Association of frailty with the use of health services in older adults: a secondary analysis of the Mexican Health and Aging Study.

BACKGROUND: Frailty has been related to adverse outcomes, but evidence on its association with the use of health services is still scarce. OBJECTIVE: The purpose of this work was to determine the association of frailty with the use of health services in Mexican adults older than 60 years. MATERIAL AND METHODS: Analysis of the Mexican Health and Aging Study for the years 2015 (baseline) and 2018 (follow-up). Frailty was defined with the frailty index. The following outcomes were included: hospitalization, medical visits, major surgery, minor surgical procedures, and dental visits. Competing risk and count analyses (negative binomial regression) were performed. RESULTS: A total of 8,526 individuals were included, whose average age was 70.8%; 55.8% corresponded to the female gender. According to the results, hospitalization days and the number of minor procedures were associated with frailty. CONCLUSIONS: Frailty could be useful in the planning of health services for older adults. On the other hand, its evaluation would allow prioritizing care for those who are at higher risk of adverse outcomes.

ANTECEDENTES: La fragilidad se ha relacionado con desenlaces adversos, pero aún es escasa la evidencia sobre su asociación con el uso de servicios de salud. OBJETIVO: Evidenciar la asociación de la fragilidad con el uso de servicios de salud en adultos mexicanos mayores de 60 años. MATERIAL Y MÉTODOS: Análisis del Estudio Nacional sobre Salud y Envejecimiento en México para 2015 (basal) y 2018 (seguimiento). La fragilidad se definió con el índice de fragilidad. Fueron incluidos los siguientes desenlaces: hospitalización, visitas médicas, cirugía mayor, procedimientos quirúrgicos menores y visitas al dentista. Se utilizaron modelos de riesgos competitivos y de número de eventos (regresión negativa binomial). RESULTADOS: Se incluyeron 8526 individuos, cuya edad promedio fue de 70.8 %; 55.8 % correspondió al sexo femenino. De acuerdo con los resultados, los días de hospitalización y el número de procedimientos menores se asociaron a fragilidad. CONCLUSIONES: La fragilidad podría ser un parámetro útil en la planeación de los servicios de salud para los adultos mayores. Por otro lado, su evaluación permitiría priorizar la atención a quienes presenten mayor riesgo de desenlaces adversos.

The coupling coordination between health service supply and regional economy in China: spatio-temporal evolution and convergence.

Background: The coordination of health service supply and regional economy is an integral path to promote China's prosperity. Methods: Based on the coupling mechanism of health service supply and regional economy, we sampled the data from 30 provinces in China from 2009 to 2021 in this study and constructed the evaluation index system. Additionally, we calculated the coupling coordination degree (HED) of the two through the coupling coordination degree model. We further used the kernel density estimation, Moran's I index, and spatial ß convergence model to assess the dynamic evolution trends, spatial aggregation effect, and spatial convergence characteristics of coupling coordination. Conclusion: (1) HED in China showed a rising trend during the study period but with large regional differences, forming a gradient distribution pattern of "high in the east and low in the west." (2) The results of Kernel density estimation show that HED has formed a gradient differentiation phenomenon within each region in China. (3) HED has modeled spatial clustering characteristics during the study period, with high-value clusters mainly appearing in the eastern region and low-value clusters appearing in the northwestern region. (4) There are absolute ß-convergence and conditional ß-convergence trends in HED in China and the three major regions during the study period, but there is an obvious regional heterogeneity in the control factors. The research provides a reference for accurately implementing policies according to different levels of health service supply and economic development, in addition to narrowing the regional differences of the coupling coordination between the regional economy and health service supply.

The association between loneliness with health service use and quality of life among informal carers in Australia.

OBJECTIVE: The demanding nature of caregiving and limited social support can lead to informal carers experiencing loneliness, which can impact their well-being and overall health service use (HSU). The study aims to examine the association between loneliness with HSU and Health state utility values among informal carers in Australia. METHODS: Data were derived from three waves (2009, 2013, and 2017) of the nationally representative longitudinal Household Income and Labour Dynamics of Australia (HILDA) survey, focusing on adult informal carers. Outcome measures included visits to the General Practitioner, the number of hospital admissions, and the SF-6D score. Generalized Estimating Equations (GEE) analysis was conducted to explore the associations between loneliness and HSU, as well as loneliness and utility values (based on SF-6D) while adjusting for age, sex, education, marital status, income, and physical/mental health conditions. RESULTS: After controlling for covariates, lonely carers reported lower utility values (IRR = 0.91, 95%CI [0.89, 0.93], p < 0.001) compared to non-lonely carers. Lonely carers reported a higher number of GP visits (IRR = 1.18, 95% CI [1.04, 1.36], p < 0.05) as well as a higher likelihood of visiting specialists (AOR = 1.31, p = 0.046) and hospital doctors (AOR = 1.42, p = 0.013) compared to the non-lonely carers. CONCLUSIONS: The findings of this study highlight the relationship between loneliness on both healthcare utilization and carers' overall well-being. Addressing loneliness through targeted interventions and social support systems can help improve health outcomes and potentially reduce the overall healthcare costs among informal carers in Australia.

COVID-19 epidemiology, health services utilisation and health care seeking behaviour during the first year of the COVID-19 pandemic in Mweso health zone, Democratic Republic of Congo.

