Carbon footprint of patient journeys through primary care: a mixed methods approach

Travel-associated carbon emissions of patients receiving cancer treatment from an urban safety net hospital

Background

Healthcare transportation, particularly the transportation of patients to access healthcare services, is a significant source of carbon emissions. This study aims to estimate the carbon emissions of patient transportation among patients receiving cancer care at an urban community safety net hospital.

Materials and Methods

We conducted a retrospective study of patients seen at the oncology clinic of an urban community safety net hospital between 1 July 2022 and 30 June 2023. Patients with at least one in-person visit in 1 year, documented home addresses, and oncologic diagnoses were included in the study. The distance between each patient's home address and the hospital was calculated using the Google Map API key and a macro to calculate distance in metres. The total estimated carbon emissions were calculated using the EPA equivalencies calculator. The primary outcome was carbon emissions from patients' round-trip travel from home to hospital.

Results

From 1 July 2022 to 30 June 2023, 13,970 visits were made to the oncology clinic. Of these, 8,235 visits made by 1,080 patients met the criteria for inclusion in the final analysis. Of the 8,235 visits recorded, 5,095 (61.8%) were follow-up/laboratory visits. The 1,080 patients who attended the clinic had a mean age of 63.8 years; 700 (64.8%) were male, and 525 (48.6%) were Black or African-American. Breast cancer was the most common diagnosis, accounting for 423 (39.2%) of cancer diagnoses. Each patient travelled 4.8 (0.3-149.3) miles for a one-way trip and 9.6 (0.7-298.6) miles for a round trip to receive cancer care. Approximately 1,520 (280-119,440) g carbon were emitted per patient visit. A total of 79,582 round-trip miles was calculated for the 8,235 visits made by all patients within 1 year, which corresponds to 31,832 kg CO2 emissions equivalent to 35,658 pounds of coal burned, 1,462 propane cylinders used for a home, or 3,872,250 smartphones charged.

Conclusion

Travel to receive cancer care is associated with significant carbon emissions and poses a climate and public health risk. Efforts to decrease the overall carbon footprint of cancer treatment are needed to minimise the contributions of cancer treatment to climate change.

Linking theory and practice to advance sustainable healthcare: the development of maturity model version 1.0

BACKGROUND

Climate change and increased awareness of planetary health have made reducing ecological footprints a priority for healthcare organizations. However, improving healthcare's environmental impact remains difficult. Numerous researchers argue these difficulties are caused by healthcare's environmental impact being multidimensional, influenced throughout the healthcare chain, and often has downstream consequences that are hard to identify or to measure. Even though existing research describes many successful approaches to reduce healthcare's environmental impact, a robust multidimensional framework to assess this impact is lacking. This research aims at developing a maturity model for sustainable healthcare that could be used for self-assessment by healthcare professionals to identify improvement actions and for sharing best practices in environmental sustainability.

METHODS

A design-oriented approach for maturity model development was combined with an expert panel and six case studies to develop, refine and expand the maturity model for environmentally sustainable healthcare.

RESULTS

A maturity model was developed containing four domains: 'Governance', 'Organization Structures', 'Processes', and 'Outcomes and Control'. Applying the model in real-world environments demonstrated the model's understandability, ease of use, usefulness, practicality and ability to identify improvement actions for environmental sustainability in healthcare organizations.

CONCLUSIONS

This study found that healthcare practitioners could apply the maturity model developed and tested in this study in several hours without training to help them gain valuable insights into the environment footprint of the healthcare setting they worked in. Systematically implementing the model developed in this study could help address the urgent need to mitigate the substantial environmental impact of healthcare. These implementations can help evaluate and improve the maturity model.

Strategies and tactics to reduce the impact of healthcare on climate change: systematic review

OBJECTIVE

To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions.

DESIGN

Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions.

DATA SOURCES

Eight databases and authoritative reports were searched from inception dates to November 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses).

RESULTS

Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48).

CONCLUSIONS

Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022383719.

