Search

Background: A robust medical claims review system is crucial for addressing fraud and abuse and ensuring financial viability of health insurance organisations. This paper assesses claims adjustment rate of the paper- and electronic-based claims reviews of the National Health Insurance Scheme (NHIS) in Ghana.Methods: The study was a cross-sectional comparative assessment of paper- and electronic-based claims reviews of the NHIS. Medical claims of subscribers for the year, 2014 were requested from the claims directorate and analysed. Proportions of claims adjusted by the paper- and electronic-based claims reviews were determined for each type of healthcare facility. Bivariate analyses were also conducted to test for differences in claims adjustments between healthcare facility types, and between the two claims reviews.Results: The electronic-based review made overall adjustment of 17.0% from GHS10.09 million (USD2.64 m) claims cost whilst the paper-based review adjusted 4.9% from a total of GHS57.50 million (USD15.09 m) claims cost received, and the difference was significant (p < 0.001). However, there were no significant differences in claims cost adjustment rate between healthcare facility types by the electronic-based (p = 0.0656) and by the paper-based reviews (p = 0.6484).Conclusions: The electronic-based review adjusted significantly higher claims cost than the paper-based claims review. Scaling up the electronic-based review to cover claims from all accredited care providers could reduce spurious claims cost to the scheme and ensure long term financial sustainability. [ABSTRACT FROM AUTHOR]

Research studies as well as anecdotal evidence suggest that there are challenges regarding the NHI plan implementation. These include problems such as an increase in illnesses and a shortage of personnel to drive the project in South African public hospitals. This is exacerbated by the existing situation of most government-funded healthcare institutions, which are characterized by bad administration, insufficient budget, inadequate infrastructure, and insufficient drug supply, as highlighted in several studies. The hospital under investigation is one such facility, with a history of patients sleeping on the floor and people being turned away owing to a shortage of experts and an overburdened staff. This situation is concerning, given that the government claims to be providing appropriate funds to the institution. The hospital under research is highly regarded by the surrounding community. However, a visit by the Health MEC in 2014 revealed that the facility had insufficient sanitary standards and a high complaint rate. Based on the foregoing, as well as the difficulties that both employees and patients are confronted with at the  selected hospital, the question that emerges is whether the hospital is fit for the implementation of the NHI.Aim: The aim of this study was to assess the preparation for the launch of the national health insurance scheme at a Johannesburg hospital.Setting: The study was conducted at a hospital situated in eastern suburbs of Johannesburg, Gauteng, South Africa.Method: The study employed a qualitative method with an explorative, descriptive, qualitative study design. The population consisted of selected hospital employees, such as doctors, dispensary officers, hospital managers, human resources workers, facility managers, and administration record officials who were employed at the selected hospital. Purposive sampling was used to select participants.Sample Size: Category saturation was used to determine the sample size. The participants for the study were chosen using purposeful sampling, with the researcher aiming for those who were familiar with the NHI scheme at the institution. Semi structured interviews and a focus group discussion were used to gather data. The data from the focus group discussion and semi-structured interviews were analysed using thematic analysis.Results: The investigation found that the hospital was preparing to for the NHI implementation, but that was riddled with lack of resources, poor infrastructure, lack of training, delays in development and poor technological advances.Recommendations: The paper suggests that human resources be increased, infrastructure be upgraded, medicines and equipment be increased, and enough training on NHI implementation be provided.Contribution: The paper adds to the body of knowledge regarding the NHI in South Africa. [ABSTRACT FROM AUTHOR]

Background: Compassionate use programs (CUP) for medicines respond to the ethical imperative of providing access to medicines before marketing approval to patients not recruited in trials. The economic impact of clinical trials has previously been investigated. No evidence on the net economic benefit of CUP exists. This research aims to address this information gap by estimating the economic consequences of 11 CUP in Italy conducted between March 2015 and December 2020 from the perspective of public health care system in Italy (National Health Service). Eight programs concern cancer treatments, two refer to spinal muscular atrophy, and one is indicated for multiple sclerosis.Methods: Since CUP medicines are covered by the industry, the net economic benefit includes: (i) avoided costs of the Standard of Care (SoC) the patients would have received had they not joined the CUP, (ii) costs not covered by the pharmaceutical industry sponsor, but instead sustained by payers, such as those associated with adverse events (only severe side effects resulting in hospitalisation and attributable to CUP medicines), and (iii) costs for combination therapies and diagnostic procedures not used with the SoC. The SoC costing relied on publicly available data. Information on adverse events and diagnostic procedures was retrieved from the CUP and monetized using the relevant fee for episode or service. One CUP was excluded since a SoC was not identified.Results: 2,713 patients were treated in the 11 CUP where a SoC was identified. The SoC mean cost per patient ranged from €11,415 to €20,299. The total cost of the SoC ranged between €31.0 and €55.1 million. The mean cost per patient covered by hospitals hosting CUP was equal to €1,646, with a total cost of €4.5 million. The net economic benefit ranged €26.5 million - €50.6 million.Conclusions: Despite research limitations, this paper illustrates for the first time the net economic impact of CUP from a public payer perspective. It is important to integrate these estimates with the prospective effects of CUP implementation, i.e., the economic value of the comparative benefit profile of medicines used in CUP versus the SoC, including effects from a societal perspective. [ABSTRACT FROM AUTHOR]

Background: The objective of this paper is to identify the key conditions that positively affect the use of e-health services in Central Eastern Europe (CEE) countries. CEE countries after the political and economic transformation in 1989/90 implemented slightly different national health care models. The research question of the study is: how do the various institutional conditions at the national level affect the use of e-health services in CEE countries?Methods: The e-health description was derived from papers indexed in Web of Science and Scopus. The data for computation were collected from the 2015 global survey by the WHO Global Observatory for eHealth. We used a narrative literature review in order to identify key terms associated to e-health and conditions for the implementation of e-health services. The search terms were "e-health" and "*" where * was particular thematic section of e-health according to WHO GOeH. The inclusion criterion was relevance of the paper to e-health and searched phase. Eligibility criteria for countries for being described as CEE countries: Estonia, Lithuania, Latvia, Poland, Hungary, Romania, Bulgaria, Czech Republic, Slovenia, and Croatia (we omitted Slovakia from the analysis because this country was not covered by the WHO Survey). We applied qualitative comparative analysis (QCA) to analyse the necessary order of conditions. The dependent variable of the study is the national rate of use of e-health services.Results: QCA shows that legal medical jurisdiction, teleprogramme and electronic health records supplemented by adequate training constitute critical conditions to achieve success in e-health implementation.Conclusions: We conclude that the more formalised a framework for e-health service delivery is, the more likely it will be used. Therefore formalisation fosters the diffusion, dissemination and implementation of e-health solutions in this area. Formalisation must be accompanied by tailored training for health care professionals and patients. Our analyses are related only to the paths of e-health implementation in CEE countries thus consequently the findings and conclusions cannot be directly applied to other countries. The limitations of this study are related the absence of a broader context of e-health development, including the development of ICT infrastructure and ICT literacy. [ABSTRACT FROM AUTHOR]

Background: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion.Methods: Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana.Results: Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme.Conclusion: The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play. [ABSTRACT FROM AUTHOR]

Background: Off-label drug use among ambulatory patients is often based on little or no scientific support. This paper reports the impact of a health warning about the risks of off-label flutamide use by women and the actions subsequently implemented by the public health service targeting such use.Method: The study was undertaken in a region in north-west Spain. We designed a segmented regression model of an interrupted time series, in which the dependent variable was the monthly value of defined daily doses of flutamide per 1000 inhabitants/day (DDD/TID), both total and stratified by sex. The following two data sources were used: flutamide prescriptions billed to the Spanish National Health Service; and flutamide deliveries made by wholesale drug distributors to pharmacies. The intervention assessed consisted of the issue of an official health warning and the actions subsequently taken to implement it.Results: There was an immediate reduction of 49.33% in DDD/TID billed to the Spanish National Health Service in respect of women; the mean value of the population percentage of DDD/TID of flutamide billed in respect of women fell from 34.4% pre-intervention to 23.72% post-intervention. There was an immediate reduction of 19.92% (95%CI: 6.68-33.15%) in total DDD/TID invoiced. There were no significant changes in DDD/TID billed in respect of men or in flutamide use in the private medical sector.Conclusions: Off-label drug misuse is a reality among ambulatory patients, even after actions are implemented following a toxicity warning issued by the competent Health Authority. [ABSTRACT FROM AUTHOR]

Background: Rapid evaluation was at the heart of National Health Service England's evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods.Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard.Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168.Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify "quick wins" and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources. [ABSTRACT FROM AUTHOR]