Background: Although the evidence about coronavirus disease 2019 (COVID-19) has increased exponentially since the beginning of the pandemic, less is known about the direct and indirect effects of the pandemic in humanitarian settings. In the Democratic Republic of the Congo (DRC), most studies occurred in Kinshasa and other cities. Limited research was conducted in remote conflict-affected settings. We investigated the COVID-19 epidemiology, health service utilisation, and health care-seeking behaviour during the first year of the pandemic (March 2020-March 2021) in the Mweso health zone, North Kivu, DRC. Methods: This mixed-methods study includes a descriptive epidemiological analysis of reported COVID-19 cases data extracted from the provincial line list, interrupted time series analysis of health service utilisation using routine health service data, qualitative perceptions of health care workers about how health services were affected, and community members' health care seeking behaviour from a representative household survey and focus group discussions. Results: The COVID-19 epidemiology in North Kivu aligns with evidence reported globally, yet case fatality rates were high due to underreporting. Testing capacity was limited and initially mainly available in the province's capital. Health service utilisation showed different patterns - child measles vaccinations experienced a decrease at the beginning of the pandemic, while outpatient consultations, malaria, and pneumonia showed an increase over time. Such increases might have been driven by insecurity and population displacements rather than COVID-19. Community members continued seeking care during the first months of the COVID-19 pandemic and visited the same health facilities as before COVID-19. Financial constraints, not COVID-19, were the main barrier reported to accessing health care. Conclusions: The first year of the COVID-19 pandemic in the Mweso health zone was characterised by low testing capacity and an underestimation of reported COVID-19 infections. The increase in health care utilisation should be further explored to understand the role of factors unrelated to COVID-19, such as insecurity, population displacement, and poverty, which remain major challenges to successfully providing health services and improving the population's health. Measles vaccination coverage dropped, which exacerbated the ongoing measles outbreak. Improved decentralised testing capacity will be crucial for future epidemics and enhanced efforts to maintain child vaccination coverage.

Damage to the public health system caused by war-related looting or vandalism in the Tigray region of Northern Ethiopia.

Background: The war that started on November 4, 2020, in the Tigray region of Northern Ethiopia severely affected the health sector. However, there is no available evidence to suggest the economic damage caused to the public health system because of war-related looting or vandalism. This study was aimed at estimating the cost of war-related looting or vandalism in Tigray's public health system in Northern Ethiopia in 2021. Methods: A provider perspective, a mixed costing method, a retrospective cross-sectional approach, a 50% inflation rate, and a 50 Ethiopian birr equivalent to one United States dollar ($) for the money value were used. The data were analyzed using Microsoft Excel, taking into consideration the Sendai framework indicators. Results: The total economic cost of the war-related looting or vandalism in monetary terms was more than $3.78 billion, and the damage to the economic value in monetary terms was more than $2.31 billion. Meanwhile, the direct economic loss to the health system in monetary terms was more than $511 million. According to this assessment, 514 (80.6%) health posts, 153 (73.6%) health centers, 16 (80%) primary hospitals, 10 (83.3%) general hospitals, and 2 (100%) specialized hospitals were damaged and/or vandalized either fully or partially due to the war. Conclusion: This war seriously affected the public health sector in the Tigray region. The Federal Government of Ethiopia, the Ministry of Health of Ethiopia, the Tigrayan Government, the Tigray Regional Health Bureau, and the international community must make efforts to find resources for the revitalization of the damaged, plundered, and vandalized healthcare system.

What Brings You in Today? Sex, Race, Substance Type, and Other Sociodemographic and Health-Related Characteristics Predict if Substance Use is the Main Reason for a Clinical Encounter.

Background: Substance-related diagnoses (SRDs) are a common healthcare presentation. This study identified sociodemographic and health-related characteristics associated with having an SRD as the primary reason for a clinical encounter compared to those with an SRD who are treated for other reasons. Methods: Electronic health record (EHR) data on patients with an SRD (n=12,358, ages 18-90) were used to assess if an SRD was the primary reason for a clinical encounter from January 1, 2012-January 1, 2018. Patients were matched on key demographic characteristics at a 1:1 ratio. Adjusting for covariates, odds ratios, and 95% confidence intervals were calculated. Results: In the matched cohort of 8,630, most reported male sex (65.8%), White race (70.0%), and single marital status (62.7%) with a mean age of 47.2 (SD=14.6). Patient reported female sex, Black race, age 70+, married status, and low-income (<$50,000) were associated with a lower likelihood of presenting to care for an SRD as the primary reason for a clinical encounter. A nicotine-, alcohol-, opioid-, or stimulant-related diagnosis was associated with a higher likelihood of presenting to care for an SRD as the primary reason for the clinical visit. Conclusion: This is the first study to investigate whether sociodemographic and health-related characteristics were associated with having an SRD as the primary reason for a clinical encounter. Using rigorous methods, we investigated a unique clinical question adding new knowledge to predictors of patients seeking clinical care. Understanding these predictors can help us better align service provision with population needs and inform new approaches to tailoring care.

Stroke services in MENA: What is there and what is needed.

