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Purpose: Access to diagnostics is vital for clinical decision-making but is rarely prioritized in national health services strategic plans (NHSSPs)[1]. Materials and Methods: An analysis was conducted of the inclusion of medical imaging as well as laboratory medicine in current NHSSPs for both low-income countries (LICs) and lower- middle-income countries (LMICs). NHSSPs of 79 countries were examined for the inclusion of key terms relevant to imaging and laboratory medicine. Results: Current and electronically available NHSSPs were found for 33 countries, 14 from LICs and 19 from LMICs. Terminology related to imaging was referenced in very few of the plans, and terminology related to laboratory medicine only slightly more. Imaging or laboratory workforce was discussed in 7% and 8% of the NHSSPs respectively. Imaging equipment, technology, or infrastructure was mentioned in 11% of NHSSPs compared to 19% that referenced “laboratory.” Information on key performance indicators and budgeting relating to imaging and laboratory were included in 12% and 21% of NHSSPs respectively. No countries referred to national radiology plans, and only three (Sierra Leone, Haiti, and Zambia) mentioned national laboratory plans. Diagnostics services are not well covered in NHSSPs and imaging is particularly disadvantaged. Conclusion: The absence of medical imaging in NHSSPs makes it less likely that these services will be incorporated into policy and then funded, hence limiting the success of Universal Health Coverage by 2030. The inclusion of imaging in the World Health Organization Essential Diagnostics List is a critical step to addressing inadequate services.

Abstract Migration is a determinant of health. Tackling the health needs of migrants and refugees will require action at the local, national, and global levels. Over the past 12 months, BMC Medicine has published a collection of articles under the title Migrant and Refugee Health (https://www.biomedcentral.com/collections/migrant-and-refugee-health) addressing a range of health issues affecting refugees and migrants in their countries of origin, on transit, and in their destination countries. In light of these articles, we herein discuss the complex and wide-ranging healthcare needs of different refugee groups in their destination countries as well as the need for accessible and culturally appropriate health services.

Objectives: The COVID-19 pandemic has caused unforeseen impacts on sexual and reproductive healthcare (SRH) services worldwide, and the nature and prevalence of these changes have not been extensively synthesized. We sought to synthesise reported outcomes on the impact of COVID-19 on SRH access and delivery in comparable countries with universal healthcare systems., Methods: Following PRISMA guidelines, we searched MEDLINE, Embase, PsycInfo, and CINAHL from January 1st, 2020 to June 6th, 2023. Original research was eligible for inclusion if the study reported on COVID-19 and SRH access and/or delivery. Twenty-eight OECD countries with comparable economies and universal healthcare systems were included. We extracted study characteristics, participant characteristics, study design, and outcome variables. The methodological quality of each article was assessed using the Quality Assessment with Diverse Studies (QuADS) tool. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed for reporting the results. This study was registered on PROSPERO (#CRD42021245596)., Synthesis: Eighty-two studies met inclusion criteria. Findings were qualitatively synthesised into the domains of: antepartum care, intrapartum care, postpartum care, assisted reproductive technologies, abortion access, gynaecological care, sexual health services, and HIV care. Research was concentrated in relatively few countries. Access and delivery were negatively impacted by a variety of factors, including service disruptions, unclear communication regarding policy decisions, decreased timeliness of care, and fear of COVID-19 exposure. Across outpatient services, providers favoured models of care that avoided in-person appointments. Hospitals prioritized models of care that reduced time and number of people in hospital and aerosol-generating environments., Conclusions: Overall, studies demonstrated reduced access and delivery across most domains of SRH services during COVID-19. Variations in service restrictions and accommodations were heterogeneous within countries and between institutions. Future work should examine long-term impacts of COVID-19, underserved populations, and underrepresented countries., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Tam et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Purpose: Lung cancer is the biggest cancer killer of indigenous peoples worldwide, including Māori people in New Zealand. There is some evidence of disparities in access to lung cancer treatment between Māori and non-Māori patients, but an examination of the depth and breadth of these disparities is needed. Here, we use national-level data to examine disparities in access to surgery, radiation therapy and systemic therapy between Māori and European patients, as well as timing of treatment relative to diagnosis., Methods: We included all lung cancer registrations across New Zealand from 2007 to 2019 (N = 27,869) and compared access with treatment and the timing of treatment using national-level inpatient, outpatient, and pharmaceutical records., Results: Māori patients with lung cancer appeared less likely to access surgery than European patients (Māori, 14%; European, 20%; adjusted odds ratio [adj OR], 0.82 [95% CI, 0.73 to 0.92]), including curative surgery (Māori, 10%; European, 16%; adj OR, 0.72 [95% CI, 0.62 to 0.84]). These differences were only partially explained by stage and comorbidity. There were no differences in access to radiation therapy or systemic therapy once adjusted for confounding by age. Although it appeared that there was a longer time from diagnosis to radiation therapy for Māori patients compared with European patients, this difference was small and requires further investigation., Conclusion: Our observation of differences in surgery rates between Māori and European patients with lung cancer who were not explained by stage of disease, tumor type, or comorbidity suggests that Māori patients who may be good candidates for surgery are missing out on this treatment to a greater extent than their European counterparts.