Implementation of decarbonisation actions in general practice: a systematic review and narrative synthesis protocol

INTRODUCTION

There is growing recognition of the importance of primary care in addressing climate change. The World Organisation of Family Doctors has urged general practitioners worldwide to commit to tackling climate change and to serve as agents of systemic and individual change. Though an increasing number of resources have become available to support the decarbonisation of primary care, there remains a lack of evidence about how primary care teams are using them, their reach across practices, their level of adoption and maintenance, their cost impact and their effect on carbon emissions. This systematic review aims to understand how primary care, with a focus on general practice or equivalent settings within the context of primary care, is implementing decarbonisation actions to reduce carbon emissions arising from its operations, assess efficacy of the actions and generate recommendations on how to assist and accelerate their implementation and effectiveness.

METHODS AND ANALYSIS

The literature search will be conducted on Medline, Embase, Web of Science, CINAHL and ProQuest, from 2007 to 29 March 2024. Article screening will be based on specified inclusion and exclusion criteria. Narrative synthesis will be used to analyse and integrate findings to offer new insights into key mechanisms that support decarbonisation in general practice and help refine an initial programme theory. The reporting of the systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis framework.

ETHICS AND DISSEMINATION

This review did not involve the collection or analysis of any data that was not included in previously published research in the public domain. The results will be disseminated through peer-reviewed publication and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42023470889.

Teleophthalmology at a primary and tertiary eye care network from India: environmental and economic impact

OBJECTIVE

To evaluate the environmental and economic impact of teleophthalmological services provided by a primary (rural) and tertiary (urban) eyecare network in India.

METHODS

This prospective study utilised a random sampling method, and administered an environmental and economic impact assessment questionnaire. The study included 324 (primary: 173; tertiary: 151) patients who received teleconsultations from July to September 2022. The primary network (rural) used a colour-coded triage system (Green: eye conditions managed by teleconsult alone; yellow: semi-urgent referral within 1 week to a month, red: urgent referral within a day to a week). The tertiary network (urban) included new and follow-up patients. The environmental impact was assessed by estimating the potential CO2 emissions saved by avoiding travel for various transport modes. Economic impact measured by the potential cost savings from direct (travel) and indirect (food and wages lost) expenses spent by yellow and red referrals (primary) and the first-visit expenses of follow-up (tertiary) patients.

RESULTS

The primary rural network saved 2.89 kg CO2/person and 80 km/person. The tertiary urban network saved 176.6 kg CO2/person and 1666 km/person. The potential cost savings on travel expenses were INR 19,970 (USD 250) for the primary (average: INR 370 (USD 4.6) per patient) and INR 758,870 (USD 9486) for the tertiary network (average: INR 8339 (USD 104) per patient). Indirect cost savings (food and wages) were of INR 29,100 (USD 364) for the primary and INR 347,800 (USD 4347) for the tertiary network.

CONCLUSION

Teleophthalmology offers substantial environmental and economic benefits in rural and urban eyecare systems.

Patient and clinician experiences with the multidisciplinary single-day cochlear implant selection (MSCS) protocol

PURPOSE

This study assessed the MSCS (Multidisciplinary Single-day Cochlear Implant Selection) protocol with a primary focus on sustaining or enhancing patient satisfaction throughout the cochlear implant selection process.

MATERIALS AND METHODS

Following the implementation of the new selection protocol, where all selection appointments take place on the same day, we surveyed 37 individuals who underwent the process. Twenty adhered to the standard procedure, while 17 followed the MSCS protocol. We also gathered feedback from seven out of eight involved healthcare providers. This method enabled us to evaluate the protocol's effectiveness in maintaining patient satisfaction and ensuring staff contentment with care delivery within a condensed timeframe.

RESULTS

Patient responses showed slight variations in average scores without statistical significant differences, indicating comparable satisfaction between the MSCS pathway and the standard protocol. The majority of patients preferred the MSCS protocol, with none of the MSCS participants opting for appointments spread over multiple days. Healthcare practitioners of the CI center also displayed similar or increased satisfaction levels with the MSCS protocol.

CONCLUSION

The adoption of the MSCS in daily clinical care has led to a decrease in patient appointment times without sacrificing patient satisfaction. Additionally, the majority of individuals actively choose the MSCS protocol. Among those who have directly experienced it, there is unanimous preference for the consolidated appointments over spreading them across multiple days. Professionals within the CI team express equal satisfaction with both the new and old protocols, indicating that the reduction in patient time does not diminish overall satisfaction.

