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Increasing value for money in the Canadian healthcare system: new findings on the contribution of primary care services

Healthc Q 12:32-44. Hollander Analytical Services Ltd., Victoria, BC, Canada This article presents a major new finding in regard to the value for money of […]

The economic value of a wellness and disease prevention program

Popul Health Manag 13:309-317. HealthMedia, Inc., Ann Arbor, MI, USA The objective of this study was to determine the economic impact of the Hawaii Medical […]

Employment of mid-level providers in primary care and control of diabetes

Prim Care Diabetes 5:25-31. Center for Health Services Research in Primary Care, Veterans Affairs Medical Center, Durham, NC, USA AIMS: Examine potential associations between inclusion […]

High-deductible insurance: two-year emergency department and hospital use

Am J Manag Care 17:e410-8. Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA OBJECTIVES: To determine the […]

Evaluating patient adherence to antidepressant therapy among uninsured working adults diagnosed with major depression: results of the Texas Demonstration to Maintain Independence and Employment study

Adm Policy Ment Health 39:374-382. Addiction Research Institute, University of Texas at Austin, Austin, TX, USA This study examined antidepressant adherence and persistence among uninsured […]

Factors associated with 90-day death after emergency department discharge for atrial fibrillation

Ann Emerg Med 61:539-548.e1. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada STUDY OBJECTIVE: More than 10% of patients treated in the emergency department (ED) […]

Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes

Health Aff 32:1942-1948. University of Wisconsin–Madison, WI, USA; University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA One approach to the patient-centered medical home, particularly […]

The influence of socio-economic status and multimorbidity patterns on healthcare costs: a six-year follow-up under a universal healthcare system

Int J Equity Health 12:69. Center of Comparative Effectiveness Research, National Center of Excellence for Clinical Trial and Research, National Taiwan University Hospital, Taipei City, […]

Spreading a medical home redesign: effects on emergency department use and hospital admissions

Ann Fam Med 11 Suppl 1:S19-S26. Group Health Physicians, Seattle, WA, USA PURPOSE: The patient-centered medical home (PCMH) is being rapidly deployed in many settings […]

High use of health services in patients with suboptimal asthma drug regimens: a population-based assessment in British Columbia, Canada

Pharmacoepidemiol Drug Saf 22:744-751. University of British Columbia, Vancouver, BC, Canada; BC Children’s Hospital, Vancouver, BC, Canada; Child and Family Research Institute, Vancouver, BC, Canada; […]

Impact of poorly controlled hypertension on healthcare resource utilization and cost

Am J Manag Care 7:389-398. MEDTAP International, Bethesda, MD, USA OBJECTIVE: To examine the relation between blood pressure (BP) control and utilization and cost of […]

Comparison of comorbidity classification methods for predicting outcomes in a population-based cohort of adults with human immunodeficiency virus infection

Ann Epidemiol 24:532-537. St. Michael’s Hospital, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Institute for Clinical Evaluative Sciences, Toronto, ON, Canada PURPOSE: We […]

Development of a predictive risk model for unplanned admissions in the Basque Country

Rev Esp Salud Publica 88:251-260. Published in Spanish. Centro de Salud de Astrabudua,.Osakidetza (Servicio Vasco de Salud), Erandio. Bizkaia, Spain; Instituto Vasco de Innovación Sanitaria. […]

Do some physician groups see sicker patients than others? Implications for primary care policy in Manitoba

Winnipeg, MB, Canada: Manitoba Centre for Health Policy. Manitoba Centre for Health Policy, Winnipeg, MB, Canada Canadian policy makers are considering a variety of new […]

Ontario MedsCheck annual pharmacy medication review service: a comparison between initial and well established implementation periods

International Conference for Pharmacoepidemiology (ICPE) – August, 2015 Boston, MA, USA. Background: A MedsCheck Annual (MCA) consultation is a government-funded, medication review service in Ontario, […]

Risks of hospitalizations and surgery in elderly-onset inflammatory bowel disease: a population based study

Gastroenterology 146:S-171. Background: The incidence of Crohn’s disease (CD) and ulcerative colitis (UC) in the elderly population is reported to be increasing. Comorbid diseases, which […]

