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1. Determinants of Unmet Healthcare Needs During the Final Stage of the COVID-19 Pandemic: Insights From a 21-Country Online Survey

Author

Samuel Lewis, Louisa Ewald, Herbert C. Duber, Ali H. Mokdad, and Emmanuela Gakidou

Subjects
health system, preventive care, chronic care, COVID-19 pandemic, healthcare utilization, Public aspects of medicine, RA1-1270
Abstract

ObjectivesDuring the COVID-19 pandemic, essential health services experienced significant disruptions, impacting preventive and chronic care across the world.MethodsUtilizing the Pandemic Recovery Survey (PRS), conducted online with Facebook’s Active User Base across 21 countries between March and May 2023, this cross-sectional study identifies the magnitude of and key factors associated with unmet preventive and chronic care needs during the late stage of the COVID-19 pandemic.ResultsApproximately 28.2% of respondents reported unmet preventive care needs, and 42.1% experienced unmet chronic care needs, with key determinants including food insecurity (aOR 1.94, 95% CI 1.81–2.07 for preventive services; aOR 1.85, 95% CI 1.68–2.03 for existing conditions) and distrust in health professionals (aOR 1.09, 95% CI 1.03–1.15 for preventive services; aOR 1.53, 95% CI 1.41–1.66 for existing conditions).ConclusionThe findings underscore a widespread unmet need for health services, highlighting the impact of social determinants and trust in health professionals on service disruption. The results suggest that pandemic recovery efforts should focus on the most affected groups to bridge health disparities and ensure an equitable recovery.

Published
2024
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2. Race, Healthcare, and Health Disparities: A Critical Review and Recommendations for Advancing Health Equity

Author

Wendy L. Macias-Konstantopoulos, Kimberly A. Collins, Rosemarie Diaz, Herbert C. Duber, Courtney D. Edwards, Antony P. Hsu, Megan L. Ranney, Ralph J. Riviello, Zachary S. Wettstein, and Carolyn J. Sachs

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

An overwhelming body of evidence points to an inextricable link between race and health disparities in the United States. Although race is best understood as a social construct, its role in health outcomes has historically been attributed to increasingly debunked theories of underlying biological and genetic differences across races. Recently, growing calls for health equity and social justice have raised awareness of the impact of implicit bias and structural racism on social determinants of health, healthcare quality, and ultimately, health outcomes. This more nuanced recognition of the role of race in health disparities has, in turn, facilitated introspective racial disparities research, root cause analyses, and changes in practice within the medical community. Examining the complex interplay between race, social determinants of health, and health outcomes allows systems of health to create mechanisms for checks and balances that mitigate unfair and avoidable health inequalities. As one of the specialties most intertwined with social medicine, emergency medicine (EM) is ideally positioned to address racism in medicine, develop health equity metrics, monitor disparities in clinical performance data, identify research gaps, implement processes and policies to eliminate racial health inequities, and promote anti-racist ideals as advocates for structural change. In this critical review our aim was to (a) provide a synopsis of racial disparities across a broad scope of clinical pathology interests addressed in emergency departments—communicable diseases, non-communicable conditions, and injuries—and (b) through a race-conscious analysis, develop EM practice recommendations for advancing a culture of equity with the potential for measurable impact on healthcare quality and health outcomes.

Published
2023
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3. Ambitions and realities: Are Global Fund investments designed to achieve resilient and sustainable systems for health? Findings from the Global Fund Prospective Country Evaluation

Author

Nicole Salisbury, Saira Nawaz, Justine Abenaitwe, Audrey Batzel, Emily Grapa, Francisco Rios Casas, Virginia Cerezo, Matthew Cooper, Herbert C. Duber, Ibrahima Gaye, Bernardo Hernandez, Constant Kingongo, Louisiana Lush, Kate Macintyre, Eugene Manika, Shakilah N. Nagasha, Tidiane Ndoye, Rosario Orozco, Allison Osterman, and Katharine D. Shelley

Subjects
Public aspects of medicine, RA1-1270
Published
2024

4. Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients

Author

Liliya Kraynov, Aaron Quarles, Andrew Kerrigan, Katherine Dickerson Mayes, Sally Mahmoud-Werthmann, Callan E. Fockele, Herbert C. Duber, Kelly M. Doran, Michelle P. Lin, Richelle J. Cooper, and Nancy Ewen Wang

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need. Methods: Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems. Results: Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government. Conclusion: The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

Published
2023
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5. 2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs

Author

Mackensie Yore, Callan Elswick Fockele, Herbert C. Duber, Kelly M. Doran, Richelle J. Cooper, Michelle P. Lin, Steffani Campbell, Vidya Eswaran, Betty Chang, Haeyeon Hong, Kessiena Gbenedio, Kimberly A. Stanford, and Nicholas Gavin

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown. Methods: Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies. Results: Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability. Conclusion: Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.

Published
2023
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6. Evaluation of an Emergency Department Influenza Vaccination Program: Uptake Factors and Opportunities

Author

Canada Parrish, Crystal A. Phares, Tim Fredrickson, John B. Lynch, Lauren K. Whiteside, and Herbert C. Duber

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: Influenza vaccines are commonly provided through community health events and primary care appointments. However, acute unscheduled healthcare visits such as emergency department (ED) visits are increasingly viewed as important vaccination opportunities. Emergency departments may be well-positioned to complement broader public health efforts with integrated vaccination programs. Methods: We studied an ED-based influenza vaccination initiative in an urban hospital and examined patient-level factors associated with screening and vaccination uptake. Our analyses included patient visits to the ED from October 1, 2019–April 1, 2020. Results: The influenza screening and vaccination program proved feasible. Of the 20,878 ED visits that occurred within the study period, 3,565 (17.1%) included a screening for influenza vaccine eligibility; a small proportion (11.5%) of the patients seen had multiple screenings. Among the patients screened eligible for the vaccine, 916 ultimately received an influenza vaccination while in the ED (43.7% of eligible patients). There was significant variability in the characteristics of patients who were and were not screened and vaccinated. Age, gender, race, preferred language, and receipt of a flu vaccine in prior years were associated with screening and/or receiving a vaccine in the ED. Conclusion: Vaccination programs in the ED can boost community vaccination rates and play a role in both preventing and treating current and future vaccine-preventable public health crises, although efforts must be made to deliver services equitably.

Published
2022
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7. Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya

Author

Maya S. Fraser, Benjamin W. Wachira, Abraham D. Flaxman, Aaron Y. Lee, and Herbert C. Duber

Subjects
Medicine, Medicine (General), R5-920
Abstract

Background: In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world. Methods: We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status. Results: We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5–6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1–10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5–14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%. Conclusion: Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities. Keywords: Emergency care, Kenya, Traffic, Poverty

Published
2020
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8. Mapping HIV prevalence in Nigeria using small area estimates to develop a targeted HIV intervention strategy

Author

Caitlin O’BRIEN-CARELLI, Krista STEUBEN, Kristen A. STAFFORD, Rukevwe ALIOGO, Matthias ALAGI, Casey K. JOHANNS, Jahun IBRAHIM, Ray SHIRAISHI, Akipu EHOCHE, Stacie GREBY, Emilio DIRLIKOV, Dalhatu IBRAHIM, Megan BRONSON, Gambo ALIYU, Sani ALIYU, Laura DWYER-LINDGREN, Mahesh SWAMINATHAN, Herbert C. DUBER, and Man CHARURAT

Subjects
Medicine, Science
Abstract

Objective Although geographically specific data can help target HIV prevention and treatment strategies, Nigeria relies on national- and state-level estimates for policymaking and intervention planning. We calculated sub-state estimates along the HIV continuum of care in Nigeria. Design Using data from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) (July–December 2018), we conducted a geospatial analysis estimating three key programmatic indicators: prevalence of HIV infection among adults (aged 15–64 years); antiretroviral therapy (ART) coverage among adults living with HIV; and viral load suppression (VLS) rate among adults living with HIV. Methods We used an ensemble modeling method called stacked generalization to analyze available covariates and a geostatistical model to incorporate the output from stacking as well as spatial autocorrelation in the modeled outcomes. Separate models were fitted for each indicator. Finally, we produced raster estimates of each indicator on an approximately 5×5-km grid and estimates at the sub-state/local government area (LGA) and state level. Results Estimates for all three indicators varied both within and between states. While state-level HIV prevalence ranged from 0.3% (95% uncertainty interval [UI]: 0.3%–0.5%]) to 4.3% (95% UI: 3.7%–4.9%), LGA prevalence ranged from 0.2% (95% UI: 0.1%–0.5%) to 8.5% (95% UI: 5.8%–12.2%). Although the range in ART coverage did not substantially differ at state level (25.6%–76.9%) and LGA level (21.9%–81.9%), the mean absolute difference in ART coverage between LGAs within states was 16.7 percentage points (range, 3.5–38.5 percentage points). States with large differences in ART coverage between LGAs also showed large differences in VLS—regardless of level of effective treatment coverage—indicating that state-level geographic targeting may be insufficient to address coverage gaps. Conclusion Geospatial analysis across the HIV continuum of care can effectively highlight sub-state variation and identify areas that require further attention in order to achieve epidemic control. By generating local estimates, governments, donors, and other implementing partners will be better positioned to conduct targeted interventions and prioritize resource distribution.

Published
2022

9. Association Between Subnational Vaccine Coverage, Migration, and Incident Cases of Measles, Mumps, and Rubella in Iraq, 2001–2016

Author

Haley Comfort, Riyadh K. Lafta, Abraham D. Flaxman, Amy Hagopian, and Herbert C. Duber

Subjects
vaccination, conflict, measles, Iraq, MMR, Public aspects of medicine, RA1-1270
Abstract

ObjectiveThis analysis examines governorate-level disease incidence as well as the relationship between incidence and the number of persons of concern for three vaccine-preventable diseases—measles, mumps, and rubella—between 2001 and 2016.MethodsUsing Iraqi Ministry of Health and United Nations High Commissioner for Refugees (UNHCR) data, we performed descriptive analyses of disease incidence and conducted a pooled statistical analysis with a linear mixed effects regression model to examine the role of vaccine coverage and migration of persons of concern on subnational disease incidence.ResultsWe found large variability in governorate-level incidence, particularly for measles (on the order of 100x). We identified decreases in incident measles cases per 100,000 persons for each additional percent vaccinated (0.82, 95% CI: [0.64, 1.00], p-value < 0.001) and for every additional 10,000 persons of concern when incorporating displacement into our model (0.26, 95% CI: [0.22, 0.30], p-value < 0.001). These relationships were insignificant for mumps and rubella.ConclusionsNational level summary statistics do not adequately capture the high geospatial disparity in disease incidence between 2001 and 2016. This variability is complicated by MMR vaccine coverage and the migration of “persons of concern” (refugees) during conflict. We found that even when vaccine coverage was constant, measles incidence was higher in locations with more displaced persons, suggesting conflict fueled the epidemic in ways that vaccine coverage could not control.

Published
2022
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10. The relative incidence of COVID-19 in healthcare workers versus non-healthcare workers: evidence from a web-based survey of Facebook users in the United States [version 2; peer review: 2 approved, 1 approved with reservations]

Author

Abraham D. Flaxman, Daniel J. Henning, and Herbert C. Duber

Subjects
Medicine
Abstract

Background: Healthcare workers are at the forefront of the COVID-19 pandemic and it is essential to monitor the relative incidence rate of this group, as compared to workers in other occupations. This study aimed to produce estimates of the relative incidence ratio between healthcare workers and workers in non-healthcare occupations. Methods: Analysis of cross-sectional data from a daily, web-based survey of 1,822,662 Facebook users from September 8, 2020 to October 20, 2020. Participants were Facebook users in the United States aged 18 and above who were tested for COVID-19 because of an employer or school requirement in the past 14 days. The exposure variable was a self-reported history of working in healthcare in the past four weeks and the main outcome was a self-reported positive test for COVID-19. Results: On October 20, 2020, in the United States, there was a relative COVID-19 incidence ratio of 0.73 (95% UI 0.68 to 0.80) between healthcare workers and workers in non-healthcare occupations. Conclusions: In fall of 2020, in the United States, healthcare workers likely had a lower COVID-19 incidence rate than workers in non-healthcare occupations.

Published
2021
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11. Improving transitions of care for patients initiated on buprenorphine for opioid use disorder from the emergency departments in King County, Washington

Author

Callan Elswick Fockele, Herbert C. Duber, Brad Finegood, Sophie C. Morse, and Lauren K. Whiteside

Subjects
Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Abstract Study objective Opioid use disorder (OUD) is on the rise nationwide with increasing emergency department (ED) visits and deaths secondary to overdose. Although previous research has shown that patients who are started on buprenorphine in the ED have increased engagement in addiction treatment, access to on‐demand medications for OUD is still limited, in part because of the need for linkages to outpatient care. The objective of this study is to describe emergency and outpatient providers’ perception of local barriers to transitions of care for ED‐initiated buprenorphine patients. Methods Purposive sampling was used to recruit key stakeholders, identified as physicians, addiction specialists, and hospital administrators, from 10 EDs and 11 outpatient clinics in King County, Washington. Twenty‐one interviews were recorded and transcribed and then coded using an integrated deductive and inductive content analysis approach by 2 team members to verify accuracy of the analysis. Interview guides and coding were informed by the Consolidated Framework for Implementation Research (CFIR), which provides a structure of domains and constructs associated with effective implementation of evidence‐based practice. Results From the 21 interviews with emergency and outpatient providers, this study identified 4 barriers to transitions of care for ED‐initiated buprenorphine patients: scope of practice, prescribing capacity, referral incoordination, and loss to follow‐up. Conclusion Next steps for implementation of this intervention in a community setting include establishing a standard of care for treatment and referral for ED patients with OUD, increasing buprenorphine prescribing capacity, creating a central repository for streamlined referrals and follow‐up, and supporting low‐barrier scheduling and navigation services.

Published
2021
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12. Healthcare spending in U.S. emergency departments by health condition, 2006–2016

Author

Kirstin Woody Scott, Angela Liu, Carina Chen, Alexander S. Kaldjian, Amber K. Sabbatini, Herbert C. Duber, and Joseph L. Dieleman

Subjects
Medicine, Science
Abstract

Background Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study’s objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time. Methods and findings This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20–44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%). Conclusions Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs.

Published
2021

13. Partnership and Participation—A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda

Author

Katharine D. Shelley, Carol Kamya, Godefroid Mpanya, Salva Mulongo, Shakilah N. Nagasha, Emily Beylerian, Herbert C. Duber, Bernardo Hernandez, Allison Osterman, David E. Phillips, Jessica C. Shearer, and on behalf of the Global Fund Prospective Country Evaluation IHME/PATH consortium collaborators

Subjects
Infectious and parasitic diseases, RC109-216, Public aspects of medicine, RA1-1270
Abstract

Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through “engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society.” Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited. Objective: To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process. Methods: We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017–May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R. Findings: Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs. Conclusions: Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

Published
2020
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14. Identifying gaps in the continuum of care for hypertension and diabetes in two Indian communities

Author

Rose Gabert, Marie Ng, Ruchi Sogarwal, Miranda Bryant, R. V. Deepu, Claire R. McNellan, Sunil Mehra, Bryan Phillips, Marissa Reitsma, Blake Thomson, Shelley Wilson, Alexandra Wollum, Emmanuela Gakidou, and Herbert C. Duber

Subjects
Effective coverage, Diabetes, Hypertension, Cardiovascular disease, India, Continuum of care, Public aspects of medicine, RA1-1270
Abstract

Abstract Background Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur. Methods We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members. Results Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG

Published
2017
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15. The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

Author

Alexandra Wollum, Emily Dansereau, Nancy Fullman, Jane Achan, Kelsey A. Bannon, Roy Burstein, Ruben O. Conner, Brendan DeCenso, Anne Gasasira, Annie Haakenstad, Michael Hanlon, Gloria Ikilezi, Caroline Kisia, Aubrey J. Levine, Samuel H. Masters, Pamela Njuguna, Emelda A. Okiro, Thomas A. Odeny, D. Allen Roberts, Emmanuela Gakidou, and Herbert C. Duber

Subjects
Antiretroviral therapy, HIV/AIDS, Health systems, Kenya, Uganda, Public aspects of medicine, RA1-1270
Abstract

Abstract Background Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda. Methods Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services. Results Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services. Conclusions Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

Published
2017
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16. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Author

Isabel A. Barata, Jamie R. Shandro, Margaret Montgomery, Robin Polansky, Carolyn J. Sachs, Herbert C. Duber, Lindsay M. Weaver, Alan Heins, Heather S. Owen, Elaine B. Josephson, and Wendy Macias-Konstantopoulos

Subjects
Medicine, Medical emergencies. Critical care. Intensive care. First aid, RC86-88.9
Abstract

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. The emergency department (ED) offers a unique opportunity to address AUD with brief screening tools and early intervention. We undertook a systematic review of the effectiveness of ED brief interventions for patients identified through screening who are at risk for AUD, and the effectiveness of these interventions at reducing alcohol intake and preventing alcohol-related injuries. Methods: We conducted systematic electronic database searches to include randomized controlled trials of AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Two authors graded and abstracted data from each included paper. Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from 12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD. Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a control intervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significant differences between control and intervention groups in their main alcohol-outcome criteria of number of drink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumption in both the control and intervention groups; of those, seven studies did not identify a significant intervention effect for the main outcome criteria, but nine observed some significant differences between BI and control conditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking and driving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g. reduction in driving while intoxicated). Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction in alcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury), and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the ED appears to have a short-term effect in reducing at-risk drinking.

Published
2017
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17. Implementation Fidelity of Chatbot Screening for Social Needs: Acceptability, Feasibility, Appropriateness

Author

Raina Langevin, Andrew B. L. Berry, Jinyang Zhang, Callan E. Fockele, Layla Anderson, Dennis Hsieh, Andrea Hartzler, Herbert C. Duber, and Gary Hsieh

Subjects
Health Information Management, Health Informatics, Computer Science Applications
Abstract

Objectives Patient and provider-facing screening tools for social determinants of health have been explored in a variety of contexts; however, effective screening and resource referral remain challenging, and less is known about how patients perceive chatbots as potential social needs screening tools. We investigated patient perceptions of a chatbot for social needs screening using three implementation outcome measures: acceptability, feasibility, and appropriateness. Methods We implemented a chatbot for social needs screening at one large public hospital emergency department (ED) and used concurrent triangulation to assess perceptions of the chatbot use for screening. A total of 350 ED visitors completed the social needs screening and rated the chatbot on implementation outcome measures, and 22 participants engaged in follow-up phone interviews. Results The screened participants ranged in age from 18 to 90 years old and were diverse in race/ethnicity, education, and insurance status. Participants (n = 350) rated the chatbot as an acceptable, feasible, and appropriate way of screening. Through interviews (n = 22), participants explained that the chatbot was a responsive, private, easy to use, efficient, and comfortable channel to report social needs in the ED, but wanted more information on data use and more support in accessing resources. Conclusion In this study, we deployed a chatbot for social needs screening in a real-world context and found patients perceived the chatbot to be an acceptable, feasible, and appropriate modality for social needs screening. Findings suggest that chatbots are a promising modality for social needs screening and can successfully engage a large, diverse patient population in the ED. This is significant, as it suggests that chatbots could facilitate a screening process that ultimately connects patients to care for social needs, improving health and well-being for members of vulnerable patient populations.

