Government-funded Health Care Research Articles

A quasi-experimental study to assess the effectiveness of planned teaching program on knowledge regarding Ayushman Bharat Yojana among community people in Panchayatan village, Greater Noida, Uttar Pradesh

Background: The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) is India’s government-funded health care program that benefits more than 10.74 million poor and vulnerable families. While Pradhan Mantri Jan Arogya Yojana (PMJAY) has helped to correct state imbalances in health care spending, it has not been sufficient to compensate for the inherent fiscal difficulties of poor states. Ayushman Bharat is a holistic need-based health care service which was developed to accomplish the sustainable development goals (SDGS). The purpose of conducting this research is to assess the knowledge regarding Ayushman Bharat Yojana to the people of Panchayatan village, Greater Noida. Methods: A quasi-experimental research design and convenience sampling technique was used to assess the effectiveness of planed teaching program on knowledge regarding Ayushman Bharat Yojana among 59 community people in Panchayatan village Greater Noida. Results: The study found that majority of the samples (64.4%) was between the ages of 16-35 years, (83.1%) were having no previous knowledge and (86.4%) were having no source of information. The findings show mean value of 11.7±4.16 knowledge level regarding Ayushman Bharat Yojana. The post-test mean score was 13.7 which was greater than the pre-test means score 9.6. Results show a significant association between the knowledge scores (post-test) with age (p=0.051) and monthly income (p=0.019). Conclusions: The findings concluded that the planned teaching program on knowledge regarding Ayushman Bharat Yojana among community people in Panchayatan village was effective in increasing the knowledge among community people.

Effect of public-funded health insurances in financial protection for hospitalisation in Rajasthan state, India: Evidence from a national sample survey

BackgroundThe high burden of out-of-pocket expenditure (OOPE) in India has led to introduction of several public-funded health insurance (PFHI) programmes. This study examined the impact of PFHI on hospitalisation-related OOPE in the Rajasthan state. MethodsData from the National Sample Survey 75th round on Social Consumption (Health), were utilized for this study. The sample of Rajasthan state, consisting of 5045 households and 28,020 individuals, was analysed to determine factors associated to PFHI coverage, choice of healthcare provider and OOPE. ResultsOne third of the population was covered by PFHI. In the private facility, although PFHI reduced OOPE (INR 17000 vs 14,700), it did not reduce catastrophic health expenditure (CHE), i.e., CHE 10% (47.1% vs 47.2%), CHE 25% (19.2 vs 23.4%). In government hospitals, PFHI reduced OOPE (INR 2500 vs. 2050), CHE 10% (11.1% vs 7.8%), and CHE 25% (3.6% vs. 2.7%). PFHI did not have any significant effect on the choice of healthcare provider in hospitalised patients in Rajasthan (AOR 0.95, P = 0.538). ConclusionThe study suggests that PFHI does not have any effect on OOPE associated with hospitalisation. Government-funded healthcare is more effective in providing financial protection compared to private healthcare with PFHI. Private facilities are still chosen despite lower OOPE in government facilities due to quality and availability concerns. These limitations of PFHIs must be thoroughly examined before switching from subsidised services to purchases from private facilities. A combination of both approaches should be integrated to achieve universal health care and financial protection for all.

Behavioral health services for urban American Indians and Alaska Natives: A thematic analysis of interviews with 10 program directors.

Urban Indian Health Programs (UIHPs) are one of the primary sources of government-funded health care for the millions of American Indian and Alaskan Native (AI/AN) people living in urban areas. The goal of this study is to better understand what services are available at UIHPs and how resources are being used to support these services. Semistructured interviews with behavioral health directors at 10 UIHPs were reported, transcribed, and thematically analyzed to address this knowledge gap. Our analysis indicates that UIHP behavioral health services were broad, encompassing numerous commitments that extend far beyond purely psychotherapeutic interactions and interventions to the periphery of behavioral health. An accurate accounting of behavioral health services at UIHPs must consider not only the ways that these services are shaped by distinctive visions to provide Indigenous cultural education and traditional healing, but also by expansive commitments to offering a full range of social services, case management, and community building under the broad umbrella of behavioral health. Implications of these findings include the need for additional funding for UIHPs, greater sponsorship of pathway training programs for AI/ANs in the mental health professions to increase the availability of AI/AN providers, future expansion of traditional healing practices, and direct empirical observation of behavioral health service delivery. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Utilization of In-Hospital Orthopaedic Spine Consultations: Evaluating the Impact of Health Care Policy

Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study’s findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers.

