The dynamics of international health system reforms: Evidence of a new wave in response to the 2008 economic crisis and the COVID-19 pandemic?

Global economic and health shocks, such as the 2008 global financial crisis and the COVID-19 pandemic typically impact healthcare financing and delivery. Cutler found that profound societal changes in the 20th century induced three waves of healthcare reform across seven major OECD countries. Our study investigates whether major crises in the 21st century induced similar reform waves. Through thematic analysis, we systematically compared health system changes in response to these shocks, using data from the Observatory on Health Systems and Policies and the OECD. Our analysis reveals similar overarching reform trends across countries in response to the 2008 economic crisis: a tendency toward re-centralization of health system governance to control and leverage the efficient rationalization of public health resources. This, to some extent, countered the effects of the market-based reforms of the previous wave. The reforms induced by the 2008 crisis were mediated by its repercussions on the countries' economies. In contrast, reforms in response to the pandemic aimed primarily to address the direct impact of the shock on the health system. Despite its negative economic impact, the pandemic resulted in a substantial but temporary increase in public health spending. A better understanding reform dynamics and their impact on overarching conflicting health system objectives may prevent unintended consequences and enhance health systems' resilience in response to future shocks.

The roads to managed competition for mixed public-private health systems: a conceptual framework

Health systems' insurance/funding can be organised in several ways. Some countries have adopted systems with a mixture of public-private involvement (e.g. Australia, Chile, Ireland, South Africa, New Zealand) which creates two-tier health systems, allowing consumers (groups) to have preferential access to the basic standard of care (e.g. skipping waiting times). The degree to which efficiency and equity are achieved in these types of systems is questioned. In this paper, we consider integration of the two tiers by means of a managed competition model, which underpins Social Health Insurance (SHI) systems. We elaborate a two-part conceptual framework, where, first, we review and update the existing pre-requisites for the model of managed competition to fit a broader definition of health systems, and second, we typologise possible roadmaps to achieve that model in terms of the insurance function, and focus on the consequences on providers and governance/stewardship.

Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework

BACKGROUND

Despite the potential for improved population mental health and wellbeing, the integration of mental health digital interventions has been difficult to achieve. In this qualitative systematic review, we aimed to identify barriers and facilitators to the implementation of digital technologies in mental healthcare systems, and map these to an implementation framework to inform policy development.

METHODS

We searched Medline, Embase, Scopus, PsycInfo, Web of Science, and Google Scholar for primary research articles published between January 2010 and 2022. Studies were considered eligible if they reported barriers and/or facilitators to the integration of any digital mental healthcare technologies. Data were extracted using EPPI-Reviewer Web and analysed thematically via inductive and deductive cycles.

RESULTS

Of 12,525 references identified initially, 81 studies were included in the final analysis. Barriers and facilitators were grouped within an implementation (evidence-practice gap) framework across six domains, organised by four levels of mental healthcare systems. Broadly, implementation was hindered by the perception of digital technologies as impersonal tools that add additional burden of care onto both providers and patients, and change relational power asymmetries; an absence of resources; and regulatory complexities that impede access to universal coverage. Facilitators included person-cantered approaches that consider patients' intersectional features e.g., gender, class, disability, illness severity; evidence-based training for providers; collaboration among colleagues; appropriate investment in human and financial resources; and policy reforms that tackle universal access to digital health.

CONCLUSION

It is important to consider the complex and interrelated nature of barriers across different domains and levels of the mental health system. To facilitate the equitable, sustainable, and long-term digital transition of mental health systems, policymakers should consider a systemic approach to collaboration between public and private sectors to inform evidence-based planning and strengthen mental health systems.

PROTOCOL REGISTRATION

The protocol is registered on PROSPERO, CRD42021276838.

Scope and Incentives for Risk Selection in Health Insurance Markets With Regulated Competition: A Conceptual Framework and International Comparison

In health insurance markets with regulated competition, regulators face the challenge of preventing risk selection. This paper provides a framework for analyzing the scope (i.e., potential actions by insurers and consumers) and incentives for risk selection in such markets. Our approach consists of three steps. First, we describe four types of risk selection: (a) selection by consumers in and out of the market, (b) selection by consumers between high- and low-value plans, (c) selection by insurers via plan design, and (d) selection by insurers via other channels such as marketing, customer service, and supplementary insurance. In a second step, we develop a conceptual framework of how regulation and features of health insurance markets affect the scope and incentives for risk selection along these four dimensions. In a third step, we use this framework to compare nine health insurance markets with regulated competition in Australia, Europe, Israel, and the United States.

Preconditions for efficiency and affordability in mixed health systems: are they fulfilled in the Australian public-private mix?

The Australian health system is characterised by high quality care by international standards, produced by a mix of public and private provision and funding of healthcare services. Despite good overall results, three issues are of concern. The first issue relates to the public procurement of healthcare, whose flaws have impacted individuals' access to care, and the high out-of-pocket spending. The second issue concerns the sustainability of the private health insurance market, given the government's goal of relieving cost and capacity from the public scheme, incentivising participation. Third, there are existing inefficiencies and inequities related to the duplication resulting from the interaction between public and private schemes. To ensure a sustainable, efficient and equitable health system, structural reforms are necessary to achieve long-term performance improvements. Using a framework for mixed public-private health systems, we assess the extent to which the Australian healthcare system achieves preconditions for efficiency and affordability in competitive healthcare markets.

Redox-mediated electrochemiluminescence enhancement for bead-based immunoassay

Electrochemiluminescence (ECL) is a highly sensitive mode of detection utilised in commercialised bead-based immunoassays. Recently, the introduction of a freely diffusing water-soluble Ir(iii) complex was demonstrated to enhance the ECL emission of [Ru(bpy)3]2+ labels anchored to microbeads, but a comprehensive investigation of the proposed 'redox-mediated' mechanism was not carried out. In this work, we select three different water-soluble Ir(iii) complexes by virtue of their photophysical and electrochemical properties in comparison with those of the [Ru(bpy)3]2+ luminophore and the TPrA co-reactant. A systematic investigation of the influence of each Ir(iii) complex on the emission of the Ru(ii) labels on single beads by ECL microscopy revealed that the heterogeneous ECL can be finely tuned and either enhanced up to 107% or lowered by 75%. The variation of the [Ru(bpy)3]2+ ECL emission was correlated to the properties of each Ir(iii)-based mediator, which enabled us to decipher the mechanism of interaction and define guidelines for the future design of novel Ir(iii) complexes to further enhance the ECL emission of bead-based immunoassays. Ultimately, we showcase the potential of this technology for practical sample analysis in commercial instruments by assessing the enhancement of the collective ECL intensity from a bead-based system.