Published
2023
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18. Behavioral Health Integration in Community Health Centers and Emergency Department Use

Author

Amber K, Sabbatini, Theresa J, Hoeft, Herbert C, Duber, Eli, Kern, Philip W, Sylling, Alexis, Desrosiers, Michael B, McKee, and Susan E, Hernandez

Subjects
Psychiatry and Mental health, Medicaid, Mental Disorders, Humans, Community Health Centers, Emergency Service, Hospital, Ambulatory Care Facilities, United States
Abstract

Medicaid enrollees with behavioral health disorders often experience fragmented care, leading to high rates of preventable use of emergency departments (EDs). As part of its Medicaid Transformation Program, the Washington Health Care Authority partnered with regional accountable communities of health to collect data on behavioral health integration in community health centers. Clinics who participated in the integrated care demonstration received technical and financial support to increase capacity for integration. This column describes results from an analysis that linked clinic surveys to Medicaid claims to explore characteristics of highly integrated clinics and assess whether clinic capacity for behavioral health integration is associated with ED visit frequency.

Published
2022
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20. Lessons Learned From Implementing Prospective, Multicountry Mixed-Methods Evaluations for Gavi and the Global Fund

Author

Jessica Shearer, Herbert C. Duber, Shakilah N Nagasha, Gilbert Asiimwe, Emily Carnahan, Carol Kamya, Baltazar Chilundo, Katharine D. Shelley, David Phillips, Godefroid Mpanya, Adama Faye, Nicole Salisbury, and Nikki Gurley

Subjects
medicine.medical_specialty, 030219 obstetrics & reproductive medicine, Process management, Financial Management, Design evaluation, Computer science, Best practice, Public health, General Medicine, Complex interventions, Global Health, Disease control, United States, 03 medical and health sciences, Identification (information), 0302 clinical medicine, Global Health Initiatives, medicine, Global health, Humans, Original Article, Prospective Studies, Public Health, 030212 general & internal medicine, Centers for Disease Control and Prevention, U.S
Abstract

Lessons learned from implementing evaluations for Gavi, the Vaccine Alliance and the Global Fund for AIDS, Tuberculosis, and Malaria can help inform the design and implementation of ongoing or future evaluations of complex interventions. We share 5 lessons distilled from over 7 years of experience implementing evaluations in 7 countries., Key Findings We present 5 key lessons distilled from 7 years of experience implementing evaluations in 7 countries, which include the importance of: Including an inception phase to engage stakeholders and inform a relevant, useful evaluation designAligning on the degree to which the evaluation is embedded in the program implementationMonitoring programmatic, organizational, or contextual changes and adapting the evaluation accordinglyHiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methodsContextualizing recommendations and clearly communicating their underlying strength of evidence Key Implications Global health initiatives, particularly those funding or implementing complex interventions, should consider embedding evaluations to understand how and why the programs are working to adapt as necessary and maximize impact.Evaluators of complex interventions should continue to share lessons learned related to balancing stakeholder priorities, aligning on “breadth” versus “depth” of the evaluation scope and ensuring use of the evaluation findings., Introduction: As global health programs have become increasingly complex, corresponding evaluations must be designed to assess the full complexity of these programs. Gavi and the Global Fund have commissioned 2 such evaluations to assess the full spectrum of their investments using a prospective mixed-methods approach. We aim to describe lessons learned from implementing these evaluations. Methods: This article presents a synthesis of lessons learned based on the Gavi and Global Fund prospective mixed-methods evaluations, with each evaluation considered a case study. The lessons are based on the evaluation team’s experience from over 7 years (2013–2020) implementing these evaluations. The Centers for Disease Control and Prevention Framework for Evaluation in Public Health was used to ground the identification of lessons learned. Results: We identified 5 lessons learned that build on existing evaluation best practices and include a mix of practical and conceptual considerations. The lessons cover the importance of (1) including an inception phase to engage stakeholders and inform a relevant, useful evaluation design; (2) aligning on the degree to which the evaluation is embedded in the program implementation; (3) monitoring programmatic, organizational, or contextual changes and adapting the evaluation accordingly; (4) hiring evaluators with mixed-methods expertise and using tools and approaches that facilitate mixing methods; and (5) contextualizing recommendations and clearly communicating their underlying strength of evidence. Conclusion: Global health initiatives, particularly those leveraging complex interventions, should consider embedding evaluations to understand how and why the programs are working. These initiatives can learn from the lessons presented here to inform the design and implementation of such evaluations.

Published
2020
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21. Impact of traffic, poverty and facility ownership on travel time to emergency care in Nairobi, Kenya

Author

Herbert C. Duber, Maya S Fraser, Benjamin Wachira, Abraham D. Flaxman, and Aaron Y. Lee

Subjects
Original article, Developing country, Poison control, lcsh:Medicine, Occupational safety and health, 03 medical and health sciences, 0302 clinical medicine, Health facility, Geochemistry and Petrology, Environmental health, Injury prevention, Traffic, Medicine, 030212 general & internal medicine, Poverty, Socioeconomic status, lcsh:R5-920, business.industry, lcsh:R, 030208 emergency & critical care medicine, Kenya, Traffic congestion, Emergency Medicine, Emergency care, business, lcsh:Medicine (General), Gerontology
Abstract

Background: In many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world. Methods: We used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status. Results: We estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5–6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1–10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5–14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%. Conclusion: Average travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities. Keywords: Emergency care, Kenya, Traffic, Poverty

Published
2020

22. Assessing Catastrophic Health Expenditures Among Uninsured People Who Seek Care in US Hospital-Based Emergency Departments

Author

Kirstin Woody, Scott, John W, Scott, Amber K, Sabbatini, Carina, Chen, Angela, Liu, Joseph L, Dieleman, and Herbert C, Duber

Subjects
Medically Uninsured, Online Only, Cross-Sectional Studies, Research, Humans, Health Expenditures, Emergency Service, Hospital, Hospitals, United States, Comments, Original Investigation, Featured
Abstract

Key Points Question What is the risk of a single treat-and-release emergency department (ED) visit contributing to a catastrophic health expenditure (CHE; health care costs exceeding 40% of post-subsistence income) among uninsured people? Findings In this cross-sectional study of 41.7 million ED visits from 2006 to 2017, nearly 1 in 5 (18%) uninsured treat-and-release ED patient encounters were at risk of CHE. This risk has grown over time and disproportionately burdens those with low incomes. Meaning Policies such as broadening financial risk protection for unscheduled care may help to mitigate CHE risk among uninsured people, who have few alternatives for care outside of the ED., Importance Uninsured people uniquely rely on the emergency department (ED) for care as they are less likely to have access to lower-cost alternatives. Prior work has demonstrated that most uninsured patients are at risk of catastrophic health expenditure (CHE) after being hospitalized for life-saving care. The risk of CHE for a single treat-and-release ED visit that does not result in a hospitalization among uninsured patient encounters is currently unknown. Objective To estimate the overall national risk of CHE among uninsured patients after a single treat-and-release ED visit from 2006 through 2017, and to characterize this risk across key traits. Design, Setting, and Population This cross-sectional study is based on a nationally representative sample of hospital-based ED visits between 2006 and 2017 in the United States (US) from the Nationwide Emergency Department Sample (NEDS). It examined outpatient ED visits among uninsured patients. Main Outcomes and Measures Risk of CHE for ED care defined as an ED charge that exceeds 40% of one’s estimated annual post-subsistence income. Results From 2006 to 2017, there were 41.7 million NEDS encounters that met inclusion criteria for this analysis, equating to a nationally weighted estimate of 184.6 million uninsured treat-and-release ED encounters over this period. The median ED charge for a single treat-and-release encounter grew from $842 in 2006 to $2033 by 2017. Approximately 1 in 5 uninsured patients (18% [95% CI, 18.0%-18.0%]) were at risk of CHE for a single treat-and-release ED visit over the study period. This estimated CHE risk increased from 13.6% (95% CI, 13.6%-13.6%) in 2006 to 22.6% (95% CI, 22.6%-22.7%) in 2017. Those living in the lowest income quartile faced a disproportionate share of this risk, with nearly 1 in 3 (28.5% [95% CI, 28.5%-28.6%]) facing CHE risk in 2017. In 2017, an estimated 3.2 million patient encounters nationally were at risk of CHE after a single treat-and-release ED visit. Conclusions and Relevance This cross-sectional analysis from 2006 to 2017 of 184.6 million uninsured treat-and-release visits found that 1 in 5 uninsured patient encounters are at risk for CHE. This risk has grown over time. Future policies designed to improve access for unscheduled care must consider the unique role of the ED as the de facto safety net and ensure that uninsured patients are not at undue risk of financial harm for seeking care., This cross-sectional study examines the risk of annual out-of-pocket medical expenses that exceed 40% of an uninsured individual’s income resulting from a single treat-and-release emergency department visit in the US.

Published
2021

23. Mapping HIV prevalence in Nigeria using small area estimates to develop a targeted HIV intervention strategy

Author

Caitlin O’BRIEN-CARELLI, Krista STEUBEN, Kristen A. STAFFORD, Rukevwe ALIOGO, Matthias ALAGI, Casey K. JOHANNS, Jahun IBRAHIM, Ray SHIRAISHI, Akipu EHOCHE, Stacie GREBY, Emilio DIRLIKOV, Dalhatu IBRAHIM, Megan BRONSON, Gambo ALIYU, Sani ALIYU, Laura DWYER-LINDGREN, Mahesh SWAMINATHAN, Herbert C. DUBER, and Man CHARURAT

Subjects
Adult, Acquired Immunodeficiency Syndrome, Multidisciplinary, Prevalence, Humans, Nigeria, HIV Infections, Viral Load
Abstract

Objective Although geographically specific data can help target HIV prevention and treatment strategies, Nigeria relies on national- and state-level estimates for policymaking and intervention planning. We calculated sub-state estimates along the HIV continuum of care in Nigeria. Design Using data from the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS) (July–December 2018), we conducted a geospatial analysis estimating three key programmatic indicators: prevalence of HIV infection among adults (aged 15–64 years); antiretroviral therapy (ART) coverage among adults living with HIV; and viral load suppression (VLS) rate among adults living with HIV. Methods We used an ensemble modeling method called stacked generalization to analyze available covariates and a geostatistical model to incorporate the output from stacking as well as spatial autocorrelation in the modeled outcomes. Separate models were fitted for each indicator. Finally, we produced raster estimates of each indicator on an approximately 5×5-km grid and estimates at the sub-state/local government area (LGA) and state level. Results Estimates for all three indicators varied both within and between states. While state-level HIV prevalence ranged from 0.3% (95% uncertainty interval [UI]: 0.3%–0.5%]) to 4.3% (95% UI: 3.7%–4.9%), LGA prevalence ranged from 0.2% (95% UI: 0.1%–0.5%) to 8.5% (95% UI: 5.8%–12.2%). Although the range in ART coverage did not substantially differ at state level (25.6%–76.9%) and LGA level (21.9%–81.9%), the mean absolute difference in ART coverage between LGAs within states was 16.7 percentage points (range, 3.5–38.5 percentage points). States with large differences in ART coverage between LGAs also showed large differences in VLS—regardless of level of effective treatment coverage—indicating that state-level geographic targeting may be insufficient to address coverage gaps. Conclusion Geospatial analysis across the HIV continuum of care can effectively highlight sub-state variation and identify areas that require further attention in order to achieve epidemic control. By generating local estimates, governments, donors, and other implementing partners will be better positioned to conduct targeted interventions and prioritize resource distribution.

Published
2021

24. Can I Talk to You about Your Social Needs? Understanding Preference for Conversational User Interface in Health

Author

Dennis T. Hsieh, Rafal Kocielnik, Kabir Yadav, Andrea L. Hartzler, Darwin P. Jones, Layla Anderson, Herbert C. Duber, Callan Fockele, Amelia Wang, James S. George, Shota Akenaga, Alexander Argyle, Raina Langevin, and Gary Hsieh

Subjects
Workflow, business.industry, Low health literacy, Health care, Internet privacy, Social needs, Context (language use), Health literacy, User interface, business, Psychology, Preference
Abstract

Conversational User Interfaces (CUI) are becoming increasingly utilized in Health applications due to their ability to engage patients and support clinical workflows. Yet recent reviews show that our understanding of CUI performance and user preferences towards them is still lacking. This work examines factors that explain people’s preference for engaging with a social needs screening CUI in a clinical context with 41 emergency department visitors. We demonstrate that people with low health literacy and high attitude towards emotional interaction (AEI) prefer responding to questions via CUI rather than a form-based survey. Specifically, participants with low health literacy appreciate the improved understandability offered by the CUI, whereas participants with high AEI appreciate the added level of engagement offered through conversational interactions. Our work advances the understanding of the benefits of CUI for different user groups in health contexts and beyond.

Published
2021
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25. Emergency department–based COVID‐19 vaccination: Where do we stand?

Author

Herbert C. Duber, Richard E. Rothman, Daniel R. Martin, Elissa M. Schechter-Perkins, Phillip Moschella, Michael J. Waxman, and Thomas Benzoni

Subjects
COVID-19 Vaccines, Coronavirus disease 2019 (COVID-19), media_common.quotation_subject, Population, Psychological intervention, 03 medical and health sciences, Commentary ‐ Unsolicited, 0302 clinical medicine, Optimism, Pandemic, Humans, Medicine, education, Pace, media_common, education.field_of_study, SARS-CoV-2, business.industry, Vaccination, COVID-19, 030208 emergency & critical care medicine, General Medicine, Emergency department, Emergency Medicine, Emergency Service, Hospital, business, Demography
Abstract

Cautious optimism suggests the COVID-19 pandemic in the United States (U.S.) has reached a turning point. Cases have declined precipitously from their heights in the early winter months and vaccine distribution and administration has moved ahead at an accelerated pace. As of late-March, more than 140 million doses of COVID-19 vaccine had been administered in the U.S., with more than 27% of the population receiving at least one dose.1 Nevertheless, challenges with COVID-19 remain. Rates are increasing in select parts of the country, as non-pharmaceutical interventions such as mask mandates and capacity limits are relaxed; more transmissible variants now represent a greater proportion of new cases; and, vaccine hesitancy persists in many sectors of the population. With this shifting landscape, it is imperative that the U.S. continue to rapidly vaccinate as many individuals as possible.

Published
2021
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26. Improving transitions of care for patients initiated on buprenorphine for opioid use disorder from the emergency departments in King County, Washington

Author

Herbert C. Duber, Sophie C Morse, Lauren K. Whiteside, Brad Finegood, and Callan Fockele

Subjects
medicine.medical_specialty, Scope of practice, Referral, RC86-88.9, business.industry, Health Policy, Medical emergencies. Critical care. Intensive care. First aid, Opioid use disorder, Emergency department, medicine.disease, Ambulatory care, Family medicine, medicine, Outpatient clinic, Implementation research, business, Original Research, Buprenorphine, medicine.drug
Abstract

Study objective: Opioid use disorder (OUD) is on the rise nationwide with increasing emergency department (ED) visits and deaths secondary to overdose. Although previous research has shown that patients who are started on buprenorphine in the ED have increased engagement in addiction treatment, access to on-demand medications for OUD is still limited, in part because of the need for linkages to outpatient care. The objective of this study is to describe emergency and outpatient providers' perception of local barriers to transitions of care for ED-initiated buprenorphine patients. Methods: Purposive sampling was used to recruit key stakeholders, identified as physicians, addiction specialists, and hospital administrators, from 10 EDs and 11 outpatient clinics in King County, Washington. Twenty-one interviews were recorded and transcribed and then coded using an integrated deductive and inductive content analysis approach by 2 team members to verify accuracy of the analysis. Interview guides and coding were informed by the Consolidated Framework for Implementation Research (CFIR), which provides a structure of domains and constructs associated with effective implementation of evidence-based practice. Results: From the 21 interviews with emergency and outpatient providers, this study identified 4 barriers to transitions of care for ED-initiated buprenorphine patients: scope of practice, prescribing capacity, referral incoordination, and loss to follow-up. Conclusion: Next steps for implementation of this intervention in a community setting include establishing a standard of care for treatment and referral for ED patients with OUD, increasing buprenorphine prescribing capacity, creating a central repository for streamlined referrals and follow-up, and supporting low-barrier scheduling and navigation services.

Published
2021
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27. Healthcare spending in U.S. emergency departments by health condition, 2006-2016

Author

Angela Liu, Kirstin W. Scott, Alexander S Kaldjian, Herbert C. Duber, Carina Chen, Amber K. Sabbatini, and Joseph L Dieleman

Subjects
Critical Care and Emergency Medicine, Time Factors, Coronavirus disease 2019 (COVID-19), Patients, Economics, Epidemiology, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Science, Social Sciences, Gastroenterology and Hepatology, Health Economics, Health spending, Health care, Medicine and Health Sciences, Medicine, Humans, Public and Occupational Health, Disease, Inpatients, Multidisciplinary, Health economics, Health Care Policy, business.industry, Health condition, Traumatic Injury Risk Factors, Biology and Life Sciences, Gallbladder, Emergency department, Health Care Costs, United States, Health Care, Liver, Age Groups, Medical Risk Factors, Biliary System, People and Places, Observational study, Falls, Population Groupings, Anatomy, business, Emergency Service, Hospital, Biliary Disorders, Demography, Research Article
Abstract

Background Healthcare spending in the emergency department (ED) setting has received intense focus from policymakers in the United States (U.S.). Relatively few studies have systematically evaluated ED spending over time or disaggregated ED spending by policy-relevant groups, including health condition, age, sex, and payer to inform these discussions. This study’s objective is to estimate ED spending trends in the U.S. from 2006 to 2016, by age, sex, payer, and across 154 health conditions and assess ED spending per visit over time. Methods and findings This observational study utilized the National Emergency Department Sample, a nationally representative sample of hospital-based ED visits in the U.S. to measure healthcare spending for ED care. All spending estimates were adjusted for inflation and presented in 2016 U.S. Dollars. Overall ED spending was $79.2 billion (CI, $79.2 billion-$79.2 billion) in 2006 and grew to $136.6 billion (CI, $136.6 billion-$136.6 billion) in 2016, representing a population-adjusted annualized rate of change of 4.4% (CI, 4.4%-4.5%) as compared to total healthcare spending (1.4% [CI, 1.4%-1.4%]) during that same ten-year period. The percentage of U.S. health spending attributable to the ED has increased from 3.9% (CI, 3.9%-3.9%) in 2006 to 5.0% (CI, 5.0%-5.0%) in 2016. Nearly equal parts of ED spending in 2016 was paid by private payers (49.3% [CI, 49.3%-49.3%]) and public payers (46.9% [CI, 46.9%-46.9%]), with the remainder attributable to out-of-pocket spending (3.9% [CI, 3.9%-3.9%]). In terms of key groups, the majority of ED spending was allocated among females (versus males) and treat-and-release patients (versus those hospitalized); those between age 20–44 accounted for a plurality of ED spending. Road injuries, falls, and urinary diseases witnessed the highest levels of ED spending, accounting for 14.1% (CI, 13.1%-15.1%) of total ED spending in 2016. ED spending per visit also increased over time from $660.0 (CI, $655.1-$665.2) in 2006 to $943.2 (CI, $934.3-$951.6) in 2016, or at an annualized rate of 3.4% (CI, 3.3%-3.4%). Conclusions Though ED spending accounts for a relatively small portion of total health system spending in the U.S., ED spending is sizable and growing. Understanding which diseases are driving this spending is helpful for informing value-based reforms that can impact overall health care costs.

