Quality of breast reconstruction service at a university hospital as assessed by the patients

Purpose: To evaluate the quality of breast reconstruction service at a university hospital, as assessed by the patients. Methods: This cross-sectional study enrolled adult women who underwent immediate or delayed breast reconstruction by any technique performed at a university hospital between 1 and 24 months before the assessment. The Brazilian version of the Health Service Quality Scale (HSQS) was self-applied to the participants. The HSQS produces percentage scores, which are expressed in values ranging from 0 to 10 for each domain of the scale, and into an overall percentage quality score. The management team was asked to establish a minimum satisfactory score for the breast reconstruction service. Results: Ninety patients were included. The management team considered 8.00 the minimum satisfactory score for the service. The overall percentage score was 93.3%. Only one domain, 'Support,' had an average score lower than that considered satisfactory (7.22 ± 3.0); while the others had higher scores. The domain that scored highest was 'Qualification' (9.94 ± 0.3), followed by 'Result' (9.86 ± 0.4). There was a positive correlation between 'type of oncologic surgery' and 'intentions of loyalty to the service' (ρ = 0.272; p = 0.009) and a negative correlation between 'education' and 'quality of the environment' (ρ = ­0.218; p = 0.039). The higher the patient's level of education, the higher the score attributed to 'relationship' (ρ = 0.261; p = 0.013) and the lower the score of 'aesthetics and functionality' (ρ = ­0.237; p = 0.024). Conclusion: The quality of the breast reconstruction service was considered satisfactory, but there is a demand for structural improvements, better interpersonal relationships, and a stronger support network for patients.

Fulfilling the Promise of Artificial Intelligence in the Health Sector: Let's Get Real.

OBJECTIVES: This study aimed to showcase the potential and key concerns and risks of artificial intelligence (AI) in the health sector, illustrating its application with current examples, and to provide policy guidance for the development, assessment, and adoption of AI technologies to advance policy objectives. METHODS: Nonsystematic scan and analysis of peer-reviewed and gray literature on AI in the health sector, focusing on key insights for policy and governance. RESULTS: The application of AI in the health sector is currently in the early stages. Most applications have not been scaled beyond the research setting. The use in real-world clinical settings is especially nascent, with more evidence in public health, biomedical research, and "back office" administration. Deploying AI in the health sector carries risks and hazards that must be managed proactively by policy makers. For AI to produce positive health and policy outcomes, 5 key areas for policy are proposed, including health data governance, operationalizing AI principles, flexible regulation, skills among health workers and patients, and strategic public investment. CONCLUSIONS: AI is not a panacea, but a tool to address specific problems. Its successful development and adoption require data governance that ensures high-quality data are available and secure; relevant actors can access technical infrastructure and resources; regulatory frameworks promote trustworthy AI products; and health workers and patients have the information and skills to use AI products and services safely, effectively, and efficiently. All of this requires considerable investment and international collaboration.

Impact of the 1115 behavioral health Medicaid waiver on adult Medicaid beneficiaries in New York State.

OBJECTIVE: To evaluate the impact of the Health and Recovery Plan (HARP), a capitated special needs Medicaid managed care product that fully integrates physical and behavioral health delivery systems in New York State. DATA SOURCES: 2013-2019 claims and encounters data on continuously enrolled individuals from the New York State Medicaid data system. STUDY DESIGN: We used a difference-in-difference approach with inverse probability of exposure weights to compare service use outcomes in individuals enrolled in the HARP versus HARP eligible comparison group in two regions, New York City (NYC) pre- (2013-2015) versus post- (2016-2018) intervention periods, and rest of the state (ROS) pre- (2014-2016) versus post- (2017-2019) intervention periods. DATA COLLECTION/EXTRACTION METHODS: Not applicable. PRINCIPAL FINDINGS: HARPs were associated with a relative decrease in all-cause (RR = 0.78, 95% CI 0.68-0.90), behavioral health-related (RR = 0.76, 95% CI 0.60-0.96), and nonbehavioral-related (RR = 0.87, 95% CI 0.78-0.97) stays in the NYC region. In the ROS region, HARPs were associated with a relative decrease in all-cause (RR = 0.87, 95% CI 0.80-0.94) and behavioral health-related (RR = 0.80, 95% CI 0.70-0.91) stays. Regarding outpatient visits, the HARPs benefit package were associated with a relative increase in behavioral health (RR = 1.21, 95% CI 1.13-1.28) and nonbehavioral health (RR = 1.08, 95% CI 1.01-1.15) clinic visits in the NYC region. In the ROS region, the HARPs were associated with relative increases in behavioral health (RR = 1.47, 95% CI 1.32-1.64) and nonbehavioral health (RR = 1.17, 95% CI 1.11-1.25) clinic visits. CONCLUSIONS: Compared to patients with similar clinical needs, HARPs were associated with a relative increase in services used and led to a better engagement in the HARPs group regardless of the overall decline in services used pre- to postperiod.

