Health System Performance Research Articles

A health system assessment approach to analysis of political parties' health proposals, Portugal.

Comparing health policy measures before elections and identifying potential gaps in the health policy debate can be challenging. We explored the use of the Health System Performance Assessment for Universal Health Coverage framework to analyse health policy proposals by classifying health policy measures outlined in political manifestos into four health system functions: governance, financing, resource generation and service delivery. As a case study, we analysed the political manifestos of all Portuguese parties with parliamentary representation ahead of the election in March 2024. We calculated the share of measures per health system function for individual political manifestos and identified potential gaps in the health policy debate. When required, we used additional classification criteria and local expertise on political and institutional knowledge. A snap general election was announced in Portugal in November2023, following an alleged corruption scandal, and political parties began publishing their manifestos on their websites in January2024. We identified and classified 350 health-related measures across the four functions: governance, 29.7% (104 measures); financing, 16.9% (59 measures); resource generation, 33.4% (117 measures); and service delivery, 20.0% (70 measures). These findings enabled characterization of the priorities of parties, facilitated cross-party comparisons and identified missing topics in the political debate. We show that the framework can be adapted to analyse political manifestos, providing a systematic method for comparing and synthesizing health policy proposals. We further demonstrate the potential for extending the framework's applicability beyond health system performance assessment, opening new avenues for policy analysis.

7.H. Round table: Advancing societal goals through health systems: Insights from the Renewed HSPA Framework

Abstract The purpose of this workshop, entitled ‘Advancing societal goals through health systems: Insights from the renewed HSPA framework,’ is to take a deeper look at the intricate relationships between health systems and broader societal objectives. We will dissect the contributions of health systems to societal well-being, a concept that stretches beyond mere economic growth to include social cohesion, environmental sustainability, and economic development. The session will examine the renewed global Health System Performance Assessment Framework, which serves as a tool for policymakers to better understand how health systems fit together and explains how they perform. This framework allows for a clearer interpretation of health data and provides a pathway to pinpoint health system issues and design that are most likely to enhance performance and resilience. The workshop will delve into the three dimensions of societal well-being-social cohesion, economic development, and environmental sustainability-nested within the HSPA framework. We will explore the health system’s role in advancing these dimensions, such as fostering community bonds, supporting economic growth through a healthy workforce, and contributing to the sustainable management of environmental resources. Integrating health system performance into societal goals is a practical obligation to create a resilient, cohesive, and economically robust society. This workshop will engage stakeholders in a discourse to translate this integration into multisectoral and actionable policies, aligning health system goals with societal aspirations for a sustainable future. This workshop will focus on: How health system assessments can capture contributions to societal goals, underpinning sustainable economic and environmental practices. Real-world case studies showcasing health systems’ role in fostering societal well-being and advancing public health policies. Interactive discussions will shed light on how health systems can be pivotal in achieving the Sustainable Development Goals, particularly in the face of modern challenges such as climate change, demographic shifts, and economic pressures. Key messages • Health systems play a pivotal role in advancing societal well-being beyond traditional health outcomes. • The renewed HSPA framework is a robust tool for policymakers to align health system performance with broader societal goals. Speakers/Panelists Scott Greer University of Michigan, European Observatory on Health Systems and Policies, Ann Arbor, USA Andrea Schmidt Austrian Public Health Institute, Vienna, Austria

Analysis of medical doctor supply in Bulgaria, Croatia, Romania, and Serbia in the last two decades

