Development and Validation of an Index to Measure the Quality of Facility-Based Labor and Delivery Care Processes in Sub-Saharan Africa

Background

High quality care is crucial in ensuring that women and newborns receive interventions that may prevent and treat birth-related complications. As facility deliveries increase in developing countries, there are concerns about service quality. Observation is the gold standard for clinical quality assessment, but existing observation-based measures of obstetric quality of care are lengthy and difficult to administer. There is a lack of consensus on quality indicators for routine intrapartum and immediate postpartum care, including essential newborn care. This study identified key dimensions of the quality of the process of intrapartum and immediate postpartum care (QoPIIPC) in facility deliveries and developed a quality assessment measure representing these dimensions.

Methods and Findings

Global maternal and neonatal care experts identified key dimensions of QoPIIPC through a modified Delphi process. Experts also rated indicators of these dimensions from a comprehensive delivery observation checklist used in quality surveys in sub-Saharan African countries. Potential QoPIIPC indices were developed from combinations of highly-rated indicators. Face, content, and criterion validation of these indices was conducted using data from observations of 1,145 deliveries in Kenya, Madagascar, and Tanzania (including Zanzibar). A best-performing index was selected, composed of 20 indicators of intrapartum/immediate postpartum care, including essential newborn care. This index represented most dimensions of QoPIIPC and effectively discriminated between poorly and well-performed deliveries.

Conclusions

As facility deliveries increase and the global community pays greater attention to the role of care quality in achieving further maternal and newborn mortality reduction, the QoPIIPC index may be a valuable measure. This index complements and addresses gaps in currently used quality assessment tools. Further evaluation of index usability and reliability is needed. The availability of a streamlined, comprehensive, and validated index may enable ongoing and efficient observation-based assessment of care quality during labor and delivery in sub-Saharan Africa, facilitating targeted quality improvement.     

The burden of rare cancer in Japan: Application of the RARECARE definition

BackgroundDespite the fact that rare cancer is a new target of cancer control in Japan, the incidence of rare cancers is unknown and there is no generally accepted definition of rare cancers in this country. With the aim of calculating incidences of rare cancers in Japan, we therefore adopted a definition and classification of rare cancers that had been published in the European Union (EU) in 2011.MethodsUsing incidence data between 1998 and 2007 submitted by 12 of population based cancer registries in Japan that met our quality criteria and drawing on the EU definition (incidence <6 per 100,000 per year), we estimated the incidences of 845 combinations of tumor sites and histological groups and thus identified the cancers that are rare in Japan.ResultsAfter identifying 193 combinations of tumor sites and histological groups that fit our criteria for rare cancers, we estimated their incidence to be about 75 per 100,000, which corresponds to about 94,800 new diagnoses in 2012 or approximately 15% of all cancer diagnoses. The categorization of rare and common cancers was almost the same in Japan as in EU.ConclusionsThe present study provides an indication of the size of the rare cancer burden in Japan and epidemiological information to explore this. We are expecting further discussion based on our results with stakeholders in order to construct a Japanese definition of rare cancers.     

Increased incidence of rare cancers and varied age distributions by cancer group: A population-based cancer registry study in Hiroshima Prefecture,Japan

BackgroundEpidemiological characteristics of many types of rare cancers are limited especially in Asia. Therefore, this study aimed to describe the burden and changing time trends of rare cancers in Hiroshima, Japan.MethodsThe internationally agreed RARECAREnet list of rare cancers was used to identify patients diagnosed with cancers from 2005 to 2015 who were registered in the Hiroshima Prefecture Cancer Registry. Quality indicators specific to rare cancers were assessed by cancer grouping. Crude incidence rates (IRs) and age-standardized rates (ASRs) were calculated for 216 single cancers (rare and common) included in the list. A joinpoint regression was used to analyze age distribution and time trends in the ASRs for 12 internationally agreed rare cancer families. Quality indicators, ASRs, and IRs in Japan were identified to examine IR differences and the effects on data accuracy.ResultsThe 231,328 cases were used to calculate the IRs of each cancer. Epithelial tumors in rare families increased with age, but nonepithelial tumors occurred at any age. The proportion of rare cancer families to total cancers was stable. The time trend for families of head and neck cancers (annual percent change and 95 % confidence interval: 2.4 %; 1.2–3.7 %), neuroendocrine tumors (6.6 %; 5.1–8.1 %), and hematological cancers (4.3 %; 3.2–5.5 %) markedly increased.ConclusionThe ASRs of several rare cancers increased because of increased knowledge of these diseases, improved diagnostic techniques, and aggressive diagnoses.     

