Hand hygiene an effective public health measure for preventing infectious diseases. Sustained hand hygiene practice requires an enabling environment that constitutes access to hand hygiene products and services, clear and effective policy provisions, financing, monitoring and coordination mechanisms. This paper analyses Kenya's national hand hygiene policy landscape and identifies the underlying governance barriers and systemic opportunities for strengthening hand hygiene policy and practice in Kenya. Guided by the Health Policy Triangle (HPT) framework, this study systematically examined the context, content, process, and actors shaping Kenya's hand hygiene policy landscape. Primary data was collected through Key Informant Interviews (KIIs) with 11 strategic stakeholders involved in policy development, implementation, regulation and program delivery. Secondary data was through a comprehensive review of 20 policy instruments, including national policies, strategies, protocols, roadmaps, and binding legal documents. In Kenya, policies are formulated at the national level and devolved to the County level for implementation, with support from state and non-state actors. The analysis showed that Kenya lacks a standalone, hand hygiene policy document. However, hand hygiene provisions are present in policy documents which cover hand hygiene in several settings such as rural areas, schools and health facilities. This reflects fragmented policy presence rather than complete absence. Barriers hindering effective implementation include weak inter-sectoral coordinating mechanisms, inadequate financing, and a lack of data. These gaps create governance and operational fragmentation, undermining the sustainability of hand hygiene interventions.To transition to an enabling environment, Kenya should establish explicit national hand hygiene standards with clear definitions and minimum requirements, secure dedicated and sustainable financing mechanisms, ensure national-County coordination, and integrate standardized hand hygiene indicators into the national and sub-national health information systems. These reforms will support a more coherent governance, evidence informed planning and accountability for hand hygiene implementation.
Senegal faces high maternal mortality, elevated levels of short‑interval births, and substantial unmet need for postpartum contraception. Supply chain challenges contribute to contraceptive nonuse in the country. Before 2013, Senegal used a pull‑based contraceptive supply chain, in which facility staff estimated demand and procured supplies, leading to frequent stockouts. The informed push model (IPM), launched in 2012, aimed to streamline distribution. We used 2014-2019 DHS data (N = 32,373) and applied an event‑study difference‑in‑differences design with district‑level data to assess changes in the prevalence of modern, long-acting, reversible, and short‑acting contraceptive methods. We further conducted subgroup analyses by wealth and urbanicity. IPM significantly increased contraceptive prevalence. Modern contraceptive use in the postpartum period rose by 7.8 percentage points within 10 quarters post-IPM. Increases were most pronounced for wealthier and more urban districts. Results underscore the value of strong supply chains but show that supply‑side efforts alone may not reach low-income and rural populations. Future work should evaluate the cost-effectiveness and sustainability of alternative financing models and integrated strategies to address persistent supply and access barriers.
Climate disasters are increasingly understood not as natural phenomena alone but as outcomes shaped by governance systems and institutional capacities. While existing scholarship has documented flood impacts and theorized governance deficits, few studies have traced the precise causal pathways through which institutional pathologies-fragmentation, spatial mismatch, and perverse incentives-produce recurrent disaster outcomes. This study addresses this gap by diagnosing the systemic governance failures that amplified the 2025 floods. Employing a Diagnostic Policy Analysis Framework for Recurrent Disasters through mixed-methods analysis of 27 official documents captured during the acute crisis phase, we demonstrate that the flood's magnitude resulted from three interconnected governance failures: (1) institutional fragmentation that crippled coordination and response; (2) spatial mismatch between uniform national policies and Pakistan's diverse hydro‑geographical regimes; and (3) perverse incentives that reward visible post‑disaster relief over proactive prevention. Our findings trace these failures to specific institutional mechanisms: irregularities in infrastructure contracting documented in audit reports, political interference in relief distribution, and the systematic disempowerment of district‑level disaster authorities. We further identify three transferable diagnostic pathways-fragmentation, spatial mismatch, and perverse incentives-that offer an analytical template for analyzing recurrent disasters in other complex governance contexts. The study concludes that building resilience requires confronting these specific institutional pathologies. For Pakistan, this means empowering district disaster authorities with mandated minimum budgets and evacuation authority under the NDMA Act, enforcing existing floodplain zoning regulations against politically connected developers, and restructuring disaster financing to pre‑position funds for pre‑emptive action triggered by meteorological forecasts.
