Levels Of Health System Research Articles

Hospital system market share and commercial prices: a cross-sectional approach using price transparency data

BackgroundThe goal of this study is to estimate the association between hospital system market share and negotiated prices.Hospital system consolidation has led to many highly concentrated markets where systems can leverage their market share to negotiate higher commercial prices. Recently, the Centers for Medicare & Medicaid Services, under its Transparency in Coverage initiative, required health insurers to release all negotiated commercial prices, providing, for the first time, publicly available, nationally representative data on commercial rates. We utilize this newly available data on negotiated prices of healthcare services to show that a hospital with 10% higher market share charges 880-1,180 more per admission.Study designWe used commercial price data for national networks of three large, national insurers and performed a linear regression based on more than 1.3 million negotiated rates across 1,784 hospitals to estimate the association between a hospital’s system-level market share and commercial negotiated rates, adjusting for service (DRG), health system, and area level time-invariant characteristics.ResultsWe find that a one percentage point increase in hospital system market share is associated with an $88 to $118 higher negotiated rate per admission. All else equal, a hospital that is part of a system with a 10-percentage point higher market share can expect from $880 to $1,180 more per admission relative to a hospital with lower system market share (5.4% to 6.2% of the median price).ConclusionThese findings confirm that higher hospital system market share is strongly associated with higher commercial negotiated prices and should aid policymakers and decisionmakers in assessing the impact of various policy options aimed at reducing provider consolidation in the healthcare market.Trial registrationNot applicable.

Exploring variations in the implementation of a health system level policy intervention to improve maternal and child health outcomes in resource limited settings: A qualitative multiple case study from Uganda.

Despite growing literature, few studies have explored the implementation of policy interventions to reduce maternal and perinatal mortality in low- and middle-income countries (LMICs). Even fewer studies explicitly articulate the theoretical approaches used to understand contextual influences on policy implementation. This under-use of theory may account for the limited understanding of the variations in implementation processes and outcomes. We share findings from a study exploring how a health system-level policy intervention was implemented to improve maternal and child health outcomes in a resource limited LMIC. Our qualitative multiple case study was informed by the Normalization Process Theory (NPT). It was conducted across eight districts and among ten health facilities in Uganda, with 48 purposively selected participants. These included health care workers located at each of the cases, policy makers from the Ministry of Health, and from agencies and professional associations. Data were collected using semi-structured, in-depth interviews to understand uptake and use of Uganda's maternal and perinatal death surveillance and response (MPDSR) policy and were inductively and deductively analyzed using NPT constructs and subconstructs. We identified six broad themes that may explain the observed variations in the implementation of the MPDSR policy. These include: 1) perception of the implementation of the policy, 2) leadership of the implementation process, 3) structural arrangements and coordination, 4) extent of management support and adequacy of resources, 5) variations in appraisal and reconfiguration efforts and 6) variations in barriers to implementation of the policy. The variations in sense making and relational efforts, especially perceptions of the implementation process and leadership capacity, had ripple effects across operational and appraisal efforts. Adopting theoretically informed approaches to assessing the implementation of policy interventions is crucial, especially within resource limited settings.

Making the transition from medical student to junior doctor

The transition between medical students and junior doctors is known to be a notoriously challenging period of time, contributed by heavy clinical responsibilities, steep learning curves, poor working conditions and various psychological stressors. In addition, there is often a significant lack of support at the organisational or health systems level for fledgling junior physicians in their transition to work life. In this article, I hope to offer several important guiding principles from the perspectives of a medical resident-in-training that I hope will be useful for graduating medical students to ease their transition into the foundational year of practice, such that they can optimise their training and work experience within what is in their control and maintain a sense of purpose even in difficult times.

Learning health system linchpins: information exchange and a common data model.