Objective: Patients diagnosed with colorectal cancer living in more deprived areas experience worse survival than those in more affluent areas. Those living in more deprived areas face barriers to accessing timely, quality healthcare. These barriers may contribute to socioeconomic inequalities in survival. We evaluated the literature for any association between socioeconomic group, hospital delay and treatments received among patients with colorectal cancer in the UK, a country with universal healthcare., Design: MEDLINE, EMBASE, CINAHL, CENTRAL, SCIE, AMED and PsycINFO were searched from inception to January 2023. Grey literature, including HMIC, BASE and Google Advanced Search, and forward and backward citation searches were conducted. Two reviewers independently reviewed titles, abstracts and full-text articles. Observational UK-based studies were included if they reported socioeconomic measures and an association with either hospital delay or treatments received. The QUIPS tool assessed bias risk, and a narrative synthesis was conducted. The review is reported to Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020., Results: 41 of the 7209 identified references were included. 12 studies evaluated 7 different hospital intervals. There was a significant association between area-level deprivation and a longer time from first presentation in primary care to diagnosis. 32 studies evaluated treatments received. There were socioeconomic inequalities in surgery and chemotherapy but not radiotherapy., Conclusion: Patients with colorectal cancer face inequalities across the cancer care continuum. Further research is needed to understand why and what evidence-based actions can reduce these inequalities in treatment. Qualitative research of patients and clinicians conducted across various settings would provide a rich understanding of the complex factors that drive these inequalities. Further research should also consider using a causal approach to future studies to considerably strengthen the interpretation. Clinicians can try and mitigate some potential causes of colorectal cancer inequalities, including signposting to financial advice and patient transport schemes., Prospero Registration Number: CRD42022347652., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Background: Digital health solutions hold the potential for supporting general practitioners in decision-making, and include telemedicine systems, decision support systems, patient apps, wearables, fitness trackers, etc. AIM: This review aimed to identify digital solutions developed for, tested, or implemented in general practice to support the decisions of GPs in disease detection and management, using Denmark as an example country of a universal healthcare setting., Methods: This study was conducted as a rapid review. The primary search included a database search conducted in Embase and MEDLINE. The supplementary search was conducted in Infomedia and additionally included a snowball search in reference lists and citations of key articles identified in the database search. Titles were screened by two reviewers., Results: The review included 15 studies as key articles describing a total of 13 digital solutions for decision support in general practice in Denmark. 1.123 titles were identified through the database search and 240 titles were identified through the supplementary and snowball search., Conclusions: The review identified 13 digital solutions for decision support in general practice in a Danish healthcare setting aimed at detection and/or management of cancer, COPD, type 2 diabetes, depression, liver disease or multiple lifestyle-related diseases. Implementation aspects should be reported more transparently in future publications to enable applicability of digital solutions as decision support to aid general practitioners in disease detection and management., (© 2023. The Author(s).)

Background: The COVID-19 pandemic was a health emergency requiring rapid fiscal resource mobilisation to support national responses. The use of effective health financing mechanisms and policies, or lack thereof, affected the impact of the pandemic on the population, particularly vulnerable groups and individuals. We provide an overview and illustrative examples of health financing policies adopted in 15 countries during the pandemic, develop a framework for resilient health financing, and use this pandemic to argue a case to move towards universal health coverage (UHC)., Methods: In this case study, we examined the national health financing policy responses of 15 countries, which were purposefully selected countries to represent all WHO regions and have a range of income levels, UHC index scores, and health system typologies. We did a systematic literature review of peer-reviewed articles, policy documents, technical reports, and publicly available data on policy measures undertaken in response to the pandemic and complemented the data obtained with 61 in-depth interviews with health systems and health financing experts. We did a thematic analysis of our data and organised key themes into a conceptual framework for resilient health financing., Findings: Resilient health financing for health emergencies is characterised by two main phases: (1) absorb and recover, where health systems are required to absorb the initial and subsequent shocks brought about by the pandemic and restabilise from them; and (2) sustain, where health systems need to expand and maintain fiscal space for health to move towards UHC while building on resilient health financing structures that can better prepare health systems for future health emergencies. We observed that five key financing policies were implemented across the countries-namely, use of extra-budgetary funds for a swift initial response, repurposing of existing funds, efficient fund disbursement mechanisms to ensure rapid channelisation to the intended personnel and general population, mobilisation of the private sector to mitigate the gaps in public settings, and expansion of service coverage to enhance the protection of vulnerable groups. Accountability and monitoring are needed at every stage to ensure efficient and accountable movement and use of funds, which can be achieved through strong governance and coordination, information technology, and community engagement., Interpretation: Our findings suggest that health systems need to leverage the COVID-19 pandemic as a window of opportunity to make health financing policies robust and need to politically commit to public financing mechanisms that work to prepare for future emergencies and as a lever for UHC., Funding: Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objective: The purpose of this study was to investigate whether animation can help to improve the comprehension of universal healthcare symbols for middle-aged and older adults., Background: The Hablamos Juntos (HJ) healthcare symbol system is a set of widely used universal healthcare symbols that were developed in the United States. Some studies indicated that HJ healthcare symbols are not well-understood by users in non-English-speaking areas. Other studies found that animations can improve users' comprehension of complex symbols. Thus, we wanted to test whether animation could help to improve users' comprehension of HJ symbols., Methods: The participants included 40 middle-aged and 40 older adults in Taiwan. We redesigned the 12 HJ symbols into three visual formats-static, basic animation, and detailed animation-and compared them to find which best improved the participants' guessability scores., Results: (1) Middle-aged adults' comprehension of static and basic animated symbols was significantly better than that of older adults, but there was no significant difference in the guessability scores between the two age groups in terms of detailed animated symbols; (2) In general, both basic animation and detailed animation significantly improved the guessability score, but the effect with detailed animation was significantly greater than that with basic animation; (3) Older women were more receptive to detailed animation and showed better guessing performance., Conclusion: Detailed animation contains more details and provides a more complete explanation of the concept of the static symbols, helping to improve the comprehension of HJ symbols for middle-aged and older adult users., Application: Our findings provide a reference for the possibility of new style symbol design in the digital and aging era, which can be applied to improve symbol comprehension., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: Competing interests: None declared.

