Impact of measles elimination activities on immunization services and health systems: findings from six countries

BACKGROUND

One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

METHODS

Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

RESULTS

This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

CONCLUSIONS

We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Calculation of costs of pregnancy- and puerperium-related care: experience from a hospital in a low-income country

Calculation of costs of different medical and surgical services has numerous uses, which include monitoring the performance of service-delivery, setting the efficiency target, benchmarking of services across all sectors, considering investment decisions, commissioning to meet health needs, and negotiating revised levels of funding. The role of private-sector healthcare facilities has been increasing rapidly over the last decade. Despite the overall improvement in the public and private healthcare sectors in Bangladesh, lack of price benchmarking leads to patients facing unexplained price discrimination when receiving healthcare services. The aim of the study was to calculate the hospital-care cost of disease-specific cases, specifically pregnancy- and puerperium-related cases, and to indentify the practical challenges of conducting costing studies in the hospital setting in Bangladesh. A combination of micro-costing and step-down cost allocation was used for collecting information on the cost items and, ultimately, for calculating the unit cost for each diagnostic case. Data were collected from the hospital records of 162 patients having 11 different clinical diagnoses. Caesarean section due to maternal and foetal complications was the most expensive type of case whereas the length of stay due to complications was the major driver of cost. Some constraints in keeping hospital medical records and accounting practices were observed. Despite these constraints, the findings of the study indicate that it is feasible to carry out a large-scale study to further explore the costs of different hospital-care services.

Variation in expenditure for common, high cost surgical procedures in a working age population: implications for reimbursement reform

BACKGROUND

In the move toward value-based care, bundled payments are believed to reduce waste and improve coordination. Some commercial insurers have addressed this through the use of bundled payment, the provision of one fee for all care associated with a given index procedure. This system was pioneered by Medicare, using a population generally over 65 years of age, and despite its adoption by mainstream insurers, little is known of bundled payments' ability to reduce variation or cost in a working-age population. This study uses a universally-insured, nationally-representative population of adults aged 18-65 to examine the effect of bundled payments for five high-cost surgical procedures which are known to vary widely in Medicare reimbursement: hip replacement, knee replacement, coronary artery bypass grafting (CABG), lumbar spinal fusion, and colectomy.

METHODS

Five procedures conducted on adults aged 18-65 were identified from the TRICARE database from 2011 to 2014. A 90-day period from index procedure was used to determine episodes of associated post-acute care. Data was sorted by Zip code into hospital referral regions (HRR). Payments were determined from TRICARE reimbursement records, they were subsequently price standardized and adjusted for patient and surgical characteristics. Variation was assessed by stratifying the HRR into quintiles by spending for each index procedure.

RESULTS

After adjusting for case mix, significant inter-quintile variation was observed for all procedures, with knee replacement showing the greatest variation in both index surgery (107%) and total cost of care (75%). Readmission was a driver of variation for colectomy and CABG, with absolute cost variation of $17,257 and $13,289 respectively. Other post-acute care spending was low overall (≤$1606, for CABG).

CONCLUSIONS

This study demonstrates significant regional variation in total spending for these procedures, but much lower spending for post-acute care than previously demonstrated by similar procedures in Medicare. Targeting post-acute care spending, a common approach taken by providers in bundled payment arrangements with Medicare, may be less fruitful in working aged populations.

Qualitative assessment of combat-related injury patterns and injury prevention in Ukraine since the Russian invasion

INTRODUCTION

The ongoing invasion of Ukraine by the Russian Federation represents one of the largest ongoing conventional military engagements in the last 20 years. Since the start of the war, an estimated 210 000 Ukrainian soldiers have been injured or killed as a result of combat. This experience could help prognosticate the nature of large-scale combat operations for modern militaries. The aim of this study was to assess current patterns of injuries among military combatants in Ukraine and identify prevention and mitigation methods.

METHODS

We conducted a series of key informant interviews during the ongoing conflict using an expanded version of the global trauma system evaluation tool. We focused the analysis on injury patterns and prevention of combat-related injuries.

RESULTS

We interviewed 36 participants from June 2023 to February 2024. Respondents described complex polytrauma as representing the injury norm, with prominent battle injuries, including blast wounds to the extremities, traumatic brain injuries and spinal cord trauma. The primary source of injury prevention on the battlefield remains combat body armour. Military commanders and the Ministry of Defence were identified as principal bodies for the authorising equipment and tactical changes. Most respondents stated there was no formal process for using data to inform injury prevention initiatives.

CONCLUSION

The current conflict in Ukraine is characterised by a high prevalence of devastating combat-related injury, with limited measures for battlefield injury prevention. We believe that the provision of additional protective gear could mitigate the severity of some combat-related injuries, while the creation of a trauma registry would provide greater insight into prevention, wounding patterns, treatment and outcomes.

