Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation.

OBJECTIVES: To determine the clinical and cost effectiveness of a multifactorial fall prevention programme compared with usual care in long term care homes. DESIGN: Multicentre, parallel, cluster randomised controlled trial. SETTING: Long term care homes in the UK, registered to care for older people or those with dementia. PARTICIPANTS: 1657 consenting residents and 84 care homes. 39 were randomised to the intervention group and 45 were randomised to usual care. INTERVENTIONS: Guide to Action for Care Homes (GtACH): a multifactorial fall prevention programme or usual care. MAIN OUTCOME MEASURES: Primary outcome measure was fall rate at 91-180 days after randomisation. The economic evaluation measured health related quality of life using quality adjusted life years (QALYs) derived from the five domain five level version of the EuroQoL index (EQ-5D-5L) or proxy version (EQ-5D-5L-P) and the Dementia Quality of Life utility measure (DEMQOL-U), which were self-completed by competent residents and by a care home staff member proxy (DEMQOL-P-U) for all residents (in case the ability to complete changed during the study) until 12 months after randomisation. Secondary outcome measures were falls at 1-90, 181-270, and 271-360 days after randomisation, Barthel index score, and the Physical Activity Measure-Residential Care Homes (PAM-RC) score at 91, 180, 270, and 360 days after randomisation. RESULTS: Mean age of residents was 85 years. 32% were men. GtACH training was delivered to 1051/1480 staff (71%). Primary outcome data were available for 630 participants in the GtACH group and 712 in the usual care group. The unadjusted incidence rate ratio for falls between 91 and 180 days was 0.57 (95% confidence interval 0.45 to 0.71, P<0.001) in favour of the GtACH programme (GtACH: six falls/1000 residents v usual care: 10 falls/1000). Barthel activities of daily living indices and PAM-RC scores were similar between groups at all time points. The incremental cost was £108 (95% confidence interval -£271.06 to 487.58), incremental QALYs gained for EQ-5D-5L-P was 0.024 (95% confidence interval 0.004 to 0.044) and for DEMQOL-P-U was 0.005 (-0.019 to 0.03). The incremental costs per EQ-5D-5L-P and DEMQOL-P-U based QALY were £4544 and £20 889, respectively. CONCLUSIONS: The GtACH programme was associated with a reduction in fall rate and cost effectiveness, without a decrease in activity or increase in dependency. TRIAL REGISTRATION: ISRCTN34353836.

Favorable Commercial and Health Behavior Impacts of a Healthy Vending Policy at an Australian University.

BACKGROUND: The World Health Organization recognizes universities as an important health-promotion setting, including in healthy food provision. Previous research shows that healthy food retail interventions also need to consider commercial sustainability, including financial outcomes, and should take a holistic approach to consumer experience. OBJECTIVE: Our aim was to determine the health behavior and commercial outcomes of a multicomponent traffic light-based healthy vending policy implemented as one part of a holistic university food policy. The hypothesis was that purchases of less healthy "red" beverages would decrease compared with predicted sales, that purchases of healthier "green" and "amber" alternatives would increase, and that there would be no change in revenue. DESIGN: A quasi-experimental design evaluated a real-world food policy using monthly aggregated sales data to compare pre-intervention (January 2016 to March 2018) and post-intervention period sales (December 2018 to December 2019). PARTICIPANTS/SETTING: Electronic sales data were collected from 51 beverage vending machines across 4 university campuses in Victoria, Australia. INTERVENTION: A multicomponent policy was implemented between April and November 2018. Beverages were classified using a voluntary state government traffic light framework. Policy included display ≤20% red beverages and ≥50% green beverages; machine traffic light labeling; health-promoting machine branding; review of machine placement; and recycled bottle packaging. MAIN OUTCOME MEASURES: Changes in red, amber, and green volume sales, and revenue compared with predicated sales. STATISTICAL ANALYSES PERFORMED: Interrupted time series analysis of sales data compared post-policy sales with predicted sales. RESULTS: In the 13th month post-policy implementation, there was a 93.2% (95% CI +35.9% to +150.5%) increase in total beverage volume sold and an 88.6% (95% CI +39.2% to +138.1%) increase in revenue. There was no change in red beverage volume sold, but increases in green (+120.8%; 95% CI +59.0% to +182.6%) and amber (+223.2%; 95% CI +122.4% to +323.9%) volume sold. CONCLUSIONS: Sustained behavior change and commercial outcomes suggest that holistic vending interventions can effectively promote healthier beverage sales.

