Health Care Use Research Articles

Women's use of Swedish health care during the postpartum period in relation to maternal country of birth-A population-based study.

Migrant women are a heterogenous group with both higher and lower risk for pregnancy complications and adverse birth outcomes compared with women in the receiving countries. This study aimed to investigate women's use of Swedish healthcare postpartum, in terms of hospital stay >48 h, readmission to hospital, and specialized out-patient clinic visits, in relation to maternal country of birth. A population-based register study including 278 219 primiparous and 367 776 multiparous women in Sweden (2014-2019) using data from Swedish Pregnancy Register, National Patient Register and Statistics Sweden. Multivariable logistic regression analyses were used to estimate associations between maternal country of birth and outcomes, adjusting for year of birth, maternal age, education, pre-gestational hypertension and diabetes, and healthcare region, presented as crude and adjusted odds ratios (aOR) with 95% confidence interval (CI) with Swedish-born women as reference. Subgroups of migrant women had higher odds of postpartum hospital stays > 48 h, particularly women from Eritrea (primiparous aOR 2.80, CI 2.49-3.15; multiparous aOR 2.78, CI 2.59-2.98), Somalia (primiparous aOR 2.61, CI 2.34-2.92; multiparous aOR 1.87, CI 1.79-1.97), and India (primiparous aOR 2.52, CI 2.14-2.97; multiparous aOR 2.61, CI 2.33-2.93), compared to Swedish-born women. Primiparous women from Afghanistan (aOR 1.32, CI 1.08-1.6), Iraq (aOR 1.30, CI 1.16-1.46), and Iran (aOR 1.23, CI 1.04-1.45) had slightly higher odds of hospital readmission, along with multiparous women from India (aOR 1.34, CI 1.02-1.76) and Somalia (aOR 1.24, CI 1.11-1.38). Specialized out-patient clinic visits were most common in primiparous women from Somalia (aOR 1.47, CI 1.35-1.59), Iran (aOR 1.31, CI 1.22-1.42) and Afghanistan (aOR 1.31, CI 1.18-1.46), and in multiparous women from Iran (aOR 1.30, CI 1.20-1.41) and Iraq (aOR 1.15, CI 1.11-1.20), however less common in women from some other countries. The use of Swedish health care during the postpartum period varied among women, depending on their country of birth. Women from certain countries had particularly high odds of postpartum hospital stays exceeding 48 h, compared to Swedish-born women, regardless of parity and pre-gestational medical disorders. Further studies are needed to determine whether the individual needs of migrant women are being met during the postpartum period or not.

Changes in Cannabis-Related Health Care Use in Alberta After Cannabis Legalization Between 2018 and 2022: A Population-Based Interrupted Time Series Study

Changes in Cannabis-Related Health Care Use in Alberta After Cannabis Legalization Between 2018 and 2022: A Population-Based Interrupted Time Series Study

Effects of Empagliflozin on Health Care Use and Quality of Life in CKD in the United Kingdom: Results from EMPA-KIDNEY

Effects of Empagliflozin on Health Care Use and Quality of Life in CKD in the United Kingdom: Results from EMPA-KIDNEY

Specification, validation and verification of social, legal, ethical, empathetic and cultural requirements for autonomous agents

Autonomous agents are increasingly being proposed for use in healthcare, assistive care, education, and other applications governed by complex human-centric norms. To ensure compliance with these norms, the rules they induce need to be unambiguously defined, checked for consistency, and used to verify the agent. In this paper, we introduce a framework for formal specification, validation and verification of social, legal, ethical, empathetic and cultural (SLEEC) rules for autonomous agents. Our framework comprises: (i) a language for specifying SLEEC rules and rule defeaters (that is, circumstances in which a rule does not apply or an alternative form of the rule is required); (ii) a formal semantics (defined in the process algebra tock-CSP) for the language; and (iii) methods for detecting conflicts and redundancy within a set of rules, and for verifying the compliance of an autonomous agent with such rules. We show the applicability of our framework for two autonomous agents from different domains: a firefighter UAV, and an assistive-dressing robot.

