Provision Of Services Research Articles

340B Participation and Safety Net Engagement Among Federally Qualified Health Centers

The 340B program provides discounts on outpatient drugs to certain hospitals and federally supported clinics (covered entities) that can be used to generate revenue to fund safety net care. While numerous studies have found no association between 340B and safety net care provision for most hospital covered entities, less is known about whether federally qualified health centers (FQHCs), the largest group of covered entities after hospitals, use the program to enhance safety net care. To assess whether a proxy for 340B revenue was associated with increased safety net care provision among FQHCs. This descriptive, retrospective cohort study examined care provided from 2005 to 2022 by 1468 FQHCs that submitted to the Health Resources and Services Administration Uniform Data System. FQHC and year-level fixed effects were included, as well as a control for differential Medicaid expansion over time. The data were analyzed between March and December 2023. One-year lagged number of locations registered to dispense or administer 340B-discounted drugs (registered locations), which included child sites, in-house pharmacies, and contract pharmacies in the 340B Outpatient Pharmacy Affairs Database. Natural logarithm of patient volume by payer, low-income status, and use of enabling services. Natural logarithm of visits in which low-profit preventive services were provided. An additional registered location was associated with increased patient volume, especially for uninsured (0.4%; 95% CI, 0.3%-0.5%) and privately insured (0.4%; 95% CI, 0.2%-0.5%) patients and low-income (0.4%; 95% CI, 0.2%-0.6%), unhoused (0.3%; 95% CI, 0.1%-0.5%), and non-English-speaking (0.3%; 95% CI, 0.1%-0.5%) patients. An additional registered location was associated with increased visits with an HIV test (0.7%; 95% CI, 0.4%-0.9%), serum lead test (0.8%; 95% CI, 0.6%-1.1%), seasonal influenza shot (0.4%; 95% CI, 0.3%-0.5%), Papanicolaou smear (0.5%; 95% CI, 0.4%-0.7%), and tobacco cessation counseling (1.0%; 95% CI, 0.5%-1.4%). Across the study period, the average annual increase in locations was 1.5. The results of this cohort study suggest that there are statistically significant increases in the provision of low-profit but high-value preventive services and care to safety net populations (those who lack insurance, have a low income, or require enabling services) and that, like public hospitals, FQHCs might use 340B revenues to enhance safety net care. This finding may inform debates on the 340B program by supporting differential 340B reforms across hospital and nonhospital covered entities.

Social inclusion gone wrong: the divisive implementation of the Temporary Protection Directive in Ireland

There were 96,338 Personal Public Service Numbers (PPSNs) given to people from Ukraine who arrived in Ireland under the Temporary Protection Directive (TPD) before October 2023. From the end of 2022 into 2023, there was also a rapid rise of far-right anti-refugee rhetoric in Ireland. We analysed how TPD policy, the Irish political discourse around it and its implementation through national institutions and local communities affected TPD beneficiaries and other groups in Ireland. This study used a combination of qualitative analysis of a governmental debate on the housing needs of TPD beneficiaries and ethnographic observations gathered while the authors worked to support the needs of TPD beneficiaries. We provide an explanation of how the TPD implementation in Ireland resulted in the social exclusion of its beneficiaries despite aiming for streamlined integration. In addition, the shortcomings in the TPD implementation had negative effects on different groups within Irish society. We use the 3N model—Narratives, Networks, and Needs to explain how the data and trends that we documented at different levels of analysis—national, intergroup and intragroup, and individual—were interconnected. This paper is focused on the first of the three studies in the ongoing research project and primarily addresses the Narratives (i.e., policy and its implementation, political discourse) while connecting them with some observed social inclusion/exclusion outcomes on the Networks and Needs dimensions. We explain how political Narratives influenced TPD implementation and the different actors involved in this process: public service providers, the general public, and TPD beneficiaries in Ireland. The uncoordinated implementation of accommodation provision led to serious disruptions of TPD beneficiaries' Networks. This hindered individuals' access to services which resulted in individual Needs remaining unmet. We also documented how racialised elements underlying the EU TPD contributed to exclusionary mechanisms within the TPD implementation in Ireland and how that created a double standard in service provision.