Sláintecare implementation status in 2020: Limited progress with entitlement expansion.

The Sláintecare report developed by political consensus sets out a ten year plan for achieving Universal Health Care (UHC) in Ireland. This paper evaluates the design and progress of the report to mid 2020, but with some reflection on the new COVID 19 era, particularly as it relates to the expansion of entitlements to achieve UHC. The authors explore how close Sláintecare is to the UHC ideal. They also review the phased strategy of implementation in Sláintecare that utilises a systems-thinking approach with interlinkages between entitlements, funding, capacity and implementation. Finally the authors review the Sláintecare milestones against the reality of implementation since the publication of the report in 2017, cognisant of government policy and practice. Some of the initial assumptions around the context of Sláintecare were not realised and there has been limited progress made toward expanding entitlements, and certainly short of the original plan. Nevertheless there have been positive developments in that there is evidence that Government's Implementation Strategy and Action Plans are focussing on reforming a complex adaptive system rather than implementing a blueprint with such initiatives as integrated care pilots and citizen engagement. The authors find that this may help the system change but it risks losing some of the essential elements of entitlement expansion in favour of organisational change.

Cost-effectiveness of implementing routine hearing screening using a tablet audiometer for pediatric cystic fibrosis patients receiving high-dose IV aminoglycosides.

BACKGROUND: Cystic fibrosis (CF) patients who receive high-dose aminoglycosides can acquire inner ear damage and subsequent hearing loss. There is no current standard protocol for assessing ototoxicity in CF centers in the United States. OBJECTIVE: To evaluate the cost-effectiveness of a pharmacist-implemented routine hearing screening for ototoxicity among pediatric patients using a clinically validated tablet audiometer to allow for earlier detection of hearing loss in an exploratory analysis. METHODS: A Markov decision-analytic model was developed to assess the cost-effectiveness of implementing routine screening with monthly cycles over a 3-year time horizon. The model measured the difference in promptly detected hearing loss, delayed detected hearing loss, and undetected hearing loss, compared with current screening practices. Model inputs were obtained through a comprehensive literature review. Primary model outcomes included total health care costs and quality-adjusted life-years (QALYs) gained with a 3% yearly discount. One-way, two-way, and probabilistic sensitivity analyses were conducted to evaluate model uncertainty. RESULTS: In a hypothetical cohort of 100 patients, routine screening using a tablet audiometer increased promptly detected hearing loss by 8 patients. There was an incremental gain of 3.2 QALYs at an increased cost of $333,826 compared with current screening practices. This resulted in an incremental cost-effectiveness ratio (ICER) of $103,771 per QALY. In the 1-way sensitivity analysis, the ICER ranged between $64,345 and $258,830 per QALY. CONCLUSIONS: Using a tablet audiometer for routine hearing screening appears to be a cost-effective option at a $150,000 per QALY willingness-to-pay threshold when only considering the immediate benefits gained. This analysis did not examine the long-term effects of early detection in language development for pediatric patients. DISCLOSURES: Huang reports funding from the University of North Carolina and GlaxoSmithKline Health Outcomes Fellowship. GlaxoSmithKline had no involvement in the study creation, analysis, or manuscript composition. The other authors have nothing to disclose.

Cost Minimization Analysis of a Teledermatology Triage System in a Managed Care Setting.

Importance: Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact. Objective: To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California. Design, Setting, and Participants: A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017. Intervention: Implementation of the TD triage system in January 2015. Main Outcomes and Measures: The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model. Results: The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378. Conclusions and Relevance: Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

