Brief parenting intervention (Triple P) for families of children with eczema: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy and costs of a brief, group-delivered parenting intervention for families of children with eczema. METHODS: A randomized controlled trial design was used. Families attending the Queensland Children's Hospital and from the community (n = 257) were assessed for eligibility (child 2-10 years, diagnosed with eczema, prescribed topical corticosteroids). Families who consented to participate (N = 59) were assessed at baseline for clinician-rated eczema severity, parent-reported eczema symptom severity, and electronically-monitored topical corticosteroid adherence (primary outcomes); and parenting behavior, parents' self-efficacy and task performance when managing eczema, eczema-related child behavior problems, and child and parent quality of life (secondary outcomes). Families were randomized (1:1, unblinded) to intervention (n = 31) or care-as-usual (n = 28). The intervention comprised two, 2-hr Healthy Living Triple P group sessions (face-to-face/online) and 28 intervention families attended one/both sessions. All families were offered standardized eczema education. Families were reassessed at 4-weeks post-intervention and 6-month follow-up, with clinician-raters blinded to condition. Costs of intervention delivery were estimated. RESULTS: Multilevel modeling across assessment timepoints showed significant intervention effects for ineffective parenting (d = .60), self-efficacy (d = .74), task performance (d = .81), and confidence with managing eczema-related child behavior (d = .63), but not disease/symptom severity, treatment adherence or quality of life. Mean cost per participating family with parenting behavior (clinically) improved was $159. CONCLUSIONS: Healthy Living Triple P is effective in reducing ineffective parenting practices and improving parents' self-efficacy and task performance when managing children's eczema and eczema-related behavior difficulties. There was no effect on disease/symptom severity, treatment adherence, or quality of life. CLINICAL TRIAL REGISTRATION: ACTRN12618001332213.

Comment on Takakura et al. Acupuncture for Japanese Katakori (Chronic Neck Pain): A Randomized Placebo-Controlled Double-Blind Study. Medicina 2023, 59, 2141.

We are writing because we have a number of concerns about the Takakura et al. [...].

An eReferral Management & Triage System for minor Oral surgery referrals from primary care dentists: a cost-effectiveness evaluation.

OBJECTIVE: Oral surgery referrals from NHS dental practices are rising, increasing the pressures on available hospital resources. We assess if an electronic referral system with consultant or peer (general dental practitioner) led triage of patient referrals from general dental practices can effectively divert patients requiring minor oral surgery into specialist led primary care settings at a reduced cost whilst providing care of the same or enhanced quality. One year of no triage (all referrals treated in secondary care) was followed by one-year of consultant led triage, which in turn was followed by year of peer-led triage. METHOD: A health economic evaluation of all patient referrals from 27 UK dental practices for oral surgery procedures. The follow-up is over a three-year period at hospital dental services in two general hospitals, one dental hospital, and a single specialist oral surgeon based in two primary care practices. The evaluation is a comparison of mean outcomes in the hospitals and in specialist primary care dental services between the study periods (i.e. periods with and without the triage system). The main outcomes of interest are mean NHS cost saving per referral (costs to the NHS and costs to broader society), proportion of diverted referrals, case-mix of referrals and patient reports of the quality of dentistry services received at their referral destination. RESULTS: The proportion of referrals diverted to specialist primary care was similar during both periods (45% under consultant-led triage and 43% under GDP-led triage). Statistically significant savings per referral diverted were found (£116.11 under consultant-led triage, £90.25 under GDP-led triage). There were no statistically significant changes in the case-mix of referrals. Cost savings varied according to the coding (and hence tariff) of referred cases by the provider hospitals. Patients reported similarly high levels of satisfaction scores for treatment in specialist primary care and secondary care settings. CONCLUSIONS: Implementation of electronic referral management in primary care, when combined with triage, led to appropriate diversions to specialist primary care. Although cost savings were realised by referral diversion these savings are dependent on the particular tariff allocation (coding) practices of provider hospitals.

