BMC Health Services Research

IntroductionIn the Netherlands, referral rates from primary to secondary care are rising due to an ageing population and complex healthcare needs, a challenge compounded by an on-going decline in the number of trained healthcare professionals. In this context, triage has shown promise in optimizing secondary care consultations. This hospital-wide study aimed to assess to what extent triaging non-emergent primary care referrals prevents outpatient consultations, as well as experiences of triage implementation by medical specialists and general practitioners (GP). MethodsA mixed-methods study was conducted using routine care data from electronic health records (EHR) and semi-structured interviews. Referrals to 15 departments between August 2019 and July 2021 were included, with a six-month follow-up period. Referrals were assessed regarding the expected added value of secondary outpatient consultation and correctly chosen specialty. To gain insight into professionals experiences, interviews were conducted with GPs and with medical specialists from each participating department. ResultsA total of 109,953 primary care referrals were registered by participating departments. Of these, 4.262 (3.9%) were directed back to primary care, with redirection varying across departments (0% to 17.1%). Of the redirected referrals with six-months of follow-up, 274 of 3461 patients (7.9%) were re-referred for the same care need within this period. Qualitative findings showed overall positive experiences among medical specialists, with major time investment as the most important barrier to triage. GPs expressed more mixed feelings, with reported barriers including a sense of undermining of autonomy and lack of collaboration, although guidance and advice from specialists was much appreciated. ConclusionThis study showed that a hospital-wide triage strategy can be effective in reducing outpatient consultations, with redirected referrals supported by advice and/or treatment guidance for the referring GP. Qualitative insights suggested that safeguarding mutual respect and cooperation between specialists and GPs needs to be addressed during the implementation of a triage system.

IntroductionThe ecology of medical care framework describes how populations interact with different levels of health services. Despite Colombias formal commitment to primary health care (PHC) and near-universal insurance coverage, limited evidence exists on how health services are actually used across territories and socioeconomic contexts. MethodsAn ecological, cross-sectional study was conducted using national administrative data to describe health service utilization patterns in Colombia during 2023. Data were obtained from official sources, including health service provision records, health workforce registries, insurance affiliation databases, population projections, and socioeconomic indicators. Health service utilization was measured as the number of individuals per 1,000 inhabitants using different levels of care. Associations between utilization rates, socioeconomic characteristics, and physician availability were examined using negative binomial regression models with population size as an offset. ResultsSubstantial heterogeneity in healthcare utilization was observed across municipalities and geographic regions. Most outpatient consultations were provided by non-specialist physicians, with comparatively smaller differences between primary care and specialist consultations. Emergency department visits and hospitalizations showed lower utilization rates overall, although some municipalities exhibited disproportionately high use of these services. Regions with higher poverty levels and unmet basic needs consistently showed lower utilization across most levels of care, while higher educational coverage was positively associated with specialist and inpatient care. ConclusionsThe ecology of medical care in Colombia reveals a health system formally oriented toward primary health care but functionally dependent on non-specialist physicians and characterized by marked territorial and socioeconomic inequities in service use. These findings suggest that universal coverage alone is insufficient to ensure equitable access and effective primary care. Understanding real-world patterns of utilization is essential to inform ongoing health system reforms aimed at strengthening PHC, improving coordination across levels of care, and addressing unmet health needs, particularly in underserved regions.

