Michael A. Talias

Background: In-center hemodialysis is the dominant kidney replacement therapy modality in Greece and generates substantial recurring expenditure for the public payer. Home hemodialysis is not currently implemented at national scale, but it may reduce long-term public expenditure if early investment in training capacity, equipment and home support is recovered over time. Objective: To evaluate, from the Greek public-payer perspective, the discounted budget impact and net present value (NPV) of implementing a national home hemodialysis program for 300 patients. Methods: We developed a deterministic investment-appraisal model comparing gradual implementation of home hemodialysis with continued in-center hemodialysis for the same projected cohort over 10 years. The in-center comparator was informed by a 2022 Greek patient-level micro-costing study. Home hemodialysis expenditure was constructed from explicit patient-flow equations, resource quantities, unit costs, capital purchases and hospital-tariff offsets. Annual incremental savings were discounted at 3% in the base case. Alternative discount rates, deterministic one-way sensitivity analyses and program-scale scenarios were examined. Fiscal benefit–cost ratio (BCR) and return on investment (ROI) were also calculated. Results: Undiscounted 10-year public expenditure was EUR 69,681,804 for home hemodialysis and EUR 86,700,267 for continued in-center hemodialysis, yielding savings of EUR 17,018,463. During the first 5 years, the program required EUR 1,724,012 in additional expenditure. At a 3% discount rate, NPV was EUR 12,696,564, the fiscal BCR was 2.89, fiscal ROI was 189.3% and discounted payback occurred during year 6. NPV remained positive at 5% (EUR 10,391,382) and across all tested one-way scenarios (range EUR 706,179 to EUR 24,686,948). Conclusions: The modeled national home hemodialysis program generated a positive 10-year public-payer NPV under the base-case and tested sensitivity assumptions. A positive NPV is not, however, a formal Greek health-system decision rule and does not capture health outcomes, patient and family costs, or equity. The findings support staged pilot implementation and prospective collection of Greek real-world data before wider rollout.

Background: Dialysis is a life-sustaining but resource-intensive treatment for patients with kidney failure. Contemporary Greek evidence on the public-payer cost of dialysis is limited, particularly for comparisons across modality, provider sector and treatment subtype. Methods: We performed a retrospective observational micro-costing study using 2022 patient-level data from five hemodialysis units and one peritoneal dialysis unit in Greece. The perspective was that of the public payer and public health budget. Annual costs included dialysis treatment and consumables, patient allowances and transport reimbursement, dialysis-related drugs, laboratory and imaging tests, hospitalizations and public dialysis-unit operating costs where applicable. Results: The analytic sample included 359 patients: 337 receiving hemodialysis and 22 receiving peritoneal dialysis. Median annual total cost was EUR 35,902.53 for hemodialysis and EUR 57,136.44 for peritoneal dialysis per patient. Peritoneal dialysis generated higher annual cost than hemodialysis, mainly because of treatment and consumable costs, and remained more costly after excluding dialysis-unit operating costs in sensitivity analysis. Public-sector hemodialysis had higher recorded median annual public-payer/public-budget cost than private-sector hemodialysis (EUR 38,794.55 versus EUR 34,836.98), but this difference was no longer statistically significant after excluding dialysis-unit operating costs. Hemodiafiltration was more costly than conventional hemodialysis, and automated peritoneal dialysis was more costly than continuous ambulatory peritoneal dialysis. National extrapolation estimated annual public expenditure of EUR 466.6 million using mean costs and EUR 446.8 million using median-based sensitivity estimates. Conclusions: Dialysis imposes substantial annual public expenditure in Greece. In this dataset and reimbursement context, peritoneal dialysis was more costly than hemodialysis, while private-sector hemodialysis generated lower recorded public-payer cost than public-sector provision. The apparent public–private hemodialysis cost difference was sensitive to the treatment of operating costs. These results may help inform reimbursement review, procurement policy and future budget-impact analyses of dialysis service redesign.

Background/Objectives: Medical devices are essential to modern healthcare, but their adoption is often driven by regulatory conformity, clinical enthusiasm, procurement pressures and vendor-led innovation rather than systematic evaluation of comparative value. CE marking and related regulatory mechanisms are necessary for market access; however, they do not determine whether a device improves patient-related outcomes compared with existing alternatives, whether its benefits justify its total costs, or whether it can be implemented safely in routine care. This narrative review examines why medical devices require a dedicated life-cycle health technology assessment (HTA) approach and proposes an operational framework linking assessment to adoption, evidence generation, reassessment and disinvestment. Methods: A structured targeted search covered peer-reviewed literature and policy or institutional documents addressing HTA, medical devices, regulation, economic evaluation, real-world evidence, hospital-based HTA, procurement digital and AI-enabled devices, patient involvement and post-market reassessment. Results: Medical devices differ from pharmaceuticals through user dependence, learning curves, procedure dependence, short product life cycles, incremental modification, heterogeneous comparators, limited randomized evidence and hidden life-cycle costs. These features create clinical, economic, organizational and implementation uncertainty after market entry. The proposed model specifies six linked phases: horizon scanning and early dialogue, pre-adoption appraisal, an explicit adoption decision, controlled implementation, real-world monitoring and scheduled or trigger-based reassessment leading to continuation, scale-up, restriction, or disinvestment. Practical constraints include fragmented data infrastructure, the cost of maintaining registries and residual confounding in real-world evidence. Conclusions: Medical device HTA should move beyond one-time pre-adoption assessment toward a decision-linked life-cycle model that integrates comparative value, patient and public involvement, procurement, implementation governance, real-world evidence, version monitoring, reassessment and disinvestment. This approach can support responsible innovation, patient safety, transparent procurement and sustainable health-system value.

