Population Health System Research Articles

Regional variation of premature mortality in Ontario, Canada: a spatial analysis

BackgroundPremature mortality is a meaningful indicator of both population health and health system performance, which varies by geography in Ontario. We used the Local Health Integration Network (LHIN) sub-regions to conduct a spatial analysis of premature mortality, adjusting for key population-level demographic and behavioural characteristics.MethodsWe used linked vital statistics data to identify 163,920 adult premature deaths (deaths between ages 18 and 74) registered in Ontario between 2011 and 2015. We compared premature mortality rates, population demographics, and prevalence of health-relevant behaviours across 76 LHIN sub-regions. We used Bayesian hierarchical spatial models to quantify the contribution of these population characteristics to geographic disparities in premature mortality.ResultsLHIN sub-region premature mortality rates ranged from 1.7 to 6.6 deaths per 1000 per year in males and 1.2 to 4.8 deaths per 1000 per year in females. Regions with higher premature mortality had fewer immigrants and higher prevalence of material deprivation, excess body weight, inadequate fruit and vegetable consumption, sedentary behaviour, and ever-smoked status. Adjusting for all variables eliminated close to 90% of geographic variation in premature mortality, but did not fully explain the spatial pattern of premature mortality in Ontario.ConclusionsWe conducted the first spatial analysis of mortality in Ontario, revealing large geographic variations. We demonstrate that well-known risk factors explain most of the observed variation in premature mortality. The result emphasizes the importance of population health efforts to reduce the burden of well-known risk factors to reduce variation in premature mortality.

Prospects and Challenges of Population Health with Online and other Big Data in Africa: Understanding the Link to Improving Healthcare Service Delivery

Big data analytics offers promises to many health care service challenges and can provide answers to many population health issues. Big data is having a positive impact in almost every sphere of life in more advanced world while developing countries are striving to meet up. Even though healthcare systems in the developed world are recording some breakthroughs due to the application of big data, it is important to research the impact of big data in developing regions of the world, such as Africa and identify its peculiar needs. The purpose of this review was to summarize the challenges faced by big data analytics and the prospects that big data opens in health care services in Africa. The systematic review examined the key research questions to address whether big data applications can improve healthcare service delivery in Africa especially during epidemics or health crises and through the population health system. The paper examined prospects and challenges that are associated with the use of big data and healthcare service in relation to population health needs through influencing factors. In this study, literatures are reviewed to present cases of big data applications in healthcare in Africa and to understand the prospect and challenges of such applications to population health.

Population Health Systems: The Intersection of Care Delivery and Health Delivery.

Population Health Systems: The Intersection of Care Delivery and Health Delivery.

Assessing local chlamydia screening performance by combining survey and administrative data to account for differences in local population characteristics

Reducing health inequalities requires improved understanding of the causes of variation. Local-level variation reflects differences in local population characteristics and health system performance. Identifying low- and high-performing localities allows investigation into these differences. We used Multilevel Regression with Post-stratification (MRP) to synthesise data from multiple sources, using chlamydia testing as our example. We used national probability survey data to identify individual-level characteristics associated with chlamydia testing and combined this with local-level census data to calculate expected levels of testing in each local authority (LA) in England, allowing us to identify LAs where observed chlamydia testing rates were lower or higher than expected, given population characteristics. Taking account of multiple covariates, including age, sex, ethnicity, student and cohabiting status, 5.4% and 3.5% of LAs had testing rates higher than expected for 95% and 99% posterior credible intervals, respectively; 60.9% and 50.8% had rates lower than expected. Residual differences between observed and MRP expected values were smallest for LAs with large proportions of non-white ethnic populations. London boroughs that were markedly different from expected MRP values (≥90% posterior exceedance probability) had actively targeted risk groups. This type of synthesis allows more refined inferences to be made at small-area levels than previously feasible.

Potential Country-level Health and Cost Impacts of Legalizing Domestic Sale of Vaporized Nicotine Products.

