Care Coverage Research Articles

Income-related inequalities in unmet dental care needs in Spain: traces left by the Great Recession

BackgroundDental health is an important component of general health. Socioeconomic inequalities in unmet dental care needs have been identified in the literature, but some knowledge gaps persist. This paper tries to identify the determinants of income-related inequality in unmet need for dental care and the reasons for its recent evolution in Spain, and it inquires about the traces left by the Great Recession.MethodsData from the EU-SILC forming a decade (2007–2017) were used. Income-related inequalities for three years were measured by calculating corrected concentration indices (CCI), which were further decomposed in order to compute the contribution of different factors to inequality. An Oaxaca-type decomposition approach was also used to analyze the origin of changes over time. Men and women were analyzed separately.ResultsPro-rich inequality in unmet dental care needs significantly increased over time (CCI 2007: − 0.0272 and − 0.0334 for males and females, respectively; CCI 2017: − 0.0704 and − 0.0776; p < 0.001). Inequality showed a clear “pro-cycle” pattern, growing during the Great Recession and starting to decrease just after the economic recovery began. Gender differences only were significant for 2009 (p = 0.004) and 2014 (p = 0.063). Income was the main determinant of inequality and of its variation along time -particularly for women-, followed by far by unemployment –particularly for men-; the contributions of both were mainly due to changes in elasticites.ConclusionsThe Great Recession left its trace in form of a higher inequality in the access to dental care. Also, unmet need for dental care, as well as its inequality, became more sensitive to the ability to pay and to unemployment along recent years. To broaden public coverage of dental care for vulnerable groups, such as low-income/unemployed people with high oral health needs, would help to prevent further growth of inequality.

Systematic Review of Literatures on Community-Based Health Insurance: Experiences from Developing Countries

Access to healthcare services are an essential for maintaining and improving health of citizen. Good health is a key to sustained economic, social development and poverty reduction. Universal health coverage means that all people have equitable access to health services, improved quality of health services, and financial-risk protection. Community Based Health Insurance (CBHI) schemes are expected as a transitional mechanism to achieving universal coverage for health care in developing countries. CBHI schemes are characterized as hybrid arrangement from both traditional risk-sharing and formal health insurance policies. CBHI schemes are built upon the principles of social solidarity and common benefits to provide financial protection against medical expenses. To assess the ability of such schemes in meeting objectives of UHC, this study aims to systematically reviews of the existing theoretical literatures and empirical evidence on three outcomes; conceptual definition, characteristics of the scheme, and challenges to the success of the community based health insurance in developing counties . The study employed a qualitative research methodology by applying the basic principles of a systematic review in order to assess the existing literatures on the effectiveness and challenges of CBHI schemes in developing countries. This study totally relies on secondary sources which were collected from published works on journals, newspapers, published and unpublished articles of credible and reliable online sources. The review of literatures shows that the major challenges of the schemes are adverse selection, limited risk pool, poor financial risk protection, lack availability and quality of services, and lack of professional and standardized management. To overcome the challenges, all possible solutions were recommended. Keywords : Community-based health insurance, Universal health coverage, Rural, Informal sector, Challenges, Effectiveness, Healthcare Financing DOI: 10.7176/JESD/11-21-03 Publication date: November 30 th 2020

Coronavirus Disease 2019 and the Case to Cover Undocumented Immigrants in California

Latinos have been affected at higher rates in California. These include undocumented immigrants who are the largest group of Californians that remains uninsured. This population has limited access to health care services and coverage options. The coronavirus disease 2019 (COVID-19) pandemic has shown that undocumented immigrants are particularly vulnerable during this outbreak as they are more likely to delay seeking medical care and lack a regular source of care. In addition, many work in essential services, have low or moderate incomes, and live in overcrowded conditions increasing their risk for exposure to COVID-19. To reduce the state's COVID-19 burden, California should expand comprehensive Medi-Cal to all eligible individuals regardless of immigration status.

