Health Policy

Improving primary care is a long-standing strategy to constrain health care spending. Yet, evaluations of primary care models focused on payment reform have shown minimal effects on total cost of care. We report the results from a large-scale, real-world evaluation of an advanced primary care model that restructures access through same-day and next-day appointments, on-demand video visits, asynchronous clinician messaging, and extended hours. Using a stacked-cohort difference-in-differences design with entropy balancing and inverse probability of censoring weighting, we analyzed multi-payer claims covering April 2022 through March 2025. Advanced primary care use was associated with an 8.6% reduction in total cost of care (-$729 per patient per year; P = 0.004), driven by lower specialist cost (-$939/year; P < 0.001) and, to a lesser degree, by reductions in inpatient (-$134/year; P < 0.001), urgent care (-$70/year; P < 0.001), and emergency department cost (-$16/year; P = 0.02), partially offset by higher primary care cost (+$350/year; P < 0.001). The specialist reduction was concentrated in knowledge-based consultative encounters (-$663/year; P < 0.001), while procedural specialist cost was largely unchanged (-$276/year; P = 0.09). Cost differences emerged in the first post-index month. These findings suggest that advanced primary care may reduce total health care spending, with observed savings driven primarily by lower spending on consultative specialty care.

Strong primary healthcare (PHC) is associated with lower costs and better population health outcomes when supported by appropriate financing. Costing analysis enables evidenced-based decisions for estimating budgets for PHC and defining provider payments. In 2021, a project supported by the World Health Organization was launched in Ukraine to collect cost data from 100 PHC providers. The objective was to assess costs for delivering services within the state-funded benefits package, with the aim of informing tariff-setting, and assessing budget need. This study used statistical analysis on the collected cost data. We applied multivariable linear regression (MLR) to assess variation in cost-per-person across locality (rural vs. urban) and ownership type (public vs. private) of the providers, after adjusting for confounders. The mean (standard deviation) cost-per-person across the sample providers was 45.46 (18.46) USD. MLR analysis showed that rural providers had a higher cost-per-person of 6.70 USD (95% CI: 1.54, 11.85) compared to urban providers, after adjusting for confounding (p=0.011). We also found strong evidence that private providers had a lower cost-per-person of 36.15 USD (95% CI: -41.82,-30.48) compared to public providers, after adjusting for confounding (p<0.001). Although our findings do not capture the impact of the Russian hostile invasion of Ukraine, they still provide valuable insights for policy discussions within Ukraine and for other nations examining PHC financing reforms. Our findings align with international evidence suggesting that rural providers incur higher costs, supporting the need to adjust capitation payments for providers in these areas. Ownership type also affects costs, potentially reflecting differences in quality standards between public and private providers. These differences allow private providers to opportunistically reduce costs by limiting staff numbers and optimizing facility size to maximize profits. To ensure equitable access to high-quality PHC, uniform service delivery standards should be applied to all PHC providers, regardless of ownership type.

Abstract Objective To describe variation in hospital costs among children with different combinations of health conditions, special educational needs or disability (SEND) and children social care (CSC) indicators. Study Setting and Design This cross-sectional study used regression analysis to test whether two-way and three-way interactions of cross-public sector service use (health, education and social care) are associated with higher hospital costs in England. Data Sources and Analytic Sample Hospital care costs between April 2022 and March 2023 for the 8.9 million children aged 5-18 years were obtained from linked administrative hospital, education or social care data in the ECHILD database. Children were classified into eight categories based on combinations of indicators of chronic health conditions, SEND or CSC. Principal Findings Over one-third (35.4%) of children had some hospital costs during the year. Average costs were 317GBP for all children and 895GBP for children with non-zero hospital costs. By age 18, few children had no indicator in any sector (35.1% of boys, 43.7% of girls) and indicators in all three sectors were not rare (7.1% of boys, 6.2% of girls). At age 5, children with indicators recorded in all three sectors had the highest hospital costs (2,952GBP for boys and 3,674GBP for girls). At age 18, males and females with indicators in all three sectors accounted for 21% and 23% of hospital costs, respectively. SEND and social care indicators without chronic health conditions were associated with only slightly higher hospital costs. Hospital costs were much higher for children with SEND if they also had a chronic health condition. Hospital costs were only higher for children with social care if they also had both a chronic health condition and SEND. Conclusions. Taking account of additional support from non-health sectors is important for understanding health sector costs. The compounding associations between use of other public sectors on health sector costs indicates scope for targeting of integrated care.