Implementing a Broad Digital Framework to Drive Network Strategy Through PROMs and PREMs

Summary The systematic collection of patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) is undoubtedly a sine qua non for strategy in value-based health care. Digital transformation is fundamental for sustainable data collection and analysis. In December 2019, Quirónsalud 4-H Network (a privately managed, government-funded health care network in Madrid, Spain, serving around 1 million inhabitants through its four tertiary hospitals) launched the E-Res Salud program (Evaluation of Health Results), a configurable digital framework for the capture and analysis of PROMs and PREMs that is flexible enough to be implemented in different clinical conditions and procedures. Here, the authors describe the framework’s design and its relevance for clinical practice and hospital management. As of June 2023, 15 conditions and procedures have been included in the E-Res Salud program, with 18,602 patients actively participating by responding to questionnaires automatically sent out over the Quirónsalud Patient Portal. Patient satisfaction is high, with more than 60% of patients (438 of 698) rating the program with a Net Promoter Score of 9 or 10 on a 0–10 scale. E-Res Salud has catalyzed Quirónsalud 4-H Network’s digital health strategy, spurring initiatives to increase patient access to its patient portal, with more than 80% of patients registered for access in 2022. Currently, the E-Res Salud database enables clinical leaders and hospital management to make data-driven decisions such as prioritizing goals and allocating resources. In daily clinical practice, patient-reported information provides patients with automated feedback and medical advice, helps physicians to communicate more effectively with their patients, facilitates symptom control, and aids the decision-making process.

Cost-Effectiveness of the ENJOY Seniors Exercise Park for Older People: A Pre-Post Intervention Study.

The Exercise interveNtion outdoor proJect in the cOmmunitY (ENJOY) Seniors Exercise Park program uses specialized outdoor equipment and a physical activity program to engage older people in physical activity, with multiple health benefits. We determined the cost-effectiveness of the ENJOY program. The economic evaluation compared health care utilization costs 6months prior to and 6months post ENJOY program participation. Incremental cost-utility analysis for the primary aim (quality of life) and incremental cost-effectiveness analysis for the secondary aim (falls) were used. Analyses took a societal perspective inclusive of Australian government-funded health care and pharmaceuticals in addition to hospitalizations, community-based nursing and allied health, and community services. Productivity costs were also calculated. Fifty participants (average age 72.8y [SD 7.4] and 78.0% [n = 39/50] women) were included. Participation in the ENJOY program reduced health care costs in the 6months following the program: preintervention, $9764.49 (SD $26,033.35); postintervention, $5179.30 (SD $3826.64); observed postintervention reduction -$4.585.20 (95% confidence interval, -$12,113.99 to $2943.59; P = .227) without compromising quality of life (mean difference [MD] 0.011; 95% confidence interval, -0.034 to 0.056; P = .631) or increasing the likelihood of a fall (-0.5; 95% confidence interval, 0.00 to -0.50; P = .160). The ENJOY intervention is likely cost-effective. Planning for shared community spaces should consider the benefits of a Seniors Exercise Park as part of the built environment.

Patient participation in defining best-practice rheumatology service provision in Aotearoa New Zealand: a qualitative study with service consumers

