Federal Health System Research Articles

Case Study: Urgent Medical Care for Asylum-Seeking Infant at US-Mexico Border

A 22-month-old male presented at a triage facility within an immigration shelter with wounds, inflammation, and swelling across legs and arms; bloody and pus-filled discharge; skin discoloration, scaling, and swelling; and significant pain. His family had been released from immigration detention after migrating from Central America to the U.S. southern border. The attending triage nurse-midwife immediately transferred the patient to a local hospital for emergency care, in addition to signing the patient’s family into Specialty Care Action Network (SCAN), a pediatric component of Health Network, a virtual system for medical care coordination. After transfer to another hospital for higher level care, where he received a diagnosis of Carvajal syndrome, the patient was sufficiently stable for transport to a hospital in California, his family’s final destination. The resident physician in San Antonio, a SCAN case manager, a network of clinicians, and the medical director in California arranged for his extensive and diverse subspecialty care, through nonprofit funding and charity care in the absence of case management or care for migrants provided by federal immigration and/or health systems.

An analysis of Nepal's federal health system in the context of the COVID-19 pandemic and the Sustainable Development Goals

Nepal's public health slogan was 'Health for All' with integrated community health services in 1991. The female community health volunteer network was created. District Public health offices (DPHO) managed these programs in their districts. After 2008 federalism, 2017 brought federal, provincial, and local governments. The federal health system substituted the administrative District Public / Health Offices in districts. The local governments or health institutions now oversee the Sustainable Development Goals (SDGs). The federal and provincial authorities should have employed qualified professionals to oversee public health at local health facilities. Healthcare efficacy and goal attainment are concerns today. This study did a microscopic investigation using health system studies. The researcher conducted field observations and stakeholder interviews and participated in public discussions. Data from Nepal's federal health system's community status was compared using SWOT analysis. The study delved into specific research gaps thoroughly. According to previous research, health infrastructure could be more effective with financial expenditures. A hypothesis was formed after comparing further information to domestic and international situations. The researcher emphasizes the need for good governance and suggests allocating 6% of national GDP to health spending, in line with WHO recommendations. To fulfil the needs of the healthcare sector, deliver quality medical services, and attain SDGs, it is imperative to ensure the presence of adequately trained health professionals at the local government level. The head of the local health institution must conduct administrative work connected to public health. Hence, public health-trained health staff are needed there.

How effectively are social accountability mechanisms being applied in mental health services within the newly federalized health system of Nepal? A multi-stakeholder qualitative study

BackgroundThe burden of mental health problems and inequalities in healthcare has emerged as critical issues, in Nepal. Strengthened citizen-driven social accountability (SA) is an effective strategy for building equitable health systems and providing quality healthcare services to all, yet SA in mental health is an under-researched area in Nepal.ObjectiveThis study explores changes in mental health service delivery in the re-configured federal health system and discusses the functioning and effectiveness of SA in the federalized context of Nepal.MethodThis case study research used a qualitative approach to data collection. We conducted Key Informant Interviews (KIIs), and Focus Group Discussions (FGDs) with local stakeholders including people with experience of mental health problems. The audio-recorded interviews and discussions were transcribed and analyzed using a thematic content method.ResultsA total of 49 participants were recruited, and 17 participated in interviews and 32 participated in six focus group discussions. From the data, eight themes emerged: Policy challenges in mental health, Governance and service delivery, Tokenism in the application of social accountability processes, Weak role of key actors in promoting accountability, Complaints and response, Discriminatory health and welfare system, Public attitudes and commitment towards mental health, and No differences experienced by the change to a federal system. It was found that existing health policies in Nepal inadequately cover mental health issues and needs. The prevailing laws and policies related to mental health were poorly implemented. There is a lack of clarity at different levels of government about the roles and responsibilities in the delivery of mental health services. Poor intra- and inter-governmental coordination, and delays in law-making processes negatively impacted on mental health service delivery. SA mechanisms such as social audits and public hearings exist within government health systems, however, application of these in mental health services was found poor. Rights-holders with mental health problems had not experienced any change in the provision of healthcare services for them even after the federalization.ConclusionMental health is insufficiently addressed by the health policies in Nepal, and SA mechanisms appeared to be rarely institutionalized to promote good governance and provide effective healthcare services to vulnerable populations. The provision of more equitable services and honest implementation of SA tools may foster greater accountability and thereby better service delivery for people with mental health problems.

