Operative or Nonoperative Treatment is Predicted Accurately for Patients Who Have Hip Complaints Consulting an Orthopedic Surgeon Using Machine Learning Algorithms Trained With Prehospital Acquired History-Taking Data

BACKGROUND

Increasing numbers of patients suffering from hip osteoartritis will lead to increased orthopaedic health care consumption. Artificial intelligence might alleviate this problem, using Machine learning (ML) to optimize orthopaedic consultation workflow by predicting treatment strategy (non-operative or operative) prior to consultation. The purpose of this study was to assess ML accuracy in clinical practice, by comparing ML predictions to the outcome of clinical consultations.

METHODS

In this prospective clinical cohort study, adult patients referred for hip complaints between January 20th to February 20th 2023 were included. Patients completed a computer-assisted history taking (CAHT) form and using these CAHT answers, a ML-algorithm predicted non-operative or operative treatment outcome prior to in-hospital consultation. During consultation, orthopaedic surgeons and physician assistants were blinded to the prediction in 90 and unblinded in 29 cases. Consultation outcome (non-operative or operative) was compared to ML treatment prediction for all cases, and for blinded and unblinded conditions separately. Analysis was done on 119 consultations.

RESULTS

Overall treatment strategy prediction was correct in 101 cases (accuracy 85%, P < .0001). Non-operative treatment prediction (n = 71) was 97% correct versus 67% for operative treatment prediction (n = 48). Results from unblinded consultations (86.2% correct predictions,) were not statistically different from blinded consultations (84.4% correct, P > .05).

CONCLUSIONS

Machine Learning algorithms can predict non-operative or operative treatment for patients with hip complaints with high accuracy. This could facilitate scheduling of non-operative patients with physician assistants, and operative patients with orthopaedic surgeons including direct access to pre-operative screening, thereby optimizing usage of health care resources.

Vaccination Effectiveness against Human Papillomavirus in Kazakhstan

OBJECTIVE

The purpose was to determine the effectiveness of human papillomavirus immunization and its impact on cervical cancer development in Kazakhstan.

METHODS

The current research is a case-control study with two groups: a main group and a control group. A total of 725 subjects participated in the research.

RESULTS

The association between vaccination and cervical cancer development was calculated both for the two groups as a whole and for individual patients, who were selected based on criteria of residence, presence of immunodeficiency or chronic cardiac or renal pathology, as well as analysis of age at which the vaccine dose was received. There was a statistically significant association between the absence of the human papillomavirus vaccine and the risk of cervical cancer in all groups. When considering the entire cohort, the chance of finding a risk factor (lack of vaccination) was almost 7 times higher in the main group than in the control group. Thus, an association between vaccination and cervical cancer risk was found in each of the pairs of subjects.

CONCLUSION

The effectiveness of vaccination in preventing cervical cancer was not observed in patients who were vaccinated after 18 years of age, while most patients in the control group were vaccinated in their teens. The practical significance of the research is not only to further study the problem of human papillomavirus (HPV) vaccination in Kazakhstan but also to popularize HPV immunization to prevent cervical cancer (CC).

[The indicators of value consistency and interpersonal conjugation of values of employees with executive as a foundation of personnel management in medical organization]

The article presents results of diagnostics of value consistence and interpersonal value conjugation in employees of medical organization. Purpose of the study is to identify the value consistence index and interpersonal value conjugation of employees of different departments of medical organization and on this basis to develop recommendations for executives concerning performance of their managerial functions. The study covered 284 employees of "The Municipal Clinical Hospital № 40 of the Moscow Health Care Department". The "Sh. Schwartz Value orientations" questionnaire was applied. The mean and centered values were calculated for each value index at both levels of values representation. At the level of normative ideals dominant value the first place in all departments except obstetrics, gynecology, and neonatology takes universalism. The employees of maternity hospital positioned safety on the first place. The second place was given to hedonism in departments of oncology, surgery and internal medicine; to kindness in departments of obstetrics, gynecology and neonatology, to achievement in department of intensive care; stimulation in department of diagnostic; safety in non-medical departments. The third place was given to safety in department of oncology, surgery and therapy; to conformity in departments of obstetrics, gynecology and neonatology; and to hedonism in non-medical departments. The comparison of value profiles of behavioral priorities established that in all departments one of the three dominant ranked values was power, in four departments - hedonism, in five departments - stimulation, in four - achievement, in one - tradition. The qualitative assessment of personality value profiles identified four types of department employees: mobile, sensitive, rational and stable one. Based on quantitative data of the Department Value Profile chart executive can develop management strategies using socio-psychological methods of personnel management.

Implementation of Machine Learning Applications in Health Care Organizations: Protocol for a Systematic Review of Empirical Studies

BACKGROUND

An increasing interest in machine learning (ML) has been observed among scholars and health care professionals. However, while ML-based applications have been shown to be effective and have the potential to change the delivery of patient care, their implementation in health care organizations is complex. There are several challenges that currently hamper the uptake of ML in daily practice, and there is currently limited knowledge on how these challenges have been addressed in empirical studies on implemented ML-based applications.