Equal Treatment, Unequal Outcomes? Debunking the Racial Disparity in Renin Angiotensin Aldosterone System Inhibitor Associated Reduction in Heart Failure Hospitalizations

BackgroundRenin angiotensin aldosterone system inhibitors (RAASi) are a mainstay treatment in patients with heart failure with reduced ejection fraction (HFrEF) in part to prevent hospitalizations. However, whether RAAS inhibitors reduce the risk of hospitalization in Black patients is not entirely clear because enrollment of Black patients in previous clinical trials was low, and a previous meta-analysis showed a significant racial disparity: reduction in hospitalizations with an RAAS inhibitor in White patients but not Black patients. Previous studies relied on the use of self-identified race instead of genomic ancestry. Therefore, this study aimed to investigate the role of self-identified race and genomic ancestry in the racial disparity in RAAS inhibitor associated reductions in HFrEF hospitalizations. MethodsThe primary outcome was time to first heart failure hospitalization. A (de-identified) heart failure patient registry and data from the GUIDE-IT multi-center randomized control trial were analyzed with Cox proportional hazards models un/adjusted for clinical risk factors, death as a competing risk, and time-varying RAAS inhibitor exposure. The proportion of Yoruba African ancestry was quantified.. Analysis of self – identified race were performed in both the registry and GUIDE-IT. Analysis of genomic ancestry was only performed in the registry since this information was not available in GUIDE-IT. A fixed effect meta-analysis combined results of both the registry and GUIDE-IT for race. ResultsThe registry had 1010 total HFrEF patients (Black = 509 and White = 501) with 852 having ancestry quantification (>80% Yoruba African Ancestry = 381 and <5% Yoruba African Ancestry = 471). GUIDE-IT had 810 HFrEF patients (Black = 322 and White = 488). There was no significant difference in the association of RAAS inhibitor exposure with heart failure hospitalization by race (meta-analysis p-value for race*RAAS inhibitor exposure interaction = 0.49; Black patients HR [95% CI] for RAAS inhibitor exposure = 0.89 [0.64-1.23)] P = 0.47; White patients = 1.20 (0.83-1.75) P = 0.34). Results were similar when analyzed by ancestry (p-value for ancestry*RAAS inhibitor exposure interaction = 0.57; >80% Yoruba African Ancestry = 0.93 [0.51-1.69] P = 0.80; <5% Yoruba African Ancestry = 1.29 [0.57-2.92] P = 0.54). ConclusionsIn contrast to a previous meta-analysis, this more contemporary analysis of 2 HFrEF patient datasets demonstrates the absence of a racial disparity in RAAS inhibitor associated reductions in heart failure hospitalizations. The difference in this racial disparity over time may be due to improvements in background heart failure therapies, racial differences in healthcare usage, and the use of more advanced statistical approaches.

A one-year weight management programme for difficult-to-treat asthma with obesity: a randomised controlled study

BackgroundObesity-associated asthma results in increased morbidity and mortality. We report one-year asthma outcomes with the Counterweight-Plus weight management programme (CWP) compared to usual care (UC) in a single-centre, randomised, controlled trial in patients with difficult-to-treat asthma and obesity. Research QuestionCan CWP use result in improved asthma control and quality of life compared to UC at one-year in patients with difficult-to-treat asthma and obesity? Study design and methodsWe randomised (1:1 CWP:UC) adults with difficult-to-treat asthma and body mass index ≥30kg/m2. CWP with dietitian support: 12-week total diet replacement phase (850kcal/day low-energy formula); food reintroduction and maintenance phases up to one-year. Outcomes include Asthma Control Questionnaire (ACQ-6), Asthma Quality of Life Questionnaire (AQLQ) and healthcare usage. Minimal clinically important difference (MCID) is 0.5 for ACQ-6 and AQLQ. ResultsOf 36 recruited, 29 attended at 52-weeks: 13 CWP, 16 UC. CWP resulted in greater weight change (median –14kg [IQR –15, –9]) compared to UC (2kg [-7, 8]; p=0.015) at 52-weeks. A greater proportion achieved MCID with CWP vs UC in AQLQ (71% vs 6% respectively; p<0.001). No between-group differences were observed in ACQ-6. Median exacerbation frequency reduced over 52-weeks with CWP from 4 (IQR 2, 5) to 0 (0, 2) (p<0.001), though no between-group difference was observed. 70% of the CWP group lost ≥10% body weight and had improvement in ACQ-6 (mean difference –1.1, 95%CI –1.9, -0.3; p=0.018) and AQLQ (1.2, 95%CI 0.4, 2.1; p=0.011) across 52-weeks. InterpretationUse of a dietitian-supported weight management programme results in sustained weight-loss and is a potential treatment for obesity in asthma. CWP resulted in a higher proportion achieving MCID improvement in AQLQ compared to UC. Within group differences in AQLQ and exacerbation frequency suggest potential with CWP. These encouraging signals justify a larger sample study to further assess asthma-related outcomes.

