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Frennert S, Erlingsdóttir G, Muhic M, Rydenfält C, Milos Nymberg V, Ekman B. 'It increases my ability to influence my ways of working': A qualitative study on digitally mediated patient management in primary healthcare. Scand J Caring Sci 2023; 37:88-105. [PMID: 35833314 DOI: 10.1111/scs.13099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 04/19/2022] [Accepted: 06/19/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Digitally mediated primary healthcare is increasingly influencing working conditions, raising questions about how digitally mediated patient management is experienced. AIM The aim of this study was to generate insights, through the lens of postphenomenology, into how digitally mediated primary healthcare affects the work and working environment, by gathering perspectives from primary healthcare professionals who regularly manage patient errands through a digital platform. METHODS Two rounds of interviews were conducted with a diversified sample of primary healthcare professionals at a primary healthcare centre. The first round of interviews was conducted during the initial phase of the deployment of a digital platform for patient management, with the second round conducted a year later (n = 24). The interview transcripts were analysed using reflexive thematic analysis. RESULTS Four themes relating to digitally mediated care work were identified: 'positive feelings towards digitally mediated primary healthcare', 'seeing a positive work atmosphere as a prerequisite for change', 'experiencing increased control over the pace of workflow' and 'reconfiguration of previous problems'. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE Building on postphenomenology, our study adds to the understanding of how material and symbolic aspects mutually affect the mediating role of a digital platform for patient management. Thus, the results indicate that the experience of using digitally mediated care processes is conditioned by the discourse towards digitalisation at the workplace and the management's approach to and inclusion of employees in the digital transition of primary healthcare, as well as the usefulness and usability of the digital platform. The findings can inform both practice and policy.
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Goude F, Garellick G, Kittelsen S, Malchau H, Peltola M, Rehnberg C. Effects of competition and bundled payment on the performance of hip replacement surgery in Stockholm, Sweden: results from a quasi-experimental study. BMJ Open 2022; 12:e061077. [PMID: 35835527 PMCID: PMC9289036 DOI: 10.1136/bmjopen-2022-061077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the effects of competition and a bundled payment model on the performance of hip replacement surgery. DESIGN A quasi-experimental study where a difference-in-differences analytical framework is applied to analyse routinely collected patient-level data from multiple registers. SETTING Hospitals providing hip replacement surgery in Sweden. PARTICIPANTS The study included patients who underwent elective primary total hip replacement due to osteoarthritis from 2005 to 2012. The final study sample consisted of 85 275 hip replacement surgeries, where the exposure group consisted of 14 570 surgeries (n=6380 prereform and n=8190 postreform) and the control group consisted of 70 705 surgeries (n=32 799 prereform and n=37 906 postreform). INTERVENTION A reform involving patient choice, free entry of new providers and a bundled payment model for hip replacement surgery, which came into force in 2009 in Region Stockholm, Sweden. OUTCOME MEASURES Performance is measured as length of stay of the surgical admission, adverse event rate within 90 days following surgery and patient satisfaction 1 year postsurgery. RESULTS The reform successfully improved the adverse event rate (1.6 percentage reduction, p<0.05). Length of stay decreased less in the more competitive market than in the control group (0.7 days lower, p<0.01). These effects were mainly driven by university and central hospitals. No effects of the reform on patient satisfaction were found (no significance). CONCLUSIONS The study concludes that the incentives of the reform focusing on avoidance of adverse events have a predictable impact. Since the payment for providers is fixed per case, the impact on resource use is limited. Our findings contribute to the general knowledge about the effects of financial incentives and market-oriented reforms.
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Affiliation(s)
- Fanny Goude
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
- Centre for Health Economics, Informatics and Health Services Research, Stockholm Health Care Services, Stockholm, Sweden
| | - Göran Garellick
- Centre of Registers Västra Götaland, Swedish Hip Arthroplasty Register, Göteborg, Sweden
| | | | - Henrik Malchau
- Department of Orthopaedics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Mikko Peltola
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Clas Rehnberg
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
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von Thiele Schwarz U, Lyon AR, Pettersson K, Giannotta F, Liedgren P, Hasson H. Understanding the value of adhering to or adapting evidence-based interventions: a study protocol of a discrete choice experiment. Implement Sci Commun 2021; 2:88. [PMID: 34380575 PMCID: PMC8356451 DOI: 10.1186/s43058-021-00187-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/11/2021] [Indexed: 12/20/2022] Open
Abstract
Background Whereas the value of an evidence-based intervention (EBI) is often determined by its effect on clinical outcomes, the value of implementing and using EBIs in practice is broader, reflecting qualities such as appropriateness, equity, costs, and impact. Reconciling these value conflicts involves a complicated decision process that has received very limited scholarly attention. Inspired by studies on decision-making, the objective of this project is to explore how practitioners appraise the values of different outcomes and to test how this appraisal influences their decisions surrounding the so-called fidelity–adaptation dilemma. This dilemma is related to the balance between using an EBI as it was designed (to ensure its effectiveness) and making appropriate adaptations (to ensure alignment with constraints and possibilities in the local context). Methods This project consists of three sub-studies. The participants will be professionals leading evidence-based parental programs in Sweden and, in Sub-study 1, parents and decision-makers. Sub-study 1 will use sequential focus groups and individual interviews to explore parameters that influence fidelity and adaptation decisions—the dilemmas encountered, available options, how outcomes are valued by practitioners as well as other stakeholders, and value trade-offs. Sub-study 2 is a discrete choice experiment that will test how value appraisals influence decision-making using data from Sub-study 1 as input. Sub-study 3 uses a mixed-method design, with findings from the two preceding sub-studies as input in focus group interviews to investigate how practitioners make sense of findings from optimal decision situations (experiment) and constrained, real-world decision situations. Discussion The project will offer unique insights into decision-making processes that influence how EBIs are used in practice. Such knowledge is needed for a more granular understanding of how practitioners manage the fidelity–adaptation dilemma and thus, ultimately, how the value of EBI implementation can be optimized. This study contributes to our knowledge of what happens once EBIs are adopted—that is, the gap between the way in which EBIs are intended to be used and the way in which they are used in practice.
