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Cho S, Shin JY, Kim HJ, Eun SJ, Kang S, Jang WM, Jung H, Kim Y, Lee JY. Chasms in Achievement of Recommended Diabetes Care among Geographic Regions in Korea. J Korean Med Sci 2019; 34:e190. [PMID: 31392852 PMCID: PMC6689488 DOI: 10.3346/jkms.2019.34.e190] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/03/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Although effective care for type 2 diabetes (T2DM) is well known, considerable inadequate care has been still existed. Variations in achievement of the recommended quality indicators inT2DM care among small areas are not well known in Korea. This study examined the quality of care T2DM care and its geographical variations. METHODS We used the national health insurance database and national health screening database. Seven quality indicators were used to evaluate continuity of care (medication possession ratio), process of care (hemoglobin A1c test, lipid profile, microalbuminuria test, and eye examination), and intermediate outcome (blood pressure control, and low-density lipoprotein control). Crude and age-standardized proportions were calculated for each 252 districts in Korea. RESULTS All quality indicators failed to achieve the recommended level. Only about 3% and 15% of the patients underwent eye examination and microalbuminuria test, respectively. Other indicators ranged from 48% to 68%. Wide variation in the quality existed among districts and indicators. Eye examination and microalbuminuria test varied the most showing tenfold (0.9%-9.2%) and fourfold (6.3%-28.9%) variation by districts, respectively. There were 32.4 and 42.7 percentage point gap between the best and the worst districts in hemoglobin A1c test and blood pressure control, respectively. CONCLUSION Considerable proportion of T2DM patients were not adequately managed and quality of care varied substantially district to district. To improve the quality of diabetes care, it is necessary to identify the poor performance areas and establish a well-coordinated care system tailored to the need of the district.
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Affiliation(s)
- Sanghyun Cho
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Yeon Shin
- Department of Preventive Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hyun Joo Kim
- Department of Nursing Science, Shinsung University, Dangjin, Korea
| | - Sang Jun Eun
- Department of Preventive Medicine, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sungchan Kang
- Department of Public Health Science, School of Public Health, Seoul National University, Seoul, Korea
| | - Won Mo Jang
- Health Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Hyemin Jung
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
- Health Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, Korea
| | - Yoon Kim
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
- Institute of Health Policy and Management, Medical Research Center, Seoul National University, Seoul, Korea
| | - Jin Yong Lee
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
- Department of Public Health and Community Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea.
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102
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Manderbacka K, Arffman M, Satokangas M, Keskimäki I. Regional variation of avoidable hospitalisations in a universal health care system: a register-based cohort study from Finland 1996-2013. BMJ Open 2019; 9:e029592. [PMID: 31324684 PMCID: PMC6661699 DOI: 10.1136/bmjopen-2019-029592] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/21/2019] [Accepted: 06/28/2019] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES A persistent finding in research concerning healthcare and hospital use in Western countries has been regional variation in the medical practices. The aim of the current study was to examine trends in the regional variation of avoidable hospitalisations, that is, hospitalisations due to conditions treatable in ambulatory care in Finland in 1996-2013 and the influence of different healthcare levels on them. SETTING Use of hospital inpatient care in 1996-2013 among the total population in Finland. PARTICIPANTS Altogether 1 931 012 hospital inpatient care episodes among all persons residing in Finland identified from administrative registers in Finland in 1996-2013 and alive in 1 January 1996. OUTCOME MEASURES We examined hospitalisations due to avoidable causes including vaccine-preventable hospitalisations, hospitalisations due to complications of chronic conditions and acute conditions treatable in ambulatory care. We calculated annual age-adjusted rates per 10 000 person-years. Multilevel models were used for studying time trends in regional variation. RESULTS There was a steep decline in avoidable hospitalisation rates during the study period. The decline occurred almost exclusively in hospitalisations due to chronic conditions, which diminished by about 60%. The overall correlation between hospital district intercepts and slopes in time was -0.46 (p<0.05) among men and -0.20 (ns) among women. Statistically highly significant diminishing variation was found in hospitalisations due to chronic conditions among both men (-0.90) and women (-0.91). The variation was mainly distributed to the hospital district level. CONCLUSIONS The results suggest that chronic conditions are managed better in primary care in the whole country than before. Further research is needed on whether this is the case or whether this has more to do with supply of hospital care.
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Affiliation(s)
- Kristiina Manderbacka
- Service System Research, National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Martti Arffman
- Service System Research, National Institute for Health and Welfare (THL), Helsinki, Finland
| | - Markku Satokangas
- Service System Research, National Institute for Health and Welfare (THL), Helsinki, Finland
- Network of Academic Health Centres and Department of General Practice and Primary Health Care, Helsingin Yliopisto, Helsinki, Finland
| | - Ilmo Keskimäki
- Service System Research, National Institute for Health and Welfare (THL), Helsinki, Finland
- Department of Social Sciences, Tampereen Yliopisto, Tampere, Finland
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103
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Walsh ME, Boland F, O’Byrne JM, Fahey T. Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study. BMJ Open 2019; 9:e028037. [PMID: 31142532 PMCID: PMC6549729 DOI: 10.1136/bmjopen-2018-028037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland. DESIGN Repeated cross-sectional study. SETTING 36 public hospitals in Ireland. PARTICIPANTS Adult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012-2016). PRIMARY OUTCOME MEASURE Standardised discharge rate (SDR). ANALYSIS Age and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure. RESULTS Across 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures. CONCLUSIONS Variation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.
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Affiliation(s)
- Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John M O’Byrne
- Professorial Unit, RCSI at Cappagh National Orthopaedic Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Herrera AM, Brand P, Cavada G, Koppmann A, Rivas M, Mackenney J, Sepúlveda H, Wevar ME, Cruzat L, Soto S, Pérez MA, León A, Contreras I, Alvarez C, Walker B, Flores C, Lezana V, Garrido C, Herrera ME, Rojas A, Andrades C, Chala E, Martínez RA, Vega M, Perillán JA, Seguel H, Przybyzsweski I. Treatment, outcomes and costs of asthma exacerbations in Chilean children: a prospective multicenter observational study. Allergol Immunopathol (Madr) 2019; 47:282-288. [PMID: 30595390 PMCID: PMC7125869 DOI: 10.1016/j.aller.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/02/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe potential regional variations in therapies for severe asthma exacerbations in Chilean children and estimate the associated health expenditures. METHODS Observational prospective cohort study in 14 hospitals over a one-year period. Children five years of age or older were eligible for inclusion. Days with oxygen supply and pharmacological treatments received were recorded from the clinical chart. A basic asthma hospitalization basket was defined in order to estimate the average hospitalization cost for a single patient. Six months after discharge, new visits to the Emergency Room (ER), use of systemic corticosteroids and adherence to the controller treatment were evaluated. RESULTS 396 patients were enrolled. Patients from the public health system and from the north zone received significantly more days of oxygen, systemic corticosteroids and antibiotics. Great heterogeneity in antibiotic use among the participating hospitals was found, from 0 to 92.3% (ICC 0.34, 95% CI 0.16-0.52). The use of aminophylline, magnesium sulfate and ketamine varied from 0 to 36.4% between the different Pediatric Intensive Care Units (ICC 0.353, 95% CI 0.010-0.608). The average cost per inpatient was of $1910 USD. 290 patients (73.2%) completed the follow-up six months after discharge. 76 patients (26.2%) were not receiving any controller treatment and nearly a fourth had new ER visits and use of systemic corticosteroids due to new asthma exacerbations. CONCLUSIONS Considerable practice variation in asthma exacerbations treatment was found among the participating hospitals, highlighting the poor outcome of many patients after hospital discharge, with an important health cost.
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Affiliation(s)
- A M Herrera
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile; School of Medicine, Los Andes University, Monseñor Alvaro del Portillo 12455, Santiago, Zip Code 7620001 Región Metropolitana, Chile.
| | - P Brand
- Isala Women's and Children's Hospital, Zwolle, The Netherlands
| | - G Cavada
- School of Medicine, Finis Terrae University, Av Providencia 1509, Santiago, Zip Code 7501015 Región Metropolitana, Chile
| | - A Koppmann
- San Borja Arriarán Hospital, Av Santa Rosa 1234, Santiago, Zip Code 8360160 Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - M Rivas
- San Borja Arriarán Hospital, Av Santa Rosa 1234, Santiago, Zip Code 8360160 Región Metropolitana, Chile
| | - J Mackenney
- Roberto del Río Hospital, Av Profesor Zañartu 1085, Santiago, Zip Code 8380418 Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - H Sepúlveda
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - M E Wevar
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - L Cruzat
- Luis Calvo Mackenna Hospital, Av Antonio Varas 360, Santiago, Zip Code 7500539 Región Metropolitana, Chile
| | - S Soto
- Concepción Regional Hospital, San Martín 1436, Concepción, Zip Code 4070038 Región del Bío Bío, Chile
| | - M A Pérez
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile
| | - A León
- Santa María Clinic, Santa María 500, Santiago, Zip Code 7520378 Región Metropolitana, Chile
| | - I Contreras
- Padre Hurtado Hospital, Esperanza 2150, Santiago, Zip Code 8880465 Región Metropolitana, Chile
| | - C Alvarez
- Alemana Clinic, Av Vitacura 5951, Santiago, Zip Code 7650568 Región Metropolitana, Chile; School of Medicine, Desarrollo University, Av Las Condes 12496, Santiago, Zip Code 7590943 Región Metropolitana, Chile
| | - B Walker
- Alemana Clinic, Av Vitacura 5951, Santiago, Zip Code 7650568 Región Metropolitana, Chile; School of Medicine, Desarrollo University, Av Las Condes 12496, Santiago, Zip Code 7590943 Región Metropolitana, Chile
| | - C Flores
- Ovalle Hospital, Ariztía Pte. 7, Ovalle, Zip Code 1842054 Región de Coquimbo, Chile
| | - V Lezana
- Gustavo Fricke Hospital, Av Alvarez 1532, Viña del Mar, Zip Code 2570017 Región de Valparaíso, Chile
| | - C Garrido
- Gustavo Fricke Hospital, Av Alvarez 1532, Viña del Mar, Zip Code 2570017 Región de Valparaíso, Chile
| | - M E Herrera
- José Joaquín Aguirre Hospital, Santos Dumont 999, Santiago, Zip Code 8380456 Región Metropolitana, Chile
| | - A Rojas
- José Joaquín Aguirre Hospital, Santos Dumont 999, Santiago, Zip Code 8380456 Región Metropolitana, Chile
| | - C Andrades
- Valdivia Hospital, Coronel Santiago Bueras y Avaria 1003, Valdivia, Zip Code 5090146 Región de los Ríos, Chile
| | - E Chala
- Fusat Hospital, Carretera el Cobre Presidente Frei Montalva 1002, Zip Code 2820945 Rancagua, VI Región, Chile; School of Medicine, Los Andes University, Monseñor Alvaro del Portillo 12455, Santiago, Zip Code 7620001 Región Metropolitana, Chile
| | - R A Martínez
- Fusat Hospital, Carretera el Cobre Presidente Frei Montalva 1002, Zip Code 2820945 Rancagua, VI Región, Chile
| | - M Vega
- Leonardo Guzmán Hospital, Veintiuno de Mayo 1310, Zip Code 1271847 Antofagasta, Región de Antofagasta, Chile
| | - J A Perillán
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile; School of Medicine, University of Chile, Chile
| | - H Seguel
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile
| | - I Przybyzsweski
- San Juan De Dios Hospital, Huérfanos 3255, Zip Code 8350488 Santiago, Región Metropolitana, Chile
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105
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Prime SJ, Marchant J, Chang AB, Petsky HL. Development of a quality improvement audit tool for the primary care of children with chronic wet cough using a modified Delphi consensus approach. J Paediatr Child Health 2019; 55:459-464. [PMID: 30251373 DOI: 10.1111/jpc.14229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 08/27/2018] [Indexed: 01/23/2023]
Abstract
AIM In the absence of quality indicators (QIs) for the management of chronic wet cough, our study's aim was to determine whether consensus on QIs reflecting good primary health care, prior to referral for children with chronic wet cough, can be achieved. METHODS A questionnaire consisting of 10 QIs was developed by a clinical working group based on current evidence and guidelines on the management of chronic wet cough in children. Each indicator reflected the quality of care provided to children with chronic wet cough in primary care prior to referral. A modified Delphi consensus questionnaire was undertaken involving expert paediatric respiratory clinicians and general paediatricians who graded the importance of each indicator for the purposes above. We a priori defined that consensus was considered achieved if >75% agreed on the indicator. RESULTS Twenty-two specialists (from Brisbane, Melbourne, Perth and Canberra) participated in the survey. The cumulative number of years of their respiratory experience was 324 and that of general clinical practice was 504. Consensus was achieved in all 10 QIs, with 6 reaching 100% agreement. Mean agreement for the 10 items was 97%. CONCLUSION As complete consensus was achieved on these QIs, it can be used as a provisional clinical audit tool and can guide the development of a robust audit tool for primary care clinical practice to assist with quality improvement initiatives.
