The legal aspect of interoperability of cross border electronic health services: A study of the european and national legal framework.

Legal interoperability constitutes a prerequisite for the provision of high-quality cross border e-health services, like ePrescription and ePatientSummary. A review of EU legislation, policy initiatives and relevant judgments of the European Court of Justice (ECJ) and the European Court of Human Rights (ECHR) was held, concerning personal medical data. Four European social welfare systems, according to Esping - Andersen's typology, were selected and a study of health policy in relation to the national legal framework regarding the data protection regulation is examined. A model of legal interoperability for cross-border eHealth services is proposed for policy makers at EU level based on the following major domains: protection and security of data, transparency and liability, further analyzed in multiple axes and combined with EU targets, policy priorities and basic European legal principles. This model could be viable because of the EU's transnational existence, the coexistence of national and Community law, and the need of novel models of political governance under a unified regulatory and normative base.

Re-engineering the Cypriot General Healthcare System for Syndemics.

To date in Cyprus, there is no dedicated "Quality Improvement" body or Public Health authority. The long-awaited general healthcare system (known as GeSy or GHS) has been completed, mid-stream of the COVID-19 pandemic. A recently proposed resilience plan in response to the lessons learnt from the pandemic was put forward by the Government of the Republic of Cyprus to strengthen the capacity of the GHS and support public health defense. The negotiator of GeSy and Health Minister 2015-2018 also provided his view that the health system needs a holistic transformation of service provision. Recognizing failures and thinking from a syndemogenesis perspective how the envisioned patient-centric healthcare delivery can be achieved, we propose that the public health response could also be linked to a politico-economic one in shielding GeSy. We make such case for a syndemic strategy (simultaneous management of COVID-19 and pre-existing epidemics on the island) and the development of the five-district model where each main district hospital is to complement the activities of the GHS through developing: 1. A training Center for training and sharing of best practices for COVID-19 and other public emergencies. 2. A public health body. 3. A quality improvement institute. 4. A commissioning center on planning and streamlining healthcare services. 5. A clinical trial platform. The rationale is based on the management literature and use of existing resources and capabilities for transforming the GeSy and generating value.

Disentangling prescribing behaviour of Cypriot physicians, within a complex framework of interacting.

The purpose of the study is to investigate how physicians' prescribing behaviour in Cyprus adopts to the fragmented healthcare system and to the inadequacies of pharmaceutical market in times of economic crisis. A survey was carried out in using a postal questionnaire administered to a stratified sample of 320 physicians. The questionnaire used was the same with the one used in 2007 survey carried out in Greece and Cyprus, along with complementary questions for prescribing within economic crisis. The comparative analysis and assessment of the findings from the two surveys revealed that the current system and the inadequacies of pharmaceutical market in Cyprus expose physicians to a contrasting environment of public and private sector in terms of incentives, governance principles, financing and market structure. In contrast to public sector prescribers who have behaved in accordance with the governance principles, there is a strong motivation for private sector physicians to favour new branded products, and generally rejecting any ideas that could limit their clinical autonomy. Economic crisis seems to be unilaterally influential, as public sector physicians became more cost conscious while private sector prescribing is still resisting due to strong financial incentives.

Same Pandemic Yet Different COVID-19 Vaccination Roll-Out Rates in Two Small European Islands: A Comparison between Cyprus and Malta.

