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Marsteller JA, Hsu YJ, Weeks K, Oduwole M, Boonyasai RT, Avornu GD, Dietz KB, Zhou Z, Brown D, Hines A, Chung S, Lubomski L, Carson KA, Ibe C, Cooper LA. Assessing Factors Influencing Commitment to a Disparities Reduction Intervention: Social Justice Attitudes and Organizational Mission. J Healthc Qual 2023; 45:209-219. [PMID: 37387405 PMCID: PMC10498376 DOI: 10.1097/jhq.0000000000000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
ABSTRACT This mixed-methods study aims to understand what the perceptions of leaders and healthcare professionals are regarding causes of disparities, cultural competence, and motivation before launching a disparity reduction project in hypertension care, contrasting perceptions in Federally Qualified Health Centers (FQHCs), and in a non-FQHC system. We interviewed leaders of six participating primary care systems and surveyed providers and staff. FQHC respondents reported more positive cultural competence attitudes and behavior, higher motivation to implement the project, and less concern about barriers to caring for disadvantaged patients than those in the non-FQHC practices; however, egalitarian beliefs were similar among all. Qualitative analysis suggested that the organizational missions of the FQHCs reflect their critical role in serving vulnerable populations. All system leaders were aware of the challenges of provider care to underserved groups, but comprehensive initiatives to address social determinants of health and improve cultural competence were still needed in both system types. The study provides insights into the perceptions and motivations of primary care organizational leaders and providers who are interested in improving chronic care. It also offers an example for care disparity programs to understand commitment and values of the participants for tailoring interventions and setting baseline for progress.
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Woods-Hill CZ, Nelson MN, Eriksen W, Rendle KA, Beidas RS, Bonafide CP, Brajcich MR, Milstone AM, Shea JA. Determinants of Blood Culture Use in Critically Ill Children: A Multicenter Qualitative Study. Pediatr Qual Saf 2023; 8:e647. [PMID: 37051407 PMCID: PMC10085482 DOI: 10.1097/pq9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 03/11/2023] [Indexed: 04/14/2023] Open
Abstract
Blood cultures are fundamental in diagnosing and treating sepsis in the pediatric intensive care unit (PICU), but practices vary widely. Overuse can lead to false positive results and unnecessary antibiotics. Specific factors underlying decisions about blood culture use and overuse are unknown. Therefore, we aimed to identify perceived determinants of blood culture use in the PICU. Methods We conducted semistructured interviews of clinicians (M.D., D.O., R.N., N.P., P.A.) from 6 PICUs who had participated in a quality improvement collaborative about blood culture practices. We developed interview questions by combining elements of the Consolidated Framework for Implementation Research and behavioral economics. We conducted telephone interviews, open-coded the transcripts, and used modified content analysis to determine key themes and mapped themes to elements of Consolidated Framework for Implementation Research and behavioral economics. Results We reached thematic saturation in 24 interviews. Seven core themes emerged across 3 Consolidated Framework for Implementation Research domains: individual characteristics [personal belief in the importance of blood cultures, the perception that blood cultures are a low-risk test]; inner setting [adherence to site-specific usual practices, site-specific overall approach to PICU care (collaborative versus hierarchical), influence of non-PICU clinicians on blood culture decisions]; and outer setting [patient-specific risk factors, sepsis guidelines]. In addition, outcome bias, default bias, and loss aversion emerged as salient behavioral economics concepts. Conclusions Determinants of blood culture use include individual clinician characteristics, inner setting, and outer setting, as well as default bias, outcome bias, and loss aversion. These determinants will now inform the development of candidate strategies to optimize culture practices.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia Pa
| | - Maria N. Nelson
- University of Pennsylvania Mixed Methods Research Laboratory
| | | | | | | | - Christopher P. Bonafide
- Section of Pediatric Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R. Brajcich
- From the Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Aaron M. Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Judy A. Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Fischer KA, Anand S, Walling A, Larson SM, Glaspy J. Cost-Health Literacy as an Educational Objective in Fellowship Training. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:1479-1485. [PMID: 33761118 DOI: 10.1007/s13187-021-01987-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 06/12/2023]
Abstract
Physicians are encouraged to communicate with their patients about financial concerns, but are infrequently taught skills necessary to do so. This study describes a curriculum for oncology fellows aimed to improve skills of cost-health literacy, and provides assessment of the curriculum impact on self-perceived cost communication practices. Oncology fellows at a large academic program in 2019 participated in a cost-health literacy curriculum over 3 months. The curriculum consisted of a didactic on financial toxicity (45 min), a problem-based learning case highlighting financial toxicity risk factors and areas for intervention (30 min), and a group discussion (30 min) to review and consolidate strategies to navigate financial toxicity in direct patient care. A cost-health literacy survey was administered at baseline and at the conclusion of the curriculum to evaluate the impact of the program. Of 19 participants, 16 completed both the pre-survey and post-survey and were included in the analysis. After the intervention, participants were more likely to report comfort discussing out-of-pocket costs (50% vs. 19%, p = 0.002) and to feel they could help a patient experiencing financial toxicity (62% vs. 6%, p = 0.005). There was no improvement in the subjective assessment of patient financial distress (57% v 50%, p = 0.759). Oncology fellows can improve self-reported cost-health literacy skills through participation in a targeted, brief curriculum. Further studies are warranted to determine how this approach can be applied in other settings and if it objectively impacts cost communication practices.
