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The Future Hospital in Global Health Systems: The Future Hospital Within the Healthcare System.
Get PDFFuture hospitals must be able to adapt in many ways to the changing demands on their roles and functions within evolving healthcare delivery infrastructures. These include changing population structures and needs, new models of healthcare provision, technological advances, and innovations in design, all while enhancing their environmental sustainability. This article sets out the issues that those determining healthcare policy and designing future hospitals must consider if they are to become and remain fit for purpose within the wider health and social care system. It also examines the need for, and challenges to, strategic healthcare planning, creating future hospitals that are sustainable, net-zero carbon organisations, and ensuring resilience in the face of a range of potential shocks. Future hospitals play a crucial role in healthcare worldwide, regardless of the country's income level. Hospitals cannot be viewed without broader health system changes, infrastructure, community and cultural factors, staffing and other considerations. We anticipate that future hospitals will enhance population health in all settings and support the move towards more consumer-centric healthcare. We urge clinical and policy planners to consider the factors discussed carefully to maximise the benefits
The iGains4Gains model guides irrigation water conservation and allocation to enhance nexus gains across water, food, carbon emissions, and nature.
Get PDFThis paper introduces and applies iGain4Gains, an Excel-based model, to reveal how changes to water conservation and allocation, and irrigation technology, can produce four nexus gains. These gains are; reduced aggregate water consumption, sustained crop production, lower carbon emissions, and enhanced water availability for nature. We developed the model with limited data and hypothetical future scenarios from the Amman-Zarqa basin in Jordan. Given its significant irrigation and urban water demands and difficult decisions regarding future water allocation and nexus choices, this basin is a highly appropriate case study. The paper's primary aim is to demonstrate the iGains4Gains nexus model rather than to build an accurate hydrological model of the basin's water resources. The model addresses two critical questions regarding increased irrigation efficiency. First, can irrigation efficiency and other factors, such as irrigated area, be applied to achieve real water savings while maintaining crop production, ensuring greenhouse gas emission reductions, and 'freeing' water for nature? Second, with the insight that water conservation is a distributive/allocative act, we ask who between four paracommoners (the proprietor irrigation system, neighbouring irrigation systems, society, and nature) benefits hydrologically from changes in irrigation efficiency? Recognising nexus gains are not always linear, positive and predictable, the model reveals that achieving all four gains simultaneously is difficult, likely leading to trade-offs such as water consumption rebounds or increased carbon emissions. Demonstrated by its use at a workshop in Jordan in February 2024, iGains4Gains can be used by students, scientists and decision-makers, to explore and understand nexus trade-offs connected to changes in irrigation management. The paper concludes with recommendations for governing water and irrigated agriculture in basins where large volumes of water are withdrawn and depleted by irrigation
Sample size estimates for biomarker-based outcome measures in clinical trials in autosomal dominant Alzheimer's disease.
Get PDFINTRODUCTION: Alzheimer disease (AD)-modifying therapies are approved for treatment of early-symptomatic AD. Autosomal dominant AD (ADAD) provides a unique opportunity to test therapies in presymptomatic individuals. METHODS: Using data from the Dominantly Inherited Alzheimer Network (DIAN), sample sizes for clinical trials were estimated for various cognitive, imaging, and CSF outcomes. Sample sizes were computed for detecting a reduction of either absolute levels of AD-related pathology (amyloid, tau) or change over time in neurodegeneration (atrophy, hypometabolism, cognitive change). RESULTS: Biomarkers measuring amyloid and tau pathology had required sample sizes below 200 participants per arm (examples CSF Aβ42/40: 47[95 %CI 25,104], cortical PIB 49[28,99], CSF p-tau181 74[48,125]) for a four-year trial in presymptomatic individuals (CDR=0) to have 80 % power (5 % statistical significance) to detect a 25 % reduction in absolute levels of pathology, allowing 40 % dropout. For cognitive, MRI, and FDG, it was more appropriate to detect a 50 % reduction in rate of change. Sample sizes ranged from 250 to 900 (examples hippocampal volume: 338[131,2096], cognitive composite: 326[157,1074]). MRI, FDG and cognitive outcomes had lower sample sizes when including indivduals with mild impairment (CDR=0.5 and 1) as well as presymptomatic individuals (CDR=0). DISCUSSION: Despite the rarity of ADAD, presymptomatic clinical trials with feasible sample sizes given the number of cases appear possible
Health Systems in Action (HSiA) Insights - Bosnia and Herzegovina
Get PDFKey points
● Bosnia and Herzegovina consists of two entities –
the Federation of Bosnia and Herzegovina, and the
Republika Srpska – and the Brčko District of Bosnia
and Herzegovina. The Federation of Bosnia and
Herzegovina is further divided into 10 cantons, each
governed independently by cantonal governments.
