There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact.Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake.Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators.Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient’s journey rather than a phase-specific silo approach to care. Cancer patients utilize a wide range of services from multiple providers across settings at various points during their cancer journey, including oncologists, non-cancer specialists, primary care physicians, nurses, pharmacists, physiotherapists and social workers . Given t12Given the diverse range of providers and settings involved in caring for cancer patients 5, there 68910121371516Existing literature indicates that the use of care plans across a variety of diseases and settings, has helped reduce in-hospital complications 18, enhanIn the absence of consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the key components of integrated care plans, identify facilitators and barriers associated with their use and examine the indicators that have been utilized to assess their impact. Scoping reviews are commonly used to understand the existing breadth of research on a topic, identify gaps in existing literature and assess the need for further research inquiry .A cursory review of grey and peer-reviewed literature was initially conducted to better understand existing terminology and develop a definition of an ‘integrated care plan’ for cancer patients. The definition development stage involved examining systematic reviews and meta-analyses focused on clinical pathways, care plans, critical pathways (and other similar concepts) to assess how these constructs are currently defined in existing literature. Following the completion of this first stage, an initial definition was drafted and feedback was obtained through widespread consultation via a panel of key experts in cancer care, which included healthcare providers, administrators/management and researchers from across the core disciplines represented in the continuum of cancer care . Following the working group consultation an integrated care plan for cancer patients was defined as a:Structured plan of care that engages two or more providers (multi-disciplinary) or is being used in two or more settings that,Involves care planning longitudinally within or across the stages of cancer , andOutlines specific steps/elements of care/mechanisms, with the goal of improving patient, family and/or provider experience, and enabling greater efficiency in care delivery.Following the development and validation of this definition for an integrated care plan by the expert panel, a scoping review was conducted to explore the core components, drivers for uptake, and key outcome measurement approaches involved in the evaluation of integrated care plans for cancer patients. The use of the term ‘integrated care plans’ for this review stems from the focus of this scoping review on cancer patients specifically. The term ‘care plans’ and ‘care planning’ are commonly used in both grey and peer-reviewed literature pertaining to the management of cancer patients 232425. T23242627Key search terms included care map, clinical pathway, care pathway, care plans, patient care planning, critical path/pathway, individualized care plans, patient care plans, advance care planning, or patient care conferences, and cancer or neoplasms, in Medline, CINAHL, Embase, PubMed and HealthStar between March 1995 and March 2015.All study designs were included since scoping reviews do not examine study quality . The folArticles were included if the:Description of the integrated care plan, care/clinical pathway/protocol (or similar terms) maps onto the integrated care plan definition that has been validated by the expert panel.Integrated care plan was being used to manage care in adults with cancer .Integrated care plan was initiated following a cancer diagnosis (screening and prevention were considered to be out of scope for this review).Article reported on either the development process and outcomes and/or barriers and facilitators associated with integrated care plan development and/or uptake.Articles were excluded if:There was no clear definition for the integrated care plan, care/clinical pathway/protocol (or similar terms) or the definition did not align with the proposed definition developed by the expert panel.The integrated care plan was not focused exclusively on organizing and delivering care for cancer patients or involved caring for children/youth with cancer.Neither outcomes nor barriers or facilitators were reported on.Level 1 (title and abstract search) and Level 2 (full-text review) screening was conducted by two independent reviewers (AIK and EA). The data extraction tool was developed and refined by the research team following a testing phase conducted by AIK, EA and VK. Common themes around the key components, facilitators and barriers, and outcome measurement approaches were examined via a thematic analysis  using NV21A total of 1061 articles underwent title and abstract review (Level 1 screening), which resulted in 805 articles being excluded. Following Level 1 screening, 256 articles were included for full text review (Level 2 screening), after which 67 articles were retained for data extraction and analysis. Figure Broadly five types of integrated care plans have been described, based primarily on the trajectory of cancer care: surgical, systemic, survivorship, palliative and comprehensive. Integrated care plans focused on organizing and delivering care during the surgical stage of cancer care were the most common type of integrated care plan (41.8%), followed by integrated care plans focused on survivorship (35.8%) and palliative (13.4%) stages of the cancer journey. Comprehensive integrated care plans, which included a transition from one stage to another, for example from treatment/surgical intervention into survivorship, represented 7.5% of the total. Only 1 article was focused on systemic treatment (1.5%). Most articles discussed the implementation of a newly developed integrated care plan, but some articles described outcomes associated with the use of an existing integrated care plan including the Journey Forward Care Plan  and the Integrated care plans were used to manage care across multiple disease sites including breast, esophageal and colorectal cancer, with the largest proportion of integrated care plans focused on breast cancer (26.9%). Some disease sites were grouped for ease of interpretation, specifically the gynecological cancer category includes cervical, ovarian, vaginal and endometrial cancers. Articles originated from a diverse range of countries including both public and private pay systems. About 40% of articles were based in the United States, followed by the United Kingdom (10.4%) and Canada (10.4%). European countries were also well represented in the total sample with integrated care plans from Denmark, Germany, Italy, Netherlands and Sweden.The medium in which the integrated care plan is delivered, i.e., electronic, paper or combination format, was not indicated for about half of included studies. Approximately 31% of included studies reported the delivery of the plan through a paper medium that providers and sometimes patients had access to, whereas only 9% reported the use of an electronic platform. The combination format ranged from paper copies being posted in the patients’ rooms and an electronic version being added to the patient’s electronic hospital record  to patieThe key themes that emerged from the thematic analysis are organized into five broad categories:Design: Inputs associated with the design of integrated care plans.Components: Core features that were observed across different types of integrated care plans.Outcome measurement: Indicators/instruments used to measure the impact of integrated care plans.Facilitators: Key factors that support the design, uptake and implementation of integrated care plans.Barriers: Challenges associated with the development and use of integrated care plans.These themes are depicted in the integrated care planning for cancer care framework available in Figure Multi-disciplinary teams were at the forefront of designing and implementing integrated care plans. Providers from multiple disciplines were engaged to examine gaps in existing care, which then served as the impetus for developing the integrated care plan . Patient6465384850856294Training for providers/staff on how to use the integrated care plan prior to full-scale implementation was seen as vital to enhancing buy-in around the use of the integrated care plan as a tool to enhance quality of care 34648286879193.8687918265487891Having an implementation point of contact, i.e., a provider tasked with supporting plan uptake, was another key design feature of integrated care plans . This ty5734356176717370Across the various types of integrated care plans, care was organized and delivered by multi-disciplinary teams, involving providers from two or more disciplines. Disciplines represented included physicians, oncologists, surgeons, specialists, and primary care physicians, nurses , pharmacists and allied health professionals such as social workers, speech pathologists, nutritionists/dieticians, as well as respiratory and physical therapists.An assessment of patient needs was observed across the various types of integrated care plans. Within survivorship care plans, psychosocial distress  and qual687050525063The establishment of goals of care that inform activities delivered within the plan was observed in integrated care plans focused on the survivorship or palliative stages of care. Although the nature of goal setting varied considerably. For example, in integrated care plans focused on the palliative stage of care, the provider examines the patient and/or family’s preferences, typically clarifies the goals of care with patients/caregivers, and then generates a treatment plan to align with those preferences . In cont35Organizing follow-up care post treatment was commonly observed in integrated care plans focused on the surgical and survivorship stages of care. Within integrated care plans focused on surgical care, the emphasis was on short-term recovery from the procedure  and scheduling post-operative consultations 505897. W5058Across the different types of integrated care plans there was a strong emphasis on the sharing of information within teams  and across organizations e.g., between hospitals and primary care practices involving hospital staff that are coordinating the discharge and transition of care to family physicians. Information exchange via integrated care plans often included aspects such as cancer type/stage, treatment, prognosis, side effects, medication lists prior to discharge, and follow-up care with oncology providers, surgeons and/or family physicians 