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ObjectivesWe aimed to examine the use and factors associated with the provision of low-value care in Japan.DesignA multicentre observational study.SettingRoutinely collected claims data that include all inpatient and outpatient visits in 242 large acute care hospitals (accounting for approximately 11% of all acute hospitalisations in Japan).Participants345 564 patients (median age (IQR): 62 (40-75) years; 182 938 (52.9%) women) seeking care at least once in the hospitals in the fiscal year 2019.Primary and secondary outcome measuresWe identified 33 low-value services, as defined by clinical evidence, and developed two versions of claims-based measures of low-value services with different sensitivity and specificity (broader and narrower definitions). We examined the number of low-value services, the proportion of patients receiving these services and the proportion of total healthcare spending incurred by these services in 2019. We also evaluated the 2015-2019 trends in the number of low-value services.ResultsServices identified by broader low-value care definition occurred in 7.5% of patients and accounted for 0.5% of overall annual healthcare spending. Services identified by narrower low-value care definition occurred in 4.9% of patients and constituted 0.2% of overall annual healthcare spending. Overall, there was no clear trend in the prevalence of low-value services between 2015 and 2019. When focusing on each of the 17 services accounting for more than 99% of all low-value services identified (narrower definition), 6 showed decreasing trends from 2015 to 2019, while 4 showed increasing trends. Hospital size and patients' age, sex and comorbidities were associated with the probability of receiving low-value service.ConclusionsA substantial number of patients received low-value care in Japan. Several low-value services with high frequency, especially with increasing trends, require further investigation and policy interventions for better resource allocation.

ObjectivesIncreases in obesity and cardiovascular diseases contribute to rapidly growing healthcare expenditures in many countries. However, little is known about whether the population-level health guidance intervention for obesity and cardiovascular risk factors is associated with reduced healthcare utilisation and spending. The aim of this study was to investigate the effect of population-level health guidance intervention introduced nationally in Japan on healthcare utilisation and spending.DesignRetrospective cohort study, using a quasiexperimental regression discontinuity design.SettingJapan's nationwide employment-based health insurers.ParticipantsParticipants in the national health screening programme (from January 2014 to December 2014) aged 40-74 years.PredictorsAssignment to health guidance intervention (counselling on healthy lifestyles, and referral to physicians as needed) determined primarily on whether the individual's waist circumference was above or below the cut-off value in addition to having at least one cardiovascular risk factor.Primary and secondary outcome measuresHealthcare utilisation (the number of outpatient visits days, any medication use and any hospitalisation use) and spending (total medical expenditure, outpatient medical expenditure and inpatient medical expenditure) within 3 years of the intervention.ResultsA total of 51 213 individuals within the bandwidth (±6 cm of waist circumference from the cut-off) out of 113 302 screening participants (median age 50.0 years, 11.9% woman) were analysed. We found that the assignment to the national health guidance intervention was associated with fewer outpatient visit days (-1.3 days; 95% CI, -11.4 to -0.5 days; p=0.03). We found no evidence that the assignment to the health guidance intervention was associated with changes in medication or hospitalisation use, or healthcare spending.ConclusionAmong working-age, male-focused Japanese from a health insurer of companies of civil engineering and construction, the national health guidance intervention might be associated with a decline in outpatient visits, with no change in medication/hospitalisation use or healthcare spending.

This article discusses the use of respiratory medications in Finland from 1990 to 2021 and their association with reduced disease burden. The study analyzes the consumption of medication for asthma, chronic obstructive pulmonary disease (COPD), rhinitis, cough, and cold, as well as the overall costs of asthma and severe COPD. The findings show that medication consumption has increased over time, but the overall burden and costs of respiratory diseases have decreased. The study also highlights the importance of systematic public health interventions in improving diagnostics, early treatment, and awareness of these diseases. [Extracted from the article]

The increasing incidence of childhood cancer in low‐ and middle‐income countries (LMICs) presents significant economic and logistical challenges, affecting health care provision and equitable treatment access. This editorial explores the economic barriers to pediatric oncology care in LMICs, highlighting resource scarcity, socioeconomic inequities, and health care complexities. It emphasizes the need for detailed cost analysis within health systems complicated by inadequate data and variable treatment protocols. Central to the discussion is the "Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity (CC‐BRIDGE) Tool" from the manuscript by Nancy Bolous et al., who proposed an innovative method to estimate the cost of integrating childhood cancer services into National Cancer Control Plans. This tool aligns with the World Health Organization's Global Initiative for Childhood Cancer to enhance survival rates and advocate for universal health coverage in pediatric oncology. The CC‐BRIDGE tool's methodological rigor provides a structured framework for cost analysis. Yet, it is recognized as an initial step requiring further enhancements for comprehensive economic forecasting and societal cost assessments. In conclusion, the editorial highlights the tool's critical role in incorporating childhood cancer care into national strategies in LMICs, contributing to the broader fight against cancer and advocating for comprehensive, equitable health care. It signifies a vital stride toward addressing pediatric oncology's economic challenges and supporting universal health coverage for childhood cancer care. This editorial examines the economic hurdles of managing childhood cancer in low‐ and middle‐income countries, emphasizing the innovative Childhood Cancers Budgeting Rapidly to Incorporate Disadvantaged Groups for Equity tool's alignment with the World Health Organization's Global Initiative to improve care and advocate for universal health coverage. It acknowledges the tool as an initial yet vital step toward a more comprehensive strategy for addressing the complexities of pediatric oncology and enhancing health care equity. [ABSTRACT FROM AUTHOR]

Abstract Objectives In this systematic review, we aimed to identify the full extent of cost-effectiveness evidence available for evaluating alternative Maternity Models of Care (MMC) and to summarize findings narratively. Methods Articles that included a decision tree or state-based (Markov) model to explore the cost-effectiveness of an MMC, and at least one comparator MMC, were identified from a systematic literature review. The MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases were searched for papers published in English, Arabic, and French. A narrative synthesis was conducted to analyse results. Results Three studies were included; all using cost-effectiveness decision tree models with data sourced from a combination of trials, databases, and the literature. Study quality was fair to poor. Each study compared midwife-led or doula-assisted care to obstetrician- or physician-led care. The findings from these studies indicate that midwife and doula led MMCs may provide value. Conclusion The findings of these studies indicate weak evidence that midwife and doula models of care may be a cost-effective or cost-saving alternative to standard care. However, the poor quality of evidence, lack of standardised MMC classifications, and the dearth of research conducted in this area are barriers to conclusive evaluation and highlight the need for more research incorporating appropriate models and population diversity.

