Cost-effectiveness of prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO) versus usual care - Protocol for a health economic evaluation alongside a randomized controlled trial.

BACKGROUND: Prehabilitation aims to improve patients' functional capacity before surgery to reduce perioperative complications, promote recovery and decrease probability of disability. The planned economic evaluation is performed alongside a large German multi-centre pragmatic, two-arm parallel-group, randomized controlled trial on prehabilitation for frail elderly patients before elective surgery compared to standard care (PRAEP-GO RCT). The aim is to determine the cost-effectiveness and cost-utility of prehabilitation for frail elderly before an elective surgery. METHODS: The planned health economic evaluation comprises cost-effectiveness, and cost-utility analyses. Analyses are conducted in the German context from different perspectives including the payer perspective, i.e. the statutory health insurance, the societal perspective and the health care provider perspective. Data on outcomes and costs, are collected alongside the ongoing PRAEP-GO RCT. The trial population includes frail or pre-frail patients aged ≥70 years with planned elective surgery. The intervention consists of frailty screening (Fried phenotype), a shared decision-making conference determining modality (physiotherapy and unsupervised physical exercises, nutrition counselling, etc.) and setting (inpatient, day care, outpatient etc.) of a 3-week individual multimodal prehabilitation prior to surgery. The control group receives standard preoperative care. Costs include the intervention costs, the costs of the index hospital stay for surgery, and health care resources consumed during a 12-month follow-up. Clinical effectiveness outcomes included in the economic evaluation are the level of care dependency, the degree of disability as measured by the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), quality-adjusted life years (QALY) derived from the EQ-5D-5L and the German utility set, and complications occurring during the index hospital stay. Each adopted perspective considers different types of costs and outcomes as outlined in the protocol. All analyses will feature Intention-To-Treat analysis. To explore methodological and parametric uncertainties, we will conduct probabilistic and deterministic sensitivity analyses. Subgroup analyses will be performed as secondary analyses. DISCUSSION: The health economic evaluation will provide insights into the cost-effectiveness of prehabilitation in older frail populations, informing decision-making processes and contributing to the evidence base in this field. Potential limitation includes a highly heterogeneous trial population. TRIAL REGISTRATION: PRAEP-GO RCT: NCT04418271; economic evaluation: OSF ( https://osf.io/ecm74 ).

Excess mortality during the COVID-19 pandemic in low-and lower-middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Although the COVID-19 pandemic claimed a great deal of lives, it is still unclear how it affected mortality in low- and lower-middle-income countries (LLMICs). This review summarized the available literature on excess mortality during the COVID-19 pandemic in LLMICs, including methods, sources of data, and potential contributing factors that might have influenced excess mortality. METHODS: We conducted a systematic review and meta-analysis on excess mortality during the COVID-19 pandemic in LLMICs in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines We searched PubMed, Embase, Web of Science, Cochrane Library, Google Scholar, and Scopus. We included studies published from 2019 onwards with a non-COVID-19 period of at least one year as a comparator. The meta-analysis included studies reporting data on population size, as well as observed and expected deaths. We used the Mantel-Haenszel method to estimate the pooled risk ratio with 95% confidence intervals. The protocol was registered in PROSPERO (ID: CRD42022378267). RESULTS: The review covered 29 countries, with 10 countries included in the meta-analysis. The pooled meta-analysis included 1,405,128,717 individuals, for which 2,152,474 deaths were expected, and 3,555,880 deaths were reported. Calculated excess mortality was 100.3 deaths per 100,000 population per year, with an excess risk of death of 1.65 (95% CI: 1.649, 1.655, p < 0.001). The data sources used in the studies included civil registration systems, surveys, public cemeteries, funeral counts, obituary notifications, burial site imaging, and demographic surveillance systems. The primary techniques used to estimate excess mortality were statistical forecast modelling and geospatial analysis. One out of the 24 studies found higher excess mortality in urban settings. CONCLUSION: Our findings demonstrate that excess mortality in LLMICs during the pandemic was substantial. However, estimates of excess mortality are uncertain due to relatively poor data. Understanding the drivers of excess mortality, will require more research using various techniques and data sources.

