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Conflicts affect health-care systems not only during but also well beyond periods of violence and immediate crises by draining resources, destroying infrastructure and perpetrating human resource shortages. Improving health-care worker (HCW) retention is critical to limiting the strain placed on health systems already facing infrastructure and financial challenges. We reviewed the evidence on the retention of HCWs in fragile, conflict-affected and post-conflict settings and evaluated strategies and their likely success in improving retention and reducing attrition. We conducted a systematic review of studies, following PRISMA guidelines. Included studies (1) described a context that is post-conflict, conflict-affected or was transformed by war or a crisis; (2) examined the retention of HCWs; (3) were available in English, Spanish or French and (4) were published between 1 January 2000 and 25 April 2021. We identified 410 articles, of which 25 studies, representing 17 countries, met the inclusion criteria. Most of the studies (22 out of 25) used observational study designs and qualitative methods to conduct research. Three studies were literature reviews. This review observed four main themes: migration intention, return migration, work experiences and conditions of service and deployment policies. Using these themes, we identify a consolidated list of six push and pull factors contributing to HCW attrition in fragile, conflict-affected and post-conflict settings. The findings suggest that adopting policies that focus on improving financial incentives, providing professional development opportunities, establishing flexibility and identifying staff with strong community links may ameliorate workforce attrition.

Countries affected by conflict often experience the deterioration of health system infrastructure and weaken service delivery. Evidence suggests that healthcare services that leverage local community dynamics may ameliorate health system-related challenges; however, little is known about implementing these interventions in contexts where formal delivery of care is hampered subsequent to conflict. We reviewed the evidence on community health worker (CHW)-delivered healthcare in conflict-affected settings and synthesized reported information on the effectiveness of interventions and characteristics of care delivery. We conducted a systematic review of studies in OVID MedLine, Web of Science, Embase, Scopus, The Cumulative Index to Nursing and Allied Health Literature (CINHAL) and Google Scholar databases. Included studies (1) described a context that is post-conflict, conflict-affected or impacted by war or crisis; (2) examined the delivery of healthcare by CHWs in the community; (3) reported a specific outcome connected to CHWs or community-based healthcare; (4) were available in English, Spanish or French and (5) were published between 1 January 2000 and 6 May 2021. We identified 1976 articles, of which 55 met the inclusion criteria. Nineteen countries were represented, and five categories of disease were assessed. Evidence suggests that CHW interventions not only may be effective but also efficient in circumventing the barriers associated with access to care in conflict-affected areas. CHWs may leverage their physical proximity and social connection to the community they serve to improve care by facilitating access to care, strengthening disease detection and improving adherence to care. Specifically, case management (e.g. integrated community case management) was documented to be effective in improving a wide range of health outcomes and should be considered as a strategy to reduce barrier to access in hard-to-reach areas. Furthermore, task-sharing strategies have been emphasized as a common mechanism for incorporating CHWs into health systems.

In response to rising costs and growing concerns about safety, quality, equity and affordability of health care, many countries have now developed and deployed performance-based incentives, targeted at facilities as well as individuals. Evidence of the effect of these efforts has been mixed; it remains unclear how effective strategies of varying design and magnitude (relative to provider salary) are at incentivizing individual-level performance. This study reviews the current evidence on effectiveness of individual-level performance-based incentives for health care in Organisation for Economic Co-operation and Development countries, which are relatively well situated to implement, monitor and evaluate performance-based incentives programs. We delineate the conditions under which sanctions or rewards - in the context of gain-seeking, loss aversion, and increased social pressure to modify behaviors - may be more effective. We find that programs that utilized positive reinforcement methods are most commonly observed - with slightly more overall bonus incentives than payment per output or outcome achieved incentives. When comparing the outcomes from negative reinforcement methods with positive reinforcement methods, we found more evidence that positive reinforcement methods are effective at improving health care worker performance. Overall, just over half of the studies reported positive impacts, indicating the need for care in designing and adopting performance-based incentives programs.

