Evaluation of healthcare efficiency in China: a three-stage data envelopment analysis of directional slacks-based measure.

Background: A consensus on the changing pattern of healthcare efficiency in China is current absent. This study tried to identify temporal fluctuations in healthcare efficiency from 2012 to 2021, and conducted a comparative analysis on the performance of 31 regions in China using region-level balanced panel data. Methods: Employing three-stage data envelopment analysis (DEA) as the analytical framework, we measured healthcare efficiency and its changes using the directional slacks-based measure and global Malmquist-luenberger (GML) indexes. We also decomposed the sources of healthcare inefficiency and extended our analysis to changes in healthcare efficiency across different primary medical service levels and regional economic development tiers. Results: The average efficiency score of medical institutions (0.956) was slightly higher than that of hospitals (0.930). We found that the average GML indexes of medical institutions in China stood at 0.990, while the average technical change (TC) index was 0.995 and the average efficiency change (EC) index was 0.998 from 2012 to 2021. The GML indexes, TC indexes, and EC indexes of hospitals were 1.002, 1.009, and 0.994, respectively. The healthcare inefficiency for both inputs and desirable outputs in medical institutions was primarily attributed to the redundant numbers of institutions, outpatient visits slacks and inpatient surgery volume slacks, accounting for 50.040, 49.644, and 28.877%, respectively. The undesirable output inefficiency values of medical institutions concerning in-hospital mortality stood at 0.012, while the figure for hospital regarding the average length of stay (LOS) was 0.002. Additionally, healthcare efficiency in both medical institutions and hospitals exhibited an upward trend from 2012 to 2021, corresponding to an increase in the volume of primary medical services, primary medical staff, and the total gross domestic product (GDP). Conclusion: Total factor productivity (TFP) of medical services declined in China from 2012 to 2021. The excessive number of medical institutions and the slack of medical service volumes were the main sources of healthcare inefficiency. Regions prioritizing primary medical services and boasting higher GDP levels exhibited superior healthcare efficiency. These findings are expected to inform policymakers' efforts in building a value-based and efficient health service system in China.

Integrated Real-World Data Warehouses Across 7 Evolving Asian Health Care Systems: Scoping Review.

BACKGROUND: Asia consists of diverse nations with extremely variable health care systems. Integrated real-world data (RWD) research warehouses provide vast interconnected data sets that uphold statistical rigor. Yet, their intricate details remain underexplored, restricting their broader applications. OBJECTIVE: Building on our previous research that analyzed integrated RWD warehouses in India, Thailand, and Taiwan, this study extends the research to 7 distinct health care systems: Hong Kong, Indonesia, Malaysia, Pakistan, the Philippines, Singapore, and Vietnam. We aimed to map the evolving landscape of RWD, preferences for methodologies, and database use and archetype the health systems based on existing intrinsic capability for RWD generation. METHODS: A systematic scoping review methodology was used, centering on contemporary English literature on PubMed (search date: May 9, 2023). Rigorous screening as defined by eligibility criteria identified RWD studies from multiple health care facilities in at least 1 of the 7 target Asian nations. Point estimates and their associated errors were determined for the data collected from eligible studies. RESULTS: Of the 1483 real-world evidence citations identified on May 9, 2023, a total of 369 (24.9%) fulfilled the requirements for data extraction and subsequent analysis. Singapore, Hong Kong, and Malaysia contributed to ≥100 publications, with each country marked by a higher proportion of single-country studies at 51% (80/157), 66.2% (86/130), and 50% (50/100), respectively, and were classified as solo scholars. Indonesia, Pakistan, Vietnam, and the Philippines had fewer publications and a higher proportion of cross-country collaboration studies (CCCSs) at 79% (26/33), 58% (18/31), 74% (20/27), and 86% (19/22), respectively, and were classified as global collaborators. Collaboration with countries outside the 7 target nations appeared in 84.2% to 97.7% of the CCCSs of each nation. Among target nations, Singapore and Malaysia emerged as preferred research partners for other nations. From 2018 to 2023, most nations showed an increasing trend in study numbers, with Vietnam (24.5%) and Pakistan (21.2%) leading the growth; the only exception was the Philippines, which declined by -14.5%. Clinical registry databases were predominant across all CCCSs from every target nation. For single-country studies, Indonesia, Malaysia, and the Philippines favored clinical registries; Singapore had a balanced use of clinical registries and electronic medical or health records, whereas Hong Kong, Pakistan, and Vietnam leaned toward electronic medical or health records. Overall, 89.9% (310/345) of the studies took >2 years from completion to publication. CONCLUSIONS: The observed variations in contemporary RWD publications across the 7 nations in Asia exemplify distinct research landscapes across nations that are partially explained by their diverse economic, clinical, and research settings. Nevertheless, recognizing these variations is pivotal for fostering tailored, synergistic strategies that amplify RWD's potential in guiding future health care research and policy decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/43741.

