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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 Health workforce planning is critical for health systems to safeguard the ability to afford, train, recruit, and retain the appropriate number and mix of health workers. This balance is especially important when macroeconomic structures are also reforming. The Kingdom of Saudi Arabia is moving toward greater diversification, privatization, and resiliency; health sector reform is a key pillar of this transition. Methods We used the Ministry of Health Yearbook data on the number of workers and health expenditures from 2007 to 2018 and projected health labor market supply and demand of workers through 2030, evaluated the potential shortages and surpluses, and simulated different policy scenarios to identify relevant interventions. We further focused on projections for health workers who are Saudi nationals and health worker demand within the public sector (versus the private sector) to inform national objectives of reducing dependency on foreign workers and better deploying public sector resources. Results We projected the overall health labor market to demand 9.07 physicians and nurses per 1,000 population (356,514) in 2030; the public sector will account for approximately 67% of this overall demand. Compared to a projected supply of 10.16 physicians and nurses per 1,000 population (399,354), we estimated an overall modest surplus of about 42,840 physicians and nurses in 2030. However, only about 17% of these workers are estimated to be Saudi nationals, for whom there will be a demand shortage of 287,895 workers. Among policy scenarios considered, increasing work hours had the largest effect on reducing shortages of Saudi workers, followed by bridge programs for training more nurses. Government resources can also be redirected to supporting more Saudi nurses while still ensuring adequate numbers of physicians to meet service delivery goals in 2030. Conclusion Despite projected overall balance in the labor market for health workers in 2030, without policy interventions, severe gaps in the Saudi workforce will persist and limit progress toward health system resiliency in Saudi Arabia. Both supply- and demand-side policy interventions should be considered, prioritizing those that increase productivity among Saudi health workers, enhance training for nurses, and strategically redeploy financial resources toward employing these workers.

BACKGROUND: HIV-associated cryptococcal meningitis is a leading cause of AIDS-related mortality. The AMBITION-cm trial demonstrated that a regimen based on a single, high-dose of liposomal amphotericin B (AmBisome arm) was non-inferior to WHO-recommended treatment of 7 daily doses of amphotericin B deoxycholate (control arm) and was associated with fewer adverse events. We present a five-country cost-effectiveness analysis. METHODS: 814 participants were recruited in Botswana, Malawi, South Africa, Uganda, and Zimbabwe. Taking a health service perspective, we collected country-specific unit costs and individual resource-use data per participant over the ten-week trial period, calculating mean cost per participant by arm, mean cost-difference between arms, and incremental cost effectiveness ratio per life-year saved. Non-parametric bootstrapping and scenarios analyses were performed including hypothetical real-world resource use. FINDINGS: Using Malawi as a representative example, mean total costs per participant were $1369 in the AmBisome arm and $1237 in the control arm. The incremental cost-effectiveness ratio was $128 (95%CI;$59-$257) per life-year saved. Excluding study protocol-driven cost, using a real-world toxicity monitoring schedule, the cost per life-year saved reduced to $80 (95%CI;$15-$275). Changes in duration of hospitalization and antifungal medication cost showed the greatest impact in sensitivity analyses. Results were similar across countries with the cost per life-year saved in the real-world scenario ranging from $71 in Botswana to $121 in Uganda. INTERPRETATION: The AmBisome regimen was cost-effective at a low incremental cost effectiveness ratio. The regimen may be even less costly and potentially cost-saving in real-world implementation given lower drug-related toxicity and the potential for shortened hospital admissions.