Abstract Introduction The shortage of medical doctors in Europe has become a priority issue, especially in the Eastern European region, where many countries are making large investments to ensure adequate supply. Training future medical professionals is a lengthy and costly process that significantly impacts healthcare accessibility and quality. As part of the project of the Laboratory for Strengthening Capacity and Performance of Health System and Workforce for Health Equity, we aimed to assess the changes in the medical doctor supply in several Balkan countries over the last two decades. Methods Data on the total number of graduated medical doctors (MD) and their rate per 100,000 population from 2000 to 2021 was retrieved from the Eurostat database. This open-access database contains the reported number of students who have graduated from medical schools for each year and selected countries (Bulgaria, Croatia, Romania, and Serbia). The standard methods of descriptive statistics were used to perform the analysis. Results During the observed period, the number of MDs graduating annually and their rates per 100,000 population have increased in all countries. Romania leads with the highest rate of MD graduates at 26.18 per 100,000 people, followed by Bulgaria (22.74), Serbia (19.15), and Croatia (16.56). From 2000 to 2021, Bulgaria experienced the highest increase in the number of medical doctor graduates, with a rise of 169.1% in absolute numbers and 200.9% in rate. In contrast, Serbia had the lowest increase, with only a 135.5% rise in the total number of medical doctor graduates and a rate increase of 152.3%. Conclusions In the last 20 years, Bulgaria, Croatia, Romania, and Serbia have seen an increase in the number of MD graduates and their rate per 100,000 population. Policymakers should consider the investments and education trends of medical professionals in relation to their employment and migrations to predict the future supply of doctors in this region. Key messages • Bulgaria, Croatia, Romania, and Serbia have seen an increase in the number of MD graduates and their rate per 100,000 population in the last twenty years. • Considering the trends in the number of newly graduated doctors, policymakers should address additional factors to ensure an adequate supply of medical doctors.

COVID-19 premature mortality in Serbia: Does the place of death matter?

Abstract Background The COVID-19 pandemic has significantly impacted healthcare services provision in Serbia and globally. Many people did not seek or reach healthcare due to various reasons, and a significant number of COVID-19 deaths were not confirmed by laboratory testing. Within the project of the Laboratory for Strengthening Capacity and Performance of Health System and Workforce for Health Equity, we assessed the differences in years of life lost (YLL) of COVID-19 death cases according to the place of death. Methods The Statistical Office of the Republic of Serbia provided average life expectancy and anonymous individual mortality data of the Serbian population in 2020, 2021, and 2022, where COVID-19 was the underlying cause of death (ICD-X codes: laboratory confirmed - U07.1 and clinically diagnosed - U07.2), also disaggregated by the place of death (at home or in a hospital). Analytical statistics and nonparametric tests were used to assess the differences in premature mortality by place of death with a significance level set at p < 0.05. Results In all observed years, a total of 45,632 death cases due to COVID-19 occurred (94.3% in hospital and 5.7% at home). Most COVID-19 deaths were coded as U07.1 (93.8% in hospital, 91.3% at home). An average of 12.12±7.50 YLLs was estimated per death, with a median of 11.50. There was a significant difference (p < 0.001) in the median number of YLLs between those who died in the hospital (11.50) and those who died at home (6.78). Furthermore, deaths occurring at home had fewer YLLs but were more frequently coded as U07.2 (p < 0.001). Conclusions The place of death is relevant when assessing the impact of COVID-19 on premature mortality in Serbia. On average, persons who died at home due to COVID-19 had a lower number of YLLs compared to those who died in a hospital. More research is necessary on the other factors contributing to premature mortality and inequalities in the COVID-19 burden in Serbia. Key messages • During the first three years of the COVID-19 pandemic in Serbia, 5.7% of COVID-19 deaths occurred at home, resulting in an average of 9.89 years of life lost. • The COVID-19 pandemic highlights the need to investigate deaths that occur at home and improve pandemic preparedness.

3.L. Round table: Outcomes from a public debate on the future health priorities of the European Union

