Factors and interventions determining the functioning of health care teams in county-level hospitals in less affluent areas of China: a qualitative study

Background

Teamwork is essential for the quality and safety of care, and research on teamwork in health care has developed rapidly in many countries. However, evidence from less affluent, non-Western countries is scarce, while improving teamwork may be especially relevant to be able to increase the quality of care in these settings. This study aims to understand the main factors that influence, and interventions used to improve, the functioning of health care teams in the context of county-level hospitals in less affluent areas of China.

Methods

We conducted semistructured interviews to explore the factors that influence team functioning and the interventions implemented to improve team functioning in these hospitals. 15 hospital presidents and 15 team leaders were selected as respondents.

Results

From the interviews, we have identified five main factors that influence team functioning in these hospitals: "stuck in the middle", local county setting, difficulty in attracting and retaining talent, strong focus on task design, and strong focus on leadership. The interventions for improving team functioning can mostly be categorized as the following: 1) measures to attract and retain talent (e.g., increase salary, train talent in national or provincial level hospitals, and provide fast-track promotions), 2) interventions focused on monodisciplinary teams (e.g., changing the team structure and leadership, and skill training), and 3) interventions to establish and improve multidisciplinary teams (e.g., simulation training and continuous team process improvements).

Conclusion

With the introduction of multidisciplinary teams, interventions into team processes have started to receive more attention. The findings depict an overview of the main factors and interventions as specifically relevant for team functioning in county-level hospitals in less affluent areas of China and may help these hospitals benefit from additional process interventions to improve teamwork and the quality of care.

The intention to use mHealth applications among Dutch older adults prior and during the COVID pandemic

Background

Mobile health (mHealth) applications are widely valued for their potential to increase self-management among older adults and reduce their healthcare demands. However, the intention to use mHealth of Dutch older adults before the COVID-19 pandemic was modest. Healthcare access was considerably reduced during the pandemic and mHealth services substituted for in person health services. As older adults utilize health services more frequently and have been particularly vulnerable to the pandemic, they can be viewed to have especially benefitted from the transition toward mHealth services. Furthermore, one might expect their intention to use these services and reap the potential benefits has increased, especially during the pandemic.

Objective

The aim of this study was to examine whether the intention of Dutch older adults to use medical applications increased during the COVID pandemic and how the explanatory power of the extended Technology Acceptance Model (TAM) developed for this purpose was affected by the onset of the pandemic.

Methods

We conducted a cross-sectional survey using two samples collected before (n = 315) and after (n = 501) the onset of the pandemic. Data was collected using questionnaires which were distributed digitally and on paper, by convenience sampling and snowballing. Participants were 65 years or older, lived independently or in a senior living facility, without cognitive impairment. A controlled analysis was performed to test for significant differences in the intention to use mHealth. The before and after differences in extended TAM variables and their relationship with intention to use (ITU) were analyzed using controlled (multivariate) logistic and linear regression models. These models were also used to explore whether the onset of the pandemic had an effect on ITU not captured by the extended TAM model.

Results

While the two samples differed in ITU (p = 0.017; uncontrolled) there was no statistically significant difference in ITU in the controlled logistic regression analysis (p = 0.107). The scores of the extended TAM variables explaining intention to use were all significantly higher, except for Subjective norm and Feelings of Anxiety. The relationships of these variables with intention to use before and after the onset of the pandemic were similar, except for Social relationships which lost its significance. We found no indications of effects of the pandemic on intention to use not captured by our instrument.

Conclusion

The intention to use mHealth applications of Dutch older adults has not changed since the onset of the pandemic. The extended TAM model has robustly explained intention to use, with only minor differences after the first months of the pandemic. Interventions targeting facilitation and support are likely to promote the uptake of mHealth. Follow-up studies are needed to investigate whether the pandemic has had long term effects on the ITU of the older adult.

A theory-informed systematic review to understand physical activity among women in Gulf Cooperation Council countries

BACKGROUND

This systematic review was conducted to identify health beliefs and modifying factors influencing physical (in) activity among adult women in Gulf Cooperation Council (GCC) countries (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates).

METHODS

A comprehensive search of the Medline (Ovid), EMBASE, Cochrane Central, Web of Science, and Google Scholar databases was conducted to identify relevant articles published between 2009 and 2019. The quality of included studies was assessed using the Mixed Methods Appraisal Tool. Data collection and analysis based on the health belief model were performed to systematically examine the relationships of health beliefs and modifying factors to physical activity.

RESULTS

The sample comprised 15 studies (Saudi Arabia, n = 6; Oman, n = 5; Qatar, n = 2; Kuwait, n = 2). Reported physical activity prevalences were low (nearly 0% to 50%) and depended on the location, subpopulation, and measurement instrument. Evidence for relationships of modifying factors and health beliefs to physical activity was scarce and sometimes inconclusive. Among modifying factors, middle age and employment were associated positively with physical activity; marital status, educational level, income, and body mass index were not associated. Regarding health beliefs, the only conclusive evidence reported was that a lack of time was not associated significantly with physical activity in a population of men and women. Women reported a lack of social support and lack of skills significantly more frequently than men; these factors may explain the gender difference in physical activity prevalence. Differences in the reporting of fear of injury and lack of willpower were not significant.

CONCLUSIONS

Robust qualitative and quantitative research on the contributions of health beliefs and modifying factors to the low prevalence of physical activity among women in GCC countries is urgently needed. Current evidence indicates that unemployed women, women aged < 25 years, and elderly women are less likely to be physically active. Women in this population are more likely than men to believe that a lack social support and skills affects their physical activity. Many known factors and health beliefs appear to be unrelated to physical activity among adult women in GCC countries.