A scoping review of research to assess the frequency, types, and reasons for end-of-life care setting transitions.

Aims: Most people approaching the end of life develop care needs, which typically change over time. Moves between care settings may be required as health deteriorates. However, in some cases, care setting transitions may have little to do with end-of-life care needs and instead reflect the needs, demands, availability, or funding provisions of the country or funding body and organizations providing care. This paper is a scoping review of the international peer-reviewed research literature to gain evidence on the frequency and types of end-of-life care setting transitions, and the reasons for these moves. Methods: All relevant print and open access research articles published in 2000+ were sought using the Directory of Open Access Journals and EBSCO Discovery Host. Results: A total of 39 research articles were identified and reviewed. However, minimal useful evidence was revealed. Most articles focused solely on hospital admissions near death, and some focused on nursing home admissions, with other moves infrequently studied. Conclusions: This review demonstrates the need to quantify and justify end-of-life care setting transitions as it appears dying people are frequently moved, often as death nears. This research is needed to distinguish transitions related to end-of-life care needs and those arising from pressures on or from care providers and others unrelated to the person's care needs.

Area-Level Variation in Children's Unmet Need for Community-Based Mental Health Services: Findings from the 2014 Ontario Child Health Study.

There is limited empirical evidence documenting the magnitude and correlates of area-level variability in unmet need for children's mental health services. Research is needed that identifies area-level characteristics that can inform strategies for reducing unmet need in the population. The study purpose is to: (1) estimate area-level variation in children's unmet need for mental health services (using Service Areas as defined by the Ontario Ministry of Children and Youth Services), and (2) identify area-level service arrangements, and geographic and population characteristics associated with unmet need. Using individual-level general population data, area-level government administrative data and Census data from Ontario, Canada, we use multilevel regression models to analyze unmet need for mental health services among children (level 1) nested within Service Areas (level 2). The study finds that 1.64% of the reliable variance in unmet need for mental health services is attributable to between-area differences. Across areas, we find that Service Areas with more agencies had a lower likelihood of unmet need for mental health services. Compared to other Service Areas, Toronto had much lower likelihood of unmet need compared to the rest of Ontario. Rural areas, areas with unsatisfactory public transport, and areas with higher levels of socio-economic disadvantage had a higher likelihood of unmet need for mental health services. These findings identify challenges in service provision that researchers, policymakers and administrators in children's mental health services need to better understand. Policy implications and potential Service Area strategies that could address equitable access to mental health services are discussed.

Needs-based planning for the oral health workforce - development and application of a simulation model.

BACKGROUND: The World Health Organization's global strategy on human resources for health includes an objective to align investment in human resources for health with the current and future needs of the population. Although oral health is a key indicator of overall health and wellbeing, and oral diseases are the most common noncommunicable diseases affecting half the world's population, oral health workforce planning efforts have been limited to simplistic target dentist-population or constant services-population ratios which do not account for levels of and changes in population need. Against this backdrop, our aim was to develop and operationalise an oral health needs-based workforce planning simulation tool. METHODS: Using a conceptual framework put forward in the literature, we aimed to build the model in Microsoft Excel and apply it in a hypothetical context to demonstrate its operability. The model incorporates a provider supply component and a provider requirement component, enabling a comparison of the current and future supply of and requirement for oral health workers. Publicly available data, including the Special Eurobarometer 330 Oral Health Survey, were used to populate the model. Assumptions were made where data were not publicly available and key assumptions were tested in scenario analyses. RESULTS: We have systematically developed a needs-based workforce planning model for the oral health workforce and applied the model in a hypothetical context over a 30-year time span. In the 2017 baseline scenario, the model produced a full-time equivalent (FTE) provider requirement figure of 899 dentists compared with an FTE provider supply figure of 1985. In the scenario analyses, the FTE provider requirement figure ranged from 1123 to 1629 illustrating the extent of the impact of changing parameter values. CONCLUSIONS: In response to policy makers' recognition of the pressing need to better plan human resources for health and the scarcity of work in this area for dentistry, we have demonstrated the feasibility of producing a workable, practical and useful needs-based workforce planning simulation tool for the oral health workforce. In doing so, we have highlighted the challenges faced in accessing timely and relevant data needed to populate such models and ensure the reliability of model outputs.