To demonstrate the potential for a centrally managed health information exchange standardized to a common data model (HIE-CDM) to facilitate semantic data flow needed to support a learning health system (LHS). The Rhode Island Quality Institute operates the Rhode Island (RI) statewide HIE, which aggregates RI health data for more than half of the state's population from 47 data partners. We standardized HIE data to the Observational Medical Outcomes Partnership (OMOP) CDM. Atherosclerotic cardiovascular disease (ASCVD) risk and primary prevention practices were selected to demonstrate LHS semantic data flow from 2013 to 2023. We calculated longitudinal 10-year ASCVD risk on 62,999 individuals. Nearly two-thirds had ASCVD risk factors from more than one data partner. This enabled granular tracking of individual ASCVD risk, primary prevention (ie, statin therapy), and incident disease. The population was on statins for fewer than half of the guideline-recommended days. We also found that individuals receiving care at Federally Qualified Health Centers were more likely to have unfavorable ASCVD risk profiles and more likely to be on statins. CDM transformation reduced data heterogeneity through a unified health record that adheres to defined terminologies per OMOP domain. We demonstrated the potential for an HIE-CDM to enable observational population health research. We also showed how to leverage existing health information technology infrastructure and health data best practices to break down LHS barriers. HIE-CDM facilitates knowledge curation and health system intervention development at the individual, health system, and population levels.

Actor Sensemaking and its Role in Implementation of the Decentralized Drug-Resistant TB Policy in South Africa.

South Africa has a high burden of drug-resistant tuberculosis (DR-TB). A policy to decentralize DR-TB treatment from specialized central hospitals to more accessible district facilities was introduced in 2011, but to date implementation has been suboptimal, with variable pace, coverage and models of care emerging. This study explored multilevel policy implementation of DR-TB decentralization in two provinces of South Africa, Western Cape and KwaZulu-Natal. Applying interpretive policy analysis, this paper describes how actors across health system levels and geographies made sense of the DR-TB policy and how this shaped implementation. In an embedded qualitative case study, districts of the two provinces were compared, through data collected in 94 in-depth interviews, and analysed using Vickers' framework of reality, value and action judgements. Five district cases characterise variation in the pace of implementation and models of DR-TB care that emerged. Individual and collective attitudes for and against the policy were underpinned by different systems of meaning for interpreting policy problems and making decisions. These meaning systems were reflected in actor stances on whether DR-TB care needed to be specialized or generalized, nurse- or doctor-led, and institutionalized or ambulatory. Actors' stances influenced their actions and implementation strategies adopted. Resistance to decentralized DR-TB care related to perceived threats of budget cuts to and loss of authority of central facilities, and was often justified in fears of increased transmission, poor quality of care and inadequate resources at lower levels. New advances in diagnosis and treatment to address the growing burden of DR-TB in South Africa will have little impact unless implementation dynamics are better understood, and attention paid to the mindsets, interests and interpretations of policy by actors tasked with implementation. Deliberative policy implementation processes will enhance the quality of discourse, communication and cross-learning between policy actors, critical for reaching synthesis of meaning systems.

Experiences with diagnostic delay among underserved racial and ethnic patients: a systematic review of the qualitative literature

ObjectiveDiagnostic delay is a pervasive patient safety problem that disproportionately affects historically underserved populations. We aim to systematically examine and synthesise published qualitative studies on patient experiences with diagnostic delay...

Commentary: Strengthening System Readiness for Health Interventions: Lessons for Implementing Interventions and Implementation Support in Low-And Middle-Income Countries.

In low- and middle-income countries (LMICs), barriers such as low system readiness, contextual mismatches, and resource limitations impede effective implementation of evidence-based interventions. This commentary offers insights into overcoming these challenges with a case study of the PRISM project, designed to reduce behavioral and psychological symptoms of dementia in older adults living in Thailand. The case highlights how combining two evidence-based models - the Reducing Disability in Alzheimer's Disease clinical intervention and the Getting To Outcomes implementation science process enhances program success. Using interviews with stakeholders across various health system levels, we identify factors critical to successful program implementation: (1) integrating interventions into policy frameworks, (2) empowering local implementers, (3) fostering collaborative learning, and (4) adapting interventions to local contexts. The case demonstrates that building system readiness through local engagement and ownership is central to scaling up health programs in LMICs. This commentary's contribution lies in its emphasis on the role of implementation science as a vehicle for translating research into practice. It presents a practical, adaptive model for embedding interventions into routine health systems, thereby offering a pathway for successfully scaling up evidence-based programs in LMICs. Such findings provide lessons for overcoming barriers to implementation in resource-limited environments.

