Pub Date : 2025-12-08DOI: 10.1016/j.healthpol.2025.105541
Ellen Kuhlmann , Gabriela Lotta , Viola Burau , Tiago Correia , Michelle Falkenbach , Marius-Ionut Ungureanu , Iris Wallenburg , Gemma A Williams , Uta Lehmann
Background
Interest in community health workers (CHWs) and the benefits for health systems are growing globally, but research is focused on low- and middle-income countries and high-income Anglo-American countries.
Objective
This comparative assessment focuses on community health systems and health and care workers as advocates and boundary spanners, aiming to connect global evidence to high-income European countries and assessing the capacities for transformative change.
Methods
A qualitative comparative approach and case study design were chosen, aligning global expertise of the CHW pioneers, Brazil and South Africa, and selected European countries: Denmark, Germany, Netherlands, Portugal, Romania, UK/England. Case studies were collected in April/May 2025, drawing on country experts and secondary sources; thematic analysis was performed following an explorative interactive consensus-based procedure.
Results
European countries create diverse occupational pathways into health systems that move beyond primary healthcare, clinical tasks, and CHWs as defined globally. Promising capacities emerge if occupational programs are interconnected with health system reform, community-based social and care services, the establishment of a regulated multi-professional community-centred group, and strengthening of public health and social support services. No country uses these capacities effectively.
Conclusions
Community-centred health and care workers need greater attention in Europe to drive health system transformations and global policy learning.
{"title":"Community health workers: a comparative assessment of capacities of a global policy approach in selected European health systems","authors":"Ellen Kuhlmann , Gabriela Lotta , Viola Burau , Tiago Correia , Michelle Falkenbach , Marius-Ionut Ungureanu , Iris Wallenburg , Gemma A Williams , Uta Lehmann","doi":"10.1016/j.healthpol.2025.105541","DOIUrl":"10.1016/j.healthpol.2025.105541","url":null,"abstract":"<div><h3>Background</h3><div>Interest in community health workers (CHWs) and the benefits for health systems are growing globally, but research is focused on low- and middle-income countries and high-income Anglo-American countries.</div></div><div><h3>Objective</h3><div>This comparative assessment focuses on community health systems and health and care workers as advocates and boundary spanners, aiming to connect global evidence to high-income European countries and assessing the capacities for transformative change.</div></div><div><h3>Methods</h3><div>A qualitative comparative approach and case study design were chosen, aligning global expertise of the CHW pioneers, Brazil and South Africa, and selected European countries: Denmark, Germany, Netherlands, Portugal, Romania, UK/England. Case studies were collected in April/May 2025, drawing on country experts and secondary sources; thematic analysis was performed following an explorative interactive consensus-based procedure.</div></div><div><h3>Results</h3><div>European countries create diverse occupational pathways into health systems that move beyond primary healthcare, clinical tasks, and CHWs as defined globally. Promising capacities emerge if occupational programs are interconnected with health system reform, community-based social and care services, the establishment of a regulated multi-professional community-centred group, and strengthening of public health and social support services. No country uses these capacities effectively.</div></div><div><h3>Conclusions</h3><div>Community-centred health and care workers need greater attention in Europe to drive health system transformations and global policy learning.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105541"},"PeriodicalIF":3.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145747607","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-08DOI: 10.1016/j.healthpol.2025.105538
Beth Parkinson, Matt Sutton, Rachel Meacock
Background
Expanding healthcare provision in the community is a common policy solution for reducing hospital pressures. While there is some evidence that strengthening primary care can influence hospital use, little is known about the impact of community health services such as nurse-led care delivered in patients’ homes.
Objective
To examine whether the size of the community health services workforce influences use of hospital care.
Methods
Multivariable regression of the size of the community nursing and nursing support workforce against rates of hospital use by patients aged 65+ in English local authorities in 2019/20, accounting for population needs and availability of other services.
Results
On average per 1000 population aged 65+, there were 4.3 FTE community staff employed, 440 planned admissions, 267 emergency admissions (of which 66 were for ambulatory care sensitive conditions), 465 emergency department attendances, and 4204 outpatient appointments. Unadjusted positive associations of community workforce provision with measures of emergency hospital use were explained by population characteristics. Community workforce provision was not significantly associated with any hospital use outcomes in the fully adjusted analyses. Sensitivity analyses confirmed these null findings.
