National Healthcare System Research Articles

Principles of the Orthogeriatric Model of Care: A Primer

It is well known that over the last few decades, there has been significant growth of the aging population worldwide and especially in Europe, with an increase of more than two years per decade since the 1960’s. Currently, in Europe, people aged over 65 years old represent 20% of the population, creating many new and complex challenges for national healthcare systems. In many countries, geriatric medicine is an established medical specialty, integrated into the primary and secondary care of the older population. In some countries, such as Portugal, specialist training in geriatric medicine is not available, even though the life-expectancy in Portugal is currently 81 years due to a decrease in fertility and mortality, and people aged over 60 currently represent nearly a third of the population. There is strong evidence in the medical literature that a fracture following a fall, and especially a neck of femur fracture, is one of the most serious events that can happen in an older person’s lifetime. These fractures have been associated with increased morbidity, loss of independence, a high rate of institutionalization, and mortality. Rates of mortality after a year from femoral fractures have been proven to be three to four times higher than the expected in the general population, ranging between 15% to 36%. This emphasizes the importance of developing well-organized care pathways for these patients, which combine specialized geriatric care (also known as orthogeriatric care). This narrative review will focus on the core principles of orthogeriatric care and how medical professionals, including those who are not specialized in geriatric care, can effectively use them.

Rapid health technology assessment to inform policy: a case study with respiratory syncytial virus

Abstract Background Respiratory syncytial virus (RSV) can cause severe acute respiratory tract infection in infants and older adults. However, until recently, no immunisation interventions were available to reduce the burden of RSV disease in the general population. New health technologies have now been authorised in Europe for infants (a long-acting monoclonal antibody (nirsevimab) and a maternal vaccine (RSVpreF)), and two vaccines for adults aged ≥60 years (RSVPreF3 and RSVpreF). A rapid health technology assessment (HTA) was requested by the Irish Department of Health to support an interim decision on RSV immunisation. Methods The rapid HTA commenced in January 2024, and comprised description of technology, a summary of international practice, national and international epidemiology and burden of disease, and a costing analysis. The summary of international practice (including underpinning evidence) was undertaken rather than a systematic review of effectiveness and safety due to the rapidly changing evidence base and short timeline within which information was required. Results While new recommendations regarding immunisation against RSV are emerging internationally in response to recently authorised technologies, implementation and funding strategies are not currently widespread. Compared with a full HTA, a rapid HTA enabled an efficient and flexible approach to producing a high quality evidence synthesis to inform a temporary policy decision, taking approximately 6 months to complete rather than 12 months or longer. A full HTA is planned to inform long-term decision-making on this topic, but would not have been feasible to inform an interim decision. Conclusions This rapid HTA will inform a temporary decision on immunisation policy for a single RSV season in Ireland. Conducting a rapid HTA prior to a full HTA has enabled timely decision-making, with implications for Ireland’s national healthcare system and people at risk of severe RSV-related disease. Key messages • Innovations in immunisation against RSV are leading to changes in policy across Europe. • Rapid HTA can support timely, evidence-based public health decision-making in a fast-evolving field.

Measures to increase the retention of migrant healthcare professionals in Germany

Abstract Background The shortage of skilled workers in the healthcare sector is a pressing issue in Germany that has been worsening in recent years. It is often compensated by the deployment of specialists from abroad. However, this is accompanied by various challenges. This article synthesizes challenges from nine years of research and proposes approaches to solutions that have proven successful in practice in Germany as well as in international settings. Methods The insights presented here condense the results from a total of six research projects (four on physicians and two on nursing). The research projects are based on exploratory qualitative interviews, quantitative questionnaires, mixed-methods designs, and the generation and testing of measures that can help with the integration of foreign skilled workers. Results The main challenges for migrated skilled workers are inadequate language and communication skills, lack of knowledge about the national healthcare system, disease and therapy concepts, unfamiliar forms of inter-hierarchical and inter-professional collaboration, a lack of understanding of administrative and bureaucratic processes and social integration. The following measures have proven successful in Germany and abroad: increasing social integration of physicians (e.g. through partner or peer programs), streamlining systems, establishing professional structures for the integration of foreign skilled workers, and creating a positive work environment. Conclusions Compared to findings from international studies, in Germany the hurdles of administrative processes, the peculiarities of the healthcare system (e.g. social medicine), and learning the language are considered to be the highest. It is important to counteract these challenges with appropriate measures in order to prevent a migration of healthcare professionals already in Germany to (mostly English-speaking) foreign countries. Key messages • In Germany the hurdles of administrative processes, the peculiarities of the German healthcare system (e.g. social medicine), and learning the German language are considered to be the highest. • It should be considered to no longer leave the migration of healthcare staff to individual integration efforts, but to create appropriate government structures that focus on their social integration.