Modelling the Costs of Sublingual Immunotherapy versus Subcutaneous Immunotherapy Based on Clinical Appointments and Impacts of Patient Travel in Sweden

Aim

In Sweden, allergy immunotherapy (AIT) is available as either subcutaneous immunotherapy (SCIT) injections or sublingual immunotherapy (SLIT) tablets and is used to treat moderate-severe allergic rhinitis (AR). This study sought to determine direct and indirect annual costs stemming from treatment-related travel, appointments, waiting times and medication costs, before exploring likely CO2 emission-related cost-savings for 20,330 patients receiving SCIT or SLIT-tablets in Sweden.

Methods

A model was developed in Python to capture each category of costs in the target patient population. Absenteeism costs arising from treatment-related travel were determined by obtaining average hourly pay data from Swedish Government sources. Absenteeism costs were also calculated for 30-minute post-dose observation times, which occurred during one clinical appointment for SLIT patients, and all clinical appointments for SCIT patients. Clinical appointment costs were obtained from healthcare price lists for Sweden. Medication costs were retrieved from the Pharmaceutical Specialities in Sweden (Fass) website, and treatment doses required for SCIT and SLIT-tablets were determined based on product labels and previously-calculated dosage regimes. High-cost protection and reimbursement scheme payment caps were applied when determining patient appointment and medication costs, respectively, and when identifying financial burdens for individual payers.

Results

Mean total annual costs for SCIT were Swedish Krona (SEK) 604.1 million (m), with clinical appointments contributing the largest share of these costs (52.7%), followed by medication (34.4%), travel-related absenteeism (8.9%), waiting time-related absenteeism (2.7%) and private transportation (1.3%). Mean total annual costs for SLIT-tablets were SEK 336.2m. Medication contributed the most to these costs (72.3%), followed by clinical appointments (22.7%), travel-related absenteeism (3.8%), waiting time-related absenteeism (0.6%) and private transportation (0.6%).

Conclusion

For patients with moderate-severe AR receiving AIT in Sweden, SLIT-tablets displayed large potential cost savings to patients, the healthcare system, and the government, whilst possessing reduced societal costs of carbon emissions relative to SCIT.

Environmentally sustainable gastroenterology practice: Review of current state and future goals

OBJECTIVES

The health-care sector contributes 4.6% of global greenhouse gas emissions, with gastroenterology playing a significant role due to the widespread use of gastrointestinal (GI) endoscopy. In this review, we aim to understand the carbon footprint in gastroenterology practice associated with GI endoscopy, conferences and recruitment, identify barriers to change, and recommend mitigating strategies.

METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted to explore the carbon footprint in gastroenterology practice, focusing on endoscopy, inpatient and outpatient settings, and recruitment practices. Recommendations for mitigating the carbon footprint were derived.

RESULTS

This narrative review analyzed 34 articles on the carbon footprint in gastroenterology practice. Carbon footprint of endoscopy in the United States is approximately 85,768 metric tons of CO2 emission annually, equivalent to 9 million gallons of gasoline consumed, or 94 million pounds of coal burned. Each endoscopy generates 2.1 kg of disposable waste (46 L volume), of which 64% of waste goes to the landfill, 28% represents biohazard waste, and 9% is recycled. The per-case manufacturing carbon footprint for single-use devices and reusable devices is 1.37 kg CO2 and 0.0017 kg CO2, respectively. Inpatient and outpatient services contributed through unnecessary procedures, prolonged hospital stays, and excessive use of single-use items. Fellowship recruitment and gastrointestinal conferences added to the footprint, mainly due to air travel and hotel stays.