Why mobile phone matters: The role of ICT in promoting farmers’ access to agricultural information and extension services in a tea outgrowing scheme in Tanzania

This article explores the role and effects of mobile phone technologies in ensuring farmers’ access to agricultural information and extension services in a tea outgrowing scheme in Tanzania. Semi-structured interviews, Focus Group Discussions, and Key Informant Interviews were employed to collect the information. The study revealed that the rapid infiltration of mobile phone technologies into Tanzania's rural areas since the late 2000s has simplified the provision of agricultural extension services. Both farmers and extension service workers perceive mobile phone technologies as an essential supplementary mechanism to ensure easy and timely access to agricultural information. In the context of a tea outgrowing scheme, farmers use mobile phone technologies to access information on input distribution, tea collection time, farmers’ meetings, and how to address some agricultural-related challenges independently. Extension service officers also rely on mobile phone technologies for sensitization. The study highlights the importance of complementing traditional and modern extension service mechanisms to ensure farmers’ efficient and timely access to agricultural extension services and information. Mobile phone affordability and its use cost are also a concern when considering improving agricultural extension service mechanisms.

Optimalisasi Partisipasi Anggota Koperasi Mahasiswa Melalui Digitalisasi Layanan Serta Potensi Pengembangan Bisnisnya

The demand to transform conventional systems into ones that utilize digital platforms is inevitable. Digital transformation is crucial, especially in the customer service sector, to facilitate transactions for consumers. The opportunity to undertake digital transformation within cooperatives is wide open due to the rapid technological advancements today. The specific objective of this research is to understand how the digitalization of services conducted by student cooperatives contributes to enhancing member participation, and also to identify the potential for the development of student cooperative businesses. This research is conducted at the Student Cooperative of Economics Education in Kendari City, Southeast Sulawesi. Informants for this study consist of cooperative advisors, management members, cooperative members, and alumni who were members of the cooperative. Data collection for this research was obtained through three methods: observation of the research location, interviews with the informants, and literature review. Data reduction, data presentation, and drawing conclusions are the methods used to analyze the qualitative data obtained from interview results. The research findings reveal that the student cooperative management has taken initiatives to optimize member participation, such as developing the "KopmaKu" application, attempting collaboration with third-party cooperative application developers, and working towards implementing Quick Response Code Indonesian Standard (QRIS) as a payment system. Student cooperative business units have significant potential to provide benefits and opportunities for alumni. These cooperatives serve not only as places for purchasing essential items, but also as platforms for collaboration, empowerment, and connections between students and alumni. The student cooperative business units can serve as a strong bridge between students and alumni. Alumni can collaborate with students in various aspects, including the provision of products or services, training, and even funding.

Strengthening nutrition policy and service delivery: Lessons learned from a six-country assessment of Alive and Thrive's technical assistance.

Alive & Thrive (A&T) provides strategic technical assistance (TA) to develop effective policies; improve maternal, infant, and young child nutrition (MIYCN) programme design and implementationand enhance system capacity to sustain quality MIYCN service delivery at scale. A qualitative assessment was conducted using document review and stakeholder interviews (n = 79) to describe a selection of A&T's TA in six countries and systematically assess the contextual and TA process-related factors that influenced the results achieved and document the lessons learned about MIYCN TA design and implementation. To facilitate the selection of different types of TA, we classified TA into two levels of stakeholder engagement and intensity. Under the Technical Advisor TA category, we assessed A&T's support to strengthen national policy formulation, monitoring, and implementation of the International Code of Marketing of Breast-milk Substitutes. For Capacity Development TA, we assessed A&T support to scale-up maternal nutrition services and to increase strategic use of data. Factors important for TA provision included identifying and engaging with the right people, using evidence to support advocacy and decision-making, using multiple ways to strengthen capacity, developing packages of tools to support programme scale-up, and reinforcing feedback mechanisms to improve service provision and data quality. Challenges included shifts in the political context, poorly functioning health systems, and limited resources to replicate or sustain the progress made. Continued investment in evidence-based and practical TA that strengthens the institutionalization of nutrition across all stakeholders-including government, medical associations, civil societyand development partners-is essential. Future TA must support governments to strengthen system capacity for nutrition, including financial and human resource gaps that hamper full scale-up.