BackgroundAotearoa New Zealand (AoNZ) has no agreed models for rheumatology service provision in government-funded health care. We aimed to describe what people with inflammatory rheumatic diseases who have used rheumatology services view as being important in those services, and map these views to previously collated statements describing best practice components of rheumatology services from international recommendations. If these statements did not capture all service aspects that people with inflammatory rheumatic diseases considered important, we aimed to co-create new statements with our patient-participants.MethodsWe conducted one focus group and an interview with people with inflammatory rheumatic disease who had used a government-funded rheumatology service in the previous 5 years (patient-participants) and analysed data using thematic analysis. The research team mapped subthemes to previously collated best practice recommendations that had been included in a Delphi consensus exercise with rheumatologists in AoNZ and proposed new statements, based on patient-participant data. Patient-participant feedback on thematic analysis and the new statements led to a refining of statements. A patient-partner in the research team informed research design and data analysis.ResultsPatient-participants viewed it as highly valuable for rheumatology services to respect and value their experiences as people and patients, and those of their whānau (Māori word for family). They expected rheumatology services to provide the right care, at the right time. Many of the subthemes mapped to the best-practice statements. However, three new principles and three new statements were developed and refined by patient-participants. The three principles addressed valuing individuals, and their whānau (family) and their experiences, and providing a patient-focused health system that supports patient participation in decision-making and self-management, and patient education. New statements related to having a specific rheumatologist and other staff for comprehensive care, having adequate nurse staffing, and active provision of outside services and support.ConclusionIt was important to patients that rheumatology services demonstrated that patients and their whānau (family) were valued. The inclusion of people with rheumatic diseases who are users of rheumatology services in service development can provide valuable insights to inform how services should be delivered.

The United Kingdom National Health Service through the lens of an overseas clinical observer: A reflective account based on personal experience.

This article provides insight into an aspect of the National Health Service (NHS) of the United Kingdom (UK) through the perspective of an overseas clinical observer. The NHS is a government-funded medical and health care service in the UK and has developed over the years providing a high standard of medical care and professionalism. The Clinical Observership Programme has been designed primarily for International Medical Graduates to experience how the NHS functions and the kind of services it offers. This article explores the overseas observer's experience in a surgical unit of the NHS including the organisational structure, delivery of care and challenges of the system. This article also highlights the observer's perspective of surgical care in the NHS compared to surgical care in low-resource income countries. The Clinical Observership is useful in learning about UK medical practice and gaining experience in a different cultural and professional environment. This is a reflective first-hand account based on personal experience.

Patients’ and Caregivers’ Experiences With Atopic Dermatitis–Related Burden, Medical Care, and Treatments in 8 Countries

Previous studies have documented the high patient and caregiver burden associated with atopic dermatitis (AD). Less is known about the factors-especially those related to treatment options and the delivery of medical care-that may relate to burden and unmet needs among patients and their caregivers. Our primary aim was to characterize and compare health-related quality of life, long-term control of symptoms, satisfaction with treatments, the financial burden, and the prevalence of patient-centered care among adult and pediatric patients with AD in 8 developed nations. We developed a 53-item anonymous online survey for adult patients and caregivers of children with AD (N= 3171; self-reported disease severity: 8.2% clear, 33.2% mild, 41.1% moderate, 17.6% severe). The survey included questions across 7 domains selected by a steering committee of 11 patient organizations that advocate for patients with AD in the 8 countries. We used validated instruments when available including the 5-level EuroQol five-dimensional questionnaire and the Atopic Dermatitis Control Tool. The survey was offered in 5 languages and promoted through social media and other communication channels of the patient organizations. The health-related quality-of-life scores for adult patients with AD (driven by 2 domains: pain/discomfort and anxiety/depression) were worse than those reported for asthma and type 2 diabetes in previous studies (0.72; 95% CI, 0.65-0.78). Patients and caregivers reported substantial financial impacts even in countries with government-funded health care systems, though the greatest impact was in the United States. In all countries, adults reported better control of symptoms than children, but neither group nor any nationality reported adequate control on average (rescaled mean, 57.5; 95% CI, 56.1-58.9), and control correlated negatively with disease severity. Similarly, satisfaction with treatments, which was moderate across countries on average, was much lower for respondents with more severe disease symptoms (F(3,3165)= 5.5; P < .001). Patients who saw a specialist (a dermatologist or an allergist) instead of a general practitioner for AD care indicated better long-term control of symptoms (by 4 points on average on the 100-point scale; 95% CI, 2.6-5.4; P < .001). Finally, self-management training and shared decision making were uncommonly reported by patients in all countries except by respondents from the United States, but both were associated with better long-term control of symptoms and higher satisfaction. The burden of AD, evaluated as health-related quality-of-life detriments, financial impacts, and uncontrolled symptoms, is significant and highest for patients with more severe atopic dermatitis who report greater challenges in achieving symptom resolution with existing treatments and approaches to care. The better outcomes associated with respondents who saw specialists suggest that patients, especially those with more severe AD, might benefit from medical care that is guided by providers with more in-depth knowledge of this complex condition. Finally, wider use of patient-centered care practices (specifically, self-management training and shared decision making) could improve outcomes and boost satisfaction with treatments for AD, though more research on this topic is warranted.