Rural communities face disproportionate burdens of chronic disease, mental illness, workforce shortages, and fragmented services despite historic national health spending. The Whole Health, Whole Communities: Dialogues to Reduce Rural Health Disparities symposium in Roanoke, Virginia, convened cross-sector leaders to identify reforms necessary to embed person-centered care into rural systems. Participants outlined staged reforms across governance, financing, workforce development, and data infrastructure. Priority actions include trauma-informed care expansion, payment redesign, sustainable community health worker funding, participatory research, and cross-sector coordination - advancing scalable, community-embedded Whole Health models to reduce rural disparities.
Health inequities across Chicago reflect structural differences in housing, food access, education, employment, and safety, producing stark gaps in outcomes, including a 24-year life expectancy divide between the Loop and West Garfield Park. Insights from the Chicago Collecting and Aligning Research to Achieve Health Equity symposium at the University of Chicago highlight misalignments in research funding, incentives, and governance that limit impact in underserved communities. Actionable strategies are presented - phased funding, shared infrastructure, community-led grantmaking, pooled financing, and reimbursement reform - to realign power, resources, and accountability, offering a scalable framework for community-driven cross-sector health equity.
Germany's longstanding separation of healthcare sectors - most prominently between outpatient and inpatient care - creates risks of fragmented service delivery, disrupted information flows, and ultimately suboptimal outcomes for patients. This position paper examines how cross-sectoral and integrated strategies can effectively mitigate or overcome this fragmentation. During a Berlin Forum of the Association of the Scientific Medical Societies in Germany (AWMF) (6 December 2024), experts presented best-practice models and discussed legal, structural, financial, and regional dimensions of integrated care. The insights from these discussions were synthesized into AWMF's recommendations. Integrated care represents a critical lever for improving the efficiency and quality of the German healthcare system. Promising examples exist across surgical, medical, psychiatric, and regionalized care settings. Key recommendations address the following topics: harmonized financing and remuneration system, regional population-based healthcare networks, interoperable information exchange across healthcare sectors, shared decision-making on care options. Health services research - and especially implementation research - plays an indispensable role in guiding and evaluating these reforms. The AWMF further emphasizes the need for integrated education and postgraduate training, particularly within structured residency networks, and offers AWMF as an important interdisciplinary and interprofessional platform for promoting cross-sectoral care. Broad implementation of integrated care, combined with robust and evidence-based monitoring of implementation, is essential for meeting the challenges posed by demographic change and increasing demands on healthcare delivery. Die bisherige Trennung der Versorgungssektoren in Deutschland – insbesondere zwischen ambulanter und stationärer Versorgung – birgt die Gefahr von unzureichend effizienten Behandlungsabläufen, Informationsverlusten und folglich einer suboptimalen Patientenversorgung. Dieses Positionspapier evaluiert, wie sektorenübergreifende Ansätze diese Fragmentierung verbessern und überwinden können. Im Rahmen eines Berliner Forums der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) (6. Dezember 2024) wurden Beispiele guter Praxis sowie rechtliche, strukturelle und regionale Aspekte der sektorenübergreifenden Versorgung durch Expertinnen und Experten vorgestellt und diskutiert. Die Ergebnisse flossen in ein Positionspapier ein, das Empfehlungen der AWMF formuliert. Die sektorenübergreifende Versorgung ist ein zentraler Ansatzpunkt zur Verbesserung der Effizienz und Qualität des deutschen Gesundheitssystems. Beispiele guter Praxis sind ermutigend. Die Empfehlungen der AWMF betreffen die folgenden Themenbereiche: Harmonisierung der Finanzierungs- und Vergütungssysteme, Etablierung regionaler Gesundheitsnetzwerke, interoperabler Informationsaustausch über alle Sektoren, partizipative Entscheidungsfindung zu Behandlungsalternativen. Die Versorgungsforschung spielt dabei eine zentrale Rolle. Die AWMF empfiehlt zudem eine sektorenübergreifende Aus- und Weiterbildung z.B. in Weiterbildungsverbünden und bietet die Nutzung der AWMF als strategische Plattform für interdisziplinäre und interprofessionelle Weiterentwicklung sektorenübergreifender Versorgung an. Eine Ausweitung der sektorenübergreifenden Versorgung mit evidenzbasiertem Monitoring der Implementierungsschritte ist essenziell, um den Herausforderungen des demografischen Wandels und den steigenden Anforderungen an die Gesundheitsversorgung zu begegnen.