OBJECTIVE

The aim of this systematic literature review is twofold: (1) to map the ML-based applications implemented in health care organizations, with a focus on investigating the organizational dimensions that are relevant in the implementation process; and (2) to analyze the processes and strategies adopted to foster a successful uptake of ML.

METHODS

We developed this protocol following the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines. The search was conducted on 3 databases (PubMed, Scopus, and Web of Science), considering a 10-year time frame (2013-2023). The search strategy was built around 4 blocks of keywords (artificial intelligence, implementation, health care, and study type). Based on the detailed inclusion criteria defined, only empirical studies documenting the implementation of ML-based applications used by health care professionals in clinical settings will be considered. The study protocol was registered in PROSPERO (International Prospective Register of Systematic Reviews).

RESULTS

The review is ongoing and is expected to be completed by September 2023. Data analysis is currently underway, and the first results are expected to be submitted for publication in November 2023. The study was funded by the European Union within the Multilayered Urban Sustainability Action (MUSA) project.

CONCLUSIONS

ML-based applications involving clinical decision support and automation of clinical tasks present unique traits that add several layers of complexity compared with earlier health technologies. Our review aims at contributing to the existing literature by investigating the implementation of ML from an organizational perspective and by systematizing a conspicuous amount of information on factors influencing implementation.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47971.

[The loyalty of patients during coronavirus period: investigation experience in the metropolitan children polyclinic]

Two years after COVID-19 pandemic starting, the studies of patient satisfaction with medical services quality become topical again. The article presents the results of three-year project (2019-2022) of studying level of loyalty (Net Promoter Score) of legal representatives of patients of one of municipal children polyclinics. It is established that in Moscow, with implementation of first restrictive measures level of loyalty in the children polyclinic increased from 45% to 70%. In following years, level of loyalty was fixed at the level of 60%. The four groups of factors determining such changes as high level of panic moods due to pandemic, changes in organization of polyclinic functioning, energetic activity of mass media and users of social networks in glorifying image of medical workers and cultural psychological characteristics of Russians. The "optimistic", "realistic" and "pessimistic" prognoses concerning further dynamics of level of loyalty are proposed. The conclusion was made that COVID-19 pandemic served as key factor of positive changes in assessments of patients (and their legal representatives) of functioning both of particular polyclinic and the Russian health care in general. As far as each following time coronavirus infection will cause less and less concern among Russians it can be expected the requirements presented to medical services will soon increase, that means workload of medical personnel will only intensify. The following prospective directions of organizing functioning of medical institutions are proposed: monitoring of psycho-social indicators of medical personnel, implementation of telemedicine technologies, transfer of part of functionality of physicians and nurses to specialists without medical education.

The role of health care organizations in patient engagement: Mechanisms to support a strong relationship between patients and clinicians

BACKGROUND

Patient engagement (PE) is critical to improving patient experience and outcomes, as well as clinician work life and lowering health care costs, yet health care organizations (HCOs) have limited guidance about how to support PE. The engagement capacity framework considers the context of engagement and examines precursors to engagement, including patients' self-efficacy, resources, willingness, and capabilities.

PURPOSE

The aim of this study was to explore clinician and patient perspectives related to mechanisms through with the HCOs can facilitate PE through the lens of the engagement capacity framework.

METHODOLOGY/APPROACH

We administered an online open-ended survey to clinicians and patient advisors across the United States, including questions focused on the influences of, barriers to, and skills and tools required for PE. A common theme emerged focusing on the role of HCOs in facilitating engagement. Our analysis examined all responses tagged with the "health care system" code.

RESULTS

Over 750 clinicians and patient advisors responded to our survey. Respondents identified offering advice and support for patients to manage their care (self-efficacy), providing tools to facilitate communication (resources), working to encourage connection with patients (willingness), and training for HCO employees in cultural competency and communication skills (capabilities) as important functions of HCOs related to engagement.

CONCLUSION

HCOs play an important role in supporting a strong partnership between the patient and clinicians. Our study identifies important mechanisms through which HCOs can fulfill this role.

PRACTICE IMPLICATIONS

HCO leadership and administration can help establish the culture of care provided. Policies and initiatives that provide appropriate communication tools and promote culturally competent care can increase engagement.

[Promoting Hospital Safety Culture: The Perspective of Safety Leadership]

Cultures of safety share a strong commitment to the goal of achieving zero harm and to continuously implementing the improvements and innovations necessary to achieve this goal. However, in some healthcare organizations today, safety is often undervalued and considered only after the occurrence of safety incidents, with no sense of commitment and no goal of zero harm. This article first briefly introduces the origin and definition of safety culture, the composition of safety culture, and the safety culture pyramid. Secondly, the definition, importance, and impact of hospital safety culture as well as the assessment tools for hospital safety culture are discussed. Finally, many practical leadership guidelines used in other countries to promote hospital safety culture are introduced as references for domestic healthcare organizations. Because patient safety is a dynamic and complex phenomenon, research and surveys of hospital safety culture conducted every two to three years are recommended to ensure best practices in patient safety. Achieving continuous improvement in patient safety and hospital safety culture requires leadership at all levels. In tandem, a total safety culture must be instilled throughout the health system. Commitment from leadership and management is critical to establishing and maintaining a safe, people-centered environment.