Impact of the COVID-19 pandemic on health-care use among patients with cancer in England, UK: a comprehensive phase-by-phase time-series analysis across attendance types for 38 cancers

The COVID-19 pandemic resulted in the widespread disruption of cancer health provision services across the entirety of the cancer care pathway in the UK, from screening to treatment. The potential long-term health implications, including increased mortality for individuals who missed diagnoses or appointments, are concerning. However, the precise impact of lockdown policies on national cancer health service provision across diagnostic groups is understudied. We aimed to systematically evaluate changes in patterns of attendance for groups of individuals diagnosed with cancer, including the changes in attendance volume and consultation rates, stratified by both time-based exposures and by patient-based exposures and to better understand the impact of such changes on cancer-specific mortality. In this retrospective, cross-sectional, phase-by-phase time-series analysis, by using primary care records linked to hospitals and the death registry from Jan 1, 1998, to June 17, 2021, we conducted descriptive analyses to quantify attendance changes for groups stratified by patient-based exposures (Index of Multiple Deprivation, ethnicity, age, comorbidity count, practice region, diagnosis time, and cancer subtype) across different phases of the COVID-19 pandemic in England, UK. In this study, we defined the phases of the COVID-19 pandemic as: pre-pandemic period (Jan 1, 2018, to March 22, 2020), lockdown 1 (March 23 to June 21, 2020), minimal restrictions (June 22 to Sept 20, 2020), lockdown 2 (Sept 21, 2020, to Jan 3, 2021), lockdown 3 (Jan 4 to March 21, 2021), and lockdown restrictions lifted (March 22 to March 31, 2021). In the analyses we examined changes in both attendance volume and consultation rate. We further compared changes in attendance trends to cancer-specific mortality trends. Finally, we conducted an interrupted time-series analysis with the lockdown on March 23, 2020, as the intervention point using an autoregressive integrated moving average model. From 561 611 eligible individuals, 7 964 685 attendances were recorded. During the first lockdown, the median attendance volume decreased (-35·30% [IQR -36·10 to -34·25]) compared with the preceding pre-pandemic period, followed by a median change of 4·38% (2·66 to 5·15) during minimal restrictions. More drastic reductions in attendance volume were seen in the second (-48·71% [-49·54 to -48·26]) and third (-71·62% [-72·23 to -70·97]) lockdowns. These reductions were followed by a 4·48% (3·45 to 7·10) increase in attendance when lockdown restrictions were lifted. The median consultation rate change during the first lockdown was 31·32% (25·10 to 33·60), followed by a median change of -0·25% (-1·38 to 1·68) during minimal restrictions. The median consultation rate decreased in the second (-33·89% [-34·64 to -33·18]) and third (-4·98% [-5·71 to -4·00]) lockdowns, followed by a 416·16% increase (409·77 to 429·77) upon lifting of lockdown restrictions. Notably, across many weeks, a year-over-year decrease in weekly attendances corresponded with a year-over-year increase in cancer-specific mortality. Overall, the pandemic period revealed a statistically significant reduction in attendances for patients with cancer (lockdown 1 -24 070·19 attendances, p<0·0001; minimal restrictions -19 194·89 attendances, p<0·0001; lockdown 2 -31 311·28 attendances, p<0·0001; lockdown 3 -43 843·38 attendances, p<0·0001; and lockdown restrictions lifted -56 260·50 attendances, p<0·0001) compared with before the pandemic. The UK's COVID-19 pandemic lockdown affected cancer health service access negatively. Many groups of individuals with cancer had declines in attendance volume and consultation rate across the phases of the pandemic. A decrease in attendances might lead to delays in cancer diagnoses, treatment, and follow-up, putting such groups of individuals at higher risk of negative health outcomes, such as cancer-specific mortality. We discuss the factors potentially responsible for explaining changes in service provision trends and provide insight to help inform clinical follow-up for groups of individuals at risk, alongside potential future policy changes in the care of such patients. Wellcome Trust, National Institute for Health Research University College London Hospitals Biomedical Research Centre, National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.

