High in-vivo accuracy of a novel robotic-arm-assisted system for total knee arthroplasty.

PURPOSE: Robotic-assisted total knee arthroplasty (TKA) has been shown to improve the accuracy and precision of bony resections and implant position. However, the in vivo accuracy of the full surgical workflow has not been widely reported. The primary objective of this study is to determine the accuracy and precision of a robotic-arm-assisted system throughout the intraoperative workflow. METHODS: This was a retrospective cohort study of adult patients who underwent primary TKA with various workflows and alignment targets by three arthroplasty-trained surgeons with previous experience using the ROSA® Knee System (Zimmer Biomet) over a 3-month follow-up period. Accuracy and precision were determined by measuring the difference between various workflow time points, including the final preoperative plan (PP), robot-validated (RV) resection angle and postoperative radiographs (PR). The absolute mean difference between the measurements determined accuracy, and the standard deviation represented precision. The lateral distal femoral angle, medial proximal tibial angle, femoral flexion angle and tibial slope were measured on postoperative coronal long-leg radiographs and true short-leg lateral radiographs. RESULTS: A total of 77 patients were included in the final analyses. The accuracy for the coronal femoral angle was 1.62 ± 1.11°, 0.75 ± 0.79° and 1.96 ± 1.29° for the differences between PP and PR, PP and RV and RV and PR. The tibial coronal accuracy was 1.44 ± 1.03°, 0.81 ± 0.67° and 1.57 ± 1.14° for PP/PR, PP/RV and RV/PR, respectively. Femoral flexion accuracy was 1.39 ± 1.05°, 0.83 ± 0.59° and 1.81 ± 1.21° for PP/PR, PP/RV and RV/PR, respectively. Tibial slope accuracy was 0.99 ± 0.72°, 1.19 ± 0.87° and 1.63 ± 1.11°, respectively. The proportion of patients within 3° was 93.2%, 95.3%, 97.3% and 94.6% for the distal femur, proximal tibia, femoral flexion and tibial slope angles when the final intraoperative plan was compared to PRs. No patients had a postoperative complication at the final follow-up. CONCLUSIONS: The ROSA Knee System has acceptable accuracy and precision of coronal and sagittal plane resections with few outliers at various steps throughout the platform's entire workflow in vivo. LEVEL OF EVIDENCE: Level III.

Identification of protective and 'at risk' HLA genotypes for the development of pseudotumours around metal-on-metal hip resurfacings.

Hip resurfacing remains a potentially valuable surgical procedure for appropriately-selected patients with optimised implant choices. However, concern regarding high early failure rates continues to undermine confidence in use. A large contributor to failure is adverse local tissue reactions around metal-on-metal (MoM) bearing surfaces. Such phenomena have been well-explored around MoM total hip arthroplasties, but comparable data in equivalent hip resurfacing procedures is lacking. In order to define genetic predisposition, we performed a case-control study investigating the role of human leucocyte antigen (HLA) genotype in the development of pseudotumours around MoM hip resurfacings. A matched case-control study was performed using the prospectively-collected database at the host institution. In all, 16 MoM hip resurfacing 'cases' were identified as having symptomatic periprosthetic pseudotumours on preoperative metal artefact reduction sequence (MARS) MRI, and were subsequently histologically confirmed as high-grade aseptic lymphocyte-dominated vasculitis-associated lesions (ALVALs) at revision surgery. 'Controls' were matched by implant type in the absence of evidence of pseudotumour. Blood samples from all cases and controls were collected prospectively for high resolution genetic a nalysis targeting 11 separate HLA loci. Statistical significance was set at 0.10 a priori to determine the association between HLA genotype and pseudotumour formation, given the small sample size. Using a previously-reported ALVAL classification, the majority of pseudotumour-positive caseswere found to have intermediate-grade group 2 (n = 10; 63%) or group 3 (n = 4; 25%) histological findings. Two further patients (13%) had high-grade group 4 lesions. HLA-DQB1*05:03:01 (p = 0.0676) and HLA-DRB1*14:54:01 (p = 0.0676) alleles were significantly associated with a higher risk of pseudotumour formation, while HLA-DQA1*03:01:01 (p = 0.0240), HLA-DRB1*04:04:01 (p = 0.0453), HLA-C*01:02:01 (p = 0.0453), and HLA-B*27:05:02 (p = 0.0855) were noted to confer risk reduction. These findings confirm the association between specific HLA genotypes and the risk of pseudotumour development around MoM hip resurfacings. Specifically, the two 'at risk' alleles (DQB1*05:03:01 and DRB1*14:54:01) may hold clinical value in preoperative screening and prospective surgical decision-making.

