Frontiers in health services最新文献

Background: Allocation of scarce donor organs must balance improving overall outcomes with protecting patients at greatest near-term risk. Urgency-focused systems such as MELD (Model for End-Stage Liver Disease) are efficient in saving lives but can reduce total post-transplant survival, whereas unconstrained utility maximization risks bypassing the sickest patients.

Methods: We propose Harm-Threshold Utilitarianism (HTU), which maximizes expected post-transplant benefit subject to two guardrails: (i) an epistemic threshold requiring sufficient confidence before acting on predicted differences, and (ii) a catastrophic harm threshold that blocks bypassing candidates at high short-term waitlist mortality risk for only marginal or uncertain gains. Using de-identified U.S. liver transplant registry data, we performed proof-of-concept simulations of offer-like pools, comparing HTU with MELD-based selection. Outcomes included Kaplan-Meier curves and 5-year restricted mean survival time (RMST). Sensitivity analyses varied the harm threshold and confidence level.

Results: HTU transparently reorders candidates relative to MELD while preserving alignment on broad priorities. In simulated pools, HTU-selected recipients achieved higher post-transplant survival; mean RMST improved by approximately 0.25 years per transplant (about three months) at baseline settings. Varying the catastrophic harm threshold produced a clear urgency-efficiency frontier: tighter thresholds selected more urgent patients with smaller gains, while looser thresholds increased gains but allowed more bypasses of urgent candidates.

Conclusions: HTU operationalizes a tunable, ethically explicit trade-off between benefit and protection of the worst-off. By encoding precaution (confidence threshold) and a non-negotiable floor against catastrophic harm, HTU offers measurable efficiency gains without sacrificing fairness, and reframes policy choices as transparent parameters open to review.

Introduction: Measurement-based care (MBC) is an evidence-based practice; however there are challenges associated with implementing and sustaining this practice in care. This study examined the outcomes of an organization-wide implementation of MBC in a technology-supported psychotherapy practice. Outcomes were patient symptom change, clinician behaviors, and clinician performance.

Methods: A total of n = 18,721 patients and 755 clinicians were included in the 6-month implementation. Change efforts targeted organizational alignment, technology integration, education and support, and cultural and operational change. Outcomes were assessed across three phases: pre-implementation, implementation, and post-implementation. Primary outcome measures for patients were percent change on the PHQ-9 and GAD-7. Estimates of differences between phases of implementation were computed using linear mixed effects models, adjusted for patient characteristics. Clinician behaviors associated with MBC were extracted from progress notes. Changes in individual clinician performance were assessed for clinicians with sufficient data across the implementation phases.

Results: Patient outcomes improved significantly from pre- to post-implementation by approximately 5 percentage points for all outcomes. This represents a relative improvement of 23.5% on a combined PHQ-9 and GAD-7 measure. Clinicians demonstrated significant increases in MBC-related documentation behaviors. Among clinicians with sufficient data, 95% showed evidence of improved performance. Notably, clinicians whose baseline performance was superior showed greater improvements in performance.

Discussion: Overall, this study suggests that structured MBC implementation was associated with improved patient outcomes, clinician behavior change, and clinician performance, although causal attributions are not possible given the retrospective non-randomized design. These results have implications for scalable implementation approaches in regular practice settings.

Diabetes self-management is critical for improving health outcomes, but people with severe mental illness (SMI) face additional barriers that complicate effective engagement with self-management behaviours and with existing diabetes services. This feasibility study assessed the acceptability and feasibility of the DIAMONDS intervention, a tailored type 2 diabetes (T2D) self-management programme designed for people with SMI and delivered by trained coaches over 16 weekly sessions, in preparation for a future randomised controlled trial (RCT). Thirty participants with both T2D and SMI were recruited, and 29 were included in the study. The thresholds for participant recruitment and retention for progression to the RCT were met. Twenty-three participants (66%) attended at least one intervention session. Consistent weekly participation proved challenging, with only 15 participants (52%) attending eight or more (50%+) sessions. However, the intervention was acceptable to both participants and coaches, as indicated by coach session logs. High completion rates were observed for self-reported measures, while physical health data and data from primary care records had some omissions, prompting refinements in data collection for the RCT. This study highlights the feasibility and acceptability of delivering an evaluation of a structured diabetes self-management intervention in people with SMI. Some modifications to study processes will be required before moving to the main RCT, including adjustments to intervention delivery (including more flexibility in the timing of intervention sessions and coach training to improve confidence in supporting the use of a mobile app), data collection processes, and intervention fidelity assessment for the RCT, to enhance adherence and accommodating the complex needs of this population. This study represents an important step towards the development and robust evaluation of a self-management intervention to improve diabetes outcomes for people with SMI, addressing a significant gap in health equity.