Aim: This study was designed to recommend strategies to improve prostate patients' access to radiotherapy treatment in the Brazilian Unified Health System, along with a cost-tool to support radiotherapy care pathways' lead times and costs. Methods: Data was collected prospectively from patients with prostate cancer receiving radiotherapy in two Brazilian centers to provide data to apply design thinking and process reengineering techniques. The current status of the radiotherapy pathway was determined and the length of time taken for in-hospital activities was measured using data exported from ARIA ® . Interviews with patients were used to estimate their waiting periods. This provided the data used to provide recommended strategies and the cost tool based on time-driven activity-based costing. The strategies were classified according to priority. Results: Data from 47 patients were analyzed. The mean interval from diagnosis to start of radiotherapy was 349 days (SD581), and the mean interval from seeking medical attention to starting treatment was 635 days (SD629). Twelve strategies affecting in-hospital processes and 11 impacting patients' care pathways and experiences are recommended, mostly focused on system improvement opportunities. A time-driven activity-based costing monitoring using data extracted from ARIA was coded and can be used by centers as a cost assessment guide. Conclusion: This study uses reengineering and design techniques to introduce priority strategies to allow more efficient and patient-centered radiotherapy.

Technology plays an important role in reducing inequalities in health care delivery and enhancing quality of life. Health insurance firms require a potent technology policy to understand social determinants of health insurance that can lead to more innovative approaches to social inclusivity initiatives. This paper explicates critical factors of technology policy of health insurance firms that can contribute to better social inclusion and move towards universal health care. Through structured survey questionnaire, data were collected from 125 senior health insurance executives from India for identifying factors important for technology policy. A technology policy scale comprising six distinct factors is developed for health insurance firms using exploratory factor analysis. The factors are "organizational technology strategy," "technology value drivers," "technology utilization," "firm agility in technology," "firm technology capabilities," and "customer focus through technology." The factors identified in this study can be utilized and integrated with enabling technologies such as machine learning, internet of things, big data analytics, and digital phenotyping for creation of electronic health records that are critical for risk management of health insurance firms. This would help to promote healthy lifestyles and disease prevention strategies to strengthen universal health care for society. This paper looks at the factors that are essential in framing a technology policy for the health insurance sector. It provides reasons on how the factors contribute in the evolving health insurance field and can increase the rate of social inclusion for health care. And, finally, it helps in distinguishing how technology requirements and utilization in health insurance is different from other businesses. [ABSTRACT FROM AUTHOR]

Universal health care (UHC) should ensure equal access to and use of surgery, but few studies have explored variation in UHC systems. The objective was to describe practice of distal pancreatectomy in Norway covered exclusively by an UHC. Data on all patients undergoing distal pancreatectomy from the Norwegian Patient Register over a 5-year period. Age- and gender-adjusted population-based resection rates (adj. per million/yr) for distal pancreatectomy were analysed across 4 regions and outcomes related to splenic salvage rate, hospital stay, reoperation, readmissions and 90-day mortality risk between regions. Risk is reported as odds ratio (OR) with 95% confidence interval (c.i.). Regional difference exist in terms of absolute numbers, with the majority of procedures done in one region (n = 331; 59.7%). Regional variation persisted for age- and gender-adjusted population-rates, with highest rate at 23.8/million/yr and lowest rate at 13.5/mill/yr (for a 176% relative difference; or an absolute difference of +10.3 resections/million/yr). Overall, a lapDP instead of an open DP was 3.5 times more likely in SouthEast compared to all other regions combined (lapDP rate: 83% vrs 24%, respectively; OR 15.4, 95% c.i. 10.1–23.5; P < 0.001). The splenic salvage rate was lower in SouthEast (19.9%) compared to all other regions (average 26.5%; highest in Central-region at 37.0%; P = 0.010 for trend). Controlled for other factors in multivariate regression, 'region' of surgery remained significantly associated with laparoscopic access. Despite a universal health care system, considerable variation exists in resection rates, use of laparoscopy and splenic salvage rates across regions. [ABSTRACT FROM AUTHOR]