Contexte: L'initiative de récupération améliorée après la chirurgie (RAAC) est un projet international d'amélioration de la qualité en chirurgie. On en sait peu sur les retombées économiques, tant à court qu'à long terme, de la mise en œuvre de multiples lignes directrices de RAAC. Méthodes: Nous avons réalisé une analyse du rendement sur l'investissement (RSI) visant la mise en œuvre de multiples lignes directrices de RAAC (pour les opérations colorectales, pancréatiques, hépatiques ou d'oncologie gynécologique et la cystectomie) dans 9 hôpitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L'incidence de la RAAC sur l'utilisation des services de santé (durée du séjour à l'hospitalisation initiale, nombre de réadmissions, durée du séjour à la réhospitalisation et nombre de visites à l'urgence, en consultation externe, chez un spécialiste et chez un omnipraticien) a été évaluée à l'aide d'un modèle multiniveau de régressions binomiales négatives à effets mixtes multivariés. Les bénéfices nets et le RSI ont été estimés à l'aide d'un processus de modélisation analytique décisionnelle. Tous les coûts ont été rapportés en dollars canadiens de 2019. Résultats: Les économies nettes du système de santé allaient de 26,35 $ à 3606,44 $ par patient, et le RSI variait de 1,05 à 7,31; chaque dollar investi dans l'initiative de RAAC a donc généré un retour sur l'investissement de 1,05 $ à 7,31 $. Les probabilités d'économie grâce au RAAC allaient de 86,5% à 99,9%. Les retombées générées augmentaient avec un horizon temporel à plus long terme, ce qui suggère que l'utilisation unique d'un horizon temporel de 30 jours aurait mené à une sousestimation des bénéfices. Conclusion: Les résultats montrent que la mise en œuvre de multiples lignes directrices de RAAC a permis des économies en Alberta. En vue d'obtenir un RSI optimal, il est important de tenir compte d'une grande variété d'utilisations des services de santé, des retombées à long terme, des économies d'échelle, de l'efficacité productive et de l'efficience des allocations pour la pérennité, la mise à l'échelle et la diffusion des projets de mise en œuvre de RAAC.

The cost-effectiveness of a program to reduce intrapartum and neonatal mortality in a referral hospital in Ghana.

OBJECTIVE: To evaluate the cost-effectiveness of a program intended to reduce intrapartum and neonatal mortality in Accra, Ghana. DESIGN: Quasi-experimental, time-sequence intervention, retrospective cost-effectiveness analysis. METHODS: A program integrating leadership development, clinical skills and quality improvement training was piloted at the Greater Accra Regional Hospital from 2013 to 2016. The number of intrapartum and neonatal deaths prevented were estimated using the hospital's 2012 stillbirth and neonatal mortality rates as a steady-state assumption. The cost-effectiveness of the intervention was calculated as cost per disability-adjusted life year (DALY) averted. In order to test the assumptions included in this analysis, it was subjected to probabilistic and one-way sensitivity analyses. MAIN OUTCOME MEASURES: Incremental cost-effectiveness ratio (ICER), which measures the cost per disability-adjusted life-year averted by the intervention compared to status quo. RESULTS: From 2012 to 2016, there were 45,495 births at the Greater Accra Regional Hospital, of whom 5,734 were admitted to the newborn intensive care unit. The budget for the systems strengthening program was US $1,716,976. Based on program estimates, 307 (±82) neonatal deaths and 84 (±35) stillbirths were prevented, amounting to 12,342 DALYs averted. The systems strengthening intervention was found to be highly cost effective with an ICER of US $139 (±$44), an amount significantly lower than the established threshold of cost-effectiveness of the per capita gross domestic product, which averaged US $1,649 between 2012-2016. The results were found to be sensitive to the following parameters: DALYs averted, number of neonatal deaths, and number of stillbirths. CONCLUSION: An integrated approach to system strengthening in referral hospitals has the potential to reduce neonatal and intrapartum mortality in low resource settings and is likely to be cost-effective. Sustained change can be achieved by building organizational capacity through leadership and clinical training.

Ending the HIV Epidemic Among Persons Who Inject Drugs: A Cost-Effectiveness Analysis in Six US Cities.

