Background: Kidney transplantation (KTx) practices vary across healthcare systems, yet the operational components of best practice (BP) along the clinical pathway remain incompletely defined. This study aimed to identify key best practice elements across the kidney transplantation journey in four European countries.Methods: A mixed-methods study was conducted across France, Germany, Italy, and Spain. A structured survey (n = 253 respondents, including patients, living donors, nephrologists, transplant surgeons, transplant coordinators, and hospital administrators) assessed clinical practice and patient experience across four domains: CKD management, kidney donation and transplantation, transplant recipient care, and service governance. Semi-structured focus group interviews were performed in each country to contextualise survey findings. Ethics approval was obtained in accordance with national requirements.Results: Key elements for best practices along the KTx clinical journey were identified: (1) development of protocols to standardise the variable monitoring of CKD, to minimize urban-rural differences in clinical practice due to limited resources and follow-up care; (2) enhanced primary care training and targeted resource allocation to diagnose and monitor early-stage CKD; (3) donor coordination and promotion of living donation, addressing gaps in patient awareness and access to care; (4) development of communication protocols on living donation; (5) implementation of targeted patient and donor educational campaigns on living donation; (6) enhanced post-transplant follow-up care by nephrologists; (7) integration of quality-of-life assessments and psychological donor support post-transplantation; (8) increased availability of transplant coordinators to promote equitable resource allocation and the adoption of innovative practices; (9) streamlined governance structures along clinical journey; and (10) equitable funding models with consistent reimbursement policies across patient groups.Conclusions: This study provides a cross-national, mixed-methods framework for strengthening equity, coordination, and quality in kidney transplantation. Addressing variability in monitoring pathways, referral structures, patient-centred outcomes, and workforce capacity may enhance implementation of international transplantation guidelines and improve patient and donor outcomes.

The general prevalence of chronic non-communicable diseases, such as diabetes mellitus is rapidly increasing while exacerbating the burden of disease on healthcare systems. Its management, as opposed to communicable diseases, is typically long term and requires ongoing healthcare interventions, such as dietary control and medication prescription, with associated costs. The prescription requires an interaction between patients and physicians, which may be sporadic or continuous, and can be used as a proxy measure for the strength of patient–doctor relationship. We hypothesize that fragmentation of care, across physician specialties and payers, plays a role on prescription behaviour, above and beyond for patient and prescription characteristics. A panel of patients’ prescriptions events with the universe of all prescriptions and dispensing in Portugal from January 2015 to October 2019 (N = 791.467) provided by Serviços Partilhados do Ministério da Saúde, EPE was considered. We measured the association between care fragmentation of care and prescription behavior of antihyperglycaemic medication using negative binomial regression models. Results suggest that Specialists play a secondary role on the prescription of DPP-4i and SGLT2i, prescribing 12.3 and 4.3% less respectively, while playing a central role on the prescription of GLP-1, in comparison with GPs. Fragmentation of care also plays a part on prescription trends, i.e., physicians with higher of continuity of care present higher rates of prescription of approximately 5.9% for DPP-4i, 6.5% for SGLT2i and 39.6% for GLP-1. The comparison of prescription trends amongst public and private payers suggests that public payers have lower rates of prescriptions (DPP-4i: 9.6%; SGLT2i: 7.2%; GLP-1: 85.6%). We find important differences in prescription patterns between specialists and primary care physicians. Higher continuity of care is associated with increased prescription frequency. Finally, public payers are associated with lower prescription rates. Physician specialty, payer, and care fragmentation all interact in the prescription patterns of antihyperglycaemic medication.

Hospitalizations for Ambulatory Care Sensitive Conditions (ACSCs) are thought to be avoidable with effective preventive care and early disease management, usually delivered in community-based ambulatory care settings. These hospitalizations are both costly and sensitive to the socioeconomic situation of patients. Understanding whether different health systems mitigate the sensitivity of ACSCs to socioeconomic gradients may direct attention to equity-improving approaches to ambulatory health care. This study sought to identify differences in the gradient of Ambulatory Care Sensitive Conditions (ACSC) relative to socioeconomic status across nine countries, namely Australia, Canada, England, Finland, France, New Zealand, Spain, Switzerland, and the United States (US).

