Decision Makers In Health-care Systems Research Articles

Makkah healthcare cluster response, challenges, and interventions during COVID-19 pandemic: A qualitative study

BackgroundThe global COVID-19 crisis has underscored the critical role of effective decision-making in healthcare systems. Saudi Arabia has shown resilience by implementing comprehensive testing, tracing, and vaccination measures. Given the unique cultural and religious characteristics of Makkah, specific challenges have prompted efforts to uncover local pandemic responses. This qualitative assessment aims to delineate the challenges faced by decision-makers during COVID-19 in Makkah and identify key interventions implemented by the Makkah healthcare cluster to manage and coordinate care. MethodUtilizing a purposive sampling approach, executive leaders within the Makkah Healthcare Cluster were invited for semi-structured interviews during the COVID-19 period. Thematic analysis was carried out in five steps, ensuring rigor and trustworthiness through multiple checks, and employing a critical and collaborative approach. ResultThroughout the COVID-19 outbreak in Makkah, participants revealed Several factors that have hindered healthcare organizations' ability to effectively manage the pandemic, including testing difficulties, resource shortages, vaccination misconceptions, continuity of care issues, infections among healthcare workers, and the need for consistent protocols. The participant leaders in Makkah's healthcare cluster specified implemented strategies that helped in overcoming the encountered challenges, such as adopting new technologies, enhancing communication, managing supply and demand, and improving workforce adaptability and development. Their experience in managing Hajj and Umrah provided valuable insights for handling the pandemic effectively. ConclusionThe study emphasizes the significance of technology adoption, effective communication, supply management, workforce development, and lessons from managing religious events. Its findings have implications for healthcare systems globally, emphasizing the importance of preparedness, response, and resilience in diverse cultural contexts.

COVID-19 Disruption To Routine Health Care Services: How 8 Latin American And Caribbean Countries Responded.

Latin America and the Caribbean was one of the regions hardest hit globally by SARS-CoV-2. This qualitative exploratory study examined how the COVID-19 pandemic disrupted the delivery of routine health services from the perspective of health care system decision makers and managers. Between May and December 2022, we conducted forty-two semistructured interviews with decision makers from ministries of health and health care managers with responsibilities during the COVID-19 pandemic in eight countries in Latin America and the Caribbean. On the basis of these interviews, we identified themes in three domains: impacts on the provision of routine health services, including postponed and forgone primary care and hospital services; barriers to maintaining routine health services due to preexisting structural health care system weaknesses and difficulties attributed to the pandemic; and innovative strategies to sustain and recover services such as public-private financing and coordination, telemedicine, and new roles for primary care. In the short term, policy efforts should focus on recovering postponed services, including those for noncommunicable diseases. Medium- and long-term health care system reforms should strengthen primary care and address structural issues, such as fragmentation, to promote more resilient health care systems.

Determinants of Employee Performance in Healthcare Organization: The Role of Work Environment, Workload, and Motivation

This study aims to determine the impact of work environment, workload, and work motivation on employee performance. The study focused on employees working at a hospital in Jakarta, and data was collected through a voluntary questionnaire from 112 respondents. The analytical method used was multiple linear regression, and hypothesis testing revealed that work environment, workload, and work motivation have a combined effect on healthcare employee performance. This study provides valuable insights for decision-makers in healthcare systems, health organizations, and government agencies to enhance the quality and efficiency of health services. It also highlights the importance of maintaining a favorable work environment, including the physical environment and workload, for employee well-being.

Priority setting in the German healthcare system: results from a discrete choice experiment.

Worldwide, social healthcare systems must face the challenges of a growing scarcity of resources and of its inevitable distributional effects. Explicit criteria are needed to define the boundaries of public reimbursement decisions. As Germany stands at the beginning of such a discussion, more formalised priority setting procedures seem in order. Recent research identified multi-criteria decision analysis (MCDA) as a promising approach to inform and to guide decision-making in healthcare systems. In that regard, this paper aims to analyse the relative weight assigned to various criteria in setting priority interventions in Germany. A discrete choice experiment (DCE) was employed in 2015 to elicit equity and efficiency preferences of 263 decision makers, through six attributes. The experiment allowed us to rate different policy interventions based on their features in a composite league table (CLT). As number of potential beneficiaries, severity of disease, individual health benefits and cost-effectiveness are the most relevant criteria for German decision makers within the sample population, the results display an overall higher preference towards efficiency criteria. Specific high priority interventions are mental disorders and cardiovascular diseases.

