To determine the relationship between cost and quality in European hospitals.
Juran’s cost–quality curve served as a theoretical framework, linked to basic efficiency concepts. Based on systematic database searches, citation searches and cross-referencing, we identify 1093 empirical studies. After exclusion of studies from outside Europe (699), non-hospital settings (10 studies), lack of a cost parameter (194) or a quality parameter (27 studies), 22 studies (28 analyses) were assessed for direction of association and methodological heterogeneity.
There was evidence of positive, negative, two-directional and no association between cost and quality. We examined whether diagnosis, procedure, type of quality measure and specification of the econometric model could explain the inconsistent evidence, but no clear explanation is identified. Despite the significant policy relevance, evidence on the relationship between costs and quality is limited. The literature is characterized by substantial methodological heterogeneity and lack of explicit definitions of the chosen cost and quality parameters, the econometric model and the underlying hypothesis for the cost–quality relationship.
It has been more than 60 years since Juran introduced the idea of failure costs, which implied that the marginal costs of quality could be non-constant. It seems imperative to acknowledge this idea in future studies.
Reducing health inequalities is an explicit goal of England’s health system. Our aim was to compare the performance of English local administrative areas in reducing socioeconomic inequality in emergency hospital admissions for ambulatory care sensitive chronic conditions.
We used local authority area as a stable proxy for health and long-term care administrative geography between 2004/5 and 2011/12. We linked inpatient hospital activity, deprivation, primary care, and population data to small area neighbourhoods (typical population 1500) within administrative areas (typical population 250,000). We measured absolute inequality gradients nationally and within each administrative area using neighbourhood-level linear models of the relationship between national deprivation and age–sex-adjusted emergency admission rates. We assessed local equity performance by comparing local inequality against national inequality to identify areas significantly more or less equal than expected; evaluated stability over time; and identified where equity performance was steadily improving or worsening. We then examined associations between change in socioeconomic inequalities and change in within-area deprivation (gentrification). Finally, we used administrative area-level random and fixed effects models to examine the contribution of primary care to inequalities in admissions.
Data on 316 administrative areas were included in the analysis. Local inequalities were fairly stable between consecutive years, but 32 areas (10%) showed steadily improving or worsening equity. In the 21 improving areas, the gap between most and least deprived fell by 3.9 admissions per 1000 (six times the fall nationally) between 2004/5 and 2011/12, while in the 11 areas worsening, the gap widened by 2.4. There was no indication that measured improvements in local equity were an artefact of gentrification or that changes in primary care supply or quality contributed to changes in inequality.
Local equity performance in reducing inequality in emergency admissions varies both geographically and over time. Identifying this variation could provide insights into which local delivery strategies are most effective in reducing such inequalities.
To use geographic variation in unplanned ambulatory care sensitive condition admission rates to identify the clinical areas and patient subgroups where there is greatest potential to prevent admissions and improve the quality and efficiency of care.
We used English Hospital Episode Statistics data from 2011/2012 to describe the characteristics of patients admitted for ambulatory care sensitive condition care and estimated geographic variation in unplanned admission rates. We contrasted geographic variation across admissions with different lengths of stay which we used as a proxy for clinical severity. We estimated the number of bed days that could be saved under several scenarios.
There were 1.8 million ambulatory care sensitive condition admissions during 2011/2012. Substantial geographic variation in ambulatory care sensitive condition admission rates was commonplace but mental health care and short-stay (<2 days) admissions were particularly variable. Reducing rates in the highest use areas could lead to savings of between 0.4 and 2.8 million bed days annually.
Widespread geographic variations in admission rates for conditions where admission is potentially avoidable should concern commissioners and could be symptomatic of inefficient care. Further work to explore the causes of these differences is required and should focus on mental health and short-stay admissions.
We explored the real cost of training the workforce in a range of primary health care professions in Australia with a focus on the impact of retention to contribute to the debate on how best to achieve the optimal health workforce mix.
The cost to train an entry-level health professional across 12 disciplines was derived from university fees, payment for clinical placements and, where relevant, cost of internship, adjusted for student drop-out. Census data were used to identify the number of qualified professionals working in their profession over a working life and to model expected years of practice by discipline. Data were combined to estimate the mean cost of training a health professional per year of service in their occupation.
General medical graduates were the most expensive to train at $451,000 per completing student and a mean cost of $18,400 per year of practice (expected 24.5 years in general practice), while dentistry also had a high training cost of $352,180 but an estimated costs of $11,140 per year of practice (based on an expected 31.6 years in practice). Training costs are similar for dieticians and podiatrists, but because of differential workforce retention (mean 14.9 vs 31.5 years), the cost of training per year of clinical practice is twice as high for dieticians ($10,300 vs. $5200), only 8% lower than that for dentistry.