Background Appointment non-attendance – often referred to as “missed appointments”, “patient no-show”, or “did not attend (DNA)” – causes volatility in health systems around the world. Of the different approaches that can be adopted to reduce patient non-attendance, behavioural economics-oriented mechanisms (i.e., psychological, cognitive, emotional, and social factors that may impact individual decisions) are reasoned to be better suited in such contexts – where the need is to persuade, nudge, and/ or incentivize patients to honour their scheduled appointment. The aim of this systematic literature review is to identify and summarize the published evidence on the use and effectiveness of behavioural economic interventions to reduce no-shows for health care appointments. Methods We systematically searched four databases (PubMed/Medline, Cochrane, Embase, Scopus, and Web of Science) for published and grey literature on behavioural economic strategies to reduce no-shows for health care appointments. Eligible studies met four criteria for inclusion; they were (1) available in English, Spanish, or French, (2) assessed behavioural economics interventions, (3) objectively measured a behavioural outcome (as opposed to attitudes or preferences), and (4) used a randomized and controlled or quasi-experimental study design. Results Our initial search of the five databases identified 1,225 articles. After screening studies for inclusion criteria and assessing risk of bias, 61 studies were included in our final analysis. Data was extracted using a predefined 19-item extraction matrix. All studies assessed ambulatory or outpatient care services, although a variety of hospital departments or appointment types. The most common behaviour change intervention assessed was the use of reminders (n = 56). Results were mixed regarding the most effective methods of delivering reminders. There is significant evidence supporting the effectiveness of reminders (either by SMS, telephone, or mail) across various settings. However, there is a lack of evidence regarding alternative interventions and efforts to address other heuristics, leaving a majority of behavioural economic approaches unused and unassessed. Conclusion The studies in our review reflect a lack of diversity in intervention approaches but point to the effectiveness of reminder systems in reducing no-show rates across a variety of medical departments. We recommend future studies to test additional behavioural economic interventions that have not been used, tested, and/or published before.

Background Emergency care systems (ECS) organize and provide access to life-saving care both during transport and at health facilities. Not enough is known about ECS in uncertain contexts such as post-conflict settings. This review aims to systematically identify and summarize the published evidence on the delivery of emergency care in post-conflict settings and to guide health sector planning. Methods We searched five databases (PubMed MEDLINE, Web of Science, Embase, Scopus, and Cochrane) in September 2021 to identify relevant articles on ECS in post-conflict settings. Included studies (1) described a context that is post-conflict, conflict-affected, or was impacted by war or crisis; (2) examined the delivery of an emergency care system function; (3) were available in English, Spanish, or French; and (4) were published between 1 and 2000 and 9 September 2021. Data were extracted and mapped using the essential system functions identified in the World Health Organization (WHO) ECS Framework to capture findings on essential emergency care functions at the scene of injury or illness, during transport, and through to the emergency unit and early inpatient care. Results We identified studies that describe the unique burden of disease and challenges in delivering to the populations in these states, pointing to particular gaps in prehospital care delivery (both during scene response and during transport). Common barriers include poor infrastructure, lingering social distrust, scarce formal emergency care training, and lack of resources and supplies. Conclusion To our knowledge, this is the first study to systematically identify the evidence on ECS in fragile and conflict-affected settings. Aligning ECS with existing global health priorities would ensure access to these critical life-saving interventions, yet there is concern over the lack of investments in frontline emergency care. An understanding of the state of ECS in post-conflict settings is emerging, although current evidence related to best practices and interventions is extremely limited. Careful attention should be paid to addressing the common barriers and context-relevant priorities in ECS, such as strengthening prehospital care delivery, triage, and referral systems and training the health workforce in emergency care principles.

IntroductionOut-of-hospital cardiac arrest (OHCA) is well studied in high-income countries, and research has encouraged the implementation of policy to increase survival rates. On the other hand, comprehensive research on OHCA in Africa is sparse, despite the higher incidence of risk factors. In this vein, structural barriers to OHCA care in Africa must be fully recognised and understood before similar improvements in outcome may be made. The aim of this study was to describe and summarise the body of literature related to OHCA in Africa.Methods and analysisUsing an a priori developed search strategy, electronic searches were performed in Medline via Pubmed, Web of Science, Scopus and Google Scholar databases to identify articles published in English between 2000 and 2020 relevant to OHCA in Africa. Titles, abstract and full text were reviewed by two reviewers, with discrepancies handled by an independent reviewer. A summary of the main themes contained in the literature was developed using descriptive analysis on eligible articles.ResultsA total of 1200 articles were identified. In the screening process, 785 articles were excluded based on title, and a further 127 were excluded following abstract review. During full-text review to determine eligibility, 80 articles were excluded and one was added following references review. A total of 19 articles met the inclusion criteria. During analysis, the following three themes were found: epidemiology and underlying causes for OHCA, first aid training and bystander action, and Emergency Medical Services (EMS) resuscitation and training.ConclusionsIn order to begin addressing OHCA in Africa, representative research with standardised reporting that complies to data standards is required to understand the full, context-specific picture. Policies and research may then target underlying conditions, improvements in bystander and EMS training, and system improvements that are contextually relevant and ultimately result in better outcomes for OHCA victims.