OBJECTIVES: Stroke represents a health care challenge to most parts of the world including the Middle East and North Africa (MENA) region. The MENA represents 6% of the world population with an age-standardized stroke rate of 87.7 (78.2-97.6) per 100,000 population. This number is subject to increase given that the cause of morbidity has recently shifted from infectious diseases to non-communicable diseases. Thus, in the coming years, treatment of stroke will pose a major burden on MENA countries which mostly lie in the low to middle income economies. Accordingly, we need to study the state of MENA stroke services in order to recognize and further inform policy makers about any gaps that need to be bridged in this domain. METHODS AND RESULTS: Stroke specialists representing 16 countries filled an online survey that included: screening for risk factors, acute management, diagnostics, medications, post-discharge services, and stroke registries. Results showed that 11 countries screen for risk factors, 16 have neuroimaging studies, 15 provide intravenous thrombolysis (IVT), 13 mechanical thrombectomy (MT) while medications for secondary prevention are available in all countries. However, stroke units are not equally available and even absent in 4 countries, and despite the availability of IVT yet, the rate of administration is still low in 6 countries (<5%), and ranges from 5-20% in 7 countries. Stroke registries and training still need to be implemented in most countries. CONCLUSION: Although imaging, revascularization therapies and medications for secondary prevention are available in most MENA countries, yet the rate of revascularization is low, so is the number of stroke units insufficient in some countries. Additionally, registries and structured training are still defective. Further field studies are required for more accurate determination of the status of stroke services in the MENA region.

Healthcare utilization, quality of life, and work productivity associated with primary hyperoxaluria: a cross-sectional web-based US survey.

Primary hyperoxaluria (PH) is a family of ultra-rare, autosomal recessive, metabolic disorders associated with frequent kidney stones, chronic kidney disease and kidney failure, and serious complications due to systemic oxalosis, resulting in significant morbidity. We investigated the burden of PH among affected patients and caregivers. This cross-sectional, web-based survey was used to quantify the burden of PH, in terms of healthcare resource utilization, health-related quality of life, and work productivity and activity impairment among adults (≥ 18 years) with PH and caregivers of children (≤ 17 years) with PH in the US. Among the 20 respondents, there were 7 adults with PH and 13 caregivers of children with PH. Adherence to hyperhydration was noted as the most, or one of the most, difficult aspects of PH by 56% of respondents. Most patients (95%) had experienced painful kidney stone events, one-third had visited the emergency room, and 29% were hospitalized for complications due to PH. Of the 24% of patients on dialysis, all found the procedure burdensome. Adult patients' quality of life was negatively affected across several domains. Most respondents (81%) reported that PH had a negative effect on their finances. Employed adult patients and caregivers, and children with PH, had moderate impairment in work productivity, school attendance, and activity. Anxiety about future PH-related sequelae was moderate to high. These findings highlight the need for improvements in PH medical management. A plain language summary is available in the supplementary information.

Cuidado em saúde mental com gestantes usuárias de crack / Mental health care with pregnant crack users / Cuidadode salud mental con mujeres embarazadas que utilizan crack

Neste manuscrito, apresentamos uma pesquisa cujo objetivo foi o de compreender como vem sendo produzidas as práticas de cuidado às gestantes usuárias de crack nos serviços de saúde de um município do interior do Rio Grande do Sul. Este estudo de abordagem qualitativa, foi realizado junto a dois serviços públicos, o Programa de Redução de Danos (PRD) e o Centro de Atenção Psicossocial para Álcool e outras Drogas (CAPSad III), com cinco mulheres voluntárias para a pesquisa. As histórias de vida foram reconstruídas a partir de suas narrativas e também de profissionais da saúde que proveram algum tipo de cuidado às participantes. Após a exposição das histórias, refletimos sobre três pistas importantes para pensarmos as práticas de cuidado às gestantes usuárias de crack: saúde mental, uso de drogas e interseccionalidade; direitos humanos, hierarquias reprodutivas e concepções de maternidade; e as práticas de cuidado em saúde. Observamos que as concepções dos profissionais acerca da maternidade direcionam as práticas de cuidado em saúde, caracterizando-se como um cuidado no espectro da saúde materno-infantil, e não um cuidado direcionado à saúde da mulher. Conhecer as demandas de cuidado dessas mulheres é essencial para que possamos pensar em práticas de saúde pautadas pela clínica ampliada. (AU)

In this manuscript, we present a research whose objective was to understand how the practicesof care to the pregnant women users of crack have been being produced in the services of health in a town of Rio Grande do Sul. This study of qualitative approach it was developed jointly to two public services, the Program of Reduction of Harms (PRH) andPsychosocial Care Centers Alcohol and other Drugs (CAPSad), with five voluntary women for the research. The life histories were rebuilt starting from their narratives and also of health's professionals that provided some care to the participants.After exposing the stories, we reflected on three important clues to think about care practices for pregnant women who use crack: mental health, drug use and intersectionality; human rights, reproductive hierarchies and conceptions of motherhood; and health care practices. We observed that the professionals' conceptions about maternity guide health care practices, characterized as care in the spectrum of maternal and child health, and not care directed at women's health.Knowing the care demands of these women is essential for us to think about health practices guided by the expanded clinic. (AU)

En este manuscrito presentamos una investigación cuyoobjetivo fue comprender cómo se ha producidolas prácticas de atención a las embarazadas usuarias de crack en los servicios de salud de una ciudad del interior de Rio Grande do Sul. Este estudio cualitativo se realizó con dos servicios públicos, el Programa de Reducción de Daños (PRD) y el Centro de Atención Psicosocial de Alcohol y Otras Drogas (CAPSad III), con cinco mujeres voluntarias para la investigación. Las historias de vida fueron reconstruidas a partir de sus narrativas y también de profesionalesde la salud que brindaron algún tipo de atención a los participantes. Luego de exponer las historias, reflexionamos sobre tres claves importantes para pensar en las prácticas de cuidado de las embarazadas que consumen crack: salud mental, consumo de drogas y interseccionalidad; derechos humanos, jerarquías reproductivas y concepciones de la maternidad; y prácticas de atención de la salud.Observamos que las concepciones de los profesionales sobre la maternidad orientan las prácticas de atención de la salud, caracterizadas como cuidados en el espectro de la salud maternoinfantil, y no cuidados dirigidos a la salud de la mujer. Conocer las demandas de atención de estas mujeres es fundamental para que pensemos en las prácticas de salud guiadas por la clínica ampliada. (AU)

Cost-effectiveness of running a paediatric oncology unit in Ethiopia.