Return on investment in training across professions is highly variable, with expected time in the profession as important as the direct training cost. These results can indicate where increased retention and/or attracting trained professionals to return to practice should be the focus of any supply expansion versus increasing the student cohort.
The credibility of a regulator could be threatened if stakeholders perceive that assessments of performance made by its inspectors are unreliable. Yet there is little published research on the reliability of inspectors’ assessments of health care organizations’ services.
We investigated the inter-rater reliability of assessments made by inspectors inspecting acute hospitals in England during the piloting of a new regulatory model implemented by the Care Quality Commission (CQC) during 2013 and 2014. Multi-professional teams of inspectors rated service provision on a four-point scale for each of five domains: safety; effectiveness; caring; responsiveness; and leadership.
In an online survey, we asked individual inspectors to assign a domain and a rating to each of 10 vignettes of service information extracted from CQC inspection reports. We used these data to simulate the ratings that might be produced by teams of inspectors. We also observed inspection teams in action, and interviewed inspectors and staff from hospitals that had been inspected.
Levels of agreement varied substantially from vignette to vignette. Characteristics such as professional background explained only a very small part of the variation. Overall, agreement was higher on ratings than on domains, and for groups of inspectors compared with individual inspectors. A number of potential causes of disagreement were identified, such as differences regarding the weight that should be given to contextual factors and general uncertainty about interpreting the rating and domain categories.
Groups of inspectors produced more reliable assessments than individual inspectors, and there is evidence to support the utility of appropriate discussions between inspectors in improving reliability. The reliability of domain allocations was lower than for ratings. It is important to define categories and rating levels clearly, and to train inspectors in their use. Further research is needed to replicate these results now that the model has been fully implemented, and to understand better the impact that inspector uncertainty and disagreement may have on published CQC ratings.
To examine the long-term effects of drug reimbursement adjustments on drug-switching decisions and to investigate whether patients with complicated or severe conditions are more affected.
A population-based, longitudinal study with a before-and-after design. Analysis of 141,703 patients with type 2 diabetes covered by the universal health insurance program in Taiwan. Observation of five 6-month phases before and after a drug reimbursement adjustment implemented in October 2009. Drug switching was defined as a brand change within the same anatomical therapeutic chemical group between two consecutive physician visits. Generalized estimating equations were employed to control for the random subject effect.
The drug-switching rates in the five phases were 10.85% and 13.71% before implementation and 31.53%, 28.29% and 15.61% after implementation. Results from the regression model revealed a higher likelihood of receiving switched drugs in phases 3, 4 and 5, with odds ratios of 3.16, 2.72 and 1.44 (with 95% confidence interval 3.04–3.29, 2.61–2.84 and 1.38–1.51), respectively, compared with phase 1. Patients with complicated or severe conditions were more likely to have their drugs switched after the reimbursement adjustment.
The drug reimbursement adjustment under the health insurance program resulted in an increase in drug-switching decisions, and patients were not exempt from medication switching regardless of the complications or the severity level of their illness.
To analyse the process of health care privatization using the case of Israeli health care reforms during the last three decades.
We used mixed methods including quantitative analysis of trends in health expenditures in Israel and qualitative critical analysis of documents describing the main health reforms.
Israel epitomizes how boundaries between the private and public sector become blurred when health care services are subject to privatization, both of finance and supply. Additionally, the continuous growth of public–private relationships in health care results in systems that lack both equity and efficiency.
More than three decades of experience show that such private–public partnerships increase both inequality and inefficiency. While most discussion surrounding the private–public mix in health care focuses on financing infrastructure, in Israel, the public–private mix has become a central way of financing and delivering services, making its damaging influence more pervasive.
Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services.
A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour.
The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness.
There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’ skills through education or joint consultations with complex patients.
Patients admitted as emergencies to hospitals at the weekend have higher death rates than patients admitted on weekdays. This may be because the restricted service availability at weekends leads to selection of patients with greater average severity of illness. We examined volumes and rates of hospital admissions and deaths across the week for patients presenting to emergency services through two routes: (a) hospital Accident and Emergency departments, which are open throughout the week; and (b) services in the community, for which availability is more restricted at weekends.
Retrospective observational study of all 140 non-specialist acute hospital Trusts in England analyzing 12,670,788 Accident and Emergency attendances and 4,656,586 emergency admissions (940,859 direct admissions from primary care and 3,715,727 admissions through Accident and Emergency) between April 2013 and February 2014.Emergency attendances and admissions to hospital and deaths in any hospital within 30 days of attendance or admission were compared for weekdays and weekends.
