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AbstractObjectiveTo review the evidence on trends and impacts of private equity (PE) ownership of healthcare operators.DesignSystematic review.Data sourcesPubMed, Web of Science, Embase, Scopus, and SSRN.Eligibility criteria for study selectionEmpirical research studies of any design that evaluated PE owned healthcare operators.Main outcome measuresThe main outcome measures were impact of PE ownership on health outcomes, costs to patients or payers, costs to operators, and quality. The secondary outcome measures were trends and prevalence of PE ownership of healthcare operators.Data synthesisStudies were classified as finding either beneficial, harmful, mixed, or neutral impacts of PE ownership on main outcome measures. Results across studies were narratively synthesized and reported. Risk of bias was evaluated using ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions).ResultsThe electronic search identified 1778 studies, with 55 meeting the inclusion criteria. Studies spanned eight countries, with most (n=47) analyzing PE ownership of healthcare operators in the US. Nursing homes were the most commonly studied healthcare setting (n=17), followed by hospitals and dermatology settings (n=9 each); ophthalmology (n=7); multiple specialties or general physician groups (n=5); urology (n=4); gastroenterology and orthopedics (n=3 each); surgical centers, fertility, and obstetrics and gynecology (n=2 each); and anesthesia, hospice care, oral or maxillofacial surgery, otolaryngology, and plastics (n=1 each). Across the outcome measures, PE ownership was most consistently associated with increases in costs to patients or payers. Additionally, PE ownership was associated with mixed to harmful impacts on quality. These outcomes held in sensitivity analyses in which only studies with moderate risk of bias were included. Health outcomes showed both beneficial and harmful results, as did costs to operators, but the volume of studies for these outcomes was too low for conclusive interpretation. In some instances, PE ownership was associated with reduced nurse staffing levels or a shift towards lower nursing skill mix. No consistently beneficial impacts of PE ownership were identified.ConclusionsTrends in PE ownership rapidly increased across almost all healthcare settings studied. Such ownership is often associated with harmful impacts on costs to patients or payers and mixed to harmful impacts on quality. Owing to risk of bias and frequent geographic focus on the US, conclusions might not be generalizable internationally.Systematic review registrationPROSPERO CRD42022329857.

Health insurance literacy (HIL) reflects individuals' ability to understand, select, and effectively use health insurance, impacting healthcare access and utilization. Existing measurement tools often lack comprehensiveness or contextual relevance. This study aimed to develop a comprehensive questionnaire for measuring HIL, encompassing all recognized dimensions and expanding upon the Health Insurance Literacy Measure (HILM), while also adapting it to the specific cultural and national context, using Israel as a case study and proof of concept. A multi-phase methodology was employed to develop a comprehensive HIL questionnaire, including an extensive literature review, expert consultations, and iterative pilot testing to ensure cultural and contextual relevance. Exploratory factor analysis (EFA) and reliability testing were conducted using data from a representative sample of 1,012 adults to validate its psychometric properties. A 75-item questionnaire was designed, covering four domains: confidence and behavior in choosing and using health insurance (HILM), self-report confidence in understanding of key insurance concepts, objective knowledge assessment, and self-assessment of HIL. The questionnaire employs a combination of Likert-type scales and binary scoring for objective knowledge items. EFA confirmed a robust multidimensional structure. The final model accounted for 61% of the variance in the confidence and behavior domains and 57% in the concept domain, while the objective knowledge domain showed less definitive factor loadings. Internal consistency was high across all domains (Cronbach's alpha = 0.80-0.95), and concurrent and convergent validity analyses demonstrated moderate to strong correlations with external measures of understanding and self-assessed knowledge, supporting its psychometric robustness. This validated questionnaire presents a robust, culturally adapted measure of HIL, integrating both objective knowledge and subjective confidence, offering insights into the multidimensional nature of HIL. It provides critical insights for policymakers and educators aiming to enhance public understanding and effective use of health insurance, setting the stage for targeted interventions and broader international applications. Not applicable.

Background Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs. Methods We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR). Results We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities ( N =39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs. Conclusion We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions. Trial registration PROSPERO: CRD42021252715 .

