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Kraft KB, Hoff EH, Nylenna M, Moe CF, Mykletun A, Østby K. Time is money: general practitioners' reflections on the fee-for-service system. BMC Health Serv Res 2024; 24:472. [PMID: 38622602 PMCID: PMC11020312 DOI: 10.1186/s12913-024-10968-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/09/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions. METHODS We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis. RESULTS We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees. CONCLUSIONS GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.
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Affiliation(s)
- Kristian B Kraft
- Cluster for Health Services Research, Norwegian Institute of Public Health, Oslo, Norway.
- Institute of Health and Society, University of Oslo, Oslo, Norway.
| | - Eivor H Hoff
- Cluster for Health Services Research, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Office of the Auditor General of Norway, Oslo, Norway
| | - Magne Nylenna
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Cathrine F Moe
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Arnstein Mykletun
- Cluster for Health Services Research, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Centre for Research and Education in Forensic Psychiatry and Psychology, Haukeland University Hospital, Bergen, Norway
| | - Kristian Østby
- Cluster for Health Services Research, Norwegian Institute of Public Health, Oslo, Norway
- Løkkegården GP Medical Centre, Ski, Norway
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Hoff EH, Kraft KB, Moe CF, Nylenna M, Østby KA, Mykletun A. The cost of saying no: general practitioners' gatekeeping role in sickness absence certification. BMC Public Health 2024; 24:439. [PMID: 38347474 PMCID: PMC10860288 DOI: 10.1186/s12889-024-17993-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.
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Affiliation(s)
- Eivor Hovde Hoff
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway.
- Office of the Auditor General of Norway, Oslo, Norway.
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.
- , Myrens verksted 3L, Oslo, 0476, Norway.
| | - Kristian B Kraft
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Cathrine F Moe
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Magne Nylenna
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kristian A Østby
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
| | - Arnstein Mykletun
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Centre for Research and Education in Forensic Psychiatry and Psychology, Haukeland University Hospital, Bergen, Norway
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Gong JH, Jiang K, Azad TD. Trends in Utilization and Reimbursement of Interspinous Process Devices in the Medicare Population. Spine (Phila Pa 1976) 2023; 48:E417-E419. [PMID: 36972146 DOI: 10.1097/brs.0000000000004636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/12/2023] [Indexed: 06/18/2023]
Affiliation(s)
- Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Does prospective payment influence quality of care? A systematic review of the literature. Soc Sci Med 2023; 323:115812. [PMID: 36913795 DOI: 10.1016/j.socscimed.2023.115812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/30/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
In the light of rising health expenditures, the cost-efficient provision of high-quality inpatient care is on the agenda of policy-makers worldwide. In the last decades, prospective payment systems (PPS) for inpatient care were used as an instrument to contain costs and increase transparency of provided services. It is well documented in the literature that prospective payment has an impact on structure and processes of inpatient care. However, less is known about its effect on key outcome indicators of quality of care. In this systematic review, we synthesize evidence from studies investigating how financial incentives induced by PPS affect indicators of outcome quality domains of care, i.e. health status and user evaluation outcomes. We conduct a review of evidence published in English, German, French, Portuguese and Spanish language produced since 1983 and synthesize results of the studies narratively by comparing direction of effects and statistical significance of different PPS interventions. We included 64 studies, where 10 are of high, 18 of moderate and 36 of low quality. The most commonly observed PPS intervention is the introduction of per-case payment with prospectively set reimbursement rates. Abstracting evidence on mortality, readmission, complications, discharge disposition and discharge destination, we find the evidence to be inconclusive. Thus, claims that PPS either cause great harm or significantly improve the quality of care are not supported by our findings. Further, the results suggest that reductions of length of stay and shifting treatment to post-acute care facilities may occur in the course of PPS implementations. Accordingly, decision-makers should avoid low capacity in this area.
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Waitzberg R, Gottlieb N, Quentin W, Busse R, Greenberg D. Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations? Int J Health Policy Manag 2022; 11:1823-1834. [PMID: 34634873 PMCID: PMC9808238 DOI: 10.34172/ijhpm.2021.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/17/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems. METHODS We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning. RESULTS Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making. CONCLUSION Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
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Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
| | - Nora Gottlieb
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Wieczorek E, Kocot E, Evers S, Sowada C, Pavlova M. Do financial aspects affect care transitions in long-term care systems? A systematic review. Arch Public Health 2022; 80:90. [PMID: 35321727 PMCID: PMC8941782 DOI: 10.1186/s13690-022-00829-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/13/2022] [Indexed: 11/19/2022] Open
Abstract
Background Suboptimal care transitions of older adults may ultimately lead to worse quality of care and increased costs for the health and social care systems. Currently, policies and financing often focus on care in specific settings only, and neglect quality of care during transitions between these settings. Therefore, appropriate financing mechanisms and improved care coordination are necessary for effective care transitions. This study aims to review all available evidence on financial aspects that may have an impact on care transitions in LTC among older adults. Methods This systematic review was performed as part of the European TRANS-SENIOR project. The databases Medline, EMBASE (Excerpta Medica Database) and CINAHL (Cumulated Index to Nursing and Allied Health Literature) were searched. Studies were included if they reported on organizational and financial aspects that affect care transitions in long-term care systems. Results All publications included in this review (19 studies) focused specifically on financial incentives. We identified three types of financial incentives that may play a significant role in care transition, namely: reimbursement mechanism, reward, and penalty. The majority of the studies discussed the role of rewards, specifically pay for performance programs and their impact on care coordination. Furthermore, we found that the highest interest in financial incentives was in primary care settings. Conclusions Overall, our results suggest that financial incentives are potentially powerful tools to improve care transition among older adults in long-term care systems and should be taken into consideration by policy-makers. Trial registration A review protocol was developed and registered in the International Prospective Register of Systematic Reviews (PROSPERO) under identification number CRD42020162566. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00829-y.
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Affiliation(s)
- Estera Wieczorek
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland. .,Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Ewa Kocot
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Silvia Evers
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Christoph Sowada
- Department of Health Economics and Social Security, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Milena Pavlova
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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Changes in Performance of Apical Suspension at the Time of Surgery for Prolapse: Assessment of the Influence of the American Urogynecologic Society and American College of Obstetricians and Gynecologists Practice Bulletin. Female Pelvic Med Reconstr Surg 2022; 28:367-371. [PMID: 35113047 DOI: 10.1097/spv.0000000000001136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the association of publication of the American Urogynecologic Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin on pelvic organ prolapse and performance of an apical suspension at the time of surgery for pelvic organ prolapse. METHODS Surgical procedures performed with a primary diagnosis of uterovaginal or female genital prolapse, cystocele, or enterocele were isolated from the 2011 to 2019 American College of Surgeons National Surgical Quality Improvement Program Database. An autoregressive interrupted time series regression estimated the overall temporal trend in performance of an apical suspension and assessed for a change in trend associated with publication of the AUGS/ACOG Practice Bulletin in April 2017. A stratified analysis was also performed depending on performance of a concomitant hysterectomy, and sensitivity analysis was performed using only diagnoses of uterovaginal or vaginal vault prolapse. RESULTS There were 72,194 individuals identified; 83.4% had a diagnosis of uterovaginal or female genital prolapse, 15.2% cystocele and 1.4% enterocele. Only 36.6% of cases had an apical suspension. Prior to the practice bulletin publication, performance of an apical suspension grew at 0.19% per quarter (95% confidence interval [CI], 0.07-0.31), with a trend toward increased utilization (+0.12%; 95% CI, -0.06 to 0.30) after publication. The increase was greater among cases with a concomitant hysterectomy (+0.35%; 95% CI, 0.08-0.62). Sensitivity analyses found similar changes in trend. CONCLUSIONS Performance of apical suspensions during surgery for prolapse remains low and is increasing at less than 1% per year. The AUGS/ACOG practice guidelines were associated with minimal changes in this pattern. Incentives or other strategies may be needed to further encourage standard of care management of prolapse.
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Giancotti M, Mauro M, Rania F. Exploring the effectiveness of a P4P scheme from the perspective of Italian general practitioners: A replication study. Int J Health Plann Manage 2022; 37:1526-1544. [DOI: 10.1002/hpm.3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/08/2021] [Accepted: 01/03/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Monica Giancotti
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Marianna Mauro
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Francesco Rania
- Department of Law, Economics and Sociology Magna Graecia University of Catanzaro Catanzaro Italy
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Mulyanto J, Kunst AE, Kringos DS. The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis. J Glob Health 2021; 10:020428. [PMID: 33312501 PMCID: PMC7719271 DOI: 10.7189/jogh.10.020428] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use. Methods Using data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities. Results Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66). Conclusions Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.
