Medical deserts in Spain-Insights from an international project

INTRODUCTION

Medical deserts are a growing phenomenon across many European countries. They are usually defined as (i) rural areas, (ii) underserved areas or (iii) by applying a measure of distance/time to a facility or a combination of the three characteristics. The objective was to define medical deserts in Spain as well as map their driving factors and approaches to mitigate them.

METHODS

A mixed methods approach was applied following the project "A Roadmap out of medical deserts into supportive health workforce initiatives and policies" work plan. It included the following elements: (i) a scoping literature review; (ii) a questionnaire survey; (iii) national stakeholders' workshop; (iv) a descriptive case study on medical deserts in Spain.

RESULTS

Medical deserts in Spain exist in the form of mostly rural areas with limited access to health care. The main challenge in their identification and monitoring is local data availability. Diversity of both factors contributing to medical deserts and solutions applied to eliminate or mitigate them can be identified in Spain. They can be related to demand for or supply of health care services. More national data, analyses and/or initiatives seem to be focused on the health care supply dimension.

CONCLUSIONS

Addressing medical deserts in Spain requires a comprehensive and multidimensional approach. Effective policies are needed to address both the medical staff education and planning system, working conditions, as well as more intersectoral approach to the population health management.

The association between air pollutions and emergency hospitalizations due to COPD and asthma across 16 Polish cities: population-based study

OBJECTIVES

In recent years numerous initiatives aimed at reducing air pollution have been undertaken in Poland. The general objective was to examine the correlation between air pollution measured by the level of particulate matter ≤10 μm in diameter (PM10) and emergency hospitalizations due to chronic obstructive pulmonary disease (COPD) and asthma in 16 Polish cities (capitals of the regions).

MATERIAL AND METHODS

The authors aimed to diagnose the situation across 16 cities over a 5‑year period (2014-2019). Data on the number of hospitalizations was retrieved from the national public insurance system, the National Health Fund. A total number of 22 600 emergency hospitalizations was analyzed (12 000 and 10 600 in 2014 and 2019, respectively). The data on air pollution was accessed via the public register of the Chief Inspectorate for Environmental Protection air quality database. The authors of this article have used the data on PM10 daily exposure in each of the 16 cities in 2014 and 2019. Statistical methods included: non-parametric tests, a 2-stage modelling approach for time-series data, and multivariate meta-analysis of the results.

RESULTS

The results indicated that there was a statistically significant decrease in PM10 concentration in 2019 in comparison to 2014 in all cities, mainly in the autumn and winter season. However, the correlation between the improvement in the air quality and a decrease in emergency hospitalizations due to asthma and COPD turned out to not be as strong as expected. The authors observed a strong correlation between PM10 concentrations and hospitalizations due to asthma and COPD, but only when air quality norms were significantly above acceptable levels.

CONCLUSIONS

Air pollution measured by PM10 concentration might be used as one of the predictors of the asthma and COPD emergency hospitalization risk, yet other factors like respiratory tract infection, health care organizational aspect, patient self-control, compliance and comorbidities should also be taken into consideration. Int J Occup Med Environ Health. 2024;37(1):110-27.

End-of-life expenditure on health care for the older population: a scoping review

BACKGROUND

The existing evidence shows that the pattern of health expenditure differs considerably between people at the end-of-life and people in other periods of their lives. The awareness of these differences, combined with a detailed analysis of future mortality rates is one of the key pieces of information needed for health spending prognoses. The general objective of this review was to identify and map the existing empirical evidence on end-of-life expenditure related to health care for the older population.

METHODS

To achieve the objective of the study a systematic scoping review was performed. There were 61 studies included in the analysis. The project has been registered through the Open Science Framework.

RESULTS

The included studies cover different kinds of expenditure in terms of payers, providers and types of services, although most of them include analyses of hospital spending and nearly 60% of analyses were conducted for insurance expenditure. The studies provide very different results, which are difficult to compare. However, all of the studies analyzing expenditure by survivorship status indicate that expenditure on decedents is higher than on survivors. Many studies indicate a strong relationship between health expenditure and proximity to death and indicate that proximity to death is a more important determinant of health expenditure than age per se. Drawing conclusions on the relationship between end-of-life expenditure and socio-economic status would be possible only by placing the analysis in a broader context, including the rules of a health system's organization and financing. This review showed that a lot of studies are focused on limited types of care, settings, and payers, showing only a partial picture of health and social care systems in the context of end-of-life expenditure for the older population.

CONCLUSION

The results of studies on end-of-life expenditure for the older population conducted so far are largely inconsistent. The review showed a great variety of problems appearing in the area of end-of-life expenditure analysis, related to methodology, data availability, and the comparability of results. Further research is needed to improve the methods of analyses, as well as to develop some analysis standards to enhance research quality and comparability.

Hospitals' financial performance across European countries: a scoping review protocol

INTRODUCTION

Hospitals remain the cornerstone of health systems in European countries. Therefore, the financial sustainability of hospitals constitutes an important determinant of healthcare provision security. The fragmentary data available indicate that hospitals in many European countries are continuously facing financial deficits and/or insolvency problems. Yet a comparative analysis of hospital financial performance across European countries has been lacking. The proposed review will, therefore, fill in an important research gap and build a knowledge base on the topic of assessing and monitoring the financial sustainability of hospitals in Europe. The general objective is to identify, synthetise and map existing evidence on hospital financial performance across European countries.

METHODS AND ANALYSIS

This scoping review will follow six stages: (1) defining the research question, (2) identifying relevant literature, (3) studies selection, (4) data extraction, (5) collating, summarising and reporting of results and (6) consultation process and involvement of knowledge users. The following databases will be searched:(1) Medline via PubMed, (2) Web of Science Core Collection, (3) Scopus and (4) ProQuest Central. In addition, a Google Engine search will also be performed. Furthermore, reference lists of relevant papers will be visually scanned to identify further studies of interest. The review will include both quantitative and qualitative empirical studies as well as theoretical papers and technical reports. The PRISMA extension for a Scoping Review checklist will be used for reporting.