Background: A peculiar phenomenon of engaging insurance intermediaries for government funded health insurance schemes for the poor, not usually found globally, is gaining ground in India. Rajiv Aarogyasri Scheme launched in the Indian state of Andhra Pradesh, is first largest tax funded community health insurance scheme in the country covering more than 20 million poor families. Aarogyasri Health Care Trust (trust), the scheme administrator, transfers funds to hospitals through two routes one, directly and the other through an insurance intermediary. The objective of this paper is to find out if engaging an insurance intermediary has any effect on cost efficiency of the insurance scheme.Methods: We used payment data of RAS for the period 2007-12, to find out the influence of insurance intermediary on the two variables, benefit cost ratio defined as benefit payment divided by premium payment, and claim denial ratio defined as benefit payment divided by treatment cost. Relationship between scheme expenditure and number of beds empanelled under the scheme is examined. OLS regression is used to perform all analyses.Results: We found that adding an additional layer of insurance intermediary between the trust and hospitals reduced the benefit cost ratio under the scheme by 12.2% (p-value = 0.06). Every addition of 100 beds under the scheme increases the scheme payments by US$ 0.75 million (p-value < 0.001). The gap in claim denial ratio between insurance and trust modes narrowed down from 2.84% in government hospitals to 0.41% in private hospitals (p-value < 0.001).Conclusions: The scheme is a classic case of Roemer's principle in operation. Introduction of insurance intermediary has the twin effects of reduction in benefit payments to beneficiaries, and chocking fund flow to government hospitals. The idea of engaging insurance intermediary should be abandoned. [ABSTRACT FROM AUTHOR]

Health-based social enterprises are spun out of the NHS, yet continue to provide NHS-funded services. With the spin-out, however, formal processes for research governance were lost. Patients have a right to take part in research, regardless of where they access healthcare. This paper discusses the barriers to social enterprises undertaking applied health research and makes recommendations to address the need for equivalence of governance processes with NHS trusts. [ABSTRACT FROM AUTHOR]

Background: Innovation in healthcare is said to be notoriously difficult to achieve and sustain yet simultaneously the health service is under intense pressure to innovate given the ever increasing demands placed upon it. Whilst many studies have looked at diffusion of innovation from an organisational perspective, few have sought to understand how individuals working in healthcare innovate successfully. We took a positive deviance approach to understand how innovations are achieved by individuals working in the NHS.Method: We conducted in depth interviews in 2015 with 15 individuals who had received a national award for being a successful UK innovator in healthcare. We invited only those people who were currently (or had recently) worked in the NHS and whose innovation focused on improving patient safety or quality. Thematic analysis was used.Findings: Four themes emerged from the data: personal determination, the ability to broker relationships and make connections, the ways in which innovators were able to navigate organisational culture to their advantage and their ability to use evidence to influence others. Determination, focus and persistence were important personal characteristics of innovators as were skills in being able to challenge the status quo. Innovators were able to connect sometimes disparate teams and people, being the broker between them in negotiating collaborative working. The culture of the organisation these participants resided in was important with some being able to use this (and the current patient safety agenda) to their advantage. Gathering robust data to demonstrate their innovation had a positive impact and was seen as essential to its progression.Conclusions: This paper reveals a number of factors which are important to the success of innovators in healthcare. We have uncovered that innovators have particular personal traits which encourage a propensity towards change and action. Yet, for fruitful innovation to take place, it is important for relational networks and organisational culture to be receptive to change. [ABSTRACT FROM AUTHOR]

Background: Ghana introduced capitation payment for primary care in 2012 with the view to containing escalating claims expenditure. This shift in provider payment method raised issues about its potential impact on patient-provider trust relationship and insured-patients' trust in the Ghana National Health Insurance Scheme. This paper presents findings of a study that explored insured-patients' perception about, and attitude towards capitation payment in Ghana; and determined whether capitation payment affect insured-patients' trust in their preferred primary care provider and the National Health Insurance Scheme in general.Methods: We adopted a survey design for the study. We administered closed-ended questionnaires to collect data from insurance card-bearing members aged 18 years and above. We performed both descriptive statistics to determine proportions of observations relating to the variables of interest and chi-square test statistics to determine differences within gender and setting.Results: Sixty-nine per cent (69 %) out of 344 of respondents selected hospital level of care as their primary care provider. The two most important motivations for the choice of a provider were proximity in terms of geographical access (40 %) and perceived quality of care (38 %). Eighty-eight per cent (88 %) rated their trust in their provider as (very) high. Eighty-two per cent (82 %) actively selected their providers. Eighty-eight per cent (88 %) had no intention to switch provider. A majority (91 %) would renew their membership when it expires. Female respondents (91 %; n = 281) were more likely to renew their membership than males (87 %; n = 63). Notwithstanding capitation payment experience, 81 % of respondents would recommend to their peers to enrol with the NHIS with rural dwellers (87 %; n = 156) being more likely to do so than urban dwellers (76 %; n = 188). Almost all respondents (92 %) rated the NHIS as (very) good.Conclusion: Health Insurance subscribers in Ghana have high trust in their primary care provider giving them quality care under capitation payment despite their negative attitude towards capitation payment. They are guided by proximity and quality of care considerations in their choice of provider. The NHIA would, however, have to address itself to the negative perceptions about the capitation payment policy. [ABSTRACT FROM AUTHOR]

Background: The older adult population is increasing all over the world. In sub-Saharan Africa, due to poverty and low policy coverage, older adults are not well catered for. The effect of socio-economic inequality in the use of healthcare services among older adult men and women in Ghana was investigated in this paper.Methods: The data employed in the study were drawn from Global Ageing and Adult Health survey SAGE Wave 1 Ghana and was based on the design for the World Health Survey 2003, SAGE Wave 0, Ghana. The survey was conducted in 2007-2008 and collected data on socio-economic characteristics and other variables of the 5573 individuals interviewed.Results: Using generalized logit model, the study found that health status is a very strong determinant of the type of healthcare services preferred by older adults Ghanaians. Men with higher income preferred the private health facilities, while those who completed tertiary education, those with health insurance and those who self-rated their health as very bad, bad or moderate preferred public facility. Self-employed men and those in informal employment, preferred other health facilities outside the formal public health service. Women with primary and secondary education, preferred the private health facilities. Women with health insurance, those in middle and upper class income quintiles or those with self-rated bad and moderate health status or being relatively younger preferred the public facility to other health services. Self-employed women and those in informal employment preferred traditional treatment. In Ghana, there are important socio-economic gradients in the use of some healthcare services. In both sexes, those without insurance and rural residents preferred the pharmacy and traditional treatment.Conclusion: These differences may be due to socio-economic inequities but could also indicate that the existing health facilities are not always used in an optimal way. Patient factors may be equally important as supply factors in explaining the differential use of health services. The public health systems in Ghana still have a major role in improving the health of older adults. National commitments in providing basic essential infrastructure and personnel to health centres for the citizenry is imperative. Policy readjustment of the national health insurance scheme to make it truly accessible to the aged is essential. [ABSTRACT FROM AUTHOR]

Background: National health insurance schemes (NHIS) in developing countries and perhaps in developed countries as well is a considered a pro-poor intervention by helping to bridge the financial burden of access to quality health care. Perceptions of quality of health service could have immense impacts on enrolment. This paper shows how perception of service quality under Ghana's insurance programme contributes to health insurance subscription.Methods: The study used the 2014 Ghana Demographic and Health Survey (GDHS) dataset. Both descriptive proportions and binary logistic regression techniques were applied to generate results that informed the discussion.Results: Our results show that a high proportion of females (33 %) and males (35 %) felt that the quality of health provided to holders of the NHIS card was worse. As a result, approximately 30 % of females and 22%who perceived health care as worse by holding an insurance card did not own an insurance policy. While perceptions of differences in quality among females were significantly different (AOR = 0.453 [95 % CI = 0.375, 0.555], among males, the differences in perceptions of quality of health services under the NHIS were independent in the multivariable analysis. Beyond perceptions of quality, being resident in the Upper West region was an important predictor of health insurance ownership for both males and females.Conclusion: For such a social and pro-poor intervention, investing in quality of services to subscribers, especially women who experience enormous health risks in the reproductive period can offer important gains to sustaining the scheme as well as offering affordable health services. [ABSTRACT FROM AUTHOR]

