National Healthcare Research Articles

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.

Endometrial Cancer - Long-Term Survival in Certified Cancer Centers and Non-Certified Hospitals: Comparative Analysis Based on a Large German Retrospective Cohort Study (WiZen).

Introduction Endometrial cancer is the most common malignant tumor of the female genital organs. In Germany, treatment is provided in both cancer centers certified by the German Cancer Society (Deutsche Krebsgesellschaft, DKG) and in non-certified hospitals. This study investigated whether treatment in DKG-certified centers leads to improved overall survival of patients with endometrial cancer. Materials and Methods Data from 11 legally independent German statutory health insurance (SHI) funds of the AOK were analyzed as well as data from four clinical cancer registries (CCR), resulting in inclusion of 30 102 AOK patients and 8190 registry patients with a diagnosis (incidental cases) of ICD-10-GM code C54 (malignant neoplasm of corpus uteri). For comparative survival analyses, multivariable Cox regressions and Kaplan-Meier analyses were used. Results The Kaplan-Meier estimator for 5-year overall survival was 66.7% for patients from certified centers and 65.0% for patients from non-certified hospitals (using SHI data; CCR data: 63.4% vs. 60.7%). Cox regression adjusted for relevant confounders showed a hazard ratio (HR) of 0.93 (SHI data; 95%CI 0.86 - 1.00; p = 0.050) and 0.935 (CCR data; 95% CI 0.827 - 1.057; p = 0.281) for all-cause mortality. In a subgroup analysis (CCR), patients with International Union against Cancer Control (UICC) stage I had a significant survival benefit if treated in a certified center (HR 0.783; 95% CI 0.620 - 0.987; p = 0.038). Conclusion The study presented herein shows that patients with endometrial cancer treated in a certified cancer center tend to have better survival rates. This should be considered when selecting the treating hospital.

Population aging management from the perspective of the health field of Iran and other countries: A scoping review

Population aging is one of the challenging phenomena where due to health changes and the importance of different levels of prevention, the country’s health system is most responsible for it. Therefore, it is responsible for providing responsible service and dealing with challenges and obstacles to successfully face the aging phenomenon. In this regard, the study was conducted aiming to identify inefficiencies and solutions to face the phenomenon of population aging from the perspective of the health field in Iran and other countries. The study is a domain review that was conducted by searching for specialized words in Web of Science, Scopus, PubMed, Cochrane, Mbase, and ProQuest databases and the Persian databases of the National Journals Information Bank, the Islamic Jihad Scientific Database, Irandoc, and the World of Islam Citation Database. The findings were analyzed based on 57 articles. In order to validate the findings, the opinions of five experts in the fields of health care management, social medicine, psychology, and health policy were used in the classification and completion of data. According to the findings, the challenges of the health system in facing the aging phenomenon were “inefficiencies of the health system”, “medication and treatment problems”, “costs and financing of the health system”, “inefficiencies related to health system employees”, “information and technology challenges”, “service challenges”, “health literacy and unfavorable lifestyle”, and “individual and social obstacles”, and the solutions to successfully face the aging phenomenon include “formulating laws and executive policies”, “prevention and treatment”, “supplying and developing resources”, “development of knowledge and technological performance”, “development of stakeholders’ participation”, “elderly centered”, and “social determinants of health”. The breadth and diversity of the findings indicate that the health system should be updated and strengthened in various social, economic, political, legislative, and executive dimensions in order to successfully tackle the aging phenomenon, and it should consider empowerment and attitude improvement programs of managers and health staff as well as the elderly.

Use of fixed-dose combinations for cardiovascular indications from 2018 to 2023: a nationwide population-based study.

