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Background: There is a lack of studies concerning the end of life (EOL) of patients with head and neck cancer (HNC).

Objectives: To investigate whether the timing of palliative care decision (PCD), that is, decision to terminate life-prolonging anticancer treatments, is associated with reduced secondary health care utilization and medical procedures at the EOL among patients with head and neck cancer.

Design and methods: A total of 108 patients with HNC treated at the Helsinki University Hospital Comprehensive Cancer Center were reviewed retrospectively. Three study groups were formed according to the timing of PCD: (1) the early PCD group (PCD >30 days prior to death), (2) the late PCD group (⩽30 days prior to death), and (3) the no PCD group.

Results: PCD was made for 78 patients (72%), of which 57 (73%) were considered as early PCD and 21 (27%) as late. The median interval between PCD and death was 71 days (IQR 108). During the last month of life, a significantly smaller proportion of patients with an early PCD was hospitalized (19% vs 67%, OR = 0.12, CI [0.04-0.37], P < .001 and 19% vs 47%, OR = 0.27, CI [0.10-0.72], P = .007) and readmitted (5% vs 29%, OR = 0.14, CI [0.03-0.62], P = .004 and 5% vs 20%, OR = 0.22, CI [0.05-0.96], P = .032) in secondary health care compared with the patients with late or no PCD. Early PCD also associated with less ED visits (28% vs 52%, OR = 0.36, CI [0.126-0.997], P = .045) compared with the late PCD in the last month of life. Compared with the late PCD group, early PCD group was more likely to receive palliative radiotherapy (42% vs 14%, OR 4.36, 95% CI [1.15-16.51], P = .022).

Conclusion: Early PCD associated with reduced utilization of secondary health care and emergency services at the EOL. The disease trajectories for patients with HNC should warrant more attention to the earlier timing of PCD.

Background: Long-term care (LTC) expenditure in Norway has increased by a far higher rate than GDP. While aging is still seen as the predominant challenge, younger users (<60 years) are disproportionately represented among the top-5% high-cost users, who accounted for 39% of LTC costs in 2019.

Aim: This study investigates how municipal leaders perceive the main drivers of LTC expenditure growth and what they consider to be the most pressing challenges.

Methods: We conducted semi-structured interviews with 13 municipal leaders between November 2023 and February 2024. Using thematic analysis, we explored their perspectives on expenditure growth, causes, and challenges. Municipalities were selected across KOSTRA groups to ensure variation in demographics and finances.

Results: Three main themes emerged. Municipal leaders identified younger users with complex mental health needs requiring intensive services, workforce shortages forcing reliance on expensive purchased services, and expanding rights creating gaps between expectations and capacity. These pressures are compounded by fiscal asymmetries-national policies expand mandates while implementation costs fall on municipalities with constrained budgets and labor markets.

Conclusions: Expenditure growth stems from both demographic drivers and governance challenges. While young users and workforce shortages directly increase costs, fiscal asymmetry makes these pressures difficult for municipalities by removing their flexibility to adapt services to available resources.

Implications for health services management: Managers need tools to manage fiscal asymmetries between national policy and local implementation.

Background: Premenstrual Dysphoric Disorder (PMDD) is associated with higher suicidality and reduced functioning. Diagnosis and treatment can improve symptoms and quality of life. Poor quality healthcare experiences for people seeking help for PMDD have been documented in other countries, but not in Australia.

Objective: To quantitatively and qualitatively describe experiences of healthcare for PMDD in Australia, including variations in experience by healthcare provider (HCP) type.

Methods: We employed mixed methods including an online survey and semi-structured interviews in adults who had sought healthcare in Australia for PMDD symptoms. Quantitative data was analysed using descriptive statistics, chi-square analyses, t-tests, and multilevel logistic modelling. Qualitative data was analysed using reflexive thematic analysis.