Conclusions
We found no evidence that the size of the community workforce was associated with hospital activity. Despite substantial geographical variation in the size of the workforce, areas with more community staff did not have lower hospital use. Expanding community services alone is unlikely to reduce hospital activity at the system level. Direct intervention in the hospital sector will likely be required to achieve this aim.
{"title":"Provision of community health services and use of hospital care in England: Nationwide retrospective observational study","authors":"Beth Parkinson, Matt Sutton, Rachel Meacock","doi":"10.1016/j.healthpol.2025.105538","DOIUrl":"10.1016/j.healthpol.2025.105538","url":null,"abstract":"<div><h3>Background</h3><div>Expanding healthcare provision in the community is a common policy solution for reducing hospital pressures. While there is some evidence that strengthening primary care can influence hospital use, little is known about the impact of community health services such as nurse-led care delivered in patients’ homes.</div></div><div><h3>Objective</h3><div>To examine whether the size of the community health services workforce influences use of hospital care.</div></div><div><h3>Methods</h3><div>Multivariable regression of the size of the community nursing and nursing support workforce against rates of hospital use by patients aged 65+ in English local authorities in 2019/20, accounting for population needs and availability of other services.</div></div><div><h3>Results</h3><div>On average per 1000 population aged 65+, there were 4.3 FTE community staff employed, 440 planned admissions, 267 emergency admissions (of which 66 were for ambulatory care sensitive conditions), 465 emergency department attendances, and 4204 outpatient appointments. Unadjusted positive associations of community workforce provision with measures of emergency hospital use were explained by population characteristics. Community workforce provision was not significantly associated with any hospital use outcomes in the fully adjusted analyses. Sensitivity analyses confirmed these null findings.</div></div><div><h3>Conclusions</h3><div>We found no evidence that the size of the community workforce was associated with hospital activity. Despite substantial geographical variation in the size of the workforce, areas with more community staff did not have lower hospital use. Expanding community services alone is unlikely to reduce hospital activity at the system level. Direct intervention in the hospital sector will likely be required to achieve this aim.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105538"},"PeriodicalIF":3.4,"publicationDate":"2025-12-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145798706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-07DOI: 10.1016/j.healthpol.2025.105529
Andreas W. Gold , Clara Perplies , Kayvan Bozorgmehr
Background
Fragmented health systems can lead to over-, under-, or misuse of services. Specific challenges arise for newly arrived population groups, such as refugees, who encounter barriers to health services. These include legal restrictions and language discordance with service providers, that further exacerbate these issues. Although nurses can play an important role in improving the response of the health system, little is known about their scope of practice and their role in caring for refugees in primary healthcare contexts.
Objective
To investigate key characteristics of three nurse-led models of care for refugees in Germany, the roles and responsibilities of nurses and to describe their potential to improve coordination and continuity.
Methods
A qualitative, multiple-case study was conducted using a purposeful sampling strategy. Data collection included semi-structured interviews with three programme managers and five nurses from three operational nurse-led models of care in Germany, a social network questionnaire and a review of documents. Data analysis comprised developing logic models and using qualitative content and social network analysis methods.
Results
Examined models involve nurses by allowing for independent management of tasks such as observation, counselling, and care coordination, providing support to patients and linking them to other healthcare services. In the absence of specific training programmes, nurses rely on-the-job learning.
Conclusions
Nurse-led models of care can effectively improve healthcare for refugees. Policymakers should recognise and advance nursing practice through legislative measures and sustainable funding models. In order to prepare nurses for working in these settings, nursing curricula should incorporate refugee-specific aspects.