What Should Be Held Steady in a Steady‐State Economy?: Interpreting Daly's Definition at the National Level

Within this article, I investigate a number of the conceptual issues that arise when attempting to translate Herman Daly's definition of a steady‐state economy (SSE) into a set of national biophysical indicators. Although Daly's definition gives a high‐level view of what would be held steady in an SSE, it also leaves many questions unanswered. How should stocks and flows be aggregated? What is the role of international trade? How should nonrenewable resources be treated? And where does natural capital fit in? To help answer these questions, I relate Daly's definition to key concepts and terminology from material and energy flow accounting. I explore topics such as aggregation, international trade, the relevance of throughput, and hidden flows. I conclude that a set of biophysical accounts for an SSE should include three types of indicators (stocks, flows, and scale), track how stocks and flows are changing over a 5‐ to 10‐year period, use aggregated data that measure the quantity of resource use (rather than its quality), measure both total and nonrenewable resource use, adopt a consumption‐based approach, include hidden flows, and exclude indicators that measure characteristics of the stock of natural capital (with the notable exception of indicators that measure the regenerative and assimilative capacities of ecosystems).     

Diagnosis and treatment of lung cancer in Denmark during the COVID-19 pandemic

BackgroundWe examined the number of lung cancers diagnosed, the quality of care and the socio-economic and clinical characteristics among patients with lung cancer during the COVID-19 pandemic compared to previous years.MethodsWe included all patients ≥ 18 years old diagnosed with lung cancer from 01 January 2018 to 31 August 2021 as registered in the Danish Lung Cancer Registry. Using a generalised linear model, we estimated prevalence ratios (PR) and 95% confidence intervals (CI) of the associations between the pandemic and socioeconomic and clinical factors, and indicators of quality.ResultsWe included 18,113 patients with lung cancer (82.0% non-small cell lung cancer (NSCLC)), which was similar to the preceding years, although a decline in NSCLC cases occurred during the first lockdown period in 2020. No difference in distribution of income or educational level was observed. No difference was observed in the quality of treatment – as measured by curative intent, proportion of patients resected or who died within 90 days of diagnosis.ConclusionUsing nationwide population-based data, our study reassuringly shows no adverse effects of the COVID-19 pandemic on the diagnosis, socio-economic characteristics nor quality of treatment of lung cancer, as compared to the preceding years.     

Validity of initial cancer diagnoses in the Diagnosis Procedure Combination data in Japan

BackgroundIn Japan, the Diagnosis Procedure Combination (DPC) data have been used as a nationwide administrative hospital discharge database for clinical studies. However, few studies have evaluated the validity of recorded diagnoses of cancer in the database.MethodsWe compared the DPC data with hospital-based cancer registries in Osaka Prefecture, Japan to assess the validity of the recorded cancer diagnoses in the DPC data. Fifteen types of cancer were included in the analysis. Cancer stage with tumor-node-metastasis (TNM) classification was assessed for eight cancer types with >400 patients. We evaluated concordance and positive predictive value of cancer diagnosis, and concordance of cancer stage between the DPC data and the hospital-based cancer registry.ResultsIn total, we identified 29,180 eligible patients. The five types of cancer with the highest number of patients were as follows: 6,765 (23.2 %) colorectal, 6,476 (22.2 %) stomach, 4,862 (16.7 %) breast, 4,445 (15.2 %) lung, and 2,257 (7.7 %) liver. Concordance of diagnosis ranged from 63.9 %–99.5 %, and twelve of the fifteen types of cancers had concordance of over 90 %. Positive predictive values of diagnosis ranged from 86.8 %–100 %. Regarding cancer stage, the overall degree of concordance was 67.2 % in all patients and the concordance was over 70 % in four types of cancers.ConclusionsThe DPC data had high validity of cancer diagnosis. However, the potential impact of the misclassifications and low concordance in cancer stage among specific type of cancers in the DPC data should be considered.     