Background/Objectives: Free riding in healthcare occurs when actors benefit from health-related public goods, risk-pooling arrangements, common resources, or cooperative institutions while contributing less than is socially optimal. This review clarifies how free-rider dynamics differ across vaccination, health insurance and universal health coverage, antimicrobial resistance, organ donation and transplant allocation, and global health cooperation. Methods: A narrative review with conceptual synthesis was conducted. Searches of PubMed and Scopus were complemented by citation tracking and targeted inclusion of foundational economics, game theory, public-health ethics, and market-design sources. Sources were mapped by domain, actors, strategies, payoff structure, information conditions, time horizon, enforcement mechanism and policy relevance. Results: Across domains, free riding arises when private payoffs diverge from collective welfare, but the underlying game differs: threshold public-good and coordination games in vaccination, adverse-selection and participation games in insurance, common-pool-resource dilemmas in antimicrobial use, donor-registration and matching-market problems in transplantation, and repeated public-goods games in global health. The review identifies three policy functions: altering payoffs, altering information and beliefs, and changing the structure, repetition, or enforceability of the game. Conclusions: Game theory is most useful as a mechanism-based framework rather than a stand-alone policy prescription. Its policy value depends on empirical calibration, institutional context, ethical legitimacy, and attention to equity, incomplete information, behavioral responses, and enforcement capacity. The synthesis also emphasizes boundary conditions: game-theoretic prescriptions can fail when political economy, asymmetric power, implementation capacity, access barriers, or trust-related drivers are ignored.

Healthcare quality systems have evolved from narrow inspection and compliance mechanisms into broader, multi-level architectures that combine standards, measurement, organizational learning, patient safety, equity and patient-reported outcomes. Yet the field remains fragmented, with substantial variation in how quality is defined, measured and operationalized across countries and healthcare settings. This narrative review synthesizes major international quality systems and frameworks used in healthcare delivery, examines principal methods for evaluating and improving quality, and critically discusses organizational and policy conditions associated with successful implementation. A purposive review of the seminal conceptual literature and authoritative documents from major international organizations was undertaken to identify cross-cutting themes relevant to hospitals, ambulatory care and health systems. The review shows that influential approaches—including the World Health Organization’s quality and patient safety frameworks, Joint Commission International accreditation, NCQA/HEDIS, the EFQM model, ISO-based management systems, AHRQ quality indicators and OECD performance initiatives such as PaRIS—should be viewed as complementary rather than competing models. Their effectiveness depends less on formal adoption alone than on leadership commitment, workforce engagement, data infrastructure, patient involvement and alignment with financing and regulation. Evidence is strongest for gains in standardization, safety processes, teamwork and selected efficiency outcomes; direct causal effects on patient outcomes remain less consistent, particularly when quality systems become compliance-driven or are insufficiently adapted to local context. Future healthcare quality systems should integrate equity, digital interoperability, AI-enabled learning capabilities, patient-reported measures and continuous improvement while reducing measurement burden and indicator proliferation.

Background: Artificial intelligence (AI) is increasingly integrated into healthcare systems, with important implications for nursing practice and clinical workflows. However, evidence regarding nurses’ digital skills, perceptions, and readiness to adopt AI-enabled technologies remains limited, particularly in national healthcare contexts such as Greece. Objectives: This study examined nurses’ digital skills, perceptions of AI, and readiness for AI adoption in clinical practice, and explored demographic and professional factors associated with these outcomes. Methods: A cross-sectional survey was conducted among 166 nurses working in two public hospitals in Greece. Results: Nurses reported moderate digital skills, with 59.1% indicating competence in email/video communication and 27.2% reporting adequate use of digital security tools, while exposure to AI remained limited (18.0% reported using AI products/services in daily life). Perceived professional impact of AI was moderate, whereas readiness for AI adoption was comparatively lower, with only 7.8% considering health professionals adequately prepared and 7.2% reporting adequate AI training. Statistical analyses indicated that educational level and computer literacy certification were positively associated with digital skills, whereas longer professional experience was negatively associated with readiness for AI adoption. Conclusions: These findings highlight a gap between general digital competence and preparedness for AI-driven healthcare applications and underline the need for targeted education and implementation strategies to support effective and ethical integration of AI in nursing practice. From a nursing workforce perspective, the results underscore the importance of integrating AI literacy into continuing professional education and aligning digital health implementation strategies with clinical nursing practice.