20.F. Workshop: Dental care – coverage and access across countries

Abstract Oral health is a central element of general health with significant impact in terms of pain, suffering, impairment of function and reduced quality of life. Although most oral disease can be prevented by health promotion strategies and routine access to primary oral health care, the GBD study 2017 estimated that oral diseases affect over 3.5 billion people worldwide (Watt et al, 2019). Given the importance of oral health and its potential contribution to achieving universal health coverage (UHC), it has received increased attention in public health debates in recent years. However, little is known about the large variations across countries in terms of service delivery, coverage and financing of oral health. There is a lack of international comparison and understanding of who delivers oral health services, how much is devoted to oral health care and who funds the costs for which type of treatment (Eaton et al., 2019). Yet, these aspects are central for understanding the scope for improvement regarding financial protection against costs of dental care and equal access to services in each country. This workshop aims to present the comparative research on dental care coverage in Europe, North America and Australia led by the European Observatory on Health Systems and Policies. Three presentations will look at dental care coverage using different methods and approaches. They will compare how well the population is covered for dental care especially within Europe and North America considering the health systems design and expenditure level on dental care, using the WHO coverage cube as analytical framework. The first presentation shows results of a cross-country Health Systems in Transition (HiT) review on dental care. It provides a comparative review and analysis of financing, coverage and access in 31 European countries, describing the main trends also in the provision of dental care. The second presentation compares dental care coverage in eight jurisdictions (Australia (New South Wales), Canada (Alberta), England, France, Germany, Italy, Sweden, and the United States) with a particular focus on older adults. The third presentation uses a vignette approach to map the extent of coverage of dental services offered by statutory systems (social insurance, compulsory insurance, NHS) in selected countries in Europe and North America. This workshop provides the opportunity of a focussed discussion on coverage of dental care, which is often neglected in the discussion on access to health services and universal health coverage. The objectives of the workshop are to discuss the oral health systems in an international comparative setting and to draw lessons on best practices and coverage design. The World Conference on Public Health is hence a good opportunity for this workshop that contributes to frame the discussion on oral health systems in a global perspective. Key messages There is large degree of variation in the extent to which the costs of dental care are covered by the statutory systems worldwide with implications for oral health outcomes and financial protection. There is a need for a more systematic collection of oral health indicators to make analysis of reliable and comparable oral health data possible.

Health Problems of Nepalese Migrant Workers and Their Access to Healthcare Services in three countries of Middle East

Background: Migrants’ health is a global public health issue. Middle East countries are the major destination for abroad job among Nepalese workers. This study carried out to identify the health problems among migrant workers and their access to health care in Saudi Arabia, United Arab Emirates (UAE) and Qatar of Middle East.&#x0D; Methods: This was a cross-sectional study; carried out among 480 returnee migrant workers who have given consent for the study. Data were collected at Tribhuvan International Airport (October 2018) using pretested structured interview schedule after taking approval from Institutional Review Committee of Pokhara University. Data were analyzed using SPSS 20 version. Percentage, mean/median, standard deviation, Chi square test and logistic regression performed.&#x0D; Results: Majority of the returnee migrants workers were male (95.0%) and their mean age was 32.38±5.54 years. Almost ten percent of the participants suffered from at least one health problem during their stay in Middle East; among them, respiratory problems were common (35.6%). Almost all participants (99.6%) had health policy to take care of migrant workers and 93.5 percent participants had health insurance coverage. Female workers (AOR 4.34; CI: 1.54-12.19), and migrants who worked for additional benefits (AOR 2.17; CI: 1.11-4.25) had significantly higher prevalence of health problems than their counterparts (P&lt;0.05).&#x0D; Conclusion: Almost ten percent migrant workers had at least one health problem during their stay in Saudi Arabia, UAE and Qatar. Almost all workers had the access to health care in Middle East countries. Female workers and the workers who performed additional work (over time) were at higher risk of the health problems. Universal coverage of quality health care for migrant workers in abroad and mainstreaming the route of permission for work is recommended.

From Political to Personal: Tracking the Use of Exemplars in Newspaper Coverage of the Affordable Care Act

ABSTRACT A content analysis (N = 520) of Affordable Care Act (ACA) coverage in The New York Times (NYT) examined the use of frames and exemplars to understand how the ACA was covered from passage through repeal attempts in 2017. Results show an increase in episodic frames as the law took effect and citizens faced health coverage decisions. There was also a change in NYT use of exemplars over the years. In the earlier stage of the ACA, the exemplars featured elites such as politicians, but later focusing more on citizen experiences and the benefits of the ACA. Findings suggest the change in how the NYT framed the ACA increasingly involved personal stories about the law’s benefits as well as the public’s experiences.

Mobile Personal Health Care System for Noninvasive, Pervasive, and Continuous Blood Pressure Monitoring: Development and Usability Study.

