Decentralized Health Care System Research Articles

Future Strategic Priorities of the Swiss Decentralized Healthcare System: A COVID-19 Case Study.

The COVID-19 pandemic exposed a multitude of vulnerabilities in Switzerland's decentralized healthcare system and highlighted the urgent need to strengthen Switzerland's capacity to respond to health crises and disease outbreaks. In this article, we draw on three distinct areas of analysis of the current functioning of the Swiss healthcare system to examine its strengths and weaknesses, which can serve as a basis for future considerations and strategic priorities. First, we analyze the different levels of nine non-pharmaceutical interventions (NPIs), as defined by the ETH KOF Stringency Index and implemented in the Swiss cantons of Zurich, Vaud, and Ticino, compared with the rate of positive COVID-19 cases, hospitalizations, and deaths. We find that there was no strong correlation between the severity of the nine non-pharmaceutical interventions implemented and lower rates of positive COVID-19 cases, hospitalizations, and deaths. Second, we examine the challenges of Switzerland's decentralized healthcare system through a literature review and with empirical data obtained from semi-structured interviews with health professionals in Switzerland. We conclude our analysis with the role of central authorities during the COVID-19 pandemic. The results demonstrate that during a national emergency in Switzerland, taking into account other factors that influence the success of a pandemic strategy, there is an opportunity for a more unified, centralized response to reduce the social and economic toll of the pandemic without necessarily risking greater health damage. We recommend that the Swiss federal government use a combination of decentralized and centralized public health and policy approaches and promote greater private-public collaboration with direct communication channels among policymakers, public health stakeholders, and the public to improve pandemic preparedness and response.

High-frequency HbA1c testing among older patients with diabetes in Japan: a longitudinal analysis using medical claims data.

We aimed to determine the rate of high-frequency HbA1c testing among older Japanese patients (≥ 75years) with type 2 diabetes who did not have diabetic complications and were not using insulin, and to explore its influencing factors and association with the number of hospital admissions. A retrospective, longitudinal observation study design based on medical claims data between 2015 and 2020 was adopted. We tracked patients for 3years to describe the annual rate and determine factors associated with high-frequency HbA1c testing using a hierarchical logistical model. We employed a zero-inflated Poisson model to examine the association between frequency of HbA1c testing and the number of hospitalizations. Among 6594 patients included (mean age 80.4years), the rates of high-frequency HbA1c testing in the first, second, and third year were 10.2%, 4.8%, and 4.7%, respectively. Follow-up year [odds ratio (OR) = 0.54, 95% confidence interval (CI) = 0.49-0.59];insulin use (OR = 1.63, 95% CI = 1.26-2.11); multi facility for HbA1c testing (OR = 5.51, 95% CI = 4.66-6.51); more than 48 outpatient days per year (OR = 2.13, 95% CI = 1.81-2.51); hospitalizations (OR = 0.66, 95% CI = 0.55-0.79); two or more classes of antidiabetic agents at baseline (OR = 1.32, 95% CI = 1.11-1.56); and dementia at baseline (OR = 0.70, 95% CI = 0.51-0.97) were significantly associated with high-frequency HbA1c testing. No significant association between frequent HbA1c testing and the number of all-cause hospitalizations was found. We revealed a high rate of HbA1c testing among older Japanese patients with type 2 diabetes in ambulatory care and indicated that high-frequency HbA1c testing was more likely to result from the decentralized healthcare system and its structure.

COVID-19 Medical and Pharmacological Management in the European Countries Compared to Italy: An Overview.

