Additional Health Care Research Articles

Obesity in Pregnancy: ACOG Practice Bulletin Summary, Number 230.

Obstetrician-gynecologists are the leading experts in the health care of women, and obesity is the most common medical condition in women of reproductive age. Obesity in women is such a common condition that the implications relative to pregnancy often are unrecognized, overlooked, or ignored because of the lack of specific evidence-based treatment options. The management of obesity requires long-term approaches ranging from population-based public health and economic initiatives to individual nutritional, behavioral, or surgical interventions. Therefore, an understanding of the management of obesity during pregnancy is essential, and management should begin before pregnancy and continue through the postpartum period. Although the care of the obese woman during pregnancy requires the involvement of the obstetrician or other obstetric care professional, additional health care professionals, such as nutritionists, can offer specific expertise related to management depending on the comfort level of the obstetric care professional. The purpose of this Practice Bulletin is to offer an integrated approach to the management of obesity in women of reproductive age who are planning a pregnancy.

Making the Best of Limited Resources: Improving Outcomes in Head and Neck Cancer.

The overwhelming majority of head and neck cancers and related deaths occur in low- and middle-income countries, which have challenges related to burden of disease versus access to care. Yet the additional health care burden of the COVID-19 pandemic has also impacted access to care for patients with head and neck cancer in the United States. This article focuses on challenges and innovation in prioritizing head and neck cancer care in Sub-Saharan Africa, the Indian experience of value-added head and neck cancer care in busy and densely populated regions, and strategies to optimize the management of head and neck cancer in the United States during the COVID-19 pandemic.

Incremental health care utilization and expenditures for sleep disorders in the United States.

To determine the incremental increases in health care utilization and expenditures associated with sleep disorders. Adults with a diagnosis of a sleep disorder (International Classification of Diseases, 10th Revision, code G47.x) within the medical conditions file of the 2018 Medical Expenditure Panel Survey medical conditions file were identified. This dataset was then linked to the consolidated expenditures file and comparisons in health care utilization and expenditures were made between those with and without sleep disorders. Multivariate analyses, adjusted for demographics and comorbidities, were conducted for these comparisons. Overall, 5.6% ± 0.2% of the study population had been diagnosed with a sleep disorder, representing approximately 13.6 ± 0.6 million adults in the United States. Those with sleep disorders were more likely to be non-Hispanic, White, and female, with a higher proportion with public insurance and higher Charlson Comorbidity Scores. Adults with sleep disorders were found to have increased utilization of office visits (16.3 ± 0.8 vs 8.7 ± 0.3, P < .001), emergency room visits (0.52 ± 0.03 vs 0.37 ± 0.02, P < .001), and prescriptions (39.7 ± 1.2 vs 21.9 ± 0.4, P < .001) vs those without sleep disorders. The additional incremental health care expenses for those with sleep disorders were increased in all examined measures: total health care expense ($6,975 ± $800, P < .001), total office-based expenditures ($1,694 ± $277, P < .001), total prescription expenditures ($2,574 ± $364, P < .001), and total self-expenditures for prescriptions ($195 ± $32, P < .001). Sleep disorders are associated with significantly higher rates of health care utilization and expenditures. By using the conservative prevalence estimate found in this study, the overall incremental health care costs of sleep disorders in the United States represents approximately $94.9 billion. Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021;17(10):1981-1986.

Too Many Appointments: Assessing Provider and Nursing Perception of Barriers to Referral for Outpatient Palliative Care.