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Affiliation(s)
- Katrina A Fischer
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA.
- 200 UCLA Medical Plaza, Suite 120, Los Angeles, CA, 90095, USA.
| | - Sidharth Anand
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - Anne Walling
- Department of Medicine (Division of General Internal Medicine & Health Services Research), UCLA School of Medicine, Los Angeles, CA, USA
| | - Sarah M Larson
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
| | - John Glaspy
- Department of Medicine (Hematology & Oncology), UCLA School of Medicine, Los Angeles, CA, USA
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Brown JB, Reichert SM, Valliere Y, McLachlan C, Webster-Bogaert S, Ratzki-Leewing A, Ryan BL, Harris SB. Health Care Providers' Emotional Responses to Their Patients' Hypoglycemic Events: Qualitative Findings From the InHypo-DM Study, Canada. Diabetes Spectr 2021; 34:388-393. [PMID: 34866872 PMCID: PMC8603122 DOI: 10.2337/ds20-0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Hypoglycemia can cause psychological distress in people with diabetes; however, less is understood about the emotional impact of hypoglycemia on their health care providers (HCPs). This article focuses on the experiences and emotions of HCPs caring for patients with diabetes. METHODS This was a descriptive qualitative study from the InHypo-DM research program. Purposive sampling was used to recruit 20 HCPs from a variety of professions for 30- to 45-minute semi-structured interviews. An iterative analysis was conducted to identify the overarching themes. RESULTS Three overarching themes encompassed the responses of participants when their patients experienced hypoglycemia. The first was a sense of professional responsibility, as participants felt they must have failed or inadequately fulfilled their professional duties. The second was a more personal range of emotions such as sadness and guilt. The final theme was how these emotions created a "call to action," prompting participants to identify potential strategies to prevent future hypoglycemic events. CONCLUSION This qualitative study highlights the emotional impact of patients' hypoglycemia on HCPs. Although it may have been expected that HCPs have a strong sense of professional responsibility, it was unexpected that these responses often became personal emotions. To ameliorate the negative impact of these responses on patient care, HCPs should engage in activities that enable them to anticipate and manage their own emotional responses. In addition, strategies to optimize hypoglycemia detection and prevention should be promoted.
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Affiliation(s)
- Judith Belle Brown
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
- Corresponding author: Judith Belle Brown,
| | - Sonja M. Reichert
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Yashoda Valliere
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Cecelia McLachlan
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Susan Webster-Bogaert
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
| | - Alexandria Ratzki-Leewing
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Bridget L. Ryan
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Stewart B. Harris
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine and Dentistry, Centre for Studies in Family Medicine, Western University, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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Goupil K, Kinsinger FS. Pro Bono Services in 4 Health Care Professions: A Discussion of Exemplars. JOURNAL OF CHIROPRACTIC HUMANITIES 2020; 27:21-28. [PMID: 33324133 PMCID: PMC7729119 DOI: 10.1016/j.echu.2020.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 09/13/2020] [Accepted: 10/08/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The purpose of this article is to discuss exemplars of pro bono and charity activities in health care professions. METHODS We searched PubMed and Google Scholar from inception to August 2019 using search terms "pro bono healthcare," "medical volunteerism," "pro bono clinics OR free clinics OR organizations," "pro bono curriculum OR education," "underserved OR uninsured OR underinsured OR disadvantaged OR poor populations." Inclusion criteria were that practitioners, students, or volunteers be involved in pro bono care or education and in any discipline, including medicine, physical therapy, chiropractic, or dentistry. RESULTS We selected 5 exemplars to review, and determined that students can benefit from participation in pro bono or charity health care such as through a student administered clinic model. Academic curricula can play a role in building confidence and create positive attitudes and behaviors regarding pro bono and charity activities, and nonprofit organizations can help build sustainable models. CONCLUSION We conclude that the implementation and delivery of health care pro bono or charity services can fill a health care gap and can be applied successfully in the health professions.