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Affiliation(s)
- Ulrica von Thiele Schwarz
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, Västerås, Sweden. .,Procome, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.
| | - Aaron R Lyon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
| | - Kristoffer Pettersson
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, Västerås, Sweden
| | - Fabrizia Giannotta
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, Västerås, Sweden
| | - Pernilla Liedgren
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, Västerås, Sweden
| | - Henna Hasson
- Procome, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden.,Unit for Implementation and Evaluation, Center for Epidemiology and Community Medicine, Region Stockholm, Stockholm, Sweden
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Wohlin J, Fischer C, Carlsson KS, Korlén S, Mazzocato P, Savage C, Stalberg H, Brommels M. As predicted by theory: choice and competition in a publicly funded and regulated regional health system yield improved access and cost control. BMC Health Serv Res 2021; 21:406. [PMID: 33933075 PMCID: PMC8088711 DOI: 10.1186/s12913-021-06392-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND New Public Management (NPM) has been widely used to introduce competition into public healthcare. Results have been mixed, and there has been much controversy about the appropriateness of a private sector-mimicking governance model in a public service. One voice in the debate suggested that rather than discussing whether competition is "good" or "bad" the emphasis should be on exploring the conditions for a successful implementation. METHODS We report a longitudinal case study of the introduction of patient choice and allowing private providers to enter a publicly funded market. Patients in need of hip or knee replacement surgery are allowed to choose provider, and those are paid a fixed reimbursement for the full care episode (bundled payment). Providers are financially accountable for complications. Data on number of patients, waiting lists and times, costs to the public purchaser, and complications were collected from public registries. Providers were interviewed at three points in time during a nine-year follow-up period. Time-series of the quantitative data were exhibited and the views of actors involved were explored in a thematic analysis of the interviews. RESULTS The policy goals of improving access to care and care quality while controlling total costs were achieved in a sustained way. Six themes were identified among actors interviewed and those were consistent over time. The design of the patient choice model was accepted, although all providers were discontent with the level of reimbursement. Providers felt that quality, timeliness of service and staff satisfaction had improved. Public and private providers differed in terms of patient-mix and developed different strategies to adjust to the reimbursement system. Private providers were more active in marketing and improving operation room efficiency. All providers intensified cooperation with referring physicians. Close attention was paid to following the rules set by the purchaser. DISCUSSION AND CONCLUSIONS The sustained cost control was an effect of bundled payment. What this study shows is that both public and private providers adhere long-term to regulations by a public purchaser that also controls entrance to the market. The compensation was fixed and led to competition on quality, as predicted by theory.
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Affiliation(s)
- Jonas Wohlin
- Accumbo AB, SE-39230, Kalmar, Sweden.,Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Clara Fischer
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Karin Solberg Carlsson
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Sara Korlén
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Pamela Mazzocato
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | - Carl Savage
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden
| | | | - Mats Brommels
- Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-17177, Stockholm, Sweden.
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Areskoug Josefsson K, Avby G, Andersson Bäck M, Kjellström S. Workers' experiences of healthy work environment indicators at well-functioning primary care units in Sweden: a qualitative study. Scand J Prim Health Care 2018; 36:406-414. [PMID: 30259767 PMCID: PMC6381530 DOI: 10.1080/02813432.2018.1523987] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Staff experiences of healthy work environment (HWE) indicators at primary care units can assist in understanding why some primary care units function better than others. The aim of the study was to create increased understanding of how workers experienced HWE indicators at well-functioning primary care units. DESIGN Fifty in-depth interviews with staff at six primary care units in Sweden were analysed with deductive content analysis, revisiting a systematic review of HWE indicators. RESULTS The study presents additional perspectives on staff experiences of HWE indicators at well-functioning primary care units. The included primary care units (PCU) shared a similar pattern of work environment indicators, with unique solutions and strategies to meet shared challenges. Staff at the included PCUs were encouraged to work to create and sustain a HWE, but each domain (indicator) also provided challenges that the staff and organisation needed to meet. The results suggest that useful approaches for a healthy work environment could be to address issues of organisational virtuousness, employee commitment and joy at work. CONCLUSIONS Both managers and staff are encouraged to actively work not only to create and sustain an HWE but also to promote organisational virtuousness, employee commitment, joy at work and to increase the performance at work, which is of benefit to staff, patients and society. Key Points Staff at well-functioning primary care units (PCUs) experienced healthy work environments The included PCUs shared a similar pattern of work environment indicators, with unique solutions and strategies to meet shared challenges. Staff at the included PCUs were encouraged to work to create and sustain a healthy work environment, but each domain (indicator) also provided challenges that the staff and organisation needed to meet. The results suggest that useful approaches for a healthy work environment could be to address issues of organisational virtuousness, employee commitment and joy at work.
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Affiliation(s)
- Kristina Areskoug Josefsson
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden;
- CONTACT Kristina Areskoug Josefsson The Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Box 1026, 551 11Jönköping, Sweden
| | - Gunilla Avby
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden;
| | | | - Sofia Kjellström
- School of Health and Welfare, Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping, Sweden;
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