Background: Integration of early outpatient palliative care for patients with advanced cancer requires overcoming logistical constraints as well as attitudinal barriers of referring providers. This pilot study assessed provider perception of logistical and attitudinal barriers to outpatient palliative care referral as well as provider acceptability of an embedded onco-palliative clinic model.Methods: This was a cross-sectional survey-based study of medical oncologists, palliative care physicians, advanced practice providers (APP), and oncology nurses at a large U.S. academic center. Participants were invited to participate through anonymous online survey. Participants rank ordered logistical barriers influencing referral to an outpatient palliative clinic. Respondents indicated level of agreement with attitudinal perception of palliative care and acceptability of an embedded palliative clinic model through five-item Likert-like scales.Results: There were a total of 54 study participants (28 oncology physicians/APPs, 15 palliative physicians/APPs, and 11 oncology nurses). Across the three cohorts, most survey respondents ranked “time burden to patients” as the primary logistical barrier to outpatient palliative care referral. Both oncology and palliative providers indicated comfort with primary palliative care skills although palliative providers were more comfortable with symptom management compared with oncology providers (93.3% vs. 32.2%). A majority of participants (94.9%) were willing to refer to a palliative care provider embedded within an oncology clinic.Conclusion: Additional health care time cost to patients is a major barrier to outpatient palliative care referral. Embedding a palliative care provider in an oncology clinic may be an acceptable model to increase patient access to outpatient palliative care while supporting the oncology team.

EHealth for Addressing Balance Disorders in the Elderly: Systematic Review.

BackgroundThe population is aging on a global scale, triggering vulnerability for chronic multimorbidity, balance disorders, and falls. Falls with injuries are the main cause of accidental death in the elderly population, representing a relevant public health problem. Balance disorder is a major risk factor for falling and represents one of the most frequent reasons for health care demand. The use of information and communication technologies to support distance healthcare (eHealth) represents an opportunity to improve the access and quality of health care services for the elderly. In recent years, several studies have addressed the potential of eHealth devices to assess the balance and risk of falling of elderly people. Remote rehabilitation has also been explored. However, the clinical applicability of these digital solutions for elderly people with balance disorders remains to be studied.ObjectiveThe aim of this review was to guide the clinical applicability of eHealth devices in providing the screening, assessment, and treatment of elderly people with balance disorders, but without neurological disease.MethodsA systematic review was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement. Data were obtained through searching the PubMed, Google Scholar, Embase, and SciELO databases. Only randomized controlled trials (RCTs) or quasiexperimental studies (QESs) published between January 2015 and December 2019 were included. The quality of the evidence to respond to the research question was assessed using Joanna Briggs Institute (JBI) Critical Appraisal for RCTs and the JBI Critical Appraisal Checklist for QESs. RCTs were assessed using the Cochrane risk of bias tool. We provide a narrative synthesis of the main outcomes from the included studies.ResultsAmong 1030 unduplicated articles retrieved, 21 articles were included in this review. Twelve studies explored different technology devices to obtain data about balance and risk of falling. Nine studies focused on different types of balance exercise training. A wide range of clinical tests, functional scales, classifications of faller participants, sensor-based tasks, intervention protocols, and follow-up times were used. Only one study described the clinical conditions of the participants. Instrumental tests of the inner ear were neither used as the gold-standard test nor performed in pre and postrehabilitation assessments.ConclusionseHealth has potential for providing additional health care to elderly people with balance disorder and risk of falling. In the included literature, the heterogeneity of populations under study, methodologies, eHealth devices, and time of follow-up did not allow for clear comparison to guide proper clinical applicability. This suggests that more rigorous studies are needed.

Measuring chronic obstructive pulmonary disease (COPD) quality indicators using primary care electronic medical records (EMRs) in Ontario, Canada

RATIONALE: Quality management standards are available for chronic obstructive pulmonary disease (COPD), but how often they are followed in community settings is uncertain. OBJECTIVES: We sought to measure the adherence to standard quality of care criteria for COPD management in primary care using primary care electronic medical records as an indicator for quality of COPD management. METHODS: We conducted a cross-sectional study using EMR data from Ontario and previously validated set of COPD quality indicators previously developed by the Ontario COPD Population Health Network. We analyzed how often the COPD quality indicators were met for patients with COPD at the population-level and at the family physician-level. MEASUREMENTS AND MAIN RESULTS: Five quality indicators were assessed at population- and family physician (FP)-levels. We included 6995 patients with COPD under care of 247 FPs. The highest performing quality indicator was the recording of patients’ smoking history in the EMR. FPs varied in their rates of provision of smoking cessation support to current smokers, recording of spirometry, administration of pneumococcal and seasonal influenza vaccines. Five additional health care or medication utilization rates were assessed for all patients with COPD regardless of disease severity, including prescriptions for short-acting and long-acting bronchodilators, combined inhaled corticosteroids and long-acting bronchodilators, evidence of pulmonary rehabilitation and oxygen therapy use. CONCLUSION: EMR data can be a useful data source to study COPD care, and there are opportunities for improvement in several areas of COPD management in primary care as well as standardization of EMR use for COPD care.

