Exploring the association of paid sick leave with healthcare utilization and health outcomes in the United States:a rapid evidence review

Objective:Paid sick leave(PSL)laws mandate employers give workers paid time off when they are sick or injured.This current study aims to examine whether access to PSL is associated with healthcare utilization and health outcomes and to summarize the types of utilization and outcomes which have been reported to be associated with PSL.Methods:We conducted a rapid evidence review.Our search of seven databases,including Medline,Embase,PsycINFO,Cochrane Library,CINAHL,Scopus,and JSTOR,on September 21,2020,identified 757 studies,30 of which were retained.Results:Previous evidence is mostly provided by cross-sectional studies with survey data.In this study,evidence suggests that PSL is significantly associated with some types of healthcare utilization and health outcomes.In terms of healthcare utilization,findings indicate PSL is associated with an increase in the use of some preventive sendees and a decrease in the use of emergency care;while findings are mixed regarding associations of PSL with health provider visits and the use of mammograms and pap smears.As for health outcomes,findings suggest PSL is associated with improved mental and self-rated health,decreased incidence of influenza-like illness,and lower occupational injuries and mortality rates.Conclusion:PSL may be an effective tool in improving some healthcare utilization and health outcomes.Future research could help identify mechanisms through which PSL access works and identify what policy components lead to better outcomes.

Satisfaction of Village Doctors with the Township and Village Health Services Integration Policy in the Western Minority-inhabited Areas of China

Township and Village Health Services Integration Management（TVHSIM） is an essential form of China＇s two-tiered health service integration plan at the township and village level. Its main purpose, also one of the target goals in China＇s new healthcare reform, is to gradually integrate rural health services and appropriately allocate rural health resources. This study aims to assess the village doctors＇ satisfaction with the TVHSIM and provide scientific base to further improve TVHSIM. A cross-sectional study was carried out in which 162 village doctors from Qinghai, Inner Mongolia and Xinjiang in western China were interviewed. Descriptive analysis, independent t-test, one-way ANOVA, Spearman rank correlation and multiple linear regression were used to analyze the difference and relevance between village doctors＇ personal characteristics and their satisfaction with TVHSIM and six subscales. Village doctors with different years of practice, social insurance status and essential medical knowledge level showed statistically significant differences in their satisfaction levels（all P〈0.05）. Age（P〈0.05） and years of practice（P〈0.01） were negatively correlated with Drug and Medical Device Management and Financing Management. Essential medical knowledge level（P〈0.05） was negatively correlated with Operations Management as well. However, social insurance status（P〈0.05） was positively correlated with Human Resources Management and Drug and Medical Device management. Gender, age and years of practice respectively had significant influence on village doctors＇ satisfaction with TVHSIM（P〈0.01）. In conclusion, in order to further promote TVHSIM policy in rural China, a well-rounded social insurance model for village doctors is urgently needed. In addition, the development of TVHSIM is regionally imbalanced. Efficient and effective measures aiming at rationalizing gender and age structure and enhancing essential medical training should be carefully considered.

Plasma Metabonomics of Human Adenovirus-infected Patients with Pneumonia and Upper Respiratory Tract Infection

Objective Human adenovirus(HAdV)infection is common and can develop to serious conditions with high mortality,yet the mechanism of HAdV infection remains unclear.In the present study,the serum metabolite profiles of HAdV-7-infected patients with pneumonia or upper respiratory tract infection(URTI)were explored.Methods In total,35 patients were enrolled in the study following an outbreak of HAdV-7 in the army,of whom 14 had pneumonia and 21 had URTI.Blood samples were collected at the acute stage and at the recovery stage and were analyzed by untargeted metabolomics.Results Over 90% of the differential metabolites identified between the pneumonia patients and URTI patients were lipids and lipid-like molecules,including glycerophospholipids,fatty acyls,and sphingolipids.The metabolic pathways that were significantly enriched were primarily the lipid metabolism pathways,including sphingolipid metabolism,glycerophospholipid metabolism,and linoleic acid metabolism.The sphingolipid metabolism was identified as a significantly differential pathway between the pneumonia patients and URTI patients and between the acute and recovery stages for the pneumonia patients,but not between the acute and recovery stages for the URTI patients.Ceramide and lactosylceramide,involved in sphingolipid metabolism,were significantly higher in the pneumonia patients than in the URTI patients with good discrimination abilities[area under curve(AUC)0.742 and 0.716,respectively;combination AUC 0.801].Conclusion Our results suggested that HAdV modulated lipid metabolism for both the patients with URTI and pneumonia,especially the sphingolipid metabolism involving ceramide and lactosylceramide,which might thus be a potential intervention target in the treatment of HAdV infection.