District division administrative disaggregation data framework for monitoring leaving no one behind in the National Health Insurance Fund of Sudan: achieving sustainable development goals in 2030.

BACKGROUND: The aim of this study is to monitor the concept of 'leaving no one behind' in the Sustainable Development Goals (SDGs) to track the implications of the mobilization of health care resources by the National Health Insurance Fund (NHIF) of Sudan. METHODS: A cross-sectional study was used to monitor 'leaving no one behind' in NHIF by analyzing the secondary data of the information system for the year 2016. The study categorized the catchment areas of health care centers (HCCS) according to district administrative divisions, which are neighborhood, subdistrict, district, and zero. The District Division Administrative Disaggregation Data (DDADD) framework was developed and investigated with the use of descriptive statistics, maps of Sudan, the Mann-Whitney test, the Kruskal-Wallis test and health equity catchment indicators. SPSS ver. 18 and EndNote X8 were also used. RESULTS: The findings show that the NHIF has mobilized HCCs according to coverage of the insured population. This mobilization protected the insured poor in high-coverage insured population districts and left those living in very low-coverage districts behind. The Mann-Whitney test presented a significant median difference in the utilization rate between catchment areas (P value < 0.001). The results showed that the utilization rate of the insured poor who accessed health care centers by neighborhood was higher than that of the insured poor who accessed by more than neighborhood in each state. The Kruskal-Wallis test of the cost of health care services per capita in each catchment area showed a difference (P value < 0.001) in the median between neighborhoods. The cost of health care services in low-coverage insured population districts was higher than that in high-coverage insured population districts. CONCLUSION: The DDADD framework identified the inequitable distribution of health care services in low-density population districts leaves insured poor behind. Policymakers should restructure the equation of health insurance schemes based on equity and probability of illness, to distribute health care services according to needs and equity, and to remobilize resources towards districts left behind.

Creating Short-Term Volume Flexibility in Healthcare Capacity Management.

It is well-known that unpredictable variations in supply and demand of capacity in healthcare systems create the need for flexibility. The main tools used to create short-term volume flexibility in the healthcare system include overtime, temporary staff from internal calling lists, moving staff across units, internal staffing pools, external staffing agencies, queuing patients, and purchasing care from external providers. We study the creation of short-term volume flexibility in healthcare systems to manage short-term capacity losses and demand fluctuations. A questionnaire was developed and distributed among healthcare managers in the Region Västra Götaland healthcare system. Respondents were asked to what extent they used each tool to create short-term flexibility in capacity. Data were analyzed using multiple regression analysis. Several significant tendencies were found, including that acute units use overtime and internal staffing pools to a larger extent, and queuing patients and external providers to a lesser extent than planned units. The prerequisites and required managerial approaches used to efficiently manage aggregate capacity in the system differ substantially between different parts of the system. These differences must be addressed when, for example, capacity pools are considered. These results serve as a stepping stone towards a more thorough understanding of efficient capacity management in healthcare systems.

Physical rehabilitation in the context of a landslide that occurred in Brazil.

BACKGROUNDS: The efforts to develop research and training on physical rehabilitation in regards to disasters is considered recent worldwide. In the late evening of the 11th up until the 12th of January of 2011, the most massive natural disaster occurred in Brazil with extremely heavy downpour, abrupt flood, as well as landslides on multiple areas of the Mountain Region of Rio de Janeiro. The objective of this research was to investigate the challenges in terms of physical rehabilitation provided by this event METHODS: The cross-sectional mixed method's study, which was conducted in the city of Nova Friburgo, used two different data sources: hospital records on traumatic injuries pre and post disaster, and interviews with key informants - victims who suffered injuries related to the disaster, professionals from rehabilitation services in the municipality, and also the city's health service management. Pearson's chi-squared test was performed to evaluate statistical significance between the week of a given incident and the type of injury. Interviews were transcribed and analysed through content analysis. RESULTS: A total of 2326 hospital records and 27 interviews were analysed. The proportion of traumatic injury in the municipal emergency service increased from 16% in the prior week, to 40% in the week post-disaster (p <  0.0001). Different injuries were identified: multiple fractures, crushing, amputation, perforation of soft tissues, inhalation of dust and establishment of chronic conditions through stress. Despite this scenario, out of the 16 health professionals interviewed, twelve did not observe an increase in the demand for outpatient rehabilitation services after the disaster. Interviews with the victims revealed that the pathways for care ran into different barriers. From 11 victims interviewed, only one received complete physiotherapy care through the public health services in the city, while all others hired additional assistance, received volunteer services, had assistance in other cities or remained without rehabilitation. CONCLUSIONS: The needs for rehabilitation increased after the disaster; however, the demand was repressed due to different barriers such as competing needs and possible lack of medical referral. Recommendations were made, including the action of performing a search of victims with rehabilitation needs.