Selection of Study Sites and Participants for Research into Nepal’s Federal Health System

Abstract Introduction: This article offers insights into the process of selecting representative study sites and participants in a longitudinal study in Nepal. As part of the research design process, the selection of representative areas in a large-scale study requires both intellectual and practical considerations. Methods: We briefly introduce our study into the impact of federalization on Nepal’s health system before outlining the criteria considered for the identification of fieldwork sites and the most appropriate study participants for the qualitative interviews and participatory components of this research. Findings: The selected areas are presented with an overview of the areas selected and their justification. The study sites and participants should consider a broader coverage with diverse participants’ backgrounds. Several factors can influence the identification and recruitment of the right participants, including the use of appropriate gatekeepers, gaining access to recruit participants, logistical challenges, and participant follow-up. Conclusion: We conclude that longitudinal qualitative research requires a carefully selected diverse set of study sites and participants to assess the complexities and dynamics of the health system and service provision to ensure that longitudinal research is representative and effective in addressing the research question(s) being investigated.

Cesarean section rates according to the Robson Classification and its association with adequacy levels of prenatal care: a cross-sectional hospital-based study in Brazil

BackgroundThe rate of Cesarean section (CS) deliveries has been increasing worldwide for decades. Brazil exhibits high rates of patient-requested CS deliveries. Prenatal care is essential for reducing and preventing maternal and child morbidity and mortality, ensuring women's health and well-being. The aim of this study was to verify the association between the level of prenatal care, as measured by the Kotelchuck (APNCU – Adequacy of the prenatal care utilization) index and CS rates.MethodsWe conducted a cross-sectional study based on data from routine hospital digital records and federal public health system databases (2014–2017). We performed descriptive analyses, prepared Robson Classification Report tables, and estimated the CS rate for the relevant Robson groups across distinct levels of prenatal care. Our analysis also considered the payment source for each childbirth – either public healthcare or private health insurers – and maternal sociodemographic data.ResultsCS rate by level of access to prenatal care was 80.0% for no care, 45.2% for inadequate, 44.2% for intermediate, 43.0% for adequate, and 50.5% for the adequate plus category. No statistically significant associations were found between the adequacy of prenatal care and the rate of cesarean sections in any of the most relevant Robson groups, across both public (n = 7,359) and private healthcare (n = 1,551) deliveries.ConclusionAccess to prenatal care, according to the trimester in which prenatal care was initiated and the number of prenatal visits, was not associated with the cesarean section rate, suggesting that factors that assess the quality of prenatal care, not simply adequacy of access, should be investigated.

A critical analysis of health system in Nepal: Perspectives based on COVID-19 response

BackgroundNepal moved from a unitary government to a federal system of government in 2015 under its constitution. Nepal is a federal democratic republic governed by three levels of government: a federal, provincial, and local level. The response to COVID-19 in Nepal has been majorly led and controlled by the federal government. All three levels of government are performing their responsibilities; however, they face various challenges in responding to COVID-19. This study aimed to critically analyze Nepal's health system in the context of the COVID-19 response. MethodsWe conducted semi-structured in-depth interviews by telephone among the policymakers, health workers, and stakeholders at the federal, provincial, and local levels (n = 41) between January to July 2021. The interviews were audio recorded, transcribed into English, and coded using inductive-deductive approaches. ResultsCOVID-19 considerably impacted routine health care, mainly maternity services and immunization. Inadequate financial resources, inadequate human resources, and the lack of ventilators, ICUs, and X-ray services were the significant challenges in tackling and managing COVID-19 effectively. ConclusionThe study found that all three levels of government perform their roles and responsibilities and effectively manage the pandemic. The federal and provincial governments focused more on the plans and policy development, while the local government demonstrated greater accountability in implementing those plans and policies. Therefore, all three tiers of government need to coordinate together for preparing and communicating information in times of emergency. Besides, it is imperative to empower local governments to maintain Nepal's federal health system.