BackgroundSmartphone-based blood pressure (BP) monitoring using photoplethysmography (PPG) technology has emerged as a promising approach to empower users with self-monitoring for effective diagnosis and control of hypertension.ObjectiveThis study aimed to develop a mobile personal health care system for noninvasive, pervasive, and continuous estimation of BP level and variability, which is user friendly for elderly people.MethodsThe proposed approach was integrated by a self-designed cuffless, calibration-free, wireless, and wearable PPG-only sensor and a native purposely designed smartphone app using multilayer perceptron machine learning techniques from raw signals. We performed a development and usability study with three older adults (mean age 61.3 years, SD 1.5 years; 66% women) to test the usability and accuracy of the smartphone-based BP monitor.ResultsThe employed artificial neural network model had good average accuracy (>90%) and very strong correlation (>0.90) (P<.001) for predicting the reference BP values of our validation sample (n=150). Bland-Altman plots showed that most of the errors for BP prediction were less than 10 mmHg. However, according to the Association for the Advancement of Medical Instrumentation and British Hypertension Society standards, only diastolic blood pressure prediction met the clinically accepted accuracy thresholds.ConclusionsWith further development and validation, the proposed system could provide a cost-effective strategy to improve the quality and coverage of health care, particularly in rural zones, areas lacking physicians, and areas with solitary elderly populations.

A Review and Considerations on Palliative Care Improvements for African Americans With Cancer.

Hospice and Palliative care benefits are infrequently realized by African American patients with cancer. With the increasing recognition of the critical role of early utilization of palliative services for optimal and quality patient care, it is important to acknowledge disparities and barriers to access that minority patients may face. The purpose of this paper is to discuss the status of palliative care delivery for African American patients within the structure and framework of the clinical practice guideline domains established by the National Consensus Project for Palliative Care. This perspectives paper describes the different aspects of palliative care and the interplay with African American culture. Here, we also attempt to identify the multilevel barriers (health care system and provider level) to palliative care among African Americans as a required step toward decreasing the disparities in access, coverage, utilization, and benefit of palliative care. Furthermore, this paper may serve as an educational guide for health care workers who care for African American patients with cancer.

Assessing the implementation of facility-based HIV testing policies in Malawi, South Africa and Tanzania from 2013–2018: Findings from SHAPE-UTT study

ABSTRACT National HIV testing policies aim to increase the proportion of people living with HIV who know their status. National HIV testing policies were reviewed for each country from 2013 to 2018, and compared with WHO guidance. Three rounds of health facility surveys were conducted to assess facility level policy implementation in Karonga (Malawi), uMkhanyakude (South Africa), and Ifakara (Tanzania). A policy ‘implementation’ score was developed and applied to each facility by site for each round. Most HIV testing policies were explicit and aligned with WHO recommendations. Policies about service coverage, access, and quality of care were implemented in >80% of facilities per site and per round. However, linkage to care and the provision of outreach HIV testing for key populations were poorly implemented. The proportion of facilities reporting HIV test kit stock-outs in the past year reduced over the study period in all sites, but still occurred in ≥17% of facilities per site by 2017. The implementation score improved over time in Karonga and Ifakara and declined slightly in uMkhanyakude. Efforts are needed to address HIV test kit stock-outs and to improve linkage to care among people testing positive in order to reach the 90-90-90 targets.

Evaluating the quality and coverage of post-abortion care in Zimbabwe: a cross-sectional study with a census of health facilities

BackgroundAn estimated 65,000 abortions occurred in Zimbabwe in 2016, and 40 % resulted in complications that required treatment. Quality post-abortion care (PAC) services are essential to treat abortion complications and prevent future unintended pregnancies, and there have been recent national efforts to improve PAC provision. This study evaluates two components of quality of care: structural quality, using PAC signal functions, a monitoring framework of key life-saving interventions that treat abortion complications; and process quality, which examines the standards of care provided to PAC patients.MethodsWe utilized a 2016 national census of health facilities in Zimbabwe with PAC capacity (n = 227) and a prospective, facility-based 28-day survey of women seeking PAC in a nationally representative sample of those facilities (n = 1002 PAC patients at 127 facilities). PAC signal functions, which are the critical services in the management of abortion complications, were used to classify facilities as having the capability to provide basic or comprehensive care. All facilities were expected to provide basic care, and referral-level facilities were designed to provide comprehensive care. We also assessed population coverage of PAC services based on the WHO recommendation for obstetric services of 5 facilities per 500,000 residents.ResultsWe found critical gaps in the availability of PAC services; only 21% of facilities had basic PAC capability and 10% of referral facilities had comprehensive capability. For process quality, only one-fourth (25%) of PAC patients were treated with the appropriate medical procedure. The health system had only 41% of the basic PAC facilities recommended for the needs of Zimbabwe’s population, and 55% of the recommended comprehensive PAC facilities.ConclusionThis is the first national assessment of the Zimbabwean health system’s coverage and quality of PAC services. These findings highlight the large gaps in the availability and distribution of facilities with basic and comprehensive PAC capability. These structural gaps are a contributing barrier to the provision of evidence-based care. This study shows the need for increased focus and investment in expanding the provision of and improving the quality of these essential, life-saving PAC services.