Abstract Objective and background In the run up to the European elections, the European Observatory on Health Systems and Policies facilitated a public debate on the future health priorities of the European Union. The purpose of the debate was to provide insights to the European Commission on the views of stakeholders and the public health community with regards to the future of the European Health Union (EHU). The EHU was established as a comprehensive health systems and public health response to the COVID-19 pandemic, featuring enhanced budgets, expanded mandates for existing bodies, and the introduction of new entities like the Health Emergency Response Authority (HERA) alongside new strategies. Methods The methodology for this comprehensive debate included workshops and plenary sessions at various conferences like the 2023 EUPHA conference in Dublin, an interactive webinar series, and a detailed stakeholder survey featuring both closed and open-ended questions. Data was collected and analyzed using diverse qualitative and quantitative tools, including AI-driven analysis of survey responses. Preliminary outcomes Preliminary analysis shows that participants actively engaged in the debate, and mostly expressed support for the EHU’s achievements to date. There was a consensus on the significant value added by the EHU, with many advocating for stronger EU action on a range of discussion topics. Stakeholders and the public health community could also relate to the discussion framework designed to guide the public debate, which included nine topics: enhancing health security; addressing the determinants of health through Health in All Policies and Health for All Policies; supporting health system transformation; enhancing the labour market for health and care workers; achieving universal health coverage; implementing digital solutions and AI; improving the performance and resilience of health systems; addressing long-term challenges, such as population ageing or climate change; and strengthening the EU’s global voice and leadership. The importance placed on these topics varied among different groups. Young participants prioritized climate-related actions, the public health community emphasized addressing the determinants of health, and policymakers concentrated on issues related to health system resilience, universal coverage, and transformation. Digital solutions and AI were recognized as crucial, but they were typically considered integral and transversal to broader issues rather than standalone priorities. The debate also surfaced priorities not initially included in the discussion framework, such as health promotion, prevention, and equity within health systems, which were repeatedly highlighted. Key messages • The debate on the EU’s future health priorities demonstrates that stakeholders and the public health community acknowledge the value of the EHU and would like to see further action to build on it. • Stakeholders and the public health community have formulated concrete action to take the EHU further. Speakers/Panelists Giada Scarpetti TU Berlin, Berlin, Germany Caroline Costongs EuroHealthNet, Brussels, Belgium Isabel de La Mata DG SANTE, European Commission, Luxembourg, Luxembourg

6.Y.1. Defining, measuring, and reducing low-value care in Europe - proposing a new definition and framework

Abstract The EU Expert Group on Health Systems Performance Assessment (HSPA) selected value-based healthcare, with a focus on low-value care, as the work topic for 2023-2024. Against the backdrop of increasing healthcare expenditures and the overall aim to deliver high quality and efficient healthcare, efforts to reduce waste and inefficiencies have long been emerging in health systems worldwide. Value-based healthcare shifts the focus towards improving patient outcomes; the concept of low-value care in particular aims to identify health services that provide little or no health benefits but expose patients to potential harm. The COVID-19 pandemic clearly demonstrated that value-based healthcare is a prerequisite for high-performing health systems and the need to steer resource allocation to those services that maintain or improve health. The reduction in certain elective services observed during the pandemic (e.g. tonsillectomies) indicates that there may be areas for potential dis-investment and reallocation of resources to higher-value care. The pandemic has thereby emphasized the need for identifying and systematizing measurable efforts directed at reducing low-value care. Tackling low-value care can contribute to alleviating health workforce constraints by ensuring that efforts are focused where they are most beneficial, and not on unnecessary services. Engaging and educating the health workforce about low-value care and how to reduce it is a key measure in this direction. What is more, there is increasing awareness about the health sector’s considerable environmental footprint. Reducing low-value care would contribute to less greenhouse gas emissions, energy consumption and air pollution from the delivery of health services. Despite intensified efforts to address waste and inefficiencies in healthcare in the last decade, the ability of health systems in Europe to identify and reduce low-value care varies. Through the Expert Group’s work, a new comprehensive definition was proposed and a framework to distinguish different types of low-value care was developed as a basis for identifying and tackling low-value care in EU Member States. Indicators to measure low-value care as well as measures to reduce it were collected. This workshop aims to present the findings of the Expert Group´s work on low-value care and to discuss them with conference participants to both raise awareness and identify priority elements for future activities. After a brief introduction on the definition, framework, obstacles and solutions, the panelists will share their views and experiences, followed by a facilitated discussion with the audience. Key messages • A comprehensive definition of low-value care and an accompanying framework for categorizing and identifying low-value care is proposed. • Country experiences with indicators to measure low-value care and strategies to reduce it, as well as related methodological obstacles, offer substantial opportunities for cross-country learning.