The cost of Medicare-funded medical and pharmaceutical services for mental disorders in children and adolescents in Australia.

ObjectiveTo examine the health care costs associated with mental disorders and subthreshold mental disorders within a nationally representative sample of children and adolescents in Australia.MethodData were derived from the Young Minds Matter Survey (N = 6,310). Mental disorders were classified using the Diagnostic Interview Schedule for Children Version IV. Participant data were linked to administrative data on health care costs. Adjusted generalized linear regression models and two-part models were used to estimate mean differences in costs between those with a mental disorder or subthreshold disorder and those without.ResultsCosts associated with health care attendances and medications were higher for children and adolescents with mental disorders and subthreshold mental disorders compared to those without a mental disorder. The additional population health care costs due to mental disorders amounted to AUD$234 million annually in children and adolescents, of which approximately 16% was attributed to out-of-pocket costs. Findings showed that those with subthreshold mental disorders or comorbid mental disorders have substantial additional costs of Medicare-funded medical and pharmaceutical services.Conclusion and implicationMental disorders in children and adolescents are associated with significant health care costs. Further research is needed to ensure that this population is receiving effective and efficient care.

Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing?

Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization. We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses. There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits. Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

Air Pollution, Health, and Avoidance Behavior: Evidence from South Korea

Using detailed data on the beneficiaries of the Korean National Health Insurance Service (c.2006-2015), this paper estimates the health effects of air pollution in South Korea while controlling for avoidance behaviors. In particular, I investigate changes in the respiratory hospitalization rates due to increases in PM10 and O3 concentrations. To address the endogeneity of air pollution, this paper applies the historical average concentration of air pollution that includes rich information about the meteorological and geographical factors that affect regional air pollution levels as an instrumental variable and compares the results with other count data models. I find that a 10mg/m3 increase in PM10 and a 10ppb increase in O3 lead to an increase in daily respiratory hospital visits of up to 10.39% (95% confidence intervals (CI): 4.04--16.80) and 10.93% (95% CI: 9.23-12.63), which results in additional health care costs of $67 million USD and $70 million USD, respectively. This paper also shows that the effects of PM10 and O3 are greater in more populated cities, on children's health, and for non-chronic respiratory patients.

Air Pollution, Health, and Avoidance Behavior: Evidence from South Korea

Using detailed data on the beneficiaries of the Korean National Health Insurance Service (c.2006–2015), this paper estimates the health effects of air pollution in South Korea while controlling for avoidance behaviors. In particular, we investigate changes in respiratory hospitalization rates due to increases in PM $$_{10}$$ and O $$_{3}$$ concentrations. To address the endogeneity of air pollution, this paper applies the historical average concentration of air pollution, which includes rich information about the meteorological and geographical factors that affect regional air pollution levels, as an instrumental variable and compares the results with other count data models. We find that a 10 $$\upmu$$ g/m $$^{3}$$ increase in PM $$_{10}$$ and a 10 ppb increase in O $$_{3}$$ lead to an increase in daily respiratory hospital visits of up to 10.39% [95% confidence interval (CI) 4.04–16.80] and 10.93% (95% CI 9.23–12.63), resulting in additional health care costs of US$67 million and US$70 million, respectively. This paper also shows that the effects of PM $$_{10}$$ and O $$_{3}$$ are elevated in highly populated cities, children, and patients without chronic respiratory diseases.

A Clinical Communication Tool (Loop) for Team-Based Care in Pediatric and Adult Care Settings: Hybrid Mixed Methods Implementation Study.