Strategic human resource management and performance in public hospitals in Ethiopia

Background

Ethiopian public hospitals struggle to meet health care needs of the Ethiopian population, in part because of the persistent human resources crisis. The health reforms and tight human resource management (HRM) regulation of the government have resulted in limited progress toward addressing this crisis. This study aims to analyze how the strategic HRM practices adopted by Ethiopian public hospitals influence employee outcomes, organizational outcomes, and patient outcomes.

Methods

Structured interviews were conducted with 19 CEOs and HR managers from 15 hospitals. Four focus groups were also conducted, with 38 participants (professionals and line managers). The transcripts were thematically analyzed using ATLAS.ti 8. Deductive coding was used based on the Contextual SHRM framework, while remaining open for codes that emerged.

Results

Intended HR practices are influenced by mandatory strict government regulations. Nevertheless, some room for self-selected (bundles of) HR practices is perceived by hospitals. Employees perceive that governmental steered HR practices may not match its intentions due to implementation issues, related to lack of support and skilled management and HR professionals. These problems are leading to dissatisfaction, demotivation, moonlighting and turnover of skilled professionals and perceived to consequently negatively influence performance (i.e., patient satisfaction and waiting time).

Conclusions

There are considerable contextual challenges for SHRM in Ethiopian public hospitals. Hospital management can benefit from having more leeway and from exploiting it more effectively to improve actual and perceived strategic human resource management practices. Adoption of commitment based practices, in addition to mandatory control oriented practices can help to motivate and retain health care professionals and consequently improve outcomes.

Does competition improve hospital performance: a DEA based evaluation from the Netherlands

Many countries have introduced competition among hospitals aiming to improve their performance. We evaluate the introduction of competition among hospitals in the Netherlands over the years 2008-2015. The analysis is based on a unique longitudinal data set covering all Dutch hospitals and health insurers, as well as demographic and geographic data. We measure hospital performance using Data Envelopment Analysis and distinguish three components of competition: the fraction of freely negotiated services, market power of hospitals, and insurer bargaining power. We present new methods to define variables for each of these components which are more accurate than previously developed measures. In a multivariate regression analysis, the variables explain more than half of the variance in hospital efficiency. The results indicate that competition between hospitals and the relative fraction of freely negotiable health services are positively related to hospital efficiency. At the same time, the policy measure to steadily increase the fraction of health services contracted in competition may well have resulted in a decrease in hospital efficiency. The models show no significant association between insurer bargaining power and hospital efficiency. Altogether, the results offer little evidence that the introduction of competition for hospital care in the Netherlands has been effective.

Human resource management in Ethiopian public hospitals

Background

In Ethiopia, public hospitals deal with a persistent human resource crisis, even by Sub-Saharan Africa (SSA) standards. Policy and hospital reforms, however, have thus far resulted in limited progress towards addressing the strategic human resource management (SHRM) challenges Ethiopia’s public hospitals face.

Methods

To explore the contextual factors influencing these SHRM challenges of Ethiopian public hospitals, we conducted a qualitative study based on the Contextual SHRM framework of Paauwe. A total of 19 structured interviews were conducted with Chief Executive Officers (CEOs) and HR managers from a purposive sample of 15 hospitals across Ethiopia. An additional four focus groups were held with professionals and managers.

Results

The study found that hospitals compete on the supply side for scarce resources, including skilled professionals. There was little reporting on demand-side competition for health services provided, service quality, and service innovation. Governmental regulations were the main institutional mechanism in place. These regulations also emphasized human resources and were perceived to tightly regulate employee numbers, salaries, and employment arrangements at detailed levels. These regulations were perceived to restrict the autonomy of hospitals regarding SHRM. Regulation-induced differences in allowances and external employment arrangements were among the concerns that decreased motivation and job satisfaction and caused employees to leave. The mismatch between regulation and workforce demands posed challenges for leadership and caused leaders to be perceived as incompetent and unable when they could not successfully address workforce needs.

Conclusions

Bottom-up involvement in SHRM may help resolve the aforementioned persistent problems. The Ethiopian government might better loosen regulations and provide more autonomy to hospitals to develop SHRM and implement mechanisms that emphasize the quality of the health services demanded rather than the quantity of human resources supplied.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08046-7.

Primary healthcare professionals' perspective on vertical integration of healthcare system in China: a qualitative study

OBJECTIVE

This study aims to present the perspectives of primary healthcare professionals (PHPs) on the impacts of implementation of vertical integration and on the underlying interprofessional collaboration process on achievement of the policy goals in China.

DESIGN

A qualitative study involving individual interview and group interview was conducted between 2017 and 2018.

SETTING

Primary healthcare institutions (PHIs) in five counties/districts of China.

PARTICIPANTS

The major participants include 12 heads of PHIs (by 12 individual interviews) and 38 PHPs (by 12 group interviews). We also interviewed other stakeholders including 24 health policy-makers (by 5 group interviews) and 5 hospital leaders (by 5 individual interviews) for triangulation analysis.