Similar numbers of patients attended Accident and Emergency on weekends and weekdays. There were similar numbers of deaths amongst patients attending Accident and Emergency on weekend days compared with weekdays (378.0 vs. 388.3). Attending Accident and Emergency at the weekend was not associated with a significantly higher probability of death (risk-adjusted OR: 1.010).
Proportionately fewer patients who attended Accident and Emergency at weekend were admitted to hospital (27.5% vs. 30.0%) and it is only amongst the subset of patients attending Accident and Emergency who were selected for admission to hospital that the probability of dying was significantly higher at the weekend (risk-adjusted OR: 1.054).
The average volume of direct admissions from services in the community was 61% lower on weekend days compared to weekdays (1317 vs. 3404). There were fewer deaths following direct admission on weekend days than weekdays (35.9 vs. 80.8). The mortality rate was significantly higher at weekends amongst direct admissions (risk-adjusted OR: 1.212) due to the proportionately greater reduction in admissions relative to deaths.
There are fewer deaths following hospital admission at weekends. Higher mortality rates at weekends are found only amongst the subset of patients who are admitted. The reduced availability of primary care services and the higher Accident and Emergency admission threshold at weekends mean fewer and sicker patients are admitted at weekends than during the week. Extending services in hospitals and in the community at weekends may increase the number of emergency admissions and therefore lower mortality, but may not reduce the absolute number of deaths.
To explore the ‘added value’ that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives.
Realist evaluation. We identified the programme theories underlying the claims made about GP ‘added value’ in commissioning from interviews with key informants. We tested these theories against observational data from four case study sites to explore whether and how these claims were borne out in practice.
The complexity of CCG structures means CCGs are quite different from one another with different distributions of responsibilities between the various committees. This makes it difficult to compare CCGs with one another. Greater GP involvement was important but it was not clear where and how GPs could add most value. We identified some of the mechanisms and conditions which enable CCGs to maximize the ‘added value’ that GPs bring to commissioning.
To maximize the value of clinical input, CCGs need to invest time and effort in preparing those involved, ensuring that they systematically gather evidence about service gaps and problems from their members, and engaging members in debate about the future shape of services.
Wayfinding in hospitals is a complex problem since patients, who are likely to be under stress, may have to navigate their way to multiple locations in the course of a single visit. While good wayfinding design can reduce stress, poor wayfinding can not only increase individuals' anxiety but also generate additional costs for the hospital due to: lost time among staff members who need to direct patients rather than concentrate on their designated task; missed appointments or delayed meetings; and additional security staff to ensure that patients do not enter restricted areas. We investigated to what extent a questionnaire, developed by collecting data about the subjective experiences of wayfinders with diverse needs and abilities, could uncover wayfinding problems in hospitals.
The methodology we developed involved four steps: creating an initial questionnaire based on the literature; customizing the questionnaire to a hospital environment; validating and verifying the questionnaire; and evaluating the questionnaire’s added value at nine other hospitals.
The questionnaire’s generality and added value were demonstrated since many types of wayfinding problems were uncovered at the nine hospitals that other methods had overlooked or regarded as relatively unimportant. The research emphasizes the centrality and uniqueness of the wayfinder rather than that of the institute in determining what people need.
Our findings can contribute to understanding wayfinding issues in hospitals and to sensitize designers to the needs and knowledge levels of wayfinders when designing hospitals.
To test whether the model of ‘diffusion of innovations’ enriches understanding of the implementation of evidence-based thrombolysis services for stroke patients.
Four case studies of the implementation of evidence on thrombolysis in stroke services in England and Sweden. Semistructured interviews with 95 staff including doctors, nurses and managers working in stroke units, emergency medicine, radiology, the ambulance service, community rehabilitation services and commissioners.
The implementation of thrombolysis in acute stroke management benefited from a critical mass of the factors featured in the model including: the support of national and local opinion leaders; a strong evidence base and financial incentives. However, while the model provided a starting point as an organizational framework for mapping the critical factors influencing implementation, to understand properly the process of implementation and the importance of the different factors identified, more detailed analyses of context and, in particular, of the human and social dimensions of change was needed.
While recognising the usefulness of the model of diffusion of innovations in mapping the processes by which diffusion occurs, the use of methods that lend themselves to in-depth analysis, such as ethnography and the application of relevant bodies of social theory, are needed.
