Health System Characteristics Research Articles

The HEROES (HEalth woRkfOrcE to meet health challengeS) Joint Action

Abstract Background The HEROES (HEalth woRkfOrcE to meet health challengeS) Joint Action aims to advance health workforce planning across the EU, addressing the pressing need for a resilient, sustainable, and accessible health service systems. Given the evident strain on health systems demonstrated during the COVID-19 pandemic, this initiative seeks to address the critical need for strategic HWF planning. Building on previous projects, HEROES will foster the capacity of EU states in workforce planning, preparing the health systems to meet future challenges. Methods The study adopts a collaborative framework involving 19 EU countries, segmented into clusters based on health system characteristics. A stepwise approach (‘AS IS,’ ‘TO BE,’ ‘TO DO’) characterizes the methodology, incorporating extensive data collection, stakeholder engagement, and scenario forecasting. Country-level information on HWF Data and Planning will be compared both across countries in clusters and across clusters. Results Initial findings indicate significant disparities in health workforce data quality, availability, and planning methodologies among the states. Identified methodologies also involve real-world data applications and predictive analytics to refine health workforce planning. Efforts are underway to define an Advanced Minimum Dataset (AMDS) to synchronize health workforce data and define planning tools across the clusters, as country-level AS IS reports have been finalized and cross-country comparisons are ongoing. Conclusions Collaborative, data-driven health workforce planning can significantly enhance health system resilience and responsiveness. Recommended public health actions include enhancing HWF data integration, forecasting capabilities, and stakeholder participation, with the aim of shaping national health policies and practices. The public health impact is profound, as it allows to improve health service delivery and workforce adaptability in response to dynamic health demands. Key messages • The HEROES Joint Action advances EU health workforce planning, with the aim of enhancing the resilience and responsiveness of health systems. • Strategic data-driven approaches in health workforce planning are pivotal for resilient, accessible and sustainable healthcare systems.

Characteristics of High-Quality Multi-Hospital Health Systems Performing Major Cancer Surgery

Objective: To identify characteristics associated with high- and low-quality multi-hospital systems for major cancer surgery Background: Although multi-hospital health systems provide most inpatient healthcare in the US, our understanding of how these systems can optimize surgical quality among their hospitals remains limited. Identifying the structural characteristics (e.g., number of hospitals, procedural volume, geographic dispersion) that distinguish high- and low-quality systems may inform actionable strategies to improve surgical quality. Methods: We conducted a retrospective cross-sectional observational study of 270,491 Medicare beneficiaries (2016-2020) undergoing major cancer surgery at a multi-hospital health system. Systems were classified into quartiles of quality based on risk- and reliability-adjusted rates of 30-day mortality using a hierarchical multivariable logistical regression model to adjust for patient, procedural, and hospital factors. Results: The adjusted 30-day operative mortality rate in the highest- versus lowest-quality quartile of systems was 1.7% versus 3.1%,(P<0.001). High-quality systems had fewer hospitals per system (median [IQR], number of system hospitals, 5 [3-11] vs. 12 [8-30];P<0.001), with each performing more procedures per hospital (median [IQR] annual procedure volume, 104 [52-218] vs. 45 [22-90];P<0.001). High-quality systems were also more geographically concentrated (median [IQR] maximum distance between hospitals, 62 [19-194] vs. 321 [91-1125] miles;P<0.001). Furthermore, high-quality systems demonstrated less variation in quality between hospitals (mean [SD] within-system absolute variation in mortality, 0.8% [0.3%] vs. 2.6% [1.0%];P<0.001). Conclusions: The highest-quality multi-hospital systems had fewer, more geographically concentrated hospitals, with each performing more procedures per hospital. Among the highest-quality systems, diverse system phenotypes were represented, suggesting the potential to overcome structural limitations and achieve high quality.

Health system resilience during the COVID-19 pandemic: A comparative analysis of disruptions in care from 32 countries.