Social inequalities and gender differences in health care management of acute ischemic strokes in France

INTRODUCTION

There are regional disparities in access to stroke units in France. Several studies have shown that living in disadvantaged areas is associated with higher frequency of stroke, worse severity at presentation, increased level of dependency, and higher mortality rates. However, few studies have explored the association between an individual's socioeconomic characteristics and stroke care. Our study aimed to determine if living standards are associated with stroke unit access for patients admitted to hospital for acute ischemic stroke.

METHODS

Using the EDP-Santé French administrative database, we selected all patients admitted to hospital for acute ischemic stroke between 2014 and 2017. Acute ischemic stroke corresponded to hospital stay with ICD-10 codes I63 or I64 as the main diagnosis. Multivariate logistic regression was used to identify if standard of living was associated with likelihood of admission to a stroke unit.

RESULTS

We identified 14 123 acute-care episodes, corresponding to 335 273 episodes in the general population when appropriately weighted. Of these, 52.9 % were admitted to a stroke unit. Being in the first (i.e., poorest) living standard quartile was associated with lower likelihood of admission to a stroke unit compared with the fourth (i.e., wealthiest) quartile, and was associated with a higher likelihood of paralysis and language disorder, and death at 1 year.

CONCLUSION

A low living standard was associated with lower likelihood of admission to a stroke unit as well as a greater chance of paralysis and aphasia at the end of hospitalization and a higher possibility of death at 1 year after stroke. Greater access to stroke units in disadvantaged people should be promoted.

Czech public health - past and present

The article deals with the concept, development, and current state of public health in the Czech lands as a theoretical and practical scientific discipline, as it has been formed and profiled during more than two hundred years of history. It identifies five developmental stages, which briefly characterizes and introduces important representatives of the field at the time. It describes the transformation of public health care after 1989 and points out some of the consequences of institutional reduction associated with the weakening of the field, which became fully apparent during the COVID-19 pandemic.

International Camps for Children with Lymphedema and Lymphatic Anomalies: When Education Links with Psychosocial Research

Background: Lymphedema in children and adolescents is a rare and chronic condition. The management of their lymphedema is mainly driven by the adaptation of treatments used in adults. The aim of our study was to explore the needs and challenges the children and adolescents face during their management with the aim of finding ways to satisfy these needs and organize an hospital-based centre accordingly with an educational program. Methods and Results: Patients and their families were given the opportunity to meet other patients, their families and professionals during social activities organised annually and during two international camps. They were invited to take part in different semi structured focus groups and interviews. All patients and families described a long journey and relief when the diagnosis was obtained followed by the shock of being told that it was a chronic condition. Meeting other children with the condition was a relief. The impact of lymphedema on body shape and genitals was a source of distress. Rejection of the compression was part of journey. Lymphedema management had an impact on all the family members including siblings. Parents were responsible for their child self-management in young children which was described as demanding. It was followed by a complex transition phase to self-management. The impact was not the same according to the age the lymphedema had started. Conclusion: Acceptance and management of lymphedema is complex and invades many aspects of families' life. Self-management is demanding. Based on these results, the management of lymphedema in the centre included meeting other children and families and an educational program based on individual needs and follow-up. Clinical Trials.gov ID:NCT01922635.

[Adaptation of Health Care Organization in a level III Maternity Hospital during the COVID-19 pandemic]

La pandémie COVID-19 a nécessité une adaptation rapide de l’organisation des soins. L’objectif était d’assurer l’accueil des patients en évitant les contaminations au moment de l’accouchement et pour le personnel soignant. Était aussi prise en compte l’instauration des liens parents–enfant essentiels au-delà de la pandémie. La réorganisation des soins a d’abord reposé sur la création d’une équipe opérationnelle multidisciplinaire qui a permis une réactivité indispensable. Ensuite, les activités ont été recentrées sur la situation épidémique avec déprogrammation des activités non urgentes et articulation avec le réseau de ville. Une réorganisation des plannings et une formation spécifique à l’habillage ont été réalisées. Une dotation en masques chirurgicaux, gels et lingettes désinfectants a été assurée. Un triage des admissions a été mis en place avec un circuit particulier et des personnels dédiés. Une salle de naissance et un bloc opératoire spécifiques armés du strict nécessaire ont été associés à un poste de réanimation néonatale particulier. En néonatologie, deux secteurs dont la pression positive a été suspendue étaient dédiés aux familles à risque. Le port du masque et le lavage des mains avec désinfection au gel hydroalcoolique a été exigé de tous les patients. Les enfants ont été laissés au chevet de leurs mères en chambre particulière. Une incitation à l’allaitement maternel a été faite. La sortie précoce dès 48 h a été systématiquement organisée avec relais par sage-femme à domicile. Au total, cette adaptation de l’organisation des soins a permis de répondre de façon satisfaisante à la situation particulière de cette pandémie.

