Health System Network Research Articles

Trauma Program Value Assessment at an Academic Health Network System Over 12 Years.

Trauma is a leading cause of global death, with 200000 deaths and over 3 million non-fatal injuries/year in the United States. We aim to assess trauma care value for patients who underwent urgent laparotomies (LAP) and thoracotomies (THO) in our Health Network System. Clinical variables (v = 84) from trauma patients (>18 yo) were retrieved retrospectively (Jan-2010 to July-2016) and prospectively (Aug-2016 to Sept-2021) from a Health System warehouse under IRB-approved protocols. Patients were divided according to their Injury Severity Score (ISS) into mild/moderate cases (ISS <15) and severe cases (ISS >15). Value was assessed using quality and cost domains. Quality surrogates included graded postoperative complications (PCs), length of stay (LOS), 30-day readmission (RA), patient satisfaction (PS), and textbook (TB) cases. Total charges (TCs) and reimbursement index (RI) were included as surrogates for cost. Value domains were displayed in scorecards comparing Observed (O) with Expected (E) (using the ACS risk calculator) outcomes. Uni-/multivariate analyses were performed using SPSS. 41,927 trauma evaluations were performed, leading to 16044 admissions, with 528 (3.2%) patients requiring urgent surgical procedures (LAP = 413 and THO = 115). Although the M:F ratio (7:3) was similar in LAP vs THO groups, age and BMI were significantly different (41.8 ± 19.1 vs 51.8 ± 19.9 years, 28.6 ± 9.9 vs 27.4 ± 7Kg/m2, respectively, P < .05). Blunt trauma was involved in 68.8/77.3% of the LAP/THO procedures, respectively (P < .05). Multivariate analyses showed ISS, age, ASA class, and medical center as factors significantly predicting PC (P < .05). Postoperative complication grades from the LAP/THO groups showed above-average outcomes; nonetheless, LOS was higher than the national averages. The Trauma Program holds high value in our Health Network System. Protocols for decreasing LOS are being implemented.

Comparative Analysis of Treatment Patterns in DoD Beneficiaries With Malignant Central Nervous System Tumors: A Focus on Care Setting.

Malignant brain and other central nervous system tumors (MBT) are deadly and disproportionately affect younger men and women in the age range of most active-duty service members. Timely and appropriate treatment is important to both survival and quality of life of patients. Information on treatment factors across direct care (DC) and private sector care (PSC) networks may be important for provider training and staffing for the DoD. The aim of this study was to analyze treatment patterns for patients with MBT within the DoD's universal access Military Health System (MHS), comparing DC and PSC networks. The Military Cancer Epidemiology database was used to identify patients 18 years and older who were diagnosed with an MBT between 1999 and 2014 who received primary treatment. Differences in first treatment type and time from diagnosis to initial treatment between DC and PSC were assessed using chi-square and Wilcoxon-Mann-Whitney tests, respectively. Frequency of treatment initiation beyond the 28-day TRICARE Prime access standard for Specialty Care was also compared between care settings using chi-square and Fisher's exact tests. Then logistic regression models generated odds of treatment initiation beyond 28 days and 95% confidence intervals (CIs) associated with care setting. Kaplan-Meier survival curves and log-rank tests compared survival between DC and PSC. The study included 857 patients, with n = 540 treated in DC and n = 317 treated in PSC. The proportion of patients receiving each initial treatment type did not differ by care setting (P = .622). Median time from diagnosis to initial treatment (interquartile range) varied significantly between DC at 6 (0 to 25) days and PSC at 12 (0 to 37) days for all treatment types combined (P < .001). For all years combined, treatment was initiated beyond 28 days for 21% of patients using DC compared to 31% of patients using PSC (P = .001). The odds of treatment initiation beyond 28 days for a patient treated in PSC were 1.61 (95% CI, 1.11 to 2.33, P = .012) compared to patients treated in DC when controlling for demographic, military, tumor, and patient variables. Survival did not differ by care setting (P = 1.000). Based on the available data between 1999 and 2014, care setting was associated with differences in time to initial treatment and odds of treatment initiation beyond 28 days among DoD beneficiaries with MBT receiving care in the MHS. Information on these differences may help inform MHS leadership decisions on the most appropriate location for military provider training and staffing.

Incidence and Dynamics of CRC Stage Migration: A Regional vs. a National Analysis.