BACKGROUND: Persons who inject drugs (PWID) are at a disproportionately high risk of HIV infection. We aimed to determine the highest-valued combination implementation strategies to reduce the burden of HIV among PWID in 6 US cities. METHODS: Using a dynamic HIV transmission model calibrated for Atlanta, Baltimore, Los Angeles, Miami, New York City, and Seattle, we assessed the value of implementing combinations of evidence-based interventions at optimistic (drawn from best available evidence) or ideal (90% coverage) scale-up. We estimated reduction in HIV incidence among PWID, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) for each city (10-year implementation; 20-year horizon; 2018 $ US). RESULTS: Combinations that maximized health benefits contained between 6 (Atlanta and Seattle) and 12 (Miami) interventions with ICER values ranging from $94 069/QALY in Los Angeles to $146 256/QALY in Miami. These strategies reduced HIV incidence by 8.1% (credible interval [CI], 2.8%-13.2%) in Seattle and 54.4% (CI, 37.6%-73.9%) in Miami. Incidence reduction reached 16.1%-75.5% at ideal scale. CONCLUSIONS: Evidence-based interventions targeted to PWID can deliver considerable value; however, ending the HIV epidemic among PWID will require innovative implementation strategies and supporting programs to reduce social and structural barriers to care.

Equipo de intervención precoz en la prevención de psicosis del Parc Taulí (TEIP 3): una visión personal de las dificultades, estado actual y retos futuros sobre la implementación de un programa dirigido a la atención de trastornos psicóticos incipientes / No disponible

Los Programas de Primeros Episodios Psicóticos (PEP), también conocidos como Programas de Atención Específica al Trastorno Psicótico Incipiente (PAE-TPI), se han implementado en diferentes países con la intención de realizar una intervención precoz de pacientes con un primer episodio psicótico o en riesgo de desarrollar una psicosis. En este documento se realiza un visión personal de la implementación de un equipo multidisciplinar para implementar el PAE-TPI del Parc Taulí (Sabadell), que contó con una primera fase sin financiación específica (2015-2017) que consistió en una reorganización de recursos humanos, seguido de una segunda fase con financiación (2018 en adelante) que permitió disponer de un equipo con una mayor dotación con profesionales a dedicación exclusiva. La implementación de una atención específica en el Parc Taulí permitió objetivar una mejoría en variables clínicas respecto a la atención estándar: reducción de la duración de la psicosis no tratada (DUP), menor necesidad de ingreso al inicio de la enfermedad, uso de menores dosis de antipsicótico y una mejoría de la recuperación funcional. Finalmente se realiza una reflexión personal sobre los retos y perspectivas de futuro de los Programas PAE-TPI

First episode psychosis (FEP) program mes have been implemented in diffe rent countries. They address the early intervention of patients with a FEP or at risk of developing psychosis. This docu ment provides a personal view of the im plementation of a multidisciplinary team that developed the FEP programme of Parc Taulí (Sabadell), which had a first sta ge without specific funding (2015-2017) that consisted of a reorganization of hu man resources, followed by a second stage with specific funding (2018 onwards) that allowed to have a team with a greater dedi cation of professionals involved in the pro gramme. The implementation of a specific care at the Parc Taulí allowed to objectify an improvement in clinical variables when compared to standard care: reduction of the duration of untreated psychosis (DUP), less need for admission at the onset of the di sease, use of lower doses of antipsychotic drugs and an improvement of functional recovery. Finally, a personal view is carried out on the challenges and future directions of FEP Programmes

Implementation of breast cancer continuum of care in low- and middle-income countries during the COVID-19 pandemic.

Breast cancer is the most common malignancy among women worldwide. The current COVID-19 pandemic represents an unprecedented challenge leading to care disruption, which is more severe in low- and middle-income countries (LMIC) due to existing economic obstacles. This review presents the global perspective and preparedness plans for breast cancer continuum of care amid the COVID-19 outbreak and discusses challenges faced by LMIC in implementing these strategies. Prioritization and triage of breast cancer patients in a multidisciplinary team setting are of paramount importance. Deescalation of systemic and radiation therapy can be utilized safely in selected clinical scenarios. The presence of a framework and resource-adapted recommendations exploiting available evidence-based data with judicious personalized use of current resources is essential for breast cancer care in LMIC during the COVID-19 pandemic.

"Stopping the itch": mass drug administration for scabies outbreak control covered for over nine million people in Ethiopia.

