New dimensions for hospital services and early detection of disease: a Review from the Lancet Commission into liver disease in the UK.

This Review, in addressing the unacceptably high mortality of patients with liver disease admitted to acute hospitals, reinforces the need for integrated clinical services. The masterplan described is based on regional, geographically sited liver centres, each linked to four to six surrounding district general hospitals-a pattern of care similar to that successfully introduced for stroke services. The plan includes the establishment of a lead and deputy lead clinician in each acute hospital, preferably a hepatologist or gastroenterologist with a special interest in liver disease, who will have prime responsibility for organising the care of admitted patients with liver disease on a 24/7 basis. Essential for the plan is greater access to intensive care units and high-dependency units, in line with the reconfiguration of emergency care due to the COVID-19 pandemic. This Review strongly recommends full implementation of alcohol care teams in hospitals and improved working links with acute medical services. We also endorse recommendations from paediatric liver services to improve overall survival figures by diagnosing biliary atresia earlier based on stool colour charts and better caring for patients with impaired cognitive ability and developmental mental health problems. Pilot studies of earlier diagnosis have shown encouraging progress, with 5-6% of previously undiagnosed cases of severe fibrosis or cirrhosis identified through use of a portable FibroScan in primary care. Similar approaches to the detection of early asymptomatic disease are described in accounts from the devolved nations, and the potential of digital technology in improving the value of clinical consultation and screening programmes in primary care is highlighted. The striking contribution of comorbidities, particularly obesity and diabetes (with excess alcohol consumption known to be a major factor in obesity), to mortality in COVID-19 reinforces the need for fiscal and other long delayed regulatory measures to reduce the prevalence of obesity. These measures include the food sugar levy and the introduction of the minimum unit price policy to reduce alcohol consumption. Improving public health, this Review emphasises, will not only mitigate the severity of further waves of COVID-19, but is crucial to reducing the unacceptable burden from liver disease in the UK.

Reducing the Risk of Cognitive Decline and Dementia: WHO Recommendations.

With population ageing worldwide, dementia poses one of the greatest global challenges for health and social care in the 21st century. In 2019, around 55 million people were affected by dementia, with the majority living in low- and middle-income countries. Dementia leads to increased costs for governments, communities, families and individuals. Dementia is overwhelming for the family and caregivers of the person with dementia, who are the cornerstone of care and support systems throughout the world. To assist countries in addressing the global burden of dementia, the World Health Organisation (WHO) developed the Global Action Plan on the Public Health Response to Dementia 2017-2025. It proposes actions to be taken by governments, civil society, and other global and regional partners across seven action areas, one of which is dementia risk reduction. This paper is based on WHO Guidelines on risk reduction of cognitive decline and dementia and presents recommendations on evidence-based, multisectoral interventions for reducing dementia risks, considerations for their implementation and policy actions. These global evidence-informed recommendations were developed by WHO, following a rigorous guideline development methodology and involved a panel of academicians and clinicians with multidisciplinary expertise and representing geographical diversity. The recommendations are considered under three broad headings: lifestyle and behaviour interventions, interventions for physical health conditions and specific interventions. By supporting health and social care professionals, particularly by improving their capacity to provide gender and culturally appropriate interventions to the general population, the risk of developing dementia can be potentially reduced, or its progression delayed.

Mild cognitive impairment: the Manchester consensus.

Given considerable variation in diagnostic and therapeutic practice, there is a need for national guidance on the use of neuroimaging, fluid biomarkers, cognitive testing, follow-up and diagnostic terminology in mild cognitive impairment (MCI). MCI is a heterogenous clinical syndrome reflecting a change in cognitive function and deficits on neuropsychological testing but relatively intact activities of daily living. MCI is a risk state for further cognitive and functional decline with 5-15% of people developing dementia per year. However, ~50% remain stable at 5 years and in a minority, symptoms resolve over time. There is considerable debate about whether MCI is a useful clinical diagnosis, or whether the use of the term prevents proper inquiry (by history, examination and investigations) into underlying causes of cognitive symptoms, which can include prodromal neurodegenerative disease, other physical or psychiatric illness, or combinations thereof. Cognitive testing, neuroimaging and fluid biomarkers can improve the sensitivity and specificity of aetiological diagnosis, with growing evidence that these may also help guide prognosis. Diagnostic criteria allow for a diagnosis of Alzheimer's disease to be made where MCI is accompanied by appropriate biomarker changes, but in practice, such biomarkers are not available in routine clinical practice in the UK. This would change if disease-modifying therapies became available and required a definitive diagnosis but would present major challenges to the National Health Service and similar health systems. Significantly increased investment would be required in training, infrastructure and provision of fluid biomarkers and neuroimaging. Statistical techniques combining markers may provide greater sensitivity and specificity than any single disease marker but their practical usefulness will depend on large-scale studies to ensure ecological validity and that multiple measures, e.g. both cognitive tests and biomarkers, are widely available for clinical use. To perform such large studies, we must increase research participation amongst those with MCI.

