Maternal-Fetal Telemedicine: the impact of a national hub and spoke model on critical access communities

Background Italy has been one of the countries most affected by the SARS-CoV-2 pandemic and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. We investigated the management of non-COVID-19 patients across all medical specialties in Italy. Methods A PRISMA guideline-based systematic review of the literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from 20 February to 22 June, 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialties in combination with our geographical focus (Italy) and COVID-19. Results Of the 4643 potentially eligible studies identified by the search, 247 studies were included. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialties have been affected by the reorganization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine. Conclusions Our work highlights the changes taking place in the Italian public healthcare system to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyze future directions for the healthcare system in the case of new pandemic scenarios.

Download Full-text

How Free Trade Agreements Affect Exports and Imports in Vietnam

VNU Journal of Science Economics and Business ◽

10.25073/2588-1108/vnueab.4126 ◽

2017 ◽

Vol 33 (5E) ◽

Author(s):

Nguyen Thi Hoang Oanh

Keyword(s):

International Trade ◽

Free Trade ◽

World Economy ◽

Free Trade Agreement ◽

Free Trade Agreements ◽

Trade Agreement ◽

Trade Agreements ◽

Trade Flows ◽

Hub And Spoke ◽

The Impact

The important year of 1995 marked Vietnam’s first integration as a member of ASEAN. By 2016, Vietnam had negotiated, signed, and implemented sixteen free trade agreements. They include both multilateral and bilateral free trade agreements such as the China-ASEAN, Vietnam-Chile, and Vietnam-Japan agreements. By signing free trade agreements Vietnam can increase trade flows in bilateral and multilateral developed-country FTA scenarios. Trade creation and diversion can be found in multilateral developing-country FTA scenarios and the author finds the impacts of each free trade agreement is different if analyzed for each 2-digit commodity. Keywords Free trade agreement, trade, import, export.t commodity References [1] Baier, S.L., Bergstrand, J.H., “Do free trade agreements actually increase members’ international trade?”, Journal of International Economics, 71 (2007), 72-95.[2] Chong, Soo Yuen & Hur, Jung, “Small Hubs, Large Spokes and Overlapping Free Trade Agreements”, The World Economy, 10.1111/j (2008), 1467-9701.[3] Hur, J., Alba, J. D., & Park, D., “Effects of hub-and-spoke free trade agreements on trade: A panel data analysis”, World Development, 38 (2010) 8, 1105-111.[4] McDonald, S. & Walmsley, Terrie, “Bilateral Free Trade Agreements and Customs Unions: The Impact of the EU Republic of South Africa Free Trade Agreement on Botswana”, The World Economy, 10.1111/j (2008),1467-9701.[5] Pan, S., Welch, M., Mohanty, S., Fadiga, M., & Ethridge, D., “Welfare analysis of the Dominican Republic-Central America-United States free trade agreement: The cotton textile and apparel industries”, The International Trade Journal, Vol. XXII (2008) 2, 1521-0545.[6] Benedictis, L., Santis, R., Vicarelli, C., “Hub-and-Spoke or else? Free trade agreements in the “enlarged” European Union”, The European Journal of Comparative Economics, 2 (2005) 2, 245-260.[7] Nguyen, Q.H., & Nguyen, T.H., “The impact of free trade agreement on trade flow of goods in Vietnam”, Vietnam Economist Annual Meeting, 2015[8] Das, R.U., Rishi, M., Dubey, J.D., “Asean plus six and successful FTAS: Can India propel intra-industry trade flows?”, The Journal of Developing Areas, 50 (2016) 2.[9] Hayakawa, K., “Impact of diagonal accumulation rule on FTA utilization: Evidence from bilateral and multilateral FTAs between Japan and Thailand”, J. Japanese Int. Economies, 32 (2014), 1-16.[10] Jennifer Y. Leung, “Bilateral vertical specialization between the U.S. and its trade partners - before and after the free trade agreements”, International Review of Economics and Finance, 45 (2016), 177-196.[11] Jongwanich, J., & Kohpaiboon, A., “Exporter responses to FTA tariff preferences: evidence from Thailand”, Asian Pacific Economic Literature (2017).[12] Lakatos, C., & Walmsley, T., “Investment creation and diversion effects of the ASEAN-China free trade agreement”, Economic Modelling, 29 (2012), 766-779.[13] Vanhnalat, B. at el., “Assessment the Effect of Free Trade Agreements on Exports of Lao PDR”, International Journal of Economics and Financial Issues, 5 (2015) 2, 365-376.[14] Vietnam Chamber of Commerce and Industry (VCCI), “Freedom of international trade in Vietnam”, Research report, Vietnam, 2015.

