Health Care System Characteristics Research Articles

The origins of social protection in healthcare: classifying healthcare systems at introduction in 165 countries

ABSTRACT While the emergence of welfare states, and the origins of social protection in healthcare, have been examined extensively for Global North countries, there is much less research with a global perspective. Addressing this gap, this study provides a descriptive and analytical account of the characteristics of healthcare systems as they were introduced worldwide. Using original and unpublished data, the study classifies healthcare systems according to the main actor type in regulation, financing, and service provision. We find two worlds of healthcare regulation – a state-regulated and a societally-regulated. Adding the financing dimension yields six clusters of healthcare regulation and financing. Based on regulation, financing, and service provision the classification reveals the existence of 12 healthcare system types. While systems that rely on societal actors mainly emerged prior to the mid-twentieth century, state-based systems have characterized system introductions since then. The classification of healthcare systems in 165 countries shows that only a limited number of actor combinations can be found empirically. However, it still presents greater variety than previous studies focusing on the Global North. The notable historical and regional patterns in the choice of healthcare system types can serve as a starting point for further research on healthcare system development.

Disparities in cancer outcomes: A comprehensive analysis of cancer incidence, mortality, and prevalence in Europe

Cancer poses a substantial challenge in Europe’s public health landscape, contributing significantly to illness burden, diminished productivity, and escalating health-care costs. This article investigates the extent to which disparities in cancer outcomes are associated with factors influencing the performance of cancer control initiatives within the European Union (EU). The characteristics of health-care systems play a pivotal role in shaping cancer outcomes through three key mechanisms: (i) Access to screening programs; (ii) quality and efficiency of health-care services; and (iii) health education and awareness programs. A multifactorial regression analysis was employed, utilizing the GLOBOCAN 2020 projections of cancer incidence, mortality, and prevalence based on the data from the International Agency for Research on Cancer. This analysis was delineated across 36 distinct cancer classifications by both gender and age categories. In countries with incomplete population coverage, patients may face limitations in accessing certain services or contend with significant financial obstacles. Furthermore, disparities in health-care service implementation, including diagnostic procedures, treatment modalities, and follow-up care, significantly affect cancer outcomes. In addition, systematic distinctions in care quality, such as early diagnosis, timely access to specialized care, and the presence of coordinated efforts, contribute significantly to diverse cancer outcomes. In conclusion, this article highlights the variations in cancer care provision across European countries, offering valuable insights for enhancing cancer patient care.

Understanding the Sociocultural Challenges and Opportunities for Affordable Wearables to Support Poststroke Upper-Limb Rehabilitation: Qualitative Study.

People who survive a stroke in many cases require upper-limb rehabilitation (ULR), which plays a vital role in stroke recovery practices. However, rehabilitation services in the Global South are often not affordable or easily accessible. For example, in Bangladesh, the access to and use of rehabilitation services is limited and influenced by cultural factors and patients' everyday lives. In addition, while wearable devices have been used to enhance ULR exercises to support self-directed home-based rehabilitation, this has primarily been applied in developed regions and is not common in many Global South countries due to potential costs and limited access to technology. Our goal was to better understand physiotherapists', patients', and caregivers' experiences of rehabilitation in Bangladesh, existing rehabilitation practices, and how they differ from the rehabilitation approach in the United Kingdom. Understanding these differences and experiences would help to identify opportunities and requirements for developing affordable wearable devices that could support ULR in home settings. We conducted an exploratory study with 14 participants representing key stakeholder groups. We interviewed physiotherapists and patients in Bangladesh to understand their approaches, rehabilitation experiences and challenges, and technology use in this context. We also interviewed UK physiotherapists to explore the similarities and differences between the 2 countries and identify specific contextual and design requirements for low-cost wearables for ULR. Overall, we remotely interviewed 8 physiotherapists (4 in the United Kingdom, 4 in Bangladesh), 3 ULR patients in Bangladesh, and 3 caregivers in Bangladesh. Participants were recruited through formal communications and personal contacts. Each interview was conducted via videoconference, except for 2 interviews, and audio was recorded with consent. A total of 10 hours of discussions were transcribed. The results were analyzed using thematic analysis. We identified several sociocultural factors that affect ULR and should be taken into account when developing technologies for the home: the important role of family, who may influence the treatment based on social and cultural perceptions; the impact of gender norms and their influence on attitudes toward rehabilitation and physiotherapists; and differences in approach to rehabilitation between the United Kingdom and Bangladesh, with Bangladeshi physiotherapists focusing on individual movements that are necessary to build strength in the affected parts and their British counterparts favoring a more holistic approach. We propose practical considerations and design recommendations for developing ULR devices for low-resource settings. Our work shows that while it is possible to build a low-cost wearable device, the difficulty lies in addressing sociotechnical challenges. When developing new health technologies, it is imperative to not only understand how well they could fit into patients', caregivers', and physiotherapists' everyday lives, but also how they may influence any potential tensions concerning culture, religion, and the characteristics of the local health care system.