A mass vaccination strategy is estimated to be the long-term solution to control COVID-19. Different European countries have committed to vaccination strategies with variable population inoculation rates. We sought to investigate the extent to which the COVID-19 vaccination strategies, inoculation rate, and COVID-19 outcome differ between Cyprus and Malta. Data were obtained from the Ministry of Health websites and COVID-19 dashboards, while vaccination data were obtained from the European Centre for Disease Prevention and Control until mid-June, 2021. Comparative assessments were performed between the two countries using Microsoft® Excel for Mac, Version 16.54. Both islands took part in the European Union's advanced purchase agreement and received their first batch of vaccines on 27 December 2020. The positivity rate and mortality between December and June differs between the two countries (average positivity rate Cyprus 1.34, Malta 3.37 p ≤ 0.01; average mortality Cyprus 7.29, Malta 9.68 p ≤ 0.01). Both the positivity rate and mortality for Cyprus declined due to strict public health measures and vaccination roll-out in early January (positivity rate by 95% and mortality by 58%). In contrast, for Malta, there was a sharp increase (64% p ≤ 0.01) with almost no public health restrictions in place and soaring cases during the Christmas and Carnival period until March, when lockdown measures were re-introduced. A distinctive difference between Cyprus and Malta in positivity rate (14 per 100,000 population; p ≤ 0.01) can also be observed between January and mid-April 2021. However, from April onwards it is evident that the positivity rate and mortality decline (positivity rate Cyprus by 82%, Malta by 95%; mortality Cyprus by 90%, Malta by 95%, p ≤ 0.01, respectively) in both countries as the vaccination roll-outs progressed, covering about 58.93% of the Maltese population, while Cyprus had fully inoculated about 38.03% of its population. The vaccine strategies and vaccination rates were similar for both countries; yet Malta had the fastest vaccine roll-out. Reluctancy to get vaccinated, significant differences in the vaccination appointment scheduling system, and the freedom of vaccination choice for the citizens in Cyprus may have contributed to a delayed vaccination roll-out. These potential contributing factors should be acknowledged and considered for future vaccination programs and potential COVID-19 boosters.

Early health system responses to the COVID-19 pandemic in Mediterranean countries: A tale of successes and challenges.

This paper conducts a comparative review of the (curative) health systems' response taken by Cyprus, Greece, Israel, Italy, Malta, Portugal, and Spain during the first six months of the COVID-19 pandemic. Prior to the COVID-19 pandemic, these Mediterranean countries shared similarities in terms of health system resources, which were low compared to the EU/OECD average. We distill key policy insights regarding the governance tools adopted to manage the pandemic, the means to secure sufficient physical infrastructure and workforce capacity and some financing and coverage aspects. We performed a qualitative analysis of the evidence reported to the 'Health System Response Monitor' platform of the European Observatory by country experts. We found that governance in the early stages of the pandemic was undertaken centrally in all the Mediterranean countries, even in Italy and Spain where regional authorities usually have autonomy over health matters. Stretched public resources prompted countries to deploy "flexible" intensive care unit capacity and health workforce resources as agile solutions. The private sector was also utilized to expand resources and health workforce capacity, through special public-private partnerships. Countries ensured universal coverage for COVID-19-related services, even for groups not usually entitled to free publicly financed health care, such as undocumented migrants. We conclude that flexibility, speed and adaptive management in health policy responses were key to responding to immediate needs during the COVID-19 pandemic. Financial barriers to accessing care as well as potentially higher mortality rates were avoided in most of the countries during the first wave. Yet it is still early to assess to what extent countries were able to maintain essential services without undermining equitable access to high quality care.

Can people afford to pay for health care? New evidence on financial protection in Cyprus

This review is part of a series of country-based studies generating new evidence on financial protection in European health systems. Financial protection is central to universal health coverage and a core dimension of health system performance.

Patient adherence to pharmaceutical care amid the economic crisis in Greece: Underlying priority areas for policy makers.

The purpose of the study was to investigate the degree to which chronic patients adhered to medication regimens during the economic crisis in Greece. It is a quantitative cross-sectional study, with a convenience sample of 1,009 residents of Western and Northern Greece, aged ≥ 18 years, with chronic health problems. The survey was conducted between February and June 2016. Data were collected via a structured questionnaire with closed-ended questions, filled out during face to face interviews with all participants. The vast majority of respondents (94.5 %) said that they were able to buy prescribed drugs but had to economise in other ways (for example, by cutting back on clothing and travel) to cope with essential household expenses, including medication. Only 71 % of participants said they remembered to take their prescribed medications every day, following all of their physicians' recommendations. Almost 70 % of participants said that using generic medications made it easier to adhere to their treatment regimens. The results of a correlation analysis showed that patients experiencing financial hardships as a result of health problems were less likely to adhere to pharmaceutical care regiments than those who were not experiencing financial difficulties (p = 0.026). Men had a higher level of adherence than women (p = 0.001).