Healthcare practice strategies for integrating personalized medicine:Management of COVID-19

Personalized medicine is the tailor-made clinical treatment to the individual characteristics of each patient.It may be considered an extension of traditional approaches to knowing and treating diseases.Personalized medicine has the potential to change the way of identification and management of health problems.Coronavirus disease 2019(COVID-19)is an infectious disease that primarily affects the patients’lungs.The first case of pneumonia of unknown cause was reported in Wuhan,China on December 31,2019.As thus,we are quickly approaching the era of personalized medicine.This review discusses the practices currently used in the management of COVID-19 and how they relate to person-alized medicine.

Impact of chronic disease self-management programs on type 2 diabetes management in primary care

AIM: To assess the effectiveness of the Chronic Disease Self-Management Program(CDSMP) on glycated hemoglobin A1c(HbA1c) and selected self-reported measures.METHODS: We compared patients who received a diabetes self-care behavioral intervention, the CDSMP developed at the Stanford University, with controls whoreceived usual care on their HbA1c and selected self-reported measures, including diabetes self-care activities, health-related quality of life(HRQOL), pain and fatigue. The subjects were a subset of participants enrolled in a randomized controlled trial that took place at seven regional clinics of a university-affiliated integrated healthcare system of a multi-specialty group practice between January 2009 and June 2011. The primary outcome was change in HbA1c from randomization to 12 mo. Data were analyzed using multilevel statistical models and linear mixed models to provide unbiased estimates of intervention effects.RESULTS: Demographic and baseline clinical characteristics were generally comparable between the two groups. The average baseline HbA1c values in the CDSMP and control groups were 9.4% and 9.2%, respectively. Significant reductions in HbA1c were seen at 12 mo for the two groups, with adjusted changes around 0.6%(P < 0.0001), but the reductions did not differ significantly between the two groups(P = 0.885). Few significant differences were observed in participants' diabetes self-care activities. No significant differences were observed in the participants' HRQOL, pain, or fatigue measures.CONCLUSION: The CDSMP intervention may not lower HbA1c any better than good routine care in an integrated healthcare system. More research is needed to understand the benefits of self-management programs in primary care in different settings and populations.

Associations of centralization with health care quality for gastric cancer patients receiving gastrectomy in China

Objective:Limited evidence is available regarding the associations of centralization with gastric cancer patients’quality of care in high surgical volume settings.The current study aimed to explore the effects of hospital volume and the Herfindahl-Hirschman index(HHI)on in-hospital mortality,total cost,and length of stay for Chinese gastrectomy patients in a nationwide database.Methods:We extracted data on gastrectomy for gastric cancer from the Hospital Quality Monitoring System Database between 2013 and 2018.Hospital volume was divided into 4 quartiles:low(1-83 cases per year),medium(84-238 cases),high(239-579 cases),and very high(580-1,193 cases).The HHI was divided into 3 categories:highly concentrated(>2,500),moderately concentrated(1,500-2,500),and unconcentrated(<1,500).We used mixed-effects models to analyze the data while accounting for data clustering.Results:We analyzed 125,683 patients in 515 institutions.In the multivariable analyses,hospital volume was significantly associated with in-hospital mortality[medium vs.low:odds ratio(OR)=0.61,95%confidence interval(95%CI)=0.43-0.84,P=0.003;high:OR=0.57,95%CI=0.38-0.87,P=0.009;and very high:OR=0.33,95%CI=0.18-0.61,P<0.001)and length of stay(high vs.low:β=-0.036,95%CI=-0.071--0.002,P=0.039)but not with total cost.Hospitals located in unconcentrated provinces had higher in-hospital mortality(OR=1.52,95%CI=1.03-2.26,P=0.036)and longer lengths of stay(β=0.024,95%CI=0.001-0.047,P=0.041)than hospitals located in highly concentrated provinces.Conclusions:Centralization of gastrectomy,measured by hospital volume and the HHI,was associated with decreased in-hospital mortality and shortened length of stay without increasing total cost.These results support the strategy of centralizing gastrectomy in high-volume settings.

