Challenging the status quo: a scoping review of value-based care models in cardiology and electrophysiology.

AIMS: The accomplishment of value-based healthcare (VBHC) models could save up to $1 trillion per year for healthcare systems worldwide while improving patients' wellbeing and experience. Nevertheless, its adoption and development are challenging. This review aims to provide an overview of current literature pertaining to the implementation of VBHC models used in cardiology, with a focus on cardiac electrophysiology. METHODS AND RESULTS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis for Scoping Reviews. The records included in this publication were relevant documents published in PubMed, Mendeley, and ScienceDirect. The search criteria were publications about VBHC in the field of cardiology and electrophysiology published between 2006 and 2023. The implementation of VBHC models in cardiology and electrophysiology is still in its infant stages. There is a clear need to modify the current organizational structure in order to establish cross-functional teams with the patient at the centre of care. The adoption of new reimbursement schemes is crucial to moving this process forward. The implementation of technologies for data analysis and patient management, among others, poses challenges to the change process. CONCLUSION: New VBHC models have the potential to improve the care process and patient experience while optimizing the costs. The implementation of this model has been insufficient mainly because it requires substantial changes in the existing infrastructures and local organization, the need to track adherence to guidelines, and the evaluation of the quality of life improvement and patient satisfaction, among others.

An overview of future EU health systems. An insight into governance, primary care, data collection and citizens' participation.

Background: Health systems in the European Union (EU) are being questioned over their effectiveness and sustainability. In pursuing both goals, they have to conciliate coexisting, not always aligned, realities. Methods: This paper originated from a workshop entitled 'Health systems for the future' held at the European Parliament. Experts and decision makers were asked to discuss measures that may increase the effectiveness and sustainability of health systems, namely: (i) increasing citizens' participation; (ii) the importance of primary care in providing integrated services; (iii) improving the governance and (iv) fostering better data collection and information channels to support the decision making process. Results: In the parliamentary debate, was discussed the concept that, in the near future, health systems' effectiveness and sustainability will very much depend on effective access to integrated services where primary care is pivotal, a clearer shift from care-oriented systems to health promotion and prevention, a profound commitment to good governance, particularly to stakeholders participation, and a systematic reuse of data meant to build health data-driven learning systems. Conclusions: Many health issues, such as future health systems in the EU, are potentially transformative and hence an intense political issue. It is policy-making leadership that will mostly determine how well EU health systems are prepared to face future challenges.

Influence of breastfeeding and postnatal nutrition on cardiovascular remodeling induced by fetal growth restriction.

BACKGROUND: Our aim was to determine the influence of breastfeeding and postnatal nutrition on cardiovascular remodeling induced by fetal growth restriction (FGR). METHODS: A cohort study including 81 children with birthweight <10th centile (FGR) and 121 with adequate fetal growth for gestational age (AGA) was conducted. Cardiovascular endpoints were left ventricular sphericity index (LVSI), carotid intima-media thickness (cIMT), and blood pressure (BP) at 4-5 y of age. The combined effect of FGR and postnatal variables-including breastfeeding, fat dietary intake, and BMI-on cardiovascular endpoints was assessed by linear and robust regressions. RESULTS: FGR was the strongest predictor of cardiovascular remodeling in childhood, leading to lower LVSI and increased cIMT and BP as compared with AGA. Breastfeeding >6 mo (coefficient: 0.0982) and healthy-fat dietary intake (coefficient: -0.0128) showed an independent beneficial effect on LVSI and cIMT, respectively. Overweight/obesity induced an additional increment of 1 SD on cIMT in FGR children (interaction coefficient: 0.0307) when compared with its effect in AGA. BMI increased systolic BP (coefficient: 0.7830) while weight catch-up increased diastolic BP (coefficient: 4.8929). CONCLUSIONS: Postnatal nutrition ameliorates cardiovascular remodeling induced by FGR. Breastfeeding and healthy-fat dietary intake improved while increased BMI worsened cardiovascular endpoints, which opens opportunities for targeted postnatal interventions from early life.

Level of distress, somatisation and beliefs on health-disease in newly arrived immigrant patients attended in primary care centres in Catalonia and definition of professional competences for their most effective management: PROMISE Project.