Results: Survey participants (n = 267) had sought help from an average of 5.1 different HCPs in seeking PMDD diagnosis and perceived an average of 51% of HCPs they had seen to have poor PMDD awareness. GPs were the most frequent HCP type seen first (74%) when seeking diagnosis. More than half reported experiencing medical gaslighting (54%) and misdiagnosis (56%). Interview participants (n = 11) reported misdiagnoses such as depression, anxiety, bipolar disorder, and personality disorders. Interview participants reported feeling that their symptoms were minimised by healthcare providers and that their health care concerns were dismissed. Participants were more likely to report poorer experiences with GPs compared to other HCP types. Less than a fifth of the survey sample (19%) had experienced diagnostic methods consistent with DSM-TR recommendations. Diagnosis was described by interview participants as resulting in increased coping, a mindset of self-compassion and reduced self-perceptions of feeling 'crazy' or having fundamental personality flaws.

Conclusions: People in Australia face similar PMDD healthcare barriers to those documented elsewhere. GP training in PMDD screening and clearer patient care pathways with specialist referral are needed to improve healthcare provision and reduce the burden of PMDD.

Background/objective: Healthcare services must provide high-quality patient care and continuously work to improve the quality of the organization. Continuous quality improvement (QI) involves systematic and ongoing enhancements of individual treatments as well as large organizational structures. To facilitate QI, suitable organizational structures are required. This study aims to describe and explore how administrative leaders organize for continuous QI in a Norwegian municipal setting.

Methods: This qualitative study examines how administrative leaders organize for QI in Norwegian municipalities by conducting semi-structured interviews with leaders and quality advisors (N = 19) in three Norwegian municipalities. The data were analyzed inductively by reflexive thematic text analysis and the software NVIVO 14.

Results: The municipalities used three main approaches to organize QI, aimed at integrating QI into their governing structures. The vertical approach aligned QI formalities with hierarchical structures. The horizontal approach created tailored structures for operationalizing and implementing QI. In the mediating approach, leaders actively and continuously worked vertically, horizontally, and across levels and units to reconcile differences, cooperate, communicate, and monitor activities, securing trust and commitment toward QI. Their responsibilities were extensive, supported by delegating responsibility to lower-level leaders and quality advisors, the latter with key roles in QI. QI functioned as a planned activity and continuous process. Trust and commitment were essential across approaches. Leaders' continuous mediating activities helped address the tensions between autonomy and commitment, specialized or integrated assistance, and balancing change, trust and control. These were critical to QI's success.

Conclusion: The different approaches to organizing QI facilitated the implementation of QI in various situations and alleviated tensions regarding the autonomous units' commitment to decisions and the integration or specialization of QI. The various approaches to QI, integrated with different bureaucratic models, created complex processes of layering new elements into existing structural forms, thereby modernizing municipal structures.

Background: High-cost older patients utilize a significant share of the economic resources in Norwegian somatic hospitals due to their complex healthcare needs and often require continued care beyond hospital settings. However, there is limited evidence on how they utilize municipal healthcare services.

Objective: This study examines how high-cost older patients utilize municipal healthcare services, emphasizing variations across age categories, and comparisons with non-high-cost older patients.

Design: Cross-sectional registry study using national registry data.

Methods: The study population included 189 336 patients aged ⩾65 years with at least one unplanned contact with somatic hospitals in 2019, consisting of 18 933 (10%) high-cost and 170 403 (90%) non-high-cost older patients. High-cost status was defined as the top 10% of patients with the highest diagnosis-related group weights. Logistic regression was used to examine differences in the odds of receiving municipal healthcare services in the study population adjusted for individual characteristics. Among those who received services (n = 61 171), gamma regression was used to examine the duration of service use (hours/days). Both regression models were stratified by age categories (65-74, 75-84, ⩾85 years).

Results: A higher proportion of high-cost than non-high-cost older patients received municipal healthcare services (54% vs 30%). This was also true after adjusting for patient characteristics (odds ratios 1.27-3.59, depending on age and type of healthcare service). High-cost patients had longer duration of service use (hours/days) than non-high-cost patients for institutional short-term treatment/examination (exp β = 1.12, P < .001) and rehabilitation/habilitation (exp β = 1.21, P < .001), but shorter duration for institutional long-term care (exp β = 0.80, P < .001).

