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Objective
To develop person-centered episodes of care (PCE) for community-dwelling individuals in the top fifth percentile of Ontario health care expenditures in order to: (1) describe the main clinical groupings for spending; and (2) identify patterns of spending by health sector (e.g. acute care, home care, physician billings) within and across PCE.Data sources
Data were drawn from population-based administrative databases for all publicly funded health care in Ontario, Canada in 2010/11.Study design
This study is a retrospective cohort study.Data collection/extraction methods
A total of 587,982 community-dwelling individuals were identified among those accounting for the top 5% of provincial health care expenditures between April 1, 2010 and March 31, 2011. PCE were defined as starting with an acute care admission and persisting through subsequent care settings and providers until individuals were without health system contact for 30 days. PCE were classified according to the clinical grouping for the initial admission. PCE and non-PCE costs were calculated and compared to provide a comprehensive measurement of total health system costs for the year.Principal findings
Among this community cohort, 697,059 PCE accounted for nearly 70% ($11,815.3 million (CAD)) of total annual publicly-funded expenditures on high-cost community-dwelling individuals. The most common clinical groupings to start a PCE were Acute Planned Surgical (35.2%), Acute Unplanned Medical (21.0%) and Post-Admission Events (10.8%). Median PCE costs ranged from $3,865 (IQR = $1,712-$10,919) for Acute Planned Surgical to $20,687 ($12,207-$39,579) for Post-Admission Events. Inpatient acute ($8,194.5 million) and inpatient rehabilitation ($434.6 million) health sectors accounted for the largest proportions of allocated PCE spending over the year.Conclusions
Our study provides a novel methodological approach to categorize high-cost health system users into meaningful person-centered episodes. This approach helps to explain how costs are attributable within individuals across sectors and has applications in episode-based payment formulas and quality monitoring. 相似文献3.
David M. Bishai Robert Cohen Y. Natalia Alfonso Taghreed Adam Shyama Kuruvilla Julian Schweitzer 《PloS one》2016,11(1)
Introduction
From 1990–2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change.Methods
This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data.Findings
The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector.Conclusions
Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors. 相似文献4.
Peter Tanuseputro Walter P. Wodchis Rob Fowler Peter Walker Yu Qing Bai Sue E. Bronskill Douglas Manuel 《PloS one》2015,10(3)
Background
Coordinated and appropriate health care across sectors is an ongoing challenge, especially at the end-of-life. Population-level data on end-of-life health care use and cost, however, are seldom reported across a comprehensive array of sectors. Such data will identify the level of care being provided and areas where care can be optimized.Methods
This retrospective cohort study identified all deaths in Ontario from April 1, 2010 to March 31, 2013. Using population-based health administrative databases, we examined health care use and cost in the last year of life.Results
Among 264,755 decedents, the average health care cost in the last year of life was $53,661 (Quartile 1-Quartile 3: $19,568-$66,875). The total captured annual cost of $4.7 billion represents approximately 10% of all government-funded health care. Inpatient care, incurred by 75% of decedents, contributed 42.9% of total costs ($30,872 per user). Physician services, medications/devices, laboratories, and emergency rooms combined to less than 20% of total cost. About one-quarter used long-term-care and 60% used home care ($34,381 and $7,347 per user, respectively). Total cost did not vary by sex or neighborhood income quintile, but were less among rural residents. Costs rose sharply in the last 120 days prior to death, predominantly for inpatient care.Interpretation
This analysis adds new information about the breadth of end-of-life health care, which consumes a large proportion of Ontario’s health care budget. The cost of inpatient care and long-term care are substantial. Introducing interventions that reduce or delay institutional care will likely reduce costs incurred at the end of life. 相似文献5.