Due to an increased rate of surveillance colonoscopy, we aim to determine the impact of stage migration on the incidence and overall survival (OS) of patients who underwent pathological staging of colorectal cancer (CRC) at our Health Network System. Two datasets were included: subjects from the tumor registry at a regional Comprehensive Cancer Center (n = 1385) and subjects from the Surveillance, Epidemiology, and End Results (SEER) national database (n = 202,391). A significant increase in the diagnosis of CRC Stage 1 and 4 was observed, with a decrease in stage 2, and no change in Stage 3 in the National datasets (p < 0.01). There was an increase in Stage 4 CRC diagnosis, with a concurrent decrease in stage 2, and no changes in stages 1 and 3 in the regional dataset (p < 0.05). OS followed the expected and progressive decrease in OS by stage (from 1 to 4, p < 0.01). The present findings confirmed CRC stage migration in our Health Network System, along with a national trend conducive to an increased OS for early CRC stages.

Use of electronic health records to characterize patients with uncontrolled hypertension in two large health system networks

BackgroundImproving hypertension control is a public health priority. However, consistent identification of uncontrolled hypertension using computable definitions in electronic health records (EHR) across health systems remains uncertain.MethodsIn this retrospective cohort study, we applied two computable definitions to the EHR data to identify patients with controlled and uncontrolled hypertension and to evaluate differences in characteristics, treatment, and clinical outcomes between these patient populations. We included adult patients (≥ 18 years) with hypertension (based on either ICD-10 codes of hypertension or two elevated blood pressure [BP] measurements) receiving ambulatory care within Yale-New Haven Health System (YNHHS; a large US health system) and OneFlorida Clinical Research Consortium (OneFlorida; a Clinical Research Network comprised of 16 health systems) between October 2015 and December 2018. We identified patients with controlled and uncontrolled hypertension based on either a single BP measurement from a randomly selected visit or all BP measurements recorded between hypertension identification and the randomly selected visit).ResultsOverall, 253,207 and 182,827 adults at YNHHS and OneFlorida were identified as having hypertension. Of these patients, 83.1% at YNHHS and 76.8% at OneFlorida were identified using ICD-10-CM codes, whereas 16.9% and 23.2%, respectively, were identified using elevated BP measurements (≥ 140/90 mmHg). A total of 24.1% of patients at YNHHS and 21.6% at OneFlorida had both diagnosis code for hypertension and elevated blood pressure measurements. Uncontrolled hypertension was observed among 32.5% and 43.7% of patients at YNHHS and OneFlorida, respectively. Uncontrolled hypertension was disproportionately higher among Black patients when compared with White patients (38.9% versus 31.5% in YNHHS; p < 0.001; 49.7% versus 41.2% in OneFlorida; p < 0.001). Medication prescription for hypertension management was more common in patients with uncontrolled hypertension when compared with those with controlled hypertension (overall treatment rate: 39.3% versus 37.3% in YNHHS; p = 0.04; 42.2% versus 34.8% in OneFlorida; p < 0.001). Patients with controlled and uncontrolled hypertension had similar incidence rates of deaths, CVD events, and healthcare visits at 3, 6, 12, and 24 months. The two computable definitions generated consistent results.ConclusionsWhile the current EHR systems are not fully optimized for disease surveillance and stratification, our findings illustrate the potential of leveraging EHR data to conduct digital population surveillance in the realm of hypertension management.

Estimating Transgender and Gender-Diverse Youth Populations in Health Systems and Survey Data.

To identify and examine demographic variation in estimates of gender-diverse youth (GDY) populations from the PEDSnet learning health system network and the Youth Risk Behavior Survey (YRBS). The PEDSnet sample included 14- to 17-years-old patients who had ≥2 encounters at a member institution before March 2022, with at least 1 encounter in the previous 18 months. The YRBS sample included pooled data from 14- to 17-year-old in-school youth from the 2017, 2019, and 2021 survey years. Adjusted logistic regression models tested for associations between demographic characteristics and gender dysphoria (GD) diagnosis (PEDSnet) or self-reported transgender identity (YRBS). The PEDSnet sample included 392 348 patients and the YRBS sample included 270 177 youth. A total of 3453 (0.9%) patients in PEDSnet had a GD diagnosis and 5262 (1.9%) youth in YRBS self-identified as transgender. In PEDSnet, adjusted logistic regression indicated significantly lower likelihood of GD diagnosis among patients whose electronic medical record-reported sex was male and among patients who identified as Asian, Black/African American, and Hispanic/Latino/a/x/e. In contrast, in the YRBS sample, only youth whose sex was male had a lower likelihood of transgender identity. GDY are underrepresented in health system data, particularly those whose electronic medical record-reported sex is male, and Asian, Black/African American, and Hispanic/Latino/a/x/e youth. Collecting more accurate gender identity information in health systems and surveys may help better understand the health-related needs and experiences of GDY and support the development of targeted interventions to promote more equitable care provision.