Boarding in the emergency department: challenges and mitigation strategies.

Herein, we conducted a review of the literature to better understand the issue of prolonged emergency department (ED) boarding by providing an overview of the current evidence on the available causes, consequences, and mitigation strategies. Severely ill patients awaiting transfer to intensive care units (ICU) imposes additional burdens on the emergency care team from both a clinical and management perspective. The reasons for prolonged ED boarding are multifactorial. ED boarding compromises patients' safety and outcomes, and is associated with increased team burnout and dissatisfaction. Mitigation strategies include the optimization of patients' flow, the establishment of resuscitative care units, deployment of mobile critical care teams, and improvements in training. Staffing adjustments, changes in hospital operations, and quality improvement initiatives are required to improve this situation, while active bed management and implementation of capacity command centers may also help. Considering the characteristics of healthcare systems, such as funding mechanisms, organizational structures, delivery models, access and quality of care, the challenge of ED boarding of critically ill patients requires a nuanced and adaptable approach. Solutions are complex but must involve the entirety of the hospital system, emergency department, staff adjustment, and education.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use – results of a scoping review

BackgroundBesides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.MethodsWe used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the ‘Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)’ recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.ResultsOf the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.ConclusionsSocioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Characteristics and outcome of COVID-19 patients admitted to the ICU: a nationwide cohort study on the comparison between the consecutive stages of the COVID-19 pandemic in the Netherlands, an update.

Previously, we reported a decreased mortality rate among patients with COVID-19 who were admitted at the ICU during the final upsurge of the second wave (February-June 2021) in the Netherlands. We examined whether this decrease persisted during the third wave and the phases with decreasing incidence of COVID-19 thereafter and brought up to date the information on patient characteristics. Data from the National Intensive Care Evaluation (NICE)-registry of all COVID-19 patients admitted to an ICU in the Netherlands were used. Patient characteristics and rates of in-hospital mortality (the primary outcome) during the consecutive periods after the first wave (periods 2-9, May 25, 2020-January 31, 2023) were compared with those during the first wave (period 1, February-May 24, 2020). After adjustment for patient characteristics and ICU occupancy rate, the mortality risk during the initial upsurge of the third wave (period 6, October 5, 2021-January, 31, 2022) was similar to that of the first wave (ORadj = 1.01, 95%-CI [0.88-1.16]). The mortality rates thereafter decreased again (e.g., period 9, October 5, 2022-January, 31, 2023: ORadj = 0.52, 95%-CI [0.41-0.66]). Among the SARS-CoV-2 positive patients, there was a huge drop in the proportion of patients with COVID-19 as main reason for ICU admission: from 88.2% during the initial upsurge of the third wave to 51.7%, 37.3%, and 41.9% for the periods thereafter. Restricting the analysis to these patients did not modify the results on mortality. The results show variation in mortality rates among critically ill COVID-19 patients across the calendar time periods that is not explained by differences in case-mix and ICU occupancy rates or by varying proportions of patients with COVID-19 as main reason for ICU admission. The consistent increase in mortality during the initial, rising phase of each separate wave might be caused by the increased virulence of the contemporary virus strain and lacking immunity to the new strain, besides unmeasured patient-, treatment- and healthcare system characteristics.

