Provision of community-based mental health care, Latvia

(c) 2020 The authors; licensee World Health Organization.Problem In Latvia, the move towards community-based mental health-care services has been slow. Approach The hospital managers of the only psychiatric hospital in Riga decided to establish two community-based clinics that were financially and administratively integrated with the hospital. The clinics were established using a step-wise approach by redistributing resources, including psychiatrists, nurses and beds, from the hospital to the new clinics. In 2005, the Veldre clinic started outpatient consultations and day care admissions. In 2009, Pardaugava clinic opened as an outpatient clinic. In 2012, an open-door inpatient ward with 30 beds was transferred from the psychiatric hospital to Veldre. In 2013, Pardaugava clinic opened a day care clinic and an open-door inpatient ward, transferring 26 beds from the psychiatric hospital. Local setting Latvians have worse mental health indicators than those of the average population in Europe. Mental care has traditionally focused on inpatient care. Relevant changes The clinics are now providing most of the outpatient services and the number of inpatients treated at the hospital has declined from 5696 patients in 2004 to 4957 patients in 2018. Patients are treated in a more open and patient-centred environment. Lessons learnt The administrative and financial integration of the new community-based clinics within the existing structures of the hospital is a successful approach. Transferring resources to the clinics seems to have improved the quality of care without requiring additional funding apart from the initial investment costs. Involving the staff members during the planning phase reduced resistance to the project.publishersversionPeer reviewe

Achieving Sustainability and Scale-Up of Mobile Health Noncommunicable Disease Interventions in Sub-Saharan Africa: Views of Policy Makers in Ghana

Background: A growing body of evidence shows that mobile health (mHealth) interventions may improve treatment and care for the rapidly rising number of patients with noncommunicable diseases (NCDs) in sub-Saharan Africa (SSA). A recent realist review developed a framework highlighting the influence of context factors, including predisposing characteristics, needs, and enabling resources (PNE), for the long-term success of mHealth interventions. The views of policy makers will ultimately determine implementation and scale-up of mHealth interventions in SSA. However, their views about necessary conditions for sustainability and scale-up remain unexplored. Objective: This study aimed to understand the views of policy makers in Ghana with regard to the most important factors for successful implementation, sustainability, and scale-up of mHealth NCD interventions. Methods: Members of the technical working group responsible for Ghana’s national NCD policy were interviewed about their knowledge of and attitude toward mHealth and about the most important factors contributing to long-term intervention success. Using qualitative methods and applying a qualitative content analysis approach, answers were categorized according to the PNE framework. Results: A total of 19 policy makers were contacted and 13 were interviewed. Interviewees had long-standing work experience of an average of 26 years and were actively involved in health policy making in Ghana. They were well-informed about the potential of mHealth, and they strongly supported mHealth expansion in the country. Guided by the PNE framework’s categories, the policy makers ascertained which critical factors would support the successful implementation of mHealth interventions in Ghana. The policy makers mentioned many factors described in the literature as important for mHealth implementation, sustainability, and scale-up, but they focused more on enabling resources than on predisposing characteristics and need. Furthermore, they mentioned several factors that have been rather unexplored in the literature. Conclusions: The study shows that the PNE framework is useful to guide policy makers toward a more systematic assessment of context factors that support intervention implementation, sustainability, and scale-up. Furthermore, the framework was refined by adding additional factors. Policy makers may benefit from using the PNE framework at the various stages of mHealth implementation. Researchers may (and should) use the framework when investigating reasons for success (or failure) of interventions.DFG, 414044773, Open Access Publizieren 2019 - 2020 / Technische Universität Berli

Effect of corruption on perceived difficulties in healthcare access in sub-Saharan Africa