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Affiliation(s)
| | - F. Stuart Kinsinger
- Corresponding author: F. Stuart Kinsinger, Canadian Memorial Chiropractic College (ret.), 412-7811 Yonge Street, Thornhill, ON, Canada
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Caulfield T, Murdoch B, Sapir-Pichhadze R, Keown P. Policy Challenges for Organ Allocation in an Era of "Precision Medicine". Can J Kidney Health Dis 2020; 7:2054358120912655. [PMID: 32231786 PMCID: PMC7088188 DOI: 10.1177/2054358120912655] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/29/2020] [Indexed: 12/27/2022] Open
Abstract
There is increasing interest in the use of precision medicine tools and evidence-based outcome measures for donor-recipient matching to optimize transplant outcomes. Although the shift toward greater precision can provide health and resource benefits, it may be perceived as conflicting with both established equity-focused organ allocation norms and the legal and ethical obligations of health care providers and related institutions. With increasing evidence that various forms of human leukocyte antigen (HLA) mismatch and/or prognostic biomarkers can affect outcomes, the tension between maximizing utility and ensuring equity seems likely to intensify. In Canada, health care providers are generally required by law to put the interests of their patient, such as access to an organ, above the needs of the health care system and other patients. In addition, transplantation right of access lawsuits, which have been successful in the past, could affect the implementation of precision approaches. These legal tensions could be further heightened by media representations, which have historically favored strong rights of access. When implementing new precision technologies in organ allocation, there will be a recurrent need for policymakers to revisit the balance of equity and utility and to assess how to craft rules that reflect our society’s conception of a fair allocation system.
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Affiliation(s)
- Timothy Caulfield
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Canada
| | - Blake Murdoch
- Health Law Institute, Faculty of Law, University of Alberta, Edmonton, Canada
| | | | - Paul Keown
- Faculty of Medicine, The University of British Columbia, Vancouver, Canada
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Vitali MM, Pires DEPD, Forte ECN, Farias JM, Soratto J. JOB SATISFACTION AND DISSATISFACTION IN PRIMARY HEALTH CARE: AN INTEGRATIVE REVIEW. TEXTO & CONTEXTO ENFERMAGEM 2020. [DOI: 10.1590/1980-265x-tce-2018-0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: identify the factors that contribute to job satisfaction or job dissatisfaction among Primary Health Care workers. Method: this integrative review was conducted in Public/Publish Medline, Scopus, American Psychological Association, Web of Science, Latin America and Caribbean Health Sciences Literature, Cumulative Index to Nursing and Allied Health Literature, and Scientific Electronic Library Online using the following descriptors and keywords: job satisfaction, personal satisfaction, dissatisfaction, health personnel, Primary Health Care. The studies presenting abstracts written in English, Spanish or Portuguese, published between 1972 and 2017, with full texts available, were included. Results: 63 papers were identified with 204 satisfaction factors and 174 dissatisfaction factors and were grouped into the following categories: career, which gathered professional aspects of the work routine; infrastructure, which included factors related to the physical work environment such as material resources and inputs; interpersonal relations comprised factors related to the professional relationship established with the work team, patients, service users and families; and psychosocial aspects, which refer to the health workers’ internal aspects and the influence of social issues. Conclusion: the factors promoting satisfaction or dissatisfaction among PHC workers are ambiguous, though aspects leading to satisfaction are mostly related to the categories career and interpersonal relations, while dissatisfaction is related to aspects that prevent an individual from achieving a promising professional career and weaknesses in the services’ infrastructure.