Introduction of ROSA robotic-arm system for total knee arthroplasty is associated with a minimal learning curve for operative time.

PURPOSE: The introduction of robotics for total knee arthroplasty (TKA) into the operating theatre is often associated with a learning curve and is potentially associated with additional complications. The purpose of this study was to determine the learning curve of robotic-assisted (RA) TKA within a multi-surgeon team. METHODS: This prospective cohort study included 83 consecutive conventional jig-based TKAs compared with 53 RA TKAs using the Robotic Surgical Assistant (ROSA) system (Zimmer Biomet, Warsaw, Indiana, USA) for knee osteoarthritis performed by three high-volume (> 100 TKA per year) orthopaedic surgeons. Baseline characteristics including age, BMI, sex and pre-operative Kellgren-Lawrence graded and Hip-Knee-Ankle Axis were well-matched between the conventional and RA TKA groups. Cumulative summation (CUSUM) analysis was used to assess learning curves for operative times for each surgeon. Peri-operative and delayed complications (infection, periprosthetic fracture, thromboembolism, and compromised wound healing) and revisions were reviewed. RESULTS: The CUSUM analysis for operative time demonstrated an inflexion point after 5, 6 and 15 cases for each of the three surgeons, or 8.7 cases on average. There were no significant differences (p = 0.53) in operative times between the RA TKA learning (before inflexion point) and proficiency (after inflexion point) phases. Similarly, the operative times of the RA TKA group did not differ significantly (p = 0.92) from the conventional TKA group. There was no discernible learning curve for the accuracy of component planning using the RA TKA system. The average length of post-operative follow-up was 21.3 ± 9.0 months. There was one revision for instability in the conventional TKA group and none in the RA TKA group. There were no significant difference (p > 0.99) in post-operative complication rates between the conventional TKA and RA TKA groups. CONCLUSIONS: The introduction of the RA TKA system was associated with a learning curve for operative time of 8.7 cases. Operative times between the RA TKA and conventional TKA group were similar. The short learning curve implies this RA TKA system can be adopted relatively quickly into a surgical team with minimal risks to patients.

Computable Guidelines and Clinical Decision Support for Cervical Cancer Screening and Management to Improve Outcomes and Health Equity.

Cervical cancer is highly preventable when precancerous lesions are detected early and appropriately managed. However, the complexity of and frequent updates to existing evidence-based clinical guidelines make it challenging for clinicians to stay abreast of the latest recommendations. In addition, limited availability and accessibility to information technology (IT) decision supports make it difficult for groups who are medically underserved to receive screening or receive the appropriate follow-up care. The Centers for Disease Control and Prevention (CDC), Division of Cancer Prevention and Control (DCPC), is leading a multiyear initiative to develop computer-interpretable ("computable") version of already existing evidence-based guidelines to support clinician awareness and adoption of the most up-to-date cervical cancer screening and management guidelines. DCPC is collaborating with the MITRE Corporation, leading scientists from the National Cancer Institute, and other CDC subject matter experts to translate existing narrative guidelines into computable format and develop clinical decision support tools for integration into health IT systems such as electronic health records with the ultimate goal of improving patient outcomes and decreasing disparities in cervical cancer outcomes among populations that are medically underserved. This initiative meets the challenges and opportunities highlighted by the President's Cancer Panel and the President's Cancer Moonshot 2.0 to nearly eliminate cervical cancer.

Characterization of convergent thickening, a major convergence force producing morphogenic movement in amphibians.

The morphogenic process of convergent thickening (CT) was originally described as the mediolateral convergence and radial thickening of the explanted ventral involuting marginal zone (IMZ) of Xenopus gastrulae (Keller and Danilchik, 1988). Here, we show that CT is expressed in all sectors of the pre-involution IMZ, which transitions to expressing convergent extension (CE) after involution. CT occurs without CE and drives symmetric blastopore closure in ventralized embryos. Assays of tissue affinity and tissue surface tension measurements suggest CT is driven by increased interfacial tension between the deep IMZ and the overlying epithelium. The resulting minimization of deep IMZ surface area drives a tendency to shorten the mediolateral (circumblastoporal) aspect of the IMZ, thereby generating tensile force contributing to blastopore closure (Shook et al., 2018). These results establish CT as an independent force-generating process of evolutionary significance and provide the first clear example of an oriented, tensile force generated by an isotropic, Holtfreterian/Steinbergian tissue affinity change.

