World Health Assembly 73: A Step Forward for Global Surgery.

Member States at this year's World Health Assembly 73 (WHA73), held virtually for the first time due to the COVID-19 pandemic, passed multiple resolutions that must be considered when framing efforts to strengthen surgical systems. Surgery has been a relatively neglected field in the global health landscape due to its nature as a cross-cutting treatment rather than focusing on a specific disease or demographic. However, in recent years, access to essential and emergency surgical, obstetric, and anesthesia care has gained increasing recognition as a vital aspect of global health. The WHA73 Resolutions concern specific conditions, as has been characteristic of global health practice, yet proper care for each highlighted disease is inextricably linked to surgical care. Global surgery advocates must recognize how surgical system strengthening aligns with these strategic priorities in order to ensure that surgical care continues to be integrated into efforts to decrease global health disparities.

A Qualitative Study of Primary Care Physicians' Experiences With Telemedicine During COVID-19.

BACKGROUND: Primary care practices rapidly adopted telemedicine visits because of the COVID-19 pandemic, but information on physician perspectives about these visits is lacking. METHODS: Fifteen semistructured interviews with practicing primary care physicians and physicians-in-training from a Southern California academic health system and group-model health maintenance organization were conducted to assess physician perspectives regarding the benefits and challenges of telemedicine. RESULTS: Physicians indicated that telemedicine improved patient access to care by providing greater convenience, although some expressed concern that certain groups of vulnerable patients were unable to navigate or did not possess the technology required to participate in telemedicine visits. Physicians noted that telemedicine visits offered more time for patient counseling, opportunities for better medication reconciliations, and the ability to see and evaluate patient home environments and connect with patient families. Challenges existed when visits required a physical examination. Physicians were very concerned about the loss of personal connections and touch, which they believed diminished expected rituals that typically strengthen physician-patient relationships. Physicians also observed that careful consideration to physician workflows may be needed to avoid physician burnout. CONCLUSIONS: Physicians reported that telemedicine visits offer new opportunities to improve the quality of patient care but noted changes to their interactions with patients. Many of these changes are positive, but it remains to be seen whether others such as lack of physical examination and loss of physical presence and touch adversely influence provider-patient communication, patient willingness to disclose concerns that may affect their care, and, ultimately, patient health outcomes.

Achieving Equity in Telehealth: "Centering at the Margins" in Access, Provision, and Reimbursement.

The SARS-CoV-2 epidemic has led to rapid transformation of health care delivery and access with increased provision of telehealth services despite previously identified barriers and limitations to this care. While telehealth was initially envisioned to increase equitable access to care for under-resourced populations, the way in which telehealth provision is designed and implemented may result in worsening disparities if not thoughtfully done. This commentary seeks to demonstrate the opportunities for telehealth equity based on past research, recent developments, and a recent patient experience case example highlighting benefits of telehealth care in underserved patient populations. Recommendations to improve equity in telehealth provision include improved virtual visit technology with a focus on patient ease of use, strategies to increase access to video visit equipment, universal broadband wireless, and inclusion of telephone visits in CMS reimbursement criteria for telehealth.

Family Physicians' Role in Simplifying Medication Abortion During the COVID-19 Pandemic.

Despite first trimester abortion being common and safe, there are numerousrestrictions that lead to barriers to seeking abortion care. The COVID-19 pandemic hasonly exacerbated these barriers, as many state legislators push to limit abortion accesseven further. During this pandemic, family physicians across the country haveincorporated telemedicine into their practices to continue to meet patient needs.Medication abortion can be offered to patients by telemedicine in most states, andmultiple studies have shown that labs, imaging, and physical exam may not beessential in all cases. Family physicians are well-poised to incorporate medicationabortion into their practices using approaches that limit the spread of the coronavirus,ultimately increasing access to abortion in these unprecedented times.

Family Medicine With Refugee Newcomers During the COVID-19 Pandemic.