Health system description and assessment: a scoping review of templates for systematic analyses.

BACKGROUND: Understanding and comparing health systems is key for cross-country learning and health system strengthening. Templates help to develop standardised and coherent descriptions and assessments of health systems, which then allow meaningful analyses and comparisons. Our scoping review aims to provide an overview of existing templates, their content and the way data is presented. MAIN BODY: Based on the WHO building blocks framework, we defined templates as having (1) an overall framework, (2) a list of indicators or topics, and (3) instructions for authors, while covering (4) the design of the health system, (5) an assessment of health system performance, and (6) should cover the entire health system. We conducted a scoping review of grey literature published between 2000 and 2023 to identify templates. The content of the identified templates was screened, analyzed and compared. We found 12 documents that met our inclusion criteria. The building block `health financing´ is covered in all 12 templates; and many templates cover ´service delivery´ and ´health workforce'. Health system performance is frequently assessed with regard to 'access and coverage', 'quality and safety', and 'financial protection'. Most templates do not cover 'responsiveness' and 'efficiency'. Seven templates combine quantitative and qualitative data, three are mostly quantitative, and two are primarily qualitative. Templates cover data and information that is mostly relevant for specific groups of countries, e.g. a particular geographical region, or for high or for low and middle-income countries (LMICs). Templates for LMICs rely more on survey-based indicators than administrative data. CONCLUSIONS: This is the first scoping review of templates for standardized descriptions of health systems and assessments of their performance. The implications are that (1) templates can help analyze health systems across countries while accounting for context; (2) template-guided analyses of health systems could underpin national health policies, strategies, and plans; (3) organizations developing templates could learn from approaches of other templates; and (4) more research is needed on how to improve templates to better achieve their goals. Our findings provide an overview and help identify the most important aspects and topics to look at when comparing and analyzing health systems, and how data are commonly presented. The templates were created by organizations with different agendas and target audiences, and with different end products in mind. Comprehensive health systems analyses and comparisons require production of quantitative indicators and complementing them with qualitative information to build a holistic picture. CLINICAL TRIAL REGISTRATION:   Not applicable.

Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations.

BACKGROUND: Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care. METHODS: We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect. RESULTS: We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective. CONCLUSIONS: We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective. TRIAL REGISTRATION: PROSPERO CRD42020182813.

A cross-country comparison of Covid-19 containment measures and their effects on the epidemic curves.

BACKGROUND: European countries are still searching to eliminate or contain the Covid-19 pandemic. A variety of approaches have achieved different levels of success in limiting the spread of the disease early and preventing avoidable deaths. Governmental policy responses may explain these differences and this study aims to describe evidence about the effectiveness of containment measures throughout the course of the pandemic in five European countries (France, Germany, Italy, Spain and the UK). METHODS: The research approach adopted consisted of three steps: 1) Build a Containment Index (C.I.) that considers nine parameters to make an assessment on the strength of measures; 2) Develop dynamic epidemiological models for forecasting purposes; 3) Predict case numbers by assuming containment measures remain constant for a period of 30 days. RESULTS: Our analysis revealed that in the five European countries we compared, the use of different approaches definitively affected the effectiveness of containment measures for the Covid-19 pandemic. CONCLUSION: The evidence found in our research can be useful to inform policy makers' decisions when deciding to introduce or relax containment measures and their timing, both during the current pandemic or in addressing possible future health crises.

The Structure and Financing of Health Care Systems Affected How Providers Coped With COVID-19.

Policy Points We compared the structure of health care systems and the financial effects of the COVID-19 pandemic on health care providers in the United States, England, Germany, and Israel: systems incorporating both public and private insurers and providers. The negative financial effects on health care providers have been more severe in the United States than elsewhere, owing to the prevalence of activity-based payment systems, limited direct governmental control over available provider capacity, and the structure of governmental financial relief. In a pandemic, activity-based payment reverses the conventional financial positions of payers and providers and may prevent providers from prioritizing public health because of the desire to avoid revenue loss caused by declines in patient visits.