(1) Background: Italy accounts for more than 150,000 deaths due to the COVID-19 pandemic, leading the top rank in SARS-CoV-2-caused deceases in Europe. A survey on the different ways by which the COVID-19 pandemic emergency was managed in the foreign European countries compared to Italy is the purpose of this paper. (2) Methods: A literature search and various mathematical algorithms to approach a rank scoring scale were used to describe in detail the different approaches used by European countries to manage the COVID-19 pandemic emergency. (3) Results: The study showed that Italy stands at the bottom ranking for COVID-19 management due to its high mortality rate. Possible causes of the observed huge numbers of hospitalization and deaths were (a) the demographic composition of the European country; (b) its decentralized healthcare system organization; (c) the role of correct pharmacology in the early stages before hospitalization. Post-mortem examinations were of paramount importance to elucidate the etiopathogenesis of COVID-19 and to tailor a suitable and proper therapy in the early symptomatic stages of COVID-19, preventing hospitalization. (4) Conclusions: Factors such as the significant impact on elderly people, the public health organization prevalently state-owned and represented mainly by hospitals, and criticism of the home therapy approach toward SARS-CoV-2-infected people, may have concurred in increasing the number of COVID-19 deaths in Italy.

DDMIA: Distributed Dynamic Mutual Identity Authentication for Referrals in Blockchain-Based Health Care Networks

Patients go to multiple healthcare providers for treatment, and their health data is generally distributed among providers. The distributed health data and the decentralized health care system structure make it ideal for blockchain-based health information systems. The authors consider the referral use case; for instance, a patient goes to his primary health Centre (PHC) for treatment and is referred to a hospital. Authentication is usually done using certificates or key cryptography, which could become cumbersome when multiple parties are involved in a healthcare interaction. The security requirements were defined, and a novel multi-party, mutual patient identity authentication scheme called “Distributed Dynamic Mutual Identity Authentication (DDMIA)” was proposed for the referral use case in a blockchain-based e-health network. The DDMIA enables the PHC to authenticate the patient to the referred hospital. The DDMIA scheme was designed using Elliptic Curve Cryptography. It was proven to be secure by assuming the hardness of the elliptic curve discrete log problem (ECDLP) and Elliptic curve computational Diffie–Hellman problem (ECDH) using CK-Model. The formal security analysis using BAN logic proved that the sessions are secure after authentication. The DDMIA scheme was simulated in the AVISPA tool and proven safe against all active attacks. DDMIA scheme was simulated in the AVISPA tool and proven safe against all active attacks. The scheme allows a patient to be authenticated by multiple parties without registering with all parties. It eliminates the need for multiple registration centers as well as digital certificates. Hence, the DDMIA scheme can be implemented for similar multiparty authentication requirements in blockchain-based networks.

A Collateral Sensor Data Sharing Framework for Decentralized Healthcare Systems

Healthcare is one of the largest domains across the globe both in terms of employment and income generation. It is continuously evolving and exploiting new technological dimensions to incorporate innovations for providing universal health coverage. Sharing of data collected by various sensors deployed at the patient’s end is a growing solicitude in healthcare as the privacy of the personal healthcare data is of paramount importance. In this paper, a blockchain based healthcare framework is proposed to address the problems related to the sensor-based patient vital body parameters collection, monitoring, secured data storage and sharing among different stakeholders. This framework uses Internet of Medical Things (IoMT) devices interfaced with MAX30205 (human body temperature), and a blood pressure including heart-rate measuring device to collect the patient vital parameters. A Markov state chain is modeled to monitor the patient medical states through various phases during the treatment and monitoring process. Application layer protocols MQTT, CoAP, and AMQP are evaluated for latency and packet loss during data transfers. Ethereum permissioned blockchain is used to deploy the proposed model. Smart contracts provide access control only to authorized users. A comparative analysis is provided in the end to highlight the merits of the proposed model over the existing similar methods. Due to the parallelism and use of blockchain, the system reports 80% improvement in terms of nodes and transaction scalability compared to the existing systems.

COVID-19 Testing in Sweden During 2020-Split Responsibilities and Multi-Level Challenges.