Certain members of society are disproportionately affected by the COVID-19 crisis and the added strain being placed on already overextended health care systems. In this article, we focus on refugee newcomers. We outline vulnerabilities refugee newcomers face in the context of COVID-19, including barriers to accessing health care services, disproportionate rates of mental health concerns, financial constraints, racism, and higher likelihoods of living in relatively higher density and multigenerational dwellings. In addition, we describe the response to COVID-19 by a community-based refugee primary health center in Ontario, Canada. This includes how the clinic has initially responded to the crisis as well as recommendations for providing services to refugee newcomers as the COVID-19 crisis evolves. Recommendations include the following actions: (1) consider social determinants of health in the new context of COVID-19; (2) provide services through a trauma-informed lens; (3) increase focus on continuity of health and mental health care; (4) mobilize International Medical Graduates for triaging patients based on COVID-19 symptoms; and (5) diversify communication efforts to educate refugees about COVID-19.

Increased Australian outpatient private practice psychiatric care during the COVID-19 pandemic: usage of new MBS-telehealth item and face-to-face psychiatrist office-based services in Quarter 3, 2020.

OBJECTIVE: The Australian federal government introduced new COVID-19 psychiatrist Medicare Benefits Schedule (MBS) telehealth items to assist with providing private specialist care. We investigate private psychiatrists' uptake of video and telephone telehealth, as well as total (telehealth and face-to-face) consultations for Quarter 3 (July-September), 2020. We compare these to the same quarter in 2019. METHOD: MBS-item service data were extracted for COVID-19-psychiatrist video and telephone telehealth item numbers and compared with Quarter 3 (July-September), 2019, of face-to-face consultations for the whole of Australia. RESULTS: The number of psychiatry consultations (telehealth and face-to-face) rose during the first wave of the pandemic in Quarter 3, 2020, by 14% compared to Quarter 3, 2019, with telehealth 43% of this total. Face-to-face consultations in Quarter 3, 2020 were only 64% of the comparative number of Quarter 3, 2019 consultations. Most telehealth involved short telephone consultations of ⩽15-30 min. Video consultations comprised 42% of total telehealth provision: these were for new patient assessments and longer consultations. These figures represent increased face-to-face consultation compared to Quarter 2, 2020, with substantial maintenance of telehealth consultations. CONCLUSIONS: Private psychiatrists continued using the new COVID-19 MBS telehealth items for Quarter 3, 2020 to increase the number of patient care contacts in the context of decreased face-to-face consultations compared to 2019, but increased face-to-face consultations compared to Quarter 2, 2020.

Prioritizing IVF treatment in the post-COVID 19 era: a predictive modelling study based on UK national data.