Seeking American Society of Clinical Oncology-Quality Oncology Practice Initiative (ASCO-QOPI) certification in a northern New England rural health system and cancer care network.

In 2006 following several years of preliminary study, the American Society ofClinical Oncology (ASCO) launched the Quality Oncology Practice Initiative (QOPI). This cancer-focused quality initiative evolved considerably over the next decade-and-a-half and is expanding globally. QOPI is undoubtedly the leading standard-bearer for quality cancer care and contemporary medical oncology practice. The program garners attention and respect among federal programs, private insurers, and medical oncology practices across the nation. The MaineHealth Cancer Care Network (MHCCN) has undergone expansive growth since 2017. The network provides cancer care to more than 70% of the cases in Maine in a largely rural health system in Northern New England. In fall 2020, the MHCCN QOPI project leadership, following collaborative discussions with the ASCO-QOPI team, elected to proceed with a health system-cancer network-wide QOPI certification. Key themes emerged over the course of our two-year journey including: (1) Developing a highly interprofessional team committed to the project; (2) Capitalizing on a single electronic medical record for data transmission to CancerLinQ; (3) Prior experience, especially policy development, in other cancer-focused accreditation programs across the network; and (4) Building consensus through quarterly stakeholder meetings and awarding Continuing Medical Education (CME) and American Board of Medical Specialists (ABMS) Maintenance of Certification (MOC) credits to oncologists. All participants demonstrated a genuine spirit to work together to achieve certification. We report our successful journey seeking ASCO-QOPI certification across our network, which to our knowledge is the first-of-its-kind endeavor.

Learning from the End of the Public-Private Partnership for Lesotho's National Referral Hospital Network.

Public-private partnerships (PPP) are one strategy to finance and deliver healthcare in lower-resourced settings. Lesotho's Queen 'Mamohato Memorial Hospital Integrated Network (QMMH-IN) was sub-Saharan Africa's first and largest integrated healthcare PPP. We assessed successes and challenges to performance of the QMMH-IN PPP. We conducted 26 semi-structured interviews among QMMH-IN executive leadership and staff in early 2020. Questions were guided by the WHO Health System Building Blocks Framework. We conducted a thematic analysis. Facilitators of performance included: 1) PPP leadership commitment to quality improvement supported by protocols, monitoring, and actions; 2) high levels of accountability and discipline; and 3) well-functioning infrastructure, core systems, workflows, and internal referral network. Barriers to performance included: 1) human resource management challenges and 2) broader health system and referral network limitations. Respondents anticipated the collapse of the PPP and suggested better investing in training incoming managerial staff, improving staffing, and expanding QMMH-IN's role as a training facility. The PPP contract was terminated approximately five years before its anticipated end date; in mid-2021 the government of Lesotho assumed management of QMMH-IN. Going forward, the Lesotho government and others making strategic planning decisions should consider fostering a culture of quality improvement and accountability; ensuring sustained investments in human resource management; and allocating resources in a way that recognizes the interdependency of healthcare facilities and overall system strengthening. Contracts for integrated healthcare PPPs should be flexible to respond to changing external conditions and include provisions to invest in people as substantively as infrastructure, equipment, and core systems over the full length of the PPP. Healthcare PPPs, especially in lower-resource settings, should be developed with a strong understanding of their role in the broader health system and be implemented in conjunction with efforts to ensure and sustain adequate capacity and resources throughout the health system.

History and current status of the survivorship care program at the University of California, Los Angeles Jonsson Comprehensive Cancer Center (UCLA JCCC).