A Hybrid Decision-Making Approach for the Service and Financial-Based Measurement of Universal Health Coverage for the E7 Economies.

The aim of this study is to measure universal health coverage in Emerging 7 (E7) economies. Within this framework, five different dimensions and 14 different criteria are selected by considering the explanations of World Health Organization and United Nations regarding universal health coverage. While weighting the dimensions and criteria, the Decision-making Trial and Evaluation Laboratory (DEMATEL) is considered with the triangular fuzzy numbers. Additionally, Multi-Objective Optimization on the basis of Ratio Analysis (MOORA) approach is used to rank E7 economies regarding Universal Health Coverage (UHC) performance. The novelty of this study is that both service and financial based factors are taken into consideration at the same time. Additionally, fuzzy DEMATEL and MOORA methodologies are firstly used in this study with respect to the evaluation of universal health coverage. The findings show that catastrophic out of pocket health spending, pushed below an international poverty line and annual growth rate of real Gross Domestic Product (GDP) per capita are the most significant criteria for universal health coverage performance. Moreover, it is also concluded that Russia is the country that has the highest universal health coverage performance whereas China, India and Brazil are in the last ranks. It can be understood that macroeconomic conditions play a very significant role on the performance of universal health coverage. Hence, economic conditions should be improved in these countries to have better universal health coverage performance. Furthermore, it is necessary to establish programs that provide exemptions or lower out-of-pocket expenditures which will not prevent the use of health services. This situation can protect people against the financial risks related to health expenditures. In addition to them, it is also obvious that high population has also negative influence on the countries such as, China and India. It indicates that it would be appropriate for these countries to make population planning for this purpose.

Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision. / Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços.

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.

O estudo analisa os arranjos regionais de governança do Sistema Único de Saúde (SUS), segundo esfera jurídica dos prestadores e distribuição espacial da produção de serviços de média e alta complexidade no Brasil. Tais arranjos expressam o modo como a reforma do Estado e do sistema de saúde promoveram a redistribuição de funções entre entes governamentais e privados no território. Realizou-se estudo exploratório com base em dados secundários de abrangência nacional, do biênio 2015-2016. Por meio da análise de agrupamentos baseada na composição dos percentuais da produção dos principais prestadores, foram classificadas 438 regiões de saúde. Na assistência de média complexidade, predominou o prestador público municipal (ambulatorial) e o prestador privado filantrópico (hospitalar). Na alta complexidade, predominou o prestador filantrópico e lucrativo (ambulatorial e hospitalar). A produção de média complexidade foi registrada em todas as regiões de saúde, porém, em 12 estados, mais da metade dela está concentrada em apenas uma região de saúde. A produção de alta complexidade é concentrada nas regiões das capitais estaduais. Os arranjos de governança podem ser mais ou menos diversos e desiguais, se considerados os diferentes segmentos e níveis de concentração regional da produção de média e alta complexidade. O estudo sugere que a convergência entre descentralização e mercantilização favoreceu o reescalonamento da função de prestação de serviços, com ampliação da escala de atuação de prestadores privados e fortalecimento dos municípios polos. As características dos arranjos de governança desafiam a regionalização do SUS orientada pelas necessidades coletivas das populações.

El estudio analiza las modalidades regionales de gestión en el Sistema Único de Salud (SUS), según la categoría jurídica de los prestadores y la distribución espacial para la provisión de servicios de media y alta complejidad en Brasil. Tales modalidades expresan el modo mediante el cual la reforma del Estado y del sistema de salud promovieron la redistribución de funciones entre entes gubernamentales y privados en el territorio nacional. Se realizó un estudio exploratorio, basado en datos secundarios de alcance nacional, durante el bienio 2015-2016. Mediante un análisis de agrupamientos, basado en la composición de porcentajes relacionados con la provisión de servicios de los principales prestadores, se clasificaron 438 regiones de salud. En la asistencia de media complejidad, predominó el prestador público municipal (ambulatorio) y el prestador privado filantrópico (hospitalario). En la alta complejidad, predominó el prestador filantrópico y lucrativo (ambulatorio y hospitalario). La provisión de media complejidad se registró en todas las regiones de salud, sin embargo, en 12 estados, más de la mitad de la misma está concentrada en sólo una región de salud. La producción de alta complejidad está concentrada en las regiones de las capitales de los estados. Las modalidades de gestión pueden ser más o menos diversas y desiguales, si se consideran los diferentes segmentos y niveles de concentración regional en la provisión de servicios de media y alta complejidad. El estudio sugiere que la convergencia entre descentralización y mercantilización favoreció el reescalonamiento de la función de prestación de servicios, con una ampliación de la escala de actuación de prestadores privados y el fortalecimiento de los municipios más importantes. Las características de las modalidades de gestión desafían la regionalización del SUS, orientada por las necesidades colectivas de las poblaciones.