CONCLUSION

Gastrointestinal endoscopy and practice contribute to the carbon footprint through the use of disposables such as single-use endoscopes and waste generation. To achieve environmental sustainability, measures such as promoting reusable endoscopy equipment over single-use endoscopes, calculating institutional carbon footprints, establishing benchmarking standards, and embracing virtual platforms such as telemedicine and research meetings should be implemented.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

Modelling the impact of sublingual immunotherapy versus subcutaneous immunotherapy on patient travel time and CO2 emissions in Sweden

In Sweden, allergy immunotherapy (AIT) is available as either subcutaneous immunotherapy (SCIT) injections or sublingual immunotherapy (SLIT) tablets and is used to treat moderate-severe allergic rhinitis (AR). This study sought to determine treatment-related CO2 emissions and travel times in Swedish patients receiving either SCIT or SLIT-tablets. A list of specialized Swedish AR clinics that administer AIT was determined, and respective co-ordinates retrieved. Swedish municipality population data were obtained from a national database. The mean distance from each Swedish municipality to the nearest AR clinic was calculated, adjusted using a detour index, and weighted by estimated patient population size. Transport modality data were obtained from a Swedish urban transport study and CO2 emissions were obtained from Government sources. The mean number of annual SLIT-tablets and SCIT doses required were calculated based on product labels and clinical expert input. The annual number of healthcare professional interactions were layered into the model to estimate changes in mean patient travel time, distance, and travel-related CO2 emissions associated with using SCIT versus SLIT-tablets. Mean annual travel-related CO2 emissions were 410 tonnes (to two significant figures [s.f.]; standard deviation [SD] 90) with SLIT-tablets, versus 1700 tonnes (SD 380) for SCIT, resulting in mean annual savings of approximately 1300 tonnes (SD 290) of CO2 if all AIT patients were to receive SLIT-tablets instead of SCIT, over 380 times greater than 2021 average Swedish CO2 emissions per capita. Approximate mean annual travel times for patients taking SLIT-tablets were 66,500 h (three s.f.; SD 14,400), and 278,000 h (SD 60,200) for SCIT, resulting in mean annual savings of 211,000 h (SD 45,800) if all AIT patients were to receive SLIT-tablets instead of SCIT. Compared with SCIT injections, SLIT-tablets led to substantial reductions in treatment-related CO2 emissions and travel times for Swedish patients.

Digital physiotherapy assessment vs conventional face-to-face physiotherapy assessment of patients with musculoskeletal disorders: A systematic review

BACKGROUND

This systematic review aimed to assess the certainty of evidence for digital versus conventional, face-to-face physiotherapy assessment of musculoskeletal disorders, concerning validity, reliability, feasibility, patient satisfaction, physiotherapist satisfaction, adverse events, clinical management, and cost-effectiveness.

METHODS

Eligibility criteria: Original studies comparing digital physiotherapy assessment with face-to-face physiotherapy assessment of musculoskeletal disorders. Systematic database searches were performed in May 2021, and updated in May 2022, in Medline, Cochrane Library, Cinahl, AMED, and PEDro. Risk of bias and applicability of the included studies were appraised using the Quality Assessment of Diagnostic Accuracy Studies-2 tool and the Quality Appraisal of Reliability Studies tool. Included studies were synthesised narratively. Certainty of evidence was evaluated for each assessment component using GRADE.

RESULTS

Ten repeated-measures studies were included, involving 193 participants aged 23-62 years. Reported validity of digital physiotherapy assessment ranged from moderate/acceptable to almost perfect/excellent for clinical tests, range of motion, patient-reported outcome measures (PROMs), pain, neck posture, and management decisions. Reported validity for assessing spinal posture varied and was for clinical observations unacceptably low. Reported validity and reliability for digital diagnosis ranged from moderate to almost perfect for exact+similar agreement, but was considerably lower when constrained to exact agreement. Reported reliability was excellent for digital assessment of clinical tests, range of motion, pain, neck posture, and PROMs. Certainty of evidence varied from very low to high, with PROMs and pain assessment obtaining the highest certainty. Patients were satisfied with their digital assessment, but did not perceive it as good as face-to-face assessment.

DISCUSSION

Evidence ranging from very low to high certainty suggests that validity and reliability of digital physiotherapy assessments are acceptable to excellent for several assessment components. Digital physiotherapy assessment may be a viable alternative to face-to-face assessment for patients who are likely to benefit from the accessibility and convenience of remote access.