Immune-mediated inflammatory diseases like rheumatoid arthritis (RA) have been successfully treated using biologic disease-modifying antirheumatic drugs. These medications are not utilized as first-line treatment, in part because of their high cost, but they are frequently seen to be cost-effective for RA patient populations that do not respond adequately to conventional disease-modifying antirheumatic drugs. Moreover, not all RA patients who meet clinical eligibility criteria can access biologics, not even as second-line therapy. Recently, there has been an increasing interest in biosimilars that are highly comparable to their originator biologics in terms of efficacy and safety but generally come at a lower price. This review summarizes the potential role of biosimilars in reducing RA expenditure and increasing RA patient access to biologic therapies. As the global landscape for biosimilars continues to evolve, it is essential to consider the unique challenges and opportunities in different healthcare systems. By leveraging the potential of biosimilars, healthcare systems can improve RA management, ease its economic burden and ensure that patients have access to effective and affordable treatments. The future of RA treatment lies in the integration of biosimilars into clinical practice, offering hope for more sustainable and equitable healthcare systems.

Background: Medical cannabis continues to generate interest as a potential therapeutic option, yet its acceptance in clinical practice faces challenges, including regulatory barriers, social stigma, and gaps in scientific evidence. Methods: This study explores the perspectives of Greek medical doctors and pharmacists on medical cannabis—key stakeholders in its clinical application—through semi-structured interviews with 12 participants from each profession. Results: Medical doctors and pharmacists expressed a range of views on medical cannabis, with many acknowledging its potential while emphasizing the need for rigorous, disease-specific research. Medical doctors highlighted the lack of consistent clinical trials, concerns about drug interactions, and the fine line between medical use and misuse. Pharmacists echoed these concerns, citing regulatory inconsistencies and the need for standardized dosing. Both groups agreed that social stigma and misinformation hinder cannabis adoption, advocating for targeted education and transparent research communication. Participants indicated that regulatory barriers also pose challenges, with calls for harmonized policies and phased market entry approaches. Effective communication strategies, including digital outreach and clear messaging, were suggested to differentiate medical cannabis from recreational use and improve trust among healthcare providers and patients. Participants also highlighted the urgent need for collaboration between policymakers, researchers, and healthcare professionals to establish medical cannabis as a credible therapeutic option. Conclusion: The insights gained provide actionable recommendations to bridge existing gaps and emphasize the need for a responsible, evidence-based approach to the acceptance of medical cannabis as a therapeutic option.

Background and Aims: In recent years, In Vitro fertilization (IVF) science has grown by leaps and bounds in the field of assisted reproduction, helping millions of couples worldwide. The aim of this study is to examine the extent to which infertile women are willing to pay for IVF services in Greece. Methods: Through the distribution of questionnaires, willingness to pay (WTP) is recorded according to IVF success rates, and the relationship between WTP and the respondents' demographic characteristics is analyzed. Subjects were divided into two groups according to age and were given a hypothetical scenario, according to the contingent valuation approach. Results: The majority of women were reluctant to pay the amount of money corresponding to the average cost of an IVF cycle in Greece. In particular, participants replied that the amount they would be willing to pay is only one‐third of the indicative amount of €6000. Moreover, WTP is not influenced by the professional status or educational level of the participating women. Conclusion: This study highlights the financial barriers many couples face when pursuing assisted reproduction. If the average cost of IVF were lower, infertile women would be willing to undergo more IVF cycles if necessary. This finding has important implications for the valuation of IVF services and the development of pricing policies to enhance affordability and accessibility. Policymakers must consider reforms that balance the cost of IVF with its societal benefits. By incorporating this aspect into pricing and policy decisions, Greece can improve the accessibility of IVF services and ensure equitable treatment opportunities for all concerned individuals.

Background/Objectives: In recent years, knowledge management and digital innovation have become pivotal in transforming healthcare systems, driving efficiency and enhancing patient outcomes. This study presents a bibliometric analysis of research trends at the intersection of knowledge management and digital innovation in healthcare, examining the scope, impact, and evolution of scholarly work in this domain. Methods: Using a comprehensive dataset from the Scopus database, we analyzed 419 publications from 1985–2023 to identify influential authors, journal collaborations, and emerging topics and methodologies in the field. Results: Our findings reveal a significant increase in research interest, highlighting themes such as data-driven healthcare, artificial intelligence in clinical decision support, and knowledge-sharing platforms’ role in improving healthcare delivery. The analysis also underscores the growing importance of interdisciplinary collaboration between healthcare providers, technologists, and policy-makers. Conclusions: By mapping the intellectual structure of knowledge management and digital innovation in healthcare, this study provides valuable insights for academics, practitioners, and policy-makers seeking to harness knowledge management practices and digital technologies to foster innovation and resilience in healthcare systems.