The System of The Provision of Oral Healthcare in the Republic of Cyprus and the Effect of the Economic Crisis.

PURPOSE: To investigate recent developments in the provision of oral healthcare in Cyprus and the population's oral health, with special reference to the impact of the recent economic crisis. RESEARCH DESIGN: cross-sectional study. MATERIALS AND METHODS: Data from oral health surveys in Cyprus over the last 30 years were reviewed and analysed together with policy documents. Information regarding oral health behaviour, dental visits and the consequences of the economic crisis on the latter was also obtained with the help of self-completed questionnaires by patients and dentists. RESULTS: Although the overall level of oral health in Cyprus can be considered satisfactory, there were statistically significant variations between districts and different socioeconomic and ethnic groups. Beyond these variations, it seemed that the three-year economic crisis (2013-2016) had negatively affected the behaviour of the population in seeking dental care, reducing the frequency of visits to the dentist, and avoiding costly dental work, especially among those from the lower socioeconomic strata. This change in citizens' behaviour led to a statistically significant decrease in dentists' income in the private sector. CONCLUSIONS: The economic crisis brought about new difficulties and challenges for both the public and the private sectors of oral healthcare, and into the implementation of a new National Health System.

Maternal socioeconomic factors and the risk of premature birth and low birth weight in Cyprus: a case-control study.

BACKGROUND: Prematurity and low birth weight are significant predictors of perinatal morbidity and mortality and are influenced by the overall health and socioeconomic status of the pregnant mother. Although Cyprus is characterized by the highest prematurity rate in Europe (13.1% in 2014), the relationship between maternal health and socioeconomic characteristics with prematurity and low birth weight has never been investigated. We aimed to investigate the association of maternal demographic, clinical and socioeconomic characteristics with premature delivery and low neonatal birth weight in Cyprus. METHODS: In a case-control design, questionnaire data were collected from 348 women who gave birth prematurely (cases) and 349 women who gave birth at term (controls). Information was obtained on gestation duration and birth weight as well as maternal demographic, socioeconomic and clinical profiles, including parameters such as smoking, body mass index, alcohol consumption, presence of gestational diabetes and mental health factors. RESULTS: Premature delivery was associated with greater maternal age (OR: 1.12, 95% CI: 1.06-1.18), absence of gestational diabetes (OR: 0.53, 95% CI: 0.30-0.97), long working hours (OR: 3.77, 95% CI: 2.08-6.84) and emotional stress (OR: 8.5, 95% CI: 3.03-23.89). Within the cases group, emotional stress was also associated with lower birth-weight (ß: -323.68 (95% CI: -570.36, - 77.00). CONCLUSIONS: The findings of this study demonstrate the positive association of maternal psychological factors, working conditions as well as maternal age with prematurity and low birth weight in Cyprus. Additional, prospective, studies are needed in the country to further investigate these associations and inform public health intervention measures.

Public engagement in setting healthcare priorities: a ranking exercise in Cyprus.

BACKGROUND: In countries such as Cyprus the financial crisis and the recession have severely affected the funding and priority setting of the health care system. There is evidence highlighting the importance of population' preferences in designing priorities for health care settings. Although public preferences have been thorough analysed in many countries, there is a research gap in terms of simultaneously investigating the relative importance and the weight of differing and competing criteria for determining healthcare priority settings. The main objective of the study was tο investigate public preferences for the relative utility and weight of differing and competing criteria for health care priority setting in Cyprus. METHODS: The 'conjoint analysis' technique was applied to develop a ranking exercise. The aim of the study was to identify the preferences of the participants for alternative options. Participants were asked to grade in a priority order 16 hypothetical case scenarios of patients with different disease and of diverse socio-economic characteristics awaiting treatment. The sample was purposive and consisted of 100 Cypriots, selected from public locations all over the country. RESULTS: It was revealed that the "severity of the disease" and the "age of the patient" were the key prioritization criteria. Participants assigned the smallest relative value to the criterion "healthy lifestyle". More precisely, participants older than 35 years old assigned higher relative importance to "age", while younger participants to the "severity of the disease". The "healthy lifestyle" criterion was assigned to the lowest relative importance to by all participants. CONCLUSION: In Cyprus, public participation in health care priority setting is almost inexistent. Nonetheless, it seems that the public's participation in this process could lead to a wider acceptance of the healthcare system especially as a result of the financial crisis and the upcoming reforms implemented such as the establishment of the General System of Health Insurance.

