Support Population Health Research Articles

Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities.

The COVID-19 pandemic has underscored the urgency to focus on the essential value of public health systems (PHSs) in fostering health equity across the US health care delivery system. PHS integration and care coordination can be successfully achieved through health information technology systems. The objective of the study was to examine the association between PHS partnerships (PHSPs), telehealth postdischarge, and racial and ethnic disparities in health care. The analysis used 2017 Centers for Medicare and Medicaid Services Medicare 100% inpatient claims data, the Medicare Beneficiary Summary File, the American Hospital Association Annual Survey, and the American Community Survey. Results showed that compared with those treated in hospitals with neither PHSP nor telehealth postdischarge services, beneficiaries treated in hospitals with PHSP encountered significantly lower Medicare payment and inpatient and readmission rates. Black patients experienced significantly lower cost, inpatient visits, and readmission rates when treated in hospitals with PHSP and telehealth postdischarge services (coefficient = -0.051, P < 0.001; incidence rate ratio [IRR] = 0.982, P = 0.007; IRR = 0.891, P = 0.003). The results of the study demonstrated the importance of combining PHSP and telehealth postdischarge services to improve the efficiency of the health care delivery system and health equity. It is urgent to ensure that PHSs have adequate funding and telehealth infrastructure to support population health.

A US National View of Prevalent and Newly Diagnosed Multiple Myeloma in 2021: A Retrospective Analysis of National All-Payer Claims Database

Introduction: Multiple myeloma (MM) is a rare and heterogeneous cancer with steadily improving patient survival in recent years due to advancement in therapies. Updates to the prevalence and incidence of MM using the latest nationally representative data are needed to support population health management, resource planning, and health economic assessments. Furthermore, disparities in disease burden, access to care, treatment patterns, and outcomes could exist across patient subpopulations with MM, prompting a need for comprehensive data to understand the population. Currently, there is a gap in such data due to the highly fragmented health care system in the US in which real-world evidence is often siloed and represents only a portion of the population. This study aims to provide a national view of MM by estimating the prevalence and incidence in US adults overall and by state/territory, payer type, race, and ethnicity in 2021. Methods: This is a retrospective study using the All-Payer Real-World Multiple Myeloma Research-Ready Data built using the US national all-payer claims database (APCD), which covers ~87% of the nationally insured population from 1/1/2014 to 1/31/2022. Data included adults with ≥2 claims with MM diagnosis (ICD-9-CM: 203.0x and ICD-10-CM: C90.0x) who had continuous capture with medical and pharmacy benefits for ≥12 months prior to and 30 days after the first MM diagnosis date. To be included in this study, patients also had to have ≥1 claim in 2021. The latest claim date in 2021 was defined as the index date. A subcohort of patients with newly diagnosed MM (NDMM; incident MM cases) were additionally required to have their first MM diagnosis date (the index date for the NDMM cohort) in 2021. Prevalence and incidence of MM were estimated using the number of patients in MM and NDMM cohorts, divided by the total APCD adult population with similar continuous capture eligibility. Prevalence and incidence were calculated for the overall population and stratified by state/territory, payer type, race, and ethnicity. Patient characteristics were captured at the index date and during the baseline period. The proportion of patients with NDMM who initiated their first treatment in 2021 and the time from diagnosis to their first treatment were captured. Results: A total of 63,281 MM and 9,674 NDMM patients met the study criteria. Mean age was 71.1 and 70.0 years, 51.4% and 52.9% were male, and 68.7% and 72.0% were covered by Medicare, respectively. Overall, about two-thirds of the patients had available race (74%), ethnicity (69%), and income data (76%), while 46% had education status. Among those with data, 15.6% of MM and 14.7% of NDMM cohorts were Black, 12.2% and 11.9% were Hispanic, 65.1% and 64.5% had an annual income ≤$50,000, and 67.5% and 67.2% had high school as their highest level of education. The overall prevalence of MM was 73.8 per 100,000 adults in 2021, with the prevalence being the highest among those who were Black (124.8), non-Hispanic (101.3), covered by Medicare (245.2), and residing in the US Virgin Islands (243.6) and Arkansas (126.5). The overall incidence of NDMM was 11.3 per 100,000 adults in 2021, and the incidence was highest among those who were Black (17.8), non-Hispanic (15.3), covered by Medicare (39.3), and those residing in Puerto Rico (24.5), the US Virgin Islands (22.8), and Washington (20.7; Tables 1 and 2). The mean Quan-Charlson comorbidity index (excluding MM diagnosis) was 2.8 for the MM cohort and 2.4 for the NDMM cohort. Commonly observed comorbidities for both cohorts included anemia (44.8% and 47.4%), diabetes with chronic complications (23.9% and 22.4%), peripheral neuropathy (24.8% and 15.2%), renal impairment (22.7% and 20.1%), and infections (21.9% and 14.4%). There were 3,377 (35%) patients with NDMM who initiated their first treatment in 2021, with a mean and median time to treatment of 50.8 (standard deviation = 67.5) and 27 days. Conclusions: While the prevalence and incidence of MM in 2021 estimated in this study were consistent with projected estimates from the literature, variations in rates of MM were observed across race, ethnicity, payer type, and state/territory, indicating potential disparities in the burden of MM. Such a comprehensive view of rates of MM could serve as a foundation for future health policy decisions, quality improvement, resource deployment, and initiatives to address health disparities across subpopulations. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Nurses and infant vaccination coverage

