Decentralized Health Care System Research Articles

A Wearable Capacitive Sensor Based on Ring/Disk-Shaped Electrode and Porous Dielectric for Noncontact Healthcare Monitoring.

Wearable sensors are gradually enabling decentralized healthcare systems. However, these sensors need to be closely attached to skin, which is unsuitable for long‐term dynamic health monitoring of the patients, such as infants or persons with burn injuries. Here, a wearable capacitive sensor based on the capacitively coupled effect for healthcare monitoring in noncontact mode is reported. It consists of a ring‐shaped top electrode, a disk‐shaped bottom electrode, and a porous dielectric layer with low permittivity. This unique design enhanced the capacitively coupled effect of the sensor, which enables a high noncontact detectivity of capacitance change. When an object approaches the sensor, its capacitance change (ΔC/C i = −38.7%) is 3–5 times higher than that of previously reported sensors. Meanwhile, the sensor is insensitive to the stretching strain and pressure (ΔC/C i < 5%) due to the unique ring‐shaped electrode and the incompressible closed cells of the porous dielectric material, respectively. Finally, various human physiological signals (pulse and respiratory) are recorded in noncontact mode, where a person wears loose and soft clothes implanted with the sensor. Thus, it is promising to build smart healthcare clothes based on it to develop wearable decentralized healthcare systems.

Direct preparation of dialysate from tap water via osmotic dilution

Preparation of dialysate for hemodialysis (or dialysis) requires dilution of the dialysis concentrate with purified water. Present practice contains two steps: first to purify water, and then water is transported to clinic to mix with the dialysate concentrate before treatment. As a new forward osmosis dialysis hybrid process, based on osmotic dilution, is evaluated for decentralized health care systems. A commercial cellulose triacetate (CTA) and a tailor-made thin film composite (TFC) polyamide FO membranes were examined. The rejection of salts in tap water by the FO membranes was investigated, and the real rejections of various ions as a function of permeate flux were well described by using a irreversible thermodynamic model. The hollow fiber TFC FO membrane showed higher water flux and lower reverse salt flux than the CTA membrane in diluting process. Both steric hindrance and electrostatic repulsion explained the rejection behavior of the membranes to the ions. Higher rejections of anions were obtained than cations, which was attributed to the anions selection characteristics of the membranes. No obvious foulings or scalings were observed in a relatively long time osmotic dilution process over 5 repeated cycles. The stable, high efficient osmotic dilution process in hemodialysis holds a strong promise in reducing the consumption of purified water or even eliminating the water purification step. This work provides a potentially new platform hemodialysis which can be portable and implementable away from major hospitals and major clinics.

Patient access to voice prostheses and heat and moisture exchangers: Factors influencing physician’s prescription and reimbursement in eight European countries

ObjectivesPatient access to the voice prosthesis and heat and moisture exchanger (HME) is not always guaranteed in Europe. Therefore, the aim of this qualitative study is to evaluate factors influencing physician's prescription and reimbursement of these devices in eight European countries, and to identify barriers of and facilitators to effective patient access. Materials and methodsIn this mixed methods study, we conducted a survey among stakeholders evaluating prescription (Part 1 of the survey), reimbursement (Part 2), and barriers of and facilitators to effective patient access (Part 3). Part 1 was completed by head and neck surgeons employed in France, Germany, the United Kingdom, Italy, Spain, Belgium, the Netherlands and Poland. Part 2 and 3 were completed by medical device company representatives in respective countries, followed by semi-structured interviews. ResultsBased on the survey, filled in by 36 surgeons, all prescribed the voice prosthesis. Four surgeons didn't prescribe the HME in Italy and Poland due to lack of both reimbursement and experience/training, and feeling uncomfortable with device use. Most restrictive factors (e.g. increased workload, insufficient staff) occurred in countries with decentralized healthcare systems including Spain and Italy. ConclusionNon-HME-usage was influenced by economical and physician-related factors. Restrictive factors were related to limited regional device reimbursement and provision. Nationwide reimbursement, guideline implementation, support for physicians by training/education and providing a rehabilitation team will increase device use.

