack of formal education as the main barrier to applying integrative nursing. OBJECTIVES: The aim of this study is to develop and validate integrative nursing learning outcomes in a competency profile for bachelor nursing students. METHODS: A two-round Delphi study was conducted with experts on integrative nursing and/or nurse education from eight European countries. The expert panelists rated their level of agreement with learning outcomes in relation to "Knowledge, Skills, Responsibility and Autonomy" on a nine-point Likert scale (1 = strongly disagree/9 = strongly agree) and were invited to add comments in an open text field. The Rand manual's description of levels of appropriateness was used, and experts' suggestions were analyzed thematically and used for reformulating or adding learning outcomes. RESULTS: In the first round, 19 out of 23 experts participated, versus 18 in the second round. In all, thirty-five learning outcomes within the three areas Knowledge, Skills and Responsibility/Autonomy were rated. After two Delphi rounds, twenty-four included learning outcomes were classified as appropriate, with median levels of appropriateness between 7 and 9; none had been classified as inappropriate. The learning outcomes include general knowledge about selected complementary therapies and non-pharmacological interventions, safety, national rules and regulations, communication and ethical skills and competencies for self-care actions and for applying simple evidence-based complementary therapies and non-pharmacological interventions in nursing practice. CONCLUSIONS: The competency profile consist of validated competencies; the high degree of consensus from the expert panelists makes the learning outcomes relevant for structuring a teaching module for nursing students about integrative nursing.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care.

PURPOSE: Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care. METHODS: Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period. RESULTS: After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05). CONCLUSIONS: Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

Why Warfarin Should Be Managed in Primary Care.

For 5 years, our family medicine clinic's physician-pharmacy team managed anticoagulation onsite. Now, against our recommendations and desires as a clinic, anticoagulation at our site is no longer managed by our local interdisciplinary team. Instead, it is being managed by our system's centralized anticoagulation team. Although some may point out that anticoagulation management is one small element of our practice, we believe eliminating this could open the door to other changes to our scope of practice. Anticoagulation belongs in primary care where comprehensive care, ongoing relationships between patients and care teams, and flexible office visit agendas optimize this service.

Dual diagnosis: A systematic review of the organization of community health services.

BACKGROUND: Dual diagnosis (DD), as the co-occurrence of a substance use disorder and a psychiatric disorder, is underestimated, under-diagnosed and often poorly treated throughout the world, although it is highly prevalent in people suffering from a mental disorder. AIMS AND METHODS: This review analyzed 48 studies from a PubMed and PsycINFO databases search, in order to verify the state of the art regarding the organization of community health services for DD treatment. RESULTS: Four macro-themes have been identified: service organization, critical issues, assessment tools and evidence-based interventions. An effective service recognizes the complexity of DD, promotes a common staff culture, and tailors the organization to local needs. The main critical issues in its implementation include the lack of specific staff training, the poor management of resources and the need for greater personalization of care plans, with attention to psychosocial interventions. Integrated service assessment tools can be used as a benchmark measure at the program level for implementation planning and at the national level to affect policy change. The integrated treatment model for DD should also aim to improve access to care and offer treatments based on scientific evidence. It is also evident that the integration of services can improve outcomes but it is not a guarantee for it. CONCLUSION: There is an urgent need to improve networking between mental health and addiction services in order to deal with DD and create new integrated intervention models, paying attention to an approach to the whole person, seen in his/her absolute uniqueness.