Background: Why issues get on the policy agenda, move into policy formulation and implementation while others drop off in the process is an important field of enquiry to inform public social policy development and implementation. This paper seeks to advance our understanding of health policy agenda setting, formulation and implementation processes in Ghana, a lower middle income country by exploring how and why less than three months into the implementation of a pilot prior to national scale up; primary care maternal services that were part of the basket of services in a primary care per capita national health insurance scheme provider payment system dropped off the agenda.Methods: We used a case study design to systematically reconstruct the decisions and actions surrounding the rise and fall of primary care maternal health services from the capitation policy. Data was collected from July 2012 and August 2014 through in-depth interviews, observations and document review. The data was analysed drawing on concepts of policy resistance, power and arenas of conflict.Results: During the agenda setting and policy formulation stages; predominantly technical policy actors within the bureaucratic arena used their expertise and authority for consensus building to get antenatal, normal delivery and postnatal services included in the primary care per capita payment system. Once policy implementation started, policy makers were faced with unanticipated resistance. Service providers, especially the private self-financing used their professional knowledge and skills, access to political and social power and street level bureaucrat power to contest and resist various aspects of the policy and its implementation arrangements - including the inclusion of primary care maternal health services. The context of intense public arena conflicts and controversy in an election year added to the high level political anxiety generated by the contestation. The President and Minister of Health responded and removed antenatal, normal delivery and postnatal care from the per capita package.Conclusion: The tensions and complicated relationships between technical considerations and politics and bureaucratic versus public arenas of conflict are important influences that can cause items to rise and fall on policy agendas. [ABSTRACT FROM AUTHOR]

Background: This paper has three objectives: to review the health development landscape in the World Health Organization African Region, to discuss the role of health policy dialogue in improving harmonisation and alignment to national health policies and strategic plans, and to provide an analytical view of the critical factors in realising a good outcome from a health policy dialogue process.Discussion: Strengthening policy dialogue to support the development and implementation of robust and comprehensive national health policies and plans, as well as to improve aid effectiveness, is seen as a strategic entry point to improving health sector results. However, unbalanced power relations, the lack of contextualised and relevant evidence, the diverse interests of the actors involved, and the lack of conceptual clarity on what policy dialogue entails impact the outcomes of a policy dialogue process. The critical factors for a successful policy dialogue have been identified as adequate preparation; secured time and resources to facilitate an open, inclusive and informed discussion among the stakeholders; and stakeholders' monitoring and assessment of the dialogue's activities for continued learning. Peculiarities of low income countries pose a challenge to their policy dialogue processes, including the chaotic-policy making processes, the varied capacity of the actors and donor dependence.Conclusion: Policy dialogue needs to be appreciated as a complex and iterative process that spans the whole process of policy-making, implementation, review and monitoring, and subsequent policy revisions. The existence of the critical factors for a successful policy dialogue process needs to be ensured whilst paying special attention to the peculiarities of low income countries and potential power relations, and mitigating the possible negative consequences. There is need to be cognisant of the varied capacities and interests of stakeholders and the need for capacity building, and to put in place mechanisms to manage conflict of interest. The likelihood of a favourable outcome from a policy dialogue process will depend on the characteristics of the issue under consideration and whether it is contested or not, and the policy dialogue process needs to be tailored accordingly. [ABSTRACT FROM AUTHOR]

Background: The Global Forum 2015 panel session dialogue entitled "From evidence to policy - thinking outside the box" was held on 26 August 2015 in the Philippines to debate why evidence was not fully translated into policy and practice and what could be done to increase its uptake. This paper reports the reasons and possible actions for increasing the uptake of evidence, and highlights the actions partners could take to increase the use of evidence in the African Region.Discussion: The Global Forum 2015 debate attributed African Region's low uptake of evidence to the big gap in incentives and interests between research for health researchers and public health policy-makers; limited appreciation on the side of researchers that public health decisions are based on multiple and complex considerations; perception among users that research evidence is not relevant to local contexts; absence of knowledge translation platforms; sub-optimal collaboration and engagement between industry and research institutions; lack of involvement of civil society organizations; lack of engagement of communities in the research process; failure to engage the media; limited awareness and debate in national and local parliaments on the importance of investing in research and innovation; and dearth of research and innovation parks in the African Region.Conclusion: The actions needed in the Region to increase the uptake of evidence in policy and practice include strengthening NHRS governance; bridging the motivation gap between researchers and health policy-makers; restoring trust between researchers and decision-makers; ensuring close and continuous intellectual intercourse among researchers, ministry of health policy-makers and technocrats during the life course of research projects or programmes; proactive collaboration between academia and industry; regular briefings of civil society, media, relevant parliamentary committees and development partners; development of vibrant knowledge translation platforms; development of action plans for implementing research recommendations, preferably in the context of the Sustainable Development Goals; and encouragement of competition on NHRS strengthening and research output and uptake among the countries using a barometer or scorecard to review their performance at various regional ministerial forums and taking into account the lessons learned from the MDG period. [ABSTRACT FROM AUTHOR]

Background: Involving doctors in management has been intended as one of the strategies to spread organizational principles in healthcare settings. However, professionals often resist taking on relevant managerial responsibility, and the question concerning by which means to engage doctors in management in a manner that best fit the challenges encountered by different health systems remains open to debate.Methods: This paper analyzes the different forms of medical management experienced over time in the Italian NHS, a relevant "lab" to study the evolution of the involvement of doctors in management, and provides a framework for disentangling different dimensions of medical management.Results: We show how new means to engage frontline professionals in management spread, without deliberate planning, as a consequence of the innovations in service provision that are introduced to respond to the changes in the healthcare sector.Conclusions: This trend is promising because such means of performing medical management appear to be more easily compatible with professional logics; therefore, this could facilitate the engagement of a large proportion of professionals rather than the currently limited number of doctors who are "forced" or willing to take formal management roles. [ABSTRACT FROM AUTHOR]

Background: The UK National Health Service Health Checks programme aims to reduce avoidable cardiovascular deaths, disability and health inequalities in England. However, due to the reported lower uptake of screening in specific black and minority ethnic communities who are recognised as being more at risk of cardiovascular disease, there are concerns that NHS Health Checks may increase inequalities in health. This study aimed to examine the feasibility and acceptability of community outreach NHS Health Checks targeted at the Afro-Caribbean community.Methods: This paper reports findings from an ethnographic study including direct observation of four outreach events in four different community venues in inner-city Bristol, England and follow up semi-structured interviews with attendees (n = 16) and staff (n = 4). Interviews and field notes were transcribed, anonymized and analysed thematically using a process of constant comparison.Results: Analysis revealed the value of community assets (community engagement workers, churches, and community centres) to publicise the event and engage community members. People were motivated to attend for preventative reasons, often prompted by familial experience of cardiovascular disease. Attendees valued outreach NHS Health Checks, reinforcing or prompting some to make healthy lifestyle changes. The NHS Health Check provided an opportunity for attendees to raise other health concerns with health staff and to discuss their test results with peers. For some participants, the communication of test results, risk and lifestyle information was confusing and unwelcome. The findings additionally highlight the need to ensure community venues are fit for purpose in terms of assuring confidentiality.Conclusions: Outreach events provide evidence of how local health partnerships (family practice staff and health trainers) and community assets, including informal networks, can enhance the delivery of outreach NHS Health Checks and in promoting the health of targeted communities. To deliver NHS Health Checks effectively, the location and timing of events needs to be carefully considered and staff need to be provided with the appropriate training to ensure patients are supported and enabled to make lifestyle changes. [ABSTRACT FROM AUTHOR]

Background: National Health Service (NHS) trusts, which provide the majority of hospital and community health services to the English NHS, are increasingly adopting a 'public firm' model with a board consisting of executive directors who are trust employees and external non-executives chosen for their experience in a range of areas such as finance, health care and management. In this paper we compare the non-executive directors' roles and interests in, and contributions to, NHS trust boards' governance activities with those of executive directors; and examine non-executive directors' approach to their role in board meetings.Methods: Non-participant observations of three successive trust board meetings in eight NHS trusts (primary care trusts, foundation trusts and self-governing (non-foundation) trusts) in England in 2008-9. The observational data were analysed inductively to yield categories of behaviour reflecting the perlocutionary types of intervention which non-executive directors made in trust meetings.Results: The observational data revealed six main perlocutionary types of questioning tactic used by non-executive directors to executive directors: supportive; lesson-seeking; diagnostic; options assessment; strategy seeking; and requesting further work. Non-executive board members' behaviours in holding the executive team to account at board meetings were variable. Non-executive directors were likely to contribute to finance-related discussions which suggests that they did see financial challenge as a key component of their role.Conclusions: The pattern of behaviours was more indicative of an active, strategic approach to governance than of passive monitoring or 'rubber-stamping'. Nevertheless, additional means of maintaining public accountability of NHS trusts may also be required. [ABSTRACT FROM AUTHOR]