Published
2021

28. The relative incidence of COVID-19 in healthcare workers versus non-healthcare workers: evidence from a web-based survey of Facebook users in the United States

Author

Daniel J. Henning, Abraham D. Flaxman, and Herbert C. Duber

Subjects
2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Relative incidence, Medicine (miscellaneous), 01 natural sciences, Biochemistry, Genetics and Molecular Biology (miscellaneous), 03 medical and health sciences, 0302 clinical medicine, Immunology and Microbiology (miscellaneous), Environmental health, Health care, Pandemic, Medicine, 030212 general & internal medicine, Positive test, 0101 mathematics, Web based survey, business.industry, healthcare workers, Health Policy, 010102 general mathematics, Public Health, Environmental and Occupational Health, COVID-19, Articles, Infection rate, business, Research Article
Abstract

Background: Healthcare workers are at the forefront of the COVID-19 pandemic and it is essential to monitor the relative infection rate of this group, as compared to workers in other occupations. This study aimed to produce estimates of the relative incidence ratio between healthcare workers and workers in non-healthcare occupations. Methods: Analysis of cross-sectional data from a daily, web-based survey of 1,788,795 Facebook users from September 6, 2020 to October 18, 2020. Participants were Facebook users in the United States aged 18 and above who were tested for COVID-19 because of an employer or school requirement in the past 14 days. The exposure variable was a self-reported history of working in healthcare in the past four weeks and the main outcome was a self-reported positive test for COVID-19. Results: On October 18, 2020, in the United States, there was a relative COVID-19 incidence ratio of 0.7 (95% UI 0.6 to 0.8) between healthcare workers and workers in non-healthcare occupations. Conclusions: Currently in the United States, healthcare workers have a substantially and significantly lower COVID-19 incidence rate than workers in non-healthcare occupations.

Published
2020

29. Partnership and Participation—A Social Network Analysis of the 2017 Global Fund Application Process in the Democratic Republic of the Congo and Uganda

Author

Carol Kamya, Godefroid Mpanya, Shakilah N Nagasha, Herbert C. Duber, David Phillips, Salva Mulongo, Jessica Shearer, Emily Beylerian, Bernardo Hernández, Allison L. Osterman, Katharine D. Shelley, and Global Fund Prospective Country Evaluation Ihme

Subjects
Economic growth, Civil society, Financial Management, media_common.quotation_subject, Stakeholder engagement, Infectious and parasitic diseases, RC109-216, Global Health, 03 medical and health sciences, 0302 clinical medicine, Humans, Uganda, 030212 general & internal medicine, media_common, Original Research, Social network, business.industry, 030503 health policy & services, Social network analysis (criminology), Citizen journalism, General Medicine, Private sector, Democracy, General partnership, Democratic Republic of the Congo, Business, Public aspects of medicine, RA1-1270, 0305 other medical science, Social Network Analysis
Abstract

Background: The Global Fund to Fight AIDS, Tuberculosis and Malaria was founded in 2002 as a public-private partnership between governments, the private sector, civil society, and populations affected by the three diseases. A key principle of the Global Fund is country ownership in accessing funding through “engagement of in-country stakeholders, including key and vulnerable populations, communities, and civil society.” Research documenting whether diverse stakeholders are actually engaged and on how stakeholder engagement affects processes and outcomes of grant applications is limited. Objective: To examine representation during the 2017 Global Fund application process in the Democratic Republic of the Congo (DRC) and Uganda and the benefits and drawbacks of partnership to the process. Methods: We developed a mixed-methods social network survey to measure network structure and assess perceptions of how working together in partnership with other individuals/organizations affected perceived effectiveness, efficiency, and country ownership of the application process. Surveys were administered from December 2017–May 2018, initially to a set of central actors, followed by any individuals named during the surveys (up to 10) as collaborators. Network analyses were conducted using R. Findings: Collaborators spanning many organizations and expertise areas contributed to the 2017 applications (DRC: 152 nodes, 237 ties; Uganda: 118 nodes, 241 ties). Participation from NGOs and civil society representatives was relatively strong, with most of their ties being to different organization types, Uganda (63%), and DRC (67%), highlighting their collaborative efforts across the network. Overall, the perceived benefits of partnership were high, including very strong ratings for effectiveness in both countries. Perceived drawbacks of partnership were minimal; however, less than half of respondents thought partnership helped reduce transaction costs or financial costs, suggesting an inclusive and participatory process may come with short-term efficiency tradeoffs. Conclusions: Social network analysis can be useful for identifying who is included and excluded from the process, which can support efforts to ensure stronger, more meaningful engagement in future Global Fund application processes.

Published
2020

30. Assessment of Disparities in COVID-19 Testing and Infection Across Language Groups in Seattle, Washington

Author

Lisa Chew, Martine Pierre-Louis, Herbert C. Duber, Esi W. Nkyekyer, Santiago Neme, Kristine F Lan, and H. Nina Kim

Subjects
Adult, Male, Washington, 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Pneumonia, Viral, Emigrants and Immigrants, Health Services Accessibility, Betacoronavirus, COVID-19 Testing, Pandemic, Prevalence, Research Letter, Humans, Medicine, Healthcare Disparities, Pandemics, Aged, Language, biology, Clinical Laboratory Techniques, SARS-CoV-2, business.industry, Research, COVID-19, Health Status Disparities, General Medicine, Middle Aged, biology.organism_classification, Virology, Online Only, Cross-Sectional Studies, Female, Public Health, Coronavirus Infections, business
Abstract

This cross-sectional study evaluates the proportion of patients tested for coronavirus disease 2019 (COVID-19) and the proportion of positive cases, using language as a surrogate for immigrant status.

Published
2020
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31. Addressing the Needs of People Living Homeless During the COVID-19 Pandemic

Author

Nancy K. Sugg, Callan Fockele, Elizabeth M. Dorn, M. Mia Shim, and Herbert C. Duber

Subjects
Washington, Coronavirus disease 2019 (COVID-19), Pneumonia, Viral, Comorbidity, law.invention, Betacoronavirus, COVID-19 Testing, law, Quarantine, Pandemic, medicine, Humans, Sociology, Pandemics, Health Services Needs and Demand, biology, Viral Epidemiology, Clinical Laboratory Techniques, SARS-CoV-2, Health Policy, Social distance, Public Health, Environmental and Occupational Health, COVID-19, biology.organism_classification, medicine.disease, Virology, United States, Pneumonia, Ill-Housed Persons, Coronavirus Infections
Published
2020

32. A Novel Approach to Monitoring the COVID-19 Pandemic using Emergency Department Discharge Diagnoses

Author

Herbert C. Duber, Karl Jablonowski, Susan A. Stern, Abraham D. Flaxman, M. Kennedy Hall, and Ali H. Mokdad

Subjects
body regions, Coronavirus disease 2019 (COVID-19), business.industry, Pandemic, medicine, Regression analysis, Medical emergency, Emergency department, Medical diagnosis, medicine.disease, business
Abstract

IntroductionTracking the COVID-19 pandemic using existing metrics such as confirmed cases and deaths are insufficient for understanding the trajectory of the pandemic and identifying the next wave of cases. In this study, we demonstrate the utility of monitoring the daily number of patients with COVID-like illness (CLI) who present to the Emergency Department (ED) as a tool that can guide local response efforts.MethodsUsing data from two hospitals in King County, WA, we examined the daily volume of CLI visits, and compare them to confirmed COVID cases and COVID deaths in the County. A linear regression model with varying lags is used to predict the number of daily COVID deaths from the number of CLI visits.ResultsCLI visits appear to rise and peak well in advance of both confirmed COVID cases and deaths in King County. Our regression analysis to predict daily deaths with a lagged count of CLI visits in the ED showed that the R2 value was maximized at 14 days.ConclusionsED CLI visits are a leading indicator of the pandemic. Adopting and scaling up a CLI monitoring approach at the local level will provide needed actionable evidence to policy makers and health officials struggling to confront this health challenge.

Published
2020
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33. US Health Care Spending by Payer and Health Condition, 1996-2016

Author

Nafis Sadat, Madeline Campbell, Ellen Squires, Taylor Matyasz, Abraham D. Flaxman, Abby Chapin, Peter Shieh, Mohsen Naghavi, Cody Horst, Alexander S Kaldjian, Christina Fitzmaurice, Kirstin W. Scott, Angela Liu, Abe Dunn, Joseph L Dieleman, Christopher J L Murray, Herbert C. Duber, Carina Chen, Jackie Cao, Anthony L. Bui, Kai Yeung, and Zhiyin Li

Subjects
Adult, Male, Adolescent, Health Status, 01 natural sciences, 03 medical and health sciences, Nursing care, Young Adult, 0302 clinical medicine, Age Distribution, Ambulatory care, Health care, Medicine, Humans, Disease, 030212 general & internal medicine, 0101 mathematics, Sex Distribution, Child, health care economics and organizations, Aged, Original Investigation, Aged, 80 and over, Health economics, Insurance, Health, Inpatient care, business.industry, 010102 general mathematics, Health condition, Infant, General Medicine, Emergency department, Middle Aged, United States, Child, Preschool, Female, Health Expenditures, business, Medicaid, Demography
Abstract

Importance US health care spending has continued to increase and now accounts for 18% of the US economy, although little is known about how spending on each health condition varies by payer, and how these amounts have changed over time. Objective To estimate US spending on health care according to 3 types of payers (public insurance [including Medicare, Medicaid, and other government programs], private insurance, or out-of-pocket payments) and by health condition, age group, sex, and type of care for 1996 through 2016. Design and Setting Government budgets, insurance claims, facility records, household surveys, and official US records from 1996 through 2016 were collected to estimate spending for 154 health conditions. Spending growth rates (standardized by population size and age group) were calculated for each type of payer and health condition. Exposures Ambulatory care, inpatient care, nursing care facility stay, emergency department care, dental care, and purchase of prescribed pharmaceuticals in a retail setting. Main Outcomes and Measures National spending estimates stratified by health condition, age group, sex, type of care, and type of payer and modeled for each year from 1996 through 2016. Results Total health care spending increased from an estimated $1.4 trillion in 1996 (13.3% of gross domestic product [GDP]; $5259 per person) to an estimated $3.1 trillion in 2016 (17.9% of GDP; $9655 per person); 85.2% of that spending was included in this study. In 2016, an estimated 48.0% (95% CI, 48.0%-48.0%) of health care spending was paid by private insurance, 42.6% (95% CI, 42.5%-42.6%) by public insurance, and 9.4% (95% CI, 9.4%-9.4%) by out-of-pocket payments. In 2016, among the 154 conditions, low back and neck pain had the highest amount of health care spending with an estimated $134.5 billion (95% CI, $122.4-$146.9 billion) in spending, of which 57.2% (95% CI, 52.2%-61.2%) was paid by private insurance, 33.7% (95% CI, 30.0%-38.4%) by public insurance, and 9.2% (95% CI, 8.3%-10.4%) by out-of-pocket payments. Other musculoskeletal disorders accounted for the second highest amount of health care spending (estimated at $129.8 billion [95% CI, $116.3-$149.7 billion]) and most had private insurance (56.4% [95% CI, 52.6%-59.3%]). Diabetes accounted for the third highest amount of the health care spending (estimated at $111.2 billion [95% CI, $105.7-$115.9 billion]) and most had public insurance (49.8% [95% CI, 44.4%-56.0%]). Other conditions estimated to have substantial health care spending in 2016 were ischemic heart disease ($89.3 billion [95% CI, $81.1-$95.5 billion]), falls ($87.4 billion [95% CI, $75.0-$100.1 billion]), urinary diseases ($86.0 billion [95% CI, $76.3-$95.9 billion]), skin and subcutaneous diseases ($85.0 billion [95% CI, $80.5-$90.2 billion]), osteoarthritis ($80.0 billion [95% CI, $72.2-$86.1 billion]), dementias ($79.2 billion [95% CI, $67.6-$90.8 billion]), and hypertension ($79.0 billion [95% CI, $72.6-$86.8 billion]). The conditions with the highest spending varied by type of payer, age, sex, type of care, and year. After adjusting for changes in inflation, population size, and age groups, public insurance spending was estimated to have increased at an annualized rate of 2.9% (95% CI, 2.9%-2.9%); private insurance, 2.6% (95% CI, 2.6%-2.6%); and out-of-pocket payments, 1.1% (95% CI, 1.0%-1.1%). Conclusions and Relevance Estimates of US spending on health care showed substantial increases from 1996 through 2016, with the highest increases in population-adjusted spending by public insurance. Although spending on low back and neck pain, other musculoskeletal disorders, and diabetes accounted for the highest amounts of spending, the payers and the rates of change in annual spending growth rates varied considerably.

Published
2020

34. Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Author

Herbert C. Duber, Isabel A. Barata, Mark Stavros, Eric Cioè-Peña, Wendy Macias-Konstantopoulos, Stephen Y. Liang, Eric M Ketcham, Lauren K. Whiteside, and Shawn A. Ryan

Subjects
Patient Transfer, medicine.medical_specialty, Article, law.invention, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, Humans, Pain Management, Medicine, 030212 general & internal medicine, Practice Patterns, Physicians', Intensive care medicine, business.industry, 030208 emergency & critical care medicine, Opioid use disorder, Emergency department, Opioid-Related Disorders, medicine.disease, Triage, Review article, Opioid, Emergency Medicine, Emergency Service, Hospital, business, Methadone, medicine.drug, Buprenorphine
Abstract

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

Published
2018
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35. Identifying gaps in the continuum of care for hypertension and diabetes in two Indian communities

Author

Shelley Wilson, Bryan K. Phillips, Miranda Bryant, Marissa B Reitsma, R. V. Deepu, Claire R. McNellan, Blake Thomson, Marie Ng, Emmanuela Gakidou, Ruchi Sogarwal, Alexandra Wollum, Rose Gabert, Sunil Mehra, and Herbert C. Duber

Subjects
Adult, Male, medicine.medical_specialty, Adolescent, Quality Assurance, Health Care, Population, Psychological intervention, India, 030204 cardiovascular system & hematology, Health administration, Effective coverage, Interviews as Topic, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Asian People, Health facility, Environmental health, Diabetes mellitus, Health care, Diabetes Mellitus, Continuum of care, Humans, Medicine, 030212 general & internal medicine, education, Qualitative Research, education.field_of_study, business.industry, Health Policy, Public health, lcsh:Public aspects of medicine, Diabetes, lcsh:RA1-1270, Continuity of Patient Care, Focus Groups, Middle Aged, medicine.disease, Cardiovascular disease, Blood pressure, Health Care Surveys, Hypertension, Female, business, Research Article
Abstract

Background Non-communicable diseases (NCDs) represent the largest, and fastest growing, burden of disease in India. This study aimed to quantify levels of diagnosis, treatment, and control among hypertensive and diabetic patients, and to describe demand- and supply-side barriers to hypertension and diabetes diagnosis and care in two Indian districts, Shimla and Udaipur. Methods We conducted household and health facility surveys, as well as qualitative focus group discussions and interviews. The household survey randomly sampled individuals aged 15 and above in rural and urban areas in both districts. The survey included questions on NCD knowledge, history, and risk factors. Blood pressure, weight, height, and blood glucose measurements were obtained. The health facility survey was administered in 48 health care facilities, focusing on NCD diagnosis and treatment capacity, including staffing, equipment, and pharmaceuticals. Qualitative data was collected through semi-structured key informant interviews with health professionals and public health officials, as well as focus groups with patients and community members. Results Among 7181 individuals, 32% either reported a history of hypertension or were found to have a systolic blood pressure ≥ 140 mmHg and/or diastolic ≥90 mmHg. Only 26% of those found to have elevated blood pressure reported a prior diagnosis, and just 42% of individuals with a prior diagnosis of hypertension were found to be normotensive. A history of diabetes or an elevated blood sugar (Random blood glucose (RBG) ≥200 mg/dl or fasting blood glucose (FBG) ≥126 mg/dl) was noted in 7% of the population. Among those with an elevated RBG/FBG, 59% had previously received a diagnosis of diabetes. Only 60% of diabetics on treatment were measured with a RBG

Published
2017
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36. Improving Hospital Performance Rankings Using Discrete Patient Diagnoses for Risk Adjustment of Outcomes

Author

Michael Hanlon, Shane M. Murphy, Herbert C. Duber, Brendan DeCenso, and Abraham D. Flaxman

Subjects
medicine.medical_specialty, Comorbidity, Hospital performance, Patient Readmission, Severity of Illness Index, Centers for Medicare and Medicaid Services, U.S, Machine Learning, 03 medical and health sciences, Sex Factors, 0302 clinical medicine, Innovative Methods in Health Services Research, medicine, Humans, 030212 general & internal medicine, Medical diagnosis, Healthcare Cost and Utilization Project, Quality Indicators, Health Care, Quality of Health Care, Heart Failure, business.industry, 030503 health policy & services, Health Policy, Age Factors, Risk adjustment, medicine.disease, United States, Benchmarking, Logistic Models, Treatment Outcome, Socioeconomic Factors, Ranking, Emergency medicine, Risk Adjustment, Diagnosis code, Medical emergency, 0305 other medical science, business, Medicaid
Abstract

Objective To assess the changes in patient outcome prediction and hospital performance ranking when incorporating diagnoses as risk adjusters rather than comorbidity indices. Data Sources Healthcare Cost and Utilization Project State Inpatient Databases for New York State, 2005–2009. Study Design Conducted tree-based classification for mortality and readmission by incorporating discrete patient diagnoses as predictors, comparing with traditional comorbidity indices such as those used for Centers for Medicare and Medicaid Services (CMS) outcome models. Principal Findings Diagnosis codes as predictors increased predictive accuracy 5.6 percent (95% CI: 4.5–6.9 percent) relative to CMS condition categories for heart failure 30-day mortality. Most other outcomes exhibited statistically significant accuracy gains and facility ranking shifts. Sensitivity analysis showed improvements even when predictors were limited to only the diagnoses included in CMS models. Conclusions Discretizing patient severity information beyond the levels of traditional comorbidity indices improves patient outcome predictions and substantially shifts facility rankings.