Decentralized Governance in the Management of Urban Health Care Systems in Developing Countries

Enhanced Health care services address not only one of the key Sustainable Development Goals (SDG) which is goal No 3, but also the development strategies for most developing countries. Good governance is critical to improving health care systems. Many developing countries therefore have decentralized health care systems as a way of improving good governance and as a means of attaining improved access to and delivering quality health care services to both urban and rural population. Decentralization involves the extent of planning, management and decision making from national to lower levels of government. From the 1990s the capacity of governments in developing countries to deliver public goods and services was stretched to the extent there was dire for partnerships. The Public Private Partnerships (PPP) therefore became fundamental in the provision of health services under decentralization. The nature of PPP differed from country to country and the level of decision making within each level of government. The paper has discussed the extent to which decentralized governance has facilitated the management of health care systems in the urban centres through Public Private Partnership initiatives, by conducting a comparative case study analysis of existing literature on urban health care systems under different forms of decentralized governance in Kenya, Uganda, Ghana and India, respectively. The study established that access to health care services differed with forms of decentralization. Secondly, there were more public private partnerships in devolved governments which also registered higher improvement in access to health care services in urban centres. The paper concluded that the more the involvement of public private partnership, the better health care services in terms of access was noted.

Redefining the State in Health Care Policy in Italy and the United States

In highly decentralized political systems such as in Italy and the United States of America (US), the global financial crises beginning in 2008 gave way to a more assertive role of the central government in policy areas including health. In the Italian National Health Service, the central government intensified cost containment, partially recentralizing policy‐making and limiting the autonomy of Regions with high deficits. In the predominantly private health system of the US, crisis ushered in dramatic federal health reform in 2010. This study asks, what role did financial crisis and an analogous intergovernmental context surrounding health care play in explaining the (re)centralization observed between two highly divergent health system types? We examine evidence particularly with a view to the concept of regulatory hybridization (Rothgang et al., 2010) and the larger explanatory model of health care system change put forth by Schmid, Cacace, Götze and Rothgang (2010) and Frisina Doetter, Götze, Schmid, Cacace and Rothgang (2015). In doing so, we explore the relationship between functionalist vs. contextual variables embedded within the model. Our findings highlight the necessity to revise the concept of regulatory hybridization to allow for greater analytical focus on territorial shifts in power to understand developments in decentralized health care systems.

PHP69 - A REVIEW OF FUNDING PATHS FOR E-HEALTH SOLUTIONS IN THE EU5, US AND CANADA

Limited healthcare resources and rising demand impose a significant burden for healthcare systems sustainability. The digital revolution represents an opportunity to enhance healthcare delivery and reduce costs. The aim of this study was to identify current funding pathways of eHealth solutions in France, Germany, Italy, Spain and the United Kingdom, United States (US) and Canada. A targeted literature review was performed in Medline and Embase, complemented by ad-hoc and primary search with eHealth country experts and payers. Few sustainable paths dedicated to eHealth solutions are available. Funding options include existing paths for health technologies and services, individual arrangements with payers, temporary pilot programs or experiments with innovative care delivery and payment models. Despite various funding sources, current level of pathways implementation is rated 2 to 3 in 6-point scale. In countries with decentralised healthcare systems (Canada, Spain, Italy), funding decisions are made at regional or local levels with differences in eHealth implementation among regions. In the UK, funding decisions are usually made by regional authorities, but central funding is also possible, however it requires evidence from prior local or regional pilots. In France, a legal framework supporting regional telemedicine pilots was defined in 2009 and sustainable national funding was recently introduced for teleconsultation and tele-expertise. National paths for various health technologies and services exist in Germany, but eHealth is usually funded through selective contracts. Coverage by private health insurance companies and out-of-pocket payments represents eHealth funding opportunity in the US and Canada but private payers require an individualized approach. Funding paths for eHealth solutions are still immature. More experience is needed to assess its potential impact on healthcare organisations. Local or regional funding is most frequently observed, usually provided under temporary programs. Positive pilot outcomes may provide grounds for expanding to other regions or applying for national funding.