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Affiliation(s)
- Samantha J Prime
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie Marchant
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Anne B Chang
- Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, Brisbane, Queensland, Australia.,Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Helen L Petsky
- School of Nursing and Midwifery, Menzies Health Institute of Queensland, Griffith University, Brisbane, Queensland, Australia
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106
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McKay R, Law M, McGrail K, Balshaw R, Reyes R, Patrick DM. What can we learn by examining variations in the use of urine culture in the management of acute cystitis? A retrospective cohort study with linked administrative data in British Columbia, Canada, 2005-2011. PLoS One 2019; 14:e0213534. [PMID: 30849104 PMCID: PMC6407775 DOI: 10.1371/journal.pone.0213534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/23/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction Urinary tract infections (UTI) are common community-based bacterial infections. Empiric antibiotic recommendations are guided by local resistance rates. Previous research suggests that cultures are overused for uncomplicated cystitis, but practice patterns have not been described in detail. Variations in culturing have implications for the interpretation of antibiotic resistance rates. Methods We used a retrospective cohort study to analyze variations in urine culturing among physicians, controlling for patient and physician characteristics. We identified all outpatient physician visits among adults and children for cystitis in British Columbia between 2005 and 2011 using administrative data and linked these to laboratory data on urine cultures. Using hierarchical generalized linear mixed models we explored variations in urine culture submissions for cystitis (ICD code 595) and the associations with patient and physician characteristics, stratified by patient sex. Results Urine cultures were associated with 16% of visits for cystitis among females and 9% among males, and 59% of visits overall were associated with antibiotic treatment. Older patients, patients with a recent antibiotic prescription, and long term care residents were significantly less likely to have a culture associated with a cystitis visit, whether male or female. Female physicians and physicians with 16–35 years’ experience were more likely to culture, while international medical graduates were less likely–particularly for female visits. Notably, there was substantial unexplained variation among physicians after controlling for physician characteristics: we found a 24-fold variation in the odds of culturing a female UTI between physicians who were otherwise similar. Conclusion Individual physicians show substantial variation in their propensity to submit cultures for cystitis visits. Reducing such variation and encouraging appropriate levels of culturing would support effective antibiotic use.
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Affiliation(s)
- Rachel McKay
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada
- * E-mail:
| | - Michael Law
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada
| | - Kimberlyn McGrail
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada
| | - Robert Balshaw
- George and Fay Yee Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Canada
| | | | - David M. Patrick
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- British Columbia Centre for Disease Control, Vancouver, Canada
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107
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Geographic variation in inpatient costs for Acute Myocardial Infarction care: Insights from Italy. Health Policy 2019; 123:449-456. [PMID: 30902531 DOI: 10.1016/j.healthpol.2019.01.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 01/02/2023]
Abstract
Geographic variations in healthcare expenditures have been widely reported within and between countries. Nevertheless, empirical evidence on the role of organizational factors and care systems in explaining these variations is still needed. This paper aims at assessing the regional differences in hospital spending for patients hospitalized for Acute Myocardial Infarction (AMI) in Tuscany and Lombardy regions (Italy), which rank high in terms of care quality and that have been, at least until 2016, characterized by quite different governance systems. Generalized linear models are performed to estimate index, 30-day and one-year hospitalization spending adjusted for baseline covariates. A two-part model is used to estimate 31-365 day expenditure. Adjusted hospital spending for AMI patients were significantly higher in Lombardy compared with Tuscany. In Lombardy, patients experienced higher re-hospitalizations in the 31-365 days and longer length of stays than in Tuscany. On the other hand, no significant regional differences in adjusted mortality rates at both acute and longer phases were found. Comparing two regional healthcare systems which mainly differ in both the reimbursement systems and the level of integration between hospital and community services provides insights into factors potentially contributing to regional variations in spending and, therefore, in areas for efficiency improvement.
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108
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National health innovation systems: Clustering the OECD countries by innovative output in healthcare using a multi indicator approach. RESEARCH POLICY 2019. [DOI: 10.1016/j.respol.2018.08.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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109
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Cook DA, Pankratz VS, Pencille LJ, Dupras DM, Linderbaum JA, Wilkinson JM. Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study. Am J Med Qual 2019; 34:596-606. [PMID: 30698036 DOI: 10.1177/1062860618824992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.
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Affiliation(s)
| | - V Shane Pankratz
- University of New Mexico Health Sciences Center, Albuquerque, NM
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110
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Coyle R, Feher M, Jones S, Hamilton M, de Lusignan S. Variation in the diagnosis and control of hypertension is not explained by conventional variables: Cross-sectional database study in English general practice. PLoS One 2019; 14:e0210657. [PMID: 30629703 PMCID: PMC6328229 DOI: 10.1371/journal.pone.0210657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 12/28/2018] [Indexed: 01/13/2023] Open
Abstract
Background Hypertension is a major cause of preventable disability and death globally and affects more than one in four adults in England. Unwarranted variation is variation in access, quality, outcome or value which is unexplained by differences in the condition or patient characteristics and which reduces quality and efficiency. Distinguishing unwarranted from variation due to clinical, organisational or patient factors can be challenging. We carried out this study to explore inter-practice variation in the diagnosis and management of hypertension in the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) network database, a large, representative surveillance database. Methods and finding We carried out a cross-sectional study using primary care data extracted from the electronic health records of 1,271,419 adults registered at RCGP RSC general practices on 31st December 2016. Logistic regression was used to indirectly standardise practice-level hypertension prevalence and control against the RCGP RSC population, adjusted for age, gender, ethnicity, deprivation, co-morbidity, NHS region and practice size. Inter-practice variation was demonstrated using funnel plots with 95% and 99.8% control limits. The prevalence of detected hypertension was 18.4% (95% CI 18.4–18.5), n = 234,165. Uncontrolled hypertension was present in 146,553 of 196,052 individuals, 25.2% (25.1–25.4), in whom blood pressure had been recorded in the previous year. Hypertension management varied markedly between practices with a three-fold difference in prevalence, 13.5–38.4%, and a four-fold difference in the proportion of uncontrolled hypertension, 11.8–47.9%. Despite adjustment for sociodemographic and practice characteristics funnel plots demonstrated marked over-dispersion. Conclusions Substantial variation in the prevalence of diagnosed hypertension and the management of hypertension was only partially explained by characteristics captured within a routine dataset. The over-dispersion suggests variation is not fully explained by these factors and that context, behaviour and processes of care delivery may contribute to variation. Routine data sources in isolation to not provide sufficient contextual data to diagnose the causes of variation.
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Affiliation(s)
- Rachel Coyle
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
- * E-mail:
| | - Michael Feher
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
| | - Simon Jones
- Department of Population Health, Division of Healthcare Delivery Science, NYU School of Medicine, New York, United States of America
| | - Mark Hamilton
- Director, Surrey Heartlands Clinical Academy, Guildford, United Kingdom
| | - Simon de Lusignan
- Department of Clinical & Experimental Medicine, University of Surrey, London, United Kingdom
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111
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Naugler C, Church DL. Clinical laboratory utilization management and improved healthcare performance. Crit Rev Clin Lab Sci 2019. [DOI: 10.1080/10408363.2018.1526164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Christopher Naugler
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Department of Family Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Deirdre L. Church
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, University of Calgary, Calgary, Canada
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Strumann C, Flägel K, Emcke T, Steinhäuser J. Procedures performed by general practitioners and general internal medicine physicians - a comparison based on routine data from Northern Germany. BMC FAMILY PRACTICE 2018; 19:189. [PMID: 30509221 PMCID: PMC6276264 DOI: 10.1186/s12875-018-0878-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/19/2018] [Indexed: 11/21/2022]
Abstract
Background In response to a rising shortage of general practitioners (GPs), physicians in general internal medicine (GIM) have become part of the German primary care physician workforce. Previous studies have shown substantial differences in practice patterns between both specialties. The aim of this study was to analyse and compare the application of procedures by German GPs and GIM physicians based on routine data. Methods The Association of Statutory Health Insurance Physicians in the federal state Schleswig-Holstein (Northern Germany) provided invoicing data of the first quarters of 2013 and 2015. Differences between GPs and GIM physicians in the implementation rate of 46 selected primary care procedures were examined by means of the Pearson χ2-test. The selection of procedures was based on international and own preliminary studies on primary care procedures. Results In the first quarter of 2013/2015 respectively, 1228/1227 GPs and 447/484 GIM physicians provided services in Schleswig-Holstein. Significant differences were found for 20 of the 46 procedures. GPs had higher application rates of procedures concerning health screening (e.g. adolescent health examination, well-child visits) and minor surgery. GIM physicians more often applied technology-oriented procedures, such as ultrasound scans, electrocardiograms (ECG), and 24-h ambulatory blood pressure measurements. The treatment patterns of both specialities did not vary much during the study period. Cardiac stress testing was the only significantly increased GP procedure in that time. Conclusions Our results suggest substantial differences in the application of procedures between GPs and GIM physicians with potential consequences for the overall primary healthcare provision. The findings could foster a discussion about training needs for procedures in primary care to ensure its comprehensiveness. The results reflect scope for changes in vocational training in the future for an effective and efficient re-allocation of primary healthcare.
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Affiliation(s)
- C Strumann
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
| | - K Flägel
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - T Emcke
- Association of Statutory Health Insurance Physicians of the Federal State of Schleswig-Holstein, Bismarckallee 1-6, 23795, Bad Segeberg, Germany
| | - J Steinhäuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
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Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery. Anesthesiology 2018; 129:1121-1131. [DOI: 10.1097/aln.0000000000002453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Manuscript Tells Us That Is New
Background
Substantial variation in primary anesthesia type for hip fracture surgery exists. Previous work has demonstrated that patients cared for at hospitals using less than 20 to 25% neuraxial anesthesia have decreased survival. Therefore, the authors aimed to identify sources of variation in anesthesia type, considering patient-, anesthesiologist-, and hospital-level variables.