Building Engagement-Capable Environments for Health System Transformation: Development and Early Implementation of a Capability Framework for Patient, Family and Caregiver Engagement in Ontario Health Teams.

Despite widespread calls to involve patients, families and caregivers (PFCs) as partners at all levels of health system planning and design, there is unevenness in how engagement efforts are supported across these settings. The concept of 'engagement-capable environments' offers a way forward to uncover the key requirements for sustainable, high-quality engagement, but more work is needed to identify the specific competencies required to create these environments. We addressed this gap by developing a capability framework for Ontario Health Teams (OHTs), a newly established structure for planning, designing, organizing and delivering care in Ontario, Canada. The framework was co-developed by a Working Group of OHT staff and leaders, PFC partners, researchers and government personnel. Project activities occurred over four phases: (1) planning, (2) evidence review and surveying of intended users to identify key competencies, (3) framework design and (4) implementation. An evidence review identified more than 90 potential competencies for this work. These results were contextualized and expanded through a survey of OHT stakeholders to brainstorm potential competencies, supports and enablers for engagement. Surveys were completed by 69 individuals; 689 knowledge and skill competency statements, 462 attitude and behaviour competency statements and 250 supports and enablers were brainstormed. The statements were analysed and organized into initial competency categories, which were reviewed, discussed and iteratively refined by Working Group members and through broader consultations with the OHT community. The final framework includes six competency domains and four support and enabler domains, each with sub-domain elements, mapped across a three-stage maturity model. The framework has been disseminated across OHTs, and its adoption and implementation are now requirements within OHT agreements. The framework combines a strong conceptual foundation with actionable elements informed by the literature and consultations with the intended users of the framework. Although developed for OHTs, the framework should be broadly applicable to other health system organizations seeking similar health system transformation goals. Patient, family and caregiver partners were involved at all stages and in all aspects of the work. As end users of the framework, their perspectives, knowledge and opinions were critical.

Patients' Nonattendance in Outpatient Specialist Consultations: A National Cohort Analysis of a Health System.

Analyzing patients' nonattendance at medical appointments helps address an issue impacting the management and sustainability of health systems globally, providing valuable insights for healthcare managers. This study aims to identify factors at both patient and health system levels that contribute to understanding missed appointments. The analysis was conducted using data from secondary care consultations within the Brazilian Unified Health System between April 2018 and March 2020. Primary care includes general medical consultations, while secondary care involves specialized services provided by doctors with advanced expertise. We examined demographic factors (age, sex, race/color, socioeconomic level) and health system practices (waiting time, hospitalization, distance to service, medical specialty, and severity of clinical condition) to assess their impact on patient attendance. A weighted analysis and receiver operating characteristic (ROC) analysis were applied to determine the relative risk of nonattendance. Of 5,003,159 consultations, 435,523 (8.7%) were missed. Nonattendance was highest among patients facing long distances to the service (13.3%, [RRR] 1.227), younger age (16-30 years: 11.8%, [RRR] 1.041), and waiting times (>30: 10.9%, [RRR] 1.738). Socially vulnerable patients were more likely to miss appointments (9.6%, [RRR] 1.055) compared to less vulnerable groups (8.6%). Practice-level factors had a slightly greater impact on nonattendance (ROC: 0.621) than patient-level factors (ROC: 0.5674). The overall predictive model achieved a C statistic of 0.6228, resulting in a fair predictive ability. However, the model showed only modest prediction of no-shows, indicating the need for more detailed data to improve accuracy. Gauging which group suffers the highest risk of nonattendance was a secondary goal of this analysis. Young, socially vulnerable patients with long commutes and extended waiting times are at higher risk of nonattendance. Effective management of these risk factors and targeted preventive actions are essential to reduce absenteeism and improve health system efficiency.