Background: Patient reported outcome measures (PROMs) have been integrated in national quality registries or specific national monitoring initiatives to inform the improvement of quality of care on a national scale. However there are many unanswered questions, such as: how these systems are set up, whether they lead to improved quality of care, which stakeholders use the information once it is available. The aim of this study was to examine supporting and hindering factors relevant to integrating patient-reported outcome measures (PROMs) in selected health information systems (HIS) tailored toward improving quality of care across the entire health system.Methods: First, a systematic search and review was conducted to outline previously identified factors relevant to the integration of PROMs in the selected HIS. A social network analysis was performed to identify networks of experts in these systems. Second, expert interviews were conducted to discuss and elaborate on the identified factors. Directive content analysis was applied using a HIS Evaluation Framework as the frame of reference. This framework is structured into four components: Organization, Human, Technology, and Net benefits.Results: The literature review revealed 37 papers for the NHS PROMs Programme and 26 papers for the SHPR and SKAR: Five networks of researchers were identified for the NHS PROMs Programme and 1 for the SHPR and SKAR. Seven experts related to the NHS PROMs Programme and 3 experts related to the SKAR and SHPR participated in the study. The main themes which revealed in relation to Organization were Governance and Capacity building; to Human: Reporting and Stakeholder Engagement; to Technology: the Selection and Collection of PROMs and Data linkage. In relation to Net benefits, system-specific considerations are presented.Conclusion: Both examples succeeded in integrating PROMs into HIS on a national scale. The lack of an established standard on what change PROMs should be achieved by an intervention limits their usefulness for monitoring quality of care. Whether the PROMs data collected within these systems can be used in routine clinical practice is considered a challenge in both countries. [ABSTRACT FROM AUTHOR]

Background: Ghana is attracting global attention for efforts to provide health insurance to all citizens through the National Health Insurance Scheme (NHIS). With the program's strong emphasis on maternal and child health, an expectation of the program is that members will have increased use of relevant services. Methods: This paper uses qualitative and quantitative data from a baseline assessment for the Maternal and Newborn errals Evaluation from the Northern and Central Regions to describe women's experiences with the NHIS and to study associations between insurance and skilled facility delivery, antenatal care and early care-seeking for sick children. The assessment included a quantitative household survey (n = 1267 women), a quantitative community leader survey (n = 62), qualitative birth narratives with mothers (n = 20) and fathers (n = 18), key informant interviews with health care workers (n = 5) and focus groups (n = 3) with community leaders and stakeholders. The key independent variables for the quantitative analyses were health insurance coverage during the past three years (categorized as all three years, 1-2 years or no coverage) and health insurance during the exact time of pregnancy. Results: Quantitative findings indicate that insurance coverage during the past three years and insurance during pregnancy were associated with greater use of facility delivery but not ANC. Respondents with insurance were also significantly more likely to indicate that an illness need not be severe for them to take a sick child for care. The NHIS does appear to enable pregnant women to access services and allow caregivers to seek care early for sick children, but both the quantitative and qualitative assessments also indicated that the poor and least educated were less likely to have insurance than their wealthier and more educated counterparts. Findings from the qualitative interviews uncovered specific challenges women faced regarding registration for the NHIS and other barriers such lack of understanding of who and what services were covered for free. Conclusion: Efforts should be undertaken so all individuals understand the NHIS policy including who is eligible for free services and what services are covered. Increasing access to health insurance will enable Ghana to further improve maternal and child health outcomes. [ABSTRACT FROM AUTHOR]

Background Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda. Methods Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data. Results Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24-27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21-27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3-6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30-37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27-34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65-76) than at public (58%, 95% CI 54-63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities. Conclusions Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations. [ABSTRACT FROM AUTHOR]

Background: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work?Method: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants.Results: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions.Conclusions: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure. [ABSTRACT FROM AUTHOR]

Background: To date, little is known about the sustainability and scalability of MyDiabetesPlan, an eHealth innovation designed to facilitate shared decision-making within diabetes care. To avoid the possibility of its short-lived implementation and promote wider adoption so as to promote patient-centred diabetes care, it is critical to understand MyDiabetesPlan's sustainability and scalability in order to ensure its long-term impact at a greater scale. We sought to identify the sustainability and scalability potential of MyDiabetesPlan and its limiting factors. Methods: Using a concurrent triangulation mixed-methods approach, data were collected from 20 individuals involved in the development and implementation of MyDiabetesPlan. The National Health Services Sustainability Model (NHSSM) and the Innovation Scalability Self-administered Questionnaire (ISSaQ) were administered using a 'think-aloud' approach and subsequently, short semi-structured interviews were conducted. Mean aggregate scores and stakeholder-specific scores were generated for the NHSSM and ISSaQ, to quantitatively determine facilitating and limiting factors to sustainability and scalability. Content analysis occurred iteratively with qualitative data, to examine commonalities and differences with the quantitative findings. Results: The top facilitating factor to sustaining MyDiabetesPlan was "Staff involvement and training to sustain the process.", whereas the top limiting factors were: "Adaptability of Improved Process", "Senior Leadership Engagement" and "Infrastructure for Sustainability". The top three facilitating factors for scale-up were "Acceptability", "Development with Theory" and "Consistency with Policy Directives." Conversely, the top three limiting factors were "Financial and Human Resources", "Achievable Adoption" and "Broad Reach". Qualitative findings corroborated the limiting/facilitating factors identified. Conclusions: Addressing staff involvement throughout the dynamic care contexts, and resource constraints impacting scale-up can enhance the sustainability and scalability of MyDiabetesPlan. As such, future plans will focus on garnering organizational leadership buy-in and support, which may address the resource constraints associated with sustainability and scalability and improve the capacity for adequate staff involvement. eHealth researchers will be able to prioritize these limiting factors from the outset of their tool development to purposefully optimize its sustainability and scalability performance. [ABSTRACT FROM AUTHOR]

Background: Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients' prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal.Methods: This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment.Results: Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients' experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization.Conclusions: This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted. [ABSTRACT FROM AUTHOR]

Background: Implementation of new technologies into national health care systems requires careful capacity planning. This is sometimes informed by data from pilot studies that implement the technology on a small scale in selected areas. A critical consideration when using implementation pilot studies for capacity planning in the wider system is generalisability. We studied the feasibility of using publicly available national statistics to determine the degree to which results from a pilot might generalise for non-pilot areas, using the English human papillomavirus (HPV) cervical screening pilot as an exemplar.Methods: From a publicly available source on population indicators in England ("Public Health Profiles"), we selected seven area-level indicators associated with cervical cancer incidence, to produce a framework for post-hoc pilot generalisability analysis. We supplemented these data by those from publicly available English Office for National Statistics modules. We compared pilot to non-pilot areas, and pilot regimens (pilot areas using the previous standard of care (cytology) vs. the new screening test (HPV)). For typical process indicators that inform real-world capacity planning in cancer screening, we used standardisation to re-weight the values directly observed in the pilot, to better reflect the wider population. A non-parametric quantile bootstrap was used to calculate 95% confidence intervals (CI) for differences in area-weighted means for indicators.Results: The range of area-level statistics in pilot areas covered most of the spectrum observed in the wider population. Pilot areas were on average more deprived than non-pilot areas (average index of multiple deprivation 24.8 vs. 21.3; difference: 3.4, 95% CI: 0.2-6.6). Participants in HPV pilot areas were less deprived than those in cytology pilot areas, matching area-level statistics. Differences in average values of the other six indicators were less pronounced. The observed screening process indicators showed minimal change after standardisation for deprivation.Conclusions: National statistical sources can be helpful in establishing the degree to which the types of areas outside pilot studies are represented, and the extent to which they match selected characteristics of the rest of the health care system ex-post. Our analysis lends support to extrapolation of process indicators from the HPV screening pilot across England. [ABSTRACT FROM AUTHOR]

Background: ADHD affects some individuals throughout their lifespan, yet service provision for adults in the United Kingdom (UK) is patchy. Current methods for mapping health service provision are resource intensive, do not map specialist ADHD teams separately from generic mental health services, and often fail to triangulate government data with accounts from service users and clinicians. Without a national audit that maps adult ADHD provision, it is difficult to quantify current gaps in provision and make the case for change. This paper describes the development of a seven step approach to map adult ADHD service provision in the UK.Methods: A mapping method was piloted in 2016 and run definitively in 2018. A seven step method was developed: 1. Defining the target service 2. Identifying key informants 3. Designing the survey 4. Data collection 5. Data analysis 6. Communicating findings 7. Hosting/updating the service map. Patients and members of the public (including clinicians and commissioners) were involved with design, data collection and dissemination of findings.Results: Using a broad definition of adult ADHD services resulted in an inclusive list of identified services, and allowed the definition to be narrowed to National Health Service (NHS) funded specialist ADHD services at data analysis, with confidence that few relevant services would be missed. Key informants included patients, carers, a range of health workers, and commissioners. A brief online survey, written using lay terms, appeared acceptable to informants. Emails sent using national organisations' mailing lists were the most effective way to access informants on a large scale. Adaptations to the methodology in 2018 were associated with 64% more responses (2371 vs 1446) collected in 83% less time (5 vs 30 weeks) than the pilot. The 2016 map of adult ADHD services was viewed 13,688 times in 17 weeks, indicating effective communication of findings.Conclusion: This seven step pragmatic method was effective for collating and communicating national service data about UK adult ADHD service provision. Patient and public involvement and engagement from partner organisations was crucial throughout. Lessons learned may be transferable to mapping service provision for other health conditions and in other locations. [ABSTRACT FROM AUTHOR]