For decades, policy makers have struggled to improve care and control costs for medically complex and socially vulnerable populations, particularly individuals dually eligible for Medicare and Medicaid. Dual-eligible beneficiaries experience high rates of chronic illness, disability, and unmet social needs, and they account for a disproportionate share of Medicare and Medicaid spending. Despite sustained efforts to shift payment from volume to value, performance-based models have often yielded uneven results among providers serving these populations. In Medicare’s Accountable Care Organization (ACO) programs, organizations caring for higher proportions of racial and ethnic minority beneficiaries and socially vulnerable patients have faced greater challenges achieving savings and sustaining participation. These patterns highlight a central dilemma in value-based payment: without careful risk adjustment and benchmarking, models designed to reward quality of care and efficiency may disadvantage providers serving communities with concentrated social risk.

Burnout and decreased well-being among primary care physicians threaten workforce sustainability and health outcomes. Understanding how primary care physician burnout and its mitigators differ across countries could inform policy changes, but evidence is limited. Using 2012–22 survey data from primary care physicians in the United States and nine other high-income countries, we found that shares reporting stress rose across countries. By 2022, the US had one of the highest shares of primary care physicians reporting burnout (44 percent). Switzerland (18 percent) and the Netherlands (12 percent) had the lowest shares reporting burnout, alongside higher shares with satisfaction and lower shares with stress. Across countries, female physicians had higher odds of burnout, whereas workplace factors—including satisfaction with income and administrative workload—and better care quality were associated with reduced odds of burnout. Efforts to reduce burnout should address disparities by sex and should include systemic supports including quality initiatives, flexible work, and arrangements for patient cross-coverage; in-depth cross-national learning could reveal additional strategies.

For more than two decades, debates about why US health care spending is so high have been shaped by the insight articulated by Gerard Anderson, Uwe Reinhardt, and Peter Hussey: that the United States does not use more health care than other high-income countries but pays much higher prices for it. The original “It’s the Prices, Stupid” argument was fundamentally about price levels, not price growth. That central insight remains as true today as when it was first articulated: across services, drugs, and inputs, the United States consistently pays substantially higher prices than its peers for comparable services, drugs, and inputs.

Female sterilization occupies a paradoxical place in reproductive policy. When chosen freely, it is a safe and effective contraceptive method, yet has also been deployed as a tool of coercion and state control. This dual legacy makes the United States, where sterilization remains more common than other high-income democracies, an important case for examining how public accountability and policy design shape permanent contraceptive use. From a theoretical perspective, highly visible, accountability-driven interventions such as the 1974 Relf v. Weinberger case might be expected to generate larger behavioral changes than less visible administrative reforms, though prior scholarship offers mixed expectations about the relative influence of legal visibility versus economic incentives. To test these competing expectations, we analyze a harmonized panel of contraceptive surveys from 190 nations (1965-2010) and apply the synthetic-control method. We examine the behavioral impact of Relf as a democratic accountability event and contrast it with a later unrelated administrative change in U.S. hospital reimbursement policy in the 1990s. We find that the public outrage and litigation following Relf produced formal consent safeguards but were associated with limited changes in the national sterilization rates. In contrast, the 1990s payment reforms, aimed at cost containment, were associated with a sustained national decline. Together, these contrasting impacts suggest that reforms driven by court decisions and financial architecture may influence entrenched policies through different, potentially complementary, channels. Taken together, the findings affirm the important role of administrative levers alongside legislative activism, levers often overlooked in reproductive rights debates despite their capacity to reshape clinical practice.

