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Health technology assessment bodies increasingly emphasise the importance of preference-weighted health-related quality of life (HRQoL) evidence. However, such measures are often absent in clinical trial publications. It is not yet clear how frequently clinical trials have incorporated these measures over the past five decades, how the use of preference-weighted HRQoL instruments has evolved over time, and how trends differ across disease areas, countries and global regions. This study aims to (1) assess changes over time in the proportions of clinical trials using each preference-weighted HRQoL instrument in adults, and (2) model secular trends in the adoption of these instruments across disease areas, countries and regions. The study will provide a comprehensive, systematic assessment of the use of preference-weighted HRQoL instruments in clinical trials since 1976 and develop a scalable approach for large-scale evidence synthesis. We will identify clinical trials involving humans published in English since 1976 through systematic searches of MEDLINE, Embase, Cochrane Library and Web of Science. We will focus on generic preference-weighted HRQoL instruments for adults, including EQ-5D-3L, EQ-5D-5L, Short Form 6 Dimensions, 12-Item Short Form Health Survey (SF-12), Health Utility Index 2, Health Utility Index 3, Assessment of Quality of Life (AQoL) series (AQoL-4D, AQoL-6D, AQoL-7D, AQoL-8D), Quality of Well-Being Scale (QWB), QWB Self-Administered (QWB-SA), 15D and Patient-Reported Outcomes Measurement Information System (PROMIS) with the Preference Scoring System (PROPr). Screening and data extraction will be automated using natural language processing (NLP) pipeline or large language models (LLMs). To determine the most accurate approach, we will benchmark NLP and LLM performance against a manually curated reference dataset of 5000 randomly sampled articles reviewed independently by three reviewers. Model performance will be evaluated using classification metrics including accuracy, recall and F1-score. Annual counts and proportions of trials using each instrument will be calculated, stratified by disease area, country and region. Trends will be modelled using basis-splines (B-splines) with 2 or 3 degrees of freedom and Bayesian spline regression to estimate secular changes in both absolute numbers and proportions of instrument use over time. This study uses only published literature and does not involve human participants or individual-level data. All results will be reported in aggregate form, with no identifiable information. Formal ethics approval is therefore not required. Findings will be disseminated via peer-reviewed publications and conference presentations, and aggregated data and analysis code will be made publicly available to support transparency and reproducibility.

In the US, several states including New York State (NYS) have adopted Medicaid value-based payment (VBP) policies to improve healthcare quality and reduce spending. However, the impacts of these policies on vulnerable Medicaid beneficiaries with high behavioral health needs including those with serious mental illness (SMI) are unknown. To inform policy efforts to improve the value of Medicaid-funded care by examining the early impacts of NYS's VBP policy implemented in 2017 on the quality of healthcare received by adult beneficiaries with SMI. We conducted a retrospective cohort study to examine the association of the VBP policy with healthcare quality among adult Medicaid beneficiaries with SMI. We estimated difference-in-differences models comparing VBP-exposed and unexposed beneficiaries during the period preceding VBP implementation (2014-2016) and in 2018, a full year following implementation. Quality was assessed with 10 validated and SMI-relevant measures of mental healthcare quality (e.g., adequate Adherence to Antipsychotic Medications for Individuals with Schizophrenia, and Follow-up after Hospitalization for Mental Illness, 30-day), physical healthcare quality (e.g., Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications; Comprehensive Diabetes Care, Eye Exam), and overall healthcare quality (All-Cause Readmissions). Models for all outcomes adjusted for concurrent policies, and models for acute care measures also adjusted for need variables. Our diverse cohort included 172,420 person-years with SMI, with 28.5% VBP-exposed. The largest diagnostic groups were schizophrenia and bipolar disorder (42.2% and 41.3%, respectively). The VBP-exposed and unexposed beneficiaries differed on most characteristics, with the unexposed being slightly younger, less diverse, and healthier relative to the VBP-exposed. After adjusting for covariates, VBP-exposure was associated with changes in only two of the 10 quality measures compared with the VBP-unexposed group: a 1.8- percentage-point (pp) increase in adequate Adherence to Antipsychotic Medications for Individuals with Schizophrenia (95% CI, 0.5-3.2) and a 1.4-pp decrease (95% CI, -2.6 to -0.1) in Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications. A year following its implementation, a Medicaid VBP policy that involved varying degrees of provider risk-bearing had few quality impacts, one positive and one negative, among the state's beneficiaries with SMI. Our study, the first to examine VBP quality impacts with several validated measures of mental, physical, and overall healthcare quality, has some limitations, including that we cannot rule out time-varying unmeasured confounding, nor can we isolate the effects of type of risk arrangement (one-sided versus two-sided) or the mix of measures potentially associated with quality of SMI care included in the VBP contracts. Additionally, our study may not have captured the full impacts of the VBP policy due to our relatively short observation period. Policymakers seeking to use VBP to improve quality of SMI care may consider VBP policy features likely to facilitate achieving this goal, for example, incentives for delivering clinically integrated care and inclusion in contracts of SMI-relevant quality measures. Future studies should be designed to confirm and extend our findings.