Opportunities and Challenges of Implementing Federal Health System in Nepal at the Time of the COVID-19 Pandemic

Nepal has been practicing the federal system in health since the promulgation of the constitution in 2015. The new three-tier system of one federal, seven provincial and 753 local governments have set up ministries, departments, and health units at each level. Less than four years into this system, the country faced the COVID-19 pandemic. The pandemic created both opportunities and challenges for the federal health system. This study aims to identify those factors from the viewpoint of implementers of the health system. After an extensive literature review, exploratory qualitative research was carried out with twenty public health workers and elected representatives from all the tiers of government, including the federal ministry and governments of Lumbini Province. The data was analyzed using the R package for Qualitative Data Analysis (RQDA). Thematic analysis was performed using the World Health Organization’s six building blocks of the health system as an analytical framework. The participants highlighted many opportunities after federalization in Nepal. The presence of government closer to people helped to make policies and plans as per local needs. Decentralized power to make decisions at the local level made human and financial resources readily available to local governments leading to better service delivery at the time of need. In contrast, the challenges were difficulty transiting into the new system of governance, poor coordination among the different government tiers, and the lack of local expertise to manage and lead the health system during severe constraints posed by the global pandemic of an unprecedented nature. The study showed that the federalization in Nepal has met the goals of devolution of the power structure and better health system management. However, there are specific areas of improvement to ensure a more functional health system.

Analytical capacity as a critical condition for responding to COVID-19 in Brazil

Abstract The coronavirus disease 2019 (COVID-19) pandemic posed several challenges to the Brazilian health system, among them the general context of ambiguity and uncertainty and the conflicting positioning of the government in power concerning scientific advice resources. Different aspects can be analyzed to explore the dynamics of strengthening and resilience of the system. This paper focuses on its analytical capacity, examining how it was developed and recently challenged. The investigation employed survey data, analysis of official documents and newspaper articles, and in-depth interviews with specialists and federal bureaucrats. The research shows the magnitude and relevance of that dimension of policy capacity in the federal health system and how it was crucial to the resilience of the system in defining the directions of the fight against COVID-19 in Brazil, although scientific-based recommendations were rejected by political leaders.

The Future of Nursing 2020–2030: Charting a path to achieve health equity

The Future of Nursing 2020–2030: Charting a path to achieve health equity

Addressing Transportation Insecurity Among Patients With Cancer.

Health-care-related transportation insecurity is common in the United States. Patients with cancer are especially vulnerable because cancer care is episodic in nature, occurs over a prolonged period, is marked by frequent clinical encounters, requires intense treatments, and results in substantial financial hardship. As a result of transportation insecurity, patients with cancer may forego, miss, delay, alter, and/or prematurely terminate necessary care. Limited data suggest that these alterations in care have the potential to increase the rates of cancer recurrence and mortality and exacerbate disparities in cancer incidence, severity, and outcomes. Transportation insecurity also negatively impacts at the informal caregiver, provider, health system, and societal levels. Recognizing that transportation is a critical determinant of outcomes for patients with cancer, there are ongoing efforts to develop evidence-based protocols to identify at-risk patients and address transportation insecurity at federal policy, health system, not-for-profit, and industry levels. In 2021, the National Cancer Policy Forum of the National Academies of Science, Engineering, and Medicine sponsored a series of webinars addressing key social determinants of health including food, housing, and transportation among patients with cancer. This commentary summarizes the formal presentations and discussions related to transportation insecurity and will 1) discuss the heterogeneous nature of transportation insecurity among patients with cancer; 2) characterize its prevalence along the cancer continuum; 3) examine its multilevel consequences; 4) discuss measurement and screening tools; 5) highlight ongoing efforts to address transportation insecurity; 6) suggest policy levers; and 7) outline a research agenda to address critical knowledge gaps.

