Sustainable Planning for Health – Review of Frameworks for Health System Strengthening

Background

Imbalances in the distribution of health as well as global interconnectedness led to the consideration of health as a global public good. Health is placed therefor at the center of the goal-based movement for sustainability led by the United Nations (UN). Health System Strengthening (HSS) is an approach to align and harmonize all stakeholders in sustainable planning for health.

Methods

Frameworks published by nation states, multilateral institutions or global health initiatives were retrieved and analyzed in form of a critical realist review informed by poststructuralist curiosity. The aim was to understand how these frameworks contribute to the context of sustainable planning for health with the overall goal of improved health system performance.

Results

Eleven frameworks published by nation states, multilateral institutions or global health initiatives were obtained for this thesis. The frameworks support an understanding of how a health system is structured, how resources are allocated, how the financing and delivery of care is organized and how the different stakeholders of a health system are governed. Frameworks for health systems are a policy tool to introduce a common language for the architecture of health systems and to describe the way in which performance relates to functions in the form of a result-chain. The stakeholders involved in the development and implementation of these approaches are limited and predominantly from the global south. Gender, Equity and Human-rights criteria (GER-criteria) to address values are not sufficiently reflected in the frameworks.

Conclusions

The analysis in this thesis shows that HSS is an approach that requires an understanding of health system architecture and how it relates to performance. Although the different frameworks make the case for performance assessment and the linkage to resources, what is missing is a value-based approach that centers the knowledge generated by the Global South.

Key messages

Frameworks for HSS are policy tools for a common language for the architecture of health systems and to describe the way in which performance relates to functions in the form of a result-chain. Value-based approaches that center the knowledge generated by the Global South need to be included in sustainable planning for health.

Patient perspective on remission in rheumatoid arthritis: Validation of patient reported outcome instruments to measure absence of disease activity

OBJECTIVE

Patients have identified pain, fatigue and independence as the most important domains that need to be improved to define remission in rheumatoid arthritis (RA). This study identified and validated instruments for these domains and evaluated their added value to the ACR/EULAR Boolean remission definition.

METHODS

Patients with a 28-joint Disease Activity Score (DAS28) ≤3.2 or in self-perceived remission (declaring their disease activity 'as good as gone') from the Netherlands, Portugal, Australia, and Canada, were assessed at 0, 3 and 6 months for patient-reported outcomes and the WHO-ILAR RA core set. Instrument validity was evaluated cross-sectionally, longitudinally and for the ability to predict future good outcome in terms of physical functioning. Logistic regression quantified the added value to Boolean remission.

RESULTS

Of 246 patients, 152 were also assessed at 3, and 142 at 6 months. Most instruments demonstrated construct validity and discriminative capacity. Pain and fatigue were best captured by a simple numerical rating scale (NRS). Measurement of independence proved more complex, but a newly developed independence NRS was preferred. NRS for pain, fatigue and independence, in addition to or instead of patient global assessment did not add enough information to justify modification of the current Boolean definition of remission in RA.

CONCLUSION

Key elements of the patient perspective on remission in RA can be captured by NRS pain, fatigue, and independence. Although this study did not find conclusive evidence to improve the current definition of remission in RA, the information from these instruments adds value to the physician's assessment of remission and further bridges the gap between physician and patient.

Emergency room services for people affected by sexualized and/or intimate partner violence in Berlin

Background

People affected by intimate partner violence (IPV) and/or sexualized violence (especially women, children and LGBTIQ*) have long-term health consequences (WHO 2016: 6). The WHO Guideline (2013) and the Istanbul Convention (2016) demand systematic and structurally anchored services at the level of care, education, training of health professions and public health research. The aim of this study was to evaluate the service provided at emergency rooms (ERs) in hospitals in Berlin, Germany.

Methods

A questionnaire with quantitative and qualitative questions including dimensions of existing interventions, available resources of trained staff and institutional frameworks was sent to the management of the 37 hospitals with ERs in Berlin. Descriptive-statistical methods were used to analyze the current state of care provided. (Response rate: 76 percent (n = 28))

Results

The care often depends on individual decisions of staff members of the ER: 5 ERs report the existence of a Standard Operating Procedure (SOP) for IPV, 6 for sexualised violence. Awareness of demographic characteristics of diversity varies widely across ERs; no staff specifically trained to serve for the needs of LGBTIQ* is available; 25% offer a gender-specific choice of doctors; 11 ERs co-hospitalize children affected by IPV.