As one of the first comprehensive cancer centers to receive a designation from the National Cancer Institute, the Jonsson Comprehensive Cancer Center at UCLA Health has served as a leader in survivorship research for three decades. A clinical survivorship program for childhood cancer survivors was established in the early 2000s as this became a standard of care in pediatric oncology. However, it was not until receipt of external funding and the establishment of a Survivorship Center of Excellence in 2006 that clinical services were expanded to include adult cancer survivors, as well as survivorship care delivery research in the community and at affiliated clinical sites. When this funding ended, there was limited institutional support for expansion of the program, and so the clinical programs did not develop further. Recently, there has been renewed interest in obtaining Commission on Cancer accreditation, and this has prompted an institutional assessment of survivorship care to inform future activities for system-wide program development. As oncology care expands throughout a large regional health system network, the future survivorship program will need to serve as a common resource for the entire health system by providing a repository of specialized services and resources as well as standard processes and pathways for a cohesive approach to care. IMPLICATIONS FOR CANCER SURVIVORS: There are many challenges to development and sustainment of cancersurvivorship programs, even in NCI-designated comprehensive cancers. As the delivery of cancer care servicesexpands and becomes more integrated in large health care systems, innovative strategies are needed to ensuredelivery of tailored care to cancer survivors through acute treatment and beyond.

COLOTEST Brussels

Introduction: Population screening for colorectal cancer is organized:&#x0D; In Flanders by the "Centrum voor Kankeropsporing" (CvKO) since 2013&#x0D; In Wallonia and Brussels by the Walloon “Centre Communautaire de Référence” (CCRéf) since 2009, based upon a collaboration with GP’s.&#x0D; In Brussels, the Brussels Coordination Center for Cancer Screening (BruPrev) took over the project in October 2018. It is a pilot project based on a partnership with pharmacy.brussels and CCRéf. &#x0D; Scope of the project: The focus group is the Brussels population aged between 50 and 74. To be effective, a test must be performed every 2 years. The screening test is an iFOB test ( “Colotest”). The Colotests are available in all Brussels pharmacies, which supply them free of charge upon presentation of a personalized invitation letter or a medical prescription. The pharmacist also engages in active sensitization with eligible patients.&#x0D; Partners: The project is a partnership between BruPrev, pharmacy.brussels and CCRéf. GP are also involved and informed. They can refer patients to the pharmacy with a medical prescription to retrieve an iFOB test. BruPrev is in charge of implementing and coordinating the project. CCRéf analyzes the iFOB tests and hosts the database.&#x0D; Implementation: The citizen, belonging to the target group presents himself at the pharmacy and is handed the test, he performs the test at home and sends it to CCRéf accredited laboratory in a provided envelope (biological material, cat.B). CCRéf processes the incoming tests daily and reports the results twice a week to BruPrev via a secured server. Patients receive their result within 9 days of receiving the iFOB at CCRéf. GP are informed via their personal secured medical messaging. In case of positive result, a postal mail is sent as well. Results are also immediately available on the secured Brussels Health Network system (Abrumet).&#x0D; Results: In 2019, 13 781 Colotests were realized. Considering the tests performed in 2018, the coverage of the eligible target group was 11%. The uptake (% Colotets performed vs. number of invitations sent) was 9.5&#x0D; In 2020, the project's activities were suspended from 14/04 to 19/05. The number of invitations in 2020 was 39.9% lower than in 2019 and the number of tests performed was 11.7% lower than in 2019. The uptake increased however from 9.5% to 13.1%. In 2021, the project was boosted by an information campaign and the number of Colotests realized (23.107) rose to nearly twice the 2019 number.&#x0D; Learnings: Access to Colotest through the pharmacy is satisfactory. Pharmacists indicated that after a sensitization interview it should be possible to immediately proceed with the delivery of a test providing patient eligibility is confirmed."

Mental Health of Youth With Autism Spectrum Disorder and Gender Dysphoria.

