Utilization of antiobesity medications within the Military Health System.

OBJECTIVE: The prevalence of overweight and obesity among beneficiaries of the Military Health System (MHS) is 41.6% and 30.5%, respectively. This incurs significant medical, fiscal, and military readiness costs. It is not currently known how the utilization of antiobesity medications (AOMs) within the MHS compares with that in the Veterans Health Administration or the private sector. Our aim was to assess the utilization of AOMs within the MHS. METHODS: A cross-sectional study was conducted using data gathered from the MHS Data Repository and the inclusion of all adult TRICARE Prime and Plus beneficiaries ages 18 to 64 years who were prescribed at least one TRICARE-approved AOM during the years 2018 to 2022. RESULTS: The total study population included 4,414,127 beneficiaries, of whom 1,871,780 were active-duty service members. The utilization of AOMs among the eligible population was 0.56% (0.44% among active-duty personnel). Liraglutide was the most-prescribed AOM (36% of the total). Female sex, age greater than or equal to 30 but less than 60 years, and enlisted or warrant officer rank were all associated with statistically significant higher odds of receiving AOMs. CONCLUSIONS: Comparable with the US private sector, the MHS significantly underutilizes AOMs, including among active-duty service members, despite coverage of AOMs since 2018.

[The analysis of medical personnel potential of stomatological service of the Subject of the Russian Federation considering its private sector].

The approaches to analysis of medical personnel of stomatological service continue to be based on principles formed in relation to state health care system that makes it difficult to objectively assess situation due to increasing proportion of specialists employed in its private sector. The study, targeted to comprehensive comparative analysis of stomatological medical personnel of state and private medical organizations in the Irkutsk Oblast, for the first time made it possible to assess provision of population of large region and its municipalities with stomatologists, considering specialists employed in private medical organizations, in dynamics and in context of separate specialties. The decrease in provision of population with stomatologists in state medical organizations by 12.3% in 2019-2023 against the background of its increase in private ones by 14.5% was revealed. In 2023, 50.5% of stomatologists were concentrated in private sector of stomatological service and 30.8% in state sector. Yet another 18.7% combined their work in medical organizations of both types. The stomatologists employed in private sector of stomatological service were mainly concentrated in metropolises, especially in regional center, where their provision exceeds average regional level by 2.6 times.

Distribution of Private Dental Healthcare Facilities in Riyadh City: A GIS-Based Approach.

BACKGROUND: The dental healthcare private sector in Riyadh city has been growing rapidly over the past few years; however, there is a lack of information on the accessibility and spatial distribution of private dental healthcare facilities (PDHFs) in the area. This study aimed to evaluate the spatial distribution of PDHFs in Riyadh city in relation to population density in each sub-municipality. METHODS: The current information regarding the number, location, and operability of PDHFs in Riyadh city was obtained from the Ministry of Health. A total of 632 operating PDHFs were included with the precise location plotted on Quantum Geographic Information System software (version 3.32.1, Essen, Germany) using Google Earth. Four levels of buffer zones-1 km, 3 km, 5 km, and >5 km-were determined. The population statistics and mean monthly individual income per district were gathered from Zadd.910ths. Microsoft Excel (version 16.0, Microsoft, Redmond, WA, USA) and RStudio software (version 4.1.3, Posit Software, PBC, Boston, MA, USA) were used for additional data analysis. RESULTS: There was an overall ratio of one PDHF per 9958 residents in Riyadh city. Olaya and Maather sub-municipalities had the largest PDHF-to-population ratios: (1:4566) and (1:4828), respectively. Only 36.3% of the city's total area was within a 1 km buffer zone from a PDHF. There was an overall weak positive correlation between the number of PDHFs and the total area in each sub-municipality (r = 0.29), and the distribution of PDHFs was uneven corresponding to the area (G* = 0.357). CONCLUSIONS: There was an uneven distribution of PDHFs in Riyadh city. Some areas were underserved while others were overserved in several sub-municipalities. Policy-makers and investors are encouraged to target underserved areas rather than areas with significant clustering to improve access to care.

Quality of work life and associated factors among health professionals working at private and government health institutions in Awi zone, Amhara regional state, Ethiopia, 2022: a comparative cross-sectional study.