Conclusions

The institutional framework and the awareness of demographic characteristics of diversity in ERs influence the services provided on a regular basis to people affected by IPV and/or sexualized violence. Development of SOP, qualification of health care professionals (HCP) and systematic collection and evaluation of related data are needed in order to implement the WHO guidelines and the provisions of the Istanbul Convention.

Key messages

Public health research regarding the care provided for people affected by IPV or sexualized violence by ERs in Berlin demonstrate the demand for guiding standard procedures and qualification of HCP. The systematic collection and evaluation of relevant data should be implemented in all countries that have signed the Istanbul Convention.

Targeting myelin lipid metabolism as a potential therapeutic strategy in a model of CMT1A neuropathy

In patients with Charcot-Marie-Tooth disease 1A (CMT1A), peripheral nerves display aberrant myelination during postnatal development, followed by slowly progressive demyelination and axonal loss during adult life. Here, we show that myelinating Schwann cells in a rat model of CMT1A exhibit a developmental defect that includes reduced transcription of genes required for myelin lipid biosynthesis. Consequently, lipid incorporation into myelin is reduced, leading to an overall distorted stoichiometry of myelin proteins and lipids with ultrastructural changes of the myelin sheath. Substitution of phosphatidylcholine and phosphatidylethanolamine in the diet is sufficient to overcome the myelination deficit of affected Schwann cells in vivo. This treatment rescues the number of myelinated axons in the peripheral nerves of the CMT rats and leads to a marked amelioration of neuropathic symptoms. We propose that lipid supplementation is an easily translatable potential therapeutic approach in CMT1A and possibly other dysmyelinating neuropathies.

EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of optimal acute care for the patients aged 50 years and over with a recent fragility fracture and the prevention of subsequent fractures in high-risk patients, which can be facilitated by close collaboration between orthopaedic surgeons and rheumatologists or other metabolic bone experts. Therefore, the aim was to establish for the first time collaborative recommendations for these patients. According to the EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations, 7 rheumatologists, a geriatrician and 10 orthopaedic surgeons met twice under the leadership of 2 convenors, a senior advisor, a clinical epidemiologist and 3 research fellows. After defining the content and procedures of the task force, 10 research questions were formulated, a comprehensive and systematic literature search was performed and the results were presented to the entire committee. 10 recommendations were formulated based on evidence from the literature and after discussion and consensus building in the group. The recommendations included appropriate medical and surgical perioperative care, which requires, especially in the elderly, a multidisciplinary approach including orthogeriatric care. A coordinator should setup a process for the systematic investigations for future fracture risk in all elderly patients with a recent fracture. High-risk patients should have appropriate non-pharmacological and pharmacological treatment to decrease the risk of subsequent fracture.

Induction chemotherapy with capecitabine and oxaliplatin followed by chemoradiotherapy before total mesorectal excision in patients with locally advanced rectal cancer

BACKGROUND

Preoperative chemoradiation in patients with locally advanced rectal cancer has no impact on overall survival (OS) and distant recurrences. The aim of the study was to evaluate local downstaging, toxicity and long-term outcome in patients with locally advanced rectal cancer after induction therapy with capecitabine and oxaliplatin (CAPEOX) followed by radiotherapy concomitant with capecitabine [chemoradiotherapy (CRT)] before total mesorectal excision (TME).

PATIENTS AND METHODS

Patients with T4 tumors, all T3N+ tumors or T3 tumors involving or with a distance ≤1 mm to the mesorectal fascia were included. Patients were planned for two cycles of CAPEOX followed by radiotherapy concomitant with capecitabine. TME was carried out 6 weeks after the completion of CRT.

RESULTS

Of 84 consecutively admitted patients starting induction CAPEOX, 77 patients underwent surgery. R0 resection was seen in 94% and T downstaging in 69%. In the intention-to-treat group, pathological complete response was seen in 23%. Five-year disease-free survival (DFS) and OS were 63% [95% confidence interval (CI), 52.2% to 73.7%] and 67% (95% CI, 56.1% to 77.3%), respectively. Grade 3/4 toxicity was seen in 18%, and four deaths occurred within 2 months of therapy.

CONCLUSION

Induction chemotherapy before CRT and surgery showed a high local control rate and promising long-term outcome as OS and DFS.

