BACKGROUND: There are significant geographic inequities in COVID-19 case fatality rates (CFRs), and comprehensive understanding its country-level determinants in a global perspective is necessary. This study aims to quantify the country-specific risk of COVID-19 CFR and propose tailored response strategies, including vaccination strategies, in 156 countries.
METHODS: Cross-temporal and cross-country variations in COVID-19 CFR was identified using extreme gradient boosting (XGBoost) including 35 factors from seven dimensions in 156 countries from 28 January, 2020 to 31 January, 2022. SHapley Additive exPlanations (SHAP) was used to further clarify the clustering of countries by the key factors driving CFR and the effect of concurrent risk factors for each country. Increases in vaccination rates was simulated to illustrate the reduction of CFR in different classes of countries.
RESULTS: Overall COVID-19 CFRs varied across countries from 28 Jan 2020 to 31 Jan 31 2022, ranging from 68 to 6373 per 100,000 population. During the COVID-19 pandemic, the determinants of CFRs first changed from health conditions to universal health coverage, and then to a multifactorial mixed effect dominated by vaccination. In the Omicron period, countries were divided into five classes according to risk determinants. Low vaccination-driven class (70 countries) mainly distributed in sub-Saharan Africa and Latin America, and include the majority of low-income countries (95.7%) with many concurrent risk factors. Aging-driven class (26 countries) mainly distributed in high-income European countries. High disease burden-driven class (32 countries) mainly distributed in Asia and North America. Low GDP-driven class (14 countries) are scattered across continents. Simulating a 5% increase in vaccination rate resulted in CFR reductions of 31.2% and 15.0% for the low vaccination-driven class and the high disease burden-driven class, respectively, with greater CFR reductions for countries with high overall risk (SHAP value > 0.1), but only 3.1% for the ageing-driven class.
CONCLUSIONS: Evidence from this study suggests that geographic inequities in COVID-19 CFR is jointly determined by key and concurrent risks, and achieving a decreasing COVID-19 CFR requires more than increasing vaccination coverage, but rather targeted intervention strategies based on country-specific risks.

Episodic memory strongly declines in healthy aging, at least partly because of reduced abilities to create and remember associations (associative memory) and to use efficient memory strategies. Several studies have shown that drawing the to-be-remembered material is a reliable encoding tool to enhance memory of individual items (item memory) because it simultaneously integrates elaborative, pictorial, and motoric processes. These processes in isolation can enhance associative memory in older adults. Nevertheless, their simultaneous impact on associative memory has never been investigated in drawing as an encoding tool. We aimed to investigate whether drawing as an encoding tool not only enhances item memory, but whether its benefit extends to associative memory in younger and older adults. Therefore, we tested 101 older and 100 younger participants in two online experiments and one in-person experiment. Using a memory task for unrelated word-pairs, we compared relational drawing and repeatedly writing (non-relational) as encoding tools and assessed immediate recognition memory of items and associations. In Experiment 2, we additionally assessed recognition memory after 1 week. The findings were consistent across the three experiments: while younger participants benefited from drawing over writing in item and associative memory, older participants benefited in item but not in associative memory. The observed effects remained after 1 week. Thus, we could extend the benefit of drawing to relational drawing in associative memory in younger adults. The lack of benefit in older adults\' associative memory might be explained by age-related difficulties in benefiting from memory strategies, and in creating and retrieving associations.

The COVID-19 pandemic has hit the tourism and hospitality sector hard. Hotel managers face uncertainty in this environment in order to survive. This study explores the impact of COVID-19 on the hospitality industry, particularly hotels in Indonesia, one of the largest developing countries. It examines the challenges faced by hotel managers and the strategies used to survive. Through the lens of complexity theory, we discuss whether the strategies being deployed are beneficial, redundant, or detrimental for hospitality businesses. Based on semi-structured interviews with 13 hotel managers in Jakarta, Bandung, and Bali, the findings shed light on the various challenges to hotels. We also highlight which challenges could turn into opportunities. The findings show that the strategies that managers are deploying could be detrimental in the future. Potential future research directions are also discussed.