Published
2017
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37. Evaluating facility-based antiretroviral therapy programme effectiveness: a pilot study comparing viral load suppression and retention rates

Author

Nancy Fullman, Gloria Ikilezi, Anne Gasasira, Jane Achan, Aubrey J. Levine, Emmanuela Gakidou, D. Allen Roberts, Herbert C. Duber, and Annie Haakenstad

Subjects
Adult, Male, 0301 basic medicine, Pediatrics, medicine.medical_specialty, Patient Dropouts, Anti-HIV Agents, Human immunodeficiency virus (HIV), HIV Infections, Pilot Projects, medicine.disease_cause, 03 medical and health sciences, 0302 clinical medicine, Acquired immunodeficiency syndrome (AIDS), Chart review, medicine, Humans, Uganda, 030212 general & internal medicine, Retrospective Studies, Adult patients, business.industry, Public Health, Environmental and Occupational Health, Retrospective cohort study, Health Services, Middle Aged, Viral Load, Patient mix, medicine.disease, 030112 virology, Antiretroviral therapy, Logistic Models, Infectious Diseases, Emergency medicine, Female, Parasitology, Health Facilities, business, Delivery of Health Care, Viral load, Program Evaluation
Abstract

Objectives Increased demand for antiretroviral therapy (ART) services combined with plateaued levels of development assistance for HIV/AIDS requires that national ART programmes monitor programme effectiveness. In this pilot study, we compared commonly utilised performance metrics of 12- and 24-month retention with rates of viral load (VL) suppression at 15 health facilities in Uganda. Methods Retrospective chart review from which 12- and 24-month retention rates were estimated, and parallel HIV RNA VL testing on consecutive adult patients who presented to clinics and had been on ART for a minimum of six months. Rates of VL suppression were then calculated at each facility and compared to retention rates to assess the correlation between performance metrics. Multilevel logistic regression models predicting VL suppression and 12- and 24-month retention were constructed to estimate facility effects. Results We collected VL samples from 2961 patients and found that 88% had a VL ≤1000 copies/ml. Facility rates of VL suppression varied between 77% and 96%. When controlling for patient mix, a significant variation in facility performance persisted. Retention rates at 12 and 24 months were 91% and 79%, respectively, with a comparable facility-level variation. However, neither 12-month (ρ = 0.16) nor 24-month (ρ = -0.19) retention rates were correlated with facility rates of VL suppression. Conclusions Retaining patients in care and suppressing VL are both critical outcomes. Given the lack of correlation noted in this study, the utilisation of VL monitoring may be necessary to truly assess the effectiveness of health facilities delivering ART services.

Published
2016
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38. Bringing a health systems modelling approach to complex evaluations: multicountry applications in HIV, TB and malaria

Author

Daniel Whitaker, Adama Faye, Katharine D. Shelley, Godefroid Mpanya, Carmen Cerezo, Jorge Matute, Bethany Huntley, Audrey Batzel, David Phillips, Guillermo Ambrosio, Roger Tine, Jennifer M. Ross, Salva Mulongo, Ibrahima Diop Gaye, Edgar Kestler, Caitlin O'Brien-Carelli, Erin B. Palmisano, Herbert C. Duber, Bernardo Hernández Prado, Emily Linebarger, Constant Kingongo, Francisco Rios Casas, and Stephen S Lim

Subjects
Computer science, malaria, Psychological intervention, HIV Infections, Structural equation modeling, 03 medical and health sciences, 0302 clinical medicine, Component (UML), Global health, medicine, Humans, mathematical modelling, 030212 general & internal medicine, Original Research, 030503 health policy & services, Health Policy, Public Health, Environmental and Occupational Health, HIV, Bayes Theorem, medicine.disease, Senegal, Variety (cybernetics), tuberculosis, Risk analysis (engineering), Mediation, 0305 other medical science, health systems evaluation, Malaria, Healthcare system
Abstract

IntroductionUnderstanding how to deliver interventions more effectively is a growing emphasis in Global Health. Simultaneously, health system strengthening is a key component to improving delivery. As a result, it is challenging to evaluate programme implementation while reflecting real-world complexity. We present our experience in using a health systems modelling approach as part of a mixed-methods evaluation and describe applications of these models.MethodsWe developed a framework for how health systems translate financial inputs into health outcomes, with in-country and international experts. We collated available data to measure framework indicators and developed models for malaria in Democratic Republic of the Congo (DRC), and tuberculosis in Guatemala and Senegal using Bayesian structural equation modelling. We conducted several postmodelling analyses: measuring efficiency, assessing bottlenecks, understanding mediation, analysing the cascade of care and measuring subnational effectiveness.ResultsThe DRC model indicated a strong relationship between shipment of commodities and utilisation thereof. In Guatemala, the strongest model coefficients were more evenly distributed. Results in Senegal varied most, but pathways related to community care had the strongest relationships. In DRC, we used model results to estimate the end-to-end cost of delivering commodities. In Guatemala, we used model results to identify potential bottlenecks and understand mediation. In Senegal, we used model results to identify potential weak links in the cascade of care, and explore subnationally.ConclusionThis study demonstrates a complementary modelling approach to traditional evaluation methods. Although these models have limitations, they can be applied in a variety of ways to gain greater insight into implementation and functioning of health service delivery.

Published
2020
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41. Public knowledge of cardiovascular disease and response to acute cardiac events in three municipalities in Brazil

Author

Danielle Souto de Medeiros, Casey K. Johanns, Fernando Antonio Camargo Vaz, Luisa Sorio Flor, Danny V. Colombara, Emily S. Bartlett, Herbert C. Duber, and Shelley Wilson

Subjects
Adult, Male, lcsh:Diseases of the circulatory (Cardiovascular) system, Health Knowledge, Attitudes, Practice, Acute coronary syndrome, medicine.medical_specialty, delivery of care, medicine.medical_treatment, resuscitation, Population, Electric Countershock, Psychological intervention, Disease, 030204 cardiovascular system & hematology, acute coronary syndrome, Coronary artery disease, 03 medical and health sciences, 0302 clinical medicine, emergency medicine, medicine, Humans, 030212 general & internal medicine, Cardiopulmonary resuscitation, Cities, education, Health Education, Socioeconomic status, Automated external defibrillator, education.field_of_study, business.industry, Middle Aged, medicine.disease, Cardiopulmonary Resuscitation, Health Literacy, Cross-Sectional Studies, lcsh:RC666-701, Cardiovascular Diseases, Heart Disease Risk Factors, Health Care Surveys, Emergency medicine, Female, Cardiology and Cardiovascular Medicine, business, Health Care Delivery, Economics and Global Health Care, Brazil, coronary artery disease, Defibrillators
Abstract

ObjectiveTo conduct a landscape assessment of public knowledge of cardiovascular disease risk factors and acute myocardial infarction symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) awareness and training in three underserved communities in Brazil.MethodsA cross-sectional, population-based survey of non-institutionalised adults age 30 or greater was conducted in three municipalities in Eastern Brazil. Data were analysed as survey-weighted percentages of the sampled populations.Results3035 surveys were completed. Overall, one-third of respondents was unable to identify at least one cardiovascular disease risk factor and 25% unable to identify at least one myocardial infarction symptom. A minority of respondents had received training in CPR or were able to identify an AED. Low levels of education and low socioeconomic status were consistent predictors of lower knowledge levels of cardiovascular disease risk factors, acute coronary syndrome symptoms and CPR and AED use.ConclusionsIn three municipalities in Eastern Brazil, overall public knowledge of cardiovascular disease risk factors and symptoms, as well as knowledge of appropriate CPR and AED use was low. Our findings indicate the need for interventions to improve public knowledge and response to acute cardiovascular events in Brazil as a first step towards improving health outcomes in this population. Significant heterogeneity in knowledge seen across sites and socioeconomic strata indicates a need to appropriately target such interventions.

Published
2020
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42. Global, regional, and national incidence, prevalence, and mortality of HIV, 1980–2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

Author

Ephrem Tsegay Asfaw, Irina Filip, Maciej Banach, Amjad Mohamadi-Bolbanabad, Girmay Teklay Weldesamuel, Joshua A. Salomon, Anemaw A Asrat, Zahra Jorjoran Shushtari, Hamidreza Komaki, Mekdes Tigistu Yilma, Reza Shirkoohi, Mostafa Qorbani, Ahamarshan Jayaraman Nagarajan, Don C. Des Jarlais, Adnan Kisa, Gebreamlak Gebremedhn Gebremeskel, Kidu Gidey Weldegwergs, Amir Kasaeian, Peter Memiah, Son Hoang Nguyen, Segun Emmanuel Ibitoye, Ali Kabir, Subash Thapa, Diego Augusto Santos Silva, Kefyalew Addis Alene, Alireza Rafiei, Huong Lan Thi Nguyen, Erlyn Rachelle King Macarayan, Kelali Kalaye Gebreyohannes, Khaled Khatab, Ghobad Moradi, Noore Alam, Aletta E. Schutte, Sharareh Eskandarieh, H. Dean Hosgood, Rakhi Dandona, Taye Abuhay Zewale, Sezer Kisa, Gessessew Bugssa Hailu, Hedayat Abbastabar, Ketema Bizuwork Gebremedhin, Smita Pakhale, Govinda Prasad Dhungana, Dina Nur Anggraini Ningrum, Bakhtiar Piroozi, Yaschilal Muche Belayneh, Tesfaye Dessale Kassa, Irfan Ullah, Sahar Saeedi Moghaddam, Jean Jacques Noubiap, Mojtaba Bagherzadeh, Akram Pourshams, Alberto L. García-Basteiro, Helen Bitew, Kindie Fentahun Muchie, Mehdi Sayyah, Kevin S Ikuta, Moses K. Muriithi, Aliasghar Ahmad Kiadaliri, Zerihun Menlkalew Zenebe, Cesar Reis, Themba G. Ginindza, Jagadish Rao Padubidri, Yoosik Youm, Saba Abraham Belay, Olayinka Stephen Ilesanmi, Neeraj Bedi, Maziar Moradi-Lakeh, Hamid Sharifi, Nefsu Awoke, Manasi Kumar, Carlos Magis-Rodriguez, Muhammad Shahdaat Bin Sayeed, Maheswar Satpathy, Andrew Blinov, Fiseha Wadilo Wada, Babak Moazen, Hadi Hassankhani, Jae Il Shin, Sanjay Basu, Aziz Eftekhari, Masood Ali Shaikh, Arya Haj-Mirzaian, Laura Dwyer-Lindgren, Haileab Fekadu Wolde, Habtamu Abera Areri, Krista M. Steuben, Lalit Dandona, Keivan Ahmadi, Aso Mohammad Darwesh, Belete Kassa, Keyghobad Ghadiri, Arash Ziapour, Raquel Crider, Alaa Badawi, Tahvi Frank, Amir Hasanzadeh, Marcel Yotebieng, Jemal Abdu Mohammed, Marcos Roberto Tovani-Palone, Emmanuel Peprah, Mekonnen Sisay, Ghulam Mustafa, Oghenowede Eyawo, Seyed Sina Naghibi Irvani, Vahid Alipour, Reza Malekzadeh, Bereket Duko Adema, Direslgne Misker Abyu, Tinuke O Olagunju, Olatunde Aremu, Roghayeh Mohammadibakhsh, Linh Phuong Doan, Mihiretu Kebede, Aman Yesuf Endries, Amira Shaheen, Belete Biadgo, Ali Rostami, Marwa Rashad Salem, Getnet Gedefaw, Stein Emil Vollset, Gurudatta Naik, Veincent Christian Filipino Pepito, Duduzile Ndwandwe, Melese Abate Reta, Aleksandra Barac, Simon I. Hay, Vishnu Renjith, Seifadin Ahmed Shallo, Kebede Deribe, Malihe Nourollahpour Shiadeh, Tewodros Eshete Wonde, Nuno Taveira, Mohammad Ali Sahraian, Marilita M Moschos, Masoud Foroutan, Alebachew Fasil Ashagre, Félix Carvalho, Yun Jin Kim, Farid Najafi, Tukur Dahiru, Chinwe Juliana Iwu, Dharmesh Kumar Lal, Varshil Mehta, Molly R Nixon, Nahla Anber, Seyedmojtaba Seyedmousavi, Mohammad Rabiee, Nauman Khalid, Felix Akpojene Ogbo, Anselm Okoro, Sanjay Zodpey, Birhanu Geta, Kebede Embaye Gezae, Shirin Djalalinia, Amanda E. Smith, Naser Mohammad Gholi Mezerji, Arvin Haj-Mirzaian, Birkneh Tilahun Tadesse, Yared Belete Belay, Saeed Amini, Ziad A. Memish, Stephanie M. Topp, Eduarda Fernandes, Mohammed Suleiman Obsa, Junaid Khan, Andem Effiong, Jane Jean-Hee Lee, Emmanuel Ngassa Laurent Mayenga, Abdallah M. Samy, Anton Sokhan, Rajesh Sagar, Dawit Zewdu Wondafrash, Atalay Goshu Muluneh, Birhan Alemnew, Asmamaw Demis, Samer Hamidi, Getnet Mengistu, Michael Tamene Haile, Gbenga A. Kayode, Huyen Phuc Do, Yoshan Moodley, Mehdi Hosseinzadeh, Moslem Mohammadi, Dayane Gabriele Alves Silveira, Samad Azari, Gulfaraz Khan, Maysaa El Sayed Zaki, Emmanuel Ankrah Odame, Anusha Ganapati Bhat, Louisa Degenhardt, Mu'awiyyah Babale Sufiyan, Harish Chander Gugnani, Sadaf G. Sepanlou, Ai Koyanagi, Ebrahim M Yimer, Maryam Adabi, Javad Nazari, Saravanan Muthupandian, Evanson Z. Sambala, Salman Khazaei, Nelson Alvis-Guzman, Hunduma Amensisa Bojia, Anwar Rafay, Richard Ofori-Asenso, Ehsan Ahmadpour, José Neves, Desalegn Tadese Mengistu, Shafiu Mohammed, Hamid Yimam Hassen, Navid Rabiee, Dinh-Toi Chu, Zoubida Zaidi, Sajjad Ur Rahman, Tilahun Belete Mossie, Olanrewaju Oladimeji, Krittika Bhattacharyya, Gebrekiros Gebremichael Meles, Hassan Magdy Abd El Razek, Stanislav S. Otstavnov, Shaimaa I. El-Jaafary, Habtamu Temesgen, Lolemo Kelbiso Hanfore, Milad Mohammadoo-Khorasani, Muktar Beshir Ahmed, Karzan Abdulmuhsin Mohammad, Carl Abelardo T. Antonio, Morteza Abdullatif Khafaie, Spencer L. James, Bhaskaran Unnikrishnan, Morteza Shamsizadeh, Kenean Getaneh Tlaye, Ziad El-Khatib, Zohreh Anbari, Aisha Elsharkawy, Nancy Fullman, Cuong Tat Nguyen, Chalachew Genet Akal, Chabila C Mapoma, Amir H. Pakpour, Rafael Alves Guimarães, Jalal Arabloo, Eyasu Ejeta Duken, Hailay Abrha Gesesew, Koku Sisay Tamirat, Batool Fatima, Tissa Wijeratne, Addisu Gize Yeshanew, Benn Sartorius, Kathryn H. Jacobsen, Abdullah T Khoja, Morenike Oluwatoyin Folayan, Phetole Walter Mahasha, Takeshi Fukumoto, Maryam Moossavi, Bahram Mohajer, Ravi Prakash Jha, Oladimeji Adebayo, Farshad Farzadfar, Francisco Rogerlândio Martins-Melo, Solomon Sisay, Ensiyeh Jenabi, Bach Xuan Tran, Eleonora Dubljanin, Farnam Mohebi, Jasvinder A. Singh, Barthelemy Kuate Defo, Masoud Behzadifar, Yousef Mohammad, Feleke Mekonnen Demeke, G Anil Kumar, Jan-Walter De Neve, Afshin Zarghi, Hosein Shabaninejad, Trang Huyen Nguyen, Degena Bahrey Tadesse, Monika Sawhney, Eyal Oren, Bayu Begashaw Bekele, Saeed Safari, Salvatore Rubino, Kenji Shibuya, Daniel Diaz, Salman Rawaf, Demelash Woldeyohannes Handiso, Ted R. Miller, Fares Alahdab, Vafa Rahimi-Movaghar, Seyyed Meysam Mousavi, Sonali Kochhar, Azeem Majeed, Till Bärnighausen, Zubair Kabir, Devasahayam J. Christopher, Malede Mequanent Sisay, Adane Teshome Kefale, Shishay Wahdey Tekelemedhin, Tsegaye Lolaso Lenjebo, Yousef Khader, Ali Bijani, Kebreab Paulos, Hagazi Gebre Meles, Euripide Frinel G Arthur Avokpaho, Alireza Ahmadi, Tuomo J. Meretoja, Padukudru Anand Mahesh, Florian Fischer, Mulugeta Melku, Fakher Rahim, Manisha Dubey, Cheru Tesema Leshargie, Vijay Kumar Chattu, Yasir Waheed, Mehdi Noroozi, Austin Carter, Chuanhua Yu, Ronny Westerman, Andualem Henok, Yousef Veisani, Sharath Burugina Nagaraja, Reta Tsegaye Gayesa, Mina Anjomshoa, Andrew T Olagunju, Getachew Mullu Kassa, Belayneh K Gelaw, Jost B. Jonas, Ejaz Ahmad Khan, Adugnaw Berhane, Chukwudi A Nnaji, Daniel Asmelash, Tomislav Mestrovic, Addisu Melese, Stephen S Lim, Yahya Salimi, Chi Linh Hoang, Christopher J L Murray, Mohammad Sadegh Rezai, Bruno F. Sunguya, Herbert C. Duber, Senad Handanagic, Ashish Awasthi, Anthony Masaka, Megha Arora, Sergey Soshnikov, Sangram Kishor Patel, Kwaku Oppong Asante, Haidong Wang, Rajendra Kadel, Bryan L. Sykes, Lucero Cahuana-Hurtado, Afarin Rahimi-Movaghar, Deepa Jahagirdar, Manaye Yihune Teshale, Samantha Leigh Larson, Martin Amogre Ayanore, Sergey K Vladimirov, Gebre Teklemariam Demoz, Fisaha Haile Tesfay, Mohsen Naghavi, Chhabi Lal Ranabhat, Walter Mendoza, Kassawmar Angaw Bogale, Khanh Bao Tran, Berhanu Yazew Wondmagegn, Carlos Miguel Rios González, Ahmad Daryani, Ali H. Mokdad, Julio Cesar Campuzano Rincon, Alemayehu Toma Mena, Navid Manafi, Andre Pascal Kengne, Victor Adekanmbi, Netsanet Fentahun, Olalekan A. Uthman, Desmond Kuupiel, Olatunji O. Adetokunboh, Zahid A Butt, Mohamed Hsairi, Bulat Idrisov, Ranjani Somayaji, Dan J. Stein, Molly H Biehl, Samuel B. Albertson, Laith J. Abu-Raddad, Parvaiz A Koul, Elias Merdassa Roro, Marek Majdan, Dereje Bayissa Demissie, Emilie R Maddison, Naohiro Yonemoto, Ahmad Ghashghaee, Young-Ho Khang, Solomon Olum, Hmwe H Kyu, Amir Radfar, Dirk Douwes-Schultz, Elham Ahmadian, Graduate School, AII - Infectious diseases, APH - Global Health, APH - Methodology, GBD 2017 HIV Collaborators, Clinicum, Institute for Molecular Medicine Finland, HUS Comprehensive Cancer Center, Staff Services, University of Helsinki, Department of Oncology, Adema, Bereket Duko, GBD 2017 HIV collaborators, and Public Health