Predicting the evolution of COVID-19 mortality risk: A Recurrent Neural Network approach

Background:In December 2020, the COVID-19 disease was confirmed in 1,665,775 patients and caused 45,784 deaths in Spain. At that time, health decision support systems were identified as crucial against the pandemic. Methods:This study applies Deep Learning techniques for mortality prediction of COVID-19 patients. Two datasets with clinical information were used. They included 2,307 and 3,870 COVID-19 infected patients admitted to two Spanish hospitals. Firstly, we built a sequence of temporal events gathering all the clinical information for each patient, comparing different data representation methods. Next, we used the sequences to train a Recurrent Neural Network (RNN) model with an attention mechanism exploring interpretability. We conducted an extensive hyperparameter search and cross-validation. Finally, we ensembled the resulting RNNs to enhance sensitivity. Results:We assessed the performance of our models by averaging the performance across all the days in the sequences. Additionally, we evaluated day-by-day predictions starting from both the hospital admission day and the outcome day. We compared our models with two strong baselines, Support Vector Classifier and Random Forest, and in all cases our models were superior. Furthermore, we implemented an ensemble model that substantially increased the system’s sensitivity while producing more stable predictions. Conclusions:We have shown the feasibility of our approach to predicting the clinical outcome of patients. The result is an RNN-based model that can support decision-making in healthcare systems aiming at interpretability. The system is robust enough to deal with real-world data and can overcome the problems derived from the sparsity and heterogeneity of data.

Assessment of Adult Women With Ovarian Masses and Treatment of Epithelial Ovarian Cancer: ASCO Resource-Stratified Guideline.

PURPOSETo provide expert guidance to clinicians and policymakers in three resource-constrained settings on diagnosis and staging of adult women with ovarian masses and treatment of patients with epithelial ovarian (including fallopian tube and primary peritoneal) cancer.METHODSA multidisciplinary, multinational ASCO Expert Panel reviewed existing guidelines, conducted a modified ADAPTE process, and conducted a formal consensus process with additional experts.RESULTSExisting sets of guidelines from eight guideline developers were found and reviewed for resource-constrained settings; adapted recommendations from nine guidelines form the evidence base, informing two rounds of formal consensus; and all recommendations received ≥ 75% agreement.RECOMMENDATIONSEvaluation of adult symptomatic women in all settings includes symptom assessment, family history, and ultrasound and cancer antigen 125 serum tumor marker levels where feasible. In limited and enhanced settings, additional imaging may be requested. Diagnosis, staging, and/or treatment involves surgery. Presurgical workup of every suspected ovarian cancer requires a metastatic workup. Only trained clinicians with logistical support should perform surgical staging; treatment requires histologic confirmation; surgical goal is staging disease and performing complete cytoreduction to no gross residual disease. In first-line therapy, platinum-based chemotherapy is recommended; in advanced stages, patients may receive neoadjuvant chemotherapy. After neoadjuvant chemotherapy, all patients should be evaluated for interval debulking surgery. Targeted therapy is not recommended in basic or limited settings. Specialized interventions are resource-dependent, for example, laparoscopy, fertility-sparing surgery, genetic testing, and targeted therapy. Multidisciplinary cancer care and palliative care should be offered.Additional information can be found at www.asco.org/resource-stratified-guidelines. It is ASCO's view that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Measuring the sustainability and resilience of blood supply chains

Blood supply chains (BSCs) play a strategic and crucial role in healthcare systems especially in unexpected situations such as earthquakes and pandemic outbreaks. Nevertheless, measuring the sustainability and resilience of BSCs is a major challenge for many decision-makers in healthcare systems. To this end, this paper presents an advanced network data envelopment analysis (NDEA) method to evaluate the sustainability and resilience of BSCs. We deal with BSCs, including blood collection centers (BCCs), blood production centers (BPCs), and blood distribution centers (BDCs). A new directional distance function (DDF) is also developed for evaluating both the overall and stage efficiency scores. Our proposed model can deal with different types of data, including integers, undesirable outputs, negative, zero, and positive. The undesirable outputs are the outputs that adversely impact the performance of DMUs. Moreover, the developed method addresses the sustainability and resilience of BSCs. A case study is provided to demonstrate the usefulness of the proposed model.

The use of innovative payment mechanisms for gene therapies in Europe and the USA.