Background: Quality of work-life issues significantly impact the economic, physical, and psychological well-being of health professionals and their families. Enhancing QWL aims to foster a conducive environment and improve work performance. This study evaluated the quality of work life of health professionals in government and private health institutions in the Awi zone, Ethiopia. Methods: A comparative cross-sectional approach was employed, with study participants selected via the lottery method in 2022. Socio-demographic and organizational-related data were collected, coded, cleaned, and entered into Epi-Data version 3.1, then analyzed using SPSS version 27. Candidate variables were selected using bivariable logistic regression (p < 0.20). We used multivariable logistic regression to identify factors associated with quality of work life, presenting AOR with a 95% CI at a 5% significance level. Results: The study included 385 private health professionals and 395 government health professionals, with response rates of 90.38 and 92.72%, respectively. Overall quality of work-life satisfaction was 53.08% (95% CI: 49.2-57.0), with private health institution workers reporting satisfaction at 42.3% (95% CI: 37.4-47.30) and government health professionals at 63.54% (95% CI: 58.78-68.31). The difference between the two groups was 21.2% (95% CI: 14.3, 27.9). Factors significantly associated with quality of work life included type of health institutions (AOR = 2.272; 1.684, 3.065), family size (AOR = 1.536; 1.122, 2.103), personnel protective equipment (AOR = 1.369; 1.006, 1.863), eye protection (AOR = 2.090; 1.514, 2.885), engineering control (AOR = 1.563; 1.140, 2.143), and accessibility of alcohol (AOR = 1.714; 1.219, 2.410). Conclusion: Health professionals in private health institutions exhibited lower quality of work-life satisfaction than government health institutions. Quality of work life was significantly associated with the type of health institutions, family size, availability of personal protective equipment, eye protection, engineering control, and accessibility of alcohol. Regular monitoring and evaluation of the quality of work life, ensuring the availability of appropriate personal protective equipment, and providing sufficient materials and equipment for both groups were recommended based on the findings.

Caries prevalence among children at public and private primary schools in Riyadh: a retrospective study.

Dental caries is a global oral health issue, especially critical in children, affecting their growth, nutrition, and education due to school absences or distractions from dental pain. The aim of the study was to investigate the correlation between school types (indicative of socioeconomic conditions) and dental caries prevalence among primary school children in Riyadh, alongside assessing the overall caries prevalence among schoolchildren in Riyadh. Retrospective study on 28,343 first and fourth-grade students from 960 public and private schools in Riyadh, using data from the Saudi Ministry of Health (Feb-April 2019). Utilized the DMFT/dmft index for assessment and collected demographic data. Most of the schools were public (76.1%), private national (17.1%), and private international (6.8%). Overall, the mean DMFT index for permanent teeth and the dmft index for primary teeth were 1.78 and 1.94, respectively. 58% of school children had no dental caries, 25% had mild caries, and 17% had moderate to severe caries. Public school children showed a higher caries prevalence than private schools. Oral disease rates were higher in girls than in boys, and grade four students had a higher prevalence than grade one students. Saudi Arabia, a developing nation, faces challenges in addressing oral health, especially in public schools. Targeted initiatives are crucial for awareness, preventive measures, and meeting oral health needs.

Trends in cesarean section rates in Brazil by Robson classification group, 2014-2020.

OBJECTIVES: to evaluate the trends in cesarean sections from 2014 to 2020 across both public and private sectors, utilizing the Robson Classification. METHODS: this time series study analyzed the proportion of women who underwent cesarean sections between 2014 and 2020, considering both the Robson classification and the type of healthcare service. Trend analysis was conducted using the Prais-Winsten regression. RESULTS: higher proportions of cesarean sections were observed in all Robson groups within the private sector compared to the public sector. This was despite a decreasing trend in the private sector and an increasing trend in the public sector. Notably, elevated proportions of cesarean sections were recorded in groups that are typically favorable to normal childbirth (Robson 1, 4, and 5). CONCLUSIONS: although there was a decreasing trend in cesarean sections within the private sector, an increasing trend was observed in the public sector. Additionally, there was a high proportion of cesarean sections among women with conditions favorable to normal childbirth. It is crucial to continuously monitor these indicators to evaluate and implement interventions aimed at reducing unnecessary cesarean sections.

Overweight and obesity and associated factors among public and private secondary school adolescent students in Harar city, Eastern Ethiopia: A comparative cross-sectional study.