Arthroscopic correction of femoroacetabular impingement improves athletic performance in male athletes.

PURPOSE: To measure the changes in athletic performance in athletes treated arthroscopically for femoroacetabular impingement and compare results to a matched controlled athletic cohort, over a 1-year period. METHODS: Male athletes scheduled for arthroscopic correction of symptomatic FAI were recruited and tested (pre-operatively and 1-year postsurgery) for measures of athletic performance which included acceleration (10-m sprint), change of direction speed (CODS), squatting depth, and reactive strength index (RSI). The FAI group was compared to a matched, healthy, control group who were tested at baseline and 1 year later with no disruption to their regular training or competition status; the prevalence of anterior groin pain during testing in either group was recorded. Hip range of motion (ROM) was also measured for both groups at baseline and at 1 year in the FAI group to look for change following intervention. RESULTS: Prior to surgery, the FAI group were slower than the control group (p < 0.001) for acceleration (3% slower) and CODS (10% slower). At 1 year, 91% of the FAI group returned to full competition at an average time of 17 weeks, while substantial reductions in pain were also noted during acceleration (51-6%, p = 0.004), CODS (62-8%, p = 0.001), and squat test (38-8%, p = 0.003). Significant improvements were seen in the FAI group for CODS (7%, p < 0.001) and squat depth measures (6%, p = 0.004) from baseline to 1 year (significant time × group interaction effects were noted for these also). The changes in performance in the control group over time were non-significant across all of the measures (n.s.). At 1-year postsurgery, there were no statistically significant differences between the groups for any of the athletic measures. There was a significant and clinically important improvement in range of hip motion in the FAI group at 1-year postsurgery (p < 0.05). CONCLUSION: Symptomatic FAI causes substantial reductions in athletic performance compared to healthy competitors placing these athletes at a distinct performance disadvantage. The results from the current study demonstrate that arthroscopic correction (including labral repair) in athletes with symptomatic FAI, reduces pain and restores athletic performance to a level which is comparable to healthy athletes, at 1 year. LEVEL OF EVIDENCE: II.

Radiofrequency ablation of osteoid osteoma: Aiming for excellent outcomes in an Australasian context.

INTRODUCTION: To report a series of patients with osteoid osteoma treated by radiofrequency ablation in whom no complications or recurrences occurred. METHODS: Over a 13-year period, 32 consecutive patients with osteoid osteoma were treated by radiofrequency ablation in an Australasian teaching centre. RESULTS: All patients had resolution of symptoms with no complication or recurrence. CONCLUSIONS: This series is further evidence for the use of radiofrequency ablation as the primary treatment for osteoid osteoma.

Patient Engagement in Type 2 Diabetes: A Collaborative Community Health Initiative.

Purpose The purpose of this study was to describe the effects of an innovative rural community-based, diabetes self-management education and support (DSMES) program on patient behaviors and outcomes. Methods A 12-month pre-post study design with physiological data collection at program initiation, 16 weeks, and 6 and 12 months postenrollment was used for program assessment. The program consisted of an American Diabetes Association-accredited curriculum provided by the hospital and interfaced with a YMCA curriculum promoting lifestyle change. The 28-session program was delivered over a 1-year period. Results The sample size was 115. Participants were primarily white and female, with a mean age of 57 years. Mean body mass index (BMI) at program initiation was 37; mean A1C was 8.5 (69.4 mmol/mol). Significant reductions were obtained in weight, BMI (at 16 weeks), and A1C (at 6 months); these reductions were sustained at 12 months. Medication intake was significantly reduced, and diabetes-related emergency department visits were below national averages. Conclusions Results support the positive impact of a year-long, community-based, healthy behavior, DSMES program on health outcomes and overall costs of care delivery in the rural setting.

Improving Hospital Performance Rankings Using Discrete Patient Diagnoses for Risk Adjustment of Outcomes.