Unhealthy lifestyles and regional differences in life expectancy in Russia

ObjectivesThe study seeks to identify the impact of smoking, sports participation, and alcohol consumption on life expectancy of men and women in Russian regions. Study designWe use official data for 2014–2020 for 77 Russian regions. We estimate factors related to life expectancy separately for men and women to account for differences in their life expectancy and lifestyles. MethodsWe run fixed-effect models to estimate regional life expectancy depending on smoking, alcohol consumption, sport participation, healthcare characteristics, and demographical and economic factors. ResultsLife expectancy was negatively associated with alcohol consumption and smoking and positively with sport participation: a 1-L increase in alcohol consumption was attributed to a 1.6-month decrease in male life expectancy and to a 1.8-month decrease in female life expectancy. If the proportion of smoking women was halved, the increase in woman's life expectancy would be 4.6 months. If sports participation rates were doubled for men and women, the expected increase in their life expectancy would be 1 and 0.9 years, respectively. Other factors attributed to life expectancy were settlement type, income inequality, characteristics of regional healthcare systems, and the COVID-19 pandemic. ConclusionWe find significant variation in life expectancy across Russian regions that can be partly explained by unhealthy lifestyles. We suggest that policies aimed at improving national health in diverse countries such as Russia adjust healthy lifestyle measures to the needs of particular region.

Implementing and evaluating care and support planning: a qualitative study of health professionals’ experiences in public polyclinics in Singapore

BackgroundTwo polyclinics in Singapore modified systems and trained health professionals to provide person-centred Care and Support Planning (CSP) for people with diabetes within a clinical trial. We aimed to investigate health professionals’ perspectives on CSP to inform future developments.MethodsQualitative research including 23 semi-structured interviews with 13 health professionals and 3 co-ordinators. Interpretive analysis, including considerations of how different understandings, enactments, experiences and evaluative judgements of CSP clustered across health professionals, and potential causal links between them.ResultsBoth polyclinic teams introduced CSP and sustained it through COVID-19 disruptions. The first examples health professionals gave of CSP ‘going well’ all involved patients who came prepared, motivated and able to modify behaviours to improve their biomedical markers, but health professionals also said that they only occasionally saw such patients in practice. Health professionals’ accounts of how they conducted CSP conversations varied: some interpretations and reported enactments were less clearly aligned with the developers’ person-centred aspirations than others. Health professionals brought different communication skill repertoires to their encounters and responded variably to challenges to CSP that arose from: the linguistic and educational diversity of patients in this polyclinic context; the cultural shift that CSP involved; workload pressures; organisational factors that limited relational and informational continuity of care; and policies promoting biomedical measures as key indicators of healthcare quality. While all participants saw potential in CSP, they differed in the extent to which they recognised relational and experiential benefits of CSP (beyond biomedical benefits), and their recommendations for continuing its use beyond the clinical trial were contingent on several considerations. Our analysis shows how narrower and broader interpretive emphases and initial skill repertoires can interact with situational challenges and respectively constrain or extend health professionals’ ability to refine their skills with experiential learning, reduce or enhance the potential benefits of CSP, and erode or strengthen motivation to use CSP.ConclusionHealth professionals’ interpretations of CSP, along with their communication skills, interact in complex ways with other features of healthcare systems and diverse patient-circumstance scenarios. They warrant careful attention in efforts to implement and evaluate person-centred support for people with long-term conditions.

Characteristics of employment history and self-perceived barriers to healthcare access.

Research suggests that people in disadvantaged social positions are more likely to perceive barriers to accessing healthcare, especially to specialists and preventive services. In this study, we analyze if adversity during past employment histories (e.g. spells of unemployment) is linked to subsequent subjectively perceived barriers in healthcare access. Further, we investigate if the associations vary according to national healthcare access and quality indicators. We use data from the Survey of Health, Ageing and Retirement in Europe with a study sample of 31 616 men and women aged 52-80 from 25 countries. Data include retrospective information on employment histories allowing us to derive characteristics of past careers, including the number of unemployment periods, main occupational position and pension contributions. Barriers to healthcare access are measured by self-perceived forgone care due to costs and unavailability of services. We apply multilevel Poisson regression for binary outcomes and test for cross-level interactions between career characteristics and national healthcare system characteristics. Career characteristics are linked to later self-perceived healthcare access barriers, consistently in the case of cost barriers and less consistently for unavailability of services. Associations are similar for men and women, and persist after controlling for current income, wealth and subjective health. We find no cross-level interactions between career characteristics and country-level healthcare access and quality indicators. Self-perceived barriers to healthcare access are linked to people's past working lives. More in-depth investigation is needed to identify the reasons for the lingering effects of characteristics of employment history on reduced healthcare access.