RE-HEPATECTOMY MEANS MORE MORBIDITY? A MULTICENTRIC ANALYSIS.

ABSTRACT - BACKGROUND:Colorectal cancer generally metastasizes to the liver. Surgical resection of liver metastasis, which is associated with systemic chemotherapy, is potentially curative, but many patients will present recurrence. In selected patients, repeated hepatectomy is feasible and improves overall survival.AIM: This study aimed to analyze patients with colorectal liver metastasis (CRLM) submitted to hepatectomy in three centers from Rio de Janeiro, over the past 10 years, by comparing the morbidity of first hepatectomy and re-hepatectomy.METHODS: From June 2009 to July 2020, 192 patients with CRLM underwent liver resection with curative intent in three hospitals from Rio de Janeiro Federal Health System. The data from patients, surgeries, and outcomes were collected from a prospectively maintained database. Patients submitted to first and re-hepatectomies were classified as Group 1 and Group 2, respectively. Data from groups were compared and value of p<0.05 was considered significant.RESULTS: Among 192 patients, 16 were excluded. Of the remaining 176 patients, 148 were included in Group 1 and 28 were included in Group 2. Fifty-five (37.2%) patients in Group 1 and 13 (46.5%) in Group 2 presented postoperative complications. Comparing Groups 1 and 2, we found no statistical difference between the cases of postoperative complications (p=0.834), number of minor (p=0.266) or major (p=0.695) complications, and deaths (p=0.407).CONCLUSIONS: No differences were recorded in morbidity or mortality between patients submitted to first and re-hepatectomies for CRLM, which reinforces that re-hepatectomy can be performed with outcomes comparable to first hepatectomy.

Federal Interventions Targeting Social Isolation and Loneliness: An Exploratory Review

Even prior to the COVID-19 Public Health and Medical Emergency, the experiences of chronic social isolation and loneliness (SIL) were growing among older adults. Countries began increasing national visibility for these issues and implementing programs and services focused on addressing them. In the United States (US), however, little is known about successful national interventions or their effectiveness in tackling SIL among older Americans. We conducted a rapid review of the peer-reviewed and grey literature from 2009-2019, focusing on existing federal programs, health systems, and health care models in the US that address SIL among older adults. Of the 110 articles identified, 36 met the inclusion criteria and were synthesized. Our review found few federal interventions that directly address SIL; several may be addressing SIL as an auxiliary outcome to addressing social determinants of health, such as group exercise, transportation support, or food insecurity. While these interventions may provide a promising opportunity, implementation and evaluation challenges were identified. Thus, federal and state agencies face significant obstacles to understanding the impact of existing interventions and their effectiveness in addressing SIL, hampering progress toward large scale implementation. As SIL receives increasing attention, we add another voice to existing literature that indicates significant heterogeneity among existing programs; we found that few evidence-based, scalable federal initiatives exist in the US that target SIL. Without resources from federal and state agencies, the ability of health entities, community-based organizations, and direct care providers to implement effective interventions is significantly diminished.

Tribes are Public Health Authorities: Protecting Tribal Sovereignty in Times of Public Health Crisis

The COVID-19 pandemic has highlighted existing gaps in public health systems across the country including federal Indian health systems. Despite treaty obligations to provide health care to American Indians and Alaska Natives, the federal government has consistently underfunded Indian health facilities. Federal Indian health programming remains piecemeal, often falling victim to Congressional politics for continued funding, requiring inter-Tribal competition for grant and cooperative agreement funding, or requiring Tribal cost sharing. Tragically, but, unsurprisingly given failures in federal Indian health policy, many American Indian and Alaska Native communities have experienced health inequities throughout the pandemic. In several states, American Indians have higher rates of COVID-19 infections as well as worse health outcomes, including higher mortality, than their non-Indian counterparts. By exercising their inherent sovereignty as Tribal Nations, many Tribes have been able to mitigate failings in federal Indian health policy in their COVID-19 response. Unfortunately, reports across Indian country have found instances of state and local governments failing to adequately engage Tribal governments in public health activities, even those implicating Tribal members on Tribal lands, citing lack of Tribal public health authority. Not only is this legally inaccurate, but it also limits Tribal public health response efforts, and infringes on Tribal sovereignty.This issue brief discusses the legal authority for Tribes to serve as public health authorities. First, it describes the inherent authority of Tribes to engage in public health activities. Second, it discusses the recognition of Tribal public health authority across federal law and programs. This issue brief ends by discussing strategies to reinforce Tribal authority in times of public health crisis.