RESULTS

Our study indicates that PHPs perceived vertical integration has resulted in improved professional competency, better care coordination and stronger capacity to satisfy patients' needs. The positive impacts have varied between integration types. Contributing factors for such progress are identified at administrative, organisational and service delivery levels. Other perceived effects are a loss of autonomy, increased workload and higher turnover of capable PHPs. Higher level hospitals play a dominant role in the interprofessional collaboration, particularly regarding shared goals, vision and leadership. These findings are different from the evidence in high-income countries. Incentive mechanisms and the balance of power with hospitals management are prominent design elements in the future.

CONCLUSIONS

Our findings are particularly valuable for other countries with a fragmented health service system and low competency of PHPs as China's experience in integrated care provides a feasible path to strengthen primary care.

The Health Value of Kidney Exchange and Altruistic Donation

OBJECTIVES

Living donor kidney transplantation (LTx) is the preferred treatment for patients with end-stage renal disease. Kidney exchange programs (KEPs) promote LTx by facilitating exchange of donors among patients who are not compatible with their donors. We analyze and maximize the efficacy and effectiveness of KEPS from a health value perspective and the health value of altruistic donation in KEPs.

METHODS

We developed a Markov model for the health outcomes of patients, which was embedded in a discrete event simulation model to assess the effectiveness of allocation policies in KEPs. A new allocation policy to maximize health value was developed on the basis of integer programing techniques. The evidence-based transition probabilities in the Markov model were based on data from the Dutch KEP using a variety of econometric models. Scenarios analysis was presented to improve robustness.

RESULTS

The efficacy of the Dutch KEP without altruistic donation is reflected by the increase in expected discounted quality-adjusted life-years (QALYs) by 3.23 from 6.42 to 9.65. The present Dutch policy and the policy to maximize the number of transplants achieve 63% of the potential efficacy gain (2.11 discounted QALYs). The new policy achieves 69% of this gain (2.33 discounted QALYs). When systematically enrolling altruistic donors in the KEP, the new policy increased expected discounted QALYs by 4.05 to 10.27 and reduced inequities for patients with blood type O.

CONCLUSIONS

The Dutch KEP can increase health value for patients by more than half. An allocation policy that maximizes health outcomes and maximally allows altruistic donation can yield significant further improvements.

Factors Influencing the Implementation of Foreign Innovations in Organization and Management of Health Service Delivery in China: A Systematic Review

Background: China has been encouraged to learn from international innovations in the organization and management of health service delivery to achieve the national health reform objectives. However, the success and effectiveness of implementing innovations is affected by the interactions of innovations with the Chinese context. Our aim is to synthesize evidence on factors influencing the implementation of non-Chinese innovations in organization and management of health service delivery in mainland China. Methods: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched seven databases for peer-reviewed articles published between 2009 and 2020. Data were analyzed and combined to generate a list of factors influencing the implementation of foreign innovations in China. The factors were classified in the categories context, system, organization, innovation, users, resources, and implementation process. Results: The 110 studies meeting the inclusion criteria revealed 33 factors. Most supported by evidence is the factor integration in organizational policies, followed by the factors motivation & incentives and human resources. Some factors (e.g., governmental policies & regulations) were mentioned in multiple studies with little or no evidence. Conclusion: Evidence on factors influencing the implementation of foreign innovations in organization and management of health service delivery is scarce and of limited quality. Although many factors identified in this review have also been reported in reviews primarily considering Western literature, this review suggests that extrinsic motivation, financial incentives, governmental and organizational policies & regulations are more important while decentralization was found to be less important in China compare to Western countries. In addition, introducing innovations in rural China seems more challenging than in urban China, because of a lack of human resources and the more traditional rural culture.

What Do We Know About Teamwork in Chinese Hospitals? A Systematic Review

Background and Objective: Improving quality of care is one of the primary goals in current Chinese hospital reforms. Teamwork can play an essential role. Characteristics of teamwork and interventions for improving teamwork in hospitals have been widely studied. However, most of these studies are from a Western context; evidence from China is scarce. Because of the contextual differences between China and Western countries, empirical evidence on teamwork from Western hospitals may have limited validity in China. This systematic review aims to advance the evidence base and understanding of teamwork in Chinese hospitals. Methods: Both English (i.e., Embase, Medline, and Web of Science) and Chinese databases (i.e., CNKI, CQVIP, and Wanfang) were searched for relevant articles until February 6, 2020. We included the studies that empirically researched teamwork in Chinese hospitals. Studies were excluded if they (1) were not conducted in hospitals in Mainland China, (2) did not research teamwork on team interventions, (3) were not empirical, (4) were not written in English or Chinese, (5) were not published in peer-reviewed journals, and (6) were not conducted in teams that provide direct patient care. Both deductive and inductive approaches were used to analyze data. The Mixed Methods Appraisal Tool (MMAT) was used to assess their methodological quality. Results: A total of 70 articles (i.e., 39 English articles and 31 Chinese articles) were included. The results are presented in two main categories: Teamwork components and Team interventions. The evidence regarding the relationships among inputs, processes, and outcomes is scarce and mostly inconclusive. The only conclusive evidence shows that females perceive better team processes than males. Similar types of training and tools were introduced as can be found in Western literature, all showing positive effects. In line with the Chinese health reforms, many of the intervention studies regard the introduction of multidisciplinary teams (MDTs). The evidence on the implementation of MDTs reveals that they have led to lower complication rates, shorter hospital stays, higher diagnosis accuracy, efficiency improvement, and a variety of better disease-specific clinical outcomes. Evidence on the effect on patient survival is inconclusive. Conclusion: The Chinese studies on teamwork components mainly focus on the input-process relationship. The evidence provided on this relationship is, however, mostly inconclusive. The intervention studies in Chinese hospitals predominantly focus on patient outcomes rather than organizational and employee outcomes. The introduction of training, tools, and MDTs generally shows promising results. The evidence from primary hospitals and rural areas, which are prioritized in the health reforms, is especially scarce. Advancing the evidence base on teamwork, especially in primary hospitals and rural areas, is needed and can inform policy and management to promote the health reform implementation. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020175069, identifier CRD42020175069.