Optics Determines the Electrochemiluminescence Signal of Bead-Based Immunoassays

Electrochemiluminescence (ECL) is an optical readout technique that is successfully applied for the detection of biomarkers in body fluids using microbead-based immunoassays. This technology is of utmost importance for in vitro diagnostics and thus a very active research area but is mainly focused on the quest for new dyes and coreactants, whereas the investigation of the ECL optics is extremely scarce. Herein, we report the 3D imaging of the ECL signals recorded at single microbeads decorated with the ECL labels in the sandwich immunoassay format. We show that the optical effects due to the light propagation through the bead determine mainly the spatial distribution of the recorded ECL signals. Indeed, the optical simulations based on the discrete dipole approximation compute rigorously the electromagnetic scattering of the ECL emission by the microbead and allow for reconstructing the spatial map of ECL emission. Thus, it provides a global description of the ECL chemical reactivity and the associated optics. The outcomes of this 3D imaging approach complemented by the optical modeling provide insight into the ECL optics and the unique ECL chemical mechanism operating on bead-based immunoassays. Therefore, it opens new directions for mechanistic investigations, ultrasensitive ECL bioassays, and imaging.

Dynamic Mapping of Electrochemiluminescence Reactivity in Space: Application to Bead-Based Assays

As an electrochemical technique offering an optical readout, electrochemiluminescence (ECL) evolved recently into a powerful microscopy technique with the visualization of a wide range of microscopic entities. However, the dynamic imaging of transient ECL events did not receive intensive attention due to the limited number of electrogenerated photons. Here, the reaction kinetics of the model ECL bioassay system was revealed by dynamic imaging of single [Ru(bpy)3]2+-functionalized beads in the presence of the efficient tripropylamine coreactant. The time profile behavior of ECL emission, the variations of the ECL layer thickness, and the position of maximum ECL intensity over time were investigated, which were not achieved by static imaging in previous studies. Moreover, the dynamics of the ECL emission were confronted with the simulation. The reported dynamic ECL imaging allows the investigation of the ECL kinetics and mechanisms operating in bioassays and cell microscopy.

Interventions for improving clinical outcomes and health-related quality-of-life for people living with skeletal dysplasias: an evidence gap map

PURPOSE

Skeletal dysplasias are rare genetic disorders that are characterized by abnormal development of bone and cartilage. There are multiple medical and non-medical treatments for specific symptoms of skeletal dysplasias e.g. pain, as well as corrective surgical procedures to improve physical functioning. The aim of this paper was to develop an evidence-gap map of treatment options for skeletal dysplasias, and their impact on patient outcomes.

METHODS

We conducted an evidence-gap map to identify the available evidence on the impact of treatment options on people with skeletal dysplasias on clinical outcomes (such as increase in height), and dimensions of health-related quality of life. A structured search strategy was applied to five databases. Two reviewers independently assessed articles for inclusion in two stages: titles and abstracts (stage 1), and full text of studies retained at stage 2.

RESULTS

58 studies fulfilled our inclusion criteria. The included studies covered 12 types of skeletal dysplasia that are non-lethal with severe limb deformities that could result in significant pain and numerous orthopaedic interventions. Most studies reported on the effect of surgical interventions (n = 40, 69%), followed by the effect of treatments on dimensions of health quality-of-life (n = 4, 6.8%) and psychosocial functioning (n = 8, 13.8%).

CONCLUSION

Most studies reported on clinical outcomes from surgery for people living with Achondroplasia. Consequently, there are gaps in the literature on the full range of treatment options (including no active treatment), outcomes and the lived experience of people living with other skeletal dysplasias. More research is warranted to examine the impact of treatments on health-related quality-of-life of people living with skeletal dysplasias, including their relatives to enable them to make preference- and valued based decisions about treatment.

Priority setting in the German healthcare system: results from a discrete choice experiment

Worldwide, social healthcare systems must face the challenges of a growing scarcity of resources and of its inevitable distributional effects. Explicit criteria are needed to define the boundaries of public reimbursement decisions. As Germany stands at the beginning of such a discussion, more formalised priority setting procedures seem in order. Recent research identified multi-criteria decision analysis (MCDA) as a promising approach to inform and to guide decision-making in healthcare systems. In that regard, this paper aims to analyse the relative weight assigned to various criteria in setting priority interventions in Germany. A discrete choice experiment (DCE) was employed in 2015 to elicit equity and efficiency preferences of 263 decision makers, through six attributes. The experiment allowed us to rate different policy interventions based on their features in a composite league table (CLT). As number of potential beneficiaries, severity of disease, individual health benefits and cost-effectiveness are the most relevant criteria for German decision makers within the sample population, the results display an overall higher preference towards efficiency criteria. Specific high priority interventions are mental disorders and cardiovascular diseases.

Electrogenerated chemiluminescence at boron-doped diamond electrodes

Electrogenerated chemiluminescence (ECL) refers to the phenomenon of light emission from molecular species which is triggered by an electrochemical reaction. Therefore, like most electrochemical systems, the electrode material plays a pivotal role and much effort has been made in order to find the best material for ECL, in terms of light signal intensity and long-term stability, especially after the development of ECL for analytical applications. In this article, we will introduce and highlight the distinctive features of boron-doped diamond (BDD) as an electrode material for ECL which has complementary properties compared to the most common metals (e.g., Au or Pt) and carbon materials (e.g., glassy carbon, carbon nanotubes and graphene). Boron-doped diamond electrodes emerged as novel electrodes, gaining more and more interest from the electrochemical community for their peculiar characteristics such as a wide solvent window, low capacitance, resistance to fouling and mechanical robustness. Furthermore, compared to metal electrodes, BDD does not form an oxide layer in aqueous solutions, and the sp³ carbon hybridization gives BDD the ability to enable peculiar electrochemical reactions that are not possible on sp² carbon materials. Electrogenerated chemiluminescence investigations with boron-doped diamond electrodes have been reported for common ECL systems (luminophores and co-reactants), and special ECL that is only possible on BDD which includes the in situ electrochemical generation of the co-reactant.