Patient based patterns of morbidity, a 17 year follow-up on patient records in primary care in Sweden

BMC Health Serv Res 7:A13. Karolinska Institute, Stockholm, Sweden BACKGROUND: Longitudinal studies on clinical categories of patients in primary health care are rare, as are […]

Development and evaluation of the Johns Hopkins University risk adjustment models for Medicare+Choice plan payment

Final report to Centers for Medicare and Medicaid Services, US Department of Health and Human Services. Baltimore, MD, USA: Johns Hopkins University. Johns Hopkins University, […]

Characteristics of Maryland residents who obtain health insurance from the small and large group markets

Bethesda, MD, USA: Project Hope Center for Health Affairs. Project Hope, Bethesda, MD, USA This report contains findings from a project conducted by the Project […]

Developing re-insurance and carve-out risk adjusters for an under 65 population

Johns Hopkins University, Lewin Group. Prepared for Health Care Financing Administration. Fairfax, VA, USA: Lewin Group. Johns Hopkins University, Baltimore, MD, USA; Lewin Group, Fairfax, […]

The ambulatory case-mix development project

Project final report. Baltimore, MD, USA: Johns Hopkins University and Aetna Health Plans. Johns Hopkins University and Aetna Health Plans, USA As the US health […]

Analysis of Medicaid payments for American Indians and Alaska Natives

Baltimore, MD, USA: CMS Tribal Affairs Group.. CMS Tribal Affairs Group, Baltimore, MD, USA The Indian Health Service (IHS) is a discretionary federal program that […]

Quality, costs and the role of primary health care

Linkoping, Sweden: Linkoping University. Linkoping University, Linkoping, Sweden The general aim of this thesis is to describe and analyse the role of primary  care in […]

Adherence to prescription drugs and adverse health events for patients with hypertension

Los Angeles, CA, USA: University of California, Los Angeles (doctoral dissertation). University of California, Los Angeles, CA, USA Increased technology in the development of effective […]

Time to readmission among chronically ill community-resident beneficiaries: variations by geographic area and provider type

Baltimore, MD, USA: Centers for Medicare and Medicaid Services. Schneider Institute for Health Policy, Heller School for Social Policy and Management, Brandeis University, Waltham, MA, […]

Optimal primary care for elders: periodic health examination and interdisciplinary geriatric team care

Waltham, MA, USA: Brandeis University (doctoral dissertation). Brandeis University, Waltham, MA, USA Health care organizations must find creative ways to achieve cost-efficient, high-quality primary care […]

Ischemic heart disease (IHD) and related health care utilization in Metis in Manitoba

Winnipeg, MB, Canada: Manitoba Metis Federation. Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada; Health & Wellness Department, Manitoba Metis Federation, Winnipeg, […]

Evaluation of the implementation of advanced nursing competencies in the Basque health care system

J Nurs Ed Pract 3:23-29. Basque Institute for Healthcare Innovation, Sondika, Bizkaia, Spain In 2011 advanced competences in nursing were defined and pilot tested in […]

Developing new comorbidity indices for cancer populations using administrative data

Dunedin, New Zealand: University of Otago (doctoral dissertation). University of Otago, Dunedin, New Zealand BACKGROUND: Comorbidity has an important impact on cancer outcomes, but the […]

Using case finding and risk stratification: A key service component for personalised care and support planning

Using case finding and risk stratification: A key service component for personalised care and support planningThis handbook describes current thinking and provides practitioner insights into […]

Data Visualization and Patient Identification – Military

The Defense Health Agency (DHA) supports the delivery of integrated, affordable, and high-quality health services to Military Health System (MHS) beneficiaries and is responsible for […]

How Health Information Technology can Impact the Delivery of Health Care

Johns Hopkins Bloomberg School of Public Health How Health Information Technology can Impact the Delivery of Health Care Karen Kinder, PhD, MBA

Tuesday-Managing hospitalization risk-Sylvia and Lu

Johns Hopkins HealthCare Develop a Risk Prediction Model to Identify Diabetic Members at High Risk of Hospitalization Martha Sylvia and Yanyan Lu

Monday-Pilot Experiences-Zhang

University of Minnesota Chinese Health Insurance System and Pilot Study for Applying ACG System to Chinese Healthcare System Yi Zhang and Stephen T. Parente, Ph.D.