Experience of integrating lean technologies into the quality management system of a medical organization providing primary medical and sanitary care

Objective. To evaluate the effectiveness of implementation of lean production methods into the practical activity of primary health care on the example of the State Institution of Health Care «Saratov City Polycli nic № 2». Materials and methods. The study was divided into three stages: data collection through anonymous sociological surveys using phones or tablets, timing and improvement of the process, and a follow-up questioning of participants to assess their satisfaction. 296 residents of Saratov receiving primary health care at the polyclinic took part in the survey. The survey was conducted using a specially developed electronic questionnaire via Google Form. For mathematical processing, the results of the study were initially transferred into an electronic database; the results of the study were analyzed using the descriptive statistics method. Results. According to the survey, the majority of respondents are satisfied with the quality of outpatient medical care. This shows that organization of the medical care is focused on the patients` needs and desire to meet their demands. The organization of the front office and the premises of the polyclinic in accordance with the requirements for the new model of the organization providing primary medical care made it possible to achieve a high evaluation of the information stands and the waiting area. The study showed that ineffective organization of the registry office contributed significantly to the patients` low assessment. In our opinion, in order to solve the problem, it is necessary to optimize the work of the registry office by introducing modern technologies and equal distribution of duties among the employees. Conclusions. In order to improve the quality and accessibility of medical services, it is necessary to make certain changes in the organization of medical care. The level of patient satisfaction with the work of medical institutions may depend on various factors, such as waiting time for a doctor, the timing of medical services provision after the appointment, the availability of necessary diagnostic tests and specialists.

A-183 Examination of the Roles and Responsibilities of Clinical Chemists as Determined by an International Peer Response-Based Survey

Abstract Background Doctoral-level clinical chemists (also termed clinical biochemists) have unique, broad roles in laboratory medicine spanning numerous clinical specialties. However, the full scope of responsibilities for a clinical chemist is not well understood, and institutional recognition and support varies. We sought to better understand the roles and responsibilities of practicing clinical chemists through distribution of an online survey designed to examine work-related responsibilities and other key factors related to job satisfaction. Survey results demonstrate the value of clinical chemists and can be used to promote parity within the profession. Methods Survey data was collected for 5 weeks from 10/10/2022-11/14/2022. The survey was targeted towards individuals holding doctoral level degrees (MD, PhD or MD/PhD), and consisted of 41 questions related to demographics, compensation, duties/responsibilities, and institutional support. Data analysis focused on responses from full-time clinical chemists located in the US and Canada (n=223/298 total respondents). Results Survey responses included male (n=109) and female (n=109) clinicians from all career stages (early <10y, n=101; mid 10-20y, n=63; late >20y, n=59). Clinical chemistry was the primary specialty reported (69%), followed by clinical pathology (16%), with 55% of responses reporting more than one specialty of practice, most often toxicology (21%). Multiple institution types (academic, community, reference laboratory, other) and academic career tracks (clinical, education, research, other) were represented; Most respondents were based in an academic hospital laboratory (n=131/223). Self-reported daily working hours varied by gender, years in practice, job duties and institutional setting; Females reported working more hours than males, working hours increased with years in practice, and the academic hospital setting reported the longest working hours, as did those on an ‘Education’ track. Responsibilities were quantified based on time spent per week; Clinical service represented the greatest time spent per week (majority result, 20-40h/week), followed by administrative (1-20h/week), research (<1-10h/week), teaching (<1-10h/week) and CE (<1-10h/week) duties. Support for clinical responsibilities was assessed further; 69% of respondents felt they had adequate time to perform clinical responsibilities, 55% reported access to adequate resources to perform clinical responsibilities and 51% reported feeling ‘Moderately’ or ‘Very’ stressed by clinical workload assignment. Top reasons for feeling overwhelmed included ‘Understaffing or inadequate support staff’ (n=113 responses), ‘Increased volume of work or caseload’ (n=73 responses) and ‘Lack of IT support to make necessary changes/improvements’ (n=70 responses). Resource quality was individually rated; Medical technologists, research technologists/scientists, LIS support and research support received a ‘Less than adequate’ rating by the majority of respondents, while compensation, administrative support and equipment received majority ‘Adequate’ ratings. Conclusions Clinical chemists work in a wide range of healthcare settings with unique career tracks, although the majority of work hours are devoted to provision of clinical service regardless of role definition. Most or all prioritize clinical work due to limited resources, which can limit research time and academic contributions. Clinical responsibilities are tied to feelings of stress and overwhelm in more than half of the survey population and could be reduced with improved quality and/or quantity of staff support.