A cross-sectional geospatial analysis of access to cesarean delivery in Uganda by facility functionality

Introduction: There is minimal data on spatial access to surgical maternal care in Uganda. We aimed to determine geospatial access to facilities performing cesarean delivery in Uganda at differing facility functional levels. Methods: We defined three levels of facility functionality: level 1 – functional by designation, i.e., health system level; level 2 – performed at least one cesarean delivery in the past year; and level 3 – performed at least 20 cesarean deliveries in the past year. We mapped facilities in ArcGIS Pro using GPS coordinates, calculated Manhattan distances, and using transportation network data, identified the area indicating 30-minute, 1-hour, and 2-hour geographic walking and driving access to facilities. The population estimate raster was overlain with drive time analysis areas to calculate the total population catchment within each travel time. Results: Of 6937 total facilities, 339 (4.9%) met level 1 functionality, 287 (4.1%) met level 2 functionality, and 241 (3.5%) met level 3 functionality. The percentages of women within 30-minute, 1-hour, and 2-hour walking times from level 1 facilities were 9.7%, 19.8%, and 34.8%, respectively. These percentages decreased to 9.2%, 19%, and 33% for level 2 functionality and 8.1%, 17.4%, and 30.5% for level 3 functionality, respectively. Access varied regionally, with the poorest access in the Northern region (20% within 2 hours walking) compared to the Central region (55.2% within 2 hours walking). Conclusion: We demonstrate a substantial proportion of the Ugandan population does not have timely access to cesarean delivery, with substantial subnational variation. This inequity in access to surgical obstetric care is vital information that can assist policymakers in achieving universal maternal health access.

Implementing Patient Health Questionnaire Depression Screening in Inflammatory Arthritis Clinic: Insights From a Quality Improvement Project at a Tertiary Rheumatology Center.

This quality improvement project evaluates the feasibility and sustainability of adopting the Patient Health Questionnaire (PHQ) depression screening tool into routine clinical care at a rheumatology fellows' inflammatory arthritis (IA) clinic at a large tertiary center. The aim was to achieve 50% compliance in documentation of PHQ after five months. Providers received a 30-minute education on the importance of depression screening in patients with IA. A week after the education, two-step depression screening with the PHQ-2 followed by the PHQ-9 was implemented. Nurses performed PHQ-2 at each IA clinic visit verbally and documented the results while rooming patients using an electronic health record (EHR) dotphrase. Patients completed paper forms of the PHQ-9 only if the PHQ-2 score was positive for depression. Fellows then reviewed the PHQ-9 during the clinic visit and documented it using a separate EHR dotphrase. We tracked both PHQ-2 and PHQ-9 documentation rates as the key outcome measures. Before to the intervention, depression documentation rate was only 2%. After initial poor participation, nurses achieved the aim after repeated reminders and ongoing education by the senior nurse. Fellows failed to achieve the aim despite repeated reminders and education. Lack of time during clinic visit was found to be the biggest challenge. Sustained adoption of the PHQ was difficult to achieve. Additional support at the health systems level that prioritizes depression screening may need to take place. Additional research demonstrating improved IA outcomes in screened patients may also be helpful to gain more buy-in from providers.

Exploring treatment decision-making at diagnosis for children with advanced cancer in low- and middle-income countries

PurposeGlobal childhood cancer survival outcomes correlate with regional contextual factors, yet upfront treatment decision-making for children with advanced or poor prognosis cancer in low- and middle-income countries (LMICs) is not well understood. This study aimed to (1) characterize the landscape of contextual factors that shape physician decision-making at diagnosis for these children in LMICs and (2) describe physician rationales for if/when to offer treatment with non-curative intent, including how they define “poor prognosis” during treatment decision-making.MethodsAn international panel of pediatric oncologists practicing in LMICs participated in two focus groups structured for the collaborative generation of factors influencing treatment decision-making, including consideration of non-curative treatment pathways at diagnosis. Thematic analysis of qualitative data was conducted, followed by member checking.ResultsEleven pediatric oncologists participated, representing all global regions defined by the World Health Organization. Participants identified a broad range of factors influencing decision-making across multiple levels, including the individual, hospital, health system, community, and country levels. All participants agreed that treatment with non-curative intent could be offered at diagnosis in certain contexts, and diverse definitions for poor prognosis were described.ConclusionsUpfront treatment decision-making for children with advanced or poor prognosis cancer in LMICs is variable and challenging. Difficulties with decision-making in LMICs may be amplified by inconsistent definitions of poor prognosis and underrepresentation of the factors that influence treatment decision-making within existing decision-making frameworks or childhood cancer treatment guidelines. Future research should explore decision-making approaches, preferences, and challenges in depth from the perspectives of pediatric cancer patients, families, and multidisciplinary clinicians.