Conclusion: High-cost older patients have substantial healthcare needs that extend from somatic hospitals into municipal healthcare, highlighting the importance of such transitional services in caring for these patients.

Background: This qualitative systematic review aims to identify, analyse and discuss barriers and facilitators to formal dementia services for South Asians in the UK with dementia. South Asian individuals in the UK are more likely to face a dementia diagnosis than the White British demographic; a trend which is expected to grow over the following decades. Despite this greater need for support, the UK South Asian demographic is less likely to access formal dementia services.

Methods: MODEM, Web of Science, PubMed, CINAHL via EBSCO, The Cochrane Library, and Scopus were searched (22nd July 2025) using a SPIDER search strategy and included studies' bibliographies were checked, in addition to existing review literature. Data on included studies was extracted using an adapted Cochrane Library data collection form and quality assessed using the JBI critical appraisal instrument for qualitative research. Themes were extracted and analysed using reflexive thematic analysis. Ten articles were found to meet the inclusion criteria and therefore included in this systematic review. While this review is framed as considering UK South Asians, data was only available from Bangladeshi, Indian and Pakistani individuals. However, much literature which claims 'South Asian' only defines South Asia as consisting of these three countries. Therefore, calling this paper a review of the 'South Asian' demographic allows us to critique this homogenisation.

Results: Five main themes were identified: Lack of Knowledge, Racism/Culturally Inappropriate Care, Stigma, a Familial Duty of Care and Service Delivery. There was disagreement in the literature regarding the existence of stigma. Previously unrecognised interrelations between these themes were identified, as a lack of knowledge had a potentially causal effect on both stigma and a familial duty of care.

Conclusion: The results indicate a need for review of current policy and practice, however further research is needed, particularly with regard to facilitators, which lacked data in comparison to barriers.

Background: Health-related social needs (HRSNs), including food insecurity, housing instability, transportation barriers, and financial strain, are increasingly recognized as critical to patient-centered care. Despite growing mandates and incentives to integrate HRSN screening and referral into routine clinical workflows, healthcare systems face significant challenges in implementing HRSN screening and referral processes at scale.

Objectives: This study explores the early implementation of HRSN screening and referral across a multistate healthcare system, using the Health Equity Implementation Framework (HEIF) and Knowledge-to-Action (KTA) Framework to examine multilevel barriers and facilitators.

Design: Qualitative descriptive design.

Methods: Semi-structured interviews (n = 23) were conducted with healthcare leaders, navigators, clinicians, and community health workers (CHW), eliciting their experience with leading and implementation of HRSN screening.

Results: Findings reveal that many frontline staff (including clinicians, navigators, and CHWs) reported disjointed workflows, unclear referral roles, and limited communication related to HRSN implementation. They also reported distress when screening occurred without available resources to address identified needs. CHW's explained their pivotal but under-integrated roles, serving as relational and cultural bridges between health systems and communities. All participant cohorts identified organizational and interpersonal misalignments between implementation mandates and on-the-ground realities. Suggested strategies for improvement included role-specific training, participatory design, improved integration of CHWs into care teams, feedback loops, and locally adapted referral protocols.

Conclusion: These findings reinforce the value of frontline staff knowledge and experience to ensure robust implementation of HRSNs. Aligning system-level priorities with the complex realities of care delivery is essential for realizing the promise of HRSN screening as a tool for health equity.

Objective: In this article, the findings from a scoping review are presented identifying what is known regarding paramedic confidence, competence and education in managing the neurodivergent patient.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) framework was used to identify what is known about the confidence, competence, preparedness and education when engaging with the neurodiverse patient.

Results: Four articles were identified that explored paramedics, their confidence, competence and education in assessment and management of the neurodivergent patient, highlighting the need to increase knowledge and understanding pertaining to the neurodivergent patient in order to improve care.

