The challenge of the first 1000 days. The dynamics of early-life health inequalities in a universal healthcare system: Evidence from Italy.

Study DesignAmbispective cohort study.ObjectiveCanada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system.MethodsSurgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively.ResultsThe CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P < .001) and were more likely to be employed (69.5% vs 60.3%, P = .003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (87.2% vs 64.8%, P < .0001) and 1 year (85.6% vs 69.6%, P < .0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P < .01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P < .001).ConclusionsDespite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to patients enrolled within a multitier health system.

The Ayushman Bharat, the universal healthcare scheme in India, faced service adoption challenges after its launch in 2018. It was an enigma for the top management in Ayushman Bharat regarding slower service adoption of a free mass healthcare coverage scheme by the target population. The case focuses on the service adoption challenges from patient and physician perspectives while implementing a universal healthcare system. It provides insights to policymakers, physicians, service operations managers, and healthcare administrators regarding managing the universal healthcare system’s implementation challenges in a developing country context. Research questions/Objective: This study aims to understand service adoption challenges in a universal healthcare system setting. The study explores the following research questions: How is service adoption theory applied in a universal health coverage program? What should be the integrated marketing communication plan to improve the awareness about a universal healthcare program? Links to theory: The study uses service adoption theory. It analyzes service adoption challenges for the universal healthcare system in India called Ayushman Bharat. It also uses literature on the Unified Theory of Acceptance and Use of Technology (UTAUT) model. Phenomenon studied: The case study uses pan India patient and physician data to explore service adoption issues in Ayushman Bharat - a universal healthcare scheme in India. Case context: The primary data collected through the field (hospital) visits and interaction with patients and physicians of Ayushman Bharat form the basis of this case study. Findings: The study emphasizes on performance expectancy, ease in availing of the service, positive social influence, and facilitating conditions for service delivery of Ayushman Bharat. The Ayushman Bharat scheme’s performance expectancy means how being a healthy individual would contribute to better performance at the workplace. The effort expectancy is the level of ease an eligible Ayushman Bharat scheme can avail the service at the empanelled hospital. The social acceptance of the Ayushman Bharat scheme by friends, peers, and people in the vicinity would create a positive social influence. The facilitating conditions in the Ayushman Bharat scheme are the government’s capacity to provide organizational and technological infrastructure to support this universal healthcare program. Discussions: The use of service adoption theory and the UTAUT model to enhance the adoption of the universal healthcare system in India have been discussed in the case study.

Socioeconomic marginalization and health outcomes in newly diagnosed multiple myeloma: A population-based cohort study.

BackgroundEquity, financial sustainability, and quality in healthcare are key goals embraced by universal health systems. However, systematic performance management strategies for achieving equity are still weaker than those aimed at achieving financial sustainability and quality of care. Using a vertical equity perspective, the overarching aim of this paper is to examine how improving equity in quality of care impacts on financial sustainability. We applied a simulation to indicators of the heart failure clinical pathway in Tuscany (central Italy), in order to quantify the equity gaps and financial resources that could be reallocated in the absence of performance inequities.MethodsThe analysis included all patients hospitalized for heart failure as a principal diagnosis in 2014. We selected five indicators: hospitalization rate, 30-day readmission, cardiology visits, and the utilization of beta-blockers, and ACE inhibitors and sartans. For each indicator, the simulation followed three steps: 1) stratification by socioeconomic status (SES), using education as a proxy for SES; 2) computation of the vertical equity indicator; and 3) assessment of the financial value of the equity gap.ResultsAll indicators showed performance gaps regarding inequities across SES-groups. For the hospitalization rate and 30-day readmission, resources could have been reallocated, if the performance of patients with a low SES had been equal to the performance of patients with a high SES, which amounted to €2,144,422 and €892,790 respectively. In contrast, limited additional resources would have been required for prescriptions and cardiology visits.ConclusionsReducing equity gaps by improving the performance of low-SES patients may be a crucial strategy to achieving financial sustainability in universal coverage healthcare systems. Universal healthcare systems, which aim to pursue financial sustainability and quality of care, are thus urged to develop performance management actions to improve equity. This approach should not only include the measurement and public disclosure of equity indicators but be part of a comprehensive evidence-based strategy for the management of chronic conditions along the clinical pathway.

