The Diabetes Prevention Program trial compared metformin, lifestyle modification and placebo (the latter, as with metformin, including basic lifestyle advice). Both metformin and lifestyle alternatives reduced diabetes versus placebo. A published cost-effectiveness analysis (CEA) of the DPP as if it were implemented in Singapore concluded that both metformin and lifestyle were cost-effective. The original work miscalculated the key metric in economic evaluations – the Incremental Cost-Effectiveness Ratio (ICER) - by comparing metformin and lifestyle each to a common alternative (here, placebo), a violation of long-established economic methods. We revisited that analysis, using the identical data, but with appropriate methods, to calculate appropriate ICERs. We showed that with correctly calculated ICERs, metformin was not even technically efficient and thereby incapable of being the more-restrictive economically efficient (cost-effective) treatment. These data show that only lifestyle was cost-effective. We also expanded the analysis, using three additional methods (Incremental Cost-Effectiveness Plane, Net Monetary Benefits and Net Loss Curves). These methods confirm the results from the correct ICERs. Had any of these been used in the original CEA, errors may have been identified by the authors. Importantly, our Net Loss calculations also show that there may be significant health and cost consequences to patients in a system that may have implemented policy based on the error that incorrectly implied metformin’s cost-effectiveness. Policymakers may easily be misled by peer-reviewed published economic evaluations that fail to follow appropriate economic methods and lead them to implement policies that are harmful and costly relative to using cost-effective treatments.

A document by Elif Güzide Emirza. Click on the document to view its contents.

Background: Numerous national-based indicators aid in designing population-centered chronic disease surveillance. However, there is little consensus on the key indicators and goals for developing a chronic disease surveillance analysis system. Objective: This study aimed to develop evidence-based indicators to measure and improve the health outcomes of chronic disease surveillance systems in Korea. Methods: A scoping review was focused on peer-reviewed literature from 2012 to 2022 using PubMed, Medline, Embase, PsychINFO, CINHAL, Wiley Online, Scopus, and Cochrane Library. Three reviewers evaluated and selected the articles in accordance with comprehensive inclusion and exclusion criteria. Data were synthesized using median descriptive analysis, prioritization, and agreement. There was a consensus meeting to discuss the recommendations, and the findings were analyzed thematically and descriptively. Results: Forty-eight articles were finalized and most of them were published in 2019 (18.8%). The studies on chronic disease-based surveillance systems and related data sources were conducted primarily in Canada (58.3%). The findings were prioritized by prevalence rate, risk factors, data linkage, complex disease, and updated indicators in a current system. The key themes of focus were mortality, survival management, diagnosis, treatment, and healthcare systems. Conclusion: Our preliminary measurement methods need validation through follow-up projects. Chronic disease surveillance will improve public health resource allocation and monitoring in real time. Public health and healthcare systems could be enhanced through timely assessments of population health at the local and regional levels. In Korea, experts will validate the chronic disease-based surveillance system’s development.

The migration of health workers remains one of the most pressing challenges facing many countries in the global South. This short communication seeks to reignite debate on the effectiveness of the 2010 WHO Global Code of Practice as a tool for managing the migration of health workers from the South. While the WHO Code of Practice was effective in reducing the migration of health workers from countries such as Zimbabwe during its first five years of its implementation, demand for health workers in the UK after Brexit and the COVID-19 pandemic has accelerated the rate of migration of health workers from countries facing critical shortages. Clearly, new solutions are needed that strike a balance between the right of the health workers in the South to migrate and the right of citizens in the region to a stable supply of health workers.

