The coronavirus disease (COVID-19) pandemic leveraged telemedicine worldwide mainly due to the need for social distancing, patient safety, and infection prevention. The Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) was a key reference site in the treatment of COVID-19 severe cases in the country. To continue patient's health care, it became necessary to increase the number of teleconsultations and standardize it institutionally. Herein, we briefly described how the HCFMUSP improved the teleconsultation health care service during the COVID-19 pandemic, highlighting the implementation of important innovations and the throughout standardization process, including patients and professional workflow. We also detailed the methodology used to implement or improve teleconsultation in a medical/multidisciplinary specialty at HCFMUSP. All these efforts made the HCFMUSP reach the goal of converting 15% of all face-to-face consultations into teleconsultations only in 2021. In addition, there were more than 370,000 teleconsultations until the end of 2022. Our experience has shown that having a supporting team, a digital certification process, and the data integration were key factors toward the successful implementation of the teleconsultation services. We believe that progressing toward teleconsultation will improve the population covered by health care services in Brazil, as well as contribute to a reduction of waiting time, and solving costs to health care institutions and patients. We expect this report of our experience in teleconsultation implementation could inspire and guide other health care institutions in the development of telemedicine. The SUS was created in 1988 and is responsible for providing free access to health care services to all Brazilian citizens. It is one of the largest public health systems in the world, covering more than 200 million people. Almost 71.5% of Brazilians do not have any private health insurance, and they rely on SUS for medical treatments, health assistance, and other health care services.5 In this context, telehealth projects emerged, with the purpose of facilitating access to health services, by expanding and speeding up diagnosis and early detection of diseases.6–8In addition, Brazil is a large and diverse country, with vast differences in geography, economic development, and population density, which affect access to health care.9 During the pandemic, teleconsultation favored social distancing, ensuring the safety of all patients involved.8 It also contributed to a significant reduction in the flux of people visiting the HCFMUSP hospital complex.10HCFMUSP provides medical care locally, in the state of São Paulo, but also to people coming from all over the country. For example, it was carried out around 1.3 million outpatient medical consultations in different specialties; 125 thousand emergency services; 11.8 million pathological exams; and 842.4 thousand imaging exams only in 2019.11 Thus, in December of 2022, the Brazilian Federal Government published the law N°14.510, which authorizes and regulates telehealth practices in the country.12 Therefore, we aimed herein at detailing the implementation of teleconsultations in the HCFMUSP, presenting goals and perspectives so far.However, at that time, there was no approved regulation for the practice of teleconsultation in Brazil. While facing a public health emergency of huge proportions, the Brazilian Ministry of Health, in a joint effort, formulated and approved guidelines for the telehealth practice.Instituto do Câncer do Estado de São Paulo—ICESP), the Central Institute , the Children Institute (Instituto da Criança—ICR), Heart Institute (Instituto do Coração—InCor), the Orthopedic Institute (Instituto de Ortopedia—IOT), the Physical Medicine and Rehabilitation Institute (Instituto de Medicina Física e Reabilitação—IMREA), and the Psychiatry Institute (Instituto de Psiquiatria—IPq) and Radiology Institute (Instituto de Radiologia—InRad).The HCFMUSP is composed of eight institutes divided according to the assistance area, including the Cancer Institute  was established. In detail, the “Global Better Health programme—BHP”Among the strategic endorsed areas, there are digital health initiatives, education, and training of health care professionals. HCFMUSP was already projecting and implementing digital health initiatives in the Brazilian public health system at that time. Therefore, HCFMUSP was selected by the BHP program to participate in a consultancy process by a third-party company to map those initiatives and help the hospital complex to implement and mature the ongoing digital health projects. In this partnership, 20 digital health solutions were proposed , aiming The first step included carrying out a proof of concept for teleconsultations. For this, the board of directors of the HCFMUSP, together with the Digital Health Board verified the capacity to perform teleconsultations, mapped the eligible specialties, as well as the current structure and the equipment needed, and then chose a “Focal Point” from each medical specialty responsible for implementing the initiative.Basically, “Focal Point” is defined as an institutional leader of a medical specialty who is responsible to report the state of the digital health implementation process in his field at the designated institute of HCFMUSP. The teleconsultations occurred preferentially by videoconferences. As a management strategy, weekly meetings were scheduled with the focal point to monitor the status report of the implementation of the teleconsultations and to adjust it according to each medical specialty.14 This decision was driven by concerns related to controlling the security and privacy of patient data within the HCFMUSP, but also ponder over the costs involved in the acquisition of a commercially available platform. By using a platform developed in house, the institution could ensure that all data registered in the services were stored securely and not shared or manipulated by third parties. This is extremely important in health care, where sensitive personal data, test results, and patient diagnoses must be kept confidential.The standardization of the teleconsultation process involved the development of an institutional platform for teleconferences (iConf).iConf offers a range of features that are useful for teleconsultations, including audio and video sharing, allows sharing presentations with extended whiteboard functionalities, such as pointer, zoom, and drawing tools, as well as public and private chat, screen sharing, and voice channels over the network with Internet Voice Over Internet Protocol (VoIP). The platform supports the presentation of documents in PDF and Microsoft Office formats, which is also a helpful feature for clinicians to share information with patients during a teleconsultation.iConf platform was developed to provide real-time communication capabilities for telemedicine sessions through a standard Hypertext Mark-up Language user interface. Therefore, the platform is supported by many web browsers like Google Chrome, Firefox, Opera, and Safari. All communication between participants is encrypted using the Secure Socket Layer protocol. In addition to these features, the iConf also allows recording of telemedicine sessions, which can be useful for auditing and traceability purposes, as it allows health care providers to review past sessions and maintain records of patient care.iConf is allocated in two web pages/mobile apps, named “Patient Portal” and the “HC at Home,” which were developed specifically to facilitate the patients' and health care professionals' access to the patient's journey, respectively. These web pages/mobile apps hosted information regarding scheduled consultations and exams, exam results, prescriptions, and an instruction guide. They also have a “teleconsultation tab,” where the patients and health care professionals can visualize the scheduled teleconsultations and access the video conference room.In addition, for the patient to access the iConf system, they need to agree on the institutional terms of free and informed consent; otherwise, their admission to the videoconference room was blocked. After completing the teleconsultation, the patient received a satisfaction survey to answer about our service. This strategy allowed us to periodically verify the quality of the services provided through the teleconsultation aiming at its improvement.Behind the teleconsultations, there was a multi-professional supporting team responsible for scheduling the teleconsultations, including send an appointment reminder to the patient on the day of the teleconsultation. In detail, an iConf link was sent to the patient before the teleconsultation, which allowed them to test their access to the platform and to provide individualized support in case of any technological issue arise. There was also a Technology Information (TI) department responsible for maintenance of computers and system operations, and to allow the virtual environment ready for the teleconsultation.The HCFMUSP decided to create a “Digital Certification Process” to guarantee the teleconsultation in a secure and efficient virtual environment. For this, several measures were defined and validated, which included the use of the two institutional web portals  for registered patients and health care professionals, individual security keys for the health care professionals involved in the teleconsultation and required for releasing electronic prescriptions, and for using electronic systems for handling medical records and for digital scheduling.One important ongoing step is the teleconsultation data integration. For this, the HCFMUSP TI department developed a unified dashboard that assemble and compile information and indicators to be evaluated, allowing a proper visualization of the teleconsultation implementation and help monitoring the process. In detail, the data compiled of each institute in the designated dashboards allowed the visualization of the number of teleconsultations performed, the absenteeism rate, the average time of teleconsultation, the type of service employed , and the results obtained from the satisfaction survey.15 At the HCFMUSP, medical specialties verified the need to start the implementation of teleconsultation practices.The process