The history of refugee and newcomer health care in Canada

Canada represents a global leader in refugee resettlement, having embraced an identity of multiculturalism that promotes the acceptance of newcomers. A crucial factor in facilitating post-arrival integration of newcomers into Canadian society is the maintenance of good health through the provision of adequate health care services. Throughout the past century, there has been an increase in the number of refugees in Canada, beginning largely in the post-World War period and extending into the second half of the twentieth century. This influx has required the development of health care systems and coverage specific to unique post-arrival medical needs of refugees. The history of refugee health care has been shaped by both policy and advocacy on behalf of refugees, resulting in a larger breadth of coverage today than ever before. This article summarizes the evolution of health care services provided to refugees, challenges that particular populations of refugees have faced in accessing care, and suggestions for continued improvements in refugee access to health care services.

Providing dental insurance can positively impact oral health outcomes in Ontario

BackgroundUniversal coverage for dental care is a topical policy debate across Canada, but the impact of dental insurance on improving oral health-related outcomes remains empirically unexplored in this population.MethodsWe used data on individuals 12 years of age and older from the Canadian Community Health Survey 2013–2014 to estimate the marginal effects (ME) of having dental insurance in Ontario, Canada’s most populated province (n = 42,553 representing 11,682,112 Ontarians). ME were derived from multi-variable logistic regression models for dental visiting behaviour and oral health status outcomes. We also investigated the ME of insurance across income, education and age subgroups.ResultsHaving dental insurance increased the proportion of participants who visited the dentist in the past year (56.6 to 79.4%, ME: 22.8, 95% confidence interval (CI): 20.9–24.7) and who reported very good or excellent oral health (48.3 to 57.9%, ME: 9.6, 95%CI: 7.6–11.5). Compared to the highest income group, having dental insurance had a greater ME for the lowest income groups for dental visiting behaviour: dental visit in the past 12 months (ME highest: 17.9; 95% CI: 15.9–19.8 vs. ME lowest: 27.2; 95% CI: 25.0–29.3) and visiting a dentist only for emergencies (ME highest: -11.5; 95% CI: − 13.2 to − 9.9 vs. ME lowest: -27.2; 95% CI: − 29.5 to − 24.8).ConclusionsFindings suggest that dental insurance is associated with improved dental visiting behaviours and oral health status outcomes. Policymakers could consider universal dental coverage as a means to support financially vulnerable populations and to reduce oral health disparities between the rich and the poor.

Potential factors associated with institutional childbirth among women in rural villages of Lao People\u2019s Democratic Republic: a preliminary study

BackgroundThe provision of quality health services has been a global priority to reduce neonatal and maternal deaths. In Lao People’s Democratic Republic (Lao PDR), the coverage of institutional childbirth stayed at a low level regardless of a sharp increase in the coverage of antenatal care (ANC) and fee exemption. The aim of the present study was to preliminary explore factors associated with increased institutional childbirth and the association between ANC attendance and maternal knowledge among women in rural villages of Lao PDR.MethodsA secondary data analysis was conducted using data collected through a pilot survey in Sekong province in Lao PDR. The study participants were women with children under 5 years of age in villages within 10 km (km) from health centers staffed with skilled birth attendants. Data were collected via a face-to-face interview using a semi-structured questionnaire and were analysed using logistic regression models to estimate odds ratios (ORs) and their 95% confidence intervals (CIs) for having institutional childbirth in relation to potential factors.ResultsA total of 302 women, 203 (67.2%) of whom gave birth at a health facility. 277 (91.7%) attended ANC at least once. Sixty-nine women (22.9%) had received no formal education, 272 (90.1%) were of an ethnic minority, 174 (57.6%) were unwaged and 99 (32.8%) lived more than 6 km from the nearest health facility. 51 (16.6%) did not know about birth complications at interview. Institutional childbirth was negatively associated with a lack of maternal knowledge about birth complications (OR, 0.27; 95% Cl, 0.14–0.54) after adjusting for covariates. Although there were few women who did not received ANC, the results suggested ANC might not be associated with maternal knowledge about birth complications (OR, 1.87; 95% Cl, 0.43–8.12).ConclusionsThe present study suggests that maternal knowledge about birth complications is an important factor in increasing the institutional childbirth in rural villages of Lao PDR where majority of residents were ethnic minority. Improving quality of ANC and attitude among health care providers may be key to increasing health-seeking behavior. However, further research is needed to understand factors influencing choice of place of childbirth.