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Affiliation(s)
- Joko Mulyanto
- Department of Public Health and Community Medicine, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia.,Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam; and Amsterdam Public Health research institute, Amsterdam, Netherlands
| | - Anton E Kunst
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam; and Amsterdam Public Health research institute, Amsterdam, Netherlands
| | - Dionne S Kringos
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam; and Amsterdam Public Health research institute, Amsterdam, Netherlands
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Lebenbaum M, Chiu M, Holder L, Vigod S, Kurdyak P. Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study. Psychol Med 2021; 51:1666-1675. [PMID: 32188517 DOI: 10.1017/s0033291720000392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission. METHODS This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors. RESULTS Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED. CONCLUSIONS We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.
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Affiliation(s)
- Michael Lebenbaum
- ICES, 2075 Bayview Avenue, G-106, Toronto, Ontario, Canada, M4N3M5
- Institute of Health Policy, Management and Evaluation, 155 College St, 4th Floor, Toronto, Ontario, Canada, M5T 3M6
| | - Maria Chiu
- ICES, 2075 Bayview Avenue, G-106, Toronto, Ontario, Canada, M4N3M5
- Institute of Health Policy, Management and Evaluation, 155 College St, 4th Floor, Toronto, Ontario, Canada, M5T 3M6
| | - Laura Holder
- ICES, 2075 Bayview Avenue, G-106, Toronto, Ontario, Canada, M4N3M5
| | - Simone Vigod
- ICES, 2075 Bayview Avenue, G-106, Toronto, Ontario, Canada, M4N3M5
- Institute of Health Policy, Management and Evaluation, 155 College St, 4th Floor, Toronto, Ontario, Canada, M5T 3M6
- Women's College Hospital and Research Institute, 76 Grenville St, Toronto, Ontario, Canada, M5G 1N8
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, Canada, M5T 1R8
| | - Paul Kurdyak
- ICES, 2075 Bayview Avenue, G-106, Toronto, Ontario, Canada, M4N3M5
- Institute of Health Policy, Management and Evaluation, 155 College St, 4th Floor, Toronto, Ontario, Canada, M5T 3M6
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, Ontario, Canada, M5T 1R8
- Center for Addiction and Mental Health, 250 College St, Toronto, Ontario, Canada, M5T 1L8
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Chukwuma A, Lylozian H, Gong E. Challenges and Opportunities for Purchasing High-Quality Health Care: Lessons from Armenia. Health Syst Reform 2021; 7:e1898186. [PMID: 33914676 DOI: 10.1080/23288604.2021.1898186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
This paper examines how purchasing decisions in Armenia may contribute to barriers in using high-quality health care, particularly for non-communicable diseases, drawing on a review of the literature and key informant interviews. The paper adapts the strategic health purchasing progress framework, to examine how characteristics of purchasing, the health system, and the political, administrative, and macro-fiscal environment may have facilitated or hindered the attainment of service delivery goals. We conclude with six lessons for reforms aimed at improving the coverage and quality of health care in Armenia. First, increasing the political priority of access to quality of health care is a pre-requisite to advancing reforms to address these issues. Second, improved purchasing governance in Armenia will require a purchaser that can make decisions without political interference, with appropriate accountability mechanisms, improvements in technical capacity, and the routine use of data systems. Third, there is a need for the regulatory framework to ensure that revisions of the benefits package contribute to reducing the disease burden and improving access to care. Fourth, regulations governing quality-related criteria for provider selection should be enforced and include considerations for process quality. Fifth, payment incentives should be revised to encourage an increase in the supply of primary health care, reduce bypassing for hospital care, and improve the quality of services. Sixth, the potential of purchasing to improve service delivery will be dependent on increased pre-paid and pooled funds and better governance of the quality of care.
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Affiliation(s)
- Adanna Chukwuma
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, USA
| | - Hratchia Lylozian
- Health, Nutrition, and Population Global Practice, World Bank Group, Washington, DC, USA
| | - Estelle Gong
- Mount Sinai Health System, New York, New York, USA
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Vengberg S, Fredriksson M, Burström B, Burström K, Winblad U. Money matters - primary care providers' perceptions of payment incentives. J Health Organ Manag 2021; ahead-of-print. [PMID: 33522211 DOI: 10.1108/jhom-06-2020-0225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work. DESIGN/METHODOLOGY/APPROACH An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system. FINDINGS Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses. PRACTICAL IMPLICATIONS Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers. ORIGINALITY/VALUE This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.
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Affiliation(s)
- Sofie Vengberg
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Mio Fredriksson
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
| | - Bo Burström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Kristina Burström
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Winblad
- Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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Jia L, Meng Q, Scott A, Yuan B, Zhang L. Payment methods for healthcare providers working in outpatient healthcare settings. Cochrane Database Syst Rev 2021; 1:CD011865. [PMID: 33469932 PMCID: PMC8094987 DOI: 10.1002/14651858.cd011865.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.
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Affiliation(s)
- Liying Jia
- Center for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China
- NHC Key Lab for Health Economics and Policy Research, Shandong University, Jinan, China
| | - Qingyue Meng
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Carlton, Melbourne, Australia
| | - Beibei Yuan
- China Center for Health Development Studies (CCHDS), Peking University, Beijing, China
| | - Lu Zhang
- Weihai Health Care Security Administration, Weihai, China
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Heider AK, Mang H. Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:655-667. [PMID: 32207083 PMCID: PMC7519000 DOI: 10.1007/s40258-020-00572-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important. OBJECTIVES The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups. METHODS In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections. RESULTS We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included. CONCLUSIONS Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.
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Affiliation(s)
- Ann-Kathrin Heider
- Faculty of Medicine, Master Program Medical Process Management, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
| | - Harald Mang
- Master Program Medical Process Management, Universitätsklinikum Erlangen, Erlangen, Germany
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Gupta N, Ayles HM. The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage. HUMAN RESOURCES FOR HEALTH 2020; 18:69. [PMID: 32962707 PMCID: PMC7507591 DOI: 10.1186/s12960-020-00512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 09/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. METHODS A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. FINDINGS Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients' sex with the policy intervention. Few (15%) of the studies controlled for the provider's sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). CONCLUSIONS There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.
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Affiliation(s)
- Neeru Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, 9 Macaulay Lane, Fredericton, New Brunswick, E3B 5A3, Canada.
| | - Holly M Ayles
- Faculty of Management, University of New Brunswick, PO Box 4400, 7 Macaulay Lane, Fredericton, New Brunswick, E3B 5A3, Canada
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Gruß I, Pihlstrom DJ, Kaplan CD, Yosuf N, Fellows JL, Guerrero EG, Polk DE. Stakeholder Assessment of Evidence-Based Guideline Dissemination and Implementation in a Dental Group Practice. JDR Clin Trans Res 2020; 6:87-95. [PMID: 32040925 DOI: 10.1177/2380084420903999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This evaluation captures the perspectives of multiple stakeholders within a salaried dental care delivery organization (dentists, dental assistants, dental hygienists, and dental management) on the implementation of a pit-and-fissure sealant guideline in the Kaiser Permanente Dental Program. Also assessed is the role of formal processes and structures in providing a framework for guideline implementation. METHODS We collected qualitative data through field observations, stakeholder interviews (n = 6), and focus groups (30 participants in 5 focus groups). Field observation notes captured summaries of conversations and other activities. Interviews and focus groups were recorded and transcribed. We analyzed transcripts and field notes using a template analysis with NVivo 12 software to identify themes related to the existing implementation process of clinical guidelines and stakeholder perspectives on the strengths and weaknesses of this process. RESULTS Stakeholders perceived 2 main barriers for achieving implementation of the pit-and-fissure sealant guideline: 1) shortcomings in the implementation infrastructure resulting in lack of clarity about the roles and responsibilities in the guideline implementation process and lack of effective mechanisms to disseminate guideline content and 2) resource constraints, such as limited human, space, and material resources. Perceived opportunities for the dissemination and implementation of guidelines included recognition of the importance of guidelines in dental practice and well-functioning workflows within dental specialties. CONCLUSION Our research points to the importance of developing and maintaining an infrastructure to ensure standardized, predictable mechanisms for implementation of guidelines and thereby promoting practice change. While addressing resource constraints may not be possible in all circumstances, an important step for improving guideline implementation-wherever feasible-would be the development of a robust implementation infrastructure that captures and delineates roles and responsibilities of different clinical actors in the guideline implementation process. KNOWLEDGE TRANSFER STATEMENT The results of this study can be used by health care leadership and administrators to understand possible reasons for a lack of guideline implementation and provide suggestions for establishing sustainable infrastructure to promote the adoption of clinical guidelines in salaried dental clinics.