Seasonal gaps in measles vaccination coverage in Madagascar.

INTRODUCTION: Measles elimination depends on the successful deployment of measles containing vaccine. Vaccination programs often depend on a combination of routine and non-routine services, including supplementary immunization activities (SIAs) and vaccination weeks (VWs), that both aim to vaccinate all eligible children regardless of vaccination history or natural infection. Madagascar has used a combination of these activities to improve measles coverage. However, ongoing massive measles outbreak suggests that the country was in a "honeymoon" period and that coverage achieved needs to be re-evaluated. Although healthcare access is expected to vary seasonally in low resources settings, little evidence exists to quantify temporal fluctuations in routine vaccination, and interactions with other immunization activities. METHODS: We used three data sources: national administrative data on measles vaccine delivery from 2013 to 2016, digitized vaccination cards from 49 health centers in 6 health districts, and a survey of health workers. Data were analyzed using linear regressions, analysis of variance, and t-tests. FINDINGS: From 2013 to 2016, the footprint of SIAs and VWs is apparent, with more doses distributed during the relevant timeframes. Routine vaccination decreases in subsequent months, suggesting that additional activities may be interfering with routine services. The majority of missed vaccination opportunities occur during the rainy season. Health facility organization and shortage of vaccine contributed to vaccination gaps. Children born in June were the least likely to be vaccinated on time. DISCUSSION: Evidence that routine vaccination coverage varies over the year and is diminished by other activities suggests that maintaining routine vaccination during SIAs and VWs is a key direction for strengthening immunization programs, ensuring population immunity and avoiding future outbreaks. FUNDING: Wellcome Trust Fund, Burroughs Wellcome Fund, Gates Foundation, National Institutes of Health.

Linking intravenous drug users to treatment through non-governmental organizations in Ukraine: how well is it working?

INTRODUCTION: Alliance for Public Health, the International Charitable Foundation, coordinates HIV prevention in Non-Governmental Organizations (NGO) working with people who inject drugs (PWID) in Ukraine. We aimed to describe the performance of the differential model of linking PWID to HIV care and treatment (Community Initiated Treatment Intervention - CITI). METHODOLOGY: A retrospective cohort study using routine program data was conducted among 8,927 PWID who were tested positive for the first time during January 2016 - June 2017. Study outcomes were enrollment into CITI and initiating antiretroviral treatment (ART). Factors associated with outcomes were estimated by logistic regressions with random effects. RESULTS: Among the study participants, 54% enrolled into CITI and 23% initiated ART. CITI enrolment was associated with being married (adjusted odds ratio (AOR) = 1.17; 95%: 1.02-1.34); less than weekly compared to daily (AOR = 1.31; 95%: 1.13-1.52); less than 5 years of drug use compared to > 14 years (AOR = 1.73; 95%: 1.40-2.13), and having no criminal records (AOR = 1.30; 95%: 1.12-1.50). Factors of non-ART initiation were male gender (AOR = 1.33; 95%: 1.16-1.53); being single (AOR = 1.48; 95%: 1.21-1.82); drug use duration > 14 years compared to < 5 years (AOR = 1.38; 95%: 1.03-1.85), unemployment (AOR = 1.45; 95%: 1.15-1.83) and history of incarceration (AOR = 1.21; 95%: 1.003-1.45). CONCLUSION: Mobilizing the NGO community and PWID to engage in outreach HIV testing activity and harm reduction for key populations has succeeded in opening the gateway to prevention, care and ART for thousands of PWID in Ukraine.

Examination of the relationship between management and clinician perception of patient safety climate and patient satisfaction.

