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Objective To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. Methods The relevant peer-reviewed and 'grey' literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Findings Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. Conclusion HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost- effectiveness of each service-delivery model. Objectif Synthetiser les donnees disponibles--sur les couts, l'efficacite et les economies d'echelle et d'envergure--pour les six programmes de base du Cadre d'investissement strategique de l'ONUSIDA, afin d'informer les responsables de la planification de l'elargissement des services de lutte contre le virus de l'immunodeficience humaine (VIH) dans les pays a revenu faible et intermediaire. Methodes Des pairs des pays a revenu faible et intermediaire ont systematiquement examine la documentation pertinente <> et revisee. La recherche et l'analyse ont applique les directives PRISMA (elements de rapport preferes pour les examens systematiques et les meta-analyses). Resultats Des 82 etudes de couts et de rendement empiriques identifiees, neuffournissaient des donnees sur les economies d'echelle. Lechelle expliquait en grande partie la variation des couts de plusieurs services anti-VIH, en particular ceux de la prevention ciblee du VIH dans les populations cles et ceux du depistage et du traitement du VIH. Il existe certaines preuves d'economies d'envergure, resultant de l'integration de services de conseilet de depistage du VIH avec plusieurs autres services. La rentabilite peut egalement etre amelioree en reduisant les prix des intrants, en deleguant des taches et en ameliorant l'adhesion des clients. Conclusion Les programmes anti-VIH doivent optimiser l'echelle de prestation des services pour etre efficaces. Les interventions qui peuvent ameliorer le potentiel des economies d'echelle comprennent l'intensification des activites de creation de la demande, la reduction des couts pour les utilisateurs des services, l'expansion des programmes existants plutot que la creation de nouvelles structures, et la reduction de l'attrition des utilisateurs des services existants. Les modeles de prestation des services integres, qui sont potentiellement plus efncaces que la mise en oeuvre de services autonomes, doivent faire l'objet d'etudes approfondies. D'autres eiements de preuve experimentaux sont requis pour trouver la meilleure facon d'obtenir des gains en termes d'efncacite dans les programmes anti-VIH, mais aussl pour evaluer le rapport cout-efficacite de chaque modele de prestation de services. Objetivo Sintetizar los datos disponibles sobre los costes, la eficacia y las economias de escala y alcance de los seis programas basicos del Marco Estrategico de Inversion de ONUSIDA e Informar a los responsables de la planificacion de la ampliacion de los servicios del virus de la !nmunodeficiencia humana (VIH) en paises con Ingresos bajosy medios. Metodos Se examino sistematicamente la literatura revisada por homologos y <> relevante de paises con Ingresos bajos y medios. La busqueda y el analisis se realizaron segun las pautas de items de Informe Preferidos para Evaluaciones Sistematicas y Meta-Analisis. Resultados De los 82 estudios empiricos sobre costes y eficacia Identificados, nueve de ellos proporcionaron datos sobre las economias de escala. La escala explico gran parte de la variacion de los costes en numerosos servicios de VIH, en particular en aquellos dirigidos a la prevencion del VIH en poblaciones clave y las pruebas y el tratamiento del VIH. Hay alguna evidencia de economias de alcance que Integran el asesoramiento sobre el VIH y los servicios de pruebas con muchos otros servidos. Tambien seria posible aumentar la costo-eficacia mediante la reduccion de los precios de los insumos, la delegacion de fundones y la mejora de la fidelidad de los clientes. Conclusion Los programas de VIH deben optimizar la escala de prestacion de servidos para conseguir ser eficaces. Las intervenciones pueden mejorar el potencial de las economias de escala, por ejemplo, al Intensificar las actividades de promocion de demanda, reducir los costes para los usuarios, expandir los programas existentes en lugar de crear estructuras nuevas y reducir el abandono de los usuarios existentes de los servidos. Se deben investigar mas los modelos de prestacion de servicios integrados, que son posiblemente mas eficaces que la implementacion de servidos independientes. Es necesario obtener mas evidencia experimental para comprender como es posible lograr mayor eficacia en los programas de VIH y evaluar la costo-eficacia de cada modelo de prestacion de servicios., ?Hay margen para el ahorro de costes y el aumento de la eficacia en los servicios de VIH? Un examen sistematico de la evidencia de paises con ingresos bajos y [...]

Increasing patient demand following health care reform has led to concerns about provider shortages, particularly in primary care and for Medicaid patients. Nurse practitioners (NPs) represent a potential solution to meeting demand. However, varying state scope of practice regulations and Medicaid reimbursement rates may limit efficient distribution of NPs. Using a national sample of 252,657 ambulatory practices, we examined the effect of state policies on NP employment in primary care and practice Medicaid acceptance. NPs had 13% higher odds of working in primary care in states with full scope of practice; those odds increased to 20% if the state also reimbursed NPs at 100% of the physician Medicaid fee-for-service rate. Furthermore, in states with 100% Medicaid reimbursement, practices with NPs had 23% higher odds of accepting Medicaid than practices without NPs. Removing scope of practice restrictions and increasing Medicaid reimbursement may increase NP participation in primary care and practice Medicaid acceptance. [ABSTRACT FROM AUTHOR]

Objectives To determine the association of hospital nursing skill mix with patient mortality, patient ratings of their care and indicators of quality of care. Design Cross-sectional patient discharge data, hospital characteristics and nurse and patient survey data were merged and analysed using generalised estimating equations (GEE) and logistic regression models. Setting Adult acute care hospitals in Belgium, England, Finland, Ireland, Spain and Switzerland. Participants Survey data were collected from 13 077 nurses in 243 hospitals, and 18 828 patients in 182 of the same hospitals in the six countries. Discharge data were obtained for 275 519 surgical patients in 188 of these hospitals. Main outcome measures Patient mortality, patient ratings of care, care quality, patient safety, adverse events and nurse burnout and job dissatisfaction. Results Richer nurse skill mix (eg, every 10-point increase in the percentage of professional nurses among all nursing personnel) was associated with lower odds of mortality (OR=0.89), lower odds of low hospital ratings from patients (OR=0.90) and lower odds of reports of poor quality (OR=0.89), poor safety grades (OR=0.85) and other poor outcomes (0.80