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Transformation of the Doctor-Patient Relationship: Big Data, Accountable Care, and Predictive Health Analytics. HEC Forum 2019; 31:261-282. [PMID: 31209679 DOI: 10.1007/s10730-019-09377-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The medical profession is steeped in traditions that guide its practice. These traditions were developed to preserve the well-being of patients. Transformations in science, technology, and society, while maintaining a self-governance structure that drives the goal of care provision, have remained hallmarks of the profession. The purpose of this paper is to examine ethical challenges in health care as it relates to Big Data, Accountable Care Organizations, and Health Care Predictive Analytics using the principles of biomedical ethics laid out by Beauchamp and Childress (autonomy, beneficence, non-maleficence, and justice). Among these are the use of Electronic Health Records within stipulations of the Health Insurance Portability and Accountability Act. Clinicians are well-positioned to impact health policy development to address ethical issues associated with the use of Big Data, Accountable Care, and Health Care Predictive Analytics as we work to transform the doctor-patient relationship towards improving population health outcomes and creating a healthier society.
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Reader TW, Reddy G, Brett SJ. Impossible decision? An investigation of risk trade-offs in the intensive care unit. ERGONOMICS 2018; 61:122-133. [PMID: 28300480 DOI: 10.1080/00140139.2017.1301573] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
In the intensive care unit (ICU), clinicians must often make risk trade-offs on patient care. For example, on deciding whether to discharge a patient before they have fully recovered in order to create a bed for another, sicker, patient. When misjudged, these decisions can negatively influence patient outcomes: yet it can be difficult, if not impossible, for clinicians to evaluate with certainty the safest course of action. Using a vignette-based interview methodology, a naturalistic decision-making approach was utilised to study this phenomena. The decision preferences of ICU clinicians (n = 24) for two common risk trade-off scenarios were investigated. Qualitative analysis revealed the sample of clinicians to reach different, and sometimes oppositional, decision preferences. These practice variations emerged from differing analyses of risk, how decisions were 'framed' (e.g. philosophies on care), past experiences, and perceptions of group and organisational norms. Implications for patient safety and clinical decision-making are discussed. Practitioner Summary: Physicians managing ICUs have to make rapid decisions with incomplete information and suboptimal resources. A qualitative vignette-based interview study examined how such decisions are made. We found physicians used a heterogeneous mixture of risk assessments, factual knowledge and prior experience to make judgements, which leads to potential for inconsistent decision-making.
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Affiliation(s)
- Tom W Reader
- a Department of Psychological and Behavioural Science , London School of Economics , London , UK
| | - Geetha Reddy
- a Department of Psychological and Behavioural Science , London School of Economics , London , UK
| | - Stephen J Brett
- b Centre for Perioperative Medicine and Critical Care Research , Imperial College Healthcare NHS Trust , London , UK
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Allard J, Fortin MC. Is it ethical to prescribe generic immunosuppressive drugs to renal transplant patients? Can J Kidney Health Dis 2014; 1:23. [PMID: 25780612 PMCID: PMC4349684 DOI: 10.1186/s40697-014-0023-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Accepted: 08/11/2014] [Indexed: 01/07/2023] Open
Abstract
PURPOSE OF THE REVIEW This review was conducted to determine the ethical acceptability of prescribing generic immunosuppressive drugs to renal transplant patients. SOURCES OF INFORMATION The literature search was conducted using Pubmed and Google Scholar. FINDINGS The use of generic immunosuppressive drugs (ISDs) in transplantation is a controversial topic. There is a consensus among transplant societies that clinical data is lacking and that caution should be exercised. The reluctance to use generic ISDs in organ transplantation is partly related to the fact that most are "critical dose drugs", and that either low dosing or overdosing could have serious adverse consequences for both patients and society (i.e., the loss of scarce organs). In this paper, we examine the various ethical issues involved such as distributive justice, physician duties, risks versus benefits, conflict of interest, informed consent, and logistical and economic issues. LIMITATIONS Our analysis was limited by the paucity of clinical data on generic ISDs and the absence of health economics studies to quantify the benefits of prescribing generic ISDs. IMPLICATIONS Our study led us to conclude that it would be ethical to prescribe generic ISDs provided certain conditions were met. These include regulatory safeguards to minimize the risks of substitution; education of patients; and further clinical and health economics studies to better inform clinicians, patients and society of the risks and costs related to drug substitution.