PURPOSE: The aim of this study was to explore the relationship between managers and clinicians' agreement on deeming the patient safety climate as high or low and the patients' satisfaction with those organizations. DATA SOURCES/STUDY SETTING: We used two secondary data sets: the Hospital Survey on Patient Safety Culture (2012) and the Hospital Consumer Assessment of Healthcare Providers and Systems (2012). METHODOLOGY/APPROACH: We used ordinary least squares regressions to analyze the relationship between the extent of agreement between managers and clinicians' perceptions of safety climate in relationship to patient satisfaction. The dependent variables were four Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores: communication with nurses, communication with doctors, communication about medicines, and discharge information. The main independent variables were four groups that were formed based on the extent of managers and clinicians' agreement on four patient safety climate domains: communication openness, feedback and communication about errors, teamwork within units, and teamwork across units. FINDINGS: After controlling for hospital and market-level characteristics, we found that patient satisfaction was significantly higher if managers and clinicians reported that patient safety climate is high or if only clinicians perceived the climate as high. Specifically, manager and clinician agreement on high levels of communication openness (ß = 2.25, p = .01; ß = 2.46, p = .05), feedback and communication about errors (ß = 3.0, p = .001; ß = 2.89, p = .01), and teamwork across units (ß = 2.91, p = .001; ß = 3.34, p = .01) was positively and significantly associated with patient satisfaction with discharge information and communication about medication. In addition, more favorable perceptions about patient safety climate by clinicians only yielded similar findings. PRACTICE IMPLICATIONS: Organizations should measure and examine patient safety climate from multiple perspectives and be aware that individuals may have varying opinions about safety climate. Hospitals should encourage multidisciplinary collaboration given that staff perceptions about patient safety climate may be associated with patient satisfaction.

Arranjos regionais de governança do Sistema Único de Saúde: diversidade de prestadores e desigualdade espacial na provisão de serviços / Modalidades regionales de gestión en el Sistema Único de Salud: diversidad de prestadores y desigualdad espacial en la provisión de servicios / Regional governance arrangements of the Brazilian Unified National Health System: provider diversity and spacial inequality in service provision

O estudo analisa os arranjos regionais de governança do Sistema Único de Saúde (SUS), segundo esfera jurídica dos prestadores e distribuição espacial da produção de serviços de média e alta complexidade no Brasil. Tais arranjos expressam o modo como a reforma do Estado e do sistema de saúde promoveram a redistribuição de funções entre entes governamentais e privados no território. Realizou-se estudo exploratório com base em dados secundários de abrangência nacional, do biênio 2015-2016. Por meio da análise de agrupamentos baseada na composição dos percentuais da produção dos principais prestadores, foram classificadas 438 regiões de saúde. Na assistência de média complexidade, predominou o prestador público municipal (ambulatorial) e o prestador privado filantrópico (hospitalar). Na alta complexidade, predominou o prestador filantrópico e lucrativo (ambulatorial e hospitalar). A produção de média complexidade foi registrada em todas as regiões de saúde, porém, em 12 estados, mais da metade dela está concentrada em apenas uma região de saúde. A produção de alta complexidade é concentrada nas regiões das capitais estaduais. Os arranjos de governança podem ser mais ou menos diversos e desiguais, se considerados os diferentes segmentos e níveis de concentração regional da produção de média e alta complexidade. O estudo sugere que a convergência entre descentralização e mercantilização favoreceu o reescalonamento da função de prestação de serviços, com ampliação da escala de atuação de prestadores privados e fortalecimento dos municípios polos. As características dos arranjos de governança desafiam a regionalização do SUS orientada pelas necessidades coletivas das populações.

El estudio analiza las modalidades regionales de gestión en el Sistema Único de Salud (SUS), según la categoría jurídica de los prestadores y la distribución espacial para la provisión de servicios de media y alta complejidad en Brasil. Tales modalidades expresan el modo mediante el cual la reforma del Estado y del sistema de salud promovieron la redistribución de funciones entre entes gubernamentales y privados en el territorio nacional. Se realizó un estudio exploratorio, basado en datos secundarios de alcance nacional, durante el bienio 2015-2016. Mediante un análisis de agrupamientos, basado en la composición de porcentajes relacionados con la provisión de servicios de los principales prestadores, se clasificaron 438 regiones de salud. En la asistencia de media complejidad, predominó el prestador público municipal (ambulatorio) y el prestador privado filantrópico (hospitalario). En la alta complejidad, predominó el prestador filantrópico y lucrativo (ambulatorio y hospitalario). La provisión de media complejidad se registró en todas las regiones de salud, sin embargo, en 12 estados, más de la mitad de la misma está concentrada en sólo una región de salud. La producción de alta complejidad está concentrada en las regiones de las capitales de los estados. Las modalidades de gestión pueden ser más o menos diversas y desiguales, si se consideran los diferentes segmentos y niveles de concentración regional en la provisión de servicios de media y alta complejidad. El estudio sugiere que la convergencia entre descentralización y mercantilización favoreció el reescalonamiento de la función de prestación de servicios, con una ampliación de la escala de actuación de prestadores privados y el fortalecimiento de los municipios más importantes. Las características de las modalidades de gestión desafían la regionalización del SUS, orientada por las necesidades colectivas de las poblaciones.