3436454851555696.5155567071768039Transitional care planning was another prominent feature especially among integrated care plans focused on the surgical stage of care, and included activities such as discharge planning 485260 an48523656593648555964Symptom or outcome monitoring, i.e., a feedback loop to inform changes to the plan was observed primarily in integrated care plans targeted towards the surgical and palliative stages of care 859192100859192596265773438596061Patient/caregiver engagement by way of involving patients in generating the integrated care plan and accounting for patient (and/or caregiver preferences) featured prominently in plans focused on survivorship and palliative stages 59626378.5962633559The designation of a key point of contact for patients (during and following treatment) was also observed in some articles 536297. T5362425359623640425562Broadly the outcomes used to assess the impact of integrated care plans can be categorized at three-levels: patient, provider and the system-level outcomes. Patient and system-level indicators were commonly reported whereas only a few studies examined provider-level outcomes.Measurement approaches for patient-level indicators were typically drawn from validated tools, i.e., Impact of Events Scale  and the 46636566Commonly observed patient-level outcomes included patient satisfaction, cancer-related distress, patient perceptions of care coordination, patient-reported provider knowledge around the effects of cancer on survivors, perceived knowledge about survivorship  and Heal8774717479808336394041434647484951545556575860616785At a patient-level, the impact of integrated care plans was fairly mixed. Some studies reported improvements in patient satisfaction 52608295,526082657483At the provider-level, there were self-reported improvements in provider capacity to better manage their patients, specifically in the context of symptom burden 90919395,9091933570System-level indicators were measured primarily in integrated care plans that focused on the surgical phase of care. Overall, general trends around changes in outcomes following the use of integrated care plans revealed improvements in system-level indicators, in particular decreased length of stay [34363738414244464750576061343839424457606241Several articles reported on the use of an existing care plan – primarily the LIVESTRONG, Journey Forward or Liverpool Care Plan respectively. Most study designs involving the Liverpool Care Pathway were either randomized control trials or had a comparable control group. One study reported statistically significant improvement in the extent to which patients were treated with respect, kindness and dignity, and the degree to which family emotional support, family self-efficacy, and coordination of care, but found no significant improvements in symptom control . Whereas87Findings associated with the LIVESTRONG Care Plan were mixed. One article reported no changes in patient-reported distress, quality of life, and patient satisfaction , while aFor the Journey Forward Care Plan – one study reported that a majority of respondents found the plan to be very useful . And in Key facilitators that enable and support the development and on-going use of integrated care plans were conceived to occur at three levels:Micro: Patient and provider-level factors that support integrated care plan development and uptakeProvider involvement in plan development and buy-in was a crucial facilitator 84909194,849091Meso: Structural or process elements at the organizational levelA dedicated provider or team that oversees integrated care plan development and implementation by serving as a conduit between providers and organizational management, and advocates for plan uptake was described as an important facilitator 628586. I62857378Macro: Policy-level factors that support the design and uptake of integrated care plansNational oncological care policies that establish or promote standards around treatment guidelines and care management provide a yardstick for quality around patient care  and crea77The barriers associated with use of integrated care plans originated mostly at the provider level and included most prominently limited provider buy-in and a lack of physician leadership 93. In on63855994Inadequate information technology support, specifically limited functionality of the electronic medical record in generating an integrated care plan for survivorship care was an important barrier due to the time and resource costs associated with providers manually entering items from the health record rather than an automated transfer . In addi647378While there is a growing emphasis on the use of care plans to guide the organization and delivery of care for cancer patients, our understanding of the components and key facilitators of integrated care plan uptake is still in its early stages. This review was unable to identify a single integrated care plan that spanned across all stages of the cancer journey from diagnosis through to survivorship or palliative care. From the articles that were included, most integrated care plans appear to be focused on a single stage. Integrated care plans that span across two stages of the cancer journey  represent less than 10% of included articles, indicating that transitions of care have not heavily featured as a core attribute of integrated care delivery for cancer patients, and that this gap requires further exploration 102103. T10218101102Similarities were however noted across the different types of integrated care plans included in this review in terms of the design features and core components observed, indicating the potential to leverage these shared elements to create an integrated care plan that spans across stages of the cancer journey, including key transition points 3.The adoption of an integrated care plan to guide the delivery of care relies heavily on provider uptake and training on how to use the integrated care plan 343943617594. T61753839104Many elements of the integrated care plan development process, including a clear identification of a target population, multi-disciplinary development, sequencing of care activities, and staff training map onto key elements of existing pathway development methodology 106. HoweMany of the patient-level metrics reported across articles reflect indicators and instruments that are increasingly categorized as patient-reported outcome measures in cancer care, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire, Brief Symptom Inventory, Functional Assessment of Cancer Therapy-G, Profile of Mood States, and the Distress Thermometer . Interes6465107108109110Compared to patient and system-level indicators, outcome measurement at the provider level was less robust, with only a handful of studies reporting on provider experiences with using integrated care plans to deliver care. Since providers are core end-users of integrated care plans, uptake relies heavily on provider commitment, and it is surprising to see a prominent gap in the assessment of provider-focused outcomes across different types of integrated care plans included in this review. In addition, findings also revealed limited reporting on process indicators, highlighting the need for greater attention towards developing indicators intended to help understand how integrated care plans affect team functioning  and inform the operational aspects of care delivery as it relates to cancer care.System-level outcome trends emerging mainly from integrated care plans focused on surgical treatment indicate reductions in length of stay [34363738424647505761343839425762456082One of the key limitations of this work is the restricted extent to which generalizations can be made about the impact of integrated care plans in terms of patient, provider and system-level outcomes. Since study quality including sample size and study design was not accounted for, findings represent a description of broad themes observed across articles. In addition the absence of a common and generally accepted definition of an integrated care plan, and a lack of consensus around the attributes of integrated care delivery as it pertains to cancer care, may have narrowed the breadth of articles that were captured in this review. Nonetheless, efforts were made to ensure that the search terms used to guide this scoping review enabled us to capture a wide range of constructs, and the search strategy was validated by the project team and with an external librarian.Another limitation is the inclusion of articles that involved the development and pilot testing of an integrated care plan, as long as the outcomes associated with pilot-testing were discussed in the article, which may not reflect the outcomes or challenges associated with full-scale implementation. In addition, authors often did not report on key operational details  associated with developing and/or implementing integrated care plans. And most studies did not report on patient characteristics (aside from site and stage), thereby the complexity of the patient population including multi-morbidity, socio-economic status, and caregiver support, and its potential impact on the uptake and effectiveness of integrated care plans is hard to quantify.Findings indicate that an integrated approach to care delivery over the course of the cancer journey is still in its early stages. Similarities in design features, core components and key facilitators across the various types of integrated care plans highlight an opportunity to leverage these shared features to move towards developing integrated care plans that span the course of a patient’s cancer journey, rather than a phase-specific silo approach that currently dictates the way care is delivered.Multi-disciplinary teams, iterative development, patient needs assessment, and transitional planning emerged as key features of integrated care plans for cancer patients. Gaps in information technology support, limited physician buy-in as well as time and resource intensity were identified as key barriers to plan uptake, and must be considered at the outset of plan development. In terms of outcome measurement, patient and system-level indicators were robustly assessed, whereas provider-level metrics were less commonly explored and typically did not involve the use of a validated measurement instruments etc. Further exploring how outcomes vary across disease sites and patient sub-groups, and expanding our knowledge base around measuring patient and provider-level outcomes are important next steps to consider. Future work on this topic is warranted, in particular validating the conceptual framework through broader expert consensus, and developing and piloting an integrated care plan in partnership with providers, patients and administrators that work in the cancer system along with other key stakeholders including primary and community care providers.


