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

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

Trends in Outpatient Antibiotic Use in 3 Health Plans.

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

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

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

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

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

Ministerio de Salud: Plan de Salud 2016-2019: Equipos de salud territoriales

Lineamientos estratégicos para desarrollar una atención primaria de acceso universal, equitativo, y oportuno. La visión del plan es desarrollar una red de cuidados integrales y progresivos, basada en las necesidades y la participación de la comunidad, que brinde servicios de calidad y eficientes en pos de la satisfacción ciudadana.

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

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

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

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

[To aim at better home medical care].

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

Valoración de los resultados del Plan Oncológico 2007-2010 de la Comunidad Valenciana: el punto de vista de los pacientes, familiares, ciudadanos y profesionales / Results assessment of the Valencian Community Cancer Plan: The point of view of patients, relatives, citizens and professionals

Objetivo. Analizar la percepción de los resultados alcanzados por el Plan Oncológico de la Comunidad Valenciana (POCV) desde el punto de vista de sus agentes clave: pacientes, familiares de pacientes, ciudadanos y profesionales sanitarios. Métodos. Estudio descriptivo en el que se combinó un análisis cualitativo (2 entrevistas grupales con 34 participantes y 4 grupos focales con 37 participantes) y otro cuantitativo (470 encuestas de opinión). Resultados. La propia existencia de un POCV se destacó como factor positivo. Se ha conseguido que, entre la población, se transmita el mensaje de que el cáncer es «curable». Se han definido objetivos clave, unificado criterios y que los comités de tumores y las comisiones contribuyan, en mayor medida, a realizar una asistencia multidisciplinar. Se consideró innovador el POCV especialmente por la introducción del Programa de Consejo Genético. Los representantes de asociaciones ciudadanas y de pacientes consideraron el Programa de Prevención de Cáncer de Mama el más conocido y mejor valorado y el Programa de Cáncer Colorrectal el menos conocido. Tanto en los grupos cualitativos como en la consulta realizada a profesionales, los aspectos mejor valorados fueron los comités de tumores, la recomendación de la citología vaginal para la prevención del cáncer de cérvix o que se haya transmitido a la población que el cáncer puede curarse, son aspectos valorados positivamente. Conclusiones. Las valoraciones del POCV 2007-2010 son positivas en términos generales, con excepciones puntuales claramente identificadas. La información de tipo cualitativo y cuantitativo obtenida en los distintos análisis es prácticamente coincidente(AU)

Objective. To assess stakeholders’ perceptions (i.e. patients, relatives, the public, and professionals) about results of the Valencian Community Cancer Plan (POCV). Methods. Qualitative analysis (34 participants in 2 interview groups, and 37 participants in 4 focus groups) and quantitative analysis (470 opinion surveys) was combined in a descriptive study. Results. The POCV's existence is highlighted as a positive factor. It has managed to send the message that “cancer can be cured” to the population. The key aims have been defined, criteria have been unified, and there have been achieved the Tumor Committees contribute most to make a multidisciplinary care. The plan is considered innovative, especially because the Genetic Counseling Program was included. Citizens leaders and patient associations find the Breast Cancer Program as the best known and the most valued, while the Colorectal Cancer Program is the least known. In both methodologies, qualitative groups and the online survey conducted on the professionals, it is concluded that the Tumor Committees, the vaginal cytology recommendation for cervical cancer prevention, and the message transmission that “cancer can be cured” are positively assessed. Conclusions. POCV 07-10 assessments are generally positive, with occasional exceptions that are clearly identified. The qualitative and quantitative information obtained in the different analyses is almost coincident(AU)

¿A quién benefician los programas de salud dirigidos a los más pobres? Éxitos y fracasos. Informe SESPAS 2008 / Who benefits from health programs aimed at the poorest? Successes and failures. 2008 SESPAS Report