The WHO health system performance assessment applied to child healthcare in Luxembourg, 2011-2022

Abstract Background Health System Performance Assessments (HSPAs) evaluate health systems in terms of their objectives and their overall goals, such as access to quality services and health improvement. Beyond the overall health system assessment, HSPA can evaluate performance in providing care to specific populations. We assessed the response of the Luxembourg health system to children’s particular health needs, by populating the WHO HSPA framework for universal healthcare with child-specific indicators. Methods We searched international databases, guidelines, policy documents, and the scientific literature to identify child-specific indicators suitable for assessing the health system objectives as defined by the WHO HSPA framework. To select the most relevant indicators, we conducted expert appraisal regarding feasibility, validity and actionability. Those indicators were calculated based on available national data. To explore inequities within the system, we performed socioeconomic stratifications. Results Twenty-nine indicators were used to populate the framework, sourced from social security databases (n = 15), monitoring and surveillance (n = 11), and surveys (n = 2). For effectiveness assessment, we used 11 indicators and found that preventive services performed best for children under two years. Five indicators showed good accessibility to primary and secondary care. Another five indicators assessed safety indicating a recent increase in the relative use of broad-spectrum antimicrobials and an overuse of caesarean sections. Additional disaggregation of three indicators didn’t expose socioeconomic inequities in service delivery. Data gaps exist to assess children’s user-experience and financing of child health services. Conclusions The WHO HSPA framework proved valuable for evaluating the Luxembourg health system’s performance for children. We identified good performance in accessibility and effectiveness for young children, alongside data gaps to assess user-experience. Key messages • The application of national child-specific indicators to the WHO health system performance assessment, highlighted strengths in accessibility and effectiveness while also pointing to key data gaps. • We used the WHO health system performance assessment (HSPA) to evaluate the health system for children in Luxembourg. This exercise enhances the development of a tailored national HSPA framework.

Patient reported outcomes, control of hypertension and dyslipidemia: results of two epidemiological studies in Romania, conducted during pandemia (Snapshot-1) and post-pandemic (Snapshot-2)

Abstract Background Coexistence of hypertension and dyslipidemia is commonly found in daily practice. Patient reported outcomes (PRO) are increasingly used to guide clinical decision-making, as well as public reporting of health system performance. Purpose To assess patient reported outcomes (PRO: socio-economic factors, depression level, and treatment adherence) and control of blood pressure (BP) and LDL-cholesterol (LDL-C) during pandemia and in the post-pandemic period. Methods Two real-world, cross-sectional, multicentre, observational studies, with a similar design, were conducted in Romania during pandemia, in June 2021 (SnapShot-1), and post-pandemic, in June 2022 (SnapShot-2). They included 5004 consecutive outpatients diagnosed with both hypertension and dyslipidemia, addressing cardiologists, diabetologists, and general practitioners: 2469 in SnapShot-1 and 2535 in SnapShot-2. Patients completed a three-part questionnaire including: (1) questions on socio-economic factors; (2) Patient Health Questionnaire (PHQ-9) (Depression scale); and (3) Hill-Bone Medication Adherence Scale (HBMAS) for hypertension and dyslipidemia. Results Characteristics of patients were similar between studies: 65.0±10.0 years and 40.9% men (SnapShot-1), 63.6±10.7 years and 43.3% men (SnapShot-2). Most of the patients declared themselves as "adherent" to the prescribed treatment: 91.8% (SnapShot-1) and 93.0% (SnapShot-2) adherent to antihypertensive treatment; 89.6% (SnapShot-1) and 90.9% (SnapShot-2) adherent to lipid lowering treatment. Socio-economic factors were similar between studies, except education, with higher education rates in SnapShot-2 (Table 1). Compared to SnapShot-1, depression scores evaluated by PHQ-9 scale were lower in SnapShot-2, conducted post-pandemic: 5.9±4.9 for SnapShot-1, suggesting a "mild" depression level, vs. 4.9±4.6 for SnapShot-2, which is below the "mild" depression threshold. Similarly, the adherence scores measured by HBMAS were lower in SnapShot-1 vs. SnapShot-2: 33.8±3.0 vs. 34.0±2.9 for antihypertensive medication, and 33.5±3.5 vs. 33.7±3.4 for lipid lowering treatment (Table 2). Conclusion Data collected from two large epidemiological studies in Romania showed an improvement of post-pandemic depression rates, as well as an improvement of adherence scores. Use of PRO assessment in routine clinical practice could support identification of patients on risk for uncontrolled BP or LDL-C, in need of more intense medical care.