Avaliação da atenção primária à saúde para coordenação das redes de atenção / Evaluation of primary health care for coordination of care networks

Introdução: Novas formas de integração dos serviços de saúde têm sido propostas, com base no fortalecimento da Atenção Primária à Saúde (APS), principalmente, por meio de seu atributo de coordenação, colocando-a como um eixo estruturante dos Sistemas Universais de Saúde. Uma das propostas de integração constitui-se na implementação de Redes de Atenção à Saúde, conceituadas como os serviços e ações que intervêm em processos de saúde-doença em diferentes densidades tecnológicas, logísticas e de gestão. Objetivo: Avaliar a capacidade da Atenção Primária à Saúde para coordenar as Redes de Atenção à Saúde. Métodos: Tratou-se de um estudo do tipo transversal analítico, que foi realizado nas Unidades de Saúde da Atenção Primária do município de Porto Alegre, Rio Grande do Sul, Brasil. Foram selecionadas 41 Unidades de Saúde por meio de amostragem aleatória sistemática. A amostra do estudo foi composta por 371 trabalhadores de saúde, selecionados por meio de amostragem por cotas. Para a coleta dos dados foi aplicado o Instrumento de Avaliação da Coordenação das Redes de Atenção à Saúde pela Atenção Primária (COPAS), no período de novembro de 2018 a maio de 2019. Resultados: A idade mediana foi de 39 anos, com um intervalo interquartílico de 32 a 48 anos. O tempo mediano de serviço na APS foi de 6 anos, com intervalo interquartílico de 4 a 10 anos. A fidedignidade do instrumento, avaliada por meio do coeficiente Alfa de Cronbach, demonstrou que todas as dimensões tiveram coeficientes acima de 0,70. Quando comparadas as dimensões do COPAS com os modelos de atenção à saúde (Estratégia de Saúde da Família e Unidade Básica de Saúde Tradicional) não houve diferença significativa entre os escores (p<0,005). Constatou-se o menor escore da dimensão "Sistemas Logísticos" (registro eletrônico, sistemas de acesso e regulação e os sistemas de transporte) em relação às demais dimensões do instrumento. A dimensão "Sistemas de Apoio" (serviços de apoio diagnóstico e terapêutico, sistemas de informação e sistemas de teleassistência) obteve o menor escore na comparação com as Gerências Distritais. O escore global da avaliação da capacidade da APS em coordenar redes de atenção atingiu 60,01%. Conclusões: A análise da capacidade da APS em coordenar as RAS mostra-se relevante no escopo da avaliação em saúde e na implementação do cuidado integrado. Além disso, reafirma o papel central da APS como porta de entrada do sistema de saúde, ordenadora de fluxos dos sistemas de saúde. O estágio de desenvolvimento da APS, classificada como "Condição boa, requer a implementação e utilização de tecnologias da informação, protocolos para regulação dos serviços e garantia de acesso aos serviços de saúde. Essas ações revelam-se necessárias para melhoria do cuidado sequencial e complementar entre os níveis de atenção.

Introduction: Based on reinforcement of Primary Health Care (PHC) it has been proposed recent ways of integrating the health services mainly focusing on the coordination attribute and thus considering it as a structuring axis of the Universal Health Care Systems. As example of integration proposals, the stablishing of Health Care Systems is taken as part of it and also taken into account as services and actions which operate on health-disease processes in different technological, logistical and management densities. Objective: To Assess the Primary Health Care capacity in order to coordinate Health Care Systems. Methods: This is an analytical cross-sectional study, carried out in Primary Care Health Units in the city of Porto Alegre, Rio Grande do Sul, Brazil. Therefore, 41 Health Units were selected through systematic random sampling composed of 371 health workers, selected through quota sampling. The Assessment of the Coordination of Integrated Health Service Delivery Networks by Primary Health Care Instrument (COPAS) was applied as data collecting tool, from November 2018 to May 2019. Results: The median age was 39 years, with an interquartile range of 32 to 48 years. The median length of service in PHC was 6 years, with an interquartile range of 4 to 10 years. The instrument's reliability, assessed by means of the Cronbach's Alpha coefficient, demonstrated that all dimensions had coefficients above 0.70. When the dimensions of COPAS were compared with the models of health care systems as Family Health Strategy and Basic Unit of Traditional Health, no significant difference between the scores (p <0.005) were evidenced. The lowest score of the dimension "Logistic Systems" (electronic record, access and regulation systems and transport systems) was found in relation to the other dimensions of the instrument. The "Support Systems" dimension (diagnostic and therapeutic support services, information systems and tele-assistance systems) presented the lowest score upon being compared with the District Managements. The assessment global score regarding Heath Care Systems reached 60.01%. Conclusion: The analysis of the PHC's ability to coordinate the Health Care Network is relevant in the scope of health assessment and in the implementation of integrated care. In addition, it reaffirms the central role of PHC as a gateway to the health system, organizing health system flows. The PHC development stage, classified as "In a good condition, requires the implementation and use of information technologies, protocols for regulating services and ensuring access to health services. These actions are necessary to improve sequential and complementary care between levels of care.