Provision of community-based mental health care, Latvia.

PROBLEM: In Latvia, the move towards community-based mental health-care services has been slow. APPROACH: The hospital managers of the only psychiatric hospital in Riga decided to establish two community-based clinics that were financially and administratively integrated with the hospital. The clinics were established using a step-wise approach by redistributing resources, including psychiatrists, nurses and beds, from the hospital to the new clinics. In 2005, the Veldre clinic started outpatient consultations and day care admissions. In 2009, Pardaugava clinic opened as an outpatient clinic. In 2012, an open-door inpatient ward with 30 beds was transferred from the psychiatric hospital to Veldre. In 2013, Pardaugava clinic opened a day care clinic and an open-door inpatient ward, transferring 26 beds from the psychiatric hospital. LOCAL SETTING: Latvians have worse mental health indicators than those of the average population in Europe. Mental care has traditionally focused on inpatient care. RELEVANT CHANGES: The clinics are now providing most of the outpatient services and the number of inpatients treated at the hospital has declined from 5696 patients in 2004 to 4957 patients in 2018. Patients are treated in a more open and patient-centred environment. LESSONS LEARNT: The administrative and financial integration of the new community-based clinics within the existing structures of the hospital is a successful approach. Transferring resources to the clinics seems to have improved the quality of care without requiring additional funding apart from the initial investment costs. Involving the staff members during the planning phase reduced resistance to the project.

A critical realist synthesis of cross-disciplinary health policy and systems research: defining characteristic features, developing an evaluation framework and identifying challenges.

BACKGROUND: Health policy and systems research (HPSR) is an inherently cross-disciplinary field of investigation. However, conflicting conceptualisations about inter-, multi- and transdisciplinary research have contributed to confusion about the characteristics of cross-disciplinary approaches in HPSR. This review was conducted to (1) define the characteristic features of context-mechanism-outcome (CMO) configurations in cross-disciplinary HPSR, (2) develop criteria for evaluating cross-disciplinarity and (3) synthesise emerging challenges of the approach. METHOD: The paper is a critical realist synthesis conducted in three phases, as follows: (1) scoping the literature, (2) searching for and screening the evidence, and (3) extracting and synthesising the evidence. Five databases, namely the International Bibliography of the Social Sciences and Web of Science, PubMed central, Embase and CINHAL, and reference lists of studies that qualified for inclusion in the review were searched. The search covered peer-reviewed original research, reviews, commentary papers, and institutional or government reports published in English between January 1998 and January 2020. RESULTS: A total of 7792 titles were identified in the online search and 137 publications, comprising pilot studies as well as anecdotal and empirical literature were selected for the final review. The review draws attention to the fact that cross-disciplinary HPSR is not defined by individual characteristics but by the combination of a particular type of research question and setting (context), a specific way of researchers working together (mechanism), and research output (outcome) that is superior to what could be achieved under a monodisciplinary approach. This CMO framework also informs the criteria for assessing whether a given HPSR is truly cross-disciplinary. The challenges of cross-disciplinary HPSR and their accompanying coping mechanisms were also found to be context driven, originating mainly from conceptual disagreements, institutional restrictions, communication and information management challenges, coordination problems, and resource limitations. CONCLUSION: These findings have important implications. First, the CMO framework of cross-disciplinary HPSR can provide guidance for researchers engaging in new projects and for policy-makers using their findings. Second, the proposed criteria for evaluating theory and practice of cross-disciplinary HPSR may inform the systematic development of new research projects and the structured assessment of existing ones. Third, a better understanding of the challenges of cross-disciplinary HPSR and potential response mechanisms may help researchers to avoid these problems in the future.

The 2010 expansion of activity-based hospital payment in Israel: an evaluation of effects at the ward level.