Health Hot Spots: Mapping Hospital Costs and Social Determinants of Health

Accountable care organizations (ACOs) and hospitals are facing additional requirements and financial rewards for improving population health. Therefore, ACOs and hospitals will need tools to understand the relationship between their patients and social determinants and health. We demonstrate the use of hot spotting for identifying geographical sources of high hospital costs and examining links between social determinants of health and these high-cost areas, known as hot spots. In 2012, using hospital data, we generated maps of inpatient costs from 2011 throughout New Haven and within an example neighborhood, Dixwell. We defined hot spots as addresses where costs were in the top 25%. We also overlaid data on concerns and assets in the community. Finally, we calculated the number of concerns and assets that fall within the 250 and 500 ft radii of the defined hot spots. We found that 34 addresses in Dixwell accounted for 70% of total costs for Dixwell. Hot spotting is a straightforward, approachable, and easily understood method for ACOs and hospitals to begin to address population health.

Containing the rising cost of insulin: select policy recommendations

Diabetes is a chronic disease that affects over 30 million people in the United States.Of these,approximately 7.4 million use one or more formulations of insulin to manage their condition.There is a significant financial burden on diabetic individuals,as the price of insulin keeps increasing each year.Such consistent and drastic increases in the price of insulin are due to the complexities in the insulin supply chain,pricing mechanisms particularly due to pharmacy benefit managers(PBMs),and the dominance of a few insulin manufacturers in the market.This policy analysis has been undertaken independently and is based on information from peer-reviewed journals,government organizations and agencies,and credible news sources.Politicians and various stakeholders in the supply chain have made several policy recommendations on the pricing of insulin.From the data and information collected,we suggest basing a patient's co-payment on the net price instead of the list price of insulin,and that there should be real-time transparency in the negotiations between PBMs and pharmaceutical companies on rebates.

Policy options for addressing the high cost of specialty pharmaceuticals

The cost to U.S.consumers of specialty drugs is too high,and cost-sharing obligations are reducing patient access to affordable and life-changing medications.While accounting only for approximately two percent of prescriptions filled,specialty drugs accounted for nearly 45 percent of the U.S.drug spend in 2018,and this rate continues to rise.This review analyzes the current state of the U.S.specialty drug market and recommends six policy options for decreasing out-of-pocket costs to consumers.A systematic review was conducted,gathering articles from peer-reviewed and government resources published from January 2014 to May 2019 using databases such as PubMed,OVID,and the Congressional Research Service(CRS).Articles were reviewed for unique and relevant information relating to cost specialty drugs,industry trends,underlying legislation and policy challenges,and viable policy options.The findings show that,while the cost of specialty drug prices is growing,the rate of growth is projected to slow to a compound annual growth rate(CAGR)of 4 to 7 percent between 2019 to 2023,as compared to a CAGR of 7.2 percent from 2014 to 2018,largely due to the Food and Drug Administration's approval of 10 new biosimilars in 2018 and early 2019.However,specialty drug spending as a percentage of total spending continues to rise and can cost payers and patients more than USD 3,500 on average per month.We recommend six policy options for reducing consumers'out-of-pocket cost obligations:(1)discourage"pay-for-delay"agreements and patent evergreening;(2)align incentives across the specialty drug supply chain with value-based pricing;(3)tighten orphan drug eligibility or impose a sales tax on drugs if the sales tax exceeds a specified threshold until federal subsidies are recouped;(4)increase transparency in transactions between specialty drug supply chain stakeholders;(5)tax the direct-to-consumer advertising of specialty drugs and use the proceeds to fund public research;and(6)support copay cards and patient assistance programs.While the consensus across the industry is that the out-of-pocket costs of specialty drugs to patients are too high,industry stakeholders must agree about which set of policy options to implement.Lawmakers must explore options for reducing the out-of-pocket costs of specialty medications and gather public input on how to best align stakeholder incentives across the specialty drug supply chain.