Essential medicines are one of the cornerstones of financial protection and health equity. The REMEDIAR Program is an initiative of the Argentine Ministry of Health aimed at ensuring free access to essential medicines for the uninsured at the point of care in primary healthcare centers (PHC). This study analyzes the financing, procurement, and distribution of this program over two decades (2002 to 2024). It evaluates how the program's capacity to navigate economic and political challenges ensured an uninterrupted supply of essential drugs at the primary healthcare level in a federal country where health services are devolved to provinces. We adopted a mixed-methods approach to examine the duality between international concessional loans and domestic treasury funding. Findings reveal that while international financing enhanced predictability and efficiency, reducing procurement timelines from 458 to 235 days, it also constrained domestic planning through external conditionalities. Conversely, while national centralized procurement achieved superior price efficiency and lower dispersion, it faced rigidities in adapting to local needs. Territorial distribution analysis confirms that REMEDIAR reduced access barriers for vulnerable households without formal insurance. However, the program entered a stabilization phase, failing to consolidate robust coordination with subnational policies, becoming entrenched in its own operational logic. The study concludes that program effectiveness depends not only on resource volume but on management quality. To guarantee long-term sustainability, transition to national financing requires profound institutional redesign. This must integrate operational capacities with federal coordination and domestic regulations, ensuring that the primary healthcare supply chain remains resilient to macroeconomic volatility and political shifts, aligned with sub-national strategies.

Background: Transition timing to post-acute rehabilitation after ischemic stroke is heavily influenced by non-clinical factors, introducing potential systemic disparities in care access. We evaluated the association between insurance payor status and acute hospital length of stay (LOS) prior to inpatient rehabilitation discharge among critically ill stroke patients. Methods: Using the MIMIC-IV database, we identified ICU-admitted adults with ischemic stroke discharged to inpatient rehabilitation (n=1,285). The primary outcome was hospital LOS prior to rehab transfer. Multivariable log-transformed linear regression evaluated the association with insurance payor (Medicare, private, other/unknown; reference: Medicaid), adjusting for demographics, diagnostic-code counts (medical complexity), and ICU LOS (acute illness severity). Results: Median hospital LOS before rehab discharge was longest for Medicaid patients (13.2 days) compared with private insurance (11.0 days) and Medicare (9.5 days). In the adjusted model, Medicare insurance was associated with a significantly shorter transition time to inpatient rehabilitation, corresponding to a 13.5% shorter acute hospital stay (adjusted LOS ratio 0.87; 95% CI: 0.79-0.96; p=0.005) relative to Medicaid. Private insurance demonstrated a descriptive trend toward shorter LOS that did not achieve statistical significance (adjusted LOS ratio 0.93; 95% CI: 0.84-1.02; p=0.122). Other and unknown payor categories showed no significant differences. Conclusions: Insurance payor status serves as an independent predictor of acute care transition timing for stroke patients requiring inpatient rehabilitation. The prolonged acute stays observed among Medicaid beneficiaries suggest significant non-clinical, administrative bottlenecks in post-acute placement, underscoring the critical need for standardized, streamlined insurance approval pathways to ensure equitable neurological recovery.

Objectives: The Pharmacy First (PF) service was introduced across England from 31 January 2024 to expand the clinical role of community pharmacies and improve access to primary care. This paper describes use of PF in its first 12 months, in terms of uptake, access routes, consultation outcomes, geographic variations, service costs and antimicrobial supply. Methods: A descriptive analysis of all PF consultations submitted for payment to NHS Business Services Authority in England between 31 January 2024 and 31 January 2025. Pharmacy-level consultation data were linked to national data on population, location and pharmacy characteristics. PF use was examined using population-standardised consultation rates and consultations per pharmacy. Results: During the first year of implementation, 2,205,731 PF consultations were recorded as delivered across 11,349 pharmacies, with payment of GBP123 million to pharmacies. Uptake increased steadily over time. Most consultations were for acute sore throat (33%) and uncomplicated urinary tract infection (27%), with corresponding antibiotics, phenoxymethylpenicillin and nitrofurantoin being the most supplied. Most people self-referred (74%) into the service, with 95% of consultations managed without onward referral. Substantial geographic variation was observed. Northern regions had higher use based on the eligible population. The South East and Midlands had higher activity per pharmacy. London showed a distinct pattern, with higher self-referral into the service, lower medication supply and higher referral to other healthcare services. Higher consultation volume was weakly associated with pharmacy characteristics, including opening hours, pharmacy type and retail setting, and local context, in terms of socio-economic and geographic factors. Conclusions: PF had immediate uptake and is operating primarily as a direct-access model for common acute conditions. Findings suggest that PF is contributing to improved access to care and may shift demand away from general practice. However, the service uptake appears to be shaped by geographic location, proximity to other healthcare services and pharmacy characteristics.

