Livestock rearing is an important income source for small-scale farmers in Myanmar, but Foot and Mouth Disease (FMD) and Newcastle disease (ND) are major constraints to livestock production. A study was conducted to identify perceptions of farmers about FMD and ND disease risks and perceptions about vaccination practices by using the modified health belief model. The majority of livestock farmers (>70%) reported that they were aware of the risk and impact of FMD and ND and were willing to vaccinate their livestock (>60%). Focusing on three main livestock farmer groups, about 17.0% of cattle, 15.4% of village chicken, but only 2.3% of small ruminant owners, indicated that the non-availability of vaccinations in the villages was the major constraint to vaccinations (p<0.001), while in contrast twice as many small ruminant farmers compared to cattle and village chicken farmers indicated they had no knowledge about vaccinations and no funds to conduct vaccinations. Limited accessibility to vaccines and vaccinators was related to size of villages . Willingness to vaccinate small ruminants against FMD was associated with the perceived impact of the disease on sales and accessibility of information about vaccination. Accessibility to information about ND vaccination influenced the willingness of village chicken farmers to conduct vaccinations. In addition, beliefs in the effectiveness of vaccinations played a major role in the willingness to carry out vaccinations on both, cattle  and village chicken farms . Our study highlights that policies that increase the accessibility of vaccines and the dissemination of information about disease prevention and vaccination practices in villages of all sizes, have the potential to increase FMD and ND vaccination rates and thereby reduce outbreak occurrence in Myanmar. On the other hand, indirect factors, such as village size strongly influenced the availability of vaccinations. Multispecies, small-scale livestock rearing is the main form of livestock production in low and middle-income countries –6. In muFoot and mouth disease (FMD) is the globally recognized animal disease affecting cattle, swine, sheep, goats and other cloven-hoofed ruminants and causing negative economic impact in animal trading due to its clinical condition, and mortality. With seven different strains , the severity of the disease could be varied depending on strain of virus. In addition, the types of species, the exposure dose, the age and species of animal and the host immunity. Even though the morbidity can reach 100% in susceptible populations, mortality is generally low in adult animals (1–5%), while higher in young calves, lambs and piglets (20% or higher). Chronically affected animals are reported to have an overall reduction of 80% in milk yield. . FMD resVaccination is an important method for preventing and controlling FMD and ND in livestock ,38. In dVarious approaches can be used to study attitudes, perceptions and behaviours ,49. One However, the HBM framework has not been widely used to research preventive veterinary actions. We used the HBM framework to investigate the relationship between the perceptions of livestock farmers on barriers and benefits of FMD and ND vaccination and their willingness to practise vaccination against FMD in cattle and small ruminants and ND in village chickens.http://epitools.ausvet.com.au/content.php?page=SurveyToolbox) [This cross-sectional study was conducted with small-scale farmers in two administrative areas in the Central Dry Zone (CDZ) of Myanmar, the Myingyan and Meikhtila Township, which were identified as representative of typical livestock production systems in the CDZ by a research-for-development project investigating livestock production . SubjectToolbox) . AccordiThe HBM questionnaire (including 13 questions relating to each livestock species) was firstly developed in English and then translated into Myanmar (Burmese) language. The questionnaire captured data on demographics, disease prevention practices, individual farmer’s perception on FMD and ND, the effectiveness of and barriers to vaccination and various factors that could impact the likelihood of farmers to have their livestock vaccinated. To test and validate if the questions were applicable to use in the field survey, pilot testing was conducted to local experts included seven members of local authorities, three animal health workers and two research officers. After the pilot testing, some items were modified in the questionnaire. A questionnaire was developed in English and was then translated into the local language (Myanmar) which further used for data collection. Then, the survey was conducted by seven trained interviewers comprising of two veterinary medicine students from the University of Veterinary Science, Yezin, four staff from LBVD and the lead author of this paper. Total interviewing time was approximately 20 minutes for each interview.The study was approved by the University of Queensland Human Research Ethics Committee  and for the local research approval, the approval was obtained from the Livestock Breeding and Veterinary Department (LBVD).We used a modified HBM framework to summarize the perceptions of farmers on their willingness to implement vaccinations against FMD and ND. Some questions on HBM components were open-ended (i.e. perceived benefits and cues to action) and were categorized or converted into multiple dichotomized (yes/no) variables for further analysis. We assumed that the farmers  who reported ‘don’t know’ to some HBM components were likely to be unaware of the particular item and included these ‘don’t know’ answers in the ‘no’ category. The following modified HBM components were utilized in this study:Knowledge about disease: Ability of farmers to recognize clinical signs for FMD in ruminants and for ND in village chickens (yes/no). Triangulation to identify farmers’ ability to recognize FMD and ND was done by asking clinical signs, and host.Perceived severity (the impact of the disease): Perception of farmers that occurrence of FMD and ND can result in economic losses  (yes/no).Perceived benefits (the effectiveness of the vaccination): Perception of farmers that FMD and ND vaccination can prevent the occurrence of FMD and ND (yes/no).Perceived barriers (the barriers to vaccination): Perceived barriers to conduct FMD and ND vaccinations were categorised into three groups: farmers’ knowledge about the use of vaccination to control FMD and ND (yes/no), availability of vaccination in the village (yes/no) and farmer’s access to funds to pay for vaccination (yes/no).Cue to action (the availability of information about vaccination): Accessibility of information on FMD and ND vaccination and vaccination programmes was categorised into four groups: availability of information about vaccination (yes/no), provision of information about vaccination through veterinary administrative officers, local veterinarians and veterinary animal health workers (yes/no); provision of information about vaccination through other farmers (yes/no); and provision of information about vaccination through traders (yes/no).Perceived susceptibility : All of the farmers agreed that their livestock were highly susceptible to the diseases (i.e. FMD and ND). Therefore, we did not take into account this variable for further analysis.The willingness of farmers to have their animals vaccinated against FMD or ND was used as the outcome variable (yes/no).We also collected data on factors that could have impacted on HBM components, such as village size, demographic information of farmers , type of animal species reared: raising single species only  or combinations), farm income ; village size ; major income source  and previous occurrence of clinical FMD and ND on farms (yes/no).A two-step approach was used to analyse the data: 1) initially descriptive statistics were produced to compare the proportion of farmers holding different perceptions on FMD and ND vaccination between livestock ownership groups; 2) then path analysis was used to investigate the causal factors influencing the willingness of farmers to conduct FMD and ND vaccination for each livestock ownership group.2 statistics were converted into F statistics and standard errors and p-value were adjusted to the survey design [All data analysis was conducted in STATA 14.0  using a survey design approach by specifying PSU and SSU, sampling weights, sampling strata (townships), clustering (villages) and a finite population correction . Using ay design ,67. BinoPath analysis is based on multiple regression models that are used to identify the correlation between the exogenous variables representing the variables which are not causally dependent on any other variables, endogenous variables representing the outcome variables explained by the model and endogenous mediator variables representing the variables which intervene between exogenous variable and endogenous outcome variables –70. We uFirst, hypothesized pathways assuming causal relationships between exogenous variables and endogenous variables were developed. Hypothesized causal pathways focussed on nine hypotheses :H1: Information availability (cues to action) may be associated with age, gender and duration of livestock reared.H2: Information availability (cues to action) such as no information available about vaccination, information about vaccination provided through local authorities or other farmers or traders may be associated with knowledge of farmers about vaccination.H3: Availability of vaccination may be associated with village size, due to factors such as infrastructure availability and likely contact with animal health services within or outside the village.H4: Availability of funds to pay for vaccination may be associated with total household income.H5: Major income source, such as cropping, livestock sale, labour, trade and supported by relatives, may be associated with household income.H6: Household income per year in USD, barriers to vaccination and previous occurrence of clinical FMD and ND on farms may be influenced by the type of livestock ownerships (rearing single livestock species or with other species).H7: Previous occurrence of clinical FMD and ND on farms may also influence the perceived impact of the disease.H8: Perceived effectiveness of the vaccination may be associated with barriers to vaccination such as knowledge about vaccination, availability of vaccination and information availability about vaccination.H9: Willingness of farmers to have their animals vaccinated may be predicted by perceived effectiveness of the vaccination, barriers to vaccination, perceived impact of the disease and type of different livestock ownerships (rearing single livestock species or with other species)To inform the model building, we estimated tetrachoric correlation coefficients for all dichotomous variables for each livestock species separately and variables with significant correlation (p<0.05) were selected for the path analysis for each livestock species . We used survey design approaches in the path analysis to account for primary sampling units (PSUs), secondary sampling units (SSUs) and sampling weights.Path coefficients ) were produced for direct, indirect and total effects. Direct effects represent the effect of one exogenous variable on an endogenous variable. Indirect effects represent the effect of one variable on another variable and thereby making changes to a third variable. Total effects are the sum of direct and indirect effects ,71,72. ODuring the interview, the selection of households was done by simple random sampling and interview was conducted with the family member of the households who volunteer to participate. Therefore, the role of interviewees in the household, participated in this survey, were