Primary oral health care in Nigeria; four decades after the Alma Ata declaration

It´s over 4 decades since the Alma-Ata declaration of comprehensive health care for all by a congregation of leaders from 67 nations across the world. Though this step was revolutionary, Primary Oral Health Care delivery is still lacking in many Primary Health Centres in Nigeria. The delivery of essential health services in the country has undergone many transitions. From a spread in just 52 local governments areas in the 80s to a ward system coverage in all the 774 local governments with over 30,000 facilities by the 90s. Despite this progress, only 20% of these facilities are functional and the delivery of primary oral health care in these centres is grossly limited. State governments have thus been encouraged to seize ownership and expand health care delivery. The burden of oral diseases remains high and has been linked with systemic conditions like diabetes, HIV and even delayed gravidity. The integration of oral health care with existing primary health care has been challenged by the limited number of human resources especially available at the rural communities. Poor funding has also hindered oral health care delivery because of the specialized nature of oral care. The National Oral Health Policy issued in 2012 stipulates the need for the integration of oral health services but lacked proper implementation guidelines and a revised edition is expected in 2020. Experts have advocated the need to have a higher proportion of dental auxiliaries to complement the demand for human resource for dental care delivery. Similarly, encouraging task-shifting at the grassroots will also provide an efficient route to expanding the coverage for oral health care in the Nigerian population. Finally, the goal of universal health coverage in Nigeria can be better served by prioritizing Primary oral health Care and full implementation of the National Oral Health Policy in Nigeria.

Participatory Action Research: Maternal and Child Health System

The birth of a child is basically very much awaited in every family. In order for the mother to be safe and the child to be born healthy, she must perform antenatal care routinely to the obstetrician or to the midwife. The longer the gestational age, the fetus will also grow and develop, so if not carried out proper supervision can cause problems both during pregnancy, at the time of delivery, even childbirth, and the worst can result in death of mother and baby. Pregnancy screening is also an effort to reduce maternal mortality. The frequency of antenatal care is used to assess the use of antenatal services in quantity. The higher the coverage of antenatal care, the more likely the process of pregnancy and childbirth can be carried out properly. So that theexamination of the womb during pregnancy is something that should not be missed and underestimated. In the obstetric examination the doctor or midwife will tell about the health of the fetus, fetal development, nutrition or any good food consumed during pregnancy, how to set a healthy diet for pregnant women, various exercise tips and healthy life that supports fetal growth and counting estimated date of birth of the baby. The estimateddate of birth of a baby is not always the same as the birth. Not a few who turned out to give birth before the estimated date and not a few also gave birth after the estimated date. From the problems, the solution to overcome this is that an Android-based application can be made that can connect between midwives and expectant mothers and can search for the nearest midwife. With this application, it is expected to help make it easier for mothers and midwives to find out the growth record of the fetus while in thewomb and facilitate the mother in the process of giving birth, especially during emergencies so that the mother will be immediately addressed by the nearest midwife and is expected to minimize the maternal mortality rate and baby during childbirth. Based on acceptance tests conducted on several users, it can be concluded that 84.3% of users agree that the application of"Sehati" is useful to support the health of pregnant women and children with an easy-to-understand appearance. Other statements include 9.1% neutral, and 6.6% disagree.

Evidence of health inequity in child survival: spatial and Bayesian network analyses of stillbirth rates in 194 countries

Estimated at 2.6 million annually, stillbirths worldwide have stayed alarmingly high, in contrast to neonatal and under-five mortality rates. It is a neglected public health challenge globally, with less attention to its social determinants. We examined spatial patterns of country-level stillbirth rates and determined the influence of social determinants of health on spatial patterns of stillbirth rates. We also estimated probabilistic relationships between stillbirth rates and significant determinants from the spatial analysis. Using country-level aggregated data from the United Nations databases, it employed ecological spatial analysis and artificial intelligence modeling based on Bayesian network among 194 World Health Organization member countries. From the spatial analysis, thirty-seven countries formed a cluster of high values (hot-spots) for stillbirth and 13 countries formed a cluster of low values (cold-spots). In the multivariate regression, gender inequality and anaemia in pregnancy were significantly associated with spatial patterns of higher stillbirth rates, while higher antenatal care (ANC) coverage and skilled birth attendants during delivery were associated with clusters of lower stillbirth rates. The Bayesian network model suggests strong dependencies between stillbirth rate and gender inequality index, geographic regions and skilled birth attendants during delivery. The Bayesian network predicted that the probability of low stillbirth rate increased from 56% to 100% when the percentage of countries with high skilled birth attendants during delivery increased from 70% to 88%, high ANC coverage increased from 55% to 70%, high prevalence of anaemia in pregnancy decreased from 27% to 11% and high gender inequality index decreased from 43% to 21%. Recognizing the urgency in reducing stillbirths globally, multi-pronged strategies should be designed to promote gender equality and strengthen the reproductive and maternal health services in Africa, Eastern Mediterranean, South Eastern Asia, and other countries with disproportionately high stillbirth rates.