Download Full-text

The impact of hub failure in hub-and-spoke networks: Mathematical formulations and solution techniques

Computers & Operations Research ◽

10.1016/j.cor.2014.05.012 ◽

2016 ◽

Vol 65 ◽

pp. 174-188 ◽

Cited By ~ 40

Author(s):

Nader Azizi ◽

Satyaveer Chauhan ◽

Said Salhi ◽

Navneet Vidyarthi

Keyword(s):

Hub And Spoke ◽

The Impact ◽

Solution Techniques ◽

Hub And Spoke Networks

Download Full-text

The impact of the ‘hub and spoke’ model of care for lung cancer and equitable access to surgery

Thorax ◽

10.1136/thoraxjnl-2014-205841 ◽

2014 ◽

Vol 70 (2) ◽

pp. 146-151 ◽

Cited By ~ 25

Author(s):

Aamir Khakwani ◽

Anna L Rich ◽

Helen A Powell ◽

Laila J Tata ◽

Rosamund A Stanley ◽

...

Keyword(s):

Lung Cancer ◽

Equitable Access ◽

Model Of Care ◽

Hub And Spoke ◽

The Impact ◽

Access To Surgery

Download Full-text

"Even though I am alone, I feel that we are many" - An appreciative inquiry study of asynchronous, provider-to-provider teleconsultations in Turkana, Kenya

10.1101/2020.05.10.20097337 ◽

2020 ◽

Author(s):

M Whitney Fry ◽

Salima Saidi ◽

Abdirahman Musa ◽

Vanessa Kithyoma ◽

Pratap Kumar

Keyword(s):

Health System ◽

Appreciative Inquiry ◽

Health Service Delivery ◽

Team Work ◽

Mobile Technologies ◽

Care Seeking ◽

Specialist Care ◽

Hub And Spoke ◽

Middle Income ◽

The Impact

Non-physician clinicians (NPCs) in low and middle-income countries (LMICs) often have little physical proximity to the resources - equipment, supplies or skills - needed to deliver effective care, forcing them to refer patients to distant sites. Unlike equipment or supplies, which require dedicated supply chains, physician/specialist skills needed to support NPCs can be sourced and delivered through telecommunication technologies. In LMICs however, these skills are scarce and sparsely distributed, making it difficult to implement commonly used real-time (synchronous), hub-and-spoke telemedicine paradigms. An asynchronous teleconsultations service was implemented in Turkana County, Kenya, connecting NPCs with a volunteer network of remote physicians and specialists. In 2017-18, the service supported over 100 teleconsultations and referrals across 20 primary healthcare clinics and two hospitals. This qualitative study aimed to explore the impact of the telemedicine intervention on health system stakeholders, and perceived health-related benefits to patients. Data were collected using Appreciative Inquiry, a strengths-based, positive approach to assessing interventions and informing systems change. We highlight the impact of provider-to-provider asynchronous teleconsultations on multiple stakeholders and healthcare processes. Provider benefits include improved communication and team work, increased confidence and capacity to deliver services in remote sites, and professional satisfaction for both NPCs and remote physicians. Health system benefits include efficiency improvements through improved care coordination and avoiding unnecessary referrals, and increased equity and access to physician/specialist care by reducing geographical, financial and social barriers. Providers and health system managers recognised several non-health benefits to patients including increased trust and care seeking from NPCs, and social benefits of avoiding unnecessary referrals (reduced social disruption, displacement and costs). The findings reveal the wider impact that modern teleconsultation services enabled by mobile technologies and algorithms can have on LMIC communities and health systems. The study highlights the importance of viewing provider-to-provider teleconsultations as complex health service delivery interventions with multiple pathways and processes that can ultimately improve health outcomes.

Download Full-text

An Efficient Accessibility Model: Applications for Airline Network Analysis

Journal of Travel Research ◽

10.1177/004728758402200304 ◽

1984 ◽

Vol 22 (3) ◽

pp. 31-36 ◽

Cited By ~ 1

Author(s):

Rex Toh

Keyword(s):

South African ◽

Far East ◽

Network Connectivity ◽

Hub And Spoke ◽

Tourist Attractions ◽

Graph Theoretic ◽

Strategic Location ◽

Airline Network ◽

The Impact ◽

Total Network

This article describes an efficient, systematic procedure for ranking the accessibility and centrality of stations, using graph theoretic methods to identify pivotal and marginal points. Alitalia Airlines' Far East route structure and South African Airlines' domestic network are used to illustrate the model and its implications on the strategic location of headquarters, technical support services, conference sites and tourist attractions. The impact on aircraft deployment is also examined. The article addresses the logistical implications of the addition or deletion of new sectors or stations by way of sensitivity analysis and anticipates the growth of hub and spoke airline networks to increase total network connectivity and accessibility.