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Affiliation(s)
- Julie Allard
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada
| | - Marie-Chantal Fortin
- Centre de recherche du Centre hospitalier de l′Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montreal, Quebec H2X 0A9 Canada ,Nephrology and Transplantation Division, Centre hospitalier de l’Université de Montréal (CHUM), 1560 Sherbrooke Street East, Montreal, Quebec H2L 4 M1 Canada ,Department of Social and Preventive Medicine, Bioethics Program, School of Public Health, Université de Montréal, Montreal, Canada
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Sabbatini AK, Tilburt JC, Campbell EG, Sheeler RD, Egginton JS, Goold SD. Controlling health costs: physician responses to patient expectations for medical care. J Gen Intern Med 2014; 29:1234-41. [PMID: 24871228 PMCID: PMC4139526 DOI: 10.1007/s11606-014-2898-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 02/25/2014] [Accepted: 05/07/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Physicians have dual responsibilities to make medical decisions that serve their patients' best interests but also utilize health care resources wisely. Their ability to practice cost-consciously is particularly challenged when faced with patient expectations or requests for medical services that may be unnecessary. OBJECTIVE To understand how physicians consider health care resources and the strategies they use to exercise cost-consciousness in response to patient expectations and requests for medical care. DESIGN Exploratory, qualitative focus groups of practicing physicians were conducted. Participants were encouraged to discuss their perceptions of resource constraints, and experiences with redundant, unnecessary and marginally beneficial services, and were asked about patient requests or expectations for particular services. PARTICIPANTS Sixty-two physicians representing a variety of specialties and practice types participated in nine focus groups in Michigan, Ohio, and Minnesota in 2012 MEASUREMENTS: Iterative thematic content analysis of focus group transcripts PRINCIPAL FINDINGS Physicians reported making trade-offs between a variety of financial and nonfinancial resources, considering not only the relative cost of medical decisions and alternative services, but the time and convenience of patients, their own time constraints, as well as the logistics of maintaining a successful practice. They described strategies and techniques to educate patients, build trust, or substitute less costly alternatives when appropriate, often adapting their management to the individual patient and clinical environment. CONCLUSIONS Physicians often make nuanced trade-offs in clinical practice aimed at efficient resource use within a complex flow of clinical work and patient expectations. Understanding the challenges faced by physicians and the strategies they use to exercise cost-consciousness provides insight into policy measures that will address physician's roles in health care resource use.
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Affiliation(s)
- Amber K Sabbatini
- Department of Emergency Medicine, University of Michigan, NCRC,2800 Plymouth Rd, Building 10, Room G015, Ann Arbor, MI, 48109-2800, USA,
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Antiel RM, Curlin FA, James KM, Tilburt JC. The moral psychology of rationing among physicians: the role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment. Philos Ethics Humanit Med 2013; 8:13. [PMID: 24010636 PMCID: PMC3847359 DOI: 10.1186/1747-5341-8-13] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 09/02/2013] [Indexed: 05/16/2023] Open
Abstract
INTRODUCTION Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called "moral foundations." The objective of this study was to determine if "harm" and "fairness" intuitions can explain physicians' judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to "purity", "authority" and "ingroup" in cost-related judgments. METHODS We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care. RESULTS 1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values > 0.05). Agreement with cost-containment was associated with higher mean "harm" (3.6) and "fairness" (3.5) intuitions compared to "in-group" (2.8), "authority" (3.0), and "purity" (2.4) (p < 0.05). In multivariate models adjusted for age, sex, region, and specialty, both "harm" and "fairness" were significantly associated with judgments about cost-containment (OR = 1.2 [1.0-1.5]; OR = 1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR = 1.2 [1.0-1.4]; OR = 0.9 [0.7-1.0]). CONCLUSIONS Moral intuitions shed light on variation in physician judgments about cost issues in health care.
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Affiliation(s)
- Ryan M Antiel
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
| | - Farr A Curlin
- Department of Medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, Illinois, USA
| | - Katherine M James
- Biomedical Ethics Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Jon C Tilburt
- Program in Professionalism and Ethics, Mayo Clinic, Rochester, Minnesota, USA
- Biomedical Ethics Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
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Affiliation(s)
- Molly Cooke
- University of California, San Francisco, San Francisco, USA
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14
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Clark NM, Nelson BW, Valerio MA, Gong ZM, Taylor-Fishwick JC, Fletcher M. Consideration of shared decision making in nursing: a review of clinicians' perceptions and interventions. Open Nurs J 2009; 3:65-75. [PMID: 19855848 PMCID: PMC2765030 DOI: 10.2174/1874434600903010065] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Revised: 09/04/2009] [Accepted: 09/04/2009] [Indexed: 12/02/2022] Open
Abstract
As the number of individuals with chronic illness increases so has the need for strategies to enable nurses to engage them effectively in daily management of their conditions. Shared decision making between patients and nurses is one approach frequently discussed in the literature. This paper reviews recent studies of shared decision making and the meaning of findings for the nurse-patient relationship. Patients likely to prefer to engage in shared decision making are younger and have higher levels of education. However, there is a lack of evidence for the effect of shared decision making on patient outcomes. Further, studies are needed to examine shared decision making when the patient is a child. Nurses are professionally suited to engage their patients fully in treatment plans. More evidence for how shared decision making affects outcomes and how nurses can successfully achieve such engagement is needed.