Inequalities in access to treatment in Argentina: Differences in management of CLL and multiple myeloma?

Health equity is today an important objective to evenly reach the population among different health care systems. This article will focus on diagnosis and treatment access inequalities in Argentina.Although different aspects must be optimized to overcome access barriers worldwide, access inequalities in some regions of Argentina may depend basically on the type of health coverage or insurance. Health care in Argentina is divided into Public, Social security and Private care systems. Access to diagnosis and disease monitoring will vary according whether the patient is under each of these systems. Reducing inequalities may help target some important aspects not covered today and that may directly impact patients' outcome. Disparities in health cancer care were analyzed according to Public, Social security and Private sectors. A disadvantage in resource access, inadequate funding and limited medical infrastructures are common characteristics of the public health care systems. In our country the disparity between the public and private sectors in terms of timely diagnosis, stage of disease at diagnosis, accuracy of diagnosis, access to novel agents and transplantation is notorious, with the public sector lagging behind in access to diagnostic and treatment resources. While the Private sector has treatment outcomes comparable to those of high-income countries, challenges remain in the Public sector for patients who rely on early and accurate diagnosis and timely access to treatment. There is an urgent need to provide equitable care for multiple myeloma and CLL patients and reduce the emotional and financial consequences of the disease for the patient.A survey about diagnosis and therapeutic resources was conducted between April and May 2023 among large centers in the Public, Social security and Private systems. A total of 49 hematologists from 31 institutions from five provinces of Argentina participated in the survey. We observed differences between the different systems with more access for the Private system on genetic diagnosis (FISH-IGVH access). More CLL patients in the public and social security systems were treated with CIT reflecting the inaccessibility in these sectors of more expensive targeted therapies rather than a gap in information since the Public centers surveyed were large hospitals with knowledgeable physicians. Access to different treatments both in first-line and relapsed settings was more equitable in the treatment of multiple myeloma for the different systems with the exception of access to daratumumab in first-line that was extremely infrequent in the public coverage. With increasing cost and treatment complexity as the introduction of CARTs and BITEs for CLL and MM, the gap will probably deepen more if the problem is not treated comprehensively by all the actors of the health sector: government, physicians, patients' organizations and pharmaceutical companies.

Health care financing and productivity of health care in OECD countries: a stochastic frontier analysis

The effects of health-care expenditure on health outcomes and the efficiency of health-care financing schemes in the OECD are estimated with a panel of 30 countries over 1995–2019. The survival rate constructed from the data on age-standardized health-related mortality is used as the health outcome variable. The stochastic frontier model used in the study accommodates nonmonotonic relationships between the factors of interest and the outcome, allowing us to find the optimal levels of the factors. The marginal effect of per capita health-care expenditure on the maximum achievable survival rate diminishes as the level of spending increases and is no longer statistically positive after health-care spending reaches $4811 (2015 PPP). The optimal share of compulsory financing in health expenditure is between 55 and 65%, and health care systems where it exceeds 90% are significantly less efficient. Health-care systems where the percentage of private financing in health expenditure is below 18% are significantly less efficient than those where it is close to the optimal level of about 62%. Further research is needed to examine the effects on health-care efficiency of more specific characteristics of health-care systems taking into account their complex interactions.

Effect of Primary Care Center Characteristics, Healthcare Worker Vaccination Status and Patient Economic Setting on Patient Influenza Vaccination Coverage Rates.