Next-generation sequencing (NGS) and bioinformatics are critical to infectious disease surveillance, outbreak detection and response, and the research and development of medical countermeasures. Achieving sustainable genomic surveillance requires countries to develop costed national strategies that integrate financial planning and budgeting across sequencing and bioinformatics activities. The genomics costing tool (GCT) was initially developed to estimate the costs of SARS-CoV-2 sequencing and associated bioinformatics. In response to growing country demand, the tool has now been expanded to support a wider range of pathogens and laboratory settings (GCT 2.0). To inform the design of GCT 2.0, a cross-sectional online survey was disseminated between September 2024 and March 2025 to assess current global next-generation sequencing and bioinformatics capacity. Respondents were recruited via professional networks, mailing lists, and partner organizations. The questionnaire captured laboratory demographics, instrumentation, reagents, throughput, data management, bioinformatics/analytical tools, and funding sources. Of the 149 respondents, 120 responses from 52 countries across all six WHO regions were included in the analysis, after excluding incomplete submissions. The median number of sequencing instruments per respondent was 3, with Illumina and Oxford Nanopore Technologies being the most predominant platforms, reported by 89.6 and 68.8% of the respondents, respectively. The median annual throughput reported was 1,940 samples in high-income countries, 850 in upper-middle-income countries, 1,205 in lower-middle-income countries, and 950 in low-income countries. Only 57.7% of respondents stored data in multiple locations, and 32.5% lacked any data backup. Funding sources varied: 54.4% relied on multiple streams, while 14.9% depended solely on government budgets, and many laboratories relied on emergency or project-based support. Global NGS and bioinformatics capacity continues to expand, yet substantial geographical and operational disparities persist. Beyond instrument availability, laboratories face constraints related to throughput, data storage, analysis capacity, and sustainable financing. Informed by these findings, GCT 2.0 incorporates expanded pathogen coverage, flexible throughput scenarios, support for multiple sequencing platforms, and detailed costing of data storage and bioinformatics workflows. By integrating these considerations, the tool aims to strengthen laboratories' capacity to plan, manage, and sustain genomic surveillance over the long term.
Expatriates represent a growing patient group seeking aesthetic dental treatments in cosmopolitan settings, yet limited evidence is available regarding factors associated with their choice between direct and indirect veneers. This study aimed to examine factors associated with veneer preference, assess the association of educational level and economic status with treatment interest, and evaluate the relationship between satisfaction and recommendation intent among expatriates in Erbil. A cross-sectional survey was conducted from January to June 2023 among 439 expatriates recruited from private dental clinics and cosmetic centres in Erbil using stratified convenience sampling. A validated 48-item questionnaire assessed demographics, prior dental experience, decision-making factors using 5-point Likert scales, veneer preference, satisfaction, and recommendation intent. Data were analysed using χ2 tests, Spearman correlations, multinomial logistic regression for veneer preference, ordinal logistic regression for satisfaction, and binary logistic regression for recommendation intent, with adjustment for relevant covariates. Durability showed the strongest independent association with preference for indirect veneers compared with direct veneers (adjusted OR 2.65 per 1-point increase, 95% CI 1.78-3.95, p<0.001). Aesthetic outcome was ranked as the most important consideration overall by 44.4% of participants, but it was no longer statistically significant after adjustment. A significant education × economic status interaction was observed (p=0.03), indicating that the association between higher education and interest in veneers was more evident among participants with good or very good economic status. Among veneer recipients (n=68), 76.5% were very or somewhat satisfied; higher satisfaction was strongly associated with recommendation intent (adjusted OR 4.21 per 1-point increase, 95% CI 2.84-6.24, p<0.001). Overall, 40.3% of participants remained undecided about veneer type. In this cross-sectional study of expatriates in Erbil, durability was associated with preference for indirect veneers, while socioeconomic status appeared to shape treatment interest. Higher satisfaction was also associated with greater willingness to recommend veneer treatment. These findings support the use of targeted patient education, transparent discussions of expected longevity, and flexible financing strategies to facilitate informed decision-making in mobile expatriate populations. Because of the cross-sectional design, these findings should be interpreted as associations rather than causal effects.