Health care policies are influenced by many groups which in turn influence each other. Our aim was to describe a network of nominated influential stakeholders and analyze how it affects attitudes to reforming primary care.
Face-to-face interviews were carried out in Belgium with 102 influential people. Each respondent was asked to score solutions for improving the role of general practice in the health care system and to nominate up to six other influential stakeholders. Social network and multivariate analyses were used to describe the nomination network and its effect on attitudes to reform.
The network was highly centralized and homophilous (tendency to bond with people who are similar) for language groups. Despite Belgium having a strong pluralist tradition of decision making, policy makers were central to the network (average indegree = 10.8) compared to professional representatives (6.9). Respondents supported an enhanced role for general practitioners but did not support radically new policies.
Social network analysis contributes to understanding why health care reforms may languish in pluralistic, decentralized health care systems. The central position of a stakeholder in a network is related to perceived influence but does not favour a radical policy orientation. In addition, language-group homophily in the ‘perceived influence network’ leads to a weak coalition that only favours small-step reform.
Our aim was to specify the requirements of an architecture to serve as the foundation for standardized reporting of health information and to provide an exemplary application of this architecture.
The World Health Organization’s International Classification of Functioning, Disability and Health (ICF) served as the conceptual framework. Methods to establish content comparability were the ICF Linking Rules. The Rasch measurement model, as a special case of additive conjoint measurement, which satisfies the required criteria for fundamental measurement, allowed for the development of a common metric foundation for measurement unit conversion. Secondary analysis of data from the North Yorkshire Survey was used to illustrate these methods. Patients completed three instruments and the items were linked to the ICF. The Rasch measurement model was applied, first to each scale, and then to items across scales which were linked to a common domain.
Based on the linking of items to the ICF, the majority of items were grouped into two domains, Mobility and Self-care. Analysis of the individual scales and of items linked to a common domain across scales satisfied the requirements of the Rasch measurement model. The measurement unit conversion between items from the three instruments linked to the Mobility and Self-care domains, respectively, was demonstrated.
The realization of an ICF-based architecture for information on patients’ functioning enables harmonization of health information while allowing clinicians and researchers to continue using their existing instruments. This architecture will facilitate access to comprehensive and consistently reported health information to serve as the foundation for informed decision-making.
Funding bodies, policy makers, researchers and clinicians are seeking strategies to increase the translation of knowledge between research and practice. Participatory research encompasses a range of approaches for clinicians’ involvement in research in the hope of increasing the relevance and usability of research. Our aim was to explore how knowledge is translated and integrated in participants’ presentations and negotiations about knowledge.
Twelve collaboration meetings were observed, and discussions between researchers and clinicians were recorded. The material was examined using the following analytical terms: knowledge object, knowledge form, knowledge position and knowledge tasks.
We identified a recurring rhetorical pattern in translational processes that we call ‘relevance testing’: a strategy by which the participants attempt to create coherence and identify relevance across different contexts. The limitation of this translational strategy was a tendency to reinforce a ‘two-communities’ logic: re-establishing the separated worlds and rationales between clinicians and researchers. The ‘translational work’ that unfolds during discussions remains implicit. It may be that participants are unable to explicitly address and identify the knowledge translation processes because they lack necessary conceptual tools.
Our results contribute to increased awareness about translational processes and provide a language through which barriers to translation can be addressed.
Interviews with ethnic minority patients provide a rich source of data to understand their perspectives of disease and its management. Language barriers are, however, often a problem so interpreters need to be used. We explored the impact of the interpreter on cross-language interviews between researchers and respondents.
Secondary analysis of four interviews between researchers and patients involving professional interpreters.
Interpreters were actively involved and influenced the interview in several ways: they assumed the interviewer’s communicative role, edited information; initiated information-seeking, took over control of the interview, and took over the respondent’s role. While the interpreter supported the interviewer, they posed risks to the quality of the interview.
Researchers need to be aware of the influence of interpreters. Researchers should instruct interpreters carefully about their roles though they may benefit from interpreters’ strategies to support them.
A wide range of patient benefits have been attributed to single room hospital accommodation including a reduction in adverse patient safety events. However, studies have been limited to the US with limited evidence from elsewhere. The aim of this study was to assess the impact on safety outcomes of the move to a newly built all single room acute hospital.
A natural experiment investigating the move to 100% single room accommodation in acute assessment, surgical and older people’s wards. Move to 100% single room accommodation compared to ‘steady state’ and ‘new build’ control hospitals. Falls, pressure ulcer, medication error, meticillin-resistant Staphylococcus aureus and Clostridium difficile rates from routine data sources were measured over 36 months.