Vascular liver diseases (VLDs) predominantly affect young adults and require lifelong monitoring. The health-related quality of life (HRQoL) of patients with VLDs is deteriorated, with high levels of fatigue and depressive symptoms, but their lived experience and unmet needs remain unknown. To fully integrate the patients' perspective and generate actionable insights, we conducted a qualitative peer-research study. Twelve peer researchers conducted interviews with patients in France, Spain, Switzerland, and the Netherlands. Analysis proceeded in three phases: individual inductive thematic analysis independently made by peer and academic researchers, followed by an international workshop to build a shared thematic framework. Third, directed content analysis, informed by the shared framework, was made by an academic researcher. From 27 interviews, five themes were identified, mapping the disease's impact on quality of life from diagnosis onward, and throughout the patient journey. First, the diagnosis trajectory was characterised by 'uncertainty and biographical disruption'. Then, long-term symptoms were described as impacting daily life through the experience of 'chronic uncertainty, loss of ability and social exclusion'. Participants' accounts also reflected the social impact of VLDs, which resulted in 'renegotiating roles, ties and identities'. All along the care journey, their healthcare experience could be marked by 'relational and institutional gaps shaping illness experience'. Finally, 'the sense of belonging to a community of peers' was highlighted as a potential but lacking resource. Living with a rare VLD involves uncertainty, unpredictable fatigue, stigma, and social disruption, alongside efforts to maintain dignity and autonomy. While patients can demonstrate resilience, this does not negate ongoing needs. Improving quality of life requires addressing not only symptoms such as fatigue, anxiety or sexual dysfunction but requires guidance on physical activity, nutrition or occupational and financial challenges. Ten patients and two caregivers were involved as peer researchers throughout the study, ensuring that priorities, interpretations, and conclusions reflected patient-defined concerns. All peer researchers contributed to the design, data collection and analysis activities. Due to professional and health constraints, about half of the PRs could only participate in the first local analysis phase. PRs were financially compensated.

Several instruments assess different aspects of quality of life (QoL), the EQ-HWB is developed to capture broader health and wellbeing constructs. Established QoL measures such as the EQ-5D-5L, QOL-ACC, and ASCOT are widely used in older populations. Analysing dimensionality across these instruments can provide insight into the constructs they cover and their conceptual relationships. This study aimed to examine the dimensionality of the EQ-HWB both on its own and alongside pooled items from these measures, to identify its underlying structure and the extent of item overlap. Analysis was conducted using data from 453 participants aged 65 years and above who completed all four instruments. Exploratory Factor Analysis (EFA) was conducted to identify the underlying factor structure. Factors were selected based on eigenvalues greater than one and scree plots. A correlation cut-off of 0.32 was applied to determine item loading on a given factor. Both oblique and orthogonal rotations were explored. EFA was conducted separately for the EQ-HWB and each instrument, as well as for the pooled items from all instruments. EFAs conducted separately for the EQ-HWB, and each instrument resulted in a 4-factor structure. However, EFA of all pooled items showed that the 5-factor structure provided a better model fit. The five factors identified were: emotional functioning, self-care and usual activities, leisure and enjoyment, cognition and senses, and pain. This study provides evidence on the dimensions of QoL captured by a select pool of health focused and broader QoL instruments in an older adult population. The results enhance understanding of the conceptual coverage of the EQ-HWB relative to other QoL measures. This study is done as there are many instruments measuring quality of life (QoL) in older adults, but it is not always clear how similar or different they are. The EQ-HWB is a newer measure designed to capture both health and broader wellbeing. However, more evidence is required to understand what areas it measures and how it compares with established tools such as the EQ-5D-5L, QOL-ACC, and ASCOT. The key issue addressed in this manuscript is whether the EQ-HWB measures the same dimensions of QoL as other instruments, and how much overlap exists between them. Understanding this helps researchers and policymakers choose the most appropriate measure. The main aim of the study was to examine the underlying structure of the EQ-HWB on its own and when combined with items from other QoL instruments. The results showed that when analysed separately, four main factors were seen. However, when all items were analysed together, five broader factors were identified: emotional functioning, self-care and usual activities, leisure and enjoyment, cognition and senses, and pain. These findings suggest that the EQ-HWB captures key areas of QoL and shares some overlap with existing measures, while also covering broader aspects of wellbeing.