Smartphone-based 3D-printed electrochemiluminescence enzyme biosensor for reagentless glucose quantification in real matrices

Three-dimensional (3D) printed electrochemical devices are increasingly used in point-of-need and point-of-care testing. They show several advantages such as simple fabrication, low cost, fast response, and excellent selectivity and sensitivity in small sample volumes. However, there are only a few examples of analytical devices combining 3D-printed electrodes with electrochemiluminescence (ECL) detection, an electrochemical detection principle widely employed in clinical chemistry analysis. Herein, a portable, 3D-printed miniaturized ECL biosensor for glucose detection has been developed, based on the luminol/H₂O₂ ECL system and employing a two-electrode configuration with carbon black-doped polylactic acid (PLA) electrodes. The ECL emission is obtained by means of a 1.5V AA alkaline battery and detected using a smartphone camera, thus providing easy portability of the analytical platform. The ECL system was successfully applied for sensing H₂O₂ and, upon coupling the luminol/H₂O₂ system with the enzyme glucose oxidase, for glucose detection. The incorporation of luminol and glucose oxidase in an agarose hydrogel matrix allowed to produce ECL devices preloaded with the reagents required for the assay, so that the analysis only required sample addition. The ECL biosensor showed an excellent ability to detect glucose up to 5 mmol L^-1, with a limit of detection of 60 μmol L^-1. The biosensor was also used to analyse real samples (i.e., glucose saline solutions and artificial serum samples) with satisfactory results, thus suggesting its suitability for point-of-care analysis. Coupling with other oxidases could further extend the applicability of this analytical platform.

Bimodal Electrochemiluminescence Microscopy of Single Cells

Electrochemiluminescence (ECL) microscopy is an emerging technique with new applications such as imaging of single entities and cells. Herein, we have developed a bimodal and bicolor approach to record both positive ECL (PECL: light-emitting object on dark background) and shadow label-free ECL (SECL: nonemissive object shadowing the background luminescence) images of single cells. This bimodal approach is the result of the simultaneous emissions of [Ru(bpy)₃]²⁺ used to label the cellular membrane (PECL) and [Ir(sppy)₃]^3- dissolved in solution (SECL). By spectrally resolving the ECL emission wavelengths, we recorded the images of the same cells in both PECL and SECL modes using the [Ru(bpy)₃]²⁺ (λ_max = 620 nm) and [Ir(sppy)₃]^3- (λ_max = 515 nm) luminescence, respectively. PECL shows the distribution of the [Ru(bpy)₃]²⁺ labels attached to the cellular membrane, whereas SECL reflects the local diffusional hindrance of the ECL reagents by each cell. The high sensitivity and surface-confined features of the reported approach are demonstrated by imaging cell-cell contacts during the mitosis process. Furthermore, the comparison of PECL and SECL images demonstrates the differential diffusion of tri-n-propylamine and [Ir(sppy)₃]^3- through the permeabilized cell membranes. Consequently, this dual approach enables the imaging of the morphology of the cell adhering on the surface and can significantly contribute to multimodal ECL imaging and bioassays with different luminescent systems.

Study protocol for an economic evaluation and budget impact of implementation strategies to support routine provision of antenatal care for gestational weight gain: a stepped-wedge cluster trial

BACKGROUND

Antenatal clinical practice guidelines recommend routine assessment of weight and provision of advice on recommended weight gain during pregnancy and referral to additional services when appropriate. However, there are barriers to clinicians adopting such best-practice guidelines. Effective, cost-effective, and affordable implementation strategies are needed to ensure the intended benefits of guidelines are realised. This paper describes the protocol for evaluating the efficiency and affordability of implementation strategies compared to the usual practice in public antenatal services.

METHOD

The prospective trial-based economic evaluation will identify, measure, and value key resource and outcome impacts arising from the implementation strategies compared with usual practice. The evaluation will comprise of (i) costing, (ii) cost-consequence analyses, where a scorecard approach will be used to show the costs and benefits given the multiple primary outcomes included in the trial, and (iii) cost-effectiveness analysis, where the primary outcome will be incremental cost per percent increase in participants reporting receipt of antenatal care for gestational weight gain consistent with the guideline recommendations. Affordability will be evaluated using (iv) budget impact assessment and will estimate the financial implications of adoption and diffusion of this implementation strategy from the perspective of relevant fund-holders.

DISCUSSION

Together with the findings from the effectiveness trial, the outcomes of this economic evaluation will inform future healthcare policy, investment allocation, and research regarding the implementation of antenatal care to support healthy gestational weight gain.

TRIAL REGISTRATION

Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819 (22/01/2021) http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380680&isReview=true .

An Economic Model for Estimating Trial Costs with an Application to Placebo Surgery Trials

BACKGROUND AND OBJECTIVE

Waste in clinical trials remains rife. We developed an economic model to predict the cost of trials based on input costs, duration, power, number of sites, recruitment eligibility and consenting rates.

METHODS

We parameterised the model for three proxy placebo-controlled surgical trials using data from a systematic review, a bespoke cost survey, and from the literature. We used the model to compare target and actual trial performance for (i) a trial that was completed on time but with more sites, (ii) a trial that completed after a time extension, and (iii) an incomplete trial.

RESULTS

Successful trials more accurately anticipated the true recruitment rate that they achieved and those that overestimated this were most likely to fail. The costs of overestimating recruitment rates were dramatic: all proxy trials had significantly higher costs than planned, with additional funding of at least AUD$600,000 (50% above budget) required for trials that completed after adding more sites or more time, and over AUD$2 million (260% above budget) for incomplete trials.