BackgroundCommunication within the circle of care is central to coordinated, safe, and effective care; yet patients, caregivers, and health care providers often experience poor communication and fragmented care. Through a sequential program of research, the Loop Research Collaborative developed a web-based, asynchronous clinical communication system for team-based care. Loop assembles the circle of care centered on a patient, in private networking spaces called Patient Loops. The patient, their caregiver, or both are part of the Patient Loop. The communication is threaded, it can be filtered and sorted in multiple ways, it is securely stored, and can be exported for upload to a medical record.ObjectiveThe objective of this study was to implement and evaluate Loop. The study reporting adheres to the Standards for Reporting Implementation Research.MethodsThe study was a hybrid type II mixed methods design to simultaneously evaluate Loop’s clinical and implementation effectiveness, and implementation barriers and facilitators in 6 health care sites. Data included monthly user check-in interviews and bimonthly surveys to capture patient or caregiver experience of continuity of care, in-depth interviews to explore barriers and facilitators based on the Consolidated Framework for Implementation Research (CFIR), and Loop usage extracted directly from the Loop system.ResultsWe recruited 25 initiating health care providers across 6 sites who then identified patients or caregivers for recruitment. Of 147 patient or caregiver participants who were assessed and met screening criteria, 57 consented and 52 were enrolled on Loop, creating 52 Patient Loops. Across all Patient Loops, 96 additional health care providers consented to join the Loop teams. Loop usage was followed for up to 8 months. The median number of messages exchanged per team was 1 (range 0-28). The monthly check-in and CFIR interviews showed that although participants acknowledged that Loop could potentially fill a gap, existing modes of communication, workflows, incentives, and the lack of integration with the hospital electronic medical records and patient portals were barriers to its adoption. While participants acknowledged Loop’s potential value for engaging the patient and caregiver, and for improving communication within the patient’s circle of care, Loop’s relative advantage was not realized during the study and there was insufficient tension for change. Missing data limited the analysis of continuity of care.ConclusionsFundamental structural and implementation challenges persist toward realizing Loop’s potential as a shared system of asynchronous communication. Barriers include health information system integration; system, organizational, and individual tension for change; and a fee structure for health care provider compensation for asynchronous communication.

Estimating the global costs of hearing loss

Objective To estimate the global costs of hearing loss in 2019. Design Prevalence-based costing model. Study sample Hearing loss data from the 2019 Global Burden of Disease study. Additional non-hearing related health care costs, educational support, exclusion from the labour force in countries with full employment and societal costs posed by lost quality of life were determined. All costs were reported in 2019 purchasing power parity (PPP) adjusted international dollars. Results Total global economic costs of hearing loss exceeded $981 billion. 47% of costs were related to quality of life losses, with 32% due to additional costs of poor health in people with hearing loss. 57% of costs were outside of high-income countries. 6.5% of costs were for children aged 0–14. In scenario analysis a 5% reduction in prevalence of hearing loss would reduce global costs by $49 billion. Conclusion This analysis highlights major economic consequences of not taking action to address hearing loss worldwide. Small reductions in prevalence and/or severity of hearing loss could avert substantial economic costs to society. These cost estimates can also be used to help in modelling the cost effectiveness of interventions to prevent/tackle hearing loss and strengthen the case for investment.

Dual MD-MPH Degree Students in the United States: Moving the Medical Workforce Toward Population Health.

A growing need exists to train physicians in population health to meet the increasing need and demand for physicians with leadership, health data management/metrics, and epidemiology skills to better serve the health of the community. This study examines current trends in students pursuing a dual doctor of medicine (MD)-master of public health (MPH) degree (MD-MPH) in the United States. We conducted an extensive literature review of existing MD-MPH databases to determine characteristics (eg, sex, race/ethnicity, MPH area of study) of this student cohort in 2019. We examined a trend in the MD community to pursue an MPH career, adding additional public health and health care policy training to the MD workforce. We conducted targeted telephone interviews with 20 admissions personnel and faculty at schools offering MD-MPH degrees in the United States with the highest number of matriculants and graduates. Interviews focused on curricula trends in medical schools that offer an MD-MPH degree. No literature describes the US MD-MPH cohort, and available MD-MPH databases are limited and incomplete. We found a 434% increase in the number of students pursuing an MD-MPH degree from 2010 to 2018. The rate of growth was greater than the increase in either the number of medical students (16%) or the number of MPH students (65%) alone. Moreover, MD-MPH students as a percentage of total MPH students more than tripled, from 1.1% in 2010 to 3.6% in 2018. As more MD students pursue public health training, the impact of an MPH degree on medical school curricula, MD-MPH graduates, and MD-MPH career pursuits should be studied using accurate and comprehensive databases.