Racial and ethnic disparities in the incidence of stroke and mortality in atrial fibrillation: a US nationwide study

Abstract Background Atrial fibrillation (AF) is the most common arrhythmia globally and is associated with increased risks of cardiovascular mortality and ischemic stroke. Prior research has demonstrated racial/ethnic disparities in AF outcomes yet this work has been limited to small cohorts and did not adjust for anticoagulant therapy. Purpose We compared incidence of ischemic stroke and death by race/ethnicity for patients with AF in the Veterans Health Administration (VA), the largest integrated, low-cost, national healthcare system in the US. Methods In this retrospective cohort study we identified those with an outpatient diagnosis of AF and a confirmatory diagnosis ≦ 180 days of their index AF diagnosis enrolled in VA from January 1, 2014 to December 31, 2021, with follow-up for outcomes from the index AF diagnosis date until May 31, 2022. To create a cohort of incident AF cases, we excluded patients with an AF diagnosis or anticoagulant therapy in the 2 years prior to their index AF diagnosis. We also excluded patients with pre-existing valvular heart disease, prior stroke, receiving hospice care or who died within 180 days of index AF diagnosis. We categorized our independent variable as race (i.e., non-Hispanic American Indian / Alaska Native [AI/AN], Asian, Black, or White [reference group]), and ethnicity (i.e., Hispanic). Our primary outcomes were incidence of stroke or death at any point within the study follow-up period. To compare these outcomes by race/ethnicity we conducted a survival analysis, adjusting for anticoagulant use as a time-varying covariate along with sociodemographic factors (age, sex, region, area deprivation index), clinical factors (CHADS2VA2Sc stroke risk and HAS-BLED bleeding risk), and facility type. Results There were 187,080 patients in the final cohort including 0.5% AI/AN, 1% Asian, 9% Black, 4% Hispanic, 85% White; mean age was 73 years. Over a mean study follow-up period of 4.43 years, 65,375 (34.9%) patients died and 24,910 (13.3%) developed stroke. The adjusted hazard ratio [95% CI] for death was lower for Hispanic (0.84 [0.78, 0.91]) and Black (0.94 [0.91, 0.97]) patients than White patients. In contrast, the adjusted hazard ratio for stroke incidence was higher for Black (1.21 [1.16, 1.27]) and Hispanic (1.10 [1.03, 1.17]) patients than White patients. There was no difference observed between AI/AN or Asian and White patients in either outcome. Conclusions In a national cohort of patients with incident AF, we identified significantly higher rates of stroke in Black and Hispanic than White patients even controlling for myriad factors including anticoagulant use. Conversely, racial/ethnic disparities in mortality appear to be eliminated in VA, counter to prior data. Understanding the factors, beyond anticoagulation, driving disparities in stroke outcomes and identifying factors reducing mortality among minority groups is critical to improving overall AF care in the largest integrated US health system.Adjusted Hazard Ratios of Study Outcomes

Benefits of cross-border access to human genomes at scale for research and healthcare

Abstract Genomics data will soon be routinely generated and integrated into national healthcare systems. To maximise the potential of genomic medicine, data should be accessible for research where possible. This is the remit of ELIXIR, an intergovernmental organisation that brings together life science resources from across Europe. Innovative solutions are needed to ensure the validated research findings for disease or preventative medicine are then integrated into healthcare. To tackle this, the 1+MG initiative, a joint initiative of 25 EU countries, the UK, and Norway, aims to enable secure access to genomics and the corresponding clinical data across Europe for better research, personalised healthcare and health policy making. In the design and scale-up phase (B1MG project), recommendations and guidelines to advance towards the deployment of personalised medicine at a European scale have been produced, adopted by 1+MG and developed into a 1+MG framework. This includes guidance on data governance, standards, quality and infrastructure, recommendations on how to approach citizen engagement and a tool for countries to self-assess implementation into healthcare. The European Genomic Data Infrastructure (GDI) project supports the scale-up and sustainability phase of the 1+MG initiative, to deploy infrastructure across 24 countries to support the overall ambition. Recommendations are being used to promote governance and technical interoperability across European initiatives including the European Health Data Space (EHDS), and European Cancer Image Initiative (EUCAIM). The 1+MG will be established as a European Data Infrastructure Consortia in 2025 and will act as an Authorised Participant in the EHDS providing access to a permanent high-quality federated data collection of genomic and health data that will accelerate research, innovation and policymaking facilitating the deployment of genomic medicine across Europe.