for implementing teleconsultation at HCFMUSP was designed by considering that digital transformation initiatives require changes in the mindset of health care professionals, as well as in the institutional values and principles.As the demand increased, the recently created Digital Health Board started to manage and organize the individual teleconsultation initiatives, to improve and standardize the practice across the whole hospital complex. Briefly, new recruited support professionals received an onboarding training in good practices in telehealth using institutional standardized guidelines created with the purpose to help them get their first steps in the teleconsultation.16Hands-on workshops were performed at the HCFMUSP to help implement teleconsultation in the institutes of pre-determined medical specialties. The content of the workshops included the introduction of good practices in telehealth, the national regulation on telehealth and the respective bill, as well as practical training activities in teleconsultation.In addition, to optimize the teleconsultation process, the HCFMUSP prepared a manual for patients and health care professionals, explaining in detail the teleconsultation procedures and its importance.In regard to the content of the bill covered during the workshops, it provides guidance on the autonomy of the health care professionals involved in the telehealth activity, the formal agreement at disposal of the patient, the right for refusal for both parts and replacement for face-to-face consultations, the imbued values in health care assistance and treatment, and the confidentiality of the patient's data. In addition, HCFMUSP produced an online asynchronous training on digital health with 20 h of duration, and fully dedicated to all health care professionals requiring qualification in the topic.Focusing on the workshops and meetings, they were designed aiming at the engagement of health care professionals in the development and in the decision-making process for a rapid teleconsultation implementation in the most demanding medical specialties of HCFMUSP. For this, a decision tree strategy helped define patient eligibility criteria and guide the overall teleconsultation implementation process.The workshops resulted in the definition and selection of additional focal points responsible for sharing the decision tree with other professionals within the medical specialty and to adjust it in their work routine. Follow-up meetings were held to ensure the decision tree's feasibility and to collect feedback, updates, and status reports. In addition to the improvement of the teleconsultation workflow in the medical specialty, the workshops allowed to increase the health care professional's perception of the benefits in adopting digital strategies, and bringing digital health and remote assistance to patient care.This was an important goal, as digital technologies can greatly enhance health care delivery and improve the patient outcomes. By involving health care professionals in the development and implementation of digital health strategies, the workshops increased the professional's adhesion and facilitated technological integration into clinical practice.The conversion from face-to-face consultation into teleconsultation depends on several factors, including the particularity of each medical specialty, the patient profile, the available infrastructure, and the technological capacity. The experience acquired by the HCFMUSP professionals in digital health affairs allowed us to figure out some essential patients' eligibility criteria to perform teleconsultations. The patient must stay in a private room with a stable internet connection. If the patient is under 18 years old, elderly, or with any type of visual, hearing, or motor difficulty, the presence of a companion to assist at the time of the teleconsultation is important.The journey of the patients and health care professionals involved in the teleconsultations can be seen in The ambitious endeavor of HCFMUSP is implementing, optimizing, and expanding the health care assistance in the Brazilian public health system, leading the institution setting the goal of converting 15% of face-to-face consultations into teleconsultations by 2021. As a result of this institutional effort, this goal was reached in 2021, considering a sum of all teleconsultations performed in the entire institution. The multi-professional specialties  showed a higher conversion rate when compared with medical specialties. We verified that medical clinic was the specialty with the highest adherence to the teleconsultation practices among all available medical specialties at the HCFMUSP.By the end of 2022, 52 workshops with a digital health and teleconsultation scope were performed, totalizing more than 100 working hours and involving more than 215 health care specialists. Also, more than 2000 health care professionals were certificated for electronic prescriptions. These efforts resulted in more than 370,000 teleconsultations, including more than 180,000 registered patients and 11,322,144 virtual interactions through the Patient Portal by the end of 2022.17The Net Promoter Score (NPS) was used to evaluate the patient's satisfaction with the HCFMUSP teleconsultation service. To briefly introduce the concept, the NPS is a measure of customer loyalty developed by Reichheld in 2003. This metric assumes that customers are either promoters (80–100), defined as satisfied users or detractors (0–60), unsatisfied users. These metrics can be used as indicators for qualifying service according to customers' feedback.According to our metrics, a 58 NPS was obtained in the end of 2022, indicating a good acceptance with the patients' HCFMUSP assisted. In detail, 69% gave positive feedback in regards to the easiness and quality offered by the virtual platform, 69% also approved the option to have online prescriptions, 71% answered that their expectations were matched with the teleconsultation service, and 74% approved the work done by the digital health TI team.We estimated that more than $500,000 were saved by the patients in travel costs, considering round trips via public transport. This value could be even higher if indirect costs were considered, such as absence of working days, food, supplies, and security. We achieved this estimated amount by multiplying the number of teleconsultations performed in 2022 by the minimum value spent by the patients in round trips to health centers for face-to-face consultations, and we then divided this number by the dollar quotation on that time.Overall, the process to implement the teleconsultation service at the HCFMUSP faced several challenges. Among them, we highlight the traditional institutional culture and the reluctance in adopting the new telehealth practices, slowing down the implementation process.We found that educational workshops held at the HCFMUSP were essential for convincing institutional leaders by demonstrating a governance strategy focused on Digital Health and Telemedicine approaches, which helped quicken the implementation process and shape a new institutional culture. In addition to these joint actions, guided weekly virtual meetings among the institutes facilitated their integration during the teleconsultation implementation process.Other relevant actions taken involved the investment and the development of a devoted infrastructure for the teleconsultation practices. For example, the feasibility study to create adapted spaces for different medical specialties to assist patients during the teleconsultation and facilitate the institutional adherence. The data integration among the institutes represented another important challenge to standardize the process; however, we overcame this by the implementation of the digital certification process across all the institutes.One of the current challenges we are facing is to attract funds to expand the teleconsultation process in some of the HCFMUSP institutes and increase the services provided to other health care institutions. Therefore, we are tackling this challenge by developing and testing strategies to attract investment from partners, either from the private sector or from public funds available for the national health care system.Besides the promising results we have had so far, the standardization and implementation of the teleconsultations in the HCFMUSP is still an ongoing process. We noticed the need to increase the workforce and its qualification to continuously improve and expand the provided telehealth practices for the public health system, and then help to create a broad digital health culture among health care professionals and patients.In addition, from now on we intend to introduce new technological solutions, such as telemonitoring strategies, to improve the patient's follow-up. We expect this new initiative will favor the teleconsultation by increasing the services provided and reducing even more the necessity of face-to-face consultations.Our experience demonstrated good acceptance and satisfaction of patients with teleconsultations services. The availability of a support digital health team was essential to make teleconsultations feasible, as well as to provide individualized attention to the patient's technological needs. In addition, the digital certification and data integration in digital informative dashboards were decisive steps to conclude on the teleconsultation implementation cycle, contributing to decision making and better planning and improvements in the implementation processes.The perspective of the HCFMUSP is to completely overhaul the patients' journey by implementing digital health practices supported by multi-professional health care, and then create a complete digital health care line and eliminate unnecessary face-to-face consulting and long and costly patient hospital trips.We believe that a mature teleconsultation service provided by the HCFMUSP will lead to an increase of population covered by specialized health assistance, including economically deprived regions of this vast country, and contribute to an even fairer Brazilian health system. Finally, we expect that HCFMUSP experience, shared in this work and future reports, can help countries in the development to consider implementing telehealth solutions as a public health strategy.