Background As a response to the COVID-19 pandemic, the United Nations Security Council passed resolution S/RES2532 (2020), requesting the cessation of hostilities. Despite initiatives for a ceasefire, descriptive evidence suggests that both conflict and violent events have remained unabated—and, in some cases, escalated during the first months of the pandemic. This study incorporates a longer time frame than previous studies to examine the impact of the COVID-19 pandemic on violent and non-violent political events—including health system-related violence—in Libya, which has been experiencing a protracted conflict since 2014. Methods We analyze data on violent and non-violent political events that took place from 1 January 2015 to 31 August 2021 in Libya. The study conducts descriptive statistics on event counts, using a Chi-square test and a Kruskal-Wallis H test. We use an interrupted time series analysis to evaluate the impact of the pandemic—both short and long term—on the incidence of violent and non-violent political events in Libya. Results We find a reduction of approximately 21 battles (p p p p p p p

To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries.Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies.Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied.We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.Revoir systématiquement et évaluer la qualité des analyses de rentabilité des interventions d'urgence dans les pays à faible et moyen revenu.Conformément aux lignes directrices de la méthode PRISMA, nous avons effectué une recherche systématique des études publiées avant mai 2019 sur PubMed®, Scopus, EMBASE®, Cochrane Library et Web of Science. Les critères d'inclusion étaient les suivants : (i) analyse de rentabilité originale des interventions ou ensembles d'interventions d'urgence, et (ii) analyse menée dans des pays à faible et moyen revenu. Pour identifier d'autres recherches primaires, nous avons également dépouillé les listes de référence des études incluses. Enfin, nous avons appliqué la grille CHEERS (Consolidated Health Economic Evaluation Reporting Standards) pour évaluer la qualité des études prises en compte.Sur les 1674 articles identifiés, 35 articles correspondaient aux critères d'inclusion. Nous avons également repéré quatre études supplémentaires dans les listes de référence. En revanche, nous avons exclu de nombreuses études car elles ne tenaient compte que des évaluations de coûts sans effectuer d'analyse de rentabilité. La plupart des études retenues étaient des analyses portant sur une seule intervention. Les interventions d'urgence examinées par ces études comprenaient les services préhospitaliers, la formation des prestataires, les programmes de traitement, les établissements et outils diagnostiques d'urgence, ainsi que le continuum de soins. La qualité des rapports figurant dans ces études était variable.Nous avons trouvé de vastes lacunes dans les indications relatives à la rentabilité des interventions d'urgence dans les pays à faible et moyen revenu. Étant donné la large gamme d'interventions pratiquées actuellement, nombre d'entre elles ne font encore l'objet d'aucune évaluation. Lors de futures recherches, il pourrait donc s'avérer nécessaire d'aider à la prise des décisions liées à l'attribution des ressources. Ces futures recherches devront être orientées en priorité vers les ensembles constitués de multiples interventions ainsi que vers les changements systémiques.Revisar y evaluar sistemáticamente la calidad de los análisis de rentabilidad de las intervenciones de atención de emergencia en los países de ingresos bajos y medios.Siguiendo las directrices de PRISMA, se realizaron búsquedas sistemáticas en PubMed®, Scopus, EMBASE®, Cochrane Library y Web of Science sobre los estudios publicados antes de mayo de 2019. Los criterios de inclusión fueron: (i) un análisis original de rentabilidad de la intervención de atención de emergencia o del paquete de intervenciones, y (ii) el análisis se llevó a cabo en un lugar de ingresos bajos y medios. Para identificar estudios primarios adicionales, se realizaron búsquedas manuales en las listas de referencias de los estudios incluidos. Se utilizó la directriz de las Normas consolidadas de los informes de la evaluación económica de la salud (De los 1674 artículos que se identificaron, 35 artículos cumplían los criterios de inclusión. Se identificaron cuatro estudios adicionales de las listas de referencia. Se excluyeron muchos estudios por considerarse evaluaciones de costos sin un análisis de efectividad. La mayoría de los estudios incluidos eran análisis de intervención única. Las intervenciones de atención de emergencia evaluadas por los estudios incluidos abarcaron servicios prehospitalarios, formación de proveedores, intervenciones de tratamiento, herramientas de diagnóstico de emergencia e instalaciones y paquetes de atención. La calidad de la información de los estudios era variada.Se encontraron grandes diferencias en las evidencias sobre la rentabilidad de las intervenciones de atención de emergencia en lugares de ingresos bajos y medios. Dada la amplitud de las intervenciones actualmente en práctica, muchas intervenciones permanecen sin evaluar, lo que sugiere la necesidad de investigaciones futuras para contribuir a las decisiones de asignación de recursos. En particular, los paquetes de intervenciones múltiples y los cambios a nivel de sistema representan un aspecto prioritario de las investigaciones futuras.