Different Levels Of Health System Research Articles

#4167 THE HEALTH, SOCIOECONOMIC AND ENVIRONMENTAL IMPACT OF CKD IN THE UK: BUILDING A CONCEPTUAL FRAMEWORK

Abstract Background and Aims The past three decades have seen an increase in the prevalence and mortality rate of chronic kidney disease (CKD). It is estimated that between 1990 and 2017, the global all-age prevalence of CKD increased by 29.3%, whilst the mortality rate rose by 41.5%. Over this period, CKD became the 12th leading cause of death worldwide, with an estimated 1.2 million deaths attributed to the disease in 2017 [1]. With global prevalence currently estimated at 10% [2], CKD is a leading cause of disability, accounting for 35.8 million disability-adjusted life years (DALYs) in 2017 [3]. This growing burden of the disease calls for robust healthcare policy interventions to improve disparities in health, socioeconomic, and environmental outcomes. The aim of this research is to build a Healthcare Policy framework for CKD that will analyse the drivers and components of the burden of disease in terms of clinical, socioeconomic and environmental outcomes. It will also incorporate current knowledge of best practices and challenges in the organisation of healthcare services to mitigate these burdens. The framework will facilitate the analysis of the burden of disease attributable to CKD and be used to inform further research on areas in which policies could be implemented to optimise CKD prevention, early detection, and treatment at different stages of CKD and different levels of health systems. The framework presented here reflects the UK context but can be adapted for different country contexts. Method The framework development included two stages. First, a scoping review of the literature in this field was conducted. The literature review included peer-reviewed articles, grey literature, policy documents, academic reports and congress and conference reports. The second stage saw the validation of the framework by a multidisciplinary expert panel in the UK. This expert panel was composed of eight UK experts in the fields of nephrology, public health, primary care, organ donation and transplantation, and other disciplines. Results The framework outlines a holistic patient pathway from pre-CKD development to kidney failure along with the corresponding interdisciplinary level of care. The framework stresses the need to implement a population-wide approach focused on preventative care strategies, chiefly on the risk reduction of kidney failure. Underlying aetiologies and disparities in access to care were found to be inherently linked to disease progression and health outcomes. Data systems were identified as vital to ensuring continuity of care between primary and specialty care which in turn could lead to improved patient outcomes. The use of greener energies coupled with a reduction in the incidence of renal failure requiring dialysis could reduce substantially the environmental footprint of this disease. The burden of disease reflects the sum of the individual and system-level impact and outcomes of CKD which are labelled as economic, social, and environmental (Fig. 1). Conclusion The conceptual framework underscores how underlying aetiologies, socioeconomic factors, and fragmentation of care are reflected in disparities in healthcare access, particularly in marginalised and underserved populations. The environmental footprint of this disease could be reduced through optimal standard of care. The framework can inform future research to model the burden of CKD in terms of clinical, societal, economic, and environmental outcomes in the UK and the targeting of policy interventions to mitigate these burdens across different country contexts.

Integration of Mental Health Support Teams in COVID-19 Units within French General Hospitals: A Qualitative Study.

This study aimed to explore the lived experience of mental health professionals (mhPs) who had been redeployed on support teams (MHSTs) implemented in general hospital for patients with coronavirus disease 2019 (COVID-19) and their families, in order to scale up mental and physical health care integration in times of epidemic crisis. This multicentered qualitative study followed an IPSE (Inductive Process to analyze the Structure of lived Experience) research design. MhPs' recruitment took place in three general hospitals of Seine-Seine-Denis department, in Paris suburbs (France). Twenty-two participants were included. Data analysis produced three central axes: 1) the mhP in the epidemic crisis, underlying how participants confronted the unknown and adapted; 2) retrieving fundamentals of support therapy, that were: being present and listening, bonding with patients' families, and ensuring care continuity; and 3) moving forward with other health professionals, highlighting the collaborative work they developed and experienced. The epidemic prompted mhPs to rethink the values likely to guide the integration of their intervention with other individual and organizational care stakeholders, at different levels of health system. Normative integration based on shared appraisal of patients' and families' needs is highly required to overcome the multiple and sometimes contradictory health issues inherent in the crisis. Person- and family-centered approach of integrated care (IC) is essential to address fragmentation between mental and physical health care in times of epidemic crisis. Hospital and political leaders should support and draw from bottom-up mental health IC initiatives such as MHSTs, that embody this vision, in order to improve health systems preparedness for future crises.