Occupational and Financial Setbacks in Caregivers of People with Colorectal Cancer: Considerations for Caregiver-Reported Outcomes.

Family caregivers of patients with cancer provide substantial physical, emotional, and functional care throughout the cancer trajectory. While caregiving can create employment and financial challenges, there is insufficient evidence to inform the development of caregiver-reported outcomes (CROs) that assess these experiences. The study purpose was to describe the occupational and financial consequences that were important to family caregivers of a patient with colorectal cancer (CRC) in the context of public health care, which represent potential considerations for CROs. In this qualitative Interpretive Description study, we analyzed interview data from 78 participants (25 caregivers, 37 patients, and 16 healthcare providers). Our findings point to temporary and long-term occupational and financial setbacks in the context of CRC. Caregiving for a person with CRC involved managing occupational implications, including (1) revamping employment arrangements, and (2) juggling work, family, and household demands. Caregiver financial struggles included (1) responding to financial demands at various stages of life, and (2) facing the spectre of lifelong expenses. Study findings offer novel insight into the cancer-related occupational and financial challenges facing caregivers, despite government-funded universal health care. Further research is warranted to develop CRO measures that assess the multifaceted nature of these challenges.

Factors influencing the preparedness for the implementation of the national health insurance scheme at a selected hospital in Gauteng Province, South Africa

Research studies as well as anecdotal evidence suggest that there are challenges regarding the NHI plan implementation. These include problems such as an increase in illnesses and a shortage of personnel to drive the project in South African public hospitals. This is exacerbated by the existing situation of most government-funded healthcare institutions, which are characterized by bad administration, insufficient budget, inadequate infrastructure, and insufficient drug supply, as highlighted in several studies. The hospital under investigation is one such facility, with a history of patients sleeping on the floor and people being turned away owing to a shortage of experts and an overburdened staff. This situation is concerning, given that the government claims to be providing appropriate funds to the institution. The hospital under research is highly regarded by the surrounding community. However, a visit by the Health MEC in 2014 revealed that the facility had insufficient sanitary standards and a high complaint rate. Based on the foregoing, as well as the difficulties that both employees and patients are confronted with at the selected hospital, the question that emerges is whether the hospital is fit for the implementation of the NHI.Aim: The aim of this study was to assess the preparation for the launch of the national health insurance scheme at a Johannesburg hospital.Setting: The study was conducted at a hospital situated in eastern suburbs of Johannesburg, Gauteng, South Africa.Method: The study employed a qualitative method with an explorative, descriptive, qualitative study design. The population consisted of selected hospital employees, such as doctors, dispensary officers, hospital managers, human resources workers, facility managers, and administration record officials who were employed at the selected hospital. Purposive sampling was used to select participants.Sample size: Category saturation was used to determine the sample size. The participants for the study were chosen using purposeful sampling, with the researcher aiming for those who were familiar with the NHI scheme at the institution. Semi structured interviews and a focus group discussion were used to gather data. The data from the focus group discussion and semi-structured interviews were analysed using thematic analysis.Results: The investigation found that the hospital was preparing to for the NHI implementation, but that was riddled with lack of resources, poor infrastructure, lack of training, delays in development and poor technological advances.Recommendations: The paper suggests that human resources be increased, infrastructure be upgraded, medicines and equipment be increased, and enough training on NHI implementation be provided.Contribution: The paper adds to the body of knowledge regarding the NHI in South Africa.