Download Full-text

The impact of the SARS-CoV-2 pandemic on healthcare provision in Italy to non-COVID patients: a systematic review

10.1101/2020.09.17.20192088 ◽

2020 ◽

Author(s):

Lugli Gianmarco ◽

Ottaviani Matteo Maria ◽

Botta Annarita ◽

Ascione Guido ◽

Bruschi Alessandro ◽

...

Keyword(s):

Systematic Review ◽

Healthcare System ◽

Public Healthcare ◽

Healthcare Provision ◽

Hub And Spoke ◽

Medical Specialties ◽

Health Crisis ◽

Outbreak Period ◽

Long Term Impact ◽

The Impact

AbstractBackgroundItaly has been one of the countries most affected by the SARS-CoV-2 pandemic and the regional healthcare system has had to quickly adapt its organization to meet the needs of infected patients. This has led to a drastic change in the routine management of non-communicable diseases with a potential long-term impact on patient health care. We investigated the management of non-COVID-19 patients across all medical specialties during the pandemic in Italy.MethodsA PRISMA guideline-based systematic review of the available literature was performed using PubMed, Embase, and Scopus, restricting the search to the main outbreak period in Italy (from 20 February to 22 June, 2020). We selected articles in English or Italian that detailed changes in the Italian hospital care for non-COVID-19 patients due to the pandemic. Our keywords included all medical specialties in combination with our geographical focus (Italy) and COVID-19.FindingsOf the 4643 potentially eligible studies identified by the search, 247 studies were included in the systematic review. A decrease in the management of emergencies in non-COVID patients was found together with an increase in mortality. Similarly, non-deferrable conditions met a tendency toward decreased diagnosis. All specialties have been affected by the reorganization of healthcare provision in the hub-and-spoke system and have benefited from telemedicine during the pandemic.InterpretationOur work highlights the changes taking place in the Italian public healthcare system in order to tackle the developing health crisis due to the COVID-19 pandemic. The findings of our review may be useful to analyze future directions for the healthcare system in the case of new pandemic scenarios.

Download Full-text

First prospective multicenter Italian study on the impact of the 21-Gene Recurrence Score (RS) in adjuvant clinical decisions for ER+/HER2- early breast cancer (BC) patients.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.15_suppl.e12038 ◽

2017 ◽

Vol 35 (15_suppl) ◽

pp. e12038-e12038

Author(s):

Maria Vittoria Dieci ◽

Valentina Guarneri ◽

Tommaso Giarratano ◽

Marta Mion ◽

Giampaolo Tortora ◽

...

Keyword(s):

Recurrence Score ◽

Absolute Difference ◽

Intermediate Risk ◽

Veneto Region ◽

Hub And Spoke ◽

Italian Study ◽

Factors Associated ◽

Number Of Patients ◽

Main Factors ◽

The Impact

e12038 Background: The Breast-DX Italy prospective study evaluated the impact of the 21-gene RS on adjuvant treatment decisions for early BC patients. Methods: The study was conducted in 9 centers of the Veneto Region (2 hub and 7 spoke). All consecutive patients with ER+/HER2-, T1 to T3, N0 to N1 early BC who met protocol-defined clinicopathological criteria for “intermediate risk” were included. Pre-RS and post-RS physicians’ treatment recommendations and treatment actually received were collected. Results: From November 2014 to August 2016, n=124 N0 and n=126 N1 patients were enrolled (65% at hub and 35% at spoke centers). The majority had PgR+ (86%), G2 (71%) and pT1c (63%) BC. Median age was 55 yrs, median Ki67 was 20% (range 2-70%). The distribution of RS was: <18 (61%), 18-30 (32%) and >30 (7%). Main factors associated with higher RS were G3 and higher ki67. The addition of chemotherapy (CT) to hormonal therapy (HT) was initially recommended for 48% of the patients (38% of N0 and 57% of N1 patients; 54% and 37% of patients enrolled at hub and spoke centers, respectively). The post-RS recommendation changed from the pre-RS recommendation for 40 patients, mostly from CT+HT to HT (n=30; n=25 with low and n=5 with intermediate RS). Change was more frequent for N1 patients (Table). Of the 72 N1 patients initially recommended to CT+HT, 28% had a post-RS indication to HT alone. The crude number of patients with pre-RS recommendation to CT significantly exceeded the number of patients who finally received it (absolute difference =31; p<0.001). The majority of CT treatments were spared at hub vs spoke centers (n=24 and n=7, respectively). Conclusions: Pre-RS indication to HT alone was frequent, in particular for N0 patients and at spoke centers. The use of the 21-gene RS further contributed in sparing CT administration, more so for N1 patients and at hub centers. The impact of the RS when used at discretion of the clinicians is currently under investigation in the prospective ROXANE study. [Table: see text]