The role of social media in in shaping the public perception of health crises is growing, yet we know little about the contribution of platforms such as YouTube in shaping knowledge regarding child undernutrition. We aimed to explore the digital discussion of and sentiment around YouTube content on child undernutrition in Pakistan, where at least 38% of children are stunted (as per global rankings). We compiled a dataset of 1847 videos and 42 963 comments YouTube users that were uploaded between January 2010 and March 2024. We used Latent Dirichlet Allocation (LDA) topic modelling to analyse this data and identify narrative frames present in the content. We also used the Valence Aware Dictionary for sEntiment Reasoning (VADER) to analyses sentiment in the comments. The analysis reveals six dominant narrative frames, where 'policy failure' made up 32% of the discourse, while just 5% addressed 'solution-focused actions'. The VADER sentiment analysis supports this with a compound score of -0.72, suggesting an overall negative and highlighting considerable public concern about institutional responses. The data further suggests specific engagement patterns that point to a clear break between crisis-oriented and solution-oriented information. Algorithms on digital platforms amplify the narratives that serve as digital determinants of health, shaping public perceptions and reinforcing public distrust in institutional policy responses. It will not be enough to simply 'get the message right' if we seek to create effective health communication - we must, instead, be prepared to actively challenge harmful discourses, champion fair and locally relevant narratives, and engage for algorithmic transparency and public health-centred content curation from these platforms. These results provide an important evidence base for the reframing of nutrition communication initiatives in Pakistan and beyond.

This study assessed the societal economic burden in terms of cost of illness and health-related quality of life (HRQoL) of posttraumatic long bone non-unions in the Netherlands. An incidence-based bottom-up approach was used, focusing on adult patients with posttraumatic long bone non-unions. The analysis included healthcare costs, patient and family costs, and productivity losses, measured using the iMCQ and iPCQ questionnaires. Cost evaluations followed Dutch costing guidelines, and productivity losses were calculated using the friction cost method. HRQoL was assessed with the EQ-5D-5L. A deterministic one-way sensitivity analysis varied baseline characteristics by ± 10%. Scenario analyses were conducted from healthcare and patient perspectives, as well as for patient subgroups. Average costs per patient during the three months before the initial visit at a non-union clinic were €8,928 (healthcare, N = 78), €1,360 (patient and family, N = 58), and €4,313 (productivity losses, N = 59), the average of the observed data calculates to 10,831 (N = 44). The mean EQ-5D-5L utility score was 0.390 (± 0.29 SD). Subgroup analysis showed no significant cost increase for patients with infections or open fractures. However, a higher Non-Union Severity Score and a lower HRQoL were significantly associated with higher total costs. Posttraumatic long bone non-unions pose a substantial economic burden on Dutch society and have a tremendous impact on HRQoL. Severe non-unions and a lower quality of life were associated with increased costs, whereas initial fracture characteristics were not. These findings highlight the importance of effective preventive and therapeutic strategies to reduce the burden of posttraumatic long bone non-unions.