Background: Enhancement of diversity within the U.S. research workforce is a recognized need and priority at a national level. Existing comprehensive programs, such as the National Research Mentoring Network (NRMN) and Research Centers in Minority Institutions (RCMI), have the dual focus of building institutional research capacity and promoting investigator self-efficacy through mentoring and training. Methods: A qualitative comparative analysis was used to identify the combination of factors that explain the success and failure to submit a grant proposal by investigators underrepresented in biomedical research from the RCMI and non-RCMI institutions. The records of 211 participants enrolled in the NRMN Strategic Empowerment Tailored for Health Equity Investigators (NRMN-SETH) program were reviewed, and data for 79 early-stage, underrepresented faculty investigators from RCMI (n = 23) and non-RCMI (n = 56) institutions were included. Results: Institutional membership (RCMI vs. non-RCMI) was used as a possible predictive factor and emerged as a contributing factor for all of the analyses. Access to local mentors was predictive of a successful grant submission for RCMI investigators, while underrepresented investigators at non-RCMI institutions who succeeded with submitting grants still lacked access to local mentors. Conclusion: Institutional contexts contribute to the grant writing experiences of investigators underrepresented in biomedical research. In order to address the current health disparities and improve minority health outcomes so as to improve overall population health, increased effectiveness of the research workforce is essential ,2. EnhanFocusing on the diversity of the biomedical research workforce and taking a comprehensive systemic approach , severalThe RCMI program was established by the U.S. Congress in 1985 to serve an integral role in the accelerated representation of underrepresented groups in biomedical and health disparity research. The program is currently administered by the National Institute on Minority Health and Health Disparities (NIMHD) and is tasked with strengthening research training, conduct, and infrastructure in minority-serving colleges and universities with the goal of developing a cadre of independent investigators from groups traditionally underrepresented in research ,18,19,20RCMI efforts specific to investigator development aim to create a supportive career development environment for postdoctoral fellows, junior faculty, and other ESIs to conduct research, with particular support for women, people with disabilities, and those from underrepresented racial and ethnic groups . FurtherRCMI capacity-building programs provide an opportunity for the improved coordination and leveraging of resources across all RCMI and interinstitutional collaborative partnerships . HoweverNRMN is a more recent NIH initiative that was established in 2014 as a trans institutional project, funded by the NIH Common Fund and managed by the National Institute of General Medical Sciences (NIGMS). NRMN seeks to increase access to mentoring across career stages, improve mentoring relationships through training, increase access to resources and career development, and promote the value of mentoring to the science community ,15. SpecIn addition to mentoring, ESIs require coaching to model successful grant-writing practices. Although many grant writing programs exist, because of the competitive nature of this process, their design and preparation require extensive time and effort that frequently extend well beyond the parameters of any such program ,13,14,15In our study, we investigated the results of participation in grant writing coaching by investigators underrepresented in research from RCMI and non-RCMI institutions to answer the following research questions:RQ1: What combinations of individual and institutional factors predict the successful NIH grant application by investigators underrepresented in research?RQ2: What combinations of individual and institutional factors predict the failure to submit an NIH grant application by investigators underrepresented in research?RQ3: To what extent do the individual and institutional factors that affect grant writing outcomes differ for investigators from RCMI and non-RCMI institutions?A qualitative comparative analysis was used to address the research questions of this study.Briefly, qualitative comparative analysis (QCA) is a mixed-method approach that investigates qualitative and/or quantitative data for a set of cases to identify the combination of factors that explain the presence or absence of an outcome of interest ,24. QCA equifinality assumption recognizes that more than one combination of factors may lead to the investigated outcome [unifinal focus would result in identifying the average years of training, average number of publications, and average number of courses taught to describe the factors predictive of appointment to a faculty position. Second, conjunctural causation assumes that an individual factor may not be sufficient to produce an outcome, but that it needs to be investigated in combination with other factors [QCA is guided by three assumptions. First, the  outcome . To illu factors . In the  factors . For exaData for this study were collected from applications and surveys completed by participants in the NRMN Strategic Empowerment Tailored for Health Equity Investigators (NRMN-SETH). We have previously reported on the overall design of the NRMN-SETH program. Briefly, this program was offered to five cohorts of early-stage and new investigators to support them in developing and submitting an independent NIH grant application. Participation for the last cohort had not concluded at the time of writing this manuscript; therefore, application and outcome data for cohorts 1–4 were included in the analyses. In total, the records of 211 participants enrolled in grant writing cohorts 1–4 were reviewed for inclusion in the analysis. The inclusion criteria were (1) position of an assistant professor , and (2) belonging to a group underrepresented in biomedical research /Hispanic, American Indian/Alaska Native, Native Hawaiian, or Pacific Islander OR reporting a disability status OR identifying as a first-generation college graduate), which resulted in the inclusion of 79 early-stage, underrepresented faculty investigators from RCMI (n = 23) and non-RCMI (n = 56) institutions. Summary information about the participants is presented in The inclusion of explanatory factors in the QCA analysis is guided by prior research and theory. For our study, we were guided by the logic model of the NRMN-SETH program, which that considers the combination of personal characteristics, such as demographics, academic position, and self-efficacy of research, as well as research environment, such as institutional support and access to mentors. The following factors were included in the analyses: RCMI or non-RCMI home institution (RCMI); perceived high or low level of institutional support (support); availability of access to a mentor at home institution (mentor); availability for high (over 16 h/week) or low (15 h/week and less) time commitment to grant writing, determined from the population mean (effort); high (15 and more papers) or low (under 15 papers) research record at the time of the NRMN program participation, determined as the number of publications below or above the NRMN-SETH population mean (record); and high (four or more courses per year) or low (three or fewer courses per year) (teaching). We looked at the submission of an NIH grant as the outcome of interest (submit). All data were converted and presented as a truth table with conditions coded as 1 or 0 for crisp-set QCA ,28.The results of the analyses presented below use a standard QCA notation, where capital letters  indicate that the presence of a factor  explains the outcome, and small letters  indicate that the absence of a factor  explains the outcome. The combination of contributing factors  is represented by an asterisk, ‘*’.RQ1 focused on identifying the combinations of factors that contribute to successful grant submissions by investigators from RCMI and non-RCMI institutions that are underrepresented in biomedical research. Five combinations of factors (For investigators from non-RCMI institutions (rcmi), institutional support, access to mentoring, committed grant writing effort, and research record were identified as consistent factors explaining the success in submitting grant applications. Interestingly, the lack of mentoring, rather than its availability, was the explanatory factor. Committed effort and research record emerged as counterfactors, and, similar to the RCMI investigators, a high teaching load was associated with low perceived institutional support.RQ2 focused on identifying the combinations of factors that explain the failure to submit a grant application. Similar to RQ1, home institution RCMI or non-RCMI was a contributing factor, which indicates that the experiences of investigators at these two types of institutions varied  emerged as a persistent predictive factor in all outcome configurations, signaling that home institution as a condition carries an explanatory role in explaining the differences in ESI investigator experiences. Combinations in which the home institution condition appeared in the analyses provide additional insights into the pathways to grant submissions for investigators underrepresented in biomedical research. Most notably, the analyses showed that for the investigators at the RCMI institutions, access to a local mentor contributed to the success in submitting a grant application, while investigators at non-RCMI institutions needed to overcome the challenge of not having access to a local research mentor.The objective of this study was to understand the combination of factors that affect the success of ESIs in submitting a grant proposal. It is also essential to recognize that ESIs in biomedical sciences at all research institutions experience a variety of pressures from institutional and departmental leaders to submit grant proposals. Institutions and departments often have specific funding goals that they want to achieve, and they may encourage or even require ESIs to submit grant proposals to help meet those goals. ESIs are often expected to produce research output at a high level, and grant funding is one of the key metrics through which research productivity is measured. Institutions and departments may pressure ESIs to submit grant proposals to ensure that they meet research expectations. It is not uncommon for academic institutions to state the goals for faculty research productivity in expected level of funding and effort coverage, and these expectations can also be linked directly to faculty performance evaluations and progress toward tenure and promotion. Therefore, grant funding becomes a key metric for ESIs’ career advancement, as it can lead to or stall promotions, tenure, and other professional opportunities. This push for quantitative markers of productivity may also create pressure for ESIs to submit proposals even if they are not fully prepared or have not fully developed their research ideas.Practically, it is important for institutions and departments to develop structures that support ESIs in their grant proposal submissions, while also recognizing the pressures they face. ESIs should have adequate time and resources to prepare their proposals, and institutional and departmental leaders should work to create a supportive environment that encourages risk taking and innovation in research. Additionally, mentoring and training programs should be in place to help ESIs develop the skills necessary to successfully navigate the grant application process. The findings of this study support the following recommendations for developing the nurturing professional development environment for ESI faculty from groups underrepresented in biomedical sciences. First, the department should assign committed research mentors to the ESI faculty rather than leaving the mentor search to the faculty. The lack of mentors will signal to the institutions that additional investments are necessary in the development of the existing faculty. This can often be achieved by providing protected time to senior faculty to signal the recognition and expectation of their role as mentors. Second, this study showed that pre-grant writing publication productivity was a predictor of a grant submission. Therefore, institutions can set up academic writing programs that provide scaffolding for ESIs to publish papers, develop institutional networks, and become acquainted with mentors. Together, these two interventions will likely address the perception of low institutional support, which, as this study showed, also contributes to failed attempts to submit a grant.This study provides fundamental interinstitutional evidence on the individual and institutional factors that affect the rates of grant writing among ESIs, and it has also identified the need to explore additional questions. Future studies are needed to explore the differences in access to mentoring, perceived institutional support, and research cultures by underrepresented investigators at minority-serving and predominantly White institutions. Furthermore, focused investigation on the researcher identity and institutional culture can provide additional understanding about the mentoring networks available to researchers underrepresented in biomedical research. Additional studies are needed to assess the contributions of external developers and mentoring networks to the success of underrepresented investigators. This may also indicate the need for changes or additional considerations in the review criteria of NIH career grants. Currently, the presence of local mentors is a score-generating criterion, whereas the absence of local mentors and lower scores may contribute to lower funding rates for underrepresented investigators. At the institutional level, studies that compare the factors that support grant writing among established and new investigators can provide an understanding of other structural and cultural factors that ultimately contribute to the success of diverse cohorts of biomedical investigators.This article adds to the growing body of literature on the science of biomedical workforce diversity. The achievement of independent grant funding is one of the basic metrics of success for biomedical researchers, but the pathways to this outcome are influenced by a variety of institutional and individual conditions. The qualitative comparative analysis reported in this article provides strong evidence that the research infrastructure created by the RCMI network makes a difference in researcher experiences by providing access to local mentors. Continued investment in and support for the RCMI network is necessary to reduce isolation and diversify the biomedical research workforce.