US hospitals are struggling with how to compete and remain viable in an increasingly turbulent and competitive environment. Using Porter\'s generic strategies and resource dependence theory, this study examined the relationship between environmental factors and business strategy choice among U.S. hospitals. The study used longitudinal data from 2006 to 2016 of US urban, general acute care hospitals from the American Hospital Association Annual Survey, Medicare cost reports, and Area Health Resource File. Multinomial regression was used to analyze the data. and Discussion: Our findings showed four types of hospital strategy: cost-leadership, differentiation, hybrid, and stuck-in-the-middle. A greater number of physicians (county-level) increases the likelihood of pursuing differentiation and hybrid strategy. On the other hand, a higher older adult population (65 years+) increases the likelihood of pursuing a cost-leadership strategy. Similarly, lower competition and higher Medicare Advantage penetration increases the likelihood of pursuing cost-leadership over hybrid strategy. An increase in the unemployment rate decreases the likelihood of pursuing differentiation and cost-leadership strategies versus the hybrid strategy. Finally, hospitals pursuing a differentiation strategy tended to be larger, teaching, and not-for-profit. The results showed the importance of environmental and organizational factors in predicting the strategy choice of hospitals.

Background: Opioid-sparing anesthesia may enhance postoperative recovery by reducing opioid-related side effects. The present study was to evaluate the effect of an opioid-sparing strategy in bariatric surgery. Methods: This study was conducted as a retrospective matched case-controlled (1:1) study. A total of 44 patients receiving either an opioid-based approach (OBA group) or an opioid-sparing strategy (OSA group) who under laparoscopic sleeve gastrectomy were included between May 2017 and October 2020. The primary outcome was the postoperative hospital length of stay (PLOS). Secondary outcomes were the hospital costs, operative opioid consumption, time to recovery, postoperative pain score at rest and rescue antiemetic administered in the PACU. Results: The clinical demographic and operative data in both groups were comparable. There were no significant differences between the two groups in the PLOS (OSA vs. OBA: 6.18 ± 0.23 days vs. 6.73 ± 0.39 days, p = 0.24). Compared to the OBA group, opioid consumption in the OSA group was significantly decreased (48.79 ± 4.85 OMEs vs. 10.57 ± 0.77 OMEs, p < 0.001). There were no significant differences in the hospital costs, time to recovery, and rescue antiemetic administered, the incidence of intravenous opioids and vasopressor use in the PACU. Conclusion: The opioid-sparing anesthesia for laparoscopic sleeve gastrectomy was feasible but did not decrease the PLOS.

