Quality of health care for the disadvantaged

Multiple Vulnerabilities in Access to and Utilising of Maternal and Child Health Services in India: A Spatial–Regional Analysis

Introduction

Although there are multiple vulnerabilities in the utilisation of maternal and child health (MCH) services in India, research has always been focused on single-dimension vulnerabilities like economic or social vulnerabilities. Individuals who are poor may also face other types of vulnerabilities that together affect access to health services. This article, therefore, investigates the linkages between multiple vulnerabilities and the utilisation of MCH care services.

Materials and Methods

Data from National Family Health Survey (2015–2016) for India and states were used for analysing the key outcome variables namely women received four or more antenatal care (ANC), institutional delivery, postnatal care (PNC) and full immunisation for children in the age group of 12–23 months. Bivariate analysis and binomial-logistic regression analysis were employed to examine the multiple vulnerabilities on utilising MCH services across three dimensions of vulnerabilities, such as education, wealth and caste.

Results

Women with multiple vulnerabilities were less likely to utilise essential MCH services. Women who faced vulnerabilities in all three dimensions were less likely to have received four or more ANC and postnatal care than those who were not deprived of any vulnerabilities (0.3 vs. 0.9 and 0.4 vs. 0.8, respectively). They were also less likely to deliver in health facilities and avail child immunisation (0.5 vs. 0.8 and 0.3 vs. 0.7, respectively).

Conclusion

A multi-sectoral approach is therefore required to deal with the issues of low access and underutilisation of MCH services.

R. Healthcare service quality: a methodology for servicescape re-design using Taguchi approach

Purpose

The purpose of this paper is to identify major healthcare service quality (HSQ) dimensions, their most preferred service levels, and their effect on HSQ perceptions of patients using a Taguchi experiment.

Design/methodology/approach

This study adopted a sequential incidence technique to identify factors relevant in HSQ and examined the relative importance of different factor levels in the service journey using Taguchi experiment.

Findings

For HSQ, the optimum factor levels are online appointment booking facility with provision to review and modify appointments; a separate reception for booked patients; provision to meet the doctor of choice; prior detailing of procedures; doctor on call facility to the room of stay; electronic sharing of discharge summary, an online payment facility. Consultation phase followed by the stay and then procedures have maximum effect on S/N and mean responses of patients. The appointment stage has a maximum effect on standard deviations.

Research limitations/implications

Theoretically, this study attempted to address the dearth of research on service settings using robust methodologies like Taguchi experiment, which is popular in the manufacturing sector. The study implies the need for patient-centric initiatives for better HSQ through periodic experiments that inform about the changing priorities of patients.

Practical implications

The trade-off between standardization and customization create challenges in healthcare. Practically, a classification of processes based on standardization vs customization potential is useful to revamp processes for HSQ.

Originality/value

This study applied the Taguchi approach to get insights in re-designing a patient-centric healthcare servicescapes.

What does quality mean to lay people? Community perceptions of primary health care services in Guinea

The success of strategies to revitalize primary health care services such as those advocated by the Bamako Initiative requires a response adapted to the expectations of the population, especially in terms of quality. The goal of this study, conducted in two rural communities in Guinea, was to identify, characterize, and classify the criteria that the public uses to judge the quality of primary health care (PHC) services. This study included 180 participants in 21 focus group discussions. Forty-four main criteria were identified. These criteria vary depending on the respondents' sex and age, and their ability to access primary health care services. Some of the criteria correspond to those used by health care providers, while others do not. The general public places considerable emphasis on outcomes, but little emphasis on preventive services. The users appear very sensitive to aspects of the interpersonal relations they have with professionals and the technical quality of the care provided. A taxonomy of perceived quality is developed, which includes the following five categories: (1) technical competence of the health care personnel; (2) interpersonal relations between the patients and care providers; (3) availability and adequacy of resources and services; (4) accessibility and (5) effectiveness of care. It is a major challenge to refocus on quality in the development of health care services. This will require considerable changes for which training may be an effective, but certainly not a sufficient means. Promoting professionalism and changing the relations between public authorities and the general public are the only means of improving the quality of health care services as well as user perception.

Validating quality indicators. Quality as relationship between structure, process, and outcome

Theory and research have not kept pace with the growing interest in evaluating quality of mental health care, resulting in the use of unvalidated quality indicators. A framework for validating quality indicators is offered by which quality is viewed as the relationship between service structures, processes, and outcomes. Adoption of this framework will facilitate the measurement of quality using valid indicators and should be useful to agencies in their continuous quality improvement efforts. Valid information about the quality of mental health care services will help purchasers and consumers make more informed health care decisions.

Perspective: riddles wrapped in enigma

Six decades of studies on healthcare quality have persisted in rendering the subject difficult to understand or explain to health researchers and policymakers. This article advances three hypotheses about why quality in healthcare is such an enigma. The first concerns problems with the conceptualization of quality. Issues of uncertainty embedded in quality are discussed in the second hypothesis. Finally, difficulties in understanding quality are discussed within a model offered by the sociology of deviance. The article highlights the contribution of each hypothesis and integrates them into a plausible explanatory framework for quality's elusive comprehensibility.