Access to musculoskeletal healthcare services in Sub-Saharan Africa is inadequate. As osteoarthritis is the most prevalent chronic osteoarticular disease globally, it's essential to understand its social and economic impact, as well as the determinants of inequities in access to healthcare services in Sub-Saharan Africa. The absence of systematised knowledge on this topic makes this review pertinent. However, due to data scarcity, assessing this burden is challenging. The objective of this scoping review is to map and summarise the available literature up to 2025 on the socioeconomic burden and health inequity determinants among the Sub-Saharan African population with osteoarthritis. A predefined search strategy will be applied to MEDLINE (via PubMed), Embase, African Journals Online and African Index Medicus to incorporate articles relevant to adults diagnosed with osteoarthritis who are residents of sub-Saharan Africa. We will also include grey literature sources such as Google Scholar, Research Square, manuals, books, medical society websites, secondary databases, theses and dissertation repositories and conference proceedings. Study selection will be conducted in two stages by a pair of reviewers who will independently screen titles and abstracts according to the eligibility criteria, followed by a full-text review of the selected studies. The search period was from October 2025 to January 2026. Data extraction will be performed using a standardised charting form developed by the review team. This scoping review maps evidence on OA-related socioeconomic impacts and healthcare inequities in Sub-Saharan Africa. As a secondary data analysis, ethical approval is not required. Findings will be disseminated via peer-reviewed journals and academic conferences to clinicians and policymakers.

In the context of Health China 2030, the Chinese government endorses the unique advantages of traditional Chinese medicine (TCM) within the public health care system and promotes the inheritance and development of TCM culture. Emerging digital formats-such as online literature, online audiovisual media, and digital games-have become important vehicles for promoting TCM culture and public health education. Consequently, Chinese digital games have increasingly incorporated elements of TCM, serving as new media for communicating health knowledge and cultural values to a broad player population. This study examines how exposure to digital games containing TCM culture, supported by national health promotion policies, influences players' willingness to accept TCM treatment, thereby contributing to the broader goal of improving residents' health welfare. However, empirical research examining how such games influence players' willingness to accept TCM-based medical treatment remains limited. This study aims to investigate the key factors and mechanisms through which digital game use motivations shape players' intention to seek TCM treatment. Based on data collected through an online questionnaire survey of 460 Chinese digital game players, PLS-SEM was utilized to examine the core factors and relationships between gaming motivations, TCM cultural identity, health self-efficacy, and TCM treatment intention. The findings reveal that three types of game use motivations-hedonic, social, and knowledge-seeking-indirectly enhance players' willingness to accept TCM treatment by strengthening their health self-efficacy and identification with TCM culture. Additionally, players' distrust of the TCM healthcare system negatively moderates the association between gaming motivations and TCM treatment intention. This study demonstrates the potential of digital games as effective tools for integrating cultural transmission with public health communication. By improving players' TCM treatment intention, digital games containing TCM culture contribute to the public health objectives outlined in the Health China 2030 strategy. The results provide both theoretical grounding and practical guidance for government agencies and enterprises seeking to leverage digital games to promote TCM cultural inheritance and enhance public health education as part of health welfare improvements.

Emerging infectious diseases (EIDs) cause significant health and economic burdens in the USA and globally. Existing methods and analyses fall short of what is required to prioritise diseases for health technology research and development (R&D), including for medical countermeasure (MCM) development within rapid response frameworks by the Center for Biomedical Advanced Research and Development Authority, part of the Administration for Strategic Preparedness and Response within the U.S. Department of Health and Human Services. We developed a method for quantifying and ranking health and economic disease burdens ('full burdens') and applied it to 15 high-priority EIDs for 223 countries and territories, including the USA and US territories, historically from 2000 to 2022 and prospectively from 2025 to 2034. Health burdens consisted of disability-adjusted life-year losses, converted into monetary values using the value of a statistical life-year. Economic burdens consisted of direct and indirect costs during the acute stage of illness for hospitalised cases. We computed unweighted and weighted burden measures, the latter controlling for global disparities in ability-to-pay to avoid EID burdens. We projected future disease burdens using Monte Carlo simulation. Pandemics caused the largest historical and projected unweighted and weighted full burdens in the USA and globally. Among non-pandemics, across unweighted and weighted burdens, dengue and cholera imposed the largest historical and projected full burdens globally; West Nile Virus imposed the largest historical and projected full burdens in the USA, and dengue imposed the largest historical full burdens in the US territories. Weighted full burdens exceeded five times the unweighted ones. Regionally, the Americas and Africa faced the largest per capita weighted burdens while the Western Pacific region faced the smallest. R&D priority-setting, including MCM development, depends on multiple criteria, including disease burdens. Our full burden quantification methods and results, along with other such criteria, can inform optimal priority-setting.

