Gaps in coverage and access in the European Union

From Vision to Reality: The EU's Pharmaceutical Reforms and the Path to Improved Access

Disparities in access to oncology medicines in European Union (EU) member states can impact patient outcomes profoundly, with availability and timely access varying significantly across and within member states. This paper discusses the intersection of the new European Health Technology Assessment Regulation (HTAR), the provisions of the proposed pharmaceutical legislation and their potential impacts on access to oncology medicines across EU member states. The HTAR, seeking to standardise the clinical evaluation of new medicines, has the potential to streamline the evaluation process but also risks oversimplifying diverse national healthcare needs. While the HTAR may accelerate access in countries with less-developed health technology assessment systems, it could potentially conflict with established practices in countries with advanced assessment systems, resulting in both joint and national clinical evaluations becoming necessary. The proposed pharmaceutical legislation reform, in both initial and updated forms, aims to incentivise an EU-wide launch of new medicines that challenges the feasibility for manufacturers, particularly in the context of diverse and complex national pricing and reimbursement systems. Both initiatives mark a significant shift towards more collaborative European healthcare policy yet faces the potential of unintended consequences owing to an apparent lack of pragmatism, such as delays in access because of increased administrative burdens and possible deterrents for innovation in Europe. The paper underscores the need for policy adaptation and multi-stakeholder collaboration to ensure the legislative changes achieve equitable and timely access to oncology treatments across the EU.

A Community-Based Reproductive Health Care Model Effectively Enhances Reproductive Health Among Lahu Women in Northern Thailand

BACKGROUND

Inadequate and delayed access to sexual and reproductive health services among the Hill Tribe population can be attributed to the intersection of socioeconomic challenges and distinct cultural practices. To address this limitation and create a tailored model capable of addressing it, this study assesses the effectiveness of the Community-Based Reproductive Health Care Model (CRHC) in enhancing reproductive health knowledge, attitudes, and practices among Lahu women, a prominent hill tribe population in Northern Thailand.

METHODS

Implementing the CRHC model includes training programs for community influencers and subsequent education for Lahu women using culturally adapted courses. The effectiveness of the model is assessed through pre-test and post-test comparisons of knowledge, attitudes, and practices related to reproductive health care and analyzed using paired t-tests and repeated ANOVA.

RESULTS

The scores for knowledge, attitudes, and practices among Lahu women changed from 8.92 ± 2.02, 52.99 ± 5.54, and 27.76 ± 6.67 to 10.47 ± 2.32 (p < 0.001), 56.61 ± 5.54 (p < 0.001), and 29.47 ± 6.76 (p = 0.030), respectively. Significant improvements are observed in these areas, particularly in maternal health practices among pregnant Lahu women (n = 11). This study additionally evaluates the model's impact on the healthcare system by analyzing changes in government performance indexes, showing increased access to high-quality antenatal care and contraceptive usage. This study highlights the challenges faced by hill tribe populations in accessing healthcare, emphasizing the need for tailored reproductive health education and the importance of addressing health insurance barriers.

CONCLUSION

The CRHC model's success illustrates the potential of community-based, culturally sensitive interventions in improving reproductive health outcomes, providing valuable insights for similar interventions in other indigenous or marginalized communities.

Reserves and their role in protecting against anxiety and depressive symptoms among undocumented migrants undergoing regularization

Resources help individual to function in everyday life, while reserves, a specific type of resources, help them to overcome shock and stress. Evidence is scarce about whether reserves (be they cognitive, economic or relational) protect people's mental health in situations of temporary stress. Based on a cohort study following undocumented migrants undergoing a stressful life course transition (regularisation with local authorities), we identified which resources and reserves, and which types, better protect mental health. To examine whether reserves, and which types, are prospectively associated with anxiety and depressive symptoms, whether this association is independent of resources, and whether reserves modify the effect of regularisation on anxiety and depressive symptoms. A two-wave cohort study followed 456 undocumented migrants (mean age 44 years) from 2017 to 2020, half (48%) of whom were involved in a pilot regularisation policy implemented by the local authorities of Geneva, Switzerland. Anxiety was measured with the Generalised Anxiety Disorder Questionnaire-7 and depressive symptoms with the Patient Health Questionnaire-9. Economic, cognitive and relational reserves were measured at baseline, as well as economic and relational resources. Generalised Estimating Equations tested the associations of reserves and resources with anxiety and depressive symptoms, and the interaction between reserves/resources and regularisation status. Economic and relational reserves were associated with lower anxiety and depressive symptoms, independent of economic and relational resources. Cognitive reserves were not associated with lower anxiety and depressive symptoms. Regularised participants reported lower anxiety and depressive symptoms compared to non-regularised undocumented participants. Reserves did not modify the effect of regularisation on anxiety and depressive symptoms. The provision of reserves for undocumented migrants may protect mental health but may not alter the impact of regularisation on mental health. Further research is needed among vulnerable groups experiencing psychologically distressing events to test the reserve hypothesis.