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Affiliation(s)
- Noreen M Clark
- Center for Managing Chronic Disease, University of Michigan, 109 Observatory, Ann Arbor, MI 48109-2029, USA.
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Lauridsen S. Administrative gatekeeping - a third way between unrestricted patient advocacy and bedside rationing. BIOETHICS 2009; 23:311-320. [PMID: 18410460 DOI: 10.1111/j.1467-8519.2008.00652.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The inevitable need for rationing of healthcare has apparently presented the medical profession with the dilemma of choosing the lesser of two evils. Physicians appear to be obliged to adopt either an implausible version of traditional professional ethics or an equally problematic ethics of bedside rationing. The former requires unrestricted advocacy of patients but prompts distrust, moral hazard and unfairness. The latter commits physicians to rationing at the bedside; but it is bound to introduce unfair inequalities among patients and lack of political accountability towards citizens. In this paper I shall argue that this dilemma is false, since a third intermediate alternative exists. This alternative, which I term 'administrative gatekeeping', makes it possible for physicians to be involved in rationing while at the same time being genuine advocates of their patients. According to this ideal, physicians are required to follow fair rules of rationing adopted at higher organizational levels within healthcare systems. At the same time, however, they are prohibited from including considerations of cost in their clinical decisions.
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Affiliation(s)
- Sigurd Lauridsen
- University of Copenhagen, Unit of Medical Philosophy and Clinical Theory, Institute of Public Health, University of Copenhagen, Panum Institute, Copenhagen, Denmark.
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Bedside rationing by general practitioners: a postal survey in the Danish public healthcare system. BMC Health Serv Res 2008; 8:192. [PMID: 18808694 PMCID: PMC2567318 DOI: 10.1186/1472-6963-8-192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2008] [Accepted: 09/22/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is ethically controversial whether medical doctors are morally permitted to ration the care of their patients at the bedside. To explore whether general practitioners in fact do ration in this manner we conducted a study within primary care in the Danish public healthcare system. The purpose of the study was to measure the extent to which general practitioners (GPs) would be willing to factor in cost-quality trade-offs when prescribing medicine, and to discover whether, and if so to what extent, they believe that patients should be informed about this. METHODS Postal survey of 600 randomly selected Danish GPs, of which 330 responded to the questionnaire. The Statistical Package for the Social Sciences (SPSS, version 14.0) was used to produce general descriptive statistics. Significance was calculated with the McNemar and the chi-square test. The main outcome measures of the study were twofold: an assessment of the proportion of GPs who, in a mainly hypothetical setting, would consider cost-quality trade-offs relevant to their clinical decision-making given their economic impact on the healthcare system; and a measure of the extent to which they would disclose this information to patients. RESULTS In the hypothetical setting 95% of GPs considered cost-quality trade-offs relevant to their clinical decision-making given the economic impact of such trade-offs on the healthcare system. In all 90% stated that this consideration had been relevant in clinical decision-making within the last month. In the hypothetical setting 55% would inform their patients that they considered a cost-quality trade-off relevant to their clinical decisions given the economic impact of such trade-offs on the healthcare system. The most common reason (68%) given for not wanting to inform patients about this matter was the belief that the information would not prove useful to patients. In the hypothetical setting cost-quality trade-offs were considered relevant significantly more often in connection with concerns about costs to the patient (86%) than they were in connection with concerns about costs to the healthcare system (55%; p < 0.001). CONCLUSION Although readiness to consider cost-quality trade-offs relevant to clinical decisions is prevalent among GPs in Denmark, only half of GPs would disclose to patients that they consider this relevant to their clinical decision-making. The results of this study raise two important ethical problems. First, under Danish law physicians are required to inform patients about all equal treatments. The fact that only a few GPs would inform their patients about all of the relevant treatments therefore seems to contravene Danish law. Second, it is ethically controversial that physicians act as economic gatekeepers.