Have Dutch Hospitals Saved Lives and Reduced Costs? A longitudinal patient-level analysis over the years 2013-2017

The purpose of this paper is to shed light on the ongoing Dutch health system reforms and identify whether hospital costs and hospital outcomes have changed over time. We present an empirical analysis that is based on granular micro-costing data and focuses on conditions for which mortality is indicative of outcome quality, that is, acute myocardial infarction (AMI), chronic heart failure (CHF), and pneumonia (PNE). We deploy a dataset of more than 80,000 inpatient episodes over 5 years (2013-2017) to estimate regression models that control for variation between patients and hospitals. We have three main findings. First, our results do not indicate significant outcome improvements over the years; that is, there is no time trend for mortality. Second, there is heterogeneity in cost developments: for patients who survive their inpatient stay, our data indicate that costs increase significantly by 0.9% per year for AMI patients, while costs decrease significantly by 1.7% per year for CHF patients and by 1.9% per year for PNE patients. For patients who pass away during their inpatient stay, our data do not indicate significant time trends. Third and finally, our results suggest the existence of substantial cost variation between hospitals.

Relationship Between Perceived Risks of Using mHealth Applications and the Intention to Use Them Among Older Adults in the Netherlands: Cross-sectional Study

BACKGROUND

Considering the increasing demand for health services by older people and the ongoing COVID-19 pandemic, digital health is commonly viewed to offer a pathway to provide safe and affordable health services for older adults, thus enabling self-management of their health while health care systems are struggling. However, several factors cause older people to be particularly reluctant to adopt digital health technologies such as mobile health (mHealth) tools. In addition to previously studied technology acceptance factors, those related to perceived risks of mHealth use (eg, leakage of sensitive information or receiving incorrect health recommendations) may further diminish mHealth adoption by older adults.

OBJECTIVE

The aim of this study was to explore the relationship between perceived risks of using mHealth applications and the intention to use these applications among older adults.

METHODS

We designed a cross-sectional study wherein a questionnaire was used to collect data from participants aged 65 years and older in the Netherlands. Perceived risk was divided into four constructs: privacy risk, performance risk, legal concern, and trust. Linear regression analyses were performed to determine the associations between these perceived risk constructs and the intention to use mHealth applications.

RESULTS

Linear regression per perceived risk factor showed that each of the four constructs is significantly associated with the intention to use mobile medical applications among older adults (adjusted for age, sex, education, and health status). Performance risk (β=-.266; P=<.001), legal concern (β=-.125; P=.007), and privacy risk (β=-.100; P=.03) were found to be negatively correlated to intention to use mHealth applications, whereas trust (β=.352; P=<.001) was found to be positively correlated to the intention to use mHealth applications.

CONCLUSIONS

Performance risk, legal concern, and privacy risk as perceived by older adults may substantially and significantly decrease their intention to use mHealth applications. Trust may significantly and positively affect this intention. Health care professionals, designers of mHealth applications, and policy makers can use these findings to diminish performance risks, and tailor campaigns and applications to address legal and privacy concerns and promote mHealth uptake and health care access for older adults, especially during the COVID-19 pandemic.

Data and optimisation requirements for Kidney Exchange Programs

Kidney Exchange Programs (KEP) are valuable tools to increase the options of living donor kidney transplantation for patients with end-stage kidney disease with an immunologically incompatible live donor. Maximising the benefits of a KEP requires an information system to manage data and to optimise transplants. The data input specifications of the systems that relate to key information on blood group and Human Leukocyte Antigen (HLA) types and HLA antibodies are crucial in order to maximise the number of identified matched pairs while minimising the risk of match failures due to unanticipated positive crossmatches. Based on a survey of eight national and one transnational kidney exchange program, we discuss data requirements for running a KEP. We note large variations in the data recorded by different KEPs, reflecting varying medical practices. Furthermore, we describe how the information system supports decision making throughout these kidney exchange programs.

Kidney Exchange Program Reporting Standards: Evidence-Based Consensus From Europe

Background: Kidney Exchange Programs can play an important role to increase access to the life saving and most cost-effective treatment for End Stage Renal Disease. The rise of national KEPs in Europe brings a need for standardized performance reporting to facilitate the development of an international evidence base on program practices.

Methods: We systematically searched and reviewed the literature to extract kidney exchange program performance measures. Reported measures were initially categorized as structure, process, and outcome measures. Expert feedback was used to redefine categories and extend the set of measures to be considered. Using the Delphi method and a panel of 10 experts, the resulting measures were subsequently classified as mandatory (Base set), optional (Extended set), or deleted.

Results: Out of the initial 1,668 articles identified by systematic literature search, 21 European publications on kidney exchange programs were included to collect performance measures, accompanied by three national program reports. The final measurement categories were Context, Population, Enrollment, Matching, Transplantation, and Outcomes. The set of performance measures resulting from the literature review was modified and classified as mandatory or optional. The resulting Base set and Extended set form the kidney exchange program reporting standard.