Expanding access to maternal, newborn and primary healthcare services through private-community-government partnership clinic models in rural Kenya: the Ubuntu-Afya kiosk model

BackgroundFifteen counties contribute 98.7% of the maternal and newborn morbidity and mortality in Kenya. The dismal maternal and newborn (MNH) outcomes in these settings are mostly attributable to limited access to skilled MNH services. Public health services are stretched and limited in reach, and many social programmes are not sustainably designed. We implemented a network of 16 self-sustaining community medical centres (Ubuntu-Afya Kiosks) in Homa Bay County, to facilitate access to MNH and other primary health services. We investigated the effect of these centres on MNH access indicators over a 2-year period of initial implementation.MethodsWe conducted a baseline and end-line survey in June 2016 and May 2018 respectively, in 10 community health units (CHU) served by Ubuntu-Afya Kiosks. We targeted women of child bearing age, ensuring equal sample across the 10 CHUs. The surveys were powered to detect a 10% increase in the proportion of women who deliver under a skilled birth attendant from a perceived baseline of 55%. Background characteristics of the respondents were compared using Fisher’s exact test for the categorical data. STATA ‘svy’ commands were used to calculate confidence intervals for the proportions taking into account the clustering within CHU.ResultsThe coverage of antenatal care during previous pregnancy was 99% at end-line compared to 81% at baseline. Seventy one percent of mothers attended at least four antenatal care visits, compared to 64% at baseline. The proportion of women who delivered under a skilled birth attendant during previous pregnancy was higher at end-line (90%) compared to baseline (85%). There was an increase in the proportion of women who had their newborns examined within 2 day of delivery from 74 to 92% at end-line. A considerable proportion of the respondents visited private clinics at end-line (31%) compared to 3% at baseline.ConclusionsUbuntu-Afya Kiosks were associated with enhanced access to MNH care, with significant improvements observed in newborn examination within 2 days after delivery. More women sought care from private clinics at end-line compared to baseline, indicating potential for private sector in supporting health service delivery gaps in under-served settings.

Characterization and Disease Management of Persons with Hemophilia A Treated with Emicizumab: A Survey Study of Hematologists in the US