Transforming the U.S. health system requires coordinated alignment across financing, care delivery, workforce, and innovation infrastructure. Persistent fragmentation, fee-for-service incentives, administrative burden, and underinvestment in primary care continue to undermine outcomes and drive unsustainable costs, particularly for communities with limited access to preventive and social supports. This article synthesizes policy and operational strategies to advance value-based care, integrate social determinants into risk adjustment, modernize data systems, strengthen safety-net capacity, and build workforce resilience. A sequenced road map outlines short-, intermediate-, and long-term actions, led by federal and state agencies, private sector partners, and community organizations, to achieve durable improvements in quality, equity, and cost.
Androgen deprivation therapy (ADT) for prostate cancer (PCa) leads to lineage plasticity in PCa cells, promoting the emergence of androgen receptor-negative neuroendocrine prostate cancer (NEPC). NEPC is a highly aggressive subtype with poor prognosis and limited treatment options. Tumor-associated macrophages (TAMs) contribute to tumor progression through exosome-mediated communication. In our previous study, we analyzed RNA-seq data to identify key genes involved in PCa progression, and the RERG gene emerged as a significant candidate that suppresses neuroendocrine differentiation (NED). In this study, we demonstrate that RERG expression is significantly reduced in CRPC cells and NEPC tissues, and its downregulation activates the Ras/ERK signaling pathway, which plays a crucial role in promoting NED. Additionally, miR-142-5p, transferred from TAMs via exosomes, downregulates RERG expression and activates the Ras/ERK pathway, thereby promoting PCa progression and NED. In vitro, miR-142-5p enhanced PCa cell proliferation, migration, invasion, and NED, while RERG overexpression reversed these effects. In vivo, RERG knockdown significantly promoted tumor growth and NED in a xenograft model. These findings highlight the role of TAM-derived miR-142-5p in regulating NED and suggest that targeting the RERG/Ras/ERK axis may provide a novel therapeutic approach for NEPC.
Short-term residential care (STRC) is a Dutch form of post-acute care intended to return older adults home to live independently, yet fewer than 55% of patients are discharged home. Because post-acute care costs are unevenly distributed, average cost trajectories may obscure clinically meaningful variation. This study examines variation in STRC cost trajectories and identifies patient characteristics associated with high-cost group membership. We conducted a retrospective longitudinal observational study using national health claims data from Statistics Netherlands for patients admitted to STRC between 1 February and 31 July 2022. Reimbursed costs across seven categories (STRC, inpatient and outpatient hospital care, district care, long-term care at home, nursing home admission, and geriatric rehabilitation) were measured from one month before to five months after admission. We defined a palliative care group a priori and applied group-based trajectory modelling to the remaining cohort. Two logistic regressions assessed patient-level predictors of high-cost membership. Among 16,278 patients, mean six-month costs were €29,859 (SD = €21,088). We identified an a priori palliative care group (n = 3,277; €23,200), a latent high-cost (n = 3,205; €58,478) and a latent low-cost (n = 9,796; €22,723) group. The high-cost group accounted for 39% of total costs, with the largest shares attributable to hospital care, nursing home admission, and longer STRC stays. These patients were more often readmitted to hospital within two weeks of discharge (16.9% versus 3.2%) and discharged to a nursing home (29.8% versus 10.7%). Dementia, institutional living, and several diagnosis groups (including stroke, oncology, organ failure, and cardiovascular disease) were associated with high-cost membership, but overall explanatory power was low (McFadden pseudo R² ≤ 0.05). STRC cost trajectories were highly skewed and poorly predicted by routinely available patient characteristics, suggesting cost variation reflects differences in care delivery more than patient case-mix. These findings point to three priorities: strengthening transitions from STRC back to home, critically evaluating STRC placement for patients likely to require nursing home admission, and scrutinizing hospital use during STRC episodes. Cost trajectories offer a promising outcome measure for evaluating intermediate and integrated care.