Patient reported outcomes following surgery for degenerative spondylolisthesis: comparison of a universal and multi-tier health care system

INTRODUCTION Canada has a universal health care system that is government funded and access to specialist care requires a referral by general practitioners. The United States utilizes a blended public and private payer system where insured patients can directly access specialists. The purpose of this study is to investigate whether there are differences in outcomes in the two systems. METHODS Surgical lumbar disc herniation patients treated between 2013 and 2016 in Canada that were enrolled in the Canadian Spine Outcome Research Network (CSORN) prospective multicenter registry. The Canadian cohort was compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient reported outcomes (PROs) were compared at 3 mo and 1 yr postoperatively. RESULTS The CSORN cohort consisted of 703 patients and the SPORT cohort was made up of 573 patients. The rate of females in each cohort was similar (47.2% vs 46.4%, P = .78), however, patients in the CSORN cohort were older (46.2 13.2 vs 41.6 10.9, P &lt; .001), had a higher rate of smoking (32.0% vs 22.8%, P &lt; .001), and were more likely to be employed (66.9% vs 61.3%, P = .034). The CSORN cohort had a slightly lower Owestry Disability score at baseline (50.515.1 vs 55.7 19.6, P &lt; .01) but had a higher proportion of patients with a symptom duration greater than 6 mo (44.5% vs 21.1%, P &lt; .0001). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 mo (74.8% vs 65.3%, P = .003) and 1 yr (81.4% vs 68.7%, P &lt; .001). Improvements in back and leg pain followed similar trajectories. CONCLUSION Patients undergoing surgical treatment for lumbar disc herniation in Canada (CSORN cohort) reported higher rates of satisfaction at 3 mo and 1 yr postoperatively compared to the United States cohort (SPORT) despite having longer durations of symptoms prior to surgery.

INTRODUCTION: Canada has a universal health care system that is funded by the government. In contrast, the United States utilizes a combined public and private payer system where patients may directly access specialists. METHODS: Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) prospective multicenter registry and were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study.Patient reported outcomes (PROs) and return to work were compared at 3 months and 1 year post-operatively were analyzed. RESULTS: The CSORN cohort consisted of 157 patients and the SPORT cohort was made up of 397 patients that were actively working at the time of surgery. The rate of depression (9.1% vs. 16.5%, p = 0.016) and symptom duration greater than 6 months were higher in the CSORN cohort (23.4% vs. 73.2%, p &lt; 0.0001). 100% of the CSORN cohort had public insurance compared to 1% in the SPORT cohort (p &lt; 0.001) and patients in the CSORN group were more likely to have compensation claims (17.8% vs. 9.1%, p = 0.0049). CSORN patients had better baseline ODI and SF36/12-PCS scores (ODI: 50.9 ± 19.7 vs. 45.8 ± 14.9, p = 0.0031; SF36/12 PCS: 29.9 ± 7.9 vs. 35.7 ± 7.4, p &lt; 0.001). At 3 months post-operatively the rate of patients that had returned to work was significantly lower in the CSORN cohort (47.8% vs. 72.8%, p &lt; 0.0001), but was not different at 12-months post-operatively (86.7% vs. 91.6%, p = 0.11). Membership in the CSORN cohort and compensation claims were significant independent predictors of not returning to work at 3-months post-operatively on multivariable logistic regression (OR 0.16, 95% CI 0.09-0.29, p &lt; 0.001; OR 0.47, 95% CI 0.26-0.85, p = 0.012). CONCLUSION: Patients undergoing surgical treatment for lumbar disc herniation in Canada (CSORN cohort) had a lower rate of return to work at 3 months but not 1 year post-operatively compared to the United States cohort (SPORT) despite better disability scores prior to surgery.