Benjawan Apinonkul Kusol Soonthorndhada Patama Vapattanawong Wichai Aekplakorn Carol Jagger 《PloS one》2015,10(3)
Objectives
To estimate health expectancies based on measures that more fully cover the stages in the disablement process for the older Thais and examine gender differences in these health expectancies.Methods
Health expectancies by genders using Sullivan’s method were computed from the fourth Thai National Health Examination Survey conducted in 2009. A total of 9,210 participants aged 60 years and older were included in the analysis. Health measures included chronic diseases; cognitive impairment; depression; disability in instrumental activities of daily living (IADL); and disability in activities of daily living (ADL).Results
The average number of years lived with and without morbidity and disability as measured by multiple dimensions of health varied and gender differences were not consistent across measures. At age 60, males could expect to live the most years on average free of depression (18.6 years) and ADL disability (18.6 years) and the least years free of chronic diseases (9.1 years). Females, on the contrary, could expect to live the most years free of ADL disability (21.7 years) and the least years free of IADL disability (8.1 years), and they consistently spent more years with all forms of morbidity and disability. Finally, and for both genders, years lived with cognitive impairment, depression and ADL disability were almost constant with increasing age.Conclusion
This study adds knowledge of gender differences in healthy life expectancy in the older Thai population using a wider spectrum of health which provides useful information to diverse policy audiences. 相似文献6.
Background
Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits.Objectives
We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events.Methods
This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events.Results
The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively.Conclusions
The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively. 相似文献7.
Karen E. Peterson Jennifer L. Spadano-Gasbarro Mary L. Greaney S. Bryn Austin Solomon Mezgebu Anne T. Hunt Emily A. Blood Chrissy Horan Henry A. Feldman Stavroula K. Osganian Maria F. Bettencourt Tracy K. Richmond 《PloS one》2015,10(8)
Introduction
Few dissemination evaluations exist to document the effectiveness of evidence-based childhood obesity interventions outside the research setting.Objective
Evaluate Healthy Choices (HC), a multi-component obesity prevention program, by examining school-level changes in weight-related behaviors and weight status and the association of implementation components with odds of overweight/obesity.Methods
We compared baseline and Year 3 school-level behavioral and weight status outcomes with paired t-tests adjusted for schools’ socio-demographic characteristics. We used generalized estimating equations to examine the odds of overweight/obesity associated with program components.Setting/Participants
Consecutive sample of 45 of 51 middle schools participating in the HC program with complete baseline and follow-up survey data including a subsample of 35 schools with measured anthropomentry for 5,665 7th grade students.Intervention
Schools developed a multi-disciplinary team and implemented an obesity prevention curriculum, before and after school activities, environmental and policy changes and health promotions targeting a 5-2-1 theme: eat ≥ 5 servings/day of fruits and vegetables (FV), watch ≤ 2 hours of television (TV) and participate in ≥ 1 hours/day of physical activity (PA) on most daysMain Outcome Measures
1) School-level percent of students achieving targeted behaviors and percent overweight/obese; and 2) individual odds of overweight/obesity.Results
The percent achieving behavioral goals over three years increased significantly for FV: 16.4 to 19.4 (p = 0.001), TV: 53.4 to 58.2 (p = 0.003) and PA: 37.1 to 39.9 (p = 0.02), adjusting for school size, baseline mean age and percent female, non-Hispanic White, and eligible for free and reduced price lunch. In 35 schools with anthropometry, the percent of overweight/obese 7th grade students decreased from 42.1 to 38.4 (p = 0.016). Having a team that met the HC definition was associated with lower odds of overweight/obesity (OR = 0.83, CI: 0.71–0.98).Conclusions and Relevance
The HC multi-component intervention demonstrated three-year improvements in weight-related behaviors and weight status across diverse middle schools. Team building appears important to the program’s effectiveness. 相似文献8.