Background and objectives Chronic musculoskeletal disorders (MSDs) are a significant contributor to pain and disability worldwide, with burden varying across different regions. The study aimed to estimate the prevalence of chronic MSDs in Puducherry, assess health-seeking behaviour, and evaluate the economic burden associated with MSD-related healthcare. Methods A community-based concurrent mixed-method study was conducted in selected areas of Puducherry. Households were selected using systematic random sampling, and individuals were chosen using simple random sampling. The WHO-ILAR COPCORD questionnaire identified individuals with MSDs. Direct and indirect costs from a patient perspective were assessed using a structured questionnaire. Data were collected through Epicollect5 and analysed using STATA v14. Prevalence was reported as proportions with 95% confidence intervals (CI). Focused group discussions (FGDs) were conducted to identify challenges in seeking healthcare. Results Among 400 participants, the prevalence of chronic MSDs was 16% (95% CI: 12.5-19.9), with the majority reporting mild disability and more common in women, but there was no urban-rural difference. Around half (48.4%) of participants reported out-of-pocket expenditures (OOPE) in the past three months, with a higher proportion in urban (53.8%) compared to rural areas (45.9%). The median expenditure was ₹204, with urban participants spending ₹308 and rural participants ₹154. FGDs revealed that while many initially preferred private facilities for quicker access to pain medications, they later returned to public facilities due to financial constraints. Interpretation and Conclusions The prevalence of chronic musculoskeletal disorders is high in Puducherry, particularly among women and older adults, causing mild disability. Despite a preference for government healthcare, many incurred out of pocket expenditures, highlighting financial challenges in accessing care.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide and imposes a substantial economic and social burden on healthcare systems and society. To analyse recent evidence (2020-2024) on the economic and social burden of COPD, including direct, indirect, and intangible costs. A systematic review was conducted to synthesise recent evidence on the economic and social burden of COPD published between January 2020 and December 2024. Searches were performed in PubMed/MEDLINE, Scopus, and Web of Science. Original studies reporting direct healthcare costs, direct non-healthcare costs, indirect costs or intangible costs related to health-related quality of life (HRQoL) were included. Thirty studies from 15 countries were included. Direct healthcare costs represent the main component of expenditure, largely driven by hospitalisations and exacerbations. Annual costs ranged from €3500 to €10,000 per patient in Europe and from US$10,000 to US$17,000 in the United States. Although absolute costs were lower in Asia, the relative financial burden on patients was considerable. Direct non-healthcare costs, including out-of-pocket expenses and long-term care, were particularly relevant in severe disease. Indirect costs related to productivity losses and unemployment were substantial and, in some middle-income countries, exceeded healthcare costs. Intangible costs included anxiety, depression, caregiver distress, impaired quality of life, and perceived financial toxicity, with high overall prevalence. COPD creates a considerable economic and social burden. Although direct costs are predominant, indirect, and intangible costs are decisive, particularly in contexts with lower healthcare coverage. Clinical factors (severity, exacerbations, and comorbidities) and socio-economic factors (educational level, income, and employment) explain much of the variability. A holistic approach that addresses health, social, and emotional dimensions is required for a more equitable and sustainable management.