The resulting complex structure includes 13 health
insurance funds and 14 ministries in charge of health.
● Health policy decisions are centralized in the
Republika Srpska and decentralized to the canton
levels in the Federation of Bosnia and Herzegovina,
complicating reform and consensus-building efforts.
● Although social health insurance schemes are
mandatory in both entities, population coverage
is not universal and varies across the entities of
Bosnia and Herzegovina and the cantons within
the Federation of Bosnia and Herzegovina, leaving
significant portions of the population with very
limited access to publicly financed health care.
● In the case of the Federation of Bosnia and
Herzegovina, resource pooling occurs at the
cantonal level, which hinders equitable distribution
and accessibility of services, particularly in
secondary and tertiary care, and results in limited
patient choice. In the Republika Srpska and the
Brčko District of Bosnia and Herzegovina pooling
takes place at the entity/district level.
● Health care provision remains largely hospitalbased, although efforts are under way to
strengthen primary health care (PHC). Other
reforms aim to improve prevention programmes
for noncommunicable diseases (NCDs) and
immunization, as well as initiatives to digitalize
health records and introduce e-health to improve
accessibility and efficiency of care.
● Public spending on health as a share of gross
domestic product (GDP) declined in the years before
the COVID-19 pandemic. Out-of-pocket (OOP)
spending is high (amounting to 31% of health
spending in 2021), which results in a relatively
high degree of financial hardship, affecting
over 8% of households in the Federation of
Bosnia and Herzegovina and almost 10% in the
Republika Srpska.
● Despite increased bed capacity in response to
the COVID-19 pandemic, Bosnia and Herzegovina
still has a comparatively low ratio of hospital beds
per population. Occupancy rates vary significantly
between entities, indicating disparities in health care
demand and/or resource utilization.
● The numbers of physicians and nurses per
population in Bosnia and Herzegovina have increased
markedly. However, the country lacks a strategic
approach to health workforce development in the
face of an ageing health workforce and increasing
emigration to other countries.
● Bosnia and Herzegovina experienced substantial
excess mortality during the COVID-19 pandemic.
Nevertheless, the pandemic did not undo gains
in maternal and infant mortality rates, with both
reaching historic lows in 2021.
● Prior to the COVID-19 pandemic, mortality rates in
the country declined, including premature mortality.
Cardiovascular disease remains the leading cause
of death and disability. Premature mortality among
adults aged 30 to 69 years is mainly due to cancer.
● Behavioural risks such as smoking and unhealthy
diets, as well as hypertension and high fasting blood
sugar, are major contributors to ill health. Ongoing
efforts are aimed at promoting healthy lifestyles,
including the implementation of stricter tobacco
policies and the provision of smoking cessation
services by family doctors
Binding and neutralising antibodies to respiratory syncytial virus and influenza A virus in serum and bronchoalveolar lavage fluid of healthy adults in the United States: A cross-sectional study.
Get PDFUsing serum and bronchoalveolar lavage (BAL) fluid collected from 20 healthy adults (23-37 years, 55 % female) in the United States, we measured immunoglobulin (Ig) A, IgG, and neutralising activity against respiratory syncytial virus (RSV) and influenza A (H1N1) virus. RSV-binding IgA and IgG measurements in serum were positively correlated with those in BAL. For influenza A (H1N1) virus, serum and BAL IgA antibodies were positively correlated, whereas IgG antibodies did not show a significant correlation. RSV-specific and influenza A (H1N1)-specific neutralising activity did not correlate between serum and BAL samples. These results demonstrate virus-specific correlations between antibodies in the serum and BAL that may not necessarily reflect correlations in functional activity. Further work is needed to confirm our preliminary observations, and define the immune correlates of neutralising activity to these and other respiratory viruses in the lower respiratory tract
Impact of patient sex on selection for abdominal aortic aneurysm repair: a discrete choice experiment.