Introduction: Examining costs and utilization in a single-payer universal health care system provides information on fiscal and resource burdens associated with head and neck cancer (HNC). Here, we examine trends in the Department of Defense (DoD) HNC population with respect to: (1) reimbursed annual costs and (2) patterns and predictors of health care utilization in military only, civilian only, and both systems of care (mixed model).Materials and Methods: A retrospective, cross-sectional study was conducted using TRICARE claims data from fiscal years 2007 through 2014 for reimbursement of ambulatory, inpatient, and pharmacy charges. The study was approved by the Defense Health Agency Office of Privacy and Civil Liberties as exempt from institutional review board full review. The population was all beneficiaries, age 18-64, with a primary ICD-9 diagnosis of HNC, on average, 2,944 HNC cases per year. The outcomes of regression models were total reimbursed health care cost, and counts of ambulatory visits, hospitalizations, and bed days. The predictors were fiscal year, demographic variables, hospice use, type and geographic region of TRICARE enrollment, use of military or civilian care or mixed use, cancer treatment modalities, the number of physical and mental health comorbid conditions, and tobacco use. A priori, null hypotheses were assumed.Results: Per annual average, 61% of the HNC population was age 55-64, and 69% were males. About 6% accessed military facilities only for all health care, 60% accessed civilian only, and 34% accessed both military and civilian facilities. Patients who only accessed military care had earlier stage disease as indicated by rates of single modality treatment and hospice use; military care only and mixed use had similar rates of combination treatment and hospice use. The average cost per patient per year was $14,050 for civilian care only, $13,036 for military care only, and $29,338 for mixed use of both systems. The strongest predictors of higher cost were chemotherapy, radiation therapy, head and neck surgery, hospice care, and mixed-use care. The strongest predictors of health care utilization were chemotherapy, use of hospice, the number of physical and mental health comorbidities, radiation therapy, head and neck surgery, and system of care.Conclusions: To a single payer, the use of a single system of care exclusively among HNC patients is more cost-effective than use of a mixed-use system. The results suggest an over-utilization of ambulatory care services when both military and civilian care are accessed. Further investigation is needed to assess coordination between systems of care and improved efficiencies with respect to the cost and apparent over-utilization of health care services. [ABSTRACT FROM AUTHOR]

The Irish health care system is unusual within Europe in not providing universal, equitable access to either primary or acute hospital care.1 There are two main categories of entitlement to public health services. Those in Category I (medical card holders) are entitled to free public health services but pay a copayment for prescription items, 2 and those in Category II are entitled to subsidized public hospital services and prescription medicines, but pay the full cost of general practitioner.

Universal school health services are expected to offer similar, needs‐based services to all students across schools, service providers and students' socio‐economic statuses and health needs. This study investigates access to school health nurses in Finland. The objectives were to study the differences in access to school health nurse between service providers, schools, students' characteristics and school health nurse resources. Access was examined through a nationwide School Health Promotion study, which is a self‐reporting, voluntary and anonymous survey for 8th and 9th graders (15 to 16‐year old, N = 71865). The ethical committee of the National Institute for Health and Welfare has approved procedure for the School Health Promotion study. Data on school health nurse resources and service providers were obtained from the national database (534 schools; 144 service providers). Multilevel logistic regression was used. Of the pupils, 15% of girls and 11% of boys reported difficult access to a school health nurse. The number of adolescents who reported difficult access ranged between service providers (0%–41%) and schools (0%–75%). Students with lower socio‐economic background, poorer well‐being at school, lack of support for studying and greater health needs reported difficult access more often. School health nurse resources were associated with difficult access only among boys, when resources were under the national recommendations. These findings raise concern about equality and unmet health needs in school health services. [ABSTRACT FROM AUTHOR]

The author comments on private sector hospital involvement for Universal health coverage (UHC) in the Western Pacific Region. Topics discussed include transitional economies providing health care services in the Western Pacific Region (WPR); hospitals moving across the spectrum from fully public to mixed public and private models with for-profit behavior; and public hospital reforms, including granting in public hospitals and introducing some forms of public–private partnerships.

The article offers information on the efforts of Asia-Pacific countries moving toward universal health coverage (UHC). Topics discussed include world leaders adopted the 2030 Agenda for Sustainable Development (SD) in 2015; national health policies and priorities on access, equity, quality, universality, accountability, efficiency, and participation shows efforts towards UHC; and demand of SD require contribution of health sector to the production of equitable and sustainable health outcomes.

In the WHO Western Pacific Region, traditional medicine has extensively been used by communities as part of primary health care which is critical foundation for achieving universal health coverage (UHC). This paper conceptualizes integration of traditional and complementary medicine (T&CM) into national health systems and explores how such integration can contribute to pathways toward UHC. Integration has been variously conceptualized at health system, service delivery, and consumer levels. Integration can be conceptualized based on the level of institutionalization of T&CM in national health systems (i.e. regulation of T&CM, education system, monitoring and health financial scheme). According to it, countries and areas of the Region can be categorized: countries with: 'well-established integration strategies'; 'in-process of developing and implementing integration policies'; 'mixed-level of integration'; or 'indigenous traditional medicine practiced outside the national healthcare system'. Integration of T&CM may offer pathways to advance five health system attributes essential to achieve UHC, namely: quality; efficiency; equity; accountability; and sustainability and resilience. It can contribute to improving quality of healthcare services through regulation of T&CM products, practitioners and services used by communities; meeting population needs in ageing population and managing non-communicable diseases; improving equitable access to care through health insurance coverage of T&CM; improving accountability by monitoring and use of data for informed-policy decisions on T&CM; and strengthening sustainability and resilience through maximizing potentials of T&CM in managing outbreaks of infectious diseases and disasters. Depending on the level of integration, actions to move forward integration of T&CM as a pathway toward UHC will be various. [ABSTRACT FROM AUTHOR]