Innovative reimbursement mechanisms have long been considered potential solutions to the data uncertainty associated with one-off, high-value gene therapies that have long-term therapeutic potential, combinedwith limited supporting evidence at launch. The launches of increasing numbers of such gene therapies in Europe and the USA in the past 5years provide valuable exemplars of how innovative reimbursement mechanisms are used by healthcare system decision makers in practice. This review details the use of such reimbursement schemes for recently launched gene therapies in key European countries and the USA, and shows that they are more widespread in Europe than in the USA. Although innovative payment schemes are increasingly used across countries, differences in healthcare system structures (e.g., single- vs multi-payer systems) and willingness to pay mean that decision makers in different countries have different incentives to manage uncertainties around long-term, real-world product value.

Healthcare workers’ perspectives on participatory system dynamics modelling and simulation: designing safe and efficient hospital pharmacy dispensing systems together

With increasingly complex safety-critical systems like healthcare being developed and managed, there is a need for a tool that permits decision-makers to better understand the complexity, test various strategies and guide effective changes. System Dynamics (SD) modelling is an effective approach that can aid strategic decision-making in healthcare systems but has been underutilised partly due to the challenge of engaging healthcare stakeholders in the modelling process. This paper, therefore, investigates the applicability of a participatory SD approach based on healthcare workers’ perspectives on ease of use (usability) and usefulness (utility). The study developed an interactive simulation dashboard platform which facilitated participatory simulation for exploring various hospital pharmacy staffing level arrangements and their impacts on interruptions, fatigue, workload, rework, productivity and safety. The findings reveal that participatory SD approach can enhance team learning by converging on a shared mental model, aid decision-making and identifying trade-offs. The implications of these findings are discussed as well as experience and lessons learned on modelling facilitation. Practitioner Summary: This paper reports the perspectives of healthcare workers, who were engaged with a participatory system dynamics modelling and simulation process for hospital pharmacy staffing level management. Evaluative feedback revealed that the participatory SD approach can be a valuable tool for participatory ergonomics by helping the participants gain a deeper understanding of the complex dynamic interactions between workload, rework, safety and efficiency. Abbreviations: SD: system dynamics; ETTO: efficiency-thoroughness trade-off

Treatment of Patients With Early-Stage Colorectal Cancer: ASCO Resource-Stratified Guideline.

PURPOSETo provide resource-stratified, evidence-based recommendations on the treatment and follow-up of patients with early-stage colorectal cancer.METHODSASCO convened a multidisciplinary, multinational Expert Panel that reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus process with additional experts for one round of formal ratings.RESULTSExisting sets of guidelines from 12 guideline developers were identified and reviewed; adapted recommendations from six guidelines form the evidence base and provide evidence to inform the formal consensus process, which resulted in agreement of 75% or more on all recommendations.RECOMMENDATIONSFor nonmaximal settings, the recommended treatments for colon cancer stages nonobstructing, I-IIA: in basic and limited, open resection; in enhanced, adequately trained surgeons and laparoscopic or minimally invasive surgery, unless contraindicated. Treatments for IIB-IIC: in basic and limited, open en bloc resection following standard oncologic principles, if not possible, transfer to higher-level facility; in emergency, limit to life-saving procedures; in enhanced, laparoscopic en bloc resection, if not possible, then open. Treatments for obstructing, IIB-IIC: in basic, resection and/or diversion; in limited or enhanced, emergency surgical resection. Treatment for IIB-IIC with left-sided: in enhanced, may place colonic stent. Treatment for T4N0/T3N0 high-risk features or stage II high-risk obstructing: in enhanced, may offer adjuvant chemotherapy. Treatment for rectal cancer cT1N0 and cT2n0: in basic, limited, or enhanced, total mesorectal excision principles. Treatment for cT3n0: in basic and limited, total mesorectal excision, if not, diversion. Treatment for high-risk patients who did not receive neoadjuvant chemotherapy: in basic, limited, or enhanced, may offer adjuvant therapy. Treatment for resectable cT3N0 rectal cancer: in enhanced, base neoadjuvant chemotherapy on preoperative factors. For post-treatment surveillance, a combination of medical history, physical examination, carcinoembryonic antigen testing, imaging, and endoscopy is performed. Frequency depends on setting. Maximal setting recommendations are in the guideline. Additional information can be found at www.asco.org/resource-stratified-guidelines.NOTICEIt is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guidelines are intended to complement but not replace local guidelines.

Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline.