IntroductionNewfoundland and Labrador (NL) faces persistent difficulty attaching its residents to primary care. We undertook a stock and flow analysis to represent how inflows and outflows of family physicians (FPs) shape effective capacity and to provide a reconciled estimate of FP supply for 2024. This approach clarifies drivers of change, exposes intervention points, and supports timely planning. MethodsWe assembled a multi-year headcount series and linked it to CIHIs "entering/leaving direct care" flows, harmonizing definitions and time frames across sources. We compared observed year-to-year stock change with net flows to identify timing and classification gaps. Stakeholder consultations informed key parameters (graduates and retention, internationally trained entrants, migration, retirement, and scope shift). Because confirmations are released with a lag, we produced a reconciled 2024 estimate using the CIHI headcount as baseline and these validated inputs. FindingsFP headcount changed from 680 (2014) to 666 (2023) (-2.1%) after peaking at 728 (2017); the ratio fell from 129 to 124 per 100,000 population. The workforce became more urban (rural 255[->]203; urban 424[->]460) and more Canada-trained (417[->]466) while foreign trained decreased (261[->]199). Net interprovincial migration averaged -24/year, with pronounced losses in 2019 (-57) and 2022 (-42). CIHI entry-exit data point to marked volatility in the FP workforce: entries/exits were 110/96 (2019), 62/88 (2020), and 71/117 (2021), with residuals versus stock change indicating definitional/timing differences. The 2024 reconciliation yielded {approx}658 FPs (net -8.5 from 2023), {approx}507 FTE at 0.77 FTE/head, and {approx}122 per 100,000 population. ConclusionInflows from local graduates and IMGs did not fully offset exits from migration, retirement, and scope/burnout in 2024. Recruitment alone is unlikely to close access gaps; retention-first strategies, scaleup of team-based care with role optimization, targeted rural supports, and routine monitoring of flows are needed to stabilize and grow effective primary care capacity in NL.

BackgroundEmergency medicine systems are vital for reducing mortality and disability, yet Cameroon faces significant healthcare access challenges, with only 0.6% of GDP allocated to public health and 70% of health expenditures paid out-of-pocket. This study assessed proportion of population benefiting from health coverage, patterns, and associated factors in Cameroon to inform policies aimed at achieving universal health coverage (UHC). MethodsA nationally representative cross-sectional survey was conducted from February to March 2024, involving 1,200 adults selected via multistage random sampling. Data were collected through face-to-face interviews by national Afrobarometer team, and analyzed with R Statistics version 4.4.2. Logistic regression identified factors associated with medical coverage, adjusting for sociodemographic, economic, and occupational variables. ResultsA proportion of 7.9% (95% CI: 6.4-9.6) of respondents reported benefiting from a health coverage in 2024, with the lowest rates reported in the North, Adamawa, Centre, and North-West regions. Private health insurance was the most common (44.3%), followed by civil servant schemes (20.5%) and community-based insurance (15.9%). Unemployed individuals were twice as likely to lack coverage (aOR = 2.22, 95% CI: 1.42-3.51). Those with secondary education had twice the odds of being uninsured compared to tertiary-educated individuals (aOR = 2.00, 95% CI: 1.21-3.27). Insured individuals were more likely to use healthcare services (9.6%; p = 0.028), reported easier access to medical care (15.8%; p = 0.010), and expressed fewer concerns about healthcare access (23.4%; p < 0.001). Barriers among the uninsured included high costs (37.1%), lack of information (31.6%), complex registration processes (8.5%) and geographical constraints. Most of the community members reported being quite (51.1%) or very satisfied (23.9%) by the medical coverage they are benefiting from. Notably, 68% of respondents supported higher taxes to improve healthcare access. ConclusionCameroons suboptimal medical coverage reflects systemic inequities tied to employment and education. Expanding employer-independent schemes, subsidizing premiums, and leveraging community-based models are critical to advancing UHC. Public willingness to contribute through taxes suggests political viability for systemic reforms.

It is critical to calculate correctly the costs of implementing health interventions to generate reliable budgets, perform planning functions (including staff planning), and conduct economic evaluations. With the recent decrease in funding for international development assistance for health and the emphasis on country-led implementation of health programs in low- and middle-income countries, understanding the true cost of providing health services is even more important. As responsibility for funding and delivering health services shifts, inaccurate cost estimates can result in under-resourced disease response programs, ultimately lowering health outcomes. Costing studies, which aim to provide details on the financial and human resources necessary to deliver health services, rarely account for the time healthcare providers spend preparing for patient visits or following up with patients after a visit is complete. This deficiency in cost data is often acknowledged by researchers but seldom corrected, and consequently health policymakers do not know the true cost of staffing health facilities. In this paper, we present an updated methodology on how non-client-facing and non-clinical provider time should be incorporated into activity-based costing and management (ABC/M) applications. These methods are also applicable to traditional time-motion costing studies, including survey instrument changes and changes in calculating provider and operational costs. We present and discuss illustrative results which indicate that provider costs could increase by approximately 50% when non-client-facing provider time is included; operational costs could also increase, but likely by a smaller percentage. It is encouraging that we now have a simple, low-cost fix to the important issue of including provider costs correctly in both ABC/M and time-motion costing applications.