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Affiliation(s)
- I Gruß
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | | | - C D Kaplan
- University of Southern California Suzanne Dworak-Peck School of Social Work, Los Angeles, CA, USA
| | - N Yosuf
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - J L Fellows
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - E G Guerrero
- I-Lead Institute-Research to End Healthcare Disparities Corp, Santa Monica, CA, USA
| | - D E Polk
- University of Pittsburgh, Pitt Dental Medicine, Pittsburgh, PA, USA
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Sineshaw HM, Sahar L, Osarogiagbon RU, Flanders WD, Yabroff KR, Jemal A. County-Level Variations in Receipt of Surgery for Early-Stage Non-small Cell Lung Cancer in the United States. Chest 2020; 157:212-222. [PMID: 31813533 PMCID: PMC6965692 DOI: 10.1016/j.chest.2019.09.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 09/09/2019] [Accepted: 09/12/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Although counties are the smallest geographic level for comprehensive health-care delivery analysis, little is known about county-level variations in receipt of curative-intent surgery for early-stage non-small cell lung cancer (NSCLC) and factors contributing to such variations in the United States. METHODS A total of 179,189 patients aged ≥ 35 years who were diagnosed with stage I to II NSCLC between 2007 and 2014 in 2,263 counties were identified from 39 states, the District of Columbia, and Detroit population-based cancer registries; the data were compiled by the North American Association of Central Cancer Registries. The percentage of patients who underwent surgery was calculated for each county with ≥ 20 cases. Adjusted risk ratios were generated by using generalized estimating equation models with modified Poisson regression. RESULTS Receipt of surgery for early-stage NSCLC during 2007 to 2014 according to county ranged from 12.8% to 48.6% in the lowest decile of counties, to 74.3% to 91.7% in the highest decile of counties. There were pockets of low surgery receipt rate counties within each state. For example, there was a 25% absolute difference between the lowest and highest surgery receipt rate counties in Massachusetts. Counties in the lowest quartile for receipt of surgery were those with a high proportion of non-Hispanic black subjects, high poverty and uninsured rates, low surgeon-to-population ratio, and nonmetropolitan status. CONCLUSIONS Receipt of curative-intent surgery for early-stage NSCLC varied substantially across counties in the United States, with pockets of low receipt counties in each state. Low surgery receipt counties were characterized by unfavorable area-level socioeconomic and health-care delivery factors.
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Affiliation(s)
| | | | | | - W Dana Flanders
- American Cancer Society, Atlanta, GA; Rollins School of Public Health, Emory University, Atlanta, GA
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Gupta N, Ayles HM. Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1303-1315. [PMID: 31401699 DOI: 10.1007/s10198-019-01097-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems. METHODS Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs. RESULTS We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts. CONCLUSION Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada.
| | - Holly M Ayles
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada
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Planning for the Rheumatologist Workforce: Factors Associated With Work Hours and Volumes. J Clin Rheumatol 2019; 25:142-146. [PMID: 29846270 DOI: 10.1097/rhu.0000000000000803] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate factors associated with rheumatologists' clinical work hours and patient volumes based on a national workforce survey in rheumatology. METHODS Adult rheumatologists who participated in a 2015 workforce survey were included (n = 255). Univariate analysis evaluated the relationship between demographics (sex, age, academic vs. community practice, billing fee for service vs. other plan, years in practice, retirement plans) and workload (total hours and number of ½-day clinics per week) or patient volumes (number of new and follow-up consults per week). Multiple linear regression models were used to evaluate the relationship between practice type, sex, age, and working hours or clinical volumes. RESULTS Male rheumatologists had more ½-day clinics (p = 0.05) and saw more new patients per week (p = 0.001) compared with females. Community rheumatologists had more ½-day clinics and new and follow-up visits per week (all p < 0.01). Fee-for-service rheumatologists reported more ½-day clinics per week (p < 0.001) and follow-ups (p = 0.04). Workload did not vary by age, years in practice, or retirement plans. In multivariate analysis, community practice remained independently associated with higher patient volumes and more clinics per week. Female rheumatologists reported fewer clinics and fewer follow-up patients per week than males, but this did not affect the duration of working hours or new consultations. Age was not associated with work volumes or hours. CONCLUSIONS Practice type and rheumatologist sex should be considered when evaluating rheumatologist workforce needs, as the proportion of female rheumatologists has increased over time and alternative billing practices have been introduced in many centers.
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Abstract
BACKGROUND Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care. OBJECTIVES Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic. SELECTION CRITERIA We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms. DATA COLLECTION AND ANALYSIS Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables. MAIN RESULTS We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance. AUTHORS' CONCLUSIONS It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.
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Affiliation(s)
- Tim Mathes
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Dawid Pieper
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Johannes Morche
- Federal Joint CommitteeMedical Consultancy DepartmentWegelystraße 8BerlinGermany
| | - Stephanie Polus
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
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van Egmond S, Wakkee M, van Rengen A, Bastiaens M, Nijsten T, Lugtenberg M. Factors influencing current low-value follow-up care after basal cell carcinoma and suggested strategies for de-adoption: a qualitative study. Br J Dermatol 2019; 180:1420-1429. [PMID: 30597525 PMCID: PMC6850416 DOI: 10.1111/bjd.17594] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Providing follow-up to patients with low-risk basal cell carcinoma (BCC) can be considered as low-value care. However, dermatologists still provide substantial follow-up care to this patient group, for reasons not well understood. OBJECTIVES To identify factors influencing current BCC follow-up practices among dermatologists and suggested strategies to de-adopt this low-value care. In addition, views of patients regarding follow-up care were explored. METHODS A qualitative study was conducted consisting of 18 semistructured interviews with dermatologists and three focus groups with a total of 17 patients with low-risk BCC who had received dermatological care. The interviews focused on current follow-up practices, influencing factors and suggested strategies to de-adopt the follow-up care. The focus groups discussed preferred follow-up schedules and providers, as well as the content of follow-up. All (group) interviews were transcribed verbatim and analysed by two researchers using ATLAS.ti software. RESULTS Factors influencing current follow-up care practices among dermatologists included complying with patients' preferences, lack of trust in general practitioners (GPs), financial incentives and force of habit. Patients reported varying needs regarding periodic follow-up visits, preferred to be seen by a dermatologist and indicated a need for improved information provision. Suggested strategies by dermatologists to de-adopt the low-value care encompassed educating patients with improved information, educating GPs to increase trust of dermatologists, realizing appropriate financial reimbursement and informing dermatologists about the low value of care. CONCLUSIONS A mixture of factors appear to contribute to current follow-up practices after low-risk BCC. In order to de-adopt this low-value care, strategies should be aimed at dermatologists and GPs, and also patients.
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Affiliation(s)
- S. van Egmond
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of Public HealthErasmus MC University Medical CenterRotterdamthe Netherlands
| | - M. Wakkee
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - A. van Rengen
- Department of DermatologyMohs KliniekenDordrechtthe Netherlands
| | - M.T. Bastiaens
- Department of DermatologyElisabeth‐TweeSteden HospitalTilburgthe Netherlands
| | - T. Nijsten
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
| | - M. Lugtenberg
- Department of DermatologyErasmus MC Cancer InstituteRotterdamthe Netherlands
- Department of Public HealthErasmus MC University Medical CenterRotterdamthe Netherlands
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Davari M, Khorasani E, Tigabu BM. Factors Influencing Prescribing Decisions of Physicians: A Review. Ethiop J Health Sci 2019; 28:795-804. [PMID: 30607097 PMCID: PMC6308758 DOI: 10.4314/ejhs.v28i6.15] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The pharmaceutical bill is increasing at an alarming rate. The physician practice variation has a pronounced effect on healthcare spending. A number of factors can influence the prescribing behavior of physicians. The aim of this review was to identify the factors affecting the prescribing decision of physicians. Methods Electronic databases including Scopus, PubMed/MEDLINE CENTRAL, Cochrane Libraries and Google scholar were searched systematically for literatures on factors influencing prescribing decisions of physicians from 2000 to 2016. There was no restriction on the study designs. Results Thirty-three studies met the inclusion criteria from 1122 search results. A total of 33 factors were identified. The most frequent factors were patients' clinical condition, pharmaceutical industries, physician attributes, patient preference and cost of medicine. Conclusion Physicians' personal attributes, cost of the medicine and pharmaceutical industries' marketing and promotion strategies were mostly mentioned to influence prescribing decision. The identified factors showed that prescribing is not only geared for patient benefit, but also towards personal interest. The use of valid and reliable practice guidelines could reduce the negative impact of wide ranges of factors and promote the rational prescribing effectively.
