A resilience perspective on healthcare personnels' experiences of managing the COVID-19 pandemic: a qualitative study in Norwegian nursing homes and come care services

BACKGROUND

The COVID-19 pandemic led to new and unfamiliar changes in healthcare services globally. Most COVID-19 patients were cared for in primary healthcare services, demanding major adjustments and adaptations in care delivery. Research addressing how rural primary healthcare services coped during the COVID-19 pandemic, and the possible learning potential originating from the pandemic is limited. The aim of this study was to assess how primary healthcare personnel (PHCP) working in rural areas experienced the work situation during the COVID-19 outbreak, and how adaptations to changes induced by the pandemic were handled in nursing homes and home care services.

METHOD

This study was conducted as an explorative qualitative study. Four municipalities with affiliated nursing homes and homecare services were included in the study. We conducted focus group interviews with primary healthcare personnel working in rural nursing homes and homecare services in western Norway. The included PHCP were 16 nurses, 7 assistant nurses and 2 assistants. Interviews were audio recorded, transcribed and analyzed using thematic analysis.

RESULTS

The analysis resulted in three main themes and 16 subthemes describing PHCP experience of the work situation during the COVID-19 pandemic, and how they adapted to the changes and challenges induced by the pandemic. The main themes were: "PHCP demonstrated high adaptive capacity while being put to the test", "Adapting to organizational measures, with varying degree of success" and "Safeguarding the patient's safety and quality of care, but at certain costs".

CONCLUSION

This study demonstrated PHCPs major adaptive capacity in response to the challenges and changes induced by the covid-19 pandemic, while working under varying organizational conditions. Many adaptations where long-term solutions improving healthcare delivery, others where short-term solutions forced by inadequate management, governance, or a lack of leadership. Overall, the findings demonstrated the need for all parts of the system to engage in building resilient healthcare services. More research investigating this learning potential, particularly in primary healthcare services, is needed.

A systematic review of moral reasons on orphan drug reimbursement

BACKGROUND

The number of market approvals of orphan medicinal products (OMPs) has been increasing steadily in the last 3 decades. While OMPs can offer a unique chance for patients suffering from rare diseases, they are usually very expensive. The growing number of approved OMPs increases their budget impact despite their low prevalence, making it pressing to find solutions to ethical challenges on how to fairly allocate scarce healthcare resources under this context. One potential solution could be to grant OMPs special status when considering them for reimbursement, meaning that they are subject to different, and less stringent criteria than other drugs. This study aims to provide a systematic analysis of moral reasons for and against such a special status for the reimbursement of OMPs in publicly funded healthcare systems from a multidisciplinary perspective.

RESULTS

With a systematic review of reasons, we identified 39 reasons represented in 243 articles (scientific and grey literature) for and against special status for the reimbursement of OMPs, then categorized them into nine topics. Taking a multidisciplinary perspective, we found that most articles came from health policy (n = 103) and health economics (n = 49). More articles took the position for a special status of OMPs (n = 97) than those against it (n = 31) and there was a larger number of reasons identified in favour (29 reasons) than against (10 reasons) this special status.

CONCLUSION

Results suggest that OMP reimbursement issues should be assessed and analysed from a multidisciplinary perspective. Despite the higher occurrence of reasons and articles in favour of a special status, there is no clear-cut solution for this ethical challenge. The binary perspective of whether or not OMPs should be granted special status oversimplifies the issue: both OMPs and rare diseases are too heterogeneous in their characteristics for such a binary perspective. Thus, the scientific debate should focus less on the question of disease prevalence but rather on how the important variability of different OMPs concerning e.g. target population, cost-effectiveness, level of evidence or mechanism of action could be meaningfully addressed and implemented in Health Technology Assessments.

Prioritisation for future surveillance, prevention and control of 98 communicable diseases in Belgium: a 2018 multi-criteria decision analysis study

Background

National public health agencies are required to prioritise infectious diseases for prevention and control. We applied the prioritisation method recommended by the European Centre for Disease Prevention and Control to rank infectious diseases, according to their relative importance for surveillance and public health, to inform future public health action in Belgium.

