Health Services Research Articles

Cost effectiveness of difelikefalin for the treatment of patients with chronic kidney disease-associated pruritus undergoing hemodialysis in Italy

Abstract Background Chronic kidney disease (CKD)-associated pruritus is a condition that strongly impacts CKD patients and is associated with increased morbidity/mortality, and worse health-related quality of life (HRQoL). Difelikefalin is currently the only drug approved in Europe specifically for treating moderate to severe CKD-associated pruritus in patients undergoing hemodialysis. The KALM-1 and KALM-2 trials showed better efficacy of difelikefalin vs placebo and best supportive care. The aim of this study was to investigate the cost-effectiveness of difelikefalin according to the Italian National Health Service (NHS) perspective. Methods A cohort model represented by four health states (No, Mild, Moderate, and Severe pruritus) was adapted to the Italian setting. The model used data from the KALM-1 and -2 trials for efficacy, integrated with other publications for HRQoL estimations. To assess the cost of disease management, a recent Italian publication on CKD-associated pruritus was used and a price of €27 per difelikefalin vial was assumed. The base case analysis over a 15-year time horizon, and an additional 10-year scenario analysis, were established. Additionally, both deterministic univariate analysis and probabilistic multivariate sensitivity analyses were developed. Discount rates of 3% were applied. An acceptability threshold of 40,000 €/quality-adjusted life-year (QALY) was considered. Results The results show that difelikefalin plus best supportive care is cost-effective vs best supportive care alone, with an incremental cost-effectiveness ratio, in the base case, of €35,823/QALY. Both the scenario and sensitivity analyses confirmed the strength of the results. Conclusions Difelikefalin was found to be a cost-effective treatment for the Italian NHS. These results support its reimbursement and its inclusion in routine clinical practice. Graphical abstract

Impact of the COVID-19 pandemic on hospital-based heart failure care in New South Wales, Australia: a linked data cohort study

BackgroundHealthcare policy implemented during the COVID-19 pandemic may have impacted the health of patients with heart failure. Australian data provide a unique opportunity to examine service disruption independent of significant COVID-19 burden. This study aimed to examine heart failure care during the pandemic in New South Wales (NSW).MethodsAnalysis of hospital utilisation among patients aged ≥ 18 years with a primary diagnosis of heart failure conducted using linked administrative health records from hospital admission, emergency department, non-admitted services, and mortality data collections. Health service utilisation and outcomes were compared “Pre-pandemic” (PP): 16th March 2018 – 28th August 2019 and “During pandemic” (DP): 16th March 2020 – 28th August 2021. Mortality data were available until December 2021.ResultsHeart failure-related ED presentations and hospital admissions were similar between the periods (PP = 15,324 vs DP = 15,023 ED presentations, PP = 24,072 vs DP = 23,145 hospital admissions), though rates of admission from ED were lower DP (PP = 12,783/15,324 (83.4% [95% CI 82.8-84.0]) vs DP = 12,230/15,023 (81.4% [95% CI 80.8-82.0%]). There was no difference according to age, sex, rurality, or socioeconomic status. Outpatient volume reduced DP (PP = 44,447 vs DP = 35,801 occasions of service), but telehealth visits increased nearly threefold (PP = 5,978/44,447 (13.4% [95% CI 13.1-13.8%]) vs DP = 15,901/35,801 (44.4% [95% CI 43.9-44.9%]) with highest uptake among the wealthy and those in major cities. Time to heart failure-related ED presentation, hospitalisation or all-cause mortality following index admission was longer DP (PP = 273 [IQR 259, 290] days, DP = 323 [IQR 300, 342] days, HR 0.91 [95% CI 0.88, 0.95]).ConclusionsPolicies implemented DP had minimal impact on volumes of inpatient heart failure care in NSW hospitals, but there were fewer admissions from ED and reduced volumes of publicly funded outpatient care. A rapid shift from patient-facing to remotely delivered care enabled compliance with restrictions and was associated with increased time to heart failure-related adverse events, but access was not afforded equally across the socio-demographic spectrum.