BACKGROUND: In 2010, Israel intensified its adoption of Procedure-Related Group (PRG) based hospital payments, a local version of DRG (Diagnosis-related group). PRGs were created for certain procedures by clinical fields such as urology, orthopedics, and ophthalmology. Non-procedural hospitalizations and other specific procedures continued to be paid for as per-diems (PD). Whether this payment reform affected inpatient activities, measured by the number of discharges and average length of stay (ALoS), is unclear. METHODS: We analyzed inpatient data provided by the Ministry of Health from all 29 public hospitals in Israel. Our observations were hospital wards for the years 2008-2015, as proxies to clinical fields. We investigated the impact of this reform at the ward level using difference-in-differences analyses among procedural wards. Those for which PRG codes were created were treatment wards, other procedural wards served as controls. We further refined the analysis of effects on each ward separately. RESULTS: Discharges increased more in the wards that were part of the control group than in the treatment wards as a group. However, a refined analysis of each treated ward separately reveals that discharges increased in some, but decreased in other wards. ALoS decreased more in treatment wards. Difference-in-differences results could not suggest causality between the PRG payment reform and changes in inpatient activity. CONCLUSIONS: Factors that may have hampered the effects of the reform are inadequate pricing of procedures, conflicting incentives created by other co-existing hospital-payment components, such as caps and retrospective subsidies, and the lack of resources to increase productivity. Payment reforms for health providers such as hospitals need to take into consideration the entire provider market, available resources, other - potentially conflicting - payment components, and the various parties involved and their interests.

Revisiting out-of-pocket requirements: trends in spending, financial access barriers, and policy in ten high-income countries.

BACKGROUND: Countries rely on out-of-pocket (OOP) spending to different degrees and employ varying techniques. The article examines trends in OOP spending in ten high-income countries since 2000, and analyzes their relationship to self-assessed barriers to accessing health care services. The countries are Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. METHODS: Data from three sources are employed: OECD statistics, the Commonwealth Fund survey of individuals in each of ten countries, and country-specific documents on health care policies. Based on trends in OOP spending, we divide the ten countries into three groups and analyze both trends and access barriers accordingly. As part of this effort, we propose a conceptual model for understanding the key components of OOP spending. RESULTS: There is a great deal of variation in aggregate OOP spending per capita spending but there has been convergence over time, with the lowest-spending countries continuing to show growth and the highest spending countries showing stability. Both the level of aggregate OOP spending and changes in spending affect perceived access barriers, although there is not a perfect correspondence between the two. CONCLUSIONS: There is a need for better understanding the root causes of OOP spending. This will require data collection that is broken down into OOP resulting from cost sharing and OOP resulting from direct payments (due to underinsurance and lacking benefits). Moreover, data should be disaggregated by consumer groups (e.g. income-level or health status). Only then can we better link the data to specific policies and suggest effective solutions to policy makers.

A realist review of mobile phone-based health interventions for non-communicable disease management in sub-Saharan Africa.

BACKGROUND: The prevalence of non-communicable diseases (NCDs) is increasing in sub-Saharan Africa. At the same time, the use of mobile phones is rising, expanding the opportunities for the implementation of mobile phone-based health (mHealth) interventions. This review aims to understand how, why, for whom, and in what circumstances mHealth interventions against NCDs improve treatment and care in sub-Saharan Africa. METHODS: Four main databases (PubMed, Cochrane Library, Web of Science, and Google Scholar) and references of included articles were searched for studies reporting effects of mHealth interventions on patients with NCDs in sub-Saharan Africa. All studies published up until May 2015 were included in the review. Following a realist review approach, middle-range theories were identified and integrated into a Framework for Understanding the Contribution of mHealth Interventions to Improved Access to Care for patients with NCDs in sub-Saharan Africa. The main indicators of the framework consist of predisposing characteristics, needs, enabling resources, perceived usefulness, and perceived ease of use. Studies were analyzed in depth to populate the framework. RESULTS: The search identified 6137 titles for screening, of which 20 were retained for the realist synthesis. The contribution of mHealth interventions to improved treatment and care is that they facilitate (remote) access to previously unavailable (specialized) services. Three contextual factors (predisposing characteristics, needs, and enabling resources) influence if patients and providers believe that mHealth interventions are useful and easy to use. Only if they believe mHealth to be useful and easy to use, will mHealth ultimately contribute to improved access to care. The analysis of included studies showed that the most important predisposing characteristics are a positive attitude and a common language of communication. The most relevant needs are a high burden of disease and a lack of capacity of first-contact providers. Essential enabling resources are the availability of a stable communications network, accessible maintenance services, and regulatory policies. CONCLUSIONS: Policy makers and program managers should consider predisposing characteristics and needs of patients and providers as well as the necessary enabling resources prior to the introduction of an mHealth intervention. Researchers would benefit from placing greater attention on the context in which mHealth interventions are being implemented instead of focusing (too strongly) on the technical aspects of these interventions.