To quantify disruptions in hospitalization and ambulatory care throughout the coronavirus disease 2019 (COVID-19) pandemic for 32 countries, and examine associations of health system characteristics and COVID-19 response strategies on disruptions. We utilized aggregated inpatient hospitalization and surgical procedure data from the Organization for Economic Co-operation and Development Health Database from 2010 to 2021. Covariate data were extracted from the Organization for Economic Co-operation and Development Health Database, World Health Organization, and Oxford COVID-19 Government Response Tracker. This is a descriptive study using time-series analyses to quantify the annual effect of the COVID-19 pandemic on non-COVID-19 hospitalizations for 20 diagnostic categories and 15 surgical procedures. We compared expected hospitalizations had the pandemic never occurred in 2020-2021, estimated using autoregressive integrated moving average modeling with data from 2010 to 2019, with observed hospitalizations. Observed-to-expected ratios and missed hospitalizations were computed as measures of COVID-19 impact. Mixed linear models were employed to examine associations between hospitalization observed-to-expected ratios and covariates. The COVID-19 pandemic was associated with 16,300,000 (95% uncertainty interval 14,700,000-17,900,000; 18.0% [16.5%-19.4%]) missed hospitalizations in 2020. Diseases of the respiratory (-2,030,000 [-2,300,000 to -1,780,000]), circulatory (-1,680,000 [-1,960,000 to -1,410,000]), and musculoskeletal (-1,480,000 [-1,720,000 to -1,260,000]) systems contributed most to the declines. In 2021, there were an additional 14,700,000 (95% uncertainty interval 13,100,000-16,400,000; 16.3% [14.9%-17.9%]) missed hospitalizations. Total healthcare workers per capita (β = 1.02 [95% CI 1.00, 1.04]) and insurance coverage (β = 1.05 [1.02, 1.09]) were associated with fewer missed hospitalizations. Stringency index (β = 0.98 [0.98, 0.99]) and excess all-cause deaths (β = 0.98 [0.96, 0.99]) were associated with more missed hospitalizations. There was marked cross-country variability in disruptions to hospitalizations and ambulatory care. Certain health system characteristics appeared to be more protective, such as insurance coverage, and number of inputs including healthcare workforce and beds. Substantial disruptions in health services associated with the coronavirus disease 2019 pandemic have placed a renewed interest in health system resilience. While there is a growing body of evidence documenting disruptions in services, there are limited comparative assessments across diverse countries with different health system designs, preparedness levels, and public health responses. Learning and adapting from health system-specific gaps and challenges highlighted by the pandemic will be critical for improving resilience. All countries experienced disruptions to hospitalizations and surgical procedures with a combined total of 30 million missed hospitalizations and 4 million missed surgical procedures in 2020-2021, but there was marked cross-country heterogeneity in disruptions. Countries with greater baseline healthcare workers, insurance coverage, and hospital beds had disproportionately lower disruptions in care. National health planning discussions may need to balance health system resiliency and efficiency to avert preventable morbidity and mortality.

Trends and determinants of the use of episiotomy in a prospective population-based registry from central India

BackgroundFindings from research and recommendations from the World Health Organization favor restrictive use of episiotomy, but whether this guidance is being followed in India, and factors associated with its use, are not known. This study sought to document trends in use of episiotomy over a five-year period (2014–2018); to examine its relationship to maternal, pregnancy, and health-system characteristics; and to investigate its association with other obstetric interventions.MethodsWe conducted a secondary analysis of data collected by the Maternal Newborn Health Registry, a prospective population-based pregnancy registry established in Central India (Nagpur, Eastern Maharashtra). We examined type of birth and use of episiotomy in vaginal deliveries from 2014 to 2018, as well as maternal and birth characteristics, health systems factors, and concurrent obstetric interventions associations with its use with multivariable Poisson regression models.ResultsDuring the five-year interval, the rate of episiotomy in vaginal birth rose from 13 to 31% despite a decline in assisted vaginal birth. Associations with episiotomy were found for the following factors: prior birth, multiple gestations, seven or more years of maternal education, higher gestational age, higher birthweight, delivery by an obstetrician (as compared to midwife or general physician), and birth in hospital (as compared to clinic or health center). After adjusting for these factors, year over year rise in episiotomy was significant with an adjusted incidence rate ratio (AIRR) of 1.10 [95% confidence interval (CI) 1.08–1.12; p = 0.002]. We found an association between episiotomy and several other obstetric interventions, with the strongest relationship for maternal treatment with antibiotics (AIRR 4.23, 95% CI 3.12–5.73; p = 0.001).ConclusionsEpisiotomy in this population-based sample from central India steadily rose from 2014 to 2018. This increase over time was observed even after adjusting for patient characteristics, obstetric risk factors, and health system features, such as specialty of the birthing provider. Our findings have important implications for maternal-child health and respectful maternity care given that most women prefer to avoid episiotomy; they also highlight a potential target for antibiotic stewardship as part of global efforts to combat antimicrobial resistance.Trial RegistrationThe study was registered at ClinicalTrials.gov under reference number NCT01073475.