The effect of hormone replacement therapy and tibolone on lipoprotein (a) concentrations in postmenopausal women: A systematic review and meta-analysis.

OBJECTIVE: Data on the effect of hormone replacement therapy (HRT) and tibolone on lipoprotein (a) [Lp(a)], an independent risk factor for cardiovascular disease, are heterogeneous and conflicting. Studies of the effect of HRT and tibolone on Lp(a) concentrations in post-menopausal women are reviewed in this meta-analysis. DESIGN AND METHODS: MEDLINE, Scopus, EMBASE and Cochrane databases were searched (up to February 10, 2017). Two researchers identified randomized controlled studies and extracted data. Potential controversies were resolved by a third reviewer. RESULTS: In 24 eligible studies, HRT caused a significant reduction in Lp(a) concentrations compared with placebo or no treatment [mean relative difference: -20.35%, 95% Confidence Interval (CI): -25.33% to -15.37%, p<0.0001], with significant heterogeneity between studies (I2=98.5%), but without evidence of publication bias. No significant effect was found for tibolone (n=7) (mean relative difference: -23.84%, 95% CI: -63.43% to 15.74%, p=0.238) (I2=98.7%, but without publication bias). Oral estrogen caused a greater reduction in Lp(a) concentrations than transdermal estrogen (n=10) (mean relative difference: 37.66%, 95% CI: 16.84% to 58.48%, p<0.0001), with significant heterogeneity between studies (I2=99%), but no evidence of publication bias. No difference was observed when continuous was compared with cyclical HRT, conventional with low-dose estrogen, and estrogen monotherapy with estrogen combined with progestogen. No difference was observed between HRT and tibolone regarding their effect on Lp(a). CONCLUSIONS: HRT significantly decreases Lp(a) concentrations, with oral being more effective than transdermal estradiol. The type of HRT, dose of estrogen and addition of progestogen do not seem to modify the Lp(a)-lowering effect of HRT.

Primary Care Doctors' Assessment of and Preferences on Their Remuneration.

Despite numerous studies on primary care doctors' remuneration and their job satisfaction, few of them have quantified their views and preferences on certain types of remuneration. This study aimed at reporting these views and preferences on behalf of Greek doctors employed at public primary care. We applied a 13-item questionnaire to a random sample of 212 doctors at National Health Service health centers and their satellite clinics. The results showed that most doctors deem their salary lower than work produced and lower than that of private sector colleagues. Younger respondents highlighted that salary favors dual employment and claim of informal fees from patients. Older respondents underlined the negative impact of salary on productivity and quality of services. Both incentives to work at border areas and choose general practice were deemed unsatisfactory by the vast majority of doctors. Most participants desire a combination of per capita fee with fee-for-service; however, 3 clusters with distinct preferences were formed: general practitioners (GPs) of higher medical grades, GPs of the lowest medical grade, residents and rural doctors. Across them, a descending tolerance to salary-free schemes was observed. Greek primary care doctors are dissatisfied with the current remuneration scheme, maybe more than in the past, but notably the younger doctors are not intended to leave it. However, Greek policy makers should experiment in capitation for more tolerable to risk GPs and introduce pay-for-performance to achieve enhanced access and quality. These interventions should be combined with others in primary care's new structure in an effort to converge with international standards.

Cost-Sharing Rates Increase During Deep Recession: Preliminary Data From Greece.