Clinical trial registration: https://www.isrctn.com/ISRCTN15328700, ISRCTN 15328700.

Background: Suicidal ideation represents a significant public health concern, serving as a crucial predictor of suicide attempts. While biological and psychological risk factors have been thoroughly delineated, the role of daily behaviors such as nutrition, oral health, physical activity, and psychological traits remains to be elucidated.

Objective: This study examined behavioral and psychological differences between Spanish adult's participants with suicidal ideation and a comparison group within a community sample. In Spain, the legal definition of "adult" is primarily determined by the age of majority, which is set at 18 years.

Methods: A total of 1,364 adults from Spain, completed an online survey assessing sociodemographic, anthropometric, nutritional, oral health, physical activity, and psychological variables. Group assignment was based on the Zung Self-Rating Depression Scale, with 20 individuals endorsing suicidal ideation and 1,344 serving as controls. Independent t-tests compared groups with a significance level of p ≤ 0.05.

Results: Compared with controls, the suicidal ideation group was younger, had lower weight and BMI, reported shorter sleep duration, poorer sleep quality, and more time on social media. They also reported lower water intake and vitality but higher consumption of pastries, protein shakes, and vitamin supplements, along with more frequent migraines and poorer digestion. Oral health findings were counterintuitive, with lower prevalence of gastritis, dry mouth, and dental sensitivity. No significant differences emerged in physical activity. Psychologically, the suicidal ideation group reported greater depression, stress, anxiety, loneliness, and psychological inflexibility, as well as higher neuroticism and openness, and lower extraversion and agreeableness.

Conclusions: Due to the preliminary nature of the study, these findings suggest the presence of distinct behavioral and psychological profiles associated with suicidal ideation. In light of the limited sample size, the single-item classification, and the cross-sectional self-report design, the findings must be regarded as preliminary associations.

Introduction: The Affordable Care Act (ACA) represents the most comprehensive U.S. health reform since Medicare and Medicaid. However, evidence on its impact on population health in the general U.S. population, particularly mental health, remains limited.

Methods: We analyzed a nationally representative sample of non-elderly adults aged 18-64 from the Medical Expenditure Panel Survey (2007-2019). Outcomes included two health-related quality of life (HRQOL) measures derived from the SF-12 v2: physical component summary (PCS) and mental component summary (MCS) scores. Using conditional-mean and quantile-regression difference-in-differences models, we examined the effect of the ACA by comparing pre-post changes in PCS and MCS scores among non-elderly adults relative to counterfactuals from TRICARE beneficiaries not subject to ACA provisions.

Results: Our conditional-mean DID estimates indicate that the ACA was associated with a 2.7% increase in PCS scores among non-elderly adults during 2011-2013. Although statistically insignificant, MCS scores exhibited increases of growing magnitude following the implementation of the major ACA major provisions in 2014. Notably, simultaneous-quantile DID estimates suggest that the increases in PCS and MCS scores attributable to the ACA were concentrated among individuals with relatively lower health levels, particularly those around the 30th to 60th percentiles of the score distributions.

Discussion: Findings indicate that the ACA led to measurable gains in physical and mental health, particularly among relatively lower-middle levels of physical and mental health. Policymakers assessing the value of the ACA, or more generally debating the value of expanding access to health insurance in the population, should consider these positive gains in population health.

Introduction: Digital competence is essential for students and professionals in health and nursing education. Based on the DigComp 2.2 framework, this study examines the self-assessed digital competencies of students from Germany, Ukraine, and Kazakhstan across five core dimensions, aiming to identify national differences and potential misalignments between perceived and reported digital competences.

Methods: A cross-sectional online survey (n = 269) was conducted among students in health-related fields. Participants rated their digital competence on 15 items aligned with DigKomp 2.2 questionnaire. Quantitative data were analyzed descriptively and with ANOVA (two-tailed, p < 0.05), using Games-Howell post-hoc tests in case of heterogeneity of variances and Kruskal-Wallis/Mann-Whitney tests as sensitivity analyses. In addition, an open-ended knowledge question asked respondents to describe their strategies for finding reliable online information. Responses were analyzed descriptively and qualitatively using inductive coding.