Defining, measuring, and reducing low-value care – proposing a new comprehensive definition and framework

Abstract Despite intensified efforts to address waste and inefficiencies in healthcare in the last decade, the ability of health systems in Europe to identify and reduce low-value care varies. Through the EU Expert Group on Health System Performance Assessment’s work, a new comprehensive definition was proposed and a framework to distinguish different types of low-value care was developed as a basis for identifying and tackling low-value care in EU Member States. Indicators to measure low-value care as well as measures to reduce it were collected. This presentation will provide a brief introduction on the definition, framework, obstacles and solutions for reducing the use of low-value care in Europe. Speakers/Panelists Reinhard Busse Berlin University of Technology, Berlin, Germany Isabel de La Mata DG SANTE, European Commission, Luxembourg, Luxembourg Pacal Meeus Institut National d’assurance Maladie-Invalidité, Brussels, Belgium Ingrid Schmidt National Board of Health and Welfare, Sweden

Variation in care in individuals hospitalised with abdominal aortic aneurysm in nine high-income countries: a cross-sectional cohort study

Abstract Background Abdominal aortic aneurysms (AAA) can be safely repaired using either endovascular aneurysm repair (EVAR) or open repair when intact, but after rupture morbidity and mortality are extremely high. Treatment patterns and outcomes for intact AAA are likely to differ between countries due to differences in AAA screening policies, health system capacity and payment approaches, and other factors, such as demographics and lifestyle, but are poorly studied. Methods We conducted a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalised for with an intact AAA and repair procedure in the same admission between 2011 and 2019 in nine countries (US, Canada, England, Denmark, Netherlands, Switzerland, Taiwan, South Korea and Israel) using population-representative administrative data. We investigated age-sex standardised (to the 2019 US population) repair rates (open repair or EVAR) and health system performance measures, including hospital length of stay (LOS), 30-day readmission, and all-cause mortality (30 days and 1 year). Results The number of intact AAA hospital admissions between 2011 and 2019 ranged from 1,290 in Israel to 199,764 in the US. The rates of intact AAA repair per 1000 population varied between countries and over time, from 0.11 per 1000 (South Korea) to 0.69 per 1000 (US) in 2011 and from 0.14 per 1000 (Taiwan) to 0.57 per 1000 (the Netherlands) in 2019. Most countries saw a decline in the rate of AAA repair over the study period. The proportion repaired using open repair vs EVAR also varied widely across the countries. In the US, Israel and Taiwan open repair was used in 11% or fewer cases whereas in the remaining countries we observed open repair in 25.1 % (South Korea) to 56.7% (Denmark) of cases. (Figure 1) Mortality was generally higher following open repairs compared to EVAR in all countries. In 2019, following EVAR, 30-day mortality varied from 0.6% (8.1% at 1 year) in South Korea to 2.3% (11.7% at 1 year) in Israel and following open repair varied from 2.9 (4.4% at 1 year) in England to 7.6% (15.1% at 1 year) in the US. (Figure 2) Mean hospital LOS in 2019 ranged from 2.5 days (US) to 12.2 days (South Korea), following EVAR and from 9.1 days (Taiwan) to 21.5 days (South Korea) following open repair. The 30-day readmission rate in 2019 ranged from 8.1% (US) to 31.8% in Israel following EVAR and from 11.4% (US) to 22.2% (South Korea) following open repair. Conclusions We observed substantial between-country variation in surgical approaches, mortality, and health system performance measures for AAA. Further research is needed to understand and plan optimal, evidence-based AAA screening and treatment strategies.Rates of EVAR and open repairAdjusted 30-day all-cause mortality

6.H. Round table: Harnessing Patient-Reported Data for Health Innovation: Insights from the OECD PaRIS Initiative