Learning From Countries on Measuring and Defining Community-Based Resilience in Health Systems: Voices From Nepal, Sierra Leone, Liberia, and Ethiopia

Background: The best approach for defining and measuring community health care resilience in times of crisis remains elusive. We aimed to synthesise definitions and indicators of resilience from countries who had recently undergone shocks (i.e., outbreaks and natural disasters). Methods: We purposively selected four countries that had recently or were currently experiencing a shock: Nepal, Ethiopia, Sierra Leone, and Liberia. Focus group discussions and key informant interviews were conducted with participants at the community, facility, district, sub-national, national, and international levels. Interviews and discussions were translated and transcribed verbatim. Data were open coded in ATLAS.ti using a grounded theory approach and were thematically collated to a pre-specified framework. Results: A total of 486 people participated in the study (n=378 community members, n=108 non-community members). Emergent themes defining community-based health system resilience included: the importance of communities, health system characteristics, learning from shocks, preventing and preparing for shocks, and considerations for sustainability and intersectoral engagement. Participants identified 193 potential indicators for measuring resilience, which fell into the domains of: 1) preparedness, 2) response and recovery, 3) communities, 4) health systems, and 5) intersectoral engagement. Conclusion: Despite varying definitions and understanding of the concept of resilience, community-centred responses to shocks were key in building resilience. Further insight is needed into how the definitions and indicators identified in this study compare to other shocks and contexts and can be used to further our understanding of health system resilience. Metrics and definitions could assist policy makers, researchers, and practitioners in evaluating the readiness of systems to respond to shocks and to allow comparability across health systems. We must build health systems that can continue to function and ensure quality, equity, community-focused care, and engagement, regardless of the pressures put upon them and ensure they are linked to strong primary health care.

Understanding barriers and facilitators to integrated HIV and hypertension care in South Africa

BackgroundThe burden of hypertension among people with HIV is high, particularly in low-and middle-income countries, yet gaps in hypertension screening and care in these settings persist. This study aimed to identify facilitators of and barriers to hypertension screening, treatment, and management among people with HIV in primary care clinics in Johannesburg, South Africa. Additionally, different stakeholder groups were included to identify discordant perceptions.MethodsUsing a cross-sectional study design, data were collected via interviews (n = 53) with people with HIV and hypertension and clinic managers and focus group discussions (n = 9) with clinic staff. A qualitative framework analysis approach guided by COM-B and the Theoretical Domains Framework were used to identify and compare determinants of hypertension care across stakeholder groups.ResultsData from clinic staff and managers generated three themes characterizing facilitators of and barriers to the adoption and implementation of hypertension screening and treatment: 1) clinics have limited structural and operational capacity to support the implementation of integrated care models, 2) education and training on chronic care guidelines is inconsistent and often lacking across clinics, and 3) clinicians have the goal of enhancing chronic care within their clinics but first need to advocate for health system characteristics that will sustainably support integrated care. Patient data generated three themes characterizing existing facilitators of and barriers to clinic attendance and chronic disease self-management: 1) the threat of hypertension-related morbidity and mortality as a motivator for lifestyle change, 2) the emotional toll of clinic’s logistical, staff, and resource challenges, and 3) hypertension self-management as a patchwork of informational and support sources. The main barriers to hypertension screening, treatment, and management were related to environmental resources and context (i.e., lack of enabling resources and siloed flow of clinic operations) and patients’ knowledge and emotions (i.e., lack of awareness about hypertension risk, fear, and frustration). Clinical actors and patients differed in perceived need to prioritize HIV versus hypertension care.ConclusionsThe convergence of multi-stakeholder data highlight key areas for improvement, where tailored implementation strategies targeting motivations of clinic staff and capacity of patients may address challenges to hypertension screening, treatment, and management recognized across groups.

