Improve Healthcare Systems Research Articles

The Necessary Shifting to Improve Health Care Systems: Underdeveloped Countries

The clinical treatment of coronary (heart) artery disease (CAD) for hundreds of thousands to millions of people

Cost-effectiveness analysis of a randomized study of depression treatment options in primary care suggests stepped-care treatment may have economic benefits

BackgroundThe stepped-care pathway (SCP) model has previously been found to be clinically effective for depressive disorder in some studies, but not all. Several groups have suggested that a stepped-care approach is the most appropriate in primary care. There is relatively little information, however, regarding which specific stepped-care pathway may be best. This analysis aimed to determine cost-effectiveness of a stepped-care pathway for depression in adults in primary care versus standard care (SC), treatment-as-usual (TAU), and online cognitive behavioural therapy (CBT).MethodsWe conducted a randomized trial with 1400 participants and 12-week follow-up to assess the impact of the four treatment options on health-related quality of life and depression severity. Costs for the groups were calculated on the basis of physician, outpatient, and inpatient services using administrative data. We then calculated the incremental cost-effectiveness ratios using this information. Cost-effectiveness acceptability curves and incremental cost-effectiveness scatterplots were created using Monte Carlo simulation with 10,000 replications. A subgroup analysis was conducted for participants who screened as depressed at baseline.ResultsFor all participants, TAU was the most expensive followed by CBT, SC, and SCP. QALYs were highest in SCP, followed by SC, CBT, and TAU. In the depressed subgroup, TAU was still the most expensive, followed by SC, SCP, and CBT, while QALYs were still highest in SCP, followed by SC, CBT, and TAU. The cost-effectiveness acceptability curves suggested that SCP had a higher probability for cost-effectiveness than the other three alternatives in all participants. In the depressed subgroup, CBT was associated with the highest probability of cost-effectiveness for a willingness-to-pay cut-off of less than approximately $50,000, while SCP was the highest at a cut-off higher than $50,000. There is considerable uncertainty around the cost-effectiveness estimates.ConclusionsOur analysis showed that even where there are no clinically significant differences in health outcomes between treatment approaches, there may be economic benefit from implementing the stepped-care model. While more work is required to identify the most clinically effective versions of a stepped-care pathway, our findings suggest that the care pathway may have potential to improve health care system value.Trial registrationNCT01975207. The trial was prospectively registered on 4 November 2013.

Cardiovascular diseases in Tanzania: The burden of modifiable and intermediate risk factors

Tanzania, like other developing countries, is facing a higher burden of cardiovascular diseases (CVDs). The country is experiencing rapid growth of modifiable and intermediate risk factors that accelerate CVD mortality and morbidity rates. In rural and urban settings, cardiovascular risk factors such as tobacco use, excessive alcohol consumption, unhealthy diet, hypertension, diabetes, hyperlipidemia, overweight, and obesity, are documented to be higher in this review. Increased urbanization, lifestyle changes, lack of awareness and rural to urban movement have been found to increase CVD risk factors in Tanzania. Despite the identification of modifiable risk factors for CVDs, there is still limited information on physical inactivity and eating habits among Tanzanian population that needs to be addressed. Conclusively, primary prevention, improved healthcare system, which include affordable health services, availability of trained health care providers, improved screening and diagnostic equipment, adequate guidelines, and essential drugs for CVDs are the key actions that need to be implemented for cost effective control and management of CVDs. Effective policy for control and management of CVDs should also properly be employed to ensure fruitful implementation of different interventions.

“Anyone can co-design?”: A case study synthesis of six experience-based co-design (EBCD) projects for healthcare systems improvement in New South Wales, Australia

“Anyone can co-design?”: A case study synthesis of six experience-based co-design (EBCD) projects for healthcare systems improvement in New South Wales, Australia