After several decades of continuous yet bumpy progress the advanced therapy medicinal products reached the stage when the first drugs with well documented efficacy started to be registered. However, in the disturbing chain of events, many of them were discontinued because of the lack of return on investment. By comparing this phenomenon to the fact that humans did not return to the Moon for already 50 years, primarily because of the lack of dedicated funds, this commentary proposes strategies how to avoid menace of the dead end threating to suffocate progress of the advanced medical therapies. While treatments for rare diseases can be defended by mixture of altruistic, inspiring and rational reasons, mostly covered by the fact that regardless of the price of the newly developed therapy, the total burden remains low, common diseases should be addressed in a different way. This needs to include precise modelling of the benefits which advanced therapy medicinal products bring for every condition, taking in account reduction of the costs of long, often life-long support of patients affected by such diseases. Without intention to steal romantic view on the scientific progress, powerful yet very expensive tools of advanced therapy medicinal products require urgent top-down decisions which include selection of priorities based on the financial modelling. Instead of spontaneous exploration in all directions, this commentary proposes an arranged marriage between scientific community and big investors sustained by combination of governmental requirements in the form of real time data sharing, reimbursement warranties according to demonstrated efficacy and clear recognition of the primary targets with accompanying pre-defined financial frameworks.

Abstract Background Self-report instruments are used to evaluate the effect of interventions. However, individuals adapt to adversity. This could result in individuals reporting higher levels of well-being than one would expect. It is possible to test for the influence of adapted preferences on instrument responses using measurement invariance testing. This study conducts such a test with the Wellbeing Related option-Freedom (WeRFree) and ICECAP-A instruments. Methods A multi-group confirmatory factor analysis was conducted to iteratively test four increasingly stringent types of measurement invariance: (1) configural invariance, (2) metric invariance, (3) scalar invariance, and (4) residual invariance. Data from the Multi Instrument Comparison study were divided into subsamples that reflect groups of participants that differ by age, gender, education, or health condition. Measurement invariance was assessed with (changes in) the Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Root Mean Square Residual (SRMR) fit indices. Results For the WeRFree instrument, full measurement invariance could be established in the gender and education subsamples. Scalar invariance, but not residual invariance, was established in the health condition and age group subsamples. For the ICECAP-A, full measurement invariance could be established in the gender, education, and age group subsamples. Scalar invariance could be established in the health group subsample. Conclusions This study tests the measurement invariance properties of the WeRFree and ICECAP-A instruments. The results indicate that these instruments were scalar invariant in all subsamples, which means that group means can be compared across different subpopulations. We suggest that measurement invariance of capability instruments should routinely be tested with a reference group that does not experience a disadvantage to study whether responses could be affected by adapted preferences.

Abstract Objective Equity in the delivery of health services, including diagnostic imaging, is crucial to achieving universal health coverage. The Health Transformation Plan (HTP), launched in 2014, represents a major healthcare policy to improve the quality and accessibility of healthcare services. This study aimed to explore the impact of the HTP on equity in the access to medical imaging in Lorestan province, located in west Iran, from 2014 to 2023. Annual growth rates (AGR) of imaging devices were calculated, whilst equity assessment of medical imaging distribution was carried out by means of the Gini coefficient and the Lorenz curve per 100,000 population. The latter was generated using the cumulative distribution of imaging devices, as well as the cumulative population ratio. Results Between 2014 and 2023, the number of imaging devices has increased threefold. The AGR of installing CT and MRI scanners in Lorestan province increased between 2014 and 2023. The Gini coefficients increased from 0.12 for CT and 0.16 for MRI in 2014 to 0.33 in 2023 for both devices. This indicates a decrease in equity in access to these fundamental health technologies despite the increase in their figures. Policymakers should better allocate medical equipment based on the specific health needs of different regions throughout Iran.

Abstract Historically, the NHS did not routinely collect cost data, unlike many countries with private insurance markets. In 1998, for the first time the government mandated NHS trusts to submit estimates of their costs of service, known as reference costs. These have informed a wide range of health economic evaluations and important functions in the health service, such as setting prices. Reference costs are collected by progressively disaggregating budgets top-down into disease and treatment groups. Despite ongoing improvements to methods and guidance, these submissions continued to suffer a lack of accuracy and comparability, fundamentally undermining their credibility for critical functions. To overcome these issues, there was a long-held ambition to collect “patient-level” cost data. Patient-level costs are estimated with a combination of disaggregating budgets but also capturing the patient-level “causality of costs” bottom-up in the allocation of resources to patient episodes. These not only aim to capture more of the drivers of costs, but also improve consistency of reporting between providers. The change in methods may confer improvements to data quality, though judgement is still required and achieving consistency between trusts will take further work. Estimated costs may also change in important ways that may take many years to fully understand. We end on a cautionary note that patient-level cost methods may unlock potential, they alone contribute little to our understanding of the complexities involved with service quality or need, while that potential will require substantial investment to realise. Many healthcare resources cannot be attributed to individual patients so the very notion of “patient-level” costs may be misplaced. High hopes have been put in these new data, though much more work is now necessary to understand their quality, what they show and how their use will impact the system.

Norway has, according to the World Health Organization, more psychiatrists engaged in public health services per head of population than any other country, and the proportionate numbers of psychologists and others engaged in mental healthcare are also among the world's highest. Approximately 10% of Norway's gross domestic product is spent on health, expenditure per capita that is the fourth highest internationally. We discuss how this wealth of expertise translates into the delivery of services to the public.

Abstract Mini abstract This work studies the direct cost of hip fractures in Egypt. The direct cost was calculated based on the incidence of hip fracture in Egypt retrieved from the national database. The result of this work raises red flags to the policy makers in Egypt that such fragility fractures are preventable, should appropriate approaches be implemented. Background This study provides an analysis for the healthcare system in Egypt. It was carried out to assess the direct annual cost incurred to the Egyptian healthcare system in 2023 as a result of fragility hip fractures in older adult Egyptians. Results The direct costs of hip fractures incurred during the first year after the injury were estimated at 1,969,385,000 Egyptian pounds (US $63,734,142.4). Time from fracture to surgery was 2.2 + 0.5 days. The average hospital stay after hip fracture surgery was 5.2 + 2.6 days. 4.5% of patients died after surgery, on average 2.3 + 0.4 months. After being discharged from the hospital, all patients needed home care. Conclusion Hip fractures have a significant clinical and financial impact on patients and the healthcare system. This study raises red flags for the healthcare policy makers in Egypt, as the financial burden due to the direct costs of hip fractures justifies extensive prevention programs for osteoporosis and fragility fractures. There is an urgent need to implement diagnostic approaches and validated management protocols for bone health disorders and its associated fractures in Egypt.