OBJECTIVE: To assess the changes in patient outcome prediction and hospital performance ranking when incorporating diagnoses as risk adjusters rather than comorbidity indices. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient Databases for New York State, 2005-2009. STUDY DESIGN: Conducted tree-based classification for mortality and readmission by incorporating discrete patient diagnoses as predictors, comparing with traditional comorbidity indices such as those used for Centers for Medicare and Medicaid Services (CMS) outcome models. PRINCIPAL FINDINGS: Diagnosis codes as predictors increased predictive accuracy 5.6 percent (95% CI: 4.5-6.9 percent) relative to CMS condition categories for heart failure 30-day mortality. Most other outcomes exhibited statistically significant accuracy gains and facility ranking shifts. Sensitivity analysis showed improvements even when predictors were limited to only the diagnoses included in CMS models. CONCLUSIONS: Discretizing patient severity information beyond the levels of traditional comorbidity indices improves patient outcome predictions and substantially shifts facility rankings.

Differences in Athletic Performance Between Sportsmen With Symptomatic Femoroacetabular Impingement and Healthy Controls.

OBJECTIVE: Femoroacetabular impingement (FAI) is a commonly recognized condition in athletes characterized by activity-related hip pain and stiffness, which if left untreated can progress to hip osteoarthritis. The aim of the study was to determine the effect of symptomatic FAI on performance in young athletes based on the hypothesis that athletes with FAI would show deficits in performance compared with healthy controls. DESIGN: The functional performance of a cohort of preoperative, competitive sportsmen with symptomatic FAI (FAI group, n = 54), was compared with that of a group of age, sex and activity-level matched controls (n = 66). OUTCOME MEASURES: Participants performed functional tests including a 10-m sprint, a modified agility T-test, a maximal deep squat test and a single-leg drop jump (reactive strength index). Hip range of motion was assessed by measuring maximal hip flexion, abduction, and internal rotation (at 90 degree hip flexion). RESULTS: The FAI group was significantly slower during the 10-m sprint (3%, P = 0.002) and agility T-test (8%, P < 0.001); flexion, abduction, and internal rotation values for the FAI group were reduced compared with controls (P < 0.001). No significant differences between groups were identified for squat depth or reactive strength index. The FAI group also reported higher levels of anterior groin pain during the 10-m sprint, modified agility T-test, and while squatting. CONCLUSIONS: Many sportsmen with confirmed FAI continue sports participation up to and after diagnosis, despite issues with activity-related pain and stiffness. This study highlights the functional limitations in speed, agility, and flexibility that are likely to be present in this group of FAI patients.

The effect of facility-based antiretroviral therapy programs on outpatient services in Kenya and Uganda.

BACKGROUND: Considerable debate exists concerning the effects of antiretroviral therapy (ART) service scale-up on non-HIV services and overall health system performance in sub-Saharan Africa. In this study, we examined whether ART services affected trends in non-ART outpatient department (OPD) visits in Kenya and Uganda. METHODS: Using a nationally representative sample of health facilities in Kenya and Uganda, we estimated the effect of ART programs on OPD visits from 2007 to 2012. We modeled the annual percent change in non-ART OPD visits using hierarchical mixed-effects linear regressions, controlling for a range of facility characteristics. We used four different constructs of ART services to capture the different ways in which the presence, growth, overall, and relative size of ART programs may affect non-ART OPD services. RESULTS: Our final sample included 321 health facilities (140 in Kenya and 181 in Uganda). On average, OPD and ART visits increased steadily in Kenya and Uganda between 2007 and 2012. For facilities where ART services were not offered, the average annual increase in OPD visits was 4·2% in Kenya and 13·5% in Uganda. Among facilities that provided ART services, we found average annual OPD volume increases of 7·2% in Kenya and 5·6% in Uganda, with simultaneous annual increases of 13·7% and 12·5% in ART volumes. We did not find a statistically significant relationship between annual changes in OPD services and the presence, growth, overall, or relative size of ART services. However, in a subgroup analysis, we found that Ugandan hospitals that offered ART services had statistically significantly less growth in OPD visits than Ugandan hospitals that did not provide ART services. CONCLUSIONS: Our findings suggest that ART services in Kenya and Uganda did not have a statistically significant deleterious effects on OPD services between 2007 and 2012, although subgroup analyses indicate variation by facility type. Our findings are encouraging, particularly given recent recommendations for universal access to ART, demonstrating that expanding ART services is not inherently linked to declines in other health services in sub-Saharan Africa.