Impact of frailty in older people on health care demand: simulation modelling of population dynamics to inform service planning.

As populations age, frailty and the associated demand for health care increase. Evidence needed to inform planning and commissioning of services for older people living with frailty is scarce. Accurate information on incidence and prevalence of different levels of frailty and the consequences for health outcomes, service use and costs at population level is needed. To explore the incidence, prevalence, progression and impact of frailty within an ageing general practice population and model the dynamics of frailty-related healthcare demand, outcomes and costs, to inform the development of guidelines and tools to facilitate commissioning and service development. A retrospective observational study with statistical modelling to inform simulation (system dynamics) modelling using routine data from primary and secondary health care in England and Wales. Modelling was informed by stakeholder engagement events conducted in Hampshire, England. Data sources included the Royal College of General Practitioners Research and Surveillance Centre databank, and the Secure Anonymised Information Linkage Databank. Population prevalence, incidence and progression of frailty within an ageing cohort were estimated using the electronic Frailty Index tool, and associated service use and costs were calculated. Association of frailty with outcomes, service use and costs was explored with multistate and generalised linear models. Results informed development of a prototype system dynamics simulation model, exploring population impact of frailty and future scenarios over a 10-year time frame. Simulation model population projections were externally validated against retrospective data from Secure Anonymised Information Linkage. The Royal College of General Practitioners Research and Surveillance Centre sample comprised an open cohort of the primary care population aged 50 + between 2006 and 2017 (approx. 2.1 million people). Data were linked to Hospital Episode Statistics data and Office for National Statistics death data. A comparable validation data set from Secure Anonymised Information Linkage was generated. Electronic Frailty Index score calculated annually and stratified into Fit, Mild, Moderate and Severe frailty categories. Other variables included age, sex, Index of Multiple Deprivation score, ethnicity and Urban/rural. Frailty transitions, mortality, hospitalisations, emergency department attendances, general practitioner visits and costs. Frailty is already present in people aged 50-64. Frailty incidence was 47 cases per 1000 person-years. Frailty prevalence increased from 26.5% (2006) to 38.9% (2017). Older age, higher deprivation, female sex, Asian ethnicity and urban location independently predict frailty onset and progression; 4.8% of 'fit' people aged 50-64 years experienced a transition to a higher frailty state in a year, compared to 21.4% aged 75-84. Individual healthcare use rises with frailty severity, but Mild and Moderate frailty groups have higher overall costs due to larger population numbers. Simulation projections indicate frailty will increase by 7.1%, from 41.5% to 48.7% between 2017 and 2027, and associated costs will rise by £5.8 billion (in England) over an 11-year period. Simulation modelling indicates that frailty prevalence and associated service use and costs will continue to rise in the future. Scenario analysis indicates reduction of incidence and slowing of progression, particularly before the age of 65, has potential to substantially reduce future service use and costs, but reducing unplanned admissions in frail older people has a more modest impact. Study outputs will be collated into a commissioning toolkit, comprising guidance on drivers of frailty-related demand and simulation model outputs. This study is registered as NCT04139278 www.clinicaltrials.gov. This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/116/43) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 44. See the NIHR Funding and Awards website for further award information.

Systemic anti-cancer treatment and healthcare utilization at end of life: A SEER Medicare analysis.