A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries.

BACKGROUND: The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs). METHODS: A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed. RESULTS: The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures. Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs. CONCLUSIONS: Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.

Healthcare Professionals' Perceptions of the Benefits and Challenges of a Teleconsultation Service in the Amansie-West District of Ghana.

OBJECTIVES: A teleconsultation service was introduced in the Amansie-West District, Ghana, in 2010 linking health center-based community health nurses (CHNs) with a teleconsultation center (TCC) at the district hospital. This study aimed to assess healthcare professionals' perceptions of the benefits and challenges of this service and to identify possible areas for improvement. MATERIALS AND METHODS: Qualitative semistructured interviews were conducted with eight CHNs and three TCC healthcare professionals to find their views on the benefits, challenges, and recommendations for improving the service. The data were analyzed using qualitative content analysis. RESULTS: Interviewees were generally positive when describing the use of the teleconsultation service. They were of the opinion that the service had improved the quality of care at health centers, thus reducing the need to refer patients to the district hospital. Practical problems, such as inadequate information provided over the phone, delays in responding to calls, and the additional workload for teleconsultation staff, were viewed as important challenges to the success of the project. Interviewees identified several possible options for improving the service through extension to other levels of the healthcare system or by adding additional functionalities to their phones. CONCLUSIONS: Teleconsultation services have the potential to improve quality of care in rural communities. However, practical problems in the operation of the service have to be taken seriously as they threaten sustainability of the intervention. Adequate training in phone-based clinical reporting appears to be essential. Teleconsultation staff should be compensated for additional workload through a reduction of other work-related tasks.

Inequalities in child mortality in ten major African cities.

BACKGROUND: The existence of socio-economic inequalities in child mortality is well documented. African cities grow faster than cities in most other regions of the world; and inequalities in African cities are thought to be particularly large. Revealing health-related inequalities is essential in order for governments to be able to act against them. This study aimed to systematically compare inequalities in child mortality across 10 major African cities (Cairo, Lagos, Kinshasa, Luanda, Abidjan, Dar es Salaam, Nairobi, Dakar, Addis Ababa, Accra), and to investigate trends in such inequalities over time. METHODS: Data from two rounds of demographic and health surveys (DHS) were used for this study (if available): one from around the year 2000 and one from between 2007 and 2011. Child mortality rates within cities were calculated by population wealth quintiles. Inequality in child mortality was assessed by computing two measures of relative inequality (the rate ratio and the concentration index) and two measures of absolute inequality (the difference and the Erreyger's index). RESULTS: Mean child mortality rates ranged from about 39 deaths per 1,000 live births in Cairo (2008) to about 107 deaths per 1,000 live births in Dar es Salaam (2010). Significant inequalities were found in Kinshasa, Luanda, Abidjan, and Addis Ababa in the most recent survey. The difference between the poorest quintile and the richest quintile was as much as 108 deaths per 1,000 live births (95% confidence interval 55 to 166) in Abidjan in 2011-2012. When comparing inequalities across cities or over time, confidence intervals of all measures almost always overlap. Nevertheless, inequalities appear to have increased in Abidjan, while they appear to have decreased in Cairo, Lagos, Dar es Salaam, Nairobi and Dakar. CONCLUSIONS: Considerable inequalities exist in almost all cities but the level of inequalities and their development over time appear to differ across cities. This implies that inequalities are amenable to policy interventions and that it is worth investigating why inequalities are higher in one city than in another. However, larger samples are needed in order to improve the certainty of our results. Currently available data samples from DHS are too small to reliably quantify the level of inequalities within cities.