Nasopharyngeal, oropharyngeal, and hypopharyngeal cancers are the three types of pharyngeal malignancies that vary in prognosis. This study aims to evaluate the global disease incidence, risk factors, and trends of pharyngeal cancer by anatomical sites. The Global Cancer Observatory, Global Burden of Disease, and Cancer Incidence in Five Continents Plus, were accessed to investigate the disease burden and related risk factors by anatomical site. Average Annual Percentage Changes were computed using Joinpoint regression to assess trends in age-standardized rates (ASR) of incidence of pharyngeal cancer. An estimated total of 316,020 (ASR=3.5) pharyngeal cancer cases were reported in 2020, with nasopharyngeal cancer being the most prevalent subtype (1.7), followed by oropharyngeal (1.1) and hypopharyngeal cancer (0.91). Nasopharyngeal, oropharyngeal, and hypopharyngeal cancers were most common in South-Eastern Asia (ASR = 5.0), Western Europe (ASR = 2.8), and South-Central Asia (ASR = 2.1), respectively. Higher Human Development Index (HDI), smoking, alcohol drinking, unhealthy dietary habits, hypertension, and lipid disorders were associated with higher pharyngeal cancer incidence. The results indicated a declining or constant trend in hypopharyngeal and nasopharyngeal cancers and a notable rise in oropharyngeal cancer. The incidence of pharyngeal cancer subtypes demonstrates significant geographical heterogeneity. While hypopharyngeal and nasopharyngeal cancers are declining or stable, oropharyngeal cancer is on a clear upward trajectory. Given the prolonged latency between risk factor exposure and clinical onset, the oropharyngeal cancer burden is projected to rise further.
Linezolid is a cornerstone therapy for multidrug-resistant Gram-positive infections. While prolonged intermittent infusion (PII) or continuous infusion (CI) can optimize the efficacy of time-dependent antibiotics, their application to linezolid remains controversial. Specifically, it is debated whether the theoretical efficacy gains of CI are negated by the elimination of the concentration nadir, which may trigger accumulation-related toxicity. Quantitative evidence dissecting this delicate trade-off is currently absent. This study aimed to quantify the interplay between infusion duration, efficacy, and toxicity. By developing a population pharmacokinetic (PopPK) model and employing a "composite efficacy-safety target", we sought to identify precision dosing strategies for critically ill patients. Plasma concentration-time data obtained from 20 critically ill patients were used to develop a PopPK model using nonlinear mixed-effects modeling (NONMEM v7.5). Based on final model parameters, Monte Carlo simulations were performed for 1,000 virtual patients. A composite target was established comprising a pharmacodynamic efficacy threshold (AUC24,ss/minimum inhibitory concentration ≥100 and %T > MIC ≥85%) and a safety threshold (steady-state trough concentration, Cmin,ss < 8 mg/L). Probability of Target Attainment (PTA) was evaluated across 7 dosing regimens (300, … , 900 mg q12 h) and 13 infusion durations (0.5, 1, 2, … , 12 h). The pharmacokinetics were best described by a one-compartment model, with body weight (WT) and creatinine clearance (CLcr) identified as critical determinants of distribution volume (V) and clearance (CL), respectively. Simulations revealed a non-linear relationship between infusion duration and composite PTA. While prolonged intermittent infusion enhanced efficacy by improving % T > MIC, indiscriminate extension to CI, particularly at moderate-to-high doses, resulted in a systematic breach of the safety threshold (Cmin,ss ≥ 8 mg/L). Consequently, composite PTA declined due to toxic over-exposure. Notably, for refractory pathogens (MIC ≥2 mg/L), traditional CI yielded near-zero success rates due to high toxicity risks. In critically ill patients, the optimal infusion duration for linezolid exhibits a non-linear dependency on dose and MIC. For high-MIC pathogens requiring intensified dosing (e.g., 900 mg q12 h), a prolonged infusion of 2-5 h optimizes the therapeutic index, synergizing maximal efficacy with a necessary elimination phase to mitigate toxicity.