RETRACTED ARTICLE: A thematic analysis of system wide learning from first wave Covid-19 in the East of England

BackgroundThe Covid-19 pandemic has created an unprecedented challenge for health and social care systems globally. There is an urgent need for research on experiences of COVID-19 at different levels of health systems, including lessons from professional, organisational and local system responses, that can be used to inform managerial and policy responses.MethodsThis paper presents the findings from a thematic analysis of front-line staff experiences working across the Norfolk and Waveney integrated care system (ICS) in the East of England during April and October 2020 to address the question “What are the experiences and perceptions of partner organisations and practitioners at multiple levels of the health system in responding to COVID-19 during the first wave of the pandemic?” This question was posed to learn from how practitioners, interdependent partner organisations and the system experienced the pandemic and responded. 176 interview transcripts derived from one to one and focus group interviews, meeting notes and feedback from a “We Care Together” Instagram campaign were submitted for qualitative thematic analysis to an external research team at a regional University commissioned to undertake an independent evaluation. Three phases of qualitative analysis were systematically undertaken to derive the findings.FindingsThirty-one themes were distilled highlighting lessons learned from things that went well compared with those that did not; challenges compared with the celebrations and outcomes; learning and insights gained; impact on role; and system headlines. The analysis supported the ICS to inform and capitalise on system wide learning for integration, improvement and innovations in patient and care home resident safety, and staff wellbeing to deal with successive waves of the pandemic as well as prioritising workforce development priorities as part of its People Plan.ConclusionsThe findings contribute to a growing body of knowledge about what impact the pandemic has had on health and social care systems and front-line practitioners globally. It is important to understand the impact at all three levels of the system (micro, meso and macro) as it is the meso and macro system levels that ultimately impact front line staff experiences and the ability to deliver person centered safe and effective care in any context. The paper presents implications for future workforce and health services policy, practice innovation and research.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

PurposeAs a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.Design/methodology/approachThe authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.FindingsWithin the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.Originality/valueThis paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

A Call to Develop Standardized Guidelines for Treatment of Spasticity

Due to the lack of understanding of spasticity across different medical disciplines, the approach and treatment strategies vary considerably among clinicians. This is further disjointed in health systems around the world due to differences in training, resources and infrastructure. Spasticity guidelines available in the literature mainly focus on clinical or specialized aspects of care. The vast majority of patients in the community across the world do not have access to specialized treatment of spasticity. To meet these requirements, this article calls for professional organizations to take the initiative at the international level to develop guidelines by involving stakeholders across different levels of health systems.

Difficulties in implementation of the National Health Map in Bulgaria

Abstract Background National Health Map (NHM) of Bulgaria determines the required minimum of healthcare facilities, hospital beds and specialists at different levels of Health System to meet population's needs of healthcare. Its main objective is to adapt structure of the healthcare network to the population health needs ensuring for every Bulgarian citizen an equal access to health services. Through it healthcare resources have been planned on a territorial basis and the national health policy has been implemented. The aim of this report is to analyze the actual availability of healthcare facilities and staff, and compare with the minimum necessary according to the NHM. Methods Content and critical analysis of statistical data of the Bulgarian Ministry of Health. Results Bulgaria is among countries with relatively low number of general practitioners (GPs) among countries of EU where the range is between 42 and 253 per 100 000 inhabitants. According to the NHM, taking into account administrative division, infrastructure and morbidity, optimum GPs/population ratio is about 67/100 000 while an actual availability is 55.9/100 000. The most serious deficiency is in remote areas where the ratio is between 26 and 32 per 100 000. Quality of primary health care is affected by the fact that 23.89% of GPs are without acquired specialty. Number of practicing nurses in Bulgarian health system is 30% lower than the recommended minimum. Nurses/population ratio is unsatisfactory. Physicians/nurses ratio is not consistent with European standards. Hospital beds are 6.3/1000 which range Bulgaria among five European countries with the highest availability of hospital beds but they are unevenly distributed both on a territorial basis and on specialties. Conclusions There is a lack of human resources in Bulgarian Health System and unequal availability and accessibility of health facilities in different regions of the country. Distribution of hospital beds on specialties also must be optimized. Key messages National Health Map of Bulgaria determines population needs of accessible outpatient and hospital care, distributes health institutions on territorial bases and implements National Health Policy. Difficulties in implementation of National Health Map are insufficient number general practitioners (GPs), a large proportion of GPs without acquired specialty, inadequate ratio physicians/nurses etc.