The Challenge of Integrating eHealth Into Health Care: Systematic Literature Review of the Donabedian Model of Structure, Process, and Outcome

BACKGROUND

Health care organizations are increasingly working with eHealth. However, the integration of eHealth into regular health care is challenging. It requires organizations to change the way they work and their structure and care processes to be adapted to ensure that eHealth supports the attainment of the desired outcomes.

OBJECTIVE

The aims of this study are to investigate whether there are identifiable indicators in the structure, process, and outcome categories that are related to the successful integration of eHealth in regular health care, as well as to investigate which indicators of structure and process are related to outcome indicators.

METHODS

A systematic literature review was conducted using the Donabedian Structure-Process-Outcome (SPO) framework to identify indicators that are related to the integration of eHealth into health care organizations. Data extraction sheets were designed to provide an overview of the study characteristics, eHealth characteristics, and indicators. The extracted indicators were organized into themes and subthemes of the structure, process, and outcome categories.

RESULTS

Eleven studies were included, covering a variety of study designs, diseases, and eHealth tools. All studies identified structure, process, and outcome indicators that were potentially related to the integration of eHealth. The number of indicators found in the structure, process, and outcome categories was 175, 84, and 88, respectively. The themes with the most-noted indicators and their mutual interaction were inner setting (51 indicators, 16 interactions), care receiver (40 indicators, 11 interactions), and technology (38 indicators, 12 interactions)-all within the structure category; health care actions (38 indicators, 15 interactions) within the process category; and efficiency (30 indicators, 15 interactions) within the outcome category. In-depth examination identified four most-reported indicators, namely "deployment of human resources" (n=11), in the inner setting theme within the structure category; "ease of use" (n=16) and "technical issue" (n=10), both in the technology theme within the structure category; and "health logistics" (n=26), in the efficiency theme within the outcome category.

CONCLUSIONS

Three principles are important for the successful integration of eHealth into health care. First, the role of the care receiver needs to be incorporated into the organizational structure and daily care process. Second, the technology must be well attuned to the organizational structure and daily care process. Third, the deployment of human resources to the daily care processes needs to be aligned with the desired end results. Not adhering to these points could negatively affect the organization, daily process, or the end results.

The importance of understanding and measuring health system structural, functional, and clinical integration

OBJECTIVE

We explore if there are ways to characterize health systems-not already revealed by secondary data-that could provide new insights into differences in health system performance. We sought to collect rich qualitative data to reveal whether and to what extent health systems vary in important ways across dimensions of structural, functional, and clinical integration.

DATA SOURCES

Interviews with 162 c-suite executives of 24 health systems in four states conducted through "virtual" site visits between 2017 and 2019.

STUDY DESIGN

Exploratory study using thematic comparative analysis to describe factors that may lead to high performance.

DATA COLLECTION

We used maximum variation sampling to achieve diversity in size and performance. We conducted, transcribed, coded, and analyzed in-depth, semi-structured interviews with system executives, covering such topics as market context, health system origin, organizational structure, governance features, and relationship of health system to affiliated hospitals and POs.

PRINCIPAL FINDINGS

Health systems vary widely in size and ownership type, complexity of organization and governance arrangements, and ability to take on risk. Structural, functional, and clinical integration vary across systems, with considerable activity around centralizing business functions, aligning financial incentives with physicians, establishing enterprise-wide EHR, and moving toward single signatory contracting. Executives describe clinical integration as more difficult to achieve, but essential. Studies that treat "health system" as a binary variable may be inappropriately aggregating for analysis health systems of very different types, at different degrees of maturity, and at different stages of structural, functional, and clinical integration. As a result, a "signal" indicating performance may be distorted by the "noise."

CONCLUSIONS

Developing ways to account for the complex structures of today's health systems can enhance future efforts to study systems as complex organizations, to assess their performance, and to better understand the effects of payment innovation, care redesign, and other reforms.

How the Integration of Telehealth and Coordinated Care Approaches Impact Health Care Service Organization Structure and Ethos: Mixed Methods Study

Background

Coordinated care and telehealth services have the potential to deliver quality care to chronically ill patients. They can both reduce the economic burden of chronic care and maximize the delivery of clinical services. Such services require new behaviors, routines, and ways of working to improve health outcomes, administrative efficiency, cost-effectiveness, and user (patient and health professional) experience.

Objective

The aim of this study was to assess how health care organization setup influences the perceptions and experience of service managers and frontline staff during the development and deployment of integrated care with and without telehealth.