We urgently need innovative strategies to combat a growing epidemic of chronic liver disease (CLD). Integrated Diagnostics for Early Detection of Liver Disease (ID-LIVER) was a collaborative project aiming to improve detection of reversible-stage CLD in a region with high prevalence of critical risk factors. This study assesses the cost-effectiveness of different ways to identify people with significant CLD (defined as METAVIR stage F2 or higher, using liver stiffness of ≥8 kPa on transient elastography as a proxy measure). Strategies of interest include proactive case-finding in the community (supplementing a reactive pathway where hepatology referrals are passively received from primary care) and/or risk-stratification (using Fibrosis-4 (FIB-4) or ID-LIVER-Machine Learning (ML)-a novel machine-learning risk-stratification tool). We developed a state-transition decision-analytic model estimating lifetime healthcare costs (2023/2024 GBP) and quality-adjusted life-years (QALYs) associated with six alternative strategies for case-finding and risk-stratification. We simulated cohorts of people with alcohol-related liver disease and metabolic dysfunction-associated steatotic liver disease. We populated the model with data collected in ID-LIVER, supplemented by parameters from the literature and routine data sources. We estimated incremental cost-effectiveness and performed deterministic and probabilistic sensitivity analyses. Any case-identification strategy costing ≤£3300 per person with significant CLD identified would meet English cost-effectiveness thresholds (£20 000/QALY). In our decision set, the cheapest strategy is to use FIB-4 in the reactive-only population; however, this misses 43.6% of people with significant CLD. ID-LIVER-ML (using a cut-off of 0.4) generates more population health at a reasonable cost (£10 498/QALY gained). Introducing proactive case-finding generates further health benefits, costing £12 952/QALY gained. Using ID-LIVER-ML in the proactive-and-reactive population has the highest probability of maximising cost-effectiveness, when valuing QALYs at £20 000. Smart methods of case-finding and risk-stratification identify people with significant CLD in the community and are likely to represent good value for money in England.
The objective of this retrospective study was to evaluate and compare the safety characteristics of patients with chronic low back pain (cLBP) without a recent positive history of opioid use disorder (OUD). This study was conducted using the Merative MarketScan® database (January 2019-December 2023). The first date of Belbuca®, buprenorphine patch, or oral schedule II (CII) opioid prescription was designated as the index date. The observational period covered a 6-month preindex period and a follow-up period that lasted until the end of index treatment or continuous healthcare coverage. Patients were required to have two low back pain diagnoses and no OUD in the preindex period and continuous healthcare coverage during the observational period. The primary outcomes were serious treatment-emergent adverse event (TEAE) rates reported as incidence rate ratios (IRR) or absolute incidence rate difference (IRD) per 1,000 person-years for TEAEs occurring in one cohort. Propensity-score matching was employed to balance differences in patient characteristics and minimize their impact on study outcomes. There were no serious TEAEs associated with higher occurrence in the Belbuca® cohort compared with oral CII opioids. Belbuca® treatment was associated with a significantly lower rate of serious opioid abuse/dependence (IRD -33.76 per 1,000 person-years, p = 0.032), osteoarthritis (IRD -78.77 per 1,000 person-years, p = 0.001), urinary discomfort (IRD -146.28 per 1,000 person-years, p < 0.001), seizures (IRR 0.11, p = 0.019), dehydration (IRR 0.13, p = 0.003), abdominal pain (IRR 0.25, p < 0.001), and nausea/vomiting (IRR 0.30, p = 0.001). The subanalysis compared incidence rates of serious TEAEs between Belbuca® and buprenorphine patch cohorts. Belbuca® demonstrated higher rates of serious coronary artery disease (IRD 39.01 per 1,000 person-years, p = 0.035), cholecystitis (IRD 39.01 per 1,000 person-years, p = 0.035), and headache (IRD 39.01 per 1,000 person-years, p = 0.035). However, the buprenorphine patch cohort had higher incidence rates of serious QT prolongation (IRD -52.78 per 1,000 person-years, p = 0.009), opioid abuse/dependence (IRD -184.75 per 1,000 person-years, p < 0.001), confusion (IRR 0.10, p = 0.007), hypertension (IRR 0.22, p = 0.043), and cellulitis (IRR 0.41, p = 0.011). The study findings suggest that Belbuca® may have a favorable safety profile relative to oral CII opioids and buprenorphine patch treatments in cLBP patients without a positive history of OUD.