Implementing patient navigation for cancer prevention among individuals with mentally ill-health

Abstract Issue In Europe, over 80 million people experience mental ill-health and there are 4 million new cancer diagnoses each year. Individuals experiencing mental ill-health exhibit higher rates of cancer morbidity and mortality, with this excess attributed to risky health behaviors and obstacles encountered when accessing often fragmented healthcare systems. Description of the problem The aim of Co-CAPTAIN is the pilot implementation and evaluation of the Patient Navigation Model (PNM) for the improvement of primary cancer prevention in individuals with mental ill-health, adapted through participatory co-design in the European context. The project will adopt a cohort-based study design, commencing data collection at baseline and succeeded by three follow-ups (6 weeks, 9 months, 18 months). It will utilize a mixed-methods approach, combining quantitative and qualitative methodologies to assess diverse outcomes of PNM, facilitating both exploratory and confirmatory research. Qualitative data will be obtained through semi-structured interviews, while quantitative data will be collected using validated questionnaires and items developed ad hoc. The project will involve four pilot sites in Europe (Austria, Greece, Poland and Spain), where the PNM will be adapted to the specificities of national healthcare and support systems. The implementation phase is expected to begin in June 2024. Results During implementation, gathering both quantitative and qualitative data will offer valuable insights into feasibility and effectiveness, establishing a baseline for reshaping health and social care policies for individuals with mental ill-health across Europe. Lessons Co-CAPTAIN project aims to reduce health disparities for individuals with mental ill-health by improving overall health and reducing cancer burdens, leading to cost reductions in European health and social care systems. Key messages • The project aims to deliver an innovative solution based on the PNM, to address health disparities among individuals with mental ill-health by reducing cancer burden. • Combination of qualitative and quantitative methodologies to assess diverse outcomes.

A socially interactive communication skills training for competent health educators

Abstract Background Every contact with expectant and new parents can be a “teachable moment” for promoting the health of mother-baby-family; yet, healthcare providers may not effectively perform their educational role. Previous studies have described various setting-specific challenges. Procedural knowledge, resulting in lack of confidence and avoidance, is a universal theme, challenging current communications skills training. Given the evolving role of midwives under the new Cyprus National Healthcare System, there is need for innovative practices. Objectives “Baby Buddy Communicators” designed, implemented and piloted tested a socially interactive digital environment on the Edubreak platform, where practicing (N = 8) and in-training (N = 7) Midwives completed an 8-week iterative hybrid communication skills course along with service-users. Results Four situational-based scenarios were co-created with ‘holders of the experience’ tapping on key priorities (elective caesarean, breastfeeding challenges, baby in NICU, postnatal depression). Participants produced video artefacts of role-play consultations and engaged in peer-to-peer and service-user feedback via the in-built video annotations and blog writing tools. Deductive content analysis of the rich material using the 18-item Health Professionals Communications Skills (HPCS) scale identified recurrent patterns tapping on both informational aspects (e.g. incomplete information gathering, overload without assessing comprehension) as well as social skills (e.g. agenda setting, early reassurance, assertiveness). Conclusions This cross-sectoral transfer of social video from sports training to healthcare is a “proof of concept”. Inverted (i.e. making current practices visible) and experiential learning (e.g. feedforward) with cross-sectoral (service-user involvement) and cross-module dimensions (i.e. communication skills and evidence-based practice) provided the basis for evaluation and a source of shared learning and reflection. Key messages • Several areas of improvement in communication skills of maternal healthcare providers were identified while peer-to-peer and service-user feedback was a source of reflection. • The use of digital technology and social video allowed immersive role-playing, observation and constructive feedback loops providing a new paradigm in health communication skills training.