Building on the literatures examining the impacts of deprivation and war and conflict on mental health, in this study, we investigate the impact of different forms of deprivation on mental health within a context of prolonged conflict in the occupied Palestinian territory(oPt). We expand the operationalization go deprivation while accounting for more acute exposures to conflict and political violence and spatial variations. We use multilevel modelling of data from the Socio-Economic & Food Security Survey 2014 conducted by the Palestinian Central Bureau of Statistics, which included a sample size of 7827 households in the West Bank(WB) and Gaza Strip(GS). We conduct the analysis for the combined sample, as for the WB and GS separately. We use a General Health Questionnaire-12 (GHQ12) score as our main outcome measure of poor health. We used various measures of deprivation including subjective deprivation, material deprivation, food deprivation, and political deprivation. In addition to the different measures of deprivation, we included acute political, health, and economic shocks in our analysis along with background socio-demographic characteristics. The results indicate significant variance at the locality level. We find a significant association between poor mental health and subjective, economic, political, and food deprivation; health, economic, and political stressors; age, and being a woman. Post-secondary education and wealth have a significant inverse association with poor mental health. Subjective deprivation is the strongest predictor of GHQ12 score in the models whereby people who feel very deprived have GHQ12 scores that are almost 4-points higher than people who do not feel deprived. Economic conditions, particularly subjective measures, are significant predictors of mental health status. Our findings confirm that political and social factors are determinants of health. Feeling deprived is an important determinant of mental health. The community effect suggests that spatial characteristics are influencing mental health, and warrant further investigation.

To understand how the COVID-19 pandemic affected women of reproductive age, specifically their economic conditions, desire for pregnancy, and access to contraceptive services during the pandemic.A total of 554 women respondents age 18 to 49 and reside in the United States were recruited using social media between May 16, 2020 and June 16, 2020. Logistic regression models assessed predictors of reporting pandemic-related changes in economic conditions, desire for pregnancy, and contraceptive access.Compared to White/Caucasian respondents, Hispanics/Latinx and Black/African Americans have 4 times the odds of experiencing inability to afford food, transportation, and/or housing (p0.01) during the pandemic; Hispanics/Latinx have twice the odds of experiencing food insecurity (p0.05). Inability to afford food, transportation, and/or housing was associated with drop in desire to be pregnant (p0.01). Despite the 25% of participants who reported a drop in desire for pregnancy, 1 in 6 reported difficulty accessing contraceptives, particularly those who experienced reduced income (p0.01).In our sample, the pandemic unevenly affected people from different socioeconomic groups. Many simultaneously experienced reduced income, difficulties in accessing contraception, and a greater desire to avoid a pregnancy. This combination of factors increases the chance that people will experience unintended pregnancies.The pandemic caused economic hardship and an increased desire to postpone or prevent pregnancy at the same time that it created new barriers to contraceptive services. This pattern may lead to a potential net effect of an increase in unintended pregnancy, particularly among people who had difficulty affording food, transportation, and/or housing during the pandemic.

OBJECTIVES To identify social and structural barriers to timely utilisation of qualified providers among children under five years in a high-mortality setting, rural Mali and to analyse how utilisation varies by symptom manifestation. METHODS Using baseline household survey data from a cluster-randomised trial, we assessed symptom patterns and healthcare trajectories of 5117 children whose mothers reported fever, diarrhoea, bloody stools, cough and/or fast breathing in the preceding two weeks. We examine associations between socio-demographic factors, symptoms and utilisation outcomes in mixed-effect logistic regressions. RESULTS Almost half of recently ill children reported multiple symptoms (46.2%). Over half (55.9%) received any treatment, while less than one-quarter (21.7%) received care from a doctor, nurse, midwife, trained community health worker or pharmacist within 24 h of symptom onset. Distance to primary health facility, household wealth and maternal education were consistently associated with better utilisation outcomes. While children with potentially more severe symptoms such as fever and cough with fast breathing or diarrhoea with bloody stools were more likely to receive any care, they were no more likely than children with fever to receive timely care with a qualified provider. CONCLUSIONS Even distances as short as 2-5 km significantly reduced children's likelihood of utilising healthcare relative to those within 2 km of a facility. While children with symptoms indicative of pneumonia and malaria were more likely to receive any care, suggesting mothers and caregivers recognised potentially severe illness, multiple barriers to care contributed to delays and low utilisation of qualified providers, illustrating the need for improved consideration of barriers.

