Does increased standardisation in health care mean less responsiveness towards individual patients' expectations? A register-based study in Swedish primary care

How much convergence exists between registered process measures and patient reported experience measures? A study on Catalan primary healthcare

The use of quality measures is important for transparency and the continuous improvement of performance. However, we do not know enough about the relationship between registered process measures and patient reported experience measures (PREMs) in primary healthcare. Recent studies point to areas of convergence that run contrary anticipated trends. This is a relevant question for healthcare management and governments as their position is stronger when system's guidelines and targets also matter to patients or, vice versa, when patient-centered measures are used to develop new process measures. Our aim is to study both type of measures, their logic and their level of convergence. We also assess the relationship between PREMs, patients' demographic characteristics and area socioeconomic level. We estimated pairwise correlations with patient experience aggregated at the health-center level and a series of multilevel regression models to assess the adjusted effect of four registered process measures on ratings of patient experience at the patient level. We use patient experience as measured by survey data, two composite quality indices and two single indicators regularly computed by the Catalan Health Service. Continuity of care with the same doctor and accessibility are positively associated with patient experience. No relationship was observed in the index created to measure quality of assistance. The index measuring the quality of prescriptions was positively associated with patient experience but only when analyzed separately. We conclude that registered process measures and PREMs are not entirely independent, hence improvements of the management side have the potential to impact patient experience.

Commissioned reports in Swedish healthcare governance - descriptive mapping and a content analysis

BACKGROUND

In order to support decisions regarding governance, organization and control models of the healthcare system, the Swedish government, as well as regional-level agencies, regularly commissions expert reports that are supposed to form the basis for decisions on new steering forms in healthcare.

AIM

The aim of this study was a) to perform a descriptive mapping of commissioned reports on Swedish healthcare governance and b) to pursue an in-depth content analysis of a strategic sample of such reports.

METHOD

Initially, 106 reports from both national and regional levels were gathered and analysed. A matrix was constructed, consisting of questions on who had commissioned the report, who had produced it, what problems the report set out to solve and what solutions were suggested. Further, questions were posed on whether the report was research-based and whether ethical assumptions and arguments were presented. Thereafter, a strategic sample of 36 reports was selected for an in-depth analysis, using inductive content analysis.

RESULTS

The descriptive mapping showed that the aim of the analysed reports differed in form and content, and that they varied from giving an overview and investigating effects and consequences of new control models to more concrete goals, such as suggesting improvement measures. Academic experts involved in creating the reports often represented economics or business studies. The content analysis revealed examples of standardization in care, characterized by requirements to follow national guidelines, but also examples of requests for increased respect for professionals' competence and experience. Further, the analysis showed how the definition of equity in care had changed, from a focus on equity in access to care in the reports produced in the 1990s to an emphasis of arguments for geographical sameness and equity in quality of care in the later reports.

DISCUSSION

Two dominant trends were identified in the material, namely increased standardization and arguments for trust in the system. The great number of reports implies that the system risks requesting more information than it can handle and result in documents where the same message is recurrently repeated or create conflicts of interest and value tensions between different suggestions.

CONCLUSION

Commissioned reports can have substantial consequences for new reforms of management practices in healthcare. It is therefore important to investigate them critically. The results of our investigation may contribute to a more comprehensive and adequate model for acquiring and using expert reports regarding healthcare governance, both in Sweden and in similar healthcare systems.

Patient and healthcare provider perceptions on using patient-reported experience measures (PREMs) in routine clinical care: a systematic review of qualitative studies

BACKGROUND

Patient-reported experience measures (PREMs) assess quality-of-care from patients' perspectives. PREMs can be used to enhance patient-centered care and facilitate patient engagement in care. With increasing quality improvement studies in clinical practice, the use of PREMs has surged. As a result, knowledge about stakeholder experiences of using PREMs to assess quality of care across diverse clinical settings is needed to inform PREM implementation efforts. To address this, this review examines the qualitative literature on patient and healthcare provider experiences of using PREMs in clinical practice.

METHODS

Medline, Embase and PsycInfo were systematically searched from inception to May 2021. Additional searching of reference lists for all included articles and relevant review articles were performed. Retrieved articles were screened for eligibility by one reviewer and 25% cross-checked by a second reviewer across all stages of the review. Full texts meeting eligibility criteria were appraised against the COREQ checklist for quality assessment and thematic analysis was used to analyze textual data extracted from the results.

RESULTS

Electronic searches identified 2683 records, of which 20 studies met eligibility criteria. Extracted data were synthesized into six themes: facilitators to PREM implementation; barriers to PREM implementation; healthcare providers' perspectives towards using PREMs; patients' perspectives towards using PREMs; advantages of using PREMs in clinical practice; limitations and practical considerations to reduce resistance of PREM usage. The primary factors facilitating and impeding the use of PREMs include organizational-, staff- and patient-related factors.

CONCLUSION

Results can be used to guide the usage and implementation of PREMs in clinical settings by addressing the identified barriers and building on the perceived benefits to encourage adoption of PREMs. Results around facilitators to PREM implementation and practical considerations could also promote appropriate use of PREMs by healthcare providers, helping to improve practice and the quality of care based on patient feedback.