The past decade has seen increasing opportunities and efforts to integrate quality improvement into health care. Practice facilitation is a proven strategy to support redesign and improvement in primary care practices that focuses on building organizational capacity for continuous improvement. Practice leadership, staff, and practice facilitators all play important roles in supporting quality improvement in primary care. However, little is known about their perspectives on the context, enablers, barriers, and strategies that impact quality improvement initiatives.
This study aimed to develop a framework to enable assessment of contextual factors, challenges, and strategies that impact practice facilitation, clinical measure performance, and the implementation of quality improvement interventions. We also illustrated the application of the framework using a real-world case study.
We developed the TITO (task, individual, technology, and organization) framework by conducting participatory stakeholder workshops and incorporating their perspectives to identify enablers and barriers to quality improvement and practice facilitation. We conducted a case study using a mixed methods approach to demonstrate the use of the framework and describe practice facilitation and factors that impact quality improvement in a primary care practice that participated in the Healthy Hearts in the Heartland study.
The proposed framework was used to organize and analyze different stakeholders\' perspectives and key factors based on framework domains. The case study showed that practice leaders, staff, and practice facilitators all influenced the success of the quality improvement program. However, these participants faced different challenges and used different strategies. The framework showed that barriers stemmed from patients\' social determinants of health, a lack of staff and time, and unsystematic facilitation resources, while enablers included practice culture, staff buy-in, implementation of effective practice facilitation strategies, practice capacity for change, and shared complementary resources from similar, ongoing programs.
Our framework provided a useful and generalizable structure to guide and support assessment of future practice facilitation projects, quality improvement initiatives, and health care intervention implementation studies. The practice leader, staff, and practice facilitator all saw value in the quality improvement program and practice facilitation. Practice facilitators are key liaisons to help the quality improvement program; they help all stakeholders work toward a shared target and leverage tailored strategies. Taking advantage of resources from competing, yet complementary, programs as additional support may accelerate the effective achievement of quality improvement goals. Practice facilitation-supported quality improvement programs may be opportunities to assist primary care practices in achieving improved quality of care through focused and targeted efforts. The case study demonstrated how our framework can support a better understanding of contextual factors for practice facilitation, which could enable well-prepared and more successful quality improvement programs for primary care practices. Combining implementation science and informatics thinking, our TITO framework may facilitate interdisciplinary research in both fields.

BACKGROUND: Soil-transmitted helminths (STH) infections still present a global health problem. Mass drug administration (MDA) is a widely applied strategy to reduce morbidity and mortality caused by STH. Yet, this approach has some shortcomings. In this study, we analyzed the impact of a multi-intervention integrated deworming approach including MDA, health education (HE), and environmental sanitation improvements (ESI) for sustained STH control in Jiangsu Province of China that was applied from 1989 to 2019.
METHODS: Data, including infection rate of STH, medications used, coverage of the medication, non-hazardous lavatory rate, and household piped-water access rate in rural areas, and actions related to HE and ESI were collected (from archives) and analyzed in this retrospective descriptive study. Pearson\'s correlation analysis was applied to test correlations.
RESULTS: There was a dramatic decline in the infection rate of STH from 1989 (59.32%) to 2019 (0.12%). From 1995 to 1999, MDA and HE were recommended in rural areas. A negative correlation was observed between infection rate and medication from 1994 to 1998 (r = - 0.882, P = 0.048). From 2000 to 2005, targeted MDA was given to high-risk populations with HE continuously promoting good sanitation behaviors. From 2006 to 2014, targeted MDA + HE and ESI were used to consolidate the control effect. ESI was strengthened from 2006, and a negative correlation was observed between the coverage rate of the non-hazardous lavatory and the infection rate from 2006 to 2019 (r = - 0.95, P < 0.001). The targeted MDA was interrupted in 2015, while continuous efforts like HE and ESI contributed in sustaining STH control.
CONCLUSIONS: Multi-intervention integrated deworming strategy contributes to the reduction of STH infections. This approach is a valuable example of how different interventions can be integrated to promote durable STH control.

BACKGROUND: The COVID-19 outbreak highlights our vulnerability to novel infections, and vaccination remains a foreseeable method to return to normal life. However, infrastructure is inadequate for the immediate vaccination of the whole population. Therefore, policies have adopted a strategy to vaccinate older adults and vulnerable populations while delaying vaccination for others.
OBJECTIVE: This study aimed to understand how age-specific vaccination strategies reduce daily cases, hospitalizations, and death rates using official statistics for Tennessee, United States.
METHODS: This study used publicly available data on COVID-19, including vaccination rates, positive cases, hospitalizations, and deaths from the Tennessee Department of Health. Data from the first date of vaccination (December 17, 2020) to March 3, 2021, were retrieved. The rates were adjusted by 2019 data from the US Census Bureau, and age groups were stratified into 10-year intervals starting with 21 years of age.
RESULTS: The findings showed that vaccination strategy can reduce the numbers of patients with COVID-19 in all age groups, with lower hospitalization and death rates in older populations. Older adults had a 95% lower death rate from December to March; no change in the death rate of other age groups was observed. The hospitalization rate was reduced by 80% for people aged ≥80 years, while people who were 50 to 70 years old had nearly the same hospitalization rate as prior to vaccination.
CONCLUSIONS: This research indicates that targeting older age groups for vaccination is the optimal way to avoid higher transmissions and reduce hospitalization and death rates.