The association between voluntary health insurance and health outcomes in older adults in Europe: A survival analysis

OBJECTIVES

Voluntary health insurance (VHI) often serves a supplementary role in Europe. The ageing population and adoption of cost-sharing models in response to economic pressures raise concerns that VHI could contribute to health inequalities among older people. This study investigates the association of VHI with health outcomes among older people across 16 European countries and Israel.

STUDY DESIGN

Prospective cohort study.

METHODS

Data on participants aged ≥50 years across 16 European countries and Israel were obtained from four waves (2013-2020) of the Survey of Health, Ageing, and Retirement in Europe (SHARE). Gompertz proportional hazards models assessed the association of VHI with mortality and multimorbidity. Hazard ratios (HR) and 95 % confidence intervals (CI) are reported.

RESULTS

VHI prevalence was 38.2 % in 2013 and 34.9 % in 2015, with a higher prevalence among higher-income groups. VHI was associated with a 13 % lower risk of mortality (HR: 0.87, 95% CI: 0.81-0.94) after accounting for demographic, socioeconomic, lifestyle, and health-related factors. VHI was also associated with a lower risk of multimorbidity (HR: 0.92, 95 % CI: 0.87-0.97).

CONCLUSIONS

VHI was associated with a reduced risk of mortality and multimorbidity, after adjusting for demographic, socioeconomic, lifestyle, and health-related factors. VHI might facilitate the access to timely and high-quality healthcare services, which may exacerbate health inequalities among older individuals.

How competition play a role in dental pricing? A study on French medico-administrative and tax reports dataset

OBJECTIVES

French dentists charge additional fees for dental prostheses. This paper aims to provide new information on the determinants of dental price setting and inform public decision-making in the context of the widespread rejection of prosthetic dental care for financial reasons. We focus on the competitive mechanism in the dental prosthetics market and measure the impact of the density of professionals and competitors' prices on the fees charged by dentists.

METHODS

We use data merging from an administrative health insurance database and information from tax declarations of French dentists. We test the effect of competitor prices and competition on individual price-setting using instrumental variables. The database obtained included 29,220 dentists.

RESULTS

Practitioners' prices grow with competitors' prices (+1€ in competitor prices entails an increase of + 0.37€ in the practitioner's price). Women set lower prices, and having a young child in the household predicts an increase in price of 6.8€ (p-value=0.014). Rural areas present lower fees than urban areas (+11.4€ (p value=0.000)).

CONCLUSION

Prosthetic prices are strategic complements that are compatible with the application of monopolistic competition in the dental care market. We encourage the regulator to develop competitive mechanisms, for example, through a public offer at moderate prices.

The prevalence and determinants of unmet healthcare needs in Bulgaria

Self-reported unmet healthcare needs are a useful indicator of access to healthcare, but there is little research from low- and middle-income countries. This study sought to investigate the prevalence and determinants of unmet needs arising from wait times, distance/transportation and financial affordability in Bulgaria using European Health Interview Survey data. We explored associations between individual characteristics and the probability of reporting unmet need by fitting logistic regression models to the data. Unaffordability-related unmet needs were the most cited barrier to access. The largest proportion of people reported unmet dental care needs (14%) or unmet needs due to unaffordability of medicines (8%); distance/transportation problems were the least cited reason (3%). People with poor physical and mental health had a substantially higher probability of experiencing unmet needs. Those with a disability, less disposable income, less social support and lower educational attainment were also more likely to report unmet healthcare needs. People who lived in rural areas experienced specific barriers to access, most notably from distance or transportation issues. Unmet healthcare needs lead to inefficiencies for the healthcare system and are more prevalent among already disadvantaged societal groups. Ensuring better access to healthcare is therefore important from both the efficiency and equity perspectives.