Conclusion: Given the unique role of the paramedic in contemporary health care, this study contributes to the discourse around appropriate levels of training for paramedics, as it highlights gaps in the literature associated with neurodiversity specific paramedic training.

Background: Unsafe abortion is a major contributor to maternal mortality in low- and middle-income countries. Despite the legalization of abortion and expanded access to services in Nepal, data on abortion practices and patient satisfaction remain limited.

Objective: This study aimed to assess abortion methods, their management, and patient satisfaction among women seeking safe abortion services at a tertiary care hospital in Kathmandu, Nepal.

Design: A hospital-based cross-sectional study.

Methods: The study was conducted from December 2023 to May 2024 among 285 women aged ⩾18 years with gestational age of up to 12 weeks. Data were collected through face-to-face interviews and clinical records, followed by 7-day post-abortion assessment via in-person visits or phone calls. Pearson's chi-square test and binary logistic regression were performed at a 5% level of significance to identify factor associated with patient satisfaction.

Result: Among 285 women, 76.8% underwent medical abortion with oral mifepristone followed by misoprostol via sublingual, buccal, or vaginal routes, while 23.2% received surgical abortion through vacuum aspiration after misoprostol pre-treatment and local anesthesia. Discharge medications commonly included analgesics (paracetamol and ibuprofen) and antibiotics (ciprofloxacin, and metronidazole). Post-abortion contraceptive uptake was 79.3%, with implants (28.8%) and condoms (28.4%) being the most chosen methods. Overall, 50.2% of women reported satisfaction with the abortion services received. Logistic regression analysis showed that higher education (AOR: 5.63; 95% CI: 2.40-13.16), extended family structure (AOR: 7.25; 95% CI: 3.11-16.91), and no history of live birth (AOR: 4.20; 95% CI: 1.48-11.93) were significantly associated with higher satisfaction, while age ⩾35 years was negatively associated (AOR: 0.52; 95% CI: 0.28-0.95).

Conclusion: Medical abortion was the preferred method, and overall management was aligned with WHO guidelines. However, patient satisfaction was moderate. Improving infrastructure, ensuring privacy, reducing waiting times, enhancing post-abortion counseling, and providing tailored health education with regular service evaluations are needed to improve the quality of abortion care and patient satisfaction.

Introduction: Globally, between the ages of 10 and 19, 15% of teenagers have mental health issues, according to the World Health Organization (WHO). Mental health issues in schools lead to dropouts, poor academic performance, social isolation, and increased substance misuse. Various strategies, including universal screening and raising mental health literacy, have been implemented. However, constraints like limited resources and inadequate training hinder effective management. Therefore, this paper aimed to explore student access to and utilisation of the school health system for mental health challenges, and to identify key barriers to its effectiveness from the perspective of students and staff in Mapanzure Masvingo District.

Methods: A mixed-method survey was used with interviews and questionnaires to gather information from key informants and 62 randomly selected students. The key informants were purposively sampled, including two nurses, two teachers, three health masters, and two administrators. Quantitative data was analysed in Excel and SPSS and presented as tables and graphs, while the qualitative data was recorded, transcribed verbatim, coded, and thematically analysed.

Results: The study found a high prevalence of self-reported mental health symptoms among students, including attention deficit (62.9%) and low self-esteem (72.6%). This high burden of need contrasted sharply with utilisation of the school health system was low (40.3%), primarily due to a lack of student awareness. This indicates a significant gap between system provision and student access. Key informants identified health clubs and guidance counselling as core components of the system, but their effectiveness was hampered by major barriers like poverty and substance abuse.

Conclusion: It can be concluded that students are experiencing mental health issues, and key informants generally view school health systems as helpful. However, there are certain obstacles, such as poverty and substance use and abuse hindering implementation and optimal functioning of school health systems. These results may help create a supportive and inclusive environment that values student health and emotional wellbeing that can lead to improved academic outcomes and positive life for students.