Children's Mental Health Need and Expenditures in Ontario: Findings from the 2014 Ontario Child Health Study.

OBJECTIVE: To estimate the alignment between the Ontario Ministry of Children and Youth Services (MCYS) expenditures for children's mental health services and population need, and to quantify the value of adjusting for need in addition to population size in formula-based expenditure allocations. Two need definitions are used: "assessed need," as the presence of a mental disorder, and "perceived need," as the subjective perception of a mental health problem. METHODS: Children's mental health need and service contact estimates (from the 2014 Ontario Child Health Study), expenditure data (from government administrative data), and population counts (from the 2011 Canadian Census) were combined to generate formula-based expenditure allocations based on 1) population size and 2) need (population size adjusted for levels of need). Allocations were compared at the service area and region level and for the 2 need definitions (assessed and perceived). RESULTS: Comparisons were made for 13 of 33 MCYS service areas and all 5 regions. The percentage of MCYS expenditure reallocation needed to achieve an allocation based on assessed need was 25.5% at the service area level and 25.6% at the region level. Based on perceived need, these amounts were 19.4% and 27.2%, respectively. The value of needs-adjustment ranged from 8.0% to 22.7% of total expenditures, depending on the definition of need. CONCLUSION: Making needs adjustments to population counts using population estimates of children's mental health need (assessed or perceived) provides additional value for informing and evaluating allocation decisions. This study provides much-needed and current information about the match between expenditures and children's mental health need.

Low prioritization of latent tuberculosis infection-A systemic barrier to tuberculosis control: A qualitative study in Ontario, Canada.

BACKGROUND: Eliminating tuberculosis (TB) in low-incidence countries is an important global health priority, and Canada has committed to achieve this goal. The elimination of TB in low-incidence countries requires effective management and treatment of latent tuberculosis infection (LTBI). This study aimed to understand and describe the system-level barriers to LTBI treatment for immigrant populations in the Greater Toronto and Hamilton Area, Ontario, Canada. METHODS: A qualitative study that used purposive sampling to recruit and interview health system advisors and planners (n = 10), providers (n = 13), and clients of LTBI health services (n = 9). Data were recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Low prioritization of LTBI was an overarching theme that impacted four dimensions of LTBI care: management, service delivery, health literacy, and health care access. These factors explained, in part, inequities in the system that were linked to variations in health care quality and health care access. While some planners and providers at the local level were attempting to prioritize LTBI care, there was no clear pathway for information sharing. CONCLUSIONS: This multiperspective study identified barriers beyond the typical socioeconomic determinants and highlighted important upstream factors that hinder treatment initiation and adherence. Addressing these factors is critical if Canada is to meet the WHO's global call to eradicate TB in all low incidence settings.

People-centred integrated care in urban China.

In most countries, the demand for integrated care for people with chronic diseases is increasing as the population ages. This demand requires a fundamental shift of health-care systems towards more integrated service delivery models. To achieve this shift in China, the World Health Organization, the World Bank and the Chinese government proposed a tiered health-care delivery system in accordance with a people-centred integrated care model. The approach was pioneered in Luohu district of Shenzhen city from 2015 to 2017 as a template for practice. In September 2017, China's health ministry introduced this approach to people-centred integrated care to the entire country. We describe the features of the Luohu model in relation to the core action areas and implementation strategies proposed and we summarize data from an evaluation of the first two years of the programme. We discuss the challenges faced during implementation and the lessons learnt from it for other health-care systems. We consider how to improve collaboration between institutions, how to change the population's behaviour about using community health services as the first point of contact and how to manage resources effectively to avoid budget deficits. Finally, we outline next steps of the Luohu model and its potential application to strengthen health care in other urban health-care systems.