Methods
Following protocol registration (NCT02787031), the authors conducted a cross-sectional analysis of a population-based cohort using linked administrative data in Ontario, Canada. The authors identified all people greater than 65 yr of age who had emergency hip fracture surgery from April 2002 to March 2014. Generalized linear mixed models were used to account for hierarchal data and measure the adjusted association of hospital-, anesthesiologist-, and patient-level factors with neuraxial anesthesia use. The proportion of variation attributable to each level was estimated using variance partition coefficients and the median odds ratio for receipt of neuraxial anesthesia.
Results
Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic. The median odds ratio for receiving neuraxial anesthesia was 2.36 between randomly selected hospitals and 2.36 between randomly selected anesthesiologists. The majority (60.1%) of variation in neuraxial anesthesia use was explained by patient factors; 19.9% was attributable to the anesthesiologist providing care and 20.0% to the hospital where surgery occurred. The strongest patient-level predictors were absence of preoperative anticoagulant or antiplatelet agents, absence of obesity, and presence of pulmonary disease.
Conclusions
While patient factors explain most of the variation in neuraxial anesthesia use for hip fracture surgery, 40% of variation is attributable to anesthesiologist and hospital-level practice. Efforts to change practice patterns will need to consider hospital-level processes and anesthesiologists’ intentions and behaviors.
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An observational study of end-tidal carbon dioxide trends in general anesthesia. Can J Anaesth 2018; 66:149-160. [PMID: 30430440 PMCID: PMC6331507 DOI: 10.1007/s12630-018-1249-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/03/2018] [Accepted: 08/05/2018] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Despite growing evidence supporting the potential benefits of higher end-tidal carbon dioxide (ETCO2) levels in surgical patients, there is still insufficient data to formulate guidelines for ideal intraoperative ETCO2 targets. As it is unclear which intraoperative ETCO2 levels are currently used and whether these levels have changed over time, we investigated the practice pattern using the Multicenter Perioperative Outcomes Group database. METHODS This retrospective, observational, multicentre study included 317,445 adult patients who received general anesthesia for non-cardiothoracic procedures between January 2008 and September 2016. The primary outcome was a time-weighted average area-under-the-curve (TWA-AUC) for four ETCO2 thresholds (< 28, < 35, < 45, and > 45 mmHg). Additionally, a median ETCO2 was studied. A Kruskal-Wallis test was used to analyse differences between years. Random-effect multivariable logistic regression models were constructed to study variability. RESULTS Both TWA-AUC and median ETCO2 showed a minimal increase in ETCO2 over time, with a median [interquartile range] ETCO2 of 33 [31.0-35.0] mmHg in 2008 and 35 [33.0-38.0] mmHg in 2016 (P <0.001). A large inter-hospital and inter-provider variability in ETCO2 were observed after adjustment for patient characteristics, ventilation parameters, and intraoperative blood pressure (intraclass correlation coefficient 0.36; 95% confidence interval, 0.18 to 0.58). CONCLUSIONS Between 2008 and 2016, intraoperative ETCO2 values did not change in a clinically important manner. Interestingly, we found a large inter-hospital and inter-provider variability in ETCO2 throughout the study period, possibly indicating a broad range of tolerance for ETCO2, or a lack of evidence to support a specific targeted range. Clinical outcomes were not assessed in this study and they should be the focus of future research.
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Muratov S, Lee J, Holbrook A, Costa A, Paterson JM, Guertin JR, Mbuagbaw L, Gomes T, Khuu W, Tarride JE. Regional variation in healthcare spending and mortality among senior high-cost healthcare users in Ontario, Canada: a retrospective matched cohort study. BMC Geriatr 2018; 18:262. [PMID: 30382828 PMCID: PMC6211423 DOI: 10.1186/s12877-018-0952-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 10/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Senior high cost health care users (HCU) are a priority for many governments. Little research has addressed regional variation of HCU incidence and outcomes, especially among incident HCU. This study describes the regional variation in healthcare costs and mortality across Ontario’s health planning districts [Local Health Integration Networks (LHIN)] among senior incident HCU and non-HCU and explores the relationship between healthcare spending and mortality. Methods We conducted a retrospective population-based matched cohort study of incident senior HCU defined as Ontarians aged ≥66 years in the top 5% most costly healthcare users in fiscal year (FY) 2013. We matched HCU to non-HCU (1:3) based on age, sex and LHIN. Primary outcomes were LHIN-based variation in costs (total and 12 cost components) and mortality during FY2013 as measured by variance estimates derived from multi-level models. Outcomes were risk-adjusted for age, sex, ADGs, and low-income status. In a cost-mortality analysis by LHIN, risk-adjusted random effects for total costs and mortality were graphically presented together in a cost-mortality plane to identify low and high performers. Results We studied 175,847 incident HCU and 527,541 matched non-HCU. On average, 94 out of 1000 seniors per LHIN were HCU (CV = 4.6%). The mean total costs for HCU in FY2013 were 12 times higher that of non-HCU ($29,779 vs. $2472 respectively), whereas all-cause mortality was 13.6 times greater (103.9 vs. 7.5 per 1000 seniors). Regional variation in costs and mortality was lower in senior HCU compared with non-HCU. We identified greater variability in accessing the healthcare system, but, once the patient entered the system, variation in costs was low. The traditional drivers of costs and mortality that we adjusted for played little role in driving the observed variation in HCUs’ outcomes. We identified LHINs that had high mortality rates despite elevated healthcare expenditures and those that achieved lower mortality at lower costs. Some LHINs achieved low mortality at excessively high costs. Conclusions Risk-adjusted allocation of healthcare resources to seniors in Ontario is overall similar across health districts, more so for HCU than non-HCU. Identified important variation in the cost-mortality relationship across LHINs needs to be further explored. Electronic supplementary material The online version of this article (10.1186/s12877-018-0952-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sergei Muratov
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada. .,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, ON, Canada.
| | - Justin Lee
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada.,Geriatric Education and Research in Aging Sciences Centre, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Andrew Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jason R Guertin
- Département de Médecine Sociale et Préventive, Faculté de Médecine, Université Laval, Quebec City, QC, Canada.,Centre de recherche du CHU de Québec, Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Québec City, QC, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare, Hamilton, ON, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Wayne Khuu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, ON, Canada.,Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Canada
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Nouhi M, Hadian M, Olyaeemanesh A. The clinical and economic consequences of practice style variations in common surgical interventions: A protocol for systematic review. Medicine (Baltimore) 2018; 97:e12439. [PMID: 30334941 PMCID: PMC6211928 DOI: 10.1097/md.0000000000012439] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Surgical intervention is one of the common therapeutic interventions applied to a vast class of diseases. Unwarranted variation in practice style in different locations is considered as practice style variations (PSVs), which cause undesirable effects on patient health status and economic consequences. The magnitude of the variations in surgical interventions and its effects on clinical outcomes of patients and also utilization of resources have been investigated in recent years. But the findings show considerable heterogeneities in magnitude and consequences. We develop a protocol to systematically review the current literature of PSV to explain the magnitude of PSV and its clinical and economic consequences. METHOD This systematic review will include observational and experimental studies to investigate magnitude and consequences of PSV in common surgical interventions, cardiovascular disease, urological, and ophthalmological diseases. Source of information is scientific databases, theses, clinical trials registrations website, and grey literature. A comprehensive electronic search will be conducted through PubMed, Web of Science, EBSCO, EMBASE, and Scopus databases. Studies are assessed systematically by 2 investigators. Methodological quality of the included studies is evaluated by the STROBE and CONSORT checklists. In case of data availability, we will pool findings of included studies by meta-analysis techniques in the CMA software. Subgroup analyses are based on the type of the interventions and selected diseases. RESULTS This study has ethical approval from ethical committee of Iran University of Medical Sciences, ethic code: IR.IUMS.REC1395.9221504203. The results will be published in a peer-reviewed journal. CONCLUSION A systematic review is considered as an appropriate scientific method for reaching a consensus on magnitude as well as consequences of PSV. Results of this study will help clinical experts to attain more knowledge about PSV and encourage them to use some tools such as clinical guidelines and shared decision making to alleviate its consequences.
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Affiliation(s)
- Mojtaba Nouhi
- School of Health Management and Information Sciences, Iran University of Medical Sciences
| | - Mohamad Hadian
- School of Health Management and Information Sciences, Iran University of Medical Sciences
| | - Alireza Olyaeemanesh
- National Institute of Health Research
- Health Equity Research Center, Tehran University of Medical Sciences, Tehran, Iran
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117
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Mercier G, Duflos C, Riondel A, Delmas C, Manzo-Silberman S, Leurent G, Elbaz M, Bonnefoy-Cudraz E, Henry P, Roubille F. Admissions to intensive cardiac care units in France in 2014: A cross-sectional, nationwide population-based study. Medicine (Baltimore) 2018; 97:e12677. [PMID: 30290655 PMCID: PMC6200530 DOI: 10.1097/md.0000000000012677] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Geographic variation in admission to the intensive cardiac care unit (ICCU) might question about the efficiency and the equity of the healthcare system. The aim was to explain geographic variation in the rate of admission to ICCU for coronary artery disease (CAD) or heart failure (HF) in France.We conducted a retrospective study based on the French national hospital discharge database. All inpatient stays for CAD or HF with an admission to an ICCU in 2014 were included. We estimated population-based age and sex-standardized ICCU admission rates at the department level. We separately modeled the department-level admission rates for HF and CAD using generalized linear models.In all, 61,010 stays for CAD and 27,828 stays for HF had at least 1 ICCU admission. The ICCU admission rates were explained by the admission rate for CAD, by the diabetes prevalence, by the proportion of the population >75 years, and by the drive time to the ICCU.This work sheds light on the finding of substantial geographic variation in the ICCU admission rates for CAD and HF in France. This variation is explained by both the age and the health status of the population and also by the drive time to the closest ICCU for HF. Moreover, ICCU admission for HF might be more prone to unwarranted variations due to medical practice patterns.
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Affiliation(s)
- Grégoire Mercier
- Economic Evaluation Unit, University Hospital of Montpellier
- CEPEL, UMR CNRS Université de Montpellier, Montpellier
| | - Claire Duflos
- Economic Evaluation Unit, University Hospital of Montpellier
| | - Adeline Riondel
- Economic Evaluation Unit, University Hospital of Montpellier
| | - Clément Delmas
- Intensive Cardiac Care Unit, Cardiology department, University Hospital of Rangueil, Toulouse
| | - Stéphane Manzo-Silberman
- Department of cardiology, Inserm U942, Lariboisière Hospital, AP-HP, Paris Diderot University, Paris
| | - Guillaume Leurent
- CHU Rennes, Service de Cardiologie et Maladies Vasculaires, Rennes, F-35000
| | - Meyer Elbaz
- Intensive Cardiac Care Unit, Cardiology department, University Hospital of Rangueil, Toulouse
| | | | - Patrick Henry
- Department of cardiology, Inserm U942, Lariboisière Hospital, AP-HP, Paris Diderot University, Paris
| | - François Roubille
- Cardiology Department, University Hospital of Montpellier, Montpellier
- PhyMedExp, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier Cedex, France
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Draaisma E, Bekhof J, Langenhorst VJ, Brand PLP. Implementing evidence-based medicine in a busy general hospital department: results and critical success factors. BMJ Evid Based Med 2018; 23:173-176. [PMID: 30049687 DOI: 10.1136/bmjebm-2018-110895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 11/04/2022]
Abstract
Implementing evidence-based medicine (EBM) in a busy hospital department is challenging, but when successful, may contribute to quality of care. This paper is a narrative review of the successes and challenges of deliberate implementation of EBM in a paediatric department in a general teaching hospital in Zwolle, the Netherlands. Key elements in this project were providing basic EBM education to the entire team of consultants and nurse practitioners, structurally embedding EBM activities into our weekly schedule and development of local practice guidelines. This deliberate practice of EBM principles has changed the way we treat common paediatric problems. It likely reduced unwarranted practice variation and promoted a reserved attitude towards the use of unnecessary diagnostics, which might improve delivery of effective, cost-conscious care. The project also positively influenced our group culture and learning environment. In accordance with previous reports, lack of time and reluctance to change routines and habits hindered the practice of EBM in our department. In our experience, these barriers can be overcome by promoting a team-wide endorsement of EBM, a willingness to acknowledge uncertainty and by deliberate practice. If these can be achieved, systematic application of EBM principles in a busy hospital department is feasible and worthwhile.
