Conjoint Professor Christian Gericke

Introduction: The aim of this study was to assess the outcomes of early vascular release in robot-assisted laparoscopic partial nephrectomy (RAPN) to reduce warm ischaemia time (WIT) and minimise renal dysfunction. RAPN is increasingly utilised in the management of small renal masses. To this end it is imperative that WIT is kept to a minimum to maintain renal function. Methods: RAPN was performed via a four-arm robotic transperitoneal approach. The renal artery and vein were individually clamped with robotic vascular bulldog clamps to allow cold scissor excision of the tumour. The cut surface was then sutured with one or two running 3-0 V-Loc TM sutures, following which the vascular clamps were released. Specific bleeding vessels were then selectively oversewn and the collecting system repaired. Renorrhaphy was then completed using a running horizontal mattress 0-0 V-Loc TM suture. Results: A total of 16 patients underwent RAPN with a median WIT of 15 minutes (range: 8-25), operative time 230 minutes (range: 180-280) and blood loss of 100 mL (range: 50-1000). There were no transfusions, secondary haemorrhages or urine leaks. There was one focal positive margin in a central 5.5 cm pT3a renal cell carcinomas (RCC). Long-term estimated glomerular filtration rate (eGFR) was not significantly different to pre-operative values. Conclusion: In this patient series, early vascular release effectively minimised WIT and maintained renal function without compromising perioperative safety.

Background: The prevalence of type 2 diabetes is rising with the majority of patients practicing inadequate disease self-management. Depression, anxiety, and diabetes-specific distress present motivational challenges to adequate self-care. Health systems globally struggle to deliver routine services that are accessible to the entire population, in particular in rural areas. Web-based diabetes self-management interventions can provide frequent, accessible support regardless of time and location Objective: This paper describes the protocol of an Australian national randomized controlled trial (RCT) of the OnTrack Diabetes program, an automated, interactive, self-guided Web program aimed to improve glycemic control, diabetes self-care, and dysphoria symptoms in type 2 diabetes patients. Methods: A small pilot trial is conducted that primarily tests program functionality, efficacy, and user acceptability and satisfaction. This is followed by the main RCT, which compares 3 treatments: (1) delayed program access: Usual diabetes care for 3 months postbaseline followed by access to the full OnTrack Diabetes program; (2) immediate program: Full access to the self-guided program from baseline onward; and (3) immediate program plus therapist support via Functional Imagery Training (FIT). Measures are administered at baseline and at 3, 6, and 12 months postbaseline. Primary outcomes are diabetes self-care behaviors (physical activity participation, diet, medication adherence, and blood glucose monitoring), glycated hemoglobin A1c (HbA1c) level, and diabetes-specific distress. Secondary outcomes are depression, anxiety, self-efficacy and adherence, and quality of life. Exposure data in terms of program uptake, use, time on each page, and program completion, as well as implementation feasibility will be conducted. Results: This trial is currently underway with funding support from the Wesley Research Institute in Brisbane, Australia. Conclusions: This is the first known trial of an automated, self-guided, Web-based support program that uses a holistic approach in targeting both type 2 diabetes self-management and dysphoria. Findings will inform the feasibility of implementing such a program on an ongoing basis, including in rural and regional locations.

Introduction: Chronic disease has become a major problem affecting the health of the Chinese population. In response to this situation, the New Rural Cooperative Medical Scheme (NRCMS) has begun to provide health cover for outpatients with chronic disease expenses, made possible by the increased risk pool of previous years. We compare the differences between Benefit Packages for Chronic Diseases Outpatients (BPCDO) in order to produce a reference for policy makers. Methods: Information on the various BPCDO was located by searching the official NRCMS website in Chinese, using certain criteria to select the ideal BPCDO. Population coverage, service coverage and cost of coverage were chosen to form the analytical framework for this paper. The diseases were classified according to the World Health Organisation's (WHO) International Classification of Diseases (ICD-10). Results: To avoid "moral hazard"?, complex processes have been created. This has resulted in chronic disease patients finding it very difficult to become beneficiaries. Forty-one types of chronic diseases were listed in 32 different BPCDO. We found that different counties have different co-payment rates, deductible lines, ceilings, coverage of drugs and tests, appointed hospitals and reimbursement frequencies. Conclusion: High mortality diseases and diseases with a heavier cost burden should be the priority on the list of reimbursement. The BPCDO scheme should be introduced urgently at the national level. It should include twenty-one types of disease and eight essential factors.