Unintended consequences of expenditure targets on resource allocation in health systems

In recent decades, several countries have reformed their health care systems leading to the devolution of power to a lower governance level and, subsequently, to re-centralisation. Due to the ambiguous results of these policies and the start of the financial crisis of 2008, a wide number of national governments implemented cutback initiatives aimed at controlling health expenditure. The literature shows that the introduction of such initiatives may have produced unintended consequences on health systems’ performance. In order to better understand the power relations and the resulting decision-making processes between national governments and local authorities, it is important to focus on the effects of such expenditure control mechanisms on the inputs of the health systems, i.e. the production factors.This research aims at investigating the effects of a cutback initiative intended to control personnel costs in a federal Beveridge health system through the analysis of resource allocation at the devolved level.The paper is based on a quantitative analysis of data resulting from the financial statements published by the 21 Italian regional health systems from 2012 to 2017.The results show that, although the Italian regional health systems managed to reduce personnel costs – i.e. hitting the target – the control of the total cost dynamic was not fully addressed. Overall, the initiative implemented by the national government had the effect of limiting the decision-making autonomy of regional authorities, pushing them toward shifting resource allocation from personnel to the purchase of services.

The 2019 Partial Government Shutdown and Its Impact on Health Care for American Indians and Alaska Natives.

The 2018-9 partial government shutdown created a 35-day gap in federal appropriations for the Indian Health Service and tribal health programs. With ongoing challenges for American Indian and Alaska Native health systems, including clinician shortages and poor health outcomes, the funding gap engendered substantial health risks. Other federal health systems have been sheltered from this and past shutdowns through receiving their appropriations in advance. Several approaches exist to implementing advance appropriations, including instituting advance appropriations across Bureau of Indian Affairs and Indian Health Service programs; or by moving Indian Health Service funding to the same appropriation as the Department of Health and Human Services. Furthermore, building and strengthening health partnerships with non-federal institutions, such as academic medical centers, may help distribute financial risk and strengthen care systems.

Job Satisfaction and Change Readiness of Public Health Workers in Context of Federal Health System of Nepal at Local Level: A Cross-Sectional Study in Banke District

Job Satisfaction and Change Readiness of Public Health Workers in Context of Federal Health System of Nepal at Local Level: A Cross-Sectional Study in Banke District

Prediction of attendance to the "60 days law" within the patient navigation program to breast cancer in Rio de Janeiro, Brazil.