INTRODUCTION: In 2018, the Ethiopian Ministry of Health embarked on a Mass Drug Administration (MDA) campaign that involved over 9 million people in Ethiopia - the largest scabies MDA campaign ever conducted on a global level. We describe its implementation and report on a) numbers screened and identified with scabies, b) treatment category and drug type and c) human resources used, duration, and cost of the campaign. METHODOLOGY: The MDA campaign was conducted according to national guidelines and activities including: planning and organization, engagement of local leaders, community mobilisation and advocacy, awareness-raising among health workers, field implementation, and monitoring and evaluation. The campaign was conducted between July and August 2018. RESULTS: The MDA campaign was implemented by about 15,000 people, mostly from the community, over an average of 6 days and reached 9, 057, 427 people. A total of 875,890 (9.7%) scabies cases were detected and 995,471 (11.0%) contacts received treatment. (Contact-to-case ratio = 1.3). Scabies prevalence varied, the highest prevalence was seen in Central Gondar (39.2%), South Gondar (16.7%) and North Gondar (15.0%), these neighbouring zones contributing more than two third of all scabies cases in the region. Of 1,738,304 (93%) who received treatment, 94% received ivermectin, the rest topical permethrin and sulfur. The average coverage capacity of an MDA campaign staff member was 84 people per day. The total cost was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD. CONCLUSIONS: This experience of rapid-large scale implementation would be useful to scale up similar interventions and "stop the itch" in other regions of Ethiopia.

Systems-level barriers to treatment in a cervical cancer prevention program in Kenya: Several observational studies.

OBJECTIVE: To identify health systems-level barriers to treatment for women who screened positive for high-risk human papillomavirus (hrHPV) in a cervical cancer prevention program in Kenya. METHODS: In a trial of implementation strategies for hrHPV-based cervical cancer screening in western Kenya in 2018-2019, women underwent hrHPV testing offered through community health campaigns, and women who tested positive were referred to government health facilities for cryotherapy. The current analysis draws on treatment data from this trial, as well as two observational studies that were conducted: 1) periodic assessments of the treatment sites to ascertain availability of resources for treatment and 2) surveys with treatment providers to elicit their views on barriers to care. Bivariate analyses were performed for the site assessment data, and the provider survey data were analyzed descriptively. RESULTS: Seventeen site assessments were performed across three treatment sites. All three sites reported instances of supply stockouts, two sites reported treatment delays due to lack of supplies, and two sites reported treatment delays due to provider factors. Of the 16 providers surveyed, ten (67%) perceived lack of knowledge of HPV and cervical cancer as the main barrier in women's decision to get treated, and seven (47%) perceived financial barriers for transportation and childcare as the main barrier to accessing treatment. Eight (50%) endorsed that providing treatment free of cost was the greatest facilitator of treatment. CONCLUSION: Patient education and financial support to reach treatment are potential areas for intervention to increase rates of hrHPV+ women presenting for treatment. It is also essential to eliminate barriers that prevent treatment of women who present, including ensuring adequate supplies and staff for treatment.

What are the benefits and harms of risk stratified screening as part of the NHS breast screening Programme? Study protocol for a multi-site non-randomised comparison of BC-predict versus usual screening (NCT04359420).

BACKGROUND: In principle, risk-stratification as a routine part of the NHS Breast Screening Programme (NHSBSP) should produce a better balance of benefits and harms. The main benefit is the offer of NICE-approved more frequent screening and/ or chemoprevention for women who are at increased risk, but are unaware of this. We have developed BC-Predict, to be offered to women when invited to NHSBSP which collects information on risk factors (self-reported information on family history and hormone-related factors via questionnaire; mammographic density; and in a sub-sample, Single Nucleotide Polymorphisms). BC-Predict produces risk feedback letters, inviting women at high risk (≥8% 10-year) or moderate risk (≥5 to < 8% 10-year) to have discussion of prevention and early detection options at Family History, Risk and Prevention Clinics. Despite the promise of systems such as BC-Predict, there are still too many uncertainties for a fully-powered definitive trial to be appropriate or ethical. The present research aims to identify these key uncertainties regarding the feasibility of integrating BC-Predict into the NHSBSP. Key objectives of the present research are to quantify important potential benefits and harms, and identify key drivers of the relative cost-effectiveness of embedding BC-Predict into NHSBSP. METHODS: A non-randomised fully counterbalanced study design will be used, to include approximately equal numbers of women offered NHSBSP (n = 18,700) and BC-Predict (n = 18,700) from selected screening sites (n = 7). In the initial 8-month time period, women eligible for NHSBSP will be offered BC-Predict in four screening sites. Three screening sites will offer women usual NHSBSP. In the following 8-months the study sites offering usual NHSBSP switch to BC-Predict and vice versa. Key potential benefits including uptake of risk consultations, chemoprevention and additional screening will be obtained for both groups. Key potential harms such as increased anxiety will be obtained via self-report questionnaires, with embedded qualitative process analysis. A decision-analytic model-based cost-effectiveness analysis will identify the key uncertainties underpinning the relative cost-effectiveness of embedding BC-Predict into NHSBSP. DISCUSSION: We will assess the feasibility of integrating BC-Predict into the NHSBSP, and identify the main uncertainties for a definitive evaluation of the clinical and cost-effectiveness of BC-Predict. TRIAL REGISTRATION: Retrospectively registered with clinicaltrials.gov (NCT04359420).