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Affiliation(s)
- Eelco Draaisma
- Women and Children's Centre, Isala, Zwolle, The Netherlands
- Lifelong Learning, Education & Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, The Netherlands
| | - Jolita Bekhof
- Women and Children's Centre, Isala, Zwolle, The Netherlands
| | | | - Paul L P Brand
- Women and Children's Centre, Isala, Zwolle, The Netherlands
- Lifelong Learning, Education & Assessment Research Network (LEARN), University Medical Centre Groningen, Groningen, The Netherlands
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Beaupre LA, Wai EK, Hoover DR, Noveck H, Roffey DM, Cook DR, Magaziner JS, Carson JL. A comparison of outcomes between Canada and the United States in patients recovering from hip fracture repair: secondary analysis of the FOCUS trial. Int J Qual Health Care 2018; 30:97-103. [PMID: 29385446 DOI: 10.1093/intqhc/mzx199] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 01/03/2018] [Indexed: 12/28/2022] Open
Abstract
Objective To determine if adjusted mortality, walking ability or return home differed after hip fracture surgery between Canada and the USA. Design Secondary analysis of the Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair (FOCUS) trial data. Setting Data were collected from 47 American and Canadian hospitals. Participants Overall, 2016 subjects with a hip fracture (USA = 1222 (60.6%); Canada = 794 (39.4%)) were randomized to a liberal or restrictive transfusion strategy. Subjects were 50 years and older, with cardiovascular disease and/or risk factors and hemoglobin <100 g/L within 3 days post-surgery. The average age was 82 years and 1527(76%) subjects were females. Intervention Demographics, health status and health services data were collected up to 60 days post-surgery and mortality to a median of 3 years post-surgery. Main outcomes Mortality, inability to walk and return home. Results US subjects had higher adjusted mortality than Canadians at 30 days (odds ratio = 1.78; 95% confidence interval: 1.09-2.90), 60 days (1.53; 1.02-2.29) and up to 3 years (hazard ratio = 1.25; 1.07-1.45). There were no differences in adjusted outcomes for walking ability or return home at 30 or 60 days post-surgery. Median hospital length of stay was longer (P < 0.0001) in Canada (9 days; interquartile range: 5-18 days) than the US (3 days; 2-5 days). US subjects (52.9%) were more likely than Canadians (16.8%) to be discharged to nursing homes for rehabilitation (P < 0.001). Conclusions Adjusted survival favored Canadians post hip fracture while walking ability and return home were not different between countries. The reason(s) for mortality differences warrant further investigation.
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Affiliation(s)
- Lauren A Beaupre
- Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
| | - Eugene K Wai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada.,Faculty of Medicine, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada.,Division of Orthopaedic Surgery, Department of Surgery, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Donald R Hoover
- Department of Statistics and Biostatistics, Rutgers University, The State University of New Jersey, 473 Hill Center, Busch Campus Rutgers University 110 Frelinghuysen Road Piscataway, NJ 08854-8019, USA
| | - Helaine Noveck
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, 125 Paterson St, New Brunswick, NJ 08901, USA
| | - Darren M Roffey
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, 725 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada
| | - Donald R Cook
- Division of General Internal Medicine, Cumming School of Medicine, University of Calgary, FMC North Tower, 1403 29th Street NW, Calgary, Alberta T2N 2T9, Canada
| | - Jay S Magaziner
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Suite 200, Howard Hall, 660 West Redwood Street, Baltimore, MD 21201, USA
| | - Jeffrey L Carson
- Division of General Internal Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Biomedical and Health Sciences, Rutgers, The State University of New Jersey, 125 Paterson St, New Brunswick, NJ 08901, USA
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Shaw J, Tepper J, Martin D. From pilot project to system solution: innovation, spread and scale for health system leaders. BMJ LEADER 2018. [DOI: 10.1136/leader-2017-000055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Promoting the scale and spread of effective health innovations requires dedicated action from health system leaders. In order to maximise the effects of leadership strategies to promote the spread and scale of health innovations, conceptual clarity and well-defined strategies are essential. In this commentary, we propose definitions of the concepts of ‘innovation’, ‘spread’ and ‘scale’, and explain how these concepts can be used by health system leaders to generate interest, excitement and commitment for specific innovations from a broad community of stakeholders. We then outline two strategies from the community organising literature that leaders can use to promote spread and scale.
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Maeda T, Babazono A, Nishi T. Surveillance of First-Generation H1-Antihistamine Use for Older Patients with Dementia in Japan: A Retrospective Cohort Study. Curr Gerontol Geriatr Res 2018; 2018:3406210. [PMID: 30065759 PMCID: PMC6051324 DOI: 10.1155/2018/3406210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/18/2018] [Accepted: 05/31/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study aimed to investigate the rate of first-generation H1-antihistamines use for older adults with dementia in Japan. METHODS The study design was retrospective cohort using claims data between fiscal years 2010 and 2013. Subjects were 75 years or older, diagnosed with dementia, and given H1-antihistamines orally during the study period after being diagnosed with dementia. We investigated the cumulative number of oral H1-antihistamines administered and the relationship between first-generation H1-antihistamine use and each explanatory variable using crude and adjusted odds ratio. RESULTS The cumulative total for use of first-generation H1-antihistamine for older adults with dementia accounted for 32.1% of all antihistamine medication. The majority of first-generation H1-antihistamine prescriptions were indicated for cold treatment. Those with upper respiratory infection or asthma had a significantly positive relationship with first-generation H1-antihistamine use. CONCLUSION The study showed that first-generation H1-antihistamine drugs were highly prescribed in older adults with dementia in Japan.
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Affiliation(s)
- Toshiki Maeda
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, 8-19-1 Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
| | - Akira Babazono
- Department of Healthcare Administration and Management, Graduate School of Healthcare Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
| | - Takumi Nishi
- Department of Healthcare Administration and Management, Graduate School of Healthcare Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Correia LCL, Barcellos GB, Calixto V, Volschan A, Barreto-Filho JAS, Lopes RD, Rassi A, Levinson W, de Paola AAV. 'Choosing Wisely' culture among Brazilian cardiologists. Int J Qual Health Care 2018; 30:437-442. [PMID: 29506135 DOI: 10.1093/intqhc/mzy028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 02/16/2018] [Indexed: 11/13/2022] Open
Abstract
Objective (i) To describe how aligned the 'Choosing Wisely' concept is with the medical culture among Brazilian cardiologists and (ii) to identify predictors for physicians' preference for avoiding wasteful care. Design Cross-sectional study. Setting Brazilian Society of Cardiology. Participants Cardiologists who agree to fill a web questionary. Intervention A task force of 12 Brazilian cardiologists prepared a list of 13 'do not do' recommendations, which were made available on the Brazilian Society of Cardiology website for affiliates to assign a supported score of 1 to 10 to each recommendation. Main Outcome Measurement Score average for supporting recommendations. Results Of 14 579 Brazilian cardiologists, 621 (4.3%) answered the questionnaire. The top recommendation was 'do not perform routine percutaneous coronary intervention in asymptomatic individuals' (mean score = 8.0 ± 2.9) while the one with the lowest support was 'do not use an intra-aortic balloon pump in infarction with cardiogenic shock' (5.8 ± 3.2). None of the 13 recommendations presented a mean grade >9 (strong support); 7 recommendations averaged 7-8 (moderate support) followed by 6 recommendations with an average of 5-7 (modest support). Multivariate analysis independently identified predictors of the score attributed to the top recommendation; being an interventionist and time since graduation were both negatively associated with support. Conclusions (i) The support of Brazilian cardiologists for the 'Choosing Wisely' concept is modest to moderate, and (ii) older generations and enthusiasm towards the procedure one performs may be factors against the 'Choosing Wisely' philosophy.
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Affiliation(s)
- Luis C L Correia
- Hospital São Rafael, Av. São Rafael, 2152 - São Marcos, Salvador - BA, Brazil.,Medical and Public Health School of Bahia, Av. Dom João VI, 275 - Brotas, Salvador - BA, Brazil
| | - Guilherme B Barcellos
- Hospital das Clinicas of Porto Alegre, R. Ramiro Barcelos, 2350 - Santa Cecilia, Porto Alegre, RS, Brazil
| | - Vitor Calixto
- Medical and Public Health School of Bahia, Av. Dom João VI, 275 - Brotas, Salvador - BA, Brazil
| | - André Volschan
- Brazilian Society of Cardiology, Av. Marechal Câmara, 160, Rio de Janeiro, RJ, Brazil
| | | | - Renato D Lopes
- Duke University Hospital, 2301 Erwin Rd, Durham, NC, USA
| | - Anis Rassi
- Brazilian Society of Cardiology, Av. Marechal Câmara, 160, Rio de Janeiro, RJ, Brazil
| | - Wendy Levinson
- University of Toronto, 27 King's College Cir, Toronto, ON, Canada
| | - Angelo A V de Paola
- Brazilian Society of Cardiology, Av. Marechal Câmara, 160, Rio de Janeiro, RJ, Brazil
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123
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Massin S, Nebout A, Ventelou B. Predicting medical practices using various risk attitude measures. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:843-860. [PMID: 28861629 DOI: 10.1007/s10198-017-0925-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 08/08/2017] [Indexed: 05/17/2023]
Abstract
This paper investigates the predictive power of several risk attitude measures on a series of medical practices. We elicit risk preferences on a sample of 1500 French general practitioners (GPs) using two different classes of tools: scales, which measure GPs' own perception of their willingness to take risks between 0 and 10; and lotteries, which require GPs to choose between a safe and a risky option in a series of hypothetical situations. In addition to a daily life risk scale that measures a general risk attitude, risk taking is measured in different domains for each tool: financial matters, GPs' own health, and patients' health. We take advantage of the rare opportunity to combine these multiple risk attitude measures with a series of self-reported or administratively recorded medical practices. We successively test the predictive power of our seven risk attitude measures on eleven medical practices affecting the GPs' own health or their patients' health. We find that domain-specific measures are far better predictors than the general risk attitude measure. Neither of the two classes of tools (scales or lotteries) seems to perform indisputably better than the other, except when we concentrate on the only non-declarative practice (prescription of biological tests), for which the classic money-lottery test works well. From a public health perspective, appropriate measures of willingness to take risks may be used to make a quick, but efficient, profiling of GPs and target them with personalized communications, or interventions, aimed at improving practices.