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Affiliation(s)
- Majid Davari
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Pharmaceutical Research Center, Tehran University of Medical Sciences
| | - Elahe Khorasani
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Pharmaceutical Research Center, Tehran University of Medical Sciences.,Faculty of Pharmacy, Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Bereket Molla Tigabu
- Department of Pharmacoeconomics and Pharmaceutical Administration, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran.,Pharmaceutical Research Center, Tehran University of Medical Sciences.,Tehran University of Medical Sciences, International Campus.,Haramaya University, School of Pharmacy, Ethiopia
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Antecedents of Symmetry in Physicians’ Prescription Behavior: Evidence from SEM-based Multivariate Approach. Symmetry (Basel) 2018. [DOI: 10.3390/sym10120721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The aim of this paper is to examine the direct impact of marketing and medical tools on the symmetry of physicians’ prescription behavior in the context of the Pakistani healthcare sector. This research also investigates the moderating influence of corporate image and customer relationship in an association of marketing & medical tools, and the symmetry of physicians’ prescription behavior. The survey involved a research sample of 740 physicians, comprising 410 general practitioners and 330 specialists. A series of multivariate approaches such as exploratory factor analysis, confirmatory factor analyses, and conditional process analysis are employed. The findings of the study showed that marketing & medical tools have a direct, positive, and significant influence on physicians’ symmetrical prescription behavior. Corporate image and customer relationship have also a significant impact as moderating variables between marketing & medical tools, and the symmetry of prescription behavior of physicians. The outcomes of this research are beneficial to marketers and medical managers in the pharmaceutical industry.
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Eliyas S, Briggs PFA, Newton JT, Gallagher JE. Feasibility of assessing training of primary care dental practitioners in endodontics of moderate complexity: mapping process and learning. Br Dent J 2018; 225:325-334. [PMID: 30141484 DOI: 10.1038/sj.bdj.2018.644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 12/28/2022]
Abstract
Objectives To explore the feasibility of measuring quality of endodontic care provided by general dental practitioners (GDPs), using clinical, radiographic and patient-related outcomes, as well as understanding practitioner views and estimating financial costs. Methods Multi-faceted mixed-methods two-part study involving retrospective analysis of the educational component (course assessments, endodontic training blocks and analysis of a sample of teeth treated at the beginning and end of training), and prospective analysis of patients treated by these dentists after completion of training. Participant Dentists working in and patients treated in primary dental care in London. Intervention Twenty-four-month training in endodontics. Comparison Dentists enrolled in the training at different time points. Outcome Measuring outcome of endodontic treatment. Results Eight dentists (mean 36 years, SD = 8.2 years) participated in training. Subsequently, five of these dentists (mean 34.2 years, SD = 7.08 years) contributed to the prospective study and recruited 135 patients. Thirty-five patients completed all patient-related outcome questionnaires, and of these there were 16 cases with complete clinical and radiographic data (12%) at follow-up (10.1–36.4 months). Preliminary analysis revealed that a minimum of 45 cases of complete data would be required for multivariate analysis, requiring the recruitment of in excess of 375 patients to future studies to account for this level of loss to follow-up. Conclusions Findings suggest it is possible to carry out mixed-methods and treatment-related outcome-based research in primary care. Measurement/data capture tools developed were tested and used successfully in measuring the adherence to treatment processes and outcome of endodontic treatment.
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Affiliation(s)
- S Eliyas
- St George's University Hospital's NHS Foundation Trust and Hodsoll House Specialist Practice, Kent, UK
| | - P F A Briggs
- Barts Health NHS Trust, Whitechapel, London, UK.,Health Education England London and South East, Stewart House, Russell Square London, UK
| | - J T Newton
- King's College London Dental Institute, Population and Patient Health Division, London, UK
| | - J E Gallagher
- King's College London Dental Institute, Population and Patient Health Division, London, UK
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Korlén S, Essén A, Lindgren P, Amer-Wahlin I, von Thiele Schwarz U. Managerial strategies to make incentives meaningful and motivating. J Health Organ Manag 2018; 31:126-141. [PMID: 28482774 PMCID: PMC5868553 DOI: 10.1108/jhom-06-2016-0122] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Purpose Policy makers are applying market-inspired competition and financial incentives to drive efficiency in healthcare. However, a lack of knowledge exists about the process whereby incentives are filtered through organizations to influence staff motivation, and the key role of managers is often overlooked. The purpose of this paper is to explore the strategies managers use as intermediaries between financial incentives and the individual motivation of staff. The authors use empirical data from a local case in Swedish specialized care. Design/methodology/approach The authors conducted an exploratory qualitative case study of a patient-choice reform, including financial incentives, in specialized orthopedics in Sweden. In total, 17 interviews were conducted with professionals in managerial positions, representing six healthcare providers. A hypo-deductive, thematic approach was used to analyze the data. Findings The results show that managers applied alignment strategies to make the incentive model motivating for staff. The managers’ strategies are characterized by attempts to align external rewards with professional values based on their contextual and practical knowledge. Managers occasionally overruled the financial logic of the model to safeguard patient needs and expressed an interest in having a closer dialogue with policy makers about improvements. Originality/value Externally imposed incentives do not automatically motivate healthcare staff. Managers in healthcare play key roles as intermediaries by aligning external rewards with professional values. Managers’ multiple perspectives on healthcare practices and professional culture can also be utilized to improve policy and as a source of knowledge in partnership with policy makers.
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Affiliation(s)
- Sara Korlén
- Medical Management Centre, LIME, Karolinska Institute , Stockholm, Sweden
| | - Anna Essén
- Center for Human Resource Management and Knowledge Work, Stockholm School of Economics, Stockholm, Sweden
| | - Peter Lindgren
- Medical Management Centre, LIME, Karolinska Institute , Stockholm, Sweden.,The Swedish Institute for Health Economics , Stockholm, Sweden
| | - Isis Amer-Wahlin
- Medical Management Centre, LIME, Karolinska Institute , Stockholm, Sweden
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Paying hospital specialists: Experiences and lessons from eight high-income countries. Health Policy 2018; 122:473-484. [DOI: 10.1016/j.healthpol.2018.03.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 02/09/2018] [Accepted: 03/08/2018] [Indexed: 01/26/2023]
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Laliberté M. Facteurs influençant la multiplication de traitements en physiothérapie : une analyse thématique de la jurisprudence québécoise. BIOÉTHIQUEONLINE 2018. [DOI: 10.7202/1044610ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
La physiothérapie est touchée par un problème de multiplication de traitements; la fréquence des traitements ou leur durée peuvent être inappropriées ou disproportionnées face aux besoins du patient. La multiplication de traitements peut avoir des conséquences financières, physiques, psychologiques et sociales. Pour explorer les facteurs influençant la fréquence et la durée des traitements dans les situations de multiplication de traitements, une analyse thématique de la jurisprudence a été réalisée. Certains facteurs cliniques et non cliniques influençant la fréquence et la durée des traitements ont pu être identifiés par cette analyse thématique de la jurisprudence. Les facteurs cliniques impliquent que l’allocation des ressources soit guidée par la condition et l’évolution du patient. Les facteurs non cliniques peuvent inclure la pression des employeurs, les demandes des autres professionnels de la santé ou les conflits d’intérêts de type financier. Cette analyse thématique de la jurisprudence est une première étape pour comprendre ce qui motive les décisions cliniques d’allocation des ressources des professionnels de la physiothérapie. Cette démarche est essentielle pour mettre en place des politiques et des normes de pratique soucieuses du contexte de pratique et des normes éthiques, déontologiques et légales qui animent la profession.
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Affiliation(s)
- Maude Laliberté
- École de réadaptation, Faculté de médecine, Université de Montréal, Montréal, Canada
- Programmes de bioéthique, Département de médecine sociale et préventive, École de santé publique de l’Université de Montréal
- Membre étudiant de l’Institut de recherche en santé publique de l’Université de Montréal (IRSPUM)
- Membre étudiant du Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR)
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Andoh-Adjei FX, Spaan E, Asante FA, Mensah SA, van der Velden K. A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries. Ghana Med J 2018; 50:207-219. [PMID: 28579626 DOI: 10.4314/gmj.v50i4.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries. METHODS We did narrative review and synthesis of the literature on the effects of capitation payment on primary care. RESULTS Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship. CONCLUSION The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care. FUNDING Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352.