CONCLUSIONS

This model shows the trade-offs between time and cost, or both, when recruitment is lower than anticipated. Greater consideration is needed to improve trial planning, reviewing, and funding of these trials to avoid costly overruns and incomplete trials.

Electrochemiluminescence Amplification in Bead-Based Assays Induced by a Freely Diffusing Iridium(III) Complex

Heterogeneous electrochemiluminescence (ECL) assays employing tri-n-propylamine as a co-reactant and a tris(2,2'-bipyridine)ruthenium(II) ([Ru(bpy)₃]²⁺) derivative as an emissive label are integral to the majority of academic and commercial applications of ECL sensing. This model system is an active research area and constitutes the basis of successfully commercialized bead-based ECL immunoassays. Herein, we propose a novel approach to the enhancement of such conventional ECL assays via the incorporation of a second metal coordination complex, [Ir(sppy)₃]^3- (where sppy = 5'-sulfo-2-phenylpyridinato-C²,N), to the experimental system. By employing ECL microscopy, we are able to map the spatial distribution of ECL emission at the surface of the bead, from [Ru(bpy)₃]²⁺ labels, and solution-phase emission, from [Ir(sppy)₃]^3-. The developed [Ir(sppy)₃]^3--mediated enhancement approach elicited a significant improvement (70.9-fold at 0.9 V and 2.9-fold at 1.2 V vs Ag/AgCl) of the ECL signal from [Ru(bpy)₃]²⁺ labels immobilized on the surface of a polystyrene bead. This dramatic enhancement in ECL signal, particularly at low oxidation potentials, has important implications for the improvement of existing heterogeneous ECL assays and ECL-based microscopy, by amplifying the signal, opening new bioanalytical detection schemes, and reducing both electrode surface passivation and deleterious side reactions.

Standardising policy and technology responses in the immediate aftermath of a pandemic: a comparative and conceptual framework

BACKGROUND

The initial policy response to the COVID-19 pandemic has differed widely across countries. Such variability in government interventions has made it difficult for policymakers and health research systems to compare what has happened and the effectiveness of interventions across nations. Timely information and analysis are crucial to addressing the lag between the pandemic and government responses to implement targeted interventions to alleviate the impact of the pandemic.

METHODS

To examine the effect government interventions and technological responses have on epidemiological and economic outcomes, this policy paper proposes a conceptual framework that provides a qualitative taxonomy of government policy directives implemented in the immediate aftermath of a pandemic announcement and before vaccines are implementable. This framework assigns a gradient indicating the intensity and extent of the policy measures and applies the gradient to four countries that share similar institutional features but different COVID-19 experiences: Italy, New Zealand, the United Kingdom and the United States of America.

RESULTS

Using the categorisation framework allows qualitative information to be presented, and more specifically the gradient can show the dynamic impact of policy interventions on specific outcomes. We have observed that the policy categorisation described here can be used by decision-makers to examine the impacts of major viral outbreaks such as SARS-CoV-2 on health and economic outcomes over time. The framework allows for a visualisation of the frequency and comparison of dominant policies and provides a conceptual tool to assess how dominant interventions (and innovations) affect different sets of health and non-health related outcomes during the response phase to the pandemic.

CONCLUSIONS

Policymakers and health researchers should converge toward an optimal set of policy interventions to minimize the costs of the pandemic (i.e., health and economic), and facilitate coordination across governance levels before effective vaccines are produced. The proposed framework provides a useful tool to direct health research system resources and build a policy benchmark for future viral outbreaks where vaccines are not readily available.

Electrochemical Characterization and CO2 Reduction Reaction of a Family of Pyridazine-Bridged Dinuclear Mn(I) Carbonyl Complexes

Three recently synthesized neutral dinuclear carbonyl manganese complexes with the pyridazine bridging ligand, of general formula [Mn₂(μ-ER)₂(CO)₆(μ-pydz)] (pydz = pyridazine; E = O or S; R = methyl or phenyl), have been investigated by cyclic voltammetry in dimethylformamide and acetonitrile both under an inert argon atmosphere and in the presence of carbon dioxide. This family of Mn(I) compounds behaves interestingly at negative potentials in the presence of CO₂. Based on this behavior, which is herein discussed, a rather efficient catalytic mechanism for the CO₂ reduction reaction toward the generation of CO has been hypothesized.

Should administrative costs in health insurance be included in the risk-equalization? An analysis of five countries

Most countries that apply risk-equalization in their health insurance market(s) perform risk-equalization on medical claims but do not include other components of the insurance premium, such as administrative costs. Using fixed effects panel regressions from individual insurers in Australia, Germany, the Netherlands, Switzerland, and the US, we find evidence that health insurers with a high morbidity population on average have higher administrative costs. We argue that administrative costs should also be included in risk-equalization and we show that such equalization results in additional equalization payments nontrivial in size. Using examples from Germany and the US, we show how in practice policymakers can include administrative costs in risk-equalization. We are skeptical about applying risk-equalization to other components of the insurance premium, such as profits or costs related to solvency requirements of insurers.

Driving up the Electrocatalytic Performance for Carbon Dioxide Conversion through Interface Tuning in Graphene Oxide-Bismuth Oxide Nanocomposites

The integration of graphene oxide (GO) into nanostructured Bi₂O₃ electrocatalysts for CO₂ reduction (CO₂RR) brings up remarkable improvements in terms of performance toward formic acid (HCOOH) production. The GO scaffold is able to facilitate electron transfers toward the active Bi₂O₃ phase, amending for the high metal oxide (MO) intrinsic electric resistance, resulting in activation of the CO₂ with smaller overpotential. Herein, the structure of the GO-MO nanocomposite is tailored according to two synthetic protocols, giving rise to two different nanostructures, one featuring reduced GO (rGO) supporting Bi@Bi₂O₃ core-shell nanoparticles (NP) and the other GO supporting fully oxidized Bi₂O₃ NP. The two structures differentiate in terms of electrocatalytic behavior, suggesting the importance of constructing a suitable interface between the nanocarbon and the MO, as well as between MO and metal.