BackgroundHigh Need-High Cost (HNHC) patients are those who experience poor health outcomes and high health care costs. Early identification may improve outcomes and lower costs. AimDevelopment of a model using retrospective data to identify patients at risk for becoming HNHC patients, in order to efficaciously plan interventions. MethodsData from a large Israeli Health Maintenance Organization (HMO) that includes 488,615 clients above the age of 21 were examined. Multivariate linear regression models were developed using 2012-2016 health expenditure as a dependent variable. ResultsThe number of yearly purchases of medications for chronic disorders, yearly outpatient visits, yearly emergency department and hospital admissions and the last measured HgA1c level were highly predictive of increased expenditure over a five-year period. Each of these indicators has a different coefficient of influence. ConclusionsWe developed a predictive model, based on easily obtained data from electronic medical records that enabled us to identify a population at risk for becoming HNHC in the next five years, a time window allows for intervention. Further research is needed to evaluate whether this is an early enough stage to implement pro-active intervention in the primary care setting. Trial registrationretrospectively registered. HIGHLIGHTSIn this study, we developed a numerical point system calculator, to indicate a risk score for health deterioration within 5 years of patients, by using numerical indicators existing in standard EMR data. The indicators introduced into this calculated risk can guide healthcare providers to the needed areas of intervention. The display of indicators also promotes optimization of care management and continuity of care. This risk score is expected to focus the attention of primary care teams on the population that will benefit most from it, as well as to evaluate the effectiveness of specific interventions.

BackgroundIn 2015, the Government of Quebec undertook a vast reorganization of its health and social services network. This reform mainly aimed to promote and simplify access to services for the population, contributing to the improvement of the quality and safety of care, and increasing the efficiency and effectiveness of the network. Since 2016, several health care organizations (HCOs) have pushed reform even further by developing management through care and service pathways (MCSP). This study aims to identify, in a processual manner, the different factors involved in implementing MCSP in different HCOs, in the turbulent context of the COVID-19 pandemic. MethodThe methodology of this research project is based on developmental evaluation. The objective of developmental evaluation is to guide organizations and actors in the adaptation and development of innovations in complex and turbulent environments. Data will be collected over a three-year period using five strategies: i) organizational questionnaires; ii) analysis of clinical-administrative databases; iii) documentary analysis (grey and scientific literatures); iv) participant observations and v) semi-structured interviews with key actors involved in the implementation of MCSP. DiscussionIn addition to the operationalization of pathways, the implementation of MCSP i) involves transforming the governance of the health care organization both at the strategic and operational levels and ii) is a demanding process that requires changes in practices, modifications in the allocation and configuration of resources and the development of new collaborations between the different actors in the organization, the partners and the users involved in this transformation. Several studies claim that governance innovations can create conditions that are favourable to the emergence of innovations in terms of available services and responding to the needs of populations. This research will develop knowledge of the factors involved in implementing MCSP in complex and turbulent contexts and propose scale-up across the province.

IntroductionHealth risk assessment (HRA) strategies are cornerstone for health systems transformation toward value-based patient-centred care. However, steps for HRA adoption are undefined. This report analyses the process of transference of the Adjusted Morbidity Groups (AMG) algorithm from the Catalan Good Practice to the Marche region (IT) and to Viljandi Hospital (EE), within the JADECARE initiative (2020-2023). DescriptionThe implementation research approach involved a twelve-month pre-implementation period to assess feasibility and define the local action plans, followed by a sixteen-month implementation phase. During the two periods, a well-defined combination of experience-based co-design and quality improvement methodologies were applied. DiscussionThe evolution of the Catalan HRA strategy (2010-2023) illustrates its potential for health systems transformation, as well as its transferability. The main barriers and facilitators for HRA adoption were identified. The report proposes a set of key steps to facilitate site customized deployment of HRA contributing to define a roadmap to foster large-scale adoption across Europe. ConclusionsSuccessful adoption of the AMG algorithm was achieved in the two sites confirming transferability. Marche identified the key requirements for a population-based HRA strategy, whereas Viljandi Hospital proved its potential for clinical use paving the way toward value-based healthcare strategies.