{"title":"Nurse-led models of care and their potential to improve primary healthcare for refugees in Germany: A qualitative multiple-case study","authors":"Andreas W. Gold , Clara Perplies , Kayvan Bozorgmehr","doi":"10.1016/j.healthpol.2025.105529","DOIUrl":"10.1016/j.healthpol.2025.105529","url":null,"abstract":"<div><h3>Background</h3><div>Fragmented health systems can lead to over-, under-, or misuse of services. Specific challenges arise for newly arrived population groups, such as refugees, who encounter barriers to health services. These include legal restrictions and language discordance with service providers, that further exacerbate these issues. Although nurses can play an important role in improving the response of the health system, little is known about their scope of practice and their role in caring for refugees in primary healthcare contexts.</div></div><div><h3>Objective</h3><div>To investigate key characteristics of three nurse-led models of care for refugees in Germany, the roles and responsibilities of nurses and to describe their potential to improve coordination and continuity.</div></div><div><h3>Methods</h3><div>A qualitative, multiple-case study was conducted using a purposeful sampling strategy. Data collection included semi-structured interviews with three programme managers and five nurses from three operational nurse-led models of care in Germany, a social network questionnaire and a review of documents. Data analysis comprised developing logic models and using qualitative content and social network analysis methods.</div></div><div><h3>Results</h3><div>Examined models involve nurses by allowing for independent management of tasks such as observation, counselling, and care coordination, providing support to patients and linking them to other healthcare services. In the absence of specific training programmes, nurses rely on-the-job learning.</div></div><div><h3>Conclusions</h3><div>Nurse-led models of care can effectively improve healthcare for refugees. Policymakers should recognise and advance nursing practice through legislative measures and sustainable funding models. In order to prepare nurses for working in these settings, nursing curricula should incorporate refugee-specific aspects.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105529"},"PeriodicalIF":3.4,"publicationDate":"2025-12-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145783609","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-06DOI: 10.1016/j.healthpol.2025.105537
C. Kranich , D. Möller , C.M. Dintsios
Background
Due to increasing pharmaceutical expenditures, Germany implemented 'guardrails' for price negotiations at the end of 2022, as part of the ‘Statutory Health Insurance Financial Stabilization Act’. They regulate the pricing of benefit-assessed pharmaceuticals with comparators under data exclusivity, to generate savings
Objective
We aimed at quantifying the targeted savings from a payer perspective.
Methods
A retrospective implementation of the ‘guard rails’ for new benefit-assessed pharmaceuticals in the period 2020 – 2022 on a subpopulation basis after application of specific exclusion criteria was chosen to estimate their potential savings by means of a simulated budget impact analysis. Comprehensive prescription data and pharmaceutical retail prices were utilized to ensure comparability over time.
Results
The analysis included 38 products with 82 subpopulations encompassing approximately 870,000 patients. The difference between negotiated prices and those regulated by the ‘guard rails’ in terms of annual therapeutic costs was statistically significant (p=0.01, CI95%: €1145,925.47 – €8914,501.69). If the ‘guard rails’ had been implemented earlier, pharmaceutical expenditure for the assessed subpopulations could have been reduced by €191.14 million, with oncological products accounting for €117.20 million (61.3% of total savings) in the examined period.
Conclusions
Despite the significant potential savings identified in this analysis, the actual annual savings are inconsistent and challenging to predict as they largely depend on the number of new product launches and the extent of their added benefit demonstrated. The application of the ‘guard rails’ remains rather complex and legally ambiguous, suggesting that further contentious discussions are likely in the future.