ETHICS AND DISSEMINATION

Formal ethical approval is not required because no primary data will be collected in this study. Results will be published in a peer-reviewed journal. The findings will also be disseminated through conference presentations and summaries to key stakeholders.

Barriers and Facilitators to Health-Care Provider Payment Reform - A Scoping Literature Review

Background

Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms.

Methods

A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms.

Results

The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform.

Conclusion

The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions.

Registration

The study was registered with the Open Science Framework.

Characteristics of Medical Deserts and Approaches to Mitigate Their Health Workforce Issues: A Scoping Review of Empirical Studies in Western Countries

BACKGROUND

Medical deserts are considered a problematic issue for many Western countries which try to employ multitude of policies and initiatives to achieve a better distribution of their health workforce (HWF). The aim of this study was to systematically map research and provide an overview of definitions, characteristics, contributing factors and approaches to mitigate medical deserts within the European Union (EU)-funded project "ROUTE-HWF" (a Roadmap OUT of mEdical deserts into supportive Health WorkForce initiatives and policies).

METHODS

We performed a scoping review to identify knowledge clusters/research gaps in the field of medical deserts focusing on HWF issues. Six databases were searched till June 2021. Studies reporting primary research from Western countries on definitions, characteristics, contributing factors, and approaches were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies according to the four defined outcomes.

RESULTS

Two-hundred and forty studies were included (n=116, 48% Australia/New Zealand; n=105, 44% North America; n=20, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=171, 71%), characteristics (n=95, 40%), contributing factors (n=112, 47%), and approaches to mitigate medical deserts (n=87, 36%). Most medical deserts were defined by the density of the population in an area. Contributing factors to HWF issues in medical deserts consisted in work-related (n=55, 23%) and lifestyle-related factors (n=33, 14%) of the HWF as well as sociodemographic characteristics (n=79, 33%). Approaches to mitigate them focused on training adapted to the scope of rural practice (n=67, 28%), HWF distribution (n=3, 1%), support/infrastructure (n=8, 3%) and innovative models of care (n=7, 3%).

CONCLUSION

Our study provides the first scoping review that presents and categorizes definitions, characteristics, contributing factors, and approaches to mitigate HWF issues in medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate the impact of factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate HWF issues.

The 2021 plan for hospital care centralization in Poland - When politics overwhelms the policy process

The health system in Poland is characterized by oversized hospital infrastructure, with simultaneous deficits in the ambulatory and long-term care sectors. The main challenges of the hospital sector involve i.a. weak stewardship and fragmented governance with a concurrent problem of persistent hospital debts as well as huge workforce deficits. The objective of this paper is to present the government's 2021 plan for hospital care centralization. The reform project aimed i.a. at improving hospital service coordination by implementing a professional and centralized system for hospital sector supervision and effective restructuration processes. The proposed regulation project focused on three major issues: (1) adjusting the existing hospital network towards better concentration of specialized services; (2) launching an independent central agency responsible for monitoring public hospital financial standing as well as initiating and/or managing hospitals restructuration processes; and (3) introducing a formal certification of hospital managers competencies. The reform plans were developed in a relatively short time frame, with a top-down approach and strongly pushed towards the adoption in 2022. Many of the health system stakeholders were strongly opposed to the project which, in connection with new challenges faced by the health system in 2022 (the economic crisis) led the reform suspension. At the same time, a new restructuration and debt relief programme for public hospitals was announced.

Competencies of hospital managers - A systematic scoping review

Hospital managers around the world work under constant pressure to adapt their organizations to new challenges and health policy goals. This requires a comprehensive set of competencies. The objective of this scoping review was to identify, map, and systematize the literature on hospital manager competencies. The review involved six steps: (1) defining research questions; (2) identifying relevant literature; (3) selecting publications; (4) data extraction; (5) data analysis and result reporting; and (6) consultations. A total of 57 full-text publications were included (46 empirical studies, six literature reviews, four expert opinions/guidelines, and one dissertation). Interest in this topic has grown in recent years, with most of the identified studies published since 2015. The empirical studies fall into three major groups: 34.8% (16/46) examined hospital managers' competencies in terms of their types or classifications; 30.4% (14/46) focused on their measurement; and 30.4% (14/46) examined both aspects. In majority of studies, both 'hard competencies,' such as specific technical knowledge or skills acquired through practical training, and 'soft competencies,' e.g., adaptability, leadership, communication, teamwork, are echoed for effective hospital management. These point out the importance of both 'external' formal education trainings as well as 'internal' peer-support and/or coaching as complementary competency improvement approaches. This scoping review helps build a knowledge base around the topic and provides implications for future research. The latter can involve: a targeted systematic review addressing the methods for measuring the level of competence of hospital managers or studies focused on identifying the need for new types of competencies.

Characteristics of medical deserts and approaches to mitigate them: a scoping review

INTRODUCTION

Medical deserts are increasingly considered problematic and many countries employ a multitude of actions and initiatives to achieve a better distribution of the health workforce (HWF). This study systematically maps research and provides an overview of the definitions/characteristics of medical deserts. It also identifies contributing factors and approaches to mitigate medical deserts.

METHODS

Embase, MEDLINE, CINAHL, Web of Science Core Collection, Google Scholar and The Cochrane Library were searched from inception to May 2021. Studies reporting primary research on definitions, characteristics, contributing factors and approaches to mitigate medical deserts were included. Two independent reviewers assessed studies for eligibility, extracted data and clustered studies.

RESULTS

Two-hundred and forty studies were included (49% Australia/New Zealand, 43% North America, 8% Europe). All used observational designs except for five quasi-experimental studies. Studies provided definitions (n=160), characteristics (n=71), contributing/associated factors (n=113), and approaches to mitigate medical deserts (n=94). Most medical deserts were defined by the density of the population in an area. Contributing/associated factors consisted in sociodemographic/characteristics of HWF (n=70), work-related factors (n=43) and lifestyle conditions (n=34). Approaches focused on training adapted to the scope of rural practice (n=79), HWF distribution (n=3), support and infrastructure (n=6) and innovative models of care (n=7).