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Affiliation(s)
- Francis-Xavier Andoh-Adjei
- National Health Insurance Authority - Research, Policy, Monitoring & Evaluation, Accra, Greater Accra, Ghana
| | - Ernst Spaan
- Radboud University Medical Centre, Radboud Institute for Health Sciences - Department for Health Evidence, Nijmegen, Netherlands
| | - Felix A Asante
- University of Ghana, Institute of Statistical, Social and Economic Research, Accra, Ghana
| | - Sylvester A Mensah
- University of Professional Studies, Centre for Universal Health Coverage, Accra, Ghana
| | - Koos van der Velden
- Radboud University Medical Centre, Radboud Institute for Health Sciences - Department for Primary Care, Nijmegen, Netherlands
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Leach B, Morgan P, Strand de Oliveira J, Hull S, Østbye T, Everett C. Primary care multidisciplinary teams in practice: a qualitative study. BMC FAMILY PRACTICE 2017; 18:115. [PMID: 29284409 PMCID: PMC5747144 DOI: 10.1186/s12875-017-0701-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 12/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Current recommendations for strengthening the US healthcare system consider restructuring primary care into multidisciplinary teams as vital to improving quality and efficiency. Yet, approaches to the selection of team designs remain unclear. This project describes current primary care team designs, primary care professionals' perceptions of ideal team designs, and perceived facilitating factors and barriers to implementing ideal team-based care. METHODS Qualitative study of 44 health care professionals at 6 primary care practices in North Carolina using focus group discussions and surveys. Data was analyzed using framework content analysis. RESULTS Practices used a variety of multidisciplinary team designs with the specific design being influenced by the social and policy context in which practices were embedded. Practices overwhelmingly located barriers to adopting ideal multidisciplinary teams as being outside of their individual practices and outside of their control. Participants viewed internal organizational contexts as the major facilitators of multidisciplinary primary care teams. The majority of practices described their ideal team design as including a social worker to meet the needs of socially complex patients. CONCLUSIONS Primary care multidisciplinary team designs vary across practices, shaped in part by contextual factors perceived as barriers outside of the practices' control. Facilitating factors within practices provide a culture of support to team members, but they are insufficient to overcome the perceived barriers. The common desire to add social workers to care teams reflects practices' struggles to meet the complex demands of patients and external agencies. Government or organizational policies should avoid one-size-fits-all approaches to multidisciplinary care teams, and instead allow primary care practices to adapt to their specific contextual circumstances.
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Affiliation(s)
- Brandi Leach
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Perri Morgan
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | | | - Sharon Hull
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Truls Østbye
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
| | - Christine Everett
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC USA
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Sommersguter-Reichmann M, Stepan A. Hospital physician payment mechanisms in Austria: do they provide gateways to institutional corruption? HEALTH ECONOMICS REVIEW 2017; 7:11. [PMID: 28251553 PMCID: PMC5332321 DOI: 10.1186/s13561-017-0148-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 02/21/2017] [Indexed: 06/06/2023]
Abstract
Institutional corruption in the health care sector has gained considerable attention during recent years, as it acknowledges the fact that service providers who are acting in accordance with the institutional and environmental settings can nevertheless undermine a health care system's purposes as a result of the (financial) conflicts of interest to which the service providers are exposed. The present analysis aims to contribute to the examination of institutional corruption in the health sector by analyzing whether the current payment mechanism of separately remunerating salaried hospital physicians for treating supplementary insured patients in public hospitals, in combination with the public hospital physician's possibility of taking up dual practice as a self-employed physician with a private practice and/or as an attending physician in private hospitals, has the potential to undermine the primary purposes of the Austrian public health care system. Based on the analysis of the institutional design of the Austrian public hospital sector, legal provisions and directives have been identified, which have the potential to promote conduct on the part of the public hospital physician that systematically undermines the achievement of the Austrian public health system's primary purposes.
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Affiliation(s)
| | - Adolf Stepan
- Institute of Management Science, Technical University Vienna, Theresianumgasse 27, A-1040 Vienna, Austria
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Abstract
This paper advances scientific understanding of social preference—a topic of longstanding cross-disciplinary interest—by studying the preferences of future physicians. In making treatment decisions, physicians make fundamental tradeoffs between their own (financial) self-interest, patient benefit, and stewardship of social resources. These tradeoffs affect patient health, adoption of new scientific medical technologies, and the equity and efficiency of our health care system. Understanding physicians’ decisions about these tradeoffs requires understanding the social preferences that are behind them. Our main finding that future physicians are substantially less altruistic and more efficiency focused than the average American challenges notions of physician altruism, the fundamental feature of medical professionalism, and has potential implications for policy in a host of health care areas. We measure the social preferences of a sample of US medical students and compare their preferences with those of the general population sampled in the American Life Panel (ALP). We also compare the medical students with a subsample of highly educated, wealthy ALP subjects as well as elite law school students and undergraduate students. We further associate the heterogeneity in social preferences within medical students to the tier ranking of their medical schools and their expected specialty choice. Our experimental design allows us to rigorously distinguish altruism from preferences regarding equality–efficiency tradeoffs and accurately measure both at the individual level rather than pooling data or assuming homogeneity across subjects. This is particularly informative, because the subjects in our sample display widely heterogeneous social preferences in terms of both their altruism and equality–efficiency tradeoffs. We find that medical students are substantially less altruistic and more efficiency focused than the average American. Furthermore, medical students attending the top-ranked medical schools are less altruistic than those attending lower-ranked schools. We further show that the social preferences of those attending top-ranked medical schools are statistically indistinguishable from the preferences of a sample of elite law school students. The key limitation of this study is that our experimental measures of social preferences have not yet been externally validated against actual physician practice behaviors. Pending this future research, we probed the predictive validity of our experimental measures of social preferences by showing that the medical students choosing higher-paying medical specialties are less altruistic than those choosing lower-paying specialties.
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Wiysonge CS, Paulsen E, Lewin S, Ciapponi A, Herrera CA, Opiyo N, Pantoja T, Rada G, Oxman AD. Financial arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011084. [PMID: 28891235 PMCID: PMC5618470 DOI: 10.1002/14651858.cd011084.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low-income countries. OBJECTIVES To provide an overview of the evidence from up-to-date systematic reviews about the effects of financial arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented in the overview. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language, or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out-of-pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non-randomised trials, 23 (8%) controlled before-after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non-randomised studies. Forty-three per cent (119/276) of the studies included in the reviews took place in low- and middle-income countries. Collection of funds: the effects of changes in user fees on utilisation and equity are uncertain (very low-certainty evidence). It is also uncertain whether aid delivered under the Paris Principles (ownership, alignment, harmonisation, managing for results, and mutual accountability) improves health outcomes compared to aid delivered without conforming to those principles (very low-certainty evidence). Insurance schemes: community-based health insurance may increase service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). It is uncertain whether social health insurance improves utilisation of health services or health outcomes (very low-certainty evidence). Purchasing of services: it is uncertain whether increasing salaries of public sector healthcare workers improves the quantity or quality of their work (very low-certainty evidence). Recipient incentives: recipient incentives may improve adherence to long-term treatments (low-certainty evidence), but it is uncertain whether they improve patient outcomes. One-time recipient incentives probably improve patient return for start or continuation of treatment (moderate-certainty evidence) and may improve return for tuberculosis test readings (low-certainty evidence). However, incentives may not improve completion of tuberculosis prophylaxis, and it is uncertain whether they improve completion of treatment for active tuberculosis. Conditional cash transfer programmes probably lead to an increase in service utilisation (moderate-certainty evidence), but their effects on health outcomes are uncertain. Vouchers may improve health service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). Introducing a restrictive cap may decrease use of medicines for symptomatic conditions and overall use of medicines, may decrease insurers' expenditures on medicines (low-certainty evidence), and has uncertain effects on emergency department use, hospitalisations, and use of outpatient care (very low-certainty evidence). Reference pricing, maximum pricing, and index pricing for drugs have mixed effects on drug expenditures by patients and insurers as well as the use of brand and generic drugs. Provider incentives: the effects of provider incentives are uncertain (very low-certainty evidence), including: the effects of provider incentives on the quality of care provided by primary care physicians or outpatient referrals from primary to secondary care, incentives for recruiting and retaining health professionals to serve in remote areas, and the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries. AUTHORS' CONCLUSIONS Research based on sound systematic review methods has evaluated numerous financial arrangements relevant to low-income countries, targeting different levels of the health systems and assessing diverse outcomes. However, included reviews rarely reported social outcomes, resource use, equity impacts, or undesirable effects. We also identified gaps in primary research because of uncertainty about applicability of the evidence to low-income countries. Financial arrangements for which the effects are uncertain include external funding (aid), caps and co-payments, pay-for-performance, and provider incentives. Further studies evaluating the effects of these arrangements are needed in low-income countries. Systematic reviews should include all outcomes that are relevant to decision-makers and to people affected by changes in financial arrangements.