Methodological aspects of estimating rare cancer prevalence in Europe: The experience of the RARECARE project

This paper describes the usage and the performance evaluation of the completeness index method in the ‘Surveillance of Rare Cancers in Europe project’ (RARECARE) for estimating rare cancer prevalence in Europe. The 15-year prevalence at 1st January 2003 for 255 cancers is obtained from a pool of 22 RARECARE cancer registries (CRs). Incidence and survival models are applied to the RARECARE database to estimate the parameters from which the completeness indices are calculated. Complete prevalence is obtained adjusting the observed 15-year prevalence by the completeness index, to account for those cancer survivors diagnosed before the CR activity started. Main factors influencing the performance of the completeness index method for rare cancers are the same as for common cancers: age distribution of incidence and lethality of the cancer. For cancers occurring in the elderly, with low survival rates and consequently a restricted number of long-term survivors we obtained completeness indices higher than 0.9. Values lower than 0.7 correspond to those cancers with good prognosis and/or incidence more concentrated at the younger ages, indicating that 15 years of follow up are insufficient to detect all prevalent cases. Validation analysis shows that for a restricted subgroup of rare cancers with very low incidence and low survival, the completeness indices were not able to adequately correct the observed prevalence even considering a registration period of 20 years. On average, sensitivity analyses show a slight overestimation of complete prevalence for rare and common cancers whose increasing incidence is known in literature. RARECARE is the largest project on rare cancers conducted to date. Improving health care programs for cancer survivors is a public health priority and prevalence data which provides important information in this field should be regularly asked to Member States and included in the EU health statistics.     

Quality of Pharmaceutical Care in Surgical Patients

Background

Surgical patients are at risk for preventable adverse drug events (ADEs) during hospitalization. Usually, preventable ADEs are measured as an outcome parameter of quality of pharmaceutical care. However, process measures such as QIs are more efficient to assess the quality of care and provide more information about potential quality improvements.

Objective

To assess the quality of pharmaceutical care of medication-related processes in surgical wards with quality indicators, in order to detect targets for quality improvements.

Methods

For this observational cohort study, quality indicators were composed, validated, tested, and applied on a surgical cohort. Three surgical wards of an academic hospital in the Netherlands (Academic Medical Centre, Amsterdam) participated. Consecutive elective surgical patients with a hospital stay longer than 48 hours were included from April until June 2009. To assess the quality of pharmaceutical care, the set of quality indicators was applied to 252 medical records of surgical patients.

Results

Thirty-four quality indicators were composed and tested on acceptability and content- and face-validity. The selected 28 candidate quality indicators were tested for feasibility and ‘sensitivity to change’. This resulted in a final set of 27 quality indicators, of which inter-rater agreements were calculated (kappa 0.92 for eligibility, 0.74 for pass-rate). The quality of pharmaceutical care was assessed in 252 surgical patients. Nearly half of the surgical patients passed the quality indicators for pharmaceutical care (overall pass rate 49.8%). Improvements should be predominantly targeted to medication care related processes in surgical patients with gastro-intestinal problems (domain pass rate 29.4%).

Conclusions

This quality indicator set can be used to measure quality of pharmaceutical care and detect targets for quality improvements. With these results medication safety in surgical patients can be enhanced.     

Measures of Quality of Care for People with HIV: A Scoping Review of Performance Indicators for Primary Care

The healthcare of people with HIV is transitioning from specialty care to the primary healthcare (PHC) system. However, many of the performance indicators used to measure the quality of HIV care pre-date this transition. The goal of this work was to examine how existing HIV care performance indicators measure the comprehensive and longitudinal care offered in a PHC setting. A scoping review consisting of peer-reviewed and grey literature searches was performed. Two reviewers evaluated study eligibility and indicators in documents meeting inclusion criteria were extracted into a database. Indicators were matched to a PHC performance measurement framework to determine their applicability for evaluating quality of care in the PHC setting. The literature search identified 221 publications, of which 47 met inclusion criteria. 1184 indicators were extracted and removal of duplicates left 558 unique indicators. A majority of the 558 indicators fell under the ‘secondary prevention’ (12%) and ‘care of chronic conditions’ (33%) domains when indicators were matched to the PHC performance framework. Despite the imbalance, nearly all performance domains in the PHC framework were populated by at least one indicator with significant concentrations in domains such as patient-provider relationship, patient satisfaction, population and community characteristics, and access to care. Existing performance frameworks for the care of people with HIV provide a comprehensive set of indicators that align well with a PHC performance framework. Nonetheless, some important elements of care, such as patient-reported outcomes, are poorly covered by existing indicators. Advancing our understanding of how the experience of care for people with HIV is impacted by changes in health services delivery, specifically more care within the PHC system, will require performance indicators to capture this aspect of HIV care.     