DISCUSSION

Our study provides the first scoping review on definitions, characteristics, contributing/associated factors and approaches to mitigate medical deserts. We identified gaps such as the scarcity of longitudinal studies to investigate factors contributing to medical deserts, and interventional studies to evaluate the effectiveness of approaches to mitigate medical deserts.

The Association Between Hospital Financial Performance and the Quality of Care - A Scoping Literature Review

BACKGROUND

Improving the quality of hospital care is an important policy objective. Hospitals operate under pressure to contain costs and might face challenges related to financial deficits. The objective of this paper was to identify and map the available evidence on the association between hospital financial performance (FP) and quality of care (Q).

METHODS

A scoping review was performed. Searches were conducted in 7 databases: Medline via PubMed, EMBASE, Web of Science, Scopus, EconLit, ABI/INFORM, and Business Source Complete. The search strategy combined multiple terms from 3 topics: hospital AND FP AND Q. The collected data were analysed using both quantitative and qualitative methods.

RESULTS

10 503 records were screened and 151 full text papers analysed. A total of 69 papers were included (60 empirical, 2 theoretical, 5 literature reviews, and 2 dissertations). The majority of identified studies were published within the last decade (2010-2021). Most empirical studies had been conducted in the United States (55/60), used cross-sectional approaches (32/60) and applied diverse regression models with FP measures as dependent variables, thus measuring the impact of Q on hospitals FP (34/60). The comparability of the studies' results is limited due to differences in applied methods and settings. Yet, the general overview shows that in almost half of the cases the association between hospital FP and Q was positive, while no study showed a clear negative association.

CONCLUSION

This scoping review provides an overview of the available literature on the association between hospital FP and Q. The results highlight numerous research gaps: (1) systematic reviews and meta-analyses of existing studies with similar measures of FP and Q are unavailable, (2) further methodological/conceptual work is needed on the metrics measuring hospital FP and Q, and (3) more empirical studies should analyse the association between FP and Q in non-US healthcare settings.

Governance of academic medical centres in changing healthcare systems: An international comparison

We provide an explorative and international comparison of the governance models of academic medical centres (AMCs). These centres face significant challenges, including disruptive external pressures and enduring financial conflicts pertaining to patient treatment, research and education. Therefore, we covered 10 European countries (Cyprus, Czechia, Denmark, Germany, Italy, Latvia, the Netherlands, Norway, Poland and Spain) and one associated state (Israel) in our analysis. In addition, we developed an expert questionnaire to collect data on the governance of AMCs in these 11 countries. Our results revealed no standardised definition of AMCs, with countries combining patient care, education/teaching and research differently. However, the ownership of such institutions is significantly homogeneous and is limited to public or private, nonprofit ownership. Furthermore, significant differences are associated with the (functional) integration level between the hospital and medical school. Therefore, most experts believe that the governance of AMCs will evolve into a more functionally integrated model of patient care, research and education.

European Union Structural Funds as the Source of Financing Health Care Infrastructure Investments in Poland—A Longitudinal Analysis

European Union (EU) structural funds aim at reducing economic and social disparities between the member states regions. The objectives of the study were to (1) provide a summary overview of all health related projects co-financed by EU structural funds in Poland between 2004 and 2020, (2) define the share of projects/funds devoted to infrastructure investments, and (3) assess the total value of EU structural funds' contribution to health care infrastructure investments in comparison to the national public budgets. Data on projects co-financed by EU structural funds covered all projects realized under three financial perspectives: 2004–2006; 2007–2013; 2014–2020. The extraction of “health-related” projects was done according to both the type priority under which the project was realized as well as the type of beneficiary. Results showed that between 2004 and 2020, 14,179 health related projects were implemented, with a total value of 33.2 billion PLN, including EU contribution of 22.8 billion PLN (68.7%). Although projects focused on education and public health prevailed in terms of their total number, infrastructural projects consumed the vast majority of funds. Within the analyzed period, a total of 6,689 health infrastructure projects were implemented with a total value of 29.5 billion PLN, including 19.7 billion PLN of EU contributions. The results confirm that the EU structural funds constituted an important source of infrastructural investments in the Polish health system and majority of them were consumed by investments in public hospitals.

Hospital financial performance and quality of care – a scoping review of empirical studies

Background

Hospitals operate under constant pressure to contain costs and improve the quality of care (Q). The potential association between hospital financial performance (FP) and Q can have two directions: (1) providers with better FP might have a greater capacity to maintain and/or improve Q; (2) a better Q might lead to better FP, i.e. increased revenues, and/or lower costs. The general objective of this study was to identify and map the available evidence on the association between hospital FP and Q.

Methods

A scoping review based on the methodological framework outlined by Arksey and O'Malley was conducted. Five databases were used: (1) Medline via PubMed; (2) Embase; (3) Web of Science; (4) Scopus; and (5) EconLit. Search strategy combined multiple terms from three topics: (1) hospital,(2) FP and (3) Q. There was no limit for publication years, but only studies in English were included.

Results

After screening 8,015 records and 129 full text papers, 54 empirical studies were included. They are mostly observational studies, applying diverse regression models, published between 1992 and 2019. FP is most often measured by profitability indicators while Q measures are much more diverse. In the majority of studies, FP measures are used as dependent variables, thus the impact of Q on FP is assessed. The comparability of the studies' results is limited, yet a general overview shows that in the majority of papers, a positive association between hospital FP and Q is identified (positive in 24 studies and positive or mixed in 10). The studies' authors emphasize numerous limitations related to both, the data used and the methods applied including the ability to identify associations yet not causality.

Conclusions

There seems to be a growing interest in exploring the association between FP and Q. Our review provides a broad overview of the existing literature and helps to identify areas for further investigations.