Timely vaccination adherence for infants can avoid costs for the health care system and support population health. Can public health interventions–such as nurse home visits–encourage timely uptake? We study this question in the context of universal home visits for new parents in Denmark. We exploit merged nurse records and administrative data and use an event study design to compare the outcomes of families, who vary in the exact timing of their nurse visit around the recommended age for infant vaccinations. We find that a nurse visit prior to the recommended vaccination age increases parents’ probability of timely vaccination adherence. In the longer run, vaccination coverage rates between treated and control parents converge, and thus our findings suggest that nurses primarily act as human vaccination reminders. However, as our heterogeneity analyses show that a timely nurse visit positively affects vaccination coverage for inexperienced parents, adequately timed nurse visits may have the potential to also increase vaccination coverage.

Use of Preventive Care Services and Hospitalization Among Medicare Beneficiaries in Accountable Care Organizations That Exited the Shared Savings Program

Thirty percent of Medicare accountable care organizations (ACOs) in the Shared Savings Program (SSP) have exited within five years of joining. Absent the potential for shared savings, exiting ACOs may choose to divest from costly resources needed to support population health, worsening clinical quality for beneficiaries aligned to these organizations. To examine the associations of SSP exit with clinical quality. Between 2019 and 2020 we conducted a retrospective cohort study with national Medicare claims from a 20% random sample of beneficiaries. We identified 1,713,237 beneficiaries aligned with an SSP ACO at some point between 2012 and 2016. We distinguished between those for whom the ACO to which they were aligned exited the SSP and those whose ACO stayed in the program. Comparing exiting ACOs with those who stayed in the SSP, we evaluated changes in the quality of care that a beneficiary received before and after the aligned ACO exited the SSP. We also examined whether findings associated with exit varied with respect to the number of years after exit. SSP exit and the number of years after exit. Annual preventive care services receipt and hospital utilization. The cohort of 1,713,237 individuals (mean [standard deviation] age at enrollment: 75.20 [7.96] years) included 998,511 (58.3%) female, 126,123 (7.4%) Black, and 1,482,823 white (86.6%) beneficiaries. SSP exit was associated with significantly lower rates of annual glycated hemoglobin testing (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.68 to 0.81), low-density lipoprotein cholesterol testing (OR, 0.86; 95% CI, 0.76 to 0.97), and all diabetes complication screening (OR, 0.90; 95% CI, 0.81 to 0.97), for beneficiaries with diabetes. The exit was not related to rates of hospital utilization, in terms of emergency department utilization and 30-day readmission after SSP exit. The associations with exit depended on the length of time since contracts end. For example, the baseline rate of annual glycated hemoglobin testing was 89.8% (95% CI, 89.5% to 90.1%) but fell to 86.9% (95% CI, 85.9% to 88.0%) and 86.8% (95% CI, 85.0% to 88.5%) in years 1 and 2 after exit, respectively, but it then rose to 91.9% (95% CI, 85.3% to 98.5%) in year 3. In this cohort study of Medicare beneficiaries, SSP exit was associated with modest declines in clinical quality. These findings were timely given recent SSP changes that could accelerate program exit.