AO_SCPLOWBSTRACTC_SCPLOWO_ST_ABSBackgroundC_ST_ABSLimited evidence exists on impacts and adaptations of global health markets during COVID-19. We examined physicians perceptions of changing employment opportunities in Brazil, to gain an insight into labour markets in low- and middle-income countries (LMICs) during the pandemic. MethodsWe conducted secondary analysis of a dataset from a representative cross-sectional survey of 1,183 physicians in Sao Paulo and Maranhao states in Brazil. We estimated prevalence and 95% Confidence Intervals (CI) for proxy variables of demand and supply of doctors, and prices of medical services for facilities of practice in the two States, stratified by public, private, and dual practice physicians. ResultsMost doctors reported increased job opportunities in the public sector (59.0%, 95% CI 56.1-61.9), particularly in Maranhao state (66.4%, 95% CI 62.3-70.3). For the private sector, increased opportunities were reported only in large private hospitals (51.4%, 95% CI 48.4-54.4), but not in smaller clinics. We recorded perceptions of slight increases in availability of doctors in Maranhao, particularly in the public sector (54.1%, 95 CI 45.7-62.3). Younger doctors recounted increased vacancies in the public sector (64%, 95 CI 58.1-68.1); older doctors only in walk-in clinics in Maranhao (47.5%, 95 CI 39.9-55.1). Those working directly with COVID-19 saw opportunities in public hospitals (65%, 95 CI 62.3-68.4), and in large private ones (55%, 95 CI 51.8-59.1) ConclusionsOur findings suggest that health labour markets in (LMICs) may not necessarily shrink during epidemics, and that impacts will depend on the balance of public and private services in national health systems. KO_SCPLOWEYC_SCPLOWO_SCPCAP C_SCPCAPO_SCPLOWMESSAGESC_SCPLOW What is already known on this topiHealth labour markets are believed to shrink during epidemics, with fewer services and jobs available because of lockdowns and reduced demand. What this study addsThe doctors we surveyed in Brazil noticed increased job opportunities in the public sector during COVID-19, particularly in Maranhao state. For the private sector, increased vacancies were reported in large private hospitals but not in smaller clinics. How this study might affect research, practice or policyThe complementary roles of health markets and publicly or privately funded systems during a health emergency might need re-examining to improve pandemic preparedness in LMICs.

BackgroundApproximately 33% of U.S. Veterans live in rural areas, often facing significant barriers to accessing healthcare due to staffing shortages at VA facilities. The Contract Buyout (CBO) program, authorized under the PACT Act of 2022, was designed to address rural healthcare staffing shortages by enabling Veterans Health Administration (VHA) facilities to buy out existing service contracts to work in rural VA facilities. Despite its potential, uptake of the program has been limited, with just 18 hires and $1.5M in expenditures, despite a congressional spending authorization of up to $40M. This evaluation explores the barriers and facilitators in implementation of the CBO program across rural VA facilities. MethodsUsing the RE-AIM framework, we conducted a mix-method qualitative evaluation. Semi-structured interviews were completed by 15 interviewees across 8 rural VA facilities, including hiring leaders and physicians. Data were analyzed using rapid qualitative analysis, supported by a descriptive survey to capture the CBO program awareness and experience. We conducted 15 interviews across 8 rural VA medical centers with facility-level hiring leaders and clinicians who were familiar with or involved in using the CBO program. ResultsHR-related delays and procedural ambiguities disrupted contract execution and undermined the CBO programs effectiveness globally. However, sites with strong internal champions and proactive HR teams reported greater success. Interviewees reported the CBO program as a promising tool, though its lack of dedicated funding and resource dissemination hindered broader adoption. ConclusionThe CBO program holds potential as a flexible rural recruitment incentive but faces structural barriers that limit its reach and adoption. Future evaluations should Evaluate whether individual rural VA sites have budgetary flexibility, funding mechanisms, and related resources required to effectively utilize the CBO program.