Background Achieving Universal Health Coverage (UHC) by improving financial protection and effective service coverage is target 3.8 of the Sustainable Development Goals. Little is known, however, about the extent to which paying bribes within healthcare acts as a financial barrier to access and, thus, UHC. Methods Using survey data in adults from 32 sub-Saharan African countries in 2014–2015, we constructed a multilevel model to evaluate the relationship between paying bribes and reported difficulties of obtaining medical care. We controlled for individual-, region-, and country-level variables. Results Having paid bribes for medical care significantly increased the odds of reporting difficulties in obtaining care by 4.11 (CI: 3.70–4.57) compared to those who never paid bribes, and more than doubled for those who paid bribes often (OR = 9.52; 95% CI: 7.77–11.67). Respondents with higher levels of education and more lived poverty also had increased odds. Those who lived in rural areas or within walking distance to a health clinic had reduced odds of reporting difficulties. Sex, age, living in a capital region, healthcare expenditures per capita, and country Corruption Perception Index were not significant predictors. Conclusions We found that bribery in healthcare is a significant barrier to healthcare access, negatively affecting the potential of African countries to make progress toward UHC. Future increases in health expenditures—which are needed in many countries to achieve UHC—should be accompanied by greater efforts to fight corruption in order to avoid wasting money. Measuring and tracking health sector-specific corruption is critical for progress toward UHC.DFG, 414044773, Open Access Publizieren 2019 - 2020 / Technische Universität Berli

Heterogeneity of European DRG systems and potentials for a common EuroDRG system Comment on “Cholecystectomy and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries”

Diagnosis-Related Group (DRG) systems across Europe are very heterogeneous, in particular because of different classification variables and algorithms as well as costing methodologies. But, given the challenge of increasing patient mobility within Europe, health systems are forced to incorporate a common patient classification language in order to compare and identify similar patients e.g. for reimbursement purposes. Beside the national adoption of DRGs for a wide range of purposes (measuring hospital activity vs. paying hospitals), a common DRG system can serve as an international communication basis among health administrators and can reduce the national development efforts as it is demonstrated by the NordDRG consortium

Costs of delivering human papillomavirus vaccination to schoolgirls in Mwanza Region, Tanzania.

BACKGROUND: Cervical cancer is the leading cause of female cancer-related deaths in Tanzania. Vaccination against human papillomavirus (HPV) offers a new opportunity to control this disease. This study aimed to estimate the costs of a school-based HPV vaccination project in three districts in Mwanza Region (NCT ID: NCT01173900), Tanzania and to model incremental scaled-up costs of a regional vaccination program. METHODS: We first conducted a top-down cost analysis of the vaccination project, comparing observed costs of age-based (girls born in 1998) and class-based (class 6) vaccine delivery in a total of 134 primary schools. Based on the observed project costs, we then modeled incremental costs of a scaled-up vaccination program for Mwanza Region from the perspective of the Tanzanian government, assuming that HPV vaccines would be delivered through the Expanded Programme on Immunization (EPI). RESULTS: Total economic project costs for delivering 3 doses of HPV vaccine to 4,211 girls were estimated at about US$349,400 (including a vaccine price of US$5 per dose). Costs per fully-immunized girl were lower for class-based delivery than for age-based delivery. Incremental economic scaled-up costs for class-based vaccination of 50,290 girls in Mwanza Region were estimated at US$1.3 million. Economic scaled-up costs per fully-immunized girl were US$26.41, including HPV vaccine at US$5 per dose. Excluding vaccine costs, vaccine could be delivered at an incremental economic cost of US$3.09 per dose and US$9.76 per fully-immunized girl. Financial scaled-up costs, excluding costs of the vaccine and salaries of existing staff were estimated at US$1.73 per dose. CONCLUSIONS: Project costs of class-based vaccination were found to be below those of age-based vaccination because of more eligible girls being identified and higher vaccine uptake. We estimate that vaccine can be delivered at costs that would make HPV vaccination a very cost-effective intervention. Potentially, integrating HPV vaccine delivery with cost-effective school-based health interventions and a reduction of vaccine price below US$5 per dose would further reduce the costs per fully HPV-immunized girl

It probably worked: a Bayesian approach to evaluating the introduction of activity-based hospital payment in Israel

