Global demand for cancer surgery and an estimate of the optimal surgical and anaesthesia workforce between 2018 and 2040: a population-based modelling study.

BACKGROUND: The growing demand for cancer surgery has placed a global strain on health systems. In-depth analyses of the global demand for cancer surgery and optimal workforce requirements are needed to plan service provision. We estimated the global demand for cancer surgery and the requirements for an optimal surgical and anaesthesia workforce, using benchmarks based on clinical guidelines. METHODS: Using models of benchmark surgical use based on clinical guidelines, we estimated the proportion of cancer cases with an indication for surgery across 183 countries, stratified by income group. These proportions were multiplied by age-adjusted national estimates of new cancer cases using GLOBOCAN 2018 data and then aggregated to obtain the estimated number of surgical procedures required globally. The numbers of cancer surgical procedures in 44 high-income countries were divided by the actual number of surgeons and anaesthetists in the respective countries to calculate cancer procedures per surgeon and anaesthetist ratios. Using the median (IQR) of these ratios as benchmarks, we developed a three-tiered optimal surgical and anaesthesia workforce matrix, and the predictions were extrapolated up to 2040. FINDINGS: Our model estimates that the number of cancer cases globally with an indication for surgery will increase by 5 million procedures (52%) between 2018 (9 065 000) and 2040 (13 821 000). The greatest relative increase in surgical demand will occur in 34 low-income countries, where we also observed the largest gaps in workforce requirements. To match the median benchmark for high-income countries, the surgical workforce in these countries would need to increase by almost four times and the anaesthesia workforce by nearly 5·5 times. The greatest increase in optimal workforce requirements from 2018 to 2040 will occur in low-income countries (from 28 000 surgeons to 58 000 surgeons; 107% increase), followed by lower-middle-income countries (from 166 000 surgeons to 277 000 surgeons; 67% increase). INTERPRETATION: The global demand for cancer surgery and the optimal workforce are predicted to increase over the next two decades and disproportionately affect low-income countries. These estimates provide an appropriate framework for planning the provision of surgical services for cancer worldwide. FUNDING: University of New South Wales Scientia Scholarship and UK Research and Innovation Global Challenges Research Fund.

Trends in Outpatient Antibiotic Use in 3 Health Plans.

OBJECTIVES: Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS: Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS: We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS: These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.

Application of Constrained Optimization Methods in Health Services Research: Report 2 of the ISPOR Optimization Methods Emerging Good Practices Task Force.

BACKGROUND: Constrained optimization methods are already widely used in health care to solve problems that represent traditional applications of operations research methods, such as choosing the optimal location for new facilities or making the most efficient use of operating room capacity. OBJECTIVES: In this paper we illustrate the potential utility of these methods for finding optimal solutions to problems in health care delivery and policy. To do so, we selected three award-winning papers in health care delivery or policy development, reflecting a range of optimization algorithms. Two of the three papers are reviewed using the ISPOR Constrained Optimization Good Practice Checklist, adapted from the framework presented in the initial Optimization Task Force Report. The first case study illustrates application of linear programming to determine the optimal mix of screening and vaccination strategies for the prevention of cervical cancer. The second case illustrates application of the Markov Decision Process to find the optimal strategy for treating type 2 diabetes patients for hypercholesterolemia using statins. The third paper (described in Appendix 1) is used as an educational tool. The goal is to describe the characteristics of a radiation therapy optimization problem and then invite the reader to formulate the mathematical model for solving it. This example is particularly interesting because it lends itself to a range of possible models, including linear, nonlinear, and mixed-integer programming formulations. From the case studies presented, we hope the reader will develop an appreciation for the wide range of problem types that can be addressed with constrained optimization methods, as well as the variety of methods available. CONCLUSIONS: Constrained optimization methods are informative in providing insights to decision makers about optimal target solutions and the magnitude of the loss of benefit or increased costs associated with the ultimate clinical decision or policy choice. Failing to identify a mathematically superior or optimal solution represents a missed opportunity to improve economic efficiency in the delivery of care and clinical outcomes for patients. The ISPOR Optimization Methods Emerging Good Practices Task Force's first report provided an introduction to constrained optimization methods to solve important clinical and health policy problems. This report also outlined the relationship of constrained optimization methods relative to traditional health economic modeling, graphically illustrated a simple formulation, and identified some of the major variants of constrained optimization models, such as linear programming, dynamic programming, integer programming, and stochastic programming. The second report illustrates the application of constrained optimization methods in health care decision making using three case studies. The studies focus on determining optimal screening and vaccination strategies for cervical cancer, optimal statin start times for diabetes, and an educational case to invite the reader to formulate radiation therapy optimization problems. These illustrate a wide range of problem types that can be addressed with constrained optimization methods.