Medicare and the care of First Nations, Métis and Inuit.

The Canada Health Act 1984 (CHA) is considered foundational to Canada's publicly funded health care system (known as Medicare). The CHA provides for the federal transfer of funding to the provinces/territories, in exchange for provincial/territorial adherence to Medicare's key principles of universality; comprehensiveness; portability; accessibility; and, public administration. Medicare is a decentralized health care system, managed independently by Canada's 10 provincial and three territorial governments, allowing for regional adaptations to fit varying degrees of urbanity, remoteness and needs. The Act is silent on its relationship to the Indigenous health care system - what some have described as Canada's 14th health care system. The CHA has not kept pace with Indigenous self-government activities that have since spread across Canada. It has unfortunately crystallized the federal/provincial/territorial/Indigenous jurisdictional fragmentation that perpetuates health inequities and has failed to clarify these jurisdictions' obligations towards Indigenous peoples. As a result of these omissions, access to health services remains a concern for many Indigenous Canadians, resulting in poorer outcomes and premature mortality. In this paper, I argue that Medicare renewal must: make an explicit commitment to Indigenous health equity; clarify jurisdictional obligations; establish effective mechanisms for addressing areas of jurisdictional dispute and/or confusion; and explicitly recognize First Nations and Inuit health care services as integral yet distinct systems, that nevertheless must be welcomed to seamlessly work with provincial health care systems to ensure continuity of care.

At the Heart of the Matter: Developing a Statewide Approach to the Developmental Needs of Children with Congenital Heart Disease Following Early Open Heart Surgery

Background: Infants with congenital heart disease (CHD) who undergo early open heart surgery are at risk of poor neurodevelopmental outcomes, and long-term surveillance is recommended. Implementation of best-practice guidelines is challenging in a decentralised healthcare system. The Queensland Paediatric Cardiac Service (QPCS) and Statewide Child and Youth Clinical Network (QCYCN) partnered to undertake a service translation initiative, to establish an integrated statewide approach to the developmental support needs of children with CHD in Queensland.

Insufficient recruitment and premature discontinuation of clinical trials in Switzerland: qualitative study with trialists and other stakeholders.

Premature discontinuation occurs in about 25% of randomised clinical trials in Switzerland; it mainly affects investigator-initiated trials and is mostly due to problems with recruitment of patients. The aim of this study was to qualitatively investigate reasons for trial discontinuation due to poor patient recruitment and suggestions to address those reasons in the Swiss context. We conducted semi-structured interviews with trialists whose trials were discontinued because of recruitment problems, other experienced trialists, and stakeholders in clinical research in Switzerland. Interviews were audio-recorded, transcribed verbatim, and anonymised. We analysed the transcripts using deductive coding and built up themes that were continuously discussed within the research team. Of 65 invited Swiss trialists and stakeholders, 39 (60%) agreed to be interviewed and contributed to this analysis. We identified four main themes of reasons for poor recruitment: (1) Switzerland has a decentralised healthcare system with many small hospitals and few patients per hospital, many research regulations, no standardisation of medical records across hospitals, and a heterogeneous ethics assessment of study protocols. There is little collaboration of different stakeholders in clinical research and a lack of prioritisation of projects. (2) Limited human and financial resources, especially in the academic setting, compromise research questions and size of clinical trials. When funding is used up this typically triggers discontinuation of already delayed clinical trials. (3) Investigators face underdeveloped research networks and a limited collaborative attitude among clinical researchers. They typically embark on clinical studies with a great deal of optimism but insufficient preparation. (4) Swiss patients have universal health coverage and many treatment options. Negative media coverage of clinical research and a lack of accessible information for patients about ongoing clinical studies frequently make participation in clinical trials less attractive. More interactive structures and collaboration across stakeholders were mentioned as potential solutions to tackle the problems. Recruitment of participants into clinical trials in Switzerland is challenging because of various, often interlinked factors related to the Swiss health system, available funding, investigators, and patients. Common goals and concerted efforts by involved stakeholders appear necessary to achieve improvement.