Methods

We applied the multi-criteria-decision-analysis approach. A working group of epidemiologists and statisticians from Belgium (n = 6) designed a balanced set of prioritisation criteria. A panel of Belgian experts (n = 80) allocated in an online survey each criteria a weight, according to perceived relative importance. Next, experts (n = 37) scored each disease against each criteria in an online survey, guided by disease-specific factsheets referring the period 2010–2016 in Belgium. The weighted sum of the criteria’s scores composed the final weighted score per disease, on which the ranking was based. Sensitivity analyses quantified the impact of eight alternative analysis scenarios on the top-20 ranked diseases. We identified criteria and diseases associated with data-gaps as those with the highest number of blank answers in the scoring survey. Principle components of the final weighted score were identified.

Results

Working groups selected 98 diseases and 18 criteria, structured in five criteria groups. The diseases ranked highest were (in order) pertussis, human immunodeficiency virus infection, hepatitis C and hepatitis B. Among the five criteria groups, overall the highest weights were assigned to ‘impact on the patient’, followed by ‘impact on public health’, while different perceptions were identified between clinicians, microbiologists and epidemiologists. Among the 18 individual criteria, ‘spreading potential’ and ‘events requiring public health action’ were assigned the highest weights. Principle components clustered with thematic disease groups. Notable data gaps were found among hospital-related diseases.

Conclusions

We ranked infectious diseases using a standardised reproducible approach. The diseases ranked highest are included in current public health programs, but additional reflection for example about needs among risk groups is recommended. Cross-reference of the obtained ranking with current programs is needed to verify whether resources and activities map priority areas. We recommend to implement this method in a recurrent evaluation cycle of national public health priorities.

Natural resistance to Fasciola hepatica (Trematoda) in Pseudosuccinea columella snails: A review from literature and insights from comparative "omic" analyses

The snail Pseudosuccinea columella is one of the main vectors of the medically-important trematode Fasciola hepatica. In Cuba, the existence of natural P. columella populations that are either susceptible or resistant to F. hepatica infection offers a unique snail-parasite for study of parasite-host compatibility and immune function in gastropods. Here, we review all previous literature on this system and present new "omic" data that provide a molecular baseline of both P. columella phenotypes from naïve snails. Comparison of whole snail transcriptomes (RNAseq) and the proteomes of the albumen gland (2D-electrophoresis, MS) revealed that resistant and susceptible strains differed mainly in an enrichment of particular biological processes/functions and a greater abundance of proteins/transcripts associated with immune defense/stress response in resistant snails. These results indicate a differential allocation of molecular resources to self-maintenance and survival in resistant P. columella that may cause enhanced responsiveness to stressors (i.e. F. hepatica infection or tolerance to variations in environmental pH/total water hardness), possibly as trade-off against reproduction and the ecological cost of resistance previously suggested in resistant populations of P. columella.

Value based maternal and newborn care requires alignment of adequate resources with high value activities

Background

Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies.

Discussion

Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, ‘from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all’.

Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are ‘the demands and beliefs of the acute sector’. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services.