Strengthening primary health care in Europe with digital solutions

This article provides an in-depth analysis of digital transformation in European primary healthcare (PHC). It assesses the impact of digital technology on healthcare delivery and management, highlighting variations in digital maturity across Europe. It emphasizes the significance of digital tools, especially during the COVID-19 pandemic, in enhancing accessibility and efficiency in healthcare. It discusses the integration of telehealth, remote monitoring, and e-health solutions, showcasing their role in patient empowerment and proactive care. Examples are included from various countries, such as Greece's ePrescription system, Lithuania's adoption of remote consultations, Spain's use of risk stratification solutions, and the Netherlands' advanced use of telemonitoring solutions, to illustrate the diverse implementation of digital solutions in PHC. The article offers insights into the challenges and opportunities of embedding digital technologies into a multidisciplinary healthcare framework, pointing towards future directions for PHC in Europe.

Oral health approach in universal health coverage

OBJECTIVE

This study aimed to map how oral health is addressed within the universal health coverage (UHC).

METHODS

This scoping review followed the Joanna Briggs Institute methodology. Searches included the WHO Library and PubMed, Scopus, Embase, LILACS, and Cochrane databases. Quantitative and qualitative studies were included without publication date and language restrictions.

RESULTS

A total of 486 studies were retrieved, of which 292 were excluded in the title and abstract screening phase; 121 full-texts were assessed. After the removal of duplicates and unavailable documents, 50 studies were included in the review and categorized according to the level of scientific evidence.

CONCLUSION

Few studies discussed oral health within the UHC, mostly because this coverage does not include oral health adequately. When offered, oral health packages are limited and include specific populations. Access and use of oral health services remain guided by economic factors, exposing the theoretical financial protectionism that perpetuates health inequalities.

Does stronger primary care improve access to health services for persons with spinal cord injury? Evidence from eleven European countries

OBJECTIVE

To determine the association between the strength of primary care and perceived access to follow-up care services among persons with chronic spinal cord injury (SCI).

DESIGN

Data analysis of the International Spinal Cord Injury (InSCI) cross-sectional, community-based questionnaire survey conducted in 2017-2019. The association between the strength of primary care (Kringos et al., 2003) and access to health services was established using univariable and multivariable logistic regression analysis, adjusted for socio-demographic and health status characteristics.

SETTING

Community in eleven European countries: France, Germany, Greece, Italy, Lithuania, the Netherlands, Norway, Poland, Romania, Spain and Switzerland.

PARTICIPANTS

6658 adults with chronic SCI.

INTERVENTION

None.

OUTCOME MEASURES

Share of persons with SCI that reported unmet healthcare needs as a measure of access.

RESULTS

Twelve percent of the participants reported unmet healthcare needs: the highest in Poland (25%) and lowest in Switzerland and Spain (7%). The most prevalent access restriction was service unavailability (7%). Stronger primary care was associated with lower odds of reporting unmet healthcare needs, service unavailability, unaffordability and unacceptability. Females, persons of younger age and lower health status, had higher odds of reporting unmet needs.

CONCLUSIONS

In all investigated countries, persons with chronic SCI face access barriers, especially with service availability. Stronger primary care for the general population was also associated with better health service access for persons with SCI, which argues for further primary care strengthening.

How can health technology assessment be improved to optimise access to medicines? Results from a Delphi study in Europe : Better access to medicines through HTA

INTRODUCTION

Access to medicines is a shared goal across healthcare stakeholders. Since health technology assessment (HTA) informs funding decisions, it shapes access to medicines. Despite its wide implementation, significant access variations due to HTA are observed across Europe. This paper elicited the opinions of European stakeholders on how HTA can be improved to facilitate access.

METHODS

A scoping review identified HTA features that influence access to medicines within markets and areas for improvement, while three access dimensions were identified (availability, affordability, timeliness). Using the Delphi method, we elicited the opinions of European stakeholders to validate the literature findings.

RESULTS

Nineteen participants from 14 countries participated in the Delphi panel. Thirteen HTA features that could be improved to optimise access to medicines in Europe were identified. Of these, 11 recorded a positive impact on at least one of the three access dimensions. HTA features had mostly a positive impact on timeliness and a less clear impact on affordability. 'Early scientific advice' and 'clarity in evidentiary requirements' showed a positive impact on all access dimensions. 'Established ways to deal with uncertainty during HTA' could improve medicines' availability and timeliness, while more 'reliance on real-world evidence' could expedite time to market access.