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Elmersjö CA, Helgesson G. Notions of just health care at three Swedish hospitals. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2008; 11:145-51. [PMID: 17619111 DOI: 10.1007/s11019-007-9084-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 06/07/2007] [Indexed: 05/16/2023]
Abstract
This article investigates what notions of "just health care" are found at three Swedish hospitals among health care personnel and whether these notions are relevant to what priorities are actually made. Fieldwork at all three hospitals and 114 in-depth interviews were conducted. Data have been subject to conceptual and ethical analysis and categorisation. According to our findings, justice is an important idea to health care personnel at the studied hospitals. Two main notions of just health care were found. The main idea was the notion of "equal treatment according to need", the basic idea being that differences in treatment should be justified by differences in needs. The competing idea that merit should affect the treatment received is occasionally encountered, the idea here being that patients, by acting irresponsibly, may no longer deserve to be treated strictly according to needs. In practice, priorities are made on grounds that only partly comply with the basic idea of justice in health care, as it is understood by staff at the studied hospitals. Exceptions are made due to regional differences, considerations of cost-effectiveness, economic incentives, tradition, the daily patient flow, research, private alternatives, patient influence and favouritism of health care personnel.
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Affiliation(s)
- Carl-Ake Elmersjö
- Centre for Bioethics at Karolinska Institutet and Uppsala University, Karolinska Institutet, Berzelius väg 3, Stockholm, Sweden
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Ballard DW, Reed ME, Wang H, Arroyo L, Benedetti N, Hsu J. Influence of patient costs and requests on emergency physician decisionmaking. Ann Emerg Med 2008; 52:643-650. [PMID: 18439723 DOI: 10.1016/j.annemergmed.2008.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2007] [Revised: 01/14/2008] [Accepted: 03/03/2008] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVES We examine emergency physician knowledge of, attitudes about, and responses to patient cost-sharing in the emergency department (ED). METHODS A convenience sample of emergency physicians from an integrated delivery system completed a questionnaire including self-report questions about knowledge of and attitudes about cost-sharing and an experimental vignette. The vignette describes a patient with an uncomplicated asthma exacerbation, with a version in which she has a $100 ED visit copayment and a version in which she does not. Subjects responded with their "best judgment" of whether they would order a chest radiograph and their decision after specific patient request. We examined the frequency of responses overall and associated characteristics with chi(2) testing. RESULTS Of 204 respondents (349 eligible participants [58%]), 203 answered the vignette questions. No respondent reported that ordering a radiograph was clinically appropriate; however, 85% reported that they would order a radiograph if the patient requested it. There were no significant differences in the percentage of physicians ordering the test across the 2 versions. Overall, 77% of respondents reported having limited awareness of an individual patient's cost-sharing level; 67% reported that patient costs sometimes affect their clinical decisions; only 10% estimated changing their decisions in greater than 20% of encounters in which the cost-sharing level was known. CONCLUSION Emergency physicians are usually not aware of a patient's cost-sharing level and, in instances which they are, report that this knowledge rarely affects their clinical decisions. However, emergency physicians are responsive to patient requests, even when the treatment request differs from their clinical judgment.
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Affiliation(s)
- Dustin W Ballard
- Department of Emergency Medicine, Kaiser Permanente San Rafael Medical Center, San Rafael, Fairfax, CA 94930, USA.
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Browman GP, Manns B, Hagen N, Chambers CR, Simon A, Sinclair S. 6-STEPPPs: A Modular Tool to Facilitate Clinician Participation in Fair Decisions for Funding New Cancer Drugs. J Oncol Pract 2008; 4:2-7. [PMID: 20859436 PMCID: PMC2793938 DOI: 10.1200/jop.0812001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To design a tool to assist clinician participation with cancer drug funding decisions. Public policy-makers and insurers are struggling with funding decisions regarding increasingly expensive new cancer drugs. Increasingly, oncologists are contributing to the process of review that leads to such decisions. We were asked to design a system for ranking new cancer drugs for priority-based funding decisions. METHODS The "Accountability for Reasonableness" framework informed the design of a six-module multistakeholder decision process blending evidence-based traditional technology assessment methods with individual and cultural values elicitation. The tool was piloted in three settings: (1) videotaped simulated multistakeholder deliberation sessions; (2) clinical oncology leaders; and (3) a regional (Canadian provincial) pharmacy and therapeutics committee making formulary decisions. The modules involve: decision clarification, drug eligibility screening (filtering), clinical performance scoring index, cost modeling, data integration and values clarification, and process evaluation. RESULTS The tool was feasible to use, acceptable to participants, and able to rank candidate drugs. The pharmacy and therapeutics committee with whom it was tested used the tool as a part of their deliberations, and the tumor group leaders requested its incorporation into organization-based decision making. CONCLUSION The decision tool can facilitate priority-based cancer drug funding decisions that meet the conditions of fairness as perceived by participants, including oncologists.