Five of 15 time series in the wards that moved to single room accommodation revealed changes that coincided with the move to the new all single room hospital: specifically, increased fall, pressure ulcer and Clostridium difficile rates in the older people’s ward, and temporary increases in falls and medication errors in the acute assessment unit. However, because the case mix of the older people’s ward changed, and because the increase in falls and medication errors on the acute assessment ward did not last longer than six months, no clear effect of single rooms on the safety outcomes was demonstrated. There were no changes to safety events coinciding with the move at the new build control site.
For all changes in patient safety events that coincided with the move to single rooms, we found plausible alternative explanations such as case-mix change or disruption as a result of the re-organization of services after the move. The results provide no evidence of either benefit or harm from all single room accommodation in terms of safety-related outcomes, although there may be short-term risks associated with a move to single rooms.
Our aim was to identify the factors influencing the selection of a model of acute stroke service centralization to create fewer high-volume specialist units in two metropolitan areas of England (London and Greater Manchester). It considers the reasons why services were more fully centralized in London than in Greater Manchester.
In both areas, we analysed 316 documents and conducted 45 interviews with people leading transformation, service user organizations, providers and commissioners. Inductive and deductive analyses were used to compare the processes underpinning change in each area, with reference to propositions for achieving major system change taken from a realist review of the existing literature (the Best framework), which we critique and develop further.
In London, system leadership was used to overcome resistance to centralization and align stakeholders to implement a centralized service model. In Greater Manchester, programme leaders relied on achieving change by consensus and, lacking decision-making authority over providers, accommodated rather than challenged resistance by implementing a less radical transformation of services.
A combination of system (top-down) and distributed (bottom-up) leadership is important in enabling change. System leadership provides the political authority required to coordinate stakeholders and to capitalize on clinical leadership by aligning it with transformation goals. Policy makers should examine how the structures of system authority, with performance management and financial levers, can be employed to coordinate transformation by aligning the disparate interests of providers and commissioners.
Steam sterilization in hospitals is an energy and water intensive process. Our aim was to identify opportunities to improve electricity and water use. The objectives were to find: the time sterilizers spent active, idle and off; the variability in sterilizer use with the time of day and day of the week; and opportunities to switch off sterilizers instead of idling when no loads were waiting, and the resultant electricity and water savings.
Analyses of routine data for one year of the activity of the four steam sterilizers in one hospital in Melbourne, Australia. We examined active sterilizer cycles, routine sterilizer switch-offs, and when sterilizers were active, idle and off. Several switch-off strategies were examined to identify electricity and water savings: switch off idle sterilizers when no loads are waiting and switch off one sterilizer after 10:00 h and a second sterilizer after midnight on all days.
Sterilizers were active for 13,430 (38%) sterilizer–hours, off for 4822 (14%) sterilizer–hours, and idle for 16,788 (48%) sterilizer–hours. All four sterilizers were simultaneously active 9% of the time, and two or more sterilizers were idle for 69% of the time. A sterilizer was idle for two hours or less 13% of the time and idle for more than 2 h 87% of the time. A strategy to switch off idle sterilizers would reduce electricity use by 66 MWh and water use by 1004 kl per year, saving 26% electricity use and 13% of water use, resulting in financial savings of AUD$13,867 (UK£6,517) and a reduction in 79 tonnes of CO2 emissions per year. An alternative switch-off strategy of one sterilizer from 10:00 h onwards and a second from midnight would have saved 30 MWh and 456 kl of water.
The methodology used of how hospital sterilizer use could be improved could be applied to all hospitals and more broadly to other equipment used in hospitals.
To assess what is known about effective patient and public engagement in health service reconfiguration processes and identify implications for further research and health care practice.
Rapid systematic review of published and grey literature to identify methods or approaches to engagement in decisions about health service reconfiguration; and to examine how engagement has worked or not worked in specific examples of system change. Following a search for literature published in English from 2000 to March 2014, eight systematic reviews, seven primary studies and 24 case studies (of which 6 were exemplars) were included. We undertook a narrative synthesis to consider five aspects of engagement with health service reconfiguration.
Engagement varied in nature and intensity, and efforts generally involved multiple methods. There was no evidence on the isolated impact of any particular engagement method or collection of methods. In general, engagement was most likely to be successful when started early, when led and supported by clinicians, and when it offered opportunities for genuine interaction. The impact of engagement was variably measured and demonstrated, and frequently defined as process measures rather than the outcomes of proposals for service reconfiguration. Little was reported on the potential negative impact of service user engagement.