Abstract Summary This round table will disseminate knowledge and foster discussions on data reported by patients with a chronic disease in primary care settings in 20 countries for enhancing health system responsiveness and effectiveness. By delving into the OECD’s Patient-Reported Indicator Surveys (PaRIS) survey’s development, adaptation, and analytical strategies, participants will leave with a richer understanding of how patient-reported data can inform and transform health policy and practice in Europe and beyond. Rationale The round table aligns with the Conference theme by focusing on the transformative potential of patient-reported data in health systems. OECD PaRIS provide a unique lens through which to examine patient-centered care, showcasing innovative methods to capture and utilize data across diverse health system contexts. This round table will explore the development, adaptation, and analysis of this flagship survey, revealing its critical role in shaping health policies and practices that are attuned to patient needs and experiences. Objectives 1. Understanding Development and Testing Processes: To gain insights into the systematic approaches used in developing patient-reported instruments that are both robust and sensitive across multiple healthcare settings; 2. Exploring Co-development and Adaptation: To discuss the challenges and strategies involved in adapting health surveys to various national contexts while ensuring stakeholder engagement and data relevancy; 3. Analyzing Data for Policy Making: To comprehend the analytical frameworks used in processing patient-reported data for crafting effective health policies and identifying factors that influence patient outcomes. Key messages • Patient reported data on experiences and outcomes provide essential information for health systems performance. • Unique insights into the systematic collection of such information can be gathered through the proposed discussion on the experience of designing and implementing the PaRIS Survey.

The Digital Transformation in Health: How AI Can Improve the Performance of Health Systems

ABSTRACT Mobile health has the potential to revolutionize health care delivery and patient engagement. In this work, we discuss how integrating Artificial Intelligence into digital health applications focused on supply chain operation, patient management, and capacity building, among other use cases, can improve the health system and public health performance. We present the Causal Foundry Artificial Intelligence and Reinforcement Learning platform, which allows the delivery of adaptive interventions whose impact can be optimized through experimentation and real-time monitoring. The system can integrate multiple data sources and digital health applications. The flexibility of this platform to connect to various mobile health applications and digital devices, and to send personalized recommendations based on past data and predictions, can significantly improve the impact of digital tools on health system outcomes. The potential for resource-poor settings, where the impact of this approach on health outcomes could be decisive, is discussed. This framework is similarly applicable to improving efficiency in health systems where scarcity is not an issue.

Community members’ perspective on social accountability in the health system: a cross- sectional study from Tanzania

Introduction: Social accountability initiatives are considered a way to address inefficiencies and improve overall health system performance. Tanzania has introduced Health Facility Governing Committees (HFGCs) to improve social accountability of the health system. However, information on how communities perceive these committees is lacking. This study aimed to assess the prevalence and social determinants of the HFGCs accountability from the community perspective in Tanzania. Methods: The research employed a cross-sectional survey design in two Tanzanian districts (Handeni and Mbarali) selected for their contrasting health performance. Data collection took place from July to October 2022, involving 1184 households in 31 villages/mitaa. The study measured social accountability through a set of six questions, focusing on community support, sensitization, feedback, trust, engagement, and overall accountability of HFGCs. Socio-demographic data such as sex, age, education, occupation, type of health facility and district were also collected and analyzed using linear regression to identify factors influencing perceptions of accountability. Results: The findings revealed a low prevalence of social accountability as measured by the variables of community awareness and engagement with the HFGCs. Only a small percentage of respondents felt adequately informed or involved in the activities of these committees. Social determinants such as higher education levels and certain occupations, such as business and retirement and those living in Handeni district, correlated positively with a better perception of social accountability. Conclusion: The study highlights significant challenges in the operational effectiveness of HFGCs in Tanzania, with a notable disconnect between these bodies and the communities they serve. Despite the theoretical framework for social accountability, actual community engagement remains low, impacting the overall efficacy of health governance at the local level. Future research should focus on improving community awareness and participation in these committees to improve their functionality and accountability, thereby aligning with national health objectives and local needs.

Distributed Opioids in Morphine Equivalent: A Global Measure of Availability for Palliative Care

ContextEstimates of serious health-related suffering (SHS) demonstrate immense unmet need for palliative care, predominately in low- and middle-income countries (LMICs). Because opioids are essential medicines in palliative care (PC), measuring their availability can be used to evaluate the capacity of health systems to meet need. ObjectivesPresent the methodology for calculating Distributed Opioids in Morphine Equivalents (DOME)— introduced in the Lancet Commission on Global Access to Palliative Care and Pain Relief report - and how it can be used as a simple indicator to quantify unmet pain relief and PC need. MethodsUsing International Narcotics Control Board (INCB) data, DOME applies relative potency estimates to convert the annualized quantities of clinically appropriate opioids procured by a country to oral morphine equivalent milligrams. To quantify unmet need, an expert group proposed health condition-specific estimates for opioid need and used available data on the burden of SHS to posit the annual opioid quantity required by country for symptomatic treatment of pain or breathlessness. Comparing this to DOME generates DOME%SHSNEED, the proportion of opioids needed for palliative care that can be fulfilled by the opioid procured by a country during a year. ResultsDOME and DOME%SHSNEED can be used to measure, over time, the capacity of countries to meet PC need, as a key component of universal health coverage. Identifying access gaps disproportionately impacting LMICs can promote better health system performance and guide countries and institutions in policy making. ConclusionDOME and DOME%SHSNEED can be used to monitor health system progress to redress disparities and promote access to medically indicated opioid therapy in palliative care.