Results: While all groups reported generally high digital competence, German students rated themselves significantly lower in the Digital content creation dimension compared to their peers and the KaWuM reference sample. However, their responses to the open-ended question revealed methodologically advanced search strategies, including systematic literature reviews (n = 8), Boolean operators (n = 6), and use of AI tools (n = 1). Ukrainian students emphasized heuristic and comparative approaches, while Kazakhstani responses reflected pragmatic strategies under infrastructural constraints.

Discussion: The findings suggest a mismatch between self-assessed and actual digital competence, particularly among German students, who may underestimate their skills. This highlights the importance of triangulating quantitative self-reports with qualitative diagnostics. The study underscores the need for embedded digital skills training, especially in Digital content creation, across national contexts in health education.

Background: Type 2 diabetes mellitus (T2DM) is a growing health burden in China. High complication rates contribute to increased morbidity, mortality, and costs. However, evidence is limited regarding how these complications develop and cluster over time in real-world settings, which this study examined.

Methods: This retrospective cohort study used big data from the Cheeloo Lifespan Electronic Health Research Data Library, comprising data from over 5 million individuals in Shandong Province, China, to investigate the trajectories, onset timing and key risk factors of T2DM-related complications.

Results: The prevalence of T2DM-related complications increased from 30.4% in 2013 to 53.1% in 2023. The median time from diagnosis to the first complication was 7.5 years. Ophthalmic, neurological, and circulatory complications were among the most common and showed the largest relative increases in prevalence over the study period. Complication profiles exacerbated over time: most patients developed multiple complications by Year 9. Frequent follow-up visits (≥4 times/year) and using primary health care (PHC) services were significantly associated with a reduced risk of complications, whereas being unmarried, being overweight, being obese, alcohol use, and poor medication adherence were significantly associated with a higher risk.

Conclusion: Patients with T2DM in China face a substantial and growing burden of complications, with most developing multiple complications within ten years of diagnosis. Follow-up visits, the use of PHC services, and regular medication adherence are potential protective factors to prevent or delay the development of complication. These findings highlight the importance of integrated, community-based, and personalized management strategies to improve outcomes in T2DM populations.

Introduction: The care provided to patients with severe mental disorders remains a major challenge for the organization of healthcare systems. Data on recent treatment patterns within mental health services are essential to estimate the unmet needs for care and to guide service planning and resource allocation.

Aim: To identify individual patient and organizational-level predictors of the provision of minimally adequate care for patients with severe mental illness.

Methods: A population-based study was designed, retrieving data from Healthcare Utilization databases of Lombardy region (Italy). 72,115 patients from Departments of Mental Health (DMHs) in care for schizophrenic, bipolar or major depressive disorder, were identified. Minimally Adequate Treatment (MAT) was calculated as either minimum psychiatric visits (≥4) with pharmacological treatment (≥2 months) or psychotherapy sessions (≥8, for major depressive disorder only). Patients meeting these criteria were considered as having received MAT; others were classified as having received less than adequate treatment. Multilevel analyses were performed to estimate the association between patients' individual (e.g., age, sex, education, marital status) and DMHs' aggregate (i.e., organizational features, activity volume, staff employed in facilities providing MHC) characteristics and provision of MAT.

Results: Overall, 45% of patients received MAT. Patients with increased probability of receiving MAT included married individuals (8%, 95% CI: 4%-12%), those with schizophrenia (11%, 95% CI: 9%-13%) or bipolar disorder (23%, 20%-25%), younger patients (22%, 20%-25%), and those with previous continuity of care (48%, 46%-51%). Differences in DMHs' structural features (e.g., number of day-treatment facilities, presence of multidisciplinary teams) contributed to heterogeneous MAT coverage. Moreover, the composition of psychiatric teams (in terms of hours worked by each category of healthcare professionals) and the number of affiliated facilities were associated with MAT delivery.

Conclusions: This study ascertained that the quality of care offered to psychiatric patients is still low and not adequate. Administrative data can usefully contribute to identify both individual and organizational-level predictors of MAT provision, offering a valuable benchmark for managing organizational features of DMHs and for optimally allocating the working hours in multidisciplinary professional teams, with the goal of maximizing the provision of adequate mental healthcare.