{"title":"The impact of the new ‘guard rails’ for price negotiations on pharmaceutical expenditure in Germany: A simulation exercise and retrospective analysis","authors":"C. Kranich , D. Möller , C.M. Dintsios","doi":"10.1016/j.healthpol.2025.105537","DOIUrl":"10.1016/j.healthpol.2025.105537","url":null,"abstract":"<div><h3>Background</h3><div>Due to increasing pharmaceutical expenditures, Germany implemented 'guardrails' for price negotiations at the end of 2022, as part of the ‘Statutory Health Insurance Financial Stabilization Act’. They regulate the pricing of benefit-assessed pharmaceuticals with comparators under data exclusivity, to generate savings</div></div><div><h3>Objective</h3><div>We aimed at quantifying the targeted savings from a payer perspective.</div></div><div><h3>Methods</h3><div>A retrospective implementation of the ‘guard rails’ for new benefit-assessed pharmaceuticals in the period 2020 – 2022 on a subpopulation basis after application of specific exclusion criteria was chosen to estimate their potential savings by means of a simulated budget impact analysis. Comprehensive prescription data and pharmaceutical retail prices were utilized to ensure comparability over time.</div></div><div><h3>Results</h3><div>The analysis included 38 products with 82 subpopulations encompassing approximately 870,000 patients. The difference between negotiated prices and those regulated by the ‘guard rails’ in terms of annual therapeutic costs was statistically significant (p=0.01, CI95%: €1145,925.47 – €8914,501.69). If the ‘guard rails’ had been implemented earlier, pharmaceutical expenditure for the assessed subpopulations could have been reduced by €191.14 million, with oncological products accounting for €117.20 million (61.3% of total savings) in the examined period.</div></div><div><h3>Conclusions</h3><div>Despite the significant potential savings identified in this analysis, the actual annual savings are inconsistent and challenging to predict as they largely depend on the number of new product launches and the extent of their added benefit demonstrated. The application of the ‘guard rails’ remains rather complex and legally ambiguous, suggesting that further contentious discussions are likely in the future.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105537"},"PeriodicalIF":3.4,"publicationDate":"2025-12-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145750315","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-05DOI: 10.1016/j.healthpol.2025.105524
Lana Kovacevic , Lindsay Forbes , Hutan Ashrafian , Erik Mayer , Elias Mossialos , David Lugo-Palacios
Recent years have seen an emergence of collaborative primary care models in the English National Health Service and other international health systems. Primary Care Networks (PCNs) were introduced in England in July 2019, marking the first time collaboration between general practices was incentivised through a nationwide policy. While participation was not mandatory, nearly all general practices joined a PCN, largely due to strong financial incentives. Our study aim was to estimate the impact of PCNs on emergency hospitalisations using an interrupted time series design. Quarterly data between October 2016 and March 2023 from the North West London Whole Systems Integrated Care dataset was used to construct two primary outcomes: all-cause and ambulatory care sensitive conditions (ACSC) emergency hospitalisations, as well as Accident and Emergency attendances, considered as a secondary outcome. Furthermore, we analysed whether the impact of PCNs varied based on practice characteristics. A reduction in all-cause and ACSC hospitalisations was observed following the PCNs’ introduction, until the start of the COVID-19 pandemic. The analysis also revealed a smaller reduction in ACSC hospitalisations among practices with more deprived patient populations and larger populations of patients with long-term conditions. While PCNs’ implementation appears to have led to a reduction in emergency hospitalisations in North West London, this effect was only observed in the very short term as it stopped with the COVID-19 pandemic. Future studies should examine the effect across England and evaluate their continued impact.
{"title":"The impact of primary care networks on emergency hospitalisations in the English NHS: An interrupted time series analysis","authors":"Lana Kovacevic , Lindsay Forbes , Hutan Ashrafian , Erik Mayer , Elias Mossialos , David Lugo-Palacios","doi":"10.1016/j.healthpol.2025.105524","DOIUrl":"10.1016/j.healthpol.2025.105524","url":null,"abstract":"<div><div>Recent years have seen an emergence of collaborative primary care models in the English National Health Service and other international health systems. Primary Care Networks (PCNs) were introduced in England in July 2019, marking the first time collaboration between general practices was incentivised through a nationwide policy. While participation was not mandatory, nearly all general practices joined a PCN, largely due to strong financial incentives. Our study aim was to estimate the impact of PCNs on emergency hospitalisations using an interrupted time series design. Quarterly data between October 2016 and March 2023 from the North West London Whole Systems Integrated Care dataset was used to construct two primary outcomes: all-cause and ambulatory care sensitive conditions (ACSC) emergency hospitalisations, as well as Accident and Emergency attendances, considered as a secondary outcome. Furthermore, we analysed whether the impact of PCNs varied based on practice characteristics. A reduction in all-cause and ACSC hospitalisations was observed following the PCNs’ introduction, until the start of the COVID-19 pandemic. The analysis also revealed a smaller reduction in ACSC hospitalisations among practices with more deprived patient populations and larger populations of patients with long-term conditions. While PCNs’ implementation appears to have led to a reduction in emergency hospitalisations in North West London, this effect was only observed in the very short term as it stopped with the COVID-19 pandemic. Future studies should examine the effect across England and evaluate their continued impact.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105524"},"PeriodicalIF":3.4,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145776478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-05DOI: 10.1016/j.healthpol.2025.105527
Asiana Elma , Alison K. Scholes , Alexander Singer , Jennifer Shuldiner , Katrina Shen , Ian Scott , Danielle O’Toole , Deena M. Hamza , Lawrence Grierson , Russell Dawe , Alexandra Cernat , Meredith Vanstone
Background
Family physicians play a key role in coordinating and managing patient referrals to specialist care. While central to patient care, the referral process has been described as a disproportionately time-consuming and administratively demanding process, contributing to family physician burnout, stress, and attrition. Given the growing recognition of how administrative burden contributes to burnout, stress, and physician attrition from family medicine, it is crucial to examine the nature and impacts of this workload.