The net impact on population health and health system costs of vaporized nicotine products is uncertain. We modeled, with uncertainty, the health and cost impacts of liberalizing the vaporized nicotine market for a high-income country, New Zealand (NZ). We used a multistate life-table model of 16 tobacco-related diseases to simulate lifetime quality-adjusted life-years (QALYs) and health system costs at a 0% discount rate. We incorporated transitions from never, former, and current smoker states to, and from, regularly using vaporized nicotine and literature estimates for relative risk of disease incidence for vaping compared with smoking. Compared with continuation of baseline trends in smoking uptake and cessation rates and negligible vaporized nicotine use, we projected liberalizing the market for these products to gain 236,000 QALYs (95% uncertainty interval [UI] = 27,000 to 457,000) and save NZ$3.4 billion (2011 NZ$) (95% UI = NZ$370 million to NZ$7.1 billion) or US$2.5 billion (2017 NZ$). However, estimates of net health gains for 0- to 14-year olds and 65+ year olds had 95% UIs including the null. Uncertainty around QALYs gained was mainly driven by uncertainty around the impact of vaporized nicotine products on population-wide cessation rates and the relative health risk of vaping compared with smoking. This modeling suggested that a fairly permissive regulatory environment around vaporized nicotine products achieves net health gain and cost savings, albeit with wide uncertainty. Our results suggest that optimal strategies will also be influenced by targeted smoking cessation advice, regulations around chemical constituents of these products, and marketing and age limits to prevent youth uptake of vaping.

Vision for a systems architecture to integrate and transform population health

Entities involved in population health often share a common mission while acting independently of one another and perhaps redundantly. Population health is in everybody’s interest, but nobody is really in charge of promoting it. Across governments, corporations, and frontline operations, lack of coordination, lack of resources, and lack of reliable, current information have often impeded the development of situation-awareness models and thus a broad operational integration for population health. These deficiencies may also affect the technical, organizational, policy, and legal arrangements for information sharing, a desired practice of high potential value in population health. In this article, we articulate a vision for a next-generation modeling effort to create a systems architecture for broadly integrating and visualizing strategies for advancing population health. This multipurpose systems architecture would enable different views, alerts, and scenarios to better prepare for and respond to potential degradations in population health. We draw inspiration from systems engineering and visualization tools currently in other uses, including monitoring the state of the economy (market performance), security (classified intelligence), energy (power generation), transportation (global air traffic control), environment (weather monitoring), jobs (labor market dynamics), manufacturing and supply chain (tracking of components, parts, subassemblies, and products), and democratic processes (election analytics). We envision the basic ingredients for a population health systems architecture and its visualization dashboards to eventually support proactive planning and joint action among constituents. We intend our ambitious vision to encourage the work needed for progress that the population deserves.

Learning health systems

Healthcare organizations have invested significant resources into integrating comprehensive electronic health record (EHR) systems into clinical care. EHRs digitize healthcare in ways that allow for repurposing of clinical information to support quality improvement, research, population health, and health system analytics. This has facilitated the development of Learning Health Systems. Learning health systems (LHS) merge healthcare delivery with research, data science, and quality improvement processes. The LHS cycle begins and ends with the clinician-patient interaction, and aspires to provide continuous improvements in quality, outcomes, and health care efficiency. Although, the health sector has been slow to embrace the LHS concept, innovative approaches for improving healthcare, such as a LHS, have shown that better outcomes can be achieved by engaging patients and physicians in communities committed to a common purpose. Here, we explore the mission of a pediatric LHS, such as PEDSnet, which is driven by the distinctive goals of a child's well-being. Its vision is to create a national LHS architecture in which all pediatric institutions can participate. While challenges still exist in the development and adoption of LHS, these challenges are being met with innovative strategies and strong collaborative relationships to reduce system uncertainty while improving patient outcomes.