Subjects
0301 basic medicine, A300 Clinical Medicine, Epidemiology, CITIES, HIV Infections, Mortalities, Global Burden of Disease, 0302 clinical medicine, Risk Factors, Seroepidemiologic Studies, Cause of Death, Prevalences, Prevalence, Global health, LIFE EXPECTANCY, 030212 general & internal medicine, 10. No inequality, education.field_of_study, CHALLENGES, Incidence, Incidence (epidemiology), Incidences, 1. No poverty, MEN, 3. Good health, AIDS, Infectious Diseases, Life Sciences & Biomedicine, GBD 2017 HIV collaborators, medicine.medical_specialty, Forecasts, Immunology, Population, Cause of Death/trends, UNITED-STATES, Context (language use), History, 21st Century, 03 medical and health sciences, SDG 3 - Good Health and Well-being, Acquired immunodeficiency syndrome (AIDS), Virology, Environmental health, medicine, Humans, education, Global Burden of Disease/trends, Estimation, Science & Technology, SEX-SPECIFIC MORTALITY, business.industry, DISABILITY, Public health, HIV, coverage of antiretroviral therapy, History, 20th Century, medicine.disease, mortality, R1, PREVENTION, TRENDS, 030112 virology, HIV Infections/mortality, 3121 General medicine, internal medicine and other clinical medicine, Life expectancy, Human medicine, business, Forecasting
Abstract

BACKGROUND: Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.METHODS: We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.FINDINGS: Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.INTERPRETATION: Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.FUNDING: Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Published
2019
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43. Identifying gaps in the continuum of care for cardiovascular disease and diabetes in two communities in South Africa: Baseline findings from the HealthRise project

Author

Zaino Petersen, Bryan K. Phillips, Danny V. Colombara, Pamela Naidoo, Anam Nyembezi, Emmanuela Gakidou, Alexandra Wollum, Rose Gabert, Miranda Bryant, Jessica M Daly, Paurvi Bhatt, Belinda Ngongo, Shelley Wilson, Claire R. McNellan, Herbert C. Duber, and Priscilla Reddy

Subjects
Male, lcsh:Medicine, Blood Pressure, Disease, 030204 cardiovascular system & hematology, Overweight, Pathology and Laboratory Medicine, Vascular Medicine, Biochemistry, Geographical locations, South Africa, 0302 clinical medicine, Endocrinology, Health facility, Medicine and Health Sciences, 030212 general & internal medicine, Community Health Services, lcsh:Science, education.field_of_study, Multidisciplinary, HIV diagnosis and management, Lipids, Hyperlipidemia, Cholesterol, Cardiovascular Diseases, Needs assessment, Hypertension, Practice Guidelines as Topic, Engineering and Technology, Female, Guideline Adherence, medicine.symptom, Community-Based Intervention, Research Article, National Health and Nutrition Examination Survey, Endocrine Disorders, Population, Hypercholesterolemia, Binge drinking, Equipment, 03 medical and health sciences, Signs and Symptoms, Diagnostic Medicine, Environmental health, medicine, Diabetes Mellitus, Humans, education, business.industry, lcsh:R, Biology and Life Sciences, Focus group, Health Care, Metabolic Disorders, Africa, lcsh:Q, People and places, business, Delivery of Health Care
Abstract

Background The HealthRise initiative seeks to implement and evaluate innovative community-based strategies for diabetes, hypertension and hypercholesterolemia along the entire continuum of care (CoC)-from awareness and diagnosis, through treatment and control. In this study, we present baseline findings from HealthRise South Africa, identifying gaps in the CoC, as well as key barriers to care for non-communicable diseases (NCDs). Methods This mixed-methods needs assessment utilized national household data, health facility surveys, focus group discussions, and key informant interviews in Umgungundlovu and Pixley ka Seme districts. Risk factor and disease prevalence were estimated from the South Africa National Health and Nutrition Examination Survey. Health facility surveys were conducted at 86 facilities, focusing on essential intervention, medications and standard treatment guidelines. Quantitative results are presented descriptively, and qualitative data was analyzed using a framework approach. Results 46.8% of the population in Umgungundlovu and 51.0% in Pixley ka Seme were hypertensive. Diabetes was present in 11.0% and 9.7% of the population in Umgungundlovu and Pixley ka Seme. Hypercholesterolemia was more common in Pixley ka Seme (17.3% vs. 11.1%). Women and those of Indian descent were more likely to have diabetes. More than half of the population was found to be overweight, and binge drinking, inactivity and smoking were all common. More than half of patients with hypertension were unaware of their disease status (51.6% in Pixley ka Seme and 51.3% in Umgungundlovu), while the largest gap in the diabetes CoC occurred between initiation of treatment and achieving disease control. Demand-side barriers included lack of transportation, concerns about confidentiality, perceived discrimination and long wait times. Supply-side barriers included limited availability of testing equipment, inadequate staffing, and pharmaceutical stock outs. Conclusion In this baseline assessment of two South African health districts we found high rates of undiagnosed hypercholesterolemia and hypertension, and poor control of hypercholesterolemia, hypertension, and diabetes. The HealthRise Initiative will need to address key supply- and demand-side barriers in an effort to improve important NCD outcomes.