e13100 Background: An applied study was conducted on how the use of machine learning techniques can help in the process of identifying compliance with the "60 Day Law", which states that all patients with cancer within the public system must initiate the treatment within 60 days after the diagnosis of cancer. Within the Patient Navigation Program (PNP) for breast cancer in Rio de Janeiro, the study aims to: 1) identify barriers to compliance with the Law; 2) ensure that at least 70% of patients recruited with breast cancer initiate treatment within the mandatory 60-day period; and 3) to construct a model that accurately predicts whether or not a patient meets the period established in the Law. Methods: From August 2017 to May 2018, 105 patients aged 33-80 years (mean 59 years) were recruited for navigation. For the development of the statistical analysis, three learning models were used AdaBoost, Decision Tree and GaussianNB. Results: Patients presented 0-I (17%), II-III (78%) and IV (5%) staging. The main barriers to compliance with the Law were fear and fatalistic thoughts (99%), financial problems (79%), and uncoordinated health care (76%).The PNP had 100% patient satisfaction and in 52% of the cases it helped at the beginning of the treatment within the period established by law. The AdaBoost learning model had superior results in relation to accuracy and f-score (0.8889 and 0.8333, respectively). Conclusions: The PNP generated a positive experience in the public health system, because it is an intentional and proactive process of individual assistance through the health system, accessing services, and actively overcoming the barriers to quality care. The study did not reach the success rate of 70% compliance with the Law as intended (having reached 52%). However, the barriers that NP cannot overcome, such as the lack of human resources and medical supplies, have been reported to health authorities and hospital administrators. We identified 38 important attributes for compliance with the Law, which simplifies the information required for model learning. In the Brazilian context, the PNP may represent an opportunity to adequately implement existing legislation and, as such, would have great potential for integration into federal, state, and local health systems. Clinical trial information: 62728616.5.0000.5274.

Abstract P5-13-15: The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil

Abstract OBJECTIVES: The main objective of this Patient Navigation Program in Rio de Janeiro (PNP Rio), Brazil, is to promote adherence to the "60 Day Law", which states that all patients with cancer within the public system should start treatment within 60 days after diagnosis of cancer. Thus, the objectives are: 1.) to establish feasibility of PNP in this setting; 2.) to identify barriers to compliance the Law of 60 days and 3.) to ensure that at least 70% of recruited breast cancer patients begin treatment within the mandated 60-day period. One report by FEMAMA states that only 30% of breast cancer patients in Rio de Janeiro to initiate treatment within the 60-day mandate. METHODS: From August 2017 to May 2018, one hundred patients aged 33-81 years (mean age 59 years) were recruited for navigation at Rio Image - an advanced breast cancer diagnosis center administered by the state health secretary and located in the capital city of Rio de Janeiro, attending patients from the public system from all 92 municipalities in the state. Patient Navigator (PN), a trained social worker, starts navigation from diagnosis, administering questionnaires to collect: patient population data, dates and information of historical milestones, and patient satisfaction. Patients were followed up by phone, e-mail or text message to identify barriers to initiation of treatment. RESULTS: Patients presented staging 0-I (17%), II-III (78%) and IV (5%). There were two deaths related to breast cancer in this group. All patients reported at least one barrier, ranging from 2 to 12 barriers (M=5). The barriers to compliance with the "Law of 60 days" were: Fear and fatalistic thoughts (99%), Financial problems (79%), Uncoordinated health care (76%), Health professionals ignore the Law of the 60 days (75%), Need to do staging exams again (52%), Concern about communicating with medical staff (52%), Transport (42%), Difficult in obtain surgical risk consultation (12%), Line of surgeries in hospitals (12%), Difficult of insertion in the regulation system in Primary Care(11%), Patient cannot express herself (5%), Social support(4%), Absent of the immunohistochemistry panel (4%), Cognitive problems (3%), Comorbidities (2%). The PNP had 100% patient satisfaction and in 60% of the cases it helped the patients to start treatment within the period established by law. CONCLUSIONS: In summary, PNP Rio generated a positive experience for patients in the public health system because it is an intentional and proactive process of assisting the individual through the cancer system, accessing services and actively overcoming barriers to quality care. The PNP Rio did not achieve the success rate of 70% of compliance with the Law as intended (achieved 60%). However, the barriers that the PN can not overcome such as lack of human resources and medical supplies, were informed to health authorities and hospital administrators. This is an opportunity for discussion of reallocation of funds, focusing on the use of scarce resources in prevention and early treatment rather than late-stage disease. In the Brazilian context, PNP may represent an opportunity to implement existing legislation adequately, and as such, would have great potential for integration at the federal, state, and local health systems. Citation Format: Gioia S, Torres C, Cavalcanti J, Brigagao L, Proencio T, Krush L, Goss P. The value of patient navigation in breast cancer being tested in Rio de Janeiro, Brazil [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-15.