Monday-Advances in modeling risk-Lemke

Johns Hopkins ACG System ACG Predictive Model for Readmission Risk Klaus Lemke

The ACG system in Leicester

NHS ACGs in Leicestershire and Leicester city Mark Pierce

Medication Therapy Management

DST Health Solutions Medication Therapy Management Amy Salls, Director Population Health Strategy Diana R. Kesser, Director Care Management Strategy

Monday(C3)-Cluster Analysis: Conditions and Variables That Are the Best Predictors of High Cost Members-Bob Gladden and Cathy Meade

Cluster Analysis: Conditions and Variables That Are the Best Predictors of High Cost Members  —Bob Gladden and Cathy Meade, CareSource

Tuesday(C8)- Use of ACG within Benefit Informatics for employer health plan cost management-Bruns

 Use of ACG within Benefit Informatics for employer health plan cost management-Bruns Benefit Focus

THE INTEGRATION OF ACG WITH THE BUSINESS INTELLIGENCE SYSTEM OF A LOCAL HEALTH UNIT IN VENETO REGION, ITALY 

N. Alba1, C. Bovo1, R. Marchi1, R. Borin1, F. Avossa2, E. Schievano2, M. Saugo2, M.C. Corti3, E. Boscolo3, C. Abrams4, K. Kinder4, D. Mantoan3;  1Local […]

ICD-10: Kelsey Rauch, DST Health Solutions

ACG System DST Health Solutions The Impact of Transitioning Coding Systems on Risk Adjustment Kelsey Rauch

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Various ACG System Applications

Amy Salls, Director of Population Health Strategy at DST Health Solutions, provides a summary on the commercialization process and the various populations, applications, and user needs that the ACG System helps in the United States. Learn More.

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Population Segmentation Case Study – Payer

Johns Hopkins Healthcare (JHHC) develops and manages medical care contracts for close to 400,000 plan members. JHHC created a framework based on an adapted version of the National Academy of Medicine taxonomy, combined with ACG System output, to provide a more extensive set of risk categories in an effort to expand their care management programs to high-risk Medicare patients.

Apples and Oranges: Four Definitions of Multiple Chronic Conditions and their Relationship to 30-Day Hospital Readmission

OBJECTIVES: To determine the extent of agreement between four commonly used definitions of multiple chronic conditions (MCCs) and compare each definition’s ability to predict 30-day […]

Are we making a difference in primary care for adults with intellectual and developmental disabilities?

Abstract Objectives. To examine the impact of the dissemination of guidelines to physicians and of a population-level health communication intervention on the percentage of adults […]

Supplement to “Equilibria in Health Exchanges: Adverse Selection versus Reclassification Risk”

This online appendix has three sections.  The first presents details of the choice model estimation algorithm, as well as additional estimates from our primary specification […]

Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders

Abstract Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency […]

Integrating Social and Behavioral Determinants of Health into Population Health Analytics: A Conceptual Framework and Suggested Road Map

Abstract There is growing recognition that social and behavioral risk factors impact population health outcomes. Interventions that target these risk factors can improve health outcomes. […]

Frailty, Implantable Cardioverter Defibrillators, and Mortality: a Systematic Review

Abstract   Background Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone […]

Impact of care provider network characteristics on patient outcomes: Usage of social network analysis and a multi-scale community detection

Abstract Objective We assess healthcare provider collaboration and the impact on patient outcomes using social network analysis, a multi-scale community detection algorithm, and generalized estimating […]

MS risk in immigrants in the McDonald era: A population-based study in Ontario, Canada

Abstract OBJECTIVE To determine risk factors for multiple sclerosis (MS) in immigrants and to compare MS risk in immigrants and long-term residents in Ontario, Canada. […]