Analysis of health system characteristics needed before performance assessment.

Analysis of health system characteristics needed before performance assessment.

Mixed-methods exploration of challenges to stoma care for ostomates in four low- and middle-income countries: STomacARe For Improvement reSearcH (STARFISH) study

Background Little is known about the challenges of stoma care and potential solutions for patients in low- and middle-income countries (LMICs). This study aimed to assess the outcomes and experience of care for patients with stomas in LMICs using a mixed methods approach. Methods A cross-sectional survey of hospitals assessed health system characteristics relevant to stoma care. A six-month retrospective audit collected data on all patients undergoing new stoma formation, and postoperative complications. Semi-structured interviews with stoma patients and informal caregivers, and key informant interviews with healthcare providers were conducted to gather information on experiences, challenges and coping strategies relating to stoma care. The results were triangulated to develop a questionnaire-based tool to assess patients’ and carers’ knowledge and attitudes towards stoma and stoma care. Results Six hospitals from the Philippines, Malawi, Nigeria and India participated in the study. Data from 446 patients demonstrated diversity case mix, outcomes and postoperative stoma counselling. Interview data from the Philippines highlighted the lack of knowledge on stoma care of the patients and carers, poor access to stoma care and resources and the lack of affordable stoma care supplies. Triangulating these inputs, a 33-item questionnaire was developed to facilitate task sharing of expert stoma care to non-expert nurses and caregivers. Conclusions This study highlighted gaps in capacity to provide stoma counselling and poor access to and affordability of stoma care supplies for patients in LMICs. This novel questionnaire can help close these gaps and improve care for new ostomates in resource limited settings. Registration The study is registered in the Philippine Health Research Registry PHRR No.210805-003783 (https://registry.healthresearch.ph/index.php/registry)

“I probably have access, but I can’t afford it”: expanding definitions of affordability in access to contraceptive services among people with low income in Georgia, USA

BackgroundDisparities in rates of contraceptive use are frequently attributed to unequal access to and affordability of care. There is a need to better understand whether common definitions of affordability that solely relate to cost or to insurance status capture the reality of individuals’ lived experiences. We sought to better understand how individuals with low incomes and the capacity for pregnancy conceptualized one domain of contraceptive access–affordability --in terms of health system and individual access and how both shaped contraceptive care-seeking in the US South.MethodBetween January 2019 to February 2020, we conducted twenty-five life-history interviews with low-income individuals who may become pregnant living in suburban counties in Georgia, USA. Interviews covered the ways individual and health system access factors influenced care-seeking for family planning over the life course. Interview transcripts were analyzed using a thematic analysis approach to identify experiences associated with individual and health system access.ResultsAffordability was identified as a major determinant of access, one tied to unique combinations of individual factors (e.g., financial status) and health system characteristics (e.g., cost of methods) that fluctuated over time. Navigating the process to attain affordable care was unpredictable and had important implications for care-seeking. A “poor fit” between individual and health system factors could lead to inequities in access and gaps in, or non-use of contraception. Participants also reported high levels of shame and stigma associated with being uninsured or on publicly funded insurance.ConclusionsAffordability is one domain of contraceptive access that is shaped by the interplay between individual factors and health system characteristics as well as by larger structural factors such as health and economic policies that influence both. Assessments of the affordability of contraceptive care must account for the dynamic interplay among multilevel influences. Despite the expansion of contraceptive coverage through the Affordable Care Act, low-income individuals still struggle with affordability and disparities persist.