Making HIS More Agile, Relevant and Public Health Friendly: Lessons from Covid-19 in India

Anthony Giddens, the noted sociologist, describes the COVID-19 pandemic as a ‘digidemic,’ emphasizing the inextricable linkages between the pandemic and the digital. As the pandemic has spread globally, countries have adopted different strategies to leverage digital technologies, in their design, development, implementation, and governance to address the pandemic. Some of these strategies have worked well and others have not so. We submitted this paper at the time when India was fighting the first COVID-19 wave and are submitting this revised version as India fights a much tougher second wave. And between these two waves, we have witnessed some flattening of the COVID-19 curve and the onset of a rigorous vaccination drive. This paper aims to try to analyse some experiences of how countries leveraged digital technologies in their information systems response, such as from Sri Lanka, South Korea and anchored in a historical understanding of public Health Information Systems (HIS) in India, build key learnings for strengthening HIS in India, both for pandemic situations and also routine health management. These include i) improving agility, reflecting the ability of the HIS to provide timely information for supporting local action; ii) improving relevance, implying providing required information for supporting the desired action for different stakeholders; and, iii) public friendliness, implying the HIS should help support population health at large in an equitable manner. We argue that these learnings are not only relevant for strengthening the HIS response to pandemic management but also more broadly for strengthening Indian public HIS covering routine systems. These learnings are particularly pertinent in the current ‘digital’ context in India, where large-scale interventions related to the National Digital Health Mission are currently being planned and implemented. For good or bad, the ‘digital’ is inevitable in public health systems globally, and it becomes important for researchers and practitioners to engage with this process of understanding the digital interventions and contribute to strengthening the health systems.

Coping with interoperability in the development of a federated research infrastructure: achievements, challenges and recommendations from the JA-InfAct

BackgroundInformation for Action! is a Joint Action (JA-InfAct) on Health Information promoted by the EU Member States and funded by the European Commission within the Third EU Health Programme (2014–2020) to create and develop solid sustainable infrastructure on EU health information. The main objective of this the JA-InfAct is to build an EU health information system infrastructure and strengthen its core elements by a) establishing a sustainable research infrastructure to support population health and health system performance assessment, b) enhancing the European health information and knowledge bases, as well as health information research capacities to reduce health information inequalities, and c) supporting health information interoperability and innovative health information tools and data sources.MethodsFollowing a federated analysis approach, JA-InfAct developed an ad hoc federated infrastructure based on distributing a well-defined process-mining analysis methodology to be deployed at each participating partners’ systems to reproduce the analysis and pool the aggregated results from the analyses. To overcome the legal interoperability issues on international data sharing, data linkage and management, partners (EU regions) participating in the case studies worked coordinately to query their real-world healthcare data sources complying with a common data model, executed the process-mining analysis pipeline on their premises, and shared the results enabling international comparison and the identification of best practices on stroke care.ResultsThe ad hoc federated infrastructure was designed and built upon open source technologies, providing partners with the capacity to exploit their data and generate dashboards exploring the stroke care pathways. These dashboards can be shared among the participating partners or to a coordination hub without legal issues, enabling the comparative evaluation of the caregiving activities for acute stroke across regions.Nonetheless, the approach is not free of a number of challenges that have been solved, and new challenges that should be addressed in the eventual case of scaling up. For that eventual case, 12 recommendations considering the different layers of interoperability have been provided.ConclusionThe proposed approach, when successfully deployed as a federated analysis infrastructure, such as the one developed within the JA-InfAct, can concisely tackle all levels of the interoperability requirements from organisational to technical interoperability, supported by the close collaboration of the partners participating in the study. Any proposal for extension, should require further thinking on how to deal with new challenges on interoperability.

Institutional factors associated with hospital partnerships for population health: A pooled cross-sectional analysis.