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.

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

18F-fluciclovine and 68Ga-prostate specific membrane antigen (PSMA) are novel PET imaging radiotracers used to characterize disease burden in biochemical recurrent prostate cancer. 18F-fluciclovine was FDA-approved in 2016 and is reimbursed through public and private payers, while 68Ga-PSMA-11 is considered investigational and accessed through clinical trials. The purpose of this study was to evaluate the demographic differences between patients receiving 18F-fluciclovine and 68Ga-PSMA-11 at a tertiary academic medical center. Methods: All 18F-fluciclovine and 68Ga-PSMA-11 PET studies performed at the University of California, San Francisco (UCSF) between October 2015 and January 2020 were reviewed. Age, race/ethnicity, primary language, body mass index, insurance type, and home address were obtained through the electronic medical record database. Home addresses were geocoded to Census Block Group and assigned to neighborhood socioeconomic status (nSES) using a previously described composite measure. A logistic regression model was used to evaluate the association between each of the predictor variables and the type of PET imaging received. Results: This study included 1,756 patients; 1,502 patients received 68Ga-PSMA-11 and 254 patients received 18F-fluciclovine. Black patients had increased odds of receiving imaging with 18F-fluciclovine versus 68Ga-PSMA-11 compared to non-Hispanic white patients. (OR 3.88, 95% CI 1.90-7.91,). There were no statistically significant differences in other patient demographics between the two groups. Conclusion: In patients receiving molecular imaging for prostate cancer at a single U.S. tertiary medical center, access to 68Ga-PSMA-11 for Black patients was limited, compared to non-Hispanic white patients, by a factor of nearly four.

217 Background: An increasing number of patients with cancer are prescribed oral anti-cancer medications and face significant challenges in affording them. Financial assistance programs may be a critical resource to mitigate this financial burden but there are often barriers to accessing them. This study evaluated factors associated with receipt of financial assistance among patients with cancer prescribed oral anti-cancer medications. Methods: We conducted a retrospective cohort study including all patients prescribed an oral anti-cancer therapy through the University of California, San Francisco (UCSF) Specialty Pharmacy between January 1,2021 and December 31, 2021. The unit of analysis was patient-drug. Information on financial assistance, including sponsor, type, and amount secured was extracted through Vivor – a financial navigation and grant tracking tool – and linked to clinical and prescription data extracted from the institutional electronic medical record. We employed a multivariate logistic regression analysis to identify variables associated of receipt of financial assistance.Results: Of 1,357 unique patient/drug combinations, 488 (36%) received some form of financial assistance. Mean age of patients was 67 years (SD = 14, range 21-97). Patients were predominantly male (69%), lived in an urban area (42%), were retired (41%), and identified as Non-Hispanic White (61%). A minority of patients (13%) were non-English speaking. The most common type of assistance received was from a foundation (35%), followed by free drug program (24%) and copayment card (23%). Healthwell Foundation (28%) and Patient Access Network Foundation (26%) were the most common sponsors for foundation-based support. Receipt of assistance varied (Χ2 = 60.8, p < 0.001) by disease state. Multivariate logistic regression indicated that patients who identified as Hispanic/Latinx ethnicity (OR 0.49, p = 0.038) or were non-English speaking (OR 0.38, p = 0.015) were less likely to receive financial assistance. Conclusions: There were disparities in receipt of financial assistance by ethnicity and primary language spoken. Some patients may not be equitably connected to existing financial resources and may be disproportionately at risk for the financial, clinical, and psychosocial implications of a high out-of-pocket cost burden. Future studies should develop and implement standardized workflows to ensure equitable access to existing financial resources for patients with cancer.