Leaving no one behind in armed conflict-affected settings of Africa: is universal health coverage a possibility or mirage?

The world is off track six years to the 2030 deadline for attaining the sustainable development goals and universal health coverage. This is particularly evident in Africa's armed conflict-affected and humanitarian settings, where pervasively weak health systems, extreme poverty and inequitable access to the social dimensions and other determinants of health continue to pose significant challenges to universal health coverage. In this article, we review the key issues and main barriers to universal health coverage in such settings. While our review shows that the current health service delivery and financing models in Africa's armed conflict-affected settings provide some opportunities to leapfrog progress, others are threats which could hinder the attainment of universal health coverage. We propose four key approaches focused on addressing the barriers to the three pillars of universal health coverage, strengthening public disaster risk management, bridging the humanitarian-development divide, and using health as an enabler of peace and sustainable development as panacea to addressing the universal health coverage challenge in these settings. The principles of health system strengthening, primary health care, equity, the right to health, and gender mainstreaming should underscore the implementation of these approaches. Moving forward, we call for more advocacy, dialogue, and research to better define and adapt these approaches into a realistic package of interventions for attaining universal health coverage in Africa's armed conflict-affected settings.

Effectiveness of hierarchical medical system and economic growth: based on China's urban vs. rural health perspectives.

Background: The hierarchical medical system is an important measure to promote equitable healthcare and sustain economic development. As the population's consumption level rises, the demand for healthcare services also increases. Based on urban and rural perspectives in China, this study aims to investigate the effectiveness of the hierarchical medical system and its relationship with economic development in China. Materials and methods: The study analyses panel data collected from Chinese government authorities, covering the period from 2009 to 2022. According to China's regional development policy, China is divided into the following regions: Eastern, Middle, Western, and Northeastern. Urban and rural component factors were downscaled using principal component analysis (PCA). The factor score formula combined with Urban-rural disparity rate (ΔD) were utilized to construct models for evaluating the effectiveness of the hierarchical medical system from an urban-rural perspective. A Vector Autoregression model is then constructed to analyze the dynamic relationship between the effects of the hierarchical medical system and economic growth, and to predict potential future changes. Results: Three principal factors were extracted. The contributions of the three principal factors were 38.132, 27.662, and 23.028%. In 2021, the hierarchical medical systems worked well in Henan (F = 47245.887), Shandong (F = 45999.640), and Guangdong (F = 42856.163). The Northeast (ΔDmax = 18.77%) and Eastern region (ΔDmax = 26.04%) had smaller disparities than the Middle (ΔDmax = 49.25%) and Western region (ΔDmax = 56.70%). Vector autoregression model reveals a long-term cointegration relationship between economic development and the healthcare burden for both urban and rural residents (ßurban = 3.09, ßrural = 3.66), as well as the number of individuals receiving health education (ß = -0.3492). Both the Granger causality test and impulse response analysis validate the existence of a substantial time lag between the impact of the hierarchical medical system and economic growth. Conclusion: Residents in urban areas are more affected by economic factors, while those in rural areas are more influenced by time considerations. The urban rural disparity in the hierarchical medical system is associated with the level of economic development of the region. When formulating policies for economically relevant hierarchical medical systems, it is important to consider the impact of longer lags.