varied: person taking leading role in the household, person taking care of the animals, and person who worked with cattle for transportation and/or draught purpose. We explored what demographic factors of farmers  influenced the ability of farmers to recognize clinical signs for FMD and ND . From ouThe majority of ruminant farmers  and village chicken farmers (81.8% of 327) believed they were able to recognize clinical signs for FMD in ruminants and for ND in village chickens.Male farmers rearing cattle were 14.6 times  more likely to report they could recognize clinical signs of FMD than female farmers. No association between gender and ability to recognize FMD or ND signs was found for small ruminant and village chicken farmers. Other factors such as age, experience and type of ownership were not associated with recognizing clinical signs of FMD and ND.Amongst only farmers who reported being able to recognize FMD or ND signs, the willingness to practise vaccinations differed between the three main livestock farmer groups (p<0.001), with 88.0% of cattle farmers, 83.9% of small-ruminant farmers and 71.3% of village chicken farmers being willing to vaccinate their animals .Focusing the rest of the analysis on the three main livestock farmer groups, there were significant differences in the barriers to practise vaccination, availability of information about disease prevention and vaccination in the villages and previous occurrences of FMD and ND signs (p<0.05). About 17.0% of cattle, 15.4% of village chicken, but only 2.3% of small ruminant owners, indicated that the non-availability of vaccinations in the villages was the major constraint to vaccinations (p<0.001), while in contrast twice as many small ruminant farmers compared to cattle and village chicken farmers indicated they had no knowledge about vaccinations and no funds to conduct vaccinations .About 19.4% of cattle, 38.3% of small ruminant, but 57.7% of village chicken owners indicated that no information is provided to them about the prevention of major infectious diseases (p<0.001). Local authorities were the main provider for information on disease prevention and vaccinations , while traders seemed to be an important additional source of information about FMD vaccinations for small ruminant farmers. The proportion of farmers who reported severe impacts of disease on the sale of animals was higher for village chicken (91.5%) and small ruminant farmers (81.0%) compared to cattle farmers (75.2%) (p<0.001). Regarding the impact of disease, small ruminants were raised for more business-oriented purpose and any ulcer or abnormality causing negative impact in animal sale was reported while cattle were raised for long term. Even though the clinical signs were more obvious in cattle, due to low mortality rate, farmers did not seem to consider FMD to be a high impact disease. This is also reflected in small ruminant and village chicken farmers reporting previous occurrence of clinical FMD and ND signs on their farms compared to cattle households .Tetrachoric correlations between farmers’ perceptions about FMD and ND vaccinations, types of livestock reared, farmers’ demographics and farmers’ willingness to conduct vaccination are shown in Perceived effectiveness of the FMD vaccine was a crucial factor for cattle farmers to implement FMD vaccinations , while poor knowledge about the use of vaccinations to control FMD reduced the overall willingness to conduct vaccinations , but also reduced farmers’ beliefs in the effectiveness of the FMD vaccine . In addition, an understanding of farmers that FMD can result in severe economic losses increased their belief in the effectiveness of FMD vaccinations . As expected, increased availability of information about FMD control increased farmers’ knowledge about the purpose and use of FMD vaccinations , while unavailability of vaccination campaigns in a village reduced farmers’ knowledge about the purpose and use of FMD vaccinations . Thus, both, the cattle farmers’ knowledge about FMD control  and the availability of FMD vaccine  are key determinants to improve cattle farmers’ willingness to practise FMD control.In larger villages, total income from cattle production was higher , resulting in more funds being available  to cattle famers to conduct FMD vaccination, which in turn also positively impacted on the availability of FMD vaccines in villages . The latter might be a result of cattle farmers with larger incomes ‘requesting’ FMD vaccination campaigns to be conducted in their villages  , while the non-availability of information about FMD vaccination was the major limiting factor ).Similarly, village size had significant indirect impact, as in larger villages greater availability of vaccination was observed , but also the income of small ruminant farmers was increased . No availability of funds to conduct vaccinations also reduced the availability of information about vaccination . This could be assumed that famers with limited funds were less likely to access information about FMD vaccinations, which in turn they cannot afford FMD vaccination or any preventive actions in general . The perceived effectiveness of FMD vaccine was not a factor impacting on the willingness of small ruminant farmers to conduct FMD vaccinations.The income measured in this study was based on income within 1 year period which mean income within a short period. According to the farmers, rearing small ruminant and village chicken could help to get income within short period regardless of health problems. This explained by the statistical result: rearing small ruminants together with village chickens increased a small ruminants farmer’s income , although the overall impact of raising these two species together on the willingness to conduct FMD vaccinations is unclear  Figs .The final path model describing the willingness of small ruminant farmers to have their animals vaccinated had a reasonable fit with a SRMR of 0.049 and CD of 0.187. The modification index suggested to include a path between village size and the willingness to conduct FMD vaccinations in the final path model.Similar to cattle households, the perceived effectiveness of the vaccine (ND) was the driving force for village chicken farmers to implement vaccinations , while an understanding of the economic losses of ND outbreaks increased farmers beliefs in the effectiveness of the ND vaccine . Unavailability of information about ND vaccination reduced willingness of farmers for ND vaccination , but was also directly related to village chicken farmers’ knowledge about the purpose and use of ND vaccinations . And once again, in smaller villages the availability of ND vaccine was limited  which directly impacted on the willingness of farmers to conduct ND vaccinations  Figs . The finThe final path models revealed similarities of direct effects for the three livestock ownership groups, but also similar indirect effects impacting on the willingness of farmers to vaccinate their animals. For example, perceived impact of the disease based on the economic losses associated with diseases (i.e. FMD and ND) , but also unavailability of vaccinations  indirectly impacted on the willingness of farmers to vaccinate , the Theory of Reasoned Action (TRA), the Theory of Planned Behaviour (TPB) and the Trans-Theoretical Model (TTM), to observe the drivers triggering health behaviour, we did use HBM in our study. Even though most of the health behaviour model have basic similarity such as consideration on vulnerability of individual, barriers and benefit, health belief model have a number of advantages such as clear identification of the role of demographic variables, the impact of cue to action, and threat on motivation of disease prevention practice and changing behaviour ,55,74,75Willingness of farmers to vaccinate their livestock differed between the three major livestock species, with cattle and small ruminant farmers being more willing to vaccinate than village chicken farmers, probably due the different value of livestock species to the household income. Interestingly, keeping combinations of different livestock species, a common feature in small-scale multispecies households in Myanmar, did not impact on the willingness of farmers to vaccinate. For cattle and village chicken owners, the perceived impact of FMD and ND, in particular reduced weight gain, reduced production and mortalities ,77 was hLimited availability of information about livestock diseases and their prevention and unavailability of vaccination campaigns were identified as major barriers. However, the availability of information and the vaccine differed between the three livestock species groups, which is a reflection of the limitations of animal health and veterinary services ,89 and iIt has been highlighted previously that promoting awareness about infectious livestock diseases will increase vaccination rates ,89. HoweOur study had a number of limitations. Firstly, responses of farmers to questions using the health belief framework were dichotomised as farmers were unable to provide more detailed answers on a Likert-type scale. Secondly, the two diseases studied here might present themselves by a wide range of clinical symptoms and farmers might not have been able to correctly identify these diseases. Therefore, we focused our analysis only on farmers who were able to recognize FMD and ND symptoms. Thirdly, the sample size calculation used in this study considered the contribution of livestock production on household income and not based on health belief model. Fourth, we did use path analysis to understand and analyze the relationship between variates and co-variates which was estimated by coefficient and the type of data used in this study were dichotomous data. In path analysis, variables were assumed as linear, causal and additives; whereas residuals are not correlated with variables; and variables were measured without error which may affect in the interpretation. For further study, we would like to suggest to test mean-adjusted weighted least squares estimation by using structural equation modelling (SEM). However, using path analysis could also explain the decomposition of correlation between the variables, thereby interpretation of relations as well as the patter of the effects of one variable to another by total effect, direct effect and indirect effects via mediation .We identified that perceptions on the effectiveness of vaccination, poor knowledge about the use of vaccination and limited availability of vaccine and vaccinators limited the willingness of farmers to conduct vaccinations, while the perceived impact of the diseases increased farmers’ willingness for preventive actions. On the other hand, indirect factors, such as village size strongly influenced the availability of vaccinations. Our study highlights that policies that increase vaccine access and the dissemination of information about disease prevention and vaccination practices in village of all sizes, have the potential to increase FMD and ND vaccination rates and thereby reduce outbreak occurrence. Our results show that village size has a huge impact on vaccine availability, indicating that vaccination practice was not widely available in rural areas where the majority of backyard farming is practiced. This may promote the prolonged existence of endemic diseases within the nation and further extend the spread of these diseases. Based on the findings from the current study, we conclude that promoting public awareness along with facilitating the vaccine availability in both urban and rural area is critically important for the national disease prevention and control strategy.S1 Checklist(DOCX)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 File(PDF)Click here for additional data file.