In South Africa, the population at risk of malaria is 10% (around six million inhabitants) and concern only three provinces of which Limpopo Province is the most affected, particularly in Vhembe District. As the elimination approaches, a finer scale analysis is needed to accelerate the results. Therefore, in the process of refining local malaria control and elimination strategies, the aim of this study was to identify and describe malaria incidence patterns at the locality scale in the Vhembe District, Limpopo Province, South Africa. The study area comprised 474 localities in Vhembe District for which smoothed malaria incidence curve were fitted with functional data method based on their weekly observed malaria incidence from July 2015 to June 2018. Then, hierarchical clustering algorithm was carried out considering different distances to classify the 474 smoothed malaria incidence curves. Thereafter, validity indices were used to determine the number of malaria incidence patterns. The cumulative malaria incidence of the study area was 4.1 cases/1000 person-years. Four distinct patterns of malaria incidence were identified: high, intermediate, low and very low with varying characteristics. Malaria incidence increased across transmission seasons and patterns. The localities in the two highest incidence patterns were mainly located around farms, and along the rivers. Some unusual malaria phenomena in Vhembe District were also highlighted as resurgence. Four distinct malaria incidence patterns were found in Vhembe District with varying characteristics. Findings show also unusual malaria phenomena in Vhembe District that hinder malaria elimination in South Africa. Assessing the factors associated with these unusual malaria phenome would be helpful on building innovative strategies that lead South Africa on malaria elimination. South Africa is one of the countries in the WHO African Region2 affected by malaria and progressing towards elimination. The total population at risk of malaria in South Africa represents 10% or about six million inhabitants4 and is spread over only three provinces  endemic for malaria: Limpopo, Mpumalanga and KwaZulu-Natal7. In addition, malaria is seasonal, with a low transmission (winter) season between June and August and a high transmission (summer) season between September and May of the following year8.In 2021, the World Health Organization (WHO) estimated 247 million malaria cases and 625,000 malaria deaths in 84 malaria-endemic countries. The WHO African Region represented about 95% of malaria cases and deaths4. However, there are challenges to achieving this goal4. Some researchers have differing views on the feasibility of malaria elimination, but generally agree that elimination in South Africa requires, among other things, good surveillance systems, the availability and the use of all effective intervention tools10. Furthermore, as countries, sub-national areas and communities approach the elimination phase of malaria, they are at different epidemiological stages, and therefore, intervention strategies need to be tailored to different regions within a country11. In addition, towards the elimination stage, transmission is generally low and spatially heterogeneous, thus requiring malaria analysis at the local, sub-district or village level12. Malaria transmission is heterogeneous across South Africa’s endemic provinces as showed in several studies14, and progress towards elimination has been similarly variable. Strategies should be tailored to the conditions of each province. Stratification of malaria intensity level is part of the WHO recommendations to accelerate the elimination process15. This stratification involves classifying geographical units according to local malaria transmission11. The aim of this approach is to group together geographical units that have not only similar intensity levels but also similar temporal dynamics.From 2015 to 2019, South Africa recorded between 10,000 and 30,000 cases of malaria per year, and the national Department of Health plans to eliminate malaria  by 202317 based on the functional data method20, was adopted first for modelling the temporal evolution or dynamics of malaria incidence intensity, then, grouping them by similar intensity levels and temporal behaviour (dynamic) over time. The use of functional data method in public health and biomedical fields is discussed in the literature21. The principle of the functional data methodology is that observations (at a regular time lag or not) of a set of geographical units time series  can be modelled by regularised smooth functions  that are estimated with a single smoothing parameter determined from the sample. This allows the understanding of their underlying dynamics and allows the comparison of their trends to each other over time possible, because they will be analysed in the same scale18. Indeed, there was no automatic and objective way to compare thresholds and intensity levels between geographical units as shown in several epidemic studies25. In addition, this method is very useful in the context of the increasing use of sophisticated tools to collect and store large amounts of health data such as the DHIS226. Thereafter, clustering algorithms27 can be applied on these functional data  to identify malaria incidence patterns according to the characteristics of their dynamics . This would help to guide the development and implementation of targeted control strategies in the local context.Therefore, the functional approach16. Then, another study adapted this to stratify and identify malaria patterns at a village scale in Myanmar17. This suggests that this approach is applicable in the context of other endemic countries, such as South Africa.This functional approach consisting of the of the functional data method for modelling malaria evolution of geographical units and to apply clustering algorithm to them for identifying malaria patterns, was first developed to stratify malaria incidence level, and to identify malaria patterns at a village scale in Senegal28, particularly in the Vhembe District, where the malaria incidence in 2018 was 3.8 cases/1000 person-years29. In the literature, no studies have been conducted on malaria incidence at the locality level, the smallest geographical scale in South Africa, due in part to the difficulty of population availability at this scale30. As malaria elimination is approached, a finer scale analysis is needed to accelerate the results. Therefore, in the process of refining local malaria control and elimination strategies, the aim of this study was to identify and to describe the temporal dynamics of malaria incidence patterns at the locality level in the Vhembe District, Limpopo Province, South Africa.In South Africa, the Limpopo province is the most affectedThis study was conducted in 474 localities in the Vhembe District located in the Limpopo Province of northern South Africa Fig. . These lThe period of this study was from July 2015 to June 2018 corresponding to three malaria seasons in South Africa: 2015/2016, 2016/2017 and 2017/2018. In this study it was essential to have for each locality, in addition to the malaria cases, the population to identify the incidence patterns and the geographical coordinates to locate them on the study site.31. A locality is present if at least one of its inhabitants has been diagnosed with malaria during the study period.Confirmed daily malaria cases were collected by the Limpopo Provincial Malaria Programme and stored in their information system32 had population data of some localities from the last census in 2011, but not for all localities. To complete them, others data sources33 and field investigations were used and combined with calculations based on known methods34 for all the years of the study period.To the best of our knowledge, all the studies done on malaria incidence dynamics in South Africa were at municipality, district or province scale, where official population data is fully available at these scales. However, this is not the case at the locality scale, which is the smallest geographical scale. The South African Department of Statistics34. This rate of change per municipality RateMun_ (2001–2011) was based on the last two national censuses of 2001 and 2011.The starting point was the populations from the last national census in 2011. For each locality the information from the home municipality is provided. This was used to make a projection for each locality from 2015 to 2018 with the population growth rate of its belonging municipality corresponding to an average annual geometric variation rate35, and confirmed by field investigations.The missing geographical coordinates for some localities were obtained from the “geoview