Barriers in the Transition of Care for Heart Failure Patients Attending Clinics in Mwanza City, Tanzania

Introduction: Transition of care strategies have shown to improve quality of lives of heart failure patients, but it has little implemented in clinical settings. Objective: To evaluate context-specific perceived barriers and experiences of heart failure patients during their admission and after they were discharged from hospital. Methods: A cross-sectional qualitative study was conducted among 13 heart failure patients at two large referral hospitals in northwestern Tanzania. In-depth interviews among heart failure patients, in line with the Consolidated Criteria for Reporting Qualitative research checklist, were used to collect data. Interviews were audio recorded, transcribed, and translated into English. Results: Three key barriers were identified, as well as possible solutions that could improve the transition of care for heart failure patients. These include strengthening healthcare provider communications, organizing medication management, and assisting with follow-up appointments. Conclusion: The barriers identified are real and challenging in clinical resource- limited settings. Findings suggest they can be overcome when realistic and tailor-made interventions are in place.

Changes in Subjective Sleep,Physical Condition,and Mental Health during the COVID-19 Pandemic:A Nationwide Survey in Japan

This study aimed to investigate how people’s subjective health changed after the coronavirus disease 2019(COVID-19)pandemic.This survey was conducted in May 2021 as a nationwide online self-reported survey in Japan.The respondents indicated how their sleep,physical condition,and mental state altered after the pandemic.Furthermore,they answered questionnaires about their intention to get vaccinated,the means of gathering information,etc.A logistic regression analysis was performed.Of the 2,573 responses,there was a decline of approximately 13.6%,14.0%,and 23.8%in subjective sleep,physical condition,and mental health after the pandemic,respectively.The logistic regression analysis demonstrated that regarding sleep,the affected group was younger,got vaccinated against influenza annually,had lower income,experienced poor sleep quality in the past month,and had worse physical and psychiatric symptoms than before the pandemic.Concerning the physical condition,the affected group lived alone,witnessed deficient sleep quality in the past month,and had deteriorated mental health status than before the COVID-19 pandemic.In terms of mental status,the affected group was younger,females,had access to more sources of information,and experienced worse sleep and physical conditions than the unchanged or improved group(p<0.05).Each group indicated an association with the background factors,confirming that the subjective sleep,physical condition,and mental state affected each other.From a preventive perspective,the results of this study suggested that factors such as youth,gender,sleep quality,pregnancy,reduced income,and greater access to information,may be necessary for physical and mental support.The above-mentioned factors should be considered in light of community life and approached accordingly.

A Systematic Analysis of Early Life Exposure to the Chinese Famine(1959-1961)and the Health of Older Adults-China,2008-2023

What is already known about this topic?There is mounting evidence indicating that the aging process initiates during early life stages,with in utero the individual’s environment playing a significant role.Consequently,it is crucial to comprehend the enduring effects of early life circumstances on health in old age.What is added by this report?In this study,we conducted a meta-analysis to examine the effects of the Chinese Famine(1959–1961)on the health of older adults.We also explored potential mechanisms underlying these effects.What are the implications for public health practice?The complex interplay between early life circumstances,multiple health-related sectors,and healthy aging necessitates a comprehensive life-course approach and strategic interventions to enhance public health in an aging society.