Demographics and scope of Australian emergency department physiotherapists

QuestionsTo provide workforce data on the status of Australian Emergency Department (ED) physiotherapy practice, including physiotherapist demographic data, staffing levels and funding sources. Evaluate the scope of practice currently undertaken by ED physiotherapists and alignment of ED physiotherapy service provision with demand levels.DesignCross sectional survey.ParticipantsAustralian physiotherapists working within an Australian ED.Outcome measuresWorkforce data, scope of practice and alignment of physiotherapy service provision to ED presentations and demand.Results94 Australian ED physiotherapists completed the survey, 76.9% were working as primary contact clinicians. They had a diverse scope of practice, 100% perform mobility assessments, 89.9% provide care for paediatric patients and 10.1% were involved in administration of medications. 86.2% of participants (75/87) reported working within a service model that provided seven-day per week physiotherapy coverage to ED.ConclusionThe sample of ED physiotherapists were found to be experienced and highly trained clinicians with a diverse scope of practice, who are well placed to meet the unpredictable and highly variable patient caseload of Australian EDs.

Gun violence exposure and population health inequality: a conceptual framework

This essay establishes a conceptual framework to understand how direct, secondar and community exposures to gun violence converge to influence population health. Our framework asserts that persistent gun violence in...

School psychology in Italy: A mixed-method study of actual and desired roles and functions

Investigating the scope of international school psychology practices may promote and influence the globalization of the profession. Although some extant studies assessed the presence and functions of school psychologists internationally, little research to date has focused on Italy. This nation-wide study provides up-to-date information about how psychological services are provided in Italian schools, what services are rendered, what populations and issues are addressed, and analyzes discrepancies between existing and desired situations. Data from the concurrent triangulation (simultaneous) mixed-method research consisted of results from an online survey of 565 Italian psychological service-providers who work in schools and 33 key informants’ interviews (i.e., school psychologists, regional /national board representatives, stakeholders’ key representatives, policymakers). Results indicated that, in the provision of school psychological services in Italy, individual counseling to students is predominant and school-based psychological helpdesk is the most common form of provision of psychological services. However, the desired service delivery model differs substantially from the reality. Implications for the development of school psychology in Italy, in terms of promoting policy design and providing more structured psychological services in schools, are described.

Health Status of People Who Are and Are Not Experiencing Homelessness: Opportunities for Improvement

This study assessed the physical and psychological health parameters of adults experiencing homelessness to inform the development and delivery of health services by comparing with a housed population in the same South Australian city. Adults experiencing homelessness, known to existing support services, were invited to participate in a comprehensive assessment of their physical and mental health using questionnaires and objective assessments. Descriptive analyses using the percentage of participants failing to attain recommended published thresholds and accumulated health deficits for 16 health assessments were compared for the young group of people experiencing homelessness (18–40 years), the middle aged and older people experiencing homelessness (40–75 years), and a housed population of the middle aged and older people (40–75 years). Those experiencing homelessness had multiple and potentially inter-related health deficits compared with a population of people not experiencing homelessness in the same city. They were significantly less likely to meet healthy population norms for clinical frailty (p < 0.001), psychological distress (p < 0.001), grip strength (p < 0.001), lung function (p < 0.001), sleep quality (p < 0.001), and pelvic floor bother (p = 0.002). Significantly more accumulated health deficits were found for people experiencing homelessness when compared with the same ages for those who were not (mean 6.5 (SD 2.4) compared with 5.0 (SD 2.1)). This considerably increased for people experiencing homelessness aged less than 40 years (mean 8.7 (1.7)). Priorities for health service provision for people of different ages experiencing homelessness, when compared with housed community dwellers, have been described. The provision of targeted health assessments and service provision that specifically address healthcare needs among people experiencing homelessness are likely to have the biggest impacts across multiple health domains.