Outcomes, Satisfaction, and Costs of a Rheumatology Telemedicine Program: A Longitudinal Evaluation.

Rural veterans with inflammatory arthritis (IA) lack medical access because of geographic barriers. Telemedicine (TM) holds great promise in relieving these disparities. We have prospectively measured patient-centered data surrounding a TM care program at a federal health system and compared these with usual care (UC). Veterans with previously established IA were enrolled in TM follow-up. Data collected longitudinally before and after entering the program included Routine Assessment of Patient Index Data 3 (RAPID-3), out-of-pocket visit costs and distances traveled, and patient satisfaction instruments. Demographics were recorded. Similar data were collected on a convenience sample of concurrent IA patients receiving UC. Eighty-five patients were observed, including 25 receiving TM care and 60 receiving UC. No differences in demographics, satisfaction scores, or RAPID-3 were noted at baseline between groups. Univariate linear regression of cross-sectional baseline data suggests satisfaction instrument scores were predicted by RAPID-3 (β = -0.64/10 points, p = 0.01), as well as distance (β = -0.19/100 miles, p = 0.02) and cost (β = -0.37/$100, p = 0.05). A multivariate model indicates both distance (β = -0.17/100 miles, p = 0.02) and RAPID-3 (β = -0.47/10 points, p < 0.03) were predictors for visit satisfaction. In longitudinal follow-up via TM, satisfaction (Δ = 0.03, p = 0.94) and RAPID-3 (Δ = 0.27, p = 0.89) remained similar to baseline among TM patients, whereas distance traveled (Δ = -384.8 miles/visit, p < 0.01) and visit costs (Δ = -$113.8/visit, p < 0.01) were reduced. Patient-reported outcomes for care delivered via TM were similar to UC, with significant cost and distance savings. Patient-centered factors such as distance to care should be considered in design care delivery models, as they appear to drive patient satisfaction in conjunction with disease control.

Reappraisal of Hepatocellular Adenoma from Federal Health System, Rio de Janeiro, Brazil

Background: Hepatocellular adenoma is a rare liver tumor that may require surgical treatment in cases of hemorrhage or suspicion of malignant lesions. Aim: To analyze data from patients who underwent hepatectomy for hepatocellular adenoma (HCA) in Rio de Janeiro, Brazil. Methods: From January 2005 to March 2019, sixty-nine patients with HCA underwent hepatectomy at centers in Rio de Janeiro. They were included in the analysis patients undergoing hepatectomy with pathological diagnosis of hepatocellular adenoma and excluded patients with hepatectomy with anatomopathological diagnosis other than hepatocellular adenoma, mainly nodular focal hyperplasia. Data related to patients, tumor and surgery were analyzed retrospectively. Results: Sixty patients (87%) were female and nine were male. Among women, 83% had a history of contraceptive use; among men, only one had an androgen intake history. Overall mean age was 36.4 years (15 - 49), with men older than women (33.9 ± 8.14 years vs. 40.4 ± 6.27 years; P = 0.02). Forty one patients reported abdominal pain, associated or not to other symptoms; 32% had an episode of hemorrhage; 28 were asymptomatic with an incidental radiological finding. In total, 45 patients presented only one lesion and overall mean size was 8.1 cm (2 - 31); tumors were larger among men (mean size 12.9 ± 9.86 cm vs. 7.7 ± 4.58 cm; P = 0.009). Twenty one surgeries were laparoscopic. Hepatocellular carcinoma (HCC) was identified in three specimens and the incidence was higher among men (22.2% vs. 1.6%; P = 0.042) and in tumors larger than 20 cm (66.6% vs. 0.02%). There was no perioperative mortality. Two of the three patients with HCC died with extrahepatic recurrence; the remaining patient is well after 36 months. Overall mean follow-up time was 14.2 months (2 - 76). Conclusion: Male patients with HCA were older and had larger tumors when compared to females. Incidence of HCC was higher among men and in lesions larger than 20 cm. Male patients with HCA should be treated more aggressively than females.