The San Francisco Health Improvement Partnership (SFHIP) promotes health equity by using a novel collective impact model that blends community engagement with evidence-to-policy translational science. The model involves diverse stakeholders, including ethnic-based community health equity coalitions, the local public health department, hospitals and health systems, a health sciences university, a school district, the faith community, and others sectors.We report on 3 SFHIP prevention initiatives: reducing consumption of sugar sweetened beverages (SSBs), regulating retail alcohol sales, and eliminating disparities in children’s oral health.SFHIP is governed by a steering committee. Partnership working groups for each initiative collaborate to 1) develop and implement action plans emphasizing feasible, scalable, translational-science–informed interventions and 2) consider sustainability early in the planning process by including policy and structural interventions.Through SFHIP’s efforts, San Francisco enacted ordinances regulating sale and advertising of SSBs and a ballot measure establishing a soda tax. Most San Francisco hospitals implemented or committed to implementing healthy-beverage policies that prohibited serving or selling SSBs. SFHIP helped prevent Starbucks and Taco Bell from receiving alcohol licenses in San Francisco and helped prevent state authorization of sale of powdered alcohol. SFHIP increased the number of primary care clinics providing fluoride varnish at routine well-child visits from 3 to 14 and acquired a state waiver to allow dental clinics to be paid for dental services delivered in schools.The SFHIP model of collective impact emphasizing community engagement and policy change accomplished many of its intermediate goals to create an environment promoting health and health equity. The San Francisco Health Improvement Partnership (SFHIP) was established in 2010 to promote health equity by using a novel collective impact model ,4 as catSan Francisco is a county and city under unitary governance, with an ethnically diverse population of about 850,000 residents. It has many health sector assets, including a well-regarded local public health department, a world-renowned health sciences university , highly rated hospitals and health systems, and robust community organizations. Nonetheless, San Francisco has prominent health disparities. For example, hospitalization rates for diabetes are 7 times higher for African Americans and twice as high for Latinos than for whites.We report on policy and community engagement objectives and how they were addressed. Although each of the 3 initiatives specified its goals for population health outcomes, initiatives set their initial sights on intermediate policy objectives that had strong evidence-based links with desired health outcomes. For example, research shows that soda taxes result in reduced consumption of SSBs ; lower cSFHIP evolved in 2 stages: the 2010 to 2013 phase (SFHIP 1.0) and the 2013-to-present phase (SFHIP 2.0). SFHIP 1.0 grew out of discussions among leaders of the UCSF Clinical and Translational Science Institute’s (CTSI’s) Community Engagement and Health Policy Program, the San Francisco Department of Public Health (SFDPH), and ethnic-based community health equity coalitions seeking to better align community-engaged translational science and public health practice to improve health equity. A steering committee was formed to govern SFHIP 1.0. A local scoping exercise assessed community health needs and existing improvement efforts to identify community health topics for initial projects by using the following criteria to prioritize topics: level of population health importance (based on data and community-identified needs), level of health inequity across population groups, amenability of the identified need to evidence-based preventive interventions, alignment of the need with research expertise at UCSF, and level of opportunity to build a new collective public health initiative or enhance an existing one. This exercise led SFHIP to prioritize 3 initiatives: obesity-related disease, alcohol-related violence, and children’s oral health. Other important health issues, such as HIV infection and tobacco use, were not included on the priority list because they already had high-performing, collaborative programs in place.Partnership working groups (PWGs) were formed for each initiative; they consisted of diverse members committed to collaborating on developing and implementing action plans to “move the dial” on their respective health issue. PWGs emphasized engaging community organizations and members. At least one faculty member from UCSF with relevant expertise participated in each PWG. PWGs were encouraged to focus on feasible, scalable, and sustainable evidence-based interventions, especially policy and structural interventions. Community members participated in developing logic models for each PWG and in delineating inputs, activities, outputs, policy outcomes, and the health impact of each. Logic models were vetted at an SFHIP summit meeting in 2013, which was attended by more than 150 community members and representatives of stakeholder organization. The UCSF CTSI served as the initial backbone institution, organizing steering committee meetings, providing staff navigators, and providing small seed grants to support each PWG.In 2013, SFHIP 1.0 joined with 2 other health improvement groups to create SFHIP 2.0. One group, Building a Healthier San Francisco, is a coalition formed by the San Francisco Hospital Council in 1994 to assess community health needs as required of nonprofit hospitals by state and now federal law. This coalition administered a comprehensive, online data repository of local population health indicators. The second group arose from an ordinance requiring a health care services master plan and SFDPH’s decision to seek accreditation by the Public Health Accreditation Board, which required an assessment of community health needs and an improvement plan (CHIP). In 2013, SFHIP 1.0, Building a Healthier San Francisco, and the CHIP group merged to form SFHIP 2.0. SFHIP.org became the data-tracking platform, and CHIP became the population health strategic plan; existing SFHIP 1.0 projects continued and new projects were launched. The SFHIP steering committee expanded its membership, and the San Francisco Hospital Council and SFDPH joined the UCSF CTSI as backbone organizations.SSBs account for 36% of the added dietary sugar consumed in the United States. SSB consumption is associated with obesity, heart and liver disease, diabetes, and dental decay . In San In 2006, then-Mayor Gavin Newsom launched the Shape UP San Francisco coalition to promote environments supporting healthy eating and active living. The SFHIP PWG on obesity began by augmenting the efforts of Shape UP San Francisco on several projects. With time, the PWG decided to concentrate its effort on policy and educational interventions to reduce SSB consumption . UCSF reCommunity engagement was essential for incorporating a community voice in policy deliberations and mobilizing residents to advocate for policy changes. PWG partners conducted a community participatory research project that used focus groups to explore attitudes toward SSB regulatory and tax policies among residents of low-income neighborhoods — communities most affected by SSB intake and heavily targeted by SSB companies’ marketing. Community members collaborated with UCSF and SFDPH personnel on all aspects of the study, and the ethnic health equity coalitions served as conveners for the focus groups. The study found that misgivings about a soda tax were partly mitigated when residents had confidence that government would spend the funds on public health programs benefiting their community and that there would be greater availability of free, clean drinking water  as an alternative to SSBs.Public policy outcomes include the Board of Supervisors enacting ordinances prohibiting purchase of SSBs with San Francisco government funds and requiring beverage companies to place labels on SSB advertisements in San Francisco warning consumers of their health risk. The Board of Supervisors also placed ballot measures to enact a soda tax before the electorate in 2014 (did not pass) and in November 2016 (did pass). Informed by the community-based participatory research study highlighting the desire of community members for better access to clean tap water in low-income communities, SFHIP worked with the San Francisco Public Utilities Commission to deploy new filtered tap-water filling stations at libraries, parks, and other public venues in low-income neighborhoods.Institutional members also implemented SSB policies. UCSF adopted a campus-wide policy eliminating SSBs from patient menus, cafeterias, retail food outlets, and vending machines. Kaiser Permanente adopted a comparable policy, and the 2 other large hospital systems in San Francisco are moving to implement healthy beverage policies. The county hospital falls under the SSB purchase prohibition of the local ordinance. San Francisco is poised to be the first city in the United States to have virtually all its hospitals prohibit distribution or sale of SSBs. The San Francisco Unified School District, which already had banned sale of SSBs on school premises, adopted a wellness policy with stringent restrictions on serving of SSBs at school events.Alcohol-related premature mortality accounts for about 10% of all years of life lost among men in San Francisco, with prominent disparities among African Americans and