STUDY QUESTION: Can we use prediction modelling to estimate the impact of coronavirus disease 2019 (COVID 19) related delay in starting IVF or ICSI in different groups of women? SUMMARY ANSWER: Yes, using a combination of three different models we can predict the impact of delaying access to treatment by 6 and 12 months on the probability of conception leading to live birth in women of different age groups with different categories of infertility. WHAT IS KNOWN ALREADY: Increased age and duration of infertility can prejudice the chances of success following IVF, but couples with unexplained infertility have a chance of conceiving naturally without treatment whilst waiting for IVF. The worldwide suspension of IVF could lead to worse outcomes in couples awaiting treatment, but it is unclear to what extent this could affect individual couples based on age and cause of infertility. STUDY DESIGN, SIZE, DURATION: A population-based cohort study based on national data from all licensed clinics in the UK obtained from the Human Fertilisation and Embryology Authority Register. Linked data from 9589 women who underwent their first IVF or ICSI treatment in 2017 and consented to the use of their data for research were used to predict livebirth. PARTICIPANTS/MATERIALS, SETTING, METHODS: Three prediction models were used to estimate the chances of livebirth associated with immediate treatment versus a delay of 6 and 12 months in couples about to embark on IVF or ICSI. MAIN RESULTS AND THE ROLE OF CHANCE: We estimated that a 6-month delay would reduce IVF livebirths by 0.4%, 2.4%, 5.6%, 9.5% and 11.8% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, while corresponding values associated with a delay of 12 months were 0.9%, 4.9%, 11.9%, 18.8% and 22.4%, respectively. In women with known causes of infertility, worst case (best case) predicted chances of livebirth after a delay of 6 months followed by one complete IVF cycle in women aged <30, 30-35, 36-37, 38-39 and 40-42 years varied between 31.6% (35.0%), 29.0% (31.6%), 23.1% (25.2%), 17.2% (19.4%) and 10.3% (12.3%) for tubal infertility and 34.3% (39.2%), 31.6% (35.3%) 25.2% (28.5%) 18.3% (21.3%) and 11.3% (14.1%) for male factor infertility. The corresponding values in those treated immediately were 31.7%, 29.8%, 24.5%, 19.0% and 11.7% for tubal factor and 34.4%, 32.4%, 26.7%, 20.2% and 12.8% in male factor infertility. In women with unexplained infertility the predicted chances of livebirth after a delay of 6 months followed by one complete IVF cycle were 41.0%, 36.6%, 29.4%, 22.4% and 15.1% in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively, compared to 34.9%, 32.5%, 26.9%, 20.7% and 13.2% in similar groups of women treated without any delay. The additional waiting period, which provided more time for spontaneous conception, was predicted to increase the relative number of babies born by 17.5%, 12.6%, 9.1%, 8.4% and 13.8%, in women aged <30, 30-35, 36-37, 38-39 and 40-42 years, respectively. A 12-month delay showed a similar pattern in all subgroups. LIMITATIONS, REASONS FOR CAUTION: Major sources of uncertainty include the use of prediction models generated in different populations and the need for a number of assumptions. Although the models are validated and the bases for the assumptions are robust, it is impossible to eliminate the possibility of imprecision in our predictions. Therefore, our predicted live birth rates need to be validated in prospective studies to confirm their accuracy. WIDER IMPLICATIONS OF THE FINDINGS: A delay in starting IVF reduces success rates in all couples. For the first time, we have shown that while this results in fewer babies in older women and those with a known cause of infertility, it has a less detrimental effect on couples with unexplained infertility, some of whom conceive naturally whilst waiting for treatment. Post-COVID 19, clinics planning a phased return to normal clinical services should prioritize older women and those with a known cause of infertility. STUDY FUNDING/COMPETING INTEREST(S): No external funding was received for this study. B.W.M. is supported by an NHMRC Practitioner Fellowship (GNT1082548) and reports consultancy work for ObsEva, Merck, Merck KGaA, Guerbet and iGenomics. S.B. is Editor-in-Chief of Human Reproduction Open. None of the other authors declare any conflicts of interest. TRIAL REGISTRATION NUMBER: N/A.

Evaluation of the cost-utility of a prescription digital therapeutic for the treatment of opioid use disorder.

Background: The opioid epidemic continues to generate a significant mental and physical health burden on patients, and claims the life of almost 150 Americans daily. Making matters worse, an increase in relapses and/or opioid-related deaths has been reported in more than 40 U.S. states since the start of the COVID-19 pandemic. Opioid use disorder (OUD) is one of the single most expensive disorders in the United States, generating average medical costs of $60B from just 2 million Americans diagnosed with the disorder. In commercial use since 2019, reSET-O is a non-drug, prescription digital therapeutic (PDT) that delivers evidence-based neurobehavioral treatment for OUD and helps overcome the barriers associated with access to care, stigma, and social distancing. Although shown to be cost effective and efficacious in clinical trials and real-world evidence studies, respectively, information on its value for money from a health utilities and cost per quality-adjusted life-year is needed to inform policy discussions.Objectives: To evaluate the impact of reSET-O on health utilities and assess its overall cost per quality-adjusted life year (QALY) gained vs. treatment-as-usual (TAU).Methods: Decision analytic model comparing reSET-O plus TAU to TAU alone (i.e. buprenorphine, face-to-face counseling, and contingency management) over 12 weeks. Clinical effectiveness data (abstinence and health utility) were obtained from a clinical trial, and resource utilization and cost data were adapted from a recent claims data analysis to reflect less frequent face-to-face counseling with the therapeutic.Results: The addition of reSET-O to TAU decreases total health care costs by -$131 and resulted in post-treatment utility values within population norms, with a corresponding gain of 0.003 QALYs. reSET-O when used adjunctively to TAU was economically dominant (less costly, more effective) vs. TAU alone.Conclusion: reSET-O is an economically-dominant adjunctive treatment for OUD and is associated with an overall reduction in total incremental cost vs TAU.

COVID-19 and mental health in America: Crisis and opportunity?