BackgroundDuring the COVID-19 pandemic, violence targeting healthcare reportedly increased. Attacks against healthcare have the potential to impair the public health response and threaten the availability of healthcare services. However, there is little systematic understanding of the extent and characteristics of healthcare attacks in the setting of a pandemic. This study aimed to investigate global trends regarding COVID-19 related attacks against healthcare from January 2020 until January 2023. MethodologyCOVID-19 related incidents that occurred between January 2020 and January 2023 were extracted from the Safeguarding Health in Conflict Coalition database and screened for eligibility. Data collected per incident included temporal factors; country; setting; attack and weapon type; perpetrator; motive; number of healthcare workers (HCWs) and patients killed, injured or kidnapped; and whether the incident caused damage to a health facility. ResultsThis study identified 255 COVID-19 related attacks against healthcare. The attacks occurred globally and throughout the course of the pandemic. Incidents were heterogeneous with regards to motives, attack types and outcomes. At least 18 HCWs were killed, 147 HCWs were injured and 86 facilities were damaged or destroyed. There were two periods with a peak incidence of reports. The first peak occurred during the beginning of the pandemic, and predominantly concerned stigma-related attacks against healthcare. The second peak, in 2021, was mainly composed of conflict-related attacks in Myanmar, and attacks targeting the global vaccination campaign. ConclusionCOVID-19 related attacks against healthcare occurred globally and in a variety of settings throughout the course of the pandemic. The findings of this study can be used to prevent and mitigate healthcare attacks during the ongoing and future pandemics.

Out-of-pocket (OOP) healthcare expenditures are a major barrier to achieving universal health coverage in low- and middle-income countries (LMICs). In Honduras, OOP payments constitute a significant burden, particularly for vulnerable populations. However, evidence on the socioeconomic distribution of these expenditures and their determinants remains scarce. This study aims to examine the socioeconomic inequalities in OOP healthcare expenditures in Honduras, focusing on outpatient and inpatient services. It seeks to identify key sociodemographic factors contributing to these disparities to inform equitable health care financing policies. Data from the 2019 ENDESA/MICS survey was used, covering 10,998 individuals for outpatient and 3,277 for inpatient services. Concentration curves (CC) and the Wagstaff concentration index (CI) were used to measure inequality in OOP expenditures. An econometric decomposition analysis of the CI was performed to identify the contribution of sociodemographic factors. The findings indicate that OOP expenditures for both outpatient (CI = 0.213) and inpatient services (CI = 0.218) are disproportionately concentrated among wealthier individuals. Education and place of residence were primary drivers of inequality, with rural residents and those without insurance experiencing greater financial burdens. The study highlights significant socioeconomic inequalities in OOP healthcare expenditures in Honduras. Policy interventions targeting financial protection for lower-income and rural populations are crucial to advancing equitable healthcare access.

BackgroundThe use of data for planning and improving healthcare delivery is sub-optimal among developing countries. In 2015, Tanzania started to implement Star Rating Assessment (SRA) process for primary health care (PHC) facilities to improve various dimensions of quality of services, including the use of data. We aimed at assessing the extent and predictors of data use in Tanzanian PHC facilities. MethodologyWe used the most current national SRA data available in DHIS2 that was collected in 2017/2018 from all 7,289 PHC facilities. A facility was considered using data if gained 80% of the allocated scores. Other dependent variables were the three components that together contribute to the use of data [If PHC facility has Health Management Information systems (HMIS) functional, disseminate information, and has proper medical records]. We determined the association between data use and facility ownership status (public or private), location of the facility (rural or urban) and facility service level (dispensary, health centre or hospital). Results are presented as proportions of facilities that qualified for data use and the three components. The associations are reported in Adjusted odds ratio (AOR) with a 95% confidence interval (CI). ResultsA total of 6,663(91.4%) PHC facilities met our inclusion criteria for analysis. Among the facilities: 1,198(18.0%) had used data for planning and services improvement; 3,792(56.9%) had functional HMIS; 1,752(26.3%) had disseminated data; and 631(9.5%) had proper medical records. PHC facilities that are publicly owned (AOR 1.25; 95% CI: 1.05-1.48) and those at higher service level [hospitals (AOR 1.77; 95% CI: 1.27-2.46) and health centres (AOR 1.39; 95% CI: 1.15-1.68) compared to dispensaries] were more likely to use data. ConclusionThe use of facility data for planning and services improvement in Tanzanian PHC facilities is low, and much effort needs to be targeted at privately-owned and low-level PHC facilities.