Methods

As part of a multinational project exploring the use of coordinated care and telehealth, questionnaires were sent to service managers and frontline practitioners. These questionnaires gathered quantitative and qualitative data related to organizational issues in the implementation of coordinated care and telehealth. Three analytical stages were followed: (1) preliminary analysis for a direct comparison of the responses of service managers and frontline staff to a range of organizational issues, (2) secondary analysis to establish statistically significant relationships between baseline and follow-up questionnaires, and (3) thematic analysis of free-text responses of service managers and frontline staff.

Results

Both frontline practitioners and managers highlighted that training, tailored to the needs of different professional groups and staff grades, was a crucial element in the successful implementation of new services. Frontline staff were markedly less positive than managers in their views regarding the responsiveness of their organization and the pace of change.

Conclusions

The data provide evidence that the setup of health care services is positively associated with outcomes in several areas, particularly tailored staff training, rewards for good service, staff satisfaction, and patient involvement.

A holistic approach to the patients/ Families with inborn errors of metabolism

Background

Diagnosis, treatment, and care of inborn errors of metabolism require well organized interdisciplinary teams. Holistic approaches comprise the system of all elements and relations between elements necessary for an optimal function of the system.

Methods

Following the rule “structure follows function” based on scientific, academic, and clinical experience the elements of the system providing diagnosis, treatment, and care for inborn errors of metabolism are defined and described.

Results

A holistic approach to inborn errors of metabolism comprising 10 elements is suggested, established, and controlled by an interdisciplinary metabolic team organized as a disease, and a case management program based on evidence-based guidelines is suggested. Quality assurance and quality control will not only improve the treatment of the individual but also the health system.

Conclusion

The holistic approach is a joint project of the team of health care professionals and the person with a condition, allowing them to see the patient’s individual medical, behavioral, social, legal, and economic context. For practical, technical, and economic reasons this will only be possible in centers caring for a critical number of individuals.

[The assessment of successfulness of management decision-making in medical organizations]

The decision-making management in health care organizations is one of the basic components of their efficiency. However, there is imbalance between requirements of everyday practice and scientific rationale of process under consideration, in particular lacking of appropriate criteria-diagnostic apparatus causing certain difficulties in decision-making. The purpose of the study was to design automated multi-criteria method of evaluating success of decision-making management in health care organizations. The survey of 62 experts, health care managers, was carried out. 23 criteria for evaluating success of decision-making management in health care organizations have been defined as well as their gradation and significance, integral model options, i.e. the multi-criteria evaluation method has been designed. The automation of method on "1C: Enterprise" software greatly facilitates assessment of not one but a number of health care organizations enabling their ranking. The machine processing results in integral evaluation and informative criteria determining it thus making possible search of case causes and ways of correction. The obtained results can be applied in daily procedures and training of executives of health care organizations.

How Health Care Organizations Approach Social Media Measurement: Qualitative Study

BACKGROUND

Many health care organizations use social media to support a variety of activities. To ensure continuous improvement in social media performance, health care organizations must measure their social media.

OBJECTIVE

The purpose of this study is to explore how health care organizations approach social media measurement and to elucidate the tools they employ.

METHODS

In this exploratory qualitative research, Australian health care organizations that use social media, varying in size and locality, were invited to participate in the study. Data were collected through semistructured interviews, and the transcripts were analyzed using thematic analysis.

RESULTS

The study identified health care organizations' approaches to social media measurement. While some measured their social media frequently, others used infrequent measurements, and a few did not measure theirs at all. Those that measured their social media used one or a combination of the following yardsticks: personal benchmarking, peer benchmarking, and metric benchmarking. The metrics tracked included one or more of the following: reach, engagement, and conversion rates. The tools employed to measure social media were either inbuilt or add-on analytics tools. Although many participants showed great interest in measuring their social media, they still had some unanswered questions.

CONCLUSIONS

The lack of a consensus approach to measurement suggests that, unlike other industries, social media measurement in health care settings is at a nascent stage. There is a need to improve knowledge, sophistication, and integration of social media strategy through the application of theoretical and analytical knowledge to help resolve the current challenge of effective social media measurement. This study calls for social media training in health care organizations. Such training must focus on how to use relevant tools and how to measure their use effectively.

Understanding U.S. Health Systems: Using Mixed Methods to Unpack Organizational Complexity

Introduction

As hospitals and physician organizations increasingly vertically integrate, there is an important opportunity to use health systems to improve performance. Prior research has largely relied on secondary data sources, but little is known about how health systems are organized "on the ground" and what mechanisms are available to influence physician practice at the front line of care.

Methods

We collected in-depth information on eight health systems through key informant interviews, descriptive surveys, and document review. Qualitative data were systematically coded. We conducted analyses to identify organizational structures and mechanisms through which health systems influence practice.

Results

As expected, we found that health systems vary on multiple dimensions related to organizational structure (e.g., size, complexity) which reflects history, market and mission. With regard to levers of influence, we observed within-system variation both in mechanisms (e.g., employment of physicians, system-wide EHR, standardization of service lines) and level of influence. Concepts such as "core" versus "peripheral" were more salient than "ownership" versus "contract."