Youth with either autism spectrum disorder (ASD) or gender dysphoria (GD) alone have also been shown to be at greater risk for mental health (MH) concerns; however, very little research has considered how cooccurring ASD and GD may exacerbate MH concerns. The purpose of this study was to examine associations between ASD, GD, and MH diagnoses (anxiety, depression, eating disorder, suicidality, and self-harm) among US adolescent populations. This is a secondary analysis of a large administrative dataset formed by 8 pediatric health system members of the PEDSnet learning health system network. Analyses included descriptive statistics and adjusted mixed logistic regression models testing for associations between combinations of ASD and GD diagnoses and MH diagnoses as recorded in the patient's electronic medical record. Based on data from 919 898 patients aged 9 to 18 years, adjusted mixed logistic regression indicated significantly greater odds of each MH diagnosis among those with ASD alone, GD alone, and cooccurring ASD/GD diagnoses compared with those with neither diagnosis. Youth with cooccurring ASD/GD were at significantly greater risk of also having anxiety (average predicted probability, 0.75; 95% confidence interval, 0.68-0.81) or depression diagnoses (average predicted probability, 0.33; 95% confidence interval, 0.24-0.43) compared with youth with ASD alone, GD alone, or neither diagnosis. Youth with cooccurring ASD/GD are more likely to also be diagnosed with MH concerns, particularly anxiety and depression. This study highlights the need to implement developmentally appropriate, gender-affirming MH services and interventions for youth with cooccurring ASD/GD.

Wuchereria bancrofti infection is associated with progression to clinical visceral leishmaniasis in VL- endemic areas in Muzaffarpur, Bihar, India.

Co-endemicity of neglected tropical diseases (NTDs) necessitates that these diseases should be considered concomitantly to understand the relationship between pathology and to support disease management and control programs. The aims of the study were to assess the prevalence of filarial infection in asymptomatic Leishmania donovani infected individuals and the correlation of Wuchereria bancrofti infection with progression to clinical visceral leishmaniasis (VL) in Bihar, India. Within the Muzaffarpur-TMRC Health and Demographic Surveillance System (HDSS) area, a cohort of Leishmania seropositive (n = 476) or seronegative individuals (n = 1130) were sampled annually for three years for filarial infection and followed for progression to clinical VL. To corroborate the results from the cohort study, we also used a retrospective case-control study of 36 VL cases and 71 controls selected from a subset of the HDSS population to investigate the relationship between progression to clinical VL and the prevalence of filarial infection at baseline. Our findings suggest a higher probability of progression to clinical VL in individuals with a history of filarial infection: in both the cohort and case-control studies, progression to clinical VL was higher among filaria infected individuals (RR = 2.57, p = 0.056, and OR = 2.52, p = 0.046 respectively). This study describes that progression to clinical VL disease is associated with serological evidence of prior infection with W. bancrofti. The integration of disease programs for Leishmania and lymphatic filariasis extend beyond the relationship of sequential or co-infection with disease burden. To ensure elimination targets can be reached and sustained, we suggest areas of co-endemicity would benefit from overlapping vector control activities, health system networks and surveillance infrastructure.

Stakeholders' Perspectives on the Quality of End-of-Life Health Care Services for Chronic Obstructive Airways Disease: A Focus Group Study.

Delivery of end-of-life care for severe chronic obstructive pulmonary disease (COPD) has been hampered by an unpredictable disease trajectory and poor integration of health care and social services. To critically explore the perspectives, values, and experiences of stakeholders in COPD end-of-life healthcare services in a large district in Aotearoa New Zealand. Focus groups analysed utilising critical theory and Actor-Network Theory. Stakeholders in end-of-life COPD healthcare services were purposively sampled from a large healthcare network in Canterbury, Aotearoa New Zealand to participate in seven focus groups (bereaved carers, community-based health professionals, non-Māori, non-Pacific patients, and support people (two groups), Māori patients, supporters and health professionals, Pacific patients, support people and health professionals, and hospital-based health professionals). Participants discussed end-of-life care services for people with COPD. Transcripts were coded utilising descriptive and structural coding to develop themes related to provision of quality care. Participants were positioned as experts. We considered how the themes arising supported and disrupted the healthcare network for end-of-life COPD. Five themes related to quality of care for end-of-life COPD were identified: compassion, competence, community, commitment, and collaboration. The absence of any of these five themes required for quality care led to power imbalances within healthcare systems. Power inequities created disconnection among stakeholders which then disrupted commitment, community, and collaboration. A dysfunctional healthcare network impeded compassion between stakeholders and did not support their competence, leading to lower quality care. All five themes were identified as essential to delivery of high-quality end-of-life care in COPD. Stakeholders' perspectives of end-of-life care for COPD identified of core features of a health system network that enabled or impeded the actions of stakeholders and allocation of resources to provide quality care.

Co-occurring Autism Spectrum Disorder and Gender Dysphoria in Adolescents.