Trends in antibiotic use in a UK secondary care prior to and during the COVID-19 pandemic: a cross-sectional retrospective study

Abstract Introduction Antimicrobial resistance (AMR) is a rapidly escalating global health challenge. To address this, the UK Government developed a 5-year action plan, 'Confronting Antimicrobial Resistance 2024 to 2029,' aimed at optimising antimicrobial use.1 The World Health Organisation (WHO) promotes antimicrobial stewardship (AMS) and developed the AWaRe classification system to guide global AMS implementation. The defined daily dose (DDD) standardises antibiotic use comparisons.2 The COVID-19 pandemic significantly impacted health services, particularly in secondary care, potentially exacerbating AMR due to increased antibiotic use.3 Aim To evaluate changes in antibiotic use in a UK secondary care setting following the onset of the COVID-19 pandemic in 2020 compared to 2019. Methods This cross-sectional retrospective study evaluated antibiotic use among adult patients admitted to an NHS Foundation Trust in England. The focus was on those prescribed antibiotics for respiratory tract infections (RTIs) and pneumonia in 2019 and 2020. Data from 640 patient records were extracted using a validated tool based on the WHO AWaRe classification, with antibiotic use measured using the Defined Daily Dose (DDD). The study included patients aged 25 and above, immunocompromised individuals, pregnant women, and those treated for RTIs. It was registered under ISRCTN number 14825813 and received ethical approval from the University of Hertfordshire Ethics and Health Research Authority (HRA). The Citizens Senate reviewed the study protocol, ensuring public and patient involvement. Results The results show a notable increase in the Defined Daily Dose (DDD) of several antibiotics during the COVID-19 pandemic. In the "Access" category, amoxicillin usage rose from 1.33 DDD pre-pandemic to 4.33 DDD in 2020. Co-amoxiclav remained nearly constant at around 15 DDD but showed a marked increase compared to other antibiotics. In the "Watch" category, azithromycin increased from 3 to 9 DDD, and clarithromycin from 32 to 35.5 DDD. Levofloxacin usage doubled from 13 to 26 DDD. The "Reserve" category showed no significant increase, indicating stable consumption. Discussion and conclusion Understanding trends in antibiotic prescribing during the COVID-19 pandemic is pivotal for effective management in secondary care settings. The significant increase in the "Watch" category of antibiotics, particularly macrolides like azithromycin and clarithromycin, highlights the need for stringent antimicrobial stewardship. This rise may reflect changes in prescribing behaviour due to the pandemic. Monitoring antibiotic use is vital to mitigate the AMR challenge. Additionally, the increased use of levofloxacin during the pandemic, despite MHRA safety alerts about its potentially severe side effects, highlights the importance of cautious antibiotic prescribing and prompt discontinuation at the first signs of adverse reactions. The COVID-19 pandemic has significantly influenced antibiotic prescribing trends, highlighting the urgent need for sustainable antimicrobial stewardship in secondary care. This study reveals a notable increase in "Watch" category antibiotics, particularly azithromycin and clarithromycin, underscoring the need for stringent stewardship. Optimised antibiotic use is crucial for patient safety, improving treatment quality, and saving lives. The increased reliance on levofloxacin, despite known risks, emphasises the importance of careful prescribing. Prioritising responsible antibiotic use is essential to combat antimicrobial resistance, necessitating enhanced monitoring and stewardship efforts.

Changes in diabetes care and management practices during the COVID-19 pandemic

Abstract Background We examined changes in diabetes care and management practices before and during the COVID-19 pandemic. Methods Population-based data regarding four diabetes-related healthcare engagement and four self-management indicators were obtained from adults with diabetes surveyed in 19 US States and Washington DC through the Behavioral Risk Factor Surveillance System. Using logistic regression, we estimated changes in the prevalence of each indicator, overall and by sociodemographic subgroups in 2019 (before the pandemic) and 2021 (during the pandemic). Results Between 2019 and 2021, the prevalence of biannual HbA1c tests reduced by 2.6 percentage points (pp; 95% confidence interval: −4.8, −0.4), from 75.4% to 73.1%, and prevalence of annual eye exams fell by 4.0 pp (−6.2, −2.8), from 72.2% to 68.7%. The composite indicator of engagement with healthcare for diabetes control fell by 3.5 pp (−5.9, −1.1), from 44.9% to 41.9%. Of self-management behaviors, avoidance of smoking increased by 2.0 pp (0.4, 3.6) from 84.7% to 87.1%. Conclusions The findings suggest a deterioration of the uptake of evidence-based, preventive health services requiring laboratory services and clinical examination for diabetes control during the pandemic. On the other hand, smoking rates decreased, suggesting potential positive impacts of the pandemic on health behaviors in people with diabetes.