Introduction Emicizumab (EMI) is a subcutaneously administered, bispecific, humanized monoclonal antibody that bridges activated factor IX (FIXa) and FX to restore the function of missing FVIIIa in persons with hemophilia A (PwHA). It was approved in the US for prophylaxis in PwHA with FVIII inhibitors in November 2017 and for PwHA without FVIII inhibitors in October 2018. In May 2019, an online survey of 50 board-certified hematologists (HEMs) was conducted with the objective of understanding the characteristics of PwHA who are being treated with EMI (PwHA-EMI) and assessing any changes in disease management of these individuals by HEMs. Methods Descriptive analysis was conducted on data collected from May 8 to May 20, 2019, through a 30-minute, online survey of 50 HEMs treating adult and pediatric PwHA with or without FVIII inhibitors in the US. These HEMs were required to have ≥2 years of experience post-residency and experience treating ≥3 PwHA per month with EMI. Results Of the 50 HEMs from 22 states who were surveyed in this study, 28% (n=14) primarily treated pediatric PwHA and 76% (n=38) practiced at federally funded hemophilia treatment centers. HEMs reported that the majority of their PwHA-EMI had severe HA, were previously treated, and did not have FVIII inhibitors. HEMs reported presence of inhibitors (40%, n=20) and high treatment burden with previous treatments (16%, n=8) as the top factors that were considered when initiating treatment with EMI. HEMs reported that they are testing less frequently for FVIII activity (52%, n=26) and inhibitors (28%, n=14) in PwHA-EMI. Most HEMs reported using multiple methods for breakthrough bleed recognition in their PwHA-EMI, such as advising them to call a healthcare provider (HCP) for diagnosis support (70%, n=35) and providing educational materials (68%, n=34). Further, 34% (n=17) reported a change in their guidance on bleed treatment in PwHA-EMI. Guidance varied by inhibitor status and type of bleed; these HEMs were more likely to recommend that their PwHA-EMI with FVIII inhibitors (65%, n=11/17) and without FVIII inhibitors (53%, n=9/17) call a HCP to discuss symptoms before treating the bleed. Also, 42% (n=21) of HEMs typically advised keeping 3-4 doses of bypassing agent or FVIII at hand in case of breakthrough bleed treatment in PwHA-EMI. A majority of HEMs (84%, n=42) reported that the recreational physical activity levels of their PwHA have remained the same or increased after starting EMI; 48% (n=24) of HEMs recommended that their patients have a gradual increase in these activities after starting EMI. Among HEMs who provided specific guidance on recreational physical activities (54%; n=27), most develop customized plans for their patients based on fitness goals (82%; n=22/27), disease severity (74%; n=20/27), and age (56%; n=15/27). For disease management support, 58% (n=29) of HEMs reported no change in the support they provide, even though EMI is a relatively new treatment. HEMs mainly attributed this to fewer bleeds in PwHA-EMI. For routine and follow-up care, 72% (n=36) and 56% (n=28) of HEMs, respectively, reported that their PwHA-EMI seek about the same levels of such care as they did prior to starting EMI, but 32% (n=16) of HEMs reported that their PwHA-EMI need less non-routine care after starting treatment with EMI. Breakthrough bleeds (22%, n=11) and trauma (20%, n=10) were reported as the top reasons for any non-routine care in PwHA-EMI. As for treatment adherence, 90% (n=45) of HEMs reported that their PwHA-EMI have similar or better adherence compared with those on other HA treatments. Lastly, 46% (n=23) of HEMs reported that their PwHA-EMI regularly experience insurance issues, including ones related to coverage for EMI and coverage for care and breakthrough bleed treatments while on EMI. Conclusions Based on the findings of this survey study, most HEMs have retained similar disease management support and practices for their PwHA-EMI. Although the frequency of routine care has not changed for most PwHA-EMI, HEMs indicated a reduction in the amount of non-routine care needed by these individuals. As EMI is prescribed and used over a longer period post approval, patient characteristics, treatment methods, and disease management practices should continue to be monitored to support HEMs' treatment and care of PwHA. Disclosures Owens: PRO Unlimited: Employment; Genentech, Inc.: Consultancy. Patel:Roche/Genentech: Equity Ownership; Genentech: Employment. Poulos:MedPanel, Inc.: Employment. Powers:MedPanel: Employment. Ko:Genentech, Inc.: Employment.

Patient Perception on Health Care Delivery for Sickle Cell Disease and Opportunities for Quality Improvement