Background: Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention.Methods: Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices.Results: Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability.Conclusions: NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients. [ABSTRACT FROM AUTHOR]

Objective: China has made remarkable achievements in poverty alleviation. However, with the change in economic development and age structure, the population stricken by poverty due to medical expenses and disability accounted for 42.3 and 14.4% of the total poverty-stricken population, respectively. Accordingly, it is crucial to accurately pinpoint the characteristics of people who are about to become poor due to illness. In this study, we analyzed the incidence of impoverishment by medical expense at the provincial, family, and different medical insurance scheme levels to identify the precise groups that are vulnerable to medical-related poverty.Method: Data were extracted from the Fifth National Health Service Survey in China in 2013 through a multi-stage, stratified, and random sampling method, leaving 93,570 households (273,626 people) for the final sample. The method recommended by World Health Organization (WHO) was adopted to calculate impoverishment by medical expense, and logistic regression was adopted to evaluate its determinants.Results: The poverty and impoverishment rate in China were 16.2 and 6.3% respectively. The poverty rate in western region was much higher than that of central and eastern regions. The rate of impoverishment by medical expense (IME) was higher in the western region (7.2%) than that in the central (6.5%) and eastern (5.1%) regions. The New Cooperative Medical Scheme (NCMS) was associated with the highest rate (9.1%) of IME cases. The top three diseases associated with IME were malignant tumor, congenital heart disease, and mental disease. Households with non-communicable disease members or hospitalized members had a higher risk on IME. NCMS-enrolled, poorer households were more likely to suffer from IME.Conclusion: The joint roles of economic development, health service utilization, and welfare policies result in medical impoverishment for different regions. Poverty and health service utilization are indicative of households with high incidence of medical impoverishment. Chronic diseases lead to medical impoverishment. The inequity existing in different medical insurance schemes leads to different degrees of risk of IME. A combined strategy to precise target multiple vulnerabilities of poor population would be more effective. [ABSTRACT FROM AUTHOR]

Background: Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services.Methods: We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness.Results: We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points).Conclusions: We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors.Trial Registration: This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ). [ABSTRACT FROM AUTHOR]

Background: Health insurance enrolment provides financial access to health care and reduces the risk of catastrophic healthcare expenditure. Therefore, the objective of this study was to assess the prevalence and correlates of health insurance enrolment among Ghanaian children under five years.Methods: We analysed secondary data from the 2017/18 Ghana Multiple Indicator Cluster Survey. The survey was a nationally representative weighted sample comprising 8,874 children under five years and employed Computer Assisted Personal Interviewing to collect data from the participants. In addition, Chi-square and Logistic Regression analyses were conducted to determine factors associated with health insurance enrolment.Results: The results showed that a majority (58.4%) of the participants were insured. Health insurance enrollment was associated with child age, maternal educational status, wealth index, place of residence and geographical region (p < 0.05). Children born to mothers with higher educational status (AOR = 2.14; 95% CI: 1.39-3.30) and mothers in the richest wealth quintile (AOR = 2.82; 95% CI: 2.00-3.98) had a higher likelihood of being insured compared with their counterparts. Also, children residing in rural areas (AOR = 0.75; 95% CI: 0.61-0.91) were less likely to be insured than children in urban areas.Conclusion: This study revealed that more than half of the participants were insured. Health insurance enrolment was influenced by the child's age, mother's educational status, wealth index, residence, ethnicity and geographical region. Therefore, interventions aimed at increasing health insurance coverage among children should focus on children from low socio-economic backgrounds. Stakeholders can leverage these findings to help improve health insurance coverage among Ghanaian children under five years. [ABSTRACT FROM AUTHOR]

Background: Accurate population-based data are required concerning the rate, economic impact, and long-term outcome from acute on chronic liver failures (ACLF) in hospitalized patients with cirrhosis. We aimed to discover time trends for the epidemiology, economic burden, and mortality of ACLF in Thailand.Methods: We conducted a nationwide, population-based, cohort study which involved all hospitalized patients with cirrhosis in Thailand during the period between 2009 and 2013, with data from the National Health Security Office. ACLF was defined by two or more extrahepatic organ failures in patients with cirrhosis. Primary outcomes were trends in hospitalizations, hospital costs, together with inpatient mortality.Results: The number of ACLF hospitalizations in Thailand doubled between 3185 in 2009 and 7666 in 2013. The average cost of each ACLF hospitalization was 3.5-fold higher than for cirrhosis ($ 1893 versus $ 519). The hospital is paid using a diagnosis-related group (DRG) payment system that is only 15% of the average treatment costs ($ 286 from $ 1893). The in-hospital fatality rate was 51% for ACLF while the additional fatality rate was 85% up to 1 year. The ACLF organ failure trends indicated sepsis with septic shock and renal failure as the majority proportion. Age, the number and types of organ failure and male sex were predictors of ACLF death.Conclusions and Relevance: Cirrhosis and ACLF both represent substantial and increasing health and economic burdens for Thailand. These data can assist national health care policy stakeholders to target high-risk patients with cirrhosis for care. [ABSTRACT FROM AUTHOR]

Background: The South African government is implementing National Health Insurance (NHI) as a monopsony health care financing mechanism to drive the country towards Universal Health Coverage (UHC). Strategic purchasing, with separation of funder, purchaser and provider, underpins this initiative. The NHI plans Contracting Units for Primary healthcare (PHC) Services (CUPS) to function as either independent sub-district purchasers or public providers and District Health Management Offices (DHMOs) to support and monitor these CUPS. This decentralised operational unit of PHC, the heartbeat of NHI, is critical to the success of NHI. The views of district-level managers, who are responsible for these units, are fundamental to this NHI implementation. This qualitative study aimed to explore district and sub-district managerial views on NHI and their role in its implementation.Methods: Purposive sampling was used to identify key respondents from a major urban district in Gauteng, South Africa, for participation in in-depth interviews. This study used framework analysis methodology within MaxQDA software.Results: Three main themes were identified: managerial engagement in NHI policy development (with two sub-themes), managerial views on NHI (with three sub-themes) and perceptions of current NHI implementation (with six sub-themes). The managers viewed NHI as a social and moral imperative but lacked clarity and insight into the NHI Bill as well as the associated implementation strategies. The majority of respondents had not had the opportunity to engage in NHI policy formulation. Managers cited several pitfalls in current organisational operations. The respondents felt that national and provincial governments continue to function in a detached and rigid top-down hierarchy. Managers highlighted the need for their inclusion in NHI policy formulation and training and development for them to oversee the implementation strategies.Conclusions: It appears that strategic purchasing is not being operationalised in PHC. NHI policy implementation appears to function in a rigid top-down hierarchy that excludes key stakeholders in the NHI implementation strategy. The findings of this study suggest an inadequate decentralisation of healthcare governance within the public sector necessary to attain UHC. District managers need to be engaged and capacitated to operationalise the planned decentralised purchasing-provision function of the DHS within the NHI Bill. [ABSTRACT FROM AUTHOR]

Background: Artificial Intelligence (AI) innovations in radiology offer a potential solution to the increasing demand for imaging tests and the ongoing workforce crisis. Crucial to their adoption is the involvement of different professional groups, namely radiologists and radiographers, who work interdependently but whose perceptions and responses towards AI may differ. We aim to explore the knowledge, awareness and attitudes towards AI amongst professional groups in radiology, and to analyse the implications for the future adoption of these technologies into practice.Methods: We conducted 18 semi-structured interviews with 12 radiologists and 6 radiographers from four breast units in National Health Services (NHS) organisations and one focus group with 8 radiographers from a fifth NHS breast unit, between 2018 and 2020.Results: We found that radiographers and radiologists vary with respect to their awareness and knowledge around AI. Through their professional networks, conference attendance, and contacts with industry developers, radiologists receive more information and acquire more knowledge of the potential applications of AI. Radiographers instead rely more on localized personal networks for information. Our results also show that although both groups believe AI innovations offer a potential solution to workforce shortages, they differ significantly regarding the impact they believe it will have on their professional roles. Radiologists believe AI has the potential to take on more repetitive tasks and allow them to focus on more interesting and challenging work. They are less concerned that AI technology might constrain their professional role and autonomy. Radiographers showed greater concern about the potential impact that AI technology could have on their roles and skills development. They were less confident of their ability to respond positively to the potential risks and opportunities posed by AI technology.Conclusions: In summary, our findings suggest that professional responses to AI are linked to existing work roles, but are also mediated by differences in knowledge and attitudes attributable to inter-professional differences in status and identity. These findings question broad-brush assertions about the future deskilling impact of AI which neglect the need for AI innovations in healthcare to be integrated into existing work processes subject to high levels of professional autonomy. [ABSTRACT FROM AUTHOR]