Comparing risk adjustment estimation methods under data availability constraints

The Italian National Healthcare Service relies on per capita allocation for healthcare funds, despite having a highly detailed and wide range of data to potentially build a complex risk-adjustment formula. However, heterogeneity in data availability limits the development of a national model. This paper implements and ealuates machine learning (ML) and standard risk-adjustment models on different data scenarios that a Region or Country may face, to optimize information with the most predictive model. We show that ML achieves a small but generally statistically insignificant improvement of adjusted R² and mean squared error with fine data granularity compared to linear regression, while in coarse granularity and poor range of variables scenario no differences were observed. The advantage of ML algorithms is greater in the coarse granularity and fair/rich range of variables set and limited with fine granularity scenarios. The inclusion of detailed morbidity- and pharmacy-based adjustors generally increases fit, although the trade-off of creating adverse economic incentives must be considered.

The Epidemiology of Major Trauma During the First Wave of COVID-19 Movement Restriction Policies: A Systematic Review and Meta-analysis of Observational Studies

Background

The objective of this systematic review is to investigate changes in the epidemiology of major trauma presentations during the implementation of movement restriction measures to manage the first wave of the SARS-CoV-2 (COVID-19) pandemic.

Methods

A systematic search in six databases, as well as a search of grey literature was performed from January 2020 to August 2021. Estimates were pooled using random-effects meta-analysis. The certainty of evidence was rated according to the GRADE approach. The review is reported using both PRISMA guideline and the MOOSE checklist.

Results

In total, 35 studies involving 36,987 patients were included. The number of major trauma admissions overall decreased during social movement restrictions (−24%; p < 0.01; 95% CI [−0.31; −0.17]). A pooled analysis reported no evidence of a change in the severity of trauma admissions (OR:1.17; 95%CI [0.77, 1.79], I² = 77%). There was no evidence for a change in mortality during the COVID-19 period (OR:0.94, 95%CI [0.80,1.11], I² = 53%). There was a statistically significant reduction in motor vehicle trauma (OR:0.70; 95%CI [0.61, 0.81], I² = 91%) and a statistically significant increase in admissions due to firearms and gunshot wounds (OR:1.34; 95%CI [1.11, 1.61], I² = 73%) and suicide attempts and self-harm (OR:1.41; 95%CI [1.05, 1.89], I² = 39%).

Conclusions and relevance

Although evidence continues to emerge, this systematic review reports some decrease in absolute major trauma volume with unchanged severity and mortality during the first wave of COVID-19 movement restriction policies. Current evidence does not support the reallocation of highly specialised trauma professionals and trauma resources.

Registration PROSPERO ID CRD42020224827.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06625-7.

Boron-Doped Diamond Electrode Outperforms the State-of-the-Art Electrochemiluminescence from Microbeads Immunoassay

Electrochemiluminescence (ECL) is a powerful transduction technique where light emission from a molecular species is triggered by an electrochemical reaction. Application to biosensors has led to a wide range of electroanalytical methods with particular impact on clinical analysis for diagnostic and therapeutic monitoring. Therefore, the quest for increasing the sensitivity while maintaining reproducible and easy procedures has brought investigations and innovations in (i) electrode materials, (ii) luminophores, and (iii) reagents. Particularly, the ECL signal is strongly affected by the electrode material and its surface modification during the ECL experiments. Here, we exploit boron-doped diamond (BDD) as an electrode material in microbead-based ECL immunoassay to be compared with the approach used in commercial instrumentation. We conducted a careful characterization of ECL signals from a tris(2,2'-bipyridine)ruthenium(II) (Ru(bpy)₃²⁺)/tri-n-propylamine (TPrA) system, both homogeneous (i.e., free diffusing Ru(bpy)₃²⁺) and heterogeneous (i.e., Ru(bpy)₃²⁺ bound on microbeads). We investigated the methods to promote TPrA oxidation, which led to the enhancement of ECL intensity, and the results revealed that the BDD surface properties greatly affect the ECL emission, so it does the addition of neutral, cationic, or anionic surfactants. Our results from homogeneous and heterogeneous microbead-based ECL show opposite outcomes, which have practical consequences in ECL optimization. In conclusion, by using Ru(bpy)₃²⁺-labeled immunoglobulins bound on microbeads, the ECL resulted in an increase of 70% and a double signal-to-noise ratio compared to platinum electrodes, which are actually used in commercial instrumentation for clinical analysis. This research infers that microbead-based ECL immunoassays with a higher sensitivity can be realized by BDD.

Patient and clinician characteristics and preferences for increasing participation in placebo surgery trials: a scoping review of attributes to inform a discrete choice experiment

Background

Orthopaedic surgeries include some of the highest volume surgical interventions globally; however, studies have shown that a significant proportion of patients report no clinically meaningful improvement in pain or function after certain procedures. As a result, there is increasing interest in conducting randomised placebo-controlled trials in orthopaedic surgery. However, these frequently fail to reach recruitment targets suggesting a need to improve trial design to encourage participation. The objective of this study was to systematically scope the available evidence on patient and clinician values and preferences which may influence the decision to participate in placebo surgery trial.

Methods

A systematic review was conducted via a literature search in the MEDLINE, Embase, PsycInfo, CINAHL, and EconLit databases as of 19 July 2021, for studies of any design (except commentaries or opinion pieces) based on two key concepts: patient and clinician characteristics, values and preferences, and placebo surgery trials.

Results

Of 3424 initial articles, we retained 18 eligible studies. Characteristics, preferences, values, and attitudes of patients (including levels of pain/function, risk/benefit perception, and altruism) and of clinicians (including concerns regarding patient deception associated with placebo, and experience/training in research) influenced their decisions to participate in placebo-controlled trials. Furthermore, some aspects of trial design, including randomisation procedures, availability of the procedure outside of the trial, and the information and consent procedures used, also influenced decisions to participate.

Conclusion

Participant recruitment is a significant challenge in placebo surgery trials, and individual decisions to participate appear to be sensitive to preferences around treatment. Understanding and quantifying the role patient and clinician preferences may play in surgical trials may contribute to the optimisation of the design and implementation of clinical trials in surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06277-x.