Dans la plupart des pays, la demande de soins intégrés pour les personnes atteintes de maladies chroniques augmente à mesure que la population vieillit. Cette demande nécessite une réorientation majeure des systèmes de soins de santé vers des dispositifs de prestation de services plus intégrés. Pour effectuer cette réorientation en Chine, l'Organisation mondiale de la Santé, la Banque mondiale et le gouvernement chinois ont proposé un système de soins de santé à plusieurs niveaux selon un dispositif de soins intégrés axés sur l'être humain. Cette approche a été utilisée pour la première fois dans le district de Luohu de la ville de Shenzhen de 2015 à 2017 en tant que modèle de pratique. En septembre 2017, le ministère chinois de la Santé a appliqué à l'ensemble du pays ce dispositif de soins intégrés axés sur l'être humain. Nous décrivons les caractéristiques du modèle de Luohu par rapport aux principaux domaines d'action et aux stratégies de mise en œuvre proposées et nous résumons les données extraites d'une évaluation des deux premières années du programme. Nous examinons les difficultés rencontrées lors de la mise en œuvre et les leçons tirées de ces difficultés pour d'autres systèmes de soins de santé. Nous réfléchissons aux moyens d'améliorer la collaboration entre les institutions, de changer le comportement de la population concernant l'utilisation des services de santé des collectivités comme premier point de contact et de gérer efficacement les ressources pour éviter les déficits budgétaires. Enfin, nous décrivons les prochaines étapes à suivre dans le cadre du modèle de Luohu et son application potentielle pour renforcer les soins de santé dans d'autres systèmes urbains de soins de santé.

En la mayoría de los países, la demanda de atención integrada para las personas con enfermedades crónicas aumenta a medida que la población envejece. Esta demanda requiere un cambio fundamental de los sistemas de atención sanitaria hacia modelos de prestación de servicios más integrados. Para lograr este cambio en China, la Organización Mundial de la Salud, el Banco Mundial y el gobierno chino propusieron un sistema escalonado de prestación de servicios sanitarios de acuerdo con un modelo de atención integrada centrada en las personas. El enfoque se introdujo en el distrito de Luohu de la ciudad de Shenzhen de 2015 a 2017 como modelo para la práctica. En septiembre de 2017, el Ministerio de Salud de China introdujo este enfoque de atención integrada centrada en las personas en todo el país. Se describen las características del modelo de Luohu en relación con las áreas centrales de acción y las estrategias de implementación propuestas y se resumen los datos de una evaluación de los dos primeros años del programa. Se exponen los desafíos enfrentados durante la implementación y las lecciones aprendidas de la misma para otros sistemas de atención sanitaria. Se considera cómo mejorar la colaboración entre las instituciones, cómo cambiar el comportamiento de la población sobre el uso de los servicios sanitarios comunitarios como primer punto de contacto y cómo gestionar eficazmente los recursos para evitar déficits de presupuesto. Por último, se esbozaron los próximos pasos del modelo de Luohu y su posible aplicación para fortalecer la atención sanitaria en otros sistemas urbanos de atención sanitaria.

Barriers to treatment adherence for individuals with latent tuberculosis infection: A systematic search and narrative synthesis of the literature.

OBJECTIVES: We investigated the rates of initiation and completion of treatment for latent TB infection (LTBI), factors explaining nonadherence and interventions to improve treatment adherence in countries with low TB incidence. DESIGN: A systematic search was performed in PubMed and Embase. All included articles were assessed for risk of bias. A narrative synthesis of the results was conducted. RESULTS: There were 54 studies included in this review. The proportion of people initiating treatment varied from 24% to 98% and the proportion of people completing treatment varied from 19% to 90%. The main barriers to adherence included the fear or experience of adverse effects, long duration of treatment, financial barriers, lack of transport to clinics (for patients), and insufficient resources for LTBI control. While interventions like peer counseling, incentives, and culturally specific case management have been used to improve adherence, the proportion of people who initiate and complete LTBI treatment still remains low. CONCLUSION: To further improve treatment and LTBI control and to fulfill the World Health Organization goal of eliminating TB in low-incidence countries, greater priority should be given to the use of treatment regimens involving shorter durations and fewer adverse effects, like the 3-month regimen of weekly rifapentine plus isoniazid, supported by innovative patient education and incentive strategies.