Political rhetoric surrounding Universal Health Care in the United States typically deals only with differences in political ideology. Research on symbolic racism, however, indicates that subtle racial prejudice may also predict attitudes toward policies like universal health care that are assumed to benefit racial minorities. This subtle racial prejudice hypothesis was supported across three studies conducted in the U.S. A measure of attitudes toward universal health care was found to be a reliable, single-dimension measure associated with political ideology (Pilot Study). Subtle racial prejudice (as measured by the Modern Racism Scale) predicted opposition to universal health care, even when statistically controlling for political ideology and attitudes toward the poor (Study 1). Moreover, reading about a Black individual (compared to a White individual) receiving universal health care benefits reduced support for universal health care, even when statistically controlling for political ideology and right-wing authoritarianism (Study 2). Being a person who takes advantage of the system (e.g., free rides) was a significant predictor of universal health care attitudes while race was not (Study 3). This work demonstrates that subtle racial prejudice plays a critical role in predicting universal health care attitudes among U.S. citizens, reflecting a long-standing history of associations between subtle racial prejudice and opposition to governmental assistance programs in the U.S.

Health often fails to figure prominently on the political agenda of countries. The United States provides an example of how ineffective political will and public pressure can impede achievement of universal health care, creating distortions such as provider dominance in the health system and expensive, specialty-centric health care. In India, years of government under-investment in health and lacking civic engagement have paved the way for private sector dominance and undermining of community-based primary care, which could be exacerbated by the COVID-19 pandemic. Thailand's journey to universal health coverage offers lessons in political commitment and civic participation in health. Such lessons cannot always be emulated by others owing to path-dependent characteristics of systems. The COVID-19 pandemic, however, can be an opportunity to break path dependence and mobilize various quarters for lasting reforms in Indian healthcare. [ABSTRACT FROM AUTHOR]

Application of economic principles can bring about a significant change in the performance of health system. An in-depth understanding of how to generate resources, how to pool funds, how to purchase health services and pay providers of health care, will affect how the health system delivers on its two important objectives, i.e. efficiency and equity. The economic underpinnings of health system are important structural and functional factors to aid in planning and delivery of health care services. Health economics can help in making informed decisions by explaining the factors that affect consumption and utilization of health services both from the demand and supply side using the principles of microeconomics. This is vital for improving the ‘coverage’ of all desired preventive and curative health care services. Most of the recent health system interventions such as increased public health subsidy, creating demand side financing mechanisms like conditional cash transfers schemes such as Janani Suraksha Yojana, performance based payments to Accredited Social Health Activist (ASHAs), incentivizing health workforce in rural and difficult areas, are all grounded in economic theories. Despite years of advocacy, resources have been and will continue to be scarce in health sector. On the contrary, demands for increasing the coverage of existing programs and introduction of newer interventions and technology are increasing. As a result hard choices need to be made for rational allocation of resources for maximizing the value of money spent. Despite a strong felt need among policy makers and program managers for health economists, there is an acute shortage of professionals who have requisite knowledge of health economics. This calls for introduction of health economics in the curriculum of medical and public health courses. Health professionals should also be encouraged to undertake research in this field of health economics and health financing.

Introduction: Solitary pulmonary nodules (SPNs) are common, but the clinical relevance of these nodules is unknown. Utilizing current screening guidelines, we sought to better characterize the national incidence of clinically important SPNs within the largest universal health care system in the nation., Materials and Methods: TRICARE data were queried to identify SPNs for ages 18-64 years. SPNs that had been diagnosed within a year with no prior oncologic history were included to ensure true incidence. A proprietary algorithm was applied to determine clinically significant nodules. Further analysis characterized incidence by age grouping, gender, region, military branch, and beneficiary status., Results: A total of 229,552 SPNs were identified with a 60% reduction seen after application of the clinical significance algorithm (N = 88,628). The incidence increased in each decade of life (all P < 0.01). Adjusted incident rate ratios were significantly higher for SPNs detected in the Midwest and Western regions. The incident rate ratio was also higher in females (1.05, confidence interval [CI] 1.018, P = 0.001) as well as non-active duty members (dependents = 1.4 and retired = 1.6, respectively, CIs 1.383-1.492 and 1.591-1.638, P < 0.01). The incidence calculated per 1,000 patients overall was 3.1/1,000. Ages 44-54 years had an incidence of 5.5/1,000 patients, which is higher than the previously reported incidence of < 5.0 nationally for the same age group., Conclusions: This analysis represents the largest evaluation of SPNs to date combined with clinical relevance adjustment. These data suggest a higher incidence of clinically significant SPNs starting at an age of 44 years in nonmilitary or retired women localized to the Midwest and Western regions of the United States., (© The Association of Military Surgeons of the United States 2023. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Morbidity and mortality related to heart failure are increasing and disparities are widening. These alarming trends, often confounded by access to care, are poorly understood. This study evaluates the prevalence of all stages of heart failure by race and socioeconomic status in an environment with no access barrier to care., Methods: We conducted a cross-sectional observational study of adult beneficiaries aged 18 to 64 years of the Military Health System (MHS), a model for universal health care for fiscal years 2018-2019. We calculated prevalence of preclinical (stages A/B) or clinical (stages C/D) heart failure stages as defined by professional guidelines. Results were analyzed by age, race, and socioeconomic status (using military rank as a proxy)., Results: Among 5,440,761 MHS beneficiaries aged 18 to 64 years, prevalence of preclinical and clinical heart failure was 18.1% and 2.5%, respectively. Persons with preclinical heart failure were middle aged, with similar proportions of men and women, while those with heart failure were older, mainly men. After multivariable adjustment, male sex (1.35 odds ratio [OR] [preclinical]; 1.95 OR [clinical]), Black race (1.64 OR [preclinical]; 1.88 OR [clinical]) and lower socioeconomic status were significantly associated with large increases in the prevalence of all stages of heart failure., Conclusion: All stages of heart failure are highly prevalent among MHS beneficiaries of working age and, in an environment with no access barrier to care, there are striking disparities by race and socioeconomic status. The high prevalence of preclinical heart failure, particularly notable among Black beneficiaries, delineates a critical time window for prevention., (Published by Elsevier Inc.)