CONCLUSIONS

Our results reiterate that increased transparency during HTA and the decision-making processes is essential; the use of and reliance on new evidence generation such as real-world evidence can optimise the availability of medicines; and better collaborations between regulatory institutions within and between countries are paramount for better access to medicines.

Unmet need for healthcare in the Russian Federation: subnational retrospective modelling analysis (2014-2018)

Introduction

Unmet need for healthcare is a proxy indicator used to assess the performance of healthcare systems throughout the world. While the Russian Federation is committed to improving healthcare for its citizens, barriers to access remain.

Methods

Using data from a region-level survey, we document and analyse the extent of the unmet need for healthcare at both national and subnational levels in the Russian Federation for the years 2014-2018. We used a panel fixed effects modelling approach to examine the link between unmet need and its correlates at the subnational level. We also used data from various sources that addressed the reasons underlying unmet need to interpret the findings from the modelling analysis.

Results

Approximately one-third of the Russian population (34.7% in 2018) reported that healthcare was not received when it was needed with little change observed between 2014 and 2018. We observed significant variation across the various regions in Russia. The prevalence of unmet need was substantially higher in the regions of the Volga, Siberia and Far East Federal Districts. Our analysis revealed that the density of hospital beds and economic development across regions were correlated with the prevalence of unmet need. Dissatisfaction with healthcare services, perceived lack of effective treatments and financial constraints were the main reasons offered for forgoing healthcare when needed.

Conclusions

An unanticipated positive link between unmet need and hospital bed density might be attributed to the low accessibility and quality of primary healthcare. High demand and supply of inpatient care do not compensate for the structural imbalances of the current healthcare model. Strengthening and improving the quality of primary care might significantly reduce the prevalence of unmet need.

Lessons learned from the Canadian Fabry Disease Initiative for future risk-sharing and managed access agreements for pharmaceutical and advanced therapies in Canada

Risk sharing agreements (RSAs) and managed access agreements have emerged as tools to overcome evidentiary uncertainty and contain costs of pharmaceuticals; however, Canada has relatively little experience with these health policy instruments. This article describes one of the few examples of national RSAs. Enzyme replacement therapies (ERT) were introduced in Canada to treat Fabry disease in the early 2000s through an RSA. Based on qualitative interviews with key participating actors, this article explains how this RSA ensured continuity of treatment for patients already on ERT, and collected robust real-world evidence to secure treatment for future Fabry patients. We show the importance of partnerships, collaborations, and active patient communities in establishing RSAs, as well as the critical role of robust registries for the collection, storage, and use of that real-world data. In doing so, this paper points to reasons that explain the relative dearth of RSAs in Canada, which can be resource (both human and finance) intensive and are difficult to broker in a federalist health system. Through these findings, policy lessons are developed concerning the need for technological and governance platforms on how RSA in Canada can be more effectively supported going forward in a broader move towards "social pharmaceutical innovation".

Dimensions of patient-centred care from the perspective of patients and healthcare workers in hospital settings in sub-Saharan Africa: A qualitative evidence synthesis

INTRODUCTION

The United States Institute of Medicine defines patient centred care (PCC), a core element of healthcare quality, as care that is holistic and responsive to individual needs. PCC is associated with better patient satisfaction and improved clinical outcomes. Current conceptualizations of PCC are mainly from Europe and North America. This systematic review summarises the perceived dimensions of PCC among patients and healthcare workers within hospitals in sub-Saharan Africa (SSA).

METHODS

Without date restrictions, searches were done on databases of the Web of Science, Cochrane Library, PubMed, Embase, Global Health, and grey literature, from their inception up to 11th August 2022. Only qualitative studies exploring dimensions or perceptions of PCC among patients, doctors and/or nurses in hospitals in (SSA) were included. Review articles and editorials were excluded. Two independent reviewers screened titles and abstracts, and conducted full-text reviews with conflicts resolved by a third reviewer. The CASP (critical appraisal skills program) checklist was utilised to assess the quality of included studies. The framework synthesis method was employed for data synthesis.