ObjectivesOne of the main objectives behind the expansion of insurance coverage is to eliminate disparities in health and healthcare. However, researchers have not yet fully elucidated the reasons for disparities in the use of high-cost treatments among patients of different occupations. Furthermore, it remains unknown whether discretionary decisions made at the hospital level have an impact on the administration of high-cost interventions in a universal healthcare system. This study investigated the adoption of drug-eluting stents (DES) versus bare metal-stents (BMS) among patients in different occupations and income levels, with the aim of gauging the degree to which the inclination of health providers toward treatment options could affect treatment choices at the patient-level within a universal healthcare system.Design and participantsWe adopted a cross-sectional observational study design using hierarchical modeling in conjunction with the population-based National Health Insurance database of Taiwan. Patients who received either a BMS or a DES between 2007 and 2010 were included in the study.ResultsDuring the period of study, 42,124 patients received a BMS (65.3%) and 22,376 received DES (34.7%). Patients who were physicians or the family members of physicians were far more likely to receive DES (OR: 3.18, CI: 2.38–4.23) than were patients who were neither physicians nor in other high-status jobs (employers, other medical professions, or public service). Similarly, patients in the top 5% income bracket had a higher probability of receiving a DES (OR: 2.23, CI: 2.06–2.47, p < .001), than were patients in the lowest income bracket. After controlling for patient-level factors, the inclination of hospitals (proportion of DES>50% or between 25% and 50%) was shown to be strongly associated with the selection of DESs (OR: 3.64 CI: 3.24–4.09 and OR: 2.16, CI: 2.01–2.33, respectively).ConclusionsEven under the universal healthcare system in Taiwan, socioeconomic disparities in the use of high-cost services remain widespread. Differences in the care received by patients of lower socioeconomic status may be due to the discretionary decisions of healthcare providers.