OBJECTIVE: To estimate the cost-effectiveness of running a paediatric oncology unit in Ethiopia to inform the revision of the Ethiopia Essential Health Service Package (EEHSP), which ranks the treatment of childhood cancers at a low and medium priority. METHODS: We built a decision analytical model-a decision tree-to estimate the cost-effectiveness of running a paediatric oncology unit compared with a do-nothing scenario (no paediatric oncology care) from a healthcare provider perspective. We used the recently (2018-2019) conducted costing estimate for running the paediatric oncology unit at Tikur Anbessa Specialized Hospital (TASH) and employed a mixed costing approach (top-down and bottom-up). We used data on health outcomes from other studies in similar settings to estimate the disability-adjusted life years (DALYs) averted of running a paediatric oncology unit compared with a do-nothing scenario over a lifetime horizon. Both costs and effects were discounted (3%) to the present value. The primary outcome was incremental cost in US dollars (USDs) per DALY averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian gross domestic product per capita (USD 477 in 2019). Uncertainty was tested using one-way and probabilistic sensitivity analyses. RESULTS: The incremental cost and DALYs averted per child treated in the paediatric oncology unit at TASH were USD 876 and 2.4, respectively, compared with no paediatric oncology care. The incremental cost-effectiveness ratio of running a paediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100 000 Monte Carlo iterations at a USD 477 WTP threshold. CONCLUSIONS: The provision of paediatric cancer services using a specialised oncology unit is most likely cost-effective in Ethiopia, at least for easily treatable cancer types in centres with minimal to moderate capability. We recommend reassessing the priority-level decision of childhood cancer treatment in the current EEHSP.

Actividad y características 2 de los pacientes con úlceras de la extremidad inferior en una consulta de heridas en 2019 / Activity and characteristics of patients with ulcers of the lower extremity in a wound consultation in 2019

Objetivos: Describir la actividad y características de los pacientes de Santa Coloma de Gramenet con úlceras de la extremidad inferior visitados durante 2019 en la consulta de heridas crónicas de la Fundación Hospital Espèrit Sant. Metodología: Se presenta un estudio retrospectivo descriptivo de los pacientes de Santa Coloma con úlceras de la extremidad inferior, que acudieron a la consulta de heridas crónicas. Resultados: Se atendieron a 100 pacientes, con un total de 724 visitas. Edad media 74,1 ± 13,2 años, el 39% mujeres. La etiología de las úlceras de la extremidad inferior se presentaba en las siguientes proporciones: diabéticas isquémicas un 36%, úlceras venosas un 28%, lesiones arteriales un 22%, pie diabético y lesiones por calcifilaxis un 6%, úlceras de Martorell un 4% y lesiones neoplásicas un 1%. La mayoría de los pacientes presentó pluripatologías, con un promedio de 4 patologías y factores de riesgo. El 82% de las visitas fueron visitas sucesivas, con un promedio de 7,24 visitas por paciente. Las lesiones que requirieron mayor número de visitas fueron las lesiones diabéticas isquémicas, con un 9,1 de promedio. El 53% de las primeras visitas procedía del servicio de urgencias. El 61% de los pacientes acudió a la consulta movilizado en silla de ruedas y el 40% se había trasladado en ambulancia. Conclusiones: El trabajo ha ayudado a reafirmar las cargas de trabajo y ha evidenciado una falta de registros útiles que ayuden tanto a nivel asistencial como para posibles futuras investigaciones (AU)

Objectives: Description of the activity and characteristics of the patients coming from Santa Coloma de Gramenet with ulcers of the lower extremity, visited during 2019 in the Chronic Wounds Clinic of the Hospital Espèrit Sant Foundation. Methodology: A descriptive retrospective study of patients from Santa Coloma with Ulcers of the lower extremity (UEI), who attended the clinic of chronic wounds. Results: 100 patients were treated, with a total of 724 visits. Average age of 74.1 ± 13.2 years, 39% women. The etiology of UEI was presented in the following proportions: diabetic-ischemic 36%, venous ulcers 28%, arterial lesions 22%, diabetic foot and calciphylaxis lesions 6%, Martorell ulcers 4% and neoplastic lesions 1%. Most of the patients presented pluri-pathologies with the average of 4 pathologies and risk factors. 82% of the visits were successive visits with an overall average of 7.24 visits per patient. The lesions that required the highest number of visits were diabeticischemic lesions with an average of 9.1. 53% of the first visits came from the emergency department. 61% of the patients came to the clinic mobilized in a wheelchair and 40% had been transferred by ambulance. Conclusions: The work supported to reaffirm the workloads and has evidenced a lack of useful records that help both at the level of care and for possible future research (AU)

Multimorbidade em idosos: prevalência, padrões de ocorrência e utilização de serviços de saúde na cidade de São Paulo, Brasil / Multimorbidity in the elderly: prevalence, patterns of occurrence, and use of health services in São Paulo, Brazil

