Investigating the Willingness to Pay for a Contributory National Health Insurance Scheme in Saudi Arabia:A Cross-sectional Stated Preference Approach

Background: The Saudi Healthcare System is universal, financed entirely from government revenue principally derived from oil, and is ‘free at the point of delivery’ (non-contributory). However, this system is unlikely to be sustainable in the medium to long term. This study investigates the feasibility and acceptability of healthcare financing reform by examining households’ willingness to pay (WTP) for a contributory national health insurance scheme. Methods: Using the contingent valuation method, a pre-tested interviewer-administered questionnaire was used to collect data from 1187 heads of household in Jeddah province over a 5-month period. Multi-stage sampling was employed to select the study sample. Using a double-bounded dichotomous choice with the follow-up elicitation method, respondents were asked to state their WTP for a hypothetical contributory national health insurance scheme. Tobit regression analysis was used to examine the factors associated with WTP and assess the construct validity of elicited WTP. Results: Over two-thirds (69.6%) indicated that they were willing to participate in and pay for a contributory national health insurance scheme. The mean WTP was 50 Saudi Riyal (US$13.33) per household member per month. Tobit regression analysis showed that household size, satisfaction with the quality of public healthcare services, perceptions about financing healthcare, education and income were the main determinants of WTP. Conclusions: This study demonstrates a theoretically valid WTP for a contributory national health insurance scheme by Saudi people. The research shows that willingness to participate in and pay for a contributory national health insurance scheme depends on participant characteristics. Identifying and understanding the main influencing factors associated with WTP are important to help facilitate establishing and implementing the national health insurance scheme. The results could assist policy-makers to develop and set insurance premiums, thus providing an additional source of healthcare financing

Report from the Annual Conference of the British Society of Echocardiography, November 2017, Edinburgh International Conference Centre, Edinburgh

No abstract available

Focused cardiac ultrasound to guide the diagnosis of heart failure in pregnant women in India

Background: Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low resource settings. The aim of our study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings. Methods: Cross-sectional study of 301 pregnant and postpartum women recruited from ten hospitals across three States in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from the Focus-Assessed Transthoracic Echocardiography. It included parasternal long axis (PLAX), parasternal short axis (PSAX), and apical four-chamber views in 2D and colour Doppler. Independent image interpretation was performed remotely by two experts, in the UK and India, using a standard semi-quantitative assessment protocol. Interrater agreement between the experts was examined using Cohen’s Kappa (κ). Diagnostic accuracy of the method was examined in a sub-sample for whom both focused and conventional scans were available. Results: Cardiac abnormalities identified using the focused method included valvular abnormalities(27%), rheumatic heart disease(6.6%), derangements in left ventricular size(4.7%) and function(22%), atrial dilatation(19.5%) and pericardial effusion(30%). There was substantial agreement on the cardiac parameters between the two experts ranging from 93.6% (k=0.84) for left ventricular ejection fraction to 100% (k=1) for valvular disease. Image quality was graded as good in 79% of PLAX, 77% PSAX and 64% apical four-chamber views. The chance corrected k coefficients indicated fair to moderate agreement (k 0.28 to 0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement) compared in 36 participants. Conclusion: The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings.</p

Left atrial function in heart failure with mid-range ejection fraction differs from that of heart failure with preserved ejection fraction: a 2D speckle-tracking echocardiographic study

Aims: Heart failure (HF) with mid-range ejection fraction (HFmrEF) shares similar diagnostic criteria to HF with preserved ejection fraction (HFpEF). Whether left atrial (LA) function differs between HFmrEF and HFpEF is unknown. We, therefore, used 2D-speckle-tracking echocardiography (2D-STE) to assess LA phasic function in patients with HFpEF and HFmrEF. Methods and results: Consecutive outpatients diagnosed with HF according to current European recommendations were prospectively enrolled. There were 110 HFpEF and 61 HFmrEF patients with sinus rhythm, and 37 controls matched by age. LA phasic function was analysed using 2D-STE. Peak-atrial longitudinal strain (PALS), peak-atrial contraction strain (PACS), and PALS-PACS were measured reflecting LA reservoir, pump, and conduit function, respectively. Among HF groups, most of left ventricular (LV) diastolic function measures, and LA volume were similar. Both HF groups had abnormal LA phasic function compared with controls. HFmrEF patients had worse LA phasic function than HFpEF patients even among patients with LA enlargement. Among patients with normal LA size, LA reservoir, and pump function remained worse in HFmrEF. Differences in LA phasic function between HF groups remained significant after adjustment for confounders. Global PALS and PACS were inversely correlated with brain natriuretic peptide, LA volume, E/A, E/e', pulmonary artery systolic pressure, and diastolic dysfunction grade in both HF groups. Conclusion: LA phasic function was worse in HFmrEF patients compared with those with HFpEF regardless of LA size, and independent of potential confounders. These differences could be attributed to intrinsic LA myocardial dysfunction perhaps in relation to altered LV function

Incomplete surgical excision of keratinocyte skin cancers: a systematic review and meta-analysis.

Background Keratinocyte or non‐melanoma skin cancer (NMSC) is the commonest malignancy worldwide. Usual treatment is surgical excision. Current guidelines underestimate incomplete excision rates. Objectives We aimed to determine the risk of incomplete excision of NMSCs through a systematic review and meta‐analysis of primary clinical studies. Methods A PRISMA‐compliant systematic review and meta‐analysis was performed using methodology proposed by Cochrane. A comprehensive search strategy was applied to MEDLINE, Embase, Scopus, CINAHL, EMCare, Cochrane Library and the grey literature (January 2000–27th November 2019). All studies were included except studies on Mohs micrographic surgery, frozen section or biopsies. Abstract screening and data extraction were performed in duplicate. The risk of bias was assessed using a tool for prevalence/incidence studies. The primary outcome was the proportion of incomplete surgical excisions. A random effects model for pooling of binominal data was used. Differences between proportions were assessed by sub‐group meta‐analysis and meta regression which were presented as risk ratios. PROSPERO CRD42019157936. Results Searching identified 3477 records, with 110 studies included, comprising 53 796 patients with 106 832 basal cell carcinomas (BCC) and 21 569 squamous cell carcinomas (SCC). The proportion of incomplete excisions for BCC was 11·0% (95% CI 9·7‐12·4%) and for SCC 9·4% (95% CI 7·6‐11·4%). Incomplete excisions by specialty were: dermatology 6·2% BCCs, 4·7% SCCs; plastic surgery 9·4% BCCs, 8·2% SCCs; general practitioners 20·4% BCCs, 19·9% SCCs. The risk of incomplete excision for general practitioners was four times that of dermatologists for both BCC (RR 3·9 [95% CI 2·0‐7·3]) and SCC (RR 4·8 [95% CI 1·0‐22·8]). Studies were heterogenous (I2=98%) and at high risk of bias. Conclusions The proportion of incomplete excisions is higher than previously reported. Excisions performed by specialists may lower the risk of incomplete excision