الغرض القيام بمراجعة منهجية وتقييم لجودة تحليلات فعالية التكلفة الخاصة بتدخلات الرعاية في حالات الطوارئ في البلدان المنخفضة والمتوسطة الدخل. الطريقة وفقًا لإرشادات PRISMA، قمنا بإجراء بحث منهجي في كل من PubMed®، وScopus، وEMBASE®، وCochrane Library، وWeb of Science، عن الدراسات المنشورة قبل مايو/أيار 2019. وكانت معايير الدمج هي: (1) تحليل فعالية التكلفة الأصلي للتدخل، أو حزمة التدخل، في الرعاية في حالات الطوارئ، و(2) أن يكون التحليل قد حدث في بيئة منخفضة الدخل ومتوسطة الدخل. لتحديد الدراسات الأولية الإضافية، قمنا بالبحث اليدوي في قوائم مراجع الدراسات المشمولة. قمنا باستخدام دليل معايير الإبلاغ عن التقييم الاقتصادي الصحي الموحد لتقييم جودة الدراسات المشمولة. النتائج من بين المقالات التي حصلنا عليها والتي وصل عددها إلى 1674 مقالة، حققت 35 مقالة معايير الاشتمال. لقد حددنا أربع دراسات إضافية من قوائم المراجع. واستبعدنا العديد من الدراسات التي تم اعتبارها ذات تقييمات مكلفة، دون تحليل الفعالية. وكانت معظم الدراسات المشمولة تحليلات لتدخل واحد. إن تدخلات الرعاية في حالات الطوارئ، والتي تم تقييمها بواسطة الدراسات المشمولة، غطت خدمات ما قبل المستشفى، وتدريب مقدمي الخدمات، وتدخلات العلاج، وأدوات ومرافق تشخيص الطوارئ، وحزم الرعاية. وكانت جودة تقارير الدراسات متنوعة. الاستنتاج لقد وجدنا ثغرات كبيرة في الأدلة المتعلقة بفعالية تكلفة تدخلات الرعاية في حالات الطوارئ، في البيئات ذات الدخل المنخفض وذات الدخل المتوسط. وفي ظل اتساع نطاق التدخلات الحالية في الممارسة العملية، تظل العديد من التدخلات دون تقييم، مما يشير إلى الحاجة إلى أبحاث مستقبلية للمساعدة في قرارات تخصيص الموارد. على وجه التحديد، تمثل حزم التدخلات المتعددة والتغييرات على مستوى النظام مجالًا له الأولوية في أبحاث المستقبل.旨在系统地评审和评估中低收入国家紧急医疗救援干预成本效益分析的质量。.我们遵循 PRISMA 指南，系统地搜索了 PubMed®、Scopus、EMBASE®、考克兰 (Cochrane) 图书库和 Web of Science，以查找 2019 年 5 月之前发表的研究。纳入标准为：(i) 紧急医疗救援干预或干预配套方案的原始成本效益分析，以及 (ii) 在中低收入环境中进行的分析。为了确定其他主要研究，我们对纳入研究的参考文献列表进行了手工检索。我们采用《综合健康经济评估报告标准》(Consolidated Health Economic Evaluation Reporting Standards) 指南来评估纳入研究的质量。.在我们确定的 1674 篇文章中，有 35 篇符合纳入标准。我们从参考文献列表中确定了另外四项研究。由于多项被视为成本评估的研究并没有进行效益分析，因此我们将其排除在外。纳入最多的研究是单项干预分析。通过纳入研究评估的紧急医疗救援干预包括院前服务、医护人员培训、治疗干预、紧急诊断工具以及设施与护理配套方案。研究的报告质量各不相同。.就中低收入环境中的紧急医疗救援干预而言，我们发现成本效益方面的证据差距很大。鉴于目前所实施干预的广泛程度，许多干预仍未得到评估，这表明需要进行进一步的研究以帮助做出资源分配决策。尤其是，多种干预配套方案和系统层面变更体现出未来研究的优先领域。.Провести систематический обзор и дать оценку качеству анализа экономической эффективности мероприятий неотложной помощи в странах с низким и средним уровнем дохода.В соответствии с рекомендациями PRISMA авторы провели систематический поиск по базам данных PubMed®, Scopus, EMBASE®, Cochrane Library и Web of Science для выявления публикаций, датируемых сроками до мая 2019 г. В обзор были включены данные, выбранные по следующим критериям: (і) исходный анализ экономической эффективности мероприятий (или комплексов мероприятий) неотложной помощи; (ii) анализ проводился в странах с низким и средним уровнем дохода. Для выявления дополнительных исходных исследований авторы провели поиск также по спискам литературы в тех исследованиях, которые были ими использованы при составлении обзора. Для оценки качества включенных исследований использовались рекомендации стандартов консолидированной отчетности о состоянии экономики в здравоохранении.Всего было выявлено 1674 статьи, из которых критериям включения отвечали 35. Авторы нашли еще 4 дополнительных исследования, изучив списки литературы. Многие исследования не вошли в обзор, так как они содержали оценку затрат, но не анализ их эффективности. Большинство вошедших в обзор исследований представляли собой анализ одного мероприятия. В изученных исследованиях рассматривались такие мероприятия неотложной помощи, как добольничные услуги, обучение поставщиков услуг, лечебные мероприятия, средства неотложной диагностики, а также объекты медицинской помощи и комплексная помощь. Качество отчетности в упомянутых исследованиях было неоднородным.Авторы обнаружили значительные недочеты в доказательствах, применяющихся в оценке экономической эффективности мероприятий неотложной помощи в странах с низким и средним уровнем дохода. С учетом широкого диапазона мероприятий, существующих в сегодняшней практике, многие из них остаются без надлежащей оценки, что говорит о необходимости дальнейших исследований, которые помогли бы правильно принимать решения о выделении средств. В частности, в первую очередь нужно проводить такие исследования в области комплексных мероприятий и системных изменений.