Autism spectrum disorder (ASD) and gender dysphoria (GD) frequently cooccur. However, existing research has primarily used smaller samples, limiting generalizability and the ability to assess further demographic variation. The purpose of this study was to (1) examine the prevalence of cooccurring ASD and GD diagnoses among US adolescents aged 9 to 18 and (2) identify demographic differences in the prevalence of cooccurring ASD and GD diagnoses. This secondary analysis used data from the PEDSnet learning health system network of 8 pediatric hospital institutions. Analyses included descriptive statistics and adjusted mixed logistic regression testing for associations between ASD and GD diagnoses and interactions between ASD diagnosis and demographic characteristics in the association with GD diagnosis. Among 919 898 patients, GD diagnosis was more prevalent among youth with an ASD diagnosis compared with youth without an ASD diagnosis (1.1% vs 0.6%), and adjusted regression revealed significantly greater odds of GD diagnosis among youth with an ASD diagnosis (adjusted odds ratio = 3.00, 95% confidence interval: 2.72-3.31). Cooccurring ASD/GD diagnoses were more prevalent among youth whose electronic medical record-reported sex was female and those using private insurance, and less prevalent among youth of color, particularly Black and Asian youth. Results indicate that youth whose electronic medical record-reported sex was female and those using private insurance are more likely, and youth of color are less likely, to have cooccurring ASD/GD diagnoses. This represents an important step toward building services and supports that reduce disparities in access to care and improve outcomes for youth with cooccurring ASD/GD and their families.

Development of the health system in Iran

This article examines the development of the health care system in Iran in the period after the “Islamic Revolution” (1979). The author aims to use factual material to show the contemporary nature of the health care system of the Islamic Republic of Iran (IRI), which has implemented a number of important reforms over the past 40 years. The most important reform was the formation of the national health network in 1983, which aimed to reduce inequalities and increase access to health care for the population in disadvantaged areas of the country. Health services and medical education had been integrated, a health insurance reform had been carried out, which had contributed to progress towards universal health insurance coverage, a family physician programme and a hospital autonomy policy had been implemented. Iran was one of the few countries that provided comprehensive health insurance for refugees on the same basis as for its own citizens. Despite the achievements of Iran’s family planning programme, which aimed not only to establish an eff ective population policy but also to improve overall socio-economic indicators, attitudes towards it have been mixed at different points in Iran’s recent history. Despite its dependence on imported raw materials, Iran has developed a fairly well-developed medical industry, which enabled the country to become an exporter of pharmaceutical products. Iran has achieved impressive progress in the sphere of medical tourism, occupying leading positions in the Middle East, South and Central Asia, as well as Transcaucasia. The Iranian national health network system had been effective in providing a unique framework for the delivery of primary health care in rural areas, which had contributed to the overall improvement of the country’s health indicators. Conclusion. The article provides a proper assessment of the level of health care development in Iran for expanding Russian-Iranian cooperation in this field.

Cross-Sectional Study of Psoriasis, Atopic Dermatitis, Rosacea, and Alopecia Areata Suggests Association With Cardiovascular Diseases.

A growing body of evidence suggests that several inflammatory skin diseases (ISDs) are associated with systemic inflammation and cardiovascular disease (CVDs). We used the TriNetX analytics platform to conduct a retrospective, cross-sectional, single-center study in the Mount Sinai Health System network. Cases (all patients &ge;18 years of age with a diagnosis of 1 of the 4 ISDs studied) were compared with matched controls (no history of any of these ISDs) to evaluate odds ratios for being diagnosed with CVD. We identified a total of 70,090 patients with ISDs, including 35,160 patients with atopic dermatitis, 19,490 with psoriasis, 12,470 with rosacea, and 2,970 with alopecia areata, and 70,090 propensity score-matched controls without any of these ISDs. Patients with atopic dermatitis and psoriasis had significantly increased odds of all CVD diagnoses analyzed compared to controls (P&lt;0.001 for all comparisons). Patients with rosacea had significantly increased odds of being diagnosed with all diseases of the circulatory system (P&lt;0.001), hypertensive diseases (P&lt;0.001), cerebrovascular diseases (P=0.037), and arterial disease (P&lt;0.001) compared to controls. Patients with alopecia areata had increased odds for all diseases of the circulatory system (P&lt;0.001), hypertensive diseases (P&lt;0.001), and arterial disease (P&lt;0.001). The prevalence of patients with elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels was significantly greater in all ISD groups compared to controls. This study identified significant associations between ISDs and several CVD diagnoses. Furthermore, CRP and ESR were elevated in all ISD groups compared to controls. Pagan AD, Jung S, Caldas S, et al. Cross-sectional study of psoriasis, atopic dermatitis, rosacea, and alopecia areata suggests association with cardiovascular diseases. J Drugs Dermatol. 2023;22(6):576-581. doi:10.36849/JDD.7424.

