Factors impacting sustained coverage in the context of donor transitions: experience from Sri Lanka.

Although not reliant on donor funding for health, the external assistance that Sri Lanka receives contributes to the improvement of the health system and health outcomes. In this study, we evaluated transition experiences of the expanded programme on immunization (EPI) that received Gavi funding to expand the vaccine portfolio and the Anti-Malaria Campaign (AMC) that received funding from the Global Fund for AIDS, Tuberculosis and Malaria to scale-up interventions to target and achieve malaria elimination. We assessed if EPI and AMC programmes were able to sustain coverage of previously donor-funded interventions post-transition and explain the facilitators and barriers that contribute to this. We used a mixed methods approach using quantitative data to assess coverage indicators and the financing mix of the health programmes and qualitative analysis guided by a framework informed by the Walt and Gilson policy triangle that brought together document review and in-depth interviews to identify facilitators and barriers to transition success. The EPI programme showed sustained coverage of Gavi-funded vaccines post-transition and the funding gap was bridged by mobilizing domestic financing facilitated by the Gavi co-financing mechanism, full integration within existing service delivery structures, well-established and favourable pharmaceutical procurement processes for the public sector and stewardship and financial advocacy by technically competent managers. Although the absence of indigenous cases of malaria since 2012 suggests overall programme success, the AMC showed mixed transition success in relation to its different programme components. Donor-supported programme components requiring mobilization of operational expenses, facilitated by early financial planning, were successfully transitioned (e.g. entomological and parasitological surveillance) given COVID-19-related constraints. Other key programme components, such as research, training, education and awareness that are dependent on non-operational expenses are lagging behind. Additionally, concerns of AMC's future financial sustainability within the current structure remain in the context of low malaria burden.

Managing transitions from external assistance: cross-national learning about sustaining effective coverage.

The often-prominent role of external assistance in health financing in low- and middle-income countries raises the question of how such resources can enable the sustained or even expanded coverage of key health services and initiatives even after donor funding is no longer available. In response to this question, this paper analyses the process and outcomes of donor transitions in health-where countries or regions within countries are no longer eligible to receive grants or concessional loans from external sources based on eligibility criteria or change in donor policy. The comparative analysis of multiple donor transitions in four countries-China, Georgia, Sri Lanka and Uganda-identifies 16 factors related to policy actors, policy process, the content of donor-funded initiatives and the broader political-economic context that were associated with sustained coverage of previously donor supported interventions. From a contextual standpoint, these factors relate to favourable economic and political environments for domestic systems to prioritize coverage for donor-supported interventions. Clear and transparent transition processes also enabled a smoother transition. How the donor-supported initiatives and services were organized within the context of the overall health system was found to be critically important, both before and during the transition process. This includes a targeted approach to integrate, strengthen and align key elements of the governance, financing, input management and service delivery arrangements with domestic systems. The findings of this analysis have important implications for how both donors and country policy makers can better structure external assistance that enables sustained coverage regardless of the source of funding. In particular, donors can better support sustained coverage through supporting long-term structural and institutional reform, clear co-financing policies, ensuring alignment with local salary scales and engaging with communities to ensure a continued focus on equitable access post-transition.

Acute exacerbations of COPD in the United States: inpatient burden and predictors of costs and mortality.

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a leading cause of hospitalizations in the United States and the major cost driver of COPD. This study determined the national inpatient burden of AECOPD and assessed the association of co-morbidities and hospital characteristics with inpatient costs and mortality. Discharge records from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample for 2006 was utilized. Outcomes of costs and mortality were assessed for AECOPD hospitalizations in cases ≥40 years of age. Multivariate regression analyses using a generalized linear model framework were conducted to determine predictors of inpatient costs and mortality controlling for patient demographics, primary payer, co-morbidity index, length of stay, hospital region, mechanical ventilation, and admission period. Overall, 1,254,703 hospitalizations for AECOPD were observed with mean costs of $9545(±12,700) and total costs of $11.9 billion. In-hospital mortality was 4.3% (N = 53,748). Discharges averaged 70.6 (±11.9) years of age. The majority were female (52.8%) and of white race (83.6% of reported race). Several co-morbidities were significantly associated with both costs and mortality (p < 0.001): acute myocardial infarction; congestive heart failure; cerebrovascular disease; lung cancer; cardiac arrhythmias; pulmonary circulation disorders; and weight loss. Significantly higher costs (p < 0.001) were associated with large and urban hospitals. The importance of co-morbidities in AECOPD is indicated in their association with prognosis and inpatient costs. Future research should determine if better management of these conditions can favorably impact the COPD disease burden.

A cancer screening intervention for underserved Latina women by lay educators.