Unprecedented and dramatic transformations are occurring in the Arctic in response to climate change, but academic, public, and political discourse has disproportionately focussed on the most visible and direct aspects of change, including sea ice melt, permafrost thaw, the fate of charismatic megafauna, and the expansion of fisheries. Such narratives disregard the importance of less visible and indirect processes and, in particular, miss the substantive contribution of the shelf seafloor in regulating nutrients and sequestering carbon. Here, we summarise the biogeochemical functioning of the Arctic shelf seafloor before considering how climate change and regional adjustments to human activities may alter its biogeochemical and ecological dynamics, including ecosystem function, carbon burial, or nutrient recycling. We highlight the importance of the Arctic benthic system in mitigating climatic and anthropogenic change and, with a focus on the Barents Sea, offer some observations and our perspectives on future management and policy. The Arctic Ocean seafloor hosts a diverse and productive benthic ecosystem that is a crucial component of an intimately coupled benthic–pelagic system Fig. . Benthic2 uptake by biomass , is difficult—partly due to an incomplete mechanistic understanding of the changing Arctic Ocean seafloor. It is currently unclear which fraction of carbon and nutrients will be metabolised and transformed at the seafloor, which interactions between microbial and macro-benthic activity dominate these transformations, and what the effects are on ecosystem structure and functioning. Seafloor recycling likely plays a significant role for the whole Arctic Ocean, with associated societal feedbacks on fisheries and other marine resources, highlighting the critical importance of understanding and quantifying biogeochemical processes at the Arctic seafloor. The carbon storage potential of marine sediments in particular has only recently been recognised and evaluated  are special because (i) they are often highly productive, with significant atmospheric COAvailable evidence suggests that conditions across the Barents Sea, and other Arctic inflow shelves, will become more akin to those of sub-Arctic seas. Warming is predicted to promote Barents Sea ‘Atlantification’ and Chukchi Sea ‘Pacification’ whereby warmer, saltier, and nutrient-richer waters routinely expand further north, often leading to higher primary productivity  that reduced sea ice in the Barents Sea may lead to increased OM export to the seafloor, we estimate the impact of this on carbon burial and degradation rates by performing a simple model sensitivity analysis Fig. . We use In a second step, to estimate the impacts of OM export changes on benthic nutrient fluxes , we expand a simple model sensitivity analysis used for TOC degradation and burial rates  and southern (Atlantic) assemblages at the operational Polar Front , commercial fisheries follow and start trawling some of the last unfished areas of the global shelf seafloor. Bottom trawling causes re-working and re-suspension of seafloor sediment  are quantified and—even then—only for some habitats (e.g. muddy glacial troughs; Faust et al.


Home visiting services for older adults have been offered for decades to maintain and promote health and independent functioning, thus enhancing quality of life. Previous systematic reviews have provided a mixed picture of the benefits of home visiting programmes in older adults, primarily because of heterogeneity in study designs, targeted populations, and intervention strategies. These reviews may also become out of date; thus, an updated synthesis of relevant studies is warranted. Our objective is to perform a systematic review of recently published primary studies on the effectiveness of multi-professional home visits on quality of life among older adults.We will perform a comprehensive search for studies investigating the effect of a multi-professional home visit approach on quality of life among older adults. We will conduct the literature search in selected electronic databases and relevant research websites from January 2010 onwards. We will include randomised controlled trials (RCTs), cluster randomised controlled trials (cluster RCTs), and observational studies that enrolled older adults without dementia over 60 years old, along with studies involving multi-professional preventive–promotive home visit approaches not related to recent hospital discharge. We will report our planned review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We will retrieve and record relevant data in a standardised data extraction form and evaluate the quality of the included articles using the Cochrane risk of bias tool and the quality assessment tool for studies with diverse designs (QATSDD). Where appropriate, outcomes will be pooled for meta-analysis using a random-effects model. The main outcomes include quality of life, incidence of falls, depression, dementia, and emergency department admissions.This review may provide evidence for the effectiveness of home visits in improving older adults’ quality of life. It will potentially benefit health care professionals, policymakers, and researchers by facilitating the design and delivery of interventions related to older generations and improve service delivery in future.CRD42021234531.PROSPERO The online version contains supplementary material available at 10.1186/s13643-021-01862-8. Population ageing is a global phenomenon. Most individuals expect to live into their sixties and beyond. The world population of adults aged 60 years and over is expected to nearly double from 12 to 22% between 2015 and 2050 . DespiteAccording to the World Health Organization (WHO), QoL refers to “an individual’s perception of life in the context of the culture and value system in which he or she lives and in relation to his or her goals, expectations, standards, and concerns” . QoL linNumerous healthcare interventions have been designed and implemented with the goal of maintaining or improving QoL among older adults, and most studies indicate the importance of active ageing. These studies have demonstrated that QoL among older adults can be enhanced through low-cost interventions, such as physical exercise –11. BesiHome visits are defined as visits to an individual’s home by professionals, which may include nurses, social workers, physicians, physiotherapists, occupational therapists, pharmacists and other specialists . There aHome visits allow health professionals to evaluate possible problems in the living environment of homebound older adults, assess their physical and mental health status, provide older adults with professional support, and refer them to specialist care if needed . By reduHome visits have been shown to positively affect patient care and provider attitudes as well as increased satisfaction among homebound older adults and providers . A previMulti-professional preventive home visit interventions involve coordination between several health care professionals towards shared goals. Effective communication among the team members is crucial when the members work within the boundaries of their expertise and subsequently discuss progress in group sessions . PreviouIn Malaysia, home visiting services for the older adult population are delivered by a multidisciplinary team and are primarily provided by the Ministry of Health . The homTo our knowledge, the most recent systematic review of primary studies examining the multi-professional preventive home visit approach for older adults included studies conducted up to December 2012 . BecauseThis study aims to systematically assess the effect of a multi-professional home visit approach on QoL among older adults.The present protocol has been registered within the PROSPERO database (registration number CRD42021234531) and is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement , 33 , cluster randomised controlled trials (cluster RCTs), and observational studies  will be included. Quasi-randomised controlled trials (quasi-RCTs), which are often associated with a high risk of bias, and cross-over studies will be excluded. Case reports, guidelines, protocols, and short communication will also be excluded.We will only include studies examining the older adults without dementia aged 60 years and above who reside in their own homes and receive treatment at primary care outpatient departments. We will exclude studies that involve older adults living in retirement homes or nursing homes.Home visits which aim to prevent or reduce risks related to ageingHome visits which utilise at least two of the following multidimensional approaches: medical, functional, psychosocial, and environmental evaluation of problems and resources, resulting in specific recommendations for solving observed problems and preventing new ones.We will include studies that aim specifically to assess the following interventions:We will measure QoL using validated scales such as the WHO QoL Questionnaires, WHOQoL-BREF  and WHOQWe will also analyse the effects of home visit interventions on the incidence of falls, depression, dementia, and emergency department admissions.We will exclude studies that involve follow-up visits for recent hospital discharge and studies targeting people with one specific illness.ClinicalTrials.gov, the metaRegister of Controlled Trials, the Turning Research into Practice (TRIP) database, Open Grey, High Wire, the National Institute for Health and Care Excellence (NICE), and the National Institutes of Health (NIH). The search will be limited to English language articles published from January 2010 onwards.A comprehensive systematic electronic search will be conducted using these databases: PubMed, Ovid MEDLINE (R), the Cochrane Library, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, In addition, cross-referencing will be performed, whereby the reference lists of articles will be scanned for relevant studies. We will hand-search Malaysian quality initiative or health systems project reports in the libraries of the Institute for Medical Research (IMR), Institute for Health Management (IHM), Institute for Health System Research (IHSR), Institute for Public Health (IPH), and Ministry of Health, Malaysia.The search strategy will be based on the key components of the research question: population, interventions, and outcomes. It will include a mix of medical subject headings (MeSH) terms and free-text terms in the title and abstract search fields of the databases. The keywords will be related to the participants , home care , and the outcomes . Examples of the search strategy are presented in Additional file 2.Two review authors will examine the titles and abstracts independently and will exclude all irrelevant studies. Two review authors will independently retrieve and screen the full text of potentially relevant articles and identify those that meet the eligibility criteria. These steps will be recorded in an Excel table along with the reasons for study exclusion. To avoid duplication, data will be identified from the main source. Any disagreements that arise will be resolved through discussions with a third author. A PRISMA flow chart showing details of studies included and excluded at each stage of the study selection process will be provided .General information: title, first author, publication year, and countryMethods: study design, study duration, sample size, and mean age of the sampleTypes of intervention: visitors’ professional group, number of visits, length of visits○ Primary outcome: QoL ○ Secondary outcomes: incidence of falls, depression, dementia, and emergency department admissionsOutcome measures:Two reviewers will independently retrieve and record data in a data extraction form. Any disagreements will be resolved through discussion with the third reviewer. The data extraction form will include the following variables:Two reviewers will evaluate the possible risk of bias for each study independently. Any disagreements will be discussed with the third reviewer. We will