The aims of this study were to investigate whether children from different culturally and linguistically diverse (CALD) backgrounds in Australia have similar Health Related Quality of Life (HRQoL), in early childhood, middle childhood, and adolescence. We used data from 9099 children from the Longitudinal Study of Australian Children (LSAC), aged between 2 and 17 years, including HRQoL measured with the parent proxy Pediatric Quality of Life Inventory (PedsQL). The study pertained to cohort data from 2004 to 2018. CALD groups were defined according to child, mother's and father's country of birth and main language spoken at home. The association of child HRQoL with CALD group, was analysed using generalised estimating equations, adjusted for age, sex, socioeconomic position (SEP) and weight status. Children of Middle Eastern or North African, South-East Asian, South and Central Asian and Oceania backgrounds had significantly lower HRQoL (p&#x2009;<&#x2009;0.05) than children from English speaking backgrounds. These disparities were greatest during middle childhood and adolescence and only partly explained by lower SEP and weight status. Disparities in physical HRQoL were greater than psychosocial HRQOL. Considerable inequity in HRQoL is present in Australian children from different CALD backgrounds. This study highlights the need for culturally tailored programs for school-aged children to improve their physical HRQoL. Health-related quality of life is an important measure of child overall health and includes physical and psychosocial health. There is evidence for lower quality of life in some culturally diverse populations, but no studies have examined this in children and adolescents. We used data from a very large Australian study that measured quality of life of children from age 2 to age 17 years and found lower quality of life among some cultural groups that developed primarily in middle childhood. Disparities in physical HRQoL were greater than psychosocial HRQOL. This highlights the need for culturally tailored programs for school-aged children to improve their physical HRQoL.

Perianal fistulas are a common complication of Crohn's disease. Despite the current treatment options, fistula recurrence/treatment failure rates are high. The aim of this study was to assess healthcare resource utilization (HCRU) among patients with new, persistent, and recurrent Crohn's perianal fistulas (CPF) in the USA. A retrospective, multi-site medical chart review was conducted in patients with CPF. Data on HCRU were collected for &#x2265;2&#x2009;years after the index date (date of most-recent episode of CPF symptoms between January 2016 and December 2018). In total, 227 patients were included among whom there were 236 fistulas: new (n&#x2009;=&#x2009;94, 39.8%), persistent (n&#x2009;=&#x2009;108, 45.8%), and recurrent (n&#x2009;=&#x2009;34, 14.4%). Mean (standard deviation [SD]) age was 47.7 (13.7) years, 81.5% were White, 50.7% were male. After index (mean follow-up 33.8&#x2009;months), 67.0% of patients received medical treatments, 59.9% had surgical interventions, and 42.7% received both. The mean (SD) number of CPF-related and all-cause outpatient visits was 8.75 (8.20) and 18.27 (16.96), the mean (SD) number of CPF-related and all-cause emergency room visits was 0.06 (0.27) and 0.65 (1.55), and the mean (SD) number of CPF-related and all-cause inpatient visits was 0.30 (0.79) and 0.83 (1.81), respectively. Patients with new fistulas had more CPF-related and all-cause outpatient visits and fewer all-cause inpatient visits than patients with persistent/recurrent fistulas (p&#x2009;<&#x2009;0.05). The use of biologics for underlying Crohn's disease before index was not captured. Furthermore, this study was subject to missing data and limited generalizability (most sites located in Midwest USA). There is a substantial HCRU burden among patients with CPF, likely owing to the requirement for multiple and repeated interventions, indicating an unmet need for effective management strategies that promote long-term fistula healing to ultimately support reduced patient burden and HCRU.

This study investigated the financial impact of introducing the once-daily single-inhaler triple therapy (SITT) fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) in Saudi Arabia for adult patients with uncontrolled asthma. The expected 5-year budget impact of introducing FF/UMEC/VI for asthma was modeled using an epidemiology-based approach that included both acquisition and efficacy-related costs. Year-on-year costs were estimated for 2026 through 2030. Changes in healthcare resource utilization after FF/UMEC/VI introduction were estimated from the expected change in asthma control reported in the Phase IIIa CAPTAIN trial. The perspective of the model was the Saudi national healthcare payer; only direct medical costs were included. The robustness of the model was tested using sensitivity and scenario analyses. It was estimated that in 2026, 12,108 patients in Saudi Arabia would receive FF/UMEC/VI, which will likely increase over subsequent years (2027: 29,615 patients; 2028: 31,191 patients; 2029: 32,938 patients; 2030: 34,727 patients), as validated by local expert opinion. The introduction of FF/UMEC/VI was estimated to save a total of United States Dollars (USD) 10,654,389 over 5&#x2009;years, or USD 16.32 per patient, with savings increasing each year after introduction. Drug acquisition costs contributed to the greatest impact on the budget, and the model was most sensitive to changes in the market uptake of FF/UMEC/VI. Across all sensitivity and scenario analyses, FF/UMEC/VI was consistently cost saving. Various model inputs could not be derived from published sources, so multiple assumptions were used. Future market share was estimated from current competitor market share data; as FF/UMEC/VI is the first SITT for asthma to be introduced into Saudi Arabia, there is no historical data on which to base these estimates. Introducing FF/UMEC/VI in Saudi Arabia has the potential to deliver meaningful clinical and economic benefits at both the individual patient and healthcare system level.