Conclusions: The evidence-based and consensus-based kidney exchange program reporting standard can harmonize practical and scientific reporting on kidney exchange programs, thus facilitating the advancement of national programs. In addition, the kidney exchange program reporting standard can promote and align cross-national programs.

'Hybrid' top down bottom up health system innovation in rural China: A qualitative analysis

Introduction

China has made considerable progress with health system reforms in recent years. Rural China, however, has lagged behind as the diversity of needs of China’s 3,000 rural counties were not always well addressed by national top-down reforms. China’s Rural Health Reform Project Health XI (HXI) piloted a hybrid process of top down and bottom up implementation of health system reforms which were tailored to rural county level needs and covered a population of more than 21 million. Different studies provide evidence that HXI counties have achieved substantial benefits given the relatively limited investment. The Effectiveness of HXI subsequently raises the question how the hybrid approach may have resulted in effective implementation of interventions. We answer this question to advance understanding of hybrid approaches in general and in the rural Chinese context in particular, where the bottom-up elements might match poorly with the traditional organisational culture and learning style.

Materials & methods

We conducted an in-depth qualitative analysis in three ‘best practice’ counties, performing document-analyses, observations, semi-structured individual and group interviews. In alignment with the research question, this study is of an explorative nature and follows a sequence of deductive and inductive steps

Results

HXI struggled initially as counties had difficulties to take initiative and autonomously select and adapt their own reforms. The initial reforms required multiple improvement iterations before achieving the planned results. The effectiveness of these bottom up reform processes has been aided by tight top down supervision and extensive domestic expert involvement. County level leadership is seen as essential to align the top down and bottom up structures and processes. Where successful, HXI has changed mind-sets and counties developed generic health improvement capabilities.

Conclusion

Tailoring innovations to fit local needs formed a severe challenge for the three ‘best practice’ counties studied. A ‘change of mindset’ to actively take initiative and assume autonomy was needed to advance. Top down supervision and extensive support of experts was required to overcome the barriers. The studied counties finally achieved sustainable improvements and developed double loop learning capabilities beyond HXI objectives. Taken together, the above findings suggest that the continuum of healthcare reform implementation approaches in which hybrid approaches reside—from bottom up to top down—has two dimensions: a content dimension and a procedural dimension. Enabled by top down procedures, counties were able to bottom up tailor the content of best practice innovations to fit local needs.

Intention to use Medical Apps Among Older Adults in the Netherlands: Cross-Sectional Study

Background

The increasing health service demand driven by the aging of the global population calls for the development of modes of health service delivery that are less human resource–intensive. Electronic health (eHealth) and medical apps are expected to play an important role in this development. Although evidence shows mobile medical apps might be effective in improving the care, self-management, self-efficacy, health-related behavior, and medication adherence of older adults, little is known about older adults’ intention to use these technologies when needed, or the factors influencing this intention.

Objective

The objective of this study was to investigate the relationship of technology acceptance factors and intention to use mobile medical apps among community-dwelling older adults.

Methods

Data was collected using questionnaires. The factors selected from the literature have been validated using Cronbach α and tested for significance using logistic regressions.

Results

Almost half (49.7%) of the included older adults reported no intention to use medical apps. Adjusted logistic regression analysis per factor showed that the factors Attitude toward use (odds ratio [OR] 8.50), Perceived usefulness (OR 5.25), Perceived ease of use (OR 4.22), Service availability (OR 3.46), Sense of control (OR 3.40), Self-perceived effectiveness (OR 2.69), Facilities (OR 2.45), Personal innovativeness (OR 2.08), Social relationships (OR 1.79), Subjective norm (OR 1.48), and Feelings of anxiety (OR 0.62) significantly influenced the intention to use mobile medical apps among older adults, whereas the factor Finance (OR 0.98) did not. When considered together, a controlled multivariate logistic regression yielded high explained variances of 0.542 (Cox-Snell R²) and 0.728 (Nagelkerke R²).

Conclusions

The high odds ratios and explained variance indicate that the factors associated with the intention to use medical apps are largely understood and the most important factors have been identified. To advance the evidence base, experimental controlled research should investigate the causality between the factors, intention to use, and actual use. For this purpose, our evidence suggests that policies designed to improve Attitude toward use appear most effective, followed by policies addressing Perceived usefulness, Perceived ease of use, Service availability, and Sense of control.

The impact of hospital attributes on patient choice for first visit: evidence from a discrete choice experiment in Shanghai, China

The underutilization of primary care in urban China threatens the efficiency and effectiveness of the Chinese health system. To guide patient flow to primary care, the Chinese government has rolled out a sequence of health care reforms which improve the affordability, the infrastructure and workforce of the primary care system. However, these measures have not yielded the desired effect on the utilization of primary care, which is lowest in urban areas. It is unclear how the factors identified to influence facility choice in urban China are actually impacting choice behaviour. We conducted a discrete choice experiment to elicit the quantitative impact of facility attributes when choosing a health care facility for first visit and analysed how the stated choice varies with these attributes. We found that the respondents placed different weights on the identified attributes, depending on whether they perceived their condition to be minor or severe. For conditions perceived as minor, the respondents valued visit time, equipment and medical skill most. For conditions perceived as severe, they placed most importance on equipment, travel time and facility size. We found that for conditions perceived as minor, only 14% preferred visiting a facility over opting out, a percentage which would more than double to 37% if community health centres were maximally improved. For conditions perceived as severe, improvements in community health centres may almost double first visits to primary care, mostly from patients who would otherwise choose higher-level facilities. Our findings suggest that for both severity conditions, improvements to medical equipment and medical skill at community health centres in urban China can effectively direct patient flow to primary care and promote the efficiency and effectiveness of the urban health system.