Introduction: Reflection and learning about the use of virtual care in healthcare delivery has become a central goal for health systems internationally. Insights drawn in the aftermath of the COVID-19 pandemic have led to vast changes to embed virtual care in health care delivery. This study explored the methodologies used to manage change that encompasses virtual care and factors contributing to success. Methods: A systematic review and narrative synthesis was undertaken. Eligible articles were those reporting structured change management processes in the context of virtual care published between 1 st January 2019 –31 st December 2023, identified by searching four electronic databases (Scopus, MedLine, PsycInfo and Business Source Premier). Data were extracted and synthesised from the eligible studies. Results: A total of 17 articles were included; studies focused on changes occurring within hospital settings and in community health centres, often within a single organisational unit, institution, or hospital network. Studies described using various methodologies for managing change during the introduction of large digital systems, embedding new digital tools, the introduction of new technologies and workflow or process design changes resulting from virtual care. Discussion: Structured change methodologies were often integrated in a strategic change framework with process improvement methods utilised to support the change process. Managing change relating to the technology with attention to the clinical and people aspects of change was considered a key gap and challenge in the context of virtual care change. Change leadership and the integration of technical and clinical teams were identified as key enablers.

Covid-19 demanded new ways of working. In this paper, we present the experience of the Vaxi Taxi, a community-orientated model of care developed when Emergency Medical Services (EMS) pivoted in response to the Covid-19 pandemic, converting its ambulances into mobile vaccination units in the Western Cape, South Africa. Using a five-year long embedded research approach, we drew on traditions of organizational ethnography and critical action research. Data collection included documenting observations and reflections in a research diary during implementation. In addition, in-depth interviews, focus group discussions and a series of sensemaking discussions with academic research team members were done. Our analysis draws on the Everyday Health Systems Resilience framework (EHSR) which understands resilience as an emergent process underpinned by system capacities (cognitive, behavioral and contextual) that can be nurtured through response to stress and shock. Responses take the form of absorptive, adaptive or transformative strategies. We consider the Vaxi Taxi as adaptive resilience strategy that nurtured system capacities which may have transformative potential in future. For health practitioners, it highlights the value of creative problem-solving to generate ‘slack in the system’ and creating ‘spaces of unlearning’ in supporting adaptive strategies. However, the experience also highlighted that the relational work to support meaningful community relationships that enable trust take time. Routine EMS operations don’t support this trust building, and this requires alternative approaches. Finally, the paper represents a rare empirical example of an adaptive response to crisis tracked over time, and thus offers globally relevant lessons to the still-small EHSR literature.

Background: Linguistic concordance between healthcare providers and patients is critical for ensuring quality healthcare. Professional interpretation can be expensive and challenging to access. This scoping review aimed to explore the evidence on the role and education of medical students as interpreters in caring for patients with limited language proficiency (LLP), and to determine the benefits and risks associated with this practice. Methods: A scoping review using the Joanna Briggs Institute methodology was conducted. Six literature databases were searched systematically between 1946 – 02 Aug 2023. All publications discussing the use of medical students as interpreters in healthcare settings were included. Retained documents were analyzed using Covidence, with coding by two raters and regular team discussions. A thematic analysis framework was used. Results: Thirteen articles met the eligibility criteria. Multilingual medical students are frequently asked to interpret in healthcare settings. This was found to be advantageous in reducing communication barriers, improving care quality, and contributing to students’ clinical experience. Concerns were raised regarding the lack of knowledge on the professional obligations of interpreters. Interpretation training programs for medical students have been implemented at selective healthcare centres and demonstrated successful results in providing care to LLP patients. Conclusions: Medical students play an important role in addressing language barriers in healthcare institutions when serving LLP patients, by combining their unique position in the healthcare team with their medical, linguistic, and cultural competency skills. Academic institutions stand to benefit from offering interpretation training programs and integrating medical students as a resource towards delivering language-concordant care.

Background: Low contraceptive prevalence rates among women of reproductive age in low-income countries, including Nigeria, continue to impede efforts to improve women’s reproductive health through family planning services. This qualitative study examines the barriers to accessing family planning clinics. Methods: In-depth interviews with 30 women aged 15 to 49 were conducted at a secondary and a tertiary health facility, Lagos. Results: The research identifies two key themes: the impact of geographic proximity and the challenges faced at the clinic in accessing family planning services.” Women living far from clinics face transportation barriers. Long waiting times, stigma and privacy are issues identified, particularly in government clinics. Despite challenges, respondents praised nurses and expressed satisfaction with services. Conclusions: The study offers contemporary insights into the specific challenges faced by women in Lagos State, aiming to inform targeted interventions and policy recommendations. The study, however, suggests that even with the removal of proximity barriers, stigma remains a limiting factor for interventions, adding a novel perspective to the discourse on reproductive health in low-income settings. Addressing these barriers in a holistic manner is vital for empowering women to make informed reproductive choices, ultimately improving maternal and child health outcomes.