Clinical guidelines support the use of fixed-dose combinations (FDC) for prevention of cardiovascular disease. Implementation of FDC into clinical care remains challenging, and current population-based data are scarce. Claims data on dispensed drugs in an outpatient care setting of approximately 87% of the German population were analysed regarding the use of FDC according to time, age of the insured persons, and active ingredients. The overarching trend for all FDC revealed a decrease from 77.3 defined daily doses per 1000 statutory health-insured (SHI) persons per day (DID) in the second half-year of 2018 (2018HY02) to 60.8 DID in the first half-year of 2023 (2023HY01) (Spearman ρ = -0.988; P < 0.001). The total DID for all antihypertensives (AHT) increased from 590.6 in 2018HY02 to 624.8 in 2023HY01 (ρ = 0.855; P = 0.002), but the DID for fixed-dose AHT (AHT-FDC) declined from 74.1 in 2018HY02 to 55.0 in 2023HY01 (ρ = -0.988; P < 0.001). Conversely, the use of all lipid-lowering agents (LLA) and LLA-FDC continuously increased: The total DID of all LLA rose from 92.5 in 2018HY02 to 134.4 in 2023HY01 (ρ = 1.000; P = 0.000), and for LLA-FDC from 3.1 in 2018HY02 to 5.5 DID in 2023HY01 (ρ = 0.915; P < 0.001). AHT-FDC and LLA-FDC were less frequently dispensed to patients at least 80 years than to patients less than 80 years. Dispensing of multiple purpose FDC increased from 2018HY02 to 2023HY01 from 0.11 DID to 0.26 DID (ρ = 1.000; P = 0.000) but remained negligible. Use of AHT-FDC in Germany is declining. In contrast, FDC containing LLA are increasingly prescribed. Dispensing of multiple purpose FDC is very low. Strategies are needed to facilitate the use of FDC as recommended by current guidelines.

Beyond perceived risk: COVID-19 vaccination more strongly linked to individual risk perception in wheat areas than rice areas

Vaccines save lives, but vaccine hesitancy remains a global health challenge. That makes it critical to explore the factors that influence whether people get vaccinated. Perceived risk is a pivotal factor in traditional theories of health behavior, such as the Risk Perception Attitude framework and the Health Belief Model. However, studies have found that these models are less predictive of COVID-19 vaccination in some cultures. Studies that test culture by comparing nations are useful, but nations have different healthcare systems and policies that are hard to equate and control for. We addressed this question by testing regional cultural differences in China. Drawing on the rice theory, we compared residents in China's historical rice-farming areas (which are more interdependent) with those in wheat-farming areas (which are more independent). Our survey data from 1872 participants in 29 provinces found that models of perceived risk explained COVID-19 vaccination mainly in historically wheat-farming areas. Conversely, in historically rice-farming areas, perceived risk did not explain vaccination behavior. These findings suggest that cultural factors that are rooted in historical farming practices influence vaccination behaviors. By comparing regions within the same country, we can rule out confounds of national policy and healthcare systems. These insights could help policymakers understand how to tailor vaccination campaigns to people from different cultures.

Implementation of socio-economic variables in risk adjustment systems: A quantitative analysis using the example of Germany

At least in Western Europe, competitive social health insurance systems have implemented systems of morbidity-based risk adjustment to establish a level playing field for insurers. However, insured persons with specific socio-economic characteristics are still underfunded, leaving incentives for risk selection. In Germany, there is an ongoing debate about (re)implementing socio-economic variables to reduce this undercompensation. This study analyses whether the following four socio-economic groups are systematically under- or over‐compensated under the present risk equalization system in Germany: insured persons with co‐payment exemption (1), recipients of basic income support for unemployment (2), of benefits of social long-term care-insurance (3) and insured persons with reduced earning capacity (4). On this basis, several attempts of incorporating these variables into the German risk adjustment system, allowing a better fit for the socio-economically disadvantaged groups, are examined. With a data set of about 9.2 million insured persons, the performance of the modifications is demonstrated for the German system. The disparate outcomes of the various models in different dimensions necessitate the consideration of trade-offs and their incorporation into the implementation of a model designed to mitigate the undercompensation of the affected insured groups.

Stroke Research Using Administrative Claims Database in Japan: A Narrative Review.