evaluate the RCT and cluster RCT articles for the methodological quality using the Cochrane risk of bias tool (RoB 2.0) . We willThe quality assessment tool for studies with diverse designs (QATSDD) , 42 willParticipant’s age: 60–79, ≥80Visitors’ professional groupIf the studies are sufficiently homogenous in terms of population, interventions, and outcomes, the results will be pooled, and a meta-analysis using a random-effects model will be conducted. Where possible, dichotomous data will be presented as relative risks (RRs) with 95% confidence intervals (CIs). Continuous data will be expressed as mean differences (MDs) or standardised mean differences (SMDs)  with 95% CIs . If the χ2) test and I2 statistic. A small p value (p < 0.1) for the χ2 test and an I2 of 50% or higher indicate moderate to substantial heterogeneity [We will interpret the heterogeneity and variability of the included studies in relation to population, interventions, outcomes, and methods. When meta-analysis is attempted, heterogeneity will be evaluated by forest plots to assess whether the CIs overlap. In addition, heterogeneity among the included studies will be measured using the chi-square , as well as the results, conclusions, and quality ranking of studies.We will assess publication bias using the Tandem method. If possible, the potential for reporting bias will be further explored using a funnel plot. A linear regression test will be performed to examine the degree of publication bias. Publication bias is significant if the p-value is less than 0.1.The quality of the evidence synthesised in this review will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology . This meThis review may serve as evidence to support effective interdisciplinary home visits that can improve health-related QoL among older adults. This will potentially benefit policymakers and healthcare managers in planning for an efficient resource utilisation and evidence-based policy designs catered to older adults’ health. Healthcare professionals and implementers will be able to deliver health programmes and interventions suited to the needs of the older adult population. Researchers and other institutions will gain knowledge of multiple health interventions. In addition, recognising international practices will provide information to policymakers regarding strategies to improve quality of care in future.This review has potential limitations. Our search strategy may miss sources of information available in languages other than the English language. In addition, we anticipate that the review will face challenges due to the heterogeneous nature of the study design, particularly in interventions and outcomes measures, which may limit the interpretability and comparability of results.Any amendments to this protocol in the carrying out of this systematic review will be documented and reported in both the PROSPERO register and any subsequent publications.The findings of this systematic review will be disseminated through publication in peer-reviewed journals and via relevant conferences. In addition, the results will also be shared with potential stakeholders, such as the Ministry of Women, Family and Community Development and the Family Health Development Division under the Ministry of Health Malaysia.Additional file 1:. PRISMA 2020 ChecklistAdditional file 2:. Search strategy


Health workers (HWs) appropriate malaria case management includes early detection and prompt treatment with appropriate anti-malarial drugs. Subsequently, HWs readiness and practice are considered authentic evidence to measure the health system performance regarding malaria control programme milestones and to issue malaria elimination certification. There is no comprehensive evidence based on meta-analysis, to measure the performance of HWs in case management of malaria. This study aimed to evaluate HWs performance in early malaria case detection (testing) and the appropriate treatment.The published literature in English was systematically searched from Medline, Scopus, Embase, and Malaria Journal up to 30th December 2020. The inclusion criteria were any studies that assessed HWs practice in early case detection by malaria testing and appropriate treatment. Eligibility assessment of records was performed independently in a blinded, standardized way by two reviewers. Pooled prevalence estimates were stratified by HWs cadre type. Meta-regression analysis was performed to explore the impact of the appropriateness of the method and risk of bias as potential sources of the heterogeneity in the presence of effective factors.The study pooled data of 9245 HWs obtained from 15 included studies. No study has been found in eliminating settings. The pooled estimate for appropriate malaria treatment and malaria testing were 60%; 95% CI: 53–67% and 57%; 95% CI: 49–65%, respectively. In the final multivariable meta-regression, HWs cadre and numbers, appropriateness of study methods, malaria morbidity and mortality, total admissions of malaria suspected cases, gross domestic product, availability of anti-malarial drugs, and year of the publication were explained 85 and 83% of the total variance between studies and potential sources of the heterogeneity for malaria testing and treating, respectively.HWs adherence to appropriate malaria case management guidelines were generally low while no study has been found in eliminating countries. Studies with the inappropriateness methods and risk of bias could be overestimating the actual proportion of malaria appropriate testing and treating. Strategies that focus on improving readiness and early identification of acute febrile diseases especially in the countries that progress to malaria elimination should be highly promoted. Globally, there were an estimated 229 million malaria cases in 2019 in 87 malaria endemic countries, declining from 238 million in 2000. Malaria case incidence (i.e. cases per 1000 population at risk) reduced from 80 in 2000 to 58 in 2015 and 57 in 2019 globally. Between 2000 and 2015, global malaria case incidence declined by 27%, and between 2015 and 2019 it declined by less than 2%, indicating a slowing of the rate of decline since 2015. However, malaria is a significant health problem in around 100 tropical, subtropical, and temperate countries [Appropriate case management of malaria patients includes early case detection and prompt treatment with appropriate anti-malarial drugs. It can prevent severe disease and fatal outcome . FurtherEarly malaria case detection from suspected cases compatible with suspected malaria is an initial key in the appropriate malaria case management process without considering positive or negative test results. It has been shown that early malaria detection (testing) among suspected malaria cases or febrile disease in any transmission setting is an effective strategy to prevent the fatal outcome, missing cases, and under-diagnosis in malaria control/elimination programme . The WorThere is no comprehensive evidence based on systematic reviews, to measure the performance of HWs in case management of malaria patients . The firThe published literature in English was systematically searched from databases including Medline via Ovid, Scopus, Embase, Malaria Journal, up to 30th December 2020. Grey literature also was explored from WHO and CDC reports, congress papers, and records. The study searched articles reporting on appropriate case management of confirmed or suspected malaria cases at any age presenting to HWs of any providers in all transmission settings.The search used both free text words and medical subject headings (MeSH terms). The initial search terms were “malaria” OR “fever” in the title and/or abstract. The final search used the relevant MeSH terms and text words related to malaria or febrile disease case management in conjunction with “malaria” OR “fever” AND “provider” OR “worker” OR “system” AND “management” OR “readiness” OR “practice” OR “performance” OR “identify” OR “diagnosis” OR “treat”. The reference lists of the retrieved studies were also screened with the purpose to identify other potential data sources.The inclusion criteria were any studies that assessed HWs routine practice or performance  in malaria case management or febrile patients compatible with suspected malaria.Exclusion criteria included studies conducted for active case finding and/or population screening, studies evaluated only HWs knowledge and attitude, studies performed for assessing effects of any particular intervention on malaria case management; reviews, letters, conference abstracts, editorials, commentaries, and qualitative studies were also excluded if they reported incomplete data on malaria case management.Eligibility assessment of records was performed independently in a blinded, standardized way by two reviewers . First, the title and abstract were screened, and the two reviewers screened and selected relevant full-text papers. Quantitative and qualitative data (with brief description) were extracted based on the pre-specified criteria into an excel sheet (HA).Extracted data included the year of publication, name of author, Country, the cadre of HWs, number of HWs, demographic characteristics of patients and HWs, number of febrile or suspected malaria cases, the type of malaria diagnostic tests including RDT or microscopy for suspected cases, proportion of malaria testing, availability of RDT and anti-malarial drugs, number of malaria confirmed patients, proportion of appropriate treatment for confirmed patients, malaria incidence (per 1000 at-risk), malaria mortality , national population size, and Gross domestic product (GDP) per capita.The quality and strength of the included articles measured using Crombie’s tool . CrombieDue to the variety of included studies from various malaria transmission setting and population, the risk of bias was assessed based on parameters of Newcastle–Ottawa Scale  and authThe final scoring system comprised 11 criteria of rating different risk of bias elements for each eligible article out of 12 scores. Scale weights (unbiased sampling and data collection method had highest weights) were recommended by authors for each parameter of the scoring system, as proposed in other meta-analyses. Studies were classified into three levels of risk of bias: low risk (9–12 points), moderate risk (5–8 points), and high risk (< 5 points)  from febrile cases compatible with suspected malaria; the secondary outcome was the proportion of appropriate first-line anti-malarial drug prescription. The study also aimed to explore and decomposing the potential sources of heterogeneity in the pooled prevalence estimates of malaria case detection (testing) and appropriate treatment.The not only prescribed any antimalarial drugs) in the particular artemisinin-based combination therapy (ACT). Conducting diagnostic tests (RDT or microscopy) from suspected cases by HWs was used as malaria testing proportion.Appropriate treatment was defined as malaria parasite-positive cases treated with the recommended dosage first-line anti-malarial drugs  were calculated for proportions of malaria testing, and appropriate treatment of confirmed cases. Pooled estimates were stratified by HWs cadre ”, “Non-MD”, “Non-MD and MD”) to evaluate the effect of HWs cadre on the proportion of malaria testing and malaria appropriate treatment. Multivariable meta-regression analysis was performed to explore the impact of the appropriateness of the method and risk of bias, potential variables and sources of the heterogeneity after retaining significant heterogeneity in the subgroup analysis, using a back-step procedure and deleting unassociated variables every step, to find significant retained variables in the regression model. STATA version 13  was used for meta-analysis.Overall, a total of 6308 records were retrieved, after searching for possible relevant studies. Of those, 6132 studies were removed due to duplicate and abstract screening and 176 studies were eligible and their full-text assessed for final inclusion. Finally, 15 articles