Sweden's use of soft response measures early in the COVID-19 pandemic received a good deal of international attention. Within Sweden, one of the most debated aspects of the pandemic response has been COVID-19 testing and the time it took to increase testing capacity. In this article, the development of and the debate surrounding COVID-19 testing in Sweden during 2020 is described in detail, with a particular focus on the coordination between national and regional actors in the decentralised healthcare system. A qualitative case study was carried out based on qualitative document analysis with a chronological presentation. To understand COVID-19 testing in Sweden, two aspects of its public administration model emerged as particularly important: (i) the large and independent government agencies and (ii) self-governing regions and municipalities. In addition, the responsibility principle in Swedish crisis management was crucial. Overall, the results show that mass testing was a new area for coordination and involved a number of national and regional actors with partly different views on their respective roles, responsibilities and interpretations of the laws and regulations. The description shows the ambiguities in the purpose of testing and the shortcomings in communication and cooperation during the first half of 2020, but after that an increasing consistency among the crucial actors. During the first half of 2020, testing capacity in Sweden was limited and reserved to protect the most vulnerable in society. Because mass testing for viruses is not normally carried out by the 21 self-governing regions responsible for healthcare and communicable disease prevention, and the Public Health Agency of Sweden stated that there was no medical reason to test members of the public falling ill with COVID-like symptoms, the responsibility for mass testing fell through the cracks during the first few months of the pandemic. This article thus illustrates problems associated with multi-level governance in healthcare during a crisis and illustrates the discrepancy between the health service's focus on the individual and the public health-oriented work carried out within communicable disease control.

Province-Wide Stool Color Card Screening for Biliary Atresia in Lower-Saxony: Experiences with Passive Distribution Strategies and Results

Background: Stool color card (SCC) screenings for biliary atresia (BA) have shown to improve Kasai timing and outcome significantly. Both obligatory and non-obligatory screenings with passive distribution strategies have proven to be effective. Therefore, we have initiated a voluntary SCC program and aim to describe our experience. Methods: Since 2017 we supply all maternity wards in Lower-Saxony with SCC. Attending pediatricians and parents of BA infants were contacted via questionnaires and asked for their evaluation of the SCC screening. Results: 85.2% of attending pediatricians support the SCC screening, but only 78.1% considered the initiative useful. In their clinical routine, only 67% of visiting parents report to have received an SCC at the maternity hospital. In the group of parents of BA infants, only 54% (7/13) had received an SCC. Out of those seven parents, only one had referred their child to a children’s hospital based on pathological SCC results. The lack of SCC education in the maternity hospitals was made responsible by parents. Within three years, only one infant with BA was identified through the SCC. Conclusions: Our voluntary SCC screening shows serious limitations with inacceptable distribution of SCCs and low acceptance of attending pediatricians. SCC programs in decentralized health care systems without educational campaigns, standardized diagnostic and treatment algorithms and the definition of reference centers are additional burdens for local health care providers without the promised benefit.

Contingency Planning and Early Crisis Management: Italy and the COVID-19 Pandemic

This study examines the level of preparedness exhibited through strategy, planning and organization to deal with the COVID-19 pandemic in Italy. A comparative analysis of four regions revealed that the implementation of pandemic plans was affected by multiple factors. For instance, some planning was outdated and insufficient to cope with the new threat posed by the pandemic; due to a decentralized health care system, there was confusion about whether regional or national decision-making was the coordinating actor; shortages in supplies and equipment such as masks, in some regions, were due to lack of implementation of existing pandemic plans. The study emphasizes the importance of a coordinated response to crises.