The impact of Cone Beam CT on financial costs and orthodontists' treatment decisions in the management of maxillary canines with eruption disturbance.

Background: Examination with Cone Beam CT (CBCT) is common for localizing maxillary canines with eruption disturbance. The benefits and costs of these examinations are unclear. Objectives: To measure: 1. the proportion of orthodontists' treatment decisions that were different based on intraoral and panoramic radiography (M1) compared with CBCT and panoramic radiography (M2); and 2. the costs of producing different treatment plans, regarding patients with maxillary canines with eruption disturbance. Subjects and methods: Orthodontists participated in a web-based survey and were randomly assigned to denote treatment decisions and the level of confidence in this decision for four patient cases presented with M1 or M2 at two occasions for the same patient case. Results: One hundred and twelve orthodontists made 445 assessments based on M1 and M2, respectively. Twenty-four per cent of the treatment decisions were different depending on which method the raters had access to, whereof one case differed significantly from all other cases. The mean total cost per examination was €99.84 using M1 and €134.37 using M2, resulting in an incremental cost per examination of €34.53 for M2. Limitations: Benefits in terms of number of different treatment decisions must be considered as an intermediate outcome for the effectiveness of a diagnostic method and should be interpreted with caution. Conclusions: For the patient cases presented in this study, most treatment decisions were the same irrespective of radiological method. Accordingly, this study does not support routine use of CBCT regarding patients with maxillary canine with eruption disturbance.

Will the Need-Based Planning of Health Human Resources Currently Undertaken in Several Countries Lead to Excess Supply and Inefficiency? A Comment on Basu and Pak.

Basu and Pak (2014) argue that need-based workforce planning models would not maximize social welfare, and use of need-based models would result in inefficiency. They propose that planning be based on service utilization to incorporate preferences or other socioeconomic factors. We show that the analysis is based on inappropriate considerations of the nature of healthcare demand, a misrepresentation of need-based approaches and misunderstanding publicly funded healthcare system objectives. We explain how current levels of utilization emerge from workload and income interests of providers that underlie utilization-based models and are incompatible with public goals of maximizing health gains. Copyright © 2016 John Wiley & Sons, Ltd.

Does capitation affect the delivery of oral healthcare and access to services? Evidence from a pilot contact in Northern Ireland.

BACKGROUND: In May 2009, the Northern Ireland government introduced General Dental Services (GDS) contracts based on capitation in dental practices newly set up by a corporate dental provider to promote access to dental care in populations that had previously struggled to secure service provision. Dental service provision forms an important component of general health services for the population, but the implications of health system financing on care delivered and the financial cost of services has received relatively little attention in the research literature. The aim of this study is to evaluate the policy effect capitation payment in recently started corporate practices had on the delivery of primary oral healthcare in Northern Ireland and access to services. METHODS: We analysed the policy initiative in Northern Ireland as a natural experiment to find the impact on healthcare delivery of the newly set up corporate practices that use a prospective capitation system to remunerate primary care dentists. Data was collected from GDS claim forms submitted to the Business Services Organisation (BSO) between April 2011 and October 2014. Health and Social Care Board (HSCB) practices operating within a capitation system were matched to a control group, who were remunerated using a retrospective fee-for-service system. RESULTS: No evidence of patient selection was found in the HSCB practices set up by a corporate provider and operated under capitation. However, patients were less likely to visit the dentist and received less treatment when they did attend, compared to those belonging to the control group (P < 0.05). The extent of preventive activity offered and the patient payment charge revenue did not differ between the two practice groups. CONCLUSION: Although remunerating NHS primary care dentists in newly set up corporate practices using a prospective capitation system managed costs within healthcare, there is evidence that this policy may have reduced access to care of registered patients.