Physical activity habits among members of the Athens Medical Society in Greece

Abstract Introduction Benefits of regular physical activity and exercise are well documented. Healthcare workers play a crucial role in counseling and appropriately referring their patients to adopt physical activity. However, doctors’ exercise habits range between different medical specialties and health service infrastructure. Purpose In this study, we assess physicians’ exercise performance according to the recommendations of 2020 ESC Guidelines. Methods The population of this cross-sectional study comprised 742 physicians of the Athens Medical Society (AMS), Greece. The study instrument was a self-administered questionnaire mailed in October 2023 to investigate physicians’ exercise habits, baseline characteristics of population, specialty, and health service infrastructure [Greek National Healthcare System (GNHS) or Private Practice (PP)]. European Society of Cardiology (ESC) Guidelines recommend at least 150 min/week of moderate-intensity exercise in all healthy adults. Subjects were divided in two groups according to their compliance to ESC Guidelines: 1. Moderate-intensity endurance exercise training per week ≥ 150 min (Group A); 2. Moderate-intensity endurance exercise training per week <150 min (Group B). Results The recommended exercise training per week goal is achieved by the majority of AMS members (53.4%) with an estimated mean exercise endurance training time of 240 ± 285 minutes. Between Group A and Group B there was no difference in age (50±12years vs. 50±13years, p=0.73), whereas there was significant difference in male sex prevalence (58% vs. 43%, p <0.001), in Body Mass Index (24.7 ± 3.8 kg/m2 vs. 26.2 ± 4.7 kg/m2, p <0.001), in Smoking habits (17.4% vs. 23.5%, p=0.04), in diabetes mellitus incidence (6.6% vs. 11.8%, p= 0.01) and in the use of activity monitoring wearables (45.2% vs. 29.8%, p<0.001). Interestingly, there was significant difference between GNHS and PP doctors representation in Group A and B with more doctors in the PP categorized in the Group A (p=0.008) (Figure 1). Importantly, logistic regression analysis revealed that even after adjustment for the aforementioned confounders there was significant under-representation of the GNHS in the Group A or otherwise doctors in the GNHS have 33% decrease odds of achieving the recommended exercise training per week (Odds Ratio: 0.676, 95%CI 0.484, 0.943, p=0.02) (Table 1). Conclusion A significant proportion of the AMS members follows the recommended ESC guidelines for minimum exercise training per week. Several factors affect their adherence to exercise time recommendation. Interestingly, AMS doctors working on the GNHS independently of other factors are less adherent to exercise recommendations. These findings emphasize the need to strengthen prevention strategies to AMS.

ESC Heart Failure Association age-adjusted natriuretic peptide thresholds for a new diagnosis of heart failure: diagnostic accuracy study

Abstract Background Natriuretic peptide (NP) testing is an important part of the heart failure (HF) diagnostic pathway. The European Society of Cardiology (ESC) HF guidelines currently recommend a NT-proBNP cut-off <125pg/mL to rule out HF in the community.1 However, NP level increases with age and an NT-proBNP above 125pg/mL is common in older people in the general population. The ESC Heart Failure Association (HFA) recently published a practical algorithm for early diagnosis of HF recommending age-specific rule-in NT-proBNP thresholds: ≥125pg/ml for patients aged under 50 years, ≥250pg/ml for patients aged 50-75 years, and ≥500pg/ml for patients over 75 years (Figure 1).2 Purpose Our aim was to assess NT-proBNP test performance for HF diagnosis at the ESC HFA age-specific thresholds. Method We analysed our existing diagnostic accuracy study dataset containing primary care data from the Clinical Practice Research Datalink (CPRD) linked to inpatient Hospital Episode Statistics (HES) inpatient data between 2004 and 2018. NT-proBNP results were taken from the GP record (index test) and the primary outcome (reference standard) was a HF diagnostic code entered in CPRD or HES within six months of the test. NT-proBNP accuracy for HF was assessed by calculating sensitivity, specificity, positive predictive values (PPV), and negative predictive value (NPV). Receiver operating characteristic (ROC) curves were plotted to assess overall test performance. Results In total, 229,580 patients had an NP test and 21,102 (9.2%) were diagnosed with HF. The current ESC NT-proBNP threshold ≥125pg/mL had sensitivity 94.6% (95% confidence intervals [CI] 94.2 to 95.0), specificity 50.0% (95%CI 49.7 to 50.3), PPV 16.4% (16.1 to 16.6), NPV 98.9% (98.8 to 99.0)). Area under the ROC curve was 0.874 (0.871 to 0.877). Age-specific NT-proBNP thresholds performance: Below 50 years (≥125pg/mL): 32,882 people tested, HF prevalence 3.8%. Sensitivity 83.5 % (81.3 to 85.5), specificity 77.6% (77.2 to 78.1), PPV 13.0% (12.2 to 13.7), NPV 99.2% (99.0 to 99.3). 50 to 75 years ≥250pg/mL: 105,771 people tested, HF prevalence 9.8%. Sensitivity 88.5% (87.9 to 89.1), specificity 67.8% (67.5 to 68.0), PPV 23.1% (22.6 to 23.5), NPV 98.2% (98.1 to 98.3). Above 75 years ≥500pg/mL: 16,694 people tested, HF prevalence 17.5%. Sensitivity 84.4% (83.0 to 85.7), specificity 63.5% (62.7 to 64.3), PPV 32.8% (31.7 to 33.9), NPV 95.0% (94.6 to 95.5). Conclusion The age-specific NT-proBNP thresholds in the HFA practical algorithm had higher specificity so fewer people without HF would be referred, reducing demand for echocardiography and cardiology assessment overall meaning people with HF could be seen earlier. However, lower sensitivity means some cases of HF would initially be missed. NT-proBNP was a reliable ‘rule-out’ test at population level. The optimal NT-proBNP threshold will depend on the priorities and capacity of the national healthcare system.

