BACKGROUND Digital therapeutics are patient-facing digital health interventions that can significantly alter the health care landscape. Despite digital therapeutics being used to successfully treat a range of conditions, their uptake in health systems remains limited. Understanding the full spectrum of uptake factors is essential to identify ways in which policy makers and providers can facilitate the adoption of effective digital therapeutics within a health system, as well as the steps developers can take to assist in the deployment of products. OBJECTIVE In this review, we aimed to map the most frequently discussed factors that determine the integration of digital therapeutics into health systems and practical use of digital therapeutics by patients and professionals. METHODS A scoping review was conducted in MEDLINE, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Relevant data were extracted and synthesized using a thematic analysis. RESULTS We identified 35,541 academic and 221 gray literature reports, with 244 (0.69%) included in the review, covering 35 countries. Overall, 85 factors that can impact the uptake of digital therapeutics were extracted and pooled into 5 categories: policy and system, patient characteristics, properties of digital therapeutics, characteristics of health professionals, and outcomes. The need for a regulatory framework for digital therapeutics was the most stated factor at the policy level. Demographic characteristics formed the most iterated patient-related factor, whereas digital literacy was considered the most important factor for health professionals. Among the properties of digital therapeutics, their interoperability across the broader health system was most emphasized. Finally, the ability to expand access to health care was the most frequently stated outcome measure. CONCLUSIONS The map of factors developed in this review offers a multistakeholder approach to recognizing the uptake factors of digital therapeutics in the health care pathway and provides an analytical tool for policy makers to assess their health system’s readiness for digital therapeutics.
Greece has fallen far behind many comparable European countries in the field of organ donation and transplantation and has made little progress over the past decade. Despite efforts to improve its organ donation and transplantation program, systemic problems persist. In 2019, the Onassis Foundation commissioned a report to be prepared by the London School of Economics and Political Science that focused on the state of the Greek organ donation and transplantation program and proposed recommendations for its improvement. In this paper, we present our analysis of the Greek organ donation and transplantation program together with an overview of our specific recommendations. The analysis of the Greek program was undertaken in an iterative manner using a conceptual framework of best practices developed specifically for this project. Our findings were further developed via an iterative process with information provided by key Greek stakeholders and comparisons with case studies that featured successful donation and transplantation programs in Croatia, Italy, Portugal, Spain, and the United Kingdom. Because of their overall complexity, we used a systems-level approach to generate comprehensive and far-reaching recommendations to address the difficulties currently experienced by the Greek organ donation and transplantation program.
Virtual primary care (VPC) services, in which patients consult with a doctor or nurse via email, text, phone, or video are presumed to offer a number of advantages over traditional, brick-and-mortar general practitioner (GP) services, particularly in terms of accessibility and cost. However, evidence of their effect on clinical outcomes and quality of care is scant. Furthermore, if integrated poorly into existing care systems and payment regimes, VPC services will not create sustainable change, but will instead have the potential to contribute to the fragmentation of the health system.1Panch T Mattie H Celi LA The "inconvenient truth" about AI in healthcare.Digital Medicine. 2019; 2: 77Crossref Scopus (126) Google Scholar A brief exploration of the economics of VPC services highlights the risks at hand. Although the focus of this Comment is on England, the questions raised are relevant wherever VPC services are in the process of being introduced. At the root of the issue is that VPC providers tend to serve specific populations. In England, GPs cross-subsidise care for complex patients with funding surpluses from those with lesser needs, and thus rely on diverse patient lists. However, data highlight that 53% of Babylon GP at Hand's users are male and 89% are between the ages of 18 and 39 years, and just 1% are older than 65 years.2Bostock N GP online, in charts: how GP at hand pulled in 32,000 new patients in 12 months.https://www.gponline.com/charts-gp-hand-pulled-32000-new-patients-12-months/article/1518915Date accessed: July 22, 2019Google Scholar In Sweden, children and metropolitan residents are the main users, whereas people older than 65 years, people with chronic diseases, and rural residents account for only a small proportion of consultations.3Blix M, Jeansson J. Telemedicine and the welfare state: the Swedish experience. IFN Working Paper, 2018.Google Scholar Although individual patient choice and technology literacy plays a major role, VPC organisations might also engage in risk selection, intentionally selecting or seeking to attract less complex patients. Furthermore, VPC services might be unsuitable for people requiring regular access to highly personalised or multidisciplinary services. When less complex patient groups deregister from their existing practices to register with practices that offer virtual services, as in England, the result is that brick-and-mortar GPs are left with increasingly complex patient lists. This segmentation of the patient population by risk is analogous to adverse selection in private health insurance markets, and might threaten the financial sustainability of traditional GP practices in a capitated payment scheme. For example, under the General Medical Services contract, most GPs in England receive a base payment of £87·92 per patient, with additions taking account of factors such as sex, age, rurality, deprivation, and turnover of patients, as well as measures of morbidity and mortality. GPs can earn additional income for achieving performance targets and for providing extra services, such as minor surgical procedures. Including these additions, the average income per patient, per year for GPs in England is £152, whereas Babylon receives, on average, about £90 per patient registered with GP at Hand.4Babylon GP at HandHow we work.https://www.gpathand.nhs.uk/how-we-workDate accessed: July 8, 2019Google Scholar This might partially account for the disparity in the complexity of patient lists, but given that a small proportion of patients with particularly complex needs accounts for the majority of health-care costs,5French E Kelly E Medical spending around the developed world.Fiscal Studies. 