Reaching the public health organizations targets of influenza vaccination in at-risk patient groups remains a challenge worldwide. Recognizing the relationship between the healthcare system characteristics and the economic environment of the population with vaccination uptake can be of great importance to improve. Several characteristics were correlated in this retrospective ecological study with data from 6.8 million citizens, 15,812 healthcare workers across 258 primary care health centers, and average income by area of the care center in Spain. No correlation between HCW vaccination status and patient vaccination was found. A weak negative significant correlation between the size of the population the care center covers and their vaccination status did exist (6 mo.-59 yr., r = 0.19, p = 0.002; 60-64 yr., r = 0.23, p < 0.001; ≥65 yr., r = 0.23, p ≥ 0.001). The primary care centers with fewer HCWs had better uptake in the at-risk groups in the age groups of 60-64 yr. (r = 0.20, p = 0.002) and ≥65 (r = 0.023, p ≥ 0.001). A negative correlation was found regarding workload in the 6 mo.-59 yr. age group (r = 0.18, p = 0.004), which showed the at-risk groups that lived in the most economically deprived areas were more likely to be vaccinated. This study reveals that the confounding variables that determine influenza vaccination in a population and in HCWs are complex. Future influenza campaigns should address these especially considering the possibility of combining influenza and SARS-CoV-2 vaccines each year.

Interprofessional weaning boards for invasively ventilated patients in intensive care units: Qualitative interview study with healthcare professionals in Germany.

Numbers of mechanically ventilated patients are increasing worldwide. Weaning Boards could support weaning from the ventilator by facilitating interprofessional consultations between Weaning Centers and nonpneumological intensive care units. This study, which is linked to the project Prevention of invasive Ventilation, aimed to explore the design and implementation of future Weaning Boards. Semistructured interviews were conducted with physicians, nurses, respiratory therapists, and physiotherapists of intensive care units and Weaning Centers in Baden-Wuerttemberg, Germany. Participants were asked to share their views on (a) required characteristics of Weaning Boards and (b) the current care of weaning patients in their wards. Qualitative data analysis included inductive and deductive steps referring to the Template for Intervention Description and Replication checklist and the Consolidated Framework for Implementation Research. The 14 interviewed healthcare professionals addressed characteristics of future Weaning Boards including (a) preconditions, (b) procedure, (c) interprofessional participants, (d) type of performance, and (d) time frame. Identified determinants for successful implementation were related to (a) individual characteristics of healthcare professionals, (b) ward characteristics, and (c) healthcare system characteristics. Weaning Boards could be a useful tool to advance knowledge sharing between professionals, improve education about weaning protocols, and support patient-oriented care. The implementation of Weaning Boards can be influenced by individual characteristics of participating professionals, difficulties in the interaction between professional groups, the present workplace culture, and the current coronavirus disease 2019 (COVID-19) pandemic.

How to measure barriers in accessing mental healthcare? Psychometric evaluation of a screening tool in parents of children with intellectual and developmental disabilities

Caring for children with intellectual and developmental disabilities (IDD) can cause an enormous physical and emotional burden, and therefore these parents have an elevated risk to experience mental health problems. The characteristics of current healthcare systems and parents’ responsibilities to care for their children seem to impede their access to mental healthcare. There is so far a lack of instruments to screen for such obstacles. The aim of this study was to develop and validate a scale for measuring barriers to accessing mental healthcare. The Parental Healthcare Barriers Scale (PHBS) was developed on the basis of an extensive literature research, input and discussion from experts and parents with lived experience. A cross-sectional survey was used to collect data from 456 parents of children with IDD. Physical health, mental health, social support, and parenting were measured for concurrent and discriminant validity of the PHBS. The PHBS scale revealed acceptable to good reliability and validity. It consists of four subscales (i.e., support accessibility, personal belief, emotional readiness, and resource availability). The PHBS found parents prioritized their children’s treatments over their own mental health challenges (93.4%), did not have enough time (90.4%), and had financial concerns (85.8%). Parents in rural and remote areas had more limited resources. Findings from our study suggest increasing financial support for the parents seeking mental health services, introducing evidence-based treatments, increasing the availability of healthcare services for parents, and adjusting current services to their needs.

A Wolf in Sheep's Clothing: Reuse of Routinely Obtained Laboratory Data in Research.