Published
2018

44. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013

Author

Meghan D. Mooney, Ken Takahashi, Andrea Stewart, Jonathan C Brown, Shireen Sindi, Amany H Refaat, Ruben Castro, Sara Sheikhbahaei, Kyle R. Heuton, Gillian M. Hansen, Chante Karimkhani, Bryan K. Phillips, Ibrahim Abubakar, Yohannes Kinfu, Victoria F Bachman, Konstantinos Stroumpoulis, Megan Coggeshall, Lucía Cuevas-Nasu, Yichong Li, Vineet K. Chadha, Andrew G. M. Bulloch, Takayoshi Ohkubo, Don C. Des Jarlais, Giancarlo Logroscino, Francis Apolinary Mhimbira, Jefferson G Fernandes, Cheng Huang, Ejaz Ahmad Khan, Fortuné Gbètoho Gankpé, Roderick J Hay, Itamar S. Santos, Zanfina Ademi, Fiona J Charlson, Norlinah Mohamed Ibrahim, Anwar Rafay, Andrew L. Thorne-Lyman, Juanita A. Haagsma, Emmanuel A. Ameh, John J. McGrath, Massimo Cirillo, Wubegzier Mekonnen, Holly Hagan, Naohiro Yonemoto, Frida Namnyak Ngalesoni, Dietrich Plass, Matias Trillini, David Phillips, Braden Te Ao, Wanqing Chen, Yun Jin Kim, David Rojas-Rueda, Christina Papachristou, Andrew E. Moran, Richard A. Gosselin, Maziar Moradi-Lakeh, Soraya Seedat, Janet L Leasher, Belinda K Lloyd, Lorenzo Monasta, Bruno F. Sunguya, Eun-Kee Park, Eduardo A. Undurraga, Mohammad A. AlMazroa, Mohammad H. Forouzanfar, Young-Ho Khang, Vasiliki Stathopoulou, Dima M. Qato, James Scott, Ileana Heredia-Pi, Luca Ronfani, Haidong Kan, Tasara T. Mazorodze, Murugesan Raju, Saeid Shahraz, Taavi Tillmann, Wang Wenzhi, Neil Pearce, Eric Y. Tenkorang, Aliya Naheed, Ferrán Catalá-López, Sudan Prasad Neupane, Emily Dansereau, Michael McKee, Derrick A Bennett, Mazeda Hossain, Paul S. F. Yip, Grant Nguyen, Norberto Perico, Miguel Angel Alegretti, Babak Eshrati, Boris Bikbov, Palwasha Anwari, Guoqing Hu, Amelia Bertozzi-Villa, Peter A. Meaney, Farshad Farzadfar, Svetlana Popova, Tara Templin, Hmwe H Kyu, Uche S. Uchendu, Kebede Deribe, Sergey Soshnikov, Nobhojit Roy, Daniel Kim, Ilana N. Ackerman, Homie Razavi, Leslie T. Cooper, Sandra Nolte, David T. Felson, John J Huang, Yang Liu, Fiorella Cavalleri, Adrian Davis, Héctor Gómez Dantés, Klara Dokova, Yuantao Hao, Catalina Medina, Austin E Schumacher, Stan Biryukov, Jane Rowley, Arindam Basu, Jose C. Adsuar, Rosana E. Norman, Yousef Khader, Rafael Alfonso-Cristancho, Sukanta Saha, Simón Barquera, Diego Gonzalez-Medina, Philip B. Mitchell, Lars Barregard, Haidong Wang, Yongmei Li, Ami R. Moore, Marie Ng, Raghib Ali, Peter T. Serina, Lijing L Yan, Ayse Abbasoglu Ozgoren, Ricky Leung, Michelle L. Bell, Tim Driscoll, Azmeraw T. Amare, Farshad Pourmalek, Tea Lallukka, Benjamin O Anderson, Raimundas Lunevicius, Corine Karema, Robert G. Weintraub, Erin C Mullany, Anders Larsson, Glen Mola, Paulo A. Lotufo, Luke Nyakarahuka, Sayed Saidul Alam, Louisa Degenhardt, Hugh R. Taylor, E. Ray Dorsey, Suzanne Polinder, Hilton Lam, Urbano Fra Paleo, David Zonies, Rahman Shiri, Marco A Avila, Alicia Elena Beatriz Lawrynowicz, Katya Anne Shackelford, Lynne Gaffikin, Konstantin Kazanjan, Mark T Mackay, Jasvinder A. Singh, Bryan L. Sykes, Sadaf G. Sepanlou, Chantal Huynh, Rakhi Dandona, Logan Sandar, Lavanya Singh, Dietrich Rothenbacher, Theo Vos, Steven E. Lipshultz, Coen H. Van Gool, Peggy P. Chiang, Mark G. Shrime, Christopher J L Murray, Scott Weichenthal, Jae-Hyun Park, Samia Alhabib, Philimon Gona, Christian Kieling, Yuichiro Yano, Ronny Westerman, Thomas Truelsen, Rajeev Gupta, Megan Bohensky, Abdullatif Husseini, Qing Lan, Luke D. Knibbs, Yousef M. Elshrek, H. Ross Anderson, Guohong Jiang, Madeline L. Moyer, Vinod K. Paul, Wim H. van Brakel, Emin Murat Tuzcu, Kara Estep, Lalit Dandona, Uchechukwu K.A. Sampson, Mohammad Tavakkoli, Ying Jiang, Joseph A Wagner, Mitsuru Mukaigawara, In-Hwan Oh, Siyi Shangguan, Noela M. Prasad, Charles D.A. Wolfe, Borja del Pozo-Cruz, Gokalp Kadri Yentur, Hilda L Harb, Elena Alvarez, Carlos A Castañeda-Orjuela, Mustafa Z. Younis, Herbert C. Duber, Erica Leigh Slepak, George A. Mensah, Knud Juel, Graeme J. Hankey, Natan M. Bornstein, Martha Híjar, Johan Ärnlöv, Mohamed Hsairi, Katherine T. Lofgren, Murray B. Stein, Renata Micha, Luigi Naldi, Margreet ten Have, Bolajoko O. Olusanya, Kyle J Foreman, Kenji Shibuya, F. Gerry R. Fowkes, Abdullah Sulieman Terkawi, Rana J. Asghar, Karen M. Tabb, Kovin Naidoo, Rogelio Pérez-Padilla, Honglei Chen, Antônio Luiz Pinho Ribeiro, Rasmus Havmoeller, Yukito Shinohara, Bongani M. Mayosi, Ernst J Kuipers, Konrad Pesudovs, Mouhanad Hammami, Lee Richardson, Rintaro Mori, Thomas D. Fleming, Pouria Heydarpour, Stephen G. Waller, Nicholas Graetz, Chanda Kulkarni, Peter Brooks, Gulfaraz Khan, Marcel Tanner, Van C. Lansingh, François Alla, Jamie Hancock, Yohannes Adama Melaku, Neeraj Bedi, Anthony D. Woolf, Tariku Jibat Beyene, Amanda W Pain, Eric L. Ding, Narayanaswamy Venketasubramanian, Semaw Ferede Abera, Devina Nand, Odgerel Chimed-Ochir, George D Thurston, Victor Aboyans, Alanur Çavlin, Jefferson Traebert, Michael R. Phillips, Yingfeng Zheng, Baffour Awuah, Carlo Irwin A. Panelo, Selen Begüm Uzun, Muhammad Imran Nisar, Samir Soneji, Veena S. Kulkarni, Mukesh Dherani, Stephen S Lim, Andre Keren, Kingsley N. Ukwaja, Sajjad Ur Rahman, Giuseppe Remuzzi, Kjetil Søreide, Blake Thomson, Samath D Dharmaratne, Christopher D. Blosser, David H. Rothstein, Amanda G. Thrift, Fabrizio Tediosi, Andrew H. Kemp, H. Dean Hosgood, Yoshihiro Kokubo, Miia Kivipelto, Amitava Banerjee, Edgar P. Simard, Reza Malekzadeh, Maggie Lind, Robert P. Dellavalle, Emerito Jose A. Faraon, Lydia S. Atkins, Tom Achoki, Aslam Pervaiz, Peter Scarborough, Hans W. Hoek, Ettore Beghi, Emilie Agardh, Abraham D. Flaxman, Dariush Mozaffarian, Juan R. Sanabria, Muluken Dessalegn, David C. Schwebel, Caitlyn Steiner, Ubai Alsharif, Richard C. Franklin, Gail Davey, Gelin Xu, Reyna A Gutiérrez, Joannie Lortet-Tieulent, Ashish Bhalla, Jost B. Jonas, Paul N. Jensen, Simon I. Hay, Xiaonong Zou, Andre Pascal Kengne, Tolesa Bekele, Brittany Wurtz, Jung-Chen Chang, Joseph Murray, Luciano A. Sposato, Stefan Ma, Summer Lockett Ohno, Charles R. Newton, Bradford D. Gessner, JianLi Wang, Scott B. Patten, Thomas Fürst, Carol Brayne, Christina Fitzmaurice, Peilin Shi, Ted R. Miller, Kinnari S. Murthy, Habib Benzian, Peter W. Gething, Cesar Diaz-Torne, Burcu Kucuk Bicer, Bo Norrving, Carly E Levitz, Adam D M Briggs, Sungroul Kim, Isabela M. Benseñor, John A. Crump, Sergey Petrovich Ermakov, Kalpana Balakrishnan, Awoke Misganaw Temesgen, Marcella Montico, Sanjay Krishnaswami, Kim Moesgaard Iburg, Ann Kristin Knudsen, Sun Ha Jee, Valery L. Feigin, Christine M. Budke, Anne Bulchis, Anand Dayama, Jonathan R. Carapetis, Cyrus Cooper, Teresa Shamah Levy, Ismael R. Campos-Nonato, Nataliya A. Foigt, Beth E. Ebel, Max Petzold, Heresh Amini, Ole Frithjof Norheim, Zulfiqar A Bhutta, Dan Poenaru, Jim van Os, Michele E. Murdoch, Samantha M. Colquhoun, Michael H. Criqui, Giorgia Giussani, Man Mohan Mehndiratta, Thomas N. Williams, Chandrashekhar T Sreeramareddy, Chuanhua Yu, Luis M. Coppola, Thomas J. Montine, Alaa Badawi, Eduardo Bernabé, Melvin Barrientos Marzan, James Leigh, Frédéric B. Piel, Ratilal Lalloo, Panniyammakal Jeemon, Maheswar Satpathy, Hélène Carabin, Corina Benjet, Seyed-Mohammad Fereshtehnejad, Ryan M Barber, Fotis Topouzis, Bin Li, Serge Resnikoff, Taavi Lai, Rachelle Buchbinder, Randah R. Hamadeh, Valeria Caso, Holly E. Erskine, Dragos Virgil Davitoiu, Miltiadis K. Tsilimbaris, Rachel L. Pullan, Ben Schöttker, Rafael Lozano, Damian G Hoy, Fiona M. Blyth, Belinda J. Gabbe, Hebe N. Gouda, Farhad Islami, Atte Meretoja, Christopher Margono, Marissa Iannarone, Ronan A Lyons, Wilkister N. Moturi, Donald H. Silberberg, Alexandra Brazinova, Monica Cortinovis, Deena Alasfoor, Richard Matzopoulos, Jerry Abraham, Francesco Saverio Violante, Monika Sawhney, Dorairaj Prabhakaran, Valentina Colistro, Derek F J Fay, Mamta Swaroop, Nima Hafezi-Nejad, John Nelson Opio, Hanne Christensen, Jun She, Soewarta Kosen, Atsushi Goto, Costas A. Christophi, Jeyaraj D. Pandian, Peter J. Hotez, K. Srinath Reddy, Al Artaman, Peter Allebeck, Jonas Minet Kinge, Graham S Cooke, Dan J. Stein, Kawkab Shishani, Laith J. Abu-Raddad, Katrina F Ortblad, Deborah Jarvis, Arsène Kouablan Adou, Barthelemy Kuate Defo, Alan D. Lopez, G Anil Kumar, K.M. Venkat Narayan, Yong Zhao, Rajiv Chowdhury, Hadi Danawi, George C Patton, Vasiliy Victorovich Vlassov, André Karch, Tommi J. Vasankari, Matthias Endres, Ione Jayce Ceola Schneider, Nelson Alvis-Guzman, Charles N Mock, Katharine J Looker, Bach Xuan Tran, Fernando Perez-Ruiz, Harish Chander Gugnani, Reza Assadi, Hannah Hamavid, Rosario Cárdenas, Mohammed I. Albittar, Sarah Derrett, Mohammad Yahya Saeedi, Traolach S. Brugha, Jan Hendrik Richardus, Alireza Esteghamati, Seok Jun Yoon, Josep Maria Haro, Michael Brainin, Ziad A. Memish, Rupert R A Bourne, Katherine B Gibney, David M. Pereira, Kathryn H. Jacobsen, Luc E. Coffeng, Joshua A. Salomon, Xia Wan, Ian Bolliger, Boris I. Pavlin, Karen Sliwa, Tati S. Warouw, Geoffrey Buckle, Chakib Nejjari, Diego De Leo, Ashkan Afshin, Vinay Nangia, Daniel Pope, Johanna M. Geleijnse, Nikhil Tandon, Kelly Bienhoff, Jed D. Blore, Walid Ammar, D. Allen Roberts, Elisabete Weiderpass, Gregory A. Roth, Manami Inoue, James D. Wilkinson, Hideaki Toyoshima, Soufiane Boufous, Ivy Shiue, Edward J Mills, Leilei Duan, Matthew M Coates, Ganesan Karthikeyan, Alberto Ortiz, Steven van de Vijver, David Carpenter, Suzanne Lyn Barker-Collo, Antony Stevens, Sanjay Basu, Maria Cecilia Bahit, Kaire Innos, Lindsay N. Boyers, Nicholas J K Breitborde, Alize J. Ferrari, Timothy M. Wolock, Simerjot K. Jassal, Mohammad Ali Sahraian, Joanna Moschandreas, Howard J. Hoffman, Hideki Higashi, George M. Ruhago, Karzan Abdulmuhsin Mohammad, Mohammed Basulaiman, D. Alex Quistberg, Justin Beardsley, Marcello Tonelli, Maurice Giroud, Karen Edmond, Norito Kawakami, Mohammad T Mashal, Neeraj Bhala, Carl Abelardo T. Antonio, David Tanne, Abhishek Singh, Kazem Rahimi, Vivekanand Jha, Wagner Marcenes, David J. Margolis, Yara A. Halasa, Zewdie Aderaw Alemu, Carrie Beth Peterson, Edson Serván-Mori, Anil Kaul, Foad Abd-Allah, Marek Majdan, Rahul Gupta, Robyn M. Lucas, Sarah Wulf, Lars Jacob Stovner, Mohsen Naghavi, Vegard Skirbekk, Ulrich Otto Mueller, Pengpeng Ye, Ali H. Mokdad, Dipan Bose, Saleem M Rana, Jeffrey D Stanaway, Abigail Mclain, Timothy J. Steiner, Amira Shaheen, Stein Emil Vollset, Andrea Werdecker, Michele Meltzer, Richie G Poulton, Joseph R. Masci, Inga Dora Sigfusdottir, Daniel Dicker, Maysaa El Sayed Zaki, Shiwei Liu, Julio C. Montañez Hernandez, Valentina Arsić Arsenijević, William Msemburi, Lope H Barrero, Linhong Wang, Soumya Swaminathan, Harvey Whiteford, Michael F. Macintyre, Berrak Bora Basara, Gregory R. Wagner, Paul I. Dargan, Hermann Brenner, Carolyn C. Gotay, Niveen M E Abu-Rmeileh, Nicholas J Kassebaum, Shams Eldin Ali Hassan Khalifa, Neil McGill, Murray, Christopher J. L, Barber, Ryan M., Foreman, Kyle J., Ozgoren, Ayse Abbasoglu, Abd-Allah, Foad, Abera, Semaw F., Aboyans, Victor, Abraham, Jerry P., Abubakar, Ibrahim, Abu-Raddad, Laith J., Abu-Rmeileh, Niveen M., Achoki, Tom, Ackerman, Ilana N., Ademi, Zanfina, Adou, Arsène K., Adsuar, José C., Afshin, Ashkan, Agardh, Emilie E., Alam, Sayed Saidul, Alasfoor, Deena, Albittar, Mohammed I., Alegretti, Miguel A., Alemu, Zewdie A., Alfonso-Cristancho, Rafael, Alhabib, Samia, Ali, Raghib, Alla, Françoi, Allebeck, Peter, Almazroa, Mohammad A., Alsharif, Ubai, Alvarez, Elena, Alvis-Guzman, Nelson, Amare, Azmeraw T., Ameh, Emmanuel A., Amini, Heresh, Ammar, Walid, Anderson, H. Ro, Anderson, Benjamin O., Antonio, Carl Abelardo T., Anwari, Palwasha, Arnlöv, Johan, Arsenijevic, Valentina S. Arsic, Artaman, Al, Asghar, Rana J., Assadi, Reza, Atkins, Lydia S., Avila, Marco A., Awuah, Baffour, Bachman, Victoria F., Badawi, Alaa, Bahit, Maria C., Balakrishnan, Kalpana, Banerjee, Amitava, Barker-Collo, Suzanne L., Barquera, Simon, Barregard, Lar, Barrero, Lope H., Basu, Arindam, Basu, Sanjay, Basulaiman, Mohammed O., Beardsley, Justin, Bedi, Neeraj, Beghi, Ettore, Bekele, Tolesa, Bell, Michelle L., Benjet, Corina, Bennett, Derrick A., Bensenor, Isabela M., Benzian, Habib, Bernabé, Eduardo, Bertozzi-Villa, Amelia, Beyene, Tariku J., Bhala, Neeraj, Bhalla, Ashish, Bhutta, Zulfiqar A., Bienhoff, Kelly, Bikbov, Bori, Biryukov, Stan, Blore, Jed D., Blosser, Christopher D., Blyth, Fiona M., Bohensky, Megan A., Bolliger, Ian W., Başara, Berrak Bora, Bornstein, Natan M., Bose, Dipan, Boufous, Soufiane, Bourne, Rupert R. A., Boyers, Lindsay N., Brainin, Michael, Brayne, Carol E., Brazinova, Alexandra, Breitborde, Nicholas J. K., Brenner, Hermann, Briggs, Adam D., Brooks, Peter M., Brown, Jonathan C., Brugha, Traolach S., Buchbinder, Rachelle, Buckle, Geoffrey C., Budke, Christine M., Bulchis, Anne, Bulloch, Andrew G., Campos-Nonato, Ismael R., Carabin, Hélène, Carapetis, Jonathan R., Cárdenas, Rosario, Carpenter, David O., Caso, Valeria, Castañeda-Orjuela, Carlos A., Castro, Ruben E., Catalá-López, Ferrán, Cavalleri, Fiorella, Çavlin, Alanur, Chadha, Vineet K., Chang, Jung-Chen, Charlson, Fiona J., Chen, Honglei, Chen, Wanqing, Chiang, Peggy P., Chimed-Ochir, Odgerel, Chowdhury, Rajiv, Christensen, Hanne, Christophi, Costas A., Cirillo, Massimo, Coates, Matthew M., Coffeng, Luc E., Coggeshall, Megan S., Colistro, Valentina, Colquhoun, Samantha M., Cooke, Graham S., Cooper, Cyru, Cooper, Leslie T., Coppola, Luis M., Cortinovis, Monica, Criqui, Michael H., Crump, John A., Cuevas-Nasu, Lucia, Danawi, Hadi, Dandona, Lalit, Dandona, Rakhi, Dansereau, Emily, Dargan, Paul I., Davey, Gail, Davis, Adrian, Davitoiu, Dragos V., Dayama, Anand, De Leo, Diego, Degenhardt, Louisa, Del Pozo-Cruz, Borja, Dellavalle, Robert P., Deribe, Kebede, Derrett, Sarah, Des Jarlais, Don C., Dessalegn, Muluken, Dharmaratne, Samath D., Dherani, Mukesh K., Diaz-Torné, Cesar, Dicker, Daniel, Ding, Eric L., Dokova, Klara, Dorsey, E Ray, Driscoll, Tim R., Duan, Leilei, Duber, Herbert C., Ebel, Beth E., Edmond, Karen M., Elshrek, Yousef M., Endres, Matthia, Ermakov, Sergey P., Erskine, Holly E., Eshrati, Babak, Esteghamati, Alireza, Estep, Kara, Faraon, Emerito Jose A., Farzadfar, Farshad, Fay, Derek F., Feigin, Valery L., Felson, David T., Fereshtehnejad, Seyed-Mohammad, Fernandes, Jefferson G., Ferrari, Alize J., Fitzmaurice, Christina, Flaxman, Abraham D., Fleming, Thomas D., Foigt, Nataliya, Forouzanfar, Mohammad H., Fowkes, F Gerry R., Paleo, Urbano Fra., Franklin, Richard C., Fürst, Thoma, Gabbe, Belinda, Gaffikin, Lynne, Gankpé, Fortuné G., Geleijnse, Johanna M., Gessner, Bradford D., Gething, Peter, Gibney, Katherine B., Giroud, Maurice, Giussani, Giorgia, Dantes, Hector Gomez, Gona, Philimon, González-Medina, Diego, Gosselin, Richard A., Gotay, Carolyn C., Goto, Atsushi, Gouda, Hebe N., Graetz, Nichola, Gugnani, Harish C., Gupta, Rahul, Gupta, Rajeev, Gutiérrez, Reyna A., Haagsma, Juanita, Hafezi-Nejad, Nima, Hagan, Holly, Halasa, Yara A., Hamadeh, Randah R., Hamavid, Hannah, Hammami, Mouhanad, Hancock, Jamie, Hankey, Graeme J., Hansen, Gillian M., Hao, Yuantao, Harb, Hilda L., Haro, Josep Maria, Havmoeller, Rasmu, Hay, Simon I., Hay, Roderick J., Heredia-Pi, Ileana B., Heuton, Kyle R., Heydarpour, Pouria, Higashi, Hideki, Hijar, Martha, Hoek, Hans W., Hoffman, Howard J., Hosgood, H Dean, Hossain, Mazeda, Hotez, Peter J., Hoy, Damian G., Hsairi, Mohamed, Hu, Guoqing, Huang, Cheng, Huang, John J., Husseini, Abdullatif, Huynh, Chantal, Iannarone, Marissa L., Iburg, Kim M., Innos, Kaire, Inoue, Manami, Islami, Farhad, Jacobsen, Kathryn H., Jarvis, Deborah L., Jassal, Simerjot K., Jee, Sun Ha, Jeemon, Panniyammakal, Jensen, Paul N., Jha, Vivekanand, Jiang, Guohong, Jiang, Ying, Jonas, Jost B., Juel, Knud, Kan, Haidong, Karch, André, Karema, Corine K., Karimkhani, Chante, Karthikeyan, Ganesan, Kassebaum, Nicholas J., Kaul, Anil, Kawakami, Norito, Kazanjan, Konstantin, Kemp, Andrew H., Kengne, Andre P., Keren, Andre, Khader, Yousef S., Khalifa, Shams Eldin A., Khan, Ejaz A., Khan, Gulfaraz, Khang, Young-Ho, Kieling, Christian, Kim, Daniel, Kim, Sungroul, Kim, Yunjin, Kinfu, Yohanne, Kinge, Jonas M., Kivipelto, Miia, Knibbs, Luke D., Knudsen, Ann Kristin, Kokubo, Yoshihiro, Kosen, Soewarta, Krishnaswami, Sanjay, Defo, Barthelemy Kuate, Bicer, Burcu Kucuk, Kuipers, Ernst J., Kulkarni, Chanda, Kulkarni, Veena S., Kumar, G Anil, Kyu, Hmwe H., Lai, Taavi, Lalloo, Ratilal, Lallukka, Tea, Lam, Hilton, Lan, Qing, Lansingh, Van C., Larsson, Ander, Lawrynowicz, Alicia E. 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Sciences et Technologies (UMR 6174) ( FEMTO-ST ), Université de Franche-Comté ( UFC ) -Centre National de la Recherche Scientifique ( CNRS ) -Ecole Nationale Supérieure de Mécanique et des Microtechniques ( ENSMM ) -Université de Technologie de Belfort-Montbeliard ( UTBM ), Tehran University, Friedrich-Alexander Universität Erlangen-Nürnberg ( FAU ), Secretariat of the Pacific Community, Public Health Division, Sociétés, Acteurs, Gouvernement en Europe ( SAGE ), Université de Strasbourg ( UNISTRA ) -Centre National de la Recherche Scientifique ( CNRS ), School of Physics and Astronomy, Washington State University ( WSU ), Laboratoire de Physique de l'ENS Lyon ( Phys-ENS ), École normale supérieure - Lyon ( ENS Lyon ) -Université Claude Bernard Lyon 1 ( UCBL ), Université de Lyon-Université de Lyon-Centre National de la Recherche Scientifique ( CNRS ), Institut de recherche en informatique de Toulouse ( IRIT ), Institut National Polytechnique [Toulouse] ( INP ) -Université Toulouse 1 Capitole ( UT1 ) -Université Toulouse - Jean Jaurès ( UT2J ) -Université Toulouse III - Paul Sabatier ( UPS ), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Centre National de la Recherche Scientifique ( CNRS ), School of Computer Science - China University of Geosciences (China University of Geosciences (East Area)), Université Catholique de Louvain ( UCL ), Div Cyclotron & Radiopharmaceut Sci ( DRDO, INMAS ), Univ New Delhi, University of St Andrews [Scotland], University of Cape Town, Department of Neuroscience, Karolinska Institutet [Stockholm], Institut de Physique Nucléaire d'Orsay ( IPNO ), Université Paris-Sud - Paris 11 ( UP11 ) -Institut National de Physique Nucléaire et de Physique des Particules du CNRS ( IN2P3 ) -Centre National de la Recherche Scientifique ( CNRS ), Department of Computer Science and Engineering [Daejeon] (Chungnam National University), Lawrence University, Gastroenterology & Hepatology, Tata Research Development and Design Center ( TRDDC ), TCS Innovation Labs, Laboratoire MOLTECH-Anjou [Angers] ( MOLTECH ANJOU ), Université d'Angers ( UA ) -Centre National de la Recherche Scientifique ( CNRS ), University of Helsinki [Helsinki], Google Inc [Mountain View], Research at Google, Swedish Defense Research Agency ( FOI ), Centre de Recherche en Information Biomédicale sino-français ( CRIBS ), Université de Rennes 1 ( UR1 ), Université de Rennes ( UNIV-RENNES ) -Université de Rennes ( UNIV-RENNES ) -Southeast University [Jiangsu]-Institut National de la Santé et de la Recherche Médicale ( INSERM ), Laboratory of Image Science and Technology [Nanjing] ( LIST ), Southeast University [Jiangsu]-School of Computer Science and Engineering, Laboratoire de glaciologie et géophysique de l'environnement ( LGGE ), Observatoire des Sciences de l'Univers de Grenoble ( OSUG ), Université Joseph Fourier - Grenoble 1 ( UJF ) -Institut national des sciences de l'Univers ( INSU - CNRS ) -Centre National de la Recherche Scientifique ( CNRS ) -Université Grenoble Alpes ( UGA ) -Université Joseph Fourier - Grenoble 1 ( UJF ) -Institut national des sciences de l'Univers ( INSU - CNRS ) -Centre National de la Recherche Scientifique ( CNRS ) -Université Grenoble Alpes ( UGA ) -Centre National de la Recherche Scientifique ( CNRS ), School of Business and Informatics, University of Boras, Department of Mechanical and Automation Engineering ( CAD Laboratory ), The Chinese University of Hong Kong [Hong Kong], Università degli studi di Bari, Heuristique et Diagnostic des Systèmes Complexes [Compiègne] ( Heudiasyc ), Université de Technologie de Compiègne ( UTC ) -Centre National de la Recherche Scientifique ( CNRS ), Department of plant pathology and microbiology - centre for sustainable pest and disease management, Rothamsted Research, RGU, Department of Rheumatology and Connective Tissue Diseases, Medical University of Lublin, Barts and The London School of Medicine and Dentistry, Queen Mary University of London ( QMUL ), Centre d'économie de la Sorbonne ( CES ), Université Panthéon-Sorbonne ( UP1 ) -Centre National de la Recherche Scientifique ( CNRS ), Paris School of Economics ( PSE ), Istituto Dalle Molle di Studi sull'Intelligenza Artificiale ( IDSIA ), Università della Svizzera italiana ( USI ) -Scuola universitaria professionale della Svizzera italiana [Manno] ( SUPSI ), Anaesthetics, Southampton University Hospital, Department of Mathematics, University of Iowa [Iowa City], College of Medicine, Alfaisal University, Saudi Ministry of Health, Institut national des recherches agricoles du Bénin, Centre de Recherches agricoles du Sud, Departments of Epidemiology and Nutrition, Unit of Human Nutrition, Agricultural University of Athens, Department of Animal Science, PennState University [Pennsylvania] ( PSU ), University of Virginia, University of Virginia [Charlottesville], Epidemiology and Biostatistics Unit, Institute for Maternal and Child Health - IRCCS ‘‘Burlo Garofolo', Jet Propulsion Laboratory ( JPL ), NASA-California Institute of Technology ( CALTECH ), Division of Cardiovascular Medicine and Channing Division of Network Medicine, Brigham and Women's Hospital [Boston], Division of Gastroenterology and Hepatology, Department of Immunology, Mayo Clinic, Department of Chemistry, Scientific Computing Research Unit, Department of dermatology, Milano University-Azienda Ospedaleria Ospedali Riuniti di Bergamo, Department of epidemiology and Public Health, Faculty of Medicine, Hong Kong Baptist University ( HKBU ), Département Optique ( OPT ), Université européenne de Bretagne ( UEB ) -Télécom Bretagne-Institut Mines-Télécom [Paris], Department of Neurology Lunds University Hospital Lund, Services répartis, Architectures, MOdélisation, Validation, Administration des Réseaux ( SAMOVAR ), Institut Mines-Télécom [Paris]-Télécom SudParis ( TSP ) -Centre National de la Recherche Scientifique ( CNRS ), Département Réseaux et Services Multimédia Mobiles ( RS2M ), Institut Mines-Télécom [Paris]-Télécom SudParis ( TSP ), Electrical Engineering and Computer Science Department - Case Western Reserve University, Case Western Reserve University [Cleveland], Institut Lumière Matière [Villeurbanne] ( ILM ), Université Claude Bernard Lyon 1 ( UCBL ), World Health Organization, Nordic School of Public Health, The James Hutton Institute, Sero, Sero consulting, Evolutionary Ecology of Infectious Disease Group, Department of Zoology, Horia Hulubei National Institute for Physics and Nuclear Engineering, Dunedin School of Medicine, University of Otago, Department of Physics, Clarendon Laboratory, Center for TeleInFrastruktur ( CTIF ), Aalborg University [Denmark] ( AAU ), Physikalisches Institut [Freiburg], Albert-Ludwigs-Universität Freiburg, Savoirs, Textes, Langage (STL) - UMR 8163 ( STL ), Université de Lille-Centre National de la Recherche Scientifique ( CNRS ), Dept.of Computer Science, Indian Institute of Technology Madras ( IIT Madras ), Istituto Mario Negri Bergamo, Centro Ricerche e Trapianti Villa Camozzi, Universidade Estadual Paulista Júlio de Mesquita ( UNESP ), Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Université Grenoble Alpes - UFR Médecine ( UGA UFRM ), Université Grenoble Alpes ( UGA ), Clinical Epidemiology and Aging Research, German Cancer Research Center, Institut Cochin ( UM3 (UMR 8104 / U1016) ), Université Paris Descartes - Paris 5 ( UPD5 ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ) -Centre National de la Recherche Scientifique ( CNRS ), Symantec, European Microsoft Innovation Center ( EMIC ), Microsoft Corporation [Redmond, Wash.], Laboratoire de Mécanique, Physique et Géosciences ( LMPG ), Université Le Havre Normandie ( ULH ), Normandie Université ( NU ) -Normandie Université ( NU ), Novartis institute for tropical diseases, Institut de Génétique et de Biologie Moléculaire et Cellulaire ( IGBMC ), Université de Strasbourg ( UNISTRA ) -Institut National de la Santé et de la Recherche Médicale ( INSERM ) -Centre National de la Recherche Scientifique ( CNRS ), Departments of Anatomy and Cell Biology, Wayne State University School of Medicine, Departments of Ophthalmology, Departments of Applied Physics [New Haven], Yale University [New Haven], Center for Mathematical Modeling ( CMM ), Universidad de Santiago de Chile [Santiago] ( USACH ), Laboratory for Atmospheric and Space Physics [Boulder] ( LASP ), University of Colorado Boulder [Boulder], University of Occupational and Environmental Health [Kitakyushu] ( UEOH ), Department of Computer Science and Engineering [New Delhi], Indian Institute of Technology Delhi ( IIT Delhi ), Institut de Recherche sur les Phénomènes Hors Equilibre ( IRPHE ), Aix Marseille Université ( AMU ) -Ecole Centrale de Marseille ( ECM ) -Centre National de la Recherche Scientifique ( CNRS ), GlaxoSmithKline, Imperial College London-Clinical Imaging Center, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, Yale School of Medicine-Yale School of Medicine-Yale Stem Cell Center, Maclean Building, Benson Lane, Crowmarsh Gifford, Centre for Ecology and Hydrology, Nanoscience Institute ( NEST ), Dipartimento di Fisica, Università di Pisa, Aristotle University of Thessaloniki, Laboratory Of Immune Cell Biology ( LICB ), National Institutes of Health ( NIH ), Institute of Human Genetics, Bonn Universität [Bonn], Occupational Health Unit, Bologna University Hospital-Sant'Orsola-Malpighi Polyclinic, Royal Institute of Technology [Stockholm] ( KTH ), Institut für Informatik [München/Munich] ( LMU ), Ludwig-Maximilians-Universität München, NICTA [Eveleigh], National ICT Australia [Sydney] ( NICTA ), Manchester Academic Health Sciences Centre, Institut d'Histoire et de Philosophie des Sciences et des Techniques ( IHPST ), Université Panthéon-Sorbonne ( UP1 ) -Département d'Etudes Cognitives - ENS Paris ( DEC ), École normale supérieure - Paris ( ENS Paris ) -École normale supérieure - Paris ( ENS Paris ) -Centre National de la Recherche Scientifique ( CNRS ), Ghent University [Belgium] ( UGENT ), German Research Centre for Geosciences - Helmholtz-Centre Potsdam ( GFZ ), Laboratoire de recherche en Hydrodynamique, Énergétique et Environnement Atmosphérique ( LHEEA ), École Centrale de Nantes ( ECN ) -Centre National de la Recherche Scientifique ( CNRS ), Institut de Recherche en Génie Civil et Mécanique ( GeM ), Université de Nantes ( UN ) -École Centrale de Nantes ( ECN ) -Centre National de la Recherche Scientifique ( CNRS ), Neurorestoration Group, King‘s College London-Wolfson Centre for Age-related Diseases, Department of Computer Science [KAIST] ( CS ), Korea Advanced Institute of Science and Technology ( KAIST ), Laboratoire de l'Accélérateur Linéaire ( LAL ), Natl Engn Res Ctr Vegetables, Key Lab Biol & Genet Improvement Hort Crops N Chi, Beijing Acad Agr & Forestry Sci, University Hospital Puerta de Hierro, Madrid, Computational Science and Engineering Department [Daresbury] (STFC), Neuroépidémiologie Tropicale (NET), CHU Limoges-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut Génomique, Environnement, Immunité, Santé, Thérapeutique (GEIST), Université de Limoges (UNILIM)-Université de Limoges (UNILIM), Weill Cornell Medicine [Qatar], Maladies chroniques, santé perçue, et processus d'adaptation (APEMAC), Université Paris Descartes - Paris 5 (UPD5)-Université de Lorraine (UL), Cancéropôle du Grand Est-Institut National de la Santé et de la Recherche Médicale (INSERM), Centro de Estudios Avanzados en Zonas Aridas (CEAZA), Ecole Polytechnique Fédérale de Lausanne (EPFL), Laboratoire d'Ingénierie des Matériaux (LIM), Centre National de la Recherche Scientifique (CNRS), Lawrence Berkeley National Laboratory [Berkeley] (LBNL), Samsung Research &Development Institute India - Bangalore (Groupe Samsung) (SRI-B), Multimedia Research Center (MRC), University of Alberta, Division of Biostatistics (Biostat - MINNEAPOLIS), University of Minnesota [Twin Cities] (UMN), University of Minnesota System-University of Minnesota System, University of Southampton, University of Cambridge [UK] (CAM), Interactions, transferts, ruptures artistiques et culturels - EA 6301 (InTRu), Université de Tours (UT), Institut Jacques Monod (IJM (UMR_7592)), Université Paris Diderot - Paris 7 (UPD7)-Centre National de la Recherche Scientifique (CNRS), Stanford University, Unité de recherche Virologie et Immunologie Moléculaires (VIM (UR 0892)), Institut National de la Recherche Agronomique (INRA), National University of Singapore (NUS), Université Paris 1 Panthéon-Sorbonne - UFR Science Politique (UP1 UFR11), Université Paris 1 Panthéon-Sorbonne (UP1), National Diagnostics Centre (NDC), National University of Ireland [Galway] (NUI Galway), Arthritis Research UK Epidemiology Unit (MANCHESTER - Arthritis Research), Universidade do Porto = University of Porto, Advanced Laboratories on Embedded Systems [Roma] (ALES), Wageningen University and Research [Wageningen] (WUR), University of Oxford, Universitat Politècnica de Catalunya [Barcelona] (UPC), Institut National de Recherche et d'Analyse Physico-Chimique (INRAP), University of Connecticut (UCONN), Norwegian Institute for Air Research (NILU), Franche-Comté Électronique Mécanique, Thermique et Optique - Sciences et Technologies (UMR 6174) (FEMTO-ST), Université de Technologie de Belfort-Montbeliard (UTBM)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Centre National de la Recherche Scientifique (CNRS)-Université de Franche-Comté (UFC), Université Bourgogne Franche-Comté [COMUE] (UBFC)-Université Bourgogne Franche-Comté [COMUE] (UBFC), University of Tehran, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Sociétés, Acteurs, Gouvernement en Europe (SAGE), Université de Strasbourg (UNISTRA)-Centre National de la Recherche Scientifique (CNRS), The George Washington University (GW), Washington State University (WSU), Laboratoire de Physique de l'ENS Lyon (Phys-ENS), École normale supérieure de Lyon (ENS de Lyon)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon-Centre National de la Recherche Scientifique (CNRS), Institut de recherche en informatique de Toulouse (IRIT), Université Toulouse Capitole (UT Capitole), Université de Toulouse (UT)-Université de Toulouse (UT)-Université Toulouse - Jean Jaurès (UT2J), Université de Toulouse (UT)-Université Toulouse III - Paul Sabatier (UT3), Université de Toulouse (UT)-Centre National de la Recherche Scientifique (CNRS)-Institut National Polytechnique (Toulouse) (Toulouse INP), Université de Toulouse (UT)-Toulouse Mind & Brain Institut (TMBI), Université Toulouse - Jean Jaurès (UT2J), Université de Toulouse (UT)-Université de Toulouse (UT)-Université Toulouse III - Paul Sabatier (UT3), Université de Toulouse (UT), Université Catholique de Louvain = Catholic University of Louvain (UCL), Div Cyclotron & Radiopharmaceut Sci (DRDO, INMAS), School of Physics and Astronomy [St Andrews], Tata Research Development and Design Center (TRDDC), MOLTECH-Anjou, Université d'Angers (UA)-Institut de Chimie du CNRS (INC)-Centre National de la Recherche Scientifique (CNRS), Helsingin yliopisto = Helsingfors universitet = University of Helsinki, Swedish Defense Research Agency (FOI), Centre de Recherche en Information Biomédicale sino-français (CRIBS), Université de Rennes (UR)-Southeast University [Jiangsu]-Institut National de la Santé et de la Recherche Médicale (INSERM), Laboratory of Image Science and Technology [Nanjing] (LIST), Laboratoire de glaciologie et géophysique de l'environnement (LGGE), Observatoire des Sciences de l'Univers de Grenoble (OSUG), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national des sciences de l'Univers (INSU - CNRS)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national des sciences de l'Univers (INSU - CNRS)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Centre National de la Recherche Scientifique (CNRS), Department of Mechanical and Automation Engineering (CAD Laboratory), Università degli studi di Bari Aldo Moro = University of Bari Aldo Moro (UNIBA), Heuristique et Diagnostic des Systèmes Complexes [Compiègne] (Heudiasyc), Université de Technologie de Compiègne (UTC)-Centre National de la Recherche Scientifique (CNRS), Biotechnology and Biological Sciences Research Council (BBSRC)-Biotechnology and Biological Sciences Research Council (BBSRC), Queen Mary University of London (QMUL), Centre d'économie de la Sorbonne (CES), Université Paris 1 Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS), Paris School of Economics (PSE), Université Paris 1 Panthéon-Sorbonne (UP1)-École normale supérieure - Paris (ENS-PSL), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-École des hautes études en sciences sociales (EHESS)-École des Ponts ParisTech (ENPC)-Centre National de la Recherche Scientifique (CNRS)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Istituto Dalle Molle di Studi sull'Intelligenza Artificiale (IDSIA), Università della Svizzera italiana = University of Italian Switzerland (USI)-Scuola universitaria professionale della Svizzera italiana = University of Applied Sciences and Arts of Southern Switzerland [Manno] (SUPSI), Pennsylvania State University (Penn State), Penn State System-Penn State System, Jet Propulsion Laboratory (JPL), NASA-California Institute of Technology (CALTECH), Hong Kong Baptist University (HKBU), Département Optique (OPT), Université européenne de Bretagne - European University of Brittany (UEB)-Télécom Bretagne-Institut Mines-Télécom [Paris] (IMT), Services répartis, Architectures, MOdélisation, Validation, Administration des Réseaux (SAMOVAR), Institut Mines-Télécom [Paris] (IMT)-Télécom SudParis (TSP), Département Réseaux et Services Multimédia Mobiles (TSP - RS2M), University of Melbourne, Organisation Mondiale de la Santé / World Health Organization Office (OMS / WHO), University of Otago [Dunedin, Nouvelle-Zélande], Center for TeleInFrastruktur (CTIF), Aalborg University [Denmark] (AAU), Savoirs, Textes, Langage (STL) - UMR 8163 (STL), Université de Lille-Centre National de la Recherche Scientifique (CNRS), Indian Institute of Technology Madras (IIT Madras), Universidade Estadual Paulista Júlio de Mesquita Filho = São Paulo State University (UNESP), Erasmus University Medical Center [Rotterdam] (Erasmus MC), Université Grenoble Alpes - UFR Médecine (UGA UFRM), Université Grenoble Alpes [2016-2019] (UGA [2016-2019]), German Cancer Research Center - Deutsches Krebsforschungszentrum [Heidelberg] (DKFZ), Institut Cochin (IC UM3 (UMR 8104 / U1016)), Université Paris Descartes - Paris 5 (UPD5)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), European Microsoft Innovation Center (EMIC), Laboratoire de Mécanique, Physique et Géosciences (LMPG), Université Le Havre Normandie (ULH), Normandie Université (NU)-Normandie Université (NU), Novartis Institute for Tropical Diseases (NITD), Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg (UNISTRA)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS), Center for Mathematical Modeling (CMM), Universidad de Chile = University of Chile [Santiago] (UCHILE), Laboratory for Atmospheric and Space Physics [Boulder] (LASP), University of Colorado [Boulder], University of Occupational and Environmental Health [Kitakyushu] (UEOH), Indian Institute of Technology Delhi (IIT Delhi), Institut de Recherche sur les Phénomènes Hors Equilibre (IRPHE), Aix Marseille Université (AMU)-École Centrale de Marseille (ECM)-Centre National de la Recherche Scientifique (CNRS), Yale University [New Haven]-Yale School of Medicine [New Haven, Connecticut] (YSM), Nanoscience Institute (NEST), University of Pisa - Università di Pisa, Laboratory Of Immune Cell Biology (LICB), National Institutes of Health [Bethesda] (NIH), Rheinische Friedrich-Wilhelms-Universität Bonn, Royal Institute of Technology [Stockholm] (KTH ), Institut für Informatik [München/Munich] (LMU), Ludwig-Maximilians-Universität München (LMU), National ICT Australia [Sydney] (NICTA), Institut d'Histoire et de Philosophie des Sciences et des Techniques (IHPST), Université Paris 1 Panthéon-Sorbonne (UP1)-Département d'Etudes Cognitives - ENS Paris (DEC), École normale supérieure - Paris (ENS-PSL), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-École normale supérieure - Paris (ENS-PSL), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-Centre National de la Recherche Scientifique (CNRS), Universiteit Gent = Ghent University (UGENT), German Research Centre for Geosciences - Helmholtz-Centre Potsdam (GFZ), Laboratoire de recherche en Hydrodynamique, Énergétique et Environnement Atmosphérique (LHEEA), École Centrale de Nantes (ECN)-Centre National de la Recherche Scientifique (CNRS), Institut de Recherche en Génie Civil et Mécanique (GeM), Université de Nantes - UFR des Sciences et des Techniques (UN UFR ST), Université de Nantes (UN)-Université de Nantes (UN)-École Centrale de Nantes (ECN)-Centre National de la Recherche Scientifique (CNRS), Department of Computer Science [KAIST] (CS), Korea Advanced Institute of Science and Technology (KAIST), Kardiyoloji, Institut Génomique, Environnement, Immunité, Santé, Thérapeutique (GEIST), Université de Limoges (UNILIM)-Université de Limoges (UNILIM)-CHU Limoges-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-Institut National de la Santé et de la Recherche Médicale (INSERM), University of Minnesota [Twin Cities], Centre National de la Recherche Scientifique (CNRS)-Université Paris Diderot - Paris 7 (UPD7), Unité de recherche Virologie et Immunologie Moléculaires (VIM), Université Panthéon-Sorbonne - UFR Science Politique (UP1 UFR11), Université Panthéon-Sorbonne (UP1), Wageningen University and Research Centre [Wageningen] (WUR), Institut National de Recherche et d'Analyse Physico-chimique (Ariana, Tunisie) (INRAP), Université de Franche-Comté (UFC)-Centre National de la Recherche Scientifique (CNRS)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Université de Technologie de Belfort-Montbeliard (UTBM), George Washington University (GW), École normale supérieure - Lyon (ENS Lyon)-Université Claude Bernard Lyon 1 (UCBL), Université Toulouse 1 Capitole (UT1)-Université Toulouse - Jean Jaurès (UT2J)-Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Centre National de la Recherche Scientifique (CNRS)-Institut National Polytechnique (Toulouse) (Toulouse INP), Université Fédérale Toulouse Midi-Pyrénées, Université Catholique de Louvain (UCL), MOLTECH-ANJOU (MOLTECH-ANJOU), Université d'Angers (UA)-Centre National de la Recherche Scientifique (CNRS), University of Helsinki, Université de Rennes 1 (UR1), Université de Rennes (UNIV-RENNES)-Université de Rennes (UNIV-RENNES)-Southeast University [Jiangsu]-Institut National de la Santé et de la Recherche Médicale (INSERM), Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut national des sciences de l'Univers (INSU - CNRS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut national des sciences de l'Univers (INSU - CNRS)-Centre National de la Recherche Scientifique (CNRS)-Université Grenoble Alpes (UGA)-Centre National de la Recherche Scientifique (CNRS), Université Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS), Università della Svizzera italiana (USI)-Scuola universitaria professionale della Svizzera italiana [Manno] (SUPSI), California Institute of Technology (CALTECH)-NASA, Institut Mines-Télécom [Paris] (IMT)-Télécom SudParis (TSP)-Centre National de la Recherche Scientifique (CNRS), Département Réseaux et Services Multimédia Mobiles (RS2M), Universidade Estadual Paulista Júlio de Mesquita Filho [São José do Rio Preto] (UNESP), Université Grenoble Alpes (UGA), Universidad de Santiago de Chile [Santiago] (USACH), Yale University [New Haven]-Yale University School of Medicine, Université Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS)-Département d'Etudes Cognitives - ENS Paris (DEC), École normale supérieure - Paris (ENS Paris)-École normale supérieure - Paris (ENS Paris), Ghent University [Belgium] (UGENT), Université de Nantes - Faculté des Sciences et des Techniques, Grelier, Elisabeth, Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Université Toulouse - Jean Jaurès (UT2J)-Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Centre National de la Recherche Scientifique (CNRS)-Institut National Polytechnique (Toulouse) (Toulouse INP), Université Fédérale Toulouse Midi-Pyrénées-Toulouse Mind & Brain Institut (TMBI), Université Toulouse - Jean Jaurès (UT2J)-Université Toulouse III - Paul Sabatier (UT3), Université Fédérale Toulouse Midi-Pyrénées-Université Fédérale Toulouse Midi-Pyrénées-Université Toulouse III - Paul Sabatier (UT3), Universidade do Porto, Université de Technologie de Belfort-Montbeliard (UTBM)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Université de Franche-Comté (UFC), Université Bourgogne Franche-Comté [COMUE] (UBFC)-Université Bourgogne Franche-Comté [COMUE] (UBFC)-Centre National de la Recherche Scientifique (CNRS), École normale supérieure - Lyon (ENS Lyon)-Centre National de la Recherche Scientifique (CNRS)-Université Claude Bernard Lyon 1 (UCBL), Université de Lyon-Université de Lyon, Université Toulouse 1 Capitole (UT1), Centre National de la Recherche Scientifique (CNRS)-Institut national des sciences de l'Univers (INSU - CNRS)-Observatoire des Sciences de l'Univers de Grenoble (OSUG), Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Institut national des sciences de l'Univers (INSU - CNRS)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry]), Università degli studi di Bari Aldo Moro (UNIBA), École des Ponts ParisTech (ENPC)-École normale supérieure - Paris (ENS Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-Université Paris 1 Panthéon-Sorbonne (UP1)-Centre National de la Recherche Scientifique (CNRS)-École des hautes études en sciences sociales (EHESS)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Università della Svizzera italiana = University of Italian Switzerland (USI)-Scuola universitaria professionale della Svizzera italiana [Manno] (SUPSI), Institut Mines-Télécom [Paris] (IMT)-Télécom Bretagne-Université européenne de Bretagne - European University of Brittany (UEB), Institut National de la Santé et de la Recherche Médicale (INSERM)-Centre National de la Recherche Scientifique (CNRS)-Université de Strasbourg (UNISTRA), École normale supérieure - Paris (ENS Paris), Université Paris sciences et lettres (PSL)-Université Paris sciences et lettres (PSL)-École normale supérieure - Paris (ENS Paris), Universiteit Gent = Ghent University [Belgium] (UGENT), Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut d'Epidémiologie Neurologique et de Neurologie Tropicale-CHU Limoges-Institut Génomique, Environnement, Immunité, Santé, Thérapeutique (GEIST), Université de Franche-Comté (UFC), Université Bourgogne Franche-Comté [COMUE] (UBFC)-Université Bourgogne Franche-Comté [COMUE] (UBFC)-Ecole Nationale Supérieure de Mécanique et des Microtechniques (ENSMM)-Centre National de la Recherche Scientifique (CNRS)-Université de Technologie de Belfort-Montbeliard (UTBM), Institut de Chimie du CNRS (INC)-Université d'Angers (UA)-Centre National de la Recherche Scientifique (CNRS), Centre National de la Recherche Scientifique (CNRS)-Université Paris Descartes - Paris 5 (UPD5)-Institut National de la Santé et de la Recherche Médicale (INSERM), Centre National de la Recherche Scientifique (CNRS)-École Centrale de Nantes (ECN), Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national des sciences de l'Univers (INSU - CNRS)-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS)-Université Joseph Fourier - Grenoble 1 (UJF)-Institut polytechnique de Grenoble - Grenoble Institute of Technology (Grenoble INP )-Institut national de recherche en sciences et technologies pour l'environnement et l'agriculture (IRSTEA)-Université Savoie Mont Blanc (USMB [Université de Savoie] [Université de Chambéry])-Centre National de la Recherche Scientifique (CNRS), Wolfson Centre for Age-related Diseases-King‘s College London, Cell biology, Public Health, Epidemiology, Health Technology Assessment (HTA), Erasmus MC other, Pathology, and Cardiothoracic Surgery