Although administrative claims databases have recently been used for clinical research in Japan, no detailed description of their utilization in stroke research is available. We reviewed stroke studies using the Diagnosis Procedure Combination (DPC), the National Database of Health Insurance Claims and Specific Health Checkups (NDB), and several commercial databases sourced from social health insurance associations, focusing on their applications and limitations. Original articles on stroke published by April 2024 using the DPC, NDB, and commercial databases were identified in Ovid MEDLINE. The characteristics of each database were compared in terms of comprehensiveness, traceability, baseline information, and outcome assessment in stroke research. A total of 114 studies were included (83 for DPC, 6 for NDB, and 25 for commercial databases). The number of stroke studies using administrative databases in Japan is still approximately 10 per year, although there is a slowly increasing trend. The DPC database was utilized for short-term outcome studies because of its detailed baseline and outcome information, although the inability to track patients once they changed facilities limits their use in long-term studies. The NDB database is potentially useful for long-term studies because of its comprehensiveness and traceability, but difficulties in data access restrict its usage. The most commonly used commercial database utilizes baseline information on lifestyle and blood test data, although the lack of coverage for those over 75 years old may limit its generalizability. Administrative claims databases are beginning to be used in stroke research in Japan but are not yet fully utilized. Researchers need to understand their applications and limitations.

Predicted Expenditure for Prescription Drugs for Multiple Sclerosis in the Italian Market Between 2023 and 2028: Results of the Oracle Project.

Multiple sclerosis (MS) is a chronic neurodegenerative disease that leads to impaired cognitive function and accumulation of disability, with significant socioeconomic burden. Serious unmet need in the context of managing MS has given rise to ongoing research efforts, leading to the launch of new drugs planned for the near future, and subsequent concerns about the sustainability of healthcare systems. This study assessed the changes in the Italian MS market and their impact on the expenditures of the Italian National Healthcare Service between 2023 and 2028. A horizon-scanning model was developed to estimate annual expenditure from 2023 to 2028. Annual expenditure for MS was calculated by combining the number of patients treated with each product (clinical inputs) and the yearly costs of therapy (economic inputs). Baseline inputs (2020-2022) were collected from IQVIA® real-world data, while input estimation for the 5-year forecast was integrated with analog analyses and the insights of clinicians and former payers. The number of equivalent patients treated in 2028 in Italy was estimated at around 67,000, with an increase of 10% versus 2022. In terms of treatment pattern evolution, first-line treatments are expected to reduce their shares from 47% in 2022 to 27% in 2028, and Bruton tyrosine kinase inhibitors are expected to reach 23% of patient shares. Overall, expenditure for MS is estimated to decrease from €721 million in 2022 to €551 million in 2028, mainly due to losses of exclusivity and renegotiation of drug prices. Despite the increase in the number of patients treated for MS and the launch of new molecules that will reach high market penetration, the model confirmed sustainability for the Italian National Healthcare Service.

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.

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.

Use of Hydrochlorothiazide in the United States Following Label Update About Skin Cancer Risk.

On August 20, 2020, the United States (U.S.) Food and Drug Administration (FDA) issued a Drug Safety Communication (DSC) along with labeling updates to inform the public about a small increased risk of non-melanoma skin cancer (NMSC) associated with hydrochlorothiazide (HCTZ) use. This study aims to assess whether the DSC impacted HCTZ use in the U.S. We conducted a trend analysis in the Sentinel Distributed Database using national healthcare administrative data from January 2017 to November 2022. We identified two cohorts each month: An overall cohort of all enrollees and a skin cancer cohort of those with a history of NMSC. For each cohort, we plotted the monthly proportion of patients receiving HCTZ-containing products among those receiving any thiazide diuretics. We performed interrupted time series analyses to quantify the impact of the DSC on these monthly proportions. Secondary analyses were conducted on the proportion of HCTZ users among patients receiving any antihypertensives. In the overall cohort, the DSC was only associated with a statistically significant but clinically negligible trend change of monthly HCTZ proportion within this cohort (0.018%; 95% CI, 0.012%-0.025%). Similar results were observed in the skin cancer cohort. The secondary analysis found no significant level change or trend change in the monthly proportion of HCTZ use among antihypertensive users. We did not observe significant changes in HCTZ use following the DSC about its NMSC risk, among the overall population and those with a history of NMSC. Our findings were in accordance with the DSC recommendation.