Hospitals are increasingly engaging in partnerships to address population health in response to national policies, such as value-based payment models. However, little is known about how institutional factors influence hospital partnerships for population health. Guided by institutional theory, we examine the association between institutional pressures (coercive, normative, and mimetic isomorphism) and hospital partnerships for population health. A pooled cross-sectional analysis used an unbalanced panel of 10,777 hospital-year observations representing respondents to a supplemental question of the American Hospital Association's annual survey (2015-2017). The analysis included descriptive and bivariate statistics, and regression models that adjusted for repeated observations to examine the relationship between key independent variables and partnerships over time. In regression analyses, we found the most support for measures of coercive (e.g., regulatory factors) isomorphism, with nonprofit status, participation in accountable care organizations, and acceptance of bundled payments, all being consistently and significantly associated with partnerships across all organization types. Modest increases were observed from 2015 to 2017 for hospital partnerships with public health organizations (+2.8% points, p < .001), governmental organizations (+2.0% points, p = .009), schools (+4.1% points, p < .001), and businesses (+2.2% points, p = .007). Our results suggest that institutional factors, particularly those related to regulatory policies and programs, may influence hospital partnerships to support population health. Findings from this study can assist hospital leaders in assessing the factors that can support or impede the creation of partnerships to support their population health efforts.

Future Role of the Clinical Lab in Population Health.

Future Role of the Clinical Lab in Population Health.

Predictive analytics and tailored interventions improve clinical outcomes in older adults: a randomized controlled trial

This study explored the potential to improve clinical outcomes in patients at risk of moving to the top segment of the cost acuity pyramid. This randomized controlled trial evaluated the impact of a Stepped-Care approach (predictive analytics + tailored nurse-driven interventions) on healthcare utilization among 370 older adult patients enrolled in a homecare management program and using a Personal Emergency Response System. The Control group (CG) received care as usual, while the Intervention group (IG) received Stepped-Care during a 180-day intervention period. The primary outcome, decrease in emergency encounters, was not statistically significant (15%, p = 0.291). However, compared to the CG, the IG had significant reductions in total 90-day readmissions (68%, p = 0.007), patients with 90-day readmissions (76%, p = 0.011), total 180-day readmissions (53%, p = 0.020), and EMS encounters (49%, p = 0.006). Predictive analytics combined with tailored interventions could potentially improve clinical outcomes in older adults, supporting population health management in home or community settings.

A randomized trial examining the effect of predictive analytics and tailored interventions on the cost of care

This two-arm randomized controlled trial evaluated the impact of a Stepped-Care intervention (predictive analytics combined with tailored interventions) on the healthcare costs of older adults using a Personal Emergency Response System (PERS). A total of 370 patients aged 65 and over with healthcare costs in the middle segment of the cost pyramid for the fiscal year prior to their enrollment were enrolled for the study. During a 180-day intervention period, control group (CG) received standard care, while intervention group (IG) received the Stepped-Care intervention. The IG had 31% lower annualized inpatient cost per patient compared with the CG (3.7 K, $8.1 K vs. $11.8 K, p = 0.02). Both groups had similar annualized outpatient costs per patient ($6.1 K vs. $5.8 K, p = 0.10). The annualized total cost reduction per patient in the IG vs. CG was 20% (3.5 K, $17.7 K vs. $14.2 K, p = 0.04). Predictive analytics coupled with tailored interventions has great potential to reduce healthcare costs in older adults, thereby supporting population health management in home or community settings.

An Agile Digital Platform to Support Population Health-A Case Study of a Digital Platform to Support Patients with Delirium Using IoT, NLP, and AI.

For an organization to be customer centric and service oriented requires that it use each encounter with a customer to create value, leverage advanced technologies to design digital services to fulfill the value, and assess perceived value-in-use to continue to revise the value as customer expectations evolve. The adaptation of value cycles to address the rapid changes in customer expectations requires agile digital platforms with dynamic software ecosystems interacting with multiple actors. For public health agencies focused on population health, these agile digital platforms should provide tailored care to address the distinct needs of select population groups. Using prior research on aging and dynamic software ecosystems, this paper develops a template for the design of an agile digital platform to support value cycle activities among clinical and non-clinical actors, including population groups. It illustrates the design of an agile digital platform to support clients that suffer from delirium, using digital services that leverage Internet of Things, natural language processing, and AI that uses real-time data for learning and care adaption. We conclude the paper with directions for future research.