Prioritizing Strategies for Building the Resilience of Public Health Systems to Disasters Across Multiple Communities and Countries

The COVID-19 pandemic highlighted the urgent need to strengthen public health systems.In response,the United Nations Disaster Risk Reduction(UNDRR) Public Health System Resilience Scorecard(Scorecard) was applied in workshops across multiple countries.The aim of our research was to explore the workshop findings to develop priority strategies for strengthening public health system resilience.We conducted a workshop from 14 to 16 March 2023,at the UNDRR Global Education and Training Institute in Incheon,Republic of Korea.A sequential modified Delphi method was utilized to develop a set of prioritized resilience strategies.These were drawn from 70 strategies identified from 13 distinct workshops in eight countries.After two surveys,23 strategies were finalized.Ten received ratings of "High" or Very High" from89% of participants.These related to the inclusion of public health risks in emergency plans,integrating multidisciplinary teams into public health,enabling local transport mechanisms,and improving the ability to manage an influx of patients.The Scorecard provides an adaptable framework to identify and prioritize strategies for strengthening public health system resilience.By leveraging this methodology,our study demonstrated how resilience strategies could inform disaster risk reduction funding,policies,and actions.

Development and Validation of a Simplified Chinese Version of the Assessment Tool for Students' Perceptions of Medical Professionalism

Professionalism is crucial in all professions and is particularly important in the medical field.Measuring students' perceptions of professionalism can help to form education targeting the enhancement of professionalism.This study aimed to validate an effective assessment tool for the measurement of medical students5 perceptions of medical professionalism in China's Mainland.The cross-sectional survey was conducted in three medical colleges in Guangdong,China.Of the 2103 eligible medical students,1976 responded,and 1856 questionnaires were deemed valid.Students from clinical medicine in these three medical colleges were randomly selected by cluster sampling.First,a Simplified Chinese Version questionnaire to measure Student's Perception of Medical Professionalism (SCV-SPMP) was constructed.Second,questionnaires from 1856 students majoring in clinical medicine at three medical colleges were included in the analysis.Third,exploratory factor analysis,Cronbach's alpha,item-subscale correlation,and confirmatory factor analysis were conducted to test the validity and reliability of the SCV-SPMP.Nine items were eliminated following exploratory factor analysis,and four subscales were extracted from the analysis.All internal consistency reliability exceeded the minimum standard.The overall Cronbach's alpha was 0.94,and four subscales' alphas were 0.82 (Accountability and excellence),0.81 (Duty),0.89 (Honor and integrity),and 0.85 (Practice habits and respect for others),respectively.The model fit was good.The convergent validity and discriminant validity were acceptable.The modified SCVSPMP was found to be a valid and reliable tool to capture the main features of Chinese students' perceptions of medical professionalism in four dimensions,and it provides a quantitative method for the measurement of the students' perceptions in China's Mainland..

Can health technology assessments assist the global campaign against poverty?

Although a key tenant of the Sustainable Development Goals is to achieve universal health coverage,the global drug gap persists-cver a third of the global population lack access to essential medicines.Without access to affordable drugs,people have worse health outcomes,higher medical expenses,and productivity loss,pushing them into poverty.Health technology assessments(HTAs)offer an opportunity to decrease the global drug gap and increase access to essential medicines by overcoming barriers to medicine access.These barriers include drug procurement,drug affordability for payers and patients,a patienfs ability to obtain essential medicines,and health system capacity.Using HTAs can therefore close the global drug gap by increasing access to affordable essential medicines.In turn,people have better health outcomes,spend less money on medical care,and can have better productivity.Ultimately,use of HTAs can lift the population out of poverty and force fewer people into poverty by creating better health outcomes at affordable prices.