Background: Patient medicines helpline services (PMHS) have been established at some National Health Service (NHS) hospitals, to provide patients with post-discharge medicines-related support. However, findings suggest that many PMHS are provided sub-optimally due to a lack of resources. This study sought to examine pharmacy professionals' perceptions of the future of PMHS.Methods: Participants comprised pharmacy professionals from NHS Trusts in England that provided a PMHS. Invitations to participate in a qualitative survey and then an interview were sent to pharmacy services at all NHS Trusts that provided a PMHS. This resulted in 100 survey participants and 34 interview participants. Data were analysed using Braun and Clarke's inductive reflexive thematic analysis.Results: Two themes were generated: Enhancing value for service users and Improving efficiency. Enhancing value for service users identifies pharmacy professionals' suggestions for improving the value of PMHS for service users. These include providing access methods extending beyond the telephone, and providing patients/carers with post-discharge follow-up calls from a pharmacist to offer medicines-related support. Improving efficiency identifies that, in the future, and in line with NHS plans for efficiency and shared resources, PMHS may become centralised or provided by community pharmacies. Centralised services were considered to likely have more resources available to provide a patient medicines information service compared to hospital pharmacies. However, such a change was perceived to only increase efficiency if patient information can be shared between relevant healthcare settings.Conclusions: PMHS are perceived by pharmacy professionals as likely to become centralised in the future (i.e., provided regionally/nationally). However, such change is dependent upon the sharing of patients' information between hospitals and the centralised hub/s or pharmacies. To enhance the value of PMHS for service users, providers should consider establishing other methods of access, such as email and video consultation. Considering the uncertainty around the future of PMHS, research should establish the best way to support all patients and carers regarding medicines following hospital discharge. [ABSTRACT FROM AUTHOR]

Background: The NHS Diabetes Prevention Programme (NHS-DPP) is a nine-month, group-based behavioural intervention for adults in England at risk of developing Type 2 diabetes. Four independent providers were commissioned to deliver versions of the NHS-DPP, in line with NHS England specifications. This observational study maps NHS-DPP delivery in routine practice against the NHS specification, and compares service delivery with observed patient experiences.Methods: Researchers observed service delivery across eight complete NHS-DPP courses (118 sessions, median 14 sessions per course), consenting 455 participants (36 staff, 398 patients, 21 accompanying persons). Key features of NHS-DPP delivery were described using the Template for Intervention Description and Replication (TIDieR) framework. Researchers wrote detailed field notes during each session, including observations of patient experience. Field notes were content analysed; instances of positive and negative experiences were labelled and grouped into categories. Researchers used a novel method of comparing observed patient experiences to variations in programme delivery.Results: Delivery broadly followed NHS England's specification and the plans set out by providers. Deviations included the scheduling and larger group sizes in some sessions. There was variation in the type and format of activities delivered by providers. Positive patient experiences included engagement, satisfaction with the programme, good within-group relationships and reported behavioural changes. Negative experiences included poor scheduling, large groups, and dissatisfaction with the venue. Where more interactive and visual activities were delivered in smaller groups of 10-15 people with good rapport, there were generally more instances of positive patient experiences, and where there were structural issues such as problems with the scheduling of sessions, poor venues and inadequate resources, there tended to be more negative patient experiences.Conclusions: Addressing issues that we have identified as being linked to negative experiences with the NHS-DPP could increase uptake, reduce patient drop-out and increase the overall effectiveness of the programme. In particular, modifying structural aspects of the NHS-DPP (e.g. reliable session scheduling, reducing group sizes, enough session resources) and increasing interaction appear particularly promising for improving these outcomes. [ABSTRACT FROM AUTHOR]

Background: This study examines the effects of a shift in medical coverage, from National Health Insurance (NHI) to Medical Aid (MA), on health care utilization (measured by the number of outpatient visits and length of stay; LOS) and out-of-pocket medical expenses.Methods: Data were collected from the Korean Welfare Panel Study (2010-2016). A total of 888 MA Type I beneficiaries and 221 MA Type II beneficiaries who shifted from the NHI were included as the case group and 2664 and 663 consecutive NHI holders (1:3 propensity score-matched) were included as the control group, respectively. We used the 'difference-in-differences' (DiD) analysis approach to assess changes in health care utilization and medical spending by the group members.Results: Differential average changes in outpatient visits in the MA Type I panel between the pre- and post-shift periods were significant, but differential changes in LOS were not found. Those who shifted from NHI to MA Type I had increased number of outpatient visits without changes in out-of-pocket spending, compared to consecutive NHI holder who had similar characteristics. However, this was not found for MA Type II beneficiaries.Conclusion: Our research provides evidence that the shift in medical coverage from NHI to MA Type I increased the number of outpatient visits without increasing the out-of-pocket spending. Considering the problem of excess medical utilization by Korean MA Type I beneficiaries, further researches are required to have in-depth discussions on the appropriateness of the current cost-sharing level on MA beneficiaries. [ABSTRACT FROM AUTHOR]

Background: In 2017, ostomy patients gained access to ostomy products in community pharmacies that are fully reimbursed by the Portuguese National Health Service. This impacted the daily lives of people with ostomy and opened a new market of products and services for pharmacies. However, little is known about the sociodemographic and clinical profile of ostomy patients. This study aims to characterize people with ostomy and their caregivers, evaluate access and satisfaction with the pharmacy and explore participants' expectations regarding services and counselling.Methods: This was an observational, cross-sectional, multicentre study involving pharmacy users who acquired ostomy products in Portuguese community pharmacies. Data were collected through a confidential self-report questionnaire between June and August 2019.Results: Approximately 56% of the participants were ostomy patients, of whom 65.9% were men. The average age of participating ostomy patients was 65.5 years old (SD = 12.9), and near 80% were retired/pensioners. Caregivers were mostly women (81.7%). More than half of the caregivers were employed and acquired products for a direct family member. Three in every four surgical interventions were consequences of cancer. Intestinal ostomy was the most common intervention (78.3%). More than 93% were satisfied with the acquisition of ostomy products at the pharmacy. Approximately 48.2% of ostomy patients received care from a specialized nurse.Conclusion: This study describes the profile of people with ostomy and their caregivers who attend community pharmacies in Portugal. Participants' perceptions of the utility of different proposed services and pharmacist knowledge, as well as the low coverage of ostomy nursing care, highlight the opportunity for an extended role of pharmacists among this group. [ABSTRACT FROM AUTHOR]

Background: Real world evidence (RWE) is becoming more frequently used in technology appraisals (TAs). This study sought to explore the use and acceptance of evidence from primary care databases, a key source of RWE in the UK, in National Institute for Health and Care Excellence (NICE) technology assessments and to provide recommendations regarding their use in future submissions.Methods: A keyword search was conducted relating to the main primary care databases in the UK on the NICE website. All NICE TAs identified through this search were screened, assessed for duplication and information on the data source and the way the data was used in the submission were extracted. Comments by the evidence review group (ERG) and the appraisal committee were also extracted and reviewed. All data extraction was performed by two independent reviewers and all decisions were reached by consensus with an additional third reviewer.Results: A total of 52 NICE TAs were identified, 47 used the General Practice Research Database /Clinical Practice Research Datalink (GPRD/CPRD) database, 10 used The Health Improvement Network (THIN) database and 3 used the QResearch databases. Data from primary care databases were used to support arguments regarding clinical need and current treatment in 33 NICE TAs while 36 were used to inform input parameters for economic models. The databases were sometimes used for more than one purpose. The data from the three data sources were generally well received by the ERGs/committees. Criticisms of the data typically occurred where the results had been repurposed from a published study or had not been applied appropriately.Conclusions: The potential of UK primary care databases in NICE submissions is increasingly being realised, particularly in informing the parameters of economic models. Purpose conducted studies are less likely to receive criticism from ERGs/committees, particularly when providing clinical input into cost effectiveness models. [ABSTRACT FROM AUTHOR]

Background: China's rapidly aging population has led to many challenges related to the health care delivery and financing. Since 2007, the Urban Residents Basic Medical Insurance (URBMI) program has provided financial protection for older adults living in urban areas not already covered by other health insurance schemes. We conducted a national level assessment on this population's health needs and health service utilization.Methods: Records for 9646 individuals over the age of 60 were extracted for analysis from two National Health Service Surveys conducted in 2008 and 2013. Multiple regression models were used to examine associations between socioeconomic factors, health needs and health service utilization while controlling for demographic characteristics and survey year.Results: Self-reported illness, especially non-communicable diseases (NCDs) increased significantly between 2008 and 2013 regardless of insurance enrollment, age group or income level. In 2013, over 75% of individuals reported at least one NCD. Outpatient services decreased for the uninsured but increased for those with insurance. Middle- and high-income groups with insurance experienced a higher increase in outpatient visits and hospital admissions than the low-income group. Forgone hospital admissions (defined as an admission indicated by a doctor but which was declined or not followed through by the patient) decreased. However, over 20% of individuals had to forgo necessary hospital admissions, and 40% of these cases were due to financial barriers. Outpatient visits and hospital admissions increased between 2008 and 2013, and insured individuals utilized more services than those without insurance.Conclusion: After the implementation of URBMI, health service utilization increased and forgone hospital admissions decreased, indicating the program helped to improve access to health services. However, there was still a marked difference in utilization among different income groups, with the high-income group experiencing the greatest increase. This factor calls for further attention to be given to issues related to equity. Prevalence of self-reported NCDs greatly increased among the study population between 2008 and 2013, suggesting that health insurance programs need to ensure they cover sufficient support for the treatment and prevention of NCDs. [ABSTRACT FROM AUTHOR]