A vicious cycle of health (IN)equity: Migrant inclusion in light of COVID-19

Objectives

Methods

Results

Conclusions

Covid 19 Vaccines and the Australian health care state

Objectives

Australia had one of the most successful early responses to the COVID-19 pandemic. Border closures and effective public health responses to outbreaks kept infection and death rates to amongst the lowest in the world. The strategy was premised on an eventual escape through the development and availability of vaccines. While effective vaccines appeared earlier than many expected, Australia's the next stage of crisis management stalled. Vaccination rates were, in mid-2021, one of the lowest in the OECD. By the end of 2021, however, Australia had a comparatively high vaccination rate. This paper accounts for this paradoxical situation.

Methods

The analysis uses Moran and Tuohy's concept of the ‘health care state’ to show how interlocking elements of consumption, production, governance and statecraft created the conditions for Australia's contradictory response to the crisis.

Results

The paper locates problems commonly attributed to ‘leadership failure’ in an analysis of the evolving dynamics of the Australian healthcare state and the governance regimes concerning collective consumption, the health professions, and technologies. Vaccine supply was delayed by the Federal government's preference for local production. The initial problems of the vaccine rollout arose from a failed experiment with outsourcing, initiated at the height of the crisis.

Conclusion

Australia's ultimate success in achieving high vaccination rates emerged from the agile stability embedded in its health care state. This delivered where ‘market inspired innovation’ had failed.

An analysis of the COVID-19 vaccination campaigns in France, Israel, Italy and Spain and their impact on health and economic outcomes

Objectives

This paper presents an overview of the vaccination campaigns in France, Israel, Italy and Spain during the first eleven months from the first COVID-19 vaccine approval (Dec 2020 - Nov 2021). These four countries were chosen as they share similar socioeconomic, and epidemiological profiles and adopted similar vaccination strategies.

Methods

A rapid review of available primary data from each country was conducted. Data were collected from official government documents whenever possible, supplemented by information from international databases and local reports. The data were analysed via descriptive and graphical analysis to identify common patterns as well as significant divergences in the structural changes of countries’ healthcare systems during the pandemic, outcomes of the vaccination roll-out, and their impact on contextual policies.

Results

The four countries adopted similar interventions to protect and strengthen their healthcare systems. The effective coordination between the governance levels, ability to ensure a large supply of doses, and trust towards health authorities were amongst the determinants for more successful vaccination outcomes. The analysis reports a positive impact of the COVID-19 vaccines on epidemiological, political and economic outcomes. We observed some evidence of a negative association between increased vaccine coverage and fatalities and hospitalisation trends.

Conclusions

The strengths and weaknesses of COVID-19 pandemic crisis management along with the various strategies surrounding the vaccination roll-out campaigns may yield lessons for policymakers amidst such decisions, including for future pandemics.

Lay summary

This paper presents an overview of the vaccination campaigns in France, Israel, Italy and Spain during the first eleven months following approval of the first COVID-19 vaccine (Dec 2020 - Nov 2021). These four countries were chosen as they share similar demographic, socioeconomic, and epidemiological profiles, and adopted similar vaccinations strategies. Effective coordination between governance levels, ability to ensure a large supply of doses, and trust towards health authorities were amongst the determinants for successful outcomes of vaccination campaigns. The strengths and weaknesses of COVID-19 pandemic crisis management, along with the various strategies surrounding the vaccination roll-out campaigns may yield lessons for policymakers amidst such decisions, including for future pandemics.

Factors Underlying Patient and Surgeon Willingness to Participate in a Placebo Surgery Controlled trial: A Qualitative Investigation

Objective

To investigate the factors underlying willingness to participate in a hypothetical trial among patients and surgeons, to inform the design of future placebo surgery controlled trials.

Background

Placebo surgery controlled trials are the gold standard for testing the efficacy of surgical procedures. However, these trials commonly fail to meet the target sample size and terminate underpowered.

Methods

From October 2019 to July 2020, eligible patients were identified from the orthopedic waiting list at a single tertiary hospital and surgeons were identified from orthopedic clinics at three tertiary hospitals in Australia. Qualitative interviews explored factors underlying willingness to participate in a hypothetical trial, including understanding of trial concepts; attitudes; and trial design preferences. Data collection and analysis were conducted in parallel. Recruitment ceased when no new concepts emerged. Interview data were analyzed using reflexive thematic analysis.

Results

The majority of surgeons and only a few patients indicated a willingness to participate in a placebo surgery controlled trial. Factors underlying willingness were captured in four themes: (1) Understanding and attitudes toward placebo; (2) Attitudes towards randomization/perception of equipoise; (3) Perception of risk; and (4) Ethical concerns.

Conclusions

To optimize recruitment in the future, trialists may consider embedding strategies into the recruitment process that validate patients' symptoms, encourage an altruistic mindset, address surgeon biases, and involve surgeons in explaining trial concepts to patients. Trialists may also consider designing three arm trials that meet surgeons' preferences for a "low" and "high" fidelity placebo.

Finding the way forward: COVID-19 vaccination progress in Germany, Austria and Switzerland

Objectives

: This paper presents an overview of the procurement and deployment of COVID-19 vaccinations in Germany, Austria and Switzerland (DACH) from the success of the first vaccine trials until the end of August 2021. Data regarding vaccination procurement and deployment is presented, followed by an analysis of the challenges these countries face in improving their vaccination rates.

Methods

: A review and analysis of available data from the DACH countries was conducted. Data was collected from official government sources whenever possible and supplemented by information from international databases and local reports. The data was analyzed to identify common patterns as well as divergences across the DACH region, especially as they relate to vaccine hesitancy and health policy.

Results

: Following initial global supply problems, the DACH countries were largely successful at administering vaccinations to their populations. However, by the end of August 2021 their vaccination progress had plateaued. This was primarily due to vaccine hesitancy in the region, which is correlated with a multitude of complex factors. These factors need to be better understood before this issue can be effectively addressed. Unlike other countries, the DACH countries have not (yet) used financial incentives or mandates to increase vaccination rates.

Conclusions

: The DACH countries displayed effective governance in their deployment of COVID-19 vaccines, but vaccine hesitancy is slowing progress. Due to various social and political factors, Germany, Austria and Switzerland have not been able to employ effective policy levers to overcome this barrier and a more nuanced strategy will have to be developed.