2016; 37: 327-344Crossref Scopus (17) Google Scholar it likely still represents an overpayment of VPC relative to traditional GP services. VPCs might also introduce cost inflation and cost shifting, which is partly due to their high registration and turnover rates.6PulseDigital practice patients three times more likely to return to prior GP surgery.http://www.pulsetoday.co.uk/news/all-news/digital-practice-patients-three-times-more-likely-to-return-to-prior-gp-surgery/20038965.articleDate accessed: July 22, 2019Google Scholar, 7Ipsos Mori and York Health Economics ConsortiumEvaluation of Babylon GP at hand. Final evaluation report.https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-Babylon-GP-at-Hand-Final-Report.pdfDate: May 2019Date accessed: July 9, 2019Google Scholar Turnover is taken into account in the Global Sum Allocation Formula, on which GP payments in England are calculated, which will increase the per-patient payment and inflate costs for the health service. There is also a risk that patients who are unable to access the services they need from their VPC provider, or are simply dissatisfied with the service, might make heavier use of the National Health Service (NHS) 111 non-emergency phone line or walk-in services. For example, despite Babylon's running in-person satellite clinics for GP at Hand Users, in February 2019, its patients were reportedly waiting weeks for travel vaccinations, with many being redirected to alternative providers. This would have the effect of shifting costs to elsewhere in the system. Although a recent evaluation of Babylon GP at Hand's deployment by Hammersmith Clinical Commissioning Group did not find evidence of this effect, the patient population was not representative of primary care services in general, and the long-term effect is uncertain.7Ipsos Mori and York Health Economics ConsortiumEvaluation of Babylon GP at hand. Final evaluation report.https://www.hammersmithfulhamccg.nhs.uk/media/156123/Evaluation-of-Babylon-GP-at-Hand-Final-Report.pdfDate: May 2019Date accessed: July 9, 2019Google Scholar Overuse is also a potential issue: one study8Ashwood JS Mehrotra A Cowling D Uscher-Pines L 2017. Direct-to-consumer telehealth may increase access to care but does not decrease spending.Health Affairs. 2019; 36: 485-491Crossref Scopus (137) Google Scholar suggested that as many as 88% of remote consultations represented new activity, as opposed to activity replacing a traditional consultation. Finally, whether VPC services such as Babylon, which prioritise access, can adequately ensure continuity of care is unclear. This is a significant concern, given the growing evidence on the benefits of a long-term therapeutic relationship between a patient and a GP in terms of patient experience, outcomes, and cost.9Barker I Steventon A Deeny S R Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.BMJ. 2017; 356: j84Crossref PubMed Scopus (217) Google Scholar On this basis, the economic case for simply adding VPCs onto existing systems without adaptation of payment models is weak. Over time, it will likely result in higher costs and less innovation in care delivery. One solution could be to increase the payment associated with particularly high-cost patients to ensure that either VPCs take on these patients, or in-person GPs are fairly compensated for their workload. Capitation formulae could also be adjusted to prevent cost inflation as a result of the high turnover rates associated with VPCs. However, these measures would not discourage the de facto creation of parallel systems for the young and the healthy, and the old and the sick. Meanwhile, a fee-for-service approach would likely give rise to a risk of VPC supplier-induced demand, particularly given the ease with which patients can access virtual services. A more sensible approach would be to create a unified system of physical and virtual primary care services. This would enable patients to access VPC services without foregoing access to their GPs, and the allocation of funds would reflect providers' actual contributions to their patients' health. The direction of travel indicated by NHS England's Long Term Plan is for greater integration of digital and physical services. It aims to provide all patients with access to digital services by April, 2021, by helping existing providers adopt digital platforms, and introducing a national framework for digital suppliers to offer access to their services on standard NHS terms.10BMA and NHS England: investment and evolution: a five-year framework for GP contract reform to implement The NHS Long Term Plan.https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/committees/gpc/gpc%20england/investment-and-evolution-five-year-framework.pdf?la=enDate: 2019Date accessed: June 3, 2019Google Scholar There is also a welcome commitment to annually update contractual terms with digital providers, to reflect developments in technology and service delivery. There are numerous potential benefits to patients of being able to access online services while retaining access to in-person primary care services, providing those services are well integrated. Conversely, a brief examination of the economics of VPC services highlights the pitfalls of allowing services to develop in parallel to traditional ones. The implications are equally important in the UK as in