Los programas de cooperación internacional en salud dirigidosa los más pobres tienen un indudable papel constructivoal aliviar el sufrimiento humano agudo, pero resultan contraproducentesy hasta lesivos si oscurecen la necesidad deeliminar las inequidades sociales, que son la causa primariade las inequidades en salud.El objetivo de este artículo es revisar la efectividad de dosprogramas estatales que recibieron ayuda de la cooperación,el primero en mejorar la seguridad alimentaria de los hogaresrurales y los grupos vulnerables urbanos en Colombia(1996-2005), y el segundo en desarrollar un sistema local desalud en la zona Norte de San Salvador, El Salvador (1992-1997).La cooperación internacional apoya programas asistencialesexitosos, como los de complementación alimentaria, quepodrían generar dependencias a los beneficiarios. Además,factores externos a la cooperación (contexto de intereses políticos-económicos) influyen en los programas que apoyan, ypueden generar conflictos sociales. Es el caso del apoyo aprogramas de los mas pobres para la promoción de su saluden El Salvador, o de mejora de las condiciones de acceso alos alimentos mediante la producción para el autoconsumoen zonas rurales de Colombia, pues benefician la producciónagraria exportable, propiedad de los más ricos, pero no al pequeñoagricultor(AU)

International aid health programs directed at the poorest playan undoubtedly constructive role in relieving acute human suffering.These programs may, however, be counterproductiveand even harmful if they obscure the need to eliminate socialinequities, which are the primary cause of health inequities.The present article reviews the effectiveness of two state programsthat received support from international aid to (a) improvefood security in rural households and vulnerable urbangroups in Colombia (1996-2005) and (b) develop a local healthsystem in the northern area of San Salvador, El Salvador(1992-1997).International aid supports successful healthcare programs,such as food programs, could generate dependency in its beneficiaries.Factors extrinsic to cooperation (political and economicfactors of the context) may affect the programs and generatesocial conflicts. This is the case of the program toimprove access to food by subsistence production in rural areasof Colombia, which failed to reach the small farmers and benefitedagricultural export production owned by wealthier groups,or interventions designed to improve health among the poorestin El Salvador(AU)

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

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

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

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

Desigualdades socioeconómicas y planes de salud en las comunidades autónomas del Estado español / Socieconomic inequalities and health plans in the Autonomous Communities of Spain

Objetivo: Analizar la sensibilidad a las desigualdades de nivel socioeconómico (NSE) en los planes de salud en vigor de las comunidades autónomas (CCAA) del Estado español. Métodos: Revisión sistemática de 14 planes de salud. Los contenidos introductorios se denominaron «contenidos simbólicos» y las propuestas de acción «contenidos operativos». En los contenidos simbólicos se valora la presencia de desagregación por NSE del análisis de la situación de salud, de principios y valores para reducir las desigualdades y de objetivos generales enunciados con este fin (índice de sensibilidad simbólica, rango 0-3). En los contenidos operativos se evalúa la consideración del NSE en el análisis de situación y en las intervenciones propuestas. Resultados: El País Vasco y Extremadura obtuvieron el máximo índice de sensibilidad simbólica (ISS = 3). Otras 6 CCAA (Canarias, Cataluña, Castilla y León, Galicia, Murcia y Navarra) presentan ISS = 0. En cuanto a los contenidos operativos destacan el País Vasco, Galicia y Canarias por ser las CCAA que más tienen en cuenta las desigualdades de NSE. El alcohol, las drogas y la salud reproductiva son las áreas relacionadas con la salud en las que con mayor frecuencia se analiza la situación teniendo en cuenta el NSE. Conclusiones: Se pone de manifiesto la escasa atención que se presta al NSE en los planes de salud, con excepción del País Vasco. Es necesario que el Gobierno del Estado español y los de las comunidades autónomas sitúen las desigualdades en salud por NSE más claramente en la agenda política, lo que se traduciría también en su presencia en los planes de salud