BACKGROUND: Newly arrived immigrant patients who frequently use primary health care resources have difficulties in verbal communication. Also, they have a system of beliefs related to health and disease that makes difficult for health care professionals to comprehend their reasons for consultation, especially when consulting for somatic manifestations. Consequently, this is an important barrier to achieve optimum care to these groups. The current project has two main objectives: 1. To define the different stressors, the level of distress perceived, and its impact in terms of discomfort and somatisation affecting the main communities of immigrants in our area, and 2. To identify the characteristics of cross-cultural competence of primary health care professionals to best approach these reasons for consultation. METHODS/DESIGN: It will be a transversal, observational, multicentre, qualitative-quantitative study in a sample of 980 people from the five main non-European Union immigrant communities residing in Catalonia: Maghrebis, Sub-Saharans, Andean South Americans, Hindustanis, and Chinese. Sociodemographic data, level of distress, information on the different stressors and their somatic manifestations will be collected in specific questionnaires. Through a semi-structured interview and qualitative methodology, it will be studied the relation between somatic manifestations and particular beliefs of each group and how these are associated with the processes of disease and seeking for care. A qualitative methodology based on individual interviews centred on critical incidents, focal groups and in situ questionnaires will be used to study the cross-cultural competences of the professionals. DISCUSSION: It is expected a high level of chronic stress associated with the level of somatisations in the different non-European Union immigrant communities. The results will provide better knowledge of these populations and will improve the comprehension and the efficacy of the health care providers in prevention, communication, care management and management of resources.

Building on value-based health care: Towards a health system perspective.

A variety of methodologies have been developed to help health systems increase the 'value' created from their available resources. The urgency of creating value is heightened by population ageing, growth in people with complex morbidities, technology advancements, and increased citizen expectations. This study develops a policy framework that seeks to reconcile the various approaches towards value-based policies in health systems. The distinctive contribution is that we focus on the value created by the health system as a whole, including health promotion, thus moving from value-based health care towards a value-based health system perspective. We define health system value to be the contribution of the health system to societal wellbeing. We adopt a framework of five dimensions of value, embracing health improvement, health care responsiveness, financial protection, efficiency and equity, which we map onto a society's aggregate wellbeing. Actors within the health system make different contributions to value, and we argue that their perspectives can be aligned with a unifying concept of health system value. We provide examples of policy levers and highlight key actors and how they can promote certain aspects of health system value. We discuss advantages of value-based approach based on the notion of wellbeing and some practical obstacles to its implementation.

From Health in All Policies to Health for All Policies.

Worldwide responses to the COVID-19 pandemic have shown that it is possible for politicians to come together across departmental boundaries. To this end, in many countries, heads of government and their health ministers work closely with all other ministries, departments, and sectors, including social affairs, internal affairs, foreign affairs, research and education, transport, agriculture, business, and state aid. In this Viewpoint, we ask if and how the Sustainable Development Goals (SDGs) can support intersectoral collaboration to promote health, since governments have already committed to achieving them. We contend that SDGs can do so, ultimately advancing health while offering co-benefits across society.

Innovation, value and reimbursement in radiation and complex surgical oncology: Time to rethink.

BACKGROUND AND PURPOSE: Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. MATERIAL AND METHODS: A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. RESULTS: Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. CONCLUSION: A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.

Drawing light from the pandemic: Rethinking strategies for health policy and beyond.

The COVID-19 pandemic is a catastrophe. It was also preventable. The potential impacts of a novel pathogen were foreseen and for decades scientists and commentators around the world warned of the threat. Most governments and global institutions failed to heed the warnings or to pay enough attention to risks emerging at the interface of human, animal, and environmental health. We were not ready for COVID-19, and people, economies, and governments around the world have suffered as a result. We must learn from these experiences now and implement transformational changes so that we can prevent future crises, and if and when emergencies do emerge, we can respond in more timely, robust and equitable ways, and minimize immediate and longer-term impacts. In 2020-21 the Pan-European Commission on Health and Sustainable Development assessed the challenges posed by COVID-19 in the WHO European region and the lessons from the response. The Commissioners have addressed health in its entirety, analyzing the interactions between health and sustainable development and considering how other policy priorities can contribute to achieving both. The Commission's final report makes a series of policy recommendations that are evidence-informed and above all actionable. Adopting them would achieve seven key objectives and help build truly sustainable health systems and fairer societies.