Latinos . Areas hThe SFHIP Alcohol Policy Partnership Working Group (APPWG) was organized to reduce disparities in alcohol-related harm, particularly violence and public nuisance activities . APPWG dThe group developed data tools and conducted applied research to inform community organizing and policymaking. With donated support from 2 technology industry nonprofit organizations, the APPWG developed a tool for mapping alcohol outlets. This interactive tool incorporates geographic data on alcohol outlets, crime rates, population demographics, and incidence of alcohol-related harms in order to illustrate graphically how the city’s alcohol environment is associated with health disparities. The tool was valuable for the group’s community capacity building and for engagement efforts with policy makers, residents of the most affected neighborhoods, and other partners. Collaboration between APPWG and the San Francisco Injury Center resulted in the Zuckerberg San Francisco General Hospital and Trauma Center’s starting a program to test patients’ blood alcohol routinely. The hospital followed with a study using data on blood alcohol levels and APPWG’s mapping tool that found that alcohol outlet density is a strong predictor of injuries involving patients with high blood alcohol levels .promotoras (Hispanic outreach worker) program to train community members to educate and empower one another about the ordinance.APPWG policy efforts focused on strengthening San Francisco’s Deemed Approved Uses Ordinance (DAO) regulating retail alcohol outlets, including requiring public health assessments with active community participation when new alcohol licenses are under consideration for approval. DAO reforms were hampered by the complexity of the ordinance, difficulty coordinating multiple regulatory offices, and interest-group resistance to change. Community focus groups conducted under the auspices of SFHIP in the most alcohol outlet-dense areas of San Francisco confirmed that residents find it difficult to understand and participate in DAO implementation and enforcement. APPWG launched a community education campaign, starting with leaders of local community organizations and expanding into a policy Armed with its research studies and mapping tools, APPWG provided a quick-response team to address urgent concerns about local alcohol retail issues, such as the emergence of powdered alcohol as a retail product and alcohol licensing of chain stores. APPWG’s statement opposing the sale of powdered alcohol was quickly ratified by SFHIP and influenced enactment of a state law banning sale of powdered alcohol. When Starbucks and Taco Bell sought liquor licenses for their San Francisco franchises, community partners brought this to the attention of APPWG, which worked with the Board of Supervisors to pass a unanimous resolution urging the state not to issue licenses in San Francisco to this class of retailer. Starbucks and Taco Bell subsequently withdrew their license applications. Another outcome was that SFDPH convened the DAO regulatory partners to analyze the ordinance and recommend changes.Dental caries is the most common childhood chronic disease . DespiteThe SFHIP Children’s Oral Health Working Group (COHWG) was formed to address disparities in prevalence of childhood caries . In consPlanning work groups transitioned into implementation teams supported by a grant from another local foundation. Following a community briefing on high caries prevalence among Chinatown children, community organizations in Chinatown mobilized to form a neighborhood children’s oral health task force that has become a leader in educational and advocacy work and has served as a model for developing task forces in other high-prevalence neighborhoods.Policy accomplishments include the San Francisco government establishing and funding a permanent oral health coordinator position in the SFDPH to coordinate the implementation of the strategic plan and the dissemination of $250,000, which was appropriated to fund neighborhood task forces on children’s oral health. The San Francisco Health Plan, the major local Medicaidmanaged-care plan, included in its performance improvement plan a financial incentive rewarding primary care clinics that administer fluoride varnish at well-child visits. Nearly 400 additional fifth and sixth graders were added to the school sealant program, and COHWG focused on qualifying preventive services provided by dental providers in schools and other nonclinic settings for Medicaid payment.At the inception of COHWG, the only medical providers routinely administering fluoride varnish were the SFDPH pediatric clinic at the county hospital and some pediatric practices at San Francisco Kaiser Permanente. Four additional primary care clinics in SFDPH and 2 Federally Qualified Health Centers are now providing fluoride varnish. SFDPH and UCSF staffs trained more than 70 medical staff members at these clinics to administer fluoride varnish.SFHIP and its working groups succeeded in helping to implement many of the policies and programs specified as key intermediate objectives. Many important groups operating outside SFHIP also played a role in advancing these goals; therefore, progress should not be considered entirely attributable to SFHIP.SFHIP demonstrates the value of a collective impact approach . Diverse stakeholders aligned around a shared agenda on health improvement initiatives. Emphasis on evidence to policy integrated translational science with public health practice, which contributes to implementation of policy and structural changes that fall in the high-yield zone of the public health impact pyramid. Examples of organizations involved in SFHIP’s collective impact approach are nonprofit hospitals that implement SSB policies congruent with local government SSB regulations, academic researchers partnering with the local health department and community organizations on participatory translational research to inform strategic SFHIP action plans, and community members advocating for SSB policies and for increased local government funding for neighborhood task forces for children’s oral health. An example of the importance of community members being directly involved is the role that residents of low income neighborhoods had in showing that policies such as a soda tax to discourage SSB consumption need to be coupled with policies to promote access to free, clean tap water for these policies to gain broader community support. Listening to the community voice following the defeat of the 2014 soda tax ballot explains in part the success of the 2016 ballot measure.Collaborative leadership and backbone resources were critical. Individuals participating in the steering committee and PWGs brought passionate commitment to health equity, tempered by willingness to invest in building trusting relationships and consensus decision-making. Many participants, especially community representatives, volunteered much time outside the scope of their compensated jobs. The SFHIP staff members who were contributed in-kind by the backbone organizations were invaluable. Particularly vital was the skill of SFHIP staff in navigating the different cultures of government agencies, community groups, universities, and other partners to build trust and common purpose. Grant funding from local foundations supported initiatives, and UCSF’s National Institutes of Health Clinical and Translational Science Award funded UCSF faculty and staff effort.SFHIP also experienced challenges. Building trust required overcoming a history of strained relationships among some of the partners and concerns about large institutional partners exerting excessive influence. It was not always easy for partners to relinquish individual agendas to forge a common one, whether it was a UCSF faculty member’s personal research agenda, a hospital’s traditional community benefit orientation, or a community organization’s programming comfort zone. Partners underestimated the time and effort required for cohesive group formation in the early stages of establishing a steering committee and setting priorities. SFHIP confronted the tension of policymaking invariably involving politics. Resistance from commercial interest groups impeded some SFHIP policy goals.Another tension was over measuring success on the basis of achieving intermediate policy goals. Some stakeholders and funders were impatient to see evidence of improved public health indicators and health equity. Such outcome-oriented evaluations are limited by the time needed for changes to materialize, and the cost of performing rigorous outcome evaluations. In areas where SFHIP projects mustered the ability to evaluate rigorously, results are encouraging; for example, evaluation of implementation of the healthy beverage policy at UCSF demonstrated significant reductions in SSB consumption among lower-wage employees — the group with the highest baseline consumption.A final tension was whether SFHIP should focus more on the first tier of the health impact pyramid: the fundamental socioeconomic determinants of health. The steering committee is still considering how SFHIP might engage in issues such as the city’s housing affordability crisis and community displacement, structural racism, and employment development.SFHIP’s novel approach to collective impact may offer lessons for health equity initiatives in other communities. SFHIP accomplished many of its intermediate goals for aligned activities and policy change, which accomplishment augurs well for improvements in community health and health equity over time.