Why Did the ACA Co-Op Program Fail? Lessons for the Health Reform Debate.

The ACA created a new type of nonprofit health insurance entity, the "Consumer Operated and Oriented Plan" ("co-op"). Most of the newly created co-ops soon lost money, and only 4 of the original 23 remain. We interviewed key stakeholders and conducted in-depth case studies of 3 of these co-ops. We discovered that politicians and regulators made it unlikely the program could succeed, that most of the co-ops did not have the management capacity to overcome these political obstacles, and that even those with good managers lacked the needed fiscal resilience. We also considered lessons suggested for those proposing a newly created "public option." The main one is that a successful public option requires a supportive political environment, strong management, and significant fiscal capacity, none of which comes easily. A better route may be a quasi-public option in which the government subcontracts the operation of its newly created plan to a private firm. Although it is uncertain whether federal regulators have the capacity to hold such private for-profit firms accountable, pragmatism suggests that a combination of public-sector regulation and private-sector implementation may be the most direct path toward a US version of affordable universal coverage.

How can we optimise antifungal use in a solid organ transplant centre? Local epidemiology and antifungal stewardship implementation: A single-centre study.

PURPOSE: We aimed to implement and to assess the impact of the antifungal stewardship programme (AFSp) on prescription appropriateness of antifungals, management and outcomes of candidaemia patients, and antifungal consumption and costs at our solid organ transplant (SOT) institute. METHODS: Local epidemiology of invasive fungal infections (IFIs) from 2009 to 2017 was analysed in order to prepare an effective AFSp, implemented in January 2018. It included suspension of empirical antifungal prescriptions after 72 hours (antifungal time-out), automated alert and infectious disease (ID) consult for empirical prescriptions and for every patient with IFI, and indication for step-down to oral fluconazole when possible. We used process measures and results measures to assess the effects of the implemented programme. RESULTS: The ASFp led to significant improvements in selection of the appropriate antifungal (40.5% in pre-AFS vs 78.6% in post-AFS), correct dosing (51.2% vs 79.8%), correct length of treatment (55.9% vs 75%) and better management of patients with candidaemia. Analysis of prescribed empirical antifungal revealed that defined daily doses (DDDs) per 100 patient days decreased by 36.7% in 2018 compared to the average of pre-AFSp period, with important savings in costs. CONCLUSION: This AFSp led to a better use of antifungal drugs in terms of appropriateness and consumption, with stable clinical and microbiological outcomes in patients with IFI.

Design and Implementation of a Hospital-based Trauma Surveillance Registry in a Resource-Poor Setting: A Cost Analysis Study.