Medical big data for smart healthcare

As most people expect, the COVID-19 pandemic will change our life radically. One of the directions is expected to minimize off-line contacts in daily lives and healthcare is surely not the exception. Big hospitals, which are centralized systems evolved to deliver healthcare most effectively, can become the media of the spread of diseases in some cases and the adoption of a decentralized healthcare system will be a helpful strategy to prevent it. This strategy can be implemented through a smart healthcare system, and it will be one more necessity of a smart healthcare system in our society. Smart healthcare, which will be delivered mainly through online contact, is a very comprehensive concept enabling otherwise not possible healthcare such as health monitoring using life-log data from the wearable device and far beyond the online consultation with a doctor. Although there will be many social, ethical, and technical challenges for smart healthcare, the discussion today will be limited to two challenges, interoperability and protecting the data subjects' rights. Smart healthcare needs to collect and process comprehensive health information from a vast number of data subjects during its development and delivery and the data subjects' rights are highly vulnerable during these processes. Collecting and exchanging health information from various sources such as hospitals, clinics, smartwatches, and so on, inevitably raises the issue of interoperability of the data from different sources. The implementation of smart healthcare requires technical solutions to both challenges. General Data Protection Regulation, recently issued by the EU, deals the data subjects' rights very seriously, such as the right to be informed, the right of access, the right to rectification, the right to erasure, the right to restrict processing, the right to data portability, the right to object, and the rights in relation to automated decision making and profiling. Technical innovations required to protect these data subjects' rights will be discussed here. Compared to traditional healthcare which mostly dealt with medical data generated within the healthcare facility itself, smart healthcare requires health data beyond the healthcare facilities. Not to mention the life-log data from different wearable devices, even the medical data from different hospitals are not interoperable. Although many health information standards have been proposed, such as Systematized Nomenclature of Medicine Clinical Terms (SMOMED CT), Logical Observation Identifier Name Code (LOINC), Health Level 7 Fast Healthcare Interoperability Resources (HL7 FHIR), and so on, the adoption of these standards in hospital information system in Korea has been very slow. This low adoption of health information standards in our hospital information system obstructs the so-called, meaningful use of electronic medical records. The necessity of adopting health information standards will be refreshed today. Smart healthcare requires the active participation of health consumers and active participation of health consumers requires their health literacy. Health literacy of health consumers will be fostered by innovative technical aids such as data visualization, the decision support system for consumers, and more. Health literacy will the most powerful driving force of smart healthcare implementation.

To Swab or Not to Swab? The Lesson Learned in Italy in the Early Stage of the COVID-19 Pandemic

Testing for the SARS-CoV-2 infection is critical for tracking the spread of the virus and controlling the transmission dynamics. In the early phase of the pandemic in Italy, the decentralized healthcare system allowed regions to adopt different testing strategies. The objective of this paper is to assess the impact of the extensive testing of symptomatic individuals and their contacts on the number of hospitalizations against a more stringent testing strategy limited to suspected cases with severe respiratory illness and an epidemiological link to a COVID-19 case. A Poisson regression modelling approach was adopted. In the first model developed, the cumulative daily number of positive cases and a temporal trend were considered as explanatory variables. In the second, the cumulative daily number of swabs was further added. The explanatory variable, given by the number of swabs over time, explained most of the observed differences in the number of hospitalizations between the two strategies. The percentage of the expected error dropped from 70% of the first, simpler model to 15%. Increasing testing to detect and isolate infected individuals in the early phase of an outbreak improves the capability to reduce the spread of serious infections, lessening the burden of hospitals.

Catastrophic Health Expenditure, Distress Financing and Impoverishment due to Out-of-Pocket Expenses for Healthcare among Patients with Chronic Liver Disease: A Cross-sectional Study among Hospitalized Patients in Bangladesh

Out-of-pocket (OOP) expenses for hospitalized patients with chronic liver disease (CLD) poses an economic challenge on affected household in the form of catastrophic health expenditure (CHE), distress financing and impoverishment. OOP Expenses data for hospitalized CLD patients from Bangladesh is scarce. This study aimed to estimate the OOP expenses and resulting CHE, distress financing and impoverishment among hospitalized patients with CLD. This cross-sectional study was conducted among conveniently selected 107 diagnosed CLD patients admitted at Bangabandhu Sheikh Mujib Medical University (BSMMU) and Dhaka Medical College Hospital (DMCH) aged 18 years and above. Data were collected from the respondents using a semi-structured questionnaire through face to face interview during discharge from hospital. Out of pocket expenditure for chronic liver disease in selected hospitals was Bangladeshi Taka (BDT) 19,262. Direct medical, direct non-medical and indirect cost was BDT 16,240; 2,165 and 1,510, respectively. Investigation cost and medicine cost contributed to 48.48% and 31.81% of the total OOP expenses, respectively. At 10% threshold level, 29% of the respondents were affected by CHE. 64.5% of the respondents were facing distress financing due to OOP expenses. Among the respondents, 1.9% slipped below the international poverty line of $1.90 (BDT 161.10, in 2019).There was statistically significant (p < 0.05) difference among the mean OOP expenses for different etiological types of chronic liver disease. The study concluded that it requires establishing a more accessible and affordable decentralized health care system for CLD treatment along with the implementation of financial risk protection.