Envisioning telemedicine in the EU health systems: Insights from policy experts and cancer patients

Abstract Background Conducted as part of WP4 (Sustainability) of the eCAN Joint Action, the aim of this foresight exercise was to understand how telemedicine services in EU-Member States (MS) could be implemented in a patient-centric way to tackle cancer. Methods Based on a literature review, we identified factors that impact on the implementation of telemedicine in EU MS; these were integrated to an online survey. Health policy experts were invited to rank 34 factors using a 7-point Likert scale to better understand the barriers and facilitators of telemedicine services at the health system level, whilst patient associations ranked 28 other factors to capture end-users’ view. Next, survey respondents were invited to a foresight workshop to collect qualitative data and gain a forward-looking perspective. Results 20 health policy experts working in digital health across 14 EU MS, predominantly from Ministries of Health, and 8 cancer patient associations from 5 EU MS responded to the surveys. For a sustainable integration of telemedicine services in the EU, policy experts recommend developing a clear legal framework, embracing a hybrid healthcare model, and enhancing digital literacy. They stress the importance of telemedicine as a complementary tool, advocating for solid IT infrastructure, privacy safeguards, and the integration of health equity. Similarly, cancer patients emphasise the importance of being able to choose between telemedicine and in-person visits, focusing on personal interaction. They advocate for the involvement of patients in the design and testing of telemedicine services, ensuring solutions meet their preferences. Conclusions Policy experts and patients are in favour of hybrid models for cancer care. Recommended public health actions include: i) develop legal frameworks to complement in-person care with telemedicine; ii) boost digital literacy and IT infrastructure, ensuring privacy and health equity; and iii) involve patients in design for tailored services. Key messages • Both the EU Member States and cancer patients view telemedicine as a useful and complementary tool, however, not as a replacement for in-person healthcare services. • Both the EU Member States and cancer patients champion telemedicine with a focus on equity, privacy, digital literacy and a hybrid model of care that respects patient preferences for cancer treatment.

Developing National Information Systems to Monitor COVID-19 Vaccination: A Global Observational Study.

Strong information systems are essential for safe and effective immunization programs. The COVID-19 vaccine rollout presented all immunization information systems (IIS) with challenging demands-requiring in-depth vaccine implementation data at all health system levels in real time. The system development approaches taken by countries were heterogeneous, with some countries opting to adapt existing systems and others implementing new ones. Using data reported by Member States to the World Health Organization (WHO), we aim to develop a global understanding of (1) the types of IIS used to monitor COVID-19 vaccination implemented in 2021 and (2) the approaches taken by countries to develop these systems. We conducted a descriptive analysis of data reported through a supplemental questionnaire of the WHO/United Nations Children's Emergency Fund (UNICEF) Joint Reporting Form on Immunization, collecting data for 2021 on (1) the use of and developmental approaches taken for 7 IIS functions (appointments, aggregate reporting, individual-level reporting, reminders, home-based records, safety surveillance, and stock management), and (2) modifications needed for digital health frameworks to permit COVID-19 vaccination monitoring. In total, 188 of 194 WHO Member States responded to the supplemental questionnaire, with 155 reporting on the IIS-related questions. Among those reporting, for each of the 7 IIS functions explored, greater than 85% of responding countries reported that the system was in place for COVID-19 vaccines. Among responding countries, "aggregate reporting system" was the system most frequently reported as being in place (n=116, 98.3%), while "reminder system" was the least (n=77, 89%). Among the countries reporting using a system, whether an existing system was adapted for COVID-19 vaccines or a new one was developed varied by system. Additionally, two-thirds (n=127, 67.6%) of countries reported establishing at least one new system, ranging from 72% (n=42) in high-income countries (HICs) to 62% (n=16) in low-income countries. Concurrently, 55.3% (n=104) of countries reported adapting at least one system already in place for COVID-19 vaccines, with 62% (n=36) of HICs reporting this compared to about 53% for other income groups. Of those reporting developing new systems, for each of the systems explored, more than 85% of countries reported that they intended to keep new systems specific to COVID-19 vaccines. Further, 147 of the 188 (78.2%) Member States responding to the supplemental questionnaire responded to the digital health frameworks question. Lastly, 31% (n=46) of responding countries reported needing to adapt them for COVID-19 vaccination systems. HICs had a higher percentage. Nearly all countries have adapted existing or developed new IIS to monitor COVID-19 vaccination. The approaches varied, notably by income group. Reflection is needed on how to sustain the investments made in IIS during the pandemic. Continued support for IIS is critical, given their essential role in program monitoring and performance.