Patients and the public can be engaged through various methods. Problems often arise because decision-makers paid insufficient attention to issues considered important by patients and the public. Guidance setting out the stages of reconfiguration and opportunities for service user input could be a helpful practical framework for future engagement activity. Future evaluation and explicit reporting of engagement and impact is needed.
To evaluate an accelerated form of experience-based co-design (EBCD), a type of participatory action research in which patients and staff work together to improve quality; to observe how acceleration affected the process and outcomes of the intervention.
An ethnographic process evaluation of an adapted form of EBCD was conducted, including observations, interviews, questionnaires and documentary analysis. Whilst retaining all components of EBCD, the adapted approach replaced local patient interviews with secondary analysis of a national archive of patient experience narratives to create national trigger films; shortened the timeframe; and employed local improvement facilitators. It was tested in intensive care and lung cancer in two English National Health Service (NHS) hospitals. A total of 96 clinical staff (primarily nursing and medical), and 63 patients and family members participated in co-design activities.
The accelerated approach proved acceptable to staff and patients; using films of national rather than local narratives did not adversely affect local NHS staff engagement, and may have made the process less threatening or challenging. Local patients felt the national films generally reflected important themes although a minority felt they were more negative than their own experience. However, they served their purpose of ‘triggering’ discussion between patients and staff, and the resulting 48 co-design (improvement) activities across the four pathways were similar to those in EBCD, but achieved more quickly and at lower cost.
Accelerated EBCD offers a rigorous and relatively cost-effective patient-centered quality improvement approach.
Hospitals are significant contributors to natural resource depletion and environmental change. Our objective was to establish the extent to which hospital environmental sustainability has been studied and the key issues that emerge for policy, practice and research.
The PubMed, Engineering Village, Cochrane and King's Fund databases were searched for articles relating to hospital environmental sustainability published in English between 1 January 1990 and 1 October 2013. Further studies were found by review of reference lists. One hundred ninety-three relevant articles were found and 76 were selected for inclusion in the review.
Common research themes were identified: hospital design, direct energy consumption, water, procurement, waste, travel and psychology and behaviour. Some countries (particularly the United Kingdom) have begun to invest systematically in understanding the environmental effects of hospitals. We found large variability in the extent of the evidence base according to topic. Research regarding the architectural fabric of hospital buildings is at a relatively mature stage. Similarly, there is a developed research base regarding devices and technologies used within hospitals to reduce the environmental effects of direct hospital energy and water use. Less is known about the clinical, psychological and social factors that influence how health care professionals use resources, travel to/from hospital, and interact with the buildings and technologies available. A significant part of the environmental footprint of hospitals relates to clinical practice, e.g. decisions regarding the use of pharmaceuticals and medical devices. Medical ‘cradle to grave’ life cycle assessment studies have been published to understand the full financial and environmental costs of hospital activities. The effects of preventive or demand management measures which avoid unnecessary hospital procedures are likely to be much greater than incremental changes to how hospital procedures are performed.
There remain significant gaps in the evidence base on hospital sustainability. Assessments of environmental impacts and natural resource use are beginning to be produced, both at the level of individual hospitals and at the health system level. These are an important start, but in many areas do not yet provide sufficiently detailed information to guide decision-making. There are many areas where the interests of patients and the environment coincide, but others where tensions exist. Rising resource costs and climate change mitigation measures are likely to create an increasing stimulus for research on hospital sustainability. Such research will benefit from inter-disciplinary coordination across research funders and countries.
Non-surgical treatment can be effective for many musculoskeletal conditions. Improving access to these options may improve the efficiency of hospitals. The Orthopaedic Physiotherapy Screening Clinic and Multidisciplinary Service offers early comprehensive assessment and coordinated, patient-centred care within a multidisciplinary framework. Our aim was to assess its cost-effectiveness compared with usual orthopaedic care.
A Markov model was constructed to estimate the quality-adjusted life years and health care costs from the perspective of health care payers for outpatients with low back, knee or shoulder conditions compared to usual orthopaedic care. Data were obtained from a retrospective chart review, administrative sources, literature and expert opinion. The time frame was five years and all costs were reported in 2011 $AUD.
Compared with usual orthopaedic care, the physiotherapist-led service costs an additional $495 per Quality Adjusted Life Year gained. The model remained cost-effective over a range of one-way sensitivity analyses.
The physiotherapist-led service is likely to be highly cost-effective. Determining the optimal mix of hospital orthopaedic outpatient services may require more advanced modeling techniques to be applied.