Blockchain‐based patient centric health care communication system

SummaryThe rapid increase in health care data breaches with the existing centralized systems emphasizes a decentralized health care system while ensuring reliability, privacy, security, and trust. Further, to ensure trust in the medical community, scientist, and pharmaceutical, it is essential to improve the quality of health care data management. In this direction, we proposed a blockchain‐based decentralized privacy‐preserving EMR management (DPEM), which can ensure accountability and integrity. We propose a four‐layered framework for DPEM consisting of a data preparation layer, access control and security layer, data sharing layer, and data storage layer with the objectives: (i) To provide privacy‐preserving in DPEM, we propose a new elliptic curve‐based content extraction signature (EC‐CES) through which patients can exclude EMR's sensitive information to eradicate leakage of privacy information in the data sharing process. (ii) To provide secure data sharing, blockchain smart contracts are used to define the predefined access permissions of the patients. (iii) To provide secure storage, we use a cloud facility to store actual EMRs, and consortium blockchain is used to store respective indexes of EMRs so that the data leakages of EMRs could be optimized and simultaneously, indexes in consortium blockchain will take care the integrity of EMRs. (iv) To provide access control in data sharing, we adopted ciphertext‐policy attribute‐based encryption (CP‐ABE) access control policy to empower the owners of data to secure the cloud storage and give access to authorized users through the encrypted link to the cloud storage with access control policies blinded. Finally, the security analysis demonstrates that DPEM is an optimized way of achieving EMRs secure data sharing.

Three-Year Trends of Healthcare-Associated Infections and Antibiotic Use in Acute Care Hospitals: Findings from 2016-2018 Point Prevalence Surveys in Sicily, Italy.

Repeated point prevalence surveys (PPSs) of healthcare-associated infections (HAIs) and antibiotic use are crucial to monitor trends over years at regional level, especially in countries with decentralized healthcare systems. Here, we reported the results of three PPSs conducted in Sicilian acute care hospitals (Italy) from 2016 to 2018, according to the European Centre for Disease Prevention and Control protocol. Overall, prevalence of patients with at least one HAI was 5.1% in 2016, 4.7% in 2017, and 5.1% in 2018, without a significant trend over years (p = 0.434). At the patient level, the most important factor associated with HAIs was antibiotic use, since patients receiving at least one antimicrobial were more likely to be infected than those who did not receive antimicrobials (OR = 18.87; 95%CI = 13.08–27.22). The analysis of the prevalence of antibiotic use indicated a significant trend across years of the PPSs: 50.5% of patients received at least one antimicrobial agent in 2016, 55.2% in 2017, and 53.7% in 2018 (p < 0.001). The most common indication for antimicrobial prescription was medical prophylaxis, while third-generation cephalosporins represented the most frequently used class of antimicrobial agents, followed by fluoroquinolones and combinations of penicillins. Our study confirms that HAIs still remain a major public health issue, which could be intensified by antibiotic abuse. This raises the need for infection prevention and control and antibiotic stewardship programs aimed to improve knowledge about appropriate antibiotic prescription and to reduce the use of broad-spectrum antimicrobials.

Health system adaptation to climate change: a Peruvian case study.