Discussion

Data from secondary sources can help identify and map health systems, but they do not adequately describe them or the variation that exists within and across systems. To examine the degree to which health systems can influence performance, more detailed and nuanced information on health system characteristics is necessary.

Conclusion

The mixed-methods data accrual approach used in this study provides granular qualitative data that enables researchers to describe multi-layered health systems, grasp the context in which they operate, and identify the key drivers of performance.

[The modernization of personnel support of the Moscow psychiatric service in 2010-2017]

The modernization of the Moscow psychiatric service consisted in reduction of hospital service and development of out-patient service. The first stage of modernization (2010-2016) the psycho-neurological dispensaries were joined to psychiatric hospitals and bed stock was reduced or restructured for different function. The second stage of modernization (2017) consisted in such modernization of hospital network as further reducing of bed stock and unification of psychiatric hospitals. The third stage (2017-2020) presupposes development of out-patient care. The purpose of study was establishing provision of personnel resources of Moscow psychiatric institutions and analysis of dynamics of personnel resources during modernization period. The study is a continuous retrospective analysis of personnel of Moscow psychiatric service in 2008-2017. In this period number of occupied job positions of district psychiatrists decreased from 0.28 to 0.25 per 10 000 of population. In the Russian Federation provision with district psychiatrists made up to 0.23 per 10 000 of population in 2017. In 2027, the provision with psychiatrists of population made up to 1.15 in Moscow and 0.83 in the Russian Federation per 10 000 of population. In 2015-2017, in Moscow, quantity and staffing of out-patient job positions in Moscow psychiatric institutions increased. In 2017, the staffing of job positions in out-patient institutions made up to 63.5%-77%. In 2008-2017, in Moscow, total number of visits per district psychiatrist increased up to 36.5% for adults and up to 140.5% for adolescents and up to 5.3% for children. The percentage of psychiatrists with qualification category decreased from 2007 to 2017 and in 2017 made up to 40.4% in Moscow and up to 50.9% in the Russian Federation.

[The Analysis of Medication Load as a Basis of Optimization of Pharmaceutical Therapy of Exacerbation of Bronchial Asthma in Children]

The article considers factors favoring increasing of prevalence and provoking exacerbations of bronchial asthma among children. The possibilities of methods of DDD ? DU90% are demonstrated as applied to analysis of medication therapy.

Hospitals Strengthened Relationships With Close Partners After Joining Accountable Care Organizations

The strategies that hospitals participating in Medicare Accountable Care Organizations (ACOs) use to achieve quality and cost containment goals are poorly understood. One possibility is that participating hospitals could try to influence where their patients receive care. To test this hypothesis, we examined whether a hospital's participation in a Medicare ACO was associated with changes in its patterns of patient sharing with other hospitals. Between 2010 and 2014, patient sharing across hospitals increased 23.3%. After controlling for hospital and regional factors, patient sharing increased 4.4% more at ACO hospitals than non-ACO hospitals (p = .001 for difference). This increase occurred disproportionately among hospitals with which ACO hospitals already shared a high proportion of their patients prior to participation, and among hospitals in ACOs characterized as physician-hospital collaborations. The increased sharing of patients among closely affiliated hospitals may serve to achieve ACO quality and cost containment goals through increased interorganizational coordination.

The BC Glomerulonephritis Network: Improving Access and Reducing the Cost of Immunosuppressive Treatments for Glomerular Diseases

Glomerulonephritis (GN) is a common cause of end-stage renal disease in Canada and worldwide, and results in significant health care resource utilization and patient morbidity. However, GN has not been a traditional priority of provincial renal health care organizations, despite the known benefits to health services delivery and patient outcomes from integrated provincial care in other types of chronic kidney disease. To address this deficiency, the British Columbia (BC) Provincial Renal Agency created the BC GN Network in 2013 to coordinate provincial GN health services delivery informed by robust population-level data capture on all GN patients in the province via the BC GN Registry. This report describes the use of the BC GN Network infrastructure to systematically develop and evaluate a provincial GN drug formulary to improve patient and physician access to evidence-based immunosuppressive treatments for GN in a cost-efficient manner that successfully halted historical trends of increasing medication costs. An example is provided of using the provincial infrastructure to implement and subsequently evaluate an evidence-informed health policy of converting brand to generic tacrolimus for the treatment of GN. The BC GN Network, including the provincial drug formulary and data infrastructure, is an example of the benefits of expanding the mandate of provincial renal health administrative organizations to include the care of patients with GN, and constitutes a viable health delivery model that can be implemented in other Canadian provinces to achieve similar goals.