other health systems that are in the process of adopting digital primary care systems, and could be even more significant in systems where primary care is funded on a fee-for-service basis, or where patients have a greater tendency to shop around. Even in an integrated system of virtual and physical primary care services, the technicalities of who gets what will need careful thought, and the optimal solution should incorporate measures to prevent risk segmentation, cost inflation, and cost shifting. This should be achievable, but it will require policy makers to be bold in their approach and sophisticated in their planning. We declare no competing interests. GAW contributed literature search, data collection, and interpretation, and wrote the majority of the Comment. HSS contributed to the development of the core arguments, identification of key sources, and provided extensive comments on and direct amendments to drafts of the Comment. AS contributed literature search, data collection and interpretation, and produced the initial draft of the Comment, and provided comments and amendments on later drafts. EM contributed to the development of the core arguments, identification of key sources, and provided extensive comments on and direct amendments to drafts of the Comment. Unicorns and cowboys in digital health: the importance of public perception2018 brought unprecedented success for the health-care and biotech industry, with 16 companies reaching the US$1 billion valuation mark needed for them to earn the title of unicorn—an indication of rarity and worth. However, despite the growing number of health-care unicorns in 2019, including Babylon Health, Doctolib, and CMR Surgical, there is still little evidence that valuation is the best way to define interventions and services that are making a difference to patients' health and wellbeing. Full-Text PDF Open Access
To map how social, commercial, political and digital determinants of health have changed or emerged during the recent digital transformation of society and to identify priority areas for policy action. We systematically searched MEDLINE, Embase and Web of Science on 24 September 2023, to identify eligible reviews published in 2018 and later. To ensure we included the most recent literature, we supplemented our review with non-systematic searches in PubMed® and Google Scholar, along with records identified by subject matter experts. Using thematic analysis, we clustered the extracted data into five societal domains affected by digitalization. The clustering also informed a novel framework, which the authors and contributors reviewed for comprehensiveness and accuracy. Using a two-round consensus process, we rated the identified determinants into high, moderate and low urgency for policy actions. We identified 13 804 records, of which 204 met the inclusion criteria. A total of 127 health determinants were found to have emerged or changed during the digital transformation of society (37 digital, 33 social, 33 commercial and economic and 24 political determinants). Of these, 30 determinants (23.6%) were considered particularly urgent for policy action. This review offers a comprehensive overview of health determinants across digital, social, commercial and economic, and political domains, highlighting how policy decisions, individual behaviours and broader factors influence health by digitalization. The findings deepen our understanding of how health outcomes manifest within a digital ecosystem and inform strategies for addressing the complex and evolving networks of health determinants.
Valuable information can be obtained from a systematic evaluation of a successful national transplant program. This paper provides an overview of Italy’s solid organ transplantation program which is coordinated by the National Transplant Network (Rete Nazionale Trapianti) and The National Transplant Center (Centro Nazionale Trapianti). The analysis is based on a system-level conceptual framework and identifies components of the Italian system that have contributed to improving rates of organ donation and transplantation. A narrative literature review was conducted and the findings were validated iteratively with input from subject matter experts. The results were organized into eight critical steps, including 1) generating legal definitions of living and deceased donation, 2) taking steps to ensure that altruistic donation and transplantation become part of the national culture and a point of pride, 3) seeking out existing examples of successful programs, 4) creating a situation in which it is easy to become a donor, 5) learning from mistakes, 6) working to diminish risk factors that lead to the need for organ donation, 7) increasing the rate of donations and transplantations via innovative strategies and policies, and 8) planning for a system that supports growth.
Over the past two decades, Portugal has become one of the world leaders in organ donation and transplantation despite significant financial constraints. This study highlights how Portugal achieved success in organ donation and transplantation and discusses how this information might be used by other countries that are seeking to reform their national programs. To accomplish this goal, we performed a narrative review of relevant academic and grey literature and revised our results after consultation with two national experts. Our findings were then synthesized according to a conceptual framework for organ donation and transplantation programs. Our results revealed several key strategies used by the Portuguese organ donation and transplantation program, including collaboration with Spain and other European nations, a focus on tertiary prevention, and sustained financial commitment. This report also explores how cooperative efforts were facilitated by geographical, governmental, and cultural proximity to Spain, a world leader in organ donation and transplantation. In conclusion, our review of the Portuguese experience provides insight into the development of organ donation and transplantation systems. However, other countries seeking to reform their national transplant systems will need to adapt these policies and practices to align with their unique cultures and contexts.