Background: Mobile outreach initiatives have emerged to address persistent barriers to care for people experiencing homelessness, substance use, and mental illness. Although these models show promise, less is known about how and under what conditions they enable engagement and coordinated care. This study explains how, why, and under what circumstances a mobile, cross sector outreach model enables access to care for marginalized populations. Methods: We conducted a realist evaluation of Supportive Outreach Services (S.O.S.), a mobile, cross sector outreach program in Grey County, Ontario. Data included 31 semi structured interviews with outreach providers, partner organizations, system leaders, and clients, supplemented by document review and stakeholder feedback. Using retroductive reasoning and constant comparison, we developed and refined context mechanism outcome configurations to construct an explanatory program theory. Results: Five interconnected realist explanations account for how the model enables access to care. Trust built through repeated, non judgmental encounters supports engagement; proximity reduces barriers to participation; accessible support enables timely help seeking; cross sector relationships enable adaptive coordination; and visible results build legitimacy that sustains participation and resources. Together, these explanations provide a linked explanatory account of how mobile outreach reduces friction between marginalized populations and fragmented services while identifying the structural conditions that constrain its effectiveness. Conclusions: The effectiveness of mobile outreach depends less on the services delivered than on its capacity to reduce friction, sustain relationships, and adapt care across organizational boundaries. The resulting program theory offers transferable explanations for designing coordinated community based services while highlighting the structural conditions required for durable change.

Background: Clinician-scientists translate clinical observation into discovery, trials, and policy, yet this workforce is shrinking across health systems worldwide. Integrated MB-PhD training, pausing medical training to complete a PhD before clinical exposure or specialisation, is one route into this career. We aimed to evaluate the long-term value of MB-PhD training and the barriers to clinical-academic careers these face after graduation. Methods: We evaluated all 131 graduates (29.8% female) who entered the University College London (UCL) MB-PhD programme over a 25-year period (1994-2018). Bibliometric outputs were collated via an inter-linked information system. Concurrently, all 131 graduates were invited to respond to open-ended questions on career benefits and structural barriers; 99 (75.6%) responded, and responses were independently coded into themes, which were then reviewed and confirmed by a Study Group of 107 individuals, including the 91 respondents who agreed to participate further. Results: Graduates produced 5,877 publications (1,141 first-author, 819 corresponding-author), attracting 350,754 citations, with a mean relative citation ratio of 3.30 {+/-} 0.47, approximately three times the field average and sustained across three decades of programme entry. Graduates secured an estimated $157.55 million across 99 grants, released 465 public datasets, and were named investigators on 31 clinical trials across five continents. Among the 99 survey respondents, 49.5% held consultant-grade posts, 72.7% remained research-active, and 25.3% had reached senior academic grade. Open-ended responses were coded into five recurring structural barriers, subsequently confirmed by the Study Group: insufficient protected research time (72.2% of responses), unsupportive training structures and limited career opportunities (36.7%, 24.4% of responses), funding and pay barriers (22.2% of responses), and lack of mentorship or geographical/family constraints (14.4%, 13.3% of responses). Conclusions: Integrated MB-PhD training generates sustained academic productivity and leadership, but structural barriers threaten retention of graduates within clinical-academic careers. Protecting research time, stabilising funding and pay, and reducing geographic instability are needed to retain the clinician-scientists that health systems have already invested in training.