RESULTS

5507 articles were retrieved. Thirty-eight studies met the inclusion criteria, of which 17 were in the specialty of obstetrics, while the rest were spread across different fields. The perceived dimensions reported in the studies included privacy and confidentiality, communication, shared decision making, dignity and respect, continuity of care, access to care, adequate infrastructure and empowerment. Separate analysis of patients' and providers' perspective revealed a difference in the practical understanding of shared-decision making. These dimensions were summarised into a framework consisting of patient-as-person, access to care, and integrated care.

CONCLUSION

The conceptualization of PCC within SSA was largely similar to findings from other parts of the world, although with a stronger emphasis on access to care. In SSA, both relational and structural aspects of care were significant elements of PCC. Healthcare providers mostly perceived structural aspects such as infrastructure as key dimensions of PCC.

TRIAL REGISTRATION

PROSPERO Registration number CRD42021238411.

How did European countries set health priorities in response to the COVID-19 threat? A comparative document analysis of 24 pandemic preparedness plans across the EURO region

The COVID-19 pandemic has forced governments across the world to consider how to prioritise the allocation of scarce resources. There are many tools and frameworks that have been designed to assist with the challenges of priority setting in health care. The purpose of this study was to examine the extent to which formal priority setting was evident in the pandemic plans produced by countries in the World Health Organisation's EURO region, during the first wave of the COVID-19 pandemic. This compliments analysis of similar plans produced in other regions of the world. Twenty four pandemic preparedness plans were obtained that had been published between March and September 2020. For data extraction, we applied a framework for identifying and assessing the elements of good priority setting to each plan, before conducting comparative analysis across the sample. Our findings suggest that while some pre-requisites for effective priority setting were present in many cases - including political commitment and a recognition of the need for allocation decisions - many other hallmarks were less evident, such as explicit ethical criteria, decision making frameworks, and engagement processes. This study provides a unique insight into the role of priority setting in the European response to the onset of the COVID-19 pandemic.

Experiences of poverty amongst low-income older adults living in a high-income country: A qualitative study

AIM

To understand the experience of low-income older adults living in poverty in a high-income country.

DESIGN

A qualitative study based on Gadamer's hermeneutic phenomenology.

METHODS

A convenience sample of twenty-seven low-income older adults were interviewed in-depth between September 2021 and January 2022. Fleming's method for conducting phenomenological qualitative studies was followed and ATLAS.ti software was used for data analysis.

RESULTS

Three main themes were extracted from the analysis: (i) 'living in the shadow of poverty', (ii) 'unprotected by the 'social shield' of the welfare state' (iii) 'the struggle to attain good health'.

CONCLUSION

Living in poverty affects all spheres of life. Older adults living in poverty feel excluded from social support policies and laws. This has a negative impact on the older adults' mental health and can lead to social isolation.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nursing interventions to promote health amongst older adults living in poverty should include an assessment of the patient's social determinants and a focus on increasing social participation. Older people living in poverty experience difficulties accessing formal social support so nurses should implement patient navigation interventions that aim to help them overcome the complexities of the system. Nursing interventions to improve mental health amongst older adults living in poverty are much needed.

IMPACT

Living in poverty increases older adults' vulnerability. Older adults living in poverty suffer from mental health issues as they live under constant pressure to meet their basic needs and lack formal social support. These findings are important for nurses, who play a pivotal role in the design, implementation and evaluation of policies and interventions that promote health equity.

REPORTING METHOD

The study has been conducted following the COREQ guidelines.

PATIENT OR PUBLIC CONTRIBUTION

There has been no public or patient involvement in the design or development of the study.

Drug use and access to drug dependency services for vulnerable migrants who use drugs in the European Union: Consensus statements and recommendations from civil society experts in Europe

BACKGROUND

The number of migrants in the European Union (EU) has been growing, including migrants at risk of using drugs. Little information is available on the actual drug use among first-generation migrants who use drugs in the EU, nor on their access to drug dependency services. This study aims to reach consensus among experts in the EU on the current situation regarding vulnerable migrants who use drugs in the EU and to develop a set of actionable recommendations.

METHODS

Between April and September 2022, a panel of 57 experts on migration and/or drug use, working in 24 countries, participated in a three-stage Delphi study to develop statements and recommendations about drug use and access to healthcare services for migrants who use drugs in the EU.