Objective
To describe the range of perspectives and experiences of family physicians on the referral process.
Methods
We conducted a systematic review of mixed-methods studies using a convergent integrative synthesis approach. Eligible studies were peer-reviewed, conducted in OECD countries, and published between 2012-2025. Quantitative data were transformed into portable narrative statements to enable integrated analysis with qualitative data. Constant comparative analysis was applied across different countries and study outcomes.
Results
Thirty-one studies were included, conducted in 13 high-income countries. The referral process was characterized as requiring clinical, technological, and social competence, involving decisions about whether and how to refer, and constructing and following up on referrals. This work was further complicated by strained and fragmented healthcare systems, positioning family physicians in the role of bridging system gaps for patients. These challenges resulted in additional paperwork, unnecessary referrals, delays, and rejections, which exacerbated system inefficiencies as opposed to improving resource use. Ultimately, this contributed to physician burnout, reduced professional autonomy, and job dissatisfaction.
Conclusions
Ameliorating referral-related burden will require system-level reform and examination of intra-professional power structures.
{"title":"Judicious resource managers or administrative intermediaries: A systematic review of family physician perspectives on the administrative process of referring patients to other clinicians in high income countries","authors":"Asiana Elma , Alison K. Scholes , Alexander Singer , Jennifer Shuldiner , Katrina Shen , Ian Scott , Danielle O’Toole , Deena M. Hamza , Lawrence Grierson , Russell Dawe , Alexandra Cernat , Meredith Vanstone","doi":"10.1016/j.healthpol.2025.105527","DOIUrl":"10.1016/j.healthpol.2025.105527","url":null,"abstract":"<div><h3>Background</h3><div>Family physicians play a key role in coordinating and managing patient referrals to specialist care. While central to patient care, the referral process has been described as a disproportionately time-consuming and administratively demanding process, contributing to family physician burnout, stress, and attrition. Given the growing recognition of how administrative burden contributes to burnout, stress, and physician attrition from family medicine, it is crucial to examine the nature and impacts of this workload.</div></div><div><h3>Objective</h3><div>To describe the range of perspectives and experiences of family physicians on the referral process.</div></div><div><h3>Methods</h3><div>We conducted a systematic review of mixed-methods studies using a convergent integrative synthesis approach. Eligible studies were peer-reviewed, conducted in OECD countries, and published between 2012-2025. Quantitative data were transformed into portable narrative statements to enable integrated analysis with qualitative data. Constant comparative analysis was applied across different countries and study outcomes.</div></div><div><h3>Results</h3><div>Thirty-one studies were included, conducted in 13 high-income countries. The referral process was characterized as requiring clinical, technological, and social competence, involving decisions about whether and how to refer, and constructing and following up on referrals. This work was further complicated by strained and fragmented healthcare systems, positioning family physicians in the role of bridging system gaps for patients. These challenges resulted in additional paperwork, unnecessary referrals, delays, and rejections, which exacerbated system inefficiencies as opposed to improving resource use. Ultimately, this contributed to physician burnout, reduced professional autonomy, and job dissatisfaction.</div></div><div><h3>Conclusions</h3><div>Ameliorating referral-related burden will require system-level reform and examination of intra-professional power structures.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105527"},"PeriodicalIF":3.4,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145750316","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-05DOI: 10.1016/j.healthpol.2025.105528
Aurora Heidar Alizadeh , Marcello Cuomo , Alessandra Burgio , Alessandro Solipaca , Paola Arcaro , Danilo Catania , Barbara Giordani , Walter Ricciardi , Giovanni Baglio , Gianfranco Damiani
Background
Avoidable hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) are key proxy indicators of Primary Care (PC) services quality. Challenges in Italy's National Health Service, worsened by COVID-19, have spurred outpatient care reforms to ultimately reduce avoidable hospitalizations.