info” website17. Firstly, the weekly malaria incidence time series of each locality was determined over the study period. In order to have the main trend of their evolution with reducing variability, regularized smooth function  was fitted from each of them with the functional data method20.This analysis was based on an approach well described in37 was performed on these 474 smooth functions through testing different measures of dissimilarity for having the most adaptive among them with the data. These measures of dissimilarity were the combination of temporal correlation and each of among Euclidean distance, Dynamic time warping and L2-metric in different levels of contribution41.Secondly, in order to identify patterns, hierarchical clustering algorithm with Ward’s method42 was performed on some validity indices 43 assessed over the clustering results done with each measure of dissimilarity by considering different potential number of patterns. The final number of patterns was the potential number of models from which a clustering result had obtained the best indices: great DUNN index, small Connectivity index, Silhouette width and percentage of inertia R2 close to 1.Lastly, for identifying the number of patterns, Principal Components Analysis (PCA)45.Statistical analyses were performed using R software . Maps were produced by the authors using QGIS software , OpenStreetMap and Shapefiles downloaded from websitesThe cumulative malaria incidence rate over the 474 localities in Vhembe was 4.1 cases/1000 person-years during the study period, from July 2015 to June 2018  and thin temporal scales (weekly)48. According to the WHO, there is no single intervention or set of interventions that will achieve malaria elimination in all countries. Rather, an arsenal of interventions tailored to the intensity and dynamics of malaria transmission in each country must be identified and used to achieve and sustain elimination. The effectiveness of interventions varies depending on where and when they are applied. In addition, accurate stratification of malaria intensity in local context is essential for effective targeting of interventions.Having data on these thin scales may be difficult in some countries or areas. However, in order to have relevant information for the development of control strategies, it would be necessary to conduct detailed analyses. This requires the implementation and effective monitoring of a data collection system50 as mainly the possibility to model simultaneously a large dataset with high dimension, the possibility to compare the spatio-temporal dynamic of malaria between them while analysing them in the same scale, the possibility to handle missing data or to deal with irregular observation times by working with estimated malaria incidence in real time during the study period, the possibility to appropriately classify malaria time series for clustering geographical units with the same intensities and same temporal dynamics52. Indeed, it is important to capture how malaria incidence evolves over time across localities. Even if two localities have the same level of malaria incidence intensity, they would need different actions due to how they evolve over time. Moreover, the mathematical properties underlying this functional method also allow the analysis of malaria speed and acceleration corresponding to the first and second derivatives of the incidence curves. These derivatives make it possible to determine epidemiological indicators such as the dates of onset, acceleration, peak, slowdown and end of the epidemic54. Although the latter points are not investigated in this study, it was important to show the potential of this method for further analysis.Therefore, the introduction of the functional approach in this framework of epidemiology may be an alternative. Indeed this approach answers simultaneously to a set of technical limits of classical methods46. Depending on the epidemiological realities of the countries, some characteristics would be different like the number of patterns, the temporal and spatial dynamic of patterns and epidemiological indicators17.One of the limitations of this approach, for operational aspects, could be the dispersion of the localities of the same pattern over the geographical space. However, this limitation can be overcome with good local coordination, i.e., at district or communal level, intervention strategies deployed on local targets and well organised priorities5. Generally, malaria cases start to increase in October, peak in January and February, and then decrease around May31. Our results showed that the last period of low transmission (June–August 2017), which was expected to have a very low level of incidence, had a sharp increase especially for the intermediate and high patterns and an unexpected peak around October 2017 in addition to the seasonal peak around February 2018: resurgence occurrence. It would be enlightening in this context to understand the factors that would be associated with the high intensity of incidence during the low transmission period of the 2017/2018 season and the occurrence of the resurgent series. These results open perspectives on the search for potential factors associated with these phenomena. However, several studies56 in South Africa has linked the recent malaria resurgence to climatic variables such as rainfall and temperature, to the mosquito abundance and arrival of new mosquito species. Under suitable conditions, mosquitoes bite more aggressively to produce more eggs, and in the process, transmit malaria faster than usual.Malaria transmission in South Africa is seasonal, with the low transmission period (winter) starting in June and ending in August; and the high transmission period (summer) starting in September and ending in May of the following year57. It has also been established that in South Africa low-lying areas (around 1000 m) are more affected by malaria58, as is the case in the Limpopo River valley and its tributaries. In addition, this northern area borders on the malaria-endemic Zimbabwe and Mozambique59, and imported cases are frequently reported due to economic migration during the rainy season (agriculture)29. In terms of malaria control, South Africa has continued to apply indoor residual spraying as their primary means of control in the country10.Furthermore, the spatial distribution of localities in Vhembe District showed that the further north one goes towards the Limpopo River , the more one encounters malaria patterns with a high level of incidence indicating a spatial trend in malaria incidence. Specifically, the high pattern localities which are along the Mutale, Limpopo and Nzhelele Rivers Fig. . One of 14. The use of these data in this work could help to identify the factors associated with the locality malaria patterns and the dynamic characteristics of the factors associated with temporal increases and decreases (variations) in incidence in these localities. This latter point can be investigated by using functional regression40 that allows finer results on the effects of factors on the dynamic of malaria.Studies have shown the relationship between climatic, environmental, entomological, preventive and social factors on malaria incidence in South AfricaThis study also proposed methodological tools for guiding intervention strategies by targeting priority areas and relevant dates for implementation and highlighted the need of:Improving the data collected at local scale across health information systems,Improving the availability of data population at local scale by official sources,Improving local environmental, economic and social surveillance for better investigating their effect at local scale,Targeting priority areas using malaria patterns,Identifying their dynamic characteristics and the factor effects over time,Additionally, defining and adapting health policies at local scale by:Implementing strategies according to their characteristics and identifying the appropriate times for each malaria pattern to apply the targeted control actions .This study showed four temporal dynamics of malaria in Vhembe District with different characteristics. It also highlighted unusual malaria phenomena in Vhembe District such as a high level of incidence during a low transmission season and the occurrence of a series of resurgence. South Africa has reached the malaria pre-elimination stage, based on the development of access to diagnostics, treatment and vector control. However, the recent resurgence of malaria in remote areas hinders malaria elimination, highlighting the need for assessing the resurgence determinants and developing innovative targeted malaria elimination strategies in keeping with the local and global goals on eliminating malaria.