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Affiliation(s)
- Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Elizabeth Paulsen
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
| | - Simon Lewin
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Andrew D Oxman
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
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Korlén S, Amer-Wåhlin I, Lindgren P, von Thiele Schwarz U. Professionals' perspectives on a market-inspired policy reform: A guiding light to the blind spots of measurement. Health Serv Manage Res 2017; 30:148-155. [PMID: 28508667 DOI: 10.1177/0951484817708941] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Implementation of market-inspired competition and incentive models in health care is increasing worldwide, assumed to drive efficiency. However, the evidence for effects is mixed and unintended consequences have been reported. There is a need to better understand the practical consequences of such reforms. The aim of the present case study is to explore what consequences of a Swedish market-inspired patient choice reform professionals identify as relevant, and why. The study was designed as an explorative qualitative study in specialized orthopedics. Nineteen interviews were conducted with health care professionals at different providers. Data were analyzed using a hypo-deductive thematic approach. Consequences for the organization of care, patients, work environment, education and research were included in the professionals' analyses, covering both the perspective of their own organization and that of the health care system as a whole. In sum, the professionals provided multiple-level analyses that extended beyond the responsibilities of their own organization. Concluding, professionals are a valuable source of knowledge when evaluating policy reforms. Their analyses can contribute by covering a broad system perspective, serving as a guiding light to areas beyond the most obvious evaluation measures that should be included in more formal evaluations.
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Affiliation(s)
- Sara Korlén
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Isis Amer-Wåhlin
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Peter Lindgren
- Department of Learning Informatics Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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Díaz-Portillo SP, Reyes-Morales H, Cuadra-Hernández SM, Idrovo ÁJ, Nigenda G, Dreser A. [Working conditions in outpatient clinics adjacent to private pharmacies in Mexico City: perspective of physicians]. GACETA SANITARIA 2017; 31:459-465. [PMID: 28473208 DOI: 10.1016/j.gaceta.2016.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 10/21/2016] [Accepted: 10/24/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyse the working conditions of physicians in outpatient clinics adjacent to pharmacies (CAFs) and their organizational elements from their own perspective. METHODS We carried out an exploratory qualitative study. Semi-structured interviews were conducted with 32 CAF physicians in Mexico City. A directed content analysis technique was used based on previously built and emerging codes which were related to the experience of the subjects in their work. RESULTS Respondents perceive that work in CAFs does not meet professional expectations due to low pay, informality in the recruitment process and the absence of minimum labour guarantees. This prevents them from enjoying the benefits associated with formal employment, and sustains their desire to work in CAF only temporarily. They believe that economic incentives related to number of consultations, procedures and sales attained by the pharmacy allow them to increase their income without influencing their prescriptive behaviour. They express that the monitoring systems and pressure exerted on CAFs seek to affect their autonomy, pushing them to enhance the sales of medicines in the pharmacy. CONCLUSIONS Physicians working in CAFs face a difficult employment situation. The managerial elements used to induce prescription and enhance pharmacy sales create a work environment that generates challenges for regulation and underlines the need to monitor the services provided at these clinics and the possible risk for users.
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Affiliation(s)
- Sandra P Díaz-Portillo
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
| | | | | | - Álvaro J Idrovo
- Departamento de Salud Pública, Escuela de Medicina, Universidad Industrial de Santander, Bucaramanga, Santander, Colombia
| | - Gustavo Nigenda
- Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos, México
| | - Anahí Dreser
- Centro de Investigación en Sistemas de Salud, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
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Bastian ND, Kang H, Nembhard HB, Bloschichak A, Griffin PM. The Impact of a Pay-for-Performance Program on Central Line-Associated Blood Stream Infections in Pennsylvania. Hosp Top 2017; 94:8-14. [PMID: 26980202 DOI: 10.1080/00185868.2015.1130542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Healthcare associated infections have significantly contributed to the rising cost of hospital care in the United States. The implementation of pay-for-performance (P4P) programs has been one approach to improve quality at a reduced cost. We quantify the impact of Highmark's Quality Blue (QB) hospital P4P program on central line-associated blood stream infections (CLABSI) in Pennsylvania. The impact of years of participation in QB on CLABSI is also evaluated. Data from 149 Pennsylvania hospitals on CLABSI from 2008-2013 are used. Negative binomial regression and fixed effects panel regression are performed. Hospitals participating in QB have 0.727 times the CLABSI as those hospitals that do not participate. Hospitals participating for four or more years have on average 3.13 fewer CLABSI per year compared to those participating for less than four years. Highmark's P4P program has shown improved outcomes with regards to CLABSI, but further research is needed to determine if QB is cost effective.
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Affiliation(s)
- Nathaniel D Bastian
- a Center for Integrated Healthcare Delivery Systems , Department of Industrial and Manufacturing Engineering, Pennsylvania State University , University Park , Pennsylvania , USA
| | - Hyojung Kang
- b Department of Systems and Information Engineering , University of Virginia , Charlottesville , Virginia , USA
| | - Harriet B Nembhard
- a Center for Integrated Healthcare Delivery Systems , Department of Industrial and Manufacturing Engineering, Pennsylvania State University , University Park , Pennsylvania , USA
| | - Andrew Bloschichak
- c Medical Policy Development , Highmark Medical Services , Camp Hill , Pennsylvania , USA
| | - Paul M Griffin
- d Center for Health and Humanitarian Systems , School of Industrial and Systems Engineering , Georgia Institute of Technology , Atlanta , Georgia , USA
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Laberge M, Wodchis WP, Barnsley J, Laporte A. Efficiency of Ontario primary care physicians across payment models: a stochastic frontier analysis. HEALTH ECONOMICS REVIEW 2016; 6:22. [PMID: 27271177 PMCID: PMC4894855 DOI: 10.1186/s13561-016-0101-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/01/2016] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The study examines the relationship between the primary care model that a physician belongs to and the efficiency of the primary care physician in Ontario, Canada. METHODS Survey data were collected from 183 self-selected physicians and linked to administrative databases to capture the provision of services to the patients served for the 12 month period ending June 30, 2013, and the characteristics of the patients at the beginning of the study period. Two stochastic frontier regression models were used to estimate efficiency scores and parameters for two separate outputs: the number of distinct patients seen and the number of visits. RESULTS Because of missing data, only 165 physicians were included in the analyses. The average efficiency was 0.72 for both outputs with scores varying from 4 % to 93 % for the visits and 5 % to 94 % for the number of patients seen. We observed that there were both very low and very high efficiency scores within each model. These variations were larger than variations in average scores across models.
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Affiliation(s)
- Maude Laberge
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions, University of Florida, 1225 Center Dr, Room 3111, Gainesville, FL, 32610, USA.
- Canadian Centre for Health Economics, Toronto, Canada.
| | - Walter P Wodchis
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Toronto Rehabilitation Institute, Toronto, Canada
| | - Jan Barnsley
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Audrey Laporte
- Canadian Centre for Health Economics, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
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Naci H, Soumerai SB. History Bias, Study Design, and the Unfulfilled Promise of Pay-for-Performance Policies in Health Care. Prev Chronic Dis 2016; 13:E82. [PMID: 27337559 PMCID: PMC4927268 DOI: 10.5888/pcd13.160133] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Huseyin Naci
- Department of Social Policy, London School of Economics and Political Science, London, United Kingdom
| | - Stephen B Soumerai
- Harvard Medical School and Harvard Pilgrim Health Care Institute, Landmark Center, 401 Park Dr, Boston, MA 02215.
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Liu C, Zhang X, Wang X, Zhang X, Wan J, Zhong F. Does public reporting influence antibiotic and injection prescribing to all patients? A cluster-randomized matched-pair trial in china. Medicine (Baltimore) 2016; 95:e3965. [PMID: 27367995 PMCID: PMC4937909 DOI: 10.1097/md.0000000000003965] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The inappropriate use and overuse of antibiotics and injections are serious threats to global population, and the public reporting of health care performance (PRHCP) has been an important instrument for improving the quality of care. However, existing evidence shows a mixed effect of PRHCP. This study is to explore the potential effectiveness of PRHCP that contributes to the convincing evidence of health policy and reform.This study was undertaken in Qian Jiang City, applying a matched-pair cluster-randomized trial. Twenty primary care institutions were treated as clusters and were matched into 10 pairs. Clusters in each pair were randomly assigned into a control or an intervention group. Physicians' prescribing information was publicly reported to patients and physicians monthly in the intervention group from October 2013. A total of 748,632 outpatient prescriptions were included for difference-in-difference (DID) regression model and subgroups (SGs) analysis.Overall, PRHCP intervention led to a slight reduction in the use of combined antibiotics (odds ratio [OR] = 0.870, P < 0.001) and slowed the average expenditure increase of patients (coefficient = -0.051, P < 0.001). SG analysis showed the effect of PRHCP varied among patients with different characteristics. PRHCP decreased the probability of prescriptions requiring antibiotics, combined antibiotics, and injections of patients aged 18 to 64 years old (OR < 1), and all results were statistically significant. By contrast, the results of elderly and minor patients with health insurance showed that PRHCP increased their probability of prescriptions requiring antibiotics and injections. PRHCP slowed the increase of average expenditure of most SGs.PRHCP intervention can influence the prescribing pattern of physicians. Patient factors such as age and health insurance influence the effect of PRHCP intervention, which imply that PRHCP should be designed for different patients. Patient education, aiming at radically changing attitudes toward antibiotics and injections, should be taken to promote the effectiveness of public reporting in China.