O objetivo deste estudo foi analisar a multimorbidade em idosos em função de sua prevalência, padrões de ocorrência e utilização de serviços de saúde. Foi realizada uma pesquisa transversal, aninhada ao ISA-Capital, na cidade de São Paulo, com 1019 idosos com 60 anos ou mais. Os dados foram analisados com auxílio do Software Stata e os resultados apresentados em três artigos científicos. A prevalência de multimorbidade foi de 40% (IC95% 36,6 - 43,8), sendo maior nas mulheres (aRP= 1,95 [comparado com homens]; IC95% 1,58 - 2,40), nos indivíduos com 75 anos ou mais (aRP=1,25 [comparado com indivíduos de 60 a 64 anos]; IC95% 1,01 - 1,60), nos pretos (aRP= 1,28 [comparado com brancos]; IC95% 1,04 -1,59), nas pessoas de alta renda (aRP=1,27 [comparado com baixa renda]; IC95% 1,09 - 1,50) e nos exfumantes (aRP=1,30 [comparado com quem nunca fumou]; IC95% 1,05 - 1,60), e menor nos que se declararam fumantes (aRP=0,72 [comparado com quem nunca fumou]; IC95% 1,09 - 1,50). Os padrões mais comuns de ocorrência da multimorbidade foram as díades hipertensão arterial sistêmica /diabetes mellitus tipo 2 (18,3%; IC95% 15,9 - 20,7; p<0,001), hipertensão arterial sistêmica/ artrite e reumatismo (15,4%; IC95% 13,1 - 17,6; p=0,008), hipertensão arterial sistêmica/ osteoporose (9,2%; IC95% 7,4 - 10,9; p=0,258); e, artrite e reumatismo/osteoporose (7,8%; IC95% 6,1 - 9,5; p<0,001). Sobre utilização de serviços, a taxa de idosos multimórbidos aumentou em todos os recortes considerados, a patamares de 35% naqueles que foram a um serviço de saúde uma ou mais vezes nos últimos 30 dias (aRP= 1,35 [comparado nenhuma vez]; IC95% 1,15 - 1,59), 28% em indivíduos com histórico de hospitalização em uma ou mais oportunidades em 12 meses (aRP=1,28 [comparado ausência de histórico de hospitalização]; IC95% 1,05 - 1,58), 20% em quem reportou cobertura por algum plano de saúde (aRP=1,20 [comparado com não coberto]; IC95% 1,02 - 1,42) e 24% em quem informou ter um equipamento de saúde como referência para atendimento (aRP=1,24 [comparado com quem não possui]; IC95% 1,01 - 1,53). Em conclusão, a prevalência de multimorbidade foi inferior a reportada na maioria dos estudos revisados, mas houve consistência sobre a sua associação com sexo, idade, cor da pele, tabagismo e nível socioeconômico. Ademais, embora com agrupamentos em torno de afecções cardiovasculares, metabólicas e músculo-esqueléticas, tal como a literatura revisada, os padrões mais comuns de ocorrência foram substancialmente diferentes dos já reportados. A maior frequência de utilização de serviços de saúde, assim como as maiores taxas de hospitalização, em indivíduos multimórbidos, foram achados consistentes com outras pesquisas, apontando para grandes desafios para os sistemas de saúde, sobretudo no que se refere a integralidade da atenção e a coordenação do cuidado com base em serviços de atenção primária.

This study aimed to analyze multimorbidity in the elderly according to its prevalence, patterns of occurrence, and use of health services. A cross-sectional study was conducted, nested at ISA-Capital, in the city of São Paulo, with 1019 elderly people aged 60 years or more. The data were analyzed using the Stata Software and the results were presented in three scientific articles. The prevalence of multimorbidity was 40% (95%CI 36.6 - 43.8), being higher in women (PRa= 1.95 [compared to men]; 95%CI 1.58 - 2.40), in individuals aged 75 years or more (PRa = 1.25 [compared to individuals aged 60 to 64]; 95%CI 1.01 - 1.60.60), in blacks (PRa = 1.28 [compared to whites]; 95%CI 1.04 - 1.59), in high-income people (PRa =1.27 [compared to low income]; 95%CI 1.09 - 1.50) and in former smokers (Arp=1.30 [compared to those who never smoked]; 95%CI 1.05 - 1.60), and less in those who declared themselves smokers (PRa =0.72 [compared to those who never smoked]; 95%CI 1.09 - 1.50). The most common patterns of occurrence of multimorbidity were systemic hypertension /diabetes mellitus type 2 (18.3%; 95%CI 15.9 - 20.7; p<0.001), systemic arterial hypertension/ arthritis, and rheumatism (15.4%; 95%CI 13.1 - 17.6; p=0.008), systemic arterial hypertension/ osteoporosis (9.2%; 95%CI 7.4 - 10.9; p=0.258); and, arthritis and rheumatism/osteoporosis (7.8%; 95%CI 6.1 - 9.5; p<0.001). Concerning the use of services, the rate of multimorbid elderly increased in all scenarios considered, at levels of 35% in those who went to a health service once or more in the last 30 days (PRa = 1.35 [compared not once]; 95%CI 1.15 - 1.59), 28% in individuals with a history of hospitalization at one or more opportunities in 12 months (PRa =1.28 [compared to no history of hospitalization]; 95%CI 1.05 - 1.58), 20% in those who reported coverage by a healthplan (PRa =1.20 [compared to not covered]; 95%CI 1.02 - 1.42) and 24% in those who reported having health equipment as a reference for care (PRa =1.24 [compared to those who do not have it]; 95%CI 1.01 - 1.53). In conclusion, the prevalence of multimorbidity was lower than that reported in most of the reviewed studies, but there was consistency in its association with sex, age, skin color, smoking, and socioeconomic status. In addition, although there were clusters around cardiovascular, metabolic, and musculoskeletal disorders, as in the reviewed literature, the most common patterns of occurrence were substantially different from those already reported. The higher frequency of use of health services, as well as the higher hospitalization rates in multimorphic individuals, were found to be consistent with other studies, pointing to major challenges for health systems, attention, and coordination of care based on primary care services.