18 Background: The use of oral anti-cancer medications- which are often high priced with significant cost sharing to the patient- is increasing. Transparency of out-of-pocket costs and payment responsibility has historically been limited due to the wide variation in coverage by insurance plans and pharmacy benefits. Our study utilized a novel pharmacy database to describe within-drug and between-drug variation in patient copayments for ten common oral anti-cancer medications. Methods: We conducted a retrospective cohort study including all patients prescribed an oral cancer-directed therapy through the University of California, San Francisco (UCSF) Specialty Pharmacy between January 1,2021 and December 31, 2021. The unit of analysis was defined as patient-drug. Copayments were standardized as 30-day costs. Data was abstracted through our institution’s Specialty Pharmacy prescribing database and linked to demographic data through the institutional electronic medical record system. Between drug variation in copayments was analyzed using Pearson chi square tests. Results: There were 1,357 total patient-drug combinations over the study period. Medicare Part D was the primary payor (44%) followed by commercial insurance (25%). The ten most frequently prescribed medications (Table) accounted for 50% of all oral anti-cancer prescriptions. Minimum monthly copayment for all medications was $0. There were significant differences across medications in the percentage of patients with a mean copayment above $150 (Χ2 = 33.9, p < 0.001) and percentage of patients receiving financial assistance (Χ2 = 63, p < 0.001). Conclusions: There was a high amount of within-drug and between-drug variation in copayments within an integrated specialty pharmacy program. It is essential to identify patients with high copayments early on in cancer treatment and connect them with tangible resources to help mitigate the growing financial impact of these medications.[Table: see text]

Introduction Acts of social good, like jury service and voting, lead to distributive societal benefits and often come with protections to ensure that everyone can participate. Clinical trial participation is an act of social good, yet it lacks protections or benefits and comes at great personal cost. Methods In this current study, we assessed the indirect costs associated with cancer clinical trial participation among patients enrolled in therapeutic cancer clinical trials at two National Cancer Institute-Designated Comprehensive Cancer Centers as part of a multi-institutional IMPACT (Improving Patient Access to Cancer Clinical Trials) program from January 2018 to August 2020. Results A total of 258 patients received financial reimbursement during the IMPACT program period. The median (interquartile range, IQR) reimbursed total amount (including all cost categories possible) in US dollars is $378 (1123); the median reimbursed amount for each category is $0 (0) as patients typically do not request for reimbursement in all categories. The median amount of requested entries was $713 (1,824) for lodging, $248 (902) for ground transportation, $208 (373) for gas/ parking/ tolls, $1080 (2105) for patient flight, and $1,001 (1793) for companion flight. Average cost per patient attributable to lodging was $342 (standard deviation, SD=1081), ground transportation was $277 (SD=843), gas/parking/tolls was $410 (SD=634), companion flight was $70 (SD=477), and patient flight was $76 (SD=506). Conclusion Our analysis of costs demonstrates that clinical trial participants incur indirect costs to engage in clinical trials, and these costs vary by institution. These data support the notion that clinical trial participants should receive the same protections and benefits that government and employers offer other social goods such as voting or jury service.