Background There are limited data on the association of poverty with outcomes and care patterns after an atrial fibrillation (AF) diagnosis in jurisdictions with universal healthcare. The Canadian province of Ontario provides publicly funded healthcare and prohibits private payment for medically necessary physician and in-hospital care. It also covers prescription medications for residents aged &amp;gt;65 years. Purpose Determine the association of neighbourhood-level poverty with outcomes and processes of care after AF diagnosis in older people within a universal healthcare system. Methods Using linked administrative databases, we conducted a population-based cohort study of community-dwelling adults aged ≥66 years who were newly diagnosed with AF in Ontario between April 1, 2007 and March 31, 2019. The primary exposure was material deprivation of patients' neighborhood of residence. This metric is derived using Canadian census data to estimate inability to access and attain basic material needs. Neighborhoods were categorized by quintile of material deprivation from Q1 (wealthiest) to Q5 (poorest). We used cause-specific hazards regression models to study the association of deprivation quintile with time to the following outcomes over one year from AF diagnosis: death, ischemic stroke, bleeding, heart failure (HF) hospitalization, cardiology services, and AF-specific treatments. Models accounted for clustering by region of residence and adjusted for age, sex, diabetes, HF, stroke/transient ischemic attack, vascular disease, hypertension, bleeding history, rural residence, renal function, and setting of AF diagnosis (hospital, emergency department [ED] or outpatient). Results We studied 350,353 patients with AF (median age 78 years, 48.9% female). People from neighborhoods in higher deprivation quintiles (poorer) were more likely to be diagnosed in hospital/ED than outpatient settings. Relative to people from the wealthiest neighbourhoods (Q1), patients in the poorest neighbourhoods (Q5) had higher prevalence of baseline hypertension, diabetes, HF, vascular disease and other comorbidities. In adjusted analyses (Figure), higher quintiles of neighborhood poverty were associated with greater rates of death, ischemic stroke, bleeding, and HF hospitalization, but lower rates of cardiology visits, cardiac testing, anticoagulation, anti-arrhythmic medications, cardioversion, or AF ablation. Conclusions In a setting of universal healthcare and prescription medication coverage, people living in poorer neighbourhoods had worse baseline health and higher rates of adverse outcomes after an AF diagnosis. Despite this, people in poorer neighbourhoods had less cardiology visits and diagnostic tests and were less likely to receive anticoagulation and rhythm control interventions. This shows that universal healthcare and medication coverage are insufficient to achieve equitable health care and outcomes for people with AF. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): This research was funded by a Canadian Institutes of Health Research Foundation grant; and is supported by ICES (formerly the Institute for Clinical Evaluative Sciences), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Background: The United States has the most expensive healthcare system in the world. Despite that, it also has worse health outcomes than that of several other countries. The United States is also the only wealthy/developed country without universal healthcare. Universal healthcare, also known as a single-payer healthcare system, refers to the concept that the government finances and governs healthcare for most, if not all residents of the country. The United States currently has a multi-payer system, which means that healthcare is financed through various sources such as the public and private sectors. Purpose: The purpose of this is to investigate the potential benefits and drawbacks of a universal healthcare system as well as identifying some of the potential barriers towards implementing a universal healthcare system in the United States, based on current, peer-reviewed literature. Methods: Peer-reviewed articles relevant to the topic were collected from databases such as PubMed. PRISMA criteria were used to identify relevant publications after applying inclusion and exclusion criteria. Data regarding health outcomes and healthcare expenses among different countries were compared and analyzed to help determine the effectiveness of universal healthcare. Results: Based on the studies, it can be inferred that the United States would significantly benefit from a universal healthcare system as studies show improved health outcomes as well as reduced healthcare expenditure, partially due to an emphasis on primary and preventative care, thus increasing access to overall care. However, there are also a few major barriers such as political lobbying that have prevented a significant overhaul of the current healthcare system in the United States. Conclusion: Universal healthcare would provide many benefits for the United States; however, political considerations pose a significant barrier that will need to be overcome before universal healthcare is implemented. That being said, there has been an increase in support for universal healthcare among Americans, in which small incremental steps can eventually lead the way there.

Integrating travel history via big data analytics under universal healthcare framework for disease control and prevention in the COVID-19 pandemic

IntroductionCommunity health workers (CHWs) are trained lay people and trusted members of communities worldwide who play crucial roles in bridging healthcare gaps in low–middle-income countries yet remain underused and not well integrated within high-income countries like Canada. The objective of this scoping review is to map out available evidence on the integration of CHWs in high-income countries with universal healthcare systems.Methods and analysisThis scoping review will include all available literature involving CHWs, or similar designations, and their integration into universal health systems within high-income countries. Literature will be excluded if it does not involve CHWs, universal healthcare systems, address integration or is conducted in low–middle-income countries. This review will include all available literature (including those that show null or negative results) that examines the integration of CHWs in high-income countries with a universal healthcare system. Documents describing integration may include, but are not limited to: tools, policies, models, frameworks, programmes or organisational features that seek to promote positive integration. Peer-reviewed and grey literature examining CHW integration in high-income countries with universal healthcare systems will be eligible for inclusion. Databases/sources to be searched (from inception until November 2025) will include: Medline (Ovid), Embase (Elsevier), Scopus (Elsevier), CINAHL (EBSCO), PsycINFO (EBSCO), Academic Search Premier (EBSCO), Business Source Complete (EBSCO), ProQuest Dissertations and Theses Global. Retrieval of full-text, all language studies (and other literature), data extraction, synthesis and mapping will be performed independently by two reviewers, following Joanna Briggs Institute methodology. Findings will be organised and presented according to the Levesque conceptual framework for healthcare access.Ethics and disseminationEthics approval is not required for this scoping review and literature search will start in October 2025 or on acceptance of this protocol. The findings of the scoping review will be available (February 2026) and will be published in a peer-reviewed journal.