Subjects
Gerontology, Male, CHANGING RELATION, Nutrition and Disease, MESH : Life Expectancy, MESH : Aged, ECONOMIC-DEVELOPMENT, Poison control, MESH: Global Health, Global Health, Socioeconomic Factor, Communicable Disease, MESH : Chronic Disease, Health Transition, Voeding en Ziekte, Quality-Adjusted Life Year, SELF-RATED HEALTH, MESH : Socioeconomic Factors, Medicine, MESH : Female, MESH: Mortality, Premature, 2. Zero hunger, MESH: Aged, education.field_of_study, MESH: Middle Aged, Mortality rate, Medicine (all), GBD2013 diseases, [ SDV.SPEE ] Life Sciences [q-bio]/Santé publique et épidémiologie, General Medicine, Middle Aged, 3. Good health, MESH : Wounds and Injuries, Epidemiological transition, MESH: Quality-Adjusted Life Years, MESH: Communicable Diseases, NONCOMMUNICABLE DISEASES, Female, Quality-Adjusted Life Years, MESH: Life Expectancy, MESH: Health Transition, Human, MESH: Socioeconomic Factors, ACUTE MYOCARDIAL-INFARCTION, MESH : Male, MORTALITY TRENDS, Population, MESH : Health Transition, Communicable Diseases, Article, Life Expectancy, EUROPEAN-UNION, SDG 3 - Good Health and Well-being, General & Internal Medicine, SYSTEMATIC ANALYSIS, Disability-adjusted life year, Humans, Life Science, MESH : Middle Aged, Mortality, education, Premature, MESH : Mortality, Premature, VLAG, Aged, MESH: Humans, business.industry, Mortality, Premature, MESH: Chronic Disease, MESH : Communicable Diseases, Wounds and Injurie, MESH : Humans, MESH : Quality-Adjusted Life Years, Non-communicable disease, Chronic Disease, Socioeconomic Factors, Wounds and Injuries, medicine.disease, MESH: Male, LOW SOCIOECONOMIC-STATUS, Years of potential life lost, [SDV.SPEE] Life Sciences [q-bio]/Santé publique et épidémiologie, MESH: Wounds and Injuries, Life expectancy, RISK-FACTORS, MESH : Global Health, [SDV.SPEE]Life Sciences [q-bio]/Santé publique et épidémiologie, business, MESH: Female, Demography
Abstract