Download Full-text

P1741Hitting the wall in converting diagnosed ST-elevation myocardial infarction patients to treating them: a humbling analysis from LATIN telemedicine

European Heart Journal ◽

10.1093/eurheartj/ehz748.0495 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Mehta ◽

R Botelho ◽

S Niklitschek ◽

F Fernandez ◽

J Cade ◽

...

Keyword(s):

Performance Metrics ◽

Population Based ◽

Health Centers ◽

Delayed Presentation ◽

Hub And Spoke ◽

Policy Makers ◽

Performance Variables ◽

St Elevation ◽

Door To Balloon ◽

The Impact

Abstract Background The behemoth telemedicine program, Latin America Telemedicine Infarct Network (LATIN) has exponentially grown in 4 countries in Central and South America. It has provided AMI coverage to >100 million patients and it has contributed to transforming AMI care in the continent by its “halo” effect. We continue our meticulous search in evaluating the impact of LATIN and in doing so, we have confronted a sobering reality. Purpose To make continued improvements in population-based AMI management, the continued success of the initiative requires participation from healthcare policy makers, health economists, and payers. Methods LATIN was created as a hub and spoke model to hugely increase access (>100 million population coverage) to quality AMI treatment primarily with short door to balloon time (D2B) PCI. Innovative telemedicine platforms were created and networked at all 350 centers that were located in small clinics and primary health centers in poor sections of the countries (spokes) and at 24/7 PCI capable institutions (hubs). Remote cardiologists, located in 3 central locations, provided immediate EKG diagnosis (time to telemedicine diagnosis, TTD <3.5 minutes) and they provided expert guidance for the entire STEMI process, Door in Door Out (DIDO), and transport times (TT). LATIN performance metrics, under its strict control, and including process metrics at the hubs, spokes, and at the command telemedicine sites, were measured and plotted. The macroeconomic variables of insurance approvals, ambulance structure, and availability of ICU beds were determined and incorporated into performance variables of the LATIN program. Results 784,395 patients were screened at 350 LATIN centers (Brazil 143, Colombia 118, Mexico 82, Argentina 7). With expanded reach, 8,440 (1.08%) patients were diagnosed and 3,924 (46.5%) urgently reperfused, including 3,048 (77.7%) with PCI. Time to Telemedicine Diagnosis (TTD) was 3 min, tele-accuracy 98.9%, D2B 51 min, and in-hospital mortality 5.2%. Over 4 years of operation, the proportion of reperfused STEMI patients has ranged between 41–48% - the major reasons for non-treatment were insurance, lack of ICU beds and delayed presentation. Conclusions Sustained improvements, as a result of stringent QA processes and continuous education, have resulted in reduced D2B, TTD, DIDO, TT, and in overall mortality. However, LATIN remains constrained with a large proportion of patients that are diagnosed but not treated, largely because of payer denials. Although this metric is showing improvement from broad dissemination of LATIN benefits, further gains from LATIN will result mainly from improved reimbursements.

Download Full-text

International Airline Alliance Network Design with Uncertainty

Applied Sciences ◽

10.3390/app11073065 ◽

2021 ◽

Vol 11 (7) ◽

pp. 3065

Author(s):

Wendong Yang ◽

Jiajia Shao ◽

Yun Jiang ◽

Zhengjia Xu ◽

Antonios Tsourdos

Keyword(s):

Network Design ◽

Design Problem ◽

Transportation Cost ◽

Network Design Problem ◽

Real World Data ◽

Hub And Spoke ◽

Robust Solution ◽

Route Network ◽

Cost Parameters ◽

The Impact

This paper addresses the alliance route network design problem considering uncertainty in the unit transportation cost. An alliance route network was constructed based on a hub-and-spoke (HS) network, in which airlines could achieve inter-area passenger transport through their international gateways. The design problem was formulated with a robust model containing a set of uncertain cost parameters. The model was established based on a three-subscript model of an HS network. A case study with real-world data was used to test the proposed model. The results showed that this robust solution can reduce the impact of cost uncertainty.

Download Full-text