Clinicians' Views On The Uptake Of Technology In Health Care

Background/Aims The NHS recognises digital technology is key in improving healthcare systems and delivery. However, the uptake of technology has been slow due to various factors including clinician attitudes and behaviours identified in the Personalised Health and Care 2020 plan. To evaluate attitudes and current use of technology within a healthcare setting of allied health professionals. Methods An online survey was designed with closed and open questions exploring the barriers and facilitators towards the uptake of technology. The survey was disseminated to 130 allied health professionals at a specialist orthopaedic hospital. The questions were based on the extended Technology Acceptance Model, which focused on perceived threat, perceived inequity, perceived usefulness and behavioural intention. Results Response rate was 44%. There were more positive results towards perceived usefulness and behavioural intention than to perceived threat and perceived inequity with regards to technology. Clinicians reported that technology has improved efficiency and effectiveness at work benefiting the patient and institution. However, the barriers related to loss of clinical time due to technical issues, lack of IT support, lack of confidence in IT skills and knowledge and patients' inability to access technology. The solutions suggested were more technical support, training and allocated time in work templates and work space. Conclusions Clinicians' behavioural intentions were positive towards the use of technology and they were willing to incorporate them more in health care. However, developments in infrastructure are required to provide staff with the tools and skills to facilitate greater use of technology within the clinical environment.

A Fairer Mirror: Equity-limited Healthcare System Rankings

Objective● Describe the diverse determinants of national health and how they are compositely graded in health care system rankings.● Articulate intrinsic reasons why equity should not be subsumed within other evaluative categories.● Design an equity-limited ratings framework for limiting maximum ratings of inequitible healthcare systems.IntroductionHealthcare systems are often evaluated using comparative health care rankings. Simulations have shown that maximally inequitable health care systems can perform well in published, influential health care system rankings by excelling in non-equity categories1, resulting in highly ranked yet grossly inequitable healthcare systems. Recently, despite below average equity rankings, the healthcare systems of Australia and New Zealand ranked among the top four in The Commonwealth Fund’s international comparative study Mirror, Mirror 20172. Equity rankings should logically limit non-equity rankings given the insignificance of healthcare system improvements to those lacking adequate healthcare coverage. We analyzed whether an equity-limited ranking methodology would limit overall rankings for significantly inequitable healthcare systems while maintaining the general findings of the Commonwealth Fund study.MethodsWe reanalyzed The Commonwealth Fund’s 2017 international health care system comparison using a modified, equity-limited methodology. For each country, maximum non-equity domain summary scores were limited to the equity domain summary score. Countries were ranked using the mean of the five domain-specific performance scores. Overall rankings were compared to the original rankings.ResultsSeven of eleven countries had an overall rank change in the equity-limited model. Countries with above average overall ratings but poor equity ratings had the greatest changes in overall rank. Australia’s overall ranking decreased from second to seventh, thereby matching its equity ranking of seventh. New Zealand changed from fourth to eighth overall, matching its equity ranking as well. Other changes were less significant, with changes of only one overall rank position. Notably, the bottom three countries and the top country were unchanged.ConclusionsEquity-limited ranking methodologies can prevent inequitable health care systems from attaining high overall ratings. Such equity-limited rankings are logical considering the diminished significance of health care system improvements to those lacking adequate health coverage. Methodologies that incorporate equity limits should be used to produce fairer rankings that respect the dignity and rights of all individuals.

Missed opportunities in the way medical schools evaluate the ethical domain in clerkship rotations.

BackgroundSeveral lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.MethodsThe authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students’ perspectives.ResultsTwenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.ConclusionsThere are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Measuring quality outcomes across hospital systems: Using a claims data model for risk adjustment of mortality rates.

Healthcare delivery systems around the world are designing care through value-based models where value is defined as a function of quality of care outcomes and cost. Mortality is a sentinel outcome measure of quality of care, of fundamental importance to patients and providers. Discovery Health (DH), an administrative funder of healthcare in South Africa (SA), uses service claims data of client medical schemes to examine standardised mortality rates (SMRs) at condition level across hospital systems for the purpose of healthcare system improvement. To accurately examine and contrast variation in condition-level SMRs across acute hospital systems, this outcome metric needs to be risk-adjusted for patient characteristics that make mortality more, or less, likely to occur. This article describes and evaluates the validity of risk-adjustment methods applied to service claims data to accurately determine SMRs across hospital systems. While service claims data may have limitations regarding case risk adjustment, it is important that we do not lose the important opportunity to use claims data as a reliable proxy to comment on the quality of care within healthcare systems. This methodology is robust in its demonstration of variation of performance on mortality outcomes across hospital systems. For the measurement period January 2014 - December 2016, the average risk-adjusted SMRs across hospital systems where DH members were hospitalised for acute myocardial infarction, stroke, pneumonia and coronary artery bypass graft procedures were 9.7%, 8.0%, 5.3% and 3.2%, respectively. This exercise of transparently examining variation in SMRs at hospital system level is the first of its kind in SA's private sector. Our methodological exercise is used to establish a local pattern of variation of SMRs in the private sector as the base off which to scrutinise reasons for variation and off which to build quality of care improvement strategies. High-performing healthcare systems must seek out opportunities for learning and continuous improvement such as those offered by examining important quality of care outcome measures across hospitals.