Challenges of Payment Methods in the Iranian Health System and Solutions: A Qualitative Study

Background: The implementation of different reimbursement methods has various positive and negative effects on the health system of different countries. Identifying the challenges of these methods is essential to improve these reimbursement methods and modify them if required. This article aimed to qualitatively assess the challenges of current hospitals' payment systems in the Iranian health system and determine the required solutions for modifying these payment systems.
 Methods: This qualitative study was conducted in 2019. Semi-structured interviews were conducted recruiting 20 experts including operational, middle and top managers working in three different levels of health systems. Data collection was continued until it reached a saturation point. MAXQDA 10 was used for data analysis. The data content analysis method was used to analyze the data and the themes and categories were determined.
 Results: The challenges of the payment systems were categorized into four main themes regarding policy, cost, regulatory and functional challenges, and 15 sub-themes. The findings related to the proposed strategies were presented in six main themes consisting of legal solutions, structural reform, cost, quality improvement, service provider and client, and monitoring and evaluation; and 12 sub-themes.
 Conclusion: This study showed that the health systems in Iran face various structural and procedural challenges in terms of reimbursement mechanisms. Therefore, it is recommended that policymakers pay attention to these challenges before making any changes. Using hybrid payment systems can be one of the proper solutions.

Factors influencing the uptake of cervical cancer screening services in Tanzania: A health system perspective from national and district levels.

AimThis study aimed at examining factors influencing uptake of cervical cancer screening services among women in Tanzania.DesignExploratory qualitative study.MethodsIn‐depth interviews were used to obtain information from 10 key Informants. Of these, three were officials (policy makers) from the Reproductive Health‐Cancer Unit of Ministry of Health and Community Development, Gender, Elderly and Children (MoHCDGEC), three were health managers working at Kinondoni Municipal health system reproductive and child health section and four were health workers from the Ocean Road Cancer Institute (ORCI). The study participants were purposively selected since they hold the responsibility of planning, coordinating and implementing the Tanzania cervical cancer prevention strategies at different levels of health system. The qualitative data analysis was done manually using thematic analysis.ResultsThe national health system factors influencing the early uptake of cervical cancer screening services include poor flow of information from national to lower level and inadequate availability of tools and instruments and shortage of skilled and competent staff. The district level health systems factors influencing uptake of cervical cancer screening services include inadequate number of partners, poor flow of information, poor collaboration with the private sector, no adequate provision of cervical cancer screening services due to lack of prioritization, poor creation of awareness and failure to use the health information system effectively.

Spatial analysis of myocardial infarction in Iran: National report from the Iranian myocardial infarction registry.

Myocardial infarction (MI) is a leading cause of mortality and morbidity in Iran. No spatial analysis of MI has been conducted to date. The present study was conducted to determine the pattern of MI incidence and to identify the associated factors in Iran by province. This study has two parts. One part is prospective and hospital-based, and the other part is an ecological study. In this study, the data of 20,750 new MI cases registered in Iranian Myocardial Infarction Registry in 2012 were used. For spatial analysis in global and local, spatial autocorrelation, Moran's I, Getis-Ord, and logistic regression models were used. Data were analyzed by Stata software and ArcGIS 9.3. Based on autocorrelation coefficient, a specific pattern was observed in the distribution of MI incidence in different provinces (Moran's I: 0.75, P < 0.001). Spatial pattern of incidence was approximately the same in men and women. MI incidence was clustering in six provinces (North Khorasan, Yazd, Kerman, Semnan, Golestan, and Mazandaran). Out of the associated factors with clustered MI in six provinces, temperature, humidity, hypertension, smoking, and body mass index (BMI) could be mentioned. Hypertension, smoking, and BMI contributed to clustering with, respectively, 2.36, 1.31, and 1.31 odds ratio. Addressing the place-based pattern of incidence and clarifying their epidemiologic dimension, including spatial analysis, has not yet been implemented in Iran. Report on MI incidence rate by place and formal borders is useful and is used in the planning and prioritization in different levels of health system.