276 Background: Use of chemotherapy at end-of-life (EOL) is associated with adverse quality of life, higher costs, increased hospitalizations (HL), emergency department (ED), and intensive care unit (ICU) utilization and lower hospice (HP) use. While EOL chemotherapy use has declined in recent years, EOL immunotherapy use has increased. It is unknown how the trend of increased immunotherapy use at the EOL is associated with healthcare utilization. We evaluated the association between types of systemic anticancer therapy (SACT) within 30 days of death and hospitalizations, emergency department, intensive care unit, and hospice use. Methods: We identified patients in the SEER-Medicare database with a diagnosis date of 2005-2019 and death date of 2015-2020 with the following cancers: breast, colorectal, lung, prostate, bladder, cervix, kidney, leukemia, liver, lymphoma, myeloma, ovarian, pancreas, skin, and uterine. EOL SACT was defined as SACT received within 30 days of death, categorized as combination chemo-immunotherapy, immunotherapy, and chemotherapy. We analyzed associations between EOL SACT use (overall and by type), and healthcare utilization in the last 30-days of life (ED, HL, ICU, and HP) with chi-square tests and multivariable regression, controlling for sociodemographic and cancer covariates. Results: Of 499,607 beneficiaries, 37,595 (7.5%) received SACT within 30 days of death. Compared to no EOL SACT, any SACT use was associated with higher ED [75.5% vs 50.8%], HL [71.0% vs 48.7%] and ICU (35.7% vs 23.3%) and lower HP enrollment (46.1% vs 59.3%) and number of days in HP (2.4 vs 6.5 days) (all p &lt;0.001, table). After adjusting for covariates, patients with EOL SACT were more likely to have HL (odds ratio [OR], 2.43; 95% confidence interval [CI], 2.38-2.49), ED visits (OR, 2.87; 95% CI, 2.80-2.94), and ICU stay (OR, 1.66; 95% CI, 1.62-1.70), and less likely to receive HP care (OR, 0.62; 95% CI: 0.61-0.64)-compared to no SACT use; All subtypes of EOL SACT were significantly more likely to have ED, HL, and ICU use and less likely to use HP than those with No EOL SACT (p-values &lt;0.001). Conclusions: All types SACT within 30 days of death were associated increased healthcare use compared with no EOL SACT, with combination chemo-immunotherapy having the highest ED, hospitalizations and ICU use and lowest hospice enrollment and duration. Healthcare utilization. Combination Chemo-Immunotherapy(n=5,171) Immunotherapy(n = 11,397) Chemotherapy(n = 21,027) Any SACT(n = 37,595) No SACT(n = 462,012) P -value* ED Visit (%) 76.9 73.7 76.1 75.5 50.8 &lt;.001 Hospitalizations (%) 72.5 67.7 72.5 71.0 48.7 &lt;.001 ICU use (%) 40.4 32.1 36.5 35.7 23.3 &lt;.001 Hospice use (%) 38.8 50.2 45.8 46.1 59.3 &lt;.001 Number of days Hospice (Days, Mean ± standard deviation) 1.7 ± 3.0 2.7 ± 3.9 2.4 ± 3.9 2.4 ± 3.8 6.5 ± 7.8 &lt;.001 *P-values for statistical difference between each individual SACT subgroup and No SACT and Any SACT and No SACT group.

Applying the theoretical domains framework to identify determinants to mental healthcare use among older African Americans with type 2 diabetes: a qualitative study

ObjectivesThere is a paucity of research focused on enhancing access to mental healthcare for older African Americans with type 2 diabetes (T2D), who may be at risk for or living...

Feasibility of a theory-based intervention towards benzodiazepine deprescribing in Belgian nursing homes: protocol of the END-IT NH cluster-randomised controlled trial

IntroductionDespite several calls to deprescribe benzodiazepine receptor agonists (BZRA) in older adults, their use among nursing home residents (NHRs) remains high. Therefore, we developed an intervention targeting general practitioners’ and...