Exploring the role of information managers in knowledge transfer and preservation among the “Elewe Omos” (Indigenous herbal medicine practitioners) of the Yorubas in Nigeria

Indigenous herbal medicine as an arm of indigenous knowledge has lived with man from existence. In spite of the peculiarity of their mode of operation and services, their method of knowledge transfer and retention remains secretive and largely informal. This is because hardly is there any formal system of learning or a stipulated number of years of study when compared with orthodox medicine. Thus the study investigates how the custodians of indigenous herbal medicine (IHM) popularly called „‟Elewe Omos‟‟ among the Yorubas of the South Western Nigeria transfer their acquired knowledge of herbal medicine from one generation to another. This is a qualitative study and so data was gathered through focus group discussion. Respondents were drawn from key practitioners from members of the National Association of Traditional Medicine Practitioners (NATMP). The study leveraged on the recent herbal fair organised by the NATMP. Thirty-eight (38) practitioners from the 6 South-western states participated in the fair. The study employed a random sampling technique to select one (1) out of every six (6) practitioners. The outcome of the study revealed among others that indigenous herbal medicine knowledge is devoid of any form of secrecy or spiritism, The study concludes that the process of knowledge transfer of indigenous herbal medicine, can be effectively coordinated by effort of information managers in preserving this age long knowledge of the African people for onward transmission to coming generation and for improved health care system. Keywords : Indigenous Herbal Medicine, Knowledge Transfer, Preservation, Information Managers, Yorubas,

Real-world data: towards achieving the achievable in cancer care.

The use of data from the real world to address clinical and policy-relevant questions that cannot be answered using data from clinical trials is garnering increased interest. Indeed, data from cancer registries and linked treatment records can provide unique insights into patients, treatments and outcomes in routine oncology practice. In this Review, we explore the quality of real-world data (RWD), provide a framework for the use of RWD and draw attention to the methodological pitfalls inherent to using RWD in studies of comparative effectiveness. Randomized controlled trials and RWD remain complementary forms of medical evidence; studies using RWD should not be used as substitutes for clinical trials. The comparison of outcomes between nonrandomized groups of patients who have received different treatments in routine practice remains problematic. Accordingly, comparative effectiveness studies need to be designed and interpreted very carefully. With due diligence, RWD can be used to identify and close gaps in health care, offering the potential for short-term improvement in health-care systems by enabling them to achieve the achievable.

Obesity needs to be put into a much wider context

Obesity needs to be put into a much wider context

Evaluation of teaching methodologies in pharmacology for undergraduates: a cross-sectional analysis in a medical college of South India

Background: Pharmacology is an important part of medical education. A competent doctor should be able to prescribe rational treatment to the patients to minimise the adverse effects and contribute to the improvement of overall healthcare system. There is a dire need to reform the undergraduate pharmacology curriculum to match up to the rapidly evolving medical field. Feedback system is one of the most successful instruments in improving any system. We have undertaken a similar feedback system to study the advantages and disadvantages of various study methods for teaching theory and practical exercises to the medical undergraduates.Methods: This is a cross sectional questionnaire based study conducted in the department of pharmacology. Students of MBBS 2nd year were enrolled into the study. The purpose of the study was explained to them and clarifications were made if any. The questionnaire included questions on various aspects of teaching methodology and graded by students on internationally accepted ‘Likert’ scale.Results: In our study students favoured teaching by blackboard method (96%) and many preferred a combination of blackboard and power point presentation. Discussing on issues of clinical significance of the topic was favoured by 96% of the students and 67% students responded that stressing on the facts concerned with Post graduate entrance exams is more important. Sixty nine percent and 85% students preferred short essays and MCQs respectively as method of evaluation and 68% of them favoured evaluation by both the methods. Regarding pharmacology practical exercises most of the students preferred clinical problems, dosage calculation, ADR reporting and other problem based learning techniques. Studying pharmacology as an integrated subject with other clinical subjects was preferred by 68% of the students.Conclusions: It is well known that students learn better when they are involved actively in learning process than when they are passive recipients. In our study we realised that undergraduate pharmacology teaching pattern should be modified mostly towards pharmacotherapeutics and clinical pharmacology.