Appropriateness-based reimbursement of elective invasive coronary procedures in low- and middle-income countries: Preliminary assessment of feasibility in India.

BACKGROUND: Elective coronary interventional procedures are often overused and sometimes inappropriately used. The incentives for overuse are greater in low- and middle-income countries, where much of healthcare is provided by poorly regulated, fee-for-service systems. Overuse and inappropriate use increase healthcare costs and are potentially harmful to patients. Linking appropriate use of elective procedures to their reimbursement might deter overuse. METHODS: We explored the feasibility of introducing appropriateness criteria as a precondition to settling reimbursement claims in a publicly funded health insurance scheme in Maharashtra, India. Clinical algorithms were developed from the current best-practice criteria and used to determine appropriateness at the time of obtaining pre-authorization for elective percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgeries. The number of PCIs as a proportion of the total number of procedures reimbursed under the scheme was the primary outcome measure. This proportion was compared for 1-year periods before and after implementation of appropriateness-based reimbursement, using the chi-square test. Comparisons were also made separately for public and private hospitals. The change in the proportion of CABG surgeries over the same time periods was used as a comparator (as they are less subject to inappropriate use). RESULTS: The insurance scheme provided cover to a population of 20 424 585 (18.2% of the population of Maharashtra) in 8 districts, through 106 hospitals (73 private and 33 public). There was a 12.3% (95% CI 8.9%-15.5%, p=0.0001) reduction in the proportion of PCIs performed in the 1-year period after the introduction of appropriateness-based reimbursement. The reduction was similar for public and private hospitals. There was no significant change in the proportion of CABG surgeries (2.3% v. 2.2%, p=0.20). At current rates, use of appropriateness-based reimbursement would result in approximately 783 (95% CI 483-1099) less PCIs with potential annual savings of about ₹ 57 million (US$ 0.93 million; 95% CI 0.57-1.3) to the government scheme. CONCLUSIONS: It seems feasible to implement an appropriateness-based system for reimbursement of elective coronary interventional procedures in a government-funded health insurance scheme in a developing country. This potentially cost-saving approach may reduce inappropriate use.

Socioeconomic disparities in orthodontic treatment outcomes and expenditure on orthodontics in England's state-funded National Health Service: a retrospective observational study.

BACKGROUND: This study aimed to assess whether there are potential areas for efficiency improvements in the National Health Service (NHS) orthodontic service in North West England and to assess the socioeconomic status (SES)-related equity of the outcomes achieved by the NHS. METHODS: The study involved a retrospective analysis of 2008-2012 administrative data, and the study population comprised patients aged ≥10 who started NHS primary care orthodontic treatment in North West England in 2008. The proportions of treatments that were discontinued early and ended with residual need (based on post-treatment Index of Orthodontic Treatment Need [IOTN] scores that met or exceeded the NHS eligibility threshold of 3.6) and the associated NHS expenditure were calculated. In addition, the associations with SES were investigated using linear probability models. RESULTS: We found that 7.6% of treatments resulted in discontinuation (which was associated with an NHS annual expenditure of £2.3 m), and a further 19.4% (£5.9 m) had a missing outcome record. Furthermore, 5.2% of treatments resulted in residual need (£1.6 m), and a further 38.3% (£11.6 m) had missing IOTN data (due to either a missing outcome record or an incomplete IOTN outcome field in the record), which led to an annual NHS expenditure of £13.2 m (44% of the total expenditure) on treatments that are a potential source of inefficiency. Compared to the patients in the highest SES group, those in the lower SES groups were more likely both to discontinue treatment and to have residual need on treatment completion. CONCLUSIONS: Substantial inefficiencies were evident in the NHS orthodontic service, with 7.6% of treatments ending in discontinuation (£2.3 m) and 5.2% ending with residual need (£1.6 m). Over a third of cases had unreported IOTN outcome scores, which highlights the need to improve the outcome monitoring systems. In addition, the SES gradients indicate inequity in the orthodontic outcomes, with children from disadvantaged communities having poorer outcomes compared to their more affluent peers.