Electronic health records (EHRs) contain valuable data for reuse in science, quality evaluations, and clinical decision support. Because routinely obtained laboratory data are abundantly present, often numeric, generated by certified laboratories, and stored in a structured way, one may assume that they are immediately fit for (re)use in research. However, behind each test result lies an extensive context of choices and considerations, made by both humans and machines, that introduces hidden patterns in the data. If they are unaware, researchers reusing routine laboratory data may eventually draw incorrect conclusions. In this paper, after discussing health care system characteristics on both the macro and micro level, we introduce the reader to hidden aspects of generating structured routine laboratory data in 4 steps (ordering, preanalysis, analysis, and postanalysis) and explain how each of these steps may interfere with the reuse of routine laboratory data. As researchers reusing these data, we underline the importance of domain knowledge of the health care professional, laboratory specialist, data manager, and patient to turn routine laboratory data into meaningful data sets to help obtain relevant insights that create value for clinical care.

Potential barriers in lipid-lowering treatment with PCSK9 inhibitors from a healthsystem perspective. Comparative evidence from ten countries

Abstract Background Gaps between clinical guidelines and attainment of LDL-C goals are evident across jurisdictions. Despite strong evidence of benefit from PCSK9-inhibitors (PCSK9i) treatment in eligible patients, significant underuse remains, suggesting considerable unmet need in clinical outcomes optimization. Purpose We investigated key performance endpoints across 10 countries to provide a comparative assessment of potential barriers in PCSK9i therapeutic integration from a healthcare system perspective. Methods We performed secondary analysis of peer-reviewed literature, health technology assessment reports, guidelines, clinical pathways since 2015 and constructed a comparative framework of pre-defined endpoints for 10 study countries (Japan, Italy, Spain, Australia, Canada, United Kingdom, Germany, France, Netherlands, USA). We identified 8 endpoints, which were clustered in 3 domains: (a) healthcare system characteristics, (b) demand-side policies, (c) medicine reimbursement policies, pertaining to cost-sharing. Approved PCSK9i indications were in scope. Results PCSK9i are reimbursed in all countries. Prescribing restrictions have been applied in all countries (Table 1). PCSK9i for primary prevention are reimbursed mainly in familial hypercholesterolemia, while additional criteria may apply depending on country and condition. PCSK9i are: (a) reserved mainly for very high- or high-risk cohorts (Japan, UK, Netherlands); (b) reimbursed for secondary prevention when additional risk factors/comorbidities exist (Australia, Germany, Netherlands); (c) recommended as 3rd line in 6 countries, as 2nd line in 3 and alone or in combination with other therapies in the USA; and (d) restricted to specialist prescribing while general practitioners cannot initiate treatment in 6 countries, potentially increasing waiting times and underuse rates. Follow-up periods may apply prior to establishing eligibility and vary from 3–12 months, while prior authorization/eligibility documentation may be necessary adding to administrative burden. Age criteria may apply in determining or continuing reimbursement (e.g. max 80 years in Italy). Regional and insurance plan variations apply in Canada and USA, respectively. LDL-C reimbursement thresholds are applied in 7 countries. Their relevance to guideline-recommended goals suggests potential underuse gaps (Fig. 1). While no threshold applies in Germany, an additional criterion of indication for LDL-apheresis determines eligibility. Cost-sharing ranges between 0–30% in co-insurance models, may include a flat fee, a deductible or combination of these. Conclusion Restrictions in the use of PCSK9i from marketing authorization labels are implemented in all 10 countries and differ across key endpoints. Significant differences exist between guideline-recommended LDL-C goals and reimbursement thresholds, while additional prescribing and documentation restrictions apply over reimbursed indications, contributing to potential underuse. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Amgen Inc.

Clinical expert consensus document on the use of percutaneous left ventricular assist devices during complex high-risk PCI in India using a standardised algorithm.

Over the past decade, percutaneous left ventricular assist devices (pLVAD), such as the Impella microaxial flow pump (Abiomed), have been increasingly used to provide haemodynamic support during complex and high-risk revascularisation procedures to reduce the risk of intraprocedural haemodynamic compromise and to facilitate complete and optimal revascularisation. A global consensus on patient selection for the use of pLVADs, however, is currently lacking. Access to these devices is different across the world, thus, individual health care environments need to create and refine patient selection paradigms to optimise the use of these devices. The Impella pLVAD has recently been introduced in India and is being used in several centres in the management of high-risk percutaneous coronary intervention (PCI) and cardiogenic shock. With this increasing utilisation, there is a need for a standardised evaluation protocol to guide Impella use that factors in the unique economic and infrastructural characteristics of India's health care system to ensure that the needs of patients are optimally managed. In this consensus document, we present an algorithm to guide Impella use in Indian patients: to establish a standardised patient selection and usage paradigm that will allow both optimal patient outcomes and ongoing data collection.