INTRODUCTION: Trauma is a leading cause of morbidity and mortality globally, with a disproportionate burden affecting low- and middle-income countries (LMIC). Rapid urbanization and differences in transportation patterns result in unique injury patterns in LMIC. Trauma registries are essential to determine the impact of trauma and the nature of injuries in LMIC to enable hospitals and healthcare systems to optimize care and to allocate resources. METHODS: A retrospective database analysis of prospectively collected data in the Kamuzu Central Hospital (KCH) Trauma Registry from 2018 - 2019 was performed. Activity-based costing, a bottom-up cost analysis method to determine the cost per patient registered, was completed after systematically analyzing the standard operating procedures of the KCH trauma registry. RESULTS: During the study period, 12,616 patients were included in the KCH Trauma Registry. Startup costs for the trauma registry are estimated at $3,196.24. This sum includes $1815.84 for personnel cost, $200 for database initiation (REDCap database), $342.50 for initial data clerk training, and $787.90 for registry and office supplies. Recurrent costs occurring in 2018, included personnel, technology, supply, and facility costs. Five data clerks, one data clerk manager, and a registry manager are required for 24/7 data collection, data integrity, and database maintenance, with an estimated cost of $29,697.24 per year. Yearly recurrent data clerk training costs are $137.00. Internet and facility costs for a data clerk office and secure record storage are $1632.60 per year. Supplies for the completion of trauma intake forms (binders, paper, pens) are $1431.80 per year. The total annual cost of the trauma registry at a tertiary hospital in Malawi is $33,361.64, which costs $2.64 per patient registered in the registry in 2018. CONCLUSION: Trauma registries are necessary for the assessment of the local trauma burden and injury pattern, but require significant financial commitment and time. To fully capture the local burden of trauma in resource-limited settings, acquiring, validating, and analyzing accurate data is crucial. Anticipating the financial burden of a trauma surveillance registry ahead of time is imperative.

The economics of drug allergy.

PURPOSE OF REVIEW: As drug allergy research aims to inform clinical practice, implementation of best practices may be influenced by financial resources required to incorporate new interventions and the resulting clinical and economic returns on those resource investments. The present review summarizes new insights into the economics of drug allergy over the past year. RECENT FINDINGS: While considering economic implications of recent drug allergy research, many studies have addressed different contextual factors related to the setting, provider, or outcomes. Advances in technology have enabled specialized allergists to support remote settings through telemedicine consultation. Training opportunities and interdisciplinary approaches to address drug allergy challenges have enabled multiple provider types to play a role in screening, diagnosis, and management. Penicillin allergy testing has been a major focus for many institutions, with several studies focused on de-labeling strategies including confirmatory skin testing and direct oral challenges. SUMMARY: Studies over the past year provide new opportunities for the field of drug allergy research. The focus of current research to capture direct health costs or savings associated with drug allergy interventions demonstrates opportunity for more cost-effective care delivery and opportunity to explore greater benefits to society.

Primary health care financing changes in the Brazilian Health System: advance ou setback? / Mudanças no financiamento da Atenção Primária à Saúde no Sistema de Saúde Brasileiro: avanço ou retrocesso?

In 2019, the Brazilian government launched a new Primary Health Care (PHC) policy for the Unified Health System (SUS). Called "PrevineBrasil", the policy changed the PHC funding for municipalities. Instead of inhabitants and Family Health Strategy (ESF) teams, intergovernmental transfers are calculated from the number of people registered in PHC services and the results achieved in a selected group of indicators. The changes will have a set of impacts for the SUS and the health of the population, which must be observed and monitored. In this paper, possible effects of the new policy are discussed from a brief context analysis of global trends in health systems financing and health services' remuneration models, as well as on the advances, challenges, and threats to PHC and the SUS. Based on the analysis, the new policy seems to have a restrictive purpose, which should limit universality, increase distortions in financing and induce the focus of PHC actions on the SUS, contributing to the reversal of historic achievements in reducing health inequalities in Brazil.

Em 2019, o governo brasileiro lançou uma nova política para a Atenção Primária à Saúde (APS) no Sistema Único de Saúde (SUS). Chamada de "Previne Brasil", a política modificou o financiamento da APS para municípios. No lugar de habitantes e de equipes de Estratégia Saúde da Família (ESF), as transferências intergovernamentais passaram a ser calculadas a partir do número de pessoas cadastradas em serviços de APS e de resultados alcançados sobre um grupo selecionado de indicadores. As mudanças terão um conjunto de impactos para o SUS e para a saúde da população que precisaram ser identificados e monitorados. Neste artigo, discute-se os possíveis efeitos da nova política a partir de uma breve análise de contexto sobre tendências globais de financiamento de sistemas de saúde e de remuneração por serviços de saúde, bem como dos avanços, desafios e ameaças à APS e ao SUS. Com base na análise realizada, entende-se que a nova política parece ter objetivo restritivo, que deve limitar a universalidade, aumentar as distorções no financiamento e induzir a focalização de ações da APS no SUS, contribuindo para a reversão de conquistas históricas na redução das desigualdades na saúde no Brasil.

Breast cancer early detection: A phased approach to implementation.

When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource-stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real-world settings are considered.