Factors associated with mental healthcare utilization among United States military personnel with posttraumatic stress disorder or depression symptoms

Introduction: Although posttraumatic stress disorder (PTSD) and depression are prominent mental health conditions affecting United States service members, only a subset of individuals with these conditions utilize mental healthcare services. Identifying factors associated with mental healthcare utilization may elucidate military subgroups with unmet mental healthcare needs. Methods: Cross-sectional survey data from the 2019–2021 Millennium Cohort Study assessment were used to examine correlates of unmet mental healthcare needs among military personnel who screened positive for PTSD or depression symptoms (n=18,420) using modified Poisson regression models. Data analyses for this study were conducted between 2023 and 2024. Results: Approximately 32–43% of service members reported receiving any mental healthcare in the past 12 months. Hispanic and Asian or Pacific Islander personnel, and those with certain service characteristics (higher pay grade, recent deployment, experienced discrimination) had a lower likelihood of mental healthcare utilization. Female sex, greater symptom severity, experiencing bullying, and other psychosocial factors were associated with greater likelihood of mental healthcare utilization. Conclusions: One-third of service members with PTSD or depression symptoms reported any mental healthcare use, highlighting the need to identify factors that may impede or delay treatment. Racial and ethnic disparities in treatment utilization persist as do differences in utilization by military characteristics. Further research and initiatives are necessary to identify potential service-specific or cultural barriers and provide equitable quality and access to needed mental health services within the Military Health System.

Redundant Telemetry Link System for Uncrewed Aerial Vehicles

Thanks to their flexibility in research, prototyping, and development, Uncrewed Aerial Vehicles (UAV) are seeing increasing use in agriculture, healthcare, logistics, and other industries. With the increase in the use of UAV in civilian sectors, comes an increase in the possibility of errors in telemetry connections. Issues with the telemetry connection may be catastrophic and cause accidents and crashes and may also adversely affect the performance of the subsystems connected to the telemetry. In this study, a low-cost software-based redundant telemetry link system for UAV is proposed. The proposed system minimises the received packet loss using packet deduplication and is compared with a dynamic link switching method. In the proposed system, both fault tolerance and robustness are introduced into the UAV telemetry link. The analysis is performed using the ArduPilot UAV Simulation environment as a producer and a Golang implementation of the proposed methods.

FOUNTAIN: a modular research platform for integrated real-world evidence generation

BackgroundReal-world evidence (RWE) plays a key role in regulatory and healthcare decision-making, but the potentially fragmentated nature of generated evidence may limit its utility for clinical decision-making. Heterogeneity and a lack of reproducibility in RWE resulting from inconsistent application of methodologies across data sources should be minimized through harmonization.MethodsThis paper’s aim is to describe and reflect upon a multidisciplinary research platform (FOUNTAIN; FinerenOne mUlti-database NeTwork for evidence generAtIoN) with coordinated studies using diverse RWE generation approaches and explore the platform’s strengths and limitations. With guidance from an executive advisory committee of multidisciplinary experts and patient representatives, the goal of the FOUNTAIN platform is to harmonize RWE generation across a portfolio of research projects, including research partner collaborations and a common data model (CDM)–based program. FOUNTAIN’s overarching objectives as a research platform are to establish long-term collaborations among pharmacoepidemiology research partners and experts and to integrate diverse approaches for RWE generation, including global protocol execution by research partners in local data sources and common protocol execution in multiple data sources through federated data networks, while ensuring harmonization of medical definitions, methodology, and reproducible artifacts across all studies. Specifically, the aim of the multiple studies run within the frame of FOUNTAIN is to provide insight into the real-world utilization, effectiveness, and safety of finerenone across its life-cycle.ResultsCurrently, the FOUNTAIN platform includes 9 research partner collaborations and 8 CDM-mapped data sources from 7 countries (United States, United Kingdom, China, Japan, The Netherlands, Spain, and Denmark). These databases and research partners were selected after a feasibility fit-for-purpose evaluation. Six multicountry, multidatabase, cohort studies are ongoing to describe patient populations, current standard of care, comorbidity profiles, healthcare resource use, and treatment effectiveness and safety in different patient populations with chronic kidney disease and type 2 diabetes. Strengths and potential limitations of FOUNTAIN are described in the context of valid RWE generation.ConclusionThe establishment of the FOUNTAIN platform has allowed harmonized execution of multiple studies, promoting consistency both within individual studies that employ multiple data sources and across all studies run within the platform’s framework. FOUNTAIN presents a proposal to efficiently improve the consistency and generalizability of RWE on finerenone.