Objective
To provide a synthetic, composite and cross-national index of avoidable hospitalizations in adults, for evaluating PC services performance.
Methods
Nine avoidable hospitalization indicators for 2017-2019 and 2020-2022 were calculated from discharge data of Italian hospitals. Their standardized z-scores, grouped into five nosological areas, were equally weighted to ensure balanced representation. A final synthetic index for each area was classified into one of five Jenks clusters.
Results
The national hospitalization rate decreased from 148.17 per 1,000 residents in 2017-2019 to 125.98 in 2020-2022. Before COVID-19, the “low” clusters were 11, whereas the “high” clusters were 14. In 2020-2022, the "low" and "high" clusters changed to 13 and 10, showing a mild improvement. The “medium-low” and “medium-high” clusters reported significant changes, from 29 to 39 and from 29 to 20, respectively. The “medium” clusters have remained essentially unchanged (from 36 to 37).
Conclusions
The index distribution offers three main insights: consistently low values suggest efficient PC services; high values may indicate weak strategies or ineffective PC policies; heterogeneous distribution shows fragmented policies, implying better integration and evaluation. Despite potential biases involving patient behaviors and healthcare system factors, the synthetic index offers an evaluation tool for PC performance, reducing access inequalities, and guiding targeted improvements.
{"title":"A composite and synthetic index of potentially avoidable hospitalization in adults to assess primary care quality: an application across Italian geopolitical areas","authors":"Aurora Heidar Alizadeh , Marcello Cuomo , Alessandra Burgio , Alessandro Solipaca , Paola Arcaro , Danilo Catania , Barbara Giordani , Walter Ricciardi , Giovanni Baglio , Gianfranco Damiani","doi":"10.1016/j.healthpol.2025.105528","DOIUrl":"10.1016/j.healthpol.2025.105528","url":null,"abstract":"<div><h3>Background</h3><div>Avoidable hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) are key proxy indicators of Primary Care (PC) services quality. Challenges in Italy's National Health Service, worsened by COVID-19, have spurred outpatient care reforms to ultimately reduce avoidable hospitalizations.</div></div><div><h3>Objective</h3><div>To provide a synthetic, composite and cross-national index of avoidable hospitalizations in adults, for evaluating PC services performance.</div></div><div><h3>Methods</h3><div>Nine avoidable hospitalization indicators for 2017-2019 and 2020-2022 were calculated from discharge data of Italian hospitals. Their standardized z-scores, grouped into five nosological areas, were equally weighted to ensure balanced representation. A final synthetic index for each area was classified into one of five Jenks clusters.</div></div><div><h3>Results</h3><div>The national hospitalization rate decreased from 148.17 per 1,000 residents in 2017-2019 to 125.98 in 2020-2022. Before COVID-19, the “low” clusters were 11, whereas the “high” clusters were 14. In 2020-2022, the \"low\" and \"high\" clusters changed to 13 and 10, showing a mild improvement. The “medium-low” and “medium-high” clusters reported significant changes, from 29 to 39 and from 29 to 20, respectively. The “medium” clusters have remained essentially unchanged (from 36 to 37).</div></div><div><h3>Conclusions</h3><div>The index distribution offers three main insights: consistently low values suggest efficient PC services; high values may indicate weak strategies or ineffective PC policies; heterogeneous distribution shows fragmented policies, implying better integration and evaluation. Despite potential biases involving patient behaviors and healthcare system factors, the synthetic index offers an evaluation tool for PC performance, reducing access inequalities, and guiding targeted improvements.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105528"},"PeriodicalIF":3.4,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145718899","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In Estonia, Latvia, and Lithuania, the push for care integration has gained momentum, being seen as an innovative approach to allocate resources more efficiently and improve patient outcomes.
Objective
This study investigates the progress of integrating care in the Baltic countries from 2019 to 2024 to detail key learnings.