Caracterización de la incidencia del cáncer de mama en un servicio público de salud chileno en el período 2006-2015 / Characterization of incidence rates of breast cancer in public health service, period 2006-2015

OBJETIVO: El cáncer de mama constituye la primera causa de muerte oncológica en mujeres chilenas. Las tasas de incidencia solo han sido estimadas según el registro 2003-2007. Nuestro objetivo fue estimar las tasas de incidencia en un período de 10 años en un servicio de salud y caracterizar dicha población. MÉTODO: Se calcularon las tasas de incidencia del período 2006-2015, por método directo, y se analizó la tendencia por Prais-Winsten. Se caracterizó la población según la edad y la etapa al diagnóstico. RESULTADOS: De 2862 casos, la tasa de incidencia estandarizada promedio fue de 66,6 por 100.000 mujeres. En el período hubo una tendencia al alza del diagnóstico de 0,63/100.000 anualmente (p = 0,5; intervalo de confianza del 95%: −1,73 a 2,99). La mayor tasa de incidencia bruta fue en el grupo de 70 y más años (154,8/100.000). El 49% correspondieron a casos diagnosticados de 50 a 69 años. El 56% se diagnosticó precozmente; la etapa I tuvo la más alta tasa (15,8/100.000). CONCLUSIONES: En este estudio, las tasas de incidencia son mayores que las reportadas en informes nacionales previos. El diagnóstico es mayoritariamente en etapas precoces, lo que difiere del resto de los países de la región. Nuestros datos pueden aportar a mejorar las políticas públicas.

OBJECTIVE: Breast cancer is the leading cause of cancer death in Chilean women. Incidence rates have only been estimated based on population records (2003-2007). Our objective was to estimate the incidence rates in a 10-year period in a health service and portray in words this cohort. METHOD: Incidence rates were calculated between 2006-2015 by direct method and trends were analyzed with the Prais-Winsten model. The population was defined according to age and stage at diagnosis. RESULTS: Of a total of 2862 cases, the average incidence rate was 66.6 out of 100,000 women. Between 2006-2015, the trend rose in breast cancer diagnosis of 0.63/100,000 annually (p = 0.5; 95% confidence interval: −1.73, 2.99). The highest crude rate of incidence was in the group aged 70 and over (154.8/100,000). 49% correspond to cases diagnosed between 50 and 69 years. 56% were in early stages, stage I, being the most frequent (15.8/100,000). CONCLUSIONS: On this research the incidence rates were higher than the ones reported on previous national reports. Diagnosis is mostly in early stages which differs from other countries in the region, our data can help improve public health policies.

Effect of Offering Care Management or Online Dialectical Behavior Therapy Skills Training vs Usual Care on Self-harm Among Adult Outpatients With Suicidal Ideation: A Randomized Clinical Trial.

Importance: People at risk of self-harm or suicidal behavior can be accurately identified, but effective prevention will require effective scalable interventions. Objective: To compare 2 low-intensity outreach programs with usual care for prevention of suicidal behavior among outpatients who report recent frequent suicidal thoughts. Design, Setting, and Participants: Pragmatic randomized clinical trial including outpatients reporting frequent suicidal thoughts identified using routine Patient Health Questionnaire depression screening at 4 US integrated health systems. A total of 18 882 patients were randomized between March 2015 and September 2018, and ascertainment of outcomes continued through March 2020. Interventions: Patients were randomized to a care management intervention (n = 6230) that included systematic outreach and care, a skills training intervention (n = 6227) that introduced 4 dialectical behavior therapy skills (mindfulness, mindfulness of current emotion, opposite action, and paced breathing), or usual care (n = 6187). Interventions, lasting up to 12 months, were delivered primarily through electronic health record online messaging and were intended to supplement ongoing mental health care. Main Outcomes and Measures: The primary outcome was time to first nonfatal or fatal self-harm. Nonfatal self-harm was ascertained from health system records, and fatal self-harm was ascertained from state mortality data. Secondary outcomes included more severe self-harm (leading to death or hospitalization) and a broader definition of self-harm (selected injuries and poisonings not originally coded as self-harm). Results: A total of 18 644 patients (9009 [48%] aged 45 years or older; 12 543 [67%] female; 9222 [50%] from mental health specialty clinics and the remainder from primary care) contributed at least 1 day of follow-up data and were included in analyses. Thirty-one percent of participants offered care management and 39% offered skills training actively engaged in intervention programs. A total of 540 participants had a self-harm event (including 45 deaths attributed to self-harm and 495 nonfatal self-harm events) over 18 months following randomization: 172 (3.27%) in care management, 206 (3.92%) in skills training, and 162 (3.27%) in usual care. Risk of fatal or nonfatal self-harm over 18 months did not differ significantly between the care management and usual care groups (hazard ratio [HR], 1.07; 97.5% CI, 0.84-1.37) but was significantly higher in the skills training group than in usual care (HR, 1.29; 97.5% CI, 1.02-1.64). For severe self-harm, care management vs usual care had an HR of 1.03 (97.5% CI, 0.71-1.51); skills training vs usual care had an HR of 1.34 (97.5% CI, 0.94-1.91). For the broader self-harm definition, care management vs usual care had an HR of 1.10 (97.5% CI, 0.92-1.33); skills training vs usual care had an HR of 1.17 (97.5% CI, 0.97-1.41). Conclusions and Relevance: Among adult outpatients with frequent suicidal ideation, offering care management did not significantly reduce risk of self-harm, and offering brief dialectical behavior therapy skills training significantly increased risk of self-harm, compared with usual care. These findings do not support implementation of the programs tested in this study. Trial Registration: ClinicalTrials.gov Identifier: NCT02326883.