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Affiliation(s)
- Sophie Massin
- Artois University, UMR 9221, Lille Economie Management (LEM), UFR EGASS, 9 Rue du Temple, BP 10665, 62030, Arras Cedex, France.
| | - Antoine Nebout
- ALISS UR1303, INRA, Université Paris-Saclay, F-94205, Ivry-Sur-Seine, France
| | - Bruno Ventelou
- Aix-Marseille Univ, CNRS, EHESS, Centrale Marseille, Aix-Marseille School of Economics, Marseille, France
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
- The Regional Health Observatory of Provence-Alpes-Cote d'Azur (ORS-PACA), Marseille, France
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124
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Feufel MA. How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine. QUALITATIVE HEALTH RESEARCH 2018; 28:1486-1498. [PMID: 29781384 DOI: 10.1177/1049732318774322] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Forty years of statistical database analyses have demonstrated the existence of unwarranted practice variation in care delivery, that is, variations independent of medical need, evidence, or patient preference. Alas, little is known about the underlying mechanisms and thus finding interventions to reduce unwarranted variations remains difficult, hampering quality, equity, and efficiency of care. Whereas statistical analyses describe deviations from ideal patterns, ethnographically inspired analyses aim at understanding when, how, and why variations occur in practice. Based on case studies derived from shadowing emergency physicians, I demonstrate that analyzing practice variation in practice helps to (a) advance the understanding of mechanisms and (b) evaluate/expand the existing repertoire of interventions. Results revealed unmet expectations and new sources of known variations as well as interventions complementing systemic changes with those that empower individuals to better cope with the existing system. These findings highlight the benefits of mixed-methods for understanding and tackling practice variation.
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Gandré C, Gervaix J, Thillard J, Macé JM, Roelandt JL, Chevreul K. Understanding geographic variations in psychiatric inpatient admission rates: width of the variations and associations with the supply of health and social care in France. BMC Psychiatry 2018; 18:174. [PMID: 29871613 PMCID: PMC5989448 DOI: 10.1186/s12888-018-1747-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/15/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Inpatient care accounts for the majority of mental health care costs and is not always beneficial. It can indeed have detrimental consequences if not used appropriately, and is unpopular among patients. As a consequence, its reduction is supported by international recommendations. Varying rates of psychiatric inpatient admissions therefore deserve to draw attention of researchers, clinicians and policy makers alike as such variations can challenge quality, equity and efficiency of care. In this context, our objectives were first to describe variations in psychiatric inpatient admission rates across the whole territory of mainland France, and second to identify their association with characteristics of the supply of care, which can be targeted by dedicated health policies. METHODS Our study was carried out in French psychiatric sectors' catchment areas for the year 2012. Inpatient admission rates per 100,000 adult inhabitants were calculated using data from the national psychiatric discharge database. Their variations were described numerically and graphically. We then carried out a negative binomial regression to identify characteristics of the supply of care (public and private care, health and social care, hospital and community-based care, specialised and non-specialised care) which were associated with these variations while adjusting our analysis for other relevant factors, in particular epidemiological differences. RESULTS Considerable variations in inpatient admission rates were observed between psychiatric sectors' catchment areas and were widespread on the French territory. Institutional characteristics of the hospital to which each sector was linked (private non-profit status, specialisation in psychiatry and participation to teaching activities and to emergency care) were associated with inpatient admission rates. Similarly, an increase in the availability of community-based private psychiatrists was associated with a decrease in the inpatient admission rate while an increase in the capacity of housing institutions for disabled individuals was associated with an increase in this rate. CONCLUSIONS Our results advocate for a homogenous repartition of health and social care for mental disorders in lines with the health needs of the population served. This should apply particularly to community-based private psychiatrists, whose heterogeneity of repartition has often been underscored.
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Affiliation(s)
- Coralie Gandré
- ECEVE, UMRS 1123, Université Paris Diderot, Sorbonne Paris Cité, INSERM, Paris, France
- AP-HP, URC-Eco, DHU PePSY, Paris, France
| | - Jeanne Gervaix
- ECEVE, UMRS 1123, Université Paris Diderot, Sorbonne Paris Cité, INSERM, Paris, France
- AP-HP, URC-Eco, DHU PePSY, Paris, France
| | - Julien Thillard
- ECEVE, UMRS 1123, Université Paris Diderot, Sorbonne Paris Cité, INSERM, Paris, France
- AP-HP, URC-Eco, DHU PePSY, Paris, France
| | - Jean-Marc Macé
- National Conservatory of Arts and Crafts, LIRSA, EA 4603 Paris, France
| | - Jean-Luc Roelandt
- ECEVE, UMRS 1123, Université Paris Diderot, Sorbonne Paris Cité, INSERM, Paris, France
- World Health Organization Collaborating Centre for Research and Training in Mental Health, Lille, France
| | - Karine Chevreul
- ECEVE, UMRS 1123, Université Paris Diderot, Sorbonne Paris Cité, INSERM, Paris, France
- AP-HP, URC-Eco, DHU PePSY, Paris, France
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Heins MJ, de Jong JD, Spronk I, Ho VKY, Brink M, Korevaar JC. Adherence to cancer treatment guidelines: influence of general and cancer-specific guideline characteristics. Eur J Public Health 2018; 27:616-620. [PMID: 28013246 DOI: 10.1093/eurpub/ckw234] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Guideline adherence remains a challenge in clinical practice, despite guidelines' ascribed potential to improve patient outcomes. We studied the level of adherence to recommendations from Dutch national cancer treatment guidelines, and the influence of general and cancer-specific guideline characteristics on adherence. Methods Based on data from a national cancer registry, adherence was evaluated for 15 treatment recommendations for breast, colorectal, prostate and lung cancer, and melanoma. Recommendations were selected by representatives of the medical specialist associations responsible for developing and implementing the guidelines. We used multivariable multilevel analysis to calculate mean adherence and variation between individual hospitals. Results Mean adherence to the different treatment recommendations ranged from 40 to 99%. Adherence differed only slightly between older and newer guidelines and between recommendations with low, moderate or high levels of evidence (range 79-84% and 77-91%, respectively), while adherence differed more between recommendations for different cancer types (range 54-99%), different treatment modalities (adherence ranged from 40 to 92%) or recommendations that advised against or recommended in favour of particular treatment (adherence ranged from 75 to 98%). Conclusion We found significant variation in adherence between different cancer treatment guidelines. While some guideline characteristics that seem to explain this variation may be considered difficult to modify, the potential for variance across cancer types and treatment modalities suggests that adherence could be further improved. At the same time, these results warrant tailored strategies for the improvement of adherence to clinical practice guidelines.
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Affiliation(s)
- Marianne J Heins
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Judith D de Jong
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Inge Spronk
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Vincent K Y Ho
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Mirian Brink
- Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Joke C Korevaar
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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127
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Johansson N, Jakobsson N, Svensson M. Regional variation in health care utilization in Sweden - the importance of demand-side factors. BMC Health Serv Res 2018; 18:403. [PMID: 29866201 PMCID: PMC5987462 DOI: 10.1186/s12913-018-3210-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Differences in health care utilization across geographical areas are well documented within several countries. If the variation across areas cannot be explained by differences in medical need, it can be a sign of inefficiency or misallocation of public health care resources. METHODS In this observational, longitudinal panel study we use regional level data covering the 21 Swedish regions (county councils) over 13 years and a random effects model to assess to what degree regional variation in outpatient physician visits is explained by observed demand factors such as health, demography and socio-economic factors. RESULTS The results show that regional mortality, as a proxy for population health, and demography do not explain regional variation in visits to primary care physicians, but explain about 50% of regional variation in visits to outpatient specialists. Adjusting for socio-economic and basic supply-side factors explains 33% of the regional variation in primary physician visits, but adds nothing to explaining the variation in specialist visits. CONCLUSION 50-67% of regional variation remains unexplained by a large number of observable regional characteristics, indicating that omitted and possibly unobserved factors contribute substantially to the regional variation. We conclude that variations in health care utilization across regions is not very well explained by underlying medical need and demand, measured by mortality, demographic and socio-economic factors.
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Affiliation(s)
- Naimi Johansson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
| | - Niklas Jakobsson
- Department of Economics, Karlstad University, SE-651 88 Karlstad, Sweden
- Norwegian Social Research (NOVA), Oslo, Norway
| | - Mikael Svensson
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, PO Box 463, SE-405 30 Gothenburg, Sweden
- Department of Economics, Williams College, Williamstown, MA USA
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128
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Garside TL, Lee RP, Delaney A, Milliss D. Clinical Practice Variation in Acute Severe Burn Injury. Anaesth Intensive Care 2018; 46:321-325. [DOI: 10.1177/0310057x1804600310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The New South Wales (NSW) Statewide Burn Injury Service Database was reviewed to identify variations in clinical practice with respect to care of severely burn-injured patients in intensive care. We compared differences in practice relating to duration of endotracheal intubation and surgical grafting. In this retrospective observational study, we reviewed all intensive care unit (ICU) admissions to the two NSW adult burns centres, ICU A and ICU B, between January 2008 and December 2015. Data were analysed for association between duration of intubation and outcome. There were 855 admissions to adult ICU, with a significant difference in the percentage total body surface area (% TBSA) of burn and inhalation injury between patients in the two units. There was a significant difference in duration of intubation and ICU length of stay (LOS) between the units, which persisted when adjusted for age, % TBSA and inhalational injury. When analysing patients with more severe burns (>20% TBSA or intubated), the difference in duration of intubation remained significant (median of three days [interquartile range, IQR, 1–11 days] in A and 2 days [IQR 1–6 days] in B, P=0.003) as did ICU LOS (median 3 days [IQR 2–11 days] for A and 2 days [IQR 1–6 days] for B, P <0.0005). There was no significant difference in mortality between the two units for the severe or the more severe subgroup of burns when adjusted for age, % TBSA and inhalational injury (adjusted odds ratio, OR, for mortality 1.17 [95% confidence intervals 0.6 to 2.3, P=0.65]). There were significant differences in clinical practice, including duration of intubation, between the two ICUs. Longer intubation was associated with a longer ICU LOS, but was not associated with a difference in mortality. Large collaborative, prospective multicentre studies in severe burns are needed to identify best practice and variations in practice to determine if they are associated with increased mortality and/or cost.
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Affiliation(s)
- T. L. Garside
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - R. P. Lee
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - A. Delaney
- Intensivist, Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales
| | - D. Milliss
- Intensivist and Former Director, Intensive Care Services, Concord Hospital, Sydney, New South Wales
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129
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Martin D, Miller AP, Quesnel-Vallée A, Caron NR, Vissandjée B, Marchildon GP. Canada's universal health-care system: achieving its potential. Lancet 2018; 391:1718-1735. [PMID: 29483027 PMCID: PMC7138369 DOI: 10.1016/s0140-6736(18)30181-8] [Citation(s) in RCA: 240] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 01/05/2023]
Abstract
Access to health care based on need rather than ability to pay was the founding principle of the Canadian health-care system. Medicare was born in one province in 1947. It spread across the country through federal cost sharing, and eventually was harmonised through standards in a federal law, the Canada Health Act of 1984. The health-care system is less a true national system than a decentralised collection of provincial and territorial insurance plans covering a narrow basket of services, which are free at the point of care. Administration and service delivery are highly decentralised, although coverage is portable across the country. In the setting of geographical and population diversity, long waits for elective care demand the capacity and commitment to scale up effective and sustainable models of care delivery across the country. Profound health inequities experienced by Indigenous populations and some vulnerable groups also require coordinated action on the social determinants of health if these inequities are to be effectively addressed. Achievement of the high aspirations of Medicare's founders requires a renewal of the tripartite social contract between governments, health-care providers, and the public. Expansion of the publicly funded basket of services and coordinated effort to reduce variation in outcomes will hinge on more engaged roles for the federal government and the physician community than have existed in previous decades. Public engagement in system stewardship will also be crucial to achieve a high-quality system grounded in both evidence and the Canadian values of equity and solidarity.