Public Interest Summary

: Germany, Austria and Switzerland (DACH) were largely successful at procuring COVID-19 vaccine doses and administering them to their populations. After the first doses were acquired, their vaccination rates continued to steadily rise, but progress began to slow down substantially by August 2021 due in part to vaccine hesitancy. Unlike in other countries, the DACH governments have not been able to implement vaccine mandates to try and overcome this issue due to their specific political and social circumstances. A deeper understanding of the factors driving vaccine hesitancy in the region will be required before effective solutions can be found.

Barriers and facilitators to the integration of digital technologies in mental health systems: A protocol for a qualitative systematic review

INTRODUCTION

Digital technology has the potential to improve health outcomes and health system performance in fragmented and under-funded mental health systems. Despite this potential, the integration of digital technology tools into mental health systems has been relatively poor. This is a protocol for a synthesis of qualitative evidence that will aim to determine the barriers and facilitators to integrating digital technologies in mental health systems and classify them in contextual domains at individual, organisational and system levels.

METHODS AND ANALYSIS

The methodological framework for systematic review of qualitative evidence described in Lockwood et al. will be applied to this review. A draft search strategy was developed in collaboration with an experienced senior health research librarian. A systematic search of Medline, Embase, Scopus, PsycInfo, Web of Science and Google Scholar, as well as hand searching of reference lists and reviews will identify relevant studies for inclusion. Study selection will be carried out independently by two authors, with discrepancies resolved by consensus. The quality of selected studies will be assessed using JBI Critical Appraisal Checklist for Qualitative Research. Data will be charted using JBI QUARI Data Extraction Tool for Qualitative Research. Findings will be defined and classified both deductively in a priori conceptual framework and inductively by a thematic analysis. Results will be reported based on the Enhancing transparency in reporting the synthesis of qualitative research. The level of confidence of the findings will be assessed using GRADE-CERQual.

ETHICS AND DISSEMINATION

This study does not require ethics approval. The systematic review will inform policy and practices around improving the integration of digital technologies into mental health care systems.

Policy Stringency, Handwashing and COVID-19 cases: Evidence from Global dataset

Objective

: Since the COVID-19 pandemic, many governments globally have introduced policy measures to contain the spread of the virus. Popular COVID-19 containment measures include lockdowns of various forms (aggregated into government response stringency index [GRSI]) and handwashing (HWF). The effectiveness of these policy measures remains unclear in the academic literature. This study, therefore, examines the effect of government policy stringency and handwashing on total daily reported COVID-19 cases.

Method

: We use a comprehensive dataset of 176 countries to investigate the effect of government policy stringency and handwashing on daily reported COVID-19 cases. In this study, we apply the Lewbel (2012) two-stage least squares technique to control endogeneity.

Results

: Our results indicated that GRSI significantly contributes to the increase in the total and new confirmed cases of COVI-19. Sensitivity analyses revealed that the 1st, 4th, and 5th quintiles of GRIS significantly reduce total confirmed cases of COVID-19. Also, the result indicated that while the 1st quintile of GRIS contributes significantly to reducing the new confirmed cases of COVID-19, the 3rd, 4th, and 5th quintiles of GRSI contribute significantly to increasing the new confirmed cases of COVID-19. The results indicated that HWF reduces total and new confirmed cases of COVID-19; however, such effect is not robust to income and regional effects. Nonlinear analysis revealed that while GRSI has an inverted U-shaped relationship with total and new confirmed cases of COVID-19, HWF has a U-shaped relationship.

Conclusion

: We suggest that policymakers should focus on raising awareness and full engagement of all members of society in implementing public health policies rather than using stringent lockdown measures.

An Expanded 2D Fused Aromatic Network with 90-Ring Hexagons

Two-dimensional fused aromatic networks (2D FANs) have emerged as a highly versatile alternative to holey graphene. The synthesis of 2D FANs with increasingly larger lattice dimensions will enable new application perspectives. However, the synthesis of larger analogues is mostly limited by lack of appropriate monomers and methods. Herein, we describe the synthesis, characterisation and properties of an expanded 2D FAN with 90-ring hexagons, which exceed the largest 2D FAN lattices reported to date.

Can risk rating increase the ability of voluntary deductibles to reduce moral hazard?

Several regulated health insurance markets include the option for consumers to choose a voluntary deductible. An important motive for this option is to reduce moral hazard. In return for a voluntary deductible, consumers receive a premium rebate, which is typically community rated. Under community rating, voluntary deductibles are particularly attractive for low-risk consumers. Since these people use relatively little medical care, the total moral hazard reduction might be relatively small compared to the total healthcare spending. This paper examines the potential moral hazard reduction under risk-rated premiums. We use Chile as a case study due to institutional features that make it a valid benchmark for other countries. Our simulations show that in the presence of self-selection and under a uniform percentage moral hazard reduction across risk types, the absolute moral hazard reduction from a voluntary deductible is indeed expected to be larger in a system with risk-rated premiums than in a system with community-rated premiums. Nevertheless, sensitivity checks show that this conclusion might no longer hold as the percentage moral hazard reduction is lower for high-risk individuals compared to low-risk individuals.

An implementation intervention to increase the routine provision of antenatal care addressing gestational weight gain: study protocol for a stepped-wedge cluster trial

Background

Weight gain during pregnancy that is outside of recommended levels is associated with a range of adverse outcomes for the mother and child, including gestational diabetes, pre-eclampsia, preterm birth, and obesity. Internationally, 60–80% of pregnant women report gaining weight outside of recommended levels. While guideline recommendations and RCT evidence support the provision of antenatal care that supports healthy gestational weight gain, less than 10% of health professionals routinely weigh pregnant women; discuss weight gain, diet, and physical activity; and provide a referral for additional support. This study aims to determine the effectiveness of an implementation intervention in increasing the provision of recommended gestational weight gain care by maternity services.