Eating and Exercise-Related Correlates of Weight Stigma: A Multinational Investigation.

Weight stigma is prevalent across the world. However, little is known about whether and how the harmful health consequences of weight stigma may vary across countries. The current study examined the association between experiences of weight stigma and multiple eating and exercise-related indicators among a large, multinational sample of adults. Adults enrolled in an international weight management program residing in Australia, Canada, France, Germany, the United Kingdom, and the United States completed identical Web-based surveys in the dominant language for their country. Participants (N = 13,996) reported on their personal experiences of weight stigma and health, including eating behaviors, attitudes toward exercise, and perceived stress. More than half of all participants in each country reported experiencing weight stigma. Participants who had experienced weight stigma reported engaging in more eating to cope, gym avoidance, and self-monitoring behaviors, as well as higher levels of stress and reduced eating self-efficacy. These associations were documented over and above sociodemographic characteristics and BMI and did not vary across countries. Study findings document uniform health-related correlates of weight stigma within a multinational context and underscore the need for global initiatives to curtail weight stigma in order to support population health.

Multi-level drivers of tobacco use and purchasing behaviors during COVID-19 "lockdown": A qualitative study in the United States.

BackgroundThe COVID-19 pandemic and associated public health prevention measures (e.g., “stay at home” orders) may impact tobacco supply and demand among consumers. This qualitative study identified multi-level drivers of shifts in inhaled tobacco product use and access patterns during the initial COVID-19 “lockdown” period in the United States.MethodsBetween April and May 2020, we conducted semi-structured telephone interviews (n = 44) with adults who use cigarettes and/or electronic nicotine delivery systems (ENDS). Transcripts were thematically analyzed using a socioecological framework.ResultsNearly all participants reported changes in their product use during lockdown, though patterns varied. Increased use was most common and was predominantly driven by individual-level factors: pandemic-related anxiety, boredom, and irregular routines. Decreased use was common among social users who cited fewer interpersonal interactions and fear of sharing products. At the community level, retail access impacted cigarette and ENDS use differently. While cigarettes were universally accessible, ENDS access was more limited, driving some to purchase products online. Delayed deliveries led some ENDS users to compensate with readily-available cigarettes.ConclusionTo mitigate ways that the COVID-19 pandemic may exacerbate an existing public health crisis, multi-level policy strategies, such as expanded virtual cessation services and implementation and enforcement of smoke-free home rules, can better support population health during this critical period. Policies that facilitate access to lower risk products can help minimize harm among those who cannot or do not want to quit smoking.

The Role of the Health Coach in a Global Pandemic.

BackgroundWhile medical teams were perplexed about the novel SARS-CoV-2 infection, transmission and impairment of organ systems and immune function, viral infections spread worldwide. Complex intersectional issues of co-morbidities coupled with marginalized, diverse ethnic/racial populations emerged as significant risks to contracting severe COVID-19.ObjectiveSince a healthy lifestyle is fundamental for lowering risk to chronic diseases, public health initiatives to manage this and future pandemics should include strategies that assist individuals to improve health status through targeted behavior changes. This conceptual paper builds a case for certified professional health coaches as primary actors in future preventive strategies, with expanded skills in addressing social determinants of health and “next generational” cultural competencies.MethodsThis concept paper primarily synthesizes fast-tracked research in 2020 regarding the demographic impact of COVID-19, specifically those groups suffering the highest morbidity and mortality rates. Exploring these intersectional issues through a conceptual lens provides strategies for certified health coaches to contribute their expertise in behavioral change within the larger contextual settings of racial/ethnic disparities and social inequities.ResultsAs the co-morbidities and other chronic conditions related to COVID-19 among individuals and families in low-income communities are worsened by dual forces (lifestyle/behavioral choices and ingrained structural inequities), adding the support of certified health coaches to build trust, provide more convenient access to address vaccine hesitancy, and dispell falsehoods, is an effective means for advancing health and wellbeing. Group coaching and one-on-one coaching can work in tandem with public health initiatives for reducing chronic disease burden and addressing social determinants of health (SDoH). Skills are identified in coaching SDoH with expanded cultural competencies for health coaches.ConclusionCertified professional health coaches can make a positive impact on general risk reduction of chronic diseases within ethnic/racial minorities, thereby supporting population health in facing future contagions with greater health resilience.