Identifying potential outcomes of patient engagement in primary care quality improvement: a modified Delphi study.

A barrier to dedicating resources towards patient engagement in primary care quality improvement is the lack of clearly identified outcomes that might result from these initiatives. We sought to identify these potential outcomes at three healthcare levels as defined by the Institute of Medicine: 1) Micro/Direct Care; 2) Meso/Microsystem; and 3) Macro/Clinic/System using a Modified Delphi technique. Two focus groups of patients and primary care clinician leaders generated a first set of outcomes. These outcomes were then vetted and expanded through three web-based surveys sent to twelve national experts. Experts indicated the level of agreement with prior elicited outcomes and generated potential new outcomes. Included outcomes achieved at least 80% agreement. The final list of 46 consensus-derived outcomes was categorized across levels. 22 were at the Micro-level, 9 were at the Meso-level, and 15 were at the Macro-level. Our findings suggest outcomes across all health system levels have the potential for progress when patients are engaged in primary care quality improvement initiatives. Future programs should consider validating and measuring these outcomes as part of their interventions.

SAHELI: Study and Action on Hysterectomy: Evidence on women’s health through the life course in India. Protocol for a mixed-methods study

Hysterectomy, removal of the uterus, is a commonly performed surgery for gynaecological morbidities. Emerging evidence indicates that hysterectomy performed before age 45 (early hysterectomy), is associated with considerable risks to women’s health. While most evidence on hysterectomy is from high-income settings, national surveys from India report high prevalence of early hysterectomy in specific regions, as well as higher prevalence amongst women in rural areas and with less education. The median age at hysterectomy in India is close to ten years before the onset of natural menopause. India has recently introduced national guidelines to address early hysterectomy, but large evidence gaps on the causes and consequences remain – which in turn limits the potential effectiveness of interventions at the clinical, health system and community level. Methods SAHELI is a Team Science study that will examine: (i) individual, social and health system determinants of early hysterectomy; (ii) women’s treatment pathways to hysterectomy and for gynaecological morbidity in general; and (iii) the consequences of undergoing hysterectomy on women’s physical, mental, economic and social well-being across the life course. This mixed-methods study includes population surveys amongst women in ages 25–49 in three high-prevalence states; qualitative health systems research to trace treatment journeys with women, health care providers and other stakeholders; evidence syntheses; and knowledge translation activities to ensure findings inform co-produced strategies and interventions. The study is grounded in a feminist epidemiology approach, aiming to examine individual and structural causes of vulnerability and prioritising the views of women, particularly in knowledge translation. Conclusions SAHELI, implemented by an all-women, multi-disciplinary team, is the first study in India to examine the causes and consequences of hysterectomy in a life course approach. We aim to influence interventions, policy and future research on women’s health, particularly access to quality gynaecological care and comprehensive health services through the life course.

The role of fear as a barrier and facilitator to antiretroviral therapy initiation in Indonesia: insights from patients and providers

ABSTRACT Initiating antiretroviral therapy (ART) in Indonesia poses major challenges, with limited studies on specific ART initiation barriers and facilitators. Using a socioecological approach, we explored, through semi-structured interviews, the perspectives of 67 participants: 17 people with HIV not (yet) on ART, 30 people with HIV on treatment, and 20 HIV service providers (HSPs). Fears emerged as pervasive barriers to initiation encompassing, at the intrapersonal level, (irrational) fears of negative medical and non-medical consequences. At the health system level, fears were linked to concerns about bureaucracy and insufficient universal coverage. On a societal level, fears stemmed from prevalent myths, misinformation on social media, and the impact of COVID-19. Interestingly, fear also served as a facilitator to initiation. At the intrapersonal level, initiation was driven by a fear of deteriorating health or death due to AIDS-related conditions. At the interpersonal level, buddies and HSPs leveraged to motivate initiation. At the societal level, accurate yet fear-inducing information on social media stimulated initiation. Perspectives differed between people with HIV and HSP, with people with HIV emphasizing barriers on intrapersonal to health system levels, while HSP focused mostly on intrapersonal and interpersonal barriers, albeit recognizing the crucial role of health systems.