Acute myocardial infarction and diagnosis-related groups: patient classification and hospital reimbursement in 11 European countries.

AIMS: As part of the diagnosis related groups in Europe (EuroDRG) project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their DRG systems deal with patients admitted to hospital for acute myocardial infarction (AMI). The study aims to assist cardiologists and national authorities to optimize their DRG systems. METHODS AND RESULTS: National or regional databases were used to identify hospital cases with a primary diagnosis of AMI. Diagnosis-related group classification algorithms and indicators of resource consumption were compared for those DRGs that individually contained at least 1% of cases. Six standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. European DRG systems vary widely: they classify AMI patients according to different sets of variables into diverging numbers of DRGs (between 4 DRGs in Estonia and 16 DRGs in France). The most complex DRG is valued 11 times more resource intensive than an index case in Estonia but only 1.38 times more resource intensive than an index case in England. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only €420 in Poland but to €7930 in Ireland. CONCLUSIONS: Large variation exists in the classification of AMI patients across Europe. Cardiologists and national DRG authorities should consider how other countries' DRG systems classify AMI patients in order to identify potential scope for improvement and to ensure fair and appropriate reimbursement.

Data for health system comparison and assessment in the African Region: A review of 63 indicators available in international databases.

Background: Achieving universal health coverage in the African region requires health systems strengthening. Assessing and comparing health systems contributes to this process, but requires internationally comparable data. The European Observatory on Health Systems and Policies has produced Health Systems in Transition (HiT) reviews in Europe, Asia, North America and the Caribbean with a standardised template. This study explores data availability in international databases for the quantitative health and health system indicators in the HiT template for the WHO African region. Methods: We identified ten databases which contained data for 40 of the 80 original HiT indicators and an additional 23 proxy indicators to fill some gaps. We then assessed data availability for the resulting 63 indicators by country and time, i.e. first/last year of data, years of data available overall and since 2000, and we explored for each indicator (1) against the country with the greatest availability overall and (2) against annual availability for all years since 2000. Results: Overall data availability was greatest in South Africa (93.0% of possible total points) and least in South Sudan (59.5%). Since 2000, Uganda (60.4%) has had the highest data availability and South Sudan (37.2%) the lowest. By topic, data availability was the highest for health financing (91.4%; median start/end date 2000/2019) and background characteristics (88.5%; 1990/2020) and was considerably lower for health system performance (54.5%; 2000/2018) and physical and human resources (44.8%; 2004/2013). Data are available for different years in different countries, and at irregular intervals, complicating time series analysis. No data are available for service provision indicators. Conclusions: Gaps in data in international databases across time, countries, and topics undermine systematic health systems comparisons and assessments, regional health systems strengthening, and efforts to achieve universal health coverage. More efforts are needed to strengthen national data collection and management and integrate national data into international databases to support cross-country assessments, peer learning, and planning. In tandem, more research is needed to understand the specific historical, cultural, administrative, and technological determinants influencing country data availability, as well as the facilitators and barriers of data sharing between countries and international databases, and the potential of new technologies to increase timeliness of data.

Excess mortality during the COVID-19 pandemic in low-income and lower middle-income countries: protocol for a systematic review and meta-analysis.

INTRODUCTION: The COVID-19 pandemic has been marked by a massive death toll. However, the overall effect of the pandemic, including potential unintended negative impacts of some control measures, on mortality remains poorly understood in low-income and lower middle-income countries (LLMICs). This review aims to summarise the available literature on excess mortality in LLMICs, focusing on the methods and data sources used in estimating excess mortality and the drivers of excess mortality. METHODS AND ANALYSIS: We will review the available literature and report results in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis. Searches will be conducted in PubMed, Embase, Web of Science, Cochrane Library, Google Scholar and Scopus. All published studies that report on the estimates of excess mortality in populations of LLMICs will be included. This will include those with a publication date from 2019 onwards and those with at least a 1-year non-COVID-19 period as the comparator in the estimation of excess mortality during the pandemic. There will be no language restrictions on the search. The meta-analysis will include studies with extractable data on excess mortality, methods, population size, and observed and expected deaths. We will use the Mantel-Haenszel method to estimate the pooled risk ratio with 95% CIs. ETHICS AND DISSEMINATION: As there is no primary data collection, there is no requirement for ethical review. The results will be disseminated through peer-reviewed journal publication and conference presentations. PROSPERO REGISTRATION NUMBER: CRD42022378267.