Management of multiple sclerosis and the integration of related specialty pharmacy programs within health systems.

PURPOSE: The management of multiple sclerosis (MS) and the integration of related specialty pharmacy programs within health systems are discussed. SUMMARY: MS is a progressive immune-mediated inflammatory disease of the central nervous system. Current treatment strategies include the use of disease-modifying therapies (DMTs) that have various degrees of efficacy and tolerability. These DMTs also differ with respect to frequency and route of administration, which can significantly impact patient compliance and ultimately their response to therapy. The introduction of oral and injectable DMTs requiring less-frequent injections and having better adverse-effect profiles may help patients improve adherence to therapy; however, access to these therapies is often restricted due to both their high cost and limited distribution. These DMTs include fingolimod, teriflunomide, dimethyl fumarate, and pegylated interferon beta-1a. All others, with the exception of fingolimod, have limited distribution. Pharmacists in health-system pharmacy programs can play a significant role in assisting patients with MS manage their disease efficiently and safely by educating them about their therapies, ensuring compliance with the associated risk evaluation and mitigation strategy (REMS) program, and helping them access these therapies in a timely manner. CONCLUSION: MS is a progressive neurologic disorder that requires lifelong treatment with DMTs. Good compliance, compliance with the associated REMS program, and timely access to these drugs may positively influence patient care and outcomes and provide an opportunity for the health-system pharmacists to have a active role in caring for these patients.

'Big push' to reduce maternal mortality in Uganda and Zambia enhanced health systems but lacked a sustainability plan.

In the past decade, "big push" global health initiatives financed by international donors have aimed to rapidly reach ambitious health targets in low-income countries. The health system impacts of these efforts are infrequently assessed. Saving Mothers, Giving Life is a global public-private partnership that aims to reduce maternal mortality dramatically in one year in eight districts in Uganda and Zambia. We evaluated the first six to twelve months of the program's implementation, its ownership by national ministries of health, and its effects on health systems. The project's impact on maternal mortality is not reported here. We found that the Saving Mothers, Giving Life initiative delivered a large "dose" of intervention quickly by capitalizing on existing US international health assistance platforms, such as the President's Emergency Plan for AIDS Relief. Early benefits to the broader health system included greater policy attention to maternal and child health, new health care infrastructure, and new models for collaborating with the private sector and communities. However, the rapid pace, external design, and lack of a long-term financing plan hindered integration into the health system and local ownership. Sustaining and scaling up early gains of similar big push initiatives requires longer-term commitments and a clear plan for transition to national control.

Exercise as a vital sign: a quasi-experimental analysis of a health system intervention to collect patient-reported exercise levels.

BACKGROUND: Lack of regular physical activity is highly prevalent in U.S. adults and significantly increases mortality risk. OBJECTIVE: To examine the clinical impact of a newly implemented program ("Exercise as a Vital Sign" [EVS]) designed to systematically ascertain patient-reported exercise levels at the beginning of each outpatient visit. DESIGN AND PARTICIPANTS: The EVS program was implemented in four of 11 medical centers between April 2010 and October 2011 within a single health delivery system (Kaiser Permanente Northern California). We used a quasi-experimental analysis approach to compare visit-level and patient-level outcomes among practices with and without the EVS program. Our longitudinal observational cohort included over 1.5 million visits by 696,267 adults to 1,196 primary care providers. MAIN MEASURES: Exercise documentation in physician progress notes; lifestyle-related referrals (e.g. exercise programs, nutrition and weight loss consultation); patient report of physician exercise counseling; weight change among overweight/obese patients; and HbA1c changes among patients with diabetes. KEY RESULTS: EVS implementation was associated with greater exercise-related progress note documentation (26.2 % vs 23.7 % of visits, aOR 1.12 [95 % CI: 1.11-1.13], p < 0.001) and referrals (2.1 % vs 1.7 %; aOR 1.14 [1.11-1.18], p < 0.001) compared to visits without EVS. Surveyed patients (n = 6,880) were more likely to report physician exercise counseling (88 % vs. 76 %, p < 0.001). Overweight patients (BMI 25-29 kg/m(2), n = 230,326) had greater relative weight loss (0.20 [0.12 - 0.28] lbs, p < 0.001) and patients with diabetes and baseline HbA1c > 7.0 % (n = 30,487) had greater relative HbA1c decline (0.1 % [0.07 %-0.13 %], p < 0.001) in EVS practices compared to non-EVS practices. CONCLUSIONS: Systematically collecting exercise information during outpatient visits is associated with small but significant changes in exercise-related clinical processes and outcomes, and represents a valuable first step towards addressing the problem of inadequate physical activity.