Background
Inappropriate overuse of antibiotics contributes to antimicrobial resistance (AMR), yet policy implementation to reduce inappropriate antibiotic use is poor in low and middle-income countries.Aims
To determine whether public sector inappropriate antibiotic use is lower in countries reporting implementation of selected essential medicines policies.Materials and Methods
Results from independently conducted antibiotic use surveys in countries that did, and did not report implementation of policies to reduce inappropriate antibiotic prescribing, were compared. Survey data on four validated indicators of inappropriate antibiotic use and 16 self-reported policy implementation variables from WHO databases were extracted. The average difference for indicators between countries reporting versus not reporting implementation of specific policies was calculated. For 16 selected policies we regressed the four antibiotic use variables on the numbers of policies the countries reported implementing.Results
Data were available for 55 countries. Of 16 policies studied, four (having a national Ministry of Health unit on promoting rational use of medicines, a national drug information centre and provincial and hospital drugs and therapeutics committees) were associated with statistically significant reductions in antibiotic use of ≥20% in upper respiratory infection (URTI). A national strategy to contain antibiotic resistance was associated with a 30% reduction in use of antibiotics in acute diarrheal illness. Policies seemed to be associated with greater effects in antibiotic use for URTI and diarrhea compared with antibiotic use in all patients. There were negative correlations between the numbers of policies reported implemented and the percentage of acute diarrhoea cases treated with antibiotics (r = -0.484, p = 0.007) and the percentage of URTI cases treated with antibiotics (r = -0.472, p = 0.005). Major study limitations were the reliance on self-reported policy implementation data and antibiotic use data from linited surveys.Conclusions
Selected essential medicines policies were associated with lower antibiotic use in low and middle income countries. 相似文献9.
Background
A growing body of research has confirmed that workplace bullying is a source of distress and poor mental health. Here we summarize the cross-sectional and longitudinal literature on these associations.Methods
Systematic review and meta-analyses on the relation between workplace bullying and mental health.Results
The cross-sectional data (65 effect sizes, N = 115.783) showed positive associations between workplace bullying and symptoms of depression (r = .28, 95% CI = .23–.34), anxiety (r = .34, 95% CI = .29–.40) and stress-related psychological complaints (r = .37, 95% CI = .30–.44). Pooling the literature that investigated longitudinal relationships (26 effect sizes, N = 54.450) showed that workplace bullying was related to mental health complaints over time (r = 0.21, 95% CI = 0.13–0.21). Interestingly, baseline mental health problems were associated with subsequent exposure to workplace bullying (r = 0.18, 95% CI = 0.10–0.27; 11 effect sizes, N = 27.028).Limitations
All data were self-reported, raising the possibility of reporting- and response set bias.Conclusions
Workplace bullying is consistently, and in a bi-directional manner, associated with reduced mental health. This may call for intervention strategies against bullying at work. 相似文献10.
Christophe R. Legendre Michael J. Demeure Timothy G. Whitsett Gerald C. Gooden Kimberly J. Bussey Sungwon Jung Tembe Waibhav Seungchan Kim Bodour Salhia 《PloS one》2016,11(3)
Context
Adrenocortical carcinomas (ACC) are a rare tumor type with a poor five-year survival rate and limited treatment options.Objective
Understanding of the molecular pathogenesis of this disease has been aided by genomic analyses highlighting alterations in TP53, WNT, and IGF signaling pathways. Further elucidation is needed to reveal therapeutically actionable targets in ACC.Design
In this study, global DNA methylation levels were assessed by the Infinium HumanMethylation450 BeadChip Array on 18 ACC tumors and 6 normal adrenal tissues. A new, non-linear correlation approach, the discretization method, assessed the relationship between DNA methylation/gene expression across ACC tumors.Results
This correlation analysis revealed epigenetic regulation of genes known to modulate TP53, WNT, and IGF signaling, as well as silencing of the tumor suppressor MARCKS, previously unreported in ACC.Conclusions
DNA methylation may regulate genes known to play a role in ACC pathogenesis as well as known tumor suppressors. 相似文献11.