Key messages

There is a great diversity of empirical studies on the association between hospital FP and Q, but the majority focuses solely on the United States market. An overview of the existing studies suggests that, although numerous additional factors need to be considered, hospitals might be able to simultaneously improve Q and profitability.

Governance and organization of Academic Medical Centers – a comparative analysis of 11 countries

Background

Academic Medical Centers (AMCs) are organizations that link three functions: providing highly specialized medical services, teaching activities and conducting research. The aim of the study was to provide an international comparison of the governance and organization models of AMCs. The analysis covered 10 European countries (Cyprus, Czechia, Denmark, Germany, Italy, Latvia, Netherlands, Norway, Poland, Spain) and Israel.

Methods

The study has an explorative and descriptive character. The methods involved: (1) the creation of a conceptual framework; (2) the development of a dedicated questionnaire; (3) data collection and analysis. The data was collected based on purposive sampling. There were 26 respondents from 11 countries.

Results

There is no standardized definition of AMCs across countries. Different types of hospital providers do link patientcare, teaching and research. Depending on the country and particular institution, the balance between these three functions, as well as the scope might vary a lot. The majority of the participating countries face either public or not-for-profit ownership for AMCs and medical faculties. However, the relationship between hospital and faculty varies substantially. Main internal governance challenges focus on lack of responsiveness to change and financial conflicts between the three core tasks. External challenges relate to financial sustainability and workforce shortages. Most respondents believe that in the nearby future the governance of AMCs will evolve to a more functionally integrated model of the three functions.

Conclusions

The study fills the gap in the literature on organization and governance of European AMCs. Although, there are substantial differences in the models of governance across countries, many challenges are highly similar. This raises important questions for future research (e.g. focusing solely on one function) as well as policy (the potential for cross-national learning).

Key messages

There is no standardized definition of AMCs across countries and different types of organizations are used to link the three functions of providing patientcare, teaching activities and research. Despite the organizational and legal differences, AMCs in different countries face similar challenges (nimbleness and financial conflicts between the three functions; health workforce shortages).

The association between hospital financial performance and the quality of care-a scoping review protocol

BACKGROUND

Hospitals operate under constant pressure to contain costs and improve the quality of care. The literature suggests that there is an association between health care providers' financial performance and the quality of care. On the one hand, providers that are financially more stable might have better capacity to maintain reliable systems and resources for quality improvement. On the other hand, providing better quality of care might lead to financial gains in the form of increased revenues or achieved savings and, in consequence, a higher profitability. The general objective of this scoping review is to identify and map the available evidence on the association between hospital financial performance and the quality of care. It aims to (1) provide a broad overview of the topic and (2) indicate a more precise research question for a future systematic review.

METHODS

This scoping review will follow five stages: (1) defining the research question; (2) identifying relevant literature; (3) study selection; (4) data extraction; (5) collating, summarizing, and reporting the results; and (6) the consultation process and engagement of knowledge users. The following databases will be searched: MEDLINE via PubMed, (2) EMBASE, (3) Web of Science, (4) Scopus, (5) EconLit, (6) ABI/INFORM, and (7) Business Source Premier. The reference lists of relevant papers will be visually scanned with the aim of identifying further studies of interest. Also, a gray literature search will be conducted by screening the websites of diverse organizations dealing with hospital performance and/or quality of care. The review will not apply a publication date limit and will include both quantitative and qualitative empirical studies as well as theoretical papers, technical reports, books/chapters, and thesis. The reporting will utilize the PRISMA extension for a Scoping Review checklist.

DISCUSSION

This scoping review will provide an overview of the existing literature on the association between hospital financial performance and the quality of care. The review process will apply a rigorous methodological approach while broad inclusion criteria should assure comprehensive coverage of the available literature. The main limitation of the review is related to the general limitation of scoping reviews, i.e., the lack of a systematic quality and risk of bias assessment of included studies. In addition, the review will include only publications in English.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework osf.io/z25ag.

Financial performance of public hospitals: a cross-sectional study among Polish providers

Background

there is growing evidence of a positive association between health care providers' financial standing and the quality of care. In Poland, the instable financial situation and growing debt of public hospitals has been a source of concern for more than two decades now. The objectives were: (1) to compare the financial performance of public hospitals, depending on the ownership and organizational form; (2) to analyze whether there is an association between financial performance and the chosen variables (e.g., total assets, revenues).

Methods

we conducted a cross sectional study covering the whole population of public hospitals operating in 2018. The total number of included units was 805 (659 classic public hospitals, 17 research institutes and 129 corporatized). The hospitals' financial outcomes were measured by several variables and compared between the hospital groups; Spearman's rank correlation was calculated and a multivariable logistic regression model was performed.

Results

in 2018, the majority of public hospitals in Poland (52%) generated a gross loss, while 40% hospitals had overdue liabilities. There were statistically significant differences between hospital groups, with university hospitals and those owned by counties (local hospitals) being in the most disadvantageous situation. Also, corporatized public hospitals performed worse than those functioning in the classic legal form of independent health care units. All three variables which can be used as proxy indicators of hospital size (total assets, revenues or costs) were positively correlated with the value of overdue liabilities and the debt ratio, and negatively correlated with the gross profit margin.

Conclusions

there is high diversity in public hospital financial standing in Poland, with numerous units facing liquidity problems in 2018. Urgent actions are needed to measure and monitor the potential impact of financial performance on the quality of care.

Key messages

The instable financial situation and growing debt of public hospitals in Poland has been a source of concern for more than two decades now. In 2018, local hospitals owned by counties as well as highly-specialized university clinics and research institutes were in the most disadvantageous financial situation.

Cancer care coordinators in Poland: activities and role in the system. A cross-sectional study

Background

Coordination of care provision has become an important health policy objective in numerous countries. In Poland, the function of cancer care coordinator (CCC) was introduced in 2015, under the oncological care organization reform, and they are mainly employed by hospital care providers. The objectives of the study were to: identify the scope of activities carried out by CCCs in Poland and assess their practical role in the oncological care system.