The Human Genome Project, completed in 2003, heralded a new era in precision medicine. Somewhat tempering the excitement of the elucidation of the human genome is the emerging recognition that there are fewer single gene disorders than first anticipated, with most diseases predicted to be polygenic or at least gene-environment modified. Hereditary haemochromatosis (HH) is an inherited iron overload disorder, for which the vast majority of affected individuals (>90%) have homozygosity for a single pathogenic variant in the HFE gene, resulting in p.Cys282Tyr. Further, there is significant benefit to an individual in identifying the genetic risk of HH, since the condition evolves over decades, and the opportunity to intervene and prevent disease is both simple and highly effective through regular venesection. Add to that the immediate benefit to society of an increased pool of ready blood donors (blood obtained from HH venesections can generally be used for donation), and the case for population screening to identify those genetically at risk for HH becomes more cogent. Concerns about genetic discrimination, creating a cohort of “worried well”, antipathy to acting on medical advice to undertake preventive venesection or simply not understanding the genetic risk of the condition adequately have all been allayed by a number of investigations. So why then has HH population genetic screening not been routinely implemented anywhere in the world? The answer is complex, but in this article we explore the pros and cons of screening for HH and the different views regarding whether it should be phenotypic (screening for iron overload by serum ferritin and/or transferrin saturation) or genotypic (testing for HFE p.Cys282Tyr). We argue that now is the time to give this poster child for population genetic screening the due consideration required to benefit the millions of individuals at risk of HFE-related iron overload.

Severe acute malnutrition (SAM) is a high-fatality condition that affected 13.7 million children under five years of age worldwide in 2022, with complicated cases requiring extensive inpatient stay with an accompanying caregiver. Our objective was to assess the costs of inpatient treatment for complicated SAM in children aged 6 to 59 months in Northern Senegal and identify cost predictors. We performed a retrospective cost analysis, including 140 children hospitalized from January to December 2020 in five SAM inpatient treatment facilities. We adopted a societal perspective, including direct medical and non-medical costs and indirect costs. We extracted patients’ sociodemographic and clinical data from medical records and conducted semi-structured interviews with healthcare staff to capture information on time allocation and care management. A multivariable generalized linear model with gamma family and a log link was used to investigate the factors associated with direct costs. Costs are expressed in 2020 international USD using purchasing power parity. Mean length of stay was 5.3 (SD = 3.2) days and diarrhoea was the cause of the admission in 55.7% of cases. Mean total cost was USD 431.9 (SD = 203.9), with personnel being the largest cost item (33% of the total). Households’ out-of-pocket expenses represented 45.3% of total costs and amounted to USD 195.6 (SD = 103.6). Costs were significantly associated with gender (20.3% lower in boys), diarrhoea (27% increase), anaemia (49.4% increase), inpatient death (44.9% decrease), and type of facility (26% higher in hospitals vs. health centre). Our study highlights the financial burden of complicated SAM in Senegal in particular for families. This underscores the need for tailored prevention and social policies to protect families from the disease’s financial burden and improve treatment adherence, both in Senegal and similar contexts.

The incidence of oropharyngeal cancer (OPC) has been rising, especially among middle-aged men. While Human Papillomavirus (HPV) has been irrevocably implicated in the pathogenesis of oropharyngeal cancer (OPC), the current HPV vaccination uptake rate remains low in the US. The aim of our study was to evaluate the impact of increased HPV vaccination coverage on HPV-associated OPC incidence and costs. A decision analytic model was constructed for hypothetical cohorts of 9-year-old boys and girls. Two strategies were compared: 1) Maintaining the current vaccination uptake rates; 2) Increasing HPV vaccination uptake rates to the Healthy People 2030 target (80%) for both sexes. Increasing HPV vaccination coverage rates to 80% would be expected to prevent 5,339 OPC cases at a cost of $0.57 billion USD. Increased HPV vaccination coverage would result in 7,430 quality-adjusted life year (QALY) gains in the overall population, and it is estimated to be cost-effective for males with an incremental cost-effectiveness ratio of $86,940 per QALY gained under certain conditions. Expanding HPV vaccination rates would likely provide a cost-effective way to reduce the OPC incidence, particularly among males.

Cost-effectiveness analysis, the most common type of economic evaluation, estimates a new option's additional outcome in relation to its extra costs. This is crucial to study within the clinical setting because funding for new treatments and interventions is often linked to whether there is evidence showing they are a good use of resources. This article describes how to analyze a cost-effectiveness dataset using the framework of a net benefit regression. The process of creating estimates and characterizing uncertainty is demonstrated using a hypothetical dataset. The results are explained and illustrated using graphs commonly employed in cost-effectiveness analyses. We conclude with a call to action for researchers to do more person-level cost-effectiveness analysis to produce evidence of the value of new treatments and interventions. Researchers can utilize cost-effectiveness analysis to compare new and existing treatment mechanisms.

Purpose: This paper aims to explore the factors influencing the profitability of hospital operations in Poland. By dividing hospitals into homogeneous groups based on various criteria, it seeks to understand the dynamics and determinants of hospital efficiency in the context of changing healthcare policies and market conditions. Methodology: The research adopts an exploratory data analysis approach, examining profitability across different hospital types and ownership models. It utilizes statistical methods to analyze changes over time, with a particular focus on profitability indicators such as Return on Sales (ROS). The study spans the period from 2012 to 2021, covering significant healthcare policy shifts and the COVID-19 pandemic's impact. Findings: The study reveals that profitability is influenced by several key factors: legislative changes in NFZ financing system, hospital size, type of ownership, urban versus rural location, and regional healthcare policies. It uncovers that urban and rural hospitals' profitability did not significantly differ in each studied year, especially in the last two. The legal form of hospital operation (corporate or SPZOZ) does not conclusively affect operational efficiency. The study confirms that certain factors like size and ownership type influence hospital profitability. Research limitations: Study suggests that other factors unique to each hospital, such as department structure and management quality also influence hospital profitability. The research opens pathways for further investigation into these factors, although data limitations present challenges. Practical implications: The findings have implications for healthcare policymakers and hospital administrators, emphasizing the need for adaptable management strategies in response to changing funding models and market conditions. They also highlight the importance of considering local factors in policy formulation. Social implications: The research underscores the importance of efficient hospital management in ensuring quality healthcare delivery, particularly in times of crisis like the COVID-19 pandemic. It also sheds light on the broader impact of healthcare policies on societal health outcomes. Originality: This paper contributes to the existing body of knowledge by providing a comprehensive analysis of Polish hospitals' efficiency in a changing legislative and economic environment. It offers valuable insights for healthcare professionals, policymakers, and researchers, emphasizing the multifaceted nature of hospital efficiency. [ABSTRACT FROM AUTHOR]