Introduction Primary care productivity and performance are hard to measure because patient health is not measured systematically and consistently. In England, productivity is measured using output (appointment volume) and two value-based metrics: waiting times and patient satisfaction. Higher productivity should improve all these metrics: more appointments should shorten waits, and shorter waits should raise patient satisfaction. However, little evidence tests how output and value-based metrics are associated. Methods We conducted a retrospective observational study of NHS primary care in England, 2018 to 2024, using Appointments in General Practice and the GP Patient Survey. Across Integrated Care Boards (ICBs), we examined the relationship between changes in appointment volume, waiting times, and patient dissatisfaction over two periods, 2018-2022 and 2022-2023, stratified by staff group and appointment mode. Results Completed appointments rose between 2018 and 2024, with care shifting towards non-GP staff and virtual delivery. Across ICBs in 2018-2022, per million additional appointments, waiting time changed by -0.04 days (95% CI: -0.10, 0.03) and dissatisfaction by 0.02 percentage points (95% CI: -0.36, 0.40). Per additional day of waiting, dissatisfaction changed by -1.40 percentage points (95% CI: -3.21, 0.42). In 2022-2023, the corresponding estimates were -0.31 days (95% CI: -0.57, -0.04), -0.75 percentage points (95% CI: -3.05, 1.56), and 2.85 percentage points (95% CI: 1.20, 4.51). Conclusion Increased appointment volume was not associated with shorter waiting times or lower patient dissatisfaction, and shorter waiting times were not associated with lower patient dissatisfaction. Either quality metrics do not respond to output, the key factor providers control, or they do not capture the dimensions of quality that matter. Performance frameworks that assess primary care productivity through these metrics should be reviewed.

Background: Brazil operates one of the world's largest national primary health care information systems. Since 2013, the Health Information System for Primary Care (SISAB), the digital platform of the e-SUS primary care strategy, has collected standardized records of all clinical and community health activities performed by Family Health Strategy teams across all Brazilian municipalities. Yet comprehensive longitudinal analyses of this national data infrastructure remain scarce in the international literature. Methods: Descriptive ecological study with time-series analysis using publicly available secondary data extracted from SISAB on May 18, 2026. Annual records were collected for four production types (Individual Care, Dental Care, Procedures, and Home Visits), disaggregated by all 27 Federative Units, covering April 2013 through March 2026. Per capita indicators were calculated using the 2022 Brazilian Demographic Census population by state. Results: The cumulative total of SISAB records from April 2013 through March 2026 is 12,421,073,299. Annual volume grew from 53.3 million in 2014 (first full year) to 1.96 billion in 2025, an approximately 37-fold increase over 11 years. A 9.0% decline in 2020 was associated with the COVID-19 pandemic, with full recovery by 2021. Procedures rose from 21.6% to 35.9% of total records between 2014 and 2025, reflecting deepening clinical record completeness. Per capita records varied 3.2-fold across federative units, from 29.0 (Distrito Federal) to 92.9 (Tocantins). Home visits, performed predominantly by Community Health Workers, accounted for 41.9% of all records, with the highest per capita rates concentrated in the Northeast region. Conclusions: SISAB constitutes a longitudinal national data infrastructure of exceptional scale, covering populations historically underrepresented in biomedical research: rural, Amazonian, and peri-urban communities. With over 12 years of continuous data and 184 million active registered patients, this system represents a strategic foundation for real-world evidence generation and the democratization of health science. Realizing this potential requires investment in data quality, interoperability, ethical governance, and scientific capacity aligned with Brazilian General Data Protection Law (Law n. 13,709/2018). Keywords: Primary Health Care; Health Information Systems; Family Health Strategy; Digital Health; Brazil; Community Health Workers; Real-World Evidence.

Background: Postpartum Medicaid coverage and support are central maternal health policy issues, but county-level tools for identifying where postpartum Medicaid populations may face overlapping administrative, clinical, and contextual access barriers remain limited. Methods: We developed and internally validated a county-level Postpartum Medicaid Access Barrier Index for all 3,144 counties and county equivalents in the 50 states and District of Columbia. Public data sources included geocoded Medicaid office locations from Shafer et al. (2024), U.S. Census county boundaries, American Community Survey 2024 5-year county indicators, the National Center for Health Statistics 2023 Urban-Rural Classification Scheme for Counties, and county-level hospital-based obstetric care status from the University of Minnesota Rural Health Research Center. Medicaid office locations were spatially assigned to counties, then merged with ACS indicators, rurality, and obstetric care status by county FIPS. The theoretical score range was 0-11; the index assigned higher weights to two core infrastructure measures and lower weights to contextual indicators. Internal validation assessed component structure, known-groups validity, geographic clustering, weighting sensitivity, added value over simpler infrastructure screens, and separation across concern levels. Results: Across 3,144 counties, observed scores ranged from 0 to 10 on the theoretical 0-11 score, with a mean of 3.65 and median of 3. High or highest concern counties accounted for 665 counties (21.2%), including 56 counties (1.8%) in the highest concern group. Component correlations were low-to-moderate, with an average absolute phi of 0.176 and no pairwise component correlation at or above 0.50. Known-groups validity was strong: dual administrative and clinical gap counties scored 4.43 points higher than counties with neither gap (Cohen's d = 3.28, p < 0.001). Scores were geographically clustered (Moran's I = 0.375, permutation p = 0.005). A dual-gap-only screen captured 386 of 665 high/highest concern counties (58.0%) but missed 279 high/highest counties; a parsimonious rule requiring one infrastructure gap plus at least four contextual flags recovered 265 of these 279 missed counties (95.0%) with 100.0% precision. Discussion: The Postpartum Medicaid Access Barrier Index provides a transparent county-level screening tool for identifying places where administrative, clinical, and contextual barriers may overlap for postpartum Medicaid populations and should be externally validated against Medicaid enrollment, renewal, churn, coverage continuity, and postpartum care outcomes.