Risk factors for liver disease among adults of Mexican descent in the United States and Mexico

AIM To compare the prevalence of chronic liver disease(CLD) risk factors in a representative sample of MexicanAmericans born in the United States(US) or Mexico, to a sample of adults in Mexico.METHODS Data for Mexican-Americans in the US were obtained from the 1999-2014 National Health and Nutrition Examination Survey(NHANES), which includes persons of Mexican origin living in the US(n = 4274). The NHANES sample was restricted to Mexican-American participants who were 20 years and older, born in the US or Mexico, not pregnant or breastfeeding, and with medical insurance.The data in Mexico were obtained from the 2004-2013 Health Worker Cohort Study in Cuernavaca, Mexico(n =9485). The following known risk factors for liver disease/cancer were evaluated: elevated aminotransferase levels(elevated alanine aminotransferase was defined as > 40 IU/L for males and females; elevated aspartate aminotransferase was defined as > 40 IU/L for males and females), infection with hepatitis B or hepatitis C,metabolic syndrome, high total cholesterol, diabetes,obesity, abdominal obesity, and heavy alcohol use. The main independent variables for this study classified individuals by country of residence(i.e., Mexico vs the US) and place of birth(i.e., US-born vs Mexico-born).Regression analyses were used to investigate CLD risk factors.RESULTS After adjusting for socio-demographic characteristics,Mexican-American males were more likely to be obese,diabetic, heavy/binge drinkers or have abdominal obesity than males in Mexico. The adjusted multivariate results for females also indicate that Mexican-American females were significantly more likely to be obese, diabetic, be heavy/binge drinkers or have abdominal obesity than Mexican females. The prevalence ratios and prevalence differences mirror the multivariate analysis findings for the aforementioned risk factors, showing a greater risk among US-born as compared to Mexico-born MexicanAmericans. CONCLUSION In this study, Mexican-Americans in the US had more risk factors for CLD than their counterparts in Mexico.These findings can be used to design and implement more effective health promotion policies and programs to address the specific factors that put Mexicans at higher risk of developing CLD in both countries.

Trends in the incidence of physician-diagnosed post-traumatic stress disorder among active-duty U.S. military personnel between 1999 and 2008

Background: The impact of combat operations in Iraq and Afghanistan on the incidence of post-traumatic stress disorder(PTSD) in military service members has been poorly quantified. The purpose of this study was to examine trends in the incidence rate of physician-diagnosed PTSD in active-duty military personnel between 1999 and 2008.Methods: We conducted a retrospective cohort study utilizing data extracted from the Defense Medical Surveillance System to identify incident cases of PTSD within the study population. The incidence rate of physician-diagnosed PTSD was the primary outcome of interest. Multivariable Poisson regression was used to analyze the data.Results: The overall incidence rate of PTSD among all active-duty US military personnel was 3.84(95% CI: 3.81, 3.87) cases per 1000 person-years. The adjusted average annual percentage increase in the incidence rate of PTSD prior to the initiation of Operation Iraqi Freedom(OIF) was a modest 5.02%(95% CI: 1.85, 8.29%). Following the initiation of OIF, the average annual percentage increase in the rate of PTSD was 43.03%(95% CI: 40.55, 45.56%). Compared to the baseline period between 1999 and 2002, the incidence rate of PTSD in 2008 was nearly 7 times higher(RR=6.85, 95% CI: 6.49, 7.24). Significant increases in the incidence rate of PTSD were observed following the initiation of OIF regardless of sex, age, race, marital status, military rank, or branch of military service. Notably, the rate of PTSD among females was 6–7 times higher prior to OIF, but there was no difference by gender by 2008.Conclusions: Overall, these data quantify the significant increase in the incidence rate of PTSD following the initiation of combat operations in Iraq and Afghanistan within the active-duty military population during the study period.