Methods

We conducted a cross sectional study covering the whole population of CCCs in Poland (employed in 403 healthcare units formally participating in the oncological care system in 2018). The questionnaire was developed based on existing literature, adjusted to Polish settings, and validated. It covered three parts: (1) characteristic of the provider institution; (2) overview of the CCC position (e.g., number of persons employed/working hours; background education); (3) the scope of activities and perceived barriers in the process of cancer care coordination. The survey was conducted between 11/2018 and 02/2019.

Results

A total number of 102 questionnaires were analysed (filled-in by CCCs employed in 92 different hospitals). The dominant education of CCCs was: nursing, public health, and other medical studies. A CCC's activities can be divided into four categories, related to communication with patients, medical staff, and other providers, and different administrative activities. More than 43% of respondents indicated realization of additional tasks, not related to cancer care coordination. The majority of respondents indicated the existence of interpersonal and system-level barriers in the process of cancer care coordination (59% and 54% respectively).

Conclusions

There is a need to better define the role of CCCs in Poland and provide them with adequate support (trainings, administrative and management tools).

Key messages

Although CCCs in Poland actively participate in communication processes related to both diagnosis and treatment of cancer patients, their role is limited to the hospital care provision. Numerous, system-level challenges exist in the process of cancer care coordination which should be addressed by policy-makers.

The economic consequences of decriminalizing sex work in Washington, DC

Background

Under repressive policies, sex workers are at disproportionate risk for violence, HIV, and sexually transmitted infections. The decriminalization of sex work between consenting adults provides increased social and health benefits to both sex workers and society at large. Proponents of decriminalization advocate for these added human rights; this is the first research that complements these arguments with a quantifiable economic impact of such a law and a model for future calculations. This research assesses the potential economic consequences of decriminalizing sex work in the District of Columbia (DC) in three areas: (1) income tax revenue, (2) criminal justice system savings, and (3) health sector savings (violence, HIV, gonorrhea, and herpes).

Methods

An economic model is developed and utilized based on a literature review and records from local and federal agencies.

Results

The decriminalization of sex work in DC will generate $5,191.61 per sex worker and $2.49 per client annually, plus an additional $20,118.17 in total criminal justice system savings a year. Per sex worker, $4,906.39 will be gained from income tax revenue, and $285.46 will be generated through health sector savings. Per client, decriminalization will generate $0.05, $2.28, and $0.16 from HIV, gonorrhea, and herpes respectively, or $8,311.67 annually after considering the total number of clients. Estimates are reported in 2019 US dollars.

Conclusions

The potential economic impact of decriminalizing sex work is widespread. In DC, this legislation should be implemented to not only promote the city's human rights but also economic growth. The presented model, in conjunction with a rights-based foundation, should urgently be used by advocates, sex workers, decision-makers, and other researchers.

Key messages

An economic analysis of a policy to decriminalize sex work in DC demonstrates its widespread economic impact across sectors. The economic model generated in this research should be utilized in other regions to strengthen human rights-based arguments in support of these policies.

Financial Performance of Public Hospitals: A Cross-Sectional Study among Polish Providers

There is growing evidence of a positive association between health care providers’ financial standing and the quality of care. In Poland, the instable financial situation and growing debt of public hospitals has been a source of concern for more than two decades now. The objectives of this paper were to compare the financial performance of public hospitals in Poland, depending on the ownership and organizational form; and analyze whether there is an association between financial performance and the chosen variables. We conducted a cross sectional study covering the whole population of public hospitals operating in 2018. The total number of included units was 805. The hospitals’ financial outcomes were measured by several variables; Spearman’s rank correlation was calculated, and a multivariable logistic regression model was performed. In 2018, the majority of public hospitals in Poland (52%) generated a gross loss, while 40% hospitals had overdue liabilities. There were statistically significant differences between hospital groups, with university hospitals and those owned by counties (local hospitals) being in the most disadvantageous situation. Additionally, corporatized public hospitals performed worse than those functioning in the classic legal form of independent health care units. Urgent actions are needed to measure and monitor the potential impact of financial performance on the quality of care.

Hospital reforms in 11 Central and Eastern European countries between 2008 and 2019: a comparative analysis

This paper aims to: (1) provide a brief overview of hospital sector characteristics in 11 Central and Eastern European countries (Bulgaria, Czech Republic, Estonia, Croatia, Latvia, Lithuania, Hungary, Poland, Romania, Slovakia, Slovenia); (2) compare recent (2008 - 2019) hospital reforms in these countries; and (3) identify common trends, success factors and challenges for reforms. Methods applied involved five stages: (1) a theoretical framework of hospital sector reforms was developed; (2) basic quantitative data characterizing hospital sectors were compared; (3) a scoping review was performed to identify an initial list of reforms per country; (4) the list was sent to national researchers who described the top three reforms based on a standardized questionnaire; (5) received questionnaires were analysed and validated with available literature. Results indicate that the scope of conducted reforms is very broad. Yet, reforms related to hospital sector governance and changes in purchasing and payment systems are much more frequent than reforms concerning relations with other providers. Most governance reforms aimed at transforming hospital infrastructure, improving financial management and/or improving quality of care, while purchasing and payment reforms focused on limiting hospital activities and/or on incentivising a shift to ambulatory/day care. Three common challenges included the lack of a comprehensive approach; unclear outcomes; and political influence. Given similar reform areas across countries, there is considerable potential for shared learning.