Global health

Abstract Global health emphasizes the importance of addressing health challenges that transcend national borders and require strong international collaboration and governance. This concept is grounded in collaborative transnational actions aimed at promoting health for all, reducing disparities, and protecting against threats. Strengthening health systems, public health infrastructure, improving health service delivery, and ensuring equal access to healthcare for all are key focus areas in global health. This plenary will address several major health challenges and critical issues, such as the rising burden of non-communicable diseases, re-emerging pandemics, environmental threats, and the suboptimal responses of national healthcare systems to manage these challenges. The need to focus on vulnerable and marginalized populations, particularly those affected by migration and ethnicity, will be highlighted. The discussion will also showcase the importance of including ethnic minority and Indigenous people’s perspectives in health policy and decision-making processes, as well as addressing the social determinants of health that disproportionately affect these communities. Central to the discussion on global health is the role of global health policy and diplomacy, focusing on how countries can collaborate to address health threats and challenges, shaping international strategies and frameworks. Innovation, including reverse innovation and the development of evidence-informed policies and effective public health strategies that can be implemented globally and is relevant also in resource-constrained contexts, is another critical aspect in addressing the intersection of health and development. Finally, strong public health leadership is needed to shape practices and policies, as well as fostering the next generation of global health leaders. The multifaceted nature of global health calls for a comprehensive approach to health—one that integrates policy, leadership, and equity into the core of public health strategies. The integration of health into all policies at the global level is vital for creating supportive environments, policies, services, and communications that promote better health for all. Moderators Iveta Nagyova President EUPHA Henrique Barros President ASPHER Speakers/Panellists Emma Rawson Te Patu President World Federation of Public Health Associations Charles Agyemang Professor of Global Migration, Ethnicity & Health, University of Amsterdam, Netherlands Agnès Buzyn Former Minister of Health and Social Affairs, France Moredreck Chibi Public Health Innovation Lead, WHO Regional Office for Europe

Incidence of Non-Communicable Diseases and Out-of-Pocket Expenditure among Senior Elderly of five Districts in Kerala

Background: The nation's healthcare system, which is already struggling with constraints, faces a significant challenge from India's growing elderly population. As the prevalence of non-communicable diseases (NCDs) rises among this demographic, concerns mount over the strain on healthcare services. Objective: the study's primary aim was to evaluate the incidence of NCDs and the financial burden of out-of-pocket expenses associated with hospital stays for the middle-aged and older segments of the population. Methods: The referenced study, employing a systematic random sampling method, sought to gather pertinent data within Kerala—a state in southern India. Conducted across five specific districts. Results: The findings from a sample of 500 individuals revealed that 45% were afflicted with NCDs. Notably, a significant majority of these patients, irrespective of their economic status, opted for private healthcare providers, accounting for 60.5% of the respondents. This preference underscores the perceived or actual disparities in the quality of care between private and public healthcare institutions. Conclusions: The study's insights are crucial in understanding the healthcare dynamics at play and could serve as a catalyst for policy reform, aiming to enhance the accessibility and affordability of healthcare for India's aging population. It also highlights the urgent need for a robust healthcare system that can accommodate the complex needs of the elderly, particularly in managing chronic conditions that require long-term care and substantial financial resources. Way ahead: Utilising frontline staff (ANMs and ASHAs) can assist in putting NCD interventions into practice at the community level.

A Generic Transformation Approach for Complex Laboratory Data Using the Fast Healthcare Interoperability Resources Mapping Language: Method Development and Implementation.