Assessing the Effectiveness of the Functional Movement Screen in Predicting Noncontact Injury Rates in Soccer Players.

Smith, PD, and Hanlon, D. Assessing the effectiveness of the functional movement screen in predicting noncontact injury rates in soccer players. J Strength Cond Res 31(12): 3327-3332, 2017-This study assessed if the Functional Movement Screen (FMS) can accurately predict noncontact injury in adult soccer players when normalizing noncontact injury occurrence against match exposure levels. Senior male players (n = 89) from 5 League of Ireland semiprofessional clubs participated in the study (mean age = 23.2 ± 4.4 years; mean height = 179.5 ± 6.6 cm; mean body mass = 77.5 ± 7.8 kg). Participants performed the FMS during preseason, and their injury occurrence rates and match minutes were tracked throughout 1 season. In total, 66 noncontact injuries were recorded. No significant difference was found in FMS composite scores between players receiving noncontact injuries and players not suffering a noncontact injury (p = 0.96). There was no significant difference in exposure-normalized noncontact injury incidence between those scoring 14 or below and those scoring above 14 on the FMS (0.36 vs. 0.29 non-contact injuries per player per 1,000 match minutes). Players scoring 14 or below on the FMS had an odds ratio of 0.63 (p = 0.45; 95% CI = 0.19-2.07) of receiving a noncontact injury. Despite previous research showing links between low FMS composite scores and subsequent injury, these results suggest that the FMS cannot accurately predict a male soccer player's likelihood of receiving a noncontact injury and that a lower FMS composite score does not significantly increase their noncontact injury incidence rate per 1,000 match minutes. Caution should therefore be used when using the FMS as a predictor of noncontact injury, and pain prevalence during the FMS, previous injuries, and training/match exposure levels should also be taken into account.

The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia.

BACKGROUND: Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion. METHODS: Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency. RESULTS: In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients. CONCLUSIONS: Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.

Efficiency of Health Care Production in Low-Resource Settings: A Monte-Carlo Simulation to Compare the Performance of Data Envelopment Analysis, Stochastic Distance Functions, and an Ensemble Model.

Low-resource countries can greatly benefit from even small increases in efficiency of health service provision, supporting a strong case to measure and pursue efficiency improvement in low- and middle-income countries (LMICs). However, the knowledge base concerning efficiency measurement remains scarce for these contexts. This study shows that current estimation approaches may not be well suited to measure technical efficiency in LMICs and offers an alternative approach for efficiency measurement in these settings. We developed a simulation environment which reproduces the characteristics of health service production in LMICs, and evaluated the performance of Data Envelopment Analysis (DEA) and Stochastic Distance Function (SDF) for assessing efficiency. We found that an ensemble approach (ENS) combining efficiency estimates from a restricted version of DEA (rDEA) and restricted SDF (rSDF) is the preferable method across a range of scenarios. This is the first study to analyze efficiency measurement in a simulation setting for LMICs. Our findings aim to heighten the validity and reliability of efficiency analyses in LMICs, and thus inform policy dialogues about improving the efficiency of health service production in these settings.

Can Trained Runners Effectively Attenuate Impact Acceleration During Repeated High-Intensity Running Bouts?

The purpose of this study was to investigate the effects of prolonged high-intensity running on impact accelerations in trained runners. Thirteen male distance runners completed two 20-minute treadmill runs at speeds corresponding to 95% of onset of blood lactate accumulation. Leg and head accelerations were collected for 20 s every fourth minute. Rating of perceived exertion (RPE) scores were recorded during the third and last minute of each run. RPE responses increased (P < .001) from the start (11.8 ± 0.9, moderate intensity) of the first run to the end (17.7 ± 1.5, very hard) of the second run. Runners maintained their leg impact acceleration, impact attenuation, stride length, and stride frequency characteristics with prolonged run duration. However, a small (0.11-0.14g) but significant increase (P < .001) in head impact accelerations were observed at the end of both first and second runs. It was concluded that trained runners are able to control leg impact accelerations during sustained high-intensity running. Alongside the substantial increases in perceived exertion levels, running mechanics and frequency domain impact attenuation levels remained constant. This suggests that the present trained runners are able to cope from a mechanical perspective despite an increased physiological demand.