The study analyzes regional Brazilian Unified National Health System (SUS, in Portuguese) governance arrangements according to providers' legal sphere and the spacial provision of middle and high-complexity services. These arrangements express the way in which State and health system reforms promoted the redistribution of functions between governmental and private entities in the territory. We carried out an exploratory study based on national-scope secondary data from 2015-2016. Using cluster analysis based on the composition of the provision percentages of the main providers, we classified 438 health regions. In middle-complexity health care, municipal public providers (outpatient) and private philanthropic providers (hospital) predominate. In high complexity provision, philanthropic and for-profit providers (outpatient and hospital) predominate. Middle-complexity provision was recorded in all health regions. However, in 12 states, more than half of the provision is concentrated in only one health region. High-complexity provision is concentrated in state capital regions. Governance arrangements may be more or less diverse and unequal, if different segments and regional concentration levels of middle and high-complexity provision are considered. The study suggests that the convergence between decentralization and mercantilization favored re-scaling of service provision, with increase in the scale of participation of private providers and strengthening of reference municipalities. Governance arrangement characteristics challenge SUS regionalization guided by the collective needs of the population.

Standard precautions questionnaire: adaptação cultural e validação semântica para profissionais de saúde no brasil / Standard precautions questionnaire: adaptación cultural y validación semántica para profesionales de salud de brasil / Standard precautions questionnaire: cultural adaptation and semantic validation for health professionals in brazil

RESUMO Objetivo: realizar a adaptação cultural e a validação semântica do Standard Precautions Questionnaire para profissionais de saúde brasileiros. Métodos: estudo desenvolvido entre 2017 e 2018 no Rio de Janeiro. A adaptação cultural incluiu a tradução, o consenso sobre a versão em português, a avaliação por especialistas, a retrotradução, o consenso e a comparação com a versão original, a avaliação semântica e a validação semântica. Todos os aspectos éticos foram respeitados. Resultados: na validação de conteúdo, as pontuações variaram de 0.60 a 1.00 e a pontuação foi igual a 0.96, indicando que os itens são muito representativos. Na avaliação semântica, 22 (80%) itens foram considerados relevantes e 24 (100%) itens foram considerados claros e compreensíveis por todos os profissionais. Conclusão: os itens da versão brasileira do instrumento foram representativos e relevantes para a prática clínica de profissionais de saúde na avaliação dos obstáculos para aderir a precauções padrão. Estudos são necessários para avaliar as propriedades psicométricas do instrumento.

RESUMEN: Objetivo: Efectuar la adaptación cultural y la validación semántica del Standard Precautions Questionnaire para profesionales de salud brasileños. Método: Estudio desarrollado entre 2017 y 2018, en Río de Janeiro. La adaptación cultural comprendió: traducción, consenso sobre la versión en portugués, evaluación de expertos, retrotraducción, consenso y comparación con la versión original, evaluación semántica y validación semántica. Se respetaron todos los aspectos éticos. Resultados: Para la validación de contenido, las puntuaciones oscilaron entre 0,60 y 1,00 y el puntaje fue de 0,96, indicando que los ítems son muy representativos. En la evaluación semántica, 22 (80%) ítems fueron considerados relevantes y 24 (100%) ítems fueron considerados claros y comprensibles por todos los profesionales. Conclusión: Los ítems de la versión brasileña del instrumento fueron representativos, relevantes en la práctica clínica del profesional de salud para evaluar los obstáculos de adhesión a las precauciones estándar. Serán necesarios estudios evaluando las propiedades psicométricas del instrumento.

ABSTRACT Objective: to accomplish the cultural adaptation and semantic validation of the Standard Precautions Questionnaire for Brazilian health professionals. Method: study developed between 2017 and 2018, in Rio de Janeiro. The cultural adaptation included translation, consensus on the Portuguese version, evaluation by experts, back-translation, consensus and comparison with the original version, semantic evaluation and semantic validation. All ethical aspects were respected. Results: for the content validation, the scores ranged from 0.60 to 1.00 and the score was 0.96, indicating that the items are very representative. In the semantic evaluation, 22 (80%) of the items were considered relevant and 24 (100%) of the items were considered clear and understandable by all professionals. Conclusion: the items of the Brazilian version of the instrument were representative, relevant for the clinical practice of health professionals in assessing the obstacles to adhere to standard precautions. Studies are needed to evaluate the psychometric properties of the instrument.

Identifying optic neuritis and transverse myelitis using administrative data.