Exploring access to, use of and benefits from population-oriented digital health services in Australia.

The provision of population-oriented, on-demand digital health services in many countries exemplifies the perceived utility of digital health services in supporting population health. Yet, limited knowledge exists regarding the equity of these services. Using mixed-method research, we recruited users of a health website and general practice patients to surveys (n = 441) and telephone interviews (n = 40). We contribute specific evidence investigating barriers to access, use and benefit from digital health services within an equity framework that incorporates social determinant factors, eHealth Literacy and trust. Our research highlights the foundational role of trust in predicting use, showcases which groups are unlikely to benefit from population-oriented digital health services, and proposes strategies to enhance the equity of these services. The theoretical framework we developed serves as a roadmap for future health promotion research and action by outlining the complex and interrelated pathways that can promote and threaten digital health equity.

How can Environmental Health Practitioners contribute to ensure population safety and health during the COVID-19 pandemic?

The COVID-19 pandemic highlighted the relevance of public health professionals all over the world, in particular Environmental Health Practitioners (EHPs), who played a major role in the containment of the novel coronavirus, SARS-CoV-2. However, as in past disasters, their involvement was oriented towards urgent tasks, and did not fully utilize EHPs’ competences and skills. Additionally, due to limited resources, during emergencies EHPs may temporarily transition away from their day-to-day role, potentially increasing other public health and safety risk factors without appropriate surveillance or intervention. To overcome this and prepare for possible future pandemics, it is important to identify and discuss the key roles of EHPs in different countries, providing a common framework for practices that can contribute to population safety and health. To this end, an international workgroup was established to discuss current environmental health practices and challenges across different countries during the pandemic. Findings from discussions concluded that, despite the observed differences across the countries, EHPs are one of the main public health emergency preparedness and response actors. However, since resources are still lagging significantly behind need, we argue that the role of these professionals during pandemics should be focused on practices that have higher impact to support population health and safety.

Remote introductory pharmacy practice experiences focused on veterans prescribed chronic opioid therapy.

The Department of Veterans Affairs (VA) Northern California Health Care System (NCHCS) uses a dashboard to identify monitoring needs for veterans prescribed chronic opioid therapy (COT). Schools of pharmacy require introductory pharmacy practice experiences (IPPEs); however, resources for providing IPPEs at medical facilities are limited. This article describes collaboration by a primary care service and a school of pharmacy to provide services for patients prescribed COT through remote access to the VA electronic health record (EHR) system. Pharmacy students in a required population health IPPE provided clinical services for veterans remotely. Students were supervised by VA clinical pharmacists and granted remote EHR access privileges. Using personally owned laptops and VA cell phones, students performed prescription drug monitoring program (PDMP) activities, reviewed urine drug screening (UDS) results, called patients to assess pain, and documented progress notes. Students completed an assessment on the first and final days of the experience; a retrospective analysis was conducted to examine differences in student knowledge of and confidence in providing COT-focused services. The dashboard scorecard and student workload were tracked over a 1-year period. In that year, 143 students wrote 7,001 PDMP notes, reviewed 6,130 UDS results, and documented 202 pain assessments. Statistically significant improvements were reported in students' level of confidence in performing population health activities for patients prescribed COT, including interpreting PDMP and UDS results and talking with patients. The ongoing collaboration provides real-world population management experiences for future pharmacists and supports monitoring requirements for veterans prescribed COT. The program has helped NCHCS accomplish its teaching mission without dedicating clinic workspace or computers and gain an additional team to address quality measures and support population health activities.