Stratification and standards: a quality assurance perspective. Presidential address

A diminished public respect for physicians, a decrease in professional autonomy, and an increased regulatory presence have led to extensive changes in medical practice in the past 25 years. Along with rising costs of medical care, there has been a resurgence in interest in the quality of health care, and a considerable body of literature on the monitoring and evaluation of health services has been produced. Quality assurance programs frequently evoke negative and skeptical responses from many physicians for a variety of reasons. Crucial to the potential effectiveness of quality assessment methods is the setting of standards. Physician clinicians should be strongly encouraged to participate directly and seriously in the development of standards. The quality assurance process should be viewed by physicians as an opportunity to recapture the control of the profession and to demonstrate to patients, in an objective manner, the legitimate high quality of care rendered.

Predicting the appropriate use of carotid endarterectomy, upper gastrointestinal endoscopy, and coronary angiography

BACKGROUND AND METHODS

In a nationally representative population 65 years of age or older, we have demonstrated that about one quarter of coronary angiographies and upper gastrointestinal endoscopies and two thirds of carotid endarterectomies were performed for reasons that were less than medically appropriate. In this paper we examine whether specific characteristics of patients (age, sex, and race), physicians (age, board-certification status, and experience with the procedure), or hospitals (teaching status, profit-making status, and size) predict whether a procedure will be performed appropriately.

RESULTS

In general, we found that little of the variability in the appropriateness of care (4 percent or less) could be explained on the basis of standard, easily obtainable data about the patient, the physician, or the hospital. For all three procedures, however, performance in a teaching hospital increased the likelihood that the reasons would be medically appropriate (P = 0.09 for angiography, P = 0.30 for endoscopy, and P less than 0.01 for endarterectomy). In addition, angiographies were more often performed for appropriate reasons in older or more affluent patients (P less than 0.01 for both). Being treated by a surgeon who performed a high rather than a low number of procedures decreased the likelihood of an appropriate endarterectomy by one third, from 40 to 28 percent (P less than 0.01).

CONCLUSIONS

Appropriateness of care cannot be closely predicted from many easily determined characteristics of patients, physicians, or hospitals. Thus, for the present, if appropriateness is to be improved it will have to be assessed directly at the level of each patient, hospital, and physician.

Measuring quality in medical case management programs

Private insurers and health care providers alike currently offer medical case management programs as a means of containing costs and enhancing the quality of care for patients with high-cost illnesses or injuries. Since 1986, Brandeis University's Bigel Institute for Health Policy has been involved in a project to evaluate medical case management programs. The study found that such programs have become popular because of the perception that high-cost patients are typically handled inefficiently. The study also found that greater attention needs to be given to developing systematic ways to measure and monitor the quality of the case management process and its effect on outcomes.

The quality of medical care received by older persons

This paper reviews studies published since 1970 on the quality of medical services received by older persons. Although many of the studies were flawed in design or limited in scope, they suggest that there are problems in the quality of care received by older persons in ambulatory, hospital, and nursing home settings. Changes in health care delivery and financing should attempt to improve, rather than merely maintain, the quality of medical and health services received by this vulnerable population.

Quality assurance and clinical pharmacy: lessons from medicine

A quarter-century of empirical work in measuring the quality of medical care has both documented serious inadequacies in care and advanced the state of the art of quality assessment. Experience with quality assurance programs at institutional, local, and national levels emphasizes that early, careful attention must be given to: specifying the purposes of a study or program, choosing the dimensions of care to be evaluated, understanding the reliability and validity of data sources and methods, and compiling appropriate evaluative criteria before projects are implemented. Superimposed on these concern are cost/benefit and cost/quality tradeoff issues. To the degree that the pharmacy profession has dealt with such conceptual and methodologic problems, it has much to offer the medical profession. To the degree that clinical pharmacy has not yet encountered them, lessons drawn from the medical experience may be helpful in implementing evaluation efforts in the future.

Neighborhood health centers: a decade of experience

The first neighborhood health center was funded in 1965 by the Office of Economic Opportunity. Now, 12 years later, 127 federally funded centers are serving over a million people. The centers have offered a high quality of service, delivered comprehensive care that includes preventive services and health supervision, developed a workable team approach in such care, and shown that this can be done at reasonable cost. Evaluative studies made on center effectiveness in disease prevention, in reduction of hospitalization and emergency room usage, and in improving the quality of care show that the centers compare favorably with other methods of providing similar care. Problems of financing are discussed, as well as possible directions for the future.

Constructing social metrics for health status indexes

Health status indexes used to make collective decisions satisfying the principles of equality and social minimum must incorporate a social metric for health. Any index or indicator applied to populations for determining health status or to health programs for evaluating outcome must confront the question of who prefers which states of health under which circumstances? Utility models, psychometric scaling, and empirical social decision valuation have been used to measure preferences for states of health. Efforts should be directed toward constructing social metrics for health that are prospective, context-independent, relevant, community-wide, ratio scalled, sensitive, empirically validated, and applicable to program evaluation. These efforts represent the application of normative social theory to research, an important advance in uncovering the mysteries of social action and its consequences.