A Multidimensional Questionnaire to Measure Career Satisfaction of Physicians: Validation of the Polish Version of the 4CornerSAT

To study physicians' satisfaction with a multidimensional approach, the 4CornerSAT questionnaire to measure the career satisfaction of physicians was conceptualized in English and later adapted into Polish. In this study, we aimed to test the reliability and validity of the adapted 4CornerSAT questionnaire in Poland and confirm its the tetra-dimensional structure. In 2018, physicians working in 15 Polish hospitals were invited to participate in a survey that included the Polish 4CornerSAT. We evaluated the questionnaire's reliability by computing Cronbach's alpha coefficients. We also computed a Pearson correlation coefficient between the reported global item of satisfaction and the standardized level of career satisfaction. A confirmatory factorial analysis (CFA) tested the tetra-dimensional structure of the questionnaire in Polish. In total, 1003 physicians participated in this study. The questionnaire's internal consistency and concurrent validity were optimal. In the CFA, good model fit indicators were observed. In conclusion, the Polish version of the 4CornerSAT demonstrated good psychometric properties. The adapted questionnaire has evidence of its validity and reliability in Poland to be used in further studies and to monitor physicians' wellness as a health care system indicator. Our approach to adapt and validate this questionnaire could be replicated in other settings.

[ASSESSMENT OF THE FINANCIAL STANDING OF SELECTED RESEARCH INSTITUTES SUPERVISED BY THE MINISTER OF HEALTH IN 2014-2018]

OBJECTIVE

The aim: The purpose of this study is the analysis of the financial situation of the institutes supervised by the Minister of Health in the period 2014-2018.

PATIENTS AND METHODS

Material and methods: The study group consisted of 10 institutes that conducted inpatient and / or outpatient medical activities in 2018. Data to analysis derived from financial statements of research institutes from 2014 to 2018. The selection of financial indicators to ratio analysis is based on Ministry of Health ordinance from 2017.

RESULTS

Results: The situation of the analyzed hospitals is difficult, with the difference between individual entities. The analyzed units were characterized by high net losses (9 out of 10 units generated a loss each year) low value of revenues in relation to costs and high share of remuneration in the structure of operating costs. There was no visible financial situation improvement per year. Simultaneously, in 2018 the difference between units were major: on a point scale 0 -70 ranged from: 51 points (73%) at the Institute of Physiology and Pathology of Hearing to 9 points (13%) at the Institute of Polish Mother's Health Center. The results are consistent with the conclusions of the Supreme Audit Office's reports, that baseline, medical institutes do not pursue a sustainable policy.

CONCLUSION

Conclusions: Based on the analyzed data, it can be concluded that the economic situation of these units in 2014-2018 is difficult and has not changed much compared to previous periods.

Situation analysis on evidence-informed health policy-making in Poland

Background

Over the last few years, increased international attention has been paid to bridging the gap between health research and policy-making. The situation analysis on evidence-informed policy-making (EIP) in Poland aims to increase understanding of interactions among a country’s research and policy-making communities, to determine where and how to best establish a knowledge translation platform (KTP), i.e. an organization or network that through its structure and functioning brings the worlds of research and policy together.

Methods

The methods were guided by the EVIPNet Europe Situation Analysis Manual and included a literature review, key-informant interviews and survey data analysis.

Results

In Poland, the existence of incentives or requirements stipulating the use of research evidence in health policy varies, depending on the type of policy. The use of evidence is a standard practice in drug policy, and in decisions related to the inclusion of services in the health benefit package. In other areas, some good practice examples of using evidence in policy can be identified. Yet these are rather individual, isolated and bottom-up initiatives, which neither occur systematically, nor routinely. Key challenges in view of strengthening a systemic approach to EIP relate to: overlapping mandates of key health system and research institutions, generally low research capacity and lack of knowledge translation skills.

Conclusions

Establishing and operationalizing a KTP can be an effective means of supporting sustainable EIP. Building such infrastructure, however, is a longer-term and complex process that needs to be based on the current characteristics of the country’s EIP landscape. The proposed model of a future KTP in Poland is a network with a joint secretariat within the Ministry of Health. Such form can take advantage of existing organizations’ competencies via information exchange and cooperation.

Key messages

Although systemic mechanisms for evidence-informed health policy are missing in Poland, its importance is recognized among major health system stakeholders. The proposed model of a future knowledge translation platform in Poland is a network with a joint secretariat within the Ministry of Health.

Career satisfaction of Polish physicians – evidence from a survey study

Background

Understanding physician satisfaction and the factors associated are relevant for physicians, their patients and decision makers. We conducted the first national-wide study evaluating the satisfaction of Polish doctors using a multidimensional approach. The aims of this study were to: 1) measure the career satisfaction of physicians working in Polish hospitals, and 2) identify the factors associated with higher levels of career satisfaction.

Methods

A quantitative, on-line survey among 15 nation-wide distributed Polish hospitals (7 general, 5 specialists, and 3 university) was conducted between March and June 2018. A 17-item questionnaire was used to measure satisfaction on a scales from 1.00 to 6.00, as well as their personal, professional, performance, and inherent satisfaction levels. In total, 1.003 questionnaires were included in the study (response rate=38%). Unconditional associations and multivariable regressions models were used to evaluate associations between satisfaction levels and their demographic and work-related factors.

Results

The mean level of physician satisfaction was 4.10 (SD = 0.69). Almost 57% of the doctors reported being from “somewhat satisfied” to “very satisfied” with their careers; although, only 8.2% reported being satisfied or very satisfied with their career (≥5.00). Doctors reported high levels of inherent satisfaction (mean=4.4, SD = 0.66) and low levels of personal satisfaction (mean=3.78, SD = 0.98). Age and work experience were positively and significantly associated with satisfaction.

Conclusions

The satisfaction of Polish physicians is moderate. Doctors reported higher levels of satisfaction with their interactions with direct supervisor, other physicians, nurses, doctor-patient relationships and the lowest satisfaction with the salary and work-life balance. Gender, numbers of working hours/week; years of work experience and the stage of professional development were the factors associated with higher satisfaction.

Key messages

The satisfaction of physicians working in Polish hospitals is moderate. The current shortage of Polish physicians makes their satisfaction especially significant for motivation and retention. Physician satisfaction is an important indicator for managers. Attention regarding levels and factors affecting doctors’ satisfaction should be one of the key issues of health workforce management.