Background: The NHS Health Check Programme is a risk-reduction programme offered to all adults in England aged 40-74 years. Previous studies mainly focused on patient perspectives and programme delivery; however, delivery varies, and costs are substantial. We were therefore working with key stakeholders to develop and co-produce an NHS Health Check Programme modelling tool (workHORSE) for commissioners to quantify local effectiveness, cost-effectiveness, and equity. Here we report on Workshop 1, which specifically aimed to facilitate engagement with stakeholders; develop a shared understanding of current Health Check implementation; identify what is working well, less well, and future hopes; and explore features to include in the tool.Methods: This qualitative study identified key stakeholders across the UK via networking and snowball techniques. The stakeholders spanned local organisations (NHS commissioners, GPs, and academics), third sector and national organisations (Public Health England and The National Institute for Health and Care Excellence). We used the validated Hovmand "group model building" approach to engage stakeholders in a series of pre-piloted, structured, small group exercises. We then used Framework Analysis to analyse responses.Results: Fifteen stakeholders participated in workshop 1. Stakeholders identified continued financial and political support for the NHS Health Check Programme. However, many stakeholders highlighted issues concerning lack of data on processes and outcomes, variability in quality of delivery, and suboptimal public engagement. Stakeholders' hopes included maximising coverage, uptake, and referrals, and producing additional evidence on population health, equity, and economic impacts. Key model suggestions focused on developing good-practice template scenarios, analysis of broader prevention activities at local level, accessible local data, broader economic perspectives, and fit-for-purpose outputs.Conclusions: A shared understanding of current implementations of the NHS Health Check Programme was developed. Stakeholders demonstrated their commitment to the NHS Health Check Programme whilst highlighting the perceived requirements for enhancing the service and discussed how the modelling tool could be instrumental in this process. These suggestions for improvement informed subsequent workshops and model development. [ABSTRACT FROM AUTHOR]

Background: National Health Service (NHS) staff support service users to change health-related behaviours such as smoking, alcohol consumption, diet and physical activity. It can be challenging to discuss behaviour changes with service users hence training is needed to equip staff with up-to-date, evidence-based behaviour change skills. In order to identify how training may help to improve health professional skills in this area, this study evaluated change in professionals' behavioural determinants following an online behaviour change skills module as part of Making Every Contact Count (MECC) training.Methods: This evaluation comprised a within-subject design in which staff from one Northwest England NHS Trust completed a 9-item survey immediately before and after training. This prospective survey identified behavioural determinants regarding adhering to MECC recommendations to hold health conversations with service users and provided written comments about their training experiences. Individuals working within the Trust in clinical or non-clinical roles were eligible to take part and were invited to contribute to the evaluation upon uptake of their usual NHS staff online training programmes.Results: Of participants completing the evaluation (n=206), 12 professional cadres accessed the module, most being female (91%), nurses/midwives (43%), working in children and family services (48%), aged 22 - 62 years. Eight behavioural determinants increased significantly following training, with effect sizes ranging from sizes ranging from 0.27 to 0.51; 'identity' did not change. Content analysis of written feedback (n=256) indicates that training enhanced staff behaviour change skills, modelled a productive and specific method of adopting a patient-led approach to behaviour change conversations, and identified that staff may require further support with embedding skills in practice.Conclusions: Behaviour change science can be translated into useful learning for NHS staff. Online training can engage staff in learning about behaviour change skills and increase their behavioural determinants to adopt these skills in practice. [ABSTRACT FROM AUTHOR]

Background: Patient medicines helpline services (PMHS) have been established at some National Health Service (NHS) Trusts in England, with the aim of providing medicines-related support to patients after they have been discharged. Addressing an important knowledge gap, this qualitative study sought to examine pharmacy professionals' experiences and perceptions of their PMHS, including perceived benefits of the services, and areas for improvement.Methods: Invitations to participate were sent to all NHS Trusts within England that were known to provide a PMHS (n = 117). Semi-structured interviews were conducted via telephone with 34 pharmacy professionals who provide a PMHS (female = 76%, male = 24%; predominantly from Acute NHS Trusts, 76%). Interviews were audio-recorded and transcribed verbatim. The RE-AIM framework for evaluating interventions (RE-AIM: Reach, Effectiveness, Adoption, Implementation, Maintenance) informed the development of the interview schedule and the analysis of the data using framework analysis.Results: Two themes were generated from the analysis: Resources, and Perceived benefits. Findings illustrate how providing a PMHS with limited resources (e.g., no specific funding, understaffed) negatively impacts the implementation, maintenance and reach of PMHS, and the ability to evidence their effectiveness. Despite operating with limited resources, PMHS are considered to have many benefits for patients and healthcare organisations (e.g., providing a 'safety net' to patients during the transfer of care period, providing reassurance to patients, helping to optimise patients' medicines, resolving medicines-related errors, reducing the burden upon other services, and providing the potential to improve hospital services based upon the content of enquiries). However, actually establishing the effectiveness and cost-effectiveness of PMHS is challenging due to perceived logistical difficulties of collecting data, and the difficulty measuring hard outcomes (e.g., prevention of readmissions).Conclusions: PMHS are typically perceived to be under-resourced, although they are considered by pharmacy professionals to have several benefits for service users and NHS Trusts. For those sites that provide a PMHS, we recommend using enquiry data to improve hospital services, and to share ideas for implementing and maintaining a PMHS within a resource-limited context. High-quality research is needed to evidence the effectiveness and cost-effectiveness of PMHS, which may help to secure adequate resources for this service in the future. [ABSTRACT FROM AUTHOR]

Background: The question of how to set the cost-effectiveness threshold for new, innovative medicines is a matter of ongoing controversy. One prominent proposal suggests that the cost-effectiveness threshold adopted by the U.K. National Institute for Health and Care Excellence (NICE) should represent the opportunity cost for the U.K. National Health Service resulting from the adoption of new medicines. The purpose of this article is to compare this proposal for the U.K. with the approach chosen by the Institute for Quality and Efficiency in Health Care (IQWiG) in Germany, which relies on indication-specific cost-effectiveness thresholds.Main Text: The 'ideal' NICE and IQWiG surprisingly share the fundamental principle of inferring the willingness to pay from existing care. For this and other reasons, indication-specific thresholds based on IQWiG's methodology do not lead to more inefficiency at the health system's level than a generic threshold based on the 'ideal' NICE (keeping other conditions the same). Also, applying either decision rule to one country will yield a similar long-term growth in population spending. Assuming that everything else is equal, both decision rules are predicted to decrease long-term expenditure growth. Convergence of the two decision rules would require, among others, ruling out waste in the 'ideal' NICE's approach and, for IQWiG's approach, using the same relative weights for life expectancy and health-related quality of life as the quality-adjusted-life-year model.Conclusion: This article shows that both decision rules have notable commonalities in terms of inferring the willingness to pay from existing care and the projected impact on long-term growth in population spending. [ABSTRACT FROM AUTHOR]

Background: The incidence and burden of depressive disorders are increasing in South Korea. There are many differences between pharmaceutically treated depression (PTD) and treatment-resistant depression (TRD), including the economic consequences; however, to our knowledge, the economic burden of depression is understudied in South Korea. Therefore, the objective of the present study was to calculate the different economic costs of PTD and TRD in South Korea, specifically by comparing several aspects of medical care.Methods: This study comprised patients aged 18 and over who were newly prescribed antidepressants for more than 28 days with a depression code included from January 1, 2012, to December 31, 2012, by the Health Insurance Review and Assessment Service (HIRA). TRD was classified as more than two antidepressant regimen failures in PTD patients. The cost was calculated based on the cost reflected on the receipt registered with HIRA.Results: Of the 834,694 patients with PTD, 34,812 patients (4.17%) were converted to TRD. The cost of medical care for TRD (6,610,487 KRW, 5881 USD) was approximately 5 times higher than the cost of non-TRD (1,273,045 KRW, 1133 USD) and was significantly higher for patients with or without depression and suicide codes. Medical expenses incurred by non-psychiatrists were roughly 1.7 times higher than those incurred by psychiatrists.Conclusions: TRD patients had significantly higher healthcare costs than PTD patients. Identifying these financial aspects of care for depression can help to establish a more effective policy to reduce the burden on mentally ill patients. [ABSTRACT FROM AUTHOR]

