Health System Strategies Research Articles

Nutrition and Exercise Strategies to Prevent Excessive Pregnancy Weight Gain: A Meta-analysis.

Objective To evaluate nutrition-only, exercise-only, and nutrition-plus-exercise interventions for optimizing gestational weight gain (GWG) based on the 2009 Institute of Medicine (IOM) guidelines. Study PubMed, Google Scholar, and 2015 Cochrane Review were searched. Analysis of variance was used to determine if significant GWG differences exist between strategies, with additional subanalyses on overweight (OV) or obese women based on 2009 IOM guidelines. Results Of 66 identified studies, 31 contributed data ( n = 8,558). Compared with routine prenatal care, nutrition-only interventions were significantly associated with reduced GWG and are most likely to produce weight gain within IOM recommendations ( p = 0.013). Exercise-only ( p = 0.069) and nutrition-plus-exercise ( p = 0.056) interventions trended toward GWG within IOM guidelines, but did not reach statistical significance. Supervised ( p = 0.61) and unsupervised ( p = 0.494) exercise programs had similar effectiveness. Subanalyses on OV or obese women produced similar results to studies that did not differentiate results based on body mass index: nutrition only ( p = 0.011), exercise only ( p = 0.308), and nutrition plus exercise ( p = 0.129). Conclusion Preventing excessive GWG is crucial, especially for OV or obese women. In the current study, nutrition-based intervention is the health system strategy that showed significant impact on preventing excessive GWG compared with routine prenatal care. Among women who are OV or have obesity, nutrition-only interventions hold the most promise compared with routine prenatal care.

The Dynamics of Health Care and Growth: A Model with Physician in Dual Practice

We present a growth model with micro-foundations of a mixed health care system and physician dual-practice, to analyze for welfare-optimal government financing strategy for a mixed health system in developing countries. Calibrating the model for Indonesia, we find that a government subsidy to private health care is both growth- and welfare-enhancing, whereas it is more effective for the government to invest in health infrastructure instead of a public-sector rewarding policy in raising government physicians’ wage if its goal is to improve physician effort in public practice. Indeed, for the rewarding policy, a dynamic trade-off in growth is found, which is not previously documented in the literature. We also find the model to produce two regimes with different welfare-optimal health financing (a “normal” regime and a low public-sector congestion regime). In the former, welfare-optimal health financing strategy appears to be promoting private health subsidy at the expense of public-sector physician wages. In the latter, the opposite is welfare-optimal.

Análisis de costo-utilidad del cardiodesfibrilador implantable para el tratamiento de pacientes con insuficiencia cardíaca NYHA II-III isquémica o no isquémica en Colombia

Introduction. The use of an implantable cardioverter-defibrillator reduces the probability of sudden cardiac death in patients with heart failure. Objective. To determine the cost-utility relationship of an implantable cardioverter-defibrillator compared to optimal pharmacological therapy for ischemic or non-ischemic NYHA II-III heart failure patients in Colombia. Materials and methods. A Markov model was developed. The model includes costs, effectiveness and quality of life from the perspective of the Colombian health system. For the baseline case, a time horizon of 10 years and discount rates of 3% for costs and 3.5% for benefits were adopted. The transition probabilities were obtained from a systematic review of the literature. The outcome used was the quality-adjusted life years. Consulting with the manufacturers of the device offered in the Colombian market, and using national-level pricing manuals, costs were calculated. Probabilistic and deterministic sensitivity analyses were conducted. Results. In the base case, the incremental cost-effectiveness ratio for the implantable cardioverter-defibrillator was 13,187 USD per quality-adjusted life year gained. For a willingness-to-pay equivalent to three times the gross domestic product per capita as a reference (19,139 USD in 2017), the device is a cost-effective strategy for the Colombian health system. However, the result is sensitive to changes in the time horizon, the probability of death and the device price. Conclusions. The use of an implantable cardioverter-defibrillator for preventing sudden cardiac death in patients with heart failure is a cost-effective strategy for Colombia. The results should be examined considering the uncertainty.

Epidemiology and Risk Factors of Stroke in Tabriz, Iran: A Population Based Study

Objective: Cerebral vascular events are the second leading cause of mortality worldwide and is increasing in developing countries. Epidemiological studies are important to improve outcomes and preventive and supportive strategies. This research was aimed to study epidemiology of stroke in Tabriz, Iran. Materials and Methods :This cross-sectional, analytic population-based study was performed from May 2009 to April 2010. Information about probable stroke events was obtained from 5000 randomly selected people. In a door-to-door process, questionnaires were completed by a trained team. Any probable stroke case was referred to a stroke expert for further evaluation. After diagnosing stroke cases, 214 healthy people were assembled for a control group to compare stroke related risk factors. Results :Out of 5000 studied people, 34(0.68%) stroke patients, with a mean age of 68.7 years (range: 38-85), were detected. Nineteen (56%) patients were male, 31 (91%) were ischemic, and 3 (9%) had hemorrhagic stroke. Six first-ever strokes occurred in the 1 year study period. Identified risk factors included hypertension in 25 (74%), hyperlipidemia in 11 (32%), diabetes mellitus in 9 (27%), smoking in 10 (29%) and coronary artery disease in 6 (18%). Conclusion : This report showed a high incidence rate of stroke of about 120 per 100,000 people and a remarkably high prevalence of hypertension. It speaks to the need to make special health system strategies to raise awareness for primary and secondary prevention of stroke.