Migration intentions among Polish physicians - the profile of a potential migrant

Background

Polish physicians migration has become a subject of interest in the context of current shortage of medical staff. The exact scale of migration is unknown due to insufficient data. The main goals of the study were to: 1) evaluate the scale of migration intentions among doctors working in Polish hospitals, 2) identify the key predictors and barriers of migration, 3) investigate an association between doctors satisfaction and their tendency to migrate.

Methods

A quantitative, on-line survey of doctors working in Polish hospitals was conducted between March and June, 2018. 15 cross-nationally distributed hospitals (7 general, 5 specialist, 3 university) were included in the study. The statistical analyses included: associations between the intention to migrate and demographic characteristics as well as work-related variables and overall satisfaction. Simple and multivariable logistic regression analysis was conducted to determine which variables are significant predictors of the intention to migrate.

Results

1.003 questionnaires were analyzed (response rate: 38%). 273 respondents declared the intention to migrate, including 45 (4.5%) answering ‘definitely yes’ and 228 (22.7%) ‘probably yes’. Men more often considered the option to migrate: 5.2% answered ‘definitely yes’ and 26.3% ‘probably yes’ in comparison to 3.7% and 19.0% respectively for females (p = 0.02). Childless physicians more often considered the option to migrate than those with kids (9.0% answered ‘definitely yes’ and 33.1% ‘rather yes’ vs 2.4% and 17.8%, respectively, p < 0.001). Almost 62% of doctors with the intention to migrate considered a temporary stay abroad. 70% of respondents indicated ‘leaving family’ as main migration barrier.

Conclusions

The intention to migrate is related to socio-demographic factors (gender, age, marital status, having children) and work-related factors (work experience, working hours). The intention to migrate is negatively related to physician satisfaction.

Key messages

The main reasons for the intention to migrate are: higher earnings abroad, better working conditions, the ability to achieve better work-life balance and better training opportunities. In Poland a holistic, systemic approach to health workforce planning should be implemented, including monitoring migration trends and improving working conditions.

Satisfaction of Physicians Working in Polish Hospitals-A Cross-Sectional Study

Physician satisfaction is a multidimensional concept associated with numerous factors. The objectives of the study were to evaluate the satisfaction of physicians practicing in hospitals in Poland and to identify factors associated with higher levels of satisfaction. A quantitative, cross-sectional survey of Polish hospitals was conducted between March and June 2018. All doctors working in the hospitals invited to the study were asked to fill in an online survey. Fifteen hospitals were included: seven general, five specialist, and three university ones. The total number of questionnaires analyzed was 1003. The questionnaire included 17 items to measure the level of satisfaction, classified into four dimensions: personal, professional, performance, and inherent. The statistical analyses included: assessment of association between levels of career satisfaction and basic demographic and work-related variables; and multivariable logistic regressions, conducted to determine which variables were associated with higher levels of career satisfaction. The mean level of career satisfaction, on a scale from 1 to 6, was 4.1 (SD = 0.69). Respondents reported high levels of inherent satisfaction: mean = 4.4 (SD = 0.66) and a low personal satisfaction: mean = 3.78 (SD = 0.98). 56.6% of respondents reported being satisfied, but only 8.2% reported a higher level of satisfaction (≥5). The satisfaction of Polish physicians is moderate. Gender, numbers of working hours/week, years of work experience, type of hospital, and stage of professional development were the identified factors associated with higher levels of career satisfaction.

Improving oncological care organization in Poland-The 2015 reform evaluation in the context of European experiences

Cancer is one of the leading causes of morbidity and mortality worldwide with a significant economic impact which has been increasing in recent decades. Numerous expert groups and/or international organizations have developed guidelines on how to build effective cancer control mechanisms, while in the European Union the majority of countries have developed national programmes. In Poland, cancer is the second leading cause of death. Compared with other European countries, Poland is characterized by a relatively low cancer incidence ratio, yet in terms of mortality and survival ratios, the situation is much worse than the average. On 1 January 2015, an oncological therapy fast track was implemented in Poland, popularly known as the "oncological package." Its formal objectives were to improve access to and systemize the process of cancer diagnostics and treatment. The reform introduced some of the solutions existing in other European countries, including waiting time limits, patient pathways, multidisciplinary medical consultations, and a care coordinator position. The preliminary evaluation analyses suggest that after the reform implementation the average waiting time for diagnostics and treatment for patients covered by the new system was significantly shortened in comparison to those excluded. Further research evaluating the reform impact on quality and/or comprehensiveness of care are needed.

Impact of the doctor deficit on hospital management in Poland: A mixed-method study

OBJECTIVES

The primary objective was to assess the scale and consequences of the doctor deficit in Poland with the main focus on hospital care providers. To provide the background for the above, an analysis of the system level responses to the problem was also conducted.

DATA AND METHODS

A mixed-method approach was used. We triangulated data collected using 3 methods: (1) a literature review, (2) an analysis of the national statistical databases, and (3) in-depth interviews with hospital managers.

RESULTS

Poland is characterized by the lowest number of physicians per 1000 population in the European Union (2.3 in 2015). Also, the age structure of the doctor working population constitutes an alarming factor (in 2015, approx. 48% of all practicing doctors and 61% of specialists were above 50). In recent years, numerous hospitals were forced to cease provision of specific services and/or close wards due to the doctor deficit. The high competition in employing doctors and pressure for wage increases puts hospital managers in situations where they must often choose between securing service provision (by offering higher wages for doctors) and maintaining the hospital's positive financial outcome (by containing costs).

CONCLUSION

In Poland, the long-term neglect of health workforce planning at the system level (there is neither a dedicated structure nor a formal strategy) has contributed to the current doctor deficit crisis. From the hospital managers' perspective, who are on the frontline of the problem impact, urgent solutions are needed that would at least alleviate its scale in the short term.

Economic evaluation of health promotion interventions for older people: do applied economic studies meet the methodological challenges?