Background: In 2013–2014, Israel accelerated adoption of activity-based payments to hospitals. While the effects of such payments on patient length of stay (LoS) have been examined in several countries, there have been few analyses of incentive effects in the Israeli context of capped reimbursements and stretched resources. Methods: We examined administrative data from the Israel Ministry of Health for 14 procedures from 2005 to 2016 in all not-for-profit hospitals (97% of the acute care beds). Survival analyses using a Weibull distribution allowed us to examine the non-negative and right-skewed data. We opted for a Bayesian approach to estimate relative change in LoS. Results: LoS declined in 7 of 14 procedures analyzed, notably, in 6 out of 7 urological procedures. In these procedures, reduction in LoS ranged between 11% and 20%. The estimation results for the control variables are mixed and do not indicate a clear pattern of association with LoS. Conclusions: The decrease in LoS freed resources to treat other patients, which may have resulted in reduced waiting times. It may have been more feasible to reduce LoS for urological procedures since these had relatively long LoS. Policymakers should pay attention to the effects of decreases in LoS on quality of care. Stretched hospital resources, capped reimbursements, retrospective subsidies and underpriced procedures may have limited hospitals' ability to reduce LoS for other procedures where no decrease occurred (e.g., general surgery).TU Berlin, Open-Access-Mittel - 202

Effects of activity-based hospital payments in Israel: A qualitative evaluation focusing on the perspectives of hospital managers and physicians

Background: Since 2010, Israel has expanded the adoption of procedure-related group (PRG) based payments for hospitals. While there is a rich quantitative literature that assesses the effects of payment reforms on efficiency or quality of care, very few qualitative studies have focused on the impacts of diagnosis-related group (DRG)-like payments on hospitals from the perspective of hospital workers as change agents. Methods: We used a qualitative, thematic analysis based on 33 semi-structured in-depth interviews with chief executive officers (CEOs), chief financial officers (CFOs), ward directors and physicians conducted in five public hospitals in Israel, sampled by maximum variation according to hospital characteristics. Results: Interviewees reported that the payment reform led to organizational changes such as increased transparency and enhanced supervision. Interviewees also reported several actions in response to the economic incentives of PRGbased payment. These included (1) shifting activities to afterhours and using operating rooms (ORs) more efficiently to enable increased surgical volumes; (2) reducing costs by shortening lengths of stay and increasing cost-consciousness in procurement; and (3) increasing revenues by improving coding and selecting procedures. Moderating factors reduced the effects of the reform. For example, organizational factors such as the public nature of hospitals or the (un)availability of healthcare resources did not always allow hospitals to increase the number of cases treated. Also, conflicting incentives such as multiple payment mechanisms or underpricing of procedures blurred the incentives of the reform. Finally, managers and physicians have many other considerations that outweigh the economic ones. Conclusion: PRG payments affected the organizational dynamics of hospitals and changed decision-making about admission and treatment policies. However, such effects were moderated by many other factors that should be considered when shaping and analyzing hospital payment reforms

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial

BACKGROUND: Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery. METHODS: Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention. DISCUSSION: Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04418271. Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820 SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13063-022-06401-x

Cost-effectiveness of Screen-Triage-Treat approach with Primary HPV Testing for Cervical Cancer Screening in Low- and Middle-Income Countries: Protocol for a Systematic Review

Background: Cervical cancer is a leading cause of mortality among women in low- and middle-income countries (LMICs). Early detection through screening is key to cervical cancer prevention. HPV DNA testing (community-based self-sampling and facility-based provider sampling) has recently been recommended by WHO as the primary screening in LMIC in a “screen, triage and treat” approach. A lack of economic evidence considering the intervention cost and the value of health gain leads to insufficient public funds allocated for healthcare. Objectives of this systematic review: 1) To summarize and compare the incremental resource use, implementation cost, and incremental cost-effectiveness of adopting different algorithms using HPV DNA primary tests followed by triage tests in LMICs. 2) To summarize and compare the resource use, implementation cost and cost-effectiveness of two sample collection methods (community-based self-sampling and facility-based provider-sampling) of the HPV-based primary screening as part of the screen-triage-treat approach for cervical cancer screening in LMICs. 3) To summarize and compare the resource use, implementation cost, and cost-effectiveness of different “Screen-triage-treat" methods in general population versus high-risk HIV-positive women. 4) To describe the methodological considerations applied in the economic evaluation studies (outcome, measures, analytical viewpoint, time horizon, discount rate, decision models) and assess the quality of economic evidence using standard CHEERS and Drummond checklists Method: A systematic review will be performed following Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) using literature from multiple databases including PubMed, Embase, Web of Science, CEA registry, NHS Economic Evaluation Database, Health Economic Evaluation Database (HEED), CINAHL, EconLit, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and Cochrane Library as well as grey literature from other sources. Details of search strategies, eligibility criteria and process for study screening, study selection, quality assessment, data extraction and analysis are described in the attachment