Beautiful but fragile: the experiences of family/carer lived experience workers within mental health services

ABSTRACT Objective Family/carer Lived Experience (LE) workers are increasingly being hired in Victorian mental health services, bringing their personal experience of supporting someone using these services and the ability to apply that experience in their roles. This project asked family/carer LE workers in Victoria, Australia to detail their experiences of working in these roles, how their personal lived experience of caring intersected with their work, and what they thought was needed to make family/carer LE work sustainable. Method A co-produced mixed-method design was used, including a survey of 62 Victorian family/carer LE workers and photovoice workshops attended by ten workers. The survey captured broad workforce trends, while the workshops provided narratives illustrating work experiences. Data from both sources were analysed separately and then combined into categories reflecting key dimensions of the family/carer LE worker experience. Results The findings were grouped into the following categories: Passion for the Work, Working Relationally in an Individualistic System, Undervalued and Poorly Understood, Workplace Conditions, Training and Development, Isolation, Beautiful but Fragile, Impact of the Work, and What is Sustaining the Work. Discussion This project emphasised the unique emotional labour family/carer LE workers perform and the specific supports they need. A clear model of practice for the profession is necessary, alongside cultural changes within mental health organisations to better integrate the strengths of this workforce.

Risk of Zonular Dialysis in Fellow-Eye Cataract Surgeries: A Multicenter Comparative Study

Purpose: To evaluate the risk of zonular dialysis (ZD) in fellow eye phacoemulsification cataract surgery and to identify risk factors, including prior first eye ZD. Setting: 8 United Kingdom National Health Service clinical centers. Design: Retrospective database study. Methods: We calculated the overall risk of ZD in the fellow eye and reported the odds ratio (OR) for the various risk factors, including first eye ZD. The main outcome measures were the risk and the predictors of intraoperative ZD in the fellow eye. Results: There was a total of 66,288 patients. At the time of the first surgery, the mean age of patients was 75.3±10.2 years, and 39.2% were males. Intraoperative ZD occurred during the first eye surgery in 333 patients (0.5%) and the fellow eye in 349 patients (0.5%). The risk of fellow eye developing ZD in patients with first eye ZD was higher than in patients without first eye ZD: 23/333 patients (6.9%) vs. 326/65,955 patients (0.5%) (p<0.001, unadjusted OR=14.9). In the adjusted logistic regression model, first eye ZD was the most significant risk factor (OR=13.3, 95% confidence interval (CI) =8.2-21.7). Other significant covariates of ZD in the fellow eye were pseudoexfoliation (OR=6, CI=3.8-9.7), previous pars-plana vitrectomy (OR=4.5, CI=1.1-18.5), and poor pupillary dilatation (OR=2.2, CI=1.4-3.3). Conclusions: The most important risk factor for the development of ZD in the fellow eye during cataract surgery was the occurrence of ZD in the first eye. Our findings have implications for patient counseling and surgery allocation.

Peer Support Specialists: SAMHSA's designation raises confusion

If you are in recovery from a substance use disorder (SUD), a peer would be another person in recovery from a SUD. At least, that's the purist way of thinking, before the word “peer” came into common usage. For years, the Substance Abuse and Mental Health Services Administration (SAMHSA) has endeavored in various ways to promote the blending of SUDs and mental illnesses, mainly in terms of the recovery workforce. Most recently, SAMHSA's publication, Peer Support Specialists: A Growing Mental Health and Addictions Workforce, adds further confusion to the issue. We asked experts in the field to comment.