BACKGROUND

In the light of demographic developments health promotion interventions for older people are gaining importance. In addition to methodological challenges arising from the economic evaluation of health promotion interventions in general, there are specific methodological problems for the particular target group of older people. There are especially four main methodological challenges that are discussed in the literature. They concern measurement and valuation of informal caregiving, accounting for productivity costs, effects of unrelated cost in added life years and the inclusion of 'beyond-health' benefits. This paper focuses on the question whether and to what extent specific methodological requirements are actually met in applied health economic evaluations.

METHODS

Following a systematic review of pertinent health economic evaluations, the included studies are analysed on the basis of four assessment criteria that are derived from methodological debates on the economic evaluation of health promotion interventions in general and economic evaluations targeting older people in particular.

RESULTS

Of the 37 studies included in the systematic review, only very few include cost and outcome categories discussed as being of specific relevance to the assessment of health promotion interventions for older people. The few studies that consider these aspects use very heterogeneous methods, thus there is no common methodological standard.

CONCLUSION

There is a strong need for the development of guidelines to achieve better comparability and to include cost categories and outcomes that are relevant for older people. Disregarding these methodological obstacles could implicitly lead to discrimination against the elderly in terms of health promotion and disease prevention and, hence, an age-based rationing of public health care.

Building hospital capacity planning mechanisms in Poland: The impact of 2016/2017 regulatory changes

Capacity planning is a crucial component of modern health care governance. The aim of this paper is to analyze the requirements that need to be met to build effective hospital capacity planning mechanisms in Poland. In this context, the recent regulatory changes strongly influencing hospital sector functioning, including introduction of health care needs maps, capital investment assessment, and hospital network regulations, are analyzed. Some possible ways forward, based on review of international experiences in hospital capacity planning, are discussed. Applied methods include literature review and analysis of statistical data as well as desk analysis of key national regulations related to hospital sector. Results indicate that at the system level, the process of capacity planning involves 4 elements: capital investment in facilities, equipment, and technology; service delivery; allocation of staff; and financial resources. For hospital capacity planning to be effective, the strategic decision at the macrolevel must be complemented by appropriate management of individual hospitals. The major challenge of building hospital capacity planning mechanism in Poland is imbedding it into the overall health system strategy. Because of the lack of such a strategy, the practical implementation of the ad hoc changes, which have been introduced, shows some inconsistencies. The regulations implemented between 2016 and 2017 provided a basis for hospital capacity planning, yet still need evaluation and adjustments. Also, including a mechanism for human resources planning is of crucial importance. The regulations should provide incentives for reducing oversized hospital infrastructure with simultaneous development of the long-term and coordinated care models.

The systematic coronary risk evaluation (SCORE) for the prevention of cardiovascular diseases. Does evidence exist for its effectiveness? A systematic review

OBJECTIVES

The SCORE model predicts the ten-year risk of cardiovascular mortality but it is still unknown whether applying the SCORE in clinical practice subsequently improves cardiovascular disease (CVD) outcomes. The objective of this study is to assess the effect of total cardiovascular risk estimation using the SCORE in preventing serious cardiovascular events in European adults without prior CVD.

METHODS AND RESULTS

Data sources: eight bibliographical databases (2003 - August 2015), other internet sources and reference lists of articles were checked. This was supplemented by contact with the board members of the European Society of Cardiology (ESC) and the authors of the SCORE model.

STUDY ELIGIBILITY CRITERIA

all prospective studies in any language investigating the effect of using the SCORE on the clinical outcome (CVD death, major events and adverse outcomes) in an adult population were examined. Two reviewers assessed the studies independently (titles, abstracts, full texts). After removal of duplicates, 5,256 records were screened and 14 full text papers considered. No eligible studies were identified. An extensive literature search revealed no randomized control trial or other prospective study comparing significant clinical outcomes between groups that used the SCORE and those who did not.

CONCLUSIONS

The effect of using the SCORE (with or without subsequent intervention) on CVD death, all-cause mortality, major CVD events like myocardial infarction and stroke, as well as adverse outcomes, is still unknown. A cluster randomised controlled trial is warranted to evaluate the use of the SCORE on important outcomes.

Economic evaluation of health promotion for older people-methodological problems and challenges

BACKGROUND

The support of health promotion activities for older people gains societal relevance in terms of enhancing the health and well-being of older people with a view to the efficient use of financial resources in the healthcare sector. Health economic evaluations have become an important instrument to support decision-making processes in many countries. Sound evidence on the cost-effectiveness of health promotion activities would encourage support for the implementation of health promotion activities for older people. This debate article discusses to what extent economic evaluation techniques are appropriate to support decision makers in the allocation of resources regarding health promotion activities for older people. We address the problem that the economic evaluation of these interventions is hampered by methodological obstacles that limit comparability, e.g. with economic evaluations of curative measures. Our central objective is to describe and discuss the specific problems and challenges entailed in the economic evaluation of health promotion activities especially for older people with regard to their usefulness for informing decision making processes.

DISCUSSION

Beyond general problems concerning the economic evaluation of health promotion, our discussion focusses on problems that pertain to the analysis of cost and outcomes of health promotion interventions for older people. With regard to costs these are general problems of economic evaluations, namely the actual implementation of a societal perspective, the appropriate measurement and valuation of informal caregiver time, the measurement and valuation of productivity costs and costs incurred in added years of life. The main problems concerning the identification and measurement of outcomes are related to the identification of outcome parameters that, firstly, adequately reflect the broad effects of health promotion interventions, especially social benefits that gain importance for older people, and secondly, ensure a comparability of effects across different age groups. In particular, the limitations of the widely used QALY for older people are discussed and recently developed alternatives are presented.

CONCLUSIONS

The key conclusion of the article is that a comparison of the effects of different health promotion initiatives between different age groups by means of economic evaluation is not recommendable. Taking into account the complex outcomes of health promotion interventions it has to be accepted that the outcomes of these interventions will often not be comparable with clinical interventions and have to be assessed differently.