Correction: The relationship between context, structure, and processes with outcomes of 6 regional diabetes networks in Europe

[This corrects the article DOI: 10.1371/journal.pone.0192599.].

Can a results-based bottom-up reform improve health system performance? Evidence from the rural health project in China

In 2008, the Rural Health Project (Health XI) was initiated in 40 Chinese counties to pilot interventions aimed at improving local health systems. Performance targets were pre-specified (results-based), and project counties were allowed to tailor their interventions (bottom-up) in recognition of the substantial regional variations. Using household data from the China National Health Services Survey in a difference-in-differences strategy combined with matching, we find that project counties have improved outcomes (both incentivized and not-directly-incentivized) in all three domains examined-medical care, public health services, and self-rated health-by 2013. In particular, the decrease in outpatient intravenous drip use and financial strain and the increase in all four components of public health services provision are robust to a variety of tests and alternative matching strategies. Results for not-directly-incentivized indicators suggest that results-based payment did not lead to multitasking problems but rather to positive spillovers. On the other hand, little improvement in inpatient-related indicators suggests that the Health XI interventions did not successfully redress the perverse incentives driving the bulk of providers' income. In general, however, our results indicate that interventions adopted in the results-based bottom-up approach generated substantial benefits given the investment.

Why patients prefer high-level healthcare facilities: a qualitative study using focus groups in rural and urban China

INTRODUCTION

Despite policy measure to strengthen and promote primary care, Chinese patients increasingly choose to access higher level hospitals. The resulting overcrowding at higher level hospitals and underutilisation of primary care are viewed to diminish the effects of the continuing health system investments on population health. We explore the factors that influence the choice of healthcare facility level in rural and urban China and aim to reveal the underlying choice processes.

METHODS

We conducted eight semistructured focus group discussions among the general population and the chronically ill in a rural area in Chongqing and an urban area in Shanghai. Respondents' discussions of (evidence-based) factors and how they influenced their facility choices were analysed using qualitative analysis techniques, from which we elicited choice process maps to capture the partial order in which the factors were considered in the choice process.

RESULTS

The factors considered, after initial illness perception, varied over four stages of health service utilisation: initial visit, diagnosis, treatment and treatment continuation. The factors considered per stage differed considerably between the rural and urban respondents, but less so between the general population and the chronically ill. Moreover, the rural respondents considered the township health centres as default and prefer to continue in primary care, yet access higher levels when necessary. Urban respondents chose higher levels by default and seldom moved down to primary care.

CONCLUSIONS

Disease severity, medical staff, transportation convenience, equipment and drug availability played important roles when choosing healthcare facilities in China. Strengthening primary care correspondingly may well be effective to increase primary care utilisation by the rural population but insufficient for the urban population. The developed four-stage process maps are general enough to serve as the basis for (partially) ordering factors influencing facility level choices in other contexts.

'We are planning to leave, all of us'-a realist study of mechanisms explaining healthcare employee turnover in rural Ethiopia

BACKGROUND

We study healthcare employees' turnover intentions in the Afar National Regional State of Ethiopia. This rural region is experiencing the globally felt crisis in human resources, which is inhibiting its ability to meet health-related sustainable development goals.

METHODS

Realist case study which combines literature study and qualitative analysis of interview and focus group discussion data, following a realist case study protocol.

RESULTS

A large majority of employees has turnover intentions. Building on Herzberg's two-factor theory, person-environment fit theory, as well as recent sub-Saharan evidence, analysis of the collected data yields four turnover mechanisms: (1) lack of social and personal opportunities in the region, (2) dissonance between management logic and professional logic, (3) standards of service operations are hard to accept, and (4) lack of financial improvement opportunities.

CONCLUSIONS

While the first and fourth mechanisms may be out of reach for local (human resource) management interventions, the second and third mechanisms proposed to explain health workforce turnover appear to be amenable to local (human resource) management interventions to strengthen healthcare. These mechanisms are likely to play a role in other remote sub-Saharan regions as well.

Factors influencing choice of health system access level in China: A systematic review

OBJECTIVE

In China, patients increasingly choose to access already severely overcrowded higher level hospitals, leaving lower level facilities with low utilization rates. This situation undermines the effectiveness and efficiency of the health system. The situation tends to worsen despite policy measures aimed at improvement. We systematically review the factors affecting patient choice to synthesize scientific understanding of health system access in China. The review provides an evidence base for measures to direct patient flow towards lower level facilities.

METHODS

We screened the peer-reviewed literature published from April 2009 to January 2016 that investigates Chinese patients' choice of health care facilities at different levels and assessed 45 studies in total. We applied two structured forms to extract data on each study's characteristics, methodology, and factors.

RESULTS OF DATA SYNTHESIS

The results identified four factor types: 1) patient, 2) provider, 3) context and 4) composite: combined patient, provider, and/or context attributes. Patient factors are mentioned the most, but the evidence on patient factors is often inconclusive. Evidence suggests that the provider factors 'drug variety' and 'equipment', and composite factor 'perceived quality', push patients from lower levels towards higher levels.

CONCLUSION

Underuse of primary care facilities and overcrowding of higher level facilities will likely be amplified by current demographic trends. Evidence suggests that improving drug availability, equipment and perceived quality of primary care services can improve the situation. Well-designed research that considers the interactions between factors is called for to better inform future interventions.