Support for pharmacy professionals returning to (clinical) practice after a break: a cross-sectional survey

Abstract Introduction The continuing expansion of clinical roles for pharmacists, combined with National Health Service workforce shortages and the COVID-19 pandemic, have significantly increased pressure on pharmacy professionals.1 These pressures have heightened stress levels, causing many to consider leaving the field.2 Addressing workforce shortages and retension is crucial, with a particular focus on the reintegration of professionals returning to practice after a break. However, those returning after extended breaks often face challenges such as decreased skills and confidence. Nevertheless, research on the effectiveness of reintegration programmes to help pharmacy professionals return remains limited. Aim To explore participants’ reasons for leaving and returning and to assess the effectiveness of the Centre for Pharmacy Postgraduate Education (CPPE)’s Return to practice (RTP) and Return to the register (RTTR) programmes in helping individuals return to pharmacy practice in England. Methods CPPE emailed an anonymous link to an online survey, with two reminders, in December 2023 and January 2024, to individuals who participated in the RTP and/or RTTR programme(s) before March 2023 (n=701) and had given consent to be contacted for evaluation purposes. The survey employed closed, Likert-type and free-text questions. Quantitative data were analysed using the Statistical Package for Social Sciences (SPSS), with inferential statistics for subgroup comparisons and thematic analysis for qualitative comments (statistical significance p≤0.05).3 Using the university’s ethical approval tool, this study did not require approval due to not collecting personal, confidentical or sensitive information, with no vulnerable groups included, or risk of disclosure. Results The valid response rate was 15% (n=106). Most respondents were female (n=67, 79.8%), aged 35 and older (n=82, 97.6%), and pharmacists (n=77, 85.6%) or pharmacy technicians (n=8, 8.9%). The primary reasons for leaving included family responsibilities, career transition, and relocation, while the main motivations for returning were career reconnection, relocation, and other personal reasons. Participants reported a high degree of satisfaction with both programmes; those who perceived high content relevance reported significantly higher satisfaction (8.90±1.47 for RTP and 8.75±1.58 for RTTR on a 10-point scale). Overall, 70.8% (n=75) successfully returned to pharmacy practice and/or the GPhC register after completing the programme(s). Of those who returned, 68.1% (n=47) took less than 6 months. It was found that those who were more satisfied and more likely to recommend the programme(s), had been off the register for less than 10 years (n=41, 78.8%), and completed the programme(s) before 2020, prior to the shift to online delivery due to COVID-19 (n=41, 83.7% for RTP and n=16, 88.90% for RTTR), were more likely to have returned. Discussion/Conclusion The CPPE RTP and RTTR programmes supported participants effectively in returning to pharmacy practice. Increasing the number of pharmacy professionals returning to practice using reintegration course(s) positively impacts workforce shortages and addresses skill gaps after a break. One study limitation is the lack of information about those who did not use or are unaware of these support programmes. Further research could explore the support needs of all those wishing to return to practice or the GPhC register.

The effect of an enhanced fetal growth ultrasound protocol on pregnancy outcomes: A retrospective service evaluation within a single UK National Health Service centre between 2014 and 2022

Aim: Growth Assessment Protocol is a fetal growth initiative designed to improve antenatal detection of babies who are small-for-gestational-age and reduce stillbirths. However, its direct impact on pregnancy outcome and stillbirth rates is questioned. This service evaluation aimed to assess Growth Assessment Protocol’s influence on pregnancy outcomes at a National Health Service hospital. Method: Anonymous, maternity and ultrasound data, routinely acquired between 2014 and 2022 were extracted from clinical databases (Viewpoint, Euroking). Trends in maternity data and ultrasound scan volume were explored with descriptive statistics. Variables of stillbirth, antenatal small-for-gestational-age detection and scan volume were compared before and after Growth Assessment Protocol implementation. Associations between these variables were evaluated using Spearman’s rho. Results: The percentage of babies born small-for-gestational-age reduced by 0.3% across the evaluation period. Antenatal small-for-gestational-age diagnosis rose from 4.1% to 14.3%. However, the number of false-positive cases of antenatally diagnosed small-for-gestational-age increased fivefold from 2.2% to 11.5%. Although stillbirth rates remained consistent post-Growth Assessment Protocol, complex scan volume (e.g. number of growth scans using Doppler) increased annually. The peak incline coincided with the Growth Assessment Protocol implementation period (2016–2018). Complex scan volume was significantly associated with overall small-for-gestational-age detection (rho = 0.8, p =< 0.001), but not with stillbirth frequency (rho = −0.1, p = 0.4). Conclusion: Small-for-gestational-age detection increased following Growth Assessment Protocol implementation, although this was associated with a high false-positive rate and no reduction in stillbirths. The potential implications associated with clinical management, parent experiences and departmental workflow, alongside the benefits for stillbirth reduction, should be fully considered prior to the introduction of a new fetal growth initiative to the antenatal care pathway.