RESULTS

High levels of agreement were reached on the 20 statements (mean=98.0%) and 15 recommendations (mean=99.7%). The recommendations focus on four main topics; 1) increasing data availability and quality, to inform guidelines; 2) increasing the availability of drug dependency services for migrants, including screening for mental health issues and involving migrants who use drugs in the development of services; 3) eliminating country and service level barriers for accessing these services, as well as providing migrants who use drugs with suitable information, and combating stigma and discrimination; 4) the need for increased collaboration among and within EU countries regarding healthcare for migrants who use drugs, at the policy level as well as the service level, including civil society organisations, peer navigation and multilingual cultural mediators.

CONCLUSION

Policy action and increased collaboration are required by the EU as a whole and by individual EU member states, in addition to collaboration among healthcare providers and social welfare services, to increase access to healthcare services for migrants who use drugs.

Indicators of integrating oral health care within universal health coverage and general health care in low-, middle-, and high-income countries: a scoping review

BACKGROUND

The World Health Organization (WHO) has recently devoted special attention to oral health and oral health care recommending the latter becoming part of universal health coverage (UHC) so as to reduce oral health inequalities across the globe. In this context, as countries consider acting on this recommendation, it is essential to develop a monitoring framework to measure the progress of integrating oral health/health care into UHC. This study aimed to identify existing measures in the literature that could be used to indicate oral health/health care integration within UHC across a range of low-, middle- and high-income countries.

METHODS

A scoping review was conducted by searching MEDLINE via Ovid, CINAHL, and Ovid Global Health databases. There were no quality or publication date restrictions in the search strategy. An initial search by an academic librarian was followed by the independent reviewing of all identified articles by two authors for inclusion or exclusion based on the relevance of the work in the articles to the review topic. The included articles were all published in English. Articles concerning which the reviewers disagreed on inclusion or exclusion were reviewed by a third author, and subsequent discussion resulted in agreement on which articles were to be included and excluded. The included articles were reviewed to identify relevant indicators and the results were descriptively mapped using a simple frequency count of the indicators.

RESULTS

The 83 included articles included work from a wide range of 32 countries and were published between 1995 and 2021. The review identified 54 indicators divided into 15 categories. The most frequently reported indicators were in the following categories: dental service utilization, oral health status, cost/service/population coverage, finances, health facility access, and workforce and human resources. This study was limited by the databases searched and the use of English-language publications only.

CONCLUSIONS

This scoping review identified 54 indicators in a wide range of 15 categories of indicators that have the potential to be used to evaluate the integration of oral health/health care into UHC across a wide range of countries.

A time-dependent subdistribution hazard model for major dental treatment events in cancer patients: a nationwide cohort study

BACKGROUND

Dental care in cancer patients tends to be less prioritized. However, limited research has focused on major dental treatment events in cancer patients after the diagnosis. This study aimed to examine dental treatment delays in cancer patients compared to the general population using a national claims database in South Korea.

METHOD

The Korea National Health Insurance Service-National Sample Cohort version 2.0, collected from 2002 to 2015, was analyzed. Treatment events were considered for stomatitis, tooth loss, dental caries/pulp disease, and gingivitis/periodontal disease. For each considered event, time-dependent hazard ratios and associated 95% confidence intervals were calculated by applying a subdistribution hazard model with time-varying covariates. Mortality was treated as a competing event. Subgroup analyses were conducted by type of cancer.

RESULTS

The time-dependent subdistribution hazard ratios (SHRs) of stomatitis treatment were greater than 1 in cancer patients in all time intervals, 2.04 within 30 days after cancer diagnosis, and gradually decreased to 1.15 after 5 years. The SHR for tooth loss was less than 0.70 within 3 months after cancer diagnosis and increased to 1 after 5 years. The trends in SHRs of treatment events for other dental diseases were similar to those observed for tooth loss. Subgroup analyses by cancer type suggested that probability of all dental treatment event occurrence was higher in head and neck cancer patients, particularly in the early phase after cancer diagnosis.

CONCLUSION

Apart from treatments that are associated with cancer therapy, dental treatments in cancer patients are generally delayed and cancer patients tend to refrain from dental treatments. Consideration should be given to seeking more active and effective means for oral health promotion in cancer patients.