Digital technologies for health financing in low-income and middle-income countries: a scoping review protocol.

INTRODUCTION: Universal health coverage (UHC) is a global priority, ensuring equitable access to quality healthcare services without financial hardship. Many countries face challenges in progressing towards UHC. Health financing is pivotal for advancing UHC by raising revenues, enabling risk-sharing through pooling of funds and allocating resources. Digital technologies in the healthcare sector offer promising opportunities for health systems. In low-income and middle-income countries (LMICs), digital technologies for health financing (DTHF) have gained traction, supporting these three main functions of health financing for UHC. As existing information on DTHF in LMICs is limited, our scoping review aims to provide a comprehensive overview of DTHF in LMICs. Our objectives include identifying and describing existing DTHF, exploring evaluation approaches, examining their positive and negative effects, and investigating facilitating factors and barriers to implementation at the national level. METHODS AND ANALYSIS: Our scoping review follows the six stages proposed by Arksey and O'Malley, further developed by Levac et al and the Joanna Briggs Institute. The reporting adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews framework. Eligibility criteria for studies reflect the three core elements of the search: (1) health financing, (2) digital technologies and (3) LMICs. We search multiple databases, including Medline via PubMed, EMBASE via Ovid, the Web of Science Core Collection, CENTRAL via Cochrane and the Global Index Medicus by the WHO. The extracted information is synthesised from both quantitative and qualitative studies. ETHICS AND DISSEMINATION: As our scoping review is based solely on information gathered from previously published studies, documents and publicly available scientific literature, ethical clearance is not required for its conduct. The findings are presented and discussed in a peer-reviewed article, as well as shared at conferences relevant to the topic.

Diagnosis-related groups for stroke in Europe: patient classification and hospital reimbursement in 11 countries.

BACKGROUND: Diagnosis-related groups (DRGs) are increasingly being used for various purposes in many countries. However, there are no studies comparing different DRG systems in the care of stroke. As part of the EuroDRG project, researchers from 11 countries (i.e. Austria, England, Estonia, Finland, France, Germany, Ireland, the Netherlands, Poland, Sweden and Spain) compared how their DRG systems deal with stroke patients. The study aims to assist clinicians and national authorities to optimize their DRG systems. METHODS: National or regional databases were used to identify hospital cases with a diagnosis of stroke. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that individually represent at least 1% of stroke cases. In addition, standardized case vignettes were defined, and quasi prices according to national DRG-based hospital payment systems were ascertained. RESULTS: European DRG systems vary widely: they classify stroke patients according to different sets of variables (between 1 and 7 classification variables) into diverging numbers of DRGs (between 1 and 10 DRGs). In 6 of the countries more than half of the patients are concentrated within a single DRG. The countries' systems also vary with respect to the evaluation of different kinds of stroke patients. The most complex DRG is considered 3.8 times more resource intensive than an index case in Finland. By contrast, in England, the DRG system does not account for complex cases. Comparisons of quasi prices for the case vignettes show that hypothetical payments for the index case amount to only EUR 907 in Poland but to EUR 7,881 in Ireland. CONCLUSIONS: Large variations in the classification of stroke patients raise concerns whether all systems rely on the most appropriate classification variables and whether the DRGs adequately reflect differences in the complexity of treating different groups of patients. Learning from other DRG systems may help in improving the national systems. Clinicians and national DRG authorities should consider how other countries' DRG systems classify stroke patients in order to optimize their DRG system and to ensure fair and appropriate reimbursement. In future, quantitative research is needed to verify whether the most important determinants of cost are considered in different patient classification systems, and whether differences between systems reflect country-specific differences in treatment patterns and, most importantly, what influence they have on patient outcomes.