Importance: The 2026 public charge rule could discourage immigrants from accessing health coverage programs, creating a chilling effect that potentially leads to negative health outcomes; However, its long-term health impact is poorly understood. Objective: To model potential impacts of the 2026 public charge rule on primary care and premature mortality among immigrants in New York City (NYC). Design, Setting, and Participants: The simulation used a deterministic compartmental model with Ordinary Differential Equations (ODEs) using 2023 NYC Vital statistics data and American Community Survey, and estimates obtained from 2 previous studies about effects of healthcare access on primary care and Medicaid expansion on premature mortality. Main Outcomes and Measures: Rates of primary care outcomes (access, doctor's visits) in 5 years, and premature mortality in 5 and 20 years, projected by the model under conservative, moderate, and aggressive scenarios of avoidance/disenrollment due to the public charge rule, known as the 'chilling effect'. Effects of the avoidance/disenrollment on primary care outcomes and premature mortality were obtained from 2 previous studies. Projected rates of the outcomes under each scenario were compared with counterfactuals to estimate the health impacts of the chilling effect. Results: Implementation of the public charge rule was projected to decrease the primary care access rate by 4.1% (conservative) to 9.9% (aggressive) over 5 years, relative to the counterfactual scenario without the rule. The rate of doctors' visits was projected to decrease over 5 years by 5.1% (conservative) to 12.2% (aggressive). Premature mortality was projected to increase by 4.4% (conservative) to 10.6% (aggressive) in 5 years and 7.4% (conservative) to 17.4% (aggressive) in 20 years. Legal noncitizens and Black immigrant New Yorkers were predicted to experience higher burdens of premature mortality attributed to the chilling effect, compared with other immigrant groups and racial/ethnic groups, respectively. Conclusions and Relevance: This study demonstrates adverse health consequences of federal public charge rule changes among immigrants in NYC. The model projected a decrease in primary care visits and increase in premature mortality across various scenarios. These findings suggest urgent reconsideration of a regulatory change that disproportionately increases risk of premature mortality among immigrants in NYC.

Objectives Emergency department (ED) crowding is recognised as an important public health concern internationally, and is driven principally by exit block, the shortage of inpatient beds for patients requiring admission. This study aimed to evaluate whether a complex intervention targeting hospital occupancy improved ED patient flow, and quantified the change in attendances. Methods A controlled interrupted time series using weekly, publicly reported Public Health Scotland data from 1 January 2022 to 1 February 2026. The multi-component intervention focused on reducing hospital occupancy and included additional adult social care funding; engagement with regional social care providers; accelerated implementation of the Discharge without Delay programme; re-evaluation of whole-hospital escalation thresholds and response; resource and data supporting inpatient department reductions in length of stay; and additional investment in remote clinical assessment. The intervention commenced at a large tertiary ED on 01 February 2025. Primary outcomes were the proportions of attendances spending [&ge;]4, [&ge;]8 and [&ge;]12 hours in the ED. The secondary outcome was attendance volume. Segmented regression was fitted with a contemporaneous control series, seasonal terms and autoregressive moving average errors. Long waits were additionally illustrated as potentially avoided deaths. Results The analysis covered 161 pre-intervention and 52 post-intervention weeks. Relative to pre-intervention levels, the proportion of attendances waiting over 4 hours fell by 10.4% (95% CI 1.6 to 19.2%), by 16.4% (95%CI 1.3 to 31.5%) over 8 hours and by 24.3% (95%CI 2.6 to 46.1%) over 12 hours. Using established associations between long ED waits and excess mortality, by one-year the intervention was potentially associated with 54 fewer excess deaths (95%CI 19 to 93). Attendances rose by 3.8% (95%CI 1.3 to 6.4%) against the counterfactual. Conclusions A complex intervention targeting hospital occupancy was associated with a reduction in long ED waits despite rising attendances. Interventions addressing hospital occupancy can meaningfully improve ED crowding.