e18550 Background: Patients with cancer, especially minority and low-income individuals, are at increased risk of financial toxicity and food insecurity. The COVID-19 pandemic has added dire economic challenges to vulnerable populations leading to a global increase in food insecurity. We sought to evaluate the severity and predictors of food insecurity among low-income patients with cancer. Methods: We conducted a cross-sectional multi-lingual survey (i.e., English, Spanish, and Chinese) on a convenience sample of patients with cancer who receive oncologic care at a safety-net hospital. Food insecurity and financial toxicity were measured using validated scales [i.e., US Department of Agriculture Household Food Security Survey and the Comprehensive Score for Financial Toxicity (COST)]. The primary outcome was food insecurity during COVID-19 and predictors of interest included sex, financial toxicity, insurance change, and degree of acculturation. Data was summarized using descriptive statistics and we explored associations between food insecurity and predictors of interest using bivariate regression. Results: A total of 140 patients participated in the study, of whom 56% were male and 47% were 50-64 years old. The most common cancer diagnoses were breast cancer (33%), followed by prostate (13%) and lung cancer (12%). The diverse study participants self-reported being 42% Hispanic/Latinx, 33% Asian, 18% Black or African American, and 14% White. Over half (52%) reported an annual household income ≤$24,999 and 50% experienced a decrease in income during the COVID-19 pandemic. The median COST score was 24 (IQR: 19-31) with 41% experiencing financial toxicity (COST < 26). Most participants experienced food insecurity, including 42% with low food security and an additional 19% with very low food security. In bivariate analysis, increasing financial toxicity (i.e., lower COST score) was associated with a 21% increased risk of very low or low food security (95% CI: 1.11-1.32) and 13% increased risk of low food security (95% CI: 1.05-1.21). Male sex was associated with 312% increased risk of very low food insecurity when compared to female sex (95% CI: 1.02-9.55). Acculturation and changes in insurance coverage were not associated with increased risk of food insecurity. Conclusions: Food insecurity was highly prevalent in this multi-ethnic cohort of low-income patients with cancer. Interestingly, male sex was significantly associated with increased risk of very low food insecurity. Further analyses should explore this potentially at-risk population, their access to nutrition-related support, and the impact of food insecurity in cancer outcomes.

Background Cancer treatment clinical trials face major challenges with patient recruitment. Strategies to address patient indirect costs associated with clinical trial participation may accelerate accrual overall. The current study examined the effect of the IMproving Patient Access to Clinical Trials (IMPACT) intervention on patient accrual to cancer treatment clinical trials at an academic medical center. The IMPACT intervention was an onsite patient navigator combined with a financial reimbursement program to address patient out of pocket costs and began on September 2018. Methods This analysis measured frequency of patient enrollment in cancer treatment clinical trials and available cancer treatment clinical trials per month between January 1, 2016 and March 31, 2020. An interrupted time-series analysis (ITSA) was conducted to estimate changes in patient enrollment attributable to the IMPACT intervention. Results During the study period, a mean of 69 patients enrolled in clinical trials per month (standard deviation (SD = 13), with 27 (SD = 7) in early phase vs 41 (SD = 12) in late phase clinical trials. The number of available clinical trials per month was 51 (SD = 2) overall, with 23 (SD = 1) in early phase vs 28 (SD = 1) in late phase context. A total of 3470 patients were enrolled in cancer treatment clinical trials during the evaluated time period, the majority of whom were men (1895, 55 %) and racially white (2267, 65 %). A statistically significant increase in the number of patients accrued as compared to the pre-intervention trend was observed; with approximately 1 additional patient accrued per month, with a larger effect on increase patient accrual for late phase clinical trials. Discussion This study observed that the IMPACT intervention accelerated clinical trial recruitment, especially among late phase clinical trials. Future research will examine strategies to leverage this infrastructure to optimize recruitment among underrepresented patients. Policy summary To improve clinical trial recruitment and ensure that trial results are representative of a diverse population it is critical for health policies consider patient out-of-pocket costs and potential reimbursement to alleviate financial burden associated with clinical trial participation. Furthermore, policies for facilitating clinical trial recruitment and participant retention should budget for and incorporate a navigation component to assist patients who may not be familiar with the healthcare system and available financial assistance.