Abstract P5-13-13: Non-clinical drivers of variation in preoperative MRI utilization for breast cancer

Background: Preoperative MRI utilization in breast cancer treatment has increased significantly over the past two decades but its use continues to have inter-provider variability and disputed clinical indications. The objective of this study was to evaluate non-clinical factors associated with preoperative breast MRI utilization.

Methods: This study utilized claims from the Military Health System Data Repository (MDR) on TRICARE Prime beneficiaries, from fiscal years 2006-2015. TRICARE provides health benefits for Active Duty service members, retirees, and their dependents at both military (direct care with salaried physicians) and civilian (purchased care with fee-for-service physicians) treatment facilities. We studied patients aged 25-64 years old with a breast cancer diagnosis who had undergone mammogram/breast ultrasound alone or with subsequent breast MRI prior to surgery. Patient demographics and treatment characteristics were abstracted from the data. The National Center for Health Statistics (NCHS) urban-rural classification was used to determine the urbanization level of the treatment facility. Adjusted multivariate logistic regression tests were used to identify independent factors associated with preoperative breast MRI utilization.

Results: Of the 25,656 identified patients, 64.4% of patients (n=16,511) received preoperative mammogram/breast ultrasound alone while 35.6% of patients (n=9,145) underwent additional MRI after mammographic and/or ultrasound imaging. On multivariable analysis, younger age, presence of two or more comorbidities, active duty or retired beneficiary category, officer rank (surrogate for socioeconomic status), Air Force service branch, metropolitan location, and purchased care were associated with increased likelihood of preoperative MRI utilization. Nonmetropolitan location and Navy service branch were associated with decreased MRI use.

  Odds Ratio95% Confidence IntervalAge Group (Ref: 55-64 years)25-34 years1.851.60-2.15 35-44 years1.591.47-1.72 45-54 years1.271.19-1.35Charlson Comorbidity Index (Ref 0-1)2+2.472.33-2.61Beneficiary Category (Ref: Dependent)Active Duty1.201.04-1.38 Retired1.231.09-1.40Rank (Ref: Senior Enlisted)Junior Enlisted0.930.78-1.11 Junior Officer1.251.14-1.37 Senior Officer1.481.36-1.60 Warrant Officer1.231.06-1.42Service Branch (Ref: Army)Air Force1.101.03-1.18 Navy0.920.85-0.99 Marines0.950.84-1.07 Coast Guard1.070.89-1.29Urban-Rural Classification (Ref: Medium Metropolitan)Large Central Metropolitan1.801.68-1.93 Large Fringe Metropolitan1.591.47-1.71 Small Metropolitan0.650.59-0.71 Micropolitan0.400.34-0.46 Noncore0.250.18-0.34Treatment Facility Care Setting (Ref: Direct Care)Purchased Care1.601.48-1.73

Conclusions: After controlling for expected clinical risk factors, patients were more likely to receive additional MRI when treated at larger metropolitan facilities or through the purchased, fee-for-service system. Both associations may point toward non-clinical incentives to perform MRI in the treatment of breast cancer.

Citation Format: Pak LM, Banaag A, Koehlmoos TP, Haider AH, Learn PA. Non-clinical drivers of variation in preoperative MRI utilization for breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-13-13.

Estimates of unintended pregnancy among US active-duty service women and the impact on Women Peace and Security objectives as measured by potential readiness days lost

INTRODUCTION

The prevalence of unintended pregnancy (UIP) in the United States is high among active-duty service women (ADSW).

OBJECTIVE

To estimate the number of UIPs and the impact these pregnancies have on the ability to meet Women, Peace and Security objectives as measured by maximum potential readiness days lost (mRDL).

METHODS

Using data from the Military Health System Data Repository, ADSW aged 18 to 44 years, were identified from fiscal year (FY) 2019 data. Deliveries were identified using Medicare Severity Diagnosis-Related Group codes. The estimated number of UIPs was calculated by multiplying both the number of ADSW and the number of deliveries by age-adjusted rates of UIP. Post partum women do not have to meet height and weight standards or complete a physical fitness test for up to 365 days after a full-term delivery. Lost readiness days were calculated by multiplying the number of UIPs by 365 days. Data were stratified by age, race, rank and branch of service.

RESULTS

A total of 230 596 ADSW were identified in FY2019. Using the number of ADSW, an estimated 12 683 ADSW experienced an unintended pregnancy, resulting in an estimated 4 629 215 mRDL. Using the number of deliveries, an estimated 6785 deliveries were a result of UIPs, resulting in an estimated 2 476 364 mRDL. The highest estimates of UIPs were among ADSW aged 18 to 24 years, of White race, in a Junior Enlisted rank and in the Army.

CONCLUSION

Estimates of UIPs among ADSW would result in considerable impact on their military career. Dealng with UIPs proactively, by encouraging comprehensive family planning and instituting additional reproductive health policies for service members by ensuring that service members can make informed decisions about their reproductive health while maintaining operational effectiveness, is important for meeting United States Department of Defense Women, Peace and Security objectives.