Xinfeng Tang Fahui Yang Tan Tang Xuemei Yang Weijun Zhang Xiaohua Wang Li Ji Yun Xiao Kun Ma Ying Wang Xianglei Kong Jianping Wang Jun Liu Qian Xu Donghua Tian Zhiyong Qu 《PloS one》2015,10(9)
Background
The delivery of mental health services in rural China has been notably limited due to lack of qualified mental health professionals among other impeding factors. A village doctor-based cognitive behavioral therapy intervention may be one way of improving accessibility. The purpose of this study was to explore the advantages and challenges of implementing this intervention, as delivered by trained village doctors, to treat late-life depression in rural China.Methods
We conducted one focus group discussion with 10 village doctors, 10 individual interviews with each of the village doctors, and individual interviews with 19 older adults. The topic guides were advantages and challenges of the intervention program from the perspective of the village doctors and older adults. Interviews were audio-recorded, transcribed, coded using NVivo 8, and analyzed using thematic analysis.Results
The village doctors stressed the importance of role-playing and using instructive manuals in the training. Proper supervision was also a key component of the program. The benefits received from the intervention for the village doctors and the elders were positive such that both the doctors and the older adults were willing to implement/receive this intervention. Cultural and political factors (renqing and perceived policy consideration) facilitated the elders’ access to mental health services. Challenges included a lack of real therapy (in contrast to role-playing) demonstrated in the training and lack of a step-by-step manual based on different types of problems encountered. Other impediments to the successful implementation of the intervention included the time constraints of village doctors and the presence of other people when conducting the intervention.Conclusions
The present study has demonstrated that the intervention program is likely to be an acceptable geriatric depression intervention in rural China if several challenges are appropriately addressed. 相似文献12.
Maria Valkonen Inge M. Wouters Martin T?ubel Helena Rintala Virissa Lenters Ritva Vasara Jon Genuneit Charlotte Braun-Fahrl?nder Renaud Piarroux Erika von Mutius Dick Heederik Anne Hyv?rinen 《PloS one》2015,10(6)
Background
The increase in prevalence of asthma and atopic diseases in Western countries has been linked to aspects of microbial exposure patterns of people. It remains unclear which microbial aspects contribute to the protective farm effect.Objective
The objective of this study was to identify bacterial groups associated with prevalence of asthma and atopy, and to quantify indoor exposure to some of these bacterial groups.Methods
A DNA fingerprinting technique, denaturing gradient gel electrophoresis (DGGE), was applied to mattress dust samples of farm children and control children in the context of the GABRIEL Advanced study. Associations between signals in DGGE and atopy, asthma and other allergic health outcomes were analyzed. Quantitative DNA based assays (qPCR) for four bacterial groups were applied on the dust samples to seek quantitative confirmation of associations indicated in DNA fingerprinting.Results
Several statistically significant associations between individual bacterial signals and also bacterial diversity in DGGE and health outcomes in children were observed. The majority of these associations showed inverse relationships with atopy, less so with asthma. Also, in a subsequent confirmation study using a quantitative method (qPCR), higher mattress levels of specifically targeted bacterial groups - Mycobacterium spp., Bifidobacteriaceae spp. and two different clusters of Clostridium spp. - were associated with a lower prevalence of atopy.Conclusion
DNA fingerprinting proved useful in identifying bacterial signals that were associated with atopy in particular. These findings were quantitatively confirmed for selected bacterial groups with a second method. High correlations between the different bacterial exposures impede a clear attribution of protective effects to one specific bacterial group. More diverse bacterial flora in mattress dust may link to microbial exposure patterns that protect against development of atopic diseases. 相似文献13.
Amy Corneli Samuel Field Emily Namey Kawango Agot Khatija Ahmed Jacob Odhiambo Joseph Skhosana Greg Guest 《PloS one》2015,10(6)
Introduction
Several clinical trials have demonstrated the efficacy of pre-exposure prophylaxis (PrEP) in reducing HIV risk. One concern with introducing PrEP is whether users will engage in riskier sexual behaviors.Methods
We assessed the effect that PrEP may have on sexual risk behaviors by administering a survey to 799 women in Bondo, Kenya, and Pretoria, South Africa. Participants were asked about their sexual behavior intentions twice — once as if they were taking PrEP and once as if they were not taking PrEP — within four risk situations (vignettes). They responded using a 5-point ordinal scale. We used a series of linear mixed effects models with an unstructured residual covariance matrix to estimate the between- and within-subject differences in the mean likelihood of engaging in risky sexual behavior across the PrEP and non-PrEP contexts. We also calculated the total percentage of participants who reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP, by vignette.Results
We found statistically significant differences in the mean likelihood of engaging in risky sexual behavior with the between-subject comparison (-0.17, p < 0.01) and with the within-subject comparison (-0.31, p < 0.001). Depending on the vignette, 27% to 40% of participants reported a greater likelihood of engaging in risky sexual behavior if taking PrEP than if not taking PrEP.Conclusions
Our findings indicate that modest increases in risky sexual behavior could occur with PrEP. Although responses from the majority of participants suggest they would not be more likely to engage in risky sexual behavior if they took PrEP, a substantial proportion might. Programs rolling out PrEP should be prepared to assist similar women in making informed choices about reducing their risk of HIV and about their sexual health beyond HIV prevention. 相似文献14.