Background: The influence of socioeconomic status on outcomes following total joint arthroplasty (TJA) in the Canadian single-payer healthcare system is yet to be elucidated. The objective of the present study was to evaluate the impact of socioeconomic status on TJA outcomes., Methods: This was a retrospective review of 7,304 consecutive TJA (4,456 knees and 2,848 hips) performed between January 1, 2001 and December 31, 2019. The primary independent variable was the average census marginalization index. The primary dependent variable was functional outcome scores., Results: The most marginalized patients in both the hip and knee cohorts had significantly worse preoperative and postoperative functional scores. Patients in the most marginalized quintile (V) showed a decreased odds of achieving a minimal important difference in functional scores at 1-year follow-up (odds ratio [OR] 0.44; 95% confidence interval [CI] [0.20, 0.97], P = .043). Patients in the knee cohort in the most marginalized quintiles (IV and V) had increased odds of being discharged to an inpatient facility with an OR of 2.07 (95% CI [1.06, 4.04], P = .033) and OR of 2.57 (95% CI [1.26, 5.22], P = .009), respectively. Patients in the hip cohort in V quintile (most marginalized) had increased odds of being discharged to an inpatient facility with an OR of 2.24 (95% CI [1.02, 4.96], P = .046)., Conclusion: Despite being a part of the Canadian universal single-payer healthcare system, the most marginalized patients had worse preoperative and postoperative function, and had increased odds of being discharged to another inpatient facility., Level of Evidence: IV., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The limited evidence available on the cost-effectiveness (CE) of expanded carrier screening (ECS) prevents its widespread use in most countries, including Italy. Herein, we aimed to estimate the CE of 3 ECS panels (ie, American College of Medical Genetics and Genomics [ACMG] Tier 1 screening, "Focused Screening," testing 15 severe, highly penetrant conditions, and ACMG Tier 3 screening) compared with no screening, the health care model currently adopted in Italy., Methods: The reference population consisted of Italian couples seeking pregnancy with no increased personal/familial genetic risk. The CE model was developed from the perspective of the Italian universal health care system and was based on the following assumptions: 100% sensitivity of investigated screening strategies, 77% intervention rate of at-risk couples (ARCs), and no risk to conceive an affected child by risk-averse couples opting for medical interventions., Results: The incremental CE ratios generated by comparing each genetic screening panel with no screening were: -14,875 ± 1,208 €/life years gained (LYG) for ACMG1S, -106,863 ± 2,379 €/LYG for Focused Screening, and -47,277 ± 1,430 €/LYG for ACMG3S. ACMG1S and Focused Screening were dominated by ACMG3S. The parameter uncertainty did not significantly affect the outcome of the analyses., Conclusion: From a universal health care system perspective, all the 3 ECS panels considered in the study would be more cost-effective than no screening., Competing Interests: Conflict of Interest Antonio Capalbo, Maurizio Poli, Matteo Figliuzzi, and Silvia Caroselli are full-time employees of Juno Genetics. All other authors declare no conflicts of interest., (Copyright © 2023 American College of Medical Genetics and Genomics. Published by Elsevier Inc. All rights reserved.)