Interregional patient mobility in a decentralized healthcare system

ABSTRACTInterregional patient mobility in a decentralized healthcare system. Regional Studies. Interregional patient mobility, measured as origin–destination patient flows between any two regions, is analysed within a dynamic spatial panel data framework using 2001–10 data on Italian hospital discharges. The aim is to assess the effects of the main determinants of patient flows, distinguishing between the impacts of regional health policies and those exerted by exogenous factors (geography, size, neighbouring regions, national policies). Empirical results indicate that the main drivers of mobility are regional income, hospital capacity, organizational structure, performance and technology. Moreover, neighbouring regions’ supply factors, specialization and performance largely affect mobility by generating significant local externalities.

Merger of two dispatch centres: does it improve quality and patient safety?

BackgroundDispatch centres (DCs) are considered an essential but expensive component of many highly developed healthcare systems. The number of DCs in a country, region, or state is usually based on local history and often related to highly decentralised healthcare systems. Today, current technology (Global Positioning System or Internet access) abolishes the need for closeness between DCs and the population. Switzerland went from 22 DCs in 2006 to 17 today. This study describes from a quality and patient safety point of view the merger of two DCs.MethodsThe study analysed the performance (over and under-triage) of two medical DCs for 12 months prior to merging and for 12 months again after the merger in 2015. Performance was measured comparing the priority level chosen by dispatcher and the severity of cases assessed by paramedics on site using the National Advisory Committee for Aeronautics (NACA) score. We ruled that NACA score > 3 (injuries/diseases which can possibly lead to deterioration of vital signs) to 7 (lethal injuries/diseases) should require a priority dispatch with lights and siren (L&S). While NACA score < 4 should require a priority dispatch without L&S. Over-triage was defined as the proportion of L&S dispatches with a NACA score < 4, and under-triage as the proportion of dispatches without L&S with a NACA > 3.ResultsPrior to merging, Dispatch A had a sensitivity/specificity regarding the use of lights and sirens and severity of cases of 86%/48% with over- and under-triage rates of 78% and 5%, respectively. Dispatch B had sensitivity and specificity of 92%/20% and over- and under-triage rates of 84% and 7%, respectively. After they merged, global sensitivity/specificity reached 87%/67%, and over- and under-triage rates were 71% and 3%, respectivelyConclusionsA part the potential cost advantage achieved by the merger of two DCs, it can improve the quality of services to the population, reducing over- and under-triage and the use of lights and sirens and therefore, the risk of accidents. This is especially the case when a DC with poor triage performance merges with a high-performing DC.

Thus do all. Social interactions in inappropriate behavior for childbirth services in a highly decentralized healthcare system

Empirical evidence supports the conjecture that social interactions among agents can produce both positive and negative effects. We build on this literature by exploring the role of social interactions in the hospital sector using the large incidence of cesarean sections, usually considered an inappropriate outcome in the childbirth service. In doing so, we lay out a simple model of hospitals’ behavior where the effect of peers’ behavior emerges simply by sharing the same regional health authority responsible for auditing inappropriate behavior. In this setting, enforcement congestion induces a peer effect among hospitals that could make inappropriate behaviors more likely and, as a result, could increase the excess variance among regions. Then, using a unique dataset of Italian hospitals and 2007–2012 cesarean data, we empirically investigate whether the behavior of each hospital is affected by the behavior of hospitals within the same region. Our empirical findings show a significant and strong presence of peer effects among hospitals.

Attitudes towards reforming primary care in Belgium: social network analysis in a pluralist context.