The impact of COVID-19 on HIV treatment and care delivery in South and Southeast Asia: a qualitative study.

The COVID-19 pandemic has significantly impacted HIV treatment worldwide, but its effects on South and Southeast Asia, particularly in India, Indonesia, and Thailand, have been less evident. Our aim was to study the perceptions of providers and policymakers to understand how interventions were implemented as part of pandemic responses and how their effectiveness was viewed. We conducted a qualitative study with semi-structured interviews focusing on the shifts in HIV care in response to the pandemic. Between June and July 2021, 40 individuals were invited for interviews; 33 (83%) agreed. Participants included 25 (76%) providers and 8 (24%) policymakers, who were from India (10; 30%), Indonesia (10; 30%), and Thailand (10; 30%), along with 3 (9.1%) regional policymakers. Sixteen (48%) were female. Our findings revealed four major themes: (1) limitations in accessing HIV care due to movement restrictions and shutdowns, such as transportation issues; (2) diversion of healthcare resources away from HIV care to COVID-19 responses, leading to reallocation of providers and hospital space; (3) setbacks in HIV-related policy implementation as COVID-19 emergency responses took priority; (4) the expansion of HIV differentiated service delivery interventions, allowing longer gaps between visits and larger-volume prescription refills to delay returns to healthcare facilities. These changes have raised concerns about the long-term consequences on HIV epidemic control and future pandemic responses. However, they have also presented opportunities for innovative care delivery, which should be sustained to address these challenges effectively.

Health Literacy and Health Care System Confidence as Determinants of Attitudes to Vaccines in France: Representative Cross-Sectional Study.

BACKGROUND: Health literacy involves individuals' knowledge, personal skills, and confidence to take action to evaluate and appraise health-related information and improve their health or that of their community. OBJECTIVE: This study aimed to analyze the association between health literacy and attitude toward vaccines, adjusted with other factors. METHODS: We used the SLAVACO Wave 3, a survey conducted in December 2021 among a sample of 2022 individuals, representative of the French adult population. We investigated factors associated with the attitude toward vaccines using respondents' different sociodemographic data, health literacy levels, and the health care system confidence levels using a multinomial logistic regression analysis. RESULTS: Among the participants, 440.4 (21.8%) were classified as "distrustful of vaccines in general," 729.2 (36.1%) were "selectively hesitant," and 852.4 (42.2%) were "nonhesitant." In our model, the level of health literacy was not statistically different between the "distrustful of vaccines in general" and the "selectively hesitant" (P=.48), but it was associated with being a "nonhesitant" (adjusted odds ratio [aOR] 1.86, 95% CI 1.25-2.76). The confidence in the health care system was a strong predictor for a "nonhesitant" attitude toward vaccines (aOR 12.4, 95% CI 7.97-19.2). We found a positive correlation of 0.34 (P<.001) between health literacy and confidence in the health care system, but the interaction term between health literacy and health care system confidence was not significant in our model. CONCLUSIONS: Health literacy was associated with a "nonhesitant" attitude toward vaccines. The findings demonstrated that health literacy and confidence in the health care system are modestly correlated. Therefore, to tackle the subject of vaccine hesitancy, the main focus should be on increasing the population's confidence and on increasing their health literacy levels or providing vaccine information addressing the needs of less literate citizens.

Factors associated with patients' healthcare-seeking behavior and related clinical outcomes under China's hierarchical healthcare delivery system.