Indicatoren voor kwaliteit van zorg. Wie worden er wijzer van, de patiënten of de managers?

In the Netherlands and abroad detailed indicators are developed to measure quality of care for a variety of treatments and care systems. These days the development of quality indicators is a profession and business in itself. The significance of these indicators is often not related to the primary care process, but based on (administrative) data for 'quality management'. The consequence is a gap between 'real' and 'measured' quality of care. Improvement in quality of care is therefore problematic. There is a need to return to the essence of care, i.e. the patient and the care professional, to develop appropriate indicators for quality of care.     

Expressions of ER,PR, HER-2, COX-2, and VEGF in Primary and Relapsed/Metastatic Breast Cancers

In the present study, we evaluated expressions of estrogen receptor (ER), progestin receptor (PR), human epidermal growth factor receptor-2 (HER-2), cyclooxygenase-2 (COX-2), and vascular endothelial growth factor (VEGF) in primary and relapsed/metastatic breast cancers to elucidate the clinical significance of these markers. The markers were evaluated by immunohistochemistry in specimens of 50 patients with primary or metastatic breast cancer. Positive rates of ER were significantly (p = 0.002) higher in primary versus relapsed/metastatic breast cancer (70 vs. 38 %, respectively). The VEGF positive expression rates were also significantly higher in primary versus metastatic cancer (82 vs. 38 %, respectively; p < 0.001). By contrast, positive rates of HER-2 and COX-2 were not significantly different between different types of cancer. COX-2 correlated with HER-2 expression in both primary and relapsed/metastatic focuses of breast cancer. COX-2 also correlated with VEGF expression in primary breast cancer. Expressions of ER, PR, HER2, and COX-2 did not correlate between primary and relapsed/metastatic breast cancers, indicating that the treatment decision should be made according to the status of these markers in relapsed/metastatic focuses. The total change rates of ER, PR, HER-2, COX-2, and VEGF were 26, 18, 10, 30, and 58 %, respectively. In conclusion, HER-2 and COX-2, along with VEGF, appear to play a role in the development and progression of breast cancer. In addition, all of the studied markers may serve as indicators of prognosis.     

Indicators of quality of care for patients with acute myocardial infarction

Background

There is a wide practice gap between optimal and actual care for patients with acute myocardial infarction in hospitals around the world. We undertook this initiative to develop an updated set of evidence-based indicators to measure and improve the quality of care for this patient population.

Methods

A 12-member expert panel was convened in 2007 to develop an updated set of quality indicators for acute myocardial infarction. The panel identified a list of potential indicators after reviewing the scientific literature, clinical practice guidelines and other published quality indicators. To develop the new list of indicators, the panel rated each potential indicator on 4 dimensions (reliability, validity, feasibility and usefulness in improving patient outcomes) and discussed the top-ranked quality indicators at a consensus meeting.

Results

Consensus was reached on 38 quality indicators: 17 that would be measurable using chart-abstracted data and 21 that would be measurable using administrative data. Of the 17 chart-review indicators, 13 address pharmacologic and nonpharmacologic care delivered to patients in hospital. In-hospital mortality was recommended as a key outcome indicator. Three system indicators were recommended to measure the collaborative responsiveness of the health care system from the call for help to intervention. It was recommended that hospitals strive for a minimum target benchmark of 90% or greater on process-of-care indicators.