TRIAL REGISTRATION

The review was registered in the PROSPERO database, CRD42021277624.

Virtual consultation in paediatric urology during the COVID-19 pandemic: The effect of pathology on the outcome

Introduction

Virtual consultation (VC) has exponentially increased during the COVID-19 pandemic. Lessons from using this modality during the pandemic will need to be appraised carefully before integrating it into the routine practice. Some paediatric urology patients can potentially be excellent candidates for routine VC.

Objectives

Investigate the ability of clinicians to make management plans using VCs and identify accordingly the group of patients that can benefit from routine VC. Evaluate the routine use of VC without travel restrictions.

Methods

Designed in two phases. Phase 1, during the lockdown, prospective collection of data after the consultation assessing the clinician satisfaction in making a decision by VC. The results were then divided according to the patient pathology; internal organ pathology (IOP), functional urological pathology (FUP) or external organ pathology (EOP). Data was then analysed to demonstrate if different outcomes can be related to the pathology. Phase 2 after the ease of the lockdown to judge the lessons learnt looking at the same parameters in patients who are selected to receive VC and evaluate journey saved by the patients, measured in miles.

Results

One hundred and forty-four consultations were assessed. One hundred and fourteen in phase 1 and 30 from phase 2. Mean age 7.2 years. In phase 1, 57% of patients were reviewed by consultants and 72% were followed up. Thirty-seven per cent had IOP, 24.5% FUP and 38.5% EOP. Clinicians were more likely to reach a decision with patients with IOP and FUP P < 0.0001 and 0.0024, respectively. Phase 2 demonstrated the change of practice where 93% of the patients were either IOP or FUP. An average of 27 miles per patient was saved on journeys.

Discussion

VC for paediatric urology patients was employed effectively to avoid hospital contact during the lockdown. From the lessons learnt that patients with IOP and FUP can continue to benefit from VC after the ease of lockdown without compromising the decision making. VC is a viable way to structure services in the future for selected paediatric urology conditions.

What is the carbon footprint of primary care practices? A retrospective life-cycle analysis in Switzerland

BACKGROUND

The medical field causes significant environmental impact. Reduction of the primary care practice carbon footprint could contribute to decreasing global carbon emissions. This study aims to quantify the average carbon footprint of a primary care consultation, describe differences between primary care practices (best, worst and average performing) in western Switzerland and identify opportunities for mitigation.

METHODS

We conducted a retrospective carbon footprint analysis of ten private practices over the year 2018. We used life-cycle analysis to estimate carbon emissions of each sector, from manufacture to disposal, expressing results as CO₂ equivalents per average consultation and practice. We then modelled an average and theoretical best- case and worst-case practices. Collected data included invoices, medical and furniture inventories, heating and power supply, staff and patient transport, laboratory analyses (in/out-house) waste quantities and management costs.

RESULTS

An average medical consultation generated 4.8 kg of CO₂eq and overall, an average practice produced 30 tons of CO₂eq per year, with 45.7% for staff and patient transport and 29.8% for heating. Medical consumables produced 5.5% of CO₂eq emissions, while in-house laboratory and X-rays contributed less than 1% each. Emergency analyses requiring courier transport caused 5.8% of all emissions. Support activities generated 82.6% of the total CO₂eq. Simulation of best- and worst-case scenarios resulted in a ten-fold variation in CO₂eq emissions.

CONCLUSION

Optimizing structural and organisational aspects of practice work could have a major impact on the carbon footprint of primary care practices without large-scale changes in medical activities.

Carbon footprint reduction associated with a surgical outreach clinic

BACKGROUND

Healthcare systems generate substantial carbon footprints that may be targeted to decrease greenhouse gas emissions. Outreach clinics may represent tools to assist in this reduction by optimizing patient related travel. Therefore, we sought to estimate the carbon footprint savings associated with a head and neck surgery outreach clinic.

METHODS

This study was a cross-sectional survey of patient travel patterns to a surgical outreach clinic compared to a regional cancer treatment centre from December 2019 to February 2020. Participants completed a self-administered survey of 12 items eliciting travel distance, vehicle details, and ability to combine medical appointments. Canadian datasets of manufacturer provided vehicular efficiency were used to estimate carbon emissions for each participant. Geographic information systems were used for analyses.