This paper focuses on financial incentives rewarding successful implementation of guidelines in the UK National Health Service (NHS). In particular, it assesses the implementation of National Institute for Health and Clinical Excellence (NICE) venous thrombo-embolism (VTE) guidance in 2010 on the risk assessment and secondary prevention of VTE in hospital in-patients and the financial incentives driving successful implementation introduced by the Commissioning for Quality and Innovation for Payment Framework (CQUIN) for 2010-2011. We systematically compared the implementation of evidence-based national guidance on VTE prevention across two specialities (general medicine and orthopaedics) in four hospital sites in the greater South West of England by auditing and evaluating VTE prevention activity for 2009 (i.e. before the 2010 NICE guideline) and late 2010 (almost a year after the guideline was published). Analysis of VTE prevention activity reported in 816 randomly selected orthopaedic and general medical in-patient medical records was complemented by a qualitative study into the practical responses to revised national guidance. This paper's contribution to knowledge is to suggest that by financially rewarding the implementation of national guidance on VTE prevention, paradoxes and contradictions have become apparent between the 'payment by volume system' of Healthcare Resource Groups and the 'payment by results' system of CQUIN.

Objectives: In January 1999, a new institutional structure for Poland's health care system was laid out, instigated by the dramatic change in both the political and economic system. Following the dissolution of state socialism, private financing of health care services was encouraged to fill an important role in meeting rising consumer demand and to encourage a more efficient use of resources through competition and private initiative. However, from the outset of the intended transformations, systemic limitations to the privatization process hindered progression, resulting in varying rates of privatization amongst the distinct health care sectors. The aim of this paper is to describe the privatization process and to analyze its pace and differences in strategic approach in all major health care sectors. Methods: Policy analysis of legislation, government directives, and published national and international scientific literature on Polish health reforms between 1999 and 2012 was conducted. Results: The analysis demonstrates a clear disparity in privatization rates in different sectors. The pharmaceutical industry is fully privatized in 2012, and the ambulatory and dental sectors both systematically increased their private market shares to around 70% of all services provided. However, despite a steady increase in the number of private hospitals in Poland since 1999, their overall role in the health care system is comparatively limited. Conclusions: Unclear legal regulations have resulted in a gray area between public and private health care, where informal payments impede the intended function of the system. If left unchanged, official health care in Poland is likely to become an increasingly residual service for the worst-off population segments that are unable to afford the legal private sector or the informal payments which guarantee a higher quality service in the public sector. © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

Aim: The implementation of the Chinese New Rural Cooperative Medical Scheme (NRCMS) spread fast since a county pilot trial in 2003. The purpose of this survey is to guide policy-makers on how to improve the current national NRCMS policy. Subject and methods: Cross-sectional survey of 1,978 farmers in 50 villages in Huxian Shaanxi Province on their attitudes towards the NRCMS administered door-to-door in 2005. Results: Most farmers hold a positive attitude towards the NRCMS. However, they do not trust the scheme management. Farmers place more trust in village doctors rather than village cadres for fund collection. More than two thirds of farmers seek care in county hospitals directly, bypassing village clinics and township hospitals. Not all hospitals and doctors fully comply with the NRCMS rules, and supplier-induced demand is still widespread. More than half of farmers worry that the NRCMS is not sustainable. Importantly, the survey showed a high enrolment rate of 92% (95% CI, 91; 93) in a voluntary insurance scheme. Conclusion: A number of remedial actions in health financing, planning and management to counteract the identified issues are proposed. © Springer-Verlag 2011.