Interpretation

Implementation of strategies by clinicians and hospitals to meet target benchmarks on these quality indicators could save the lives of many individuals with acute myocardial infarction.There is a large practice gap between optimal and actual patterns of care for patients with acute myocardial infarction in hospitals around the world.¹ Acute myocardial infarction is a highly treatable condition for which many advances in treatment have occurred over the past several decades. However, the uptake of many of these advances and their incorporation into routine clinical practice has often lagged behind their development and publication in clinical journals by many years.^2–4 To reduce this gap and improve quality of care, many jurisdictions are using indicators of the quality of care for patients with acute myocardial infarction. These quality indicators are intended to measure adherence to selected key clinical practice guidelines in routine clinical care and serve as a foundation for efforts to improve quality.⁵ They define the minimum standard of care that might be expected for all “ideal” patients who meet certain criteria and have no contraindications for a given health care intervention.National organizations in Canada, the United States, the United Kingdom and other OECD (the Organisation for Economic Co-operation and Development) countries have all developed indicators to measure and improve the quality of care for patients with acute myocardial infarction both within and across countries, regions and hospitals.^6–9 In 2003, the Canadian Cardiovascular Outcomes Research Team (a Canadian Institutes of Health Research Interdisciplinary Health Research Team) worked in association with the Canadian Cardiovascular Society to develop and publish the first set of quality indicators for myocardial infarction in Canada.⁶ The Canadian Cardiovascular Outcomes Research Team comprises more than 30 leading outcome researchers who work together on projects to measure and improve cardiac care. From the outset, we recognized that the indicators would need to be modified over time to reflect changes in practice guidelines and clinical evidence. In 2007, a Canadian expert panel was convened by the Canadian Cardiovascular Outcomes Research Team to develop and recommend a set of quality indicators that took into account the best indicators developed elsewhere and that also included some unique indicators that were felt to be of particular relevance and use to Canadian clinicians and hospitals.     

Time-to-cure and cure proportion in solid cancers in France. A population based study

BackgroundIn cancer care, the cure proportion (P) and time-to-cure (TTC) are important indicators for practitioners, patients, and healthcare policy makers. The recent definition of TTC as the time at which the probability of belonging to the cured group reaches 95% was used for the first time.MethodsThe data stem from the common database of French cancer registries including 335,358 solid tumours diagnosed between 1995 and 2009 at 27 sites. P and TTC were estimated through a flexible parametric net survival cure model for each cancer site, sex, and age at diagnosis with acceptable assumption of cure (excess mortality rate ≤0.05).ResultsTTC was ≤5 years and P was >80% for skin melanoma and thyroid and testis cancers. It was 0 for testis cancer in men <55 and for thyroid cancer in men <45 and women <65. TTC was between 5 and 10 years for all digestive cancers except small intestine and all gynaecologic cancers except breast. It was ≥10 years in prostate, breast, and urinary tract. The range of P according to age and sex was 37–79% for urinary tract 72–88% for prostate and breast, 4–16% for pancreatic and 47–62% for colorectal cancer.ConclusionTime-to-cure was estimated for the first time from a large national database and individual probabilities of cure. It was 0 in the younger patients with testis or thyroid cancer and <12 years in most cancer sites. These results should help improve access to credit and insurance for patients still alive past the estimated TTCs.     

Assessing Coverage,Equity and Quality Gaps in Maternal and Neonatal Care in Sub-Saharan Africa: An Integrated Approach

BackgroundGaps in coverage, equity and quality of health services hinder the achievement of the Millennium Development Goals 4 and 5 in most countries of sub-Saharan Africa as well as in other high-burden countries, yet few studies attempt to assess all these dimensions as part of the situation analysis. We present the base-line data of a project aimed at simultaneously addressing coverage, equity and quality issues in maternal and neonatal health care in five districts belonging to three African countries.MethodsData were collected in cross-sectional studies with three types of tools. Coverage was assessed in three hospitals and 19 health centres (HCs) utilising emergency obstetric and newborn care needs assessment tools developed by the Averting Maternal Death and Disability program. Emergency obstetrics care (EmOC) indicators were calculated. Equity was assessed in three hospitals and 13 HCs by means of proxy wealth indices and women delivering in health facilities were compared with those in the general population to identify inequities. Quality was assessed in three hospitals using the World Health Organization’s maternal and neonatal quality of hospital care assessment tool which evaluates the whole range of aspects of obstetric and neonatal care and produces an average score for each main area of care.ResultsAll the three hospitals qualified as comprehensive EmOC facilities but none of the HCs qualified for basic EmOC. None of the districts met the minimum requisites for EmOC indicators. In two out of three hospitals, there were major quality gaps which were generally greater in neonatal care, management of emergency and complicated cases and monitoring. Higher access to care was coupled by low quality and good quality by very low access. Stark inequities in utilisation of institutional delivery care were present in all districts and across all health facilities, especially at hospital level.ConclusionOur findings confirm the existence of serious issues regarding coverage, equity and quality of health care for mothers and newborns in all study districts. Gaps in one dimension hinder the potential gains in health outcomes deriving from good performances in other dimensions, thus confirm the need for a three-dimensional profiling of health care provision as a basis for data-driven planning.     