Get PDFOBJECTIVES: Women with an abdominal aortic aneurysm (AAA) are less likely to receive elective repair than men. This study explored the effect of patient sex and other attributes on vascular surgeons' decision-making for infrarenal AAA repair. DESIGN: Discrete choice experiment. SETTING: Simulated environment using case scenarios with varying patient attributes. PARTICIPANTS: Vascular surgeons. INTERVENTIONS: Surgical decision-making. MAIN OUTCOME MEASURES: AAA repair versus no repair and endovascular versus open repair. RESULTS: 182 surgeons completed 2987 scenarios. When all other attributes were equal, a woman was more likely to be offered an AAA repair (marginal rate of substitution (MRS) 3.86 (95% CI 2.93, 4.79)), while very high anaesthetic risk (MRS -4.33 (95% CI -5.63, -3.03)) and hostile anatomy (MRS -3.28 (95% CI -4.55, -2.01)) were deterrents. Increasing age did not adversely affect the likelihood of offering repair to men but decreased the likelihood for women, which negated women's selection advantage from the age of 83 years. Women were also more likely to be offered endovascular repair (MRS 2.57 (95% CI 1.30, 3.84)). CONCLUSIONS: Patient sex alone did not account for real-world disparity observed in selection for surgery. Rather, being a woman was associated with a higher likelihood of being offered AAA repair but also a higher likelihood of being offered less invasive endovascular repair. Increased age decreased the likelihood of surgical selection for women but not men. Preference for less invasive repair, combined with inferior rates of anatomical suitability, and the comparably older age of women at the time of AAA repair selection may account for lower rates of repair for women observed
Workload in antenatal care before and after implementation of an electronic decision support system: an observed time-motion study of healthcare providers in Nepal.
Get PDFBACKGROUND: Healthcare interventions are shaped by the resources needed to implement them, including staff time. This study, part of a process evaluation, aims to compare time spent on antenatal care (ANC) and related recordkeeping in two rural primary-level health facilities in Nepal, before and after implementation of an electronic decision support system intervention to improve ANC quality that required additional electronic documentation. METHODS: The study is a before-and-after, observational time-motion assessment. Researchers used the WOMBAT (Work Observation Method By Activity Timing) software to observe and record activities performed by auxiliary nurse midwives providing ANC in two rounds of data collection. We summed the observation time (in minutes) spent on activity categories for each day of observation, in each round of data collection. For each auxiliary nurse midwife, we estimated the proportion of total observation time spent on activities and compared these proportions before and after intervention implementation. We also compared the mean minutes per day spent on ANC and recordkeeping in the two rounds. RESULTS: Six auxiliary nurse midwives were observed over two data collection rounds (41 total observation days). Prior to intervention, providers spent 7% of their workday on ANC and 6% on related recordkeeping, and time spent on these activities did not change after intervention implementation. Only one of the six auxiliary nurse midwives demonstrated a statistically significant increase in time spent on ANC and recordkeeping after implementation. There was considerable day-to-day variation in ANC time, and substantial periods of "non-work" time (on break or not engaged in work-related activity). Non-work time reduced from 42% in the first round to 26% in the second round of data collection. CONCLUSIONS: Time spent on ANC and related recordkeeping was low and did not change after implementation of the electronic decision support system. ANC and recordkeeping time was sensitive to day-to-day fluctuations in numbers of women attending for ANC at these rural facilities, which may have masked the intervention's effects. However, the large amount of non-work time observed suggests time constraints during the workday were not a major factor inhibiting use of the electronic decision support system
Tuberculosis and undernutrition: improving estimates to reinforce the policy imperative.
Get PDFUndernutrition is a key driver of the global tuberculosis epidemic, increasing the risk of people developing tuberculosis disease and of poor outcomes in those who do.1 Each year, WHO publishes estimates of the number of tuberculosis disease episodes attributable to undernutrition and other risk factors, based on population attributable fractions (PAFs). These PAF values allow stakeholders to compare the relative role of different risk factors in the tuberculosis epidemic, shaping policy and setting research agendas
Rapid inference of antibiotic susceptibility phenotype of uropathogens using metagenomic sequencing with neighbor typing.