Reaching meaningful interoperability between proprietary health care systems is a ubiquitous task in medical informatics, where communication servers are traditionally used for referring and transforming data from the source to target systems. The Mirth Connect Server, an open-source communication server, offers, in addition to the exchange functionality, functions for simultaneous manipulation of data. The standard Fast Healthcare Interoperability Resources (FHIR) has recently become increasingly prevalent in national health care systems. FHIR specifies its own standardized mechanisms for transforming data structures using StructureMaps and the FHIR mapping language (FML). In this study, a generic approach is developed, which allows for the application of declarative mapping rules defined using FML in an exchangeable manner. A transformation engine is required to execute the mapping rules. FHIR natively defines resources to support the conversion of instance data, such as an FHIR StructureMap. This resource encodes all information required to transform data from a source system to a target system. In our approach, this information is defined in an implementation-independent manner using FML. Once the mapping has been defined, executable Mirth channels are automatically generated from the resources containing the mapping in JavaScript format. These channels can then be deployed to the Mirth Connect Server. The resulting tool is called FML2Mirth, a Java-based transformer that derives Mirth channels from detailed declarative mapping rules based on the underlying StructureMaps. Implementation of the translate functionality is provided by the integration of a terminology server, and to achieve conformity with existing profiles, validation via the FHIR validator is built in. The system was evaluated for its practical use by transforming Labordatenträger version 2 (LDTv.2) laboratory results into Medical Information Object (Medizinisches Informationsobjekt) laboratory reports in accordance with the National Association of Statutory Health Insurance Physicians' specifications and into the HL7 (Health Level Seven) Europe Laboratory Report. The system could generate complex structures, but LDTv.2 lacks some information to fully comply with the specification. The tool for the auto-generation of Mirth channels was successfully presented. Our tests reveal the feasibility of using the complex structures of the mapping language in combination with a terminology server to transform instance data. Although the Mirth Server and the FHIR are well established in medical informatics, the combination offers space for more research, especially with regard to FML. Simultaneously, it can be stated that the mapping language still has implementation-related shortcomings that can be compensated by Mirth Connect as a base technology.

Cost and resource comparison analysis for THA in Switzerland and Austria.

Total hip arthroplasty (THA) is an orthopedic intervention that generates substantial costs to national healthcare systems due to the number of interventions and the cost per intervention. We performed a cost comparison analysis in Austria and Switzerland. Data from the national joint arthroplasty register in Switzerland and internal information from the national healthcare services in Austria and Switzerland were compared for patient demographics, interventional characteristics, and costs adjusted for inflation and purchasing power from 2015 to 2021. The average age for primary THA in Austria was from 67.4 to 67.8years with 55.9-57.2 percent female patients and from 68.5 to 69.3years with 52.4-53.8 percent female patients in Switzerland. The annual incidence rate for primary THA rose from 210.28/100k to 216.6/100k in Austria and from 212/100k to 250/100k in Switzerland. After correction for inflation, costs were -1.91 percent lower in Austria in 2021 than in 2015 and -2.57 percent lower in Switzerland. After correction for purchasing power, costs were higher in Austria. The average hospital stay after THA in Austria was reduced by 20 percent (11.7days/2015 vs. 9.4days/2021) and 25 percent in Switzerland (8.4days/2015 vs. 6.4days/2021). Revision rate was 2.5-3.2 percent in Austria and 2.8-3.2 percent in Switzerland. The patient population was comparable while patients undergoing primary THA in Austria stay longer in hospital and have relatively higher costs when adjusted for currency, purchasing power, and inflation. The use of standardized registers would be helpful to compare outcomes and costs.

Feasibility of an environmental scan-based approach to collecting information about factors impacting cancer genetics services in Latin American countries.

Clinical cancer genetics services are expanding globally, but national policy and health care systems influence availability and implementation. Understanding the environmental factors within a country is required to appropriately implement, adapt, and evaluate cancer genetics service delivery models. An environmental scan (ES) is an approach used in business, public health, health care and other sectors to collect information about an environment or system for strategic decision making and program planning. An ES has been previously used to assess cancer genetics clinic-level factors to inform quality improvement efforts in the United States. We assessed the feasibility of using an ES to collect information about factors that may influence cancer genetics service delivery in the outer-most socio-ecological model environmental levels (policy, national agencies, healthcare systems, cultural considerations) in three Latin American countries. Oncology and Genetics care team members at three participating sites used publicly available sources and personal experiences to complete a data collection form (DCF) that included questions about subtopics: laws and policies, relevant agencies and regulations, health care systems and insurance, and cultural considerations. Time to complete the DCF and DCF completeness were used to measure ES feasibility. Participating sites completed the DCF in 3 months, and most questions (average, 87.0%) were answered. Questions in the cultural considerations subtopic had the fewest answers (average, 77.8%). Overall, the ES was feasible and identified a lack of published literature related to cultural considerations impacting health care and genetics services uptake in Latin America. Environmental factors impact cancer genetics services, and identification of these factors will facilitate future collaborative research and genetics service delivery dissemination efforts.