were included in the systematic review, meta-analysis, and meta-regression for assessing appropriate malaria case management and the pooled estimates in the proportions of malaria testing and appropriate treatment by HWs , medical doctors (MD), clinicians and medical assistance, nurses and nurse aid, drug stores and pharmacies, attendant, and midwives. Overall, HWs categorize into three groups including “Non-MD”, “MD and Non-MD”, and “MD” based on primary studies reporting. A total of 9245 HWs and 7004 Health facilities (HFs) have participated in included studies. Out of those, three and one of the studies were not reported the number of HFs and HWs in their studies, respectively. Almost, 51% of HWs were female. Gender of provider was not reported in six studies. The mean age (35.6 years) of HWs ranged from 29 to 40 ; I2 = 94.1%, p < 0.001 ; IConcerning malaria testing prevalence and subgroup analysis by cadre type, the pooled meta-analysis result using random effects for overall prevalence was 63%  among MD & Non-MD and 55%  among Non-MD, 44%  among MD ; and appropriate treatment based on RDT or microscopy results ; were generally low among HWs. Regarding subgroup analysis of malaria testing and treating by HWs cadre, MD providers had the highest proportion of appropriate treatment (79%) while the lowest malaria testing and screening proportions from suspected cases was seen also among MD cadre (44%). The highest proportion of appropriate malaria treatment was found in Namuyinga  The results of multivariable meta-regression analysis explored the effects of variables including HW cadre, number of HWs, malaria incidence, malaria mortality, total admissions and malaria suspected cases, and year of the publication on pooled proportion estimate of conducting malaria testing form suspected cases, as the potential sources of the heterogeneity. Likewise, appropriateness of methods and sampling, HWs cadre and numbers, GDP per capita, malaria incidence and mortality, and availability of anti-malarial drugs were the potential sources of the heterogeneity in the pooled proportion estimating of appropriate treatment by HWs. Risk of bias assessment found that articles with the appropriateness of sampling and methods, using appropriate data collection methods for example assessed HWs practice by valid and reliable methods including direct view, performed blood samples of the patients, interviews with HWs, and/or having a gold standard for evaluating HWs practice estimated actual parameter estimation in the percentage of appropriate malaria treatment, due to the robust and unbiased methods and sampling strategies. On the other hand, studies with a high risk of bias and inappropriateness of methods overestimate the prevalence/proportion of appropriate malaria treatment by HWs.Treatment with first-line anti-malarial drugs and ACT  are critical to preventing the progression of malaria to severe disease and lethal outcome. The case fatality rate of untreated severe malaria has been estimated 13–21% . AlthougThere are a number of reasons why HWs may not be providing appropriate anti-malarial drugs and malaria diagnostic tests to patients with a malaria diagnosis in the included studies. Testing may be incomplete because HFs lack a licensed microscopist or laboratory technician, because HWs symptom-based identification, or high patient volumes and/or high out-of-pocket costs of the diagnostic tests . In sub-Regarding the availability of anti-malarial drugs and diagnostic tests, the study results showed that an overall proportion of 82.5 and 65%, respectively. Considering the high diagnostic accuracy of RDT (99% sensitivity vs 90% specificity) for both falciparum and non-falciparum malaria, the availability of RDT provide prompt diagnosis and treatment for malaria cases and also prevent malaria misdiagnosis . So, HWsIn the absence or low availability of RDT, the introduction of the quality assurance system for malaria microscopy, prioritization of microscopy for febrile inpatient management, and increased health facilities availability of malaria RDTs focusing on outpatient malaria screening should be the programmatic and organizational priorities targeting improved diagnostic services in the various settings .This study findings provided a comprehensive evidence for evaluating HWs readiness and practice and also weakness and strengthens in the appropriate malaria case management. HWs appropriate malaria case management is a key measure to minimize malaria mortality and morbidity in both low and high malaria transmission settings and to promote malaria control programmes. Moreover, HWs readiness and practice are considered authentic evidence to measure the health system readiness regarding malaria control programme milestones and to issue malaria elimination certification . LikewisMalaria elimination programmes are rigorous and included appropriate case management, testing all febrile cases in all ages throughout the year, treating all confirmed malaria patients with ACT, case investigation to determine whether the case was locally acquired, and reinforcing malaria knowledge and practices despite the declining risk . CurrentThis is the first systematic review, meta-analysis, and meta-regression analysis indicating the pooled prevalence estimate of malaria testing from suspected cases and malaria appropriate treatment by various HWs cadre. However, the present study had limitations. The main concern was including different studies from the different populations (countries) with various malaria transmission settings for estimating the pooled prevalence of appropriate malaria testing and treatment. To solve this problem, we measured and involved the potential effects of population size, malaria transmission setting , GDP of countries, and also the appropriateness of sampling and methods (risk of bias) using multivariable meta-regression analysis to explore the potential source of heterogeneity.This systematic review and meta-analysis findings demonstrated the pooled proportion estimate of appropriate treatment ; and malaria testing . HWs compliance to appropriate malaria case management were generally low while no study was found in countries in eliminating phase.In the final multivariable meta-regression analysis model, appropriateness of sampling and methods, HWs cadre and numbers, malaria mortality and morbidity, total admissions and malaria suspected cases, availability of antimalarial drugs, GDP per capita, and year of the study conducted explained almost 85.0% of the total variance between studies and potential sources of the heterogeneity in the proportion of malaria testing and appropriate treatment. Studies with the inappropriateness methods and risk of bias could be overestimating the actual prevalence of malaria appropriate testing and treating.Establishments of the effective supply chain for HWs, providing in-service training programs, quality-assured diagnostics, ongoing support for HWs to deliver care conferring to the guidelines, and close monitoring of the systems readiness and clinical practices will ultimately determine the attainment of the policy translation continue the importance of practice and quality of appropriate malaria case-management are required.Continued progress in the quality of care for malaria requires deeper research into the lingering obstacles and facilitators of appropriate malaria case management especially in eliminating settings where they are progressing for malaria elimination certification and by emphasizing that no studies have been conducted in these countries.Strategies that focus on improving the identification of acute febrile diseases especially with similar clinical and epidemiological features with malaria should be highly promoted. Moreover, role-playing and implementation research are recommended to recognize the underlying factors that can affects to the success of large-scale interventions in the appropriate malaria case management and progress measures for malaria elimination certification.


We used nationwide population-based data to identify optimal hospital and surgeon volume thresholds and to discover the effects of these volume thresholds on operative mortality and length of stay (LOS) for coronary artery bypass surgery (CABG).Retrospective cohort study.General acute care hospitals throughout Taiwan.A total of 12,892 CABG patients admitted between 2011 and 2015 were extracted from Taiwan National Health Insurance claims data.Operative mortality and LOS. Restricted cubic splines were applied to discover the optimal hospital and surgeon volume thresholds needed to reduce operative mortality. Generalized estimating equation regression modeling, Cox proportional-hazards modeling and instrumental variables analysis were employed to examine the effects of hospital and surgeon volume thresholds on the operative mortality and LOS.The volume thresholds for hospitals and surgeons were 55 cases and 5 cases per year, respectively. Patients who underwent CABG from hospitals that did not reach the volume threshold had higher operative mortality than those who received CABG from hospitals that did reach the volume threshold. Patients who underwent CABG with surgeons who did not reach the volume threshold had higher operative mortality and LOS than those who underwent CABG with surgeons who did reach the volume threshold.This is the first study to identify the optimal hospital and surgeon volume thresholds for reducing operative mortality and LOS. This supports policies regionalizing CABG at high-volume hospitals. Identifying volume thresholds could help patients, providers, and policymakers provide optimal care. The volume-outcome relationship has been established for various surgeries, including cardiac and noncardiac specialty surgeries. For coronary artery bypass surgery (CABG), previous studies have found that patients who received CABG from high-volume hospitals or surgeons had lower operative mortality ,2 and leMost of the volume-outcome studies rely on adjusting for observable covariates, but potential bias in volume-effect estimates may emerge because we do not consider self-selection into hospitals based on volume and unobserved covariates, such as a patient’s health risk ,9. If siIn Taiwan, the National Health Insurance Administration (NHIA) introduced the national health insurance (NHI) scheme in March 1995. The NHI scheme is a single-payer system that provides universal health coverage to Taiwan’s 23.5 million residents, and almost all of the hospitals and clinics have contracts with the NHIA. Patients can freely select a hospital where they receive CABG. A single, prospectively determined fixed bundled payment for CABG was implemented in Taiwan, and it includes all services provided by the hospital, surgeon, and other practitioners during the entire inpatient stay. A closed-staff system is carried out by hospitals in Taiwan, which allows surgeons employed by hospitals to treat patients admitted to their hospitals and treat their outpatients. Public reporting and selective referral are not available for patients in Taiwan, so they cannot use public quality data and cannot obtain recommendations from a referral physician to select better-performing providers. Moreover, a regionalization or centralization policy for CABG care has not been developed, so Taiwan’s healthcare delivery system may not influence the volume-outcome relationship for CABG.This study, using nationwide, population-based data from Taiwan, discovered optimal hospital and surgeon volume thresholds for reducing operative mortality and LOS for patients with CABG. We also examined the effects of hospital and surgeon volume thresholds on the operative mortality and LOS of CABG.We used the national research database, which is provided by the Health and Welfare Data Science Center in Taiwan. The deidentified secondary database contained the following files: NHI inpatient medical claims, outpatient medical claims, NHI beneficiaries, medical facilities, and death certificate. The protocol for this study was approved