Enterprise Technology Architecture solution for eHealth System and implementation Strategy

ICT has covered most of the industries are also playing a very important role in healthcare. In this paper, I propose the drafting and implementation of the Health System Strategy, based on ICT solutions, as well as in this document will be proposed the steps for the establishment and development of the health information system, which provides access to electronic health records to support decision-making in healthcare institutions, including human resource management, patient management, disease management, health status management, pharmaceutical management, and participation in open market The health information system is the establishment of a standardized interchange platform of patient’s data, through network infrastructure, hardware equipment, and software solutions. Below is the strategy, I will try to visualize the architecture of the eHealth Information System. For us, it is very important to emphasize the life cycle of different entities and their interactions in the ecosystem of all the interoperable architecture, which is the basis for the proposed strategy. The information system architecture feasibility analysis is based on a personalized medical system, and interoperable between different modules or data.

Health system strategies to increase HIV screening among pregnant women in Mesoamerica

BackgroundTo propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador.MethodsWe interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening.ResultsOverall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%.ConclusionsTo meet WHO’s recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.

Building hospital capacity planning mechanisms in Poland: The impact of 2016/2017 regulatory changes.

Capacity planning is a crucial component of modern health care governance. The aim of this paper is to analyze the requirements that need to be met to build effective hospital capacity planning mechanisms in Poland. In this context, the recent regulatory changes strongly influencing hospital sector functioning, including introduction of health care needs maps, capital investment assessment, and hospital network regulations, are analyzed. Some possible ways forward, based on review of international experiences in hospital capacity planning, are discussed. Applied methods include literature review and analysis of statistical data as well as desk analysis of key national regulations related to hospital sector. Results indicate that at the system level, the process of capacity planning involves 4 elements: capital investment in facilities, equipment, and technology; service delivery; allocation of staff; and financial resources. For hospital capacity planning to be effective, the strategic decision at the macrolevel must be complemented by appropriate management of individual hospitals. The major challenge of building hospital capacity planning mechanism in Poland is imbedding it into the overall health system strategy. Because of the lack of such a strategy, the practical implementation of the ad hoc changes, which have been introduced, shows some inconsistencies. The regulations implemented between 2016 and 2017 provided a basis for hospital capacity planning, yet still need evaluation and adjustments. Also, including a mechanism for human resources planning is of crucial importance. The regulations should provide incentives for reducing oversized hospital infrastructure with simultaneous development of the long-term and coordinated care models.

Health systems in the SDG era: consolidating and building on the gains

Global health today stands at cross-roads, with unanticipated problems challenging the unprecedented progress achieved over the last two decades. To achieve the targets established for the sustainable development goal 3 of “ensuring healthy lives and promote well-being for all at all ages”, significant resources and comprehensive health systems must play a critical and integral role. World Health Organization’s (WHO) framework for action on “Strengthening Health Systems to Improve Health Outcomes” has well identified the challenges of global health. The Global Strategy for Women's, Children's and Adolescents' Health 2015-2030 states that for women’s and children’s health investments in high-impact health interventions for RMNCH at a cost of US$5 per person per year up to 2035 in 74 high-burden countries, could yield up to nine times that value in economic and social benefits. As global health marches towards achieving universal health coverage (UHC), innovative health financing schemes and health system design will be the major determinants of equity and efficiency in resource allocation and health care delivery. Because we are now in a critical phase, it is imperative that the initial years of the SDGs receive utmost thrust from all relevant stakeholders across countries to initiate and maintain a sustained momentum for achieving the targets. The primary priority for the health-related targets’ therefore’ necessitates the need for formulation of robust, responsive and resilient health systems strategies by all the major policy makers and concerned stakeholders.

Implementation strategies for health systems in low-income countries: an overview of systematic reviews.