Simulating future supply of and requirements for human resources for health in high-income OECD countries.

BACKGROUND: As part of efforts to inform the development of a global human resources for health (HRH) strategy, a comprehensive methodology for estimating HRH supply and requirements was described in a companion paper. The purpose of this paper is to demonstrate the application of that methodology, using data publicly available online, to simulate the supply of and requirements for midwives, nurses, and physicians in the 32 high-income member countries of the Organisation for Economic Co-operation and Development (OECD) up to 2030. METHODS: A model combining a stock-and-flow approach to simulate the future supply of each profession in each country-adjusted according to levels of HRH participation and activity-and a needs-based approach to simulate future HRH requirements was used. Most of the data to populate the model were obtained from the OECD's online indicator database. Other data were obtained from targeted internet searches and documents gathered as part of the companion paper. RESULTS: Relevant recent measures for each model parameter were found for at least one of the included countries. In total, 35% of the desired current data elements were found; assumed values were used for the other current data elements. Multiple scenarios were used to demonstrate the sensitivity of the simulations to different assumed future values of model parameters. Depending on the assumed future values of each model parameter, the simulated HRH gaps across the included countries could range from shortfalls of 74 000 midwives, 3.2 million nurses, and 1.2 million physicians to surpluses of 67 000 midwives, 2.9 million nurses, and 1.0 million physicians by 2030. CONCLUSIONS: Despite important gaps in the data publicly available online and the short time available to implement it, this paper demonstrates the basic feasibility of a more comprehensive, population needs-based approach to estimating HRH supply and requirements than most of those currently being used. HRH planners in individual countries, working with their respective stakeholder groups, would have more direct access to data on the relevant planning parameters and would thus be in an even better position to implement such an approach.

A synthesis of recent analyses of human resources for health requirements and labour market dynamics in high-income OECD countries.

BACKGROUND: Recognition of the importance of effective human resources for health (HRH) planning is evident in efforts by the World Health Organization (WHO) and the Global Health Workforce Alliance (GHWA) to facilitate, with partner organizations, the development of a global HRH strategy for the period 2016-2030. As part of efforts to inform the development of this strategy, the aims of this study, the first of a pair, were (a) to conduct a rapid review of recent analyses of HRH requirements and labour market dynamics in high-income countries who are members of the Organisation for Economic Co-operation and Development (OECD) and (b) to identify a methodology to determine future HRH requirements for these countries. METHODS: A systematic search of peer-reviewed literature, targeted website searches, and multi-stage reference mining were conducted. To supplement these efforts, an international Advisory Group provided additional potentially relevant documents. All documents were assessed against predefined inclusion criteria and reviewed using a standardized data extraction tool. RESULTS: In total, 224 documents were included in the review. The HRH supply in the included countries is generally expected to grow, but it is not clear whether that growth will be adequate to meet health care system objectives in the future. Several recurring themes regarding factors of importance in HRH planning were evident across the documents reviewed, such as aging populations and health workforces as well as changes in disease patterns, models of care delivery, scopes of practice, and technologies in health care. However, the most common HRH planning approaches found through the review do not account for most of these factors. CONCLUSIONS: The current evidence base on HRH labour markets in high-income OECD countries, although large and growing, does not provide a clear picture of the expected future HRH situation in these countries. Rather than HRH planning methods and analyses being guided by explicit HRH policy questions, most of the reviewed studies appeared to derive HRH policy questions based on predetermined planning methods. Informed by the findings of this review, a methodology to estimate future HRH requirements for these countries is described.

Coordination of care in the Chinese health care systems: a gap analysis of service delivery from a provider perspective.