by the Institutional Review Board of the National Taiwan University Hospital (protocol # 201804039RINA). The requirement of informed consent was waived because the dataset we used in this study was deidentified secondary data.Patients who received CABG    from acuThe primary outcome was all-cause operative mortality, which was defined as death from any cause before hospital discharge or within 30 days of hospitalization ,2,12. ThThe secondary outcomes was LOS, which is an indicator of resource usage and is a proxy of efficiency . Length For each CABG, hospital volume was defined as the total number of CABG procedures carried out by that hospital in the calendar year before the year of the patient’s admission , using uAfter reviewing the related literature, we included several patient, surgeon, and hospital covariates that might have influenced the risk of adverse outcomes after CABG admission. The patient characteristics included sex, age, low-income status, in-hospital treatments, history of percutaneous coronary intervention (PCI), comorbid conditions, medical history, and traveling distance ,16–18.The Charlson-Deyo index was applied to calculate each patient’s comorbidities . The indThe surgeon characteristics included age. The hospital characteristics included size , geographic location , and urban/rural area. We divided hospital size into two equal groups based on the number of beds. The hospitals located in a rural area were classified as rural hospitals according to the definition of urbanization established by Taiwan’s National Health Research Institutes ,21. We dRestricted cubic splines (RCSs) were applied to explore the nonlinear relationship between provider volume and risk-standardized operative mortality for CABG ,15,22–31In the RCS analysis, 7 knots were selected for the hospital volume, and 4 knots were applied to the surgeon volume, according to the minimum Akaike information criterion ,25,31,33Generalized estimating equation regression and Cox proportional-hazards modeling as well as instrumental variable (IV) estimation were used to explore the effects of hospital and surgeon volume thresholds on operative mortality and LOS after adjusting for observed covariates and unobserved covariates. We applied an IV approach to address the endogeneity of independent variables due to unobserved variables, such as health risks . The modFor the IV approach, we applied two-stage residual inclusion (2SRI) estimation, which would not be biased because of the nonlinearity of the regression model . The IV The 2SRI estimations were inferred from the generalized estimating equation models. The first stage regressed the hospital volume threshold, including the IV, surgeon volume threshold, and all covariates, and obtained the residual terms. The second stage added these residual terms into generalized estimating equation logistic regression models for operative mortality and into Cox proportional-hazards model with a robust sandwich variance estimate for LOS . The CoxThere was a negative nonlinear relationship, which was demonstrated by the restricted cubic splines of hospital and surgeon volumes vs the log of the operative mortality . IncreasPearson chi-squared or t-tests revealed relationship of lower hospital and surgeon volumes to higher operative mortality and longer LOS . PatientThis study used nationwide population-based data and applied restricted cubic spline regression and ROC curve analysis to identify optimal hospital and surgeon volume thresholds for reducing operative mortality for CABG. We also used the IV approach to explore the impact of hospital and surgeon volume thresholds on operative mortality and LOS. We found that the optimal hospital and surgeon annual volume thresholds were 55 cases and 5 cases, respectively. After adjusting for observed and unobserved covariates, we found that patients who received CABG from hospitals with previous annual volumes of < 55 cases and surgeons with previous annual volumes of < 5 cases had higher operative mortality. Patients who received CABG from low-volume surgeons had lower probability of discharge, which meant that patients receiving CABG from low-volume surgeons had longer LOS.The rate of IMA use in Taiwan was low (70.1% between 2011 and 2015); one might expect use to be higher given IMA use is usually in the 90% range . High-voRecent evidence has explored the optimal hospital or surgeon volume threshold for various surgeries. For CABG, the Leapfrog Group, and the American College of Cardiology Foundation, and the American Heart Association have recommended hospital volume thresholds for CABG. As the number of CABG decreases, the hospital volume threshold for CABG declines from 450 cases per year to 125–150 cases per year . GutackeBoth hospital and surgeon volume thresholds were related to operative mortality. Our finding was similar to that of Birkmeyer et al . Based oThe surgeon volume threshold had an impact on LOS, but the hospital volume threshold did not. Our finding is similar to that of Chou and Tung  regardinThe volume-outcome relationship for CABG may imply that the implementation of regionalization for CABG can improve outcomes. Although the implementation of regionalization could bring benefits to patients, many patients may need to travel long distances to receive care from high-volume providers ,48–52. WIn the current study, we found the nonlinear correlation of hospital and surgeon volume with risk-standardized operative mortality. We applied multivariate analysis with RCS to identify the hospital or surgeon volume corresponding to the inflection points relating to the greatest change in the log of the operative mortality. The advantages of the approach included the use of all data points to estimate the complex or linear association of hospital and surgeon volume with operative mortality and elimination of the need for prespecifying a possible threshold. Moreover, a linear correlation of hospital volume and surgeon volume with the operative mortality may not maintain at very low volume or very high volume of the model; as a result, the adoption of a RCS regression was rational than adoption of a linear regression model ,54.Moreover, we found that patients who received CABG from older surgeons had lower odds of operative mortality than those from younger surgeons. Provider age has been a surrogate for experience –57. PrevOur study has limitations. First, the results are from Taiwan, where the number of CABG cases is much lower than in the United States and Europe, and there may be particular aspects of Taiwan’s healthcare system and patient population that may not be applied to other parts of the word. The number of CABG cases has decreased since PCI was introduced . In TaiwOur national population-based study showed that the hospital volume threshold was 55 cases per year and that the surgeon volume threshold was 5 cases per year. Both hospital and surgeon volume thresholds can reduce operative mortality, but only the surgeon volume threshold can improve LOS. Our study might suggest the regionalization for CABG, and our findings exhibited that the traveling distance may not influence outcomes. Moreover, determining how to ensure that surgeons reach the optimal volume threshold to increase their experience is important. For high-volume hospitals, redistributing patients within a hospital could enable some surgeons to achieve the volume threshold and prevent some surgeons from being overloaded. For small hospitals, centralizing patients to a small number of surgeons or designating a surgeon(s) to perform all CABG procedures could help surgeons achieve the volume threshold. Additionally, the optimal surgeon volume threshold can be applied in fellowship programs, which allow fellows to increase their experience with CABG procedures. Overall, it is vital to ascertain a more accurate definition of hospital and surgeon volume to help patients, providers, and policymakers deliver optimal CABG care.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Lack of interoperability is one of the greatest challenges facing healthcare informatics. Recent interoperability efforts have focused primarily on data transmission and generally ignore data capture standardization. Structured Data Capture (SDC) is an open-source technical framework that enables the capture and exchange of standardized and structured data in interoperable data entry forms (DEFs) at the point of care. Some of SDC’s primary use cases concern complex oncology data such as anatomic pathology, biomarkers, and clinical oncology data collection and reporting. Its interoperability goals are the preservation of semantic, contextual, and structural integrity of the captured data throughout the data’s lifespan. SDC documents are written in eXtensible Markup Language (XML) and are therefore computer readable, yet technology agnostic—SDC can be implemented by any EHR vendor or registry. Any SDC-capable system can render an SDC XML file into a DEF, receive and parse an SDC transmission, and regenerate the original SDC form as a DEF or synoptic report with the response data intact. SDC is therefore able to facilitate interoperable data capture and exchange for patient care, clinical trials, cancer surveillance and public health needs, clinical research, and computable care guidelines. The usability of SDC-captured oncology data is enhanced when the SDC data elements are mapped to standard terminologies. For example, an SDC map to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) enables aggregation of SDC data with other related data sets and permits advanced queries and groupings on the basis of SNOMED CT concept attributes and description logic. SDC supports terminology maps using separate map files or as terminology codes embedded in an SDC document. Interoperability is greatly enhanced by standardizing the structure of contextually related data fields, before capturing in an electronic health record (EHR) system.Interoperability, in the context of complex oncology data sets, is the ability to share and reuse data across multiple nodes without semantic, contextual, or structural loss.Key ObjectiveReview the current state of the Structured Data Capture (SDC) initiative in the oncology data ecosystem.Knowledge GeneratedSDC is a computer-readable information model that defines the information content of data-entry forms, supports multiple approaches for SDC data exchange, and enables secondary use of standardized data.RelevanceSDC templates allow clinical information to be standardized for data capture before entry into computer systems. SDC is especially valuable for the collection and exchange of rapidly versioned data elements such as those found in pathology data sets, cancer staging, and clinical trials.2 The design of data fields and DEF structure by centralized expert teams can make data entry more consistent and efficient, aiding in the data entry process. Standardization of data entry with consistent evidence-based data fields helps to ensure complete collection of clinically critical data in a familiar format and enables the generation of consistent, standardized, and structured reports, regardless of EHR vendor, institution, or variations in the cosmetics of DEF and report formats.5For patient care, preservation of structure and context is critical, from the data entry form (DEF) through all downstream clinical reports. Centralized standardization of data entry fields during the data collection design process, with a focus on downstream interoperability and data reuse, has several benefits.7 The lack of precapture semantic, contextual, and structural standardization is thus a significant barrier to the complex data analyses required in oncology investigations and is a barrier to sharing data with patients, their care teams, and other EHR systems.8Unfortunately, this type of precapture standardization is rarely addressed by EHR vendors. Attempts to standardize and/or aggregate data fields across EHRs after the data are collected often require a significant effort in data aggregation and