Determinants of basic childhood vaccination coverage in European and OECD countries

ABSTRACT Vaccination coverage varies between countries and over time. Using official databases, we extracted data on 50 national-level immunization, socio-economic, demographic, healthcare, and cultural factors, and the uptake of the third dose of diphtheria toxoid, tetanus toxoid, and pertussis vaccines (DTP3) and the first dose of measles-containing vaccines (MCV1) for 61 countries between 1990 and 2019. The main branch of the analysis included all covariates, while a secondary branch excluded life-expectancy and child mortality. The statistical analysis was completed in three stages: a variable-selection stage via random forests; multilevel multiple imputation for missing data in the reduced dataset; and generalized estimating equations (GEE) over all imputed datasets with pooled results. Less than 20 covariates were retained after variable-selection. Among a relatively small number of statistically significant (p-value <.05) effects in the pooled GEE results of our main branch, under-5 mortality and long-term orientation culture showed negative associations with both uptake outcomes and GDP per capita a positive association. For MCV1, whether a second dose was integrated into routine immunization appeared as the overall strongest negative correlate. In the secondary analytical branch, results were largely consistent, with a few additional statistically significant effects emerging, mainly related to immunization and healthcare system characteristics. These insights improve our understanding of the main factors influencing vaccine uptake, some of which are broadly contextual (e.g., GDP, socio-cultural factors), requiring bespoke vaccine program approaches, in order to maximize childhood vaccine uptake over time.

COVID-19 therapies for inpatients: a review and quality assessment of clinical guidelines.

Due to condensed development processes, expanding evidence and differences in healthcare system characteristics, many COVID-19 guidelines differ in their quality and treatment recommendations, which has consequences for clinical practice. This review aimed to identify COVID-19 treatment guidelines, assess their quality, and summarise their recommendations. Guidelines were identified for five therapies most commonly used among inpatients with COVID-19 (remdesivir, dexamethasone, tocilizumab, baricitinib, and casirivimab/imdevimab) from 11 countries. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool. Full details of recommendations and supporting evidence were analysed for high-quality guidelines, defined as those scoring ≥50% in Domain 3 (Rigour of Development) of AGREE-II. Overall, guidelines differed substantially in their quality and, even among high-quality guidelines using the same evidence, recommendations regarding specific therapeutics varied. Potential reasons for this heterogeneity, including the availability and consistency of clinical data, visibility of trial endpoints, and context-specific factors, are discussed.

Combining and comparing regional SARS-CoV-2 epidemic dynamics in Italy: Bayesian meta-analysis of compartmental models and global sensitivity analysis.

During autumn 2020, Italy faced a second important SARS-CoV-2 epidemic wave. We explored the time pattern of the instantaneous reproductive number, R0(t), and estimated the prevalence of infections by region from August to December calibrating SIRD models on COVID-19-related deaths, fixing at values from literature Infection Fatality Rate (IFR) and average infection duration. A Global Sensitivity Analysis (GSA) was performed on the regional SIRD models. Then, we used Bayesian meta-analysis and meta-regression to combine and compare the regional results and investigate their heterogeneity. The meta-analytic R0(t) curves were similar in the Northern and Central regions, while a less peaked curve was estimated for the South. The maximum R0(t) ranged from 2.15 (South) to 2.61 (North) with an increase following school reopening and a decline at the end of October. The predictive performance of the regional models, assessed through cross validation, was good, with a Mean Absolute Percentage Error of 7.2% and 10.9% when considering prediction horizons of 7 and 14 days, respectively. Average temperature, urbanization, characteristics of family medicine and healthcare system, economic dynamism, and use of public transport could partly explain the regional heterogeneity. The GSA indicated the robustness of the regional R0(t) curves to different assumptions on IFR. The infectious period turned out to have a key role in determining the model results, but without compromising between-region comparisons.