Preoperative frailty predicts adverse short‐term postoperative outcomes in patients treated with radical nephroureterectomy

Abstract Background To investigate the effect of frailty on short‐term postoperative outcomes and total hospital charges (THCs) in patients with non‐metastatic upper urinary tract carcinoma, […]

Who is discharged to intermediate care facilities? An Italian study in the population of Udine

ABSTRACT The objective of this study was to assess complexity of patients discharged from hospital to intermediate care facility in an Italian setting. Multiple anonymous […]

Alive and at home: Five-year outcomes in older adults following emergency general surgery

Abstract BACKGROUND While the short-term risks of emergency general surgery (EGS) admission among older adults have been studied, little is known about long-term functional outcomes […]

Shorter Diagnosis-to-Treatment Interval in Diffuse Large B-Cell Lymphoma is Associated With Inferior Overall Survival in a Large, Population-Based Registry

Abstract Background Because of prolonged screening requirements, patient and time-dependent selection have been proposed as potential biases in clinical trials. The screening process may exclude […]

Association of Preexisting Disability With Severe Maternal Morbidity or Mortality in Ontario, Canada

Abstract Objective To determine the risk of severe maternal morbidity or mortality among women with a physical, sensory, or intellectual/developmental disability compared with women without […]

Integrating E-Prescribing and Pharmacy Claims Data for Predictive Modeling: Comparing Costs and Utilization of Health Plan Members Who Fill Their Initial Medications with Those Who Do Not

Abstract BACKGROUND Nonfilling of prescribed medications is a worldwide problem of serious concern. Studies of health care costs and utilization associated with medication nonadherence frequently […]

Delay of Pregnancy Among Physicians vs Nonphysicians

Abstract Importance Women physicians may delay childbearing and experience childlessness more often than nonphysicians, but existing knowledge is based largely on self-reported survey data. Objective […]

How different combinations of comorbidities affect healthcare use by elderly patients with obstructive lung disease

Abstract Objective Previous research had shown the number of comorbidities is a major factor influencing the burden of care for elderly patients with obstructive lung […]

Comparison of 4-Year Health Care Expenditures Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

Abstract Objective To compare 4-year health care expenditures after RYGB vs sleeve gastrectomy, identify factors independently associated with 4-year health care expenditures, and compare the […]

No Difference in Outcomes Between Short and Longer-Stay Total Joint Arthroplasty with a Discharge Home

Abstract Background: Outcomes following total hip arthroplasty (THA) and total knee arthroplasty (TKA) with a short length of hospital stay have been reported; however, most […]

Remote, proactive, telephone based management of toxicity in outpatients during adjuvant or neoadjuvant chemotherapy for early stage breast cancer: pragmatic, cluster randomised trial

Abstract Objective To evaluate the effectiveness of remote proactive management of toxicities during chemotherapy for early stage breast cancer. Design Pragmatic, cluster randomised trial. Setting […]

Case Study: The Distilling of a Biased Algorithmic Decision System through a Business Lens

Abstract Technological advances embedded within algorithmic decision systems are being deployed every day. Some of these investments are unquestionably worthwhile, while some others prioritize commercialization […]

The Effect of Depression on Paid Sick Leave due to Metabolic and Cardiovascular Disease in low-wage workers. (Depression and Sick Leave)

Abstract Background Colombia’s health system allows workers to claim paid sick leave due to health conditions, some of this conditions are related to metabolic and […]

Changing patterns of multimorbidity among patients with ambiguous diagnoses: The case of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Abstract Introduction Increased attention has been given to multimorbidity. This phenomenon often has been explored through associations between diseases based on the frequency of combinations […]

Association of frailty with perioperative and survival outcomes in patients with gynecologic cancers: A population-based study

Abstract Objectives The relationship between frailty and both short- and long-term outcomes remains underexplored in gynecologic oncology (GO). We sought to evaluate the association of […]

Impact of frailty on outcomes after multiple rib fractures and flail chest undergoing surgical stabilization of rib fractures: a propensity score-matched analysis of the Nationwide Inpatient Sample 2005–2020