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Affiliation(s)
- Danielle Martin
- Women's College Hospital and Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
| | - Ashley P Miller
- Division of General Internal Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Amélie Quesnel-Vallée
- McGill Observatory on Health and Social Services Reforms, Department of Epidemiology, Biostatistics and Occupational Health, and Department of Sociology, McGill University, Montréal, QC, Canada
| | - Nadine R Caron
- Department of Surgery, Northern Medical Program and Centre for Excellence in Indigenous Health, University of British Columbia, Prince George, BC, Canada
| | - Bilkis Vissandjée
- School of Nursing and Public Health Research Institute, Université de Montréal, SHERPA Research Centre, Montréal, QC, Canada
| | - Gregory P Marchildon
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Johnson-Shoyama Graduate School of Public Policy, University of Regina, Regina, SK, Canada
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130
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Gutacker N, Bloor K, Bojke C, Walshe K. Should interventions to reduce variation in care quality target doctors or hospitals? Health Policy 2018; 122:660-666. [PMID: 29703654 PMCID: PMC6022214 DOI: 10.1016/j.healthpol.2018.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 10/16/2017] [Accepted: 04/06/2018] [Indexed: 11/29/2022]
Abstract
Performance management initiatives are increasingly targeting individual doctors as well as hospitals. Less than 25% of variation in clinical outcomes is attributable to providers. More variation in clinical outcomes is associated with doctors than with hospitals. Performance estimates for individual doctors are unreliable due to small samples.
Interventions to reduce variation in care quality are increasingly targeted at both individual doctors and the organisations in which they work. Concerns remain about the scope and consequences for such performance management, the relative contribution of individuals and organisations to observed variation, and whether performance can be measured reliably. This study explores these issues in the context of the English National Health Service by analysing comprehensive administrative data for all patients treated for four clinical conditions (acute myocardial infarction, hip fracture, pneumonia, ischemic stroke) and two surgical procedures (coronary artery bypass, hip replacement) during April 2010–February 2013. Performance indicators are defined as 30-day mortality, 28-day emergency readmission and inpatient length of stay. Three-level hierarchical generalised linear mixed models are estimated to attribute variation in case-mix adjusted indicators to individual doctors and hospital organisations. Except for length of stay after hip replacement, no more than 11% of variation in case-mix adjusted performance indicators can be attributed to doctors and organisations with the rest reflecting random chance and unobserved patient factors. Doctor variation exceeds hospital variation by a factor of 1.2 or more. However, identifying poor performance amongst doctors is hampered by insufficient numbers of cases per doctor to reliably estimate their individual performances. Policy makers and regulators should therefore be cautious when targeting individual doctors in performance improvement initiatives.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - Karen Bloor
- Department of Health Sciences, University of York, United Kingdom.
| | - Chris Bojke
- Centre for Health Economics, University of York, United Kingdom.
| | - Kieran Walshe
- Alliance Manchester Business School, University of Manchester, United Kingdom.
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131
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Lee J, Bahk J, Kim I, Kim YY, Yun SC, Kang HY, Lee J, Park JH, Shin SA, Khang YH. Geographic Variation in Morbidity and Mortality of Cerebrovascular Diseases in Korea during 2011-2015. J Stroke Cerebrovasc Dis 2018; 27:747-757. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/06/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022] Open
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Association of Hospital-level Neuraxial Anesthesia Use for Hip Fracture Surgery with Outcomes. Anesthesiology 2018; 128:480-491. [DOI: 10.1097/aln.0000000000001899] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
There is consistent and significant variation in neuraxial anesthesia use for hip fracture surgery across jurisdictions. We measured the association of hospital-level utilization of neuraxial anesthesia, independent of patient-level use, with 30-day survival (primary outcome) and length of stay and costs (secondary outcomes).
Methods
We conducted a population-based cohort study using linked administrative data in Ontario, Canada. We identified all hip fracture patients more than 65 yr of age from 2002 to 2014. For each patient, we measured the proportion of hip fracture patients at their hospital who received neuraxial anesthesia in the year before their surgery. Multilevel, multivariable regression was used to measure the association of log-transformed hospital-level neuraxial anesthetic-use proportion with outcomes, controlling for patient-level anesthesia type and confounders.
Results
Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic; utilization varied from 0 to 100% between hospitals. In total, 9,122 (8.5%) of patients died within 30 days of surgery. Survival independently improved as hospital-level neuraxial use increased (P = 0.009). Primary and sensitivity analyses demonstrated that most of the survival benefit was realized with increase in hospital-level neuraxial use above 20 to 25%; there did not appear to be a substantial increase in survival above this point. No significant associations between hospital neuraxial anesthesia-use and other outcomes existed.
Conclusions
Hip fracture surgery patients at hospitals that use more than 20 to 25% neuraxial anesthesia have improved survival independent of patient-level anesthesia type and other confounders. The underlying causal mechanism for this association requires a prospective study to guide improvements in perioperative care and outcomes of hip fracture patients.
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Cook DA, Sorensen KJ, Linderbaum JA, Pencille LJ, Rhodes DJ. Information needs of generalists and specialists using online best-practice algorithms to answer clinical questions. J Am Med Inform Assoc 2018; 24:754-761. [PMID: 28339685 DOI: 10.1093/jamia/ocx002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/31/2016] [Indexed: 11/13/2022] Open
Abstract
Objective To better understand clinician information needs and learning opportunities by exploring the use of best-practice algorithms across different training levels and specialties. Methods We developed interactive online algorithms (care process models [CPMs]) that integrate current guidelines, recent evidence, and local expertise to represent cross-disciplinary best practices for managing clinical problems. We reviewed CPM usage logs from January 2014 to June 2015 and compared usage across specialty and provider type. Results During the study period, 4009 clinicians (2014 physicians in practice, 1117 resident physicians, and 878 nurse practitioners/physician assistants [NP/PAs]) viewed 140 CPMs a total of 81 764 times. Usage varied from 1 to 809 views per person, and from 9 to 4615 views per CPM. Residents and NP/PAs viewed CPMs more often than practicing physicians. Among 2742 users with known specialties, generalists ( N = 1397) used CPMs more often (mean 31.8, median 7 views) than specialists ( N = 1345; mean 6.8, median 2; P < .0001). The topics used by specialists largely aligned with topics within their specialties. The top 20% of available CPMs (28/140) collectively accounted for 61% of uses. In all, 2106 clinicians (52%) returned to the same CPM more than once (average 7.8 views per topic; median 4, maximum 195). Generalists revisited topics more often than specialists (mean 8.8 vs 5.1 views per topic; P < .0001). Conclusions CPM usage varied widely across topics, specialties, and individual clinicians. Frequently viewed and recurrently viewed topics might warrant special attention. Specialists usually view topics within their specialty and may have unique information needs.
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Affiliation(s)
- David A Cook
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Mayo Clinic Online Learning, Mayo Clinic College of Medicine, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic
| | | | - Jane A Linderbaum
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Department of Cardiovascular Diseases, Mayo Clinic
| | - Laurie J Pencille
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Center for the Science of Health Care Delivery, Mayo Clinic
| | - Deborah J Rhodes
- Knowledge Delivery Center, Mayo Clinic, Rochester, MN, USA.,Division of Preventive Medicine, Mayo Clinic
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Grilli R, Chiesa V. Overuse in cancer care: do European studies provide information useful to support policies? Health Res Policy Syst 2018; 16:12. [PMID: 29458403 PMCID: PMC5819192 DOI: 10.1186/s12961-018-0287-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 01/19/2018] [Indexed: 02/06/2023] Open
Abstract
Health services overuse has been acknowledged as a relevant policy issue. In this study, we assessed the informative value of research on the quality of cancer care, exploring to what extent it is actually concerned with care overuse, thus providing policy-makers with sound estimates of overuse prevalence. We searched Medline for European studies, reporting information on the rate of use of diagnostic or therapeutic procedures/interventions in breast, colorectal, lung and prostate cancer patients, published in English between 2006 and 2016. Individual studies were classified with regards to their orientation towards overuse according to the quality metrics adopted in assessing rates of use of procedures and interventions. Out of 1882 papers identified, 100 accounting for 94 studies met our eligibility criteria, most of them on breast (n = 38) and colorectal (n = 30) cancer. Of these, 46 (49%) studies relied on process indicators allowing a direct measure of under- or overuse, the latter being addressed in 22 (24%) studies. Search for overuse in patterns of care did not increase over time, with overuse being measured in 24% of the studies published before 2010, and in only 13% of those published in 2015–2016. Information on its prevalence was available only for a relatively limited number of procedures/interventions. Overall, estimates of overuse tended to be higher for diagnostic procedures (median prevalence across all studies, 24%) than for drugs, surgical procedures or radiotherapy (median overuse prevalence always lower than 10%). Despite its increasing policy relevance, overuse is still an often overlooked issue in current European research on the quality of care for cancer patients.
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Affiliation(s)
- Roberto Grilli
- Clinical Governance Program, Local Health Authority - IRCCS of Reggio Emilia, Reggio Emilia, Italy.
| | - Valentina Chiesa
- Department of Medicine and Surgery, Unit of Biomedical, Biotechnological and Translational Science, University of Parma, Parma, Italy
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135
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Mercuri M, Gafni A. Examining the role of the physician as a source of variation: Are physician-related variations necessarily unwarranted? J Eval Clin Pract 2018; 24:145-151. [PMID: 28556526 DOI: 10.1111/jep.12770] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/17/2017] [Accepted: 04/18/2017] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The physician is often implicated as an important cause of observed variations in health care service use. However, it is not clear if physician-related variation is problematic for patient care. This paper illustrates that observed physician-related variation is not necessarily unwarranted. METHODS This is a narrative review. RESULTS Many studies have attributed observed variations to the physician, but little attention is given towards discriminating between those variations that exist for good reasons and those that are unwarranted. Two arguments can be made for why physician-related variation is unwarranted. The first posits that physician-related factors should not play a role in management of care decisions because such decisions should be driven by science (which is imagined to be definitive). The second considers the possibility of supplier-induced demand as a factor driving observed variations. We show that neither argument is sufficient to rule out that physician-related variations may be warranted. Furthermore, the claim that such variations are necessarily problematic for patients has yet to be substantiated empirically. CONCLUSIONS It is not enough to simply show that physician-related variation can exist-one must also show where it is unwarranted and what is the magnitude of unwarranted variations. Failure to show this can have significant implications on how we interpret and respond to observed variations. Improved measurement of the sources of variation, especially with respect to patient preferences and context, may help us start to disentangle physician-related variation that is desirable from that which is unwarranted.
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Affiliation(s)
- Mathew Mercuri
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada.,African Centre for Epistemology and Philosophy of Science, Department of Philosophy, University of Johannesburg, Auckland Park, South Africa
| | - Amiram Gafni
- Centre for Health Economics and Policy Analysis, Department of Health Services Research, Evaluation and Impact, McMaster University, Hamilton, Ontario, Canada
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Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants. PLoS One 2018; 13:e0191943. [PMID: 29385203 PMCID: PMC5792011 DOI: 10.1371/journal.pone.0191943] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 01/13/2018] [Indexed: 11/21/2022] Open
Abstract
Objective To understand clinicians' beliefs about practice variation and how variation might be reduced. Methods We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs. Results Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small. Conclusions Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.