Disparities of Access, Use, and Barriers to Seeking Health Care Services in Arizona.

BACKGROUND: Access to health care (HC) services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all persons. OBJECTIVES: We assess social indicators among people living in Arizona that are associated with access, use, and barriers to seeking HC services. RESEARCH DESIGN: We analyzed data (n=8073) from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) to describe demographic and health characteristics among persons by HC access and use, and for whom costs were a barrier to seeking care. RESULTS: Among Arizona adults, 13.5% reported lacking HC coverage, 28.7% reported lacking a personal doctor, and medical costs were a barrier to seeking care for 14.1%. Arizonans aged 18-34 years or with a high school education or less more often reported lacking HC coverage, a personal doctor, or not visiting a doctor because of costs. Past year medical and dental checkups were less common among less educated (≤high school) and never married persons. Hispanic persons more often reported lacking HC coverage or not visiting a doctor because of costs, and less often reported past year dental checkups. CONCLUSIONS: BRFSS can be analyzed to identify and quantify unique HC disparities, and the findings can serve as the basis for improving HC in communities. Expansion of HC services and providers may be achieved, in part, through incentives for providers to work in designated health professional shortage areas and/or leveraging telehealth/telemedicine in rural and urban underserved communities.

Assessing the efficacy of an integrated intervention to create demand for fishermen's schistosomiasis and HIV services (FISH) in Mangochi, Malawi: Study protocol for a cluster randomized control trial.

BACKGROUND: Both HIV and schistosomiasis are major public health problems worldwide with 1.8 million new HIV infections, and up to 110 million untreated schistosomiasis cases globally. Although a causal link has not been established, there are strong suggestions that having schistosomiasis increases onward transmission of HIV from co-infected men to women. With both HIV and schistosomiasis treatment readily available in Malawi, there is a need to investigate the feasibility, acceptability and health impacts of joint management of these two hazards, with special focus on health education and demand-creation for fishermen. The aim of this project is to identify optimal models of delivering integrated HIV and schistosomiasis services for fishermen, particularly investigating the effect of using social networks, HIV self-test kits and beach clinic services in Mangochi, Malawi. METHODS: We have mapped 45 boat teams or landing sites for a 3-arm cluster randomized trial using "boat team" as the unit of randomization. The three arms are: 1) Standard of care (SOC) with leaflets explaining the importance of receiving presumptive treatment for schistosomiasis (praziquantel) and HIV services for fishermen, and two intervention arms of 2) SOC + a peer explaining the leaflet to his fellow fishermen in a boat team; and 3) arm 2 with HIV self-test kits delivered to the boat team fishermen by the peer. The primary outcomes measured at 9 months of trial delivery will compare differences between arms in the proportions of boat-team fishermen: 1) who self-report starting antiretroviral therapy or undergoing voluntary medical male circumcision; and 2) who have ≥1 S. haematobium egg seen on light microscopy of the filtrate from 10mls urine ("egg-positive"). DISCUSSION: This is the first evaluation of an integrated HIV and schistosomiasis services intervention for fishermen, particularly investigating the effect of using social networks, HIVST kits and beach clinic services. The findings will support future efforts to integrate HIVST with other health services for fishermen in similar settings if found to be efficacious. TRIAL REGISTRATION: This trial is registered in the ISRCTN registry: ISRCTN14354324; date of registration: 05 October 2020. https://www.isrctn.com/ISRCTN14354324?q=ISRCTN14354324&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10&searchType=basic-search. Linked to protocol version number 1.4 of 11 January 2021.

Social beliefs and women's role in sanitation decision making in Bihar, India: An exploratory mixed method study.