The communicative constitution of population health systems

Introduction: Population health systems integrate services across multiple sectors. They are widely regarded as an effective approach for addressing challenges posed by an ageing population and the associated spread of chronic diseases. However, we still know little about how we can successfully implement such systems that typically span multiple levels and organizations. Thus, this study explores practices facilitating the implementation of population health systems. Theory and methods: We conducted a qualitative longitudinal single case study in collaboration with the Healthcare Center Lower Engadin, which is considered the hub of a pioneering population health system in Switzerland. Data collection included 35 semi-structured interviews, 96 participant observations, and 46 archival records and data analysis followed an abductive approach. After a first round of inductive coding, we realized how important communication was for the emergence and change of the system. In a second round, we consulted additional literature to develop richer theoretical explanations. Recent work suggesting that complex organizations are constituted primarily in and through communication turned out to be a particularly helpful analytical device. Inspired by this lens, we went back to our empirical data, this time coding for communicative practices facilitating and impeding the implementation of the system, understanding communicative practices as structuring patterns of interaction. Results: Drawing on the work of McPhee and Zaug, we found that the population health system in the Lower Engadin was implemented in and through four interrelated communicative practices. A first practice was membership negotiation, through which actors recruited and maintained a relationship with member organizations. A second practice was organizational self-structuring, through which actors created adequate decision and control (governance) structures. A third practice was activity coordination, through which actors coordinated health, social care, and administrative activities within and across the boundaries of member organizations. A final practice was institutional positioning, through which actors legitimized the formation and maintenance of the system among political decision-makers and the regional population. We describe how regional actors mobilized these four practices to re-organize the provision of health and social care in the Lower Engadin. Discussion and conclusions: Population health systems are widely regarded as a promising approach for addressing an increasingly fragmented value creation in health and social care. Previous research has already emphasized the pivotal role of communication for implementing such systems. Goodwin underlines the need of effective communication strategies to deliver clear communication messages to relevant stakeholders. With this study, we confirm this need and draw attention to four communicative practices actors may want to consider when planning their communication activities. These practices are important not only for delivering ready-made information, but also for the social construction of new meaning regarding innovative ways of coordinating health and social care across sectoral and organizational boundaries. Limitations and future research: This study is limited to one population health system in Switzerland. Further research is required to explore the four identified practices in more detail to understand their specifics and interrelationships and to explore to what extent other systems are constituted by similar or different communicative practices.

Collaboration between Local Public Health Units and Regional Health Authorities in Canada for Integrated Health System Planning Using a Population Health Approach: Research

Background : In the province of Ontario, Canada, public health has remained outside of regional health authority governance structures that are responsible for health care e.g., hospitals, long-term care, primary care, addiction services. Ontario’s Patients First Act 2016 requires public health units to work with regional health authorities [Local Health Integration Networks LHINs] towards integrated health services planning to meet the local community’s health needs using a population health approach. This provides a unique lens to explore strategies for these organizations to work collaboratively in health system planning to improve population health outcomes. The purpose of this study was to explore “What are the key elements for a successful collaboration between LHINs and Public Health Units, as directed by Patients First legislation, to achieve an improved health system in Ontario informed by a population health approach?” Methods : This mixed methods study engaged 68 participants in interviews and focus groups including board members, senior and middle management, and staff in LHINs, Public Health Units, government, relevant agencies, as well as key informants from other Canadian provinces. Broader input was gained through an online survey completed by over 300 Ontario respondents. Results: Local Health Integration Networks and Public Health Units recognize the importance of health system planning through a population health lens. Both already are working together in partnerships through leadership councils, working groups, and local program planning to measure, monitor, report, and share data to determine priority community needs. Clarifying expectations, shared accountability, and funding supports are critical for successful LHIN-Public Health Unit collaborations. Survey results point to key strategies and tools to overcome barriers and foster collaborations. Conclusions : The study provides insight into intrapersonal, interpersonal, organizational, and systemic factors that promote successful LHIN-Public Health Unit collaboration. It prioritizes categories of population health and health system data, indicators, and information that could potentially strengthen collaborations and offer solutions to overcome LHIN-Public Health Unit collaboration barriers. Lessons Learned : With expanding roles and responsibilities of regional health authorities and public health’s growing need to address population health issues, this research informs strategies for these organizations to effectively conduct integrated program planning to best meet the unique needs of their local populations. This work can be applied to similar jurisdictions charged with collaborating towards integrated population health system planning. Limitations : Although our sampling for the qualitative interviews attempted to reach all jurisdictions across the province, we could not achieve representation from all 36 public health units and 14 Local Health Integration Networks. The quantitative survey helped to address this limitation. Suggestions for future research : Future research should include in-depth case studies of successful collaborations between public health organizations and regional health authorities charged with health care planning to identify factors influencing success as well as measurement of population health impacts of integrated planning.

Population Health Management: Are Existing Tools Fit for Purpose?