Despite mitigation attempts, the trajectory of climate change remains on an accelerated path, with devastating health impacts. As a response to the United Nations Framework Convention on Climate Change call for National Adaptation Plans, Peru has developed a national and decentralized regional adaptation plans. The purpose of this article is to understand the role and priority status of health within the adaptation planning and process. Peru was used as a case study to analyse the policy process in the creation of adaptation plans, encompassing the need to address climate change impacts on health with a particular focus on marginalized people. An actor, content and context policy analyses were conducted to analyse 17 out of 25 regional adaptation plans, which are available. The national adaptation plans (2002, 2015) do not include health as a priority or health adaptation strategies. In a decentralized health care system, regional plans demonstrate an increased improvement of complexity, systematization and structure over time (2009-17). In general, health has not been identified as a priority but as another area of impact. There is no cohesiveness between plans in format, content, planning and execution and only a limited consideration for marginalized populations. In conclusion, the regional departments of Peru stand on unequal footing regarding adapting the health sector to climate change. Findings in the strategies call into question how mitigation and adaption to climate change may be achieved. The lack of local research on health impacts due to climate change and a particular focus on marginalized people creates a policy vacuum. The Peruvian case study resembles global challenges to put health in the centre of national and regional adaptation plans. In-depth cross-country analysis is still missing but urgently needed to learn from other experiences.

Coronavirus infection COVID-19. Scientific challenges and possible ways to treat and prevent the disease

The COVID-19 pandemic has exposed pain points of decentralized healthcare systems in the global world and a failure in scientific systems analysis of old and new infections. Eighteen years ago severe acute respiratory syndrome (SARS) was underestimated and etiopathogenetic research conducted around the world was not used to develop effective treatments and prevention of the disease. Moreover, the anti-epidemic tactics in the recommendations of the World Health Organization and national health systems in the fight against the pandemic were inconsistent and relied on the historical experience of the influenza pandemic and other epidemics of respiratory infections with an emphasis on the study of the biology of the pathogen and the adaptation of society to establish biological and social balance with it.The study of the SARS-CoV-2 virus (severe acute respiratory syndrome-related coronavirus 2) from the point of view of its origin, genome, mutated strains, damaging factors in cell culture in vitro and autopsies in experimental animals and humans in foci of infection in no way answers the question of the reasons for the various responses of the host, including asymptomatic carriage with/without the formation of an immune response; definition of syndromic complexes and their periodization; options for the uncomplicated and complicated course of the disease; outcomes, including recovery with/without the formation of specific immunity and thanatogenesis, with the search for evidence of direct or indirect involvement of SARS-CoV-2 virus in adverse outcomes.The underestimation of the host's responses to the effects of beta-coronavirus has led to syndromic polypharmacy using more than 30 drugs with anti-inflammatory, antiviral, antibacterial, anticoagulant, immunosuppressive, and other effects, including passive immunotherapy with plasma of recovered patients or therapeutic exchange plasmapheresis. Seven months of the fight against COVID-19 led, as one would expect, to the proven effect of only tough anti-epidemic measures, personal protective measures and hygiene in the absence of effective treatment and prevention measures. In fact, an empirical selection of national and international treatment protocols with a combination of non-specific syndromic drugs is underway in the world.The critical review discusses scientific data and hypotheses of the origin of a new coronavirus infection, human ontogenetic response to infection with SARS-CoV-2, and emerging bioinformatic concepts of the pathogenesis of the disease and approaches to pathogenetic treatment.

Investigating the geographic disparity in quality of care: the case of hospital readmission after acute myocardial infarction in Italy

Unwarranted variation in the quality of care challenges the sustainability of healthcare systems. Especially in decentralised healthcare systems, it is crucial to understand the drivers behind regional differences in hospital qualities such as unplanned readmissions. This paper examines the factors that influence the risk of unplanned hospital readmission and the geographic disparity of readmission rate in Italy. We use hospital discharge data from 2010 to 2015 for patients above 65 years old admitted with Acute Myocardial Infarction. Employing hierarchical models, we identified the patient and hospital-level determinants for unplanned readmission. In line with the literature, the risk of readmission increases with age and being male, while hospitals with higher patient volume and capacity tend to have lower unplanned readmission. In particular, we find that after patient risk-adjustments, there are differential effects of hospitalisation length-of-stay on the probability of readmission across the hospitals that are governed by different payment systems. For hospitals under a prospective payment system, the effect of length-of-stay in reducing the probability of readmission is weaker than hospitals under an ex-post global budget, but the overall readmission rates are the lowest. Moreover, there are substantial geographic variations in readmission rate across Local Health Authority and regions, and these variations of unplanned readmission are explained by differences in hospital length-of-stay and surgical procedures used. Our results demonstrate that differential hospital behaviours can be one of the potential mechanisms that drive geographic quality disparities.