Background Advanced life support (ALS) short training courses are in demand across Africa, though overwhelmingly designed and priced for non-African contexts. The continental expansion of emergency care is driving wider penetration of these courses, but their relevance and accessibility is not known. We surveyed clinicians within emergency settings to describe ALS courses' prevalence and perceived value in Africa. Methods We conducted a cross-sectional quantitative analysis of 235 clinicians' responses to the African Federation for Emergency Medicine's online needs assessment for an open-access ALS course in Africa. Participants responded to multiple-choice and open answer questions assessing demographics, ALS course certification and availability, perceptions of ALS courses, and barriers and facilitators to undertaking such courses. Results 235 clinicians working in 23 African nations responded. Most clinicians reported ALS course completion within the past three years (73%) and in-country access to ALS courses (76%). Most believed the content adequately met their region's needs (60%). Price and course availability were the most common barriers to taking an ALS course. The most common courses were cardiac and paediatric-focused, and the most common reasons to take a course included general career development, personal interest, and departmental requirements. Conclusion One-quarter of emergency care clinicians lack access to ALS courses in twenty-three African nations. Most clinicians believe that ALS courses have value in their clinical settings and meet the needs of their region. Our findings illustrate the need for an affordable, widely available ALS course tailored to lower-resource African settings that could reach rural and peri-urban clinicians.