Background: Musculoskeletal disorders are common in the general population and a leading cause for care seeking. Despite the large number of patients with musculoskeletal disorders seeking care, little is known of the clinical course, pathways and predictors of healthcare utilization among these patients. The purposes of the study were to 1) describe the clinical course and related healthcare utilization in primary care physiotherapy and secondary healthcare among patients with neck, shoulder and low-back pain treated in physiotherapy practice, and 2) identify independent clinical, socio-demographic, psychological and general health predictors of healthcare utilization.Methods: The study was a prospective cohort study of patients seeking physiotherapy treatment for neck, shoulder, or low-back pain in physiotherapy practices across Denmark. A total of 759 physiotherapy patients completed questionnaires containing information on clinical course and potential predictors of healthcare utilization. Healthcare utilization was obtained from the Danish National Health Service Register and National Patient Register. Associations between potential predictors and low/high primary care physiotherapy utilization and hospital contacts in relation to specific neck, shoulder or low-back disorders were analysed using binomial regression analyses and adjusted for age, sex, duration of pain and comorbidity.Results: During 6 months follow-up, patients experienced clinically relevant improvements in pain, fear avoidance and psychological wellbeing. Patients with higher baseline pain and disability and who were on sickness leave were more likely to have high primary care physiotherapy utilization. Hospital contacts were predicted by higher levels of pain, disability and low psychological wellbeing.Conclusions: Clinical factors and sickness leave seems to be the main predictors of primary care physiotherapy utilization, whereas for secondary care contacts, psychological factors may also be of importance. The study contributes to the on-going research into clinical pathways and may identify future target areas to reduce healthcare utilization in patients with musculoskeletal disorders. [ABSTRACT FROM AUTHOR]

Background: There are increasing calls for developing robust processes of community-based accountability as key components of health system strengthening. However, implementation of these processes have shown mixed results over time and geography. The Community Action for Health (CAH) project was introduced as part of India's National Rural Health Mission (now National Health Mission) to strengthen community-based accountability through community monitoring and planning. In this study we trace the implementation process of this project from its piloting, implementation and abrupt termination in the South Indian state of Tamil Nadu.Methods: We framed CAH as an innovation introduced into the health system. We use the framework on integration of innovations in complex systems developed by Atun and others. We used qualitative approaches to study the implementation. We conducted interviews among a range of individuals who were directly involved in the implementation, focusing on the policy making organizational level.Results: We uncover what we have termed "dissonances" and "disconnects" at the state level among individuals with key responsibility of implementation. By dissonances we refer to the diversity of perspective on the concept of community-based accountability and its perceived role. By disconnects we refer to the lack of spaces and processes for "sense-making" in a largely hierarchically functioning system. These constructs we believe contributes significantly to making sense of the initial uptake and the subsequent abrupt termination of the project.Conclusions: This study contributes to the overall field of policy implementation, especially the phase between the emergence on the policy agenda and its incorporation into the day to day functioning of a system. It focuses on the implementation of contested interventions like community-based accountability, in Low- and Middle-income country settings undergoing transitions in governance. It highlights the importance of "problematization" a dimension not included in most currently popular frameworks to study the uptake and spread of innovations in the health system. It points not only to the importance of diverse perspectives present among individuals at different positions in the organization, but equally importantly the need for spaces and process of collective sense-making to ensure that a contested policy intervention is integrated into a complex system. [ABSTRACT FROM AUTHOR]

Background: According to the World Health Organization, essential surgery should be recognized as an essential component of universal health coverage. In Ghana, insurance is associated with a reduction in maternal mortality and improved access to essential medications, but whether it eliminates financial barriers to surgery is unknown. This study tested the hypothesis that insurance protects surgical patients against financial catastrophe.Methods: We interviewed patients admitted to the general surgery wards of Korle-Bu Teaching Hospital (KBTH) between February 1, 2017 - October 1, 2017 to obtain demographic data, income, occupation, household expenditures, and insurance status. Surgical diagnoses and procedures, procedural fees, and anesthesia fees incurred were collected through chart review. The data were collected on a Qualtrics platform and analyzed in STATA version 14.1. Fisher exact and Student T-tests were used to compare the insured and uninsured groups. Threshold for financial catastrophe was defined as health costs that exceeded 10% of household expenditures, 40% of non-food expenditures, or 20% of the individual's income.Results: Among 196 enrolled patients, insured patients were slightly older [mean 49 years vs 40 years P < 0.05] and more of them were female [65% vs 41% p < 0.05]. Laparotomy (22.2%) was the most common surgical procedure for both groups. Depending on the definition, 58-87% of insured patients would face financial catastrophe, versus 83-98% of uninsured patients (all comparisons by definition were significant, p < .05).Conclusion: This study-the first to evaluate the impact of insurance on financial risk protection for surgical patients in Ghana-found that although insured patients were less likely than uninsured to face financial catastrophe as a result of their surgery, more than half of insured surgical patients treated at KBTH were not protected from financial catastrophe under the Ghana's national health insurance scheme due to out-of-pocket payments. Government-specific strategies to increase the proportion of cost covered and to enroll the uninsured is crucial to achieving universal health coverage inclusive of surgical care.Trial Registration: Registered at www.clinical trials.gov identifier NCT03604458. [ABSTRACT FROM AUTHOR]

Background: Psychological treatment delivered by telephone is recommended by the National Institute for Health and Care Excellence (NICE) for mild to moderate depression and anxiety, and forms a key part of the Improving Access to Psychological Therapy (IAPT) programme in the UK. Despite evidence of clinical effectiveness, patient engagement is often not maintained and psychological wellbeing practitioners (PWPs) report lacking confidence and training to deliver treatment by telephone. This study aimed to explore the perspectives of professional decision makers (both local and national) on the barriers and facilitators to the implementation of telephone treatment in IAPT.Methods: Sixteen semi-structured qualitative telephone interviews and one focus group were carried out with decision makers (n = 21) who were involved locally and nationally in policy, practice and research. The interviews and focus group were coded thematically, and then mapped onto the four core constructs of Normalisation Process Theory (NPT).Results: The use of telephone for psychological treatment was universally recognised amongst participants as beneficial for improving patient choice and access to treatment. However, at service level, motives for the implementation of telephone treatments are often misaligned with national objectives. Pressure to meet performance targets has become a key driver for the use of telephone treatment, with promises of increased efficiency and cost savings. These service-focussed objectives challenge the integration of telephone treatments, and PWP acceptance of telephone treatments as non-inferior to face-to-face. Ambivalence among a workforce often lacking the confidence to deliver telephone treatments leads to reluctance among PWPs to 'sell' treatments to a patient population who are not generally expecting treatment in this form.Conclusions: Perceptions of a need to 'sell' telephone treatment in IAPT persist from top-level decision makers down to frontline practitioners, despite their conflicting motives for the use of telephone. The need for advocacy to highlight the clinical benefit of telephone treatment, along with adequate workforce support and guidance on best practice for implementation is critical to the ongoing success and sustainability of telephone treatment in primary care mental health programmes. [ABSTRACT FROM AUTHOR]

Background: The United Kingdom aortic aneurysms (AA) services have undergone reconfiguration to improve outcomes. The National Health Service collects data on all hospital admissions in England. The complex administrative datasets generated have the potential to be used to monitor activity and outcomes, however, there are challenges in using these data as they are primarily collected for administrative purposes. The aim of this study was to develop standardised algorithms with the support of a clinical consensus group to identify all AA activity, classify the AA management into clinically meaningful case mix groups and define outcome measures that could be used to compare outcomes among AA service providers.Methods: In-patient data about aortic aneurysm (AA) admissions from the 2002/03 to 2014/15 were acquired. A stepwise approach, with input from a clinical consensus group, was used to identify relevant cases. The data is primarily coded into episodes, these were amalgamated to identify admissions; admissions were linked to understand patient pathways and index admissions. Cases were then divided into case-mix groups based upon examination of individually sampled and aggregate data. Consistent measures of outcome were developed, including length of stay, complications within the index admission, post-operative mortality and re-admission.Results: Several issues were identified in the dataset including potential conflict in identifying emergency and elective cases and potential confusion if an inappropriate admission definition is used. Ninety six thousand seven hundred thirty-five patients were identified using the algorithms developed in this study to extract AA cases from Hospital episode statistics. From 2002 to 2015, 83,968 patients (87% of all cases identified) underwent repair for AA and 12,767 patients (13% of all cases identified) died in hospital without any AA repair. Six thousand three hundred twenty-nine patients (7.5%) had repair for complex AA and 77,639 (92.5%) had repair for infra-renal AA.Conclusion: The proposed methods define homogeneous clinical groups and outcomes by combining administrative codes in the data. These methodologically robust methods can help examine outcomes associated with previous and current service provisions and aid future reconfiguration of aortic aneurysm surgery services. [ABSTRACT FROM AUTHOR]