In low- and middle-income countries, poor autonomy prevents women from making financial decisions, which may impact their access to improved sanitation facilities. Inadequate access to improved sanitation disproportionately affects women's and children's health and wellbeing. Although socio-cultural factors are known contributors to gender inequity, social beliefs that potentially motivate or dissuade women from making sanitation-related household decisions are not well understood. These beliefs may vary across settlement types. To empower more women to make sanitation-related decisions, the relevant socio-cultural norms and underlying social beliefs need to be addressed. In this mixed methods study, we explored women's role in sanitation-related decision making in three settlement types, urban slums, peri-urban, and rural communities in Bihar. Trained qualitative researchers conducted six focus group discussions with women of two age groups: 18-30 years old, and 45-65 years old to understand the norm-focused factors around women's role in getting a toilet for their household. Using insights generated from these group discussions, we developed and conducted a theory-driven survey in 2528 randomly selected participants, to assess the social beliefs regarding women making toilet construction decisions in these communities. Overall, 45% of the respondents reported making joint decisions to build toilets that involved both men and women household members. More women exclusively led this decision-making process in peri-urban (26%) and rural areas (35%) compared to urban slums (12%). Social beliefs that men commonly led household decisions to build toilets were negatively associated with women's participation in decision making in urban slums (adjusted prevalence ratio, aPR: 0.53, 95% CI: 0.42, 0.68). Qualitative insights highlighted normative expectations to take joint decisions with elders, especially in joint family settings. Surrounding norms that limited women's physical mobility and access to peers undermined their confidence in making large financial decisions involved in toilet construction. Women were more likely to be involved in sanitation decisions in peri-urban and rural contexts. Women's involvement in such decisions was perceived as widely acceptable. This highlights the opportunity to increase women's participation in sanitation decision making, particularly in urban contexts. As more women get involved in decisions to build toilets, highlighting this norm may encourage gender-equitable engagement in sanitation-related decisions in low-resource settings.

Clinical impact, costs, and cost-effectiveness of hospital-based strategies for addressing the US opioid epidemic: a modelling study.

BACKGROUND: The syndemic of injection drug use and serious injection-related infections is leading to increasing mortality in the USA. Although outpatient treatment with medications for opioid use disorder reduces overdose risk and recurrent infections, hospitalisation remains common. We evaluated the clinical impact, costs, and cost-effectiveness of hospital-based strategies to address the US opioid epidemic. METHODS: We developed a microsimulation model to compare the cost-effectiveness of: standard hospital care-detoxification for opioids, no addiction consult service (status quo); expanded inpatient prescribing of medications for opioid use disorder, including bridge prescriptions (ie, medication until they can see an outpatient provider) when possible (medications for opioid use disorder with bridge); implementation of addiction consult services within the hospital (addiction consult services alone); and a combined medication for opioid use disorder with addiction consult services strategy (combined). We used clinical trials and observational cohorts to inform model inputs. Outcomes were life-years, discounted costs, incremental cost-effectiveness ratios, hospitalisations, and deaths. We did deterministic sensitivity analyses on key model inputs related to costs and sequelae of drug use and probabilistic sensitivity analysis to further address uncertainty. FINDINGS: Among people who inject opioids in the USA, we estimated that expanding medications for opioid use disorder with bridge prescriptions would reduce hospitalisations and overdose deaths by 3·2% and 3·6%, respectively, and the combination of expanded medications with opioid use disorder along with addiction consult sevices would reduce hospitalisations and overdoses by 5·2% and 6·6%, respectively, compared with the status quo. Mean lifetime costs ranged from US$731 400 (95% credible interval 447 911-859 189 for the medications for opioid use disorder strategy) to $741 200 (470 930-868 551 for the combined strategy) per person. Assuming a willingness-to-pay threshold of $100 000 per life-year gained, medications for opioid use disorder with bridge and combined strategies were cost-effective ($7600 and $14 300, respectively). A scenario that assumed ideal access to harm reduction services came to the same conclusions as the base case and our results were robust in deterministic and probabilistic sensitivity analyses. INTERPRETATION: The combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics. FUNDING: National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.

The burden of OA-health services and economics.

Osteoarthritis (OA) is a highly prevalent and disabling condition that affects over 7% of people globally (528 million people). Prevalence levels are even higher in countries with established market economies, which have older demographic profiles and a higher prevalence of obesity, such as the US (14%). As the 15th highest cause of years lived with disability (YLDs) worldwide, the burden OA poses to individuals is substantial, characterized by pain, activity limitations, and reduced quality of life. The economic impact of OA, which includes direct and indirect (time) costs, is also substantial, ranging from 1 to 2.5% of gross national product (GNP) in countries with established market economies. In regions around the world, the average annual cost of OA for an individual is estimated between $700-$15,600 (2019 USD). Though trends in OA prevalence vary by geography, the prevalence of OA is projected to rise in regions with established market economies such as North America and Europe, where populations are aging and the prevalence of obesity is rising.

Disparities in Eye Care Utilization During the COVID-19 Pandemic.

PURPOSE: To assess the relationship between telemedicine utilization and sociodemographic factors among patients seeking eye care. DESIGN: Comparative utilization analysis. METHODS: We reviewed the eye care utilization patterns of a stratified random sample of 1720 patients who were seen at the University of Michigan Kellogg Eye Center during the height of the COVID-19 pandemic (April 30 to May 25, 2020) and their odds of having a video, phone, or in-person visit compared with having a deferred visit. Associations between independent variables and visit type were determined using a multinomial logistic regression model. RESULTS: Older patients had lower odds of having a video visit (P = .007) and higher odds of having an in-person visit (P = .023) compared with being deferred, and in the nonretina clinic sample, older patients still had lower odds of a video visit (P = .02). Non-White patients had lower odds of having an in-person visit (P < .02) in the overall sample compared with being deferred, with a similar trend seen in the retina clinic. The mean neighborhood median household income was $76,200 (±$33,500) and varied significantly (P < .0001) by race with Blacks having the lowest estimated mean income. CONCLUSION: Disparities exist in how patients accessed eye care during the COVID-19 pandemic with older patients-those for whom COVID-19 posed a higher risk of mortality-being more likely to be seen for in-person care. In our affluent participant sample, there was a trend toward non-White patients being less likely to access care. Reimbursing telemedicine solely through broadband internet connection may further exacerbate disparities in eye care.