Using New Instruments of Clustering Policy in the Health Care System. The Case of Poland

The issue of clusters as a form of organization of market entities has recently attracted an increasing attention of health care management theoreticians and practitioners. In our opinion the existing theoretical basis gives a foundation for considering clusters as a source of potential for increasing the effectiveness of health policy and health care organizations. It can be assumed that in case of health care clusters there is a possibility of interregional diffusion of innovation, based on ventures undertaken on the health care market, increasing not only the potential of the entities in the cluster, but also of its surroundings and subcontractors. It is possible to realize the idea of a flexible health care implemented regionally with the use of modern techniques of communication, knowledge transfer and high specialization. Nonetheless, in case of Poland the potential of clustrification remains untapped, being characterized by a limited actions of public and private bodies, marginal role of non-profit sector organizations and limited engagement of R&D sector. This is because a general distrust in the cluster formula, and the lack of relevant knowledge among local officials and health business leaders. For this reason the process of clustrification among health care entities requires external support through the increased efforts to create a system of legal and tax preferences for cluster initiatives and provision of organizational support in terms of know-how, targeted particularly at bodies and individuals, who may act as cluster leaders.

[Realities of the prophylactic health care of workers in Poland]

BACKGROUND

The Polish occupational health system (OHS), existing over the past 17 years, has recently been contested as never before. Critical voices pertain to both legislative and executive aspects of the system, in which key roles are played by employers and occupational medicine service. There are some reasons for making a hypothesis that relevant norms are not always respected by the main actors.

MATERIAL AND METHODS

The data on the observance of norms by entities responsible for providing workers with prophylactic health care were analyzed. They were obtained from the existing external resources and materials collected during the implementation of tasks assigned by the Ministry of Health.

RESULTS

Legal norms, which constitute OHS in Poland are generally neither respected by the employers, nor by the representatives of occupational medicine service. Nearly half (45-47%) of employers infringe provisions relating to medical examinations of workers. Such a degree of non-observance of respective laws would have not been the case if it was not for the attitudes and "silent approval" of many (but not all) occupational physicians. Laws defining the responsibilities of occupational medicine service units on one hand, and of employers on the other, are for many reasons infringed by both groups.

CONCLUSIONS

The data analyses indicate that the Polish OHS is, to a large extent, not acceptable and should be replaced with another one founded on other assumptions and responsive to contemporary occupational health challenges. New provisions should be formulated on the basis of merit and guided by socially accepted norms.

Between ideals and reality in home-based rehabilitation

SETTING AND OBJECTIVE

The growing elderly population and the rising number of people with chronic diseases indicate an increasing need for rehabilitation. Norwegian municipalities are required by law to offer rehabilitation. The aim of this study was to investigate how rehabilitation work is perceived and carried out by first-line service providers compared with the guidelines issued by Norway's health authorities.

DESIGN AND SUBJECTS

In this action research project, qualitative data were collected through 24 individual interviews and seven group interviews with employees--service providers and managers--in the home-based service of two boroughs in Oslo, Norway. The data were analysed using a systematic text-condensation method.

RESULTS

The results show that rehabilitation receives little attention in the boroughs and that patients are seldom rehabilitated at home. There is disagreement among professional staff as to what rehabilitation is and should be. The purchaser-provider organization, high speed of service delivery, and scarcity of resources are reported to hamper rehabilitation work.

CONCLUSION AND IMPLICATIONS

A discrepancy exists between the high level of ambitious goals of Norwegian health authorities and the possibilities that practitioners have to achieve them. This situation results in healthcare staff being squeezed by the increasing expectations and demands of the population and the promises and statutory rights coming from politicians and administrators. For the employees in the municipalities to place rehabilitation on the agenda, it is a requirement that authorities understand the clinical aspect of rehabilitation and provide the municipalities with adequate framework conditions for successful rehabilitation work.

KEY POINTS

Home-based rehabilitation is documented to be effective, and access to rehabilitation has been established in Norwegian law. The purchaser-provider organization, high rate of speed, and a scarcity of resources in home-based services hamper rehabilitation work. Healthcare providers find themselves squeezed between the health authorities' overarching guidelines and requirements and the possibilities of achieving them. Rehabilitation must be placed on the agenda on the condition that authorities understand the clinical aspect of rehabilitation.

Expert knowledge elicitation using computer simulation: the organization of frail elderly case management as an illustration

BACKGROUND

Various elderly case management projects have been implemented in Belgium. This type of long-term health care intervention involves contextual factors and human interactions. These underlying complex mechanisms can be usefully informed with field experts' knowledge, which are hard to make explicit. However, computer simulation has been suggested as one possible method of overcoming the difficulty of articulating such elicited qualitative views.

METHODS

A simulation model of case management was designed using an agent-based methodology, based on the initial qualitative research material. Variables and rules of interaction were formulated into a simple conceptual framework. This model has been implemented and was used as a support for a structured discussion with experts in case management.

RESULTS

The rigorous formulation provided by the agent-based methodology clarified the descriptions of the interventions and the problems encountered regarding: the diverse network topologies of health care actors in the project; the adaptation time required by the intervention; the communication between the health care actors; the institutional context; the organization of the care; and the role of the case manager and his or hers personal ability to interpret the informal demands of the frail older person.

CONCLUSION

The simulation model should be seen primarily as a tool for thinking and learning. A number of insights were gained as part of a valuable cognitive process. Computer simulation supporting field experts' elicitation can lead to better-informed decisions in the organization of complex health care interventions.