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137
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Muratov S, Lee J, Holbrook A, Paterson JM, Guertin JR, Mbuagbaw L, Gomes T, Khuu W, Pequeno P, Costa AP, Tarride JE. Senior high-cost healthcare users' resource utilization and outcomes: a protocol of a retrospective matched cohort study in Canada. BMJ Open 2017; 7:e018488. [PMID: 29282266 PMCID: PMC5770942 DOI: 10.1136/bmjopen-2017-018488] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Senior high-cost users (HCUs) are estimated to represent 60% of all HCUs in Ontario, Canada's most populous province. To improve our understanding of individual and health system characteristics related to senior HCUs, we will examine incident senior HCUs to determine their incremental healthcare utilisation and costs, characteristics of index hospitalisation episodes, mortality and their regional variation across Ontario. METHODS AND ANALYSIS A retrospective, population-based cohort study using administrative healthcare records will be used. Incident senior HCUs will be defined as Ontarians aged ≥66 years who were in the top 5% of healthcare cost users during fiscal year 2013 but not during fiscal year 2012. Each HCU will be matched to three non-HCUs by age, sex and health planning region. Incremental healthcare use and costs will be determined using the method of recycled predictions. We will apply multivariable logistic regression to determine patient and health service factors associated with index hospitalisation and inhospital mortality during the incident year. The most common causes of admission will be identified and contrasted with the most expensive hospitalised conditions. We will also calculate the ratio of inpatient costs incurred through admissions of ambulatory care sensitive conditions to the total inpatient expenditures. The magnitude of variation in costs and health service utilisation will be established by calculating the extremal quotient, the coefficient of variation and the Gini mean difference for estimates obtained through multilevel regression analyses. ETHICS AND DISSEMINATION This study has been approved by Hamilton Integrated Research Ethics Board (ID#1715-C). The results of the study will be distributed through peer-reviewed journals. They also will be disseminated at research events in academic settings, national and international conferences as well as with presentations to provincial health authorities.
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Affiliation(s)
- Sergei Muratov
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Justin Lee
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Geriatric Education and Research in Aging Sciences Centre, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anne Holbrook
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - J Michael Paterson
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Jason Robert Guertin
- Département de médecine sociale et préventive, Faculté de Médecine, Université Laval, Quebec City, Quebec, Canada
- Centre de recherche du CHU de Québec, Université Laval, Axe Santé des Populations et Pratiques Optimales en Santé, Quebec City, Quebec, Canada
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Tara Gomes
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Wayne Khuu
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Priscila Pequeno
- Institute for Clinical Evaluative Sciences (ICES), Toronto, Ontario, Canada
| | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Big Data and Geriatric Models of Care Cluster, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joe's Hamilton, St. Joseph's Healthcare, Hamilton, Ontario, Canada
- Center for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, Ontario, Canada
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138
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Duell D, Koolman X, Portrait F. Practice variation in the Dutch long-term care and the role of supply-sensitive care: Is access to the Dutch long-term care equitable? HEALTH ECONOMICS 2017; 26:1728-1742. [PMID: 28251712 PMCID: PMC5811918 DOI: 10.1002/hec.3494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/17/2016] [Accepted: 01/12/2017] [Indexed: 05/05/2023]
Abstract
Universal access and generous coverage are important goals of the Dutch long-term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010-December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long-term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long-term IC.
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Affiliation(s)
- Daisy Duell
- Talma Institute, Department of Health SciencesVU University AmsterdamAmsterdamNetherlands
| | - Xander Koolman
- Talma Institute, Department of Health SciencesVU University AmsterdamAmsterdamNetherlands
| | - France Portrait
- Talma Institute, Department of Health SciencesVU University AmsterdamAmsterdamNetherlands
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139
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Scheffer M, Saluja S, Alonso N. Surgical care in the public health agenda. CAD SAUDE PUBLICA 2017; 33:e00104717. [PMID: 29091173 DOI: 10.1590/0102-311x00104717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 06/28/2017] [Indexed: 11/22/2022] Open
Abstract
The current article examines surgical care as a public health issue and a challenge for health systems organization. When surgery fails to take place in timely fashion, treatable clinical conditions can evolve to disability and death. The Lancet Commission on Global Surgery defined indicators for monitoring sustainable universal access to surgical care. Applied to Brazil, the global indicators are satisfactory, but the supply of surgeries in the country is marked by regional and socioeconomic inequalities, as well as between the public and private healthcare sectors.
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Affiliation(s)
- Mário Scheffer
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
| | - Saurabh Saluja
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, U.S.A.,Department of Surgery, Weill Cornell Medical College, New York, U.S.A
| | - Nivaldo Alonso
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brasil
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140
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Franklin JM, Donneyong MM, Desai RJ, Markson L, Girman CJ, McKay C, Patel MD, Mavros P, Schneeweiss S. Variation in adherence to medications across the healthcare system in two comparative effectiveness research cohorts. J Comp Eff Res 2017; 6:613-625. [PMID: 29039693 DOI: 10.2217/cer-2016-0095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To assess heterogeneity in adherence to medications in two example comparative effectiveness research studies. PATIENTS & METHODS We analyzed data from commercially insured patients initiating a statin or anticoagulant during 2005-2012. We calculated the cross-validated R2 from a series of hierarchical linear models to assess variation in 1-year adherence. RESULTS There was less heterogeneity in adherence in the statin cohort compared with the anticoagulant cohort, where patient characteristics explained 7.2% of variation in adherence, and adding therapy and provider characteristics increased the proportion of variation explained to 8.0 and 8.5%, cumulatively. Random effects provided essentially no explanatory power, even in the statin cohort with large numbers of patients clustered within each pharmacy, prescriber and provider. CONCLUSION The dependence of adherence on the healthcare system was stronger when the healthcare system influenced treatment choice and patient access to medication and when indications for treatment were strong.
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Affiliation(s)
- Jessica M Franklin
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Macarius M Donneyong
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Rishi J Desai
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology & Pharmacoeconomics, Department of Medicine, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
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141
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Keliddar I, Mosadeghrad AM, Jafari–Sirizi M. Rationing in health systems: A critical review. Med J Islam Repub Iran 2017; 31:47. [PMID: 29445676 PMCID: PMC5804460 DOI: 10.14196/mjiri.31.47] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Indexed: 11/22/2022] Open
Abstract
Background: It is difficult to provide health care services to all those in need of such services due to limited resources and unlimited demands. Thus, priority setting and rationing have to be applied. This study aimed at critically examining the concept of rationing in health sector and identifying its purposes, influencing factors, mechanisms, and outcomes. Methods: The critical interpretive synthesis methodology was used in this study. PubMed, Cochrane, and Proquest databases were searched using the related key words to find related documents published between 1970 and 2015. In total, 161 published reports were reviewed and included in the study. Thematic content analysis was applied for data analysis. Results: Health services rationing means restricting the access of some people to useful or potentially useful health services due to budgetary limitation. The inherent features of the health market and health services, limited resources, and unlimited needs necessitate health services rationing. Rationing can be applied in 4 levels: health care policy- makers, health care managers, health care providers, and patients. Health care rationing can be accomplished through fixed budget, benefit package, payment mechanisms, queuing, copayments, and deductibles. Conclusion: This paper enriched our understanding of health services rationing and its mechanisms at various levels and contributed to the literature by broadly conceptualizing health services rationing.
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Affiliation(s)
| | | | - Mehdi Jafari–Sirizi
- School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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142
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Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, Nagpal S, Saini V, Srivastava D, Chalmers K, Korenstein D. Evidence for overuse of medical services around the world. Lancet 2017; 390:156-168. [PMID: 28077234 PMCID: PMC5708862 DOI: 10.1016/s0140-6736(16)32585-5] [Citation(s) in RCA: 535] [Impact Index Per Article: 76.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 06/29/2016] [Accepted: 07/18/2016] [Indexed: 12/17/2022]
Abstract
Overuse, which is defined as the provision of medical services that are more likely to cause harm than good, is a pervasive problem. Direct measurement of overuse through documentation of delivery of inappropriate services is challenging given the difficulty of defining appropriate care for patients with individual preferences and needs; overuse can also be measured indirectly through examination of unwarranted geographical variations in prevalence of procedures and care intensity. Despite the challenges, the high prevalence of overuse is well documented in high-income countries across a wide range of services and is increasingly recognised in low-income countries. Overuse of unneeded services can harm patients physically and psychologically, and can harm health systems by wasting resources and deflecting investments in both public health and social spending, which is known to contribute to health. Although harms from overuse have not been well quantified and trends have not been well described, overuse is likely to be increasing worldwide.
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Affiliation(s)
- Shannon Brownlee
- Lown Institute, Brookline, MA, USA; Department of Health Policy, Harvard T.H. Chan School of Public Health, Cambridge, MA, USA.
| | - Kalipso Chalkidou
- Institute for Global Health Innovation, Imperial College, London, UK
| | - Jenny Doust
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Adam G Elshaug
- Lown Institute, Brookline, MA, USA; Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Paul Glasziou
- Center for Research in Evidence-Based Practice, Bond University, Gold Coast, QLD, Australia
| | - Iona Heath
- Royal College of General Practitioners, London, UK
| | | | | | - Divya Srivastava
- LSE Health, London School of Economics and Political Science, London, UK
| | - Kelsey Chalmers
- Menzies Centre for Health Policy, School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
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143
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Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-area Analysis Using Insurance Claims Data. Med Care 2017; 55:155-163. [PMID: 27579912 PMCID: PMC5266421 DOI: 10.1097/mlr.0000000000000634] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Health care spending increases sharply at the end of life. Little is known about variation of cost of end of life care between regions and the drivers of such variation. We studied small-area patterns of cost of care in the last year of life in Switzerland. Methods: We used mandatory health insurance claims data of individuals who died between 2008 and 2010 to derive cost of care. We used multilevel regression models to estimate differences in costs across 564 regions of place of residence, nested within 71 hospital service areas. We examined to what extent variation was explained by characteristics of individuals and regions, including measures of health care supply. Results: The study population consisted of 113,277 individuals. The mean cost of care during last year of life was 32.5k (thousand) Swiss Francs per person (SD=33.2k). Cost differed substantially between regions after adjustment for patient age, sex, and cause of death. Variance was reduced by 52%–95% when we added individual and regional characteristics, with a strong effect of language region. Measures of supply of care did not show associations with costs. Remaining between and within hospital service area variations were most pronounced for older females and least for younger individuals. Conclusions: In Switzerland, small-area analysis revealed variation of cost of care during the last year of life according to linguistic regions and unexplained regional differences for older women. Cultural factors contribute to the delivery and utilization of health care during the last months of life and should be considered by policy makers.
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144
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Morgan DJ, Leppin A, Smith CD, Korenstein D. A Practical Framework for Understanding and Reducing Medical Overuse: Conceptualizing Overuse Through the Patient-Clinician Interaction. J Hosp Med 2017; 12:346-351. [PMID: 28459906 PMCID: PMC5570540 DOI: 10.12788/jhm.2738] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Overuse of medical services is an increasingly recognized driver of poor-quality care and high cost. A practical framework is needed to guide clinical decisions and facilitate concrete actions that can reduce overuse and improve care. We used an iterative, expert-informed, evidence-based process to develop a framework for conceptualizing interventions to reduce medical overuse. Given the complexity of defining and identifying overused care in nuanced clinical situations and the need to define care appropriateness in the context of an individual patient, this framework conceptualizes the patient-clinician interaction as the nexus of decisions regarding inappropriate care. This interaction is influenced by other utilization drivers, including healthcare system factors, the practice environment, the culture of professional medicine, the culture of healthcare consumption, and individual patient and clinician factors. The variable strength of the evidence supporting these domains highlights important areas for further investigation. Journal of Hospital Medicine 2017;12:346-351.