Introduction: The hierarchical healthcare delivery system is an important measure to improve the allocation of medical resources and promote equitable distribution of basic medical and health services. It is one of the key factors in the success or failure of China's medical reform. This study aims to analyze the factors influencing patients' healthcare-seeking behaviors, including socioeconomic and clinical outcomes, under China's hierarchical healthcare delivery system, and to provide potential solutions. Methods: Patients receiving outpatient treatment in the past 14 days and inpatient care in the past 1 year were investigated. The multivariate logistic regression was used to analyze the influencing factors of patient's medical treatment behavior selection, and to compare whether the clinical outcomes of primary medical institutions and grade A hospitals are the same. Results: Nine thousand and ninety-eight person-times were included in the study. Of these, 4,538 patients were outpatients, 68.27% of patients were treated in primary medical institutions; 4,560 patients were hospitalized, 58.53% chose to be hospitalized in grade A hospitals. Provinces and cities, urban and rural areas, occupation, education level, medical insurance type, income, whether there are comorbid diseases, and doctors' medical behavior are the factors affecting the choice of medical treatment behavior. Patients who choose primary medical institutions and grade A hospitals have different control levels and control rate for the blood pressure, blood lipids, blood glucose. Conclusion: Under the hierarchical diagnosis and treatment system, the patients' choice of hospital is mainly affected by their level of education, medical insurance types, and the inpatients are also affected by whether there are comorbid conditions. Clinical outcomes of choosing different levels of hospitals were different.

Damage to the public health system caused by war-related looting or vandalism in the Tigray region of Northern Ethiopia.

Background: The war that started on November 4, 2020, in the Tigray region of Northern Ethiopia severely affected the health sector. However, there is no available evidence to suggest the economic damage caused to the public health system because of war-related looting or vandalism. This study was aimed at estimating the cost of war-related looting or vandalism in Tigray's public health system in Northern Ethiopia in 2021. Methods: A provider perspective, a mixed costing method, a retrospective cross-sectional approach, a 50% inflation rate, and a 50 Ethiopian birr equivalent to one United States dollar ($) for the money value were used. The data were analyzed using Microsoft Excel, taking into consideration the Sendai framework indicators. Results: The total economic cost of the war-related looting or vandalism in monetary terms was more than $3.78 billion, and the damage to the economic value in monetary terms was more than $2.31 billion. Meanwhile, the direct economic loss to the health system in monetary terms was more than $511 million. According to this assessment, 514 (80.6%) health posts, 153 (73.6%) health centers, 16 (80%) primary hospitals, 10 (83.3%) general hospitals, and 2 (100%) specialized hospitals were damaged and/or vandalized either fully or partially due to the war. Conclusion: This war seriously affected the public health sector in the Tigray region. The Federal Government of Ethiopia, the Ministry of Health of Ethiopia, the Tigrayan Government, the Tigray Regional Health Bureau, and the international community must make efforts to find resources for the revitalization of the damaged, plundered, and vandalized healthcare system.

Service delivery in acute ischemic stroke patients: Does sex matter?

BACKGROUND AND PURPOSE: Women with acute ischemic stroke (AIS) are older and have greater preexisting handicap than men. Given that these factors do not fully explain their poorer long-term outcomes, we sought to investigate potential sex differences in the delivery of acute stroke care in a large cohort of consecutive AIS patients. METHODS: We analyzed all patients from ASTRAL (Acute Stroke Registry and Analysis of Lausanne) from March 2003 to December 2019. Multivariable analyses were performed on acute time metrics, revascularization therapies, ancillary examinations for stroke workup, subacute symptomatic carotid artery revascularization, frequency of change in goals of care (palliative care), and length of hospital stay. RESULTS: Of the 5347 analyzed patients, 45% were biologically female and the median age was 74.6 years. After multiple adjustments, female sex was significantly associated with higher onset-to-door (adjusted hazard ratio [aHR] = 1.09, 95% confidence interval [CI] = 1.04-1.14) and door-to-endovascular-puncture intervals (aHR = 1.15, 95% CI = 1.05-1.25). Women underwent numerically fewer diagnostic examinations (adjusted odds ratio [aOR] = 0.94, 95% CI = 0.85-1.04) and fewer subacute carotid revascularizations (aOR = 0.69, 95% CI = 0.33-1.18), and had longer hospital stays (aHR = 1.03, 95% CI = 0.99-1.07), but these differences were not statistically significant. We found no differences in the rates of acute revascularization treatments, or in the frequency of change of goals of treatments. CONCLUSIONS: This retrospective analysis of a large, consecutive AIS cohort suggests that female sex is associated with unfavorable pre- and in-hospital time metrics, such as a longer onset-to-door and door-to-endovascular-puncture intervals. Such indicators of less effective stroke care delivery may contribute to the poorer long-term functional outcomes in female patients and require further attention.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program.

Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Health Care Challenges in the Management of Primary Aldosteronism in Southeast Asia.

CONTEXT: While guidelines have been formulated for the management of primary aldosteronism (PA), following these recommendations may be challenging in developing countries with limited health care access. OBJECTIVE: We aimed to assess the availability and affordability of health care resources for managing PA in the Association of Southeast Asian Nations (ASEAN) region, which includes low-middle-income countries. METHODS: We instituted a questionnaire-based survey to specialists managing PA, assessing the availability and affordability of investigations and treatment. Population and income status data were taken from the national census and registries. RESULTS: Nine ASEAN country members (48 respondents) participated. While screening with aldosterone-renin ratio is performed in all countries, confirmatory testing is routinely performed in only 6 countries due to lack of facilities and local assays, and cost constraint. Assays are locally available in only 4 countries, and some centers have a test turnaround time exceeding 3 weeks. In 7 countries (combined population of 442 million), adrenal vein sampling (AVS) is not routinely performed due to insufficient radiological facilities or trained personnel, and cost constraint. Most patients have access to adrenalectomy and medications. In 6 countries, the cost of AVS and adrenalectomy combined is more than 30% of its annual gross domestic product per capita. While most patients had access to spironolactone, it was not universally affordable. CONCLUSION: Large populations currently do not have access to the health care resources required for the optimal management of PA. Greater efforts are required to improve health care access and affordability. Future guideline revisions for PA may need to consider these limitations.

Effectiveness of RADAR on diabetes processes of care for First Nations communities in Alberta, Canada.

The epidemic of type-2 diabetes in First Nations communities is tragic. Culturally-appropriate approaches addressing multiple components, focusing beyond glycemic control, are urgently needed. Using an intention-to-treat framework, 13 processes of care indicators were assessed to compare proportions of patients who received care at baseline relative to 2-year follow-up. Clinical improvements were demonstrated across major process of care indicators (e.g. screening, education, and vaccination activities). We found RADAR improved reporting for most diabetes processes of care across seven FN communities and was effective in supporting diabetes care for FN communities, in Alberta Canada.

Changes in Employment in the US Health Care Workforce, 2016-2022.

This study examines the rate of employment in US health care in the postpandemic period, through the end of 2022.

Cohort profile: The Trauma Outcomes Project, a prospective study of New Zealanders experiencing major trauma.

PURPOSE: Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand's (NZ's) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Maori (Indigenous population in Aotearoa me Te Waipounamu/NZ). PARTICIPANTS: Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy. FINDINGS TO DATE: TOP recruited 870 participants, including 119 Maori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Maori participants was 53%; for non-Maori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury. FUTURE PLANS: The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network's quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Maori.

Racial Disparities in Emergency Department Physical Restraint Use: A Systematic Review and Meta-Analysis.