How can we recognize continuous quality improvement?

Objective

Continuous quality improvement (CQI) methods are foundational approaches to improving healthcare delivery. Publications using the term CQI, however, are methodologically heterogeneous, and labels other than CQI are used to signify relevant approaches. Standards for identifying the use of CQI based on its key methodological features could enable more effective learning across quality improvement (QI) efforts. The objective was to identify essential methodological features for recognizing CQI.

Design

Previous work with a 12-member international expert panel identified reliably abstracted CQI methodological features. We tested which features met rigorous a priori standards as essential features of CQI using a three-phase online modified-Delphi process.

Setting

Primarily United States and Canada.

Participants

119 QI experts randomly assigned into four on-line panels.

Intervention(s)

Participants rated CQI features and discussed their answers using online, anonymous and asynchronous discussion boards. We analyzed ratings quantitatively and discussion threads qualitatively.

Main outcome measure(s)

Panel consensus on definitional CQI features.

Results

Seventy-nine (66%) panelists completed the process. Thirty-three completers self-identified as QI researchers, 18 as QI practitioners and 28 as both equally. The features ‘systematic data guided activities,’ ‘designing with local conditions in mind’ and ‘iterative development and testing’ met a priori standards as essential CQI features. Qualitative analyses showed cross-cutting themes focused on differences between QI and CQI.

Conclusions

We found consensus among a broad group of CQI researchers and practitioners on three features as essential for identifying QI work more specifically as ‘CQI.’ All three features are needed as a minimum standard for recognizing CQI methods.

Healthcare Information Systems to Assess Influenza Outbreaks: An analysis of the 2009 H1N1 Epidemic in Buenos Aires

OBJECTIVE

To determine whether a private HIS could have detected the influenza epidemic outbreaks earlier through changes in morbidity and mortality patterns.

METHODS

Data Source included a health information system (HIS) from an academic tertiary health care center integrating administrative and clinical applications. It used a local interface terminology server which provides support through data autocoding of clinical documentation. Specific data subsets were created to compare the burden of influenza during the epidemiological week (EW) 21 to 26 for years 2007 to 2009 among 150,000 Health Maintenance Organization members in Argentina. The threshold for identifying an epidemic was considered met when the weekly influenza-like illness (ILI) rate exceeded 200 per 100,000 visits. Case fatality rates and mortality rates of severe acute respiratory infection (SARI) from 2007 to 2009 were retrospectively compared. Case fatality rates and mortality rates for A/H1N1 influenza 2009 also were estimated.

RESULTS

The HIS detected the outbreak in EW 23 while the government Ministry of Health (MoH) gave a national epidemic alert during EW 25. The number of visits for ILI increased more than fourfold when comparing 2009 to the period 2007-2008. The SARI mortality rate in 2009 was higher than in 2008 (RR 2.8; 95%CI 1.18-6.63) and similar to that of 2007 (RR 1.05; 95%CI 0.56-1.49). 2009 was the first year with mortalities younger than 65 years attributable to SARI. The estimated A/H1N1 case fatality rate for SARI was 6.2% (95%CI 2.5 to 15.5) and A/H1N1 mortality rate was 6 per 100,000 (95%CI 0 to 11.6).

CONCLUSION

Our HIS detected the outbreak two weeks before than the MoH gave a national alert. The information system was useful in assessing morbidity and mortality during the 2009 influenza epidemic H1N1 outbreak suggesting that with a private-public integration a more real-time outbreak and disease surveillance system could be implemented.

Does affiliation of physician groups with one another produce higher quality primary care?

PURPOSE

Recent reports have emphasized the importance of delivery systems in improving health care quality. However, few prior studies have assessed differences in primary care quality between physician groups that differ in size and organizational configuration. We examined whether larger physician group size and affiliation with networks of multiple groups are associated with higher quality of care.

METHODS

We conducted a cross-sectional observational analysis of 132 physician groups (including 4,358 physicians) who delivered primary care services in Massachusetts in 2002. We compared physician groups on performance scores for 12 Health Plan Employer Data and Information Set (HEDIS) measures reflecting processes of adult primary care.

RESULTS

Network-affiliated physician groups had higher performance scores than non-affiliated groups for 10 of the 12 HEDIS measures (p < 0.05). There was no consistent relationship between group size and performance scores. Multivariable models including group size, network affiliation, and health plan showed that network-affiliated groups had higher performance scores than non-affiliated groups on 8 of the 12 HEDIS measures (p < 0.05), and larger group size was not associated with higher performance scores. Adjusted differences in the performance scores of network-affiliated and non-affiliated groups ranged from 2% to 15%. For 4 HEDIS measures related to diabetes care, performance score differences between network-affiliated and non-affiliated groups were most apparent among the smallest groups.

CONCLUSIONS

Physician group affiliation with networks of multiple groups was associated with higher quality, and for measures of diabetes care the quality advantage of network-affiliation was most evident among smaller physician groups.