The Role of Artificial Intelligence in Revolutionizing Mental Health Services: A Data-Driven Approach

The potential of artificial intelligence (AI) to transform mental health care through individualized treatment approaches is significant. This research investigates the application of AI and extensive healthcare datasets to improve the precision of mental health diagnoses and treatments. The study employs various machine learning techniques, such as Random Forest, CatBoost, K-Nearest Neighbors, XGBoost, Convolutional Neural Networks, and Long Short-Term Memory networks, to analyze diverse data sources including electronic health records, neuroimaging, genetic information, and demographic data. Following thorough data preprocessing, model training, and evaluation using metrics like accuracy, precision, recall, F1 score, and Cohen's Kappa, the Random Forest algorithm emerges as the top performer with 98.7% accuracy. The research highlights the importance of addressing ethical considerations, such as protecting patient privacy, ensuring data security, and mitigating algorithmic bias when implementing AI in mental health services. The findings indicate that AI-based approaches can markedly improve diagnostic accuracy, provide tailored treatment suggestions, and facilitate early relapse detection, thus promoting proactive mental health management. Key Words: Artificial Intelligence, Mental Health, Data- Driven approach, Personalized Treatment, Machine Learning, Natural Language Processing.

Determinants of macrosomia among newborns delivered in Jigjiga City, Eastern Ethiopia: a case-control study

BackgroundMacrosomia is a forgotten health problem that directly or indirectly affects maternal and neonatal health outcomes. There is a lack of evidence on the factors that affect macrosomia in eastern Ethiopia. This study aimed to assess the determinants of macrosomia among newborns delivered in Jigjiga City, Eastern Ethiopia.MethodsAn institutional-based case-control study was conducted among 82 cases and 164 controls in Jigjiga City from June 25 to August 24, 2023. Bivariable and multivariable logistic regression were used to identify the determinants of macrosomia. An adjusted odds ratio (AOR) with a 95% confidence interval was used to report the strength of the association, and the statistical significance was declared at a p-value < 0.05.ResultsThis study found that lack of preconception care (AOR = 2.48, 95% CI: 1.29, 4.76); post-term pregnancy (AOR = 2.90, 95% CI: 1.16, 7.28); inadequate physical activity (AOR = 3.52, 95% CI: 1.55, 7.98), having previous macrosomia (AOR = 4.52, 95% CI: 2.18, 9.36), and gestational diabetic mellitus (AOR = 2.58, 95% CI: 1.10, 6.28) were the main risk factors of macrosomia.ConclusionThis study indicated that failed utilization of preconception care, inadequate physical activity during pregnancy, post-term pregnancy, gestational diabetic mellitus, and having previous macrosomia were the risk factors for fetal macrosomia. Encouraging women to utilize reproductive health services and providing special care for high-risk mothers are essential to reducing and preventing the level of fetal macrosomia and its consequences.

How to combat stigma surrounding mental health disorders: a scoping review of the experiences of different stakeholders

BackgroundThe stigma associated with mental health disorders (MHDs) results in delayed help-seeking, limited access to health services, suboptimal treatment, poor treatment outcomes, and an increased risk of human rights violations. This scoping review summarizes qualitative research on the lived experiences of different stakeholders regarding strategies and interventions to combat stigma for people with MHDs.MethodsThis study was a six-step scoping review using the Arksey and O’Malley framework. A comprehensive search of the following electronic databases was conducted to identify relevant records: PubMed, Scopus, Web of Science (WoS) and Google Scholar, as well as a manual search of the reference lists. All steps, including screening of eligible studies, data extraction, and analysis, were performed independently by multiple reviewers, with disagreements resolved by discussion. The data were synthesized based on the for-content synthesis guidelines.ResultsA total of 25 studies were included in this review of the 32,976 initial identified citations. The included studies were from all countries (low, middle, and high income), stigmatized disorders (e.g., schizophrenia, bipolar disorder, etc.) and target populations (e.g., people with MHDs and their families, health care providers, the general community, and students and school members). The thematic synthesis revealed six types of interventions and strategies and 17 themes related to reducing stigma in patients on MHDs. Strategies and interventions were classified by patient (self-stigma), family (family stigma), healthcare professionals’ stigma, workplace stigma, public/societal stigma, and structural type of stigma (institutional stigma).ConclusionsThis review contributes new evidence that should be considered in future interventions and policies to reduce stigma against MHDs. Multilevel and multistakeholder strategies and interventions are needed to reduce the stigmatization of MHDs.