Pairing assistance (PA) of health professionals between county hospitals and township health centers is one of the key components of the reform of medical alliances in China to strengthen the development of health workforce in primary health care (PHC). This study aims to examine the effect of PA on healthcare utilization for patients with chronic diseases in rural areas. Two waves of National Health Services Survey (2013 and 2018) were used. A total of 13893 and 22725 rural residents with chronic diseases were included in the 2013 and 2018 waves, respectively. Multiple logistic regressions were used to examine the associations between PA and outpatient and inpatient service utilization in PHC. Chow test was used to examine the difference between PA in two models. Among rural patients with chronic diseases, two-week outpatient visits increased from 22.69% to 27.54%, and annual hospitalization admission increased from 20.72% in 2013 to 25.44%. PA was associated with a significant decrease in outpatient visits (p<0.001) in 2018 after controlling for individual and county characteristics. Patients in PA counties were 1.45 times (95% CI 1.10-1.90) more likely to use PHC outpatient care in 2013, but the difference disappeared in 2018 (OR=0.85, 95% CI 0.71-1.01). PA did not reverse the downward trend in the share of PHC outpatient visits. PA under medical alliances in China provides a potential model for building integrated people-centered health systems for other low- and middle-income countries.

The objective of this study was to explore the dynamics of efficiency and productivity of Greek public hospitals during the crisis, as well as to review the effect of implemented policies on hospital efficiency before and the implementation of the claw-back for hospital pharmaceutical expenditure. We implemented Data Envelopment Analysis and decomposed the Malmquist productivity index (MPI) to investigate the fluctuations of the Greek public hospital productivity frontier and therefore their technical efficiency between 2009 and 2019. The MPI components allowed us to capture the frontier shift, as well as pure efficiency changes and scale efficiency changes. Through the period 2009-2019 hospital inputs were reduced drastically. Doctors were reduced by 54% while beds were reduced by 15%. Hospital expenditure was decreasing between 2009 and 2015 but increased by 23% since due to fixed hospital budgets and the “claw-back”. Moreover, output seems to have increased. Patient discharges increased by 14% while diagnostic procedures were reduced by 10% between 2009 and 2016 but have been continuously rising since. Nonetheless, under variable returns to scale (VRS) average hospital efficiency was stable (~75%) for most of the period under study while declining since 2016. Policymakers in Greece have always chosen to implement cost- or input-oriented policies, instead of opting to improve outputs and quality of services. Our analysis indicated that fixed-budget-oriented reforms have impacted hospital efficiency negatively by creating a counterincentive to adopting best practices and improving hospital efficiency. Highlights Technical Efficiency under CRS was stable in Greece (0.70) over the period 2012-2016, and declined to 0.51 in 2019. Hospital Fixed Budget reforms had a negative impact on hospital efficiency. During the economic crisis 2009-2019 hospital inputs were reduced drastically Memorandum Policies introduced by Troika focused exclusively in reducing cost and not improving efficiency.

With the development of medical treatment partnership and “internet + medical service” in China, this study proposes a remote patient perceived value satisfaction model (RPPVSM) with online medical service for specialties from the perspective of patient perceived value. Taking Shanghai Pulmonary Hospital Specialist Alliance (SPHSA) as the research subject, RPPVSM was constructed based on ACSI and TAM. Structural Equation Modeling (SEM) was modified to have a better degree of fitness and validation outcomes of the hypothesis as follows: Perceived ease of use has a significantly positive impact on perceived value with coefficient being 0.248; perceived usefulness has a significantly positive impact on the satisfaction with coefficient being 0.577; perceived value has a significantly positive impact on satisfaction with coefficient being 0.163. Perceived synergy has a significantly positive impact on perceived value with coefficient of 0.547; perceived ease of use will have a significantly positive impact on satisfaction through the perceived value variable with coefficient of mediation being 0.094; perceived synergy has a significant impact on satisfaction through perceived value with mediation coefficient being 0.196. The results suggest that the inclusion of the patient’s perception value index in the medical information platform is conducive to the construction of RPPVSM.