Primary Care Guidance for Providers of Care for Persons With Human Immunodeficiency Virus: 2024 Update by the HIV Medicine Association of the Infectious Diseases Society of America.

Advances in antiretroviral therapy (ART) have made it possible for persons with human immunodeficiency virus (HIV) to live a lifespan approaching that of people without HIV, without progressing to AIDS or transmitting HIV to sexual partners or infants. There is, therefore, increasing emphasis on maintaining health throughout the lifespan. To receive optimal medical care and achieve desired outcomes, persons with HIV must be consistently engaged in care and able to access uninterrupted treatment, including ART. Comprehensive evidence-based HIV primary care guidance is, therefore, more important than ever. Creating a patient-centered, stigma-free care environment is essential for care engagement. Barriers to care must be decreased at the societal, health system, clinic, and individual levels. As the population ages and noncommunicable diseases arise, providing comprehensive health care for persons with HIV becomes increasingly complex, including management of multiple comorbidities and the associated challenges of polypharmacy, while also attending to HIV-specific health concerns. Clinicians must address issues specific to preventive health, including cancer screening, providing recommended vaccinations, as well as promoting sexual health, including sexually transmitted infection diagnosis, treatment, and prevention. Clinicians also must address issues for specific populations, including persons of childbearing potential, including during preconception and pregnancy; children; adolescents; and transgender and gender-diverse individuals. This guidance from an expert panel of the HIV Medicine Association of the Infectious Diseases Society of America updates the previous 2020 HIV Primary Care Guidance.

'Whatever the GP says, is what I'll do'-A qualitative study of patient perspectives in accessing primary eye care for type 2 diabetes.

To investigate the perspectives of people accessing a general medical practitioner (GP)-optometry model of collaborative care that was established to increase access to diabetes eye care. Qualitative study of patient barriers and facilitators to accessing primary diabetes eye care located in a metropolitan area in Australia. One-on-one interviews were recorded, transcribed and thematically analysed using a determinant framework on patient-centred access to health care. Twenty-four people with type 2 diabetes, including 15 males and 9 females, who accessed the service between September 2021 and June 2022 agreed to participate. Mean (SD) age of the participants was 52 (12) years and 50% had been diagnosed with diabetes for <2 years. Facilitators to accessing diabetes eye care included a referral from a GP or GP nurse, fee-free consultations, availability of after-hours appointments and short waiting times. Barriers to access included perceived out-of-pocket costs, competing responsibilities and lack of awareness of diabetic retinopathy screening recommendations. Considering diabetic retinopathy may present asymptomatically, primary health practitioners (optometrists and GPs) are well positioned to raise patient awareness of the importance of routine eye examinations. In Australia, access to routine screening could be facilitated by fee-free eye checks and personalised text message reminders implemented at a health system level.

Exploring the links between periodontal diseases and obstructive sleep apnoea: An overview for clinicians.

Both periodontal diseases (PDs) and obstructive sleep apnoea (OSA) are highly prevalent disorders with global impact, associated with a large burden at individual patient and health system levels. These disorders often co-exist, but there is growing evidence that the association between the disorders goes beyond an overlap between two highly prevalent diseases that have shared risk factors. Evidence suggests a potential causal relationship, although further research is required to verify this. Regardless of any causal relationship, the co-existence of these disorders is important to recognize since they may act in combination to heighten health risks, particularly cardiovascular risk. Thus, dentists have an important role in screening for OSA in patients presenting with PDs, and similarly, they need to evaluate periodontal health in patients requiring treatment for OSA. Here we provide a narrative review of the association between PDs and OSA to raise awareness among clinicians and promote multidisciplinary collaborations that aim at an evidence-based and effective management of such patients.