Methods
We undertook a cross-country study to better understand the progress in care integration in the Baltics with a two-round, 21-item questionnaire on the adoption of integrated care reforms in 2019 and 2024. Responses were analyzed to capture countries’ policy environments and their conduciveness to the uptake of integrated care. Country-specific experiences with implementation of care were further explored via case studies of pilot programmes.
Results
The pace of implementing integrating care varied. Existing barriers, workforce challenges and payment schemes have impeded integration across health and social care. Despite this, political commitment across successive governments to new and innovative service delivery and collaboration for chronic care management underscores an important prerequisite toward achieving more integrated and person-centred healthcare. The three case studies illustrate hurdles that come with shifting care settings and expanding roles for some workers.
Conclusions
Integrating care across providers and the social and health sectors is an incremental process that needs long-term political support to address persistent barriers. The Baltic countries’ experiences indicate challenges in bringing together stakeholders in areas such as data interoperability, new financing models and reorganization of workforce and skills mixing. Further work should advance evidence on patient-centred solutions for evolving needs.
{"title":"Integrated care in the Baltic countries over a five-year period: an expert-informed cross-country analysis of progress, challenges and future directions","authors":"Nathan Shuftan , Giada Scarpetti , Katherine Polin , Kaija Kasekamp , Daiga Behmane , Liubove Murauskiene , Verena Struckmann","doi":"10.1016/j.healthpol.2025.105526","DOIUrl":"10.1016/j.healthpol.2025.105526","url":null,"abstract":"<div><h3>Background</h3><div>In Estonia, Latvia, and Lithuania, the push for care integration has gained momentum, being seen as an innovative approach to allocate resources more efficiently and improve patient outcomes.</div></div><div><h3>Objective</h3><div>This study investigates the progress of integrating care in the Baltic countries from 2019 to 2024 to detail key learnings.</div></div><div><h3>Methods</h3><div>We undertook a cross-country study to better understand the progress in care integration in the Baltics with a two-round, 21-item questionnaire on the adoption of integrated care reforms in 2019 and 2024. Responses were analyzed to capture countries’ policy environments and their conduciveness to the uptake of integrated care. Country-specific experiences with implementation of care were further explored via case studies of pilot programmes.</div></div><div><h3>Results</h3><div>The pace of implementing integrating care varied. Existing barriers, workforce challenges and payment schemes have impeded integration across health and social care. Despite this, political commitment across successive governments to new and innovative service delivery and collaboration for chronic care management underscores an important prerequisite toward achieving more integrated and person-centred healthcare. The three case studies illustrate hurdles that come with shifting care settings and expanding roles for some workers.</div></div><div><h3>Conclusions</h3><div>Integrating care across providers and the social and health sectors is an incremental process that needs long-term political support to address persistent barriers. The Baltic countries’ experiences indicate challenges in bringing together stakeholders in areas such as data interoperability, new financing models and reorganization of workforce and skills mixing. Further work should advance evidence on patient-centred solutions for evolving needs.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"166 ","pages":"Article 105526"},"PeriodicalIF":3.4,"publicationDate":"2025-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"146068330","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-04DOI: 10.1016/j.healthpol.2025.105525
Zachary D.V. Abel , Laurence S.J. Roope , Raymond Duch , Sophie Cole , Philip M. Clarke
{"title":"On “Inequality in COVID-19 vaccine acceptance and uptake”","authors":"Zachary D.V. Abel , Laurence S.J. Roope , Raymond Duch , Sophie Cole , Philip M. Clarke","doi":"10.1016/j.healthpol.2025.105525","DOIUrl":"10.1016/j.healthpol.2025.105525","url":null,"abstract":"","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"164 ","pages":"Article 105525"},"PeriodicalIF":3.4,"publicationDate":"2025-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145748632","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-03DOI: 10.1016/j.healthpol.2025.105523
Eray Ontas , Cavit Işık Yavuz
Background
Health systems worldwide face compound crises that test workforce resilience and equity. Turkey’s centralized healthcare system offers a critical case to examine how governance models perform under sustained, sequential shocks.