Background: Under the DRG/DIP payment reform, the cost structure and its driving factors for laparoscopic cholecystectomy (LC) in resource-limited plateau regions remain unclear. Methods: Based on a single-center cohort of 605 plateau LC patients from May 2020 to October 2025, natural log transformation was applied to total hospitalization costs. Pearson/Spearman correlation, multivariate linear regression (traditional clinical model vs system-driven model with year dummies), and quantile regression were used. Results: Mean hospitalization cost 8097.49+/-936.85 CNY, CV=11.6%, Gini=0.062, demonstrating high homogenization. Traditional six-variable clinical model yielded R^2=0.008 (F=0.78, P=0.587), no significant predictors. The system-driven model achieved R^2=0.143 (F=3.42, P=0.001), with year dummies as dominant predictors. The study proposes the SAO (System-Allocation-Outcome) paradigm to replace the traditional SPO framework.

This study aims to map significant cold spots of postacute rehabilitation therapy delivery rates for Original Medicare beneficiaries in the U.S. and determine the prevalence of those cold spots in rural areas. Statistical spatial clustering of postacute therapy delivery rates was conducted in ArcGIS Pro using hot and cold spot analyses (Getis-Ord Gi*). County-level therapy delivery volume was defined as the total minutes of physical, occupational, and speech therapy provided by skilled nursing facilities (SNFs), home health agencies (HHAs), and inpatient rehabilitation facilities (IRFs). Therapy delivery rates were then computed as minutes per Original Medicare beneficiary at the county level and adjusted using a county-level Hierarchical Condition Category risk score. Spatial clustering identified cold spots (statistically significant clusters of low rates) and hot spots (clusters of high rates). We also computed the proportion of cold spots in rural counties and the relative percentage difference compared to the national rural county baseline, using two rural classification systems. Identified coldspots varied by provider type. For SNFs, they were notably identified in the Mountain and West North Central US divisions. For HHAs, cold spots appeared across more U.S. Census Divisions, including areas (e.g., Kentucky, Indiana, southern Illinois) where SNFs showed hot spots. Cold spots were more prevalent in rural--and especially in small rural--counties across all provider types. In rural counties, cold spot rates were 42.8% to 71.5% higher than the rural county baseline. In small rural counties, differences were larger, at 69.1% to 95.5% higher. Concluding, cold spots of postacute therapy delivery varied across the continental U.S. by provider type but were more prevalent in rural and especially in rural counties with smaller population size -- across provider types. Identifying these cold-spot locations may support geographically targeted policy responses and the development of alternative service?delivery models in underserved areas.

The COVID-19 pandemic exposed critical vulnerabilities in globally concentrated biomedical supply chains and accelerated interest in nearshoring and hemispheric health-security strategies. The Dominican Republic, already the third-largest medical device exporter in Latin America, occupies a strategically significant but institutionally constrained position within this realignment. This study evaluates stakeholder perceptions of the principal opportunities and barriers affecting biomedical ecosystem development in the Dominican Republic, with particular attention to governance, workforce capacity, and value-chain upgrading pathways. Methods. A concurrent mixed-methods design was employed, integrating a cross-sectional electronic survey of 142 purposively sampled domain experts (administered September-December 2025) with a qualitative executive consultation with senior government and industry leaders. Survey analyses combined descriptive statistics, one-sample t-tests against the scale neutral midpoint, chi-square goodness-of-fit tests, Friedman non-parametric ranking, Spearman rank correlations, and exploratory linear and logistic multivariable regression. Qualitative responses were analyzed using a framework approach grounded in the Triple Helix model of innovation systems. Results. Perceived government support was significantly below neutral (mean = 2.67, SD = 1.12; p = 0.034). Workforce shortages (83.3%) and weak academia-industry collaboration (71.4%) were the most frequently endorsed barriers ({chi}2(5) = 18.7, p = 0.002). Regulatory modernization (88.1%) and workforce development (85.7%) ranked as the highest-priority policy levers (Friedman p = 0.005). Clinical trials and contract research organization services were the dominant sub-sector priority (76.2%, binomial p < 0.001). In multivariable analysis, perceived government support, talent availability, and confidence in IP protection jointly explained 46% of the variance in sector competitiveness (R2 = 0.46, p < 0.001). Strong majority support existed for a formal public-private biomedical coordination authority (73.8%, p < 0.001).Conclusion. Institutional credibility and advanced human capital--rather than geography or market access--are the perceived binding constraints on the Dominican Republics biomedical trajectory. Regulatory modernization, targeted workforce investment, and the establishment of a national biomedical coordination authority represent the highest-leverage interventions for positioning the country as a hemispheric hub for biomedical manufacturing, clinical research, and health security.