Diminishing marginal returns and sufficiency in health-care resource use: an exploratory analysis of outcomes, expenditure, and emissions

Increasing health expenditure in low-income countries is associated with rapid gains in health status. Less attention has been paid to the possibility of diminishing marginal returns to health expenditure at high levels of spending, or to the relationship between health-care greenhouse gas emissions and outcomes. Our study aimed to investigate the existence, scale, and implications of diminishing marginal returns to health-care expenditure and emissions. Segmented (piecewise) regression analysis was used to explore the relationship between two measures of health outcome from the Global Burden of Disease project (mortality amenable to health care [MAH] and health-adjusted life expectancy [HALE]), four aggregates of health expenditure per capita from the WHO Global Health Expenditure Database, and health-care sector greenhouse gas emissions per capita derived from a 2020 study by Lenzen and colleagues. Turning point knots-points at which the elasticity or velocity of increasing returns to expenditure and emissions changed substantially-were estimated and countries in the vicinity of these knots identified. Rapidly increasing returns (improvements in population health as measured by MAH and HALE) to health expenditure were estimated in low-income and lower-middle-income countries; at levels of spending above approximately US$500 per capita, these returns start to slow. At levels of spending above those seen in high-income countries such as Italy (approximately US$3400), there is little or no evidence of further health returns to additional spending or to increasing health-care greenhouse gas emissions. Dramatic improvements in population health outcomes could be achieved by additional investment in health expenditure in low-income countries. Conversely, continuing growth in health expenditure in high-income countries will, by itself, be unlikely to yield rapid improvements in health outcomes. Our findings inform the emerging debate on the importance of sufficiency within planetary boundaries-low-income countries need rapid growth in health expenditure, whereas high-income countries could potentially achieve better health outcomes at substantially lower levels of resource use. None.

Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

ObjectivesThis study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort.MethodsPatients from 31 centres in 10...

Remote monitoring to improve low adherence in non-invasive ventilation: a protocol for a randomised controlled clinical trial (READ-NIV trial).

Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder. Non-invasive ventilation (NIV) is essential for managing hypercapnic respiratory failure in patients with obesity hypoventilation syndrome (OHS) and those with co-existing OSA, where continuous positive airway pressure (CPAP) alone is insufficient. However, adherence to NIV can be challenging, with substantial non-compliance occurring due to factors such as discomfort and phobia. The objective of this protocol is to assess the improvement of adherence to NIV remotely monitored, as well as to record symptom control and long-term clinical outcomes, and to optimise healthcare resource usage. This is a prospective, randomised, and controlled (usual care) trial with a two-arm parallel group design, testing remote monitoring of home NIV (T4P device, SRETT, Paris, France) for 3 months in patients with OSA/OHS who have previously had low NIV adherence (<4 hours/night). This project has been approved by the research ethics committee/Health Research Authority (HRA) [Integrated Research Application System (IRAS) ID: 270108], as well as by Guy's & St Thomas' NHS Foundation Trust R&D Department. Outcomes will be compared between the intervention and the control group (NIV with vs. without remote monitoring). The trial will also assess suitability of the outcome parameters, and test whether the data collection, symptom questionnaires, and used healthcare resources are suitable to describe the impact on patient-related outcomes. This study is registered at ClinicalTrials.gov (NCT04884165).

Loneliness in the Republic of Srpska: advocating for social prescribing.

This study explores the potential implementation of social prescribing in the Republic of Srpska, Bosnia and Herzegovina, where the approach is non-existent, and supporting structures are underdeveloped despite a recognized need for intervention. As social prescribing gains global recognition for improving health, the study investigates its feasibility in an uncharted area. The research assesses the necessity for social prescribing by examining loneliness rates and healthcare utilization in the Republic of Srpska, a region seldom studied in public health literature. Data from 1231 individuals aged 16-86 were collected in May 2021, marking the first initiative to gather information on loneliness and healthcare usage in the country. Loneliness rates in the Republic of Srpska were comparable to the UK. Using a negative binomial model, the study establishes significant links between loneliness, chronic health conditions, age, and healthcare service utilization. Loneliness, chronic health conditions, and age predict the use of general practitioner services. In the 44-54 and 65+ age groups, loneliness predicts accident and emergency service use. Specialist healthcare services are positively predicted by loneliness, having one chronic health condition, and being above 44 years of age. Notably, a COVID-19 diagnosis negatively predicts the use of all healthcare services. Gender and place of residence do not significantly impact healthcare service utilization. The study concludes that observed loneliness rates and correlated healthcare usage patterns in the Republic of Srpska indicate a need for social prescribing. The paper discusses the feasibility of implementing social prescribing in this particular case.