Objectives: The current European crisis in human resources in health has opened the debate about working conditions and fair wages. This is the case with Resident doctors, which have faced challenges throughout Europe. In Portugal, they account for about a third of the doctors in the Portuguese National Health Service. No studies to date objectively demonstrate the working conditions and responsibilities undertaken. This study aims to quantify the residents' workload and working conditions. Methods: Observational, retrospective cross-sectional study which involved a survey on the clinical and training activity of Portuguese residents, actively working in September 2020. The survey was distributed through e-mail to residents' representatives and directly to those affiliated with the Independent Union of Portuguese Doctors. The descriptive analysis assessed current workload, and logistic regression models analyzed associations with geographical location and residency seniority. Results: There were a total of 2,012 participants (19.6% of invited residents). Of the residents giving consultations, 85.3% do so with full autonomy. In the emergency department, 32.1% of the residents work 24 h shifts and 25.1% work shifts without a specialist doctor present. Regarding medical training, 40.8% invest over EUR 1,500 annually. Autonomy in consultations was associated with being a Family Medicine resident (OR 4.219, p < 0.001), being a senior resident (OR 5.143, p < 0.001), and working in the Center (OR 1.685, p = 0.009) and South regions (OR 2.172, p < 0.001). Seniority was also associated with investing over EUR 1,500 in training annually (OR 1.235, p = 0.021). Conclusion: Residents work far more than the contracted 40 h week, often on an unpaid basis. They present a high degree of autonomy in their practice, make a very significant personal and financial investment in medical training, with almost no time dedicated to studying during working hours. There is a need to provide better working conditions for health professionals, including residents, for the sake of the sustainability of health systems across Europe. [ABSTRACT FROM AUTHOR]

Objectives: In this systematic review, we aimed to identify the full extent of cost-effectiveness evidence available for evaluating alternative Maternity Models of Care (MMC) and to summarize findings narratively. Methods: Articles that included a decision tree or state-based (Markov) model to explore the cost-effectiveness of an MMC, and at least one comparator MMC, were identified from a systematic literature review. The MEDLINE, Embase, Web of Science, CINAHL and Google Scholar databases were searched for papers published in English, Arabic, and French. A narrative synthesis was conducted to analyse results. Results: Three studies were included; all using cost-effectiveness decision tree models with data sourced from a combination of trials, databases, and the literature. Study quality was fair to poor. Each study compared midwife-led or doula-assisted care to obstetrician- or physician-led care. The findings from these studies indicate that midwife and doula led MMCs may provide value. Conclusion: The findings of these studies indicate weak evidence that midwife and doula models of care may be a cost-effective or cost-saving alternative to standard care. However, the poor quality of evidence, lack of standardised MMC classifications, and the dearth of research conducted in this area are barriers to conclusive evaluation and highlight the need for more research incorporating appropriate models and population diversity. Highlights: • No conclusions could be drawn regarding the cost-effectiveness of individual MMCs due to the limited and low-quality studies eligible for inclusion in this review. • Very few studies exist in the literature that use modelling to assess the cost-effectiveness of MMCs. This paucity of evidence hinders the determination of the best value maternity services and may lead to inappropriate policy and funding. [ABSTRACT FROM AUTHOR]

Non-communicable diseases (NCD) are associated with high costs for healthcare systems. We evaluated changes in total costs, comprising direct and indirect costs, due to a 24-month non-randomized, controlled lifestyle intervention trial with six measurement time points aiming to improve the risk profile for NCDs. Overall, 187 individuals from the general population aged ≥18 years were assigned to either the intervention group (IG; n = 112), receiving a 10-week intensive lifestyle intervention focusing on a healthy, plant-based diet; physical activity; stress management; and community support, followed by a 22-month follow-up phase including monthly seminars, or a control group (CG; n = 75) without intervention. The complete data sets of 118 participants (IG: n = 79; CG: n = 39) were analyzed. At baseline, total costs per person amounted to 67.80 ± 69.17 EUR in the IG and 48.73 ± 54.41 EUR in the CG per week. The reduction in total costs was significantly greater in the IG compared to the CG after 10 weeks (p = 0.012) and 6 months (p = 0.004), whereas direct costs differed significantly after 10 weeks (p = 0.017), 6 months (p = 0.041) and 12 months (p = 0.012) between the groups. The HLCP-2 was able to reduce health-related economic costs, primarily due to the reduction in direct costs. [ABSTRACT FROM AUTHOR]

Traditionally it has been the case for orthopaedic consultants to review GP referrals for the orthopaedic outpatient clinic where possible in amongst other clinical commitments. This could sometimes lead to unsuitable patients being reviewed and both patients and clinicians becoming frustrated. Building on the virtual fracture clinic, a new screening tool was implemented to streamline new referrals. The aim of this study is to investigate the change in patients given outpatient appointments following the introduction of a new streamlining protocol. Referrals had to meet the criteria of BMI under 40 or evidence of weight loss effort, recent radiographs and appropriate clinical details in keeping with Getting It Right First Time (GIRFT). Consultant were given dedicated clinical time to review and either triage the patient to the most appropriate clinic type, or return the referral with advice to the GP. 10 months of data was collected prior to the protocol and 10 months after implementation. 1781 patients were referred pre-protocol with an average of 14.2% of these being returned. Post protocol there were 2110 patients referred with 31.2% returned. There was an increase in 195% of referrals returned to the GP (p < 0.0001). The highest proportion of these was for mild to moderate osteoarthritis on the radiograph which has been proven to be unsuitable for intervention. At 12 month analysis there was no significant increase in patients re-referred to the service (p = 0.53) The new screening tool allows more appropriate referrals to be seen in clinic allowing less frustration to clinicians and patients by reducing therapeutic inertia. Furthermore it allows new referrals to be seen by the most appropriate sub-specialist. It allows advice to be given to GPs on further management for the patient. 619 appointments were saved. At a cost of £120 per appointment, this leads to a real terms cost saving of £74,280, with further savings in time and travel. • The first study documenting a system to streamline new outpatient referrals. • Ensures all referrals have the minimum required clinical information as per GIRFT. • 619 outpatient appointments were saved in the study period (£74,280). • GP feedback is taken into consideration as the protocol develops. [ABSTRACT FROM AUTHOR]