Background A small proportion of hospitalized patients generates a disproportionate share of inpatient admissions, bed-day utilization, and associated health expenditure globally. In Saudi Arabia, where Vision 2030 mandates measurable reductions in preventable hospitalizations and hospitals consume approximately 79% of public health expenditure, population-level evidence on inpatient frequent utilization is absent from the published literature. A key methodological limitation of existing studies is reliance on a single threshold that cannot distinguish acute high-frequency episodes from sustained multi-year hospital dependence. Methods A retrospective cross-sectional study analyzed electronic health records from three public hospitals in Jeddah - East Jeddah Hospital (EJH), King Abdul-Aziz Hospital (KAAH), and Thagher Hospital (TH) - for January 2022 to December 2024. Records from two clinical information systems (Oasis at KAAH and TH; Careware at EJH) were harmonized using an eight-stage data quality protocol applied to 258,391 raw encounters, yielding a final cohort of 82,160 unique patients and 100,685 valid inpatient visits. Three complementary definitions were applied: Frequent Utilizer (FU: >=3 admissions within any rolling 365-day window), Persistent Utilizer (PU: >=3 admissions with >=24 months between first and last), and Yearly Utilizer (YU: >=1 admission in each of 2022, 2023, and 2024). Analyses were conducted in JASP 0.95.4. Results FU prevalence was 2.96% (n=2,434), PU 0.60% (n=494), and YU 0.62% (n=507). Overlap analysis identified 177 compound utilizers (0.22%) satisfying all three criteria simultaneously, with a median of 7 admissions and 33.44 bed days - more than thirteen times the standard patient median. Compound utilizers had the youngest median age of any utilizer group (24 years), while Saudi nationality concentration rose progressively from 75.0% in standard patients to 87.6% in compound utilizers, and female predominance was highest in the persistence-defined groups (PU-only 62.9%, YU-only 63.6%). All three ANOVA models confirmed significant utilizer status x hospital interactions (all p<.001). Logistic regression confirmed age, Saudi nationality, and hospital as independent predictors across all definitions. A gender discrepancy - significant for males in FU Model 1 (OR=1.090, p=.039) but not Model 2 (p=.181) - was attributable to age confounding. Conclusions Approximately one in thirty-four inpatients meets the FU criterion in this Jeddah system, with significant between-hospital variation. The three-definition framework reveals clinically distinct utilization phenotypes invisible to any single threshold, including compound utilizers with extraordinary burden and unexpectedly young age, and persistent users entirely missed by annual-window definitions. Saudi nationality is the strongest and most consistent predictor across all definitions. Integrated clinical pathways connecting primary care and community services to hospital care, with shared accountability for quality across levels, are the recommended system response aligned with Vision 2030.

Objective: to describe the provision of preconception care across publicly funded or contracted health and social care settings in the UK. Design and setting: online cross-sectional survey conducted October-December 2025. Population: healthcare professionals delivering preconception care, recruited via professional organisations and networks. Methods: quantitative data were analysed using descriptive statistics and qualitative free-text responses using inductive content analysis. Outcome measures: preconception care content, target population, frequency of provision, funding and commissioning models, and approaches for reporting and monitoring. Results: Eighty-seven healthcare professionals completed the survey. Most were women (89.3%), aged 41-60 (63.1%) and based in England (84.5%). Participants represented diverse roles, mainly obstetric/maternal-fetal specialists (23.0%), specialist nurses (16.0%), GPs and midwives (13.8% each). Preconception care primarily targeted women [&ge;]20 years (98.9%), with fewer targeting men and adolescents. Care was usually embedded within relevant consultations (69.4%), particularly contraception, medication and health condition reviews, and often a one-off interaction (75.3%). Content focused on condition-related management/medication (68.6%), folic acid (66.3%), risky behaviours (smoking, alcohol, illicit drugs) (40.7%), diet (37.2%) and weight (36.0%). Services were mostly not formally commissioned (62.4%), lacked financial incentives (84.7%) and had no audit/service evaluation requirements (81.2%). Conclusions: Preconception care in the UK is delivered by a wide range of healthcare professionals. Their engagement has improved considerably when compared with studies conducted over a decade ago, but preconception care remains fragmented, opportunistic and poorly supported by commissioning and system infrastructure. Strengthening integrated care pathways, funding mechanisms and use of standardised resources is essential to achieve consistent and equitable preconception care.