[To aim at better home medical care].

As Japan has been confronting rapid aging of the population, the government is promoting home medical care, with reforming medical service policy, offering subsidies, and revising payment system of medical service. Hereafter, home medical care will play an important role in order to build the integrated community care system by cooperating with long-term care services. More physicians, not only of specialized clinics, but also of general ones, are expected to visit home to provide medical service to their own immobile patients.

Strategic approach for improving the medication-use process in health systems: the high-performance pharmacy practice framework.

PURPOSE: A strategic approach to improving the medication-use process in health systems by using a framework for setting priorities on the basis of feasibility, the potential for financial return, and the effect on quality and safety is described. SUMMARY: A panel consisting of leaders in health-system pharmacy identified seven dimensions of high-performance pharmacy (HPP) framework: medication preparation and delivery, patient care services, medication safety, medication-use policy, financial performance, human resources, and education. Performance elements, which are specific policies, procedures, activities, and practices that indicate high performance and result in a financial or clinical return on investment of resources, within each dimension were identified. References, practice standards, and policies related to each performance element were also identified. By consensus, the panel assigned qualitative metric scores for each of the 69 performance elements that represent the panel's assessment of the resources necessary to achieve full implementation of the element and the potential financial and quality and safety returns if the element has not yet been implemented. It is noted that a pharmacy department's actual outlay of resources and expected financial return will differ depending on the size of the health system, the size of pharmacy staff, and the extent of previous implementation efforts. The framework can also be used to rejustify existing services and programs and identify opportunities for improvement. CONCLUSION: The HPP framework characterizes pharmacy performance elements on the basis of feasibility, financial return, and effect on quality and safety. The framework provides pharmacists with a means to establish priorities in improving the medication-use system.

Qualidade em saúde: tópicos para discussão / Health care quality: tópicos for discussion

A avaliação da qualidade dos cuidados em saúde é questão das mais atuais na prática clínica e na formulação das políticas de saúde.Vários são os aspectos envolvidos na definição de qualidade e várias são as suas formas de avaliação.Os avanços tecnológicos e os custos crescentes dos métodos diagnósticos e dos tratamentos são uma realidade e, particularmente na cardiologia, são muito frequêntes, ainda que rotineiramente essa questão não seja percebida.A incorporação dessas novas medidas, tanto do ponto de vista técnico como do ponto de vista social, deve ser amplamente discutida.Esse artigo busca trazer a algumas reflexões sobre a avaliação da qualidade dos cuidados em saúde

Current efforts toward implementation of an urban health strategy: the Henry Ford Health System.

The Henry Ford Health System is one of the nation's major comprehensive nonprofit health systems. Though it serves seven counties in southeastern Michigan, it is based in the heart of the city of Detroit. Detroit, like many of the nation's largest cities, has high rates of poverty, single-parent households, unemployment, and violence. The health status of the population is well below national norms and Healthy People 2000 goals. Through the combined efforts of public and private organizations and the people of southeastern Michigan, Detroit is experiencing a renaissance. Henry Ford Health System is contributing to this renaissance and is working to define its role in improving the health status and quality of life of Detroit's residents. The system's current strategy centers on moving beyond civic projects and philanthropic efforts to the incorporation of care for the uninsured and underinsured in its core operations and plans for growth. To make this change, we have developed a systemwide process that focuses on designing and implementing new delivery models, on partnership development with a variety of organizations, and on managing the care of populations. Our efforts are a work in progress, but they are having an impact on our patients, our organization, and our community.