Impact of the COVID-19 pandemic on health-care use among patients with cancer in England, UK: a comprehensive phase-by-phase time-series analysis across attendance types for 38 cancers

The COVID-19 pandemic resulted in the widespread disruption of cancer health provision services across the entirety of the cancer care pathway in the UK, from screening to treatment. The potential long-term health implications, including increased mortality for individuals who missed diagnoses or appointments, are concerning. However, the precise impact of lockdown policies on national cancer health service provision across diagnostic groups is understudied. We aimed to systematically evaluate changes in patterns of attendance for groups of individuals diagnosed with cancer, including the changes in attendance volume and consultation rates, stratified by both time-based exposures and by patient-based exposures and to better understand the impact of such changes on cancer-specific mortality. In this retrospective, cross-sectional, phase-by-phase time-series analysis, by using primary care records linked to hospitals and the death registry from Jan 1, 1998, to June 17, 2021, we conducted descriptive analyses to quantify attendance changes for groups stratified by patient-based exposures (Index of Multiple Deprivation, ethnicity, age, comorbidity count, practice region, diagnosis time, and cancer subtype) across different phases of the COVID-19 pandemic in England, UK. In this study, we defined the phases of the COVID-19 pandemic as: pre-pandemic period (Jan 1, 2018, to March 22, 2020), lockdown 1 (March 23 to June 21, 2020), minimal restrictions (June 22 to Sept 20, 2020), lockdown 2 (Sept 21, 2020, to Jan 3, 2021), lockdown 3 (Jan 4 to March 21, 2021), and lockdown restrictions lifted (March 22 to March 31, 2021). In the analyses we examined changes in both attendance volume and consultation rate. We further compared changes in attendance trends to cancer-specific mortality trends. Finally, we conducted an interrupted time-series analysis with the lockdown on March 23, 2020, as the intervention point using an autoregressive integrated moving average model. From 561 611 eligible individuals, 7 964 685 attendances were recorded. During the first lockdown, the median attendance volume decreased (-35·30% [IQR -36·10 to -34·25]) compared with the preceding pre-pandemic period, followed by a median change of 4·38% (2·66 to 5·15) during minimal restrictions. More drastic reductions in attendance volume were seen in the second (-48·71% [-49·54 to -48·26]) and third (-71·62% [-72·23 to -70·97]) lockdowns. These reductions were followed by a 4·48% (3·45 to 7·10) increase in attendance when lockdown restrictions were lifted. The median consultation rate change during the first lockdown was 31·32% (25·10 to 33·60), followed by a median change of -0·25% (-1·38 to 1·68) during minimal restrictions. The median consultation rate decreased in the second (-33·89% [-34·64 to -33·18]) and third (-4·98% [-5·71 to -4·00]) lockdowns, followed by a 416·16% increase (409·77 to 429·77) upon lifting of lockdown restrictions. Notably, across many weeks, a year-over-year decrease in weekly attendances corresponded with a year-over-year increase in cancer-specific mortality. Overall, the pandemic period revealed a statistically significant reduction in attendances for patients with cancer (lockdown 1 -24 070·19 attendances, p<0·0001; minimal restrictions -19 194·89 attendances, p<0·0001; lockdown 2 -31 311·28 attendances, p<0·0001; lockdown 3 -43 843·38 attendances, p<0·0001; and lockdown restrictions lifted -56 260·50 attendances, p<0·0001) compared with before the pandemic. The UK's COVID-19 pandemic lockdown affected cancer health service access negatively. Many groups of individuals with cancer had declines in attendance volume and consultation rate across the phases of the pandemic. A decrease in attendances might lead to delays in cancer diagnoses, treatment, and follow-up, putting such groups of individuals at higher risk of negative health outcomes, such as cancer-specific mortality. We discuss the factors potentially responsible for explaining changes in service provision trends and provide insight to help inform clinical follow-up for groups of individuals at risk, alongside potential future policy changes in the care of such patients. Wellcome Trust, National Institute for Health Research University College London Hospitals Biomedical Research Centre, National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.

The impact of Sustainability Practices on Healthcare Institutions: Evidence from Public Healthcare Institutions in Saudi Arabia

This article aims to investigate sustainable development practices in hospitals, for three primary reasons: preserving the surrounding environment, impacting sustainability through service provision, and ensuring a safe and environmentally friendly atmosphere. The study addresses the gap in understanding the dimensions and implementation of green practices, offering insights into the green hospitals model. The study figured out eight practices that reflected sustainability activities in the Saudi public hospitals, with their significant impact on sustainable development. The study used descriptive methodology with quantitative technique to collect data pertaining to the impact of green practices on sustainable development in the Saudi public hospitals. A questionnaire survey with valid responses was distributed to 118 members working in the hospitals as (doctors, nurses, and administrators) in April 2024. The PLS-SEM statistical method was used for data analysis. The results of this study revealed a positive relationship between four green transition practices and Sustainable development. Keywords: Green practices in hospitals, sustainability, Sustainable development, public hospitals, healthcare institutions