Understanding the cultural environment of the outpatient care setting for patients with dementia receiving cancer treatment: A qualitative study

INTRODUCTION

People with dementia have poorer cancer outcomes than those without dementia, and experience inequalities in access to, and quality of, care. Outpatient environments, where radiotherapy, chemotherapy and immunotherapy cancer treatments typically take place, have largely been excluded from research. This study was conducted to understand provision of treatment and support and experiences of care for people with dementia undergoing cancer treatment in the outpatient setting.

MATERIALS AND METHODS

Using observation, interviews and document analysis, data were collected to scrutinize the cultural environment of ambulatory care, comprising the physical fabric of the care setting; interactions, behaviours and perceptions of those in the care setting; and the organizational, clinical and interactional processes involved in care delivery. The study was conducted in the outpatient oncology departments of two large teaching hospitals in England between January 2019 and July 2021.

RESULTS

Data were gathered from a wide range of sources, including 15 h of observation, and interviews with patients (n = 2), caregivers (n = 7) and staff (n = 20). Evidence from this study suggests that the cultural environment of the outpatient care setting reflects and supports the standardized processing of people for cancer treatment. Dementia introduces a wider set of care requirements not catered for by this standardized treatment model and associated processes. Data showed that the needs of patients with dementia could be addressed most effectively when individualized care, as opposed to standardized care, was offered.

CONCLUSION

There is work to be done in outpatient cancer services to ensure responsiveness to individual patient need. This could be achieved by having an established way (or ways) of eliciting needs, preferences and expectations, a belief that a person's needs and expectations are legitimate and that effort should be made to address them, with the ability to accommodate these needs and expectations.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the study design and development of study materials including the interview topic guide. They also assisted with discussion and clarification of study findings.

Pursuing the objectives of support to providers and external accountability through enabling controls - a study of governance models in Swedish primary care

Background

The purpose of this study was to contribute to knowledge about what is regarded as an appropriate governance model in welfare markets in healthcare, from the perspective of government. The study draws on a framework about governance in healthcare systems as a continuous process of priority setting, monitoring and accountability. It relates to various dimensions of management controls; a view on management controls as a package with interdependence between different controls, a use of management controls as coercive or enabling, and implications of involving providers in the design of control systems.

Methods

The empirical material is limited to experiences of governance models used in Swedish primary care. Data from the 21 county councils responsible for organizing and financing healthcare in Sweden was gathered during 2016–2017 through a survey, interviews and document review. Data was analyzed using conventional content analysis.

Results

According to the county councils, governance is a continuous process. Four controls are used in all county councils: contracts, reimbursement systems, dialogue and performance measurement systems (PMS). The appropriateness of different controls is associated with their interdependence, e.g. the more formalized the use of dialogue, the more enabling the use of PMS. An appropriate governance model should on the one hand support innovations and quality improvements and on the other hand ensure external accountability for the use of allocated resources and adherence to agreements. The interviewed representatives described the intended role as both coercive and enabling but in favor of enabling. Using management controls in a way that improves the providers’ attitude towards and capacity to achieve the assigned task of delivering high-quality healthcare was described as central.

Conclusions

An appropriate governance model in healthcare systems should enable governments to combine two roles: to force compliance with agreements to ensure external accountability for the use of allocated resources and to offer support to learning and quality improvement in the healthcare system. Governance can be regarded as a continuous process where several management controls operate as a package and the appropriateness of different controls is associated with their interdependence. An appropriate governance model should, from the perspective of government, encompass a high level of formalization of both coercive and enabling types of control but with greater emphasis on enabling types. Governments may pursue the objectives of support to providers and external accountability in healthcare systems by using management controls in enabling ways.

Process measures or patient reported experience measures (PREMs) for comparing performance across providers? A study of measures related to access and continuity in Swedish primary care

Aim To study (a) the covariation between patient reported experience measures (PREMs) and registered process measures of access and continuity when ranking providers in a primary care setting, and (b) whether registered process measures or PREMs provided more or less information about potential linkages between levels of access and continuity and explaining variables.

BACKGROUND

Access and continuity are important objectives in primary care. They can be measured through registered process measures or PREMs. These measures do not necessarily converge in terms of outcomes. Patient views are affected by factors not necessarily reflecting quality of services. Results from surveys are often uncertain due to low response rates, particularly in vulnerable groups. The quality of process measures, on the other hand, may be influenced by registration practices and are often more easy to manipulate. With increased transparency and use of quality measures for management and governance purposes, knowledge about the pros and cons of using different measures to assess the performance across providers are important.

METHODS

Four regression models were developed with registered process measures and PREMs of access and continuity as dependent variables. Independent variables were characteristics of providers as well as geographical location and degree of competition facing providers. Data were taken from two large Swedish county councils. Findings Although ranking of providers is sensitive to the measure used, the results suggest that providers performing well with respect to one measure also tended to perform well with respect to the other. As process measures are easier and quicker to collect they may be looked upon as the preferred option. PREMs were better than process measures when exploring factors that contributed to variation in performance across providers in our study; however, if the purpose of comparison is continuous learning and development of services, a combination of PREMs and registered measures may be the preferred option. Above all, our findings points towards the importance of a pre-analysis of the measures in use; to explore the pros and cons if measures are used for different purposes before they are put into practice.