Abstract Background This study examined the impact of frailty on in-hospital outcomes in patients undergoing surgical stabilization of multiple rib fractures and flail chest (SSRF). […]

COVID-19 Vaccination, Hospitalization Rates, and Mortality Differ Between People with Diagnosed Immune Mediated Inflammatory Disease and the General Population: A Population-Based Study

Abstract Background: Vaccination reduces Coronavirus disease-19 (COVID-19) infection severity. We evaluated COVID-19 vaccine uptake and effectiveness in people with immune mediated inflammatory diseases (pIMIDs) versus […]

Machine learning identifies clusters of multimorbidity among decedents with inflammatory bowel disease

Abstract Background: Multimorbidity is the co-occurrence of two or more chronic conditions in one person. Providing quality, patient-centered care requires understanding multimorbidity. Our objective was […]

Trends in use of poly (ADP-ribose) polymerase inhibitor (PARPi) in ovarian cancer

Abstract Background To assess population-level trends in use of poly (ADP-ribose) polymerase inhibitors (PARPis) among ovarian cancer patients in the years following initial FDA approvals. […]

Factors Associated With the Receipt of Female Breast Cancer Treatment Among People Living With Intellectual or Developmental Disabilities: A Population-Based Retrospective Cohort Study

ABSTRACT Background People with intellectual or developmental disabilities (IDD) experience breast cancer care inequities relative to those without IDD. Identifying factors associated with receipt of […]

Twenty-Five Year Outcomes of Patients Undergoing Valve Surgery for Infective Endocarditis

ABSTRACT Objectives Infective endocarditis is associated with significant morbidity and mortality. Long-term outcome data after surgery are limited. We sought to analyze 25-year outcomes following […]

Physician Work Patterns in Pregnancy, Parental Leave, and Return to the Workforce

Abstract Importance Pregnancy and parental leave remain poorly supported in medical culture, yet little is known about how physicians adjust their workloads around childbirth. Objective […]

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Risk Stratification with only EHR Data – White Paper

Risk stratification models have traditionally used medical and pharmacy claims data combined with other sources, such as electronic health records (EHRs).  But provider organizations often […]

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Reducing Emergency Department Use

People usually go to the Emergency Department (ED) when they are experiencing a medical emergency. But some people choose the ED for non-urgent care, which […]

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Case Mix Measurement

This webinar provides an introduction to the principle of case mix and the constructs within the ACG System that make this possible. This session is a […]

Applications of the ACG System in the UK

This white paper provides an overview of the ACG System and how it is being used to support a range of clinical and commissioning activities […]

Physician referral rates: style without much substance?

Med Care 38:836-846. Department of Family Medicine, University of Rochester, New York, NY, USA BACKGROUND: Primary care physicians (PCPs) exhibit widely varying referral rates, resulting […]

Constructing ”behavioral” comparison groups: a difference-in-difference analysis of the effect of copayment based on the patient’s price elasticity

Eval Health Prof 37:434-456. National Kaohsiung First University of Science and Technology, Kaohsiung, Taiwan It is well known that the differences-in-differences (DD) estimator is based […]

Revisiting the economic efficiencies of observation units

Manag Care 24:46-52. University of Texas, Houston, TX, USA; Michael E. DeBakey Veterans Affairs Medical Center HSR&D, Houston, TX, USA; Baylor College of Medicine, Houston, […]

Profiling resource use: do different outcomes affect assessments of provider efficiency?

Am J Manag Care 8:1105-1115. Center for Health Quality, Outcomes and Economic Research, Bedford Veterans Affairs Medical Center, Bedford, MA, USA OBJECTIVES: To examine whether […]

The case for case-mix adjustment in practice profiling. When good apples look bad

JAMA 272:871-874. Harvard Community Health Plan, Brookline, MA, USA OBJECTIVE: To assess the influence of patient characteristics on practice profiling. Using the example of specialty […]

The patient-centered medical home and associations with health care quality and utilization: a 5-year cohort study

Ann Intern Med 164:395-405. Weill Cornell Medical College, New York, NY, USA BACKGROUND: Effects of the patient-centered medical home (PCMH) are unclear. Previous studies had […]