Adolescent overweight and obesity are growing public health concerns in developing nations like Ethiopia. They are closely linked to an increased risk of non-communicable diseases, a deterioration in health-related quality of life, subpar academic performance, and a decline in social and emotional well-being. There is, however, little research in this field. Thus, this study aimed to assess overweight and obesity and associated factors among public and private secondary school adolescent students in Harar city, Eastern Ethiopia. A school-based comparative cross-sectional study was conducted among 781 secondary school adolescents in Harar city from February to March 2022. Multi-stage sampling was used to identify 781 study participants (586 in public and 195 in private schools). Anthropometric measures and self-administered structured questionnaires were used to obtain the data. Bivariate and multivariate logistic regression were used to determine the association between independent variables and overweight and obesity. Statistical significance was declared at P < .05. The overall magnitude of overweight and obesity was 9.3% [95% confidence interval (CI) = 7.2-11.4%] with 16.2% in private schools. Being female [adjusted odd ratio (AOR) = 2.04, 95% CI: 1.17-3.55], late adolescent age [AOR = 0.53, 95% CI: 0.31-0.90], bigger family size [AOR = 0.55, 95% CI: 0.31-0.97], high paternal education level [AOR = 2.03, 95% CI: 1.08-3.81], eating meat [AOR = 3.41, 95% CI: 1.27-9.17] and not consuming breakfast daily [AOR = 2.13, 95% CI: 1.24-3.67] were factors associated with overweight and obesity among all secondary school adolescents. A high maternal educational level, not eating breakfast and dinner daily in private secondary school adolescents and having a feminine gender, eating eggs, and not walking or riding a bicycle for at least 10 minutes continuously in public secondary school adolescents were factors associated with overweight and obesity. The extent of overweight and obesity was notably higher in the study area. Communities and educational institutions should work together to promote healthy lifestyle choices among adolescents, with a special emphasis on girls and students enrolled in private schools.

Horizontal and vertical equity and public subsidies for private health insurance in the U.S.

The United States offers two markedly different subsidy structures for private health insurance. When covered through employer-based plans, employees and their dependents benefit from the exclusion from taxable income of the premiums. Individuals without access to employer coverage may obtain subsidies for Marketplace coverage. This paper seeks to understand how the public subsidies embedded in the privately financed portion of the U.S. healthcare system impact the payments families are required to make under both ESI and Marketplace coverage, and the implications for finance equity. Using the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) and Marketplace premium data, we assess horizontal and vertical equity by calculating public subsidies for and expected family spending under each coverage source and using Lorenz curves and Gini and concentration coefficients. Our study pooled the 2018 and 2019 MEPS-HC to achieve a sample size of 10,593 observations. Our simulations showed a marked horizontal inequity for lower-income families with access to employer coverage who cannot obtain Marketplace subsidies. Relative to both the financing of employer coverage and earlier Marketplace tax credits, the more generous Marketplace premium subsidies, first made available in 2021 under the American Rescue Plan Act, substantially increased the vertical equity of Marketplace financing. While Marketplace subsidies have clearly improved equity within the United States, we conclude with a comparison to other OECD countries highlighting the persistence of inequities in the U.S. stemming from its noteworthy reliance on employer-based private health insurance.

Public versus Private Care in the Military Health System: Evidence From Low Back Pain Patients.