He Korowai Manaaki (Pregnancy Wraparound Care): Protocol for a Cluster Randomized Clinical Trial.

BackgroundMaternal and infant health inequities between Māori (the Indigenous peoples of Aotearoa New Zealand) and New Zealand European women are well documented and cannot be explained solely by socioeconomic status. A research center-iwi (tribal group) partnership aims to address these disparities and improve maternal and infant health outcomes by implementing an augmented maternity care pathway (He Korowai Manaaki) to improve access to services and evidence-informed care.ObjectiveThe objective of this study is to test whether an augmented maternity care pathway improves Māori infant health outcomes.MethodsThis is a Kaupapa Māori (by, with, and for Māori) cluster randomized clinical trial involving 8 primary care practices allocated to either an intervention arm or control arm. The intervention arm comprises an augmented maternity care pathway (He Korowai Manaaki) offering clinical care through additional paid health care appointments and improved access to social support (eg, housing, transport). The control arm is usual care. The primary outcome is increased timely vaccination for Māori infants, defined as all age-appropriate vaccinations completed by 6 months of age.ResultsRecruitment commenced in November 2018 and was completed in June 2020, with 251 enrolled women recruited in intervention primary care practices before 20 weeks of pregnancy. Publication of results is anticipated in late 2023.ConclusionsThe results will inform primary health care policy including whether the provision of augmented maternal care pathways reduces disparities in the structural determinants of health. If effective, He Korowai Manaaki will strengthen the health and well-being of pregnant Māori women and their babies and improve their health outcomes, laying a strong foundation for lifelong health and well-being.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12619001155189; https://tinyurl.com/yypbef8qInternational Registered Report Identifier (IRRID)DERR1-10.2196/18154

Using Dental Health Care Personnel During a Crisis : COVID-19 Pandemic in the Bronx, New York.

The first few months of the coronavirus disease 2019 (COVID-19) pandemic challenged health care facilities worldwide in many ways. Inpatient and intensive care unit (ICU) beds were at a premium, and personnel shortages occurred during the initial peak of the pandemic. New York State was the hardest hit of all US states, with a high concentration of cases in New York City and, in particular, Bronx County. The governor of New York and leadership of hospitals in New York City called upon all available personnel to provide support and patient care during this health care crisis. This case study highlights the efforts of Jacobi Medical Center, located in the northeast Bronx, from March 1 through May 31, 2020, and its use of nontraditional health care personnel, including Department of Dentistry/OMFS (Oral and Maxillofacial Surgery) staff members, to provide a wide range of health care services. Dental staff members including ancillary personnel, residents, and attendings were redeployed and functioned throughout the facility. Dental anesthesiology residents provided medical services in support of their colleagues in a step-down COVID-19-dedicated ICU, providing intubation, ventilator management, and critical and palliative care. (Step-down units provide an intermediate level of care between ICUs and the general medical-surgical wards.) Clear communication of an acute need, a well-articulated mission, creative use of personnel, and dedicated staff members were evident during this challenging time. Although not routinely called upon to provide support in the medical and surgical inpatient areas, dental staff members may provide additional health care personnel during times of need.