Knowledge, Attitude and Practice about Ayushman Bharat Digital Mission and Digital Health among hospital patients

ABSTRACT Aim: The Government of India launched the Ayushman Bharat Digital Mission (ABDM) to digitize the national healthcare system. The aim of this study was to estimate the knowledge, attitude and practice regarding the ABDM and benefits of digital health among urban patients, who are likely to be early adopters of digital technologies. Methods: We interviewed 150 outpatients above 18 years of age, in a hospital in urban Bengaluru, India. Our questionnaire captured the knowledge, attitude and practice regarding ABDM and Digital Health, including open-ended questions to evaluate perceptions of the benefits and concerns regarding digital health. Results: Most of the participants belonged to the upper and upper middle socioeconomic classes. Only 8% of participants knew about the ABDM, although their knowledge and practice related to other Government digital services, like National Teleconsultation services (eSanjeevani), Arogya Setu and DigiLocker, were high. Many participants perceived digital health to be beneficial, but there were serious concerns regarding data safety, data privacy and misuse of health data by insurance companies. Conclusion: We established a baseline survey for assessing the knowledge, attitudes and practices of ABDM and digital health among urban patients. The results suggest that implementation agencies of ABDM should increase the Information, Education and Communication (IEC) and devise new strategies to create awareness, disseminate correct information and address the concerns of citizens.

Deprescribing in Older Adults: Attitudes, Awareness, Training, and Clinical Practice Among Portuguese Physicians.

The importance of deprescribing in clinical practice is growing, particularly in aging populations with polypharmacy scenarios, making it a crucial matter in Portugal, one of Europe's most aged nations. The aim of this study was to investigate deprescribing awareness, training, attitudes, and practices among Portuguese physicians to inform future healthcare strategies. A cross-sectional study using an anonymous online questionnaire was disseminated through the Portuguese Medical Association. It gathered sociodemographic and professional data, and insights into deprescribing awareness, attitudes, training, and practices. Descriptive statistics were summarized as frequencies, percentages, medians, and interquartile ranges. For inferential analysis, the Chi-square test and Fisher's exact test were used to evaluate categorical variables, and the Mann-Whitney U test was used for continuous variables. The significance level was set at p < 0.05. A total of 425 valid questionnaires were included. The participants were mostly women (61.6%), with a median age of 45 (IQR 34 - 42). General practice/family medicine (34.1%) and internal medicine (16.2%) were the most common medical specialties. While 81.2% of the respondents were familiar with the term 'deprescribing', 55.4% reported no training. A vast majority (91.9%) reported practicing deprescribing, but a smaller fraction employed specific methodologies to deprescribe (39.8%) and criteria for identifying potentially inappropriate medications (38.7%). Training in deprescribing was significantly associated with higher deprescribing awareness (p < 0.001), the use of specific deprescribing methods (p < 0.001), the use of criteria to identify potentially inappropriate medications (p < 0.001) and having certification in geriatrics by the Portuguese Medical Association (p = 0.006). Family physicians showed higher familiarity with and training in deprescribing than hospital-based specialists (p < 0.001). Deprescribing methodologies were adopted more often by family physicians than by hospital-based specialists (p = 0.004). This study highlights widespread deprescribing awareness among Portuguese physicians, while simultaneously uncovering considerable gaps in training and inconsistencies in its application. These findings highlight the pressing need for targeted educational initiatives that could contribute to medication optimization for older adults in the national healthcare system. Furthermore, these findings emphasize the importance of policy development and medical education in promoting safe deprescribing.