Management Factors Associated with Operation-Level Prevalence of Antibodies to Cache Valley Virus and Other Bunyamwera Serogroup Viruses in Sheep in the United States.

A cross-sectional study was performed to identify operation-level risk factors associated with prevalence of antibody to Bunyamwera (BUN) serogroup viruses in sheep in the United States. Sera were obtained from 5150 sheep in 270 operations located in 22 states (three in the west, nine central states, and 10 in the east) and tested at a dilution of 1:20 by a plaque reduction neutralization test (PRNT) using Cache Valley virus (CVV). Antibodies that neutralized CVV were identified in 1455 (28%) sheep. Animal-level seroprevalence was higher in the east (49%) than the central (17%) and western (10%) states. A convenient subset (n = 509) of sera with antibodies that neutralized CVV was titrated and further analyzed by PRNT using all six BUN serogroup viruses that occur in the United States: CVV, Lokern virus (LOKV), Main Drain virus (MDV), Northway virus (NORV), Potosi virus (POTV), and Tensaw virus (TENV). Antibodies to CVV and LOKV were identified in sheep in all three geographic regions; MDV and POTV activity was detected in the central and eastern states, NORV activity was restricted to the west, and antibodies to TENV were not detected in any sheep. Several management factors were significantly associated with the presence of antibodies to BUN serogroup viruses. For instance, sheep housed during the lambing season inside structures that contained four walls and a roof and a door closed most of the time were more likely to be seropositive than other sheep. In contrast, herded/open-range sheep were less likely to be seropositive than their counterparts. These data can be used by producers to implement strategies to reduce the likelihood of BUN serogroup virus infection and improve the health and management practices of sheep.

National health accounts data from 1996 to 2010: a systematic review.

OBJECTIVE: To collect, compile and evaluate publicly available national health accounts (NHA) reports produced worldwide between 1996 and 2010. METHODS: We downloaded country-generated NHA reports from the World Health Organization global health expenditure database and the Organisation for Economic Co-operation and Development (OECD) StatExtract website. We also obtained reports from Abt Associates, through contacts in individual countries and through an online search. We compiled data in the four main types used in these reports: (i) financing source; (ii) financing agent; (iii) health function; and (iv) health provider. We combined and adjusted data to conform with OECD's first edition of A system of health accounts manual, (2000). FINDINGS: We identified 872 NHA reports from 117 countries containing a total of 2936 matrices for the four data types. Most countries did not provide complete health expenditure data: only 252 of the 872 reports contained data in all four types. Thirty-eight countries reported an average not-specified-by-kind value greater than 20% for all data types and years. Some countries reported substantial year-on-year changes in both the level and composition of health expenditure that were probably produced by data-generation processes. All study data are publicly available at http://vizhub.healthdata.org/nha/. CONCLUSION: Data from NHA reports on health expenditure are often incomplete and, in some cases, of questionable quality. Better data would help finance ministries allocate resources to health systems, assist health ministries in allocating capital within the health sector and enable researchers to make accurate comparisons between health systems.

Pharmaceutical availability across levels of care: evidence from facility surveys in Ghana, Kenya, and Uganda.

OBJECTIVE: In this study we use facility-level data from nationally representative surveys conducted in Ghana, Kenya, and Uganda to understand pharmaceutical availability within the three countries. METHODS: In 2012, we conducted a survey to capture information on pharmaceuticals and other facility indicators from over 200 facilities in each country. We analyze data on the availability of pharmaceuticals and quantify its association with various facility-level indicators. We analyze both availability of essential medicines, as defined by the various essential medicine lists (EMLs) of each respective country, and availability of all surveyed pharmaceuticals deemed important for treatment of various high-burden diseases, including those on the EMLs. RESULTS: We find that there is heterogeneity with respect to availability across the three countries with Ghana generally having better availability than Uganda and Kenya. To analyze the relationship between facility-level factors and pharmaceutical stock-out we use a binomial regression model. We find that the factors associated with stock-out vary by country, but across all countries both presence of a laboratory at the facility and presence of a vehicle at the facility are significantly associated with reduced stock-out. CONCLUSION: The results of this study highlight the poor availability of essential medicines across these three countries and suggest more needs to be done to strengthen the supply system so that stock remains uninterrupted.