Around 40% of mortality after injuries is avoidable with access to quality care. Investments in interventions which maximise the number of injured persons who access and receive quality care are paramount, especially in low-resourced settings. Selecting such interventions within complex adaptive health systems is challenging due to the multiple interactions within these systems. We created a conceptual map, or causal loop diagram (CLD), representing the health system for injury care, focused on challenges to improving patient outcomes in low- or middle-income countries (LMICs). We used the stages of seeking, reaching, receiving and remaining in care as the care pathway framework to conceptualise the diagram. Based on expert opinion and literature searches, we elicited micro (patient and their family), meso (health service) and macro (country context) factors which affect access to quality care at each stage of the care pathway and mapped interactions between them. Factors and their interactions were adjusted during a workshop with external experts. A CLD was created using Vensim to show relationships between all factors at all stages of the care pathway. Feedback loops within the CLD which are either reinforcing (perpetuating positive or negative change) or balancing (limiting change) were elicited. Leverage points were identified as factors which are present in multiple causal loops and are potential intervention points for maximal change. We initially identified 41 factors affecting stage 1, 13 affecting stage 2, 51 affecting stage 3 and 49 affecting stage 4. Consolidating factors of a similar theme gave 45 unique factors for the overarching model; 13 micro, 20 meso and 12 macro. We constructed two CLDs-one for the overarching health system and the other focused on healthcare services at facilities. The health service-specific map contained 22 meso factors. We identified 928 reinforcing or balancing causal loops acting within the health system for injury care affecting health outcomes. Factors acting as leverage points involved in the largest number of feedback loops relate to trust in or perceptions of the health system (748 loops and 694 loops, respectively) and willingness to seek care (636 loops). The health service-focused CLD identified funding and the provision of quality care as the main leverage points (112 loops each). Our work, using injury care as an exemplar, moves beyond understanding the impact of factors on patient outcomes in silos. Rather, in considering comprehensive connections between all factors on outcomes, we show interactions which could lead to unintended consequences and rapidly worsen or improve health outcomes. Our identification of trust and willingness to seek care as key leverage points suggests these should be focal points for research and investment.

Healthcare-associated infections (HAIs) represent a significant source of harm related to healthcare delivery and are associated with substantial costs. A more precise estimation of the economic burden imposed by these infections can assist healthcare providers and payers in justifying investments in prevention strategies. To quantify the direct economic burden of healthcare-associated infections and identify the specific types of HAIs that impose the greatest economic costs. This is a retrospective case-control study. We enrolled all inpatients with hospitalizations lasting three calendar days or longer (from January 2023 to December 2024) at a Grade A tertiary hospital in Shenzhen, China, and propensity score matching (PSM) was applied for analysis. Demographic/clinical characteristics and direct medical costs were extracted from the EMR-integrated data analytics platform. In contrast, HAI surveillance data and laboratory parameters were sourced from the real-time HAI monitoring system. Following PSM, the HAI group had significantly higher median total hospitalization costs than the non-HAI group (USD 7,158 vs. USD 1,212; p <&#x202f;0.001), with all 11 cost components differing-pharmaceuticals (USD 1,650 (95% CI: 1457, 1891)) and lab tests (USD 928 (95% CI: 859, 1,042)) as primary contributors. When stratified by HAI type, LRTIs were the most prevalent and exhibited the higher total charges difference (USD 9,597; 95% CI: 8,099 to 10,968). This difference was primarily driven by higher median charges for pharmaceuticals (USD 2,698; 95% CI: 1,019 to 7,156) and laboratory tests (USD 1,574; 95% CI: 776 to 3,194). Among all infection categories, CLABSIs were associated with the highest increase in laboratory test charges. The HAI group incurred higher total hospitalization charges compared to the non-HAI group, with increases observed across all individual charge components, including pharmaceuticals and laboratory test charges, which were the primary drivers of the overall increase. Among the various types of HAIs, CLABSIs resulted in the highest laboratory charges, while LRTIs were identified as the most prevalent and demonstrated significantly increased direct medical charges.