114P Epidemiology and therapeutic outcomes of patients with spinal muscular atrophy: results from a 12-year real-world study based on the French National Healthcare database (SNDS)

114P Epidemiology and therapeutic outcomes of patients with spinal muscular atrophy: results from a 12-year real-world study based on the French National Healthcare database (SNDS)

Does younger children's social health insurance alleviate household impoverishment due to illness?

The ambitious expansion of social health insurance in China has played a crucial role in preventing and alleviating poverty caused by illness. However, there is no government-sponsored health insurance program specifically for younger children and inequities are more pronounced in healthcare utilization, medical expenditure, and satisfaction in some households with severely ill children. This study assessed the effectiveness of child health insurance in terms of alleviating poverty caused by illness. Data were collected from two rounds of follow-up surveys using the China Family Panel Studies 2016 and 2018 child questionnaires to investigate the relationship between child health insurance and household medical impoverishment (MI). Impoverishing health expenditure (IHE) and catastrophic health expenditure (CHE) were measured to quantify "poverty due to illness" in terms of absolute and relative poverty, respectively. Propensity score matching with the difference-in-differences (PSM-DID) method, robustness tests, and heterogeneity analysis were conducted to address endogeneity issues. Social health insurance for children significantly reduced household impoverishment due to illness. Under the shock of illness, the incidences of IHE and CHE were significantly lower in households with insured children. The poverty alleviation mechanism transmitted by children enrolled in social health insurance was primarily driven by hospitalization reimbursements and the proportion of out-of-pocket medical payments among the total medical expenditure for children. Children's possession of social health insurance significantly reduced the likelihood of household poverty due to illness. The poverty-reducing effect of social medical insurance is most significant in rural areas, low-income families, no-left-behind children, and infants. Targeted poverty alleviation strategies for marginalized groups and areas would ensure the equity and efficiency of health system reforms, contributing to the goal of universal health insurance coverage in China.

Adaptation of Well-being Literacy Scale to Turkish: Validity and Reliability Study

The view that well-being cannot be taught directly to individuals, but rather individuals can be taught to use language to improve their well-being, has led to the concept of "well-being literacy". Recent studies in the field of positive educational practices emphasize the importance of well-being literacy, which is defined as the ability to improve the well-being of oneself and others, in the social field as well as in the field of education. This study aimed to adapt the Well-being Literacy Scale to Turkish and test its validity and reliability in adults. Also, the relationship between well-being literacy, socioeconomic status, perceived general success, and health was investigated. The study group consists of 307 adults, 210 women and 96 men. Personal Information Form, Well-being Literacy Scale, General Well-being Scale Short Form, and Subjective Socio-economic Scale were used as data collection tools. It was found that the Well-being Literacy Scale had good levels of fit index in the confirmatory factor analysis results. Within the scope of criterion validity studies, a positive and moderate relationship was found between the Well-being Literacy Scale and the General Well-being Scale Short Form (r=.413, p=.000). Within the scope of reliability analysis, a .75 test-retest coefficient and a .88 Cronbach Alpha coefficient were determined. The second stage of the study found that the socioeconomic level predicted well-being literacy, though it is very low. Also, it was found that well-being literacy predicted individuals' perceived success at a low level but did not have a significant predictive effect on perceived general health levels. It is suggested that studies to investigate the sources and outputs of well-being literacy, which has started to become an essential focus in positive education practices and social health policies, will contribute to the field. In addition, adapting measurement tools in lower age groups may be necessary to focus on these skills in educational institutions.