Association between electronic health records and health care utilization

Appl Clin Inform 6:42-55. Weill Cornell Medical College, New York, NY, USA BACKGROUND: The federal government is investing approximately $20 billion in electronic health records […]

Indication for pharmacological treatment is often lacking: a cross-sectional study on the quality of drug therapy among the elderly

BMC Geriatr 15:117. Lund University, Malmö, Sweden; Stanford University School of Medicine, Stanford, CA, USA; University of Southern Denmark, Odense C, Denmark BACKGROUND: Although the […]

Infliximab in ulcerative colitis: the impact of preoperative treatment on rates of colectomy and prescribing practices in the province of British Columbia, Canada

Dis Colon Rectum 57:83-90. University of British Columbia, Vancouver, BC, Canada BACKGROUND: Approximately 20% of patients with ulcerative colitis will require surgical treatment. Recent data […]

Effect of practice variation on resource utilization in infants hospitalized for viral lower respiratory illness.

Pediatrics 108:851-855. University of Virginia Children’s Medical Center, Charlottesville, Virginia, USA OBJECTIVE: Hospital care for children with viral lower respiratory illness (VLRI) is highly variable, […]

Benefits and pitfalls in applying the experience of prepaid group practices to the U.S. physician supply

Health Aff W4:73-75. Center for Health Workforce Studies, School of Public Health, University at Albany, State University of New York, Rensselaer, NY, USA The paper […]

Does a diagnosis of schizophrenia reduce rates of mammography screening? A Manitoba population-based study

Schizophr Res 113:95-100. Department of Psychiatry, University of Manitoba, CancerCare Manitoba, Winnipeg, MB, Canada It is estimated that mammography screening can reduce mortality from breast […]

Using multiple data features improved the validity of osteoporosis case ascertainment from administrative databases.

J Clin Epidemiol 61:1250-1260. Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, MB, Canada OBJECTIVES: The aim was to construct and validate algorithms for […]

Risk adjustment in health insurance exchanges for individuals with mental illness

Am J Psychiatry 169:704-709. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA OBJECTIVE: In 2014, an estimated […]

Prevalence of health problems and primary care physicians’ specialty referral decisions

J Fam Pract 50:427-432. Health Services Research and Development Center, Department of Health Policy and Management, Johns Hopkins School of Hygiene and Public Health, Baltimore, […]

Early dropout from psychotherapy for depression with group- and network-model therapists

Adm Policy Ment Health 39:440-447. Group Health Research Institute, Seattle, WA, USA Administrative data were used to examine early dropout among 16,451 health plan members […]

Using the Johns Hopkins Aggregated Diagnosis Groups (ADGs) to predict mortality in a population-based cohort of adults with schizophrenia in Ontario, Canada

Psychiatry Res 196:32-37. Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, ON, Canad Administrative health care databases are increasingly used for health services and […]

Multimorbidity patterns in primary care: interactions among chronic diseases using factor analysis

PLoS One 7:e32190. IIS Aragón, Aragón Health Sciences Institute, Miguel Servet University Hospital, University of Zaragoza, Zaragoza, Spain OBJECTIVES: The primary objective of this study […]

The effect of capitation on switching primary care physicians

Health Serv Res 38:191-209. University of Rochester School of Medicine and Dentistry, Department of Community and Preventive Medicine, Rochester, NY, USA OBJECTIVE: To examine the […]

How well do Ambulatory Care Groups predict expenditures on mental health and substance abuse patients?

Adm Policy Ment Health 24:339-357. Department of Health Care Policy, Harvard Medical School, Boston, MA, USA This paper evaluates the ability of Ambulatory Care Groups […]

Stratification of the population in the Basque Country: results in the first year of implementation

Aten Primaria 45:54-60. Published in Spanish. Instituto Vasco de Innovación Sanitaria, Sondika, Bizkaia, Spain Predictive models allow populations to be stratified according to their health […]

Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network

BMC Health Serv Res 12:153. Department of Health Care Management and Policy, University of Surrey, Guildford, UK BACKGROUND: Internationally health services are facing increasing demands […]