Background Healthcare workers are at a higher risk of COVID-19 infection during care encounters compared to the general population. Personal Protective Equipment (PPE) have been shown to protect COVID-19 among healthcare workers, however, Kenya has faced PPE shortages that can adequately protect all healthcare workers. We, therefore, examined the health and economic consequences of investing in PPE for healthcare workers in Kenya. Methods We conducted a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model following the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines. We examined two outcomes: 1) the incremental cost per healthcare worker death averted, and 2) the incremental cost per healthcare worker COVID-19 case averted. We performed a multivariate sensitivity analysis using 10,000 Monte Carlo simulations. Results Kenya would need to invest $3.12 million (95% CI: 2.65–3.59) to adequately protect healthcare workers against COVID-19. This investment would avert 416 (IQR: 330–517) and 30,041 (IQR: 7243 – 102,480) healthcare worker deaths and COVID-19 cases respectively. Additionally, such an investment would result in a healthcare system ROI of $170.64 million (IQR: 138–209) – equivalent to an 11.04 times return. Conclusion Despite other nationwide COVID-19 prevention measures such as social distancing, over 70% of healthcare workers will still be infected if the availability of PPE remains scarce. As part of the COVID-19 response strategy, the government should consider adequate investment in PPE for all healthcare workers in the country as it provides a large return on investment and it is value for money.

Background Uganda experiences a high morbidity and mortality burden due to conditions amenable to emergency care, yet few public hospitals have dedicated emergency units. As a result, little is known about the costs and effects of delivering lifesaving emergency care, hindering health systems planning, budgeting and prioritization exercises. To determine healthcare costs of emergency care services at public facilities in Uganda, we estimate the median cost of care for five sentinel conditions and 13 interventions. Methods A direct, activity-based costing was carried out at five regional referral hospitals over a four-week period from September to October 2019. Hospital costs were determined using bottom-up micro-costing methodology from a provider perspective. Resource use was enumerated via observation and unit costs were derived from National Medical Stores lists. Cost per condition per patient and measures of central tendency for conditions and interventions were calculated. Kruskal-Wallis H-tests and Nemyeni post-hoc tests were conducted to determine significant differences between costs of the conditions. Results Eight hundred seventy-two patient cases were captured with an overall median cost of care of $15.53 USD ($14.44 to $19.22). The median cost per condition was highest for post-partum haemorrhage at $17.25 ($15.02 to $21.36), followed by road traffic injuries at $15.96 ($14.51 to $20.30), asthma at $15.90 ($14.76 to $19.30), pneumonia at $15.55 ($14.65 to $20.12), and paediatric diarrhoea at $14.61 ($13.74 to $15.57). The median cost per intervention was highest for fracture reduction and splinting at $27.77 ($22.00 to $31.50). Cost values differ between sentinel conditions (p p Conclusion This study is the first to describe the direct costs of emergency care in hospitals in Uganda by observing the delivery of clinical services, using robust activity-based costing and time motion methodology. We find that emergency care interventions for key drivers of morbidity and mortality can be delivered at considerably lower costs than many priority health interventions. Further research assessing acute care delivery would be useful in planning wider health care delivery systems development.

BackgroundIn this paper, we predict the health and economic consequences of immediate investment in personal protective equipment (PPE) for health care workers (HCWs) in low- and middle-income countries (LMICs).MethodsTo account for health consequences, we estimated mortality for health care workers (HCW), and present a cost-effectiveness and return on investment (ROI) analysis using a decision-analytic model with Bayesian multivariate sensitivity analysis and Monte Carlo simulation. Inputs were used from the World Health Organization Essential Supplies Forecasting Tool and the Imperial College of London epidemiologic model.ResultsAn investment of $9.6 billion USD would adequately protect HCWs in all LMICs. This intervention saves 2,299,543 lives across LMICs, costing $59 USD per HCW case averted and $4,309 USD per HCW life saved. The societal ROI is $755.3 billion USD, the equivalent of a 7,932% return. Regional and national estimates are also presented. In scenarios where PPE remains scarce, 70-100% of HCWs will get infected, irrespective of nationwide social distancing policies. Maintaining HCW infection rates below 10% and mortality below 1% requires inclusion of a PPE scale-up strategy as part of the pandemic response.DiscussionIn conclusion, wide-scale procurement and distribution of PPE for LMICs is an essential strategy to prevent widespread HCW morbidity and mortality. It is cost-effective and yields a large downstream return on investment.

