The Development and Evaluation of Hospital Pay-for-Performance in Lebanon: Casemix, Readmissions and Patient Perspectives.

Background: Pay-for-performance (P4P) has been widely used in healthcare, but there are few experiences of hospital-based P4P at scale. The evidence of impact from these has been mixed, and there has been increased recognition of the importance of different contexts, designs, incentives and other factors. In 2014, the Lebanese Ministry of Public Health integrated a P4P model for determining hospital reimbursement tiers. In 2018, this model was updated to include a readmissions component, in addition to the preexisting components such as casemix and patient satisfaction. The impact of these interventions was previously undetermined. This also provided an opportunity to contribute to some of the known knowledge gaps regarding hospital P4P. The purpose of this thesis was to describe the development and evaluate the impact of hospital P4P in Lebanon, and ultimately to contribute more broadly to improved design and implementation of value-based healthcare, particularly in limited resource settings.Methods: This thesis uses a mixed methods approach, combining quantitative and qualitative study designs, to conduct four research investigations. The first paper uses descriptive analysis to address how and why hospital P4P was developed in Lebanon. The second and third papers both use an interrupted time series design on data collected from the Ministry hospitalization database. The former uses Newey-OLS regression, and the latter uses Autoregressive Integrated Moving Average models. The second paper analyzes the impact of the 2014 P4P integration on casemix index, and the third paper analyzes the impact of the 2018 model update on readmissions. The fourth paper uses qualitative content analysis on data collected from eight focus groups discussions with patient participants.Results: The Ministry developed hospital P4P after recognizing the limitations of the previous model that had been solely based on accreditation status. Casemix index was included in the P4P model, to improve the appropriateness and fairness of the Ministry-hospitals relation. The analysis of P4P integration impact on casemix included 1,353,025 hospitalizations between 2011 and 2016. This revealed an abrupt increase in casemix among short-stay cases, and a gradual increase in medium-stay cases. Code-level analysis suggested this was attributable to a decrease in unnecessary hospitalizations and improved coding practices. The analysis of P4P impact on readmissions included 1,333,691 hospitalizations across 2011-2019. An abrupt decrease of cholecystectomy and stroke readmissions was found, but not of general and pneumonia readmissions. Our qualitative investigation allowed us to identify six patient perspectives, including satisfaction, health status, perceptions on each of quality, access and health system, and valuing of health, all of central relevance to health systems performance.Conclusion: Hospital P4P in Lebanon led to several positive impacts, including improving the relation between hospitals and the Ministry of Public Health, and providing a tool for continuous development of the health system. The 2014 and 2018 P4P interventions improved system effectiveness and related patient outcomes, by decreasing unnecessary hospitalizations and decreasing some types of readmissions. The Ministry should develop its P4P model to capture the entire spectrum of hospital visits. Using appropriate interrupted time series analysis on readily available data is a useful way to evaluate the effects of health system interventions in contexts with limited resources. Patients in Lebanon highly valued health and supported improving public hospitals and measures to counter the influence of personal connections and money. Health systems canmore widely engage people for their perspectives, and patients can have a fundamental role in shaping the values and functions of a health system

Effective strategies against COVID-19 and the importance of infection sequelae

COVID-19 is a serious threat to human health and development. The acute burden of the pandemic includes more than 18.2 million deaths worldwide, and is unprecedented in modern times. This represents only a fraction of the total burden, as it excludes infection sequelae. An effective global strategic paradigm has been missing throughout the pandemic. The ‘flattening the curve’ approach neglected the importance of infection sequelae, and being centered on healthcare capacity was conceptually contrary to a people-centered health system. In March 2022, the World Health Organization revised its pandemic approach, importantly shifting emphasis away from managing transmission and towards prevention. Despite limitations, this now recognizes the role of infection sequelae, whose impact is becoming clearer in both variety and scale. Drawing on the foundational concepts of Sun Tzu and Carl von Clausewitz, most country approaches do not qualify as strategies, but rather as operational plans. They are also largely ineffective, neglecting infection sequelae, viral evolution dangers and other parameters. The purpose of this article is to summarize the evidence on COVID-19 infection sequelae, and alongside other contextual parameters use this to motivate that infection should be prevented

COVID-19 herd immunity in the absence of a vaccine : an irresponsible approach

As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to spread rapidly throughout the human population, the concept of "herd immunity" has attracted the attention of both decision-makers and the general public. In the absence of a vaccine, this entails that a large proportion of the population will be infected to develop immunity that would limit the severity and/or extent of subsequent outbreaks. We argue that adopting such an approach should be avoided for several reasons. There are significant uncertainties about whether achieving herd immunity is possible. If possible, achieving herd immunity would impose a large burden on society. There are gaps in protection, making it difficult to shield the vulnerable. It would defeat the purpose of avoiding harm caused by the virus. Lastly, dozens of countries are showing that containment is possible

Smoking behavior and sociodemographic differences among young people: Further evidence from southern Sweden based on public health survey data.

Aims: Tobacco-smoking behaviours of young people between the age of 18 and 25 years are less understood than those of middle-aged people. The aim of this study is to contribute to improved knowledge of some of the factors that are associated with smoking and cessation among young people. Methods: We use the most recently available public health survey data from the southern region of Skåne in Sweden to analyze these factors. The survey is a cross-sectional study with a total sample size of 28,198 individuals with 2801 in the age category of interest. We apply statistical measures of association between smoking and gender and also model the relationship between smoking and smoking cessation and the role of a set of sociodemographic determinants by means of logistic regression to estimate odds ratios. Results: The findings include significant differences between the younger age group and the older group with respect to the odds of smoking and method of cessation. We also find differences between young women and men with regard to smoking prevalence, intensity and cessation methods. In particular, young women attempt to quit smoking by means of unassisted methods to a significantly higher extent than do young men. Conclusions: There are significant differences between young people and older individuals with respect to a range of smoking behaviours. There are also strong gender effects within the group of young people. Policy development and anti-smoking interventions need to take such differences into consideration for improved effectiveness

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores.Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures.Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found.Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data

Towards a Zero-COVID Lebanon: A Call for Action

In its first report, the Independent Lebanese Committee for the Elimination of COVID-19, a group of concerned citizens with various health-related expertise, addresses weaknesses in current government policy and highlights several directions and actions for a more coherent and sustainable national strategy. The Lebanese government has the responsibility to protect the health of all its citizens and residents. The early and decisive interventions implemented in the spring to address the COVID-19 pandemic allowed Lebanon to avoid what would have been an exponential rise in cases. These included thorough contact tracing, border closure, partial lockdown and (initially) centralized case isolation in hospitals