Taking opioids in times of crisis: Institutional oversight, chronic pain and suffering in an integrated healthcare delivery system in the U.S.

BACKGROUND: Opioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews. METHODS: We interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12. RESULTS: The experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients' relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain. CONCLUSION: We highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.

Mission and service innovation of urban public hospitals in line with the integrated health care ;delivery system / 中华医院管理杂志

The authors reviewed the practice of integrated health care delivery system( IDS) at home and abroad, and based on experiences of collaborations between medical service institutions in Zhejiang province,proposed the strategic positioning,responsibilities and service innovation of urban public hospitals in a regional medical service system. It is held that the direction of China′s health care reform should move towards IDS in the future,and such hospitals should play an active role in the process via integration of its own resource and provide multi-level,diversified services for the regional health care system.

The Cancer Research Network: a platform for epidemiologic and health services research on cancer prevention, care, and outcomes in large, stable populations.

PURPOSE: The ability to collect data on patients for long periods prior to, during, and after a cancer diagnosis is critical for studies of cancer etiology, prevention, treatment, outcomes, and costs. We describe such data capacities within the Cancer Research Network (CRN), a cooperative agreement between the National Cancer Institute (NCI) and organized health care systems across the United States. METHODS: Data were extracted from each CRN site's virtual data warehouse using a centrally written and locally executed program. We computed the percent of patients continuously enrolled ≥1, ≥5, and ≥10 years before cancer diagnosis in 2012-2015 (year varied by CRN site). To describe retention after diagnosis, we computed the cumulative percentages enrolled, deceased, and disenrolled each year after the diagnosis for patients diagnosed in 2000. RESULTS: Approximately 8 million people were enrolled in ten CRN health plans on December 31, 2014 or 2015 (year varied by CRN site). Among more than 30,000 recent cancer diagnoses, 70 % were enrolled for ≥5 years and 56 % for ≥10 years before diagnosis. Among 25,274 cancers diagnosed in 2000, 28 % were still enrolled in 2010, 45 % had died, and 27 % had disenrolled from CRN health systems. CONCLUSIONS: Health plan enrollment before cancer diagnosis was generally long in the CRN, and the proportion of patients lost to follow-up after diagnosis was low. With long enrollment histories among cancer patients pre-diagnosis and low post-diagnosis disenrollment, the CRN provides an excellent platform for epidemiologic and health services research on cancer incidence, outcomes, and costs.

Divergent modes of integration: the Canadian way.

INTRODUCTION: The paper highlights key trajectories and outcomes of the recent policy developments toward integrated health care delivery systems in Quebec and Ontario in the primary care sector and in the development of regional networks of health and social services. It particularly explores how policy legacies, interests and cultures may be mitigated to develop and sustain different models of integrated health care that are pertinent to the local contexts. POLICY DEVELOPMENTS: In Quebec, three decades of iterative developments in health and social services evolved in 2005 into integrated centres for health and social services at the local levels (CSSSs). Four integrated university-based health care networks provide ultra-specialised services. Family Medicine Groups and network clinics are designed to enhance access and continuity of care. Ontario's Family Health Teams (2004) constitute an innovative public funding for private delivery model that is set up to enhance the capacity of primary care and to facilitate patient-based care. Ontario's Local Health Integration Networks (LHINs) with autonomous boards of provider organisations are intended to coordinate and integrate care. CONCLUSION: Integration strategies in Quebec and Ontario yield clinical autonomy and power to physicians while simultaneously making them key partners in change. Contextual factors combined with increased and varied forms of physician remunerations and incentives mitigated some of the challenges from policy legacies, interests and cultures. Virtual partnerships and accountability agreements between providers promise positive but gradual movement toward integrated health service systems.

