The impact of international health worker migration and recruitment on health systems in source countries: Stakeholder perspectives from Colombia, Indonesia, and Jordan.

INTRODUCTION: To address domestic shortages, high-income countries are increasingly recruiting health workers from low- and middle-income countries. This practice is much debated. Proponents underline benefits of return migration and remittances. Critics point in particular to the risk of brain drain. Empirical evidence supporting either position is yet rare. This study contributes to filling this gap in knowledge by reporting high-level stakeholders' perspectives on health system impacts of international migration in general, and active recruitment of health workers in specific, in Colombia, Indonesia, and Jordan. METHOD: We used a multiple case study methodology, based on qualitative methods integrated with information available in the published literature. RESULTS: All respondents decried a lack of robust and detailed data as a serious challenge in ascertaining their perspectives on impacts of health worker migration. Stakeholders described current emigration levels as not substantially aggravating existing health workforce availability challenges. This is due to the fact that all three countries are faced with health worker unemployment grounded in unwillingness to work in rural areas and/or overproduction of certain cadres. Respondents, however, pleaded against targeting very experienced and specialised individuals. While observing little harm of health worker migration at present, stakeholders also noted few benefits such as brain gain, describing how various barriers to skill enhancement, return, and reintegration into the health system hamper in practice what may be possible in theory. CONCLUSION: Improved availability of data on health worker migration, including their potential return and reintegration into their country of origin's health system, is urgently necessary to understand and continuously monitor costs and benefits in dynamic national and international health labour markets. Our results imply that potential benefits of migration do not come into being automatically, but need in-country supportive policy and programming, such as favourable reintegration policies or programs targeting engagement of the diaspora

Evaluation of Family Planning Counselling in North Jordan

Objectives: Counselling plays a key role in enhancing reproductive services, providing contraception-related information and supporting long-term family planning for women of childbearing age. This study aimed to evaluate family planning counselling sessions in selected governmental and private clinics in northern Jordan. Methods: This cross-sectional study was conducted between January and June 2016 in Irbid, Jordan. A total of 200 women attending two private clinics affiliated with the Jordanian Association for Family Planning and Protection (JAFPP) and six governmental clinics were invited to participate in the study. Counselling sessions were attended by an independent observer and evaluated with regards to their compliance with the standard Greet, Ask, Tell, Help, Explain, Return (GATHER) framework. Results: A total of 198 women participated in the study (response rate: 99.0%), including 80 women (40.4%) from JAFPP clinics and 118 (59.6%) from governmental clinics. In total, 42.9% of the counselling sessions were deemed adequate, with providers applying 80% or more of the GATHER framework, while 26.8% of the sessions were deemed semi-adequate and 30.3% were considered inadequate. Counselling services provided in the governmental clinics were significantly less adequate than those provided in JAFPP clinics (P <0.001). Conclusion: The quality of counselling services in governmental family planning centres in Jordan needs to be improved to ensure that women receive the highest possible level of care. Healthcare policymakers should therefore focus on developing and supporting effective family planning counselling services in northern Jordan

Dysregulation of the RANKL/RANK/OPG axis in thalassemia intermedia patients

Abstract Objective Thalassemia intermedia (TI) describes a disease ranging in severity between β thalassemia major (TM) and β thalassemia trait. Osteoporosis is observed in TI and TM. The exact reason of osteoporosis in TI could be hypogonadism and/or an increase in erythropoietin (EPO) levels. The carboxy-terminal collagen cross links (CTX), a marker of bone resorption, and the N-terminal propeptide of type 1 collagen (P1NP), a marker of bone formation are serum markers of osteoporosis. The receptor activator of NF-kappaB ligand (RANKL)/receptor activator of NF-kappaB (RANK)/osteoprotegerin (OPG) axis plays an important role in metabolic bone diseases. Herein, we tested the relationship between the RANKL/RANK/OPG axis and the bone-turnover markers CTX and P1NP in TI. Results We recruited 44 TI patients and 33 non-thalassemic controls and measured the serum levels of hemoglobin, sex steroid hormones, CTX, P1NP, RANKL and OPG. We then used a general linear model to test the association of the above variables with CTX and P1NP as outcome variables. We showed that EPO levels were the strongest predictor of CTX change (P < 0.000), followed by RANKL (P = 0.017). On the other hand, RANKL was the strongest predictor of P1NP change (P < 0.000), followed by OPG (P = 0.009) and EPO (P = 0.024)

Assessment of patient safety culture in two emergency departments in Australia: a cross sectional study

Purpose: Patient safety culture is a vital element to create patient safety in healthcare organisations. Emergency department (ED) professionals operate in unstable conditions that may pose risk to patient safety on day-to-day basis. The aim of this study was to assess the status of patient safety culture and to quantify the dimensions of safety culture in the ED setting. Design/methodology/approach: This was a descriptive cross sectional study that used a validated questionnaire distributed to the staff working in the nominated EDs. Perceptions on various dimensions of safety culture were reported and the frequency of positive responses for each dimension was calculated. Findings: “Teamwork” is the only dimension that rated positive by over 70% of participants. Other dimensions rated below 50%, except for “Organisational learning–continuous improvement” which rated 51.2%. Areas that rated the lowest were “Handover and transitions”, “Staffing”, “Non-punitive response to error” and “Frequency of event reporting” with average positive response rate of 15.4%, 26%, 26.8% and 27.6%, respectively. Originality/value: This study displayed a concerning perceptions held by participants about the deficiency of patient safety culture in their EDs. Moreover, it provided a baseline finding giving a clearer vision of the areas of patient safety culture that need improvement.</p

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research