To investigate whether the eye movement pattern is different between facial emotion recognition and real social scene emotion recognition, and which can better reflect the social function and the clinical symptoms using a novel theme identification task.Total 29 patients with schizophrenia and 31 healthy controls completed the theme identification task, in which subjects selected which word, out of positive, neutral and negative, described the theme of a picture under facial emotion recognition and real social scene emotion recognition. Positive and negative syndrome scale (PANSS) and social function in psychosis inpatients (SSPI) were used to assess the symptom and social function.The schizophrenia’s eye movement paradigms under both facial emotion and social scene show decreased number of fixation , decreased number of saccades , decreased scan path length , decreased fixation number in interest area . Different from facial emotion cognition, the eye movement under social scene cognition showed lower percentage of fixation number in interest area than that in healthy subjects (P=0.01), furthermore, the length of scan path under the negative social scene pictures was associated with the total score of SSPI , the PANSS total score , the positive symptoms score , the general score .The patients showed more abnormal eye tracking indicators under social scene than facial emotion. Under negative emotion social scene, the length of scan path related to social function and clinical symptoms, it may be a potential indicator to evaluate social function and degree of disease.


Patients with advanced disease are living longer and commonly used patient-reported outcome measures (PROMs) may miss relevant elements of the quality of extended survival. This systematic review examines the measures used to capture aspects of the quality of survival including impact on patients’ everyday lives such as finances, work and family roles.Searches were conducted in MEDLINE, EMBASE, CINAHL and PsycINFO restricted to English language articles. Information on study characteristics, instruments and outcomes was systematically extracted and synthesised. A predefined set of criteria was used to rate the quality of studies.struggles with parenting were identified. Social difficulties were common and associated with multiple factors including being a caregiver. Many studies were single time-point surveys and used non-validated measures. Exceptions were employment of the COST and Social Difficulties Inventory (SDI), validated measures of financial and social distress respectively.From 2761 potentially relevant articles, 22 met all inclusion criteria, including 10 concerning financial distress, 3 on roles and responsibilities and 9 on multiple aspects of social well-being. Generally, studies were not of high quality; many lacked bias free participant selection, had confounding factors and had not accounted for all participants. High levels of financial distress were reported and were associated with multiple demographic factors such as age and income. There were few reports concerned with impacts on patients’ roles/responsibilities in everyday life although practical and emotional .Impact on some important parts of patients’ everyday lives is insufficiently and inconsistently captured. Further PROM development focussing on roles and responsibilities, including work and caring for dependents, is warrantedFactors such as finances, employment and responsibility for caring for dependants (e.g. children and elderly relatives) can affect the well-being of cancer survivors. There is a need to ensure that any instruments used to assess patients’ social well-being are broad enough to include these areas so that any difficulties arising can be better understood and appropriately supported. Rapidly emerging novel treatments in oncology, particularly in advanced disease, mean that more patients are living longer ; for thoThe measurement of a patient’s subjective experience of both the symptoms of disease and treatment-related toxicity within clinical trials has increased , 3. ThisAlthough the more frequent use of PROMs is encouraging, there may well be areas of concern impacting the quality of survival that are insufficiently assessed. A previous systematic review by Muzzati and Annunziata  showed tThe current review aims to provide summary and evaluation of PROMs used in studies for reporting the impact of cancer on wider social aspects of patients’ lives, particularly those which may be salient to living with the illness for an extended period, in other words, expanding assessments to look at lifestyle impacts under a conceptual framework which is in the early stages of delineation and referred to as ‘quality of survival’  . This wiWe followed the general principles published by the NHS Centre for Reviews and Dissemination  and carrhost). Terms were modified as appropriate for each database and limited to English language only. A combination of controlled syntax (MeSH) and free-text terms were used. Two groups of terms were generated describing (i) the population and (ii) social aspects of interest. The terms within each group were combined with a Boolean OR command and were searched in combination using a Boolean AND command. Searches were run on 5 March 2015 and an update conducted 8 January 2016 . The reference lists of pertinent review articles were also checked for relevant articles.Searches were run in MEDLINE (MEDLINE(R) in-process and other non-indexed citations and MEDLINE(R) 1946-present) and EMBASE (1947-present) (both via OvidSP) and CINAHL (1937-present) and PsycINFO (from 1800s–present) (both via EBSCOInclusion criteria were articles in the English language on any quantitative study containing the report of the impact of advanced (or secondary or metastatic or stages III or IV) cancer, as assessed by the use of PROs, on the wider social aspects of adult patients’ lives, that is on financial situation, lifestyle, occupational circumstances, roles and responsibilities with dependents (looking after young offspring or elderly parents) and there was no date restriction.Excluded were qualitative studies, those with children or caregivers as the sole participants, those involving populations with early cancer (i.e. disease stages I or II) or the very final end-of-life stage; also excluded were studies focussed on the metrics of an instrument, reviews, editorials, letters, opinion, reports published on meeting abstracts and academic theses, any of which an English language version of the PRO had not been developed. Pure monetary costing surveys and functional workability assessment surveys were not included as these give no information on perceived impact on the patient, e.g. recording in a diary a certain amount of money was spent on a hospital parking charge does not establish if, or how, burdensome it was.A schema for identification and selection of eligible articles can be seen in Fig. Backwards citation chasing (one generation) using reference lists of all papers included in the review and forwards citation chasing (one generation) using Science Citation Index Expanded and Social Science Citation Index Expanded via Web of Science were conducted.For each included paper, the following descriptive data were extracted into a standardised form: first author name, publication year, setting/country, study design and aim, study population (cancer type and demography), number of participants, what social factor/s were assessed and how, reported outcomes and study limitations. Data were extracted and the quality of studies appraised by one reviewer (RS) and checked by a second (SC or VS). Quality appraisal criteria are shown in Box 2 and were developed in accordance with the principles published by the National Health Service Centre for Reviews and Dissemination . WithoutThe initial search yielded 3115 articles; an additional 6 were identified from hand searches . The second [, which g Scale’ . The remg Scale’ , 49–54 uThree articles –57 invesMoore et al.  combinedWalsh et al.  investigNine articles used multidimensional instruments , 62, 64 The finding that cancer and its treatments commonly impact the social aspects of patients’ lives was evident in three papers , 65, 66 Social and financial impacts were also reported using a non-validated questionnaire in a study contrasting rural and urban cancer patients’ experiences . Sixty-fThough the studies reviewed here were diverse in terms of study objectives, methods and patient populations, the patient-reported outcomes reported by them repeatedly show cancer and its treatments have significant impact on patients’ finances, roles and responsibilities and on the various facets of their social life.Moreover, the findings complement reports from published quantitative studies –33 that The studies