BackgroundA key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low‐income countries. Implementing interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision‐makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.ObjectivesTo provide an overview of the available evidence from up‐to‐date systematic reviews about the effects of implementation strategies for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.MethodsWe searched Health Systems Evidence in November 2010 and PDQ‐Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well‐conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low‐income countries.Main resultsWe identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high‐income countries. There were no studies from low‐income countries in eight reviews.Implementation strategies addressed in the reviews were grouped into four categories – strategies targeting:1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);4. healthcare recipients (e.g. medication adherence; 15 reviews).Overall, we found the following interventions to have desirable effects on at least one outcome with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects.1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient‐centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in‐service neonatal emergency care training.3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self‐management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community‐based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.Authors' conclusionsReliable systematic reviews have evaluated a wide range of strategies for implementing evidence‐based interventions in low‐income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process‐based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.

Reducing the Global Burden of Cardiovascular Disease, Part 1: The Epidemiology and Risk Factors.

Current global health policy goals include a 25% reduction in premature mortality from noncommunicable diseases by 2025. In this 2-part review, we provide an overview of the current epidemiological data on cardiovascular diseases (CVD), its risk factors, and describe strategies aimed at reducing its burden. In part 1, we examine the global epidemiology of cardiac conditions that have the greatest impact on CVD mortality; the predominant risk factors; and the impact of upstream, societal health determinants (eg, environmental factors, health policy, and health systems) on CVD. Although age-standardized mortality from CVD has decreased in many regions of the world, the absolute number of deaths continues to increase, with the majority now occurring in middle- and low-income countries. It is evident that multiple factors are causally related to CVD, including traditional individual level risk factors (mainly tobacco use, lipids, and elevated blood pressure) and societal level health determinants (eg, health systems, health policies, and barriers to CVD prevention and care). Both individual and societal risk factors vary considerably between different regions of the world and economic settings. However, reliable data to estimate CVD burden are lacking in many regions of the world, which hampers the establishment of nationwide prevention and management strategies. A 25% reduction in premature CVD mortality globally is feasible but will require better implementation of evidence-based policies (particularly tobacco control) and integrated health systems strategies that improve CVD prevention and management. In addition, there is a need for better health information to monitor progress and guide health policy decisions.

Primary Prevention with Statins: Strategies to Support Shared Decision-Making

This paper proposes several strategies for health systems, primary care clinicians, cardiologists, and other members of the healthcare team to better engage individuals in decisions around primary preventive statin therapy. The 2013 American College of Cardiology and American Heart Association (ACC/AHA) guidelines for cholesterol management provide an opportunity to better engage patients in decisions about primary prevention of cardiovascular disease, including the initiation of statin therapy. In the shared decision making process, clinicians and patients work together to determine what is best for the patient, taking into account the scientific evidence informing guideline recommendations, the clinician’s knowledge and experience, the known burdens of taking a daily lifelong medication, and the patient’s preferences, values and goals. Several challenges exist to adopting shared decision making as a patient-centered model of care.

Community Action for Health in India’s National Rural Health Mission: One policy, many paths

Community participation as a strategy for health system strengthening and accountability is an almost ubiquitous policy prescription. In 2005, with the election of a new Government in India, the National Rural Health Mission was launched. This was aimed at ‘architectural correction’ of the health care system, and enshrined ‘communitization’ as one of its pillars. The mission also provided unique policy spaces and opportunity structures that enabled civil society groups to attempt to bring on to the policy agenda as well as implement a more collective action and social justice based approach to community based accountability. Despite receiving a lot of support and funding from the central ministry in the pilot phase, the subsequent roll out of the process, led in the post-pilot phase by the individual state governments, showed very varied outcomes. This paper using both documentary and interview based data is the first study to document the roll out of this ambitious process. Looking critically at what varied and why, the paper attempts to derive lessons for future implementation of such contested concepts.

Now is the time for ambulatory centralised scheduling: How to assess your organisation's readiness

This paper will explore the advantages of incorporating centralised scheduling into your performance improvement strategy and initiatives to prepare for value-based care reimbursement and accountable care. It includes a checklist to assess your organisation's readiness to make the transition and best practices that will support the implementation. After reviewing the paper, readers will have an understanding of the four main reasons that ambulatory central scheduling can be essential to a health system's strategy moving forward — providing appropriate access to care, preventing network leakage, furnishing price transparency, and improving the patient experience.

Functional evaluation of breath: spirometry and body plethysmography comparison in people with cystic fibrosis.

[Purpose] The aim of the present study was to establish up-to-date data regarding the lung function of cystic fibrosis (CF) patients. [Subjects and Methods] Forty-eight patients of both genders, with a diagnosis of CF, were recruited. As a result our sample presented, according to the GOLD criteria, 23 patients with mild lung obstruction (FEV1%pred: 89.86), 16 patients with moderate lung obstruction (FEV1%pred: 56.1) and 9 patients with severe obstruction (FEV1%pred: 32.1). [Results] All patients presented normal total lung capacity followed by an important residual volume increase. [Conclusion] Our results were important to illustrate the CF patient’s lung functional status and to improve the health system strategy in treating such individuals.