Regulatory Quality in the International Circulation of Medicinal Products

Since 2014, the World Health Organization has been implementing a large-scale project to strengthen and develop national regulatory systems, which is aimed at increasing the availability of safe, effective and high-quality medicines and medical devices for the population of all countries, but primarily low- and middle-income countries. The project analyzes the maturity of national regulatory systems using a global benchmarking tool developed based on various regulatory authority assessment systems and has undergone extensive discussion and pilot testing; the results of national authorities that have reached high levels of maturity are published. A WHO List of Regulatory Authorities is also being formed, replacing the previously used concept of "stringent regulatory authorities". This List is recommended for use in regulatory reliance procedures by national regulatory authorities, purchasing structures of various levels and status: commercial, public, state or international. The regulatory quality of drug regulation is one of the critical factors of any national healthcare system. At the global level, it is directly related to goals 1,3,8,9 and 11 of sustainable development defined by the UN. The WHO project under consideration to assess maturity) of the regulatory system of the pharmaceutical sector is fundamentally different from similarly focused projects carried out in the past. First of all, the project focuses not on legal and regulatory/methodological documents, but on institutional and procedural aspects, i.e. on the structure and functions of regulatory bodies. Along with this, the project can have a significant impact on global pharmaceutical markets.

Analysis of prescriptive monitoring regarding the current therapeutic landscape of rheumatoid arthritis: the experience of an Italian local health authority

ABSTRACT Introduction Rheumatoid Arthritis (RA) is among the most prevalent chronic inflammatory diseases affecting millions of people with a significant expenditure of resources by National Healthcare Systems. This study aimed to analyze all available treatments exclusively for RA to highlight the costs of each treatment type and raise awareness of the use of biosimilar drugs. Methods In an Italian healthcare authority, all prescriptions made for the diagnosis of RA were extracted to verify consumption expressed in Defined Daily Dose (DDD) and the expenditure incurred expressed in euros. Consequently, a grouping into three major drug categories has been performed: anti – tumor necrosis factor alpha agents (TNFα), other injectable formulations, and novel oral formulations. Results Prescriptions for the second half-year 2022 and 2023 have been analyzed, with a total cost of almost 7 million euros in the sample considered. All pharmaceutical categories showed an increase in consumption, but only anti- TNFα recorded a decrease in costs from 25% in 2022 to 22% in 2023, thanks to the lower cost of the biosimilar drug. Conclusion The costs of RA may represent a significant spending commitment for central governments. As a result, actions are needed to encourage the preferential use of biosimilar drugs.

Determinants of brain drain among physicians in Turkey: Findings from a national exploratory study.

The shortage of physicians in Turkey is a highly critical emergency. In fact, physicians' migration to developing or high-income countries, defined as brain drain, threatens the sustainability of the national healthcare system. This study explored the driving factors associated with Turkish Physicians' brain drain, including high-economic inflation, social-politics, poor-living, equity, violence, and the desire to practice medical activity abroad. A cross-sectional survey of 1,861 Turkish physicians aged 25 to 65 years old was conducted employing the Brain Drain questionnaire, the Depression Anxiety Stress Scale (DASS-21), the Patient Health Questionnaire 9 (PHQ-9), and the Fatigue Assessment Scale (FAS). Significant differences were observed among physicians staying in Turkey versus considering migration to Western countries, regarding their age, gender, marital status, educational level, occupational status, work years, hospital night shifts, income, and cigarette/nargileh smoking habits (all p ⩽ .018). The main reasons for brain drain included transport problems, harassment, low salary, malpractice, bad environment, job insecurity, workload, burnout, treating difficult patients, inadequate postgraduate systems, peer-pressure, health safety concerns, and favoritism in the workplace, as well as stress and depression caused by work overload. In fact, depression, anxiety, stress, fatigue, and burnout varied significantly among the different groups of physicians (all p ⩽ .013). Additionally, key predictors of brain drain were better job opportunities, poor hospital management (in Turkey), job-related stress, dealing with difficult patients, research deficiencies, workload, burnout, transportation issues, short consultation time, low salary, and fatigue. Among the general factors contributing to the brain drain in the Turkish Health System, we identified significant issues related to research deficiencies, compulsory working duties, poor quality of postgraduate, inadequate medical-schools, poor hospital management, and shortage of consultants. Physicians' migration is a major global public health concern, leading to substantial risks for healthcare services, especially in Turkey. Many physicians decide to migrate to work in Western countries.