Objective. The objective of this research is to appraise current practice in hospitals against the ‘Framework to achieve value in healthcare’ (the Framework) and to identify additional contributory factors that support or hinder its application. Methods. A multi-site case study was undertaken with five hospitals in Australia, the USA and UK using purposeful sampling to identify hospitals to participate. Data collection took place between September and November 2022. The hospitals included in the study had Process Improvement (PI) programs of more than 5 years duration, with strong executive engagement and broad outcomes measurement, including financial benefits. All hospitals were acute public hospitals or private, not for profit. Results. All hospitals indicated current practice according to Steps 1–5 for some part of their PI programs. All hospitals indicated that they were more likely to include financial benefits measurement for activities aimed specifically at improving cost rather than reducing non-value adding activities or improving the value of clinical care. Step 5 (reinvestment of cost savings) of the Framework is dependent on the accomplishment of Step 4 (measurement and realisation of financial benefits) and the contributory elements are important in supporting hospitals to utilise the Framework. Conclusions. The ‘Framework to achieve value in healthcare’ provides a practical guide for hospitals to reduce non-value adding activities, improve the value of clinical care and reduce costs. Further research is indicated to establish its reliability in hospitals in other countries and hospitals that do not have an established PI program. [ABSTRACT FROM AUTHOR]

Backgrounds: Intraductal papillary mucinous neoplasms (IPMN) are cystic neoplasms of the pancreatic ductal system. These incidental cystic lesions are increasingly found on radiological imaging and screened for malignant transformation. The Fukuoka consensus guidelines recommend screening with computed tomography, magnetic resonance imaging or endoscopic ultrasound. Branch duct IPMN (BD‐IPMN) have significantly lower malignancy and mortality rates compared to main duct IPMN. Our aim was to assess the cost‐effectiveness of guideline's recommendations for BD‐IPMN screening of cysts between 2 and 3 cm in an Australian context. Methods: Markov model decision analysis was used to calculate the incremental cost‐effectiveness ratio (ICER) of screening. The ICER was compared to a willingness to pay (WTP) threshold of $50 000. We performed scenario analysis to examine the effect of cyst size and non‐linearity of malignancy rate on ICER. Probabilistic sensitivity analyses (PSA) were performed on our input parameters. Results: Screening resulted in 586 quality adjusted life years gained and a net present value of $20 379 939, resulting in a base‐case ICER of $34 758. After scenario analysis for non‐linearity of malignancy rate the ICER increases to $64 555, which is above the WTP threshold. PSA indicates that ICER is most susceptible to the pre‐test malignancy rate. Conclusion: This cost analysis demonstrates that screening of 2–3 cm BD‐IPMN according to current guidelines is unlikely to be cost‐effective in an Australian context. To determine the true ICER, a cost analysis on real‐world data is required. [ABSTRACT FROM AUTHOR]

Background: Tunafasi is a community-based rehabilitation (CBR) programme for persons with disability, implemented by a local non-governmental organisation in Uvira, Democratic Republic of Congo, in partnership with government. To assess affordability and support discussions with the government about continued financing and implementation, Tunafasi representatives commissioned a cost-effectiveness study of the programme's health component. Objectives: This study aimed to estimate the programme's impacts, costs, cost per disability-adjusted life year (DALY) averted and affordability of the health component implemented from February 2019 to December 2021. Method: Health-related improvements were assessed for a sample of 511 persons with disability and converted to DALYs averted. Total expenditure during the period February 2019 to December 2021 was estimated from audited financial statements. The cost per DALY averted was estimated by dividing total programme expenditure by the sum of DALYs averted and compared against newly generated, country-specific thresholds to assess affordability. Results: The programme cost $55 729.00 to implement from February 2019 to December 2021 and averted 234 DALYs in 511 persons, at a cost per DALY averted of $224.00. This falls above the affordability threshold of $54.00 – $199.00. Conclusion: While the cost per DALY averted is higher than what thresholds consider affordable for Democratic Republic of Congo, improved engagement from CBR facilitators and greater possibilities for treatment in the post-pandemic era should improve results. Contribution: This new CBR implementation modality offers a possibly affordable solution to African governments struggling to operationalise disability commitments such as United Nations Convention on the Rights of Persons with Disabilities. [ABSTRACT FROM AUTHOR]

Introduction: This international survey explored the ongoing impact of COVID‐19 on pediatric anesthesiology. It assessed COVID‐19's impact on the practice of pediatric anesthesiology, staffing, job satisfaction, and retention at the beginning of 2022 and addressed what should be done to ameliorate COVID‐19's impact and what initiatives hospitals had implemented. Methods: This survey focused on five major domains: equipment/medication, vaccination/testing, staffing, burnout, and economic repercussions. Pilot testing for questionnaire clarity was conducted by members of the Pediatric Anesthesia COVID‐19 Collaborative. The survey was administered by e‐mail to a representative of the 72 collaborative centers. Respondents were instructed to answer based on their institution's practice from February through April of 2022. Descriptive statistics with 95% confidence intervals are reported. Results: Seventy of seventy‐two institutions participated in this survey (97% response rate). Fifty‐nine (84%) were from the United States, and 11 (16%) included other countries. The majority experienced equipment (68%) and medication (60%) shortages. Many institutions reported staffing shortages in nursing (37%), perioperative staff (27%), and attending anesthesiologists (11%). Sixty‐two institutions (89%) indicated burnout was a frequent topic of conversation among pediatric anesthesiologists. Forty‐three institutions (61%) reported anesthesiologists leaving current practice and 37 (53%) early retirement. Twenty‐eight institutions (40%) canceled elective cases. The major suggestions for improving job retention included improving financial compensation (76%), decreasing clinical time (67%), and increasing flexibility in scheduled clinical time (66%). Only a minority of institutions had implemented the following initiatives: improving financial compensation (19%), increased access to mental health/counseling services (30%), and assistance with child or elder care (7%). At the time of the survey, 34% of institutions had not made any changes. Conclusion: Our study found that COVID‐19 has continued to impact pediatric anesthesiology. There are major discrepancies between what anesthesiologists believe are important for job satisfaction and faculty retention compared to implemented initiatives. Data from this survey provide insight for institutions and departments for addressing these challenges. [ABSTRACT FROM AUTHOR]