Human resources in dentistry geographical distribution in Brazil and Colombia: Comparative analysis from the perspective of historical institutionalism

The Human Resource in Health constitutes one of the six core components of health systems, playing a crucial role in realizing the right to health and ensuring access and service quality. Additionally, institutional frameworks within each country, encompassing laws, decrees, political systems, and health system characteristics, exert a significant influence on HRH and, specifically, in Human Resources in Dentistry (HRD). Both Brazil and Colombia experienced neoliberal reforms in the 1990s, introducing new institutions within the existing model and altering the social, political, and economic dynamics of each country. This study aims to examine the impact of institutional arrangements stemming from the 1990s neoliberal reforms in Brazil and Colombia on HRDs, focusing on geographic distribution. Employing a comparative analysis and adopting a historical institutionalism perspective, the research relies on a methodology involving multiple case studies with embedded units. Results reveal that the neoliberal reforms represented critical junctures reshaping the social and economic policies of both nations. In this context, the reforms influenced wealth distribution in both countries, subsequently impacting the unequal geographical distribution of HRD. These effects were closely tied to factors such as labor flexibility and the unregulated, unplanned expansion of dentistry courses. These elements initiated positive feedback loops, characterized by path dependence and increasing returns, which have contributed to the institutionalization and persistence of these phenomena within the state and have become entrenched in HRDs over time.

The effect of institutional characteristics and social norms on corruption in healthcare

AbstractCorruption in healthcare is widespread and consequential. Informal payments (IPs) are a common form of petty corruption, especially in low‐ and middle‐income countries. Using data from the Life in Transition Survey encompassing 33 countries across Europe and Central Asia, I analyze the prevalence and reasons behind IPs made to public health providers. In addition to individual‐ and system‐level factors often used in literature, I also introduce a latent measure of social norms related to high levels of corruption. These are associated with a significantly higher prevalence of paying informally. This paper also bridges a gap between the corruption literature and health‐related research by introducing a typology of IPs based on why they were made. I find that the association between health system characteristics and IPs prevalence differs based on the reason for payment. This difference is further exacerbated by the existence of corruption‐related social norms. The results of this analysis highlight the need to revisit existing anti‐corruption policies and align them to the underlying social norms.

Preferences and feasibility of long-acting technologies for treatment of hepatitis C virus in low- and middle-income countries: A survey of providers and policymakers.

Long-acting technologies (LATs) for hepatitis C virus (HCV) are under development as a strategy to improve linkage to care, treatment adherence and outcomes. We conducted a survey of HCV treatment prescribers and HCV policymakers in low- and middle-income countries (LMICs) regarding acceptability and feasibility of HCV LATs. We included one-time intramuscular injection, subdermal implant and transdermal patch as potential LAT options. We surveyed participants regarding optimal health system and patient characteristics, concerns, potential barriers, overall feasibility and preferences for HCV LAT as compared to daily oral medication. Overall, 122 providers and 50 policymakers from 42 LMICs completed the survey. Among providers, 93% (113/122) expressed willingness to prescribe LAT and 72% (88/120) of providers preferred LAT if provided at comparable efficacy, safety and cost as current oral treatments. Of providers preferring HCV LAT to daily oral medication, 67% (59/88) preferred injection, 24% (21/88) preferred patch and 9% (8/88) preferred implant. Only 20% (24/122) would prescribe LAT if it were more costly than oral treatment. In regression analysis, no provider characteristics were associated with preference for LAT over oral treatment. Policymakers reported high likelihood that LAT would be included in treatment guidelines (42/50; 84%) and national drug formularies (39/50; 78%) if efficacy, safety and cost were similar to oral treatment. HCV LATs could advance progress to HCV elimination in LMICs by diversifying treatment options to improve treatment coverage and outcomes. Provider preferences from LMICs are a critical consideration in the development of HCV LATs to ensure its early and equitable availability in LMICs.