Conference Equity in Community Medicine: A Brief Analysis of Financial and Geographical Barriers to Participation at Community Medicine Conferences

Background: Academic conferences in community medicine offer valuable learning platform for postgraduate residents and faculty. However, to demonstrate commitment towards conference equity, financial and geographical barriers need to be enumerated and eliminated. Materials &amp; Methods: Academic medical conferences representing the specialty of community medicine or preventive and social medicine, held between 1st April 2023 – 31st March 2024, were included under the study. Variables identified for the study included registration fees, location, affiliation to professional society, geographical scope, presence of virtual/hybrid component, and availability of scholarship/travel grant for postgraduate residents. Results: None of the conferences were held in resource-constrained states of India – the North Eastern Region (except Assam) and islands of Andaman, Nicobar, and Lakshadweep. Only 2 out of 31 conferences had virtual or hybrid component and none of the conferences offered financial support for postgraduate residents. The study found no significant difference in conference registration fees between members and non-members for postgraduate residents and faculty. Conclusions: Registration fees and location of conferences are critical geographical and financial barriers to effective participation. Membership to societies offer no advantage over non-membership in terms of financial benefits of participation at conference.

"If They Help Us, We Can Help Them": First Nations Peoples Identify Intercultural Health Communication Problems and Solutions in Hospital in Northern Australia.

Effective intercultural communication between First Nations peoples and healthcare providers in colonised countries is required to deliver equitable healthcare and improve patient experiences and health outcomes. This paper presents First Nations peoples' perspectives and proposed solutions to problematic communication experiences at Royal Darwin Hospital in northern Australia. The study's methodological foundations comprise decolonising principles rooted in Critical Race Theory, Freirean pedagogy, and cultural safety. Eleven individuals from diverse First Nations backgrounds receiving treatment at the largest hospital in the Northern Territory, participated in in-depth interviews conducted in their preferred languages. Data were inductively analysed, adapted from a constructivist grounded theory approach and guided by First Nations knowledges. First Nations patients at Royal Darwin Hospital described a culturally unsafe hospital due to ineffective intercultural communication. Patient "counterstories" recounted instances of confusion, aggression, healthcare provider resistance to shared decision-making opportunities, pressure to abandon cultural protocols, and institutional neglect. Poor communication incited anger among staff and patients, and contributed to experiences of racism, missed appointments, clinical mistakes, patients prematurely discharging before completing treatment, and patients experiencing financial troubles and homelessness. In a spirit of generosity, patients proposed solutions focused on relationship building and mutual understanding so that new decolonised systems, which draw on First Nations and Western knowledges, can be codesigned. This study serves as a call to action for policymakers, administrators, and healthcare providers to prioritise improving intercultural communication by addressing the behaviour of staff and changing systemically racist policies in the pursuit of health equity and cultural safety for First Nations peoples.

The study protocol for a multicenter observational headache registry: Brazilian Headache Registry - REBRACEF II

ObjectiveThis article presents the protocol for the Brazilian Headache Registry (REBRACEF), the first national registry designed to systematically collect real-world data on patients with primary and secondary headaches at specialized centers in Brazil. The main objective is to describe the methods for patient selection, the registry infrastructure, data collection, and the standardized instruments used.MethodologyREBRACEF is a prospective, observational, multicenter cohort study conducted in real-world settings.Expected resultsThis protocol aims to standardize and enable the structuring of the registry, allowing its implementation in other centers across Brazil. It also ensures external feasibility by establishing a robust framework that can be replicated in other national and international healthcare institutions.ConclusionThe registry protocol provides a standardized framework for the collection of real-world data on patients with primary and secondary headaches, facilitating the improvement of headache management and research in Brazil.

Macroeconomic Analysis of Social Health Insurance Implementation in Kazakhstan

Over the past three decades, Kazakhstan put a lot of efforts and resources into implementation of the Social Health Insurance. Debates on health policy often focuses on contribution rates in SHI that should limit the growth of out-of-pocket spending. We investigate a central issue to the debates: are the contribution rates stipulated by the law sufficient to minimize the out-of-pocket health payments? We develop a simple dynamic stochastic general equilibrium (DSGE) model based on over-lapping generations macroeconomic model (OLG) to describe the process of healthcare reforms in Kazakhstan. The numeric results argue that current contribution rates will not be enough to reduce the share of ou-of-pocket health payments in the economy. On contrary, optimal inter-temporary consumption-saving decision of households may bring us to the optimal composition of total spending that shifts toward health, and the out-of-pocket health expenditures can easily exceed current level of 40 percent.