Summary Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. Funding Bill & Melinda Gates Foundation. BACKGROUND: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. METHODS: We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. FINDINGS: Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. INTERPRETATION: Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition-in which increasing sociodemographic status brings structured change in disease burden-is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions. FUNDING: Bill & Melinda Gates Foundation.

Published
2015
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45. Appropriate and timely antibiotic administration for neonatal sepsis in Mesoamérica

Author

Herbert C, Duber, Emily A, Hartford, Alexandra M, Schaefer, Casey K, Johanns, Danny V, Colombara, Emma, Iriarte, Erin B, Palmisano, Diego, Rios-Zertuche, Paola, Zuniga-Brenes, Bernardo, Hernández-Prado, and Ali H, Mokdad

Subjects
paediatrics, Research, child health, health systems, health systems evaluation
Abstract

Neonatal sepsis is a leading cause of mortality among children under-5 in Latin America. The Salud Mesoamérica Initiative (SMI), a multicountry results-based aid programme, was designed to improve maternal, newborn and child health in impoverished communities in Mesoamérica. This study examines the delivery of timely and appropriate antibiotics for neonatal sepsis among facilities participating in the SMI project. A multifaceted health facility survey was implemented at SMI inception and approximately 18 months later as a follow-up. A random sample of medical records from neonates diagnosed with sepsis was reviewed, and data regarding antibiotic administration were extracted. In this paper, we present the percentage of patients who received timely (within 2 hours) and appropriate antibiotics. Multilevel logistic regression was used to assess for potential facility-level determinants of timely and appropriate antibiotic treatment. Among 821 neonates diagnosed with sepsis in 63 facilities, 61.8% received an appropriate antibiotic regimen, most commonly ampicillin plus an aminoglycoside. Within 2 hours of presentation, 32.3% received any antibiotic and only 26.6% received an appropriate regimen within that time. Antibiotic availability improved over the course of the SMI project, increasing from 27.5% at baseline to 64.0% at follow-up, and it was highly correlated with timely and appropriate antibiotic administration (adjusted OR=5.36, 95% CI 2.85 to 10.08). However, we also found a decline in the percentage of neonates documented to have received appropriate antibiotics (74.4% vs 51.1%). Our study demonstrated early success of the SMI project through improvements in the availability of appropriate antibiotic regimens for neonatal sepsis. At the same time, overall rates of timely and appropriate antibiotic administration remain low, and the next phase of the initiative will need to address other barriers to the provision of life-saving antibiotic treatment for neonatal sepsis.

Published
2017

46. The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda

Author

Nancy Fullman, D. Allen Roberts, Emily Dansereau, Kelsey Bannon, Herbert C. Duber, Emelda A. Okiro, Thomas A. Odeny, Emmanuela Gakidou, Alexandra Wollum, Ruben Conner, Gloria Ikilezi, Pamela Njuguna, Caroline Kisia, Brendan DeCenso, Michael Hanlon, Aubrey J. Levine, Jane Achan, Anne Gasasira, Samuel H. Masters, Annie Haakenstad, and Roy Burstein

Subjects
medicine.medical_specialty, Pediatrics, HIV Infections, Health informatics, Health administration, 03 medical and health sciences, 0302 clinical medicine, Health systems, Ambulatory care, Acquired immunodeficiency syndrome (AIDS), Environmental health, parasitic diseases, Ambulatory Care, Humans, Outpatient clinic, Medicine, Uganda, 030212 general & internal medicine, Service (business), business.industry, 030503 health policy & services, Health Policy, Nursing research, Public health, lcsh:Public aspects of medicine, lcsh:RA1-1270, medicine.disease, Kenya, Antiretroviral therapy, Anti-Retroviral Agents, Regression Analysis, HIV/AIDS, 0305 other medical science, business, Research Article
Abstract

Background Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda. Methods Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services. Results Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services. Conclusions Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

Published
2017

47. Health Care Spending on Diabetes in the U.S., 1996-2013

Author

Ellen Squires, Herbert C. Duber, Madeline Campbell, Jackie Cao, Abigail Chapin, Zhiyin Li, Joseph L Dieleman, Cody Horst, Taylor Matyasz, Alex Reynolds, and Irl B. Hirsch

Subjects
Research design, Adult, Male, Endocrinology, Diabetes and Metabolism, 030209 endocrinology & metabolism, Disease, 03 medical and health sciences, Young Adult, 0302 clinical medicine, Ambulatory care, Environmental health, Diabetes mellitus, Health care, Internal Medicine, Ambulatory Care, Diabetes Mellitus, Prevalence, Population growth, Medicine, Humans, 030212 general & internal medicine, Disease burden, Aged, Advanced and Specialized Nursing, Aged, 80 and over, business.industry, Clinical Care/Education/Nutrition/Psychosocial Research, Diabetes prevalence, Health Care Costs, Middle Aged, medicine.disease, United States, Female, Health Expenditures, business
Abstract

OBJECTIVE Health care spending on diabetes in the U.S. has increased dramatically over the past several decades. This research describes health care spending on diabetes to quantify how that spending has changed from 1996 to 2013 and to determine what drivers are increasing spending. RESEARCH DESIGN AND METHODS Spending estimates were extracted from the Institute for Health Metrics and Evaluation’s Disease Expenditure 2013 database. Estimates were produced for each year from 1996 to 2013 for each of 38 age and sex groups and six types of care. Data on disease burden were extracted from the Global Burden of Disease 2016 study. We analyzed the drivers of spending by measuring the impact of population growth and aging and changes in diabetes prevalence, service utilization, and spending per encounter. RESULTS Spending on diabetes in the U.S. increased from $37 billion (95% uncertainty interval $32–$42 billion) in 1996 to $101 billion ($97–$107 billion) in 2013. The greatest amount of health care spending on diabetes in 2013 occurred in prescribed retail pharmaceuticals (57.6% [53.8–62.1%] of spending growth) followed by ambulatory care (23.5% [21.7–25.7%]). Between 1996 and 2013, pharmaceutical spending increased by 327.0% (222.9–456.6%). This increase can be attributed to changes in demography, increased disease prevalence, increased service utilization, and, especially, increases in spending per encounter, which increased pharmaceutical spending by 144.0% (87.3–197.3%) between 1996 and 2013. CONCLUSIONS Health care spending on diabetes in the U.S. has increased, and spending per encounter has been the biggest driver. This information can help policy makers who are attempting to control future spending on diabetes.

Published
2017

48. Public knowledge of cardiovascular disease and response to acute cardiac events in three cities in China and India

Author

Miranda Bryant, Alexandra Wollum, Kate Allen, Alexander Woldeab, Marie Ng, Maigeng Zhou, Blake Thomson, Bryan K. Phillips, Jonathan C Brown, Herbert C. Duber, R B Guptam, Piyusha Majumdar, Claire R. McNellan, Gregory A. Roth, Yichong Li, and Shelley Wilson

Subjects
Adult, Male, medicine.medical_specialty, China, Emergency Medical Services, Health Knowledge, Attitudes, Practice, Adolescent, Urban Population, medicine.medical_treatment, Psychological intervention, India, Disease, 030204 cardiovascular system & hematology, Chest pain, 03 medical and health sciences, Young Adult, 0302 clinical medicine, medicine, Global health, Humans, 030212 general & internal medicine, Cardiopulmonary resuscitation, Myocardial infarction, Registries, Aged, business.industry, Incidence, Sudden cardiac arrest, Middle Aged, medicine.disease, Focus group, Cardiopulmonary Resuscitation, Survival Rate, Population Surveillance, Emergency medicine, Female, Medical emergency, medicine.symptom, Cardiology and Cardiovascular Medicine, business, Out-of-Hospital Cardiac Arrest
Abstract

ObjectiveTo inform interventions targeted towards reducing mortality from acute myocardial infarction (AMI) and sudden cardiac arrest in three megacities in China and India, a baseline assessment of public knowledge, attitudes and practices was performed.MethodsA household survey, supplemented by focus group and individual interviews, was used to assess public understanding of cardiovascular disease (CVD) risk factors, AMI symptoms, cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs). Additionally, information was collected on emergency service utilisation and associated barriers to care.Results5456 household surveys were completed. Hypertension was most commonly recognised among CVD risk factors in Beijing and Shanghai (68% and 67%, respectively), while behavioural risk factors were most commonly identified in Bangalore (smoking 91%; excessive alcohol consumption 64%). Chest pain/discomfort was reported by at least 60% of respondents in all cities as a symptom of AMI, but 21% of individuals in Bangalore could not name a single symptom. In Beijing, Shanghai and Bangalore, 26%, 15% and 3% of respondents were trained in CPR, respectively. Less than one-quarter of participants in all cities recognised an AED. Finally, emergency service utilisation rates were low, and many individuals expressed concern about the quality of prehospital care.ConclusionsOverall, we found low to modest knowledge of CVD risk factors and AMI symptoms, infrequent CPR training and little understanding of AEDs. Interventions will need to focus on basic principles of CVD and its complications in order for patients to receive timely and appropriate care for acute cardiac events.

Published
2017

49. Febrile Illness in a Young Traveler: Dengue Fever and its Complications

Author

Herbert C. Duber and Stephen M. Kelly

Subjects
Adult, Travel, medicine.medical_specialty, Fever, business.industry, Incidence (epidemiology), Developing country, Tropical disease, Outbreak, Nicaragua, Dengue Virus, Dengue virus, Antibodies, Viral, medicine.disease_cause, medicine.disease, Dengue fever, Dengue, 2009 Bolivian dengue fever epidemic, Epidemiology, Emergency Medicine, medicine, Humans, Female, Intensive care medicine, business
Abstract

Background Dengue fever, a tropical disease once confined mostly to endemic areas in developing countries, is becoming more prevalent. Globalization has led to an increased incidence of the virus both in foreign travelers returning home and local outbreaks in traditionally nonendemic areas, such as the southern United States and southern Europe. Advances in diagnostic tests, therapies, and vaccines for dengue virus have been limited, but research is ongoing. Objectives To review the current literature regarding the diagnosis and management of dengue fever. Case Report This case report describes a young woman returning from Central America with many of the common signs and symptoms who was misdiagnosed both abroad and at home. We explore the epidemiology, disease course, complications, and treatment of dengue fever. Conclusion Emergency physicians should consider dengue fever in patients with acute febrile illnesses, especially among those with recent travel.

Published
2013
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50. Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review

Author

I.A. Barata, Carolyn J. Sachs, Lindsay Weaver, Elaine B. Josephson, Alan Heins, Herbert C. Duber, Margaret Montgomery, Heather S. Owen, Wendy Macias-Konstantopoulos, Robin Polansky, and Jamie Shandro

Subjects
Counseling, medicine.medical_specialty, alcohol screening, Alcohol Drinking, Referral, injury, alcohol dependence, MEDLINE, Psychological intervention, and emergency department, lcsh:Medicine, 030508 substance abuse, motivational interviewing, Risk Assessment, alcohol consumption (related terms), brief intervention, 03 medical and health sciences, 0302 clinical medicine, Risk Factors, Intervention (counseling), Behavioral Health, Humans, Mass Screening, Medicine, 030212 general & internal medicine, computerized intervention, tailored feedback, Referral and Consultation, Mass screening, business.industry, lcsh:R, lcsh:Medical emergencies. Critical care. Intensive care. First aid, lcsh:RC86-88.9, General Medicine, Emergency department, alcohol reduction, Alcoholism, brief negotiated interview, Emergency Medicine, Physical therapy, Systematic Review, Brief intervention, Emergency Service, Hospital, 0305 other medical science, Risk assessment, business
Abstract

Introduction: Alcohol use disorders (AUD) place a significant burden on individuals and society. Theemergency department (ED) offers a unique opportunity to address AUD with brief screening tools andearly intervention. We undertook a systematic review of the effectiveness of ED brief interventions forpatients identified through screening who are at risk for AUD, and the effectiveness of these interventionsat reducing alcohol intake and preventing alcohol-related injuries. Methods: We conducted systematic electronic database searches to include randomized controlled trialsof AUD screening, brief intervention, referral, and treatment (SBIRT), from January 1966 to April 2016. Twoauthors graded and abstracted data from each included paper. Results: We found 35 articles that had direct relevance to the ED with enrolled patients ranging from12 to 70 years of age. Multiple alcohol screening tools were used to identify patients at risk for AUD.Brief intervention (BI) and brief motivational intervention (BMI) strategies were compared to a controlintervention or usual care. Thirteen studies enrolling a total of 5,261 participants reported significantdifferences between control and intervention groups in their main alcohol-outcome criteria of number ofdrink days and number of units per drink day. Sixteen studies showed a reduction of alcohol consumptionin both the control and intervention groups; of those, seven studies did not identify a significant interventioneffect for the main outcome criteria, but nine observed some significant differences between BI and controlconditions for specific subgroups (i.e., adolescents and adolescents with prior history of drinking anddriving; women 22 years old or younger; low or moderate drinkers); or secondary outcome criteria (e.g.reduction in driving while intoxicated). Conclusion: Moderate-quality evidence of targeted use of BI/BMI in the ED showed a small reduction inalcohol use in low or moderate drinkers, a reduction in the negative consequences of use (such as injury),and a decline in ED repeat visits for adults and children 12 years of age and older. BI delivered in the EDappears to have a short-term effect in reducing at-risk drinking.

Published
2017
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