Objective: The purpose of this qualitative case study was to assess the feasibility of scaling up exclusive breastfeeding for 6 months, antibiotics for pneumonia and integrated management of childhood illness (IMCI) child interventions in three districts of the Cusco region, Peru. Methods: During field visits, constraints, synergies and solutions to the implementation of the selected interventions were collected through observational recording and interviews of mothers, health workers, and health managers/decision makers. Results are presented for each intervention according to the health system level where they occurred: mother/community, health worker, health centre, and political/managerial levels. Findings: This case study demonstrates that it is feasible to scale up exclusive breastfeeding, antibiotics for pneumonia and IMCI interventions in poverty-stricken rural areas of a low-income country. Factors that helped and hindered the implementation were identified for each intervention. Conclusions: The need for a coherent multi-sector approach that includes regulation, implementation and monitoring of health policies and education of all involved stakeholders was apparent. This study also demonstrates that global health interventions need to undergo local adaptation. Identifying local constraints and facilitating factors in a systematic way as proposed in this study is a useful step to increase their effectiveness and reach at the local level and to identify areas for improvement in the original intervention policies. © 2012 Sarganas G et al.

In this correspondence we discuss the results of the meta-analysis by De Luca et al. (2012) in the Archives of Internal Medicine which found that late myocardial reinfarction and stent thrombosis is more common in drug-eluting stents than in bare-metal stents. We discuss the clinical implications of this paper for dual anti-platelet therapy which did not receive sufficient attention in the original publication and the accompanying editorial. © 2012 Mohasseb I et al.

The health financing schemes is the foundation for the nation's health care system, and the health insurance is a main one of some options for financing health care. This article compares two health care financing schemes in urban areas before and after the health reform, and targets at the impacts facing coverage groups, the financing methods, decision-making power or financial management (i.e. the distribution of responsibility and rights between the central government and local governments), payment arrangement and cost containment of health care financing mechanisms. Prior to reform, the equal access and universal coverage of health care services were implemented through the employment-based health insurance in a state-controlled economy with guaranteed full employment and central control in general. The decentralization reforms of fiscal system and tax sharing reforms disrupts the past economic foundation, the rebuilding health insurance system which still benefits the employed bring the limited coverage. The next trend is to make transition from health insurance covering only part of the employed population to what are in effect national health services covering the whole population in urban areas. © 2009 Higher Education Press and Springer-Verlag.

Background: After the fall of communism, Poland implemented one of the widest reaching programmes of socio-economic reforms. However, in comparison health system reforms were less radical. At the end of the 1990s a change process had been started, but the political fight for power has heavily influenced the health reforms and led to two different reform concepts being implemented over a period of a few years. Aim: The paper assesses the chances of implementation of the reform proposed in 2001 to recentralise health financing and organisation by replacing regional sickness funds by a National Health Fund. A hypothetical model is proposed which is placed at the start of the reforms and compares the model to the actual political course observed. Methods: PolicyMaker software was used for a political mapping analysis. The policy content (goals and mechanisms) was based on official political documents as well as verbal declarations made by key policymakers in the media, newspapers and magazines. Results: The analysis showed that the political situation was in favour of the government implementing a single National Health Fund. Nevertheless, this generated a strong resistance by the political opposition, experts and health care workers which could be a substantial obstacle for the realisation and effectiveness of the implemented model. The feasibility of the project could have been increased by implementing a number of strategies aimed at modifying the attitude of key stakeholders and by introducing the proposed reform as part of an overall improvement of the work environment for health professionals. Conclusions: The concept of a National Health Fund generated important opposition against the proposed changes in the health care system. With its majority in Parliament, the government was nevertheless able to establish the new system. The actual course of the reforms however contained a large number of formal errors, which led the Constitutional Court to rule the reform as unconstitutional. Substantial imperfection of the reform caused a destabilization of the whole health care system. In addition, defeat of the reform caused a decrease of electoral support for the governing coalition. © 2007 Springer-Verlag.