Effectiveness of Paliperidone Palmitate on Treatment Adherence and Relapse in the Adult Schizophrenia Population: A One-Year Mirror-Image Study in a Colombian Mental Health Care Facility

IntroductionThe benefits of long-acting injectable antipsychotics have been documented in several observational studies, but data remain scarce in Latin America. This study aimed at evaluating the effectiveness of paliperidone palmitate once monthly (PP1M) on treatment adherence and relapse in the schizophrenia population followed in a government-funded mental health care facility in Colombia. MethodsA mirror-image study was conducted. Adult schizophrenia patients treated with oral antipsychotics who subsequently received ≥2 PP1M injections between Jan. 1st, 2015 and Oct. 31st, 2018 were included. The study consisted of two retrospective phases: 12 months before and after the first PP1M injection. Outcomes were treatment adherence (proportion of days covered ≥80%), hospitalized relapse, hospital length of stay, and non-hospitalised relapse. Effect of PP1M on outcomes was assessed through multivariable conditional Poisson regression. Results123 patients were eligible (mean age, 30.3 years; 79.7% males). Adherence was 23.6% in the pre-phase and 89.4% in the post-phase (RR=3.77; 95%CI, 2.75-5.17). The proportion of patients with hospitalised relapse decreased from 46.3% to 35.0% (RR=0.76; 95%CI, 0.59-0.99). In the 75 (61.0%) patients who continued PP1M throughout post-phase, beneficial effect on hospitalised relapse was stronger (RR=0.64; 95%CI, 0.42-0.98). The proportion of patients with non-hospitalised relapse symptoms increased from 6.5% to 18.7% (RR=2.27; 95%CI, 1.11-4.64). ConclusionsPP1M initiation led to a dramatic improvement in treatment adherence and a decrease in hospitalised relapse. Observed increase in non-hospitalised relapse may be explained by a decrease in severity. Limitations are absence of a parallel comparison group and a generalisability limited to the population treated at this facility. Study provides data for the Latin America region and strength is the assessment of non-hospitalised relapse symptoms.

Cost-Effectiveness of Mobile Stroke Unit Care in Norway.

Background:Acute ischemic stroke treatment in mobile stroke units (MSUs) reduces time-to-treatment and increases thrombolytic rates, but implementation requires substantial investments. We wanted to explore the cost-effectiveness of MSU care incorporating novel efficacy data from the Norwegian MSU study, Treat-NASPP (the Norwegian Acute Stroke Prehospital Project).Methods:We developed a Markov model linking improvements in time-to-treatment and thrombolytic rates delivered by treatment in an MSU to functional outcomes for the patients in a lifetime perspective. We estimated incremental costs, health benefits, and cost-effectiveness of MSU care as compared with conventional care. In addition, we estimated a minimal MSU utilization level for the intervention to be cost-effective in the publicly funded health care system in Norway.Results:MSU care was associated with an expected quality-adjusted life-year-gain of 0.065 per patient, compared with standard care. Our analysis suggests that about 260 patients with ischemic stroke need to be treated with MSU annually to result in an incremental cost-effectiveness ratio of about NOK385 000 (US$43 780) per quality-adjusted life-year for MSU compared with standard care. The incremental cost-effectiveness ratio varies between some NOK1 000 000 (US$113 700) per quality-adjusted life-year if an MSU treats 100 patients per year and to about NOK340 000 (US$38 660) per quality-adjusted life-year if 300 patients with acute ischemic stroke are treated.Conclusions:MSU care in Norwegian settings is potentially cost-effective compared with conventional care, but this depends on a relatively high annual number of treated patients with acute ischemic stroke per vehicle. These results provide important information for MSU implementation in government-funded health care systems.

Cost-effectiveness of Robotic-Assisted Radical Prostatectomy for Localized Prostate Cancer in the UK

The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS). To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK. This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021. Robotic-assisted radical prostatectomy, LRP, and ORP. Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs). Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99. These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.