Effective interventions for potentially modifiable risk factors for late-onset dementia: a costs and cost-effectiveness modelling study.

BACKGROUND: The potential economic value of interventions to prevent late-onset dementia is unknown. We modelled this for potentially modifiable risk factors for dementia. METHODS: For this modelling study, we searched PubMed and Web of Science from inception to March 12, 2020, and included interventions that: successfully targeted any of nine prespecified potentially modifiable risk factors (hypertension, diabetes, hearing loss, obesity, physical inactivity, social isolation, depression, cigarette smoking, and less childhood education); had robust evidence that the intervention improved risk or risk behaviour; and are feasible to enact in an adult population. We established when in the life course each intervention would be delivered. We calculated dementia incidence reduction from annual incidence of dementia in people with each risk factor, and population attributable fraction for each risk, corrected for risk factor clustering, and how effectively the intervention controls the risk factor. We calculated the discounted value of lifetime health gain and effect on cost (including NHS, social care and carer costs) per person eligible for treatment. We estimated annual total expenditure on the fully operational intervention programme in England. FINDINGS: We found effective interventions for hypertension, smoking cessation, diabetes prevention, and hearing loss. Treatments for stopping smoking and provision of hearing aids reduced cost. Treatment of hypertension was cost-effective by reference to standard UK thresholds. The three interventions when fully implemented would save £1·863 billion annually in England, reduce dementia prevalence by 8·5%, and produce quality-adjusted life-year gains. The intervention for diabetes was unlikely to be cost-effective in terms of effect on dementia alone. INTERPRETATION: There is a strong case for implementing the three effective interventions on grounds of cost-effectiveness and quality-of-life gains, as well as for improvements in general health. The interventions have the potential to remain cost-saving or cost-effective even with variations in dementia incidence and costs and effectiveness of interventions. FUNDING: Economic and Social Research Council.

[Améliorer l'expérience des patients par la personnalisation des services de santé].

De nombreux leaders trouvent difficile de mobiliser les patients, dont les attentes envers les services de santé exigent désormais une approche plus personnalisée. Le présent article porte sur les tendances de consommation qui influent sur la mobilisation et l'autonomisation des patients à l'égard des technologies numériques. Éclairés par les tendances de consommation et de santé en population susceptibles de personnaliser les services de santé, les leaders peuvent adopter trois stratégies pour renforcer l'expérience des patients : mettre davantage l'accent sur la santé et le bien-être personnels, amorcer un virage vers des soins de santé personnalisés plutôt que normalisés et faciliter la démocratisation de l'information en matière de santé.

Enhancing patient experience through personalization of health services.

Patient engagement is a challenge many leaders are facing, as consumer expectations of health services demand a more personalized approach to care. This article examines consumer trends that are influencing patient engagement and empowerment relative to the use of digital technologies. Informed by consumer and population health trends that can personalize health services, three strategies leaders can engage to strengthen patient experience include placing greater focus on personal health and wellness, shifting towards personalized rather than standardized healthcare, and facilitating the democratization of healthcare information.

The link between health governance models and global health innovation: an exploration of OECD nations.

PURPOSE: While there is established research that explores individual innovations across countries or developments in a specific health area, there is less work that attempts to match national innovations to specific systems of health governance to uncover themes across nations. DESIGN/METHODOLOGY/APPROACH: We used a cross-comparison design that employed content analysis of health governance models and innovation patterns in eight OECD nations (Australia, Britain, Canada, France, Germany, The Netherlands, Switzerland, and the United States). FINDINGS: Country-level model of health governance may impact the focus of health innovation within the eight jurisdictions studied. Innovation across all governance models has targeted consumer engagement in health systems, the integration of health services across the continuum of care, access to care in the community, and financial models that drive competition. ORIGINALITY/VALUE: Improving our understanding of the linkage between health governance and innovation in health systems may heighten awareness of potential enablers and barriers to innovation success.

Facilitating consumer access to health information.

The lead paper from Zelmer and Hagens details the substantive evolution occurring in health information technologies that has the potential to transform the relationship between consumers, health practitioners and health systems. In this commentary, the authors suggest that Canada is experiencing a shift in consumer behaviour toward a desire to actively manage one's health and wellness that is being facilitated through the advent of health applications on mobile and online technologies platforms. The result is that Canadians are now able to create personalized health solutions based on their individual health values and goals. However, before Canadians are able to derive a personal health benefit from these rapid changes in information technology, they require and are increasingly demanding greater real-time access to their own health information to better inform decision-making, as well as interoperability between their personal health tracking systems and those of their health practitioner team.