Innovation, value and reimbursement in radiation and complex surgical oncology: Time to rethink.

BACKGROUND AND PURPOSE: Complex surgery and radiotherapy are the central pillars of loco-regional oncology treatment. This paper describes the reimbursement schemes used in radiation and complex surgical oncology, reports on literature and policy reviews. MATERIAL AND METHODS: A systematic review of the literature of the reimbursement models has been carried out separately for radiotherapy and complex cancer surgery based on PRISMA guidelines. Using searches of PubMed and grey literature, we identified articles from scientific journals and reports published since 2000 on provider payment or reimbursement systems currently used in radiation oncology and complex cancer surgery, also including policy models. RESULTS: Most European health systems reimburse radiotherapy using a budget-based, fee-for-service or fraction-based system; while few reimburse services according to an episode-based model. Also, the reimbursement models for cancer surgery are mostly restricted to differences embedded in the DRG system and adjustments applied to the fees, based on the complexity of each surgical procedure. There is an enormous variability in reimbursement across countries, resulting in different incentives and different amounts paid for the same therapeutic strategy. CONCLUSION: A reimbursement policy, based on the episode of care as the basic payment unit, is advocated for. Innovation should be tackled in a two-tier approach: one defining the common criteria for reimbursement of proven evidence-based interventions; another for financing emerging innovation with uncertain definitive value. Relevant clinical and economic data, also collected real-life, should support reimbursement systems that mirror the actual cost of evidence-based practice.

The impact of clinical maternal chorioamnionitis on neurological and psychological sequelae in very-low-birth weight infants: a case-control study.

AIMS: To assess the relationship between clinically maternal chorioamnionitis and outcome in preterm very-low-birth weight (VLBW) infants. METHODS: An observational case-control study was conducted in the neonatology departments of 12 acute care teaching hospitals in Spain. Between January 2004 and December 2006, all consecutive VLBW (≤1500 g) infants who were born to a mother with clinical chorioamnionitis were enrolled. The controls included infants who were born to mothers without chorioamnionitis, matched by gestational age, and immediately born after each index case. At a corrected age of 24 months, a neurological examination and a psychological assessment of the surviving children were performed. RESULTS: Sixty-six of the newborn infants died; therefore, 262 infants from the original sample were available for the study. Follow-up data were obtained at a corrected age of 24 months from a total of 209 children (106 cases and 103 controls, 80% of the original sample size). Seventy children (33.5%) were diagnosed with some type of sequelae. The following conditions were all more prevalent in infants born to mothers with chorioamnionitis in comparison to controls: low development quotient (98.3±12.15 vs. 95.9±15.64; P=0.497), cerebral palsy (4.9% vs. 10.4%; P=0.138), seizures (1.0% vs. 3.8%; P=0.369), and other neurological or sensorial sequelae (32.0% vs. 34.9%; P=0.611). CONCLUSIONS: After controlling for gestational age, the study population demonstrated that the neurological outcomes in infants at a corrected age of 24 months was not worsened by chorioamnionitis.

Effect of maternal clinical chorioamnionitis on neonatal morbidity in very-low birthweight infants: a case-control study.

AIMS: To assess the relationship between maternal clinical chorioamnionitis and neonatal outcome in preterm very-low birthweight (VLBW) infants. METHODS: An observational case-control study was conducted in the Neonatology Services of 12 acute-care teaching hospitals in Spain. Between January 2004 and December 2006, all consecutive VLBW (< or =1500 g) infants born to a mother with clinical chorioamnionitis were enrolled. Controls were infants without chorioamnionitis matched by gestational age who were born immediately after each index case. RESULTS: There were 165 cases and 163 controls. A significantly higher percentage of cases than controls required intubation (53% vs. 35.8%), had normal intrauterine growth (98.1% vs. 84.7%), were born in a tertiary center (inborn) (95.1% vs. 89.1%), from single gestations (76.4% vs. 65.6%) and vaginal delivery (47.3% vs. 33.3%), showed a lower Apgar score at 5 min, and presented a higher rate of early-onset sepsis (10.4% vs. 1.2%). Older maternal age (32.5 vs. 30.8 years), premature labor (67.3% vs. 25.8%), premature rupture of membranes (61.3% vs. 25.8%), and antibiotic treatment (88.5% vs. 52.3%) were significantly more frequent among cases than controls. CONCLUSIONS: After controlling by gestational age, maternal chorioamnionitis was associated with neonatal depression and early sepsis but not with other prematurity-related complications.