This study ai ms to verify and analyze the existence of cognitive dissonance in the self-assessment of health by individuals in Brazil, that is, the difference between self-rated health and the health status of individuals. To accomplish this, we use data from the 2013 National Health Survey, which collected the self-assessments that individuals made of their health and information about their health status. This information was used to build indices that seek to represent a person's health status in relation to chronic illnesses, physical and mental well-being, eating habits and lifestyle. To identify the presence of cognitive dissonance, the CUB (Combination of a discrete Uniform and shifted Binomial distributions) model was used, which relates self-assessed health with the developed indices. Cognitive dissonance was identified in self-assessed health in relation to eating habits and lifestyle, and this dissonance may be associated with a present bias in the self-assessment of health in Brazil. [ABSTRACT FROM AUTHOR]

Background: The Blue Book (2005), recommended guidelines for patients care with fragility fractures. Together with introduction of a National Hip Fracture Database Audit and Best Practice Tariff model to financially incentivise hospitals by payment of a supplement for patients whose care satisfied six clinical standards), have improved hip fracture after-care. However, there is a lack of data-driven evidence to support its effectiveness. We aimed to verify the impact of an orthogeriatric service on hospital length of stay (LOS)—duration from admission to discharge. Methods: We conducted a repeated cross-sectional study over a 10 year period of older individuals aged ≥ 60 years admitted with hip fractures to a hospital. Results: Altogether 2798 patients, 741 men and 2057 women (respective mean ages; 80.5 ± 10.6 and 83.2 ± 8.9 years) were admitted from their own homes with a hip fracture and survived to discharge. Compared to 2009–2014, LOS during 2015–2019, when the orthogeriatric service was fully implemented, was shorter for all discharge destinations: 10.4 vs 17.5 days (P < 0.001). Each discharge destination showed reductions: back to own homes, 9.7 vs 17.7 days (P < 0.001); to rehabilitation units: 10.8 vs 13.1 days (P < 0.001); to residential care: 15.4 vs 26.2 days (P = 0.001); or nursing care, 24.4 vs 53.1 days (P < 0.001). During 2009–2014, the risk of staying > 3 weeks in hospital was greater by six-fold and pressure ulcers by three-fold. The number of bed days for every thousand patients per year was also shortened during 2015–2019 by: 1665 days for discharge back to own homes; 469 days with transfer to rehabilitation units; 1258 days for discharge to residential care, and 5465 days to nursing care. Estimated annual savings (2017 costs) per thousand patients after complete establishment of the service was about £2.7 m. Conclusions: Implementation of an orthogeriatric service generated significant reductions in hospital LOS for all patients, with associated cost-savings, especially for those discharged to nursing care. [ABSTRACT FROM AUTHOR]

Objectives: To determine demographic, socioeconomic, and clinical factors associated with being high-cost users (HCUs) in adult patients (≥ 18 years) who received acute care in Canada. Research design: We conducted a retrospective study among adults who had at least one encounter with acute care facilities each year from 2011 to 2014 using national linked data sets. We defined HCUs as patients on the top 10% of the highest acute care cost users in the province, where the care was provided. Risk factors associated with being HCUs were identified using multilevel logistic regression. Provincial variations of identified risk factors were examined using logistic regression. Sensitivity analyses were also performed to investigate the influences of using different metrics and different thresholds to define high system users, missing data, and the inclusion of interaction terms on the study results. Results: Between 2011 and 2014, a total of 3,891,410 patients with 6,017,430 hospitalizations were included. Patients who were male [odds ratio (OR), 1.60; 95% confidence interval (CI) 1.59–1.61], with low incomes [OR 1.42; 95% CI 1.41–1.43), with higher comorbidity score (OR 1.41; 95% CI 1.40–1.41] and older [OR 1.18; 95% CI 1.17–1.18] were more likely to be acute care HCUs. Significant interactions existed between comorbidity score and age/sex/income status. Across provinces, the associations between socioeconomic factors and being HCUs has the largest variation. When using various high system users (HSUs) definitions, the impacts of living in rural area and being visible minority on the odds of being HSUs differ. Conclusions: A few demographic, socioeconomic, and clinical factors was associated with high acute care expenditures. The associations between included risk factors and being acute care HCUs vary across provinces and different definitions of high system users (HSUs). [ABSTRACT FROM AUTHOR]

The introduction of robotics in orthopedic surgery has led to improved precision and standardization in total knee arthroplasty (TKA). Clinical benefits of robotic versus manual TKA have been well established; however, evidence for economic and healthcare resource utilization outcomes (HRU) is lacking. The primary objective of this study was to compare economic and HRU outcomes for robotic and manual TKA. The secondary objective was to explore comparative robotic and manual TKA pain and opioid consumption outcomes. Multi-database literature searches were performed to identify studies comparing robotic and manual TKA from 2016 to 2022 and meta-analyses were conducted. This review included 50 studies with meta-analyses conducted on 35. Compared with manual TKA, robotic TKA was associated with a: 14% reduction in hospital length of stay (P = 0.022); 74% greater likelihood to be discharged to home (P < 0.001); and 17% lower likelihood to experience a 90-day readmission (P = 0.043). Robotic TKA was associated with longer mean operating times (incision to closure definition: 9.27 min longer, P = 0.030; general operating time definition: 18.05 min longer, P = 0.006). No differences were observed for total procedure cost and 90-day emergency room visits. Most studies reported similar outcomes for robotic and manual TKA regarding pain and opioid use. Coupled with the clinical benefits of robotic TKA, the economic impact of using robotics may contribute to hospitals' quality improvement and financial sustainability. Further research and more randomized controlled trials are needed to effectively quantify the benefits of robotic relative to manual TKA. [ABSTRACT FROM AUTHOR]