LGBTQ+ non-discrimination and religious freedom in the context of government-funded faith-based education, social welfare, health care, and aged care

Anti-discrimination laws around the world have explicitly protected LGBTQ+ people from discrimination with various levels of exceptions for religion. Some conservative religious organisations in Australia are advocating to be allowed to discriminate against LGBTQ+ people in certain organisations they manage. The political debate in Australia has focused on religiously affiliated organisations that provide services in education, social welfare, health care, and aged care. We argue that religious exceptions allowing discrimination should be narrow because they cause considerable harm, reinforce, disadvantage and because LGBTQ+ people are deserving of respect and rights. We draw on a national representative survey to demonstrate that the views of some conservative religious lobby groups do not represent the views of the majority of religious people in Australia or the views of the majority of Christian people.

Patient-Reported Outcomes Following Surgery for Lumbar Disc Herniation: Comparison of a Universal and Multitier Health Care System.

Ambispective cohort study. Canada has a government-funded universal health care system. The United States utilizes a multitier public and private system. The objective is to investigate differences in clinical outcomes between those surgically treated for lumbar disc herniation in a universal health care and multitier health system. Surgical lumbar disc herniation patients enrolled in the Canadian Spine Outcome Research Network (CSORN) were compared with the surgical cohort enrolled in the Spine Patients Outcome Research Trial (SPORT) study. Baseline demographics and spine-related patient-reported outcomes (PROs) were compared at 3 months and 1 year post-operatively. The CSORN cohort consisted of 443 patients; the SPORT cohort had 763 patients. Patients in the CSORN cohort were older (46.4 ± 13.5 vs 41.0 ± 10.8, P < .001) and were more likely to be employed (69.5% vs 60.3%, P = .003). The CSORN cohort demonstrated significantly greater rates of satisfaction after surgery at 3months (87.2% vs 64.8%, P < .0001) and 1year (85.6% vs 69.6%, P < .0001). Improvements in back and leg pain followed similar trajectories in the two cohorts, but there was less improvement on ODI in the CSORN cohort (P < .01). On multivariable logistic regression, the CSORN cohort was a significant independent predictor of patient satisfaction at 1-year follow-up (P < .001). Despite less improvement on ODI, patients enrolled in CSORN, as part of a universal health care system, reported higher rates of satisfaction at 3months and 1year post-operatively compared to patients enrolled within a multitier health system.

433 SAME SPECIALITY, DIFFERENT REALITY?

Abstract Introduction The United Kingdom and Spain run government-funded social and health care services, free for the user at the point of delivery. Acute Geriatric Units (AGU) carrying out Comprehensive Geriatric Assessments improve the clinical outcomes of older patients. Little is known about the similarities and differences between countries, and how these may impact on clinical outcomes. Methods Prospective observational study of consecutive patients admitted to AGU of 2 hospitals in the UK and 4 hospitals in Spain between the 1st to the 30th of October 2019 and from the 1st to the 29th of February 2020. We followed up the patients for a 90 day period. Conclusions Frailty, multimorbidity and polypharmacy were prevalent in both cohorts. English patients were younger, with shorter hospital stay, mortality and use of antipsychotic medication but higher readmission rates. Involvement from Allied health care professionals was higher in UK hospitals.

Prevalence of winter migration to warmer destinations among Ontarians ("snowbirds") and patterns of their use of health care services: a population-based analysis.

Background:Older Canadians frequently migrate to warmer destinations for the winter season (snowbirds). Our aim was to examine the prevalence of migration to warmer destinations among Ontarians, and to compare the characteristics and use of health care services of snowbirds to those of older Ontarians who did not migrate for the winter.Methods:We conducted a population-based analysis using health administrative databases from Ontario. We compiled 10 seasonal cohorts (2009/10 to 2018/19) of adults aged 65 or more who filled a travel supply of medications under the Ontario Drug Benefits program (snowbirds) between September and January (snowbird season). We calculated the seasonal prevalence of snowbirds per 100 Ontarians aged 65 or more. We matched each snowbird in the 2018/19 season to 2 nonsnowbirds on age and sex, and compared their characteristics and patterns of use of government-funded health care services.Results:Over the 10-year period, 53 431 to 70 863 Ontarians aged 65 or more were identified as snowbirds (seasonal prevalence 2.6%–3.3%). Compared to nonsnowbirds, snowbirds were more likely to be recent migrants, live in higher-income neighbourhoods, have fewer comorbidities and make more visits to primary care physicians. From January to March 2019, snowbirds accessed government-funded health care services for a median of 0 days (interquartile range [IQR] 0–1 d), compared to 4 days (IQR 2–8 d) among nonsnowbirds.Interpretation:About 3% of older Ontarians migrate to warmer destinations for the winter each season. Since few access health care services in Ontario from January to March, researchers are encouraged to consider the snowbird population and the impact of their absence on evaluations that assume continuous observation.