[Prediction of mortality in premature neonates. An updated systematic review]. / Predicción de mortalidad en recién nacidos prematuros. Revisión sistemática actualizada.

INTRODUCTION: Extreme prematurity is associated with high mortality rates. The probability of death at different points in time is a priority for professionals and parents, and needs to be established on an individual basis. The aim of this study is to carry out a systematic review of predictive models of mortality in premature infants that have been published recently. METHODS: A double search was performed for article published in PubMed on models predicting mortality in premature neonates. The population studied were premature neonates with a gestational age of ≤30 weeks and / or a weight at birth of ≤1500g. Works published with new models from June 2010 to July 2019 after a systematic review by Medlock (2011) were included. An assessment was made of the population, characteristics of the model, variables used, measurements of functioning, and validation. RESULTS: Of the 7744 references (1st search) and 1435 (2nd search) found, 31 works were selected, with 8 new models finally being included. Five models (62.5%) were developed in North America and 2 (25%) in Europe. A sequential model (Ambalavanan) enables predictions of mortality to be made at birth, 7, 28 days of life, and 36 weeks post-menstrual. A multiple logistic regression analysis was performed on 87.5% of the models. The population discrimination was measured using Odds Ratio (75%) and the area under the curve (50%). "Internal Validation" had been carried out on 5 models. Three models can be accessed on-line. There are no predictive models validated in Spain. CONCLUSIONS: The making of decisions based on predictive models can lead to the care given to the premature infant being more individualised and with a better use of resources. Predictive models of mortality in premature neonates in Spain need to be developed.

Gestational age-specific cutoff levels of TDx-FLM II for the prediction of neonatal respiratory distress syndrome.

AIM: To construct a predictive model for respiratory distress syndrome (RDS) from gestational age (GA) at delivery and TDx-FLM II value. METHODS: Pregnant women who underwent an amniocentesis in which TDx-FLM II was determined were included in the study. A model for the occurrence of RDS was constructed by means of a logistic regression procedure from TDx-FLM II values and GA at delivery. RESULTS: The mean value of TDx-FLM II was 47.11 mg/g. The mean GA at delivery was 33.4 weeks. The incidence of RDS was 7.8% (18/231). The optimal cutoff of predicted risk for respiratory distress was found to be 8.8%, resulting in a sensitivity and specificity of 89 and 83%, respectively. CONCLUSIONS: The adjustment of the TDx-FLM II value for GA at delivery results in a significant improvement in the predictive capacity of the test for the occurrence of RDS. The use of GA-specific cutoff values may simplify clinical decisions.

Small-for-gestational-age fetuses with normal umbilical artery Doppler have suboptimal perinatal and neurodevelopmental outcome.

OBJECTIVE: To evaluate the perinatal and neurodevelopmental outcome of small-for-gestational-age fetuses with normal umbilical artery Doppler managed expectantly during pregnancy and delivery. STUDY DESIGN: Perinatal and neurodevelopmental outcome was assessed from a cohort of singleton small-for-gestational-age fetuses with normal umbilical artery Doppler and normally grown controls matched by gestational age at delivery, parity and parental socio-economic level. Neurodevelopmental outcome was prospectively evaluated by means of the 24-month Age&Stage Questionnaire (ASQ). RESULTS: A total of 129 small-for-gestational-age fetuses and 259 controls were included. Small-for-gestational-age fetuses had a higher risk for neonatal intensive care unit admission (15.5% versus 3.9%; p<0.001) and significant neonatal morbidity (2.3% versus 0%; p=0.04) than controls. At 24-months, these fetuses showed significantly lower neurodevelopmental centile in the problem solving (42.8 versus 52.1; p=0.001) and personal-social (44.4 versus 54.6; p<0.001) areas than controls. CONCLUSION: Perinatal and neurodevelopmental outcome in small-for-gestational-age fetuses with normal umbilical artery Doppler is suboptimal, which may challenge the role of umbilical artery Doppler to discriminate between normal-SGA and growth-restricted fetuses.