Health care policies are influenced by many groups which in turn influence each other. Our aim was to describe a network of nominated influential stakeholders and analyze how it affects attitudes to reforming primary care. Face-to-face interviews were carried out in Belgium with 102 influential people. Each respondent was asked to score solutions for improving the role of general practice in the health care system and to nominate up to six other influential stakeholders. Social network and multivariate analyses were used to describe the nomination network and its effect on attitudes to reform. The network was highly centralized and homophilous (tendency to bond with people who are similar) for language groups. Despite Belgium having a strong pluralist tradition of decision making, policy makers were central to the network (average indegree = 10.8) compared to professional representatives (6.9). Respondents supported an enhanced role for general practitioners but did not support radically new policies. Social network analysis contributes to understanding why health care reforms may languish in pluralistic, decentralized health care systems. The central position of a stakeholder in a network is related to perceived influence but does not favour a radical policy orientation. In addition, language-group homophily in the 'perceived influence network' leads to a weak coalition that only favours small-step reform.

Decentralized control of human visceral leishmaniasis in endemic urban areas of Brazil: a literature review.

ObjectivesHuman migration and concomitant HIV infections are likely to bring about major changes in the epidemiology of some parasitic infections in Brazil. Human visceral leishmaniasis (HVL) control is particularly fraught with intricacies. It is against a backdrop of decentralized health care that the complex HVL control initiatives are brought to bear. This comprehensive review aims to explore the obstacles facing decentralized HVL control in urban endemic areas in Brazil.MethodA literature search was carried out in December 2015 by means of three databases: MEDLINE, Google Scholar, and Web of Science.ResultsAlthough there have been many strides that have been made in elucidating the eco-epidemiology of Leishmania infantum, which forms the underpinnings of the national control program, transmission risk factors for HVL are still insufficiently elucidated in urban settings. Decentralized HVL epidemiological surveillance and control for animal reservoirs and vectors may compromise sustainability. In addition, it may hamper timely human HVL case management. With the burgeoning of the HIV-HVL co-infection, the potential human transmission may be underestimated.ConclusionHVL is a disease with focal transmission at a critical juncture, which warrants that the bottlenecks facing the control program within contexts of decentralized healthcare systems be taken into account. In addition, HIV-driven HVL epidemics may substantially increase the transmission potential of the human reservoir. Calculating the basic reproductive number to fine-tune interventions will have to take into consideration the specific socio-economic development context.

Health care provisions for asylum-seekers : Anationwide survey of public health authorities in Germany

Nation-wide studies on the health care situation of asylum-seekers in Germany are lacking, but decision-makers increasingly need such information. The aim of the study was to assess structures, processes and needs related to the health care provision for asylum-seekers along the continuum of reception centres to community dwellings from the perspective of the German public health authorities. A nation-wide cross-sectional mixed-methods survey was carried out. All heads of public health authorities in Germany (N= 389) were invited to complete astandardized questionnaire related to: (1) medical procedures and screening; (2) prevention and health promotion; (3) communication; (4) documentation and information; (5) coordination; (6) structural resources and needs. The quantitative survey was complemented by qualitative semi-structured interviews. In total, 123heads of public health authorities (response rate: 31,6 %) completed the questionnaire, and 29 were interviewed. Priority areas to improve the health care situation were better coordination and standardisation of care, enhancing vaccination capacities, standardised documentation, better health information exchange (in line with data protection laws), and astronger focus on afew relevant infectious diseases in the scope of compulsory health entry examinations. The instruments proved useful to assess the health care situation of asylum-seekers in adecentralized health care system. Repeated surveys with afocus on selected domains of the questionnaire could help monitor the health care situation on aregular basis.