Summary

To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

Real-farming emissions of reactive nitrogen - Necessities and challenges

Reactive nitrogen (Nr) is both a principal factor regulating growth in biological systems and a significant pollutant for the environment. The objective of this paper is to reflect on the challenges of the nutrient management related to and priorities needed to clarify how Nr is employed appropriately whilst striving to mitigate emissions at the same time. To create orientation, valid data are needed reflecting the real-farming emissions (RFE) from individual farms to assess what is needed to balance partly contradicting goals, and to bridge the gap between current and envisaged levels. Furthermore, knowledge is required of which tools and measures are at the farmer's disposal to mitigate Nr emissions. Finally and of utmost importance, the farm management is in need of action knowledge, i.e. knowing how to select the most appropriate and cost-effective tools and measures for the specific conditions on each farm, while taking the possible impacts of their implementation on the balance between Nr-related productivity and threats into account. Dealing with such a complex issue requires a systemic approach, considering the farm system not only as a one-compartment model (1st scale) with quantifiable Nr inputs and outputs at the farm gate but as divisible into sub-systems (2nd scale). The Nr-flow through the sub-systems: feed, livestock, manure and utilised land area, represents an inner-farm Nr-cycle. Each sub-system can be further sub-divided into sub-sub-systems (3rd scale) such as feeding groups within livestock, which could be differentiated in individual animals (4th scale). This approach enables to determine where (and to what extent) nutrients may be allocated more effectively and more cost-efficiently. The allocation of Nr resources between sub-units within the respective sub-systems determines the efficiency in the use of Nr and thus the proportion of Nr contributing either to an increase in productivity or to Nr-related environmental pollution. Quantifying the N-flows through sub-systems of a farm on the 2nd scale is the starting point for benchmarking; providing orientation for the regulation of processes both inside and outside the farm system. It creates target figures for the farm management while identifying the gap between the current ranking level of the farm and its potential rank. Improving the recycling of Nr throughout the whole farm system and increasing the efficiency in the use of Nr on the 3rd and 4th scale are seen as major opportunities for the farm management to balance the trade-offs without comprising productivity. It is concluded that the lack of benchmark RFE values in relation to the amount of food and feed produced can be seen as one of the main barriers in the fight to mitigate environmental Nr emissions from agricultural processes. If benchmarking has not been established, the farm management lacks orientation regarding the target figures it should aim at. Without target figures it is not possible to formulate concise working hypotheses regarding the most effective and cost-efficient use of means that are to the farmer's disposal as well as strategies for an improved allocation of resources in a farm specific context.

A Framework for Aiding the Translation of Scientific Evidence into Policy: The Experience of a Hospital-Based Technology Assessment Unit

OBJECTIVES

Very few practical frameworks exist to guide the formulation of recommendations at hospital-based health technology assessment (HTA) units. The objectives of our study were: (i) to identify decision criteria specific to the context of hospital-based health technologies and interventions, (ii) to estimate the extent to which the expert community agrees on the importance of the identified criteria, (iii) to incorporate the identified criteria into a decision-aid tool, and (iv) to illustrate the application of a prototype decision-aid tool.

METHODS

Relevant decision criteria were identified using existing frameworks for HTA recommendations, our past experience, a literature search, and feedback from a survey of diverse stakeholders.

RESULTS

Based on the survey results, twenty-three decision criteria were incorporated into the final framework. We defined an approach that eschewed a scoring system, but instead relied on a visual means for arriving at a final recommendation, by juxtaposing the importance rating for each criterion against the results of the health technology assessment. For a technology to be approved, a majority of criteria considered important should also have received favorable findings.

CONCLUSIONS

We created a simple and practical decision-aid tool that incorporates all decision criteria relevant to a hospital-based HTA unit. With its ease of use and accessibility, our tool renders the subjective decision-making process more structured and transparent.

Operational characteristics of antiretroviral therapy clinics in Zambia: a time and motion analysis

BACKGROUND

The mass scale-up of antiretroviral therapy (ART) in Zambia has taken place in the context of limited infrastructure and human resources resulting in many operational side-effects. In this study, we aimed to empirically measure current workload of ART clinic staff and patient wait times and service utilization.

METHODS

We conducted time and motion (TAM) studies from both the healthcare worker (HCW) and patient perspectives at 10 ART clinics throughout Zambia. Trained personnel recorded times for consecutive discrete activities based on direct observation of clinical and non-clinical activities performed by counselors, clinical officers, nurses, and pharmacy technicians. For patient TAM, we recruited consenting patients and recorded times of arrival and departure and major ART services utilized. Data from 10 clinics were pooled to evaluate median time per patient spent for each activity and patient duration of stay in the clinic.