What is the quality of quality of medical care measures? Rashomon-like relativism and real-world applications

Much attention has been directed toward the measurement of health outcomes and the quality of medical care. Some policymakers tout outcomes measurement as a promising tool for improving health care, while others question whether current quality of care assessment is valid and of practical importance. Although significant advances have been made in the ability to measure quality of care with validity, several major methodological challenges remain. We analyze the quality of quality of medical care measures, using a conceptual framework that outlines the purpose of the measures; paradigms of the quality of care, including Donabedian's structure-process-outcome model and continuous quality improvement; and other key elements, such as scope, time, unit of analysis, and perspectives. Patient preferences and organizational contexts have been underemphasized, and should be incorporated into the framework for conceptualizing quality of care. Quality of care has relativistic and dynamic aspects. Different perspectives lead to different views of what high quality care is, and quality of care is a changing concept since medical science and treatment are constantly evolving. The most appropriate quality measures depend upon whose perspective one takes and the purpose of the measures; if the measures are chosen wisely, the current state of quality of medical care measurement is adequate for both accountability and quality improvement.     

Many colorectal cancers are “flat” clonal expansions

Population geneticists can reconstruct the ancestries of macroscopic populations from polymorphisms in present day individuals. For example, the migration “out of Africa” is recorded in human genome variation in different parts of the world. Here we apply this approach to human colorectal cancer cell populations and polymorphic passenger methylation patterns. By sampling molecular variation from different parts of the same cancer, it should be possible to infer how individual tumors grow because recent clonal expansions should be less diverse than older expansions. Average diversity was different between cancers implying that some cancers are older clonal expansions than others. For individual cancers, methylation pattern diversity was relatively uniform throughout the tumor (right versus left side, superficial versus invasive), which is more consistent with a single, uniform or “flat” clonal expansion than with stepwise sequential progression. Many colorectal cancers appear to invade and expand early, but subsequently stall. Epiallele diversity within individual small cancer gland fragments was high and more consistent with frequent rather than extremely rare cancer stem cells (CSCs). These studies suggest that many human colorectal cancers are relatively old uniform clonal expansions, that cancer cell populations contain frequent long-lived CSC lineages, and that some passenger methylation patterns record somatic cell ancestry.     

Monitoring Intervention Coverage in the Context of Universal Health Coverage

Monitoring universal health coverage (UHC) focuses on information on health intervention coverage and financial protection. This paper addresses monitoring intervention coverage, related to the full spectrum of UHC, including health promotion and disease prevention, treatment, rehabilitation, and palliation. A comprehensive core set of indicators most relevant to the country situation should be monitored on a regular basis as part of health progress and systems performance assessment for all countries. UHC monitoring should be embedded in a broad results framework for the country health system, but focus on indicators related to the coverage of interventions that most directly reflect the results of UHC investments and strategies in each country. A set of tracer coverage indicators can be selected, divided into two groups—promotion/prevention, and treatment/care—as illustrated in this paper. Disaggregation of the indicators by the main equity stratifiers is critical to monitor progress in all population groups. Targets need to be set in accordance with baselines, historical rate of progress, and measurement considerations. Critical measurement gaps also exist, especially for treatment indicators, covering issues such as mental health, injuries, chronic conditions, surgical interventions, rehabilitation, and palliation. Consequently, further research and proxy indicators need to be used in the interim. Ideally, indicators should include a quality of intervention dimension. For some interventions, use of a single indicator is feasible, such as management of hypertension; but in many areas additional indicators are needed to capture quality of service provision. The monitoring of UHC has significant implications for health information systems. Major data gaps will need to be filled. At a minimum, countries will need to administer regular household health surveys with biological and clinical data collection. Countries will also need to improve the production of reliable, comprehensive, and timely health facility data. Please see later in the article for the Editors'' Summary