Direct and Indirect Management Models in Public Health in the Framework of Mental Health

This article analyzes the relationship between per capita expenditure and financial and macroeconomic variables in the framework of mental health, in regions where the prevailing system is public healthcare governed by the state and in regions where the prevailing system is that of public ownership. The period 2006-2017 was analyzed. A simple linear regression analysis was carried out to determine the relationship between the expenditure per inhabitant and a series of relevant variables such as asset turnover, cash flow, and expenditure as a percentage of gross domestic product (GDP), applying statistical tests to validate the study. In regions where public-private co-financing prevails in the health system, two crucial variables to measure per capita expenditure on mental health were GDP per capita and cash flow of mental health providers. In the regions where management is direct, the crucial variables were asset turnover of mental health providers and expenditure on mental health as a percentage of GDP per capita. These elements are key to determining how to develop public investment policies in hospital systems in the different regions of Europe and the world.

Emergency Surgery Rates Among Medicare Beneficiaries With Access Sensitive Surgical Conditions

INTRODUCTION

Access sensitive surgical conditions should be treated electively with optimal access but result in emergency operations when access is limited. However, the rates of emergency procedures for these conditions are unknown.

METHODS

Cross-sectional retrospective review of Medicare beneficiaries who underwent access sensitive surgical procedures (abdominal aortic aneurysm repair, colectomy for colorectal cancer, or incisional hernia repair) between 2014 and 2018. Risk-adjusted outcomes using a multivariable logistical regression that adjusted for patient factors (age, sex, race, and Elixhauser comorbidities), hospital characteristics (ownership, size, geographic region, surgical volume) and type of operation were compared between planned and emergency (urgent and emergent) surgical procedures. Outcome measures were rates of emergency procedures as well as associated postoperative outcomes.

RESULTS

Of the 744,818 Medicare beneficiaries undergoing access sensitive surgical procedures, 259,541 (34.9%) were done in the emergency setting. Risk-adjusted rates of emergency surgery varied widely across hospital service areas from 23.28% (lowest decile) to 54.88% (highest decile) (Odds Ratio 4.74; P < 0.001). Emergency procedures were associated with significantly higher rates of 30-d mortality (8.15% versus 3.65%, P < 0.001) and readmissions (16.28% versus 12.88%, P < 0.001) compared to elective procedures. Sensitivity analysis with younger and healthier beneficiaries demonstrated persistently high rates (23.3%) of emergency surgery with wide regional variation and worse patient outcomes.

CONCLUSIONS

Emergency surgery for access sensitive surgical conditions is extremely common and varied almost fivefold across United States hospital service areas. This suggests there are opportunities to improve access for these common surgical conditions.

Policies Supporting Oral Health in Ageing Populations Are Needed Worldwide

This literature review examines the need to develop appropriate policies specific to the oral health needs of older people that are individualised, cost-effective, and sustainable. Poor oral health and impaired oral function negatively affect the health and quality of life of older adults. Developing care systems that aim to meet patients' normative needs as well as their perceived needs and expectations is one factor in successful delivery of appropriate dental care. Cost is another significant driver of utilisation, and many older adults worldwide lack adequate resources for dental care. Failure to address these issues results in poor outcomes and increased costs of dental and medical care. Disease prevention and control at early stages can preserve public and private financial resources as well as quality of life and well-being for older adults at any stage of life.

Impact of Stress and Financials on Romanian Infertile Women Accessing Assisted Reproductive Treatment

Around 20% of couples worldwide are affected by infertility issues, with numbers in the European Union reaching as high as 25%, while access to reproductive care varies significantly by geopolitical and country-specific variables. The purpose of this research is to shed light on the unique social, psychological, and financial difficulties faced by Romanian couples seeking access to assisted reproductive therapy (ART). A cross-sectional study was conducted between 2017 and 2019 to involve women who accessed ART at fertility clinics in Romania by completing two infertility surveys. We analyzed the data in terms of all facets of infertility and ART, including the effect of personal background and stress levels on succeeding to conceive, the impact of treatment costs, and household income. A total of 829 participants completed the survey. We observed that high stress exposure leads to a substantially higher duration to conceive using ART, although the proportions of successful pregnancies did not differ between low-stress and high-stress groups. A significantly higher number of couples achieved pregnancy when their monthly household income was higher than EUR 1000 and if the ART method was more expensive. Additionally, we observed that advanced age, high stress levels, and the high cost of ART had a negative association with achieving pregnancy using ART. The findings indicated that Romanian couples experiencing infertility must contend with significant expenses for specialist infertility treatments, as well as treatment-related stress, both of which have a detrimental effect on their odds of attaining conception.

Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach

BACKGROUND

Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach.

METHODS

We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists.

RESULTS

Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care.

CONCLUSIONS

According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care.