IntroductionComplex chronic patients (CCP) are prone to unplanned hospitalizations leading to a high burden on healthcare systems. To date, interventions to prevent unplanned admissions show inconclusive results. We report a co-creation process performed into the EU initiative JADECARE (2020-2023) to elaborate an integrated care program aiming at preventing unplanned hospitalizations. MethodsA two-phase process of structured interviews and design thinking (DT) sessions was conducted. Firstly, we assessed the management of CCP in Catalonia (ES) through twenty interviews (five patients and fifteen professionals), including the results of a cluster analysis of 761 hospitalizations, followed by two DT sessions (Oct 2021 to Feb 2022). Then, we examined the 30- and 90-day post-discharge periods of 49,604 hospitalizations as input for two DT sessions with seven professionals. DiscussionThe co-creation process identified poor personalization of the interventions, the need for organizational changes, immature digitalization, and suboptimal services evaluation as main explanatory factors of the observed efficacy-effectiveness gap. Additionally, a program for prevention of unplanned hospitalizations, to be evaluated during 2023-2025, was generated. ConclusionsA digitally enabled adaptive case management approach to foster collaborative work, as well as organizational re-engineering, are endorsed for value-based prevention of unplanned hospitalizations.

BackgroundRural emergency departments (EDs) are critical to ensuring equitable access to acute care, yet face persistent systemic challenges. In Quebec, Canada, reforms to healthcare governance, funding and resource allocation, and service delivery have transformed rural ED operations. This study aimed to document characteristics, challenges, and improvement priorities for all rural EDs in the province. MethodsA participatory mixed-methods design was used. 26 rural EDs in Quebec were included. Data sources comprised administrative statistics, structured site surveys, individual stakeholder semi structured interviews, and a validation survey of identified local champions. Analyses comprised a triangulation of the quantitative and qualitative data using transversal thematic analysis to determine common issues. Potential solutions identified were validated through stakeholder questionnaires. The study was reported in accordance with the COREQ reporting guideline. ResultsMost respondents were women (64%) and professionals with more than 5 years of experience. Four main themes were identified: governance, healthcare organization, access to resources, and professional practice. Governance challenges included reduced local autonomy, administrative complexity, and budgeting models poorly adapted to rural realities. Participants emphasized the need for standardized but locally flexible administrative processes, regional emergency service managers, and rural-sensitive performance metrics. Organizational barriers included geographic isolation, limited access to primary care, and difficulties with interfacility transfers due to referral-center capacity and ambulance shortages. Resource constraints centered on shortages of human resources, diagnostic services and specialty coverage, especially anesthesia, obstetrics, and psychiatry. Professional practice was shaped by the need to maintain broad competencies in low-volume contexts, while contending with professional isolation and proximity to patients. Local champions prioritized expanding telemedicine, strengthening prehospital services, enhancing continuing education, and implementing tailored recruitment strategies. ConclusionThis study provides the first province-wide documentation of characteristics, challenges, and improvement priorities for all rural EDs. Findings highlight the need for systemic reforms that restore local decision-making authority, strengthen transfer and prehospital capacity, expand telehealth and specialty access, and support professional development. These results provide a foundation for evidence-based policies and actions to sustain equitable emergency care in rural regions.

BackgroundThe necessary data for delivering targeted population health management (PHM) interventions in Belgium is insufficient and scattered due to limited, non- interoperable data sources. Insights on data availability, user needs, and analysis capabilities should be obtained to develop a Belgian PHM dashboard. We aimed to identify visual, content, and access requirements for a PHM dashboard, and visualize user needs through a mock-up dashboard to enhance quintuple aim. MethodsFive focus groups were conducted in three Belgian locoregional health networks (collaborations of primary care zones), comprising 35 potential future dashboard users with various backgrounds. Insights were gathered using open-ended questions based on frameworks of successful international examples. These insights were incorporated into a mock-up dashboard. Subsequently, the mock-up dashboard was discussed in a second round of focus groups. Data from the focus groups were analysed using the Qualitative Analysis Guide of Leuven (QUAGOL) method. ResultsDifferentiated user requirements can be classified into: (1) General Exploration allowing for assessing the health and socioeconomic status and risk factors in a region using PHM indicators, (2) Risk Stratification and Selection of Interventions enabling matching of resources and interventions to at-risk subpopulations, (3) Research Community providing advanced tools for data exploration and collaboration with the research community. The mock-up dashboard meets these requirements according to respondents, by supporting population health managers, healthcare professionals and policymakers with easy access to insights and expert population health managers, such as researchers and data analysts, with options for advanced data analysis. ConclusionsOur study identified exploration, risk stratification, intervention selection and advanced data analysis as key components of an interoperable and customizable dashboard, contributing to a more efficient and equitable healthcare system. The developed PHM mock-up dashboard encapsulates these features, aiming to achieve the quintuple aim in Belgium.