Comparison of price, volume and composition of services provided to inpatients for two procedures between a US and a Japanese academic hospital

Background: To drill down into why per capita health expenditures vary between the US and Japan, this exploratory study compares the price, volume and composition of services provided to inpatients for two procedures in an academic hospital in the US, and one in Japan. Methods: Detailed analysis of the amount reimbursed and services delivered was made from claims data for 449 acute myocardial infarction treated with coronary stents placed by percutaneous coronary intervention (PCI) and 115 heart valve dysfunction with heart valve replacement (HVR) cases in Johns Hopkins Hospital (JHH) Baltimore, Maryland, and 34 PCI and 21 HVR cases in Keio University Hospital (KUH), Tokyo. Results: After making appropriate adjustments, the reimbursed amount per discharge at JHH was significantly higher (Wilcoxon ranksum test, p < 0.01) for both medical conditions. This was due to more use of higher priced technology and higher prices for the same technology at JHH compared with KUH. However, medical imaging was performed more frequently at KUH and the reimbursed amounts per unit for the devices were higher at KUH. Analysis of room and board costs showed that the higher staffing level and wages of nurses at JHH was compensated by its shorter average length of stay for PCI, but not for HVR. Conclusion: Detailed analysis of the reimbursed amount and the utilization of services are needed to understand international variations in healthcare spending.

Satisfaction about Patient-centeredness and Healthcare System among Patients with Chronic Multimorbidity

The aim of the present study was to measure the prevalence of multimorbidity in Bangladesh,India and China,and to assess the relationship between multimorbidity and patient's opinion regarding their involvement in healthcare decision-making and overall satisfaction of healthcare system.Cross-sectional data on 18696 men and women aged 18 and above were collected from the World Health Survey of World Health Organization(WHO).Outcome variables were subjective rating of(1)healthcare system's ability to involve patients in decision-making,and(2)satisfaction with the way healthcare system runs in the country.Self-reported chronic conditions were used to measure the prevalence of multimorbidity.Out of 9 chronic conditions,back pain,arthritis,and chronic cough appeared to be the most prevalent ones among majority of the participants.About one-third of the participants in China(30.7%)and two-thirds in Bangladesh(66.1%)and India(66.6%)reported having at least one chronic illness.Prevalence of multimorbidity was highest in India(34.3%)followed by Bangladesh(28.8%)and China(14.3%).In Bangladesh,India and China,respectively 70.5%,41.7%,61.3%women and 54.5%,42.8%and 58.8%men expressed dissatisfaction regarding the way healthcare system runs in their country.In Bangladesh and India,men who were living with multimorbidity were more likely to rate the patient-centeredness as"bad"than those who had no disease illness.This study suggests that the prevalence of multimorbidity was remarkably high especially in Bangladesh and India.Higher likelihood of dissatisfaction about healthcare system among multimorbid patients might be indicative of inadequacy in the provision of care in qualitative and quantitative terms.

Longitudinal assessment of liver stiffness by transient elastography for chronic hepatitis C patients

BACKGROUND Liver fibrosis is a common pathway of liver injury and is a feature of most chronic liver diseases.Fibrosis progression varies markedly in patients with hepatitis C virus(HCV).Liver stiffness has been recommended as a parameter of fibrosis progression/regression in patients with HCV.AIM To investigate changes in liver stiffness measured by transient elastography(TE)in a large,racially diverse cohort of United States patients with chronic hepatitis C(CHC).METHODS We evaluated the differences in liver stiffness between patients treated with direct-acting antiviral(DAA)therapy and untreated patients.Patients had≥2 TE measurements and no prior DAA exposure.We used linear regression to measure the change in liver stiffness between first and last TE in response to treatment,controlling for age,sex,race,diabetes,smoking status,human immunodeficiency virus status,baseline alanine aminotransferase,and baseline liver stiffness.Separate regression models analyzed the change in liver stiffness as measured by kPa,stratified by cirrhosis status.RESULTS Of 813 patients,419(52%)initiated DAA treatment.Baseline liver stiffness was 12 kPa in 127(16%).Median time between first and last TE was 11.7 and 12.7 mo among treated and untreated patients,respectively.There was no significant change in liver stiffness observed over time in either the group initiating DAA treatment(0.016 kPa/month;CI:-0.051,0.084)or in the untreated group(0.001 kPa/mo;CI:-0.090,0.092),controlling for covariates.A higher baseline kPa score was independently associated with decreased liver stiffness.CONCLUSION DAA treatment was not associated with a differential change in liver stiffness over time in patients with CHC compared to untreated patients.