IoT-based intensive care secure framework for patient monitoring and tracking

This paper aims to design a prototype of the real-time patient control system. The proposed framework is used to quantify the physical parameters of the patient such as the temperature of the body, rate of heartbeat and ECG observation with the assistance of sensors. The collected data is sent to the cloud, then to the nurse station, specialist and the patient tablet or the web application. In this framework, the patient's health is checked consistently and the data obtained through the networks are transmitted. If any irregularity is noticed from the patient's signs, it will be sent to nurses and doctors for any suggestions to help the patient. The system is implemented through Arduino advanced controller and simulation results are obtained. The Smart Intensive Care Unit (SICU) provides a new way for health monitoring of patients in order to improve healthcare systems and patients' care and safety. The cloud system is provided by a group of micro-services hosted in many servers the simulate a small cloud system. To secure the patient's data through this framework is provided by using OAuth server to authenticate the users and the sensors and generate the tokens. This system can assist doctors and nurses to achieve their missions and improve the healthcare system.

IoT-based intensive care secure framework for patient monitoring and tracking

This paper aims to design a prototype of the real-time patient control system. The proposed framework is used to quantify the physical parameters of the patient such as the temperature of the body, rate of heartbeat and ECG observation with the assistance of sensors. The collected data is sent to the cloud, then to the nurse station, specialist and the patient tablet or the web application. In this framework, the patient's health is checked consistently and the data obtained through the networks are transmitted. If any irregularity is noticed from the patient's signs, it will be sent to nurses and doctors for any suggestions to help the patient. The system is implemented through Arduino advanced controller and simulation results are obtained. The Smart Intensive Care Unit (SICU) provides a new way for health monitoring of patients in order to improve healthcare systems and patients' care and safety. The cloud system is provided by a group of micro-services hosted in many servers the simulate a small cloud system. To secure the patient's data through this framework is provided by using OAuth server to authenticate the users and the sensors and generate the tokens. This system can assist doctors and nurses to achieve their missions and improve the healthcare system.

The Burden of Injury in China, 1990-2017: Findings from the Global Burden of Disease Study 2017

Background: A comprehensive evaluation of the burden of injury is an important foundation for selecting and formulating strategies of injury prevention. We present results from the Global Burden of Disease (GBD) 2017 study of non-fatal and fatal outcomes of injury at the national and subnational level, and the changes in burden for key causes of injury over time in China. Methods: Using the methods and results from GBD 2017, we describe the burden of total injury and four key causes of injury (road injuries, falls, drowning and self-harm) based on the rates of incidence, cause-specific mortality, and disability-adjusted life years (DALYs) in China. We additionally evaluate these results at provincial level in 2017, measure the change of injury burden from 1990 to 2017, and compare age-standardized DALY rates of injuries for the 34 subnational locations of China against the expected rates based on the socio-demographic index (SDI), a measure of development combining an equal weighting of lag-distributed income per capita, average years of education in the population over age 15 years, and total fertility rate under 25 years of age. Findings: In 2017, in China, there were 77.1 (95% uncertainty interval 72.5-81.7) million new cases of injury severe enough to warrant health care, and 733,517 (681,254-767,007) deaths due to injuries. Injuries accounted for 7.0% (6.6-7.2) of total deaths, and 10.0% (9.5-10.5) of all-cause DALYs in China. In 2017, there was a three-fold variation in age-standardized injury DALY rates between provinces of China, with the lowest value in Macao and the highest in Yunnan. Between 1990 and 2017, the age-standardized incidence rate of all injuries increased by 50.6% (46.6%- 54.6%) in China, while the age-standardized mortality and DALY rates rapidly decreased, by 44.3% (41.1% - 48.9%) and 48.1% (44.6% - 51.8%), respectively. All provinces of China experienced a substantial decline in DALY rates from all injuries ranging between 16.4% (3.1% - 28.6%) and 60.4% (53.7% - 66.2%) between 1990 and 2017. Age-standardized DALY rates for drowning; fire, heat and hot substances; self-harm; animal contact; adverse effects of medical treatments; environmental heat and cold exposure; and executions and police conflict each declined by more than 60% between 1990 and 2017. Interpretation: China has experienced a decrease in the age-standardized DALY and mortality rates due to injury from 1990 to 2017, despite an increase in the age-standardized incidence rate. These trends have occurred in all provinces. The divergent trends in terms of incidence and mortality indicate that with rapid socio-demographic improvements the case fatality of injuries has declined, which could be attributed to an improving health care system but also to a decreasing severity of injuries over this time period. Funding Statement: Bill & Melinda Gates Foundation Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at icmje.org/coi_disclosure.pdf and declare support from the Bill & Melinda Gates Foundation; no financial relationships with any organizations that might have an interest in the submitted work; no other relationships or activities that could appear to have influenced the submitted work. Ethics Approval Statement: The authors state that there were No patients directly involved in this study.