The effectiveness of antidepressant therapy against anhedonia in patients with alcohol dependence

The article presents the results of a scientific study aimed at determining the effectiveness of the drug Vortioxetine (Brintellix) in the treatment of affective spectrum disorders in patients with alcohol dependence in a drug treatment hospital, since the drug is promising for widespread use in the drug therapy of a number of mental disorders and in the future could be included in the standard of medical care in the field of psychiatry-addictology. It is known that anhedonia is one of the mental disorders in withdrawal syndrome, which provokes relapses of an addictive disorder and negatively affects the duration and quality of remissions of patients with an addiction profile. At the same time, the study of antidepressant therapy in the treatment of alcohol dependence remains relevant, since poor tolerance, side effects, and deterioration of the patient's general condition may affect adherence to drug therapy. In the present study, anhedonia was assessed on the Snaith-Hamilton SHAPS scale, anxiety-depressive manifestations using the HADS hospital anxiety and depression scale and quality of life according to the SF-36 questionnaire during 24 weeks of follow-up.The result of drug therapy with Vortioxetine was the relief of affective disorders in alcohol dependence, which contributed to the improvement of overall subjective well-being, the degree of satisfaction with the quality of life and a decrease in anxiety-depressive tendencies and anhedonia. In addition, minimal and minor adverse reactions when taking Vortioxetine affected the increased adherence of the examined patients to medical prescriptions and recommendations.Conclusions. The use of Vortioxetine in the treatment of affective disorders among patients suffering from alcohol dependence provides new opportunities to help people suffering from alcohol addiction. Vortioxetine can be recommended both at the stage of inpatient care and outpatient treatment, since when it was taken, stable positive dynamics of antidepressant, anti-anxiety and antiangedonic effects were recorded.

Determinants of out-of-pocket expenditure on medicines among adults in Saudi Arabia: a cross-sectional study

IntroductionTo achieve universal health coverage consistent with World Health Organization recommendations, monitoring financial protection is vital, even in the context of free medical care. Toward this end, this study investigated out-of-pocket (OOP) expenditure on medicines and their determinants among adults in Saudi Arabia.MethodsThis analysis was based on cross-sectional data derived from the Family Health Survey conducted by the General Authority for Statistics in 2018. Data analyses for this study were based on the total sample of 10,785 respondents. Descriptive statistics were used to identify the sample distribution for all variables included in the study. Tobit regression analysis was used to examine the determinants of OOP expenditure on medicines.ResultsThe average OOP expenditure on medicines was estimated to be 279.69 Saudi Riyal in the sampled population. Tobit regression analysis showed that age, average household monthly income, education level, and suffering a chronic condition were the main determinants of OOP expenditure on medicines. Conversely, being married and employed were associated with a lower probability of OOP expenditure on medicines.ConclusionThis study could assist policy makers to provide additional insurance funding and benefits to reduce the possibility of catastrophic OOP expenditure on medicines, especially for the most vulnerable demographic.