India envisions achieving universal health coverage to provide its people with access to affordable quality health services. A breakthrough effort in this direction has been the launch of the world's largest health assurance scheme Ayushman Bharat Pradhan Mantri Jan Arogya Yojana , the implementation of which resides with the National Health Authority. Appropriate provider payment systems and reimbursement rates are an important element for the success of PM-JAY, which in turn relies on robust cost evidence to support pricing decisions. Since the launch of PM-JAY, the health benefits package and provider payment rates have undergone a series of revisions. At the outset, there was a relative lack of cost data. Later revisions relied on health facility costing studies, and now there is an initiative to establish a national hospital costing system relying on provider-generated data. Lessons from PM-JAY experience show that the success of such cost systems to ensure regular and routine generation of evidence is contingent on integrating with existing billing or patient information systems or management information systems, which digitise similar information on resource consumption without any additional data entry effort. Therefore, there is a need to focus on building sustainable mechanisms for setting up systems for generating accurate cost data rather than relying on resource-intensive studies for cost data collection., Competing Interests: Competing interests: Dr. Shankar Prinja has formerly served as the Executive Director of the National Health Authority, and Dr. Basant Garg is currently serving as the Additional Chief Executive Officer of the National Health Authority, Government of India., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

We examined the impact of the first year of the COVID-19 pandemic on unmet healthcare need among New Yorkers and potential differences by race/ethnicity and health insurance. Data from the Community Health Survey, collected in 2018, 2019, and 2020, were merged to compare unmet healthcare need within the past 12 months during the pandemic versus the 2 years prior to 2020. Univariate and multivariable logistic regression models evaluated change in unmet healthcare need overall, and we assessed whether race/ethnicity or health insurance status modified the association. Overall, 12% of New Yorkers (N = 27,660) experienced unmet healthcare during the 3-year period. In univariate and multivariable models, the first year of the pandemic (2020) was not associated with change in unmet healthcare need compared with 2018-2019 (OR = 1.04, p = 0.548; OR = 1.03, p = 0.699, respectively). There was no statistically significant interaction between calendar year and race/ethnicity, but there was significant interaction with health insurance status (interaction p = 0.009). Stratifying on health insurance status, those uninsured had borderline significant lower odds of experiencing unmet healthcare need during 2020 compared to the 2 years prior (OR = 0.72, p = 0.051) while those with insurance had a slight increase that was not significant (OR = 1.12, p = 0.143). Unmet healthcare need among New Yorkers during the first year of the pandemic did not differ significantly from 2018-2019. Federal pandemic relief funding, which offered no-cost COVID-19 testing and care to all, irrespective of health insurance or legal status, may have helped equalized access to healthcare., (© 2023. The New York Academy of Medicine.)

Objective: Nurse home visiting (NHV) is designed to redress child and maternal health inequities. Of the previous trials to investigate NHV benefits beyond preschool, none were designed for populations with universal healthcare. To address this evidence gap, we investigated whether the Australian 'right@home' NHV programme improved child and maternal outcomes when children turned 6 and started school., Methods: A screening survey identified pregnant women experiencing adversity from antenatal clinics across two states (Victoria, Tasmania). 722 were randomised: 363 to the right@home programme (25 visits promoting parenting and home learning environment) and 359 to usual care. Child measures at 6 years (first school year): Strengths and Difficulties Questionnaire (SDQ), Social Skills Improvement System (SSIS), Childhood Executive Functioning Inventory (CHEXI) (maternal/teacher-reported); general health and paediatric quality of life (maternal-reported) and reading/school adaptation items (teacher-reported). Maternal measures: Personal Well-being Index (PWI), Depression Anxiety Stress Scales, warm/hostile parenting, Child-Parent Relationship Scale (CPRS), emotional abuse and health/efficacy items. Following best-practice methods for managing missing data, outcomes were compared between groups (intention-to-treat) using regression models adjusted for stratification factors, baseline variables and clustering (nurse/site level)., Results: Mothers reported on 338 (47%) children, and teachers on 327 (45%). Patterns of group differences favoured the programme arm, with small benefits (effect sizes ranging 0.15-0.26) evident for SDQ, SSIS, CHEXI, PWI, warm parenting and CPRS., Conclusions: Four years after completing the right@home programme, benefits were evident across home and school contexts. Embedding NHV in universal healthcare systems from pregnancy can offer long-term benefits for families experiencing adversity., Trial Registration Number: ISRCTN89962120., Competing Interests: Competing interests: The 'right@home' sustained nurse home visiting trial is a research collaboration between the Australian Research Alliance for Children and Youth (ARACY); the Translational Research and Social Innovation (TReSI) Group at Western Sydney University and the Centre for Community Child Health (CCCH), which is a department of The Royal Children’s Hospital and a research group of Murdoch Children’s Research Institute. Ownership of the right@home implementation and support license, which is purchased by Australian state governments for roll out for fidelity support, is shared between institutes., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Indigenous Peoples have higher morbidity rates and lower life expectancies than non-Indigenous Canadians. Identification of disparities between Indigenous and non-Indigenous men regarding prostate cancer (PCa) screening, diagnoses, management, and outcomes was sought., Methods: An observational cohort of men diagnosed with PCa between June 2014 and October 2022 was studied. Men were prospectively enrolled in the province-wide Alberta Prostate Cancer Research Initiative. The primary outcomes were tumor characteristics (stage, grade, and prostate-specific antigen [PSA]) at diagnosis. Secondary outcomes were PSA testing rates, time from diagnosis to treatment, treatment modality, and metastasis-free, cancer-specific, and overall survivals., Results: Examination of 1,444,974 men for whom aggregate PSA testing data were available was performed. Men in Indigenous communities were less likely to have PSA testing performed than men outside of Indigenous communities (32 vs. 46 PSA tests per 100 men [aged 50-70 years] within 1 year; p < .001). Among 6049 men diagnosed with PCa, Indigenous men had higher risk disease characteristics: a higher proportion of Indigenous men had PSA ≥ 10 ng/mL (48% vs. 30%; p < .01), TNM stage ≥ T2 (65% vs. 47%; p < .01), and Gleason grade group ≥ 2 (79% vs. 64%; p < .01) compared to non-Indigenous men. With a median follow-up of 40 months (interquartile range, 25-65 months), Indigenous men were at higher risk of developing PCa metastases (hazard ratio, 2.3; 95% CI, 1.2-4.2; p < .01) than non-Indigenous men., Conclusions: Despite receiving care in a universal health care system, Indigenous men were less likely to receive PSA testing and more likely to be diagnosed with aggressive tumors and develop PCa metastases than non-Indigenous men., (© 2023 The Authors. Cancer published by Wiley Periodicals LLC on behalf of American Cancer Society.)