Trends in and Predictors of Patient Pharmacogenomic Test Uptake in a National Healthcare System

Better understanding patient uptake of pharmacogenomic (PGx) testing may inform its implementation and maximize the benefits that such testing can confer. This study examined patient and provider factors associated with PGx test ordering in a national healthcare system where panel-based testing was implemented as part of routine care. We used a retrospective matched cohort design and data from the Veterans Health Administration Corporate Data Warehouse. A conditional logistic model was used to identify factors associated with a PGx order receipt and estimate odds ratios and 95% confidence intervals. The following patient factors predicted receipt of a PGx test order: younger age, married status, rural residence, non-Hispanic Black or Hispanic race/ethnicity, PGx educational mailer receipt, depression diagnosis, allergy to a drug on the panel, prescriptions for drugs on the panel, and specialty care visits (p<0.05). Additionally, patients whose providers were female, younger, a nurse practitioner/physician assistant or pharmacist, or participated in an educational mailer program were more likely to receive an order (p<0.05). This study highlights factors that may facilitate or hinder the widespread and equitable implementation of PGx testing in a large national healthcare system. The information is being used to further refine the program.

Evolving Concepts of Pain Management in Elderly Patients.

The elderly population typically suffer from a variety of diseases that mostly reflect the degenerative changes linked with the aging process. These diseases may be exacerbated by acute pain or by an abrupt aggravation of previously stable chronic pain. Physical and psychological changes associated with aging may influence one's experience of pain and, as a result, the severity of pain. Pain treatment in the elderly can be complex and is often a budgetary burden on the nation's health care system. These difficulties arise, in part, because of unanticipated pharmacodynamics, changed pharmacokinetics, and polypharmacy interactions. Therefore, it is critical to integrate a multidisciplinary team to develop a management strategy that incorporates medical, psychological, and surgical methods to control persistent pain conditions. It is in this critical process that pain prediction models can be of great use. The purpose of pain prediction models for the elderly is the use of mathematical models to predict the occurrence and intensity of pain and pain-related conditions. These mathematical models employ a vast quantity of data to ascertain the many risk factors for the development of pain problems in the elderly, whether said risks are adjustable or not. These models will pave the way for more informed medical decision making that are based on the findings of thousands of patients who have previously experienced the same illness and related pain conditions. However, future additional research needs to be undertaken to build prediction models that are not constrained by substantial legal or methodological limitations.

Key steps and barriers in the journey of patients with epilepsy through the National Healthcare System in Spain: The EPIPASS qualitative study.

Epilepsy requires continuous medical attention from multiple healthcare specialists, specialized facilities, and community-based care. In Spain, there is no standardized approach to epilepsy care. The aim of this study was to identify the factors impacting on the delivery of high-quality care by exploring key steps and barriers along the patient journey through the Spanish National Healthcare System (NHS). A qualitative study was conducted using opinions and experiences of neurologists, nurses, patients, and caregivers shared in discussion meetings. Using thematic content analyses, relevant aim-focused statements were coded according to prespecified issues in a discussion map (i.e., key steps and barriers), and sub-coded according to emerging issues. Thematic saturation and co-occurrence of key steps/barriers were evaluated to identify the most relevant factors impacting on the delivery of high-quality care. Sixty-five stakeholders took part in discussion meetings (36 neurologists, 10 nurses, 10 patients, and nine caregivers). Six key steps on the patient journey were identified: emergency care, diagnosis, drug therapy, follow-up, referral, and interventional treatment. Of these, follow-up was the most relevant step impacting on the delivery of high-quality patient care, followed by drug therapy and diagnosis. Emergency care was considered a hot-spot step with impact throughout the patient journey. Communication (among HCPs and between HCPs and patients) was a barrier to the delivery of high-quality care at several stages of the patient journey, including drug therapy, follow-up, referral, and interventional treatment. Resource availability was a barrier for diagnosis (especially for confirmation), drug therapy (drug availability), and referral (lack of professionals and specialized centers, and long waiting lists). This is the first study capturing perspectives of four key stakeholders involved in epilepsy care in Spain. We provide an overview of the patient journey through the Spanish NHS and highlight opportunities to improve the delivery of patient-centered care with a chronicity perspective. Patients with epilepsy may require prolonged medical care. In Spain, care is provided by a range of specialist and non-specialist centers. In this study, a team of Spanish neurologists, nurses, patients and caregivers identified barriers that affect the delivery of high-quality care for patients with epilepsy at each stage of their journey through the Spanish NHS. Specific epilepsy training for healthcare providers, appropriate resources for diagnosing and treating patients, and good communication between healthcare workers and patients were identified as important factors in providing high-quality care for patients with epilepsy.