An interdisciplinary approach to improving health research capacity in Haiti: The research training to research project model

Going Forward: Ongoing challenges: UHC can only meet its goals with the necessary human resources. Well designed and implemented programs that address the shortcomings of the SSY may incentivize graduating medical students to complete their year in rural areas, empower them to improve the quality of care they provide, and inspire them to continue caring for the underserved throughout their careers. Unmet goals: CES plans to continue expanding the program to other states so that more students can experience a truly transformative SSY. How may future program activities change as a result? Each state in Mexico’s decentralized health care system is unique, and ongoing program implementation will need to adapt to each context. Funding: Partners In Health Fundraising. Abstract #: 01ETC074

Greater patient access to immuno-oncology therapies-what can policymakers do?

Greater patient access to immuno-oncology therapies-what can policymakers do?

On the supply of China's healthcare resources in a decentralized healthcare system

The structure of China's current governance bears prominent features of fiscal decentralization. The supply of healthcare resources in China has clearly witnessed slower growth in the last two decades during which the fiscal decentralization process has taken place. Using China's provincial panel data, we examine the determinants of healthcare resource supply while paying particular attention to the role of fiscal decentralization. We find that the supply of healthcare resources is inversely related to the degree of decentralization, which, using spatial econometrics, is attributed to the presence of strategic substitutes in healthcare spending across city governments. These findings have important implications for policy makers in making fiscal arrangements among different government tiers.

The Refereess are Biased, Further Solidifying Entrenched Professional Boundaries: An Expository Dilemma of Interprofessional Work in Healthcare

The practice of teamworking in primary care among interdisciplinary medical-paramedical health professionals presents with varying depths of problematic dilemmas. For a typical tertiary teaching hospital in Ghana with a decentralized healthcare system, the professional dilemma is one which is juxtaposed between the refereeing public media advocacy as to ‘who is who’ and ‘influence’ in government at policy level and who the ‘marginalized’ professional groups apparently turns to. This dilemma is further expatiated through very strong legitimate professional turf protective boundaries from all parties involved in primary care; doctors, pharmacists, nurses and other paramedics. The multifaceted healthcare delivery system in Ghana is one that amply demonstrates this and empirical ethnographic evidence depicts a call for the media, legal and quasi-legal forums to be referees in adjudicating ‘who is who’ or can be key player(s) in healthcare teams. Consequentially, this paper depicts that, the referees (public: media, legal and quasi-legal forums) though external to the healthcare team membership, apparently unwittingly are making and have made one health professionals’ grouping win this debate through an all too common perceptible reality. Furthermore, those health groupings expressing a sense of being marginalized interestingly seeks, and turns to these referees.

Multi-tier drugs assessment in a decentralised health care system. The Italian case-study

ObjectiveTo investigate the organisation and decision-making processes of regional and local therapeutic committees in Italy, as a case-study of decentralised health care systems. MethodsA structured questionnaire was designed, validated, and self-administered to respondents. Committee members, prioritisation, assessment process and criteria, and transparency of committees were investigated. ResultsThe respondents represent 100% of the 17 regional committees out of 21 regions (in 4 regions there is not any regional formulary), 88% of the 16 hospital networks and 42% of the 183 public hospitals. The assessment process appears fragmented and may take a long time: drugs inclusion into hospital formularies requires two steps in most regions (regional and local assessment). Most of the therapeutic committees are closed to industry and patients associations involvement. Prioritisation in the assessment is mostly driven by disease severity, clinical evidence, and the absence of therapeutic alternatives. Only 13 out of the 17 regional committees have a public application form for drugs inclusion into regional formulary. Regional and local committees (i) often re-assess the clinical evidence already evaluated at central level and (ii) mostly rely on comparative drug unit prices per DDD and drug budget impact. The level of transparency is quite low. ConclusionsThe Italian case-study provides useful insights into an appropriate management of multi-tier drugs assessment, which is particularly complex in decentralised health care systems, but exists also in centralised systems where drugs are assessed by local therapeutic committees. A clear definition of regulatory competences at different levels, a higher collaboration between central, regional and local actors, and increased transparency are necessary to pursue consistency between central policies on price and reimbursement and budget accountability at the regional and local levels.