Factors influencing the timing of regulatory submission for new drugs across countries are poorly understood. We identified all new drugs approved by the Food and Drug Administration (FDA) or European Medicines Agency (EMA) during the period 2014–18 and tracked their regulatory submissions to the US, the European Union, Canada, Japan, and Australia through 2022. We assessed whether disease area, orphan status, therapeutic value, market size, and launch price were associated with submission delays. The FDA received the highest proportion of first submissions (70 percent). Median submission delays ranged from zero months (FDA) to 18.5 months (Australia). The range of median regulatory review times was small (9.2–14.1 months) compared with the range of median submission delays. Drugs with moderate-to-high therapeutic value were associated with a six-month earlier submission time compared to drugs with low therapeutic value, on average. Higher-price drugs were associated with earlier submission, on average. Overall, cross-national differences in drug availability largely reflected differences in submission, not regulatory review, times. Although the US had greater and faster availability of novel therapeutics, the difference was smaller for drugs that offered moderate-to-high therapeutic value.

Private equity (PE) firms are increasingly investing in healthcare, seeking short-term returns through market consolidation, price increases, asset sales, and financial engineering. Although PE is transforming the healthcare sector, many countries lack systematic data to determine whether a regulatory response is warranted. Using data from PitchBook, we document substantial and growing PE investment in health care across 25 of 38 Organization of Economic Cooperation and Development (OECD) countries, totalling over 8,400 reported deals and $1.4 trillion in capital between 2013 and 2023. Outpatient clinics represent the dominant target of investment, while hospital and elder care sectors have attracted investments in select countries. Exploratory regression analyses suggest that PE firms are less likely to invest in countries with a social health insurance system and that PE deal volume is positively associated with health expenditures. Country-specific deviations from model predictions underscore the importance of unmeasured country-specific factors such as regulation, payment policy, and market competition. Eight case studies illustrate the operational, financial, and social implications of PE investments, as well as diverse regulatory contexts. Given the lack of disclosure requirements, a key policy priority for governments is to enhance transparency to enable effective monitoring of the financialisation of health care delivery.

Question: How have medical device patents contributed to periods of market exclusivity on drug-device combinations?

Findings: In this cohort study of 331 drug-device combinations approved by the Food and Drug Administration (FDA) from 1986 to 2023, 1751 of 3241 individual patent listings were on the delivery devices of these products. Medical device patents extended periods of protection for 180 products (54.4%) by a median (IQR) of 7.5 (2.8-13.9) years, with most device patents failing to mention the active pharmaceutical ingredients in their claims.

Meaning: Patenting strategies on drug-device combinations may impede generic entry and keep prices high for patients and payers.

Background: The Global Fund to Fight AIDS, Tuberculosis, and Malaria is one of the world’s largest global health donor agencies, playing a key role by filling recipient countries’ domestic health financing gaps; however, little is known about how well it achieves value for money. Given the current uncertainty regarding global health development assistance, it is critical to understand how to prioritize external donor funding allocations in an effort to maximize health impact.

Methods: In this study, we evaluated 66 recipient countries’ efficiency relative to peers in achieving improvement in health outcomes for TB, malaria, and HIV given their 2017–2019 Global Fund expenditures for (1) health products, (2) program activities, and (3) program management. Using a combination of frontier analysis, linear regression, and cluster analysis, we examined how macroeconomic conditions, epidemiological context, health system factors, and Global Fund spending decisions explain variation in country program performance.

Results: For malaria and HIV, we found a negative relationship between Global Fund spending on program activity and health product costs respectively and countries’ efficiency at translating funds to health impact. For malaria and HIV, there was also significant variation in efficiency across countries according to their economic capacity, disease burden, and most prominent spending area.

Conclusions: Our results suggest possible structural inefficiencies in country program management, dampening the health impact of frontline programs. The lack of broad patterns to predict performance signals the importance of tailoring spending strategies to country-specific contexts.

Question: How did obstetric-related Emergency Medical Treatment and Labor Act (EMTALA) violations change in association with state-level abortion policy?

Findings: In this difference-in-differences analysis of EMTALA violations from 2018 to the first quarter of 2023, states with no health exceptions saw a substantial rise in obstetric-related violations that were associated with policies adopted by Texas. There was a concurrent rise in emergency department utilization, and screening failures suggest that violations may have increasingly occurred on arrival before treatment.

Meaning: The study results suggest that state abortion laws may undermine federally protected care in obstetric emergencies.