cleaning and often yield suboptimal results.9 An SDC template specifies the content of a DEF that can be rendered by any EHR vendor in a technology-agnostic manner, while maintaining an exact representation of the data definitions, allowing the captured data to be exchanged in an interoperable manner. SDC-based DEFs are particularly useful for designing and exchanging complex oncology data sets, such as those needed for anatomic pathology, biomarkers, and clinical oncology reporting.Structured Data Capture (SDC) is an open-source technical framework published by the Quality Research and Public Health committee of the standards organization Integrating the Healthcare Enterprise (IHE). SDC was designed to solve the problem of precapture data standardization in an interoperable manner. SDC can be viewed as a model that specifies the structure of related data elements (DEs) and preserves their semantic and contextual integrity. Furthermore, SDC specifies the information content of interoperable DEFs so that the DEF user can capture, store, and exchange complex, context-rich data in standardized DEs.11 Much of the data captured by these forms are submitted to North American cancer registries for public health surveillance.13 Other clinical specialties  are exploring the use of SDC for standardizing data entry, delivering standardized clinical reports, and facilitating downstream data usages. The eCC program is described in another paper in this issue.10Since 2019, SDC has been the delivery format for the electronic Cancer Checklists (eCCs) from the College of American Pathologists (CAPs). These checklists are used by 35%-40% of North American pathologists.14 IHE was selected as the organization to host the specification. The IHE profile for SDC was first published in October 2016, is maintained by the IHE SDC Working Group, and is regularly tested at IHE Connectathons.16The SDC project was initiated in early 2013 by the Office of the National Coordinator for Health Information Technology (ONC) through its Standards and Interoperability Framework initiative.17 to produce a hybrid, functionally equivalent FHIR SDC model. However, complete harmonization was not achieved, and the two approaches diverged because of differences in objectives and design principles. In 2017, both IHE SDC and FHIR SDC became community-led initiatives. This paper addresses only IHE SDC.The ONC also sponsored an attempt to harmonize FHIR Questionnaire with IHE SDC,18 which includes question-answer sets and fill-in questions, although SDC can also handle standard media types such as images in questions and responses. Each question and answer has a unique identifier (ID), which remains constant unless the contextual semantics of the question or answer changes. To help represent context and control the display of form parts, SDC sections and DEs may be repeated and nested to any level of depth.SDC is an information model that describes how various types of generic clinical information should be represented for technology-agnostic data capture. The primary information type addressed by SDC is the DE,19The structure of SDC is defined by a set of nested eXtensible Markup Language (XML) schemas. The schemas constrain the structure of SDC XML to recurring patterns and are also used to generate programming code to create the SDC Object Model (OM). The OM is used to generate SDC XML from SDC modeling tools and may also be used to control the behavior of SDC-based DEFs. Details about the SDC Schema set may be found in the SDC Technical Reference Guide.SDC XML documents Fig  that are21 SDC’s use of CDEs provides an important layer of data interoperability and reuse by predefining sharable DEs that are needed for the FDF clinical content.22SDC can also define common data elements (CDEs). CDEs are DEs that are common across multiple data sets and/or are shared across clinical domains and/or reused in many different FDFs.23 Terminology standards are critical to provide the semantic meaning and context of CDE components when CDEs are separated from their SDC source, when used by analysts who may not have access to the SDC or CDE definition, or when combining with data sets from non-SDC and/or non-CDE sources. Similarly, SDC DEs also benefit from being mapped to standard terminologies.Ideally, CDEs should be paired with appropriate standard terminologies to optimize interoperability and encourage CDE reuse.The SDC content management workflow is improved by using ancillary SDC mapping files for CDEs and terminologies, rather than placing CDE and terminology metadata directly in FDFs. External FDF maps promote centralized mechanisms for terminology management, validation, distribution, and searching for new and updated code sets, and they also enable the transmission of smaller SDC messages. However, some use cases may require the transmission of terminology codes within the FDF, and SDC supports this model as well.24 In 2014, investigators at the University of Nebraska Medical Center began development of SNOMED CT concepts specific to the eCC SDC content to address terminology deficiencies noted by the Centers for Disease Control and Prevention (CDC) for cancer reporting.26 An example of the new SNOMED CT modeling for the eCC SDC templates is provided in Figure Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) is the most comprehensive controlled medical terminology and is broadly adopted internationally. SNOMED CT is polyhierarchical, allowing multiple parent nodes per clinical concept. It is composed of 19 domain hierarchies, such body structure, observable entity, and clinical finding. Each concept may be defined (rendered computable) by specifying supertype(s) and additional defining attributes from the various domain hierarchies. Defined concepts are subjected to computer classification, which moves each concept under its logical parent concepts and creates additional logical concept relationships. The result is a robust searchable ontology that allows for granular, specific concept definitions, concept aggregations, and concept grouping by defining characteristics.SDC IDs for answer choices change whenever the answer choice semantics change. For SDC questions, the SDC ID changes whenever any change is made to the semantics of the question or any of its child answer choices. This provides clear documentation whenever the DE’s composite semantics changes. However, this level of semantic version control in SDC can be undesirable when stable IDs are desired for querying across DE versions, where SDC IDs are used as query targets. SNOMED CT, when mapped to each SDC question and answer, solves this problem by providing stable semantic IDs for each SDC ID. Additionally, the SNOMED CT ontology provides new opportunities for analytics such as increasing or decreasing the granularity of queries through drilldowns and rollups, which would be impossible with SDC IDs alone. Finally, SNOMED CT provides a robust analytics capability that can survive minor DE version changes that alter SDC IDs.27 which uses Health Level Seven International (HL7) v.2.5.1, or IHE SDC on FHIR28 (discussed below). While recreating the transmitted DEF at the end point node is a trivial task if the FDF-R is transmitted intact, the question and answer responses can be extracted and reconstructed into an SDC DEF after using any of the above transmission techniques.When an SDC DEF is filled out, the user’s responses may be stored inside the FDF XML, which is now called an FDF with Responses (FDF-R). The FDF-R may undergo cycles of edit-save-edit revisions before being transmitted (using standard IHE transactions) to one or more end points, such as EHRs and public health agencies. Alternatively, responses may be extracted from the DEF or FDF-R and transmitted in any suitable format, such as North American Association of Central Cancer Registries (NAACCR) Volume V,28 This approach wraps or converts SDC forms to a variety of FHIR resources. A FHIR resource is a reusable data structure that represents a small domain of healthcare information. Examples include patient, practitioner, claim, and location. IHE SDC on FHIR uses the resources named DocumentReference and Observation.30 This approach provides seamless interoperability between FHIR and IHE SDC. SDC forms and data are transported in a FHIR DocumentReference wrapper, and the FDF-R question and answer content is parsed into individual FHIR Observation objects.31 The SDC Observations can be processed and queried like any other FHIR data, expanding the downstream usability of the SDC data.The IHE SDC working group is developing a transmission specification for IHE SDC using FHIR as the wrapper or transport mechanism for SDC forms.SDC DEs and FHIR Observations both support repurposing of SDC data for reuse in other types of data sets, eg, biospecimen annotations, clinical trial forms, reports, and rules engines. The SDC IDs and mapped terminology codes allow downstream systems to reconstruct the semantic, contextual, and structural aspects of the DEs, and if required, to trace back to the SDC form where the data originated.10 In addition, 92% of Ontario, Canada pathologists were using the eCCs as of 2012, and according to the Cancer Care Ontario website, 100% of Ontario pathologists are currently using the eCCs, now released only in SDC format.33The standardization of SDC features across implementers allows accreditation organizations to support their requirements through interoperable, metadata-driven content and behavior. The extent of SDC adoption can be gauged by the number of licensed users of CAP eCCs. Currently, 45% of hospitals with > 400 beds in the United States are licensed to use the eCC.9 These features are specified declaratively inside the FDF XML, without any procedural code. In the BCSC reference implementation, small JavaScript services were used to read the FDF XML metadata and implement the above behavior when DEF buttons were pressed and when the form results were submitted to the CDC server. This pilot served as a demonstration of a multipart SDC form that is used by three different physicians in sequence to produce an integrated staging report for automating both clinical and pathological AJCC staging. Introducing these features for vendor implementation would likely require 1-2 years of additional work after the project plan is approved by the various stakeholders.One important example of new feature testing involves the implementation of an SDC-based Breast Cancer Staging Calculator (BCSC) that uses the American Joint Committee on Cancer (AJCC) staging application programming interface. New features piloted in the BCSC reference implementation included a more advanced use of skip logic (turning DEF parts of/off depending on the user type [pathologist or oncologist]) the use of surrogate codes in a format required by the staging web service, the aggregation of parameter values from selected answers and user-entered values, the sending of those parameter values to a staging web service (created by AJCC and CDC), return of the values to designated parts of the SDC DEF, generation of a full synoptic report on the basis of the user responses and values returned from the staging web service, and also transmission of that report to a CDC server using the IHE SDC SubmitForm transaction.35 The technical framework is based on the FHIR Clinical Practice Guidelines Implementation Guide by the HL7 Clinical Reasoning Work Group.36 In a CCG, data are collected by SDC form components, which are used to trigger FHIR-based rule blocks called Cards, on the basis of FHIR ActivityDefinition.37 Cards are connected to each other using SDC-derived responses and mapped terminology codes transmitted as FHIR transactions.The Computable Care Guideline (CCG) technical framework reinterprets written guidelines as interoperable computer operations.39 The DEs inside the SDC forms were mapped to terminology codes that enabled coordination between the DEFs, cards, and the EHR in the demonstration.For example, a cancer diagnosis or staging guideline can