Background. In 2001, the Government of Thailand introduced a universal coverage scheme with the aim of ensuring equitable health care access for even the poorest citizens. For a flat user fee of 30 Baht per consultation, or for free for those falling into exemption categories, every scheme participant may access registered health services. The exemption categories include children under 12 years of age, senior citizens aged 60 years and over, the very poor, and volunteer health workers. The functioning of these exemption mechanisms and the effect of the scheme on health service utilisation among the poor is controversial. Methods. This cross-sectional study investigated the prevalence of 30-Baht Scheme registration and subsequent self-reported health service utilisation among an urban poor population in the Teparuk community within the Mitrapap slum in Khon Kaen city, northeastern Thailand. Furthermore, the effectiveness of the exemption mechanisms in reaching the very poor and the elderly was examined. Factors for users' choice of health facilities were identified. Results. Overall, the proportion of the Teparuk community enrolled with the 30-Baht Scheme was high at 86%, with over one quarter of these exempted from paying the consultation fee. User fee exemption was significantly more frequent among households with an above-poverty-line income (64.7%) compared to those below the poverty line (35.3%), ¿2 (df) = 5.251 (1); p-value = 0.018. In addition, one third of respondents over 60 years of age were found to be still paying user fees. Self-reported use of registered medical facilities in case of illness was stated to be predominantly due to the service being available through the scheme, with service quality not a chief consideration. Overall consumer satisfaction was high, especially among those not required to pay the 30 Baht user fee. Conclusion. Whilst the 30-Baht Scheme seems to cover most of the poor population of Mitrapap slum in Khon Kaen, the user fee exemption mechanism only works partially with regard to reaching the poorest and exempting senior citizens. Service utilisation and satisfaction are highest amongst those who are fee-exempt. Service quality was not an important factor influencing choice of health facility. Ways should be sought to improve the effectiveness of the current exemption mechanisms. © 2007 Coronini-Cronberg et al; licensee BioMed Central Ltd.

One of the guiding principles of health policy in many European countries is equitable access to health care services. One of the life saving procedures is percutaneous transluminal coronary angioplasty (PTCA) performed after coronary angiography. Introducing payment for these procedures would limit access for low-income patients. Fortunately, despite political debate, invasive cardiology develops well in Poland. It is important to notice that within the European Union Polish citizens would be able to receive this treatment in other member states and, according to a European Court of Justice ruling, the costs would have to be reimbursed by the National Health Fund. The wider implication is that the 10 new EU member states now have to realise that health care is no longer a matter of national sovereignty - a fact legislators and health care managers in the 15 member states of the pre-accession EU are still struggling with.

Aim: The Government of Egypt has embarked on a process of reforming health care financing in the country. Under the influence of external advisers it, has so far focused on social health insurance as the main funding mechanism. Other options, in particular tax-based financing, have hardly been considered. In this article, social health insurance and taxation-based financing are analysed on their ability to meet Egypt's stated health policy goals and their viability. Subjects and methods: Review of current health care financing arrangements in Egypt, of potential areas for improvement, and of stated health policy goals. Analysis of social health insurance and taxation-based financing on their ability to meet the stated policy goals and their viability. Results: Although both funding mechanisms have distinct advantages and disadvantages when applied to the Egyptian health system, tax-based financing seems better able to meet the official policy goals of the Government of Egypt than social health insurance on grounds of efficiency, equity and technical feasibility. Conclusions: The Government of Egypt will have to raise public health expenditure substantially to finance care at an adequate level. Expanding and refining the present tax-based financing scheme, rather than switching to an insurance-based scheme seems the technically superior strategy. Other measures to improve the coordination of financing, such as the creation of a single fundholding agency, are needed as well as tighter regulation of private providers and the pharmaceutical market. © Springer-Verlag 2005.

Egypt and Cuba are both lower-middle income countries with a history of socialist rule, which have embarked on economic liberalization since the 1990s. Cuba has achieved exemplary health status whereas health status in Egypt is lower than could be expected for its level of income. In this article, health care financing mechanisms in both countries are analysed on their effectiveness, efficiency, and equity, with the objective of identifying the determinants of success in the Cuban health system from which valuable lessons for current health reforms in Egypt may be derived.

A conceptual framework to analyze the importance of intervention design in expanding access to and utilization of health services in a systematic way in developing countries are discussed. Four dimensions of intervention designs required for the framework include characteristics of the basic intervention, characteristics of delivery, the requirements the intervention imposes on government capacity, and usage characteristics. the application of the proposed frame work to produce safe drinking water using solar disinfection is also presented. The proposed framework could also be used as a tool for health policy makers, planners, and program managers when considering the expansion of existing projects.