Challenges to effective governance in a low income healthcare system: a qualitative study of stakeholder perceptions in Malawi

BackgroundAll countries face challenging decisions about healthcare coverage. Malawi has committed to achieving Universal Health Coverage (UHC) by 2030, the timeframe set out by the Sustainable Development Goals (SDGs). As in other low income countries, scarce resources stand in the way of more equitable health access and quality in Malawi. Its health sector is highly dependent on donor contributions, and recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The 2017 National Health Plan II and accompanying Health Strategic Plan II identify the importance of improved governance and strategies to achieve more effective cooperation with stakeholders. This study explores health sector stakeholders’ perceptions of the challenges to improving governance in Malawi’s national health system within the post-2017 context of government attempts to articulate a way forward.MethodsA qualitative study design was used. Interviews were conducted with 22 representatives of major international and faith-based non-government organisations, civil society organisations, local government and government-funded organisations, and governance bodies operating in Malawi. Open questions were asked about experiences and perceptions of the functioning of the health system and healthcare decision-making. Content relating to healthcare governance was identified in the transcripts and field notes and analysed using inductive content analysis.ResultsStakeholders view governance challenges as a significant barrier to achieving a more effective and equitable health system. Three categories were identified: accountability (enforceability; answerability; stakeholder-led initiatives); health resource management (healthcare financing; drug supply); influence in decision-making (unequal power; stakeholder engagement).ConclusionsHealth sector stakeholders see serious political, structural, and financial challenges to improving governance in the national health system in Malawi which will impact the government’s goal of achieving UHC by 2030. Stakeholders identify the need for improved oversight, implementation, service delivery and social accountability of government-funded service providers to communities. Eighteen months after the introduction of the policy documents, they see little evidence of improved governance and have little or no confidence in the government’s ability to deliver UHC. The difficulties stakeholders perceive in relation to building equitable and effective healthcare governance in Malawi have relevance for other resource-limited countries which have also committed to the goal of UHC.

Challenges to effective governance in developing health systems: a qualitative study in Malawi

Abstract Effective governance is vital in maintaining and improving health systems but has received little attention in research, especially in developing countries. All United Nations (UN) members have committed to Universal Health Coverage (UHC) by 2030. Malawi, a member and one of the five poorest countries in the world, is highly dependent on donor contributions. Recent poor governance of government-funded healthcare saw donors withdraw funding, limiting services and resources. The government identifies the need for better oversight to improve health system efficiency and achieve UHC. This study contributes to a better understanding of the relationship between governance and health systems in developing countries moving towards UHC by identifying stakeholder perceptions of the challenges in this area, using Malawi as a case study. Interviews were conducted with 22 representatives of non-government organisations, civil society groups, local government and government-funded organisations and governance bodies and the transcripts and field notes were analysed using inductive thematic analysis. Four main issues emerged: accountability; resource management; power dynamics; non-government actors. We conclude that political, structural and financial challenges are seen as barriers to effective health governance at all levels (national, local, service provider). These include little monitoring of health policy implementation, little accountability of the government to the public on health policies and spending decisions, and poor resource management, especially in the drug supply chain. In response to the government's perceived disinterest, non-government initiatives (often supported by donors) advocate for greater governance and monitor the health sector, including progress towards UHC. Poor governance adversely affects health system functioning and may prevent developing countries achieving UHC by 2030. Key messages There are political, structural and financial challenges at all levels of the Malawian health system (national, local, service provider) that are perceived as barriers to effective health governance. Poor governance adversely affects health system functioning, limiting the services and resources available, and may prevent the goal of Universal Health Coverage by 2030 in developing countries.