be converted to a set of cascading SDC forms and cards that communicate with an EHR system. As clinical results from the SDC form are saved into the patient’s health record, card instructions will present EHR notifications to appropriate members of the care team with the next steps for their patient.40 Like SDC, CAR/DS is also designed to be an open framework for the creation of additional guidelines. The CAR/DS and SDC groups are developing a pilot to correlate radiology (CAR/DS) and pathology (SDC) cancer diagnoses through the use of FHIR transactions.41 Because CAR/DS and SDC both can capture data at the point of care and then convert them to FHIR Observations, they can be made interoperable through FHIR technology. By mapping common DEs across CAR/DS and SDC templates, radiologists will be able to automate the creation of concordance reports that compare the radiologic diagnosis with the pathologic diagnosis. Concordance reports help radiologists determine the accuracy of their radiographic assessments. A pilot project between American College of Radiologists and CAP is applying this approach to the Thyroid Imaging Reporting & Data System (TI-RADS) and the Thyroid eCC SDC template.The CAR/DS framework (no relationship to CCG Cards) is a machine-readable XML-based definition format for representing radiology reporting clinical guidelines created by the American College of Radiologists.43 This data dictionary is complex, containing generic DEs applicable to all tumor types and Site-Specific Data Items applicable only to certain tumors.44 Frequent NAACCR volume II changes are a challenge for the various kinds of software that must be updated and the systems that must analyze changing data sets. Furthermore, NAACCR volume II must maintain compatibility with other cancer data standards such as the eCCs, AJCC staging, and the International Classification of Diseases for Oncology, third edition (ICD-O-3) cancer classification system. The CAP and the CDC are exploring ways to represent the NAACCR Volume II DEs in SDC format, on a tumor-specific bases, with one FDF per tumor type. The tumor pathology would be drawn largely from existing eCC CDEs, which are already harmonized with AJCC staging, ICD-O-3 and other clinical standards. In this pilot model, each FDF would serve as both a data dictionary and as a DEF template for registry software vendors, potentially alleviating some of the NAACCR versioning challenges.NAACCR maintains an extensive composite data dictionary, known as NAACCR Volume II, for cancer registries.45 mCODE data may be collected using a variety of tools, including SDC-based DEFs. Current work is exploring ways to transmit SDC-collected data as mCODE resources. Future work may include mapping from specific SDC DEs to mCODE FHIR resources. Additionally, mCODE DEs may be combined with SDC data using FHIR bundles to create a more comprehensive report.The minimal Common Oncology Data Elements (mCODE) project curates a standardized set of oncology data represented as FHIR resources. mCODE resources are designed to promote data transfer between EHRs and other systems such as registries and clinical trials software. mCODE began as a collaboration between ASCO and the MITRE Corporation.43 tools to extract and display the transmitted data, bulk data transmissions to facilitate large data sets in public health use cases (Fig 47 sharing patient data with multiple members of a distributed care team in diverse locations, and automated trigger-based clinical decision support.Additional ongoing SDC work involves testing of SDC schema enhancements, improving documentation, and piloting new approaches to data bundling, transmission, and downstream use. Examples include pilots using SDC + FHIR bundles containing arbitrarily complex SDC and FHIR content,In conclusion, IHE SDC is a technology designed to meet both data capture and interoperability needs. Complex, frequently changing, oncology data sets were a major design focus. SDC synergizes with technologies such as FHIR and SNOMED CT to greatly increase the capabilities of standardized structured reporting. Some capabilities include improving guideline adherence, clinical decision support, public health surveillance, and data aggregation for research and clinical trials.49 Because of its flexible and interoperable features, SDC could play an important role in data capture for healthcare by creating centrally standardized DEFs for diseases like cancer and could be leveraged for emerging diseases such as COVID-19.Although most vendors who use SDC opt for desktop application DEF technology, SDC-enabled DEF software is also straightforward to implement using standard web technologies. An open-source, web-based SDC reference implementation is available on the IHE-SDC-WG GitHub.


To reach its goal of ending AIDS by 2030, Thailand has adopted antiretroviral treatment as prevention and HIV pre-exposure prophylaxis for men who have sex with men (MSM) and transgender women (TGW) as its core HIV control strategy. However, in the absence of reliable epidemiologic indicators, the impact of these policies on the course of the HIV epidemic in these groups remains unknown. To help answer this question, we formulated an HIV epidemic consensus initiative for Bangkok, Thailand, to analyze epidemiologic and program data and reach agreement between experts and stakeholders on the evolving state of the HIV epidemic among MSM and TGW. A customized Delphi process was used to consult and consolidate viewpoints of experts and stakeholders. Experts presented and discussed HIV prevalence and incidence data from recent and ongoing studies among MSM and TGW in Bangkok (2014 to 2018) during a meeting with stakeholders representing government, donors, and civil society. Agreement about the course of the HIV epidemic among MSM and TGW was attained by voting consensus. Based on presented data, meeting participants agreed that HIV prevalence and incidence had decreased among Bangkok MSM from 2014 to 2018. Despite these declines, HIV prevalence and incidence were found to remain high. This was particularly the case among younger MSM. Participants agreed that there was no evidence for a decrease in HIV prevalence and incidence among Bangkok TGW. Introduction of antiretroviral treatment as prevention and HIV pre-exposure prophylaxis may have contributed to these declines. However, HIV prevalence and incidence remained high, and no signs of a decrease were reported among Bangkok TGW. At the current rate of new HIV infections in MSM and TGW, Thailand will not reach its goal of ending AIDS by 2030. This HIV consensus initiative may serve as a model for building agreement and advocacy on epidemiologic and program data and their implications for a large metropolitan city. Thailand has made dramatic and clear achievements in controlling its HIV epidemic, and is internationally recognized for high-quality HIV research and programming . In 1991Thailand again served as a role model by introducing its National Access Program to ARV drugs for people with HIV in 2001, the first non-high-income country doing so . In 2006Notwithstanding these successes, integrated behavioral and biological surveillance (IBBS) among men who have sex with men (MSM) in Bangkok in 2003 found an HIV prevalence of 17.3%, further increasing to over 30% by 2005 and 2007 . This hiTransgender women (TGW) were first included in IBBS in 2005 , and incReceptive anal intercourse, lack of condom use, high levels of sexual partner turnover, drug use during sex, and finding casual partners via the internet have all been found to be associated with higher HIV prevalence and incidence among Bangkok MSM and TGW –15. In aThe HIV epidemic among MSM and TGW continued to unfold during the beginning of the past decade. During this period, however, two highly effective biomedical interventions emerged from phase 3 efficacy trials: 1) ARV HIV pre-exposure prophylaxis, or PrEP , and 2) As part of its commitment to ending AIDS by 2030 , the ThaWhile it may be assumed that these activities increased access to and uptake of HIV testing, earlier initiation of treatment, and use of PrEP, their overall impact on the course of the HIV epidemic among MSM and TGW in Bangkok remains unknown. There is no existing structure to aggregate research, surveillance, and program data into reliable HIV epidemiologic indicators. For this reason, we conceptualized the Bangkok HIV epidemic consensus initiative to: (1) establish a panel of local experts in HIV strategic information; (2) select, review, and discuss recent published and unpublished local epidemiological data  for presentation and deliberation with stakeholders; and (3) reach consensus between experts and stakeholders about the current and possible future course of the HIV epidemic among MSM and TGW in Bangkok. The outcomes of this process are expected to identify new or ongoing HIV prevention challenges and guide appropriate interventions among MSM and TGW in the Thai capital.This consensus-building exercise applied a modified Delphi process to reach consensus between a panel of experts from government agencies and academia with stakeholders from non-government and community-based organizations about the current and possible future course of the HIV epidemic among MSM and TGW in Bangkok. Originally, the Delphi technique was developed as an iterative process of soliciting expert opinions for the purpose of reaching consensus about a complex problem and has been used by metropolitan areas to reach agreement on multiple and complex HIV epidemiologic data , 30. It Local representatives from government, non-government, and private organizations who have served in in HIV epidemiology, strategic information, and prevention among MSM and TGW  were approached to take part in the expert panel. Stakeholders were invited from non-government and community-based organizations and civil society groups involved in HIV prevention, treatment, and equal rights advocacy for MSM and TGW.Published and unpublished recent HIV prevalence and incidence data (2014 to 2018) among MSM and TGW were presented by experts during a consensus meeting with stakeholders in April 2019. Where possible, experts were asked to disaggregate data by calendar year and age. Following presentation and deliberation of data, six items regarding the epidemiology of HIV infection among MSM and TGW were presented for voting consensus (agree/disagree). Items were informed and prepared by the expert panel after reviewing available data. A copy of the set of voting items is included as Study protocols of published and unpublished research data presented at the consensus meeting were approved by the Institutional Review Boards of Chulalongkorn University, Bangkok, Thailand  in the Bangkok Online HIV Testing in Young MSM Study . Qu. Qu39]. HIV incidence estimates from cross-sectional studies. Directly observed estimates of HIV incidence among MSM are difficult to obtain, especially among young MSM [oung MSM . In thesoung MSM , and appoung MSM . EstimatThe presence of acute HIV infection (during the first month after acquisition) can be derived from sequential emergence of serological markers while the person is still testing HIV seronegative by conventional laboratory methods . TherefoHIV incidence in follow-up studies. Currently, few observational follow-up studies assess HIV incidence among Bangkok MSM. Data were presented from the Bangkok sites of the Test, Treat, and Prevent HIV Program [ Program ,  [ung MSM) , HIV incung MSM) , 11. EstObserved HIV incidence. HIV incidence data among TGW are limited and were reported at the consensus meeting only by the Tangerine Clinic. The number of TGW who were repeatedly tested for HIV infection at Tangerine increased from 98 in 2016 to 407 in 2018. The HIV incidence density in these women increased from zero (0/36) in 2016 and 2.3 (2/87) in 2017 to 3.3 (6/182) per 100 PY in 2018 [ in 2018 .After presentation and deliberation of available data the following items were presented for voting consensus Click here for additional data file.