Background
To integrate immigrants into their societies, European countries have adopted different types of policies, which may influence health through both material and psychosocial determinants. Recent studies have suggested poorer health outcomes for immigrants living in countries with poorly rated integration policies.Objective
To analyse mortality differences of immigrants from the same country of origin living in countries with distinct integration policy contexts.Methods
From the mortality dataset collected in the Migrant Ethnic Health Observatory (MEHO) project, we chose the Netherlands (linked data from 1996-2006), France (unlinked; 2005-2007) and Denmark (linked; 1992-2001) as representatives of the inclusive, assimilationist and exclusionist policy models, respectively, based on the Migrant Integration Policy Index. We calculated for each country sex- and age-standardized mortality rates for Turkish-, Moroccan- and local-born populations aged 20-69 years. Poisson regression was used to estimate the mortality rate ratios (MRRs) for cross-country and within-country comparisons. The analyses were further stratified by age group and cause of death.Results
Compared with their peers in the Netherlands, Turkish-born immigrants had higher all-cause mortality in Denmark (MRR men 1.92; 95% CI 1.74-2.13 and women 2.11; 1.80-2.47) but lower in France (men 0.64; 0.59-0.69 and women 0.58; 0.51-0.67). A similar pattern emerged for Moroccan-born immigrants. The relative differences between immigrants and the local-born population were also largest in Denmark and lowest in France (e.g., Turkish-born men MRR 1.52; 95% CI 1.38-1.67 and 0.62; 0.58-0.66, respectively). These patterns were consistent across all age groups, and more marked for cardiovascular diseases.Conclusions
Although confounders and data comparability issues (e.g., French cross-sectional data) may affect the findings, this study suggests that different macro-level policy contexts may influence immigrants’ mortality. Comparable mortality registration systems across Europe along with detailed socio-demographic information on immigrants may help to better assess this association. 相似文献15.
Objectives
This study examines whether belief in the food addiction construct is associated with support for obesity-related policies (e.g., restrictions on foods served in schools and workplace cafeterias, subsidies on fruits and vegetables), while simultaneously examining other factors associated with policy support (e.g., political party affiliation).Design
Cross-sectional.Setting
Online Community.Participants
200 individuals were recruited through Amazon Mechanical Turk.Measurements
Participants (n = 193) responded to three questions about belief in food addiction and a measure evaluating support for 13 obesity-related policy initiatives. Individuals also completed the modified Yale Food Addiction Scale (mYFAS), self-reported height and weight, and provided demographic information (age, gender, race, political party affiliation).Results
Belief in food addiction was significantly associated with greater support for obesity-related initiatives, even when accounting for the significant associations of age, gender, and political party. Belief in food addiction and political party both had moderate effect sizes for predicting support for obesity-related policy. There was an interaction between age and belief in food addiction, with significant associations with policy support for both younger and older individuals, though the effect was larger for younger participants.Conclusion
The current study provides evidence that belief in food addiction is associated with increased obesity-related policy support, comparable to the influence of one’s political party. Growing evidence for the role of an addictive process in obesity may have important implications for public support of obesity-related policy initiatives. 相似文献16.