Advancing the development of national childhood cancer care strategies in Latin America

BackgroundDespite a rising burden of cancer among children in low- and middle-income countries (LMICs), few efforts to develop system-wide strategies to combat childhood cancer exist. Such efforts are hampered both by gaps in research evidence and by weak links among stakeholders spanning the trajectory from research and care to policy. Deliberative dialogues have emerged as a promising means of advancing evidence-informed policy, by providing a structured forum for key stakeholders to integrate and explore scientific and experiential knowledge about complex health system issues. MethodsWe convened a two-day deliberative forum with a broad array of stakeholders to collectively identify core problems, objectives, potential solutions, and key implementation considerations related to the development of national childhood cancer strategies in Latin America. Resultsfrom this deliberative process describe broadly endorsed elements of a solution to the challenges posed by childhood cancer in the region, both at the level of individual countries and through supra-national collaboration. Key findings include: the potential role for a pan-regional task force on childhood cancer in advancing collective goals; the import of structured health system guidance to national policy and program development on childhood cancer; and the crucial need for enhanced capacity to monitor and evaluate childhood cancer systems and policies. ConclusionThe fruits of this deliberative process include novel policy-relevant research and advocacy endeavours, and enhanced relationships among diverse regional stakeholders to support evidence and policy development relevant to childhood cancer care in Latin America. Deliberative dialogues hold promise for advancing evidence-informed health system strategies on childhood cancer care in other LMIC contexts.

Affirmative and Responsible Health Care for People with Nonconforming Gender Identities and Expressions.

Although recent changes in health care delivery have improved routine and gender-affirming care for transgender people, common approaches to care are still often based on a binary (i.e., male/female) gender framework that can make patients with gender-nonconforming (GNC) identities and expressions feel marginalized. Binary representation perpetuates invisibility, discrimination, and victimization-and subsequent poorer health-among GNC patients. In response, clinicians and health care systems should extend their efforts to provide gender-affirming and responsible care to GNC people. This article reviews terminology related to gender, the limited research-and necessary directions for future research-on GNC communities, and provides strategies for health care professionals and systems to ensure provision of gender-affirming and responsible care to GNC patients.

Implementando estrategias para mejorar el gobierno institucional del Sistema Nacional de Salud

The 2008 economic crisis made the issue of good governance more present and visible, but the debate risks stalling in an academic and political discourse that barely exceeds the declarative. We acknowledge the existence of noteworthy documents from scientific medical societies and some institutional proposals that point towards promising changes. Viewing good governance as accountability, participation, transparency, intelligence and integrity, our objective is to identify the determinants of inaction and remove the barriers that prevent the adoption of rational and widely agreed-upon proposals. This led us: 1) to allocate the proposals to their appropriate governance level (macro, meso, micro and system environment) so as to more directly engage the agents of change; and 2) to highlight some decision nodes that can act as levers to catalyse selective transformations and to initiate the change processes. Taking into account the diversity of actors and scenarios, a top-down rational, integrated and reformist strategy for the whole Spanish National Health System does not seem likely or viable. Therefore, the purpose of this paper is to promote changes, setting a targeted and reasoned agenda to visualise key issues and to enable multilevel and multidimensional thinking and advocacy of health-sector and society stakeholders.

Control of blood pressure and risk attenuation

Background:High blood pressure (BP) is the leading attributable risk for cardiovascular disease globally. There is little information on effective and sustainable public health system strategies for managing hypertension in South Asian countries. We conducted a feasibility study to gather preliminar

Health and Usage Monitoring System (HUMS) Strategy to enhance the Maintainability & Flight Safety in a Flight Control Electromechanical Actuator (EMA)

Concerning flight control actuation systems, the current state of the art is the fly-by-wire control of servo actuators hydraulically operated. In the last decades several research programs have been dedicated to analyze the replacement of these equipments with the implementation of Electro-Hydrostatic Actuators (EHA) or Electro-Mechanical Actuators (EMA), pursuing the challenge to get More Electrical Aircraft (MEA).This paper focuses on the HUMS strategy proposed to provide diagnosis and prognosis of the EMA as one way to enhance Flight Safety and Maintainability for its use in Primary Flight Controls.Considerations related to Flight Safety are analyzed, specially linked to the main problem associated to the EMA, the critical effects derived from the mechanical jamming of some parts of the EMA, and the advantages of the HUMS implementation to anticipate and mitigate these consequences.

One Client, One Team: Health system integration for leaders.

This article examines the implementation of the strategy and Integrated Client Care Program, a multi-level health system strategy to break down the barriers in a solid health system and a program to integrate care for populations with the most complex needs. Specific reference is made to two specialized programs, older adults with complex care needs and a palliative care program whose goal is to meet the needs of patients and their families in a community setting.