INTRODUCTION: There is a longstanding debate about whether health care is more efficiently provided by the public or private sector. The debate is particularly relevant to the Military Health System (MHS), which delivers care through a combination of publicly funded federal facilities and privately contracted providers. This study compares outcomes, treatments, and costs for MHS patients obtaining care for low back pain (LBP) from public versus private providers. MATERIALS AND METHODS: A retrospective cohort study was completed using TRICARE Prime claims data from April 2015 to December 2018. The cohort was identified using International Classification of Diseases Ninth Revision and Tenth Revision diagnostic codes and then followed for 12 months after the index diagnosis to assess treatments, outcomes, and costs. Claims were classified as originating from either public or private providers. The primary outcome measure was resolution of LBP, defined as an absence of LBP diagnoses during the 6-to-12-month window following the index event. Instrumental variable models were used to assess the impact of care setting (i.e., private versus public), conditioning on the covariates. A regional measure of the fraction of private care was used as an instrument. RESULTS: Resolution of LBP was achieved for 79.7% of 144,866 patients in the cohort. No significant association was found between resolution of LBP and fraction of privately provided care. Higher fraction of private care was associated with a greater likelihood of opioid treatments (odds ratio, 1.22; 95% CI, 1.02-1.46) and a lower likelihood of benzodiazepine (odds ratio, 0.56; 95% CI, 0.45-0.70) and physical therapy (odds ratio 0.55; 95% CI, 0.42-0.74) treatments; manual therapy was not significantly associated with the fraction of private care. There was a significant negative association between the fraction of private care and cost (coefficient -0.27; 95% CI, -0.44, -0.10). CONCLUSION: This study found that privately provided care was associated with significantly higher opioid prescribing, less use of benzodiazepines and physical therapy, and lower costs. No systematic differences in outcomes (as measured by resolved cases) were identified. The findings suggest that publicly funded health care within the MHS context can attain quality comparable to privately provided care, although differences in treatment choices and costs point to possibilities for improved care within both systems.

Impact of Lung Cancer on Health-Related Quality of Life, Financial Toxicity, and Household Economics in Patients From the Public and the Private Healthcare Sector in Argentina.

OBJECTIVES: Non-small cell lung cancer (NSCLC) is Argentina's first cause of cancer death. Most patients have an advanced stage at diagnosis, with poor expected survival. This study aimed to characterize the health-related quality of life (HRQOL) and economic impact of patients treated in the private healthcare sector and compare it with that of the public sector. METHODS: We undertook an observational cross-sectional study that extended a previous study to a referral private center in Argentina. Outcomes included the EuroQol EQ-5D-3L (to assess HRQOL), Comprehensive Score for Financial Toxicity (financial toxicity instrument), Work Productivity and Activity Impairment - General Health (to assess productivity loss), and out-of-pocket expenses in adults diagnosed of NSCLC. RESULTS: We included 30 consecutive patients from a private healthcare center (July 2021 to March 2022), totaling 131 patients (n = 101 from previous public study). The whole sample had low quality of life and relevant economic impact. Patients in the private healthcare sector showed lower disease severity and higher educational level and household income. In addition, private healthcare system patients showed higher utility (0.77 vs 0.73; P < .05) and lower impairment of daily activities (41% vs 59%; P = .01). Private health system patients also showed lower financial toxicity as measured by the Comprehensive Score for Financial Toxicity score (23.9 vs 20.14; P < .05) but showed no differences when financial toxicity was assessed as a dichotomic variable. CONCLUSIONS: Although patients with NSCLC treated in a private healthcare center in Argentina showed a relevant HRQOL and economic impact, this impact was smaller than the one observed in publicly funded hospitals.

An epidemic of cataract surgery in Korea: the effects of private health insurance on the National Health Insurance Service.

OBJECTIVES: In Korea, the National Health Insurance Service (NHIS) covers essential healthcare expenses, including cataract surgery. To address concerns that private health insurance (PHI) might have inflated the need for such procedures, we investigated the extent of the PHI-attributable increase in cataract surgery and its impact on NHIS-reimbursed expenses. METHODS: This retrospective, observational study uses nationwide claims data for cataract surgery from 2016 to 2020. We examined trends in utilization and cost, and we estimated the excess numbers of (1) cataract operations attributable to PHI and (2) types of intraocular lenses used for cataract surgery in 2020. RESULTS: Between 2016 and 2020, a 36.8% increase occurred in the number of cataract operations, with increases of 63.5% and 731.8% in the total healthcare costs reimbursed by NHIS and PHI, respectively. Over a 5-year period, the surgical rate per 100,000 people doubled for patients aged <65 years (from 328 in 2016 to 664 in 2020). Among the 619,771 cases in 2020 of cataract surgery reimbursed by the Korean diagnosis-related group system, more non-NHIS-covered intraocular lenses were used for patients aged <65 years than ≥65 years (68.1 vs. 14.2%). In 2020 alone, an estimated 129,311 excess operations occurred, accounting for an excess cost of US$115 million. CONCLUSIONS: A dramatic increase in the number and cost of cataract operations has occurred over the last 5 years. The PHI-related increase in operations resulted in increased costs to NHIS. Measures to curtail the non-indicated use of cataract surgery should be implemented regarding PHI.