Thromboembolectomy in geriatric patients from long-stay wards

The results of arterial embolectomy with the Fogarty balloon catheter in patients over 70 years of age with acute ischaemia of the lower limbs were evaluated. Twenty-three geriatric patients from long-stay wards, median age 81 years, range 70-92, were compared with 45 independent patients, median age 81 years, range 70-91, living in their own homes. The period of ischaemic symptoms before admission was on average shorter for patients coming from long-stay wards, but the outcome was less successful. Recurrent occlusion during the first postoperative month took place in 12 patients (52%) from long-stay wards as compared to eight (18%) among independent patients (p < 0.01). The mortality was 35% and 18% respectively (p > 0.2). After six months, only 35% of patients from geriatric institutions were alive with a functional extremity as compared to 62% in the independent group (p > 0.01).

Pulmonary hamartoma

Eighty-nine cases of pulmonary hamartoma were studied. There were 51 men and 38 women, with a mean age of 57.5 years (range 14 to 76 years). A histologic diagnosis from examination of the resection specimens was obtained in all patients who had operations. Moreover, transthoracic needle aspiration biopsies were performed in 40 patients, with a diagnostic result in 34 (85%). The hamartomas were equally distributed in the pulmonary lobes; mean transverse diameter at the time of diagnosis was 21.7 +/- 16.2 mm. Tumor size was independent of the anatomic localization, but it correlated with the age of the patients (p less than 0.01). Tumor growth was recorded in 15 of 31 patients who had follow-up (45%); mean expansion in transverse diameter was 3.2 +/- 2.6 mm per year during an average observation time of 4.1 years (range 1 to 20 years). Pulmonary symptoms were present in 35 patients (39%). Seventy-five patients underwent operations as follows: enucleation (54), resection (11), lobectomy (5), pneumonectomy (4), and bronchoscopic removal (1). Since most pulmonary hamartomas are nonexpanding or slowly growing neoplasms, it is concluded that operation is necessary only when expansion is recorded in young or middle-aged patients and in patients with pulmonary symptoms.

[Retrograde colo-colic invagination]

A case of retrograde colo-colic intussusception, diagnosed preoperatively by straight films of the abdomen and confirmed by barium enema X-ray, is presented. The mechanisms behind intussusception are discussed briefly.

Predictability of esophagus- and cardiatumor resectability by preoperative computed tomography

Prior to operation, 32 patients with a tumor in the esophagus or in the cardia region were examined with computed tomography (CT), to evaluate the predictability of tumor resectability by CT. Twenty patients had the tumor operatively resected, in 2 patients the bulk of tumor could only be partly resected, and 10 patients were non-resectable due to invasion into the surrounding structures. The tumor resectability evaluated by preoperative CT resulted in positive/negative predictive values of 91 and 90%, respectively. This indicates that CT is a valuable method in planning the therapeutic strategy in cases of carcinoma of the oesophagus and the cardia region. The predictability of lymph-node involvement in the mediastinum and abdomen was less convincing.

Correlation of abdominal ultrasound and computed tomography scans with second- or third-look laparotomy in patients with ovarian carcinoma

To determine the best noninvasive means of evaluating response in patients with advanced ovarian carcinoma, 50 abdominal ultrasound (US) and computed tomography (CT) scans were performed in clinically disease-free ovarian cancer patients. The scans were correlated with the results obtained at a subsequent second- or third-look laparotomy. CT and US were not complementary, and only metastases larger than 2 cm were detected. The overall positive predictive value of nonconcordant scans was 57% compared with 100% for concordant CT and US (95% confidence limits: 18.4-90.1 and 29.2-100%, respectively). The corresponding negative predictive values were 45 and 47% (30.2-59.9 and 30.4-61.2%, respectively), if undetected microscopic disease was classified as a false-negative result. The negative predictive value of US and CT increased only to 60% in both cases, if undetected microscopic disease was registered as a true-negative result. Compared with the pelvic examination CT and US added positive information for 4 of 22 (18%) patients with macroscopic residual disease. In this study neither CT nor US was sensitive enough to preclude second-look laparotomy.

[Candidiasis of the stomach as a complication of hiatal hernia surgery]

Candidiasis in the stomach after hiatus hernia sac operation has not previously been reported in the literature. We present a case in which a 46 year old woman developed candidiasis of the stomach, two months after hiatus hernia sac operation. The disease was primarily diagnosed radiologically and was later confirmed by gastroscopy and culture of gastric fluid. The pentagastrin test was performed six months after the operation and showed significantly reduced acid production. The most probable explanation for the condition is peroperative accidental lesion of branches of the vagus nerve resulting in reduced acid production thus facilitating growth of gastric candidiasis.