Consensus group sessions: a useful method to reconcile stakeholders' perspectives about network performance evaluation.

BACKGROUND: Having a common vision among network stakeholders is an important ingredient to developing a performance evaluation process. Consensus methods may be a viable means to reconcile the perceptions of different stakeholders about the dimensions to include in a performance evaluation framework. OBJECTIVES: To determine whether individual organizations within traumatic brain injury (TBI) networks differ in perceptions about the importance of performance dimensions for the evaluation of TBI networks and to explore the extent to which group consensus sessions could reconcile these perceptions. METHODS: We used TRIAGE, a consensus technique that combines an individual and a group data collection phase to explore the perceptions of network stakeholders and to reach a consensus within structured group discussions. RESULTS: One hundred and thirty-nine professionals from 43 organizations within eight TBI networks participated in the individual data collection; 62 professionals from these same organisations contributed to the group data collection. The extent of consensus based on questionnaire results (e.g. individual data collection) was low, however, 100% agreement was obtained for each network during the consensus group sessions. The median importance scores and mean ranks attributed to the dimensions by individuals compared to groups did not differ greatly. Group discussions were found useful in understanding the reasons motivating the scoring, for resolving differences among participants, and for harmonizing their values. CONCLUSION: Group discussions, as part of a consensus technique, appear to be a useful process to reconcile diverging perceptions of network performance among stakeholders.

Does a public single payer system deliver integrated care? A national survey study among professional stakeholders in Denmark.

BACKGROUND: Integrated health care delivery is a goal of health care systems; to date there has been limited information on the integration of medical care in practice. PURPOSE: To examine and compare perceptions of clinical integration and to identify associated strategic, cultural, technical and structural factors. DESIGN AND SETTING: A NATIONAL SURVEY ADDRESSED TO: all county administrative managers (n=15); all hospital managers (n=44); and randomized selected samples of hospital department physician managers (n=200) and general practitioners (n=700) in Denmark. RESULTS: Several initiatives have been implemented in Denmark to integrate care. Nevertheless, most physicians agree that only half of all patients experience well coordinated pathways. Clinical integration is a strategic priority at the managerial levels, but this is not visible at the functional levels. Financial incentives are not used to encourage coordination. The information communication technology to facilitate clinical integration is perceived to be inadequate. CONCLUSION: The scope for improvement is high due to the structural composition of the system. Increased managerial stewardship, alignment of the financial incentives, and expanded use of information communication technology to link sub-organisations will be a way to move the system forward to meet its explicit goal of providing an integrated delivery of services.

A literature review on integrated perinatal care.

CONTEXT: The perinatal period is one during which health care services are in high demand. Like other health care sub-sectors, perinatal health care delivery has undergone significant changes in recent years, such as the integrative wave that has swept through the health care industry since the early 1990s. PURPOSE: The present study aims at reviewing scholarly work on integrated perinatal care to provide support for policy decision-making. RESULTS: Researchers interested in integrated perinatal care have, by assessing the effectiveness of individual clinical practices and intervention programs, mainly addressed issues of continuity of care and clinical and professional integration. CONCLUSIONS: Improvements in perinatal health care delivery appear related not to structurally integrated health care delivery systems, but to organizing modalities that aim to support woman-centred care and cooperative clinical practice.