Neglecting possible growth heterogeneity and focusing only on the overall pattern of prostate cancer mortality rates can result in misunderstandings and incorrect conclusions about the growth process of the outcome. The main goal of this study was to capture the heterogeneity of prostate cancer mortality rates among countries from 1990 to 2019. To accomplish this aim, we performed the Bayesian latent Growth Mixture Model (GMM). In this longitudinal study, Prostate cancer mortality rates data from 1990 to 2019, as well as the Human Development Index (HDI), the Gross National Income (GNI), and the Life Expectancy at Birth (LEB), were obtained from WHO and UNDP platforms. The Bayesian GMM was used to discover homogeneous subgroups and estimate the pattern of prostate cancer mortality rates in each subgroup. The HDI, GNI and life expectancy effects were estimated using a Bayesian conditional Latent Growth Model (LGM). Globally, the intercept and the slope of the Bayesian LGM were equal to 8.77 and 0.19, respectively. The Bayesian GMM classified the 109 countries into four groups, which had significant positive growth patterns with different slopes except for the first class. The effect of HDI was not significant on the overall prostate cancer death rates, but GNI and LEB had a significantly positive effect on the model’s intercepts and a significantly negative effect on the slope. Although the prostate cancer mortality rate increased globally, it has four distinct latent subgroups with various patterns. Additionally, the effects of HDI, GNI, and LEB on prostate cancer mortality rates varied significantly among the four subgroups, indicating a need for further investigation to identify causal factors. Prostate cancer is a challenging disease that represents a major cause of illness and mortality among men and has a significant global impact on millions of individuals . It is tPrevious researches show the occurrence of prostate cancer worldwide is positively associated with the Human Development Index (HDI) and Gross Domestic Product (GDP), which typically results in higher incidence rates in developed countries compared to less developed countries , 5. The Analyzing the patterns of growth in prostate cancer mortality rates over time can offer valuable insights for policymakers to identify and investigate risk factors associated with the disease. There are several statistical techniques that can be utilized to evaluate trends over time. Latent Growth Models (LGM) are a more generalized approach that allows for the inclusion of latent variables in modeling and can handle multiple outcome growth processes . HoweverBased on our literature review, we couldn’t find published research that evaluates the patterns of prostate cancer mortality rates over the past few decades while accounting for the heterogeneity among countries worldwide. Hence, the objective of the current study was to cluster countries into homogeneous subgroups based on the prostate cancer mortality rates pattern by implementing Bayesian GMM on the World Health Organization (WHO) data and using Global Barden of Disease (GBD) dataset as prior information. The findings of the investigation may help to improve our understanding of the trends in prostate cancer mortality rates, and the categorization of countries could provide insights into potential risk factors and guide public health interventions.In this longitudinal study, data was obtained from three international sources—World Health Organization (WHO), Global Burden of Disease (GBD), and United Nations Development Programme (UNDP). The prostate cancer mortality rates data per 100,000 men was obtained from the WHO platform which included 111 countries and territories with thirty time points from 1990 to 2019 . HoweverLatent Growth Models (LGM) are a specific type of Structural Equation Modeling (SEM) that utilize two latent components, known as intercept and slope, to estimate the patterns of a response variable in longitudinal study . The conIn Due to restrictions on using the Maximum Likelihood Ratio (MLR) method for small sample sizes, particularly for clusters, the Bayesian approach was used to estimate the parameters. It is worth mentioning that the Bayesian statistical analysis with non-informative priors was done on the GBD dataset, and then the information used to run the Bayesian analysis on the WHO dataset with informative priors came from the GBD dataset analysis. In other words, the information from two datasets was combined to give us better estimates about the pattern of prostate cancer death rates. In the Bayesian analysis of WHO data, the prior’s distributions regarding intercepts and slopes are assumed to be normal, and the mean and standard deviation are calculated using the GBD dataset.In the first step, the Bayesian LGM with non-informative priors was applied to GBD data, and then the information was used to run the Bayesian LGM with informative priors on WHO data to estimate the overall growth. In the next step, we used Bayesian GMM to classify countries based on their growth patterns. In order to determine the optimal number of classes, the Bayesian GMM was first performed with two classes, and then the number of classes was increased in subsequent analyses until the best model fit was achieved. The best model with appropriate number of classes was determined by using the Entropy criterion which is using for assessing the quality of class membership classification . The ranTo overcome the missing data problem, we used the "longitudinalData" package in the R software that provides functions to estimate missing data in longitudinal studies . Also, MThe overall growth trajectory of prostate cancer mortality rates per 100,000 men from 1990 to 2019 in 109 countries was estimated using Bayesian LGM of WHO data with informative priors from GBD data. Due to the inability of the Bayesian LGM model to account for the heterogeneity in the pattern of prostate cancer death rates across countries during the study period, a Bayesian GMM was employed to identify latent subgroups with distinct growth trajectories. The Bayesian GMM model with four classes yielded the highest Entropy statistic of 0.94, indicating a high-quality classification compared to other models with varying numbers of classes. The findings of the Bayesian GMM model with non-informative priors and four classes are presented in The intercept and the slope of the second class were 2.48 and 0.15, respectively, which indicates 57.8% of the study sample in the second class had the lowest death rates in the initial stage  and then increased linearly by 0.15 persons per 100,000 in each time point from 1990 to 2019. Although the slope of the first class was -0.06 and non-significant, its intercept was 25.61, which is very high in comparison to other classes. It can be concluded that the death rates of the first class was 25.61 persons per 100,000 in the beginning, and there was no significant pattern in the death rates of this class during the study period. In comparison to other classes, the third class had the highest increasing rate, which was equal to 0.51 person per 100,000 men. The last class, which comprised 30 countries, had an intercept of 13.67 and a non-significant slope. Hence, the initial death rate for this class was 13.67 per 100,000 men, and the trend did not change significantly over time. The Bayesian GMM analysis was done with non-informative priors, but after the class membership of each country was determined, the Bayesian LGMs with informative priors were conducted for each class. The results are shown in The results of the unconditional Bayesian LGMs with informative priors, as presented in The results of conditional Bayesian LGM models with informative priors are shown in In this longitudinal study, the Bayesian LGM was utilized to estimate the overall mortality rate trend of prostate cancer in 109 countries from 1990 to 2019. The findings indicated an increasing overall growth trajectory of mortality rates across all 109 countries during the study period. However, the growth pattern of the prostate cancer mortality rate varied among different groups of countries. To explore the variation in growth trajectories of mortality rates among different countries, the Bayesian GMM was employed. The analysis identified four distinct latent subgroups with various intercepts and different growth patterns over time. The observed international variations in prostate cancer mortality rates could be associated with multiple factors, including ethnicity, life expectancy, income, education, the PSA screening program, health-care resources, HDI, and other risk factors such as obesity prevalence , 10, 11.The first subgroup, which includes Switzerland, Norway, Sweden, and the two Caribbean countries of Martinique and Barbados, had the highest mortality rates initially and showed a relatively stable trend over time. Switzerland, Norway, and Sweden are among the countries with the highest standard of living in the world. However, they are also highly ranked in terms of mortality rates for men with prostate cancer , 24, whiThe conditional Bayesian LGM results indicated that the HDI had a positive but non-significant impact on both the intercept and slope of the total data. These results were inconsistent with the previous studies, that have reported a negative correlation between HDI and adjusted mortality rates , 29. TheThe main strength of this study lies in its application of the Bayesian approach to integrate two data sources, (WHO and GBD) in order to estimate prostate cancer mortality rates. Furthermore, this study addressed the heterogeneity in prostate cancer mortality rates through the Bayesian GMM approach and estimated the effects of HDI, GNI, and LEB for each subgroup. Nevertheless, it is important to acknowledge several limitations in our study. The quality and accessibility of the original data in the GBD platform varied between countries, and some data were indirectly estimated using modeling techniques. Another important limitation is the possibility of underreporting of prostate cancer data by the WHO in countries with limited resources. This could lead to an underestimation of the actual mortality rates in these regions, which may impact the accuracy of the findings. Finally, it is essential to acknowledge that the covariates we analyzed exhibited a high degree of correlation. This could lead to multicollinearity, making it challenging to account for the impact of each individual covariate. Thus, caution is warranted in interpreting the results, as there could be other confounding factors that influence the association. It is crucial to keep in mind that a significant association does not necessarily imply causation. Furthermore, there are several variables that we did not consider in our statistical analysis, such as race and ethnicity, percentage of immigrant population, and smoking rate. These factors represent additional limitations of our study.The mortality rate due to prostate cancer has increased globally, but the trend varies between countries. Northern European countries and those in the Caribbean region have recorded the highest mortality rates. Developed countries have consistently high mortality rates, while less developed countries show a rising pattern despite having lower mortality rates. Moreover, the impact of HDI, GNI, and LEB on mortality rates differs considerably among the four subgroups, signifying a need for further investigation to identify the causal factors.S1 Table* Significant at 0.05 level.(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.