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Affiliation(s)
- George P. Browman
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
| | - Braden Manns
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
| | - Neil Hagen
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
| | - Carole R. Chambers
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
| | - Anita Simon
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
| | - Shane Sinclair
- The Alberta Cancer Board, Edmonton; Institute of Health Economics, University of Alberta, Edmonton; The University of Calgary, Calgary; The Calgary Health Region, Calgary, Alberta, Canada
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Monnickendam M, Monnickendam SM, Katz C, Katan J. Health care for the poor—An exploration of primary-care physicians’ perceptions of poor patients and of their helping behaviors. Soc Sci Med 2007; 64:1463-74. [PMID: 17234317 DOI: 10.1016/j.socscimed.2006.11.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2006] [Indexed: 10/23/2022]
Abstract
This paper explores the ways in which primary-care physicians in Israel perceive and help poor patients. Our findings are based on a qualitative study that utilized a focus group and in-depth interviews with 16 primary-care physicians who qualified both in Israel and in the former Soviet Union, and who work in community clinics one Health Maintenance Organization serving poor populations of diverse cultural, ethnic and socioeconomic backgrounds (immigrants from the former Soviet Union and from Ethiopia, Bedouin, ultra-orthodox Jews, the chronic poor, and the 'new' poor). It was found that the physicians presume causality between poverty and health, identify and distinguish between different types of poverty, and make associations based on the type of poverty and type of patient problem. Their thinking on poverty is patient-oriented rather than socially oriented. An analysis of these findings resulted in a conceptualization of five types of physician helping behavior: emotional and personal instrumental, reinforcing socially desirable behavior, preferential help and bending the rules, rights realization and working the system, and minimal community involvement. The components of this conceptual model depict and chart issues affecting the helping behavior of the primary-care physician, i.e., type of poverty, type of problem, administrative context and, particularly, physician attributes, such as gender and country where notable. Our findings reveal little social consciousness on the part of the physicians, and we conclude with remarks on the potential for change in this area.
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Muula AS. Ethical and practical consideration of women choosing cesarean section deliveries without "medical indication" in developing countries. Croat Med J 2007; 48:94-102. [PMID: 17309146 PMCID: PMC2080500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
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Morgan CL, Beerstecher HJ. Primary care funding, contract status, and outcomes: an observational study. Br J Gen Pract 2006; 56:825-9. [PMID: 17132348 PMCID: PMC1927089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND The introduction of the Quality and Outcomes Framework (QOF) provides a quantitative way of assessing quality of care in general practice. We explore the achievements of general practice in the first year of the QOF, with specific reference to practice funding and contract status. AIM To determine the extent to which differences in funding and contract status affect quality in primary care. DESIGN OF STUDY Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000. SETTING One hundred and sixty-four practices from six primary care trusts (PCTs) in England. METHOD Practice data for all 164 practices were collated for income and contract status. The outcome measure was QOF score for the year 2004-2005. All data were analysed statistically. RESULTS Contract status has an impact on practice funding, with Employed Medical Services (EMS) and Personal Medical Services (PMS) practices receiving higher levels of funding than General Medical Services (GMS) practices (P<0.001). QOF scores also vary according to contract status. Higher funding levels in EMS practices are associated with lower QOF scores (P=0.04); while GMS practices exhibited the opposite trend, with higher-funded practices achieving better quality scores (P<0.001). CONCLUSION GMS practices are the most efficient contract status, achieving high quality scores for an average of pound 62.51 per patient per year. By contrast, EMS practices are underperforming, achieving low quality scores for an average of pound 105.37 per patient per year. Funding and contract status are therefore important factors in determining achievement in the QOF.
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