Background : As part of the global move towards value-based care, many health systems are experimenting with new forms of population health management. Population health management assumes an organization taking over responsibility to assess the needs of a population in, while identifying groups of patients at risk that might benefit from an intervention to alter the natural cause of their disease. Population health management also often provides aggregate or provider specific performance data to track performance and identify opportunities to improve clinical and financial outcomes Groene, Pimperl & Hildebrandt 2017. Historically, data utilised for population health management has been dispersed at a range of institutions, such as GP practices, hospitals, municipalities, registries or statistical offices. Furthermore, data has mostly been limited to administrative data data collected for billing purposes. The linkage of health care data to other data sources, such as demographic or census data has been an exception Chadwick, Varagunam & Groene 2015. With health systems increasingly focusing on population health management, commercial providers have developed a suite of tools that aim to extract data from a range of sources, link them in a data warehouse, apply tools for patient segmentation and construct performance dashboards to guide population health management. Aim : We will a describe reporting requirements for population health management such as CMS indicators for Accountable Care Organizations, b compare the data sources, functionality and indicators included in existing population health management tools and c map these on established frameworks of population health and health system performance. After an input presentation covering these aims, we will d engage a panel of three experts to discuss the implication of the work. Initial findings : Our initial findings suggest that existing tools for population health management are underutilized in many health systems. USA based Accountable Care Systems have to report on a minimum set of performance indicators, thus driving IT providers to produce appropriate tools. Elsewhere, in absence of similar standardized requirements, a more heterogeneous approach to assessing and managing population health can be observed. Second, population health management suites represent a rather wide range of services, from simple reporting tools, over business intelligence including patient segmentation tools and predictive modelling, to tools that provide nudges to improve individual patients´ care management. Third, and more importantly, the mapping of existing population health management tools on OECD and WHO frameworks suggests that they are insufficient to address to wider determinants of population health. Rather, existing tools are naturally build around formal reporting requirements and limited to well-established disease-focused care programmes. Implications : With the increasing focus on rewarding the value of service delivery health systems need to apply population health management tools much more coherently than in the past. Various IT providers have prepared tools with compelling functionality, however, existing tools still map poorly on the conceptual frameworks of population health as proposed by OECD and WHO. The presentation will outline which steps are required to ensure that future upgrades address the determinants of population health in a more consistent manner.

“Joining up the dots”: Integrated care as an element of the Andalusian public health strategy

Introduction: “The notion of integrated care has begun to recognise the need to take a more population-oriented approach to promote public health, prevent ill-health and secure wellbeing for populations. Yet, for the most part, public health has remained somewhat separate to the planning and purchasing of health and social care services and, as a result, public health interventions have often tended to operate in separate silos to traditional care provision” Goodwin and Ferrer 2017. Hence, there have been calls for those involved in integrated care and public health to 'join up the dots' Alderwick et al., 2015. Description of policy context and objective: The Autonomous Community of Andalucia is widely recognised for having led the public health agenda in Spain, having embraced over time the “Health in all policies” through different policies and interventions, aiming at reducing health disparities and promoting health assets IV Health Plan, 2014. This agenda has crystallised into transformative interventions such as the Local Health Action Network Red de Accion Local en Salud, RELAS - which promotes the development of local public health plans under the leadership of local authorities – or the Strategy to support people suffering from high adversity situations RED AL LADO, that redefines care pathways by working with care professionals, patient associations and the community. The notion and goal of care coordination and health and social care collaboration has been debated in Andalucia since the 1980s, frequently intertwining with the public health agenda. Many policies, strategies and interventions had been developed within the integrated care objective: actually, there is a long list of integrated care interventions from Andalusia registered as best practices at the Spanish Observatory on Integrated Care OMIS. However, these efforts had not translated into formal coordination structures or been framed into the wider public health strategy. Highlights: In 2017, the Andalusian Health Department has started the formulation of an integrated care framework that latches onto its broader public health agenda. The framework builds upon the contributions and initiatives that have been developed over the years, including the development and adoption of integrated clinical pathways procesos asistenciales integrados, the expansion of the role of nursing care managers, the production of different narratives for person-centred coordinated care see, for example, the 2002 PAI Ataque Cerebrovascular or the integrated health information systems. The presentation will describe the ongoing initiative, which includes the development of the bases for the Andalusian integrated care model and a person-centred integrated care narrative through collaborative and inclusive processes. Conclusions: At the time of the ICIC18, a local pilot will be launched, so the authors hope to be able to present preliminary insights of progress, challenges and strategies being developed.