reviewed which have attempted to quantify patients’ self-perceived financial distress have all done so using different, and in the majority of cases , 49–54, Additionally, there is a survey literature –33, not Two validated multidimensional PROs were identified, the IIRS  and SDI Nevertheless, clearly insufficient data are being gathered with patients to comprehensively understand their problems and needs to enable supporting them living well with their disease, including making decisions about ongoing treatment options. Impacts on the social domain need to be consistently assessed more comprehensively and this has implications for the current HRQoL instruments commonly used. Options for the future include using the SDI in tandem with the existing well-validated quality of life measures and/or generating further assessment modules  for the existing instruments.This review was intentionally restricted to identifying studies that reported the use of PRO instruments dedicated solely to the assessment of the financial situation, lifestyle, occupational circumstances, and roles and responsibilities with dependents (looking after young offspring or elderly parents) of adult cancer patients living with advanced disease. In taking this approach, we acknowledge that we have not conducted a mapping and review process of existing social domain subscales of either the general or the more specific health-related quality of life instruments available to use in oncology and that such an undertaking could reveal further useful validated measurement items. One such tool absent from the current review is the Patient-Reported Outcomes Measurement Information System (PROMIS) , a produThere is a need and opportunity for further work, both in terms of instrument use and development, to ensure that the social areas of patients’ lives are comprehensively assessed. Our tools must keep pace with changes happening in cancer treatment outcomes so that salient social problems are anticipated and/or ameliorated. The COST and SDI, two well-developed and validated tools, could be used to supplement shortfalls in the commonly employed HRQoL instruments. But, there is also scope for developing additional subscales within the existing modular systems to enhance them. In particular, attention needs to be directed towards roles and responsibilities, including work and patients with dependents.


Markers of imaging, structure, and function reflecting vascular damage, integrating a long time accumulation effect of traditional and unrecognized cardiovascular risk factors, can be regarded as surrogate endpoints of target organ damage before the occurrence of clinical events. Prevention of cardiovascular disease requires risk stratification and treatment of traditional risk factors, such as smoking, hypertension, hyperlipidemia, and diabetes. However, traditional risk stratification is not sufficient to provide accurate assessment of future cardiovascular events. Therefore, vascular injury related parameters obtained by ultrasound or other noninvasive devices, as a surrogate parameter of subclinical cardiovascular disease, can improve cardiovascular risk assessment and optimize the preventive treatment strategy. Thus, we will summarize the research progress and clinical application of early assessment technology of vascular diseases in the present review. In the year of 2010, a concept of “ideal cardiovascular health” was put forward, including ideal healthy behavior, such as status of smoking, body mass index, physical activity and diet, and ideal healthy factors, such as blood pressure, blood glucose, and blood lipids . TherefoVascular endothelial cells as a layer of single cell interface between blood flow and vessel wall, responding to the stimulation of body fluid, the nerve, especially the hemodynamics, can regulate vascular tone by the synthesis and release of vasoactive substances, regulate platelet function, inflammatory response, and vascular smooth muscle cell growth and migration, and play an important role in the pathogenesis of vascular diseases , 5. VascAcetylcholine stimulation by coronary angiography is the traditional method of vascular endothelial function detection . It is tDoppler ultrasound equipment was used to measure the baseline and cuff released diameter of brachial artery, and FMD was calculated as the rate of brachial artery diameter changes. It reflects the flow-mediated endothelial nitric oxide (NO) release function and is considered as a commonly used noninvasive method. The method is simple, noninvasive, economical and accurate, reproducible, and clinically beneficial for the promotion of early vascular lesion detection . FMD as FMD reflects NO-mediated function of conduit brachial artery and is measured by Doppler ultrasound apparatus. Measurement of digital pulse amplitude tonometry (PAT) is based on a technique similar to that of FMD. It uses photoplethysmography to measure pulse wave amplitude (PWA) in the fingers reflecting small vessel microcirculation function and gets the reactive hyperemia index (RHI). RHI is defined as the ratio of postdeflation to baseline pulse amplitude in the hyperemic finger divided by that in the contra-lateral finger . StudiesBoth brachial FMD and RHI are independent predictors of cardiovascular events and all-cause mortality and both with similar prognostic magnitude , 18. RHITherefore, whether the prognostic values of these 2 methods are independent of each other and whether an endothelial function-guided strategy can provide benefit in improving cardiovascular outcomes need further research to determine .Arterial stiffness is mainly determined by larger arteries, because the thoracic aorta and abdominal aorta contribute the greatest to arterial buffering function. Elastic properties of conduit arteries vary along the arterial tree, with proximal arteries being more elastic and distal ones stiffer. In addition, aging and blood pressure are the major determinants of arterial stiffness, which causes a decrease in elastic protein synthesis and an increase in degradation, while the synthesis of type 3 and type 1 collagen is increased and the degradation is reduced . StudiesPWV is a common indicator of arterial stiffness and can be obtained by measurement of distance and pulse wave transit time between two points of vessels . It can β and can be calculated by the electrocardiogram, phonocardiogram, and brachial ankle artery pulse waveform and pulse waveform records and is mainly related to aortic stiffness and compliance [CAVI is a new evaluation index of arterial stiffness in recent years and can also be measured by means of arteriosclerosis detection device. Compared with PWV, CAVI does not depend on the immediate effect of blood pressure. CAVI comes from the stiffness coefficient mpliance . A seriempliance –35. In ampliance , and CAVmpliance . In addimpliance .Central aortic pressure (CAP) can be measured by invasive cardiac catheterization and noninvasive applanation tonometry of the radial or carotid artery , 40. CAPAugmentation index (AI) was obtained from the synthesized aortic pressure waveform . AI, meaPulse pressure (PP), with simple and convenient measurement, is widely used as roughly reflection of arterial stiffness, and increased PP showed increased arterial stiffness .The large artery elasticity index (C1) and small artery elasticity index (C2) obtained by the pulse waveform analysis of the radial artery are two of the parameters of arterial elasticity, getting through the analysis of the radial artery diastolic blood pressure pulse waveform. Studies suggested that C1 and C2 were better than the traditional blood pressure detection for clinical application of early recognition of the cardiovascular disease , and C1 Most importantly, the common limitation of CAP, AI, C1, or C2 is the lack of reference values and adequate evidence to date, therefore limiting the current widely clinical application.ABI concept was proposed by Winsor in the 50s in twentieth Century, which was originally proposed as a noninvasive diagnostic technique for peripheral arterial disease (PAD) . In 1982Ultrasound imaging technique as a noninvasive detection for clinical evaluation of carotid plaque (CP), carotid stenosis, and carotid artery intima-media thickness carotid (CIMT) is widely used. Ultrasound detection of carotid atherosclerotic lesions can be used as the observation window of the whole vascular bed atherosclerosis and can observe early atherosclerotic lesions dynamically. Its operating convenience, low cost, and good reproducibility made it a noninvasive screening of some high-risk and asymptomatic vascular disease patients . AlthougWhether CIMT and CP are distinct phenotypes or represent a different stage of atherosclerotic development is unclear. Some studies indicated that common CIMT can independently predict CP occurrence and suggested that increased CIMT might occur in an earlier phase of the atherosclerotic process , 69. HowAn article summarizing studies on CIMT and CP showed that CP was a better marker of CVD risk than CIMT and combined CIMT with CP assessment appear better than either measure alone . Meta-anCACS can be used for early diagnosis of coronary heart disease, review, and follow-up after treatment, screening for cardiovascular disease and high-risk population, and coronary artery CT angiography is the main noninvasive method for quantitative coronary artery calcified plaque at present . CACS isThe ambulatory blood pressure recording instrument is composed of a transducer, a miniature recording box, and a recovery system and can automatically store data within 24 hours of the day and night, including systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, and the highest and lowest values. The 2013 European updated guidelines on hypertension stressed the importance of ABPM for the prognosis of clinical cardiovascular events, especially for clinic blood pressure and family pressure in apparent inconsistency, night hypertension, and blood pressure variability assessment . 