Determining the role of remote consultations in general surgical practice in Scotland: a qualitative questionnaire-based study

INTRODUCTION Telemedicine consultations became widespread during the COVID-19 pandemic to deliver healthcare while minimising viral transmission. Research around establishing the role of remote appointments in general surgery outpatient clinics after the pandemic has not been undertaken. The aim of this study was to investigate views on remote consultations to determine this. METHODS Patients attending the adult general surgical outpatient clinic at Aberdeen Royal Infirmary between August 2021 and January 2022 as well as general surgeons from three neighbouring hospitals were invited to complete an anonymous questionnaire on the acceptability of remote and face-to-face (F2F) appointments in pre and postoperative scenarios. Differences in patients’ preferences between demographic groups, and between patients’ and surgeons’ views were analysed. RESULTS A total of 51 patients and 26 surgeons responded. Patients’ views differed depending on demographic parameters and the scenario. Patients and surgeons had similar views on preoperative consultations. Given the choice of telephone, video or F2F appointments, the F2F option was overall most popular. Patients and surgeons differed in their views on remote consultations following surgery and acute admissions. In some scenarios, young patients, those who lived in remote regions and those in employment/education preferred remote appointments. CONCLUSIONS While telemedicine is feasible and acceptable in general surgery clinics, there are differences in preferences between surgeons and patients. Patients’ preferences varied depending on their background, home circumstances and clinical context. Service provision should ensure that when remote consultations are available, patient preference is prioritised rather than surgeon ease.

Practice Patterns and Challenges in Managing Inherited Retinal Diseases across Asia-Pacific: A Survey from the APIED Network

PurposeThe objective of this paper is to shed light on the current landscape of genotyping practices, phenotyping practices and availability of essential vision rehabilitation management for inherited retinal diseases (IRD) in the Asia-Pacific (APAC) Region. MethodsThe 62-item questionnaire was distributed electronically via email. The questions covered five domains: (1) structure of the IRD service and registry/database; (2) genotyping practices; (3) genetic counselling; (4) deep phenotyping practices; (5) low-vision rehabilitation services. ResultsThe survey was completed by 36 of 45 centres in twelve countries and regions in APAC. Among these centres, 42% reported managing more than 1000 patients. Notably, 39% of centres lack an IRD database or registry, and 44% of centres have tested less than one-quarter of their IRD patients. The majority of centres (67%) do not have genetic counsellors. While there was consistency in the imaging-based investigations, there was marked heterogeneity for functional testing using electrophysiology and formal perimetry. Only 34% of centres confirmed the availability of access to low-vision assistive devices. ConclusionsThis study reveals several critical gaps in managing IRDs in the APAC region. These include the lack of IRD database/registry in one-third of centres, a substantial proportion of patients remaining genetically undiagnosed, and limited availability of genetic counsellors. The findings also underscore a need to harmonise investigations for evaluating retinal function and identify areas for improvement in the provision of low-vision rehabilitation services.

Understanding the Provision of Late Effects Services within the UK

Understanding the Provision of Late Effects Services within the UK

Structural Requirements for the Outpatient Treatment of Benign Diseases of the Uterus.

In many cases, outpatient surgical treatment of benign diseases of the uterus has advantages over inpatient care. This has been demonstrated by the healthcare situation in other countries. However, the prerequisite for the provision of outpatient services is that this does not lead to any impairment in the quality of care or of patient safety. The ultimate goal should not be to reduce costs but rather to maintain and, ideally, improve the quality of care. This requires that services are not just defined by the surgical procedure but also by the entire treatment chain, including, for example, psychosocial support, and are remunerated accordingly. It is particularly worrying that the final decision as to whether an outpatient operation is possible is not the responsibility of the operating unit, but of the "Medizinischer Dienst," with the corresponding options and threats of sanctions. This situation is unique internationally and requires a paradigm shift. Furthermore, structural prerequisites must be maintained which currently only exist inadequately in Germany. Since a substantial proportion of planned outpatient operations require immediate or secondary inpatient treatment, there must be a barrier-free transition between the outpatient and inpatient sectors. This will require the creation of networks between outpatient service providers and one or more hospitals that are equipped and competent to manage even complex complications. It is important to create structures that, with intensive involvement of the operating unit, include adequate preoperative evaluation and patient education as well as needs-oriented postoperative care at home. The current separation of sectors is a significant hinderance. Moreover, when expanding and promoting outpatient surgery, the aspect of training and further education of specialist staff must be taken into account, as well as cross-sectoral quality assurance. Based on a review of the international literature, this article presents 13 recommendations for adequate structures when providing outpatient services which should serve as a prerequisite for the greatest possible guarantee of patient safety.