RESULTS

The percentage of observed clinical time for direct patient interaction (median time per patient encounter) was 43.1% for ART counselors (4 min, interquartile range [IQR] 2-7), 46.1% for nurses (3 min, IQR 2-4), 57.2% for pharmacy technicians (2 min, IQR 1-2), and 78.5% for clinical officers (3 min, IQR 2-5). Patient workloads for HCWs were heaviest between 8 AM and 12 PM with few clinical activities observed after 2 PM. The length of patient visits was inversely associated with arrival time - patients arriving prior to 8 AM spent 61% longer at the clinic than those arriving after 8 AM (277 vs. 171 min). Overall, patients spent 219 min on average for non-clinical visits, and 244 min for clinical visits, but this difference was not significant in rural clinics. In comparison, total time patients spent directly with clinic staff were 9 and 12 min on average for non-clinical and clinical visits.

CONCLUSION

Current Zambian ART clinic operations include substantial inefficiencies for both patients and HCWs, with workloads heavily concentrated in the first few hours of clinic opening, limiting HCW and patient interaction time. Use of a differentiated care model may help to redistribute workloads during operational hours and prevent backlogs of patients waiting for hours before clinic opening, which may substantially improve ART delivery in the Zambian context.

Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine

Demand for intensive care unit (ICU) resources often exceeds supply, and shortages of ICU beds and staff are likely to persist. Triage requires careful weighing of the benefits and risks involved in ICU admission while striving to guarantee fair distribution of available resources. We must ensure that the patients who occupy ICU beds are those most likely to benefit from the ICU's specialized technology and professionals. Although prognosticating is not an exact science, preference should be given to patients who are more likely to survive if admitted to the ICU but unlikely to survive or likely to have more significant morbidity if not admitted. To provide general guidance for intensivists in ICU triage decisions, a task force of the World Federation of Societies of Intensive and Critical Care Medicine addressed 4 basic questions regarding this process. The team made recommendations and concluded that triage should be led by intensivists considering input from nurses, emergency medicine professionals, hospitalists, surgeons, and allied professionals. Triage algorithms and protocols can be useful but can never supplant the role of skilled intensivists basing their decisions on input from multidisciplinary teams. Infrastructures need to be organized efficiently both within individual hospitals and at the regional level. When resources are critically limited, patients may be refused ICU admission if others may benefit more on the basis of the principle of distributive justice.

Floral advertisement and the competition for pollination services

Flowering plants are a major component of terrestrial ecosystems, and most of them depend on animal pollinators for reproduction. Thus, the mutualism between flowering plants and their pollinators is a keystone ecological relationship in both natural and agricultural ecosystems. Though plant-pollinator interactions have received considerable amount of attention, there are still many unanswered questions. In this paper, we use methods of evolutionary game theory to investigate the co-evolution of floral advertisement and pollinator preferences Our results indicate that competition for pollination services among plant species can in some cases lead to specialization of the pollinator population to a single plant species (oligolecty). However, collecting pollen from multiple plants - at least at the population level - is evolutionarily stable under a wider parameter range. Finally, we show that, in the presence of pollinators, plants that optimize their investment in attracting vs. rewarding visiting pollinators outcompete plants that do not.

Allocation of health care resources in the neonatal and perinatal area -CPS Symposium 1996

There have been publically expressed concerns about the costs and allocation of neonatal and perinatal health care resources in Canada and elsewhere for the past 15 years. This paper reports information from a symposium held during the 1996 Canadian Paediatric Society (CPS) annual meeting sponsored by the CPS Section on Perinatal Medicine. Experts in perinatal epidemiology, health care economics, public policy and finance, and consumer perspectives on the outcomes of neonatal and perinatal intensive care explored the following questions: How should the need for health care resources in the neonatal and perinatal area be objectively determined? When there are competing needs between the maternal-newborn area and other areas, how should these be rationalized? What evidence should be used (or should be available) to support the present use of resources? What evidence should be available (or is needed) to change or introduce new uses of resources? The conclusions indicated that there are no generally accepted methods to determine the allocation of health care resources but that considerations need to include population characteristics, desired outcomes, achievable results, values, ethics, legalities, cost-benefit analyses and political objectives. Information from families and adolescents who required the use of high technology and/or high cost programs will contribute individual, family and societal values that complement cost-efficacy analyses.