RESULTS

One hundred thirteen patients were included for analysis. The majority of patients (85.8%) used their own personal vehicle to travel to the outreach clinic. The median distance to the clinic and regional centre were 29.0 km (IQR 6.0-51.9) and 327.0 km (IQR 309.0-337.0) respectively. The mean carbon emission reduction per person was therefore 117,495.4 g (SD: 29,040.0) to 143,570.9 g (SD: 40,236.0). This represents up to 2.5% of an average individual's yearly carbon footprint. Fewer than 10% of patients indicated they were able to carpool or group their appointments.

CONCLUSION

Surgical outreach clinics decrease carbon footprints associated with patient travel compared to continued care at a regional centre. Further research is needed to determine possible interventions to further reduce carbon emissions associated with the surgical care of patients.

Life cycle assessment as decision support tool for environmental management in hospitals: A literature review

BACKGROUND

Life cycle assessment (LCA) is an environmental accounting tool aimed at determining environmental impacts of products, processes, or organizational activities over the entire life cycle. Although this technique already provides decision-makers in other sectors with valuable information, its application in the health care setting has not yet been examined.

PURPOSE

The aim of this study was to provide a comprehensive overview of scientific research on the application of LCA in hospitals and its contribution to management decision-making.

METHOD

We perform a systematic literature review by searching a range of databases with synonyms of "LCA" in combination with the term "hospital" in order to identify peer-reviewed studies. The final sample of 43 studies were then subjected to a content analysis.

RESULTS

We categorize existing research and show that single and multi-indicator LCA approaches are used to examine several products and processes in hospitals. The various approaches are favored by different scientific communities. Whereas researchers from environmental sciences perform complex multi-indicator LCA studies, researchers from health care sciences focus on footprints. The studies compare alternatives and identify environmental impacts and harmful hotspots.

PRACTICE IMPLICATIONS

LCA results can support health care managers' traditional decision-making by providing environmental information. With this additional information regarding the environmental impacts of products and processes, managers can implement organizational changes to improve their environmental performance. Furthermore, they can influence upstream and downstream activities. However, we recommend more transdisciplinary cooperation for LCA studies and to place more focus on actionable recommendations when publishing the results.

Molecular epidemiology of HIV-1 infection in Europe: An overview

Human Immunodeficiency Virus type 1 (HIV-1) is characterised by vast genetic diversity. Globally circulating HIV-1 viruses are classified into distinct phylogenetic strains (subtypes, sub-subtypes) and several recombinant forms. Here we describe the characteristics and evolution of European HIV-1 epidemic over time through a review of published literature and updated queries of existing HIV-1 sequence databases. HIV-1 in Western and Central Europe was introduced in the early-1980s in the form of subtype B, which is still the predominant clade. However, in Eastern Europe (Former Soviet Union (FSU) countries and Russia) the predominant strain, introduced into Ukraine in the mid-1990s, is subtype A (A_FSU) with transmission mostly occurring in People Who Inject Drugs (PWID). In recent years, the epidemic is evolving towards a complex tapestry with an increase in the prevalence of non-B subtypes and recombinants in Western and Central Europe. Non-B epidemics are mainly associated with immigrants, heterosexuals and females but more recently, non-B clades have also spread amongst groups where non-B strains were previously absent - non-immigrant European populations and amongst men having sex with men (MSM). In some countries, non-B clades have spread amongst the native population, for example subtype G in Portugal and subtype A in Greece, Albania and Cyprus. Romania provides a unique case where sub-subtype F1 has predominated throughout the epidemic. In contrast, HIV-1 epidemic in FSU countries remains more homogeneous with A_FSU clade predominating in all countries. The differences between the evolution of the Western epidemic and the Eastern epidemic may be attributable to differences in transmission risk behaviours, lifestyle and the patterns of human mobility. The study of HIV-1 epidemic diversity provides a useful tool by which we can understand the history of the pandemic in addition to allowing us to monitor the spread and growth of the epidemic over time.