In the light of Welfare State Literature, both the United Kingdom (UK) and the United States of America (USA) are categorized as Liberal Welfare Regime by Esping-Andersen, whose classification is widely accepted in the literature, and other researchers. But as a significant difference, whereas the UK has a universal free healthcare system contrary to typical Liberal Welfare State Regime, the US doesn’t have a universal healthcare system and furthermore, the healthcare system is mostly based on private insurance schemes. Moving from that point, health expenditures in the UK and the US has been compared and analyzed since the conditions create a significant comparing chance. This study’s main argument is based on the claim of even though the US health expenditures are about two times higher than the UK (per capita and as a rate of GDP) health system in the UK is financially more efficient than the US in terms of better public health outcomes and quality. In order to do so, the study analyzes the quantity and quality of healthcare expenditures in both countries by using literature, World Health Organization and different rating systems and furthermore both systems are discussed by 8 selected public health outcomes. The study concludes that the UK’s National Health Service (NHS) is giving better quality of service with almost two times lesser financial resources in terms of public health outcomes and some policy recommendations have been made.

Background Long COVID-19 patients experience a multitude of complex symptoms for an extended time, therefore often requiring increased medical care. Despite the global incidence of around 400 million (2023), little is known about potential issues related to healthcare access. This study analyses healthcare access barriers and facilitators encountered by long COVID-19 patients in the universal Austrian healthcare system and assesses the role of central coordination units in potentially alleviating the patient burden. Methods Data collection via survey took place 10-12/2024 in Austria (n = 433). Conceptualized along the five steps of the ‘access to care’ framework, the questionnaire covered 47 barriers and 10 facilitators derived from a previous qualitative study. Descriptive statistics, Whitney-Mann-U and t-tests were used in the statistical analysis. Results Long COVID-19 patients encountered barriers in all access steps, with the mean number of barriers considered problematic being 31.9 (SD 8.4) out of 47. The most common barriers were lacking information and the burden of self-organising one's treatment (perceived as problematic by over 90%), followed by the need to consult private doctors due to lacking expertise in the public sector and difficulties in treating symptoms by GPs and specialists (over 85%). Although the overall burden remained high, participants in federal states offering central coordination to the existing facilities encountered statistically significantly fewer barriers, particularly regarding the availability of services in the public sector and incurred costs. Main facilitators were the patient's social environment and the (information) exchange with other patients. Conclusions While the study finds severely impeded healthcare access for long COVID-19 patients in Austria, it supports the introduction of central coordination units and further research assessing the implementation of long COVID-19 pathways to improve patients’ healthcare access. Key messages • Long COVID-19 patients in Austria face widespread and severe access barriers, especially due to the burden of self-organising one’s treatment and lack of expertise within the public system. • Given the availability of sufficient services allowing for care coordination, central coordination shows promise in easing access to care for long COVID-19 patients in a universal healthcare system.

Background: Canada has a universal health care system while the United States utilizes a combined public and private payer system. The purpose of this study is to investigate whether there are differences in clinical outcomes between those surgically treated for spinal stenosis in Canada as compared to the United States. Methods: Surgical lumbar spinal stenosis patients treated in Canada that were enrolled in the Canadian Spine Outcome Research Network (CSORN) prospective multicenter registry were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Spine-related patient reported outcomes (PROs) were compared at 3 months and 1 year post-operatively. Results: The CSORN cohort consisted of 432 patients and the SPORT cohort was made up of 278 patients. The CSORN cohort had a higher proportion of patients with a symptom duration greater than 6 months (92.3% vs. 58.3%, p&lt;0.0001). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3 months (p=0.003) and 1 year (p&lt;0.001). Conclusions: Patients undergoing surgical treatment for lumbar spinal stenosis in Canada (CSORN cohort) reported higher rates of satisfaction at 3 months and 1 year post-operatively compared to the United States cohort (SPORT) despite having longer durations of symptoms prior to surgery.