There is opportunity in every crisis. COVID-19 has presented an unprecedented crisis. What opportunity can be gleaned from it? Unlike crises in the more recent past, such as the bombing of the Twin Towers and Pentagon on 9/11, COVID-19 is an ongoing global pandemic, affecting nearly every person on the planet in some shape or form. It is not only the physical effects of the SARS-CoV-2 virus that are lethal; the mental health effects are also taking their toll. The impact of physical distancing, stay-at-home orders, job loss, isolation, and fear have resulted in a considerably greater number of people's experiencing symptoms of anxiety disorder and depressive disorder in the United States. Accessing health care services has been a particular challenge given concerns about exposure to the virus and an overwhelmed health care delivery system. In response, policymakers at the federal and state levels implemented changes aimed at addressing access to essential care to include telehealth services. As the public experiences firsthand the struggles of coping with mental health issues in a fragmented dysfunctional health system, there is an opportunity is to use this crisis as a springboard to advocate for permanent changes to promote telehealth, to elevate the importance of integrated behavioral health, and to support the destigmatization of mental illness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Healthcare risk management during the SARS-CoV-2 virus pandemic in the European Union: The guaranteed access to medicines.

BACKGROUND: The disease caused by the novel coronavirus SARS-CoV-2 has rapidly spread escalating the situation to an international pandemic. The absence of a vaccine or an efficient treatment with enough scientific evidence against the virus has generated a healthcare crisis of great magnitude. The precautionary principle justifies the selection of the recommended medicines, whose demand has increased dramatically. METHODS: we carried out an analysis of the healthcare risk management and the main measures taken by the state healthcare authorities to a possible shortage of medicines in the most affected countries of the European Union: Spain, France, Italy and Germany. RESULTS: the healthcare risk management in the European Union countries is carried out based on the precautionary principle, as we do not have enough scientific evidence to recommend a specific treatment against the new virus. Some measures aimed to guarantee the access to medicines for the population has been adopted in the most affected countries by the novel coronavirus. CONCLUSIONS: in Spain, Italy and Germany, some rules based on the precautionary principle were pronounced in order to guarantee the supply of medicines, while in France, besides that, the competences of pharmacists in pharmacy offices have been extended to guarantee the access to medicines for the population.

Ensuring contact: calling rural Appalachian older adults during the COVID-19 epidemic.

INTRODUCTION: Older adults, especially those aged 85 years or older, remain at significantly higher risk for COVID-19. This group, along with those with pre-existing heart and lung disease and diabetes, have accounted for 80% of hospitalizations and an even higher percentage of COVID-19 related deaths in the USA. West Virginia, the only state in the USA located completely within Appalachia, has a higher percentage of elderly than all but two states in the nation. Rural seniors are hesitant to use hospital emergency departments and attend routine care visits for fear of exposure to the virus. Restricted cell phone and internet service may limit effective technological outreach to more isolated rural older adults. More information is needed to develop effective, safe, and acceptable approaches to care for rural, isolated older adults. METHODS: Telephone interviews were conducted with 124 community-dwelling residents in four counties in rural Appalachia between 1 and 22 April 2020. Participants were aged 75 years or older. Descriptive statistics were calculated and Fisher's Exact Test was used to examine for associations among variables. RESULTS: Participants consisted of 86 (69.4%) women and 38 (30.6%) men with an average age of 82.5 years. Telephone contact was the preferred method of contact among all but four participants (96.8%). Seventeen calls (13.7%) resulted in some form of intervention, including arranging for emergent home repairs, treatment of severe hypertension, scheduling urgent laboratory testing, arranging for terminal care, treating acute conditions, and providing durable medical equipment. The 17 participants requiring intervention were significantly more likely to be aged 85 years or older (p=0.004), and report two or more chronic conditions (p<0.001). Those describing themselves as 'lonely' were significantly more likely to live alone (p=0.009) and describe themselves as 'anxious' or 'depressed' (p<0.001). CONCLUSION: A telephone call appears to be the most effective means of communication with patients in these rural Appalachian counties. Patients aged 85 years or older and those living alone should be given highest priority for regular outreach by healthcare providers. In this population, systematically calling rural elderly patients during the COVID-19 epidemic and its aftermath represents an effective strategy for providers who care for elderly rural patients.