684. The impact of rapid molecular respiratory testing on provider and parental decision making for children with respiratory illness evaluated in an ED setting

BackgroundRapid respiratory testing (RRT) can decrease ancillary testing, length of stay and antibiotic use for hospitalized children. Less is known regarding the impact of RRT in the emergency department (ED).Our objectives were to determine if RRT impacts ED provider clinical decision making, family acceptance, and subsequent healthcare visitation for children with influenza-like illness (ILI).MethodsRandomized controlled trial of children 1 month-18 years of age presenting to a tertiary care pediatric ED with ILI. All children received a nasopharyngeal swab and RRT and were randomized to the intervention group (RRT result given to clinicians/families) or control group (results not available unless obtained clinically). Outcomes included provider decision-making (anti-infective prescribing, ED diagnostic testing, disposition), family acceptance of RRT (willingness to undergo future testing) and repeat healthcare visits (clinic or ED). Providers in the intervention group were surveyed after RRT results were available, and families in both arms were contacted 1 and 10 days later.ResultsThere were 920 ED visits from 908 enrolled children; 629 (68%) families from both arms and 443 (96%) providers from the intervention arm completed surveys. Most providers (33%) were ED trained and < 5 years post-training (37%). Clinical decisions were changed in 17% of visits based on RRT results, most commonly by ED trained physicians, advanced practice providers, and those < 5 years post-training (Table). The most common decision changes were antiviral use and avoidance of diagnostic tests (Figure). Families were more willing to undergo future RRT if they were in the intervention group, or if RRT results were available in 20 minutes. In the control arm, 22 families (7%) stated they would not have sought additional medical visits if RRT results were available. In the intervention group, 20 families (6.7%) reported that the RRT influenced how their child received care, and 14 families (17%) sought additional care due to RRT results.Figure. Provider Clinical Decision Making Based on Results of Rapid Respiratory Testing, n = 443 Characteristics of providers and patients by provider decision type ConclusionRRT impacts clinical decision making for 1 in 5 ED visits, specifically antiviral prescribing and reduced diagnostic testing. Most families were in favor of RRT, which impacts additional health care visits after the ED encounter.Disclosures Suchitra Rao, MD, BioFire (Grant/Research Support) Molly Lamb, PhD, BioFire (Grant/Research Support) Rakesh Mistry, MD, MSCE, BioFire (Grant/Research Support) Samuel Dominguez, MD, PhD, BioFire (Consultant, Research Grant or Support)

PROBLEMS CAUSED BY THE PANDEMIC IN PUBLIC PROCUREMENT OF GEORGIA

The spread of the new coronavirus in the world, including in Georgia, had a significant negative impact on both public and private organizations, which has affected the public procurement process in the country. Georgia has spent a large amount of money to deal with the virus. As a result, administrative costs have been reduced in order to finance the 2020 state budget deficit - 57 million GEL for labor costs and 107 million GEL for goods and services. It should be noted that 195 million GEL is used on arranging quarantine spaces and other additional health care costs while 1.31 billion GEL is provided for goods and services. During the pandemic, demand from the state increased significantly in the health sector, while declining in other areas, many planned purchases were canceled, tenders were not held, were suspended or their announcement was delayed. This has affected companies whose major activities include state orders. Also rising inflation and currency devaluation have made goods and services more expensive. Consequently, complex problems arose for the entities participating in public procurement, namely: - From the moment the first case of the virus was reported in Georgia, it became mandatory for public and private organizations to follow the recommendations of the World Health Organization and the National Center for Disease Control and Public Health. So, large amount of money was spent on hygiene, disinfection and other means of protecting against the virus to ensure the safety of customers and employees. - Some public and private organizations continued to work remotely, for which they incurred additional costs for equipping employees at home (with computer or other technological resources). Other organizations, which were not prohibited the operation, funded the transportation of staff to the workplace, because of emergency was declared and public transport was restricted. - In order to free up financial resources, procurement organizations have restricted the announcement of planned tenders. Even the winner had already been identified or the bidder had been invited to sign the contract. At the same time, according to the Unified Public Procurement Electronic System a number of tenders have been suspended, including largescale infrastructure projects, most of which were in the selection stage or successful bidder was revealed and invited to sign the contract. - Due to the global pandemic, most companies failed to meet their contractual obligations on time. Contract authorities change the terms of the contract, including increased delivery time and services. In the case of infrastructure projects, based on the decree of the Government of Georgia, contract authorities were given the right to increase the contract value by 10% -20% in order to finance the increase of supplier costs on construction materials - Amendments were made to the legislation governing public procurement. For example, Procurement of goods and services under the many of CPV codes were restricted to contract authorities without the consent of the Government of Georgia. In the original version of the resolution, only 30 out of 200 codes were restricted, and from April 1, 2020, the number of restricted CPV codes has increased to 160. There are number of classified goods and services, whose purchase does not require government consent: agricultural and food products, outerwear, pharmaceutical products, miscellaneous transport equipment and spare parts, Works for complete or part construction and civil engineering work, laboratory services, refuse and waste related services. Because agreement with the government and electronic procedures takes a long time, procurement organizations were forced to purchase goods and services through a simplified procurement in the case of urgent necessity. This means that in accordance with the law, the contract authorities directly signed a contract with the company and after agreed with the State Procurement Agency. Therefore, it is necessary to analyze the additional costs incurred in the field of public procurement due to the coronavirus to make predictions about the procurement process for the next year.