Methods

A stepped-wedge controlled trial, with a staggered implementation intervention, will be conducted across maternity services in three health sectors in New South Wales, Australia. The implementation intervention will consist of evidence-based, locally-tailored strategies including guidelines and procedures, reminders and prompts, leadership support, champions, training, and monitoring and feedback. Primary outcome measures will be the proportion of women who report receiving (i) assessment of gestational weight gain; (ii) advice on gestational weight gain, dietary intake, and physical activity; and (iii) offer of referral to a telephone coaching service or local dietetics service. Measurement of outcomes will occur via telephone interviews with a random sample of women who attend antenatal appointments each week. Economic analyses will be undertaken to assess the cost, cost-consequence, cost-effectiveness, and budget impact of the implementation intervention. Receipt of all care elements, acceptance of referral, weight gain during pregnancy, diet quality, and physical activity will be measured as secondary outcomes. Process measures including acceptability, adoption, fidelity, and reach will be reported.

Discussion

This will be the first controlled trial to evaluate the effectiveness of a implementation intervention in improving antenatal care that addresses gestational weight gain. The findings will inform decision-making by maternity services and policy agencies and, if the intervention is demonstrated to be effective, could be applied at scale to benefit the health of women and children across Australia and internationally.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12621000054819. Registered on 22 January 2021

Thermally Induced Synthesis of Anthracene-, Pyrene- and Naphthalene-Fused Porphyrins

The synthesis of π-extended porphyrins containing anthracenyl moieties still represents an important challenge. Here, we report on the synthesis of a series of unsubstituted naphthyl-, pyrenyl- and anthracenyl-fused zinc porphyrin derivatives. To this aim, meso-substitued porphyrins are synthesized and the fusion of the PAHs (Polycyclic Aromatic Hydrocarbon) on the β-positions are performed through thermally induced dehydro-aromatization. The fused zinc-porphyrin derivatives are fully characterized and their optical absorption and photoluminescence properties are reported. We also demonstrate that zinc can be removed from the porphyrin core, giving rise to pure C, H, N materials. This work constitutes the first step towards the synthesis of the fully-fused tetra-anthracenylporphyrin.

Electrochemiluminescent immunoassay enhancement driven by carbon nanotubes

Electrochemiluminescence (ECL) is a leading analytical technique for clinical monitoring and early disease diagnosis. Carbon nanotubes are used as efficient nanomaterials for ECL signal enhancement providing new insights into the mechanism for the ECL generation but also affording application in bead-based immunoassay and ECL microscopy-based bioimaging.

DNA-Based Nanoswitches: Insights into Electrochemiluminescence Signal Enhancement

Electrochemiluminescence (ECL) is a powerful transduction technique that has rapidly gained importance as a powerful analytical technique. Since ECL is a surface-confined process, a comprehensive understanding of the generation of ECL signal at a nanometric distance from the electrode could lead to several highly promising applications. In this work, we explored the mechanism underlying ECL signal generation on the nanoscale using luminophore-reporter-modified DNA-based nanoswitches (i.e., molecular beacon) with different stem stabilities. ECL is generated according to the "oxidative-reduction" strategy using tri-n-propylamine (TPrA) as a coreactant and Ru(bpy)₃²⁺ as a luminophore. Our findings suggest that by tuning the stem stability of DNA nanoswitches we can activate different ECL mechanisms (direct and remote) and, under specific conditions, a "digital-like" association curve, i.e., with an extremely steep transition after the addition of increasing concentrations of DNA target, a large signal variation, and low preliminary analytical performance (LOD 22 nM for 1GC DNA-nanoswtich and 16 nM for 5GC DNA-nanoswitch). In particular, we were able to achieve higher signal gain (i.e., 10 times) with respect to the standard "signal-off" electrochemical readout. We demonstrated the copresence of two different ECL generation mechanisms on the nanoscale that open the way for the design of customized DNA devices for highly efficient dual-signal-output ratiometric-like ECL systems.

Lighting up the Electrochemiluminescence of Carbon Dots through Pre- and Post-Synthetic Design

Carbon dots (CDs), defined by their size of less than 10 nm, are a class of photoluminescent (PL) and electrochemiluminescent (ECL) nanomaterials that include a variety of carbon-based nanoparticles. However, the control of their properties, especially ECL, remains elusive and afflicted by a series of problems. Here, the authors report CDs that display ECL in water via coreactant ECL, which is the dominant mechanism in biosensing applications. They take advantage of a multicomponent bottom-up approach for preparing and studying the luminescence properties of CDs doped with a dye acting as PL and ECL probe. The dependence of luminescence properties on the surface chemistry is further reported, by investigating the PL and ECL response of CDs with surfaces rich in primary, methylated, or propylated amino groups. While precursors that contribute to the core characterize the PL emission, the surface states influence the efficiency of the excitation-dependent PL emission. The ECL emission is influenced by surface states from the organic shell, but states of the core strongly interact with the surface, influencing the ECL efficiency. These findings offer a framework of pre- and post-synthetic design strategies to improve ECL emission properties, opening new opportunities for exploring biosensing applications of CDs.

Wavy graphene sheets from electrochemical sewing of corannulene

The presence of non-hexagonal rings in the honeycomb carbon arrangement of graphene produces rippled graphene layers with valuable chemical and physical properties. In principle, a bottom-up approach to introducing distortion from planarity of a graphene sheet can be achieved by careful insertion of curved polyaromatic hydrocarbons during the growth of the lattice. Corannulene, the archetype of such non-planar polyaromatic hydrocarbons, can act as an ideal wrinkling motif in 2D carbon nanostructures. Herein we report an electrochemical bottom-up method to obtain egg-box shaped nanographene structures through a polycondensation of corannulene that produces a new conducting layered material. Characterization of this new polymeric material by electrochemistry, spectroscopy, electron microscopy (SEM and TEM), scanning probe microscopy, and laser desorption-ionization time of flight mass spectrometry provides strong evidence that the anodic polymerization of corannulene, combined with electrochemically induced oxidative cyclodehydrogenations (Scholl reactions), leads to polycorannulene with a wavy graphene-like structure.

A bottom-up synthesis of wavy graphene structures obtained through an anodic polymerization process, combined with an electrochemically triggered oxidative cyclodehydrogenation, of the bowl-shaped polyaromatic hydrocarbon corannulene.