Access to childbirth care services in the interior of Pernambuco, Northeast region of Brazil.

To analyze the access of women to the public health system network to childbirth care, highlighting the barriers related to the "availability and accommodation" dimension in a health macroregion of Pernambuco. Ecological study, conducted based on hospital birth records from the Hospital Information System of the Brazilian Unified Health System (SUS), and information from the state's Hospital Beds Regulation Center, about women residing in health macroregion II, in 2018. Displacements were reviewed considering the geographic distance between the municipality of residence and that of the childbirth; estimated time of displacement of pregnant women; ratio of shifts blocked for admission of pregnant women for delivery; and the reason for unavailability. In 2018, health macroregion II performed 84% of usual risk childbirths, and 46.9% of high-risk childbirths. The remaining high-risk childbirths (51.1%) occurred in macroregion I, especially in Recife. The reference maternity for high-risk childbirths in that macroregion had 30.4% of the days of day shifts and 38.9% of the night shifts blocked for admission of childbirths; the main reason was the difficulty in maintaining the full team in service. Women residing in the health macroregion II of Pernambuco face great barriers of access in search of hospital care for childbirth, traveling great distances even when pregnant women of usual risk, leading to pilgrimage in search of this care. There is difficulty regarding availability and accommodation in high-risk services and obstetric emergencies, with shortage of physical and human resources. The obstetric care network in macroregion II of Pernambuco is not structured to ensure equitable access to care for pregnant women at the time of childbirth. This highlights the need for restructuring this healthcare services pursuant to what is recommended by the Cegonha Network.

Abstract P4-07-56: Mayo Clinic Enterprise patterns of growth-factor utilization for sacituzumab govitecan (SG)-induced neutropenia among patients with metastatic triple negative breast cancer

Abstract Background: SG was approved in 2020 for the treatment of metastatic triple negative breast cancer (TNBC). The most common grade 3/4 adverse event in the ASCENT trial was neutropenia (51.2%) with a 6% incidence of febrile neutropenia. 1 Package insert recommendations do not endorse primary prophylactic growth factor support, rather only initiating if severe neutropenia occurs on treatment.2 Objective: This study retrospectively reviewed the utilization of growth factor support in patients (pts) with metastatic TNBC initiated on SG at each Mayo Clinic Enterprise site. Methods: We performed a multi-center, retrospective review of all pts with TNBC who received SG from January 2021 to December 2021 at Mayo Clinic sites in Minnesota, Florida, Arizona, and its community-based health system network. Data collected included history of neutropenia with previous cycles of SG resulting in a treatment delay, number of cycles, grade of neutropenia and cycle/day of treatment plan when growth factor added. Pts who received only one dose of SG were excluded. The Fisher’s exact test was utilized to compare the difference in the use of primary prophylaxis between sites. Results: 67 pts received at least two doses of SG. Within this cohort, 42 pts (63%) received growth factor support during treatment with SG. Growth factor support was most often added during the first two cycles (59.5%). A total of 12 patients initiated growth factor with no history of delays related to neutropenia and without neutropenia at the time of administration. Eleven of these pts had growth factor support added on Cycle 1 as primary prophylaxis. Primary prophylaxis was most common at Mayo Clinic – Rochester compared to the other sites (Table 1), however there was not a statistically significant difference (p=0.27). There were 26 pts (39%) with a treatment delay due to neutropenia while receiving SG, of which 21 (81%) were managed with the addition of growth factor (13 pegfilgrastim, 8 filgrastim). The median number of cycles for all pts was 5 (range: 1-25). Pts who received growth factor were treated with a median of 5 cycles (range: 1-25) and pts who did not receive growth factor were treated with a median of 4 cycles (range: 1-19) (p=0.10). Conclusions: We observed wide variability in the use of prophylactic growth factor between Mayo Clinic sites with SG. The optimal practice of growth factor use with SG warrants further exploration.