Abortion access barriers shared in “r/abortion” after Roe: a qualitative analysis of Reddit community post-Dobbs decision leak in 2022

With drastic changes to abortion policy, the months following the Dobbs leak and subsequent decision in 2022 were a uniquely uncertain and difficult time for abortion access in the US. To understand experiences of challenges to abortion access during that time, we used a hybrid inductive and deductive thematic coding approach to analyse descriptions of barriers and their impacts shared in an abortion subreddit (r/abortion). A simple random sample of 10% of posts was obtained from those shared from 02 May 2022 through 23 December 2022; comments were purposively sampled during the coding process. In this sample of submissions (n = 523 posts, 88 comments), people described structural barriers identified in past research, including state abortion bans and gestational limits, high costs, limited appointment availability, and long travel required. Posters also commonly described known social barriers, including limited social support and abortion stigma. Several impactful barriers not well-described in past research emerged inductively, including wait time for receiving mail-ordered abortion medication, low credibility of online ordering platforms, and concerns about legal risks of accessing abortion or related medical care. The most common consequences of experiencing barriers were adverse mental health outcomes, delayed access to care, and being compelled to self-manage their abortion because of access barriers. This analysis provides timely insights into the experiences and impacts of abortion access barriers in a group of people with a range of engagement with clinical abortion care, lived experiences, and points in their abortion processes, with public health implications for mental health and abortion access.

Racial and Ethnic Disparities in Referral Rejection from Postacute Care Facilities among People with Opioid Use Disorder in Massachusetts

Objectives The aim of the study was to examine the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection from private postacute care facilities among hospitalized individuals with opioid use disorder (OUD). Methods In this retrospective cohort study, we linked electronic postacute care referrals from Boston Medical Center in 2018 to electronic medical record data, which we used to ascertain OUD status and race and ethnicity. Using multivariable logistic regression, we examined the association between Black, White, and Hispanic or Latino race and ethnicity and referral rejection, adjusting for individual-level characteristics including medication for opioid use disorder treatment type and for facility-level factors using facility random effects. Results We identified 159 hospitalizations from 141 individuals with OUD referred to private postacute medical care, corresponding to 1272 referrals to 244 facilities. Hospitalizations comprised 53 (33%) non-Hispanic Black, 28 (18%) Hispanic or Latino, and 78 (49%) non-Hispanic White individuals. In adjusted analyses, referrals for non-Hispanic Black individuals had significantly higher odds of rejection compared to referrals for non-Hispanic White individuals (adjusted odds ratio 1.83, 95% confidence interval [1.24, 2.69], P = 0.002). There were no significant differences between referrals for Hispanic or Latino individuals and non-Hispanic White individuals (adjusted odds ratio 1.11, 95% confidence interval [0.67, 1.84], P = 0.69). Conclusions Among people with OUD referred to private postacute care in Massachusetts, non-Hispanic Black individuals were more likely to be rejected compared to non-Hispanic White individuals, demonstrating racism in postacute care admissions. Efforts to address discrimination against people with OUD in postacute care admissions must also address racial equity.

Exploring Spiritual Care Competency in Palliative Medicine: A Narrative Inquiry of Physician Care Notes on Spiritual Distress

Background: Spiritual care is a critical component of hospice and palliative medicine; however, physicians frequently lack the necessary competencies to adequately address patients’ spiritual needs. This study aims to examine the spiritual care competencies of physicians as reflected in their care notes, thereby providing insights into their approaches for managing spiritual distress. Methods: A narrative inquiry approach was employed to qualitatively analyze interaction notes from 30 palliative care patients experiencing spiritual distress. Data were collected from a medical university professor’s care notes between April 2019 and February 2024. Results: The most common form of spiritual distress observed was reluctance to leave life, followed by loss of dignity. Physicians demonstrated expertise in holistic care, addressing physical, psychological, and spiritual needs with a comprehensive approach. Their demeanor reflects acceptance of mortality and acknowledgment of the limitations of medical care, helping foster gratitude and contentment in patients. Effective communication was pivotal, involving the conveyance of information, empathetic engagement, and active listening. Compassionate interactions emphasized the importance of spiritual care in patient-centered care delivery. Conclusions: Spiritual care competencies are essential for improving patient outcomes and advancing comprehensive palliative care. Future efforts should integrate these competencies into communication training within medical education to more effectively enhance health care providers’ competencies.