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

Background Research has documented the positive impact of the nurse practitioner workforce on patient and system outcomes in multiple countries. Achieving these outcomes relies on successfully integrating the workforce into the health system. Research has reported negative effects of integration barriers on the ability for nurse practitioners to improve outcomes. Barriers include scope of practice restrictions, organizational climates inconducive to nurse practitioner care, and lacking mentorship. To design efficacious policies, organizational and national policy decision-makers require knowledge of the factors affecting the integration of this human resource into care settings. No research has synthesized these factors into an easily understandable and applicable inventory for policy decision-makers. This study aimed to reach expert consensus on an inventory of factors affecting the integration of nurse practitioners into the health system. Methods This study used a Delphi method to survey experts in integrating nurse practitioners into the United States health system. Participants were asked to rate their level of agreement with each factor and its description. Participants provided open-ended feedback. Summary statistics were used to analyze ratings and inductive content analysis was used to analyze open-ended feedback. Three rounds of analysis by separate team members occurred to determine changes to the inventory. Data collection ceased once expert consensus was reached on the inventory. Results There were 29 participants. The final inventory included 17 factors spanning national, organizational, and care team levels. National-level factors included clear scope of practice and reasonable financial support for nurse practitioner services. Organizational-level factors included onboarding and retention strategies, organizational culture, and organizational leadership messaging. Care-team level factors included relationships with care team members and patient understanding of the nurse practitioner role. Conclusions The results highlight the importance of organizational-level management strategies, such as representation and recognition, fair and reasonable nurse practitioner compensation and professional development. The factors aligned closely with implementation science frameworks, indicating that the integration of the nurse practitioner workforce could be conceptualized as an implementation issue. The inventory may be useful to aid in designing policies to better integrate nurse practitioners into health systems.

Background Decisions regarding health systems are sometimes made without the input of timely and reliable evidence, leading to less than optimal health outcomes. Healthcare organizations can implement tools and infrastructures to support the use of research evidence to inform decision-making. Objectives The purpose of this study was to profile the supports and instruments ( i.e ., programs, interventions, instruments or tools) that healthcare organizations currently have in place and which ones were perceived to facilitate evidence-informed decision-making. Methods In-depth semi-structured telephone interviews were conducted with individuals in three different types of positions ( i.e ., a senior management team member, a library manager, and a ‘knowledge broker’) in three types of healthcare organizations ( i.e ., regional health authorities, hospitals and primary care practices) in two Canadian provinces ( i.e ., Ontario and Quebec). The interviews were taped, transcribed, and then analyzed thematically using NVivo 9 qualitative data analysis software. Results A total of 57 interviews were conducted in 25 organizations in Ontario and Quebec. The main findings suggest that, for the healthcare organizations that participated in this study, the following supports facilitate evidence-informed decision-making: facilitating roles that actively promote research use within the organization; establishing ties to researchers and opinion leaders outside the organization; a technical infrastructure that provides access to research evidence, such as databases; and provision and participation in training programs to enhance staff’s capacity building. Conclusions This study identified the need for having a receptive climate, which laid the foundation for the implementation of other tangible initiatives and supported the use of research in decision-making. This study adds to the literature on organizational efforts that can increase the use of research evidence in decision-making. Some of the identified supports may increase the use of research evidence by decision-makers, which may then lead to more informed decisions, and hopefully to a strengthened health system and improved health.

Autonomy refers to the right of a profession to self-govern, setting its own standards, scope of practice and educational frameworks based on evidence and professional consensus.8 Independence is the ability to act on that autonomy without external oversight or constraint.9 In midwifery, autonomy grants midwives the authority to define their professional standards and protocols.6 Independence enables midwives to translate professional standards into practice by acting as primary care providers, exercising clinical judgement and leading midwifery models of care.10 Without independence, autonomy remains theoretical; without autonomy, independence lacks foundation. Midwifery is one of the most evidence-supported healthcare interventions for improving maternal and neonatal outcomes.4 10 Midwives have a broad scope of practice, defined by the WHO to include sexual, reproductive, maternal, neonatal and adolescent health (SRMNAH), and, when adequately supported, can meet up to 90% of essential healthcare needs across the women’s healthcare spectrum.10 Studies across low-income, middle-income and high-income countries consistently show that continuity of midwife care (CoMC) reduces maternal and neonatal morbidity and mortality, lowers healthcare costs, raises patient satisfaction and decreases unnecessary interventions.4 CoMC is defined as care provided autonomously and independently by a known midwife, or a small team of midwives, throughout pregnancy, birth and the postnatal period.10 A recent Lancet study found that if every woman had access to a midwife, 4.3 million lives could be saved.1 Yet, this life-saving potential is too often obstructed by health policies that do not reflect or support the evidence.11 12 Many healthcare systems fail to recognise or support this dual foundation of autonomy and independence, leaving midwifery constrained by systemic barriers that undermine its potential.13 As a result, midwifery risks remaining a profession caught in limbo. To truly practise independently, midwives must have the ability to diagnose, treat, prescribe medications and tests, refer to specialists, admit and discharge, and lead care models.16 They must also have the authority to order and interpret diagnostic tests and provide seamless continuity of care across the full SRMNAH continuum, including all phases of pregnancy, birth and the postnatal period, as fully independent and autonomous healthcare professionals.10 Yet in practice, levels of autonomy and independence for midwives vary significantly across countries, reflecting major differences in legal frameworks, regulation and systemic support. Realising the full potential of this framework requires more than acknowledgement; it demands deliberate investment in the systems that make autonomy and independence possible.3 Education must encompass all stakeholders, from midwives in training to the highest levels of healthcare leadership, fostering mutual understanding and respect across disciplines.23 Evidence shows that when midwives are educated to international standards, such as those outlined in the ICM Essential Competencies for Midwifery Practice24 and the ICM Global Standards for Midwifery Education,25 they are fully equipped to function as autonomous, independent practitioners across the full spectrum of SRMNAH care.10 15 However, the quality of education and regulation remains highly variable across settings, with midwifery education often underfunded and inconsistent, with gaps in hands-on clinical experience, assessment and competency development.26 To address this, ICM has developed a comprehensive competency mapping tool,27 aimed at harmonising quality standards while allowing for contextual adaptation.