The relationship between context, structure, and processes with outcomes of 6 regional diabetes networks in Europe

Background

While health service provisioning for the chronic condition Type 2 Diabetes (T2D) often involves a network of organisations and professionals, most evidence on the relationships between the structures and processes of service provisioning and the outcomes considers single organisations or solo practitioners. Extending Donabedian’s Structure-Process-Outcome (SPO) model, we investigate how differences in quality of life, effective coverage of diabetes, and service satisfaction are associated with differences in the structures, processes, and context of T2D services in six regions in Finland, Germany, Greece, Netherlands, Spain, and UK.

Methods

Data collection consisted of: a) systematic modelling of provider network’s structures and processes, and b) a cross-sectional survey of patient reported outcomes and other information. The survey resulted in data from 1459 T2D patients, during 2011–2012. Stepwise linear regression models were used to identify how independent cumulative proportion of variance in quality of life and service satisfaction are related to differences in context, structure and process. The selected context, structure and process variables are based on Donabedian’s SPO model, a service quality research instrument (SERVQUAL), and previous organization and professional level evidence. Additional analysis deepens the possible bidirectional relation between outcomes and processes.

Results

The regression models explain 44% of variance in service satisfaction, mostly by structure and process variables (such as human resource use and the SERVQUAL dimensions). The models explained 23% of variance in quality of life between the networks, much of which is related to contextual variables. Our results suggest that effectiveness of A1c control is negatively correlated with process variables such as total hours of care provided per year and cost of services per year.

Conclusions

While the selected structure and process variables explain much of the variance in service satisfaction, this is less the case for quality of life. Moreover, it appears that the effect of the clinical outcome A1c control on processes is stronger than the other way around, as poorer control seems to relate to more service use, and higher cost. The standardized operational models used in this research prove to form a basis for expanding the network level evidence base for effective T2D service provisioning.

Explaining regional variation in home care use by demand and supply variables

In the Netherlands, home care services like district nursing and personal assistance are provided by private service provider organizations and covered by private health insurance companies which bear legal responsibility for purchasing these services. To improve value for money, their procurement increasingly replaces fee-for-service payments with population based budgets. Setting appropriate population budgets requires adaptation to the legitimate needs of the population, whereas historical costs are likely to be influenced by supply factors as well, not all of which are necessarily legitimate. Our purpose is to explain home care costs in terms of demand and supply factors. This allows for adjusting historical cost patterns when setting population based budgets. Using expenses claims of 60 Dutch municipalities, we analyze eight demand variables and five supply variables with a multiple regression model to explain variance in the number of clients per inhabitant, costs per client and costs per inhabitant. Our models explain 69% of variation in the number of clients per inhabitant, 28% of costs per client and 56% of costs per inhabitant using demand factors. Moreover, we find that supply factors explain an additional 17-23% of variation. Predictors of higher utilization are home care organizations that are integrated with intramural nursing homes, higher competition levels among home care organizations and the availability of complementary services.

Forecasting Human African Trypanosomiasis Prevalences from Population Screening Data Using Continuous Time Models

To eliminate and eradicate gambiense human African trypanosomiasis (HAT), maximizing the effectiveness of active case finding is of key importance. The progression of the epidemic is largely influenced by the planning of these operations. This paper introduces and analyzes five models for predicting HAT prevalence in a given village based on past observed prevalence levels and past screening activities in that village. Based on the quality of prevalence level predictions in 143 villages in Kwamouth (DRC), and based on the theoretical foundation underlying the models, we consider variants of the Logistic Model-a model inspired by the SIS epidemic model-to be most suitable for predicting HAT prevalence levels. Furthermore, we demonstrate the applicability of this model to predict the effects of planning policies for screening operations. Our analysis yields an analytical expression for the screening frequency required to reach eradication (zero prevalence) and a simple approach for determining the frequency required to reach elimination within a given time frame (one case per 10000). Furthermore, the model predictions suggest that annual screening is only expected to lead to eradication if at least half of the cases are detected during the screening rounds. This paper extends knowledge on control strategies for HAT and serves as a basis for further modeling and optimization studies.

The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente

BACKGROUND

Patient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited.

METHODS

This paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development?

RESULTS

We identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design.

CONCLUSIONS

These findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs.

What do we know about developing patient portals? a systematic literature review

OBJECTIVE

Numerous articles have reported on the development of patient portals, including development problems and solutions. We review these articles to inform future patient portal development efforts and to provide a summary of the evidence base that can guide future research.

MATERIALS AND METHODS

We performed a systematic review of relevant literature to answer 5 questions: (1) What categories of problems related to patient portal development have been defined? (2) What causal factors have been identified by problem analysis and diagnosis? (3) What solutions have been proposed to ameliorate these causal factors? (4) Which proposed solutions have been implemented and in which organizational contexts? (5) Have implemented solutions been evaluated and what learning has been generated? Through searches on PubMed, ScienceDirect and LISTA, we included 109 articles.

RESULTS

We identified 5 main problem categories: achieving patient engagement, provider engagement, appropriate data governance, security and interoperability, and a sustainable business model. Further, we identified key factors contributing to these problems as well as solutions proposed to ameliorate them. While about half (45) of the 109 articles proposed solutions, fewer than half of these solutions (18) were implemented, and even fewer (5) were evaluated to generate learning about their effects.

DISCUSSION

Few studies systematically report on the patient portal development processes. As a result, the review does not provide an evidence base for portal development.