BACKGROUND: Given the impact of politico-economic sanctions on the pharmaceutical supply chain, this study aims to identify practical strategies to improve the resilience of the Iranian supply chain in pharmaceutical procurement under politico-economic sanctions.
METHODS: This is a qualitative content analysis study conducted in 2018. Semi-structured interviews were conducted using snowball sampling, and saturation was achieved after 18 interviews. Guba and Lincoln\'s criteria, namely credibility, confirmability, transferability, and dependability, were considered to ensure the validity and transparency of the study. A five-step framework analysis was applied to analyze the data using MAX QDA10.
RESULTS: The results led to the identification of nine main themes and 26 subthemes as strategies to improve the resilience of the pharmaceutical chain. According to the thematic map, some of these strategies have an extra-sectoral character: \'insurance organizations\', \'strengthening relations with other countries\', \'mechanization of the distribution system\', and \'suppliers and manufacturers\'. At the same time, some inter-sectoral strategies can help the pharmaceutical chain maintain its resilience: \'healthcare management and policy\', \'exploiting local potential\', \'pricing\', and \'integrated health information systems.\' As a strategy, \'Medical community and consumers\' also plays a crucial role in this regard. According to the subthemes, revisions of health management, more supervision, privatization, clinical policies, strategic purchasing, improvement of the referral system, inter-sectoral cooperation, support of indigenous medicines, rational pricing, insurance system, improvement of medical coverage, and development of electronic prescription should be considered by health systems. Sufficient support for indigenous medication and supervision of the distribution system should be considered by the pharmaceutical industry, taking into account the cooperation between consumers and patients.
CONCLUSIONS: Integration of the pharmaceutical supply chain and modern technologies, more attention to business complexity, economic development, intense competition, rapid changes in customer needs, and appropriate relationship between manufacturers, distributors, prescribers, and insurance organizations as purchasers should be considered by policymakers to improve supply chain resilience.

BACKGROUND: It is unclear how people with hypertension are responding to the COVID-19 pandemic given their increased risk, and whether targeted public health strategies are needed.
OBJECTIVE: This retrospective case-control study compared people with hypertension to matched healthy controls during the COVID-19 lockdown to determine whether they have higher risk perceptions, anxiety, and vaccination intentions.
METHODS: Baseline data from a national survey were collected in April 2020 during the COVID-19 lockdown in Australia. People who reported hypertension with no other chronic conditions were randomly matched to healthy controls of similar age, gender, education, and health literacy level. A subset including participants with hypertension was followed up at 2 months after restrictions were eased. Risk perceptions, anxiety, and vaccination intentions were measured in April and June.
RESULTS: Of the 4362 baseline participants, 466 (10.7%) reported hypertension with no other chronic conditions. A subset of 1369 people were followed up at 2 months, which included 147 (10.7%) participants with hypertension. At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group reported greater anxiety compared to the controls and were more willing to vaccinate against influenza, but COVID-19 vaccination intentions were similar. At follow-up, these differences were no longer present in the longitudinal subsample. Perceived seriousness and anxiety had decreased, but vaccination intentions for both influenza and COVID-19 remained high across groups (>80%).
CONCLUSIONS: Anxiety was above normal levels during the COVID-19 lockdown. It was higher in the hypertension group, which also had higher vaccination intentions. Groups that are more vulnerable to COVID-19 may require targeted mental health screening during periods of greater risk. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination intentions remained high, which is encouraging for the future prevention of COVID-19.