What initiatives do healthcare leaders agree are needed for healthcare system improvement? Results of a modified-Delphi study

PurposeThe purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented.Design/methodology/approachA multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments.FindingsThe process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people.Research limitations/implicationsInformation could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input.Practical implicationsThe practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems.Originality/valueThis study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

Decentralized Governance in the Management of Urban Health Care Systems in Developing Countries

Enhanced Health care services address not only one of the key Sustainable Development Goals (SDG) which is goal No 3, but also the development strategies for most developing countries. Good governance is critical to improving health care systems. Many developing countries therefore have decentralized health care systems as a way of improving good governance and as a means of attaining improved access to and delivering quality health care services to both urban and rural population. Decentralization involves the extent of planning, management and decision making from national to lower levels of government. From the 1990s the capacity of governments in developing countries to deliver public goods and services was stretched to the extent there was dire for partnerships. The Public Private Partnerships (PPP) therefore became fundamental in the provision of health services under decentralization. The nature of PPP differed from country to country and the level of decision making within each level of government. The paper has discussed the extent to which decentralized governance has facilitated the management of health care systems in the urban centres through Public Private Partnership initiatives, by conducting a comparative case study analysis of existing literature on urban health care systems under different forms of decentralized governance in Kenya, Uganda, Ghana and India, respectively. The study established that access to health care services differed with forms of decentralization. Secondly, there were more public private partnerships in devolved governments which also registered higher improvement in access to health care services in urban centres. The paper concluded that the more the involvement of public private partnership, the better health care services in terms of access was noted.

Advancing consumer engagement: Supporting, developing and empowering youth leadership in cancer care.

Advancing consumer engagement: Supporting, developing and empowering youth leadership in cancer care.

Formalisation and subordination: a contingency theory approach to optimising primary care teams

ObjectiveWhile there is consensus on the need to strengthen primary care capacities to improve healthcare systems’ performance and sustainability, there is only limited evidence on the best way to organise...

The sensitive detection of ODAM by using sandwich-type biosensors with a cognate pair of aptamers for the early diagnosis of periodontal disease

This research aims to develop biosensors which could diagnose periodontal diseases in early phases and predict the illness stage of patients, in order to give them adequate treatment timely. Human odontogenic ameloblast-associated protein (ODAM) is considered to be a potential biomarker for periodontal diseases, based on high correlation between the level of ODAM in gingival crevicular fluid (GCF) and the degree of periodontitis. Many aptamers, including a cognate pair of aptamers which can bind to the different sites of ODAM, were successfully screened in a very stringent condition employing saliva as a counter target through the graphene oxide-based systemic evolution of ligands by exponential enrichment (GO-SELEX). For the characterization of the aptamer candidates, GO-based fluorescence resonance energy transfer (GO-FRET) and surface plasmon resonance (SPR) assays were conducted. The sandwich-type binding of a cognate pair of aptamers to ODAM was additionally confirmed by employing circular dichroism (CD) and magnetic beads-based fluorescence imaging methods. The resulting cognate pair of aptamers, OD64 and OD35, were found to have their dissociation constant (Kd), 47.71 nM and 51.36 nM, respectively. The minimum detectable concentrations of a sandwich-type SPR biosensor were found to be 0.24 nM and 1.63 nM, respectively, for both buffered and saliva samples. Finally, using this cognate pair of aptamers, a sandwich-type lateral flow strip biosensor was successfully realized. This research shows the potential for implementation of a cognate pair of aptamers on point-of-care biosensors which enables simple, rapid, and non-invasive saliva-based diagnosis of periodontal-related diseases that can overcome current diagnostic methods and improve health care system.