CONCLUSION

Our findings support a set of recommendations for advancement of the evidence base: future research should build on existing evidence, draw on principles from design sciences conveyed in the problem-solving cycle, and seek to produce evidence within various different organizational contexts.

Characteristics of patient portals developed in the context of health information exchanges: early policy effects of incentives in the meaningful use program in the United States

BACKGROUND

In 2014, the Centers for Medicare & Medicaid Services in the United States launched the second stage of its Electronic Health Record (EHR) Incentive Program, providing financial incentives to providers to meaningfully use their electronic health records to engage patients online. Patient portals are electronic means to engage patients by enabling secure access to personal medical records, communication with providers, various self-management tools, and administrative functionalities. Outcomes of patient portals have mainly been reported in large integrated health systems. This may now change as the EHR Incentive Program enables and supports the use of patient portals in other types of health systems. In this paper, we focus on Health Information Exchanges (HIE): entities that facilitate data exchange within networks of independent providers.

OBJECTIVE

In response to the EHR Incentive Program, some Health Information Exchanges in the United States are developing patient portals and offering them to their network of providers. Such patient portals hold high value for patients, especially in fragmented health system contexts, due to the portals' ability to integrate health information from an array of providers and give patients one access point to this information. Our aim was to report on the early effects of the EHR incentives on patient portal development by HIEs. Specifically, we describe the characteristics of these portals, identify factors affecting adoption by providers during the 2013-2014 time frame, and consider what may be the primary drivers of providers' adoption of patient portals in the future.

METHODS

We identified four HIEs that were developing patient portals as of spring 2014. We collected relevant documents and conducted interviews with six HIE leaders as well as two providers that were implementing the portals in their practices. We performed content analysis on these data to extract information pertinent to our study objectives.

RESULTS

Our findings suggest that there are two primary types of patient portals available to providers in HIEs: (1) portals linked to EHRs of individual providers or health systems and (2) HIE-sponsored portals that link information from multiple providers' EHRs. The decision of providers in the HIEs to adopt either one of these portals appears to be a trade-off between functionality, connectivity, and cost. Our findings also suggest that while the EHR Incentive Program is influencing these decisions, it may not be enough to drive adoption. Rather, patient demand for access to patient portals will be necessary to achieve widespread portal adoption and realization of potential benefits.

CONCLUSIONS

Optimizing patient value should be the main principle underlying policies intending to increase online patient engagement in the third stage of the EHR Incentive Program. We propose a number of features for the EHR Incentive Program that will enhance patient value and thereby support the growth and sustainability of patient portals provided by Health Information Exchanges.

How outcomes are achieved through patient portals: a realist review

OBJECTIVE

To examine how patient portals contribute to health service delivery and patient outcomes. The specific aims were to examine how outcomes are produced, and how variations in outcomes can be explained.

METHODS

We used a realist review method, which aims to describe how 'an intervention works, for whom, and in what circumstances' by analyzing patterns between context, mechanism, and outcomes. We reviewed 32 evaluation studies of patient portals published since 2003.

RESULTS

The reviewed evaluations indicate that as a complement to existing health services, patient portals can lead to improvements in clinical outcomes, patient behavior, and experiences. Four different mechanisms are reported to yield the reported outcome improvements. These are patient insight into personal health information, activation of information, interpersonal continuity of care, and service convenience. The vast majority of evaluations were conducted in integrated health service networks in the USA, and we detected no substantial variation in outcomes across these networks.

DISCUSSION AND CONCLUSIONS

Patient portals may impact clinical outcomes and health service delivery through multiple mechanisms. Given the relative uniformity of evaluation contexts, we were not able to detect patterns in how patient portals work in different contexts. Nonetheless, it appears from the overwhelming proportion of patient portal evaluations coming from integrated health service networks, that these networks provide more fertile contexts for patient portals to be effective. To improve the understanding of how patient portals work, future evaluations of patient portals should capture information about mechanisms and context that influence their outcomes.

Allocation and matching in kidney exchange programs

Living donor kidney transplantation is the preferred treatment for patients suffering from end-stage renal disease. To alleviate the shortage of kidney donors, many advances have been made to improve the utilization of living donors deemed incompatible with their intended recipient. The most prominent of these advances is kidney paired donation (KPD), which matches incompatible patient-donor pairs to facilitate a kidney exchange. This review discusses the various approaches to matching and allocation in KPD. In particular, it focuses on the underlying principles of matching and allocation approaches, the combination of KPD with other strategies such as ABO incompatible transplantation, the organization of KPD, and important future challenges. As the transplant community strives to balance quantity and equity of transplants to achieve the best possible outcomes, determining the right long-term allocation strategy becomes increasingly important. In this light, challenges include making full use of the various modalities that are now available through integrated and optimized matching software, encouragement of transplant centers to fully participate, improving transplant rates by focusing on the expected long-run number of transplants, and selecting uniform allocation criteria to facilitate international pools.

Optimizing sterilization logistics in hospitals

This paper deals with the optimization of the flow of sterile instruments in hospitals which takes place between the sterilization department and the operating theatre. This topic is especially of interest in view of the current attempts of hospitals to cut cost by outsourcing sterilization tasks. Oftentimes, outsourcing implies placing the sterilization unit at a larger distance, hence introducing a longer logistic loop, which may result in lower instrument availability, and higher cost. This paper discusses the optimization problems that have to be solved when redesigning processes so as to improve material availability and reduce cost. We consider changing the logistic management principles, use of visibility information, and optimizing the composition of the nets of sterile materials.