OBJECTIVE: We aimed to validate administrative case definitions to identify individuals with optic neuritis (ON) or transverse myelitis (TM), and to distinguish which of these individuals had a monophasic presentation versus multiple sclerosis (MS). METHODS: Using population-based administrative (health claims) data from Manitoba, Canada, we developed case definitions for ON and TM, and distinguished individuals who had monophasic presentations (ON-nonMS, TM-nonMS) versus those later diagnosed with MS (ON-MS, TM-MS). We compared performance of these case definitions to diagnoses based on medical records review in a reference cohort (n = 1251) using sensitivity, specificity, positive predictive value and negative predictive value. We estimated the annual incidence of these conditions for a three-year period (2011-2013). RESULTS: When compared to medical records, using ≥1 physician visit, the case definition for ON had good sensitivity (88.5%), and specificity (82.7%) whereas the case definition for TM had low sensitivity (25.9%) and higher specificity (89.0%). Findings for the other case definitions tested were: ON-MS (sensitivity: 84.1%, specificity: 83.9%), ON-nonMS (sensitivity: 66.7%, specificity 98.5%), TM-MS (sensitivity: 22.2%, specificity: 90.4%), and TM-nonMS (sensitivity: 3.7%, specificity: 99.7%). After applying the ON and TM case definitions to administrative data, the average annual incidence of ON over the period 2011-2013 was 75.9 per 100,000 person-years (95%CI: 72.8, 79.1) and of TM was 18.3 per 100,000 person-years (95%CI: 16.8, 19.8). CONCLUSION: Administrative data can be used to identify individuals with incident ON and TM, and to distinguish those with monophasic syndromes from those with an incident presentation of MS.

Informing Targeted Interventions to Optimize the Cascade of HIV Care Using Cluster Analyses of Health Resource Use Among People Living with HIV/AIDS.

Increased awareness of the secondary preventive benefits of antiretroviral treatment (ART) has strengthened the desire to optimize health care systems' response to HIV/AIDS. We identified clusters of health resource utilization (HRU) among people living with HIV (PLHIV) to inform targeted interventions aimed to optimize the cascade of HIV care. Using linked population-level health databases in British Columbia, Canada, we selected two analytic samples of PLHIV with 3 years of follow-up between 2006-2011 that were classified as intermittently retained in care or intermittently engaged in ART, and executed a probabilistic model-based clustering analysis for each sample with 5 and 9 quarterly HRU variables, respectively. We found clear HRU profile differences among both samples with similar HIV-related care: one featured active involvement in non-HIV care, the other little or no health care interaction following linkage to care. Differential reengagement intervention strategies capitalizing on missed opportunities in non-HIV care and further engaging physicians delivering HIV care are needed to optimize the response to the HIV epidemic.

Frequency of low-value care in Alberta, Canada: a retrospective cohort study.

OBJECTIVE: To determine how frequently 10 low-value services highlighted by Choosing Wisely are done and what factors influence their provision. METHODS: This is a retrospective cohort study using routinely collected health data from five linked data sets from 2012 to 2015 in the Canadian province of Alberta to determine the frequency with which 10 low-value services were provided. RESULTS: Between 2012 and 2015, 162 143 people (4% of all 3 814 536 adult Albertans and 5% of the 3 423 135 who saw a physician at least once in that time frame) received at least one of the 10 low-value services, including 29.8% of Albertans older than 75 years (57 811 of 194 068). The proportion of adults receiving low-value services ranged from carotid artery imaging in 0.1% of asymptomatic adults without cerebrovascular disease, to prostate-specific antigen (PSA) testing in 55.5% of men 75 years or older without a history of prostate cancer. Although age, Charlson scores and frequency of primary care visits were associated with low-value service provision, the directions of the association differed across services; however, higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians in the patient's region were associated with an increased risk of receiving all of the low-value services we examined. The low-value services which resulted in the greatest costs to the healthcare system were cervical cancer screening in women older than 65 without history of cervical dysplasia or genital cancer, PSA testing in men older than 75 without history of prostate cancer and preoperative stress testing/cardiac imaging before non-cardiac surgery. CONCLUSIONS: Even within a universal coverage healthcare system, the proportion of patients receiving low-value services varied widely (from <0.1% to 56%). Increased use was associated with higher socioeconomic status, increased frequency of specialist contact and higher ratio of specialists to primary care physicians.

Clozapine and concomitant medications: Assessing the completeness and accuracy of medication records for people prescribed clozapine under shared care arrangements.