The Health Resources and Services (HRSA)-sponsored Sickle Cell Disease (SCD)Treatment Demonstration Regional Collaborative Program, EMBRACE SCD Florida has three aims: 1. To educate providers about SCD, 2. To assess patients' perception on health care and barriers encountered, and 3. To increase hydroxyurea (HU) treatment as disease-modifying therapy. We report the patients' perception on health care delivery as assessed by surveys of 65 patients at two SCD centers in South Florida. All participants signed the IRB-approved informed consent/assent and completed a 46-question survey. Surveys addressed patient demographics, HU use, pain experienced, facility utilization and confidence in SCD doctors and primary care providers (PCPs). Parents represented 62 % of the sample respondents. There were 37 female and 28 male patients, with a mean age of 14.8 years, median 12 years (range 1-45). Patients were self-identified as SS (N=42, 65%), SC (N=8), sickle-β+ thalassemia (N=5), sickle-β0 thalassemia (N=2), other (N=1), and 7 (11%) did not know their genotype. Most (55%) were African-Americans; 26% Haitians, 12% Black non-African-American or other, and 6% were White. Nine percent were Hispanic. Insurance coverage was identified as Medicaid (75%), Managed Care Organization (7%), Medicare (13%), and private insurance (5%). Of the 44 patients with SS and Sβ0, 84% (N=37) received medical advice to take HU from SCD provider. In addition, 12 patients (4 unknown type, 5 Sβ+ and 3 SC) were advised to take HU for a total of 49 or 75% of all patients surveyed. Seventy-eight percent (N=38) of those agreed to be treated, and 22% (N=11) declined HU. Eighty-four percent of those who agreed to be treated (N=32) reported taking HU as prescribed. Those patients who have received HU identified many barriers: lack of money to pay (N=5), nausea (N=5), hair loss (N=1), do not like the taste (N=8), do not like to take medications so they either do not take it frequently (N=7) or force themselves to take it (N=12), lack of effectiveness for their pain (N=10), and forgetting to take HU (N=18). Eighteen of 49 (37%) said they had no problems taking HU. We asked all patients about their pain experience. Of the 63 who responded, 30 (47.6%) said pain was managed well all the time, whereas the rest perceived difficulties in pain management: 20 (31.7%), 12 (19%), and one (1.6%) perceived their pain was managed well 75% of time, 50% of the time, and 25% or less of the time, respectively. The frequency of taking pain medications was variable among patients. The most common frequency of taking pain medications was several times a month (24 of 63 or 38%), but ranged from taking pain medication daily (N=9, 14%) to never or almost never (N=10, 16%). The emergency room (ER) was the first place they would go to when they get sick. One patient reported he prefers staying home. Patients reported a median of two ER visits (range 0-45) and two hospitalizations (range 0-30) in the previous 12 months. Almost all (92%) patients reported having a PCP. Sixty-seven percent visited the PCP 1-3 times per year, whereas 88% visited the SCD doctor 4-12 times per year. Whereas 68.3% patients trusted their PCP to manage their SCD, their level of trust with the SCD doctor was 95.2% (p &lt;0.01). Similarly, 68% patients agreed that both the PCP and the SCD doctor should share responsibilities in their care. The table shows what participants considered most important for their PCP and their SCD doctor to know or learn about SCD. The most common single thing participants would change about the health care system was insurance/health care coverage (N=7), improved communication with providers (N=4), better care (N=2), or to have a cure for SCD (N=2). Six would not change anything. Eighty-four percent of patients did not know how to contact Sickle Cell Disease of America (SCDAA). Nine patients or parents (14%) felt discriminated against by health providers (N=3, doctors, nurses, pharmacy) and others (N=6, employers, classmates, others) as a result of their SCD. We identified five opportunities for quality improvement: 1. Improve pain control as 52.4% patients viewed their pain was sub-optimally managed, 2. Further examine and decrease barriers for HU treatment, 3. PCP education, as 31.7% of patients lacked trust in their competence, 4. Educate and encourage patient interaction with community-based organizations like SCDAA, and 5. Explore policy change in health care insurance coverage. Table Disclosures Alvarez: Forma Therapeutics: Consultancy; Novartis: Consultancy. Clay:Novartis: Speakers Bureau. Black:NHLBI: Research Funding; Micelle BioPharma: Research Funding; Pfizer: Research Funding; Sancilio and Company: Research Funding; Sanofi: Consultancy; Prolong Pharmaceuticals: Consultancy; Novartis: Research Funding; HRSA: Research Funding. Osunkwo:Novartis: Consultancy, Speakers Bureau; Pfizer: Consultancy; Terumo: Speakers Bureau; Micella Biopharma: Other: DSMB member.

Geographic differences in maternal and child health care utilization in four Ethiopian regions; a cross-sectional study

BackgroundMaternal and child health (MCH) care utilization often vary with geographic location. We analyzed the geographic distribution and determinants of utilization of four or more antenatal care visits, health facility delivery, child immunization, and care utilization for common childhood illnesses across four Ethiopian regions.MethodsA cross-sectional community-based study was employed with two-staged stratified cluster sampling in 46 districts of Ethiopia. A total of 6321 women (13–49 years) and 3110 children below the age of 5 years residing in 5714 households were included. We performed a cluster analysis of the selected MCH care utilization using spatial autocorrelation. We identified district-specific relationships between care coverage and selected factors using geocoded district-level data and ordinary least squares and hotspot analysis using Getis Ord Gi*.ResultsOf the 6321women included in the study, 714 had a live birth in the 12 months before the survey. One-third of the women (30, 95% CI 26–34) had made four or more antenatal visits and almost half of the women (47, 95% CI 43–51) had delivered their most recent child at a health facility. Nearly half of the children (48, 95% CI 40–57) with common childhood illnesses (suspected pneumonia, diarrhoea, or fever) sought care at the health facilities. The proportion of fully immunized children was 41% (95%, CI 37–45). Institutional delivery was clustered at district level (spatial autocorrelation, Moron’s I = 0.217, P < 0.01). Full immunization coverage was also spatially clustered (Moron’s I = 0.156, P-value < 0.1). Four or more antenatal visits were associated with women’s age and parity, while the clustering of institutional delivery was associated with the number of antenatal care visits. Clustering of full immunization was associated with household members owning a mobile phone.ConclusionsThis study showed evidence for geographic clustering in coverage of health facility deliveries and immunization at the district level, but not in the utilization of antenatal care and utilization of health services for common childhood illnesses. Identifying and improving district-level factors that influenced these outcomes may inform efforts to achieve geographical equitability and universal health coverage.