Beyond the dichotomy: How ride-hailing competes with and complements public transport.

Since ride-hailing has become an important travel alternative in many cities worldwide, a fervent debate is underway on whether it competes with or complements public transport services. We use Uber trip data in six cities in the United States and Europe to identify the most attractive public transport alternative for each ride. We then address the following questions: (i) How does ride-hailing travel time and cost compare to the fastest public transport alternative? (ii) What proportion of ride-hailing trips do not have a viable public transport alternative? (iii) How does ride-hailing change overall service accessibility? (iv) What is the relation between demand share and relative competition between the two alternatives? Our findings suggest that the dichotomy-competing with or complementing-is false. Though the vast majority of ride-hailing trips have a viable public transport alternative, between 20% and 40% of them have no viable public transport alternative. The increased service accessibility attributed to the inclusion of ride-hailing is greater in our US cities than in their European counterparts. Demand split is directly related to the relative competitiveness of travel times i.e. when public transport travel times are competitive ride-hailing demand share is low and vice-versa.

Space-time clustering-based method to optimize shareability in real-time ride-sharing.

Real-time ride-sharing has become popular in recent years. However, the underlying optimization problem for this service is highly complex. One of the most critical challenges when solving the problem is solution quality and computation time, especially in large-scale problems where the number of received requests is huge. In this paper, we rely on an exact solving method to ensure the quality of the solution, while using AI-based techniques to limit the number of requests that we feed to the solver. More precisely, we propose a clustering method based on a new shareability function to put the most shareable trips inside separate clusters. Previous studies only consider Spatio-temporal dependencies to do clustering on the mobility service requests, which is not efficient in finding the shareable trips. Here, we define the shareability function to consider all the different sharing states for each pair of trips. Each cluster is then managed with a proposed heuristic framework in order to solve the matching problem inside each cluster. As the method favors sharing, we present the number of sharing constraints to allow the service to choose the number of shared trips. To validate our proposal, we employ the proposed method on the network of Lyon city in France, with half-million requests in the morning peak from 6 to 10 AM. The results demonstrate that the algorithm can provide high-quality solutions in a short time for large-scale problems. The proposed clustering method can also be used for different mobility service problems such as car-sharing, bike-sharing, etc.

Measuring the quality of dental care among privately insured children in the United States.

OBJECTIVE: To examine whether quality of dental care varies by age and over time and whether community-level characteristics explain these patterns. DATA SOURCE: Deidentified medical and dental claims from a commercial insurer from January 2015 to December 2019. STUDY DESIGN: A retrospective cohort study. The primary outcome was a composite quality score, derived from seven dental quality measures (DQMs), with higher values corresponding to better quality. Hierarchical regression models identified person- and zip code-level factors associated with the quality. DATA COLLECTION/EXTRACTION METHODS: Continuously enrolled US dental insurance beneficiaries younger than 21 years of age. PRINCIPAL FINDINGS: Quality was assessed for 4.88 million person-years covering 1.31 million persons. Overall quality slightly improved over time, mostly driven by substantial improvements among children aged 0-5 years by 0.153 points/year (95% confidence interval [CI]:0.151, 0.156). Quality was poorest and declined over time among adolescents with only 20.5% of DQMs met as compared to 42.6% among aged 0-5 years in 2019. Dental professional shortage, median household income, percentages of African Americans, unemployed, and less-educated populations at the zip code level were associated with the composite score. CONCLUSION: Quality of dental care among adolescents remains low, and place of residence influenced the quality. Increasing the supply of dentists and oral health promotion strategies targeting adolescents and low-performing localities should be explored.

Trends, wealth inequalities and the role of the private sector in caesarean section in the Middle East and North Africa: A repeat cross-sectional analysis of population-based surveys.