Defects in Value Associated With Hospital-Acquired Conditions: How Improving Quality Could Save U.S. Healthcare $50 Billion.

Hospital-acquired conditions in the United States are considered avoidable complications but remain common statistics reflecting on health system performance and are a leading cause of patient fatality. Currently, over 3.7 million patients experience a hospital-acquired condition in the United States each year, which costs the U.S. healthcare delivery system an excess of $48 billion. Evidence-based clinical practice guidelines for common hospital-acquired conditions (e.g., infections, falls, pressure injuries) to reduce risk to the patient. In each of these instances, preventing the outcome with these guidelines costs less than treating the outcome, in addition to keeping the patient safe from harm. By applying the framework of defects in value to hospital-acquired conditions, we estimate that U.S. health systems could avert this $48 billion in spending on treating harmful hospital-acquired conditions; more so, these systems of care could recuperate over $35 billion after investing proportionally in a system that delivers greater quality by preventing hospital-acquired conditions over treating them. Currently, the Centers for Medicare and Medicaid Services only withholds reimbursements for hospital-acquired conditions and penalizes health systems with high rates of these outcomes. However, payers do not offer any reward-based incentives for hospital-acquired condition prevention. A series of policy and health system solutions, including tracking of hospital-acquired condition rates in electronic health records, identifying centers of excellence at reducing rates of harm with the use of clinical practice guidelines, and rewarding them monetarily for reduced rates could create equal-sided risk and opportunity to engage health systems in improved performance.

Measuring and improving the cradle-to-grave environmental performance of urological procedures.

An urgent need for societal transformation exists to reduce the environmental impact of humanity, because environmental healthaffects human health. Health care causes ~5% of global greenhouse gas emissions and other substantial and ongoing environmental harms. Thus, health-care professionals and managers must lead ongoing efforts to improve the environmental performance of health systems. Life-cycle assessment (LCA) is a methodology that enables estimation of environmental impacts of products and processes. It models environmental effects from 'cradle' (raw material extraction) to 'grave' (end of useful life) and conventionally reports a range of different impact categories. LCA is a valuable tool when used appropriately. Maximizing its utility requires rational assumptions alongside careful consideration of system boundaries and data sources. Well-executed LCAs are detailed and transparently reported, enabling findings to be adapted or generalized to different settings. Attention should be given to modelling mitigation solutions in LCAs. This important step can guide health-care systems towards new and innovative solutions that embed progress towards international climate agreements. Many urological conditions are common, recurrent or chronic, requiring resource-intensive management with large associated environmental impacts. LCAs in urology have predominantly focussed on greenhouse gas emissions and have enabled identification of modifiable 'hotspots' including electricityuse, travel, single-use items, irrigation, reprocessing and waste incineration. However, the methodological and reporting quality of published urology LCAs generally requires improvement and standardization. Health-care evaluation and commissioning frameworks that value LCA findings alongside clinical outcomes and cost could accelerate sustainable innovations. Rapid implementation strategies for known environmentally sustainable solutions are also needed.

How do we fund Public Health in Australia? How should we?

ObjectiveTo map how public health is funded in Australia. To assess whether changes to funding methods might improve system performance. MethodsReview of publicly accessible documents and discussions with public health key informants. ResultsAustralia spent $140 per person on public health in 2019-20, (1.8% of total health spending). But there is considerable state and territory variation. This money flows through multiple channels and payment mechanisms. Responsibility for what is funded is largely delegated to authorities close to the problems. This makes it easier to choose the best mechanism for funding an activity. Much information is hidden from view, however. This makes it impossible to assess whether the potential for population benefit is fully realised. ConclusionsAustralia avoids some of the difficulties experienced elsewhere because funding is largely devolved to states in block grants; they shape their own investments. The US, by contrast, prefers categorical funds for specific purposes. Three suggestions for making the funding system here more visible, useful and accountable are canvassed, including ‘satellite accounts’. Implications for Public HealthFunding needs to be more transparent before it is possible to assess whether public health system performance could be improved through changes to the way public health is funded.