Objectives: To summarise the extent and type of evidence available regarding economic evaluations of adult critical care pharmacy services in the context of UK practice. Methods: A literature search was conducted in eight electronic databases and hand searching of full-text reference lists. Of 2409 journal articles initially identified, 38 were included in the final review. Independent literature review was undertaken by two investigators in a two-step process against the inclusion and exclusion criteria; title and abstract screening were followed by full-text screening. Included studies were taken from high-income economy countries that contained economic data evaluating any key aspect of adult critical care pharmacy services. Grey literature and studies that could not be translated into the English language were excluded. Results: The majority were before-and-after studies (18, 47%) or other observational studies (17, 45%), and conducted in North America (25, 66%). None of the included studies were undertaken in the UK. Seven studies (18%) included cost-benefit analysis; all demonstrated positive cost-benefit values for clinical pharmacist activities. Conclusions: Further high-quality primary research focussing on the economic evaluation of UK adult critical care pharmacy services is needed, before undertaking a future systematic review. There is an indication of a cost-benefit value for critical care pharmacist activities. The lack of UK-based economic evaluations is a limitation to further development and standardisation of critical care pharmacy services nationally. [ABSTRACT FROM AUTHOR]

Objectives: Since 2013 community pharmacies in Wales have been commissioned to provide a common ailments service (CAS), providing pharmacy medicine without charge to patients. In the first review of national pharmacy data, this study aimed to describe the relationship between provision of CAS and deprivation. Methods: A retrospective observational study, using CAS claims data from April 2022 to March 2023 collected as part of routine service delivery. Consultation data were matched to the index of multiple deprivation (IMD) decile of the providing pharmacy. Linear regression was used to describe the correlation between CAS claims data and IMD deciles of the pharmacy postcode. Key findings: In the study period, 239 028 consultations were recorded. More than twice as many consultations were carried out in pharmacies located in the most deprived decile (33 950) than in pharmacies in the least deprived decile (14 465). Linear regression demonstrated a significant correlation r(10) = −0.927, P < 0.001. There was a strong relationship between greater numbers of consultations and greater deprivation of the pharmacy postcode (R2 = 0.887). This significant correlation with deprivation was also found in the majority of individual conditions. There was no significant correlation between deprivation decile and the number of consultations per patient. Conclusions: Community pharmacies offer a key resource for tackling health inequalities. Patients in those areas with the greatest need are those most likely to use the CAS in pharmacies and receive the care they need. Commissioning services like this naturally supports deprived communities, through a combination of patient behaviours, location, and accessibility. [ABSTRACT FROM AUTHOR]

The most comprehensive and inclusive estimates for the economic burden of foodborne illness yield values as high as $97.4 billion USD annually. However, broad incidence and cost estimates have limited use if they cannot be attributed to specific foods, for the purposes of food safety control. In this study, we estimated the economic burden of foodborne illnesses resulting from flour and flour‐based food products in the United States from the years 2001 to 2021. The outbreak, illness burden, and health economic data are combined to generate these estimates. Our model combined outbreak data with published Centers for Disease Control and Prevention multipliers to estimate the annual number of illnesses associated with flour‐borne pathogens. We then integrated illness severity data with an updated economic model that accounts for costs related to medical care, productivity loss, loss of life, along with the quality of life loss that entails pain and suffering. In total, 752 cases and 223 hospitalizations from flour‐related illnesses were reported from 2001 to 2021, with an average of 37.6 cases of reported cases annually. However, the actual number of cases, accounting for underreporting and underdiagnosis, can be as high as 19,440 annually. Pathogens involved in these outbreaks are Salmonella, E. coli O157:H7, and E. coli O121. Our estimates suggest average annual economic losses, including healthy years of life lost, of $108 and $258 million using two alternative models. [ABSTRACT FROM AUTHOR]

Objective: Equity in the delivery of health services, including diagnostic imaging, is crucial to achieving universal health coverage. The Health Transformation Plan (HTP), launched in 2014, represents a major healthcare policy to improve the quality and accessibility of healthcare services. This study aimed to explore the impact of the HTP on equity in the access to medical imaging in Lorestan province, located in west Iran, from 2014 to 2023. Annual growth rates (AGR) of imaging devices were calculated, whilst equity assessment of medical imaging distribution was carried out by means of the Gini coefficient and the Lorenz curve per 100,000 population. The latter was generated using the cumulative distribution of imaging devices, as well as the cumulative population ratio. Results: Between 2014 and 2023, the number of imaging devices has increased threefold. The AGR of installing CT and MRI scanners in Lorestan province increased between 2014 and 2023. The Gini coefficients increased from 0.12 for CT and 0.16 for MRI in 2014 to 0.33 in 2023 for both devices. This indicates a decrease in equity in access to these fundamental health technologies despite the increase in their figures. Policymakers should better allocate medical equipment based on the specific health needs of different regions throughout Iran. [ABSTRACT FROM AUTHOR]

Historically, the NHS did not routinely collect cost data, unlike many countries with private insurance markets. In 1998, for the first time the government mandated NHS trusts to submit estimates of their costs of service, known as reference costs. These have informed a wide range of health economic evaluations and important functions in the health service, such as setting prices. Reference costs are collected by progressively disaggregating budgets top-down into disease and treatment groups. Despite ongoing improvements to methods and guidance, these submissions continued to suffer a lack of accuracy and comparability, fundamentally undermining their credibility for critical functions. To overcome these issues, there was a long-held ambition to collect "patient-level" cost data. Patient-level costs are estimated with a combination of disaggregating budgets but also capturing the patient-level "causality of costs" bottom-up in the allocation of resources to patient episodes. These not only aim to capture more of the drivers of costs, but also improve consistency of reporting between providers. The change in methods may confer improvements to data quality, though judgement is still required and achieving consistency between trusts will take further work. Estimated costs may also change in important ways that may take many years to fully understand. We end on a cautionary note that patient-level cost methods may unlock potential, they alone contribute little to our understanding of the complexities involved with service quality or need, while that potential will require substantial investment to realise. Many healthcare resources cannot be attributed to individual patients so the very notion of "patient-level" costs may be misplaced. High hopes have been put in these new data, though much more work is now necessary to understand their quality, what they show and how their use will impact the system. [ABSTRACT FROM AUTHOR]