Timely diagnosis of oral cancers is critical, and performing biopsies of oral lesions with suspected malignancy is a crucial step in achieving this goal. The waiting time for the diagnosis may be related to the progression and prognosis of malignant neoplasms.The aim of this observational, cross-sectional, national-level study was to identify the factors associated with the waiting time for scheduling an oral biopsy, based on the identification of its need.We used secondary data from the Brazilian public health system, obtained from the 2nd cycle of the National Program to Improve Access and Quality of Dental Specialty Centers (PMAQ-CEO). The study outcome was the waiting time for scheduling an oral biopsy, starting from the identification of the need for the exam. We analyzed individual and contextual variables using multilevel statistical analysis.In 51.8% of DSC the waiting time for scheduling a biopsy was non-immediate; in 58.1% of CEOs, the sum of the weekly workload of dentists working in the Stomatology specialty is up to 20 h per week; in terms of coverage, 67.1% of the CEOs have only municipal coverage and 34.0% are references for up to 12 oral health teams in primary health care; only the coverage variable remained significant in the multivariate model (p < 0.05). Of the contextual variables, none of the variables remained significant (p > 0.05). When these were analyzed together, only the coverage remained significant (p < 0.05);Our analysis indicates that the waiting time for scheduling an oral biopsy is longer in CEOs that cover only one municipality and is not related to contextual factors. Oral cancer represents an important public health problem in Brazil  and worlThe chance of survival from oral cancer – whose average estimate is 50% in 5 years , 6, 7 – Sistema Único de Saúde) is the Brazilian public health system that provides care through multiprofessional teams, including Community Health Agents (CHAs), delivering services to a specific population within a designated territory. In accordance with the National Oral Health Policy , SUS also offers comprehensive oral health care to the Brazilian population [Centros de Especialidades Odontológicas). These comprise the Secondary Oral Health Care , being a reference for the Oral Health teams  of Primary Health Care (PHC), in Brazil mainly represented by the Family Health Strategy . Faced with the diagnosis of malignancy or in the presence of lesions that require a complex surgical-ambulatory approach in the head and neck region, a referral is made to Tertiary Health Care (THC) for treatment and rehabilitation at hospital level [Rede de Atenção à Saúde Bucal ) is constituted in Brazil.The Unified Health System  guidelines [Programa Nacional de Melhoria do Acesso e da Qualidade dos Centro de Especialidades Odontológicas), carried out in 2018, in Brazil [This was an analytical, cross-sectional, epidemiological, national-base study that used secondary data and was reported in accordance with the idelines . This stn Brazil .The PMAQ-CEO was established within the scope of the National Oral Health Policy through Ordinance Number 261/GM/MS, of February 21, 2013, and its main objective was to increase access and improve the quality of CEOs throughout Brazil. Microdata related to module II, which evaluated the work process of the CEOs, were used.The study universe comprised the Dental Specialty Centers that joined the program and answered the external evaluation questionnaire and their respective municipalities. Of the 1097 CEOs operating in Brazil in 2018, 1042 answered the external evaluation questionnaire. Of these, 142 were excluded for not answering the outcome question. Therefore, the final sample comprised 900 CEOs from 745 municipalities in Brazil, which correspond to 82.04% of the total establishments operating in the Brazilian territory in 2018.The outcome established in this study was the waiting time for scheduling an oral biopsy, starting from the identification of the need for the exam. The independent variables were organized into four blocks, according to the adopted theoretical model , as showThe variables used in the study, the way they were treated and the sources from which they were collected are shown in Chart All secondary data were organized in spreadsheets that comprised the researcher’s own database, using the Microsoft Excel program.Descriptive analyses of variables were performed using absolute and relative frequencies, followed by crude analyses of each variable in relation to the outcome. For this purpose, simple logistic regression models were used. The degree of association between the variables was described by crude odds ratios with the respective 95% confidence intervals. Then, a multilevel multiple regression was performed, considering the variables that had p < 0.20 in the crude analyses. In the first step, the contextual effect was evaluated from an empty model, using the intraclass correlation coefficient to verify the part of the total variation that was due to the municipal variables. Subsequently, three models were tested, only with individual level variables (CEOs), only with contextual level variables  and with both individual and contextual levels. In all models, the CEOs were considered nested within the municipalities, since more than one CEO per municipality was evaluated. Based on multiple multilevel models, the adjusted odds ratios were estimated, with their respective 95% confidence intervals. The fit of the models was evaluated using the QICc (Quasi-likelihood information criterion). The analyses were performed using the R program.Data from 900 CEOs from 745 Brazilian municipalities were evaluated. According to the data in Table Table The results of this study indicate that, for a significant part of the investigated CEO, when the need for oral biopsies is identified, these are not scheduled immediately. This is a result that deserves to be registered, considering that the performance of the biopsy is a critical step for the diagnosis of lesions suspected of malignancy. This finding is aggravated by the fact that, between the first and second cycles of the PMAQ-CEO, there was a decrease in the number of establishments that performed biopsies .Once the malignancy is confirmed, the SUS user still faces a series of limitations in terms of access to cancer treatment at the THC level, although there are national laws that ensure a period of up to 30 days for carrying out the necessary tests to confirm cases when the main diagnostic hypothesis is malignant neoplasm ; and, inFrom this perspective, it should be noted that, in more than 60% of the CEO, the histopathological report is available 15 days after the biopsy is performed; however, this period can be as long as two months . An exteThe relationship between PHC and ASSB is important to promote health care. The greater number of appointments in the PHC until the decision for referral to the ASSB and the degree of refinement of protocols, the worse the prognosis and outcomes for confirmed cases of oral and oropharyngeal cancer , 12. In Specific aspects of human resources in the area of Stomatology, the specialty responsible for investigating these cases, may aggravate this situation, considering that in most CEOs investigated in this study, the workload for the specialty was only 20 h per week. In addition, it is plausible to consider that matters related to the infrastructure and availability of materials directly related to the feasibility of performing biopsies in the CEOS  interferAlthough there have been improvements in relation to the registration of users with suspected/confirmed diagnosis of oral cancer between the first and second cycles of the PMAQ-CEO , in 26.6Most CEO were a reference service for only one municipality, which did not guarantee the immediate scheduling of the biopsy exam, since in these establishments, there are 1.46-fold more chances of this scheduling being carried out within a period longer than one day. The CEO that are references for more than one municipality are faster in terms of scheduling the biopsy. In these places, procedural and organizational issues of the RASB, with better attainment of the previously mentioned characteristics, may be related to the better performance of these establishments in relation to the outcome variable.Pre-defined quotas for the PHC eSB to refer users to Stomatology occur in most CEO. Although this suggests the organization of flows and the work process for the reference to the ASSB, it is worth reflecting that, despite the work overload and high demands, there may be stagnation of patients with urgent diagnostic needs in the PHC. In this sense, it is necessary to review strict protocols, considering the community orientation and the sociodemographic characteristics of the territory, so that the diagnosis can be attained within a shorter period of time. Despite the convergence between the PNSB and the National Policy for Cancer Prevention and Control, with the expansion of services in the last 15 years, population coverage remains low. This implies barriers to timely diagnosis and treatment, interfering with the quality of life and survival of users and increased costs for SUS, factors that could be mitigated through the implementation of processes of regionalization and universalization of access .The faster scheduling of biopsies was not related to the contextual variables used in this study. Consequently, it is suggested that this outcome may be related to factors that are proximal to the work process, human, financial and infrastructure resources, or to more specific contextual determinants of the territories in which they are located.This study has limitations inherent to the use of secondary data. Secondary data obtained from national information systems with public and unrestricted access offer numerous advantages, such as broad population coverage and low cost for collecting information. However, as these data are usually collected in routine health services without previous research purposes, the absence of important information for the analyses of interest can represent significant disadvantages .In turn, the quality of information from databases can be assessed in two dimensions: completeness and accuracy. Completeness refers to the extent to which data are missing from the perspective of the outlined research question. Missing data are unavoidable; however, it is often necessary to understand the extent to which important variables are missing and the possible reasons for their absence. Another important dimension is accuracy. Information from electronic system records, such as procedure codes or numeric values, can sometimes be inaccurately recorded . It is nAs future investigation perspectives, our results highlight the urgent need to conduct in-depth studies that can contribute to expanding our knowledge about the critical aspects related to reference and counter-reference procedures in oral cancer care. These studies should consider the overall structure of the RASSB, the experiences of healthcare professionals and patients, and the connections between tertiary care and diagnostic laboratories. Furthermore, we must assess the average waiting time required to obtain the final microscopic diagnosis of diagnosed cancer cases to identify areas of improvement.Another crucial aspect to consider in future research is the training and qualification of Dental Specialties Centers to diagnose oral lesions with suspected malignancy. Given the complexity of this issue, we recommend conducting mixed studies to identify and understand the specificities of care in this context, ultimately leading to implementation studies. By adopting a multidisciplinary approach and examining various factors, we can enhance our understanding of the challenges and opportunities for improving oral cancer care. This will pave the way for developing effective interventions that can benefit both healthcare professionals and patients.The present study provided information on relevant aspects of care for oral cancer in the CEO in Brazil, reinforcing the need to consider it a priority in public oral health policies . In the It was concluded that the waiting time until the scheduling of biopsies is longer in Dental Specialties Centers with municipal coverage only . And we did not identify any significant contextual factors that influenced the waiting time for scheduling biopsies.