Applied Public Health Informatics: An eHealth Discipline Focused on Populations

The discipline of public health informatics, part of the broader eHealth field, brings methods, knowledge, and theories from computer science and information science to support population health and well-being. This branch of informatics is most often found in governmental public health agencies that focus on population-level activities, including surveillance of disease as well as disease prevention. There are several specialised public health information systems used to prevent or mitigate disease, including syndromic surveillance, electronic laboratory reporting, and population health dashboards. This article defines and describes public health informatics and its role in eHealth. The article further discusses the role of public health information systems and challenges they face for the future. Strengthening public health will require greater investment in interoperability as well as analytics and the workforce. Disease outbreaks like COVID-19, Ebola, and H1N1 demonstrate the need for robust public health informatics applications and methods. Yet there is much work to be done to evolve existing tools and methods to strengthen the public health infrastructure for the next pandemic.

UK's fruit and vegetable supply increasingly dependent on imports from climate vulnerable producing countries.

Domestic contribution to total fruit and vegetable supply in the UK decreased from 42% in 1987 to 22% in 2013. The impact of this changing pattern of UK fruit and vegetable imports, from countries with different vulnerabilities to projected climate change, on the resilience of the UK food system is currently unknown. Here, we used the UN FAO bilateral trade database over a period of 27 years to estimate changes in fruit and vegetable supply in the UK, and the NDGAIN climate vulnerability categories to assess the climate vulnerability of countries supplying fruit and vegetables to the UK. The diversity of fruit and vegetable supply has increased from 21 crops, comprising the top 80% of all fruit and vegetables supplied to the UK in 1987, to 34 crops in 2013. The contribution of tropical fruits has rapidly increased while that of more traditional vegetables, such as cabbages and carrots, has declined. The proportion of fruit and vegetables supplied to the UK market from climate vulnerable countries increased from 20% in 1987 to 32% in 2013. Sensitivity analyses - using climatic and freshwater availability indicators - supported these findings. Increased reliance on fruit and vegetable imports from climate vulnerable countries could negatively affect the availability, price and consumption of fruit and vegetables in the UK, affecting dietary intake and health particularly of older people and low-income households. Inter-sectoral actions across agriculture, health, environment, and trade are critical in both the UK and countries that export to the UK to increase the resilience of the food system, and support population health.

Effectiveness of PEHRs use to increase vaccine uptake: a systematic review

Abstract Background The digital transformation provides tools to empower individuals and enable feedback and interaction between users and healthcare providers. Although Personal Electronic Health Records (PEHR) have been identified as innovative tools enabling the provision of patient-centered care and prevention, evidence on their impact is scant. Methods We conducted a systematic review following the PRISMA guidelines to retrieve, quantitatively pool and critically appraise the effectiveness of PEHR access on vaccine uptake. Analysis on effectiveness were carried out for the following comparison strata: i) PEHR access vs no intervention, ii) PEHR access vs access with additional features. Results Of identified 3125 citations, 8 studies were included, the majority published in the US before 2015. Four studies assessed differences between subjects with and without access to PEHR. Access to PEHR was reported to be an effective tool to increase vaccine uptake: when accessing PEHR, study participants were 6.7% more likely to receive influenza vaccine, parents to have children vaccinated, lifetime pneumococcal vaccination was reported to be higher in diabetic patients, a positive impact on preventive behaviors was reported. Four included studies reported on the effect of access to PEHR with or without additional communication features. In one study, the effect of electronic messages delivered through PEHRs wasn't differentially distributed in the arm receiving tailored messages on influenza, and in the arm receiving educational messages on other diseases. In other studies, active PEHR users were more likely to be vaccinated against influenza and Herpes Zoster, subjects who in addition received reminders had higher rates of influenza vaccination. Conclusions While immunization programs are struggling to achieve optimal coverage targets, our findings can partially outline the association between PEHR access and vaccine uptake and further experimental research is needed. Key messages PEHRs offer great potential to support population health and in particular immunization programs, helping to put people and patients at the center of care delivery, supporting patient empowerment. Although our findings suggest immunization coverage might benefit from people accessing PEHR, there is an urgent need to produce solid experimental evidence to quantify such effect.