Determinants of public health expenditure in the EU.

Public health expenditure is one of the fastest-growing spending items in EU member states. As the population ages and wealth increases, governments allocate more resources to their health systems. In view of this, the aim of this study is to identify the key determinants of public health expenditure in the EU member states. This study is based on macro-level EU panel data covering the period from 2000 to 2018. The association between explanatory variables and public health expenditure is analyzed by applying both static and dynamic econometric modeling. Although GDP and out-of-pocket health expenditure are identified as the key drivers of public health expenditure, there are other variables, such as health system characteristics, with a statistically significant association with expenditure. Other variables, such as election year and the level of public debt, result to exert only a modest influence on the level of public health expenditure. Results also indicate that the aging of the population, political ideologies of governments and citizens' expectations, appear to be statistically insignificant. Since increases in public health expenditure in EU member states are mainly triggered by GDP increases, it is expected that differences in PHE per capita across member states will persist and, consequently, making it more difficult to attain the health equity sustainable development goal. Thus, measures to reduce EU economic inequalities, will ultimately result in reducing disparities in public health expenditures across member states.

1965 US Voting Rights Act Impact on Black and Black Versus White Infant Death Rates in Jim Crow States, 1959-1980 and 2017-2021.

Objectives. To investigate the impact of the US Voting Rights Act (VRA) of 1965 on Black and Black versus White infant deaths in Jim Crow states. Methods. Using data from 1959 to 1980 and 2017 to 2021, we applied difference-in-differences methods to quantify differential pre-post VRA changes in infant deaths in VRA-exposed versus unexposed counties, controlling for population size and social, economic, and health system characteristics. VRA-exposed counties, identified by Section 4, were subject to government interventions to remove existing racist voter suppression policies. Results. Black infant deaths in VRA-exposed counties decreased by an average of 11.4 (95% confidence interval [CI] = 1.7, 21.0) additional deaths beyond the decrease experienced by unexposed counties between the pre-VRA period (1959-1965) and the post-VRA period (1966-1970). This translates to 6703 (95% CI = 999.6, 12 348) or 17.5% (95% CI = 3.1%, 28.1%) fewer deaths than would have been experienced in the absence of the VRA. The equivalent differential changes were not significant among the White or total population. Conclusions. Passage of the VRA led to pronounced reductions in Black infant deaths in Southern counties subject to government intervention because these counties had particularly egregious voter suppression practices. (Am J Public Health. 2024;114(3):300-308. https://doi.org/10.2105/AJPH.2023.307518).

Impact of Corticosteroid Therapy on ICU Patient Outcomes in Severe COVID-19 Cases: A Retrospective Cohort Study in Saudi Arabia.

The COVID-19 pandemic has presented significant challenges in clinical management, and intensive care units (ICUs) worldwide have become epicenters of high-stakes treatment decisions. Among these, corticosteroid therapy has risen as a pivotal, yet controversial, treatment modality. In Saudi Arabia, where unique demographic and health system characteristics intersect, understanding the specific effects of corticosteroids on ICU patient outcomes is not just critical but a pressing necessity in tailoring effective COVID-19 management strategies. This study aims to elucidate the effects of corticosteroid therapy on the outcomes of severe COVID-19 patients in Saudi Arabian ICUs, providing critical insights into treatment efficacy and guiding future clinical practices. In this cohort study, we meticulously reviewed the medical records of 1085 severe COVID-19 patients admitted to Saudi Arabian ICUs. Our analysis focused on demographic details, ICU outcomes, and the extent and implications of corticosteroid therapy. The study employed comprehensive methods for data collection, evaluation criteria, and statistical analysis, ensuring a thorough understanding of the impact of corticosteroids in this context. The study encompassed 1085 patients, predominantly male (74.5%, N=806), with an average age of 56 and a mean BMI of 30.07. A significant portion (72.3%, N=784) received corticosteroid therapy. These patients generally experienced longer ICU (mean 23 days) and hospital stays (mean 16 days), along with higher rates of microbiological cure (72.3%, N=648) and increased ICU discharge likelihood. Conversely, corticosteroid recipients showed higher mortality rates at ICU discharge. The statistical analysis confirmed the significance of these findings, reinforcing their importance in managing COVID-19 in ICUs. The research highlights the intricate dynamics of corticosteroid use in treating severe COVID-19 cases in ICUs. While associated with prolonged ICU stays and increased mortality, corticosteroids also correlate with higher microbiological cure rates and discharge likelihood. These insights call for careful deliberation in applying corticosteroid therapy, with implications for enhancing clinical protocols and guiding future research in severe COVID-19 treatment.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries.