Abstract Objective This study aims to explore the spatiotemporal disparities in the equalization of basic medical and health services in China, in order to provide reference and guidance for promoting the equalization process of basic medical and health services and ensuring the fair enjoyment of citizens’ right to life and health. Methods Based on the theory of Structure-Process-Outcome(SPO), a comprehensive evaluation index system of equalization level was constructed with 22 core indicators of basic medical and health services, from the three dimensions of medical and health investment, health service utilization, and medical service effectiveness. The Generalized Principal Component Analysis (GPCA) model was used to calculate the equalization level of basic medical and health services in 31 provinces, municipalities, and autonomous regions from 2011 to 2021. Furthermore, the kernel density estimation and Moran’s I model was employed to analyze the correlation and disparity at the spatial level. Results 1. From a national perspective, the level of equalization of basic medical and health services in China has significantly improved from 2011 to 2021. The mean score of national equalization level increased from -0.605 to 0.174, with an increase of 128.75%.

As the Universal Health Insurance Plan (RAMU) is being implemented in Mali, community-based health insurance (CBHI) — one of the pillars— must innovate to meet the challenge of universal health coverage. An experimental CBHI was tested in central Mali between 2017 and 2021. This innovative CBHI professionalizes and organizes risk sharing on a larger scale, moving from municipalities to circles (department). A mixed-method study was carried out to assess the acceptability of this innovation among elected representatives of CBHI offices. In April 2021, 118 questionnaires were administered, followed by 43 qualitative interviews from the same sample in October 2021. Sekhon el al. (2017) seven dimensions of acceptability was used as the conceptual model. More than half of individuals (58%) reported above-average acceptability. Elected officials feel well supported in their activities by the Technical Union of Malian Mutuality (UTM), the umbrella organization of CBHI. They show some confidence in their ability to perform their duties effectively despite varying levels of commitment that often fall short of expectations and needs, which they justify by their volunteer status. Elected officials note that the system is very effective despite the nonoptimal conditions linked to the prevailing insecurity. Professionalization appears to be an unavoidable condition for the performance of the innovation, as well as the new community assembly. However, elected officials are concerned about the sustainability. The UTM will play an important role in continuing its support and fulfilling its functions as a delegated management organization within the framework of the RAMU.

A document by Hamed Khalili. Click on the document to view its contents.

The 35 member states (MS) of the Pan American Health Organization (PAHO) have been committed to training physicians in leadership competencies since 2008. However, four reviews on teaching leadership using competency-based education (CBE) in undergraduate medical education (UME) identified only two MS: Canada and the USA that worked on identifying gaps in teaching leadership in UME. Previous reviews did not focus on factors influencing leadership education and did not use qualitative methodology to support their findings. Therefore, this review aims to identify facilitating and inhibiting factors in teaching leadership in UME using a scoping review and thematic analysis. Six databases containing grey and indexed literature in English, Spanish, and Portuguese were searched including hand search and authors’ consultations. Forty-eight documents out of 7849 were selected based on eligibility criteria. Braun and Clarke’s thematic analysis guide was used, resulting in seven themes: curriculum, intended learning outcomes, teaching methods, assessment, addressing barriers, supporting organizational change, and building networks. Considering these themes, the authors propose a critical route for teaching leadership in UME in the Americas. First, institutional design should consider governance gaps, such as having national and international policies for leadership in UME with an inter-professional, trans-professional, and citizen-focused approach. This means that there is a pressing need to equip physicians and other professionals from the government, academia, non-governmental organizations, hospitals, and national and international organizations whose missions are related to health or education with leadership competencies. Networking among actors for leadership education and teacher training is also essential. Second, instructional design reveals knowledge-do gaps in MS when incorporating leadership into the medical curriculum. This includes using leadership frameworks, defining learning outcomes, and employing assessment and monitoring tools for leadership education. Mechanisms to reduce these gaps in MS include the Equator Network and Evidence-Informed Policy Networks which foster knowledge translation and governance.