A policy analysis of the chronic care policies in Belgium

Abstract Introduction Chronic diseases form the largest burden of disease in European countries. Redesign of health systems towards chronic integrated care is needed, with more collaboration between first and second line, between medical and social services and support to prevention and self-management. What are the levers for change in such health systems? This study addresses this knowledge gap, through a policy analysis of barriers and facilitators for change towards chronic integrated care. Methods 26 central level stakeholders were selected, based upon their influence in regulation and policy, financing, health care provision and community representation. Semi-structured face-to-face interviews were held covering assessment of past and current policies and implementation, barriers and opportunities for change. Results Reforms have taken place, such as the stimulation of local initiatives for chronic integrated care projects and the set-up of local care councils. Most stakeholders assessed the current Belgium's implementation of integrated care as low, despite a growing awareness for the need for change. A context factor often mentioned to constrain implementation was a state reform which led to a partial decentralization, fragmentation of decision power and a division of healthcare competences between federal and federated levels. Other barriers were the current financing system, the lack of investments in new models of care and the vested interests of providers. Discussion This analysis shows that chronic care reform in Belgium is constrained by partial decentralization of primary health care, and by the financing system and vested interests. It points to the need for coordination of health policy making and implementation. Disentangling the levels of decision-making and the financial leverage at these levels gives insights for change and change management, for the Belgium health system and other countries with a strong decentralized system. Key messages The current Belgium’s implementation of integrated care was assessed as low, due to different contexts factors such as division of health care competencies between different governmental levels. In a country as Belgium with a strong decentralized health care system coordination of health policy making and implementation is key in order to scale up integrated care for chronic diseases.

Global Dialysis Perspective: Argentina.

Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal government–sponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient …

Nudges against pandemics: Sweden’s COVID-19 containment strategy in perspective

ABSTRACT Sweden’s strategy to contain the COVID-19 pandemic stands out internationally as more liberal in terms of not ordering a complete lockdown of society. Sweden kept its primary schools, daycare centers and industries largely open. The government financially supported furloughed workers and increased its support to regional and local governments delivering healthcare and elderly care. However, the death toll in Sweden which passed 4000 by late May 2020 stands in stark contrast to those of other, comparable countries, raising questions about the design of the strategy, and its appropriateness. The paper argues that key assumptions sustaining the strategy, for instance that symptom-free people do not carry, and cannot transmit the Coronavirus, or that local and regional government staff had the necessary training and equipment to tackle the pandemic, along with problems associated with coordinating a decentralized healthcare system, may explain the poor performance of the Swedish containment strategy.

Are burn centers in German-speaking countries prepared to respond to a burn disaster? Survey-based study

Burn disasters present a challenge not only to burn centers but the entire healthcare system. Most burn centers worldwide are unprepared to deal with a burn disaster as it is an uncommon event. We investigated the status of burn center preparedness in German-speaking countries to respond to a burn disaster. Self-administered survey questionnaires were sent to the directors of burn centers; the questions of survey used before in a similar way in Belgium were translated into German language. Of the 46 questioned burn centers, 32 (78%) responded, including all of the German adult burn centers. A clear difference in the preparation status of the burn centers in the three countries was observed due to geopolitical factors such as decentralized healthcare systems. However, the healthcare system is generally well-prepared concerning command, transfer, and capacity to provide sustained supplies to handle a massive influx of patients. Nevertheless, there are some gaps in the areas of planning and preparation, funding for disaster activities, and regular training of staff for burn disasters. We call for a unified burn disaster plan and increased cooperation between burn centers and civil defense regarding communication and training. We strongly recommend the implementation of a special disaster fund and telemedicine in disaster management to circumvent shortages in burn staff.