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

Initial and Long-Term Prescribing of Opioids and Non-steroidal Anti-inflammatory Drugs Following Total Hip and Knee Arthroplasty.

Limited evidence exists on health system characteristics associated with initial and long-term prescribing of opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) following total hip and knee arthroplasty (THA/TKA), and if these characteristics differ among individuals based on preoperative NSAID exposure. We identified orthopedic surgeon opioid prescribing practices, hospital characteristics, and regional factors associated with initial and long-term prescribing of opioids and NSAIDs among older adults receiving THA/TKA. This observational study included opioid-naïve Medicare beneficiaries aged ≥65years receiving elective THA/TKA between January 1, 2014 and July 4, 2017. We examined initial (days 1-30 following THA/TKA) and long-term (days 90-180) opioid or NSAID prescribing, stratified by preoperative NSAID exposure. Risk ratios (RRs) for the associations between 10 health system characteristics and case-mix adjusted outcomes were estimated using multivariable Poisson regression models. The study population included 23,351 NSAID-naïve and 10,127 NSAID-prevalent individuals. Increases in standardized measures of orthopedic surgeon opioid prescribing generally decreased the risk of initial NSAID prescribing but increased the risk of long-term opioid prescribing. For example, among NSAID-naïve individuals, the RRs (95% confidence intervals [CIs]) for initial NSAID prescribing were 0.95 (0.93-0.97) for 1-2 orthopedic surgeon opioid prescriptions per THA/TKA procedure, 0.94 (0.92-0.97) for 3-4 prescriptions per procedure, and 0.91 (0.89-0.93) for 5+ opioid prescriptions per procedure (reference: <1 opioid prescription per procedure), while the RRs (95% CIs) for long-term opioid prescribing were 1.06 (1.04-1.08), 1.08 (1.06-1.11), and 1.13 (1.11-1.16), respectively. Variation in postoperative analgesic prescribing was observed across U.S. regions. For example, among NSAID-naïve individuals, the RR (95% CIs) for initial opioid prescribing were 0.98 (0.96-1.00) for Region 2 (New York), 1.09 (1.07-1.11) for Region 3 (Philadelphia), 1.07 (1.05-1.10) for Region 4 (Atlanta), 1.03 (1.01-1.05) for Region 5 (Chicago), 1.16 (1.13-1.18) for Region 6 (Dallas), 1.10 (1.08-1.12) for Region 7 (Kansas City), 1.09 (1.06-1.12) for Region 8 (Denver), 1.09 (1.07-1.12) for Region 9 (San Francisco), and 1.11 (1.08-1.13) for Region 10 (Seattle) (reference: Region 1 [Boston]). Hospital characteristics were not meaningfully associated with postoperative analgesic prescribing. The relationships between health system characteristics and postoperative analgesic prescribing were similar for NSAID-naïve and NSAID-prevalent participants. Future efforts aiming to improve the use of multimodal analgesia through increased NSAID prescribing and reduced long-term opioid prescribing following THA/TKA could consider targeting orthopedic surgeons with higher standardized opioid prescribing measures. Orthopedic surgeon opioid prescribing measures and U.S. region were the greatest health system level predictors of initial, and long-term, prescribing of opioids and prescription NSAIDs among older Medicare beneficiaries following THA/TKA. These results can inform future studies that examine why variation in analgesic prescribing exists across geographic regions and levels of orthopedic surgeon opioid prescribing.