PurposeThe purpose of this new resource-stratified guideline is to provide expert guidance to clinicians and policymakers on implementing palliative care of patients with cancer and their caregivers in resource-constrained settings and is intended to complement the Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update of 2016.MethodsASCO convened a multidisciplinary, multinational panel of experts in medical oncology, family medicine, radiation oncology, hematology/oncology, palliative and/or hospice care, pain and/or symptom management, patient advocacy, public health, and health economics. Guideline development involved a systematic literature review, a modified ADAPTE process, and a formal consensus-based process with the Expert Panel and additional experts (consensus ratings group).ResultsThe systematic review included 48 full-text publications regarding palliative care in resource-constrained settings, along with cost-effectiveness analyses; the evidence for many clinical questions was limited. These provided indirect evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% (by consensus ratings group including Expert Panel).RecommendationsThe recommendations help define the models of care, staffing requirements, and roles and training needs of team members in a variety of resource settings for palliative care. Recommendations also outline the standards for provision of psychosocial support, spiritual care, and opioid analgesics, which can be particularly challenging and often overlooked in resource-constrained settings. Additional information is available at www.asco.org/resource-stratified-guidelines.It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Abstract 202: Outcomes of Region-Wide Cardiac Rehabilitation

Background: Cardiac rehabilitation (CR) is recommended for patients with cardiovascular disease, however the impact of a region-wide, centrally managed CR model with local non-medical community-based delivery of CR is unknown in a universal health care system setting. Objectives: To determine the impact of a regional 6-month, once per week supervised exercise session CR model on mortality and re-hospitalization compared to a matched control within a regional health care system. Methods: The regional CR service comprised: a standardized regional referral strategy for patients with established cardiac disease including stable heart failure, local (within a 30-minute drive time from place of residence) CR service delivery by trained CR professionals. Patient data that was prospectively entered into a regional CR database for patients referred to CR from 2012 through 2014, was linked to government mandated administrative databases and all-cause mortality and hospitalization rates were compared between patients who were referred to CR vs. a matched cohort who were not. Matching included age, sex, year of referral, socioeconomic status, and cardiac condition at hospital discharge. Mortality and re-hospitalization were assessed at 1-yr post index cardiac event excluding the initial 6-month period to account for immortal time bias. Results: Fewer patients who completed CR compared to matched controls died (14/1,318 or 1.1% vs. 31/1,318 or 2.4%, p=0.011), or were readmitted to hospital (128 or 9.7% vs. 190 or 14.4%, p<0.001). Fewer patients who started but did not complete CR (CR non-completers) died compared to matched controls (10/639 or 1.6% vs. 21/639 or 3.3%, p=0.045), however there was no difference in hospital readmission rates between CR non-completers compared to matched controls (18.0% vs. 14.9%, p=0.13). More patients who were referred to CR but did not enroll in CR, died compared to matched controls (241/3,933 or 6.1% vs. 196/3,933 or 5.0%, p=0.027), or were readmitted to hospital (932 or 23.7% vs. 643 or 16.3%, p<0.001). Conclusions: In a universal health-care system, patients who completed a regionally coordinated, locally delivered, standardized CR program close to home, experienced lower mortality or re-hospitalization rates compared to matched patients not referred to CR. This association was not likely due to a referral bias as patients who were referred to CR but did not enroll in CR faired worse, not better, compared to matched non-CR referred patients. Health care system decision makers (e.g. provincial governments in Canada) should strongly consider funding regional CR strategies.

Evidence-based management of Caribbean health systems: barriers and opportunities

PurposeThe purpose of this paper is to explore and assess barriers and opportunities for evidence-based management (EBMgt) and decision-making in healthcare systems of the small island developing states (SIDSs) of English-speaking Caribbean.Design/methodology/approachThe study utilized grounded theory to collect and analyze data on experiences and perceptions of 20 senior managers/leaders from seven Ministries of health in the region. It used semi-structured, in-depth interviews comprising open-ended questions. Data analysis comprised open, focused and theoretical coding.FindingsEBMgt and decision-making is not a prominent approach taken by top officials of health systems because of internal and external barriers to its use. Indeed the absence of a culture of decision-making based on evidence pervades the public services of Caribbean island states. Notwithstanding, there are opportunities for meaningful application of this management/leadership strategy.Originality/valueTo the author’s knowledge, this is the first assessment of the application of EBMgt to health systems of SIDSs of the Caribbean. This paper is concerned with the approach to decision-making in health systems across island states and lends support to the use of evidence in decision-making and policy development. It provides useful direction for policy makers, and senior managers/leaders of these systems.

Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline.

PurposeTo provide resource-stratified (four tiers), evidence-based recommendations on the primary prevention of cervical cancer globally.MethodsThe American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group) for one round of formal ratings.ResultsExisting sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%.RecommendationsIn all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus–related cancers and diseases. Basic settings: vaccinating boys is not recommended.It is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Secondary Prevention of Cervical Cancer: ASCO Resource-Stratified Clinical Practice Guideline.

PurposeTo provide resource-stratified, evidence-based recommendations on the secondary prevention of cervical cancer globally.MethodsASCO convened a multidisciplinary, multinational panel of oncology, primary care, epidemiology, health economic, cancer control, public health, and patient advocacy experts to produce recommendations reflecting four resource-tiered settings. A review of existing guidelines, a formal consensus-based process, and a modified ADAPTE process to adapt existing guidelines were conducted. Other experts participated in formal consensus.ResultsSeven existing guidelines were identified and reviewed, and adapted recommendations form the evidence base. Four systematic reviews plus cost-effectiveness analyses provided indirect evidence to inform consensus, which resulted in ≥ 75% agreement.RecommendationsHuman papillomavirus (HPV) DNA testing is recommended in all resource settings; visual inspection with acetic acid may be used in basic settings. Recommended age ranges and frequencies by setting are as follows: maximal: ages 25 to 65, every 5 years; enhanced: ages 30 to 65, if two consecutive negative tests at 5-year intervals, then every 10 years; limited: ages 30 to 49, every 10 years; and basic: ages 30 to 49, one to three times per lifetime. For basic settings, visual assessment is recommended as triage; in other settings, genotyping and/or cytology are recommended. For basic settings, treatment is recommended if abnormal triage results are present; in other settings, colposcopy is recommended for abnormal triage results. For basic settings, treatment options are cryotherapy or loop electrosurgical excision procedure; for other settings, loop electrosurgical excision procedure (or ablation) is recommended. Twelve-month post-treatment follow-up is recommended in all settings. Women who are HIV positive should be screened with HPV testing after diagnosis and screened twice as many times per lifetime as the general population. Screening is recommended at 6 weeks postpartum in basic settings; in other settings, screening is recommended at 6 months. In basic settings without mass screening, infrastructure for HPV testing, diagnosis, and treatment should be developed.Additional information can be found at www.asco.org/rs-cervical-cancer-secondary-prev-guideline and www.asco.org/guidelineswiki.It is the view of of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement, but not replace, local guidelines.

Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline Summary

PurposeToprovideevidence-based,resource-stratifiedglobalrecommendationstocliniciansandpolicymakers on the management and palliative care of women diagnosed with invasive cervical cancer. Methods ASCO convened a multidisciplinary, multinational panel of cancer control, medical and radiation oncology,healtheconomic,obstetricandgynecologic,andpalliativecareexpertstoproducerecommendations reflectingresource-tieredsettings.Asystematicreviewofliteraturefrom1966to2015failedtoyieldsufficiently strong quality evidence to support basic- and limited-resource setting recommendations; a formal consensusbased process was used to develop recommendations. A modified ADAPTE process was also used to adapt recommendations from existing guidelines. ResultsFive existing sets of guidelines were identified and reviewed, and adapted recommendations form the evidence base. Eight systematic reviews, along with cost-effectiveness analyses, provided indirect evidence to inform the consensus process, which resulted in agreement of 75% or greater. Recommendations Clinicians and planners should strive to provide access to the most effective evidencebased antitumor and palliative care interventions. If a woman cannot access these within her own or neighboringcountryorregion,shemayneedtobetreatedwithlower-tiermodalities,dependingoncapacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care. For women with early-stage cervical cancer in basic settings, cone biopsy or extrafascial hysterectomy may be performed. Fertility-sparing procedures or modified radical or radical hysterectomy may be additional options in nonbasic settings. Combinations of surgery, chemotherapy, and radiation therapy (including brachytherapy) should be used for women with stage IB to IVA disease, depending on available resources. Pain controlisavitalcomponentofpalliativecare.Additionalinformationisavailableatwww.asco.org/rs-cervicalcancer-treatment-guidelineandwww.asco.org/guidelineswiki.ItistheviewofASCOthathealthcareproviders and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Management and Care of Women With Invasive Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Clinical Practice Guideline.