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Affiliation(s)
| | - Xinping Zhang
- School of Medicine and Health Management, Tongji Medical School, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
- Correspondence: Xinping Zhang, School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Hangkong Road No. 13, Wuhan, Hubei Province, China (e-mail: )
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Atuoye KN, Vercillo S, Antabe R, Galaa SZ, Luginaah I. Financial sustainability versus access and quality in a challenged health system: an examination of the capitation policy debate in Ghana. Health Policy Plan 2016; 31:1240-9. [DOI: 10.1093/heapol/czw058] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2016] [Indexed: 11/12/2022] Open
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Using Incentives to Improve Resource Utilization: A Quasi-Experimental Evaluation of an ICU Quality Improvement Program. Crit Care Med 2016; 44:162-70. [PMID: 26496444 DOI: 10.1097/ccm.0000000000001395] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Healthcare systems strive to provide quality care at lower cost. Arterial blood gas testing, chest radiographs, and RBC transfusions provide an important example of opportunities to reduce excess resource utilization within the ICU. We describe the effect of a multifaceted quality improvement program designed to decrease the avoidable arterial blood gases, chest radiographs, and RBC utilization on utilization of these resources and patient outcomes. DESIGN Prospective pre-post cohort study. SETTING Seven ICUs in an academic healthcare system. PATIENTS All adult ICU patients admitted to study ICUs during consecutive baseline (n = 7,357), intervention (n = 7,553), and follow-up (n = 7,657) years between September 2010 and August 2013. INTERVENTIONS A multifaceted quality improvement program including provider education, audit and feedback, and unit-based provider financial incentives targeting arterial blood gas, chest radiograph, and RBC utilization. MEASUREMENTS AND MAIN RESULTS The primary outcome was the number of orders for arterial blood gases, chest radiographs, and RBCs per patient. Compared with the baseline period, unadjusted arterial blood gas, chest radiograph, and RBC utilization in the intervention period was reduced by 42%, 26%, and 17%, respectively (p < 0.01). After adjusting for potentially relevant patient factors, the intervention was associated with 128 fewer arterial blood gases, 73 fewer chest radiographs, and 16 fewer RBCs per 100 patients (p < 0.01). This effect was durable during the follow-up year. This reduction yielded an approximate net savings of $1.5 M in direct costs over the intervention and follow-up years after accounting for the direct costs of the program. Unadjusted hospital mortality decreased from 7% in the baseline period to 5.2% in the intervention period (p < 0.01). This reduction remained significant after adjusting for patient factors (odds ratio = 0.43; p < 0.01). CONCLUSIONS Implementation of a multifaceted quality improvement program including financial incentives was associated with significant improvements in resource utilization. Our findings provide evidence supporting the safety, effectiveness, and sustainability of incentive-based quality improvement interventions.
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Bosch M, Tavender EJ, Brennan SE, Knott J, Gruen RL, Green SE. The Many Organisational Factors Relevant to Planning Change in Emergency Care Departments: A Qualitative Study to Inform a Cluster Randomised Controlled Trial Aiming to Improve the Management of Patients with Mild Traumatic Brain Injuries. PLoS One 2016; 11:e0148091. [PMID: 26845772 PMCID: PMC4742078 DOI: 10.1371/journal.pone.0148091] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 01/12/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Neurotrauma Evidence Translation (NET) Trial aims to design and evaluate the effectiveness of a targeted theory-and evidence-informed intervention to increase the uptake of evidence-based recommended practices for the management of patients who present to an emergency department (ED) with mild head injuries. When designing interventions to bring about change in organisational settings such as the ED, it is important to understand the impact of the context to ensure successful implementation of practice change. Few studies explicitly use organisational theory to study which factors are likely to be most important to address when planning change processes in the ED. Yet, this setting may have a unique set of organisational pressures that need to be taken into account when implementing new clinical practices. This paper aims to provide an in depth analysis of the organisational context in which ED management of mild head injuries and implementation of new practices occurs, drawing upon organisational level theory. METHODS Semi-structured interviews were conducted with ED staff in Australia. The interviews explored the organisational context in relation to change and organisational factors influencing the management of patients presenting with mild head injuries. Two researchers coded the interview transcripts using thematic content analysis. The "model of diffusion in service organisations" was used to guide analyses and organisation of the results. RESULTS Nine directors, 20 doctors and 13 nurses of 13 hospitals were interviewed. With regard to characteristics of the innovation (i.e. the recommended practices) the most important factor was whether they were perceived as being in line with values and needs. Tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) was relatively low for managing acute mild head injury symptoms, and mixed for managing longer-term symptoms (higher change commitment, but relatively low change efficacy). Regarding implementation processes, the importance of (visible) senior leadership for all professions involved was identified as a critical factor. An unpredictable and hectic environment brings challenges in creating an environment in which team-based and organisational learning can thrive (system antecedents for innovation). In addition, the position of the ED as the entry-point of the hospital points to the relevance of securing buy-in from other units. CONCLUSIONS We identified several organisational factors relevant to realising change in ED management of patients who present with mild head injuries. These factors will inform the intervention design and process evaluation in a trial evaluating the effectiveness of our implementation intervention.
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Affiliation(s)
- Marije Bosch
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
- * E-mail:
| | - Emma J. Tavender
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
| | - Sue E. Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jonathan Knott
- Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Emergency Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Russell L. Gruen
- Department of Surgery, Central Clinical School, Monash University, Melbourne, Australia
- National Trauma Research Institute, The Alfred, Monash University, Melbourne, Australia
- The Alfred Trauma Service, The Alfred Hospital, Melbourne, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Sally E. Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews. BMJ Open 2015; 5:e009993. [PMID: 26700290 PMCID: PMC4691771 DOI: 10.1136/bmjopen-2015-009993] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. DESIGN Systematic review of reviews. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. DATA SYNTHESIS Extracted data were synthesised using a narrative approach. RESULTS 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. CONCLUSIONS There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO REGISTRATION NUMBER CRD42014009410.
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Affiliation(s)
- Rosa Lau
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Fiona Stevenson
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Scotland, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton,UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Derby, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
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Eriksen II, Melberg HO. The effects of introducing an electronic prescription system with no copayments. HEALTH ECONOMICS REVIEW 2015; 5:56. [PMID: 26174807 PMCID: PMC4502047 DOI: 10.1186/s13561-015-0056-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/25/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND To examine the impact of introducing an electronic prescription system with no copayments on the number of prescriptions, the size of prescriptions, and the number of visits and phone calls to primary physicians. METHODS Fixed regression models using monthly data on per capita prescriptions claims and consultations between 2009 and 2013 at the municipality level, before and after the introduction of the electronic prescription system. RESULTS The electronic prescription system with no copayment increased the number of prescriptions by between 6.0 and 8.1 %. It decreased the average size of each prescription, but it did not decrease the number of consultations. CONCLUSION The reduced direct and indirect costs of obtaining prescriptions after the introduction of the electronic prescription system changed the financial incentives facing the patients and physicians. This led to significant changes in the level and size of prescriptions and illustrates the importance of financial incentives.
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Affiliation(s)
- Ida Iren Eriksen
- Institute for Health and Society, University of Oslo, Oslo, Norway
| | - Hans Olav Melberg
- University of Oslo, OCBE and Department of Health Management and Health Economics, Box 1089 Blindern, 0317 Oslo, Norway
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Joudaki H, Rashidian A, Minaei-Bidgoli B, Mahmoodi M, Geraili B, Nasiri M, Arab M. Improving Fraud and Abuse Detection in General Physician Claims: A Data Mining Study. Int J Health Policy Manag 2015; 5:165-72. [PMID: 26927587 DOI: 10.15171/ijhpm.2015.196] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 10/27/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We aimed to identify the indicators of healthcare fraud and abuse in general physicians' drug prescription claims, and to identify a subset of general physicians that were more likely to have committed fraud and abuse. METHODS We applied data mining approach to a major health insurance organization dataset of private sector general physicians' prescription claims. It involved 5 steps: clarifying the nature of the problem and objectives, data preparation, indicator identification and selection, cluster analysis to identify suspect physicians, and discriminant analysis to assess the validity of the clustering approach. RESULTS Thirteen indicators were developed in total. Over half of the general physicians (54%) were 'suspects' of conducting abusive behavior. The results also identified 2% of physicians as suspects of fraud. Discriminant analysis suggested that the indicators demonstrated adequate performance in the detection of physicians who were suspect of perpetrating fraud (98%) and abuse (85%) in a new sample of data. CONCLUSION Our data mining approach will help health insurance organizations in low-and middle-income countries (LMICs) in streamlining auditing approaches towards the suspect groups rather than routine auditing of all physicians.