BACKGROUND: Increases in health care utilization and costs, resulting from the rising prevalence of chronic conditions related to the aging population, is exacerbated by a high level of fragmentation that characterizes health care systems in China. There have been several pilot studies in China, aimed at system-level care coordination and its impact on the full integration of health care system, but little is known about their practical effects. Huangzhong County is one of the pilot study sites that introduced organizational integration (a dimension of integrated care) among health care institutions as a means to improve system-level care coordination. The purposes of this study are to examine the effect of organizational integration on system-level care coordination and to identify factors influencing care coordination and hence full integration of county health care systems in rural China. METHODS: We chose Huangzhong and Hualong counties in Qinghai province as study sites, with only Huangzhong having implemented organizational integration. A mixed methods approach was used based on (1) document analysis and expert consultation to develop Best Practice intervention packages; (2) doctor questionnaires, identifying care coordination from the perspective of service provision. We measured service provision with gap index, overlap index and over-provision index, by comparing observed performance with Best Practice; (3) semi-structured interviews with Chiefs of Medicine in each institution to identify barriers to system-level care coordination. RESULTS: Twenty-nine institutions (11 at county-level, 6 at township-level and 12 at village-level) were selected producing surveys with a total of 19 schizophrenia doctors, 23 diabetes doctors and 29 Chiefs of Medicine. There were more care discontinuities for both diabetes and schizophrenia in Huangzhong than in Hualong. Overall, all three index scores (measuring service gaps, overlaps and over-provision) showed similar tendencies for the two conditions. The gap indices of schizophrenia (> 5.10) were bigger for diabetes (< 2.60) in both counties. The over-provision indices of schizophrenia (> 3.25) were bigger than diabetes (< 1.80) in both counties. Overlap indices for the two conditions exceeded justified overlaps, especially for diabetes. Gap index scores for schizophrenia interventions at the township-level and over-provision index scores for diabetes interventions at both village- and township-level showed big differences between the two counties. Insufficient medical staff with appropriate competencies, lack of motivation for care coordination and related supportive policies as well as unconnected information system were identified as barriers to system-level care coordination in both counties. CONCLUSION: Findings demonstrate that organizational integration in Huangzhong has not achieved a higher level of care coordination at this stage. System-level care coordination is most problematic at village-level institutions in Hualong, but at county-level institutions in Huangzhong. These findings suggest that attention be given to other aspects of integration (e.g., clinical and service integration) to promote system-level care coordination and contribute to the full integration of health care system in the pilot county.

Disability Grant: a precarious lifeline for HIV/AIDS patients in South Africa.

BACKGROUND: In South Africa, HIV/AIDS remains a major public health problem. In a context of chronic unemployment and deepening poverty, social assistance through a Disability Grant (DG) is extended to adults with HIV/AIDS who are unable to work because of a mental or physical disability. Using a mixed methods approach, we consider 1) inequalities in access to the DG for patients on ART and 2) implications of DG access for on-going access to healthcare. METHODS: Data were collected in exit interviews with 1200 ART patients in two rural and two urban health sub-districts in four different South African provinces. Additionally, 17 and 18 in-depth interviews were completed with patients on ART treatment and ART providers, respectively, in three of the four sites included in the quantitative phase. RESULTS: Grant recipients were comparatively worse off than non-recipients in terms of employment (9.1 % vs. 29.9 %) and wealth (58.3 % in the poorest half vs. 45.8 %). After controlling for socioeconomic and demographic factors, site, treatment duration, adherence and concomitant TB treatment, the regression analyses showed that the employed were significantly less likely to receive the DG than the unemployed (p < 0.001). Also, patients who were longer on treatment and receiving concomitant treatment (i.e., ART and tuberculosis care) were more likely to receive the DG (significant at the 5 % level). The qualitative analyses indicated that the DG alleviated the burden of healthcare related costs for ART patients. Both patients and healthcare providers spoke of the complexity of the grants process and eligibility criteria as a barrier to accessing the grant. This impacted adversely on patient-provider relationships. CONCLUSIONS: These findings highlight the appropriateness of the DG for people living with HIV/AIDS. However, improved collaboration between the Departments of Social Development and Health is essential for preparing healthcare providers who are at the interface between social security and potential recipients.