Current aspects of the organization of first aid to military personnel of the NATO bloc (using the example of the Bundeswehr army)

The study examines the most pressing issues of the organization of first aid to military personnel in the countries of the NATO bloc (using the example of the Bundeswehr army). It has been established that the system of first aid to the wounded and injured is based on the principles of “tactical medicine”, including the possession by military personnel of algorithms for providing assistance in the “red” and “yellow” combat zones, as well as methods of evacuation to the stage of medical care. It is emphasized that in order to quickly and effectively carry out self- and mutual assistance activities on the battlefield, NATO military personnel have appropriate training in the use of a standard individual first aid kit. It is shown that the Bundeswehr army has successfully implemented a training program consisting of two consecutive and logically related medical training courses: an initial training cycle (course “A”) and a special medical training course (course “B”). Only military personnel who have successfully completed both training courses are allowed to provide first aid in combat and emergency situations. It was revealed that within the framework of initial military training, students master a set of measures for phased first aid to the wounded and injured in accordance with the “C–A–B–C–D–E” scheme. The subsequent course of special medical training is aimed at training military personnel in emergency resuscitation measures in conditions as close as possible to combat. The purpose of the study was to analyze the literature data devoted to the study of the peculiarities of the existing system of first aid to the wounded and injured in the armies of NATO countries, including in the aspect of the organization of the training process for servicemen. The research methodology included the analysis of scientific publications selected from domestic and foreign databases, such as e-Library and PubMed. The methods of content analysis, synthesis, method of historical comparison, and bibliographic research method were used.

A qualitative study on the current status and problems of pharmacists in home healthcare from the viewpoint of care managers in medically underpopulated areas in Japan

BackgroundUnlike in urban areas, community healthcare in medically underpopulated areas in Japan is constantly challenged because of the uncertainty in effectively using the limited resources. However, no study has focused on human resources or identified the actual state of pharmacists’ support in the community. Therefore, our study identified the actual status and problems of pharmacists involved in home medical care in medically underpopulated areas and discussed the roles required of pharmacists and specific methods of support.MethodsThe content of semi-structured interviews with care managers involved in home healthcare in Misugi town, Tsu City, between November 10, 2023 and March 13, 2024, was analyzed qualitatively using the grounded theory approach.ResultsFive care managers participated in the study. Semi-structured interviews on the actual situation and challenges faced by pharmacists indicated that the following roles were required for pharmacists: as in other regions, it was observed that elderly people with dementia and those living alone managed their medicines, adjusted leftover medicines, collaborated with other professions, bridged with physicians, checked medication status through frequent visits, and adhered to internal medication regimens. Issues related to the characteristics of depopulated areas were identified including human resources, limitations of healthcare resources, economic burden, limits on the number of visits by pharmacists. As a characteristic of communities with no pharmacies and only in-hospital prescribing, pharmacists were expected by care managers to manage the problems caused by in-hospital prescribing.ConclusionsOur findings suggest that pharmacists should ensure the number of visits and collaborate with attending physicians, visiting nurses, and care managers to conduct drug management for patients with dementia and older adults living alone. Community healthcare specialists and those involved in the healthcare planning system can also utilize these findings while planning home healthcare to those who live in medically underpopulated areas in Japan.

Towards cultural inclusion for older adults from culturally and linguistically diverse communities: A commentary on recent aged care reforms

AbstractObjectiveDue to the high and increasing number of older people from culturally and linguistically diverse (CALD) backgrounds in Australia, it is essential to ensure that the upcoming Support at Home program and other new initiatives incorporate culturally responsive aged care provision. Failing to address these challenges perpetuates inequalities in access to quality care for CALD older adults.MethodsThis paper reviews recent reforms and initiatives in aged care, identifies culturally responsive provisions and proposes new approaches for upcoming reforms that focus on CALD older people and their support networks. We summarise current standards of cultural appropriateness in aged care to identify areas for improvement.ResultsThere are instructive interactions between cultural responsiveness and standardising or mainstreaming provision in recent aged care policies and initiatives. We argue that culturally adapting the aged care assessments and Support at Home frameworks through co‐production collaborations in the Aged Care Data and Digital Strategy (2024–2029) is not just beneficial but necessary. These actions involve (i) developing culturally tailored assessment tools that consider linguistic and cultural factors, such as using bilingual questionnaires and incorporating culturally responsive communication materials, and (ii) incorporating cultural competence training. Implementing these changes, though complex, will enable equitable and inclusive aged care. It involves overcoming language and cultural barriers that impede effective communication and care.ConclusionsWe advocate for ongoing testing and evaluation of these approaches to determine their feasibility for integration into digitisation plans within the aged care sector.