Abstract Background and Aims Chronic kidney disease (CKD) is a major source of morbidity and mortality, with an increasing incidence and prevalence worldwide. Patients with CKD experience diminished quality of life associated with increased risk of cardiovascular (CV) events, acute kidney injury (AKI), and reduced renal function. Late-stage CKD (stage 5) is also associated with significant economic burden related to renal replacement therapy (RRT). Public health and policy planning should consider the broader burden of CKD, including its societal and environmental burden, in addition to its clinical impacts and direct costs. Hence, IMPACT CKD aims to quantify the clinical, economic, humanistic, societal, and environmental burden of CKD in the United Kingdom (UK). Method A patient-level simulation model was developed to simulate the UK population using parameter data from published literature, national statistics, and health surveys. Individuals were assigned key characteristics associated with CKD, such as estimated glomerular filtration rate (eGFR), albuminuria, co-morbidities (e.g., diabetes, hypertension, heart failure), and prior CV events (e.g., myocardial infarction and stroke). Individuals were categorized as not having CKD (i.e., non-CKD) or CKD stage 1, 2, 3a, 3b, 4 or 5, based on their eGFR and albuminuria levels. Among those with CKD, patients were either classified as diagnosed or undiagnosed. Progression through the CKD stages was predicted by the simulated patient's annual eGFR rate of decline. Risk of CV and AKI events, as well as co-morbidity development were also considered in the model. Clinical progression and outcomes for the CKD population were simulated over 10 years. CKD prevalence was projected by stage and diagnosis status, as well as associated CKD and RRT costs, productivity losses from patients and caregivers, and environmental impacts as determined by CO2 emissions. Extensive validation and calibration was conducted. Results From 2022 to 2032, the prevalence of CKD is expected to increase by 4% from 8.27 million to 8.61 million people in the UK. Growth in the CKD population is driven by eGFR decline and increases in albuminuria, related to kidney function decline and AKI as the model population ages. In 2032, the prevalence of CKD by stage is projected to be 30.36%, 21.07%, 29.78%, 11.86%, 4.15%, and 2.78% in stage 1, 2, 3a, 3b, 4, and 5 patients, respectively. The diagnosed CKD population is projected to be 32.43% of the total CKD population and is primarily composed of CKD stage 3a/b, 4, and 5 patients in 2032. Patients with CKD receiving RRT are projected to increase by 44% from 73,365 in 2022 to 105,860 in 2032. The increase in late-stage CKD population is associated with an increase in RRT costs from £1.09 billion in 2022 to £1.85 billion in 2032. Over the 10-year time horizon, CKD is projected to result in 81.60 million missed workdays in diagnosed patients with CKD, and 11.89 million missed workdays by caregivers of patients with CKD. Environmental impacts equivalent to 1.35 million tonnes of CO2 emissions for patients receiving in-centre hemodialysis are predicted; however, the total environmental impact would likely be larger if the total CKD care pathway was included. Conclusion The IMPACT CKD model forecasts the prevalence and burden of CKD to remain high in the UK over the next ten years. In addition to the significant clinical burden and direct costs, CKD was also associated with extensive productivity loss and detrimental environmental impact. The model provides a validated framework for testing the sensitivity of the projections to data uncertainty, thereby identifying areas for further research.
Background Digital therapeutics are patient-facing digital health interventions that can significantly alter the health care landscape. Despite digital therapeutics being used to successfully treat a range of conditions, their uptake in health systems remains limited. Understanding the full spectrum of uptake factors is essential to identify ways in which policy makers and providers can facilitate the adoption of effective digital therapeutics within a health system, as well as the steps developers can take to assist in the deployment of products. Objective In this review, we aimed to map the most frequently discussed factors that determine the integration of digital therapeutics into health systems and practical use of digital therapeutics by patients and professionals. Methods A scoping review was conducted in MEDLINE, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. Relevant data were extracted and synthesized using a thematic analysis. Results We identified 35,541 academic and 221 gray literature reports, with 244 (0.69%) included in the review, covering 35 countries. Overall, 85 factors that can impact the uptake of digital therapeutics were extracted and pooled into 5 categories: policy and system, patient characteristics, properties of digital therapeutics, characteristics of health professionals, and outcomes. The need for a regulatory framework for digital therapeutics was the most stated factor at the policy level. Demographic characteristics formed the most iterated patient-related factor, whereas digital literacy was considered the most important factor for health professionals. Among the properties of digital therapeutics, their interoperability across the broader health system was most emphasized. Finally, the ability to expand access to health care was the most frequently stated outcome measure. Conclusions The map of factors developed in this review offers a multistakeholder approach to recognizing the uptake factors of digital therapeutics in the health care pathway and provides an analytical tool for policy makers to assess their health system’s readiness for digital therapeutics.
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