Regulated healthcare markets rely on provider competition to improve efficiency and access. During the COVID‑19 pandemic, Dutch hospitals were urged to prioritise emergency COVID care, while independent treatment centres (ITCs) were largely exempt. This reallocation of capacity substantially reduced hospitals' ability to deliver elective gynecological care and may have affected medium‑run market dynamics between provider types. This study examines how the COVID-19 pandemic affected revenues, treatment volumes, and surgical care proportions in benign gynecological care across different provider types in the Netherlands over time. We used nationwide monthly claims data from 2016 to 2022 covering all Dutch hospitals. Focusing on six common gynecological care pathways, we assessed changes before, during, and after the initial COVID-19 shock. Regression models with hospital and care-path fixed-effects were used to estimate the impact of the immediate COVID-19 shock and the subsequent COVID-adjustment period, distinguishing between academic, top-clinical, general hospitals, and ITCs. All provider types experienced an initial revenue decline during the COVID-shock, with general hospitals most affected. ITCs saw smaller losses and rebounded strongly, increasing their revenue by 23.62% and surgical care share by 21.34% relatively. In contrast, general, top-clinical and academic hospitals, responsible for emergency COVID care, suffered deeper, more persistent losses. Providers exempt from emergency COVID-19 care showed different adjustment trajectories than hospitals delivering emergency services, with prolonged implications for their relative market positions up to 2022. This indicates that crisis conditions can affect market dynamics and should be explicitly considered when shaping emergency response policies.
Financial pressure on the German healthcare system is rising, and physicians face high pressure in balancing patient care and research. Into this environment comes an ethics approval process for retrospective studies that is becoming more complex and requires a greater volume of documentation. The objective of this study was to first describe and calculate the costs incurred by the ethics approval process. Using ChatGPT and Gemini, the required times for preparation, creation, and submission, as well as the time required for the ethics committee to process and vote on ethics approval, were estimated. Costs were calculated based on the newest version of the collective agreement for physicians at German university hospitals (Tarifvertrag für Ärzte an Universitätskliniken). Time required for submitting adds up to approximately 4-10 hours, and 4.5-8.5 hours for submission control and voting, respectively. Summing up, this amounts to 161.7-388.1 € for submission and 241.6-456.3 € for the ethics committee, respectively. In total, 8.5-18.5 hours are required for ethics approval for a retrospective study, resulting in a total of 403.3-844.4 €. Ethics approval is of major relevance to ensure good ethical practice and shall therefore not be omitted. Nevertheless, processes can be tightened to facilitate clinical research, free up resources, and save costs. Der finanzielle Druck auf das deutsche Gesundheitssystem nimmt zu, während Ärztinnen und Ärzte zunehmend gefordert sind, klinische Versorgung und Forschung miteinander zu vereinbaren. Gleichzeitig wird das Ethikgenehmigungsverfahren für retrospektive Studien zunehmend komplexer und erfordert einen steigenden Dokumentationsaufwand. Ziel dieser Studie war es, den zeitlichen und finanziellen Aufwand des Ethikgenehmigungsverfahrens zu beschreiben und zu quantifizieren. Unter Verwendung von ChatGPT und Gemini wurden die benötigten Zeiten für Vorbereitung, Erstellung und Einreichung der Unterlagen sowie die Bearbeitungsdauer durch die Ethikkommission einschließlich Prüfung und Beschlussfassung abgeschätzt. Die Kostenberechnung erfolgte auf Grundlage der aktuellen Fassung des Tarifvertrags für Ärztinnen und Ärzte an Universitätskliniken (TV-Ärzte). Der Zeitaufwand für die Antragstellung beträgt etwa 4–10 Stunden, für Antragsprüfung und Votierung durch die Ethikkommission 4,5–8,5 Stunden. Daraus ergeben sich Kosten von 161,7–388,1 € für die Antragstellung sowie 241,6–456,3 € für die Antragsbearbeitung und -prüfung. Insgesamt werden für das Ethikgenehmigungsverfahren einer retrospektiven Studie 8,5–18,5 Stunden benötigt, was Gesamtkosten von 403,3–844,4 € entspricht. Die Ethikgenehmigung ist von zentraler Bedeutung zur Sicherstellung guter wissenschaftlicher Praxis und darf daher nicht entfallen. Dennoch sollten bestehende Prozesse optimiert werden, um klinische Forschung zu erleichtern, Ressourcen freizusetzen und Kosten zu reduzieren.