Background: Costs related to the care of melanoma patients have been rising over the past few years due to increased disease incidence as well as the introduction of innovative treatments. The aim of this study is to analyse CMM cost items based on stage at diagnosis, together with other diagnostic and prognostic characteristics of the melanoma. Methods: Analyses were performed on 2,647 incident cases of invasive CMM that were registered in 2015 and 2017 in the Veneto Cancer Registry (RTV). Direct melanoma-related costs per patient were calculated for each year ranging from 2 years before diagnosis to 4 years after, and were stratified by cost items such as outpatient services, inpatient drug prescriptions, hospital admissions, hospice admissions, and emergency room treatment. Average yearly costs per patient were compared according to available clinical-pathological characteristics. Lastly, log-linear multivariable analysis was performed to investigate potential cost drivers among these clinical- pathological characteristics. Findings: Overall, the average direct costs related to melanoma are highest in the first year after diagnosis (€2,903) and then decrease over time. Hospitalization costs are 8 to 16 times higher in the first year than in subsequent years, while the costs of outpatient services and inpatient drugs decrease gradually over time. When stratified by stage it is observed that the higher expenditure associated with more advanced stages of CMM is mainly due to inpatient drug use. Conclusion: The results of the present study show that grouping patients according to tumour characteristics can improve our understanding of the different cost items associated with cutaneous malignant melanoma. CMM patients experience higher costs in the first year after diagnosis due to higher hospitalization and outpatient services. Policy makers should consider overall and stage-specific annual costs when allocating resources for the management of CMM patients. [ABSTRACT FROM AUTHOR]

Background: Self-report instruments are used to evaluate the effect of interventions. However, individuals adapt to adversity. This could result in individuals reporting higher levels of well-being than one would expect. It is possible to test for the influence of adapted preferences on instrument responses using measurement invariance testing. This study conducts such a test with the Wellbeing Related option-Freedom (WeRFree) and ICECAP-A instruments. Methods: A multi-group confirmatory factor analysis was conducted to iteratively test four increasingly stringent types of measurement invariance: (1) configural invariance, (2) metric invariance, (3) scalar invariance, and (4) residual invariance. Data from the Multi Instrument Comparison study were divided into subsamples that reflect groups of participants that differ by age, gender, education, or health condition. Measurement invariance was assessed with (changes in) the Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), and Root Mean Square Residual (SRMR) fit indices. Results: For the WeRFree instrument, full measurement invariance could be established in the gender and education subsamples. Scalar invariance, but not residual invariance, was established in the health condition and age group subsamples. For the ICECAP-A, full measurement invariance could be established in the gender, education, and age group subsamples. Scalar invariance could be established in the health group subsample. Conclusions: This study tests the measurement invariance properties of the WeRFree and ICECAP-A instruments. The results indicate that these instruments were scalar invariant in all subsamples, which means that group means can be compared across different subpopulations. We suggest that measurement invariance of capability instruments should routinely be tested with a reference group that does not experience a disadvantage to study whether responses could be affected by adapted preferences. [ABSTRACT FROM AUTHOR]

Aim: Selective root‐canal retreatment has been proposed as an alternative to full retreatment in multirooted, root‐canal‐filled teeth with evidence of apical pathology, where only the affected root(s) is retreated. Whilst this option may save costs initially, failures and retreatments may compensate for these initial savings. We assessed the cost‐effectiveness of full versus selective root‐canal retreatment using data from a recent clinical pilot study, employing a modelling approach. Methodology: A Markov model was constructed to follow up a previously root‐canal treated maxillary molar with apical pathology on a single root (mesio‐buccal), receiving either selective or full root‐canal retreatment. A private‐payer perspective in Dutch health care was adopted. Permanent molar teeth with apical lesions on the mesial root were simulated over the lifetime of initially 50‐year‐old patients. Teeth could have endodontic complications and require interventions such as retreatment or tooth extraction and replacement. Costs were calculated based on the Dutch dental fee catalogues. Monte‐Carlo microsimulations were performed to assess lifetime costs and effectiveness (measured as tooth retention time), and the resulting cost‐effectiveness. Probabilistic joint uncertainty and sensitivity analyses were performed, and cost‐effectiveness at different willingness‐to‐pay‐thresholds was evaluated. Results: In the base‐case scenario, selective retreatment was less costly (2137; 2.5%–97.5% percentiles: 1944–2340 Euro) and more effective (19.6; 18.3–20.8 Years) than full retreatment (2495; 2305–2671 Euro; 16.5; 15.2–17.9 Years) in 100% of the simulations and regardless of the willingness‐to‐pay threshold. Only in a worst case scenario was selective retreatment more costly, but remained more effective. Conclusions: Selective retreatment, when clinically applicable, is likely to be more cost‐effective than full retreatment in endodontically treated molars with persistent apical periodontitis. Our results should be interpreted with caution because the quality of the underlying data is limited. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot by antibiotics management index and health economics index. Methods 40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department of Air Force Medical Center from April to September 2017 were selected as control group, and 40 hospitalized patients with diabetic foot of Wagner Grade 4 in the Endocrine Department from April to September 2019 were selected as interventional group. No clinical pharmacists were involved in drug treatment of patients in the control group, while the clinical pharmacists in the interventional group participated in drug treatment, and implemented antimicrobial stewardship, medication reconciliation, pharmaceutical care and medication education. Antibiotics management indexes (use intensity of antibiotics, use rate of special class antibiotics) and health economics indexes (medicine expenses, hospitalization expenses) of the two groups were compared. Results The efficacy of the two groups was similar. The use intensity of antibiotics and use rate of special class antibiotics of the interventional group in which clinical pharmacists participated were significantly lower than the control group (P<0.01), so were the medicine expenses and hospitalization expenses (P<0.01). Conclusion Clinical pharmacists participating in the treatment of hospitalized patients with diabetic foot could reduce antibiotics administration index and health economics index, promote rational medicine use and save medical expenses. [ABSTRACT FROM AUTHOR]

Norway has, according to the World Health Organization, more psychiatrists engaged in public health services per head of population than any other country, and the proportionate numbers of psychologists and others engaged in mental healthcare are also among the world's highest. Approximately 10% of Norway's gross domestic product is spent on health, expenditure per capita that is the fourth highest internationally. We discuss how this wealth of expertise translates into the delivery of services to the public. [ABSTRACT FROM AUTHOR]