BackgroundIn 2013, Marshfield Clinic Health System (MCHS) implemented the Dragon Medical One (DMO) system provided by Nuance Management Center (NMC) for Real-Time Dictation (RTD), embracing the idea of streamlined clinic workflow, reduced dictation hours, and improved documentation legibility. Since then, MCHS has observed a trend of reduced time in documentation, however, the target goal of 100% adoption of voice recognition (VR)-based RTD has not been met. ObjectiveTo evaluate the uptake/adoption of VR technology for RTD in MCHS, between 2018-2020. MethodsDMO data for 1,373 MCHS providers from 2018-2020 were analyzed. The study outcome was VR uptake, defined as the number of hours each provider used VR technology to dictate patient information, used as continuous, and classified as no/yes. Covariates included sex, age, US-trained/international medical graduates, trend, specialty, and facility. Descriptive statistics and unadjusted and adjusted logistic regression analyses were performed. Stata/SE.version.17 was used for analyses. P-values less than/equal to 0.05 were considered statistically significant. ResultsOf the 1,373 MCHS providers, the mean (SD) age was 48.3 (12.4) years. VR uptake was higher than no uptake (72.0% vs. 28.0%). In both unadjusted and adjusted analyses, VR uptake was 4.3 times and 7.7 times higher in 2019-2020 compared to 2018, respectively (OR:4.30,95%CI:2.44-7.46 and AOR:7.74,95%CI:2.51-23.86). VR uptake was 0.5 and 0.6 times lower among US-trained physicians compared to internationally-trained physicians (OR:0.53,95%CI:0.37-0.76 and AOR:0.58,95%CI:0.35-0.97). Uptake was 0.2 times lower among physicians aged 60/above than physicians aged 29/less (OR:0.20,95%CI:0.10-0.59, and AOR:0.17,95%CI:0.27-1.06). ConclusionSince 2018, VR adoption has increased significantly across MCHS. However, it was lower among US-trained physicians than among internationally-trained physicians (although internationally physicians were in minority) and lower among more senior physicians than among younger physicians. These findings provide critical information about VR trends, physician factors, and which providers could benefit from additional training to increase VR adoption in healthcare systems.

ObjectiveThe COVID-19 pandemic has led to increased waiting times for elective treatments in many countries. This study seeks to address a deficit in the literature concerning the effect of long waits on the wider consumption of healthcare resources. MethodsWe carried out a retrospective treatment-control study in a healthcare system in South West England from 15 June 2021 to 15 December 2021. We compared weekly contacts with health services of patients waiting over 18 weeks for treatment ( Treatments) and people not on a waiting list ( Controls). Controls were matched to Treatments based on age, sex, deprivation and multimorbidity. Treatments were stratified by the clinical specialty of the awaited treatment, with healthcare usage assessed over various healthcare settings. T-tests assessed whether there was an increase in healthcare utilisation and bootstrap resampling was used to estimate the magnitude of any differences. ResultsA total of 44,616 patients were waiting over 18 weeks (the constitutional target in England) for treatment during the study period. Evidence suggests increases (p < 0.05) in healthcare utilisation for all specialties. Patients in the Cardiothoracic Surgery specialty had the largest increase, requiring 17.9 [4.3, 33.8] additional contacts with secondary care and 17.3 [-1.1, 34.1] additional prescriptions per year. ConclusionPeople waiting for treatment consume higher levels of healthcare than comparable individuals not on a waiting list. These findings are relevant for clinicians and managers in better understanding patient need and reducing harm. Results also highlight the possible false economy in failing to promptly resolve long elective waits. HighlightsO_LILong waits for elective care can result in additional healthcare needs to manage symptoms up to the point of definitive treatment. While previous studies indicate some association, these mainly consider only a single elective specialty and are limited in the range of healthcare settings covered. C_LIO_LIThe large number of long-wait pathways produced as a consequence of COVID-19 disruption allows for a more holistic analysis, covering the full range of elective treatment specialties and wider healthcare impacts across primary, secondary, mental health, and community care, as well as emergency service calls and prescriptions. C_LIO_LIAnalysis of 44,616 elective care pathways reveals evidence of increases in wider healthcare consumption additional to that expected for similar patients not awaiting elective treatment. This suggests a false economy in failing to promptly resolve elective pathways, which should be reflected by healthcare providers in long-term resource allocation decisions. C_LI