A Population Health Approach: Addressing equity and social determinants of health in Canadian healthcare

Introduction: Currently, there is limited knowledge about operationally feasible strategies that help link the provision of integrated care with the population health approach1,2. The scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between public health, health care and social care1,3. This broader focus for integrated health care would enable health systems to address the social determinants of health SDOH of populations4. Using results from an ongoing multi-case study investigating implementation of population health approach in Canada and abroad, we will present an analysis of strategies used by select Canadian primary care and speciality care organizations that have taken on the population health approach and link the provision of integrated care, and successfully tackle issues of inequity and the SDOHs. Methods: In this multi-case study we use field visits, interviews, document analysis and other resources to identify key strategies, barriers and enablers to implementation of the population health approach. Population health experts and health planners nominated potential cases that were then assessed against the criteria that identify population health systems. Integrated knowledge translation has been incorporated to link knowledge users and academic researchers throughout the study. The study draws on the expanded chronic care model, socio-ecological model and equity lenses. Expected results: The study will identify and provide evidence about the effectiveness of specific strategies, including creative approaches and innovations that help routinely screen for the SDOHs and integrate social supports into delivery of care. We will map out strategic partnerships and inter-sectoral collaborations designed to support integrated delivery of health promotion and disease prevention, health care services and social care. Discussion/conclusion: This study will contribute to the knowledge about the planning and implementation of population-based integrated systems of care that successfully address a range of SDOH. Findings may help inform relevant policy and strategy and are directly relevant to ICIC 2018 theme "Population Health Management", sub-themes: Tackling inequalities and the social determinants of health, Improving population health outcomes and Strategy development, partnerships & leadership. Potential suggestions for future research: As the population health approach is adopted across the continuum of care, future research needs to facilitate the spread and scale up of integrated care in the context of population health.

A Population Health Approach: Addressing equity and social determinants of health in Canadian healthcare

Introduction: Currently, there is limited knowledge about operationally feasible strategies that help link the provision of integrated care with the population health approach1,2. The scope of integrated care needs to be expanded to bridge the gaps not only within the health system, but also between public health, health care and social care1,3. This broader focus for integrated health care would enable health systems to address the social determinants of health SDOH of populations4. Using results from an ongoing multi-case study investigating implementation of population health approach in Canada and abroad, we will present an analysis of strategies used by select Canadian primary care and speciality care organizations that have taken on the population health approach and link the provision of integrated care, and successfully tackle issues of inequity and the SDOHs. Methods: In this multi-case study we use field visits, interviews, document analysis and other resources to identify key strategies, barriers and enablers to implementation of the population health approach. health experts and health planners nominated potential cases that were then assessed against the criteria that identify population health systems. Integrated knowledge translation has been incorporated to link knowledge users and academic researchers throughout the study. The study draws on the expanded chronic care model, socio-ecological model and equity lenses. Expected results: The study will identify and provide evidence about the effectiveness of specific strategies, including creative approaches and innovations that help routinely screen for the SDOHs and integrate social supports into delivery of care. We will map out strategic partnerships and inter-sectoral collaborations designed to support integrated delivery of health promotion and disease prevention, health care services and social care. Discussion/conclusion: This study will contribute to the knowledge about the planning and implementation of population-based integrated systems of care that successfully address a range of SDOH. Findings may help inform relevant policy and strategy and are directly relevant to ICIC 2018 theme Population Health Management, sub-themes: Tackling inequalities and the social determinants of health, Improving population health outcomes and Strategy development, partnerships & leadership. Potential suggestions for future research: As the population health approach is adopted across the continuum of care, future research needs to facilitate the spread and scale up of integrated care in the context of population health.

Potential impact of influenza vaccine roll-out on antibiotic use in Africa.

BackgroundInfluenza infections result in both inappropriate and appropriate antibiotic prescribing. There is a huge burden of both influenza and infections caused by antimicrobial-resistant pathogens in Africa. Influenza vaccines have the potential to reduce appropriate antibiotic use, through reduction of secondary bacterial infections, as well as to reduce levels of influenza misdiagnosed and treated as a bacterial infection (inappropriate).ObjectivesTo estimate potential reductions in antibiotic use that are achievable by introducing an influenza vaccine into various African settings.MethodsInfluenza incidence was combined with population size, vaccine and health system characteristics.ResultsWe estimated that the direct impact of vaccination could avert more than 390 prescriptions per 100 000 population per year if a 50% efficacious influenza vaccine at 30% coverage was introduced to adults >65 years old in South Africa or children 2–5 years old in Senegal. Across Africa, purely through reducing the number of severe acute respiratory infections, the same vaccine characteristics could avert at least 24 000 antibiotic prescriptions per year if given to children <5 years old.ConclusionsThe introduction of an influenza vaccine into multiple African settings could have a dramatic indirect impact on antibiotic usage. Our values are limited underestimates, capturing only the direct impact of vaccination in a few settings and risk groups. This is owing to the huge lack of epidemiological information on antibiotic use and influenza in Africa. However, it is likely that influenza vaccination in Africa could substantially impact antibiotic usage in addition to influenza-related mortality and morbidity.