Traditional ecological knowledge (TEK) refers to the traditional and cumulative knowledge, skills, and beliefs about the relationship between humans and nature that are passed on from generation to generation within indigenous cultures. As communities worldwide grapple with mental health issues, environmental deterioration, social disintegration, and the loss of indigenous knowledge systems, there is a growing interest in approaches that integrate TEK to promote holistic well-being. The current mixed-methods study was carried out in Southwestern China among ethnic communities to investigate the role of TEK in mental health education and sustainable community well-being. Data were collected through a validated 32-item questionnaire (internal consistency reliability: Cronbach's α = 0.89) completed by 240 participants and semi-structured interviews, focus group discussions, and participatory observations of 48 participants. Pearson correlation analysis revealed that TEK participation was positively associated with mental health awareness (r = 0.71, p < 0.01), emotional resilience (r = 0.78, p < 0.01), and sustainability engagement (r = 0.74, p < 0.01). Multiple linear regression analysis also revealed that TEK participation was the most significant predictor of emotional resilience (β = 0.48, p < 0.001), followed by mental health awareness (β = 0.31, p < 0.001) and sustainability engagement (β = 0.24, p < 0.001), accounting for 64% of the variance in emotional resilience (R2 = 0.64). Results showed that communities with higher levels of TEK participation exhibited stronger social cohesion, lower perceived stress, higher emotional resilience, and higher environmental responsibility.
Space launch costs have fallen dramatically over the past six decades, opening new economic and scientific frontiers. Yet precise, long-term estimates of these cost reductions remain sparse, and the underlying rate of technological learning is poorly understood. We introduce the largest standardized dataset of rocket launches to date, covering more than 4,400 launches (1960 to 2025) across 16 spacefaring geographical entities and show that the average cost of sending a kilogram to orbit has dropped from 87,023 USD in 1960 to 3,868 USD in 2025. Using a Wright's Law framework, we estimate that for each doubling of cumulative payload to orbit, the average cost of sending a kilogram to orbit decreases by 21.2%, revealing an exceptionally steep experience curve, outpacing that of other transformative technologies, including 19th-century steamship freight and modern solar photovoltaics. We leverage our empirical model to produce out-of-sample projections under a set of scenario-based and data-driven approaches. In our central estimate, the average cost is expected to fall to 1,600 USD/kg by 2030 and 300 USD/kg by 2040. Nonetheless, geopolitical shifts, potential monopolistic behavior in commercial launch markets, and the rising challenges of orbital debris may temper these gains. Overall, our findings underscore the importance of continued research and policy focus on launch technology, given that breakthroughs in cost reduction could accelerate the evolution of the space economy and its diverse near-term applications.
The Brazilian Public Health System predominantly performs cystoscopy in hospitals using rigid cystoscopes in operating room settings. This approach results in high operational costs and scheduling delays associated with hospital admission and preoperative protocols. Flexible cystoscopy can be performed in an outpatient setting and may substantially reduce both costs and waiting times. To compare the costs and waiting times associated with rigid and flexible cystoscopy in São Paulo, Brazil. A retrospective review at a municipal hospital in Brazil identified patients who underwent diagnostic rigid cystoscopy. The analysis estimated the cost of the procedure and the time from indication to examination. Because no public hospital performed flexible cystoscopy during the study period, fees from private hospitals were collected as a proxy and incorporated into a one-way sensitivity analysis. The mean cost per rigid cystoscopy reached BRL 8,319.45 (US$1,618.82), ranging from BRL 6,187.10 (US$1,203.90) to BRL 10,512.34 (US$2,045.52). Costs were higher when biopsy occurred (mean BRL 9,744.20) and lower when biopsy was not performed (mean BRL 6,609.75). Fees for flexible cystoscopy ranged from BRL 1,523.81 (US$296.51) to BRL 2,300.00 (US$447.54), with a mean value of BRL 1,800.60 (US$350.37). The mean interval from indication to procedure was 55.64 days for rigid cystoscopy compared with 6.34 days in centers that perform flexible cystoscopy. In sensitivity analysis, even when public-sector flexible cystoscopy costs reached 1.5-3.0× the private fee (BRL 2,701-5,402), the procedure remained approximately 35-68% less expensive than rigid cystoscopy. Management of bladder cancer imposes a substantial economic burden on Brazilian Public Health System. Despite the asymmetry between public and private data sources, these findings support adoption of outpatient flexible cystoscopy to accelerate diagnosis and reduce costs, with important implications for health policy.