PurposeTo provide evidence-based, resource-stratified global recommendations to clinicians and policymakers on the management and palliative care of women diagnosed with invasive cervical cancer.MethodsASCO convened a multidisciplinary, multinational panel of cancer control, medical and radiation oncology, health economic, obstetric and gynecologic, and palliative care experts to produce recommendations reflecting resource-tiered settings. A systematic review of literature from 1966 to 2015 failed to yield sufficiently strong quality evidence to support basic- and limited-resource setting recommendations; a formal consensus-based process was used to develop recommendations. A modified ADAPTE process was also used to adapt recommendations from existing guidelines.ResultsFive existing sets of guidelines were identified and reviewed, and adapted recommendations form the evidence base. Eight systematic reviews, along with cost-effectiveness analyses, provided indirect evidence to inform the consensus process, which resulted in agreement of 75% or greater.RecommendationsClinicians and planners should strive to provide access to the most effective evidence-based antitumor and palliative care interventions. If a woman cannot access these within her own or neighboring country or region, she may need to be treated with lower-tier modalities, depending on capacity and resources for surgery, chemotherapy, radiation therapy, and supportive and palliative care. For women with early-stage cervical cancer in basic settings, cone biopsy or extrafascial hysterectomy may be performed. Fertility-sparing procedures or modified radical or radical hysterectomy may be additional options in nonbasic settings. Combinations of surgery, chemotherapy, and radiation therapy (including brachytherapy) should be used for women with stage IB to IVA disease, depending on available resources. Pain control is a vital component of palliative care. Additional information is available at www.asco.org/rs-cervical-cancer-treatment-guideline and www.asco.org/guidelineswiki. It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Letter from the new editor-in-chief: my perspective for future development

As I come onboard as editor-in-chief of the Journal of Public Health, I would like to share my thoughts with you about a vision for taking the Journal of Public Health to the next level. First and foremost, I am committed to continuing the culture of excellence and quality of the journal as admirably lead by outgoing editor-in-chief, Prof. Dr. Wilhelm Kirch (who deceased this year). Now in its 24th year, the Journal of Public Health has become a well-recognized journal in the field. Supported by the German Society of Health Sciences and Public Health, the journal is an interdisciplinary publication for advances and new approaches in international public health. In a recent survey, 90 % of the authors were satisfied with the overall publication process of the Journal of Public Health. However, we could do better! One crucial point for authors is the speed of publication. With our online first tool, articles are published before they are printed. In conjunction with shorter peer review times, we would like to become even more attractive for authors. The Journal of Public Health is listed in important indexes in the field. One challenge for the future is to find additional ways to reach decision-makers in health care systems as well. Together with the international, interdisciplinary editorial board, the Journal of Public Health aspires to serve as one of the leading publication platforms in the field. Now it’s up to you to match our efforts by submitting your best science while we take care of the rest!

A system of system lenses for leadership decision-making.

The sheer volume and dynamics among system agents in healthcare makes decision-making a daunting task at all levels. Being clear about what leaders mean by "healthcare system" is critical in aligning system strategy and leadership decision-making. This article presents an emerging set of lenses (ideology and beliefs, rational and irrational information processing, interpersonal social dynamics, process and value creation, and context) to help frame leadership decision-making in healthcare systems.

PSS9 - The Epidemiology of Medical Treatment for Glaucoma and Ocular Hypertension in Germany

The purpose of this study is to review the epidemiology and the treatment paradigm of German glaucoma population and to assess the frequency of switches from monotherapy to second- or third line combination therapy in primary open angle glaucoma (POAG) patients. Glaucoma is the second leading cause of blindness globally. The newly published EGS guidelines state that if the first choice monotherapy is well tolerated and has effective intra ocular pressure (IOP) lowering but has not succeeded in reaching the target pressure, the addition of a second drug should be considered. German patient databases were searched in the following areas: glaucoma prevalence and incidence studies in German population as well as treatment paradigm in glaucoma patients. Our analysis underlines the high number of glaucoma patients in Germany and the relevance of this disease for the German health care system. The study also demonstrates that a considerable number of glaucoma patients do not reach IOP target under monotherapy and have to be treated with a combination therapy. In general, treatment with a combination of agents of different classes is associated with superior IOP lowering efficacy. With an increasing number of available fixed dose combination products, more options become available for combination therapy of glaucoma patients. Glaucoma care needs to be given high priority in public health programs. Especially treatment options for glaucoma patients in need for a combination therapy should be in the focus of health care system decision makers as well as further research in glaucoma clinical trials and clinical care.