Ana Fernandez John Black Mairwen Jones Leigh Wilson Luis Salvador-Carulla Thomas Astell-Burt Deborah Black 《PloS one》2015,10(4)
Background
Floods are the most common type of global natural disaster. Floods have a negative impact on mental health. Comprehensive evaluation and review of the literature are lacking.Objective
To systematically map and review available scientific evidence on mental health impacts of floods caused by extended periods of heavy rain in river catchments.Methods
We performed a systematic mapping review of published scientific literature in five languages for mixed studies on floods and mental health. PUBMED and Web of Science were searched to identify all relevant articles from 1994 to May 2014 (no restrictions).Results
The electronic search strategy identified 1331 potentially relevant papers. Finally, 83 papers met the inclusion criteria. Four broad areas are identified: i) the main mental health disorders—post-traumatic stress disorder, depression and anxiety; ii] the factors associated with mental health among those affected by floods; iii) the narratives associated with flooding, which focuses on the long-term impacts of flooding on mental health as a consequence of the secondary stressors; and iv) the management actions identified. The quantitative and qualitative studies have consistent findings. However, very few studies have used mixed methods to quantify the size of the mental health burden as well as exploration of in-depth narratives. Methodological limitations include control of potential confounders and short-term follow up.Limitations
Floods following extreme events were excluded from our review.Conclusions
Although the level of exposure to floods has been systematically associated with mental health problems, the paucity of longitudinal studies and lack of confounding controls precludes strong conclusions.Implications
We recommend that future research in this area include mixed-method studies that are purposefully designed, using more rigorous methods. Studies should also focus on vulnerable groups and include analyses of policy and practical responses. 相似文献17.
Carol Dayo Obure Sedona Sweeney Vanessa Darsamo Christine Michaels-Igbokwe Lorna Guinness Fern Terris-Prestholt Esther Muketo Zelda Nhlabatsi Integra Initiative Charlotte E. Warren Susannah Mayhew Charlotte Watts Anna Vassall 《PloS one》2015,10(5)
Objective
To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services.Design
A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland.Methods
Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider’s perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars.Results
The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity.Conclusion
For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements. 相似文献18.
Background
Obstetric hemorrhage (OH), which includes hemorrhage from multiple etiologies during pregnancy, childbirth, or postpartum, is the leading cause of maternal mortality and accounts for one-quarter of global maternal deaths. The Non-pneumatic Anti-Shock Garment (NASG) is a first-aid device for obstetric hemorrhage that can be applied for post-partum/post miscarriage and for ectopic pregnancies to buy time for a woman to reach a health care facility for definitive treatment. Despite successful field trials, and endorsement by safe motherhood organizations and the World Health Organization (WHO), scale-up has been slow in some countries. This qualitative study explores contextual factors affecting uptake.Methods
From March 2013 to April 2013, we conducted 13 key informant interviews across four countries with a large burden of maternal mortality that had achieved varying success in scaling up the NASG: Ethiopia, India, Nigeria, and Zimbabwe. These key informants were health providers or program specialists working with the NASG. We applied a health policy analysis framework to organize the results. The framework has five domains: attributes of the intervention, attributes of the implementers, delivery strategy, attributes of the adopting community, the socio-political context, and the research context.Results
The interviews from our study found that relevant facilitators for scale-up are the simplicity of the device, local and international champions, well-developed training sessions, recommendations by WHO and the International Federation of Gynecology and Obstetrics, and dissemination of NASG clinical trial results. Barriers to scaling up the NASG included limited health infrastructure, relatively high upfront cost of the NASG, initial resistance by providers and policy makers, lack of in-country champions or policy makers advocating for NASG implementation, inadequate return and exchange programs, and lack of political will.Conclusions
There was a continuum of uptake ranging in both speed and scale. Ethiopia while not the first country to use the NASG has the most rapid scale-up, followed by Nigeria, then India, and finally Zimbabwe. Increasing the coverage of the NASG will require collaboration with local NASG champions, greater NASG awareness among clinicians and policymakers, as well as stronger political will and advocacy. 相似文献19.