Introduction The COVID-19 pandemic profoundly disrupted healthcare delivery worldwide, with cancer care among the most affected services. Prior studies documented delays in referrals, reduced specialist access, and increased provider burden. However, the extent to which these experiences were reflected at the system level remains unclear. Objective To document cancer care experiences and examine whether these experiences were reflected in population-level health system indicators across Ontario, Canada. Methods We used an exploratory sequential mixed-methods design. Qualitative data were collected through focus groups and semi-structured interviews with 32 participants, including patients with cancer (n=8), caregivers (n=5), healthcare providers (n=14), and decision-makers (n=5) across two hospital settings in Ontario, Canada. Emergent themes informed the development of quantitative indicators. We then conducted a retrospective population-based analysis of linked administrative health databases for cancer patients in Ontario (n=87,786) to assess the prevalence of identified themes. Results Four themes emerged: (I) delays in diagnosis and screening; (II) disrupted access to primary care; (III) barriers to specialist and mental health services; and (IV) fragmented care for patients with multimorbidity. Quantitative findings corroborated major themes. Screening rates declined for cervical (64.8% to 57.5%) and breast cancer (64.5% to 57.2%). While in-person primary care shifted almost entirely to virtual modalities (8.5% to 95.4%), overall visit volumes remained stable. Specialist care showed uneven patterns, with increased oncology visits but declines in cardiology and mental health services. Patients with multiple comorbidities experienced the largest reductions in non-oncology specialist care. Conclusion The pandemic disrupted key components of cancer care, particularly screening, access to certain specialist services, and care for patients with complex needs. Integrating qualitative and quantitative evidence highlights areas of system vulnerability and underscores the need for coordinated, resilient cancer care capable of maintaining essential services during future crises.

People with a learning disability experience marked health inequalities. In Wales, Acute Learning Disability Liaison Services (ALDLS) are delivered by specialised learning disability services, and all roles within them are undertaken by Learning Disability Liaison Nurses (LDLN). These services aim to enable access to, and delivery of, secondary care by supporting reasonable adjustments, facilitating communication, and coordinating care for people with learning disability during hospital encounters. However, independent evidence of the impact of ALDLS on patient care remains limited. This evaluation tries to address this evidence gap by examining hospital staff perceptions of the visibility, role, and impact of ALDLS across Welsh Health Boards, with the aim of informing service design and development and improving secondary care access and care for people with learning disability. The service evaluation used a qualitative approach involving interviews and a focus group with hospital staff across the seven Welsh Health Boards who had experience working with or interacting with ALDLS staff to care for patients with learning disability. Findings cover six key areas including i) visibility and delivery of ALDLS, ii) Barriers and challenges to effective ALDLS delivery, iii) Enablers of effective ALDLS delivery, iv) Positive impacts for patients with learning disability, v) Negative impacts and unintended consequences when the service is absent or limited, and vi) Participants recommendations for future improvements of ALDLS. To synthesise the findings, we developed an overview diagram, which illustrates how ALDLS may influence care quality in acute hospitals. The overview places the liaison service at the centre, showing how organisational enablers and barriers shape its delivery, and how its core functions support improvements in safety, timeliness, effectiveness, efficiency, equity, and patient-centred care. From the findings we have identified recommendations for practice and policy. These include that ALDLS should be recognised as a core, safety-critical component of acute hospital care for people with a learning disability, rather than an optional add-on. In practice, services should be more visibly embedded within routine pathways, with consistent site-based presence, clear referral criteria, early identification through electronic flagging and notification systems, and routine involvement in multidisciplinary planning for complex admissions and procedures. At policy level, ALDLS provision should be recognised within equality and patient safety frameworks as an essential service requiring sustained investment, national minimum configuration standards, adequate staffing, and better-integrated digital systems to support continuity, equitable access, and person-centred care.