Telephone-accessed health care plays a significant part in the delivery of urgent care internationally. NHS 111 is a telephone service set up to improve and simplify access to non-emergency National Health Service health care in England. The first aim of this research was to describe population awareness and use of this new service, overall and within different sub-groups. In doing so, the second aim was to identify any inequity in awareness or use of telephone-accessed health care.
We undertook a telephone survey to assess awareness and use of NHS 111 in four sites. Random digit dialing was undertaken to identify 2000 respondents in each site. The survey was undertaken in 2011, approximately 9–10 months after the launch of NHS 111 in each site. Eight thousand and ten members of the general population completed a questionnaire.
Fifty-nine percent of respondents had heard of NHS 111 and 9% reported ever using NHS 111. Respondents were less likely to have used NHS 111 if they were older (p ≤ 0.001), male (p ≤ 0.001), and did not have a disability/limiting long-term illness (p ≤ 0.001) or own their home (p = 0.039).
The use of the telephone as an important means of access to urgent care may be problematic if some groups in the population are less likely to use it. Policy makers and service providers may need to consider other ways of offering access to care or deliver targeted publicity campaigns to encourage the use of telephone-accessed health care amongst specific groups within a population.
Several countries in sub-Saharan Africa have implemented policies to remove or reduce user fees. Our aim was to identify criteria guiding such decisions among national policy entrepreneurs, those who link up problem definition, solution development and political processes.
We administered a best–worst scaling (BWS) experiment to 89 policy entrepreneurs, asking them to identify the most and the least important criteria on a series of predefined sets. Sets were compiled using a Balance Incomplete Block Design which generated random combinations of all 11 criteria included in the experiment. In turn, those had emerged from a prior set of focus group discussions organized among policy entrepreneurs. Ordered logit models were used to investigate the value of single criteria as well as heterogeneity of preferences.
Political commitment was identified as the most important criterion guiding policy decisions on user fee abolition or reduction to the overall sample, but particularly so for more experienced respondents aged over 50 years. International pressure and donor money were identified as least important while equity and institutional capacity were deemed of relatively little importance. Respondents more involved in advising on policy than on formulating policy rated economic issues such as financial sustainability and cost-effectiveness as less important.
It is feasible to apply BWS experiments in low-income countries, although whether the technique can be adjusted to elicit preferences among non-literate respondents in these settings is unclear.
To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS).
Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework.
Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria.
A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.
Despite the increased focus on health care consumers’ active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or ‘nudges’.
We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, ‘nudging’ consumers toward particular choices. We hypothesized that these ‘nudges’ might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept ‘nudges’.
We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were ‘nudged’ towards.
Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.
The Malta–UK cross-border health care collaboration gives Maltese patients access to highly specialized care that is not available locally. Our aim was to identify the issues that arise in cross-border specialized care for rare childhood diseases.
We conducted 31 semi-structured face-to-face interviews with policy makers, consultant pediatricians from Mater Dei Hospital in Malta, the Royal Marsden Hospital and Great Ormond Street Hospital in England and the parents of a random sample of children referred for treatment abroad in 2011. We conducted qualitative thematic analysis of the data.
Respondents viewed the collaboration as successful in providing timely access to high quality specialist care. Four factors facilitated implementation: long established personal relationships; communication and data sharing; shared care approach; and well established support systems. The key challenges are logistical, financial, communication and cultural and psychological.
Cross-border care pathways can successfully support access to high quality specialized care that is acceptable to health professionals and patients.
Our aim was to investigate contractual mechanisms in physician–hospital exchanges. The concepts of risk-sharing and the nature of physician–hospital exchanges – transactional versus relational – were studied.
Two qualitative case studies were performed in Belgium. Hospital executives and physicians were interviewed to develop an in-depth understanding of contractual and relational issues that shape physician–hospital contracting in acute care hospitals. The underlying theoretical concepts of agency theory and social exchange theory were used to analyse the data.
Our study found that physician–hospital contracting is highly complex. The contract is far more than an economic instrument governing financial aspects. The effect of the contract on the nature of exchange – whether transactional or relational – also needs to be considered. While it can be argued that contractual governance methods are increasingly necessary to overcome the difficulties that arise from the fragmented payment framework by aligning incentives and sharing financial risk, they undermine the necessary relational governance. Relational qualities such as mutual trust and an integrative view on physician–hospital exchanges are threatened, and may be difficult to sustain, given the current fragmentary payment framework.