Political Determinants of Health: Health Care Privatization and Population Health in Europe.

The extent to which health care reforms affect health remains understudied. Health care reforms result in policy outputs that determine provision of medical services, which have consequences for the health of the population. The authors scrutinize this relationship between health policy outputs and population health by focusing on legislative changes implying privatization of health care delivery and finance. They ask the following question: What is the relationship between reforms that privatize health care provision and population health in terms of health outcomes and inequalities? They answer this question by relying on fixed-effects time-series cross-section models. The authors use an original dataset of health care reforms passed in 36 European countries from 1989 to 2019. Health outcomes are operationalized with measures of subjective health status, unmet health needs, and resulting health inequalities. Their results show that privatization of health care is associated with higher rates of bad subjective health and unmet health needs several years after the passing of reforms. These effects are stronger for individuals in the lower tiers of income and education, resulting in greater socioeconomic inequalities. The article contributes to conceptualization of the political determinants of health as health policy outputs and a better understanding of the relationship between policy outputs and population health outcomes.

Health care under the military government (1964-1985) and its legacy for the SUS: the public-private hybrid Unified Health System

This article analyzes the health care policy developed during the military government in Brazil (1964-1985), with a core focus on the relationship between the public and private sectors in the provision of health services, in the different modalities in which this occurred, and its repercussions. The objective, from an institutionalist and historical perspective, which considers the mechanisms by means of which prior policies affect the subsequent decision-making process and impose limits on the possibilities for change, is to identify the effects of this policy on the configuration of health policy reform, implemented in the democratization process, which led to the creation of a universal and comprehensive health system. Among these, the political effects on the configuration of the health area stand out; cognitive effects related to the perception of health policy, and effects on the government's capacity to provide and regulate services. The result was the continuation of a duality in the health system, resulting in the coexistence of a vigorous private sector with an allegedly universal public system which posed/poses difficulties for the SUS, but did not prevent its implementation and institutionalization. The article is taken from a previously published book.

Integrating ecosystem services trade-off, drivers and zoning into watershed water environment management in Nansihu Lake Basin, China

A series of ecosystem services (ESs) have a significant impact on water environment. How these ESs can be integrated into water environment management in the lens of coupled human and natural system (CHANS) is still lack exploration. This study proposes an integrating framework that connects the ESs with water environment management to facilitate the watershed sustainable development. We employ the InVEST model to evaluate typical ESs in the Nansihu Lake Basin (largest freshwater lake in Shandong, China), and analyze the spatiotemporal characteristics and trade-off of multiple ESs indicators. By revealing the interaction mechanism and key drivers of ESs and conducting ecological functional zoning, we investigate how ESs can facilitate water environment management in the Nansihu Lake Basin. The results indicated that: (1) the high-value areas of agricultural supply service are mainly distributed in the western plain area of the basin while high-value areas of water provision, water purification and soil conservation services are in the mountainous and hilly areas in the eastern part of the basin. (2) There is a significant trade-off between crop supply service and water purification services. Crop and livestock supply services have a greater effect on water purification services (TN) than other services. (3) Crop area sown, total power of agricultural machinery and fertilizer application are the main drivers of water purification services (TN). (4) The basin can be divided into three ecological function zones, the agricultural production zone, the ecological regulation zone and the ecological redline zone. These findings imply that water environment management should be integrated with ESs by strengthening intersectoral collaboration, conducting zoning management in watershed planning and applying differentiated control measures in each zone. This includes optimizing the scale and structure of agriculture, and implementing circular economy and clean production practices. This study explored a comprehensive framework of integrating ESs into water environment management to facilitate the sustainable development of watershed.