Universal Health Coverage (UHC) promises access to care without financial hardship, yet in many low- and middle-income settings this ideal is undermined by pervasive informal payments. This perspective introduces the concept of the "illusion of free care" to explain how official fee-exemption policies coexist with hidden, off-the-record charges that reshape access and equity. Drawing on Somalia as a critical case of health system fragility, we argue that informal payments are not isolated acts of corruption but predictable responses to chronic underfunding, weak governance, and workforce precarity. We conceptualize this dynamic as a four-stage process linking policy promises, systemic constraints, the normalization of informal payments, and inequitable patient outcomes. These practices disproportionately exclude the poorest, erode trust, and stratify care along socioeconomic and gender lines. Conventional policy responses, including anti-corruption measures and nominally free care policies, fail to address underlying structural drivers. Achieving equitable UHC requires shifting from rhetorical commitments to systemic reforms in financing, workforce protection, and accountability.

Mammography still remains the gold standard for breast cancer screening, considering its impact on breast cancer mortality. However, it has a relatively low utilization rate in Nigeria. Although the National Strategic Cancer Control Plan (NSCCP) has a goal of making screening services and early detection of cancer available for all Nigerians, there is currently no national breast cancer screening program implemented in Nigeria. The modelling study aimed to evaluate the cost-effectiveness of mammography screening from the healthcare provider's perspective and to determine the appropriate screening interval for Nigerian women, aiming to enhance the efficiency and effectiveness of breast cancer detection programs. A state-transition Markov model was adapted to simulate annual and biennial mammography, breast cancer diagnosis, and treatment in a cohort of cancer-free Nigerian women aged 40 years and followed them for a lifetime. The study was conducted from the healthcare provider's perspective. Disability-adjusted life year (DALY) averted, representing the health outcomes, was used to estimate the incremental cost-effectiveness ratio (ICER). Costs and outcomes were discounted at an annual rate of 5%. Annual mammography screening costs US$238.60, averted a DALY of 1.060, and was the most cost-effective intervention with an ICER of US$207.24 (95% CI US$213.31 - US$216.88)/DALY averted, which was below the willingness-to-pay threshold of $1074. Mammography screening strategies were estimated to be cost-effective from the healthcare payer's perspective under the model assumptions. Annual screening showed the most favorable cost-effectiveness profile among the strategies evaluated, but this finding is model-dependent and should be interpreted as comparative economic evidence rather than a definitive screening recommendation. These results can inform future research, policy discussions, and consideration of sustainable financing for breast cancer screening in Nigeria.

Nigeria's health reforms aim to accelerate progress toward Universal Health Coverage (UHC). In alignment with these efforts, Gombe State has leveraged national policy frameworks to implement health sector reforms that have improved maternal, newborn, and child health outcomes. To consolidate gains and define future priorities, the State convened the Maiden Gombe State Health Summit in October 2025. The Summit was a two-day hybrid event with over 500 participants from government, development partners, civil society, academia, and the private sector. Data were drawn from rapporteur reports, recordings, presentations, session transcripts, keynote speeches, and policy documents. A thematic analysis approach was used to synthesize key discussions and outcomes. The Summit highlighted strong political commitment, revitalization of 228 primary health centres, upgrades to secondary facilities, expanded immunization coverage, and strengthened disease surveillance. Health workforce reforms, including Human Resources for Health (HRH) governance structures, biometric attendance tracking, training programmes, and welfare improvements, enhanced accountability and productivity. Financial protection was strengthened through the Gombe State Contributory Health Insurance Scheme, covering over 380,000 residents. Implementation of the Sector Wide Approach (SWAp) improved coordination of partner investments. These reforms contributed to measurable reductions in under-five, infant, and child mortality between 2018 and 2023. Gombe State's experience demonstrates how subnational governments can advance UHC through political leadership, alignment with national reforms, primary healthcare strengthening, health workforce investment, sustainable financing, and inclusive stakeholder engagement. The lessons from the Summit provide actionable insights for sustaining reform momentum and strengthening health systems in similar settings.