Purpose: The provision of accessible eye care services can help reduce the prevalence of avoidable blindness within a population by providing timely high-quality interventions to those in need. Our aim was to identify and quantify barriers to accessing eye care for the elderly population in Pakistan, which prevent effective eye care delivery to this group. Patients’ experiences with the Sehat Sahulat (health insurance) programme (SSP) in relation to eye care were also explored. Methods: Using an exploratory sequential mixed methods design, an initial qualitative phase explored participant experiences and identified specific barriers. The qualitative study provided the basis for the development of a customised survey tool. The survey tool was used in a second phase to obtain quantitative data of barriers and costs associated with accessing eye care. Results: Numerous considerable barriers were identified, including illiteracy, long travel times, female gender, old age, mobility issues, and costs, all of which limited access to eye care in Pakistan. Awareness surrounding the use of the SSP was poor, with the programme seldom used for eye care costs. Conclusions: This study provides valuable evidence on patient experience with eye care services in urban and rural areas of Pakistan, including expenditure, patient priorities, and enablers and barriers to accessing eye care. Areas for improvement should focus on educating the public on eye health, increasing the availability of secondary eye care services in rural areas, improving accessibility within eye care facilities, addressing gender disparities, and reducing costs associated with eye care treatments, potentially through advancement of the SSP.

Objective: To integrate the qualitative research on self-management experience of breast cancer patients, and conduct a systematic review on their self-management experience. Methods: Using a computer to search a series of databases such as CNKI, Wanfang, VIP, and China Biomedical Database, systematically collect and integrate qualitative research on the self-management experience of breast cancer patients, and the search time is limited to 2010 January to December 2022. The qualitative research quality evaluation standard of the Joanna Briggs Institute (JBI) Center for Evidence-Based Health Care in Australia was used as the evaluation standard of this project to complete the accurate evaluation of the literature; Meta-analysis was used to complete the effective integration of the results. Results: A total of 17 literatures were included in this project, and 37 research results with strong integrity were extracted accordingly. On this basis, 7 different categories were summarized, and 3 integrated results were obtained, which were experience of maintaining self-management, symptom recognition, and self-management. Conclusion: In the different stages of self-management of breast cancer patients, medical staff should give targeted guidance to help patients obtain good prognosis. Patient or Public Contribution： Patients, service users, care-givers, people with lived experience or members of the public were involved at several stages of the trial, including the design, management and conduct of the trial, but all the information was collected from public database. The statement is not applicable.

Background. Discharge against medical advice (DAMA) is used in healthcare facilities in a situation where patients refuse care or decide to leave the hospital before the treating physician recommends discharge. Previous studies have found DAMA to be prevalent among patients with various chronic conditions. The study had four objectives. The study aimed to investigate: 1) the prevalence of DAMA during COVID-19 (2020-2021) among Jordanian patients with chronic diseases, 2) the association between DAMA and sociodemographic and clinical characteristics of patients with chronic diseases, 3) the predictors of DAMA, and 4) the reasons behind DAMA at the patient, hospital, and environmental levels. Methods. A descriptive cross-sectional correlational design was used in the study. A convenience sampling approach was used to collect data from 1576 patients with chronic diseases from 3 private hospitals. Results. The study found that the prevalence rate of DAMA was 33.3%. There was a significant association between the sociodemographic and clinical characteristics of patients with chronic diseases and DAMA. Health insurance found to be the strongest predictor of DAMA. Finally, the study found that patient, hospital, and environmental- related factors had a low impact on DAMA. Conclusions: DAMA is prevalent among patients with chronic diseases in Jordan during COVID-19 pandemic. The current study’s findings can serve as an empirical basis for planning and implementing DAMA prevention programs and/or establishing or revising policies for the target population.