BackgroundThe healthcare sector has a shortage of physicians. Strategies to better retain medical professionals in the workforce in General Internal Medicine must rely on an in-depth understanding of factors associated with wanting to quit their job. Here, we investigated sex-specific associations of workplace-related and personal factors associated with wanting to quit work among physicians. MethodsIn a cross-sectional questionnaire among physicians working in General Internal Medicine in Switzerland, we assessed personal and workplace-related factors in association with the desire to quit their job. The outcome variable of wanting to quit ones job was dichotomized from a 6-point Likert scale. We performed sex-stratified analyses by Wilcoxon rank sum test, Chi-square test and multiple logistic regression adjusting for demographic variables. ResultsThis study included 682 physicians, 278 (41%) men and 404 (59%) women aged 37{+/-}11 years (mean {+/-} standard deviation). A majority of 78% men and 75% worked in hospitals. Overall, a desire to quit their job was prevalent in 33% of respondents of either sex. Almost all workplace-related items were associated with the probability of wanting to quit among both sexes: Having a good network, mentoring or supervisors support were associated with a lower probability of wanting to quit, whereas having a bad work-life balance or dissatisfaction with autonomy at work. Problematic or workplace inclusiveness and experienced gender-related discrimination at work were associated with a higher probability of wanting to quit in univariable analysis in both sexes. The main sex difference was that the associations of workplace inclusiveness or gender discrimination with wanting to quit were robust to adjustment by type of workplace and language region in men, whereas in women upon multivariable adjustments the associations disappeared. Finally, in men (but not women) having no adequate childcare was more likely to desire quitting their job. ConclusionThis study identified several factors of which some may exert a causal relationship with the desire to quit a physician job. Modifying such factors by interventions may ultimately increase the likelihood of a physician continuing working in his profession.

IntroductionHealthcare systems worldwide face mounting challenges in resource allocation amid the rising burden of chronic diseases and persistent budgetary constraints. In Brazil, the Unified Health System (SUS) must deliver comprehensive care for people with diabetes mellitus (DM) while optimizing scarce resources. Fuzzy inference approaches provide a flexible framework capable of accommodating these complexities; however, evidence regarding their application to national-level diabetes care planning remains scarce. ObjectiveTo develop and validate a fuzzy logic-based optimization model to identify more effective, equitable, and outcome-oriented resource allocation strategies for diabetes care within SUS. MethodsWe conducted a retrospective cross-sectional study utilizing DATASUS, SIH-SUS, and Hiperdia registries spanning January 2015 to December 2024 across 5,570 Brazilian municipalities, and constructed a hierarchical Mamdani-type fuzzy inference system incorporating epidemiologic, economic, clinical, and structural indicators. The model was calibrated using historical data, validated through technical, empirical, and expert assessment, and embedded within a multi-objective optimization framework to evaluate alternative investment scenarios across varied budget constraints. ResultsThe integrated dataset comprised 8,347,219 diabetes-related hospitalizations. The fuzzy inference system demonstrated 97.3% coverage and outperformed conventional approaches with mean absolute percentage error of 12.4% for expenditure predictions. Under baseline conditions, the model recommended increasing primary care investments from 31.2% to 42.7% while reducing tertiary hospital care from 38.4% to 28.9%. These reallocations predicted 8.4% improvement in glycemic control, 12.7% reduction in hospitalizations, and 6.2% mortality decrease over five years. Geographic analysis identified 847 highest-priority municipalities requiring targeted intervention. ConclusionFuzzy logic-based optimization demonstrates substantial potential for enhancing diabetes care efficiency through strategic reallocation prioritizing primary care expansion and equity-focused interventions in underserved regions.