Importance: Recent studies have demonstrated that people of color are more likely to be restrained in emergency department (ED) settings compared with other patients, but many of these studies are based at a single site or health care system, limiting their generalizability. Objective: To synthesize existing literature on risk of physical restraint use in adult EDs, specifically in reference to patients of different racial and ethnic backgrounds. Data Sources: A systematic search of PubMed, Embase, Web of Science, and CINAHL was performed from database inception to February 8, 2022. Study Selection: Included peer-reviewed studies met 3 criteria: (1) published in English, (2) original human participants research performed in an adult ED, and (3) reported an outcome of physical restraint use by patient race or ethnicity. Studies were excluded if they were conducted outside of the US, or if full text was unavailable. Data Extraction and Synthesis: Four independent reviewers (V.E., M.M., D.D., and A.H.) abstracted data from selected articles following Meta-Analysis of Observational Studies in Epidemiology guidelines. A modified Newcastle-Ottawa scale was used to assess quality. A meta-analysis of restraint outcomes among minoritized racial and ethnic groups was performed using a random-effects model in 2022. Main Outcome(s) and Measure(s): Risk of physical restraint use in adult ED patients by racial and ethnic background. Results: The search yielded 1597 articles, of which 10 met inclusion criteria (0.63%). These studies represented 2 557 983 patient encounters and 24 030 events of physical restraint (0.94%). In the meta-analysis, Black patients were more likely to be restrained compared with White patients (RR, 1.31; 95% CI, 1.19-1.43) and to all non-Black patients (RR, 1.27; 95% CI, 1.23-1.31). With respect to ethnicity, Hispanic patients were less likely to be restrained compared with non-Hispanic patients (RR, 0.85; 95% CI, 0.81-0.89). Conclusions and Relevance: Physical restraint was uncommon, occurring in less than 1% of encounters, but adult Black patients experienced a significantly higher risk of physical restraint in ED settings compared with other racial groups. Hispanic patients were less likely to be restrained compared with non-Hispanic patients, though this observation may have occurred if Black patients, with a higher risk of restraint, were included in the non-Hispanic group. Further work, including qualitative studies, to explore and address mechanisms of racism at the interpersonal, institutional, and structural levels are needed.

Predicting the drop out from the maternal, newborn and child healthcare continuum in three East African Community countries: application of machine learning models.

BACKGROUND: For optimal health, the maternal, newborn, and child healthcare (MNCH) continuum necessitates that the mother/child receive the full package of antenatal, intrapartum, and postnatal care. In sub-Saharan Africa, dropping out from the MNCH continuum remains a challenge. Using machine learning, the study sought to forecast the MNCH continuum drop out and determine important predictors in three East African Community (EAC) countries. METHODS: The study utilised Demographic Health Surveys data from the Democratic Republic of Congo (DRC) (2013/14), Kenya (2014) and Tanzania (2015/16). STATA 17 was used to perform the multivariate logistic regression. Python 3.0 was used to build five machine learning classification models namely the Logistic Regression, Random Forest, Decision Tree, Support Vector Machine and Artificial Neural Network. Performance of the models was assessed using Accuracy, Precision, Recall, Specificity, F1 score and area under the Receiver Operating Characteristics (AUROC). RESULTS: The prevalence of the drop out from the MNCH continuum was 91.0% in the DRC, 72.4% in Kenya and 93.6% in Tanzania. Living in the rural areas significantly increased the odds of dropping out from the MNCH continuum in the DRC (AOR:1.76;95%CI:1.30-2.38), Kenya (AOR:1.23;95%CI:1.03-1.47) and Tanzania (AOR:1.41;95%CI:1.01-1.97). Lower maternal education also conferred a significant increase in the DRC (AOR:2.16;95%CI:1.67-2.79), Kenya (AOR:1.56;95%CI:1.30-1.84) and Tanzania (AOR:1.70;95%CI:1.24-2.34). Non exposure to mass media also conferred a significant positive influence in the DRC (AOR:1.49;95%CI:1.15-1.95), Kenya (AOR:1.46;95%CI:1.19-1.80) and Tanzania (AOR:1.65;95%CI:1.13-2.40). The Random Forest exhibited superior predictive accuracy (Accuracy = 75.7%, Precision = 79.1%, Recall = 92.1%, Specificity = 51.6%, F1 score = 85.1%, AUROC = 70%). The top four predictors with the greatest influence were household wealth, place of residence, maternal education and exposure to mass media. CONCLUSIONS: The MNCH continuum dropout rate is very high in the EAC countries. Maternal education, place of residence, and mass media exposure were common contributing factors to the drop out from MNCH continuum. The Random Forest had the highest predictive accuracy. Household wealth, place of residence, maternal education and exposure to mass media were ranked among the top four features with significant influence. The findings of this study can be used to support evidence-based decisions in MNCH interventions and to develop web-based services to improve continuity of care retention.