Wilms Tumor in Sub-Saharan Africa: Molecular and Social Determinants of a Global Pediatric Health Disparity.

Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.

Utilisation of dental services for people with special health care needs in Australia

BackgroundTo explore the profile of patients and treatment delivered at specialist referral centres for individuals with special needs.MethodsA cross-sectional audit was conducted of the health records of all patients with appointments at two of Australia’s largest referral centres for patients with special needs, the Integrated Special Needs Department at the Royal Dental Hospital of Melbourne and the Special Needs Unit at the Adelaide Dental Hospital, for the month of August 2015.ResultsThe profile of patients treated at these specialist units demonstrates the diversity of individuals with additional health care needs that general dentists feel require specialised oral health care. The Adelaide-based clinic had a greater proportion of complex medical patients in comparison to those treated in Melbourne who were more likely to have a disability or psychiatric condition and were less likely to be able to self-consent for treatment. Interestingly, despite similar workforce personnel numbers, there were approximately twice as many appointments at the Special Needs Unit in Adelaide than the Integrated Special Needs Department in Melbourne during the study period which may have reflected differences in workforce composition with a greater use of dental auxiliaries at the Adelaide clinic.ConclusionsThe results of this study provide an initial profile of patients with special needs referred for specialist care in Australia. However, the differences in patient profiles between the two units require further investigation into the possible influence of service provision models and barriers to access of care for individuals with special needs and to ensure equitable access to health care.

Racial-Ethnic Disparities in Diabetes Technology use Among Young Adults with Type 1 Diabetes.

Background: Recent studies highlight racial-ethnic disparities in insulin pump and continuous glucose monitor (CGM) use in people with type 1 diabetes (T1D), but drivers of disparities remain poorly understood beyond socioeconomic status (SES). Methods: We recruited a diverse sample of young adults (YA) with T1D from six diabetes centers across the United States, enrolling equal numbers of non-Hispanic (NH) White, NH Black, and Hispanic YA. We used multivariate logistic regression to examine to what extent SES, demographics, health care factors (care setting, clinic attendance), and diabetes self-management (diabetes numeracy, self-monitoring of blood glucose, and Self-Care Inventory score) explained insulin pump and CGM use in each racial-ethnic group. Results: We recruited 300 YA with T1D, aged 18-28 years. Fifty-two percent were publicly insured, and the mean hemoglobin A1c was 9.5%. Large racial-ethnic disparities in insulin pump and CGM use existed: 72% and 71% for NH White, 40% and 37% for Hispanic, and 18% and 28% for NH Black, respectively. After multiple adjustment, insulin pump and CGM use remained disparate: 61% and 53% for NH White, 49% and 58% for Hispanic, and 20 and 31% for NH Black, respectively. Conclusions: Insulin pump and CGM use was the lowest in NH Black, intermediate in Hispanic, and highest in NH White YA with T1D. SES was not the sole driver of disparities nor did additional demographic, health care, or diabetes-specific factors fully explain disparities, especially between NH Black and White YA. Future work should examine how minority YA preferences, provider implicit bias, systemic racism, and mistrust of medical systems help to explain disparities in diabetes technology use.