RATIONALE, AIM, AND OBJECTIVE: The objective of the study is to assess the completeness and accuracy of medication records held by stakeholders (secondary care, general practice, and community pharmacy) for clozapine consumers managed in a shared care programme. METHODS: This was an exploratory, descriptive study examining secondary and primary care medication records in a large, urban, public mental health service setting in Queensland, Australia. Consumers (18-65 years old) prescribed clozapine under shared care management with capacity to consent were eligible (n = 55) to participate. Information from medication and dispensing records was used by a pharmacist to compile a best possible medication history for each consumer. Discrepancies were identified through reconciliation of stakeholder records with the history. Discrepancies were defined as an omission, addition, or administration discrepancy (difference in dose, frequency, or clozapine brand). RESULTS: Thirty-five (63.6%) consumers consented for records to be reviewed. Overall, 32 (91.4%) consumers had at least 1 discrepancy in their records with a mean of 4.9 discrepancies per consumer. Of 172 discrepancies, 127 (73.8%) were omissions. Primarily, concomitant medicines were omitted in 19/35 (54%) of secondary care records while clozapine was omitted in 13/32 (40.6%) of community pharmacies records. CONCLUSIONS: Discrepancies were highly prevalent in the shared care medication records of clozapine consumers of this service. Where there is incomplete and inaccurate medication information, there is a risk of suboptimal clinical decision making, increasing the likelihood of adverse drug events. This study demonstrates a need for improved documentation and timely access to accurate and complete medication records for shared care stakeholders. Expanding the pharmacist's role in this setting could improve medication accuracy in documentation and related communication.

Does access to a demand-led evidence briefing service improve uptake and use of research evidence by health service commissioners? A controlled before and after study.

BACKGROUND: The Health and Social Care Act mandated research use as a core consideration of health service commissioning arrangements in England. We undertook a controlled before and after study to evaluate whether access to a demand-led evidence briefing service improved the use of research evidence by commissioners compared with less intensive and less targeted alternatives. METHODS: Nine Clinical Commissioning Groups (CCGs) in the North of England received one of three interventions: (A) access to an evidence briefing service; (B) contact plus an unsolicited push of non-tailored evidence; or (C) unsolicited push of non-tailored evidence. Data for the primary outcome measure were collected at baseline and 12 months using a survey instrument devised to assess an organisations' ability to acquire, assess, adapt and apply research evidence to support decision-making. Documentary and observational evidence of the use of the outputs of the service were sought. RESULTS: Over the course of the study, the service addressed 24 topics raised by participating CCGs. At 12 months, the evidence briefing service was not associated with increases in CCG capacity to acquire, assess, adapt and apply research evidence to support decision-making, individual intentions to use research findings or perceptions of CCG relationships with researchers. Regardless of intervention received, participating CCGs indicated that they remained inconsistent in their research-seeking behaviours and in their capacity to acquire research. The informal nature of decision-making processes meant that there was little traceability of the use of evidence. Low baseline and follow-up response rates and missing data limit the reliability of the findings. CONCLUSIONS: Access to a demand-led evidence briefing service did not improve the uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. Commissioners appear well intentioned but ad hoc users of research. Further research is required on the effects of interventions and strategies to build individual and organisational capacity to use research.

Head 23: Ministry of Health: Programme budget for the year 2016-2017

This is an extract of the Barbados Ministry of Health Programme Budget for the Year 2016-2017. It consists of selected items from the Executive Summary that relate to funding, ceiling allocation and explanations for exceeding the ceiling. As well, aspects of one of the Ministry's sub-programmes viz. the Vector Control Programme, are described.

The World Health Organization's mechanisms for increasing the health sector budget: The South African context.

South Africa (SA) has limited scope for raising income taxes, and the proposed National Health Insurance (NHI) scheme will necessitate growth in the health sector budget. The NHI White Paper suggests five funding scenarios to meet the expected shortfall. These scenarios are a mixture of a surcharge on taxable income, an increase in value-added tax and a payroll tax. Five alternative options, suggested by the World Health Organization, are interrogated as ways to decrease the general taxation proposed in the White Paper. The five mechanisms (corporate tax, financial transaction levy, and taxes on tobacco, alcohol and unhealthy foods) were chosen based on their fund-raising potential and their mandatory element. A literature review provides the information for a discussion of the potential costs of each mechanism. Within specific assumptions, potential budgetary contribution is compared with the requirement. First, raising corporate tax rates could raise enough funds, but the losses due to capital flight might be too much for the local economy to bear. Second, a levy on currency transactions is unlikely to raise the required resources, even without a probable decrease in the number of transactions. Third, the increase in the tax on tobacco and alcohol would need to be very large, even assuming that consumption patterns would remain unchanged. Lastly, a tax on unhealthy food products is a new idea and could be explored as an option - especially as the SA Treasury has announced its future implementation. Implementing only one of the mechanisms is unlikely to increase available funding sufficiently, but if they are implemented together the welfare-maximising tax rate for each mechanism may be high enough to fulfil the NHI scheme's budgetary requirement, moderating the increases in the tax burden of the SA population.