The Impact of Public Health on Health Systems

Public health is a critical determinant of health system effectiveness, shaping health outcomes and system performance through policies, initiatives, and preventive strategies. This review examines the interconnectedness of public health and health systems, with a focus on two case studies: Ontario’s health units and Uganda’s disease management. It examines the historical evolution of public health, its key components, and the challenges and opportunities in integrating public health into health systems. The findings emphasize that public health initiatives can significantly enhance health system efficiency and effectiveness by addressing broader social determinants of health and fostering community engagement. The review concludes that an integrated approach to public health and health systems can lead to improved health outcomes and long-term sustainability of health systems. Keywords: Public health, Health systems, Disease prevention, Health promotion, Health Policy.

Applying Newly Identified Financially Focused Home Care Quality and Performance Indicators In Alberta's $23.5B/annum Health System - Preliminary Findings

Through a multi-phased mixed-method research program including an international scoping review and a modified-Delphi panel with expert policy/academic/operational representatives from across Canada, three health-system, financially focused quality and performance home care indicators were identified. This presentation will provide preliminary results of the application of the three financial indicators on overall health-system measures, system utilization and population outcomes within the province of Alberta. The time-period covered is the last five years data leading up to the start of the deceleration of the covid-19 global pandemic. Based on provincial annual financial reporting, baseline 2016/17 fiscal year home care expenditures were $585K, this rose to significantly to $716M for fiscal year 2019/20, with the most significant increase (13%) occurred between the 2017/18 and 2018/19 years. Prior to 2016/17 home care expenditures increased at a rate less than 3%. These significant home care investments increased the percent of the overall expenditures in Alberta from 3.94 to 4.6%. Furthermore, the average annual expenditures per home care client rose from $5,417 to $6,112. During this same time-period, numerous health-system indicators shifted to more favorable positions, with notable decreases in acute care days prior to death, number of those waiting in hospital for LTC, and preventing/delaying the need for LTC overall. Based on comparisons of home care investments on the overall health-system and key health-system performance indicators focused on measuring system efficiencies, preliminary examinations suggest that significant home care focused investments in Alberta significantly improved health-system performance, efficiencies, and overall outcomes for the population.

Developing and reporting a healthcare-associated infection composite score for health system board review

Background One strategy for supporting a hospital or health system's board of directors (Board), with their quality oversight responsibility is to review the organization's performance on quality measures. But for large systems, the number of measures needing review is quite burdensome and makes priority setting difficult. Our goal was to develop a scoring method that summarizes multiple quality measures together, while still maintaining the Board's opportunity to examine individual measures where there are specific concerns. Methods We calculated an overall health system-level composite performance score using six publicly reported healthcare-associated infections reported by the Centers for Medicare and Medicaid Services on their Care Compare website [central-line associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), surgical site infections (SSIs) for colon surgery and abdominal hysterectomy, hospital-onset Methicillin-resistant Staphylococcus aureus bacteremia (MRSA), and hospital-onset Clostridioides difficile ( C. diff)], where relative weights assigned to each infection type reflect the severity of patient harm. We also calculated a health-system composite performance target. For individual infection types, we calculated system-wide scores and targets and categorized individual hospital performance into three performance categories. Results The health system's composite score between 2015 and 2019 ranged from a high of 1.10 to a low of 0.71. The health system's composite score in 2017–2019 was better than the composite target. Of the 34 measures used to calculate the 2019 composite score, 20 were better than internal standardized infection ratio (SIR) targets, seven were between internal targets and SIR of 1.0, and seven were worse than SIR of 1.0. Discussion The Board communicated they find this composite score reporting approach helpful for streamlining their understanding of HAI performance, as compared to traditional approaches of reporting out individual performance measures. Approaches that streamline Board review of quality and safety performance are important as we hold Board members accountable for overseeing quality, seek greater engagement from the Board, and work to minimize measure review overload.