Criteria-based outpatient scheduling at a nephrology clinic: prospective evaluation of patient pre-assessment and its corresponding adaptive scheduling strategy

BackgroundOutpatient Clinics (OCs) are under pressure because of increasing patient volumes and provider shortages. At the same time, many patients with chronic diseases receive routine follow-up consultations that are not always necessary. These patients block access to care for patients that are in actual need for care. Pre-assessing patient charts has shown to reduce unnecessary outpatient visits. However, the resulting late cancellations due to the pre-assessment, challenge efficient alignment of capacity with actual patient demand, leading to either empty slots or overtime. This study aims to develop a method to analyse the effect of pre-assessing patients before inviting them to the OC. This involves 1) to select who should come and 2) to optimize the impact of pre-assessment on the schedule and efficient use of OC staff.MethodsThis prospective mixed-methods evaluation study consists of 1) an expert meeting to determine a pre-assessment strategy; 2) a retrospective cohort study to review the impact of this strategy (12 months of a Dutch nephrology OC); 3) mathematical optimization to develop an optimal criteria-based scheduling strategy; and 4) a computer simulation to evaluate the developed strategy. Primary outcomes are the staff idle time and staff overtime. Secondary outcomes evaluate the number of weekly offered appointments.ResultsThe expert group reached consensus about the pre-assessment criteria. 875 (18%) of the realized appointments in 2022 did not meet the OC visit pre-assessment criteria. In the best performing scheduling strategy, 94 slots (87% of the available capacity) should be scheduled on a weekly basis. For this schedule, 26.8% of the OC weeks will experience idle time (μ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\mu$$\\end{document}=2.51, σ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\sigma$$\\end{document}=1.44 appointment slots), and 21% of the OC weeks will experience overtime (μ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\mu$$\\end{document}=2.26, σ\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\sigma$$\\end{document}=1.65 appointment slots) due to the variation in patient appointment requests. Using the pre-assessment strategy combined with the best performing scheduling strategy under full capacity (108 slots), up to 20% increase in patient demand can be handled with equal operational performance.ConclusionsThis evaluation study allows OC managers to virtually test operational impact of pre-assessment strategies on the capacity of their OC, and shows the potential of increasing efficient use of scarce healthcare capacity.Trial registrationNot applicable.

Physiotherapy-led care versus physician-led care for persons with low back pain: A systematic review

Objective To summarise the evidence on the effect of physiotherapy-led versus physician-led care on clinical outcomes, healthcare use, and costs in persons with low back pain. Data sources PubMed, Web of Science, CINAHL, Embase, and PEDro were systematically searched with the latest search performed in July 2024. Reference lists of articles were hand-searched. Review methods Studies comparing clinical outcomes, healthcare use, or costs between adults with low back pain first consulting a physiotherapist and those first consulting a physician were included. Methodological quality was assessed with the Newcastle-Ottawa Scale. Study design, clinical setting, patient characteristics, and group effects were extracted. Findings on outcomes assessed in two or more studies were synthesised narratively. Certainty of evidence was determined using the GRADE approach. Results Eighteen studies comprising 1,481,980 persons with low back pain were included. Most studies were non-randomised retrospective or prospective cohort studies. In primary care (15 studies), consistent evidence, though of mostly very low certainty, indicated that physiotherapy-led care leads to higher patient satisfaction, less use of medication, injections and imaging, fewer physician's visits, lower total healthcare costs, and less sick leave compared to physician-led care, without increased harm. In emergency care (three studies), evidence of very low certainty showed that physiotherapy-led care leads to shorter waiting and treatment times, and fewer hospital admissions. Conclusion Physiotherapy-led care is a clinically, time- and cost-effective care pathway for low back pain, although the certainty of evidence was overall very low. Further high-quality research with a greater focus on clinical outcomes is warranted.