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Affiliation(s)
- Hossein Joudaki
- Health Economics Group, Social Security Organization, Tehran, Iran
| | - Arash Rashidian
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mahmood Mahmoodi
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Bijan Geraili
- Department of Education Management, School of Psychology and Education, University of Tehran, Tehran, Iran
| | - Mahdi Nasiri
- School of Computer Engineering, Iran University of Science and Technology, Tehran, Iran
| | - Mohammad Arab
- Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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Olthof M, Groenhof F, Berger MY. Towards a differentiated capitation system: relation between patient characteristics, contacts and costs. Fam Pract 2015; 32:545-50. [PMID: 26082456 DOI: 10.1093/fampra/cmv043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND OBJECTIVE A new payment system could curb primary health care costs. A differentiated capitation system based on patient characteristics could be the best mix for payment. To test the feasibility of such a system, we examined the number of contacts between patients and general practitioners (GPs), the related costs and the relationship with age, sex and comorbidity. METHODS A retrospective observational study included 29304 primary care patients in the Netherlands. Age, sex and comorbidity were related to number of contacts per patients per year and costs using a negative binomial regression analysis. RESULTS Males, younger patients and patients with no comorbidities visit their GP least often. Medically unexplained physical symptoms, diabetes and severe back complaints generate the most contacts; diabetes is specifically related to higher costs. CONCLUSION Several patient characteristics are related to the number of contacts patients have with their GP and the consecutive remuneration. This study can be used as an input to create a differentiated capitation system.
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Affiliation(s)
- Marijke Olthof
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Feikje Groenhof
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marjolein Y Berger
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Maun A, Wessman C, Sundvall PD, Thorn J, Björkelund C. Is the quality of primary healthcare services influenced by the healthcare centre's type of ownership?-An observational study of patient perceived quality, prescription rates and follow-up routines in privately and publicly owned primary care centres. BMC Health Serv Res 2015; 15:417. [PMID: 26410077 PMCID: PMC4583720 DOI: 10.1186/s12913-015-1082-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 09/18/2015] [Indexed: 01/07/2023] Open
Abstract
Background Primary healthcare in Sweden has undergone comprehensive reforms, including freedom of choice regarding provider, freedom of establishment and increased privatisation aiming to meet demands for quality and availability. In this system privately and publicly owned primary care centres with different business models (for-profit vs non-profit) coexist and compete for patients, which makes it important to study whether or not the type of ownership influences the quality of the primary healthcare services. Methods In this retrospective observational study (April 2011 to January 2014) the patient perceived quality, the use of antibiotics and benzodiazepine derivatives, and the follow-up routines of certain chronic diseases were analysed for all primary care centres in Region Västra Götaland. The outcome measures were compared on a group level between privately owned (n = 86) and publicly owned (n = 114) primary care centres (PCC). Results In comparison with the group of publicly owned PCCs, the group of privately owned PCCs were characterized by: a smaller, but continuously growing share of the population served (from 32 to 36 %); smaller PCC population sizes (avg. 5932 vs. 9432 individuals); a higher fraction of PCCs located in urban areas (57 % vs 35 %); a higher fraction of listed citizens in working age (62 % vs. 56 %) and belonging to the second most affluent socioeconomic quintile (26 % vs. 14 %); higher perceived patient quality (82.4 vs. 79.6 points); higher use of antibiotics (6.0 vs. 5.1 prescriptions per 100 individuals in a quarter); lower use of benzodiazepines (DDD per 100 patients/month) for 20–74 year olds (278 vs. 306) and >74 year olds (1744 vs.1791); lower rates for follow-ups of chronic diseases (71.2 % vs 74.6 %). While antibiotic use decreased, the use of benzodiazepines increased for both groups over time. Conclusions The findings of this study cannot unambiguously answer the question of whether or not the quality is influenced by the healthcare centre’s type of ownership. It can be questioned whether the reform created conditions that encouraged quality improvements. Tendencies of an (unintended) unequal distribution of the population between the two groups with disparities in age, socio-economy and geography might lead to unpredictable effects. Further studies are necessary for evidence-informed policy-making.
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Affiliation(s)
- Andy Maun
- Department of Medicine, Division of General Practice, University Medical Centre Freiburg, Elsässerstr. 2 m, D-79110, Freiburg, Germany. .,Institute for Quality Management and Social Medicine, University Medical Centre Freiburg, Engelbergerstr. 21, D-79106, Freiburg, Germany. .,Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden.
| | - Catrin Wessman
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden. .,Centre for Applied Biostatistics, The Sahlgrenska Academy, University of Gothenburg, Box 414, SE-405 30, Göteborg, Sweden.
| | - Pär-Daniel Sundvall
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden. .,Research and Development Unit, Primary Health Care in Southern Älvsborg County, Sven Eriksonsplatsen 4, SE-503 38, Borås, Sweden.
| | - Jörgen Thorn
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden.
| | - Cecilia Björkelund
- Department of Public Health and Community Medicine/Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Box 454, SE-405 30, Göteborg, Sweden.
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McCarter K, Britton B, Baker A, Halpin S, Beck A, Carter G, Wratten C, Bauer J, Booth D, Forbes E, Wolfenden L. Interventions to improve screening and appropriate referral of patients with cancer for distress: systematic review protocol. BMJ Open 2015; 5:e008277. [PMID: 26391631 PMCID: PMC4577928 DOI: 10.1136/bmjopen-2015-008277] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION It is estimated that 35-40% of patients with cancer experience distress at some stage during their illness. Distress may affect functioning, capacity to cope, treatment compliance, quality of life and survival of patients with cancer. Best practice clinical guidelines recommend routine psychosocial distress screening and referral for further assessment and/or psychosocial support for patients with cancer. However, evidence suggests this care is not provided consistently. METHODS AND ANALYSIS We developed our methods following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The review is registered with PROSPERO and any amendments to the protocol will be tracked. The primary aim of this systematic review is to examine the impact of interventions delivered in healthcare settings that are aimed at (1) improving routine screening of patients for psychosocial distress and (2) referral of distressed patients with cancer for further assessment and/or psychosocial support. The effectiveness of such interventions in reducing psychosocial distress, and any unintended adverse effect of the intervention will also be assessed in patients with cancer. Data sources will include the bibliographic databases Cochrane Central Register of Controlled trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, PsycINFO and CINAHL. Eligible studies must compare an intervention (or two or more interventions) in a healthcare setting to improve the rate of screening for psychosocial distress and/or referral for further assessment and/or psychosocial support for patients with cancer with no intervention or 'usual' practice. Two investigators will independently review titles and abstracts, followed by full article reviews and data extraction. Disagreements will be resolved by consensus and if necessary, a third reviewer. Where studies are sufficiently homogenous, trial data will be pooled and meta-analyses performed. ETHICS AND DISSEMINATION No ethical issues are foreseen. The findings of this study will be disseminated widely via peer-reviewed publications and conference presentations. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD4 2015017518.
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Affiliation(s)
- Kristen McCarter
- School of Psychology, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Ben Britton
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Amanda Baker
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Sean Halpin
- School of Psychology, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Alison Beck
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Gregory Carter
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Chris Wratten
- Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Waratah, New South Wales, Australia
| | - Judy Bauer
- Centre for Dietetics Research, The University of Queensland, St Lucia, Queensland, Australia
| | - Debbie Booth
- University Library, University of Newcastle, Callaghan, New South Wales, Australia
| | - Erin Forbes
- Faculty of Health and Medicine, Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Luke Wolfenden
- School of Medicine & Public Health, The University of Newcastle, Callaghan, New South Wales, Australia
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Abstract
Pay-for-performance (P4P) schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals' behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost-benefit emerges.
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Affiliation(s)
- Stephen Gillam
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
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50
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Affiliation(s)
- Liying Jia
- Shandong University; Center for Health Management and Policy, Key Lab for Health Economics and Policy Research, Ministry of Health; Jinan Shandong China 250012
- Ministry of Health; Key Lab for Health Economics and Policy Research; Shandong China
| | - Beibei Yuan
- Peking University; China Center for Health Development Studies (CCHDS); 38 Xueyuan Road Beijing Beijing China 100191
| | - Qingyue Meng
- Peking University; China Center for Health Development Studies (CCHDS); 38 Xueyuan Road Beijing Beijing China 100191
| | - Anthony Scott
- The University of Melbourne; Melbourne Institute of Applied Economic and Social Research; Level 7, Alan Gilbert Building Barry Street Carlton, Melbourne VIC Australia 3053
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