Background Molecular imaging with novel radiotracers is changing the treatment landscape in prostate cancer (PCa). Currently, standard of care includes either conventional and molecular imaging at time of biochemical recurrence (BCR). This study evaluated the determinants of and cost associated with utilization of molecular imaging for BCR PCa. Methods This is a retrospective observational cohort study among men with BCR PCa from June 2018 to May 2019. Multivariate logistic regression models were employed to analyze the primary outcome: receipt of molecular imaging (e.g. Fluciclovine PET and Prostate Specific Membrane Antigen PET) as part of diagnostic work‐up for BCR PCa. Multivariate linear regression models were used to analyze the secondary outcome: overall healthcare cost within a 1‐year time frame. Results The study sample included 234 patients; 79.1% White, 2.1% Black, 8.5% Asian/Pacific Islander, and 10.3% Other. The majority were 55 years or older (97.9%) and publicly insured (74.8%). Analysis indicated a one‐unit reduction in PSA is associated with 1.3 times higher likelihood of receiving molecular imaging (p, This study evaluated the determinants of and cost associated with utilization of molecular imaging for biochemically recurrent prostate cancer. Higher prostate‐specific antigen level was associated with lower likelihood for molecular imaging and higher cost in a 1‐year timeframe.

Background: In low-resource settings (LRS), a COVID-19 severity scoring tool could ensure timely access to appropriate care and guide use of critically limited resources. We systematically evaluated existing literature for associations between COVID-19 illness severity, and historical characteristics, clinical presentations, and investigations measurable in LRS. Methods: A systematic review of four databases from December 01, 2019 to June 01, 2020 identified all studies assessing potential associations between clinical characteristics and investigations, and illness severity. Data for all variables that were statistically analysed in relation to COVID-19 disease severity were extracted. A meta-analysis was conducted to generate pooled estimates of odds ratios (pORs). This review was registered with PROSPERO (CRD42020178098). Findings: Of 8402 relevant articles, 79 were eligible for inclusion, analysing 27713 patients with laboratory-confirmed COVID-19. A total of 202 features were analysed in relation to COVID-19 severity. Of these, 81 were deemed feasible for assessment in LRS: appropriate data were available for meta-analysis of 44 (54·3%). Meta-analysis identified 19 significant predictors of severe COVID-19, including: stroke (pOR: 3.08 (95% CI [1.95, 4.88])), shortness of breath (pOR: 2·78 (95% CI [2·24-3·46])), and chronic kidney disease (pOR: 2.55 (95% CI [1.52-4.29])). I 2 testing suggested substantial heterogeneity across samples. Interpretation: We identified multiple variables predictive of severe COVID-19. Due to the novelty of the disease, there is currently no prognostication tool purpose-designed and validated for LRS. Findings may inform such a tool that can offer guidance on clinical treatment and disposition, ultimately reducing morbidity and mortality due to the pandemic. Funding: No funding was received for this study. Declaration of Interests: The authors declare no competing interests.

297 Background: Molecular imaging with novel radiotracers is changing treatment landscape in prostate cancer (PCa). Currently, standard of care includes both conventional and molecular imaging, leaving uncertainty in prescription decision. This study evaluated the determinants of and disparities in utilization of molecular imaging for biochemical recurrent (BR) PCa. Methods: This is an observational, single institution, cohort study within the University of California, San Francisco (UCSF). Data were obtained on all men with BR PCa seen at UCSF from June 2018 to May 2019, regardless of histologic subtype. Multivariate logistic regression models were employed to analyze the primary outcome: receipt of molecular imaging (e.g. Fluciclovine PET, Prostate Specific Membrane Antigen PET) as part of diagnostic work-up for BR PCa. Multivariate linear regression models were used to analyze the secondary outcome: overall healthcare cost (hereafter cost) within a one-year time-frame. Results: The study sample included 245 patients; 88% non-Hispanic White (White), 2 % non-Hispanic Black (Black), 9% Asian/Pacific Islander (Asian), and 10% Other. The majority were 55 years or older (66%) and privately insured (73%). Analysis indicated that a one unit reduction in PSA is associated with 1.4 times higher likelihood of receiving molecular imaging (p