24-hourThe study of dynamic electrocardiogram was initiated in 1957 by Holter and first applied in the monitoring of cardiac electrical activity, thus also called Holter ECG. It can continuously record the daily activity under the condition of 24 hours of ECG changes, is noninvasive and easy to operate, and is widely used in clinical practice. The results of Holter ECG include heart rate, arrhythmia analysis, ST-T segment analysis, and analysis of heart rate variability. Statement of clinical application of ECG and dynamic ECG in the United States made dynamic ECG monitoring an important indication .About early assessment of vascular disease, in addition to direct or indirect imaging techniques or noninvasive evaluation techniques for arterial stiffness, there are also many risk biomarkers of vascular disease, including traditional biomarkers and some new markers found in recent years. Basic research showed that vascular endothelial cells are an important paracrine organ and play a variety of physiological roles through the secretion or release of a series of biologically active medium, and vascular endothelial dysfunction can lead to some abnormal indicators. Therefore, the detection of biomarkers can be used as the evaluation index of endothelial dysfunction . In addiArteriosclerosis is not the patent of the modern society, its existence precedes the modern civilized society and the present risk factor , and traHyperhomocysteinemia (HHcy) is characterized by elevated plasma total homocysteine levels and associated with increased risk of cardiovascular disease and stroke . StudiesAll the technologies of vascular early detection mentioned above were summarized within a table see , includiBased on the preliminary research foundation, in 2006, our research team released the first report of Chinese vascular disease early detection technology application guide . The guiAt present, there are a variety of cardiovascular risk prediction models , to pred


To determine the diagnostic value of diascopy and other non-invasive clinical aids on recent differential diagnosis algorithms of oral mucosal pigmentations affecting subjects of any age.Data Sources: this systematic review was conducted by searching PubMed, Scopus, Dentistry & Oral Sciences Source and the Cochrane Library (2000-2015); Study Selection: two reviewers independently selected all types of English articles describing differential diagnosis algorithms of oral pigmentations and checked the references of finally included papers; Data Extraction: one reviewer performed the data extraction and quality assessment based on previously defined fields while the other reviewer checked their validity.Data Synthesis: eight narrative reviews and one single case report met the inclusion criteria. Diascopy was used on six algorithms (66.67%) and X-ray was included once ; these were considered helpful tools in the diagnosis of intravascular and exogenous pigmentations, respectively. Surface rubbing was described once in the text (11.11%).Diascopy was the most applied method followed by X-ray and surface rubbing. The limited scope of these procedures only makes them useful when a positive result is obtained, turning biopsy into the most recommended technique when diagnosis cannot be established on clinical grounds alone. Key words:Algorithm, differential diagnosis, flow chart, oral mucosa, oral pigmentation, systematic review. Oral mucosal pigmentations are relatively common in daily dental practice and usually mean a diagnostic challenge for clinicians -3.In this sense, diascopy has been proposed as a possible diagnostic tool for this type of conditions, being defined as a procedure of removing the camouflaging effect of congested blood to reveal the true colour of underlying lesions . This is-The following objectives were addressed:•Primary: to determine the current diagnostic value of diascopy on the differential diagnosis of oral mucosal pigmentations, all types of recently published articles that described a differential diagnosis algorithm about such lesions in which this diagnostic technique was present were reviewed, against those that did not use it, aimed at subjects of any age affected by these oral conditions.•Secondary: to determine the diagnostic value of other non-invasive clinical aids on the previously mentioned differential diagnosis flow charts, as well as the most recommended method to reach a definitive diagnosis.- ProtocolThis systematic review was conducted according to a previously established protocol. Likewise, the PRISMA Statement recommended items were addressed whenever possible .- Eligibility criteriaTypes of studies: all kind of recently published articles describing differential diagnosis flow charts of oral mucosal pigmentations, including diascopy or not as a diagnostic step were considered. Only the most mentioned lesions in several related review articles were taken into account ,3,14,15,Types of participants: subjects of any age affected by oral mucosal pigmentations.Types of intervention: application of diascopy or other non-invasive clinical aids on oral mucosal pigmentations.Types of comparator: no application of diascopy or other non-invasive clinical aids on such lesions.Types of outcome measures: 1. Primary: the diagnostic value of diascopy on current differential diagnosis protocols of oral mucosal pigmentations; 2. Secondary: the diagnostic value of other non-invasive clinical techniques on these protocols and the most recommended method to achieve a definitive diagnosis.- Information sourcesFour electronic databases were searched: PubMed , Dentistry & Oral Sciences Source, DOSS (EBSCO Host), and the Cochrane Library (Wiley Online Library) and Scopus (Elsevier). A time filter was imposed from 1 January 2000 to 25 May 2015 and all the databases were researched up to 1 June 2015 . No language filter was imposed in this phase. Reference checking of finally included articles was also performed. Additionally, authors of these finally selected papers were contacted to clarify doubtful information, absent data and confirm the extracted evidence. The search protocol was developed and conducted by one of the reviewers (DPL), once it was validated by the group.- Search The following search terms were used to search the four databases: oral cavity, oral mucosa, pigmented, pigmentation, pigmentations, vascular, discoloration, discolorations, discolouration, discolourations, hyperpigmentation, hyperpigmentations, lesion, lesions, diagnosis, flow chart, protocol, differential diagnosis, algorithm, and guide. The search strategy for each database was previously specified in the systematic review protocol.- Study selection Once the articles were retrieved from each of the four databases and the duplicates were dismissed by one of the reviewers (DPL), the eligibility assessment of all the references was independently carried out by two reviewers (DPL and MPC). As a first step, the titles and abstracts were screened by language and inclusion criteria. Then, the full texts of potentially relevant studies were examined for inclusion criteria compliance. Reference checking of finally included studies was first performed by title; if the corresponding abstracts were considered suitable, the full texts were examined. When titles and abstracts did not provide enough information to make a decision or the abstracts were not available but the titles were considered suspicious of being related to the purposes of the review, the respective full articles were assessed. Reasons for exclusion were stated at each stage, except for title selection during reference checking. Disagreements between reviewers were solved by consensus at each step. If the two reviewers did not agree, a third investigator (IT) was contacted.