Elements of integrated care approaches for older people: a review of reviews

ObjectiveThe World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge...

Climate Change and Health under the Shared Socioeconomic Pathway Framework.

A growing body of literature addresses how climate change is likely to have substantial and generally adverse effects on population health and health systems around the world. These effects are likely to vary within and between countries and, importantly, will vary depending on different socioeconomic development patterns. Transitioning to a more resilient and sustainable world to prepare for and manage the effects of climate change is likely to result in better health outcomes. Sustained fossil fuel development will likely result in continued high burdens of preventable conditions, such as undernutrition, malaria, and diarrheal diseases. Using a new set of socioeconomic development trajectories, the Shared Socioeconomic Pathways (SSPs), along with the World Health Organization’s Operational Framework for Building Climate Resilient Health Systems, we extend existing storylines to illustrate how various aspects of health systems are likely to be affected under each SSP. We also discuss the implications of our findings on how the burden of mortality and the achievement of health-related Sustainable Development Goal targets are likely to vary under different SSPs.

Generalizability of Indicators from the New York City Macroscope Electronic Health Record Surveillance System to Systems Based on Other EHR Platforms.

Introduction:The New York City (NYC) Macroscope is an electronic health record (EHR) surveillance system based on a distributed network of primary care records from the Hub Population Health System. In a previous 3-part series published in eGEMS, we reported the validity of health indicators from the NYC Macroscope; however, questions remained regarding their generalizability to other EHR surveillance systems.Methods:We abstracted primary care chart data from more than 20 EHR software systems for 142 participants of the 2013–14 NYC Health and Nutrition Examination Survey who did not contribute data to the NYC Macroscope. We then computed the sensitivity and specificity for indicators, comparing data abstracted from EHRs with survey data.Results:Obesity and diabetes indicators had moderate to high sensitivity (0.81–0.96) and high specificity (0.94–0.98). Smoking status and hypertension indicators had moderate sensitivity (0.78–0.90) and moderate to high specificity (0.88–0.98); sensitivity improved when the sample was restricted to records from providers who attested to Stage 1 Meaningful Use. Hyperlipidemia indicators had moderate sensitivity (≥0.72) and low specificity (≤0.59), with minimal changes when restricting to Stage 1 Meaningful Use.Discussion:Indicators for obesity and diabetes used in the NYC Macroscope can be adapted to other EHR surveillance systems with minimal validation. However, additional validation of smoking status and hypertension indicators is recommended and further development of hyperlipidemia indicators is needed.Conclusion:Our findings suggest that many of the EHR-based surveillance indicators developed and validated for the NYC Macroscope are generalizable for use in other EHR surveillance systems.

Correlates of maternal mortality in developing countries: an ecological study in 82 countries

BackgroundMaternal mortality is a major public health issue in developing countries due to its shocking magnitude and lower declining pattern. With appropriate strategy and intensive implementation programs, some countries have made remarkable progress, however in developing countries where 99% of maternal death is occurring; little or no progress has been made. Identifying determinants and designing intervention will have important role to overcome the problem. Therefore this study aimed to identify correlates of maternal mortality in developing countries.MethodsThis study was conducted using international data bases of health metrics from 2008 to 2016 using aggregates of health indicator data from WHO, World Bank, UNDP and UNICEF data bases for 82 developing countries. The dependent variable was the maternal mortality ratio, while the independent variable was socio-economic, health care related and morbidity variables. Data was compiled in excel and analyzed using SPSS version 21.ResultsMaternal mortality ratio is very high in developing countries and enormously varies among countries. A significant relationship between the maternal mortality ratio and socio-economic, health care and morbidity indicator variables was observed. There was an inverse and significant correlation of the maternal mortality ratio with Antenatal care coverage, skilled birth attendance, access to an improved water source and sanitation, adult literacy rate, the Gross National Income per capita and positive relation with disease incidence, unmet need and others.ConclusionsMaternal mortality is correlated with multiples of socio-economic factors, health care system associated factors, disease burden and their complex interactions. Therefore Policy and programs targeted to improve maternal health and reduce maternal deaths should consider population dynamics, socio-economic influence and health system factors that impose a major risk on mothers.