Get PDFTimely diagnostic tools are needed to improve antibiotic treatment. Pairing metagenomic sequencing with genomic neighbor typing algorithms may support rapid clinically actionable results. We created resistance-associated sequence elements (RASE) databases for Escherichia coli and Klebsiella spp. and used them to predict antibiotic susceptibility in directly sequenced (Oxford Nanopore) urine specimens from critically ill patients. RASE analysis was performed on pathogen-specific reads from metagenomic sequencing. We evaluated the ability to predict (i) multi-locus sequence type (MLST) and (ii) susceptibility profiles. We used neighbor typing to predict MLST and susceptibility phenotype of E. coli (64/80) and Klebsiella spp. (16/80) from urine samples. When optimized by lineage score, MLST predictions were concordant for 73% of samples. Similarly, a RASE-susceptible prediction for a given isolate was associated with a specificity and a positive likelihood ratio (LR+) for susceptibility of 0.65 (95% CI, 0.54-0.76) and 2.26 (95% CI, 1.75-2.92), respectively, with an increase in the probability of susceptibility of 10%. A RASE-non-susceptible prediction was associated with a sensitivity and a negative likelihood ratio (LR-) for susceptibility of 0.79 (95% CI, 0.74-0.84) and 0.32 (95% CI, 0.24-0.43) respectively, with a decrease in the probability of susceptibility of 20%. Numerous antibiotic classes could reasonably be reconsidered empiric therapy by shifting empiric probabilities of susceptibility across relevant treatment thresholds. Moreover, these predictions can be available within 6 h. Metagenomic sequencing of urine specimens with neighbor typing provides rapid and informative predictions of lineage and antibiotic susceptibility with the potential to impact clinical decision-making.
IMPORTANCE: Urinary tract infections (UTIs) are a common diagnosis in hospitals and are often treated empirically with broad-spectrum antibiotics. These broad-spectrum agents can select for resistance in these bacteria and co-colonizing organisms. The use of narrow-spectrum agents is desirable as an antibiotic stewardship measure; however, it is counterbalanced by the need for adequate therapy. Identification of causative organisms and their antibiotic susceptibility can help direct treatment; however, conventional testing requires days to produce actionable results. Methods to quickly and accurately predict susceptibility phenotypes for pathogens causing UTI could thus improve both patient outcomes and antibiotic stewardship. Here, expanding on previous work showing accurate prediction for certain Gram-positive pathogens, we demonstrate how the use of RASE from metagenomic sequencing can provide informative and rapid phenotype prediction results for common Gram-negative pathogens in UTI, highlighting the future potential of this method to be used in clinical settings to guide empiric antibiotic selection
Characterization of Shigella flexneri serotype 6 strains from geographically diverse low- and middle-income countries.
Get PDFShigella flexneri serotype 6 (Sf6) is one of the most common serotypes recovered from surveillance studies of moderate to severe diarrhea. Despite the clinical significance of Sf6, this serotype is understudied. In this work, we have performed both serotype-specific genomic and phenotypic comparisons of Sf6 isolates to one another and non-S. flexneri serotypes. Comparative genomic analyses identified significant nucleotide homology between Sf6 strains (n = 325), despite a broad range of collection timeframes and geographic locations. We identified Sf6 specific factors, including a potential novel Shigella virulence factor (type II secretion system). Additionally, we identified established Shigella virulence genes (ospG) and metabolic genes (rutABCDEFGR) that were absent in Sf6 strains while present in the majority of 728 non-Sf6 strains. Complete sequencing of 11 clinical Sf6 strains, demonstrated that the Sf6 virulence plasmid (pINV) is ~38 kb smaller than the average non-Sf6 pINV (~228 kb). Comparisons of S. flexneri species level antibiotic susceptibility highlighted that clinical Sf6 isolates from Africa in the Global Enteric Multicenter Study (GEMS) and Vaccine Impact on Diarrhea in Africa (VIDA) study demonstrated geographic, serotype-specific susceptibility pattern. Phenotypic analyses of Sf6 identified reduced intracellular invasion and cytokine induction from HT-29 cells, as well as reduced Ipa protein effector secretion, compared with S. flexneri serotype 2a strain 2457T. Together these data highlight conserved and unique serotype-specific genotypic and phenotypic features for Sf6. This level of conservation has not been noted for other S. flexneri serotypes and is promising for vaccine and diagnostic assays to provide global Sf6-specific coverage.IMPORTANCEShigellosis is an ongoing global public health crisis with >270 million annual episodes among all age groups; however, the greatest disease burden is among children in low- and middle-income countries (LMIC). The lack of a licensed Shigella vaccine and the observed rise in antimicrobial-resistant Shigella spp. highlights the urgency for effective preventative and interventional strategies. The inclusion of S. flexneri serotype 6 (Sf6) is a necessary component of a multivalent vaccine strategies based on its clinical and epidemiological importance. Given the genomic diversity of Sf6 compared with other S. flexneri serotypes and Sf6 unique O-antigen core structure, serotype-specific characterization of Sf6 is a critical step to inform Shigella-directed vaccine and alternative therapeutic designs. Herein, we identified conserved genomic content among a large collection of temporally and geographically diverse Sf6 clinical isolates and characterized genotypic and phenotypic properties that separate Sf6 from non-Sf6 S. flexneri serotypes