Objective: To systematically examine sensitivity to socioeconomic (SE) inequalities in the policies formulated in the health plans of the Autonomous Communities of Spain. Methods: We performed a systematic review of 14 health plans. The introductory content of the health plans was called the «symbolic content» and was separated from specific interventions, or «operative content». The symbolic content was analyzed through the presence or absence of SE description of the health areas, the principles and values to reduce SE inequalities in health, and the general objectives for this topic (sensitivity index, range 0-3). To review the operative content, consideration of SE inequalities in the description of health areas and proposed interventions were evaluated. Results: The Basque Country and Extremadura had a sensitivity index of 3 for symbolic content. Six Autonomous Communities had an index of 0 (Canary Islands, Catalonia, Castilla-León, Galicia, Murcia and Navarre). Regarding operative content, the Autonomous Communities that most clearly took SE inequalities into account were the Basque Country, Galicia and the Canary Islands. The specific health-related areas most frequently analyzed according to SE inequalities were alcohol and drug consumption and reproductive health. Conclusions: This study shows that little attention is paid to SE inequalities in the health plans of the various Autonomous Communities, with the exception of the Basque Country. The national and regional governments of Spain should prioritize inequalities in health in the political agenda, which would translate into their presence in the health plansObjective: To systematically examine sensitivity to socioeconomic (SE) inequalities in the policies formulated in the health plans of the Autonomous Communities of Spain. Methods: We performed a systematic review of 14 health plans. The introductory content of the health plans was called the «symbolic content» and was separated from specific interventions, or «operative content». The symbolic content was analyzed through the presence or absence of SE description of the health areas, the principles and values to reduce SE inequalities in health, and the general objectives for this topic (sensitivity index, range 0-3). To review the operative content, consideration of SE inequalities in the description of health areas and proposed interventions were evaluated. Results: The Basque Country and Extremadura had a sensitivity index of 3 for symbolic content. Six Autonomous Communities had an index of 0 (Canary Islands, Catalonia, Castilla-León, Galicia, Murcia and Navarre). Regarding operative content, the Autonomous Communities that most clearly took SE inequalities into account were the Basque Country, Galicia and the Canary Islands. The specific health-related areas most frequently analyzed according to SE inequalities were alcohol and drug consumption and reproductive health. Conclusions: This study shows that little attention is paid to SE inequalities in the health plans of the various Autonomous Communities, with the exception of the Basque Country. The national and regional governments of Spain should prioritize inequalities in health in the political agenda, which would translate into their presence in the health plans

Estadisticas de salud: enero a agosto gestion 2003 / Health statistics: january to august management 2003

Cada vez mas ha crecido la necesidad de contar con datos y analisis actualizados sobre el comportamiento de los indicadores de salud establecidos por USAID y los comprometidos por el Ministerio de Salud y Deporte con otros organismos de cooperacion internacional. Esta necesidad, en el presente aumenta; debido a que el PROSIN requiere insumos para el diseño de la estrategia 2005 al 2009. La primera version del documento contiene informacion y analisis correspondiente al periodo enero a agosto del presente año, posteriormente el mismo se producira cada dos meses.

El informe de la Organización Mundial de la Salud 2000: un juego de ordenador políticamente incorrecto / The World Health Organization Report 2000: a politically incorrect computer game

El Informe de la Organización Mundial de la Salud 2000 trata de fundamentar el desarrollo de los sistemas de salud en el mundo en la evidencia disponible sobre políticas sanitarias. El informe ha suscitado un importante debate político y académico. Este artículo revisa las aportaciones del informe a la política de salud, y además analiza y comenta las principales críticas publicadas. A través de una recapitulación de la reformas acontecidas en los últimos 15 años en el panorama internacional, la OMS realiza un cambio sustancial en los planteamientos clásicos que ha mantenido, decantándose por los sistemas de salud con financiación universal y conducción gubernamental, donde exista una mayor compartición de riesgo financiero, colaboración público-privada y desregulación de la gestión pública. La OMS realiza al mismo tiempo una baremación de los 191 sistemas de salud de acuerdo con su (..) (AU)

The World Health Organization Report 2000 is aimed at supporting an evidence-based development of health care systems in the world. The report has brought about a significant political and academic debate. This article reviews the contribution of the WHO Report to current health care policy, aswell as analyzes and comments the main published critiques. Through a commented compilation of the health care reforms implemented over the last fifteen years in the world, WHO shifts radically its traditional position supporting now universal access to health care and a strong government’s conduction role, but within a financial risk sharing environment, public and private co-operation and deregulation of the public management (..) (AU)