BACKGROUND: Measures taken over the past four years in Greece to reduce pharmaceutical expenditure have led to significant price reductions for medicines, but have also changed patient cost-sharing rates for prescription drugs. This study attempts to capture the resulting increase in patients' out-of-pocket (OOP) expenses for prescription drugs during the 2011-2014 period. METHODS: The authors conducted a retrospective review of financial data derived from 39 883 prescriptions, dispensed at three randomly chosen pharmacies located in Lamia, central Greece. RESULTS: The study recorded an average contribution rate per prescription as follows: 11.28% for 2011 (95% CI: 10.76-11.80), 14.10% for 2012, 19.97% for 2013, and 29.08% for 2014. Correspondingly, the mean patient charge per prescription for 2011 was €6.58 (95% CI: 6.22-6.94), €8.28 for 2012, €8.35 for 2013, and €10.87 for 2014. During the 2011-2014 period, mean percentage rate of patient contribution increased by 157.75%, while average patient charge per prescription in current prices increased by 65.22%. The use of a newly introduced internal reference price (IRP) system increased the level of prescription charge at a rate of 2.41% for 2012 (100% surcharge on patients), 26.24% for 2013 (49.95% on patients and 50.04% on the appropriate health insurance funds), and 47.72% for 2014 (85.06% on patients and 14.94% on funds). CONCLUSION: Increased cost-sharing rates for prescription drugs can reduce public pharmaceutical expenditure, but international experience shows that rising OOP expenses can compromise patients' ability to pay, particularly when it comes to chronic diseases and vulnerable populations. Various suggestions could be effective in refining the cost-sharing approach by giving greater consideration to chronic patients, and to the poor and elderly.

Assessing Patient Participation in Health Policy Decision-Making in Cyprus.

Although the importance of patient participation in the design and evaluation of health programs and services is well-documented, there is scarcity of research with regard to patient association (PA) participation in health policy decision-making processes. To this end, the present study aimed to validate further a previously developed instrument as well as to investigate the degree of PA participation in health policy decision-making in Cyprus. A convenient sample of 114 patients-members of patients associations took part in the study. Participants were recruited from an umbrella organization, the Pancyprian Federation of Patient Associations and Friends (PFPA). PA participation in health policy decision-making was assessed with the Health Democracy Index (HDI), an original 8-item tool. To explore its psychometric properties, Cronbach α was computed as regards to its internal consistency, while its convergent validity was tested against a self-rated question enquiring about the degree of PA participation in health policy decision-making. The findings revealed that the HDI has good internal consistency and convergent validity. Furthermore, PAs were found to participate more in consultations in health-related organizations and the Ministry of Health (MoH) as well as in reforms or crucial decisions in health policy. Lower levels were documented with regard to participation in hospital boards, ethics committees in clinical trials and health technology assessment (HTA) procedures. Overall, PA participation levels were found to be lower than the mid-point of the scale. Targeted interventions aiming to facilitate patients' involvement in health policy decision-making processes and to increase its impact are greatly needed in Cyprus.

Workplace ostracism and employee silence in nursing: the mediating role of organizational identification.

AIMS: The aim of this study was to examine the direct and indirect effect, through organizational identification, of workplace ostracism on nurses' silence towards patient safety. BACKGROUND: Employee silence in nursing has recently received attention in relation to its antecedents. Yet, very little is known about the role of workplace ostracism in generating nurses' silence. DESIGN: A cross-sectional survey was conducted in a public hospital in Cyprus. METHOD: Data were collected from 157 nurses employed in a public hospital of Cyprus between November 2014-January 2015. To examine the present hypotheses bootstrapping analysis and Sobel test were conducted. RESULTS: Results demonstrated that workplace ostracism has an effect on nurses' silence towards patient safety. Moreover, this effect was partially mediated through organizational identification. CONCLUSIONS: Workplace ostracism among nurses significantly affects both nurses' attitude and behaviour namely organizational identification and employee silence.

Reconsidering Planning and Management of Medical Devices Procurement in Public Health Services in Cyprus.

Hospital procurement is a crucial field for any health care system, not only for economic reasons but also for reasons related to the quality and safety of the services provided. That is why the process of procurement is, in most countries, governed by a strict legal framework and policy mechanisms. This study investigates the problems and inefficiencies associated with the procurement of medical devices in public hospitals in Cyprus and formulates empirically documented proposals for improvement. Using the Delphi method, a group of 38 experts approach the procurement system in Cyprus from different angles, achieving high rates of consensus on 35 different statements on the weaknesses and problems of the current medical device procurement system, as well as presenting proposals and recommendations for improvement. The findings are highly valuable for future policy initiatives in Cyprus in the light of the economic crisis and the expected implementation of the new General Health Insurance System (GeSY), which the Government of the Republic of Cyprus and the Troika has agreed.