Assessment of total cardiovascular risk using WHO/ISH risk prediction charts in three low and middle income countries in Asia.

BackgroundRecent research has used cardiovascular risk scores intended to estimate “total cardiovascular disease (CVD) risk” in individuals to assess the distribution of risk within populations. The research suggested that the adoption of the total risk approach, in comparison to treatment decisions being based on the level of a single risk factor, could lead to reductions in expenditure on preventive cardiovascular drug treatment in low- and middle-income countries. So that the patient benefit associated with savings is highlighted.MethodsThis study used data from national STEPS surveys (STEPwise Approach to Surveillance) conducted between 2005 and 2010 in Cambodia, Malaysia and Mongolia of men and women aged 40–64 years. The study compared the differences and implications of various approaches to risk estimation at a population level using the World Health Organization/International Society of Hypertension (WHO/ISH) risk score charts. To aid interpretation and adjustment of scores and inform treatment in individuals, the charts are accompanied by practice notes about risk factors not included in the risk score calculations. Total risk was calculated amongst the populations using the charts alone and also adjusted according to these notes. Prevalence of traditional single risk factors was also calculated.ResultsThe prevalence of WHO/ISH “high CVD risk” (≥20% chance of developing a cardiovascular event over 10 years) of 6%, 2.3% and 1.3% in Mongolia, Malaysia and Cambodia, respectively, is in line with recent research when charts alone are used. However, these proportions rise to 33.3%, 20.8% and 10.4%, respectively when individuals with blood pressure > = 160/100 mm/Hg and/or hypertension medication are attributed to “high risk”. Of those at “moderate risk” (10- < 20% chance of developing a cardio vascular event over 10 years), 100%, 94.3% and 30.1%, respectively are affected by at least one risk-increasing factor. Of all individuals, 44.6%, 29.0% and 15.0% are affected by hypertension as a single risk factor (systolic ≥ 140 mmHg or diastolic ≥ 90 mmHg or medication).ConclusionsUsed on a population level, cardiovascular risk scores may offer useful insights that can assist health service delivery planning. An approach based on overall risk without adjustment of specific risk factors however, may underestimate treatment needs.At the individual level, the total risk approach offers important clinical benefits. However, countries need to develop appropriate clinical guidelines and operational guidance for detection and management of CVD risk using total CVD-risk approach at different levels of health system. Operational research is needed to assess implementation issues.

Health systems, communicable diseases and integration

The HIV/AIDS, tuberculosis and malaria pandemics pose substantial challenges globally and to health systems in the countries they affect. This demands an institutional approach that can integrate disease control programmes within health and social care systems. Whilst integration is intuitively appealing, evidence of its benefits remains uncertain and evaluation is beset by lack of a common understanding of what it involves. The aim of this paper is to better define integration in health systems relevant to communicable disease control. We conducted a critical review of published literature on concepts, definitions, and analytical and methodological approaches to integration as applied to health system responses to communicable disease. We found that integration is understood and pursued in many ways in different health systems. We identified a variety of typologies that relate to three fundamental questions associated with integration: (1) why is integration a goal (that is, what are the driving forces for integration); (2) what structures and/or functions at different levels of health system are affected by integration (or the lack of); and (3) how does integration influence interactions between health system components or stakeholders. The frameworks identified were evaluated in terms of these questions, as well as the extent to which they took account of health system characteristics, the wider contextual environment in which health systems sit, and the roles of key stakeholders. We did not find any one framework that explicitly addressed all of these three questions and therefore propose an analytical framework to help address these questions, building upon existing frameworks and extending our conceptualization of the 'how' of integration to identify a continuum of interactions that extends from no interactions, to partial integration that includes linkage and coordination, and ultimately to integration. We hope that our framework may provide a basis for future evaluations of the integration of programmes and health systems in the development of sustainable and effective responses to communicable diseases.