OBJECTIVES: Inadequate screening adherence for breast, cervical, and colorectal cancer among Latinas places them at greater risk for poor survival rates, once diagnosed. The purpose of this study was to examine two delivery methods of lay health educators (promotoras de salud) to increase screening behavior and evaluate costs. METHODS: This community-based group randomized trial assigned Latinas due for breast, cervical, or colorectal cancer screening (n=1006) to promotora-taught cancer screening/prevention classes delivered individually (IND) or in social support groups (SSG) over 8 weeks. Screening behaviors were assessed immediately after and 3 and 15 months after intervention. Intervention costs per study arm were compared. RESULTS: Screening and maintenance behaviors were not significantly different between SSG and IND for any one type of cancer screening, but with a study entry requirement that participants were either never screened or due for screening, postintervention screening rates (that is, completing a screening that was due) were notable (39.4% and 45.5%, respectively). The cost of achieving any one screening was much higher for IND participants. CONCLUSIONS: SSG vs. IND delivery did not significantly affect cancer screening behaviors, but both interventions produced robust achievement of screenings for previously nonadherent participants. Group-based promotora-led interventions supporting social involvement are recommended as a more cost-effective approach to achieving cancer screening among Latina women.

Evaluation of prescriber responses to pharmacist recommendations communicated by fax in a medication therapy management program (MTMP).

BACKGROUND: As defined by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, medication therapy management programs (MTMPs) must be designed to decrease adverse drug events and improve patient outcomes by promoting appropriate medication use. WellPoint Inc. contracted with the pharmacist-run University of Arizona College of Pharmacy Medication Management Center (UA MMC) to provide a pilot telephone-based MTMP to approximately 5,000 high-risk beneficiaries from among its nearly 2 million Medicare prescription drug plan (PDP) beneficiaries. Eligibility for the program was determined by a minimum of 2 of 6 chronic diseases (dyslipidemia, cardiovascular disease, depression, diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease; at least 1 of the latter 2 diseases must be present), at least 3 Part-D covered medications, and greater than $4,000 per year in predicted drug spending. In addition to these criteria, WellPoint Inc. used the Johns Hopkins adjusted clinical groups (ACG) predictive model to identify the high-risk beneficiaries to be enrolled in the program. Medication therapy reviews were conducted for these patients. If any medication-related problems (MRPs) were identified, the patient's prescribers were contacted via a fax communication with recommendation(s) to resolve these MRPs. The UA MMC fax interventions were categorized as cost saving, guideline adherence, or safety concerns. OBJECTIVES: To (a) determine prescriber responses to pharmacist-initiated recommendations in an MTMP for the 3 intervention categories, (b) compare prescriber responses between intervention categories, and (c) compare prescriber response by prescriber type (primary care physician [PCP] vs. specialist) within each intervention category. METHODS: A retrospective analysis of pharmacist-initiated interventions from August through December 2008 was performed using data collected from the UA MMC database. Data were collected on intervention category (cost saving, guideline adherence, or safety concerns), and responses of prescribers were recorded as either approval or decline (no response was considered decline). Prescriber specialty was identified from searching records of state medical boards. Logistic regression analyses with the robust variance option to adjust for correlation within prescribers were conducted to compare prescriber approval rates between and within intervention categories. Significance was assessed at alpha 0.05. RESULTS: Of 4,967 Medicare Part D beneficiaries determined to be MTMP-eligible, 4,277 beneficiaries (86.1%) were available for assessment (400 declined, 186 disenrolled, and 104 were deceased). Pharmacists initiated 1,548 valid medication recommendations (i.e., recommendations were excluded for deceased patients, incorrect prescribers, and where prescriber specialty was not identified). These recommendations for 1,174 beneficiaries (27.5% of those available) were faxed to prescribers requesting approval. Mean (SD) age for beneficiaries having recommendations was 72.9 (9.4) years, and the majority (57.6%) was female. By category of recommendation, 58.3% (n=902) were guideline adherence, 33.3% (n=515) were cost saving, and 8.5% (n=131) were safety concerns. Prescriber approval rates were 47.2% overall (n =731/1,548), 41.4% (n=373/902) for guideline adherence, 58.3% (n=300/515) for cost savings, and 44.3% (n=58/131) for safety concerns; 817 recommendations were not approved by prescribers (n= 255 [16.5%] denials and 562 no response [36.3%]). Prescriber approval was significantly higher for cost-saving interventions compared with guideline adherence interventions (odds ratio [OR]=1.98, 95% CI=1.56-2.51, P< 0.001) and compared with safety interventions (OR=1.76, 95% CI=1.19, 2.59, P=0.004); there was no significant difference in the prescriber approval rates for the interventions for safety versus guideline adherence. The overall approval rate was higher for PCPs (49.8%, n=525/1,054) versus specialists (41.7%, n=206/494; OR=1.39, 95% CI=1.08-1.78, P=0.011) and for the category for guideline adherence interventions (44.0% for PCPs vs. 35.9% for specialists; OR =1.40, 95% CI=1.01-1.95, P=0.044), but not for the other 2 intervention categories. CONCLUSIONS: Prescriber approval rates for pharmacist recommendations for drug therapy changes for MTMP beneficiaries were approximately 47% overall and higher for recommendations that involved cost savings compared with recommendations for safety concerns or guideline adherence. Compared with specialists, PCPs had higher approval rates for pharmacist recommendations overall and for the intervention category guideline adherence.