- Data collection processa priori established data items was developed and accordingly modified after pilot-testing it on three of the finally included studies. On this occasion, only one of the reviewers (DPL) extracted the data from the corresponding studies while the other reviewer (MPC) checked its validity. Again, disagreements were solved by consensus. If no agreement could be reached, a third investigator (IT) was consulted.A data extraction sheet based on As stated, authors of the finally included articles were contacted to obtain ambiguous or absent data, as well as to confirm the performed data extraction.- Data itemsInformation was extracted from each included study on.1) Study design: justification, aims, type of study according to previously reported classification , type an2) Participants: features of the population for which the differential diagnosis protocol was developed, type of included lesions, and features of case reports, if present.3) Intervention/comparator: main aspect that determines the first step on the differential diagnosis protocol; presence of diascopy, at which level and type of lesions; and presence of other clinical diagnostic techniques, at which level and type of lesions.4) Outcomes: diagnostic value of diascopy and other non-invasive clinical techniques applied on the included protocols, as well as the most recommended method for reaching a definitive diagnosis, and other conclusions.a priori, but three additional items were added after reading the finally included articles. It was decided to include the type and language of the documents cited on finally included papers to provide information about what kind of data they were based on. Likewise, the assessment of the main aspect or procedure that determined the first step on each of the differential diagnosis protocols was introduced since it was considered to be a very useful contribution to daily dental practice.As already reported, the data extraction sheet was developed - Quality assessmentper se and another one focused on the article text were initially proposed for the quality appraisal: one classificatory aspect per step , self-explanation of each step , presence of distinctly specified lesions (to clarify which types of lesions clinicians should mainly consider with each protocol) and description of outstanding malignancies in text . This checklist was modified after completely reading the articles selected by screening titles and abstracts, with two more text parameters added: thorough explanation of the algorithm (to reinforce its understanding and solve any doubt from its isolated assessment) and clearly stated algorithm limitations (to become aware of its scope).Since the finally included studies were expected to mainly consist of narrative reviews, risk of bias assessment was not considered. For this reason, their “quality” was assessed through a self-designed checklist based on six parameters that were considered important for their clinical application. Based on the authors’ clinical experience, three features related to the algorithm As in the data collection process, the quality assessment was performed by one of the reviewers (DPL), while the other reviewer (MPC) checked its validity. In the case of several flow charts, only algorithms based on oral pigmentations were considered. Disagreements were solved by consensus. If no agreement could be reached, a third investigator (IT) took part.- Summary measures and synthesis of resultsA descriptive data analysis was performed. The following aspects were considered: the percentage of studies applying diascopy or other non-invasive clinical techniques (either in protocols or in protocol/text combination), the most recommended method for a definitive diagnosis and its percentage of use (regardless of its place of mention), and the different main aspects or procedures that determined the first step in the several algorithms and their prevalence  .- Study selectionA total of nine studies were finally included in the review. The searches of PubMed, Scopus, DOSS and the Cochrane Library databases provided a total of 172 studies. After adjusting for duplicates, 155 remained. Of these, 137 studies were discarded after reviewing their titles and abstracts since it was considered that they did not meet the inclusion criteria. The exclusion criteria in this phase were classified into four groups: group 1 (n= 41), involving studies that mentioned the previously reported included lesions without evidence of a differential diagnosis flow chart; group 2 (n= 26), in relation to studies that described other oral lesions (distinct from caries); group 3 (n= 60), comprising studies of other medical disciplines, congress abstracts, articles related to caries or not focused on differential diagnosis (regardless of the type of lesions assessed), lesions beyond the limits of the oral cavity, and miscellaneous; and group 4 (n= 10), concerning non-English studies. Thus, 18 studies were selected for the full texts to be read. It appeared that ten studies did not meet the inclusion criteria and another one could not be retrieved, so seven articles were included in the systematic review from the database electronic search. Additionally, seven studies were also considered for full text reading by checking the references of the seven studies mentioned above; five of them were excluded for not providing a differential diagnosis flow chart. Therefore, a total of nine studies were finally included in our review .- Study characteristics , being mainly applied to red, blue or purple, focal and multifocal/diffuse oral pigmentations, to distinguish between intravascular conditions and other type of lesions ,18-21,23Only one of the nine algorithms 11.11%) reported the use of X-ray on brown or black focal lesions . Nonethe1.11% repLikewise, one article (11.11%) described in its text the procedure of surface rubbing in the diagnosis of oral malignant melanoma, without evaluating its diagnostic value .Biopsy was recommended without exception to reach a definitive diagnosis when this cannot be made on clinical grounds alone 100%)  included differential diagnosis protocols ,18,19. TMany narrative reviews have been published describing large sets of oral pigmented lesions without providing a differential diagnosis flow chart ,15,25-31In relation to X-ray, amalgam tattoo is more present on oral pigmentation-related reviews and the application of this technique has been well-mentioned on its differential diagnosis ,26,30,31Despite the frequent presence of oral melanoma in many narrative reviews, surface rubbing is not described as a clinical tool on its diagnosis ,15,25-31As expected, histopathology assessment has elsewhere been considered the gold standard method for reaching a definitive diagnosis in oral pigmented lesions -28,30,31Our study has several limitations. Regarding the study and review level, the search retrieved results were screened for just including English-language publications and only studies published in the last 15 years were considered. Additionally, the set of included lesions may have obviated some conditions that could have led us to other diagnostic flow diagrams. Likewise, the performed title/abstract search restriction was applied to best focus on potentially eligible papers since it was assumed that articles without including any of those words would not be selected. In relation to the quality assessment, the evaluated parameters were based more on the applicability of the diagnostic flows than on their quality, so the punctuations are not directly associated with the latter. Finally, the Oxford Centre for Evidence-Based Medicine does not currently consider narrative reviews or single case reports on its Levels of Evidence Table . In thisBased on this evidence, it was finally concluded that diascopy was the most applied diagnostic technique on the recent differential diagnosis algorithms of oral pigmented lesions, followed by X-ray and surface rubbing. The limited scope of these techniques only makes them useful when a positive result is obtained and turns biopsy into the most recommended procedure when a diagnosis cannot be made on clinical grounds alone.Interested authors are encouraged to clearly state all of the clinical techniques applied on their case report and case series studies, as well as the respective obtained results, also providing a histopathological diagnosis. Such information will allow investigators and clinicians to accurately assess the diagnostic value and limits of those applied procedures and their relation to different types of lesions and their variants.