Objective
To assess how Turkey’s compulsory service–based physician distribution system responded to major crises over the past decade and to introduce a novel metric for evaluating workforce retention efficiency.
Methods
This 12-year longitudinal ecological study (2013–2024) analysed Ministry of Health physician stock (active density) and flow (new appointments) data across 81 provinces. A "retention efficiency" metric (ΔStock/Flow) quantified system performance, and distributional inequality was assessed. Quasi-experimental methods, including difference-in-differences and interrupted time series analyses, assessed the impacts of the Syrian refugee influx, COVID-19 pandemic, and the 2023 earthquakes.
Results
Physician density under MoH increased by 57 % (2013–2023), yet regional inequality worsened markedly (Weighted-Gini:0.079→0.116; +47 %). A "revolving door" dynamic was identified: western regions retained physicians efficiently(>0.95), while peripheral eastern regions suffered catastrophic retention inefficiency(<0.10), rendering compulsory service ineffective. Crisis response phenotypes varied significantly. The 2023 earthquakes triggered a "volatile surge" with dose-response characteristics: the 3 epicentre provinces showed +239 % increase (ITS: +36.4;95 %CI: 35.4–37.4), declining 58.3 % by 2024. In contrast, the Syrian refugee influx elicited an "integrated absorption" pattern, with no significant targeted response (DiD:0.80; p = 0.574) despite increased demand.
Conclusion
Compulsory service enables short-term absorptive capacity but fails to ensure lasting equity. The retention efficiency metric exposes hidden inefficiencies that conventional density measures miss. Transitioning from coercive placements toward bundled incentives and investment in professional ecosystems is essential to achieve sustainable workforce resilience.
{"title":"Healthcare workforce distribution during multiple crises: a 12-year analysis of physician allocation, retention and equity patterns in Turkey","authors":"Eray Ontas , Cavit Işık Yavuz","doi":"10.1016/j.healthpol.2025.105523","DOIUrl":"10.1016/j.healthpol.2025.105523","url":null,"abstract":"<div><h3>Background</h3><div>Health systems worldwide face compound crises that test workforce resilience and equity. Turkey’s centralized healthcare system offers a critical case to examine how governance models perform under sustained, sequential shocks.</div></div><div><h3>Objective</h3><div>To assess how Turkey’s compulsory service–based physician distribution system responded to major crises over the past decade and to introduce a novel metric for evaluating workforce retention efficiency.</div></div><div><h3>Methods</h3><div>This 12-year longitudinal ecological study (2013–2024) analysed Ministry of Health physician stock (active density) and flow (new appointments) data across 81 provinces. A \"retention efficiency\" metric (ΔStock/Flow) quantified system performance, and distributional inequality was assessed. Quasi-experimental methods, including difference-in-differences and interrupted time series analyses, assessed the impacts of the Syrian refugee influx, COVID-19 pandemic, and the 2023 earthquakes.</div></div><div><h3>Results</h3><div>Physician density under MoH increased by 57 % (2013–2023), yet regional inequality worsened markedly (Weighted-Gini:0.079→0.116; +47 %). A \"revolving door\" dynamic was identified: western regions retained physicians efficiently(>0.95), while peripheral eastern regions suffered catastrophic retention inefficiency(<0.10), rendering compulsory service ineffective. Crisis response phenotypes varied significantly. The 2023 earthquakes triggered a \"volatile surge\" with dose-response characteristics: the 3 epicentre provinces showed +239 % increase (ITS: +36.4;95 %CI: 35.4–37.4), declining 58.3 % by 2024. In contrast, the Syrian refugee influx elicited an \"integrated absorption\" pattern, with no significant targeted response (DiD:0.80; <em>p</em> = 0.574) despite increased demand.</div></div><div><h3>Conclusion</h3><div>Compulsory service enables short-term absorptive capacity but fails to ensure lasting equity. The retention efficiency metric exposes hidden inefficiencies that conventional density measures miss. Transitioning from coercive placements toward bundled incentives and investment in professional ecosystems is essential to achieve sustainable workforce resilience.</div></div>","PeriodicalId":55067,"journal":{"name":"Health Policy","volume":"165 ","pages":"Article 105523"},"PeriodicalIF":3.4,"publicationDate":"2025-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145783601","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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