Background: Over the last two decades, many countries have moved from malaria control toward malaria elimination. However, some sub-Saharan African countries, like Malawi, have recently seen a reversal in malaria control progress with reported increases in confirmed malaria cases. This may be the result of inadequate access to effective malaria control interventions by key population groups that perpetuate transmission. This study aimed to assess the barriers to accessing malaria treatment among school-aged children (SAC) in Malawi., Methods: A qualitative study was conducted between September and October 2020, where data were gathered in rural Malawi using free-listing interviews, key-informant interviews, semi-structured interviews and focus group discussions. Purposively sampled participants included SAC, parents of SAC, health workers and key stakeholders at community and district levels. Interviews were digitally recorded and transcribed verbatim. Data were organized using NVivo 12 software and analysed using the thematic method., Results: The study recruited 252 participants, with 156 being SAC, equally divided between boys and girls. Health system barriers to malaria treatment included long waiting hours and queues at clinics, frequent stock-outs of medical supplies, and travel time to the facility. Provider barriers included negative attitude and limited service hours. Individual and cultural barriers included fear of malaria tests and beliefs associating witchcraft as the best treatment for malaria. In addition, COVID-19-related barriers included the inability to follow preventive measures, a shift in focus from malaria to COVID-19, and fear of contracting COVID-19 and/or being tested for COVID-19 at the facility., Conclusions: This study shows most of the barriers to accessing malaria treatment among SAC are similar to those experienced by other population groups. Furthermore, COVID-19 adversely affected SAC's access to treatment. Interventions that support SAC access to prompt diagnosis and treatment are urgently needed to improve the effective control of malaria., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Importance: Multiple sclerosis (MS) severity may be informed by premorbid sociodemographic factors., Objective: To determine whether premorbid education, income, and marital status are associated with future MS disability and symptom severity, independent of treatment, in a universal health care context., Design, Setting, and Participants: This nationwide observational cohort study examined data from the Swedish MS Registry linked to national population registries from 2000 to 2020. Participants included people with MS onset from 2005 to 2015 and of working age (aged 23 to 59 years) 1 year and 5 years preceding disease onset., Exposures: Income quartile, educational attainment, and marital status measured at 1 and 5 years preceding disease onset., Main Outcome and Measures: Repeated measures of Expanded Disability Status Scale (EDSS) scores and patient-reported Multiple Sclerosis Impact Scale (MSIS-29) scores. Models were adjusted for age, sex, relapses, disease duration, and treatment exposure. Secondary analyses further adjusted for comorbidity. All analyses were stratified by disease course (relapse onset and progressive onset)., Results: There were 4557 patients (mean [SD] age, 37.5 [9.3] years; 3136 [68.8%] female, 4195 [92.1%] relapse-onset MS) with sociodemographic data from 1-year preonset of MS. In relapse-onset MS, higher premorbid income and education correlated with lower disability (EDSS, -0.16 [95% CI, -0.12 to -0.20] points) per income quartile; EDSS, -0.47 [95% CI, -0.59 to -0.35] points if tertiary educated), physical symptoms (MSIS-29 physical subscore, -14% [95% CI, -11% to -18%] per income quartile; MSIS-29 physical subscore, -43% [95% CI, -35% to -50%] if tertiary educated), and psychological symptoms (MSIS-29 psychological subscore, -12% [95% CI, -9% to -16%] per income quartile; MSIS-29 psychological subscore, -25% [95% CI, -17% to -33%] if tertiary educated). Marital separation was associated with adverse outcomes (EDSS, 0.34 [95% CI, 0.18 to 0.51]; MSIS-29 physical subscore, 35% [95% CI, 12% to 62%]; MSIS-29 psychological subscore, 25% [95% CI, 8% to 46%]). In progressive-onset MS, higher income correlated with lower EDSS (-0.30 [95% CI, -0.48 to -0.11] points per income quartile) whereas education correlated with lower physical (-34% [95% CI, -53% to -7%]) and psychological symptoms (-33% [95% CI, -54% to -1%]). Estimates for 5-years preonset were comparable with 1-year preonset, as were the comorbidity-adjusted findings., Conclusions and Relevance: In this cohort study of working-age adults with MS, premorbid income, education, and marital status correlated with disability and symptom severity in relapse-onset and progressive-onset MS, independent of treatment. These findings suggest that socioeconomic status may reflect both structural and individual determinants of health in MS.