Determinants of First‐Line Nurse Managers’ Span of Control: A Delphi Study

Aims: The main goal of this research is to identify, through expert consensus, the key factors that determine the span of control (SOC) of first‐line nurse managers (FLNMs) in the Spanish healthcare system.Background: The SOC is a management concept which has usually been defined as the number of subordinates reporting to a superior. In nursing, however, it is much more complex. This complexity is shaped by various factors related to patients, healthcare professionals and organisational structures. Nursing leaders must thoroughly consider these factors and their determinants, which necessitate a comprehensive assessment. Given the significant impact an inadequate SOC can have on patients, professionals and the organisation, it would be beneficial to address this issue. In nursing, studies on this subject are practically nonexistent and focus solely on the number of subordinates, highlighting the need for research in this area.Methods: Between September and December 2022, a Delphi study was conducted. Forty‐five experts were invited to participate. The study involved nurse administrators, FLNMs, university professors, renowned researchers and other non–health professionals related to health management. The participants completed an online survey over three phases. Factor analysis was performed on the items for which consensus was reached. The jamovi software version 2.3.15 was used for data analysis.Results: A total of 35 experts participated in at least one of the three phases of the Delphi study. Following a comprehensive analysis of the identified factors, a consensus was reached on 31 of them. These were subsequently grouped into four categories: unit category (16 items, including complexity, resource management, conflicts and protocolisation and monitoring of activities), professional category (five items: number of staff, staffing stability and skill level and diversity of staff), FLNM category (four items: autonomy, experience and education and leadership style) and organisation category (six items: digitisation and information systems, education, research and implementation evidence‐based practice and performing guards).Conclusions: Our research shows a high degree of consensus amongst participants in identifying the determinants and degree of relevance of SOC‐related aspects. Although SOC is not currently assessed, all stakeholders agree that there are a large number of variables that should be considered when appointing a FLNM.Implications for Nurse Managers: Nursing managers can better assess the health of the organisation and improve performance by understanding the factors that influence the SOC of FLNMs. Due to the lack of previous studies, understanding these factors will allow the development of methods and tools tailored to the characteristics of different health systems.

Geospatial analysis and participant characteristics associated with colorectal cancer screening participation in Alberta, Canada: a population-based cross-sectional study

BackgroundColorectal cancer (CRC) is a leading cause of death in Canada and early detection can prevent deaths through screening. However, CRC screening in Alberta, Canada remains suboptimal and varies by sociodemographic and health system characteristics, as well as geographic location. This study aimed to further the understanding of these participant and health system characteristics associated with CRC screening in Alberta and identify clusters of regions with higher rates of overdue or unscreened individuals.MethodsWe included Albertans aged 52 to 74 as of December 31, 2019 (index date) and we used data from administrative health data sources and linked to the Alberta Colorectal Cancer Screening Program database to determine colorectal cancer screening rates. We used multivariable multinomial logistic regression analysis to investigate the relationship between sociodemographic, health system characteristics and participation in CRC screening. We used optimized Getis-Ord Gi* hot-spot analysis to identify hot and cold-spots in overdue for and no record of CRC screening.ResultsWe included 919,939 Albertans, of which 65% were currently up to date on their CRC screening, 21% were overdue, and 14% had no record of CRC screening. Compared to Albertans who were currently up to date, those who were in older age groups, those without a usual provider of care, those who were health system non-users, and those living in more deprived areas were more likely to have no record of screening. Areas with high number of Albertans with no record of screening were concentrated in the North and Central zones.ConclusionsOur study showed important variation in colorectal cancer screening participation across sociodemographic, health system and geographical characteristics and identified areas with higher proportions of individuals who have no record of screening or are under-screened in Alberta, Canada.

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BackgroundPrimary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.MethodsWe developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010–2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.ResultsCountries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.ConclusionsOur results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.