Background The Kingdom of Saudi Arabia (KSA), as part of its 2030 National Transformation Program, set a goal of transforming the healthcare sector to increase access to, and improve the quality and efficiency of, health services. To assist with the workforce planning component, we projected the needed number of physicians and nurses into 2030. We developed a new needs-based methodology since previous global benchmarks of health worker concentration may not apply to the KSA. Methods We constructed an epidemiologic “needs-based” model that takes into account the health needs of the KSA population, cost-effective treatment service delivery models, and worker productivity. This model relied heavily on up-to-date epidemiologic and workforce surveys in the KSA. We used demographic population projections to estimate the number of nurses and physicians needed to provide this core set of services into 2030. We also assessed several alternative scenarios and policy decisions related to scaling, task-shifting, and enhanced public health campaigns. Results When projected to 2030, the baseline needs-based estimate is approximately 75,000 workers (5788 physicians and 69,399 nurses). This workforce equates to 2.05 physicians and nurses per 1000 population. Alternative models based on different scenarios and policy decisions indicate that the actual needs for physicians and nurses may range from 1.64 to 3.05 per 1000 population in 2030. Conclusions Based on our projections, the KSA will not face a needs-based health worker shortage in 2030. However, alternative model projections raise important policy and planning issues regarding various strategies the KSA may pursue in improving quality and efficiency of the existing workforce. More broadly, where country-level data are available, our needs-based strategy can serve as a useful step-by-step workforce planning tool to complement more economic demand-based workforce projections.

Background Effective prevention-focused, value-based strategies are needed to improve oral health. Despite evidence that monetary incentives can motivate healthy behavior, well-powered studies have yet to examine incentives for improving children's oral hygiene. Aim Describe the rationale and design of the BEhavioral EConomics for Oral health iNnovation (BEECON) trial, which tests lottery-based monetary incentives as a consumer-oriented, value-based care model for improving children's oral hygiene. Design Phase II, stratified, permuted block randomized, controlled, two-arm, parallel groups, prevention trial. Setting Study visits occur at three Los Angeles, CA health clinics. Participants Two hundred and forty-four parent-child dyads with a child aged 6-48 months. Interventions Eligible dyads were randomized in equal allocation to one of two groups: lottery incentive group or waitlist (delayed incentive) control group. Weekly lottery incentives were offered for 6 months based on Bluetooth-recorded toothbrushing frequency. Both groups received weekly text message feedback on toothbrushing performance. Outcomes The primary outcome was toothbrushing performance from baseline to 6 months, measured as the mean number of qualifying half-day Bluetooth-recorded episodes per week when the child's teeth were brushed. Secondary outcomes included toothbrushing performance sustainability through 12 months and dental caries status. Conclusions BEECON offers a consumer-oriented approach to promoting value-based oral health care. We hypothesize that lottery-based incentives can improve oral hygiene in young children. Study results will inform programming efforts to enhance oral disease prevention in young children. Trial registration ClinicalTrials.gov identifier NCT03576326.

To analyze differences in length of stay, opioid use, and other perioperative outcomes in patients undergoing radical cystectomy with urinary diversion who received either liposomal bupivacaine (LB) or epidural analgesia.This was a single center, retrospective cohort study of patients undergoing open radical cystectomy with urinary diversion from 2015-2019 in the early recovery after surgery (ERAS) pathway. Patients received either LB or epidural catheter analgesia for post-operative pain control. LB was injected at the time of fascial closure to provide up to 72 hours of local analgesia. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative opioid use, time to solid food, time to ambulation, and direct hospitalization costs. Multivariable Cox proportional hazards regression was used to determine associations between analgesia type and discharge.LB use was independently associated with shorter post-operative length of stay compared to epidural use (median (IQR) 4.9 days (3.9-5.8) vs 5.9 days (4.9-7.9), P.001), less total opioid use (mean 188.3 vs 612.2 OME, P.001), earlier diet advancement (mean 1.6 vs 2.4 days, P.001), and decreased overall direct costs ($23,188 vs $29,628, P.001). 45% of patients who received LB were opioid-free after surgery, none in the epidural group. On multivariable Cox proportional hazards regression modeling, LB use was independently associated with earlier discharge (HR 2.1, IQR 1.0-4.5).Use of LB in open radical cystectomy is associated with reduced LOS, less opioid exposure, and earlier diet advancement.

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.

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 Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. Methods In preparation for the launch of Tanzania’s first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. Discussion We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of “proven” guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.