Post-graduate medical education in public health: the case of Italy and a call for action

SummaryPublic health technical expertise is of crucial importance to inform decision makers’ action in the field of health and its broader determinants. Improving education and training of public health professionals for both practice and research is the starting point to strengthen the role of public health so that current health challenges can be efficiently tackled. At the Association of Schools of Public Health in the European Region (ASPHER) Deans’ & Directors’ 2017 Annual Retreat, we presented the structure and management of public health training system in Italy, and we reported recent data on Italian public health specialists’ educational experience, employment opportunities and job satisfaction. Public health training in Italy is implemented in the context of the post-graduate medical education residency programme in Hygiene and Preventive Medicine, delivered by 34 University-based Schools of Public Health. We report relatively high employment rates across the county and wide spectrum of career opportunities for young public health specialists. However, job security is low and training expectations only partially met. We call upon other Schools of Public Health to scale up the survey within the broad ASPHER community in a shared and coordinated action of systematically collecting useful data that can inform the development of public health education and training models, their implementation and fruitful interaction with population health, health systems and services.

Cost-effectiveness of an Integrated Care Home Support Service in Oxfordshire, England

Background: Multi-morbidity is an increasing threat to population health and healthcare systems. A high proportion of people living in care homes have dementia, mental illness and/or physical frailty. Thus, this population has high and complex care needs, which require substantial healthcare expenditure. Intervention: An Integrated Care Home Support Service (CHSS) in Oxfordshire, England, combined two evidence based approaches to deliver a stepped care and treatment to meet both physical and mental health needs, called the BRIghTER DAWN programme. These evidenced based approaches trained staff to deliver Dementia Assessment of Wellbeing and Needs (DAWN) and/or a personalised intervention focusing on Building Relationships and Individually Tailored Evaluation and Responses (BRIghTER). Methods: Different data sources and methods were combined in this observational study to perform an economic evaluation of the CHSS. Individual patient data (IPD) on two-year community care utilisation and time alive since admission to a care home were used to calculate community care costs and Life Years (LYs) per patient. Mahalanobis one-to-one propensity score matching (PSM) was used to match 443 residents who received DAWN and/or BrighTER with residents from a control cohort of 5,339 residents with respect to community care costs at baseline, date admitted to a care home, date of birth, mental health cluster codes, gender, and care home. Multiple imputation by predictive mean matching was used to impute missing observations in community care cost at baseline. To reduce remaining confounding, 5,000 bootstrapped samples were generated from the paired dataset and for each one, Generalised Linear Models were specified to estimate incremental community care costs and incremental Lys adjusting for confounders. Difference-in-differences analysis supplemented with inverse probability weighting for propensity score matching was performed to estimate incremental non-elective hospital costs based. A decision model was built to combine the incremental costs and effects from the two different analyses to estimate costs per LY gained and to perform probabilistic sensitivity analysis. Uncertainty was displayed in cost-effectiveness acceptability curves. Results: The CHSS resulted to £575 higher costs and 0.04 more Lys than usual care resulting to an ICER of £13,886, which is considered to be cost-effective under conventional NICE thresholds (i.e. £20,000-£30,000). Looking at the interventions separately, DAWN was even more cost-effective (ICER=£2,081), while DAWN was less cost-effective (ICER=14,837) but still under NICE’s threshold. The probability of the interventions to be cost-effective at £20.000 ceiling ration was more than 80%. Discussion: This study demonstrated a series of methods to be used by health economists when dealing with Murphy’s law in the economic evaluation of complex interventions. Conclusion: The Integrated Care Home Support Service implemented in Oxfordshire was very likely to be cost-effective. Lessons learned: Evidence-based, integrated, and in-reach care home services improve health outcomes at reasonable costs. These value-for-money interventions can improve efficiency in elderly care and meet the complex needs of an rapidly increasing part of the population. Limitations: The impact of the CHSS on quality of life is not included in the economic evaluation. Suggestions for future research: Investigate whether the cost-effectiveness results are sustainable in time and replicable in other settings.