Baccalaureate nursing students' perceptions of learning and supervision in the clinical environment.

This study is an exploration of nursing students' experiences within the clinical learning environment (CLE) and supervision provided in hospital settings. A total of 357 second-year nurse students from all universities in Cyprus participated in the study. Data were collected using the Clinical Learning Environment, Supervision and Nurse Teacher instrument. The dimension "supervisory relationship (mentor)", as well as the frequency of individualized supervision meetings, were found to be important variables in the students' clinical learning. However, no statistically-significant connection was established between successful mentor relationship and team supervision. The majority of students valued their mentor's supervision more highly than a nurse teacher's supervision toward the fulfillment of learning outcomes. The dimensions "premises of nursing care" and "premises of learning" were highly correlated, indicating that a key component of a quality clinical learning environment is the quality of care delivered. The results suggest the need to modify educational strategies that foster desirable learning for students in response to workplace demands.

The introduction of Greek Central Health Fund: Has the reform met its goal in the sector of Primary Health Care or is there a new model needed?

BACKGROUND: The National Organization for Healthcare Provision (EOPYY) originates from the recent reform in Greek healthcare, aiming amidst economic predicament, at the rationalization of health expenditure and reactivation of the pivotal role of Primary Health Care (PHC). Health funding (public/private) mix is examined, alongside the role of pre-existing health insurance funds. The main pursuit of this paper is to evaluate whether EOPYY has met its goals. METHODS: The article surveys for best practices in advanced health systems and similar sickness funds. The main benchmarks focus on PHC provision and providers' reimbursement. It then turns to an analysis of EOPYY, focusing on specific questions and searching the relevant databases. It compares the best practice examples to the EOPYY (alongside further developments set by new legislation in L 4238/14), revealing weaknesses relevant to non-integrated PHC network, unbalanced manpower, non-gatekeeping, under-financing and other funding problems caused by the current crisis. Finally, a new model of medical procedures cost accounting was tested in health centers. RESULTS: An alternative operation of EOPYY functioning primarily as an insurer whereas its proprietary units are integrated with these of the NHS is proposed. The paper claims it is critical to revise the current induced demand favorable reimbursement system, via per capita payments for physicians combined with extra pay-for-performance payments, while cost accounting corroborates a prospective system for NHS's and EOPYY's units, under a combination of global budgets and Ambulatory Patient Groups (APGs) CONCLUSIONS: Self-critical points on the limitations of results due to lack of adequate data (not) given by EOPYY are initially raised. Then the issue concerning the debate between 'copying' benchmarks and 'a la cart' selectively adopting and adapting best practices from wider experience is discussed, with preference to the latter. The idea of an 'a la cart' choice of international examples is proposed. The 'results' discussing EOPYY's dual function and induced-demand favorable reimbursement system are further critically examined. International experience shows evidence of effective alternatives, such as per capita and pay-for-performance payments for practicing doctors as well as per case reimbursement for health centers under global budget principles.

Access and utilisation of health services by domestic helpers in Cyprus.

BACKGROUND: Immigrants have always been a very vulnerable group with severe inequalities in the access and utilisation of health services. The aim of this study was to investigate the conditions of access and utilization of health services from domestic helpers in Cyprus. METHODS: A cross-sectional study with 625 domestic helpers was carried out during October 2010-April 2011. The sampling method was snowball sampling. Statistical analysis included x(2) test, x(2) trend test, Mann-Whitney test, t-test and multivariate logistic regression analysis. RESULTS: The main reasons of health service utilization were blood tests, short-term illnesses and injuries/poisonings. Eighteen percent of domestic helpers reported a need for health services, which was not met. Ten percent responded that there was a need for pharmaceuticals that remained unmet. Sixty-two percent reported that their first action in case of a health problem is seeking advice and assistance from their employer. After adjustment, only increased length of stay in Cyprus was associated with increased use of health services (p < 0.001). CONCLUSION: The barriers of language and communication, ignorance of the system and the different culture are largely evident in Cyprus. The role of the employers is very important with regard to the access and use of health services.