Performance of the Health System Network in Formosa, Argentina, in the Diagnosis of Leprosy.

Leprosy is a chronic, neglected tropical infectious disease, currently endemic in Formosa, a province in northwestern Argentina. To analyze the performance, distribution, and effectiveness of the health system in leprosy diagnosis in Formosa, we estimated the trend of the number of new cases of leprosy diagnosed between 2002 and 2019 and estimated a forecast for 2022 at the primary health care centers (PHCCs) of at the first level of care (1stLC), at district hospitals (DHs) of the second level of care (2ndLC), high-complexity hospitals at the third level of care (3rdLC), and in rural and urban areas. The general trend was calculated based on the new cases detection rate (NCDR) using the autoregressive-moving average model (ARMA). The 1stLC, 2ndLC, and 3rdLC and the rural/urban variables were assessed using a proportional Bayesian trend ARMA (TrARMA) model. A predictive model was used for estimated forecasts. Markov-Monte Carlo chains were applied with A Metropolis-Hastings's algorithm. The highest median proportion (Mp) of new cases of leprosy was diagnosed at the 2ndLC (Mp, 0.67; 97.5% credibility interval [CI] [0.56-0.77]), at the 3rdLC (Mp, 0.11; 97.5% CI [0.08-0.15]), and in urban areas (urban median proportion (uMp), 0.86; 97.5% CI [0.83- 0.88]), whereas the lowest proportion of new cases was diagnosed at the 1stLC (Mp, 0.082; 97.5% CI [0.061-0.108]) and in rural areas (rural median proportion (rMp), 0.13; 97.5% CI [0.11-0.16]). Our model predicts for 2022 that a median number of new cases of leprosy of 19.70 will be diagnosed in urban areas (97.5% CI [15.94-23.80]), and will continue to be diagnosed at the 2ndLC (median number of cases, 15.33; 97.5% CI [12.40-10.52]) and 3rdLC (median number of cases, 2.43; 97.5% CI [1.97-2.94]).

Understanding networks in low-and middle-income countries' health systems: A scoping review.

Networks are an often-employed approach to improve problems of poor service delivery and quality of care in sub-optimally functioning health systems. There are many types of health system networks reported in the literature and despite differences, there are identifiable common characteristics, uses, purposes, and stakeholders. This scoping review systematically searched the literature on networks in health systems to map the different types of networks to develop an understanding of what they are, when and what they are used for, and the purposes they intend to achieve. Peer-reviewed literature was systematically searched from six databases (Medline (Ovid), EMBASE (Ovid), Global Health (Ovid), the Cochrane Library, Web of Science Core Collection, Global Index Medicus's Africa Index Medicus) and grey literature was purposively searched. Data from the selected literature on network definitions, characteristics, stakeholders, uses, and purposes were charted. Drawing on existing frameworks and refining with the selected literature, a five-component framework (form and structure, governance and leadership, mode of functioning, resources, and communication), broadly characterizing a network, is proposed. The framework and mapping of uses, purposes, and stakeholders is a first step towards further understanding what networks are, when and what they are used for, and the purposes they intend to achieve in health systems.

The Indian Health and Demographic Surveillance System Network: Opportunity to Generate Evidence for Public Health Policy.

The Health and Demographic Surveillance System (HDSS) is a valuable longitudinal cohort study that tracks the health and demographic changes of a geographically defined population, serving as a platform for research and evidence-based policymaking. In India, there are nearly 20 HDSS sites covering diverse areas and populations totaling around two million. To foster collaboration, the Indian HDSS Network (IHN) was formed, comprising 19 sites from 16 institutes, covering a population of 1.5 million. The IHN aims to standardize data collection processes while allowing site-specific autonomy, generating high-quality longitudinal health, and demographic data. To ensure effective coordination, a governance structure with a rotating secretariat and working committee was proposed. The IHN envisions conducting robust multicentric research, supporting data-driven efforts to improve population health, and promoting research-policy synergy. The network's outcomes have the potential to optimize health research funding, generate epidemiological data, and provide evidence for public health policy. Collaboration within the IHN strengthens HDSS sites in newer technologies and community-based research, fostering capacity building. Seed funding is being sought to formalize and support the day-to-day functioning of the network, which holds promise for advancing population health and informing policymaking in India.