Neuroimaging in conjunction with a neurologic examination has become a valuable resource for today's intensive care unit (ICU) physicians. Imaging provides critical information during the assessment and ongoing neuromonitoring of patients for toxic-metabolic or structural injury of the brain. A patient's condition can change rapidly, and interventions may require imaging. When making this determination, the benefit must be weighed against possible risks associated with intrahospital transport. The patient's condition is assessed to decide if they are stable enough to leave the ICU for an extended period. Intrahospital transport risks include adverse events related to the physical nature of the transport, the change in the environment, or relocating equipment used to monitor the patient. Adverse events can be categorized as minor  or major  and may occur in preparation or during transport. Regardless of the type of event experienced, any intervention during transport impacts the patient and may lead to delayed treatment and disruption of critical care. This review summarizes the commentary on the current literature on the associated risks and provides insight into the costs as well as provider experiences. Approximately, one-third of patients who are transported from the ICU to an imaging suite may experience an adverse event. This creates an additional risk for extending a patient's stay in the ICU. The delay in obtaining imaging can negatively impact the patient's treatment plan and affect long-term outcomes as increased disability or mortality. Disruption of ICU therapy can decrease respiratory function after the patient returns from transport. Because of the complex care team needed for patient transport, the staff time alone can cost $200 or more. New technologies and advancements are needed to reduce patient risk and improve safety. Standard of care (SOC) for patients in the intensive care unit (ICU) requires proper diagnosis, baseline measurements, and establishing progression of care so that the patient spends the shortest time necessary in the ICU , 2. ImagIntrahospital transport of the patient to the MRI suite from the ICU and back is time-consuming. It can become costly and dangerous; therefore, the risks to the patient must be weighed carefully by the transport team and treating physician Figures  and 2 1–10.From a patient safety and quality perspective, transport for neuroimaging while the patient is critically ill requires consideration of several issues. First, what is the potential damage or risk to the patient during intrahospital transport? Second, what is the risk to the patient being away from the prescribed SOC in the ICU? Third, how will delays in obtaining imaging impact needed care and extend ICU and hospital lengths of stay? From the physician perspective, the physical findings of a physical exam combined with MRI may serve as a decision point for the best treatment option. Thus, precious time delays in obtaining neuroimaging results are compounded by the wait for a transport team to prepare the patient, obtain a scan, and return the patient to the ICU setting, all of which can take hours. Fourth, what are the potential costs related to neuroimaging and intrahospital transport? Fifth, what are the costs related to the hospital system for adverse events (AEs) during intrahospital transport and how does this disruption impact patient care?A significant challenge while the patient is being imaged in conventional high-field MRI is the patient is physically separated from the nurse who is supposed to monitor the patient during the scan. This results in limited visibility of the patient during the scan, and the nurse may not be able to quickly access the patient if an emergency arises. The potential for life-threatening emergencies increases because the staff is unable to hear any alarms on pumps, ventilators, or other life support equipment. Additionally, there can be a delay in accessing the patient during an emergency because only a handful of people previously cleared can access the patient in MRI. If the patient requires additional support personnel, they will need to be moved to the safest zone to minimize the risk of having to shut down the magnet. Emergency interventions to a patient during a scan can only be performed by personnel who know the direct route to the patient.The evidence that has been collected regarding AEs during transport and in the MRI tends to differ from what is reported at the hospital level because policy requires AEs to be self-reported by staff, which may not occur. The problems with the current SOC and staffing shortages, the evidence of AEs recorded during transport and in the MRI, the risk factors for AEs during transport, risk associated with delay of imaging and delay of care, and the financial implications of these issues are the focus of discussion. Solutions to these problems are not the focus of discussion but are suggested when appropriate and additional research is needed to provide steppingstones for improvement.Globally and more specifically in the United Kingdom and US-based ICUs, the standard patient to provider ratio is two to one; although for specific situations where patient acuity is worse, the ratio can be increased to one to one –16. HoweIn the neurocritical care setting, the ordering physician needs to consider the risk to the patient by choosing a CT scan over MRI. Often the risks to the patient from the CT scan itself are not considered; for example, exposure to radiation from CT scans has been found to increase risk for cancer in adult and pediatric patients but lower risk in 60 year olds , 23. TheThere are numerous risks for ICU patients being transported to the MRI suite that span the patient, staff, and hospital system Figures  and 3 88. The trDuring transport, numerous studies have reported AEs ranging from 22% to 79% of cases  6, 7, 1, 30, 31.2O and treatment modification for transport were significant risk factors. Jia et al. [2) <80, abnormal lactate and glucose levels, heart rate <50 or >110, respiratory rate <12 or >25, pulse oximetry <95, and sedation were significant for multivariate analysis [Several studies have conducted univariate and multivariate analyses to determine the most important risk factors in patients who experience an AE during transport. Parmentier-Decrucq et al.  found ina et al.  found thThe MRI suite itself represents challenges to care related to requirements for modification of ventilation parameters, complex hemodynamic variations, and positional needs for patients with elevated intracranial pressures, as well as limitation of alarm response . There aFor patients with persistent neurological deficit not explained by CT, MRI may provide the information that is critical to determining the next steps. Several studies show that the information obtained via MRI helps improve traumatic brain injury (TBI) outcomes  by informing more intensive treatment –44. It fIn addition to the risks associated with the actual transport of the ICU patient, studies have shown that the patient's condition will worsen because of their removal from the ICU environment and the continuity of care  , 46, 47.A study by Meng et al.  found thCosts associated with ICU patient transport must be evaluated on several levels. First, there is the cost of the imaging itself, which is absorbed by the hospital under fixed, diagnostic-related grouping-based reimbursement. Second, the staff cost of transport to the MRI suite and back to the ICU is on average $352 based on our calculations, but this does not include the cost and staffing differences in high-risk versus low-risk patients and the extra time and staff that may be needed for higher risk patients for transport . Conducting MRI on the evening shift or off-hours incurs an additional cost of $100 for these scans.https://www.in2013dollars.com/Medical-care/price-inflation) increases to $6,255 per injury. Payment methods have changed substantially since 2005 and with the approval of the Affordable Care Act, by becoming more fixed and making it harder for hospitals to bill payers for AE costs while also absorbing more of the AE-related costs. This makes the cost figures from this study very conservative for our estimations; therefore, we assume an average cost of $6,255 per AE borne by hospitals. Adler et al. [Prior to the Affordable Care Act, Mello et al.  evaluater et al.  determinr et al.  (nationar et al.  (ICU-venAdditional parameters that influence costs associated with ICU patients and the daily cost of an ICU day were considered through evaluation of the additional expense of mechanical ventilation. We used the 2003 cost figures shown by Dasta et al.  for the From a patient's perspective, the main objectives for receiving care in the ICU are to reduce treatment delay, length of stay, and morbidity and mortality in the shortest and most efficient manner . FurtherApproximately, 5 million patients are admitted to the ICU annually , and aboCritical care providers require imaging for their patients to provide a diagnosis or rule out life-threatening complications, yet providers must weigh the risks the patient will be exposed to during the transport for neuroimaging and the time away from the ICU. The risks of not obtaining neuroimaging and transporting the patient can cause delays in making critical care decisions that can lead to complications. The provider must balance the information gained from neuroimaging with the risks of transporting the patient and the time spent outside the ICU. When intrahospital transport is initiated, the cost associated with ICU patient transport to the imaging suite is high and could be further reduced with the introduction of new technology, such as a portable MRI machine or care approaches which limit the need for transport and minimizing AEs during that transport estimated to cost the U.S. healthcare system approximately $1.79 billion annually. Further research is needed to support these advancements.