METHODS: Data spanning 2011 to 2019, sourced from the WHO Global Health Observatory and the World Bank Database, form the foundation of this study. This study employs an enhanced two-stage data envelopment analysis (DEA) to assess the efficiency of health system stages in ASEAN countries. Equity in health resource distribution is evaluated using health resource agglomeration degree and concentration curves across demographic, geographic, and economic aspects. Furthermore, the Entropy-Weighted TOPSIS method is utilized to integrate equity across these dimensions, measuring the overall fairness in health resource allocation across different countries. Finally, rankings of health system fairness and efficiency are compared to assess the overall development level of health systems.
RESULTS: The overall efficiency of the ASEAN health systems from 2011 to 2019 averaged 0.231, with an upward trend in the first stage efficiency at 0.559 and a downward trend in the second stage at 0.502. The health resource agglomeration degree indicated that Singapore, Brunei, and Malaysia had HRAD and HRPD values significantly greater than 1, and Cambodia, Myanmar, and Laos predominantly had indices significantly less than 1. The concentration curve for hospital beds was the closest to the line of absolute equity. During the study period, the health resource concentration curve increasingly approached absolute equity, shifting from above to below the concentration curve. Singapore, Brunei, and Malaysia consistently remained in the first quadrant of the quadrant plot, and Myanmar and Cambodia were consistently in the third quadrant.
CONCLUSION: ASEAN countries face two key challenges in their healthcare systems: first, while many nations such as Indonesia, Thailand, and Vietnam have improved resource allocation efficiency, this hasn't yet translated into better health services. To address this, establishing national health sector steering committees, focusing on workforce training and retention, and implementing centralized monitoring systems are crucial. Second, there is a growing disparity in healthcare development across ASEAN. Promoting balanced resource distribution and leveraging ASEAN's economic integration for regional collaboration will help bridge these gaps and foster more equitable healthcare systems.
METHODS: LA reservoir strain (LASr), LA conduit strain (LAScd), and LA contractile strain (LASct) were measured using speckle-tracking echocardiography. The primary outcome was a composite of all-cause mortality, heart failure hospitalization, progression to New York Heart Association functional class III or IV, acute coronary syndrome, or syncope. Secondary outcomes 1 and 2 comprised the same end points but excluded acute coronary syndrome and additionally syncope, respectively. The prognostic performance of phasic LA strain cutoffs was evaluated in competing risk analyses, aortic valve replacement being the competing risk.
RESULTS: Among 173 patients (mean age, 69 ± 11 years; mean peak transaortic velocity, 4.0 ± 0.8 m/sec), median LASr, LAScd, and LASct were 27% (interquartile range [IQR], 22%-32%), 12% (IQR, 8%-15%), and 16% (IQR, 13%-18%), respectively. Over a median of 2.7 years (IQR, 1.4-4.6 years), the primary outcome and secondary outcomes 1 and 2 occurred in 66 (38%), 62 (36%), and 59 (34%) patients, respectively. LASr < 20%, LAScd < 6%, and LASct < 12% were identified as optimal cutoffs of the primary outcome. In competing risk analyses, progressing from echocardiographic to echocardiographic-clinical and combined models incorporating N-terminal pro-B-type natriuretic peptide, LA strain parameters outperformed other key echocardiographic variables and significantly predicted clinical outcomes. LASr < 20% was associated with the primary outcome and secondary outcome 1, LAScd < 6% with all clinical outcomes, and LASct < 12% with secondary outcome 2. LAScd < 6% had the highest specificity (95%) and positive predictive value (82%) for the primary outcome, and competing risk models incorporating LAScd < 6% had the best discriminative value.
CONCLUSIONS: In well-compensated patients with moderate to severe aortic stenosis and preserved left ventricular ejection fractions, LA strain was superior to other echocardiographic indices and incremental to N-terminal pro-B-type natriuretic peptide for risk stratification. LAScd < 6%, LASr < 20%, and LASct < 12% identified patients at higher risk for adverse outcomes.