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Affiliation(s)
- Daniel J. Morgan
- VA Maryland Healthcare System, University of Maryland School of Medicine and Centers for Disease Dynamics, Economics and Policy, Baltimore, MD, USA
| | - Aaron Leppin
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester MN, USA
| | | | - Deborah Korenstein
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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145
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Pollmanns J, Romano PS, Weyermann M, Geraedts M, Drösler SE. Impact of Disease Prevalence Adjustment on Hospitalization Rates for Chronic Ambulatory Care-Sensitive Conditions in Germany. Health Serv Res 2017; 53:1180-1202. [PMID: 28332190 DOI: 10.1111/1475-6773.12680] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To explore effects of disease prevalence adjustment on ambulatory care-sensitive hospitalization (ACSH) rates used for quality comparisons. DATA SOURCES/STUDY SETTING County-level hospital administrative data on adults discharged from German hospitals in 2011 and prevalence estimates based on administrative ambulatory diagnosis data were used. STUDY DESIGN A retrospective cross-sectional study using in- and outpatient secondary data was performed. DATA COLLECTION Hospitalization data for hypertension, diabetes, heart failure, chronic obstructive pulmonary disease, and asthma were obtained from the German Diagnosis Related Groups (DRG) database. Prevalence estimates were obtained from the German Central Research Institute of Ambulatory Health Care. PRINCIPAL FINDINGS Crude hospitalization rates varied substantially across counties (coefficients of variation [CV] 28-37 percent across conditions); this variation was reduced by prevalence adjustment (CV 21-28 percent). Prevalence explained 40-50 percent of the observed variation (r = 0.65-0.70) in ACSH rates for all conditions except asthma (r = 0.07). Between 30 percent and 38 percent of areas moved into or outside condition-specific control limits with prevalence adjustment. CONCLUSIONS Unadjusted ACSH rates should be used with caution for high-stakes public reporting as differences in prevalence may have a marked impact. Prevalence adjustment should be considered in models analyzing ACSH.
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Affiliation(s)
| | | | - Maria Weyermann
- Niederrhein University of Applied Sciences, Krefeld, Germany
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146
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Crowson MG, Ryan MA, Rocke DJ, Raynor EM, Puscas L. Variation in tonsillectomy rates by health care system type. Int J Pediatr Otorhinolaryngol 2017; 94:40-44. [PMID: 28167009 DOI: 10.1016/j.ijporl.2017.01.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/07/2017] [Accepted: 01/10/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To analyze variation in tonsillectomy procedure rates between health care system types around the world. STUDY DESIGN International database analysis. METHODS The 2015 Organization for Economic Co-operation and Development (OECD) Health Statistics surgical procedures database was used to ascertain tonsillectomy procedure volumes for 31 countries. Each country's health system type and structure were classified by overall system type, and by health care regulation, financing, and provision methods. Each system type and structure variable were compared using the rate of tonsillectomy procedures per 100,000 citizens. RESULTS 10.5 million tonsillectomy procedures completed between 1993 and 2014 were analyzed. Overall, social health insurance system types had higher total tonsillectomy rates versus other health care system types (p < 0.05 for each comparison). Health systems with private care provision had a higher procedure rate versus state provided care (159.1 vs. 131.1 per 100,000 citizens; p = 0.002). Health care systems with societal regulation and financing had a higher procedure count versus state regulated or financed care (regulation 193.3 vs. 139.7 per 100,000 citizens, p < 0.0001; financing 168.2 vs. 135.0 per 100,000 citizens, p = 0.0004). CONCLUSIONS The volume of tonsillectomy procedures is associated with a health care system's overall structure, regulation, financing, and provision methods. International health care systems with state mediated provision, regulation, and financing had lower tonsillectomy rates versus systems with private provision, and societal regulation or financing. Further study is needed to determine differences in indications for tonsillectomy between countries, but these results underscore potential variation in health care delivery in different systems.
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Affiliation(s)
- Matthew G Crowson
- Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Marisa A Ryan
- Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel J Rocke
- Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC, USA
| | - Eileen M Raynor
- Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC, USA
| | - Liana Puscas
- Division of Otolaryngology-Head & Neck Surgery, Duke University Medical Center, Durham, NC, USA
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147
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Goodman DC, Goodman AA. Medical care epidemiology and unwarranted variation: the Israeli case. Isr J Health Policy Res 2017; 6:9. [PMID: 28239448 PMCID: PMC5319107 DOI: 10.1186/s13584-017-0135-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/10/2017] [Indexed: 11/10/2022] Open
Abstract
In an article in this Journal, Mendlovic and colleagues report on regional variation in medical care across Israeli regions. This study joins a growing literature demonstrating generally high variation in the provision of health care services within developed countries. This commentary summarizes the status of medical care epidemiology and its studies of unwarranted variation in health care, and provides a conceptual framework to guide future studies. Recommendations are offered for advancing studies in Israel that could guide policy development and clinical improvement.
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Affiliation(s)
- David C. Goodman
- The Geisel School of Medicine at Dartmouth, The Williamson Translational Research Building, The Dartmouth Institute for Health Policy and Clinical Improvement, Lebanon, 03756 NH USA
| | - Andrew A. Goodman
- Goodman Health Services, 65 Whitney Farms Rd, North Yarmouth, 04097 ME USA
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148
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Hoxha I, Syrogiannouli L, Luta X, Tal K, Goodman DC, da Costa BR, Jüni P. Caesarean sections and for-profit status of hospitals: systematic review and meta-analysis. BMJ Open 2017; 7:e013670. [PMID: 28213600 PMCID: PMC5318567 DOI: 10.1136/bmjopen-2016-013670] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Financial incentives may encourage private for-profit providers to perform more caesarean section (CS) than non-profit hospitals. We therefore sought to determine the association of for-profit status of hospital and odds of CS. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from the first year of records through February 2016. ELIGIBILITY CRITERIA To be eligible, studies had to report data to allow the calculation of ORs of CS comparing private for-profit hospitals with public or private non-profit hospitals in a specific geographic area. OUTCOMES The prespecified primary outcome was the adjusted OR of births delivered by CS in private for-profit hospitals as compared with public or private non-profit hospitals; the prespecified secondary outcome was the crude OR of CS in private for-profit hospitals as compared with public or private non-profit hospitals. RESULTS 15 articles describing 17 separate studies in 4.1 million women were included. In a meta-analysis of 11 studies, the adjusted odds of delivery by CS was 1.41 higher in for-profit hospitals as compared with non-profit hospitals (95% CI 1.24 to 1.60) with no relevant heterogeneity between studies (τ2≤0.037). Findings were robust across subgroups of studies in stratified analyses. The meta-analysis of crude estimates from 16 studies revealed a somewhat more pronounced association (pooled OR 1.84, 95% CI 1.49 to 2.27) with moderate-to-high heterogeneity between studies (τ2≥0.179). CONCLUSIONS CS are more likely to be performed by for-profit hospitals as compared with non-profit hospitals. This holds true regardless of women's risk and contextual factors such as country, year or study design. Since financial incentives are likely to play an important role, we recommend examination of incentive structures of for-profit hospitals to identify strategies that encourage appropriate provision of CS.
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Affiliation(s)
- Ilir Hoxha
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | | | - Xhyljeta Luta
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Kali Tal
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Bruno R da Costa
- Institute of Primary Health Care, University of Bern, Bern, Switzerland
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Department of Medicine, University of Toronto, Canada
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149
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Calara PS, Althin R, Carlsson KS, Schmitt-Egenolf M. Regional Differences in the Prescription of Biologics for Psoriasis in Sweden: A Register-Based Study of 4168 Patients. BioDrugs 2017; 31:75-82. [PMID: 28097638 PMCID: PMC5258782 DOI: 10.1007/s40259-016-0209-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Observational studies suggest an inequitable prescription of biologics in psoriasis care, which may be attributed to geographical differences in treatment access. Sweden regularly ranks high in international comparisons of equitable healthcare, and is, in connection with established national registries, an ideal country to investigate potential inequitable access. OBJECTIVE The aim was to determine whether the opportunity for patients to receive biologics depends on where they receive care. METHODS Biologic-naïve patients enrolled in the Swedish National Register for Systemic Treatment of Psoriasis (PsoReg) from 2008 to 2015 (n = 4168) were included. The association between the likelihood of initiating a biologic and the region where patients received care was analyzed. The strength of the association was adjusted for patient and clinical characteristics, as well as disease severity using logistic regression analysis. The proportion of patients that switched to a biologic (switch rate) and the probability of switch to a biologic was calculated in 2-year periods. RESULTS The national switch rate increased marginally over time from 9.7 to 11.0%, though the uptake varied across regions. Adjusted odds ratios for at least one region were significantly different from the reference region in every 2-year period. During the latest period (2014-2015), the average patient in the lowest prescribing region was nearly 2.5 times less likely to switch as a similar patient in the highest prescribing region. CONCLUSIONS Geographical differences in biologics prescription persist after adjusting for patient characteristics and disease severity. The Swedish example calls for further improvements in delivering equitable psoriasis care.
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Affiliation(s)
- Paul S Calara
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | - Rikard Althin
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
| | - Katarina Steen Carlsson
- The Swedish Institute for Health Economics (IHE), Lund, Sweden
- Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden
| | - Marcus Schmitt-Egenolf
- Department of Public Health and Clinical Medicine, Dermatology, Umeå University, 901 87, Umeå, Sweden.
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Healthcare Provider Type and Switch to Biologics in Psoriasis: Evidence from Real-World Practice. BioDrugs 2016; 30:145-51. [PMID: 26883786 DOI: 10.1007/s40259-016-0163-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous research indicates an uneven uptake of biologics in patients with moderate-to-severe psoriasis in Sweden. Therefore, it is essential to scrutinise variations in treatment patterns. OBJECTIVE The aim of this study was to evaluate the extent to which the uptake of biologics for psoriasis differs between types of healthcare provider. METHODS Three types of provider were identified within 52 units participating in the Swedish National Registry for Systemic Psoriasis Treatment (PsoReg): university hospitals, non-university hospitals and individual practices. Biologics-naïve patients (n = 3165) were included in analyses to investigate the probability of switch to biologics. The numbers of patients fulfilling the criteria for moderate-to-severe psoriasis [Psoriasis Area and Severity Index (PASI) ≥10 and Dermatology Life Quality Index (DLQI) ≥10] among patients who switched to biologics and patients who did not switch were reported. A logistic regression model was used to calculate how healthcare provider type influenced the probability of switch to biologics whilst adjusting for patient characteristics and disease severity. RESULTS During registration, 16% of patients switched to biologics while 84% remained on conventional systemic treatment. In 7% of patients, the criteria PASI ≥10 and DLQI ≥10 was fulfilled at their last visit without switching to biologics, whereas in 10% of patients the criteria was not fulfilled prior to switch. After controlling for patient characteristics and disease severity, small or no difference in the probability of switch was observed between provider types. CONCLUSIONS Disease severity does not explain the decision to switch or not to switch to biologics for a disproportionate number of patients. There seems to be an uneven uptake of biologics in Swedish clinical practice, but the type of healthcare provider cannot explain this variation. More research is needed on what factors influence the prescription of biologics.
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