OBJECTIVE: To examine trends and variations of caesarean section by economic status and type of healthcare facility in Arab countries in the Middle East and North Africa (MENA). METHODS: Secondary data analysis of nationally representative household surveys conducted between 2008-2020 across nine Arab countries in the MENA region. The study population was women aged 15-49 years with a live birth in the two years preceding the survey. Temporal changes in the proportion of deliveries by caesarean section in each country were calculated using generalised linear models and presented as risk differences (RD) with 95% confidence intervals (95%CI). Caesarean section was disaggregated by household wealth index and type of healthcare facility. RESULTS: Use of caesarean section ranged from 57.3% (95%CI:55.6-59.1%) in Egypt to 5.7% of births (95%CI:4.9-6.6%) in Yemen. Overall, the use of caesarean section has increased across the MENA region, except in Jordan, where there was no evidence of change (RD -2.3 (95%CI: -6.0 ‒1.4)). Across most countries, caesarean section use was highest in the richest quintile compared to the poorest quintile, for example, 42.8% (95%CI:38.0-47.6%) vs. 22.6% (95%CI:19.6-25.9%) in Iraq, respectively. Proportion of caesarean section was higher in private sector facilities compared to public sector: 21.8% (95%CI:18.2-25.9%) vs. 15.7% (95%CI:13.3-18.4%) in Yemen, respectively. CONCLUSION: Variations in caesarean section exist within and between Arab countries, and it was more commonly used amongst the richest quintiles and in private healthcare facilities. The private sector has a prominent role in observed trends. Urgent policies and interventions are required to address non-medically indicated intervention.

In search of the last malaria cases: ethnographic methods for community and private-sector engagement in malaria elimination in Vietnam, Laos, and Cambodia.

BACKGROUND: Despite significant strides made in reducing malaria morbidity and mortality in the Greater Mekong Subregion, malaria transmission continues amongst the most 'hard-to-reach', such as forest-goers and mobile and migrant populations, who face access obstacles to malaria diagnosis and treatment. As such, regional malaria elimination strategies endeavour to incorporate the private sector and local communities in improving surveillance and detection of the last malaria cases in remote forested areas. The question remains, however, whether such strategies can reach these hard-to-reach populations and effectively reduce their disproportionate burden of malaria. This paper evaluates the strategy of community and private sector engagement in a malaria elimination project in Vietnam, Laos, and Cambodia. METHODS: Ethnographic research, incorporating in-depth interviews, participant observations with informal discussions, and group discussions were conducted in Bu Gia Map commune, Binh Phuc province of Vietnam; in Phouvong district, Attapeu province of Laos; and, in nine newly established and informal communities in the provinces of Mondul Kiri, Steung Treng, Kratie, Kampong Thom, and Prah Vihear of Cambodia. RESULTS: Different types of factors limited or enhanced the effectiveness of the participatory approaches in the different settings. In Vietnam, inter-ethnic tensions and sensitivity around forest-work negatively affected local population's health-seeking behaviour and consequent uptake of malaria testing and treatment. In Laos, the location of the project collaborative pharmacies in the district-centre were a mismatch for reaching hard-to-reach populations in remote villages. In Cambodia, the strategy of recruiting community malaria-workers, elected by the community members, did manage to reach the remote forested areas where people visited or stayed. CONCLUSIONS: 'Hard-to-reach' populations remain hard to reach without proper research identifying the socio-economic-political environment and the key dynamics determining uptake in involved communities and populations. Solid implementation research with a strong ethnographic component is required to tailor malaria elimination strategies to local contexts.

A retrospective, observational study of medicolegal cases against obstetricians and gynaecologists in South Africa's private sector.

BACKGROUND:  The viability of obstetric practice in the private sector has been threatened as a result of steep increases in professional indemnity fees over the past 10 years. Despite this, empirical research investigating key aetiological factors to target risk management interventions has been lacking. OBJECTIVES: To explore private practice medicolegal data linked to obstetricians and gynaecologists (O&Gs) to identify factors in clinical practice associated with claims, for the purposes of guiding future research and risk management solutions. METHODS:  This was a retrospective, observational study of private sector O&Gs' medicolegal case histories. All incidents declared to a prominent local professional indemnity insurer were categorised in terms of medicolegal case type, as well as clinical parameters. To allow for risk-adjusted calculations of case incidence, year of entry into private practice was estimated for all practitioners. RESULTS:  Steep increases in medicolegal investigations and demands were demonstrated for both obstetrics- and gynaecology-related cases from about 2003 to 2012. Whereas the total numbers of claims, regulatory complaints and requests for records were similar for obstetrics and gynaecology in recent years (accounting for 52% v. 48% of known cases, respectively), a significantly greater percentage of demands and paid settlements related to gynaecology rather than obstetrics (58% and 76% v. 42% and 24% of cases, respectively). In obstetrics, about half of all cases on record with a paid settlement were in the context of severe neonatal birth-related neurological injury (n=9). For gynaecology, procedure-related complications accounted for 92% of settlements, of which at least 41% were for intraoperative injuries to internal organs and vessels. Laparoscopic procedures were most frequently associated with such intraoperative injuries, followed by vaginal and abdominal hysterectomies/oophorectomies and caesarean sections. For O&Gs in private practice for >2 years, 50/458 (11%) accounted for 138/228 (61%) of demands over a 10-year period. CONCLUSIONS:  The higher number of gynaecological demands and settlements in comparison with obstetric cases was unexpected and is contrary to international experiences and public sector findings, calling for more research to identify reasons for this finding. Other than further exploring surgical outcomes in private sector gynaecological patients, aspects of surgical training and accreditation standards in gynaecology may need review. Regarding birth-related injuries, the contribution of system failures needs quantification and further interrogation. The high contribution towards the medicolegal burden by a small group of practitioners suggests a need for doctor-focused interventions, including strengthening of peer review and regulatory oversight.