Summary Points

• Monitoring universal health coverage (UHC) should be integral to overall tracking of health progress and performance, which requires regular assessment of health system inputs (finances, health workforce, and medicines), outputs (service provision), coverage of interventions, and health impacts, as well as the social determinants of health.
• Within this overall context, we propose that UHC monitoring focus on financial protection and intervention coverage indicators, with a strong equity focus. This paper focuses on intervention coverage.
• Progress towards UHC should be tracked using tracer intervention coverage indicators selected on the basis of objective considerations and designed to keep the numbers of indicators small and manageable while covering a range of health interventions to capture the essence of the UHC goal.
• Since UHC is about progressive realization and countries differ in epidemiology, health systems, socioeconomic development, and people''s expectations, the indicator sets will not be the same everywhere.
• Coverage indicators should cover promotion and prevention, as well as treatment, rehabilitation, and palliation. While there are several suitable indicators for the first two, there are major gaps for coverage indicators of treatment, as population need for treatment is difficult to measure.
• A small set of well-established international intervention tracer coverage indicators can be identified for monitoring UHC. Where no good indicators are currently available, proxy indicators and equity analysis of service utilization can provide some insights.
• Special attention needs to be paid to quality of services, either through the tracer indicator itself (referred to as effective coverage) or through additional indicators on quality of services or health impact of the intervention.
• Targets should be set in accordance with baseline, historical rate of progress, and measurement considerations.
• The main data sources of intervention coverage indicators are household surveys and health facility reports. Investments in both are needed to improve the ability of countries to monitor progress towards UHC.
• It is essential to find effective ways of communicating progress towards UHC in ways that are meaningful to the general public and that capture the attention of policy makers.

This paper is part of the PLOS Universal Health Coverage Collection.

     

Environmental Health Indicators in New Zealand: Drinking Water—A Case Study

This study examines and quantifies the linkages between population health, environmental risks, and its determinants for drinking water in New Zealand using routinely collected data. It was conducted as part of the national environmental health indicators project in New Zealand. The project is based on the World Health Organization’s (WHO) “Environmental and Health Information System” program. Drinking water quality indicators based on the Driving force–Pressure–State–Exposure–Effect–Action (DPSEEA) framework as part of this program were analyzed to validate the model by quantifying the linkages between the indicators. The results of the model suggested over the study period, the state (drinking water quality) and exposure (water access) indicators are significant independent predictors of the effect indicator (waterborne disease rate). This study suggests that routinely collected data can be structured using the DPSEEA framework and tested quantitatively using standard Poisson regression models, thus, illustrating that the model can be used routinely to provide a basis for consideration of the costs and benefits of any interventions to reduce the burden of waterborne disease. Data quality issues need to be considered if such routinely collected data linkages are to be performed for policy purposes. The online version of this article (doi:) contains electronic supplementary material, which is available to authorized users. Supplemental histograms are available in the online appendix.     

Evidence-based maatwerk voor ouderen met kanker

Cancer is a disease that disproportionately affects the elderly. Evidence-based treatment is the golden standard of current medical care, and this is also true for older cancer patients. In developing guidelines, all available evidence is collected, appraised and summarized. Subsequent recommendations are then translate to criteria used to judge the quality of care. The heterogeneity of the elderly population requires tailoring of care, which is the opposite of the often strictly formulated treatment recommendations in guidelines and protocols. This paper discusses several issues regarding evidence based treatment versus tailored care for older cancer patients.     

国内外心力衰竭治疗质量评价的研究现状

心力衰竭是世界主要的公共卫生问题之一,庞大的心力衰竭患者消耗着大量的医疗资源。近几十年,世界各国专家越来越关注心力衰竭的治疗质量,评价治疗质量已成为医疗体制改革的一项措施。通过总结国内外心力衰竭治疗质量评价的组织机构、评价指标、治疗质量改善项目及有关评价研究,探讨我国心力衰竭治疗质量评价与国外的差距,针对出现的问题,提出相应的建议,为改善我国心力衰竭的治疗质量提供新思路。