In their study of manifestations of policy support organizations (PSOs), Al Sabahi et al found that PSOs are united in their goal to support evidence-informed policy-making (EIPM), albeit with differing approaches. Their article is an important contribution to the body of research on evidence utilization and implementation. The unprecedented evidence climate presented by coronavirus disease 2019 (COVID-19) provides a unique window to motivate EIPM implementation. Research such as Al Sabahi and colleagues must prompt a dialogue regarding how best to address some of the current shortcomings in the field of EIPM. Monitoring and evaluation of best practices in EIPM is scarce. EIPM uptake is unsatisfactory, and the scientific community needs to ask itself why that is and what can be done. And, we should strive to develop a gradient that discerns between the convenient and the essential so countries can evaluate and pursue the policies to best address their greatest pain points through evidence.

Correspondence to Dr Moriah Ellen, Health Policy and Management, Ben-Gurion University of the Negev, Beer-Sheva, 8400711, Israel; ellenmo@bgu.ac.il Ellen and colleagues argue that expanding the geographical and professional reach and thematic scope of choosing wisely could help achieve greater impact Choosing wisely (CW) is a campaign for healthcare professionals and patients to engage in conversations about unnecessary tests, treatments and procedures, and to help them make smart and effective choices to ensure high-quality care.1 Through this partnership, national organisations representing medical specialists identify tests or procedures commonly used in their field whose necessity should be questioned and discussed. A successful decade has passed since CW recommendation ‘five things to question’ lists were first published in the USA in 2012 based on the input of 9 different medical societies.2 3 The past decade has included a plethora of accomplishments, including the internationalisation and local adaptation of the campaign in countries such as Canada, the Netherlands, Australia, New Zealand, Israel and the UK, as well as the successful implementation of various recommendations, for example, reducing unnecessary blood chemistry testing in the emergency department or reducing unnecessary antibiotic prescribing and antipsychotics use.4 5 Potential harms of overuse for patients include overdiagnosis,6 overtreatment,7 antibiotic resistance8 and radiation exposure.9 Up until now, the emphasis of many campaigns has been to raise awareness about overuse as an important problem to address. [...]expanding CW a step beyond a clinical approach focused on the individual encounter between clinicians and patients to address the systemic causes of overuse. Hospital systems are controlled by the administration and other systems may be controlled by payers or governments, for example, ordering systems for lab tests and financial incentives for interventions.21 Some overuse is ‘baked in’ to the system and individual clinicians have little or no influence on these; changes need to happen at the system level that is often controlled by payers in a top-down fashion.

Background The use of health policy and systems research (HPSR) to inform health policy-making is an international challenge. Incorporating HPSR into decision-making primarily involves two groups, namely researchers (knowledge producers) and policy-makers (knowledge users). The purpose of this study was to compare the perceptions of Israeli health systems and policy researchers and health services policy-makers regarding the role of HPSR, factors influencing its uses and potential facilitators and barriers to HPSR, and implementation of knowledge transfer and exchange (KTE) activities. Methods A cross-sectional survey was administered to researchers and policy-makers in Israel. The survey consisted of seven closed questions. Descriptive analyses were carried out for closed-ended questions and comparative analysis were conducted between groups using the χ 2 test. Results A total of 37 researchers and 32 policy-makers responded to the survey. While some views were in alignment, others showed differences. More policy-makers than researchers perceived that the use of HPSR in policy was hindered by practical implementation constraints, whereas more researchers felt that its use was hindered by a lack of coordination between knowledge producers and users. A larger percentage of policy-makers, as compared to researchers, reported that facilitators to the KTE process are in place and a larger percentage of researchers perceived barriers within the KTE environment. A larger percentage of policy-makers perceived KTE activities were in place as compared to researchers. Results also showed large differences in the perceptions of the two groups regarding policy formulation and which organisations they perceived as exerting strong influence on policy-making. Conclusions This research demonstrated that there are differences in the perceptions of knowledge producers and users about the process of KTE. Future work should focus on minimising the challenges highlighted here and implementing new KTE activities. These activities could include making the researchers aware of the most effective manner in which to package their results, providing training to policy-makers and assuring that policy-makers have technical access to appropriate databases to search for HPSR. These results underscore the need for the groups to communicate and clarify to each other what they can offer and what they require.