The utilisation of public and private health care among Australian women with diabetes: Findings from the 45 and Up Study.

AIM: To describe the prevalence of health care utilisation and out-of-pocket expenditure associated with the management of diabetes among Australian women aged 45 years and older. DESIGN: Cross-sectional survey design. METHODS: The questionnaire was administered to 392 women (a cohort of the 45 and Up Study) reporting a diagnosis of diabetes between August and November 2016. It asked about the use of conventional medicine, complementary medicine (CM) and self-prescribed treatments for diabetes and associated out-of-pocket spending. RESULTS: Most women (88.3%; n = 346) consulted at least one health care practitioner in the previous 12 months for their diabetes; 84.6% (n = 332) consulted a doctor, 44.4% (n = 174) consulted an allied health practitioner, and 20.4% (n = 80) consulted a CM practitioner. On average, the combined annual out-of-pocket health care expenditure was AU$492.6 per woman, which extrapolated to approximately AU$252 million per annum. Of this total figure, approximately AU$70 million was spent on CM per annum. CONCLUSIONS: Women with diabetes use a diverse range of health services and incur significant out-of-pocket expense to manage their health. The degree to which the health care services women received were coordinated, or addressed their needs and preferences, warrants further exploration. Limitations of this study include the use of self-report and inability to generalise findings to other populations.

Availability, affordability and stock-outs of commodities for the treatment of snakebite in Kenya.

BACKGROUND: Annually, about 2.7 million snakebite envenomings occur globally. Alongside antivenom, patients usually require additional care to treat envenoming symptoms and antivenom side effects. Efforts are underway to improve snakebite care, but evidence from the ground to inform this is scarce. This study, therefore, investigated the availability, affordability, and stock-outs of antivenom and commodities for supportive snakebite care in health facilities across Kenya. METHODOLOGY/PRINCIPAL FINDINGS: This study used an adaptation of the standardised World Health Organization (WHO)/Health Action International methodology. Data on commodity availability, prices and stock-outs were collected in July-August 2020 from public (n = 85), private (n = 36), and private not-for-profit (n = 12) facilities in Kenya. Stock-outs were measured retrospectively for a twelve-month period, enabling a comparison of a pre-COVID-19 period to stock-outs during COVID-19. Affordability was calculated using the wage of a lowest-paid government worker (LPGW) and the impoverishment approach. Accessibility was assessed combining the WHO availability target (≥80%) and LPGW affordability (<1 day's wage) measures. Overall availability of snakebite commodities was low (43.0%). Antivenom was available at 44.7% of public- and 19.4% of private facilities. Stock-outs of any snakebite commodity were common in the public- (18.6%) and private (11.7%) sectors, and had worsened during COVID-19 (10.6% versus 17.0% public sector, 8.4% versus 11.7% private sector). Affordability was not an issue in the public sector, while in the private sector the median cost of one vial of antivenom was 14.4 days' wage for an LPGW. Five commodities in the public sector and two in the private sector were deemed accessible. CONCLUSIONS: Access to snakebite care is problematic in Kenya and seemed to have worsened during COVID-19. To improve access, efforts should focus on ensuring availability at both lower- and higher-level facilities, and improving the supply chain to reduce stock-outs. Including antivenom into Universal Health Coverage benefits packages would further facilitate accessibility.