Since health care policy makers are increasing the financial risk borne by health care providers, it can be argued that this also increases the need to share financial risk and to align incentives between physician and hospital. However, our study demonstrates that while economic alignment is important in determining physician–hospital contracts, the corresponding impact on working relationships should also be considered. Moreover, it is important to avoid a relationship between hospital and physician predominantly characterized by transactional exchanges thereby fostering an unhealthy us-and-them divide and mentality. Relational exchange is a valuable alternative to contractual exchange, stimulating an integrated hospital–physician relationship. Unfortunately, the fragmented payment framework characterized by unaligned incentives is perceived as an obstacle to realize effective collaboration.
There are multiple barriers to kidney transplantation from a living donor for patients. A critical factor is their own approach to pursuing opportunities for transplantation, including their preferences for living or deceased donation and their concerns about living donation. As part of a wider study into barriers to living donor transplantation in New Zealand, our aim was to examine the preferences and concerns of New Zealand patients who are waiting for kidney transplantation.
Mixed methods were used, incorporating a mailed survey of patients on the waiting list for a deceased donor transplant, followed by in-depth semi-structured interviews. The survey included questions about preferences for living or deceased donation, willingness to accept a kidney from a potential donor if offered and concerns about aspects of living donation. Responses were received from 193 (38.2%) patients. These issues were explored in more depth in follow-up interviews with 17 patients.
The majority of patients were positive about living donor transplantation with only a few actively preferring a deceased donor. The vast majority would accept an offer from a potential donor. Donors being financially out-of-pocket and being upset if the transplant failed were the highest ranked concerns. Impacts on donor health were also a significant concern for patients. Positive views about living donor transplantation and stated willingness to accept offers could be undermined by deep, unresolved concerns and could result in patients declining offers from potential donors. Being well-informed about the risks to donors and having confidence in the donor evaluation process were important for reducing patients’ concerns.
The preferences and concerns of patients in New Zealand are similar to those reported elsewhere. Education needs to address the concerns of patients and ensure they have accurate knowledge about living donation. Concerns about financial impacts on donors, however, arise from New Zealand’s policy of not fully reimbursing living donors for lost income and cannot be addressed through improved education.
To estimate the costs and potential efficiency gains of changing the frequency of clinic appointments and drug dispensing arrangements for stable HIV patients compared to the costs of hospital pharmacy dispensing and home delivery.
We estimated the annual costs per patient (HIV clinic visits and either first-line treatment or a common second-line regimen, with some patients switching to a second-line regimen during the year). The cost of three-, four- and six-monthly clinic appointments and drug supply was estimated assuming hospital dispensing (incurring value-added tax) and home delivery. Three-monthly appointments and hospital drug dispensing (baseline) were compared to other strategies.
The baseline was the most costly option (£10,587 if first-line treatment and no switch to second-line regimen). Moving to six-monthly appointments and home delivery yielded savings of £1883 per patient annually. Assuming patients start on different regimens and may switch to second-line therapies, six-monthly appointments and three-monthly home delivery of drugs is the least expensive option and could result in nearly £2000 savings per patient. This translates to annual cost reduction of about £8 million for the estimated 4000 eligible patients not currently on home delivery in London, England.
Different appointment schedules and drug supply options should be considered for stable HIV patients based on efficiency gains. However, this should be assessed for individual patients to meet their needs, especially around adherence and patient support.
Health services contribute significantly to greenhouse gas emissions. New models of delivering care closer to patients have the potential to reduce travelling and associated emissions. We aimed to compare the emissions of patients attending a teleconsultation – an outpatient appointment using video-conferencing equipment – with those of patients attending a face-to-face appointment.
We estimated the total distances travelled and the direct and indirect greenhouse gas emissions for 20,824 teleconsultations performed between 2004 and 2011 in Alentejo, a Portuguese region. These were compared to the distances and emissions that would have resulted if teleconsultations were not available and patients had to attend face-to-face outpatient appointments. Estimates were calculated using survey data on mode of transport, and national aggregate data for car engine size and fuel. A sensitivity analysis using the lower and upper quartiles for survey distances was performed.
Teleconsultations led to reductions in distances and emissions of 95%. 2,313,819 km of travelling and 455 tonnes of greenhouse gas emissions were avoided (22 kg of carbon dioxide equivalent per patient). The incorporation of modes of transport and car engine size and fuel in the analysis led to emission estimates which were 12% smaller than those assuming all patients used an average car.
The availability of remote care services can significantly reduce road travel and associated emissions. At a time when many countries are committed to reducing their carbon footprint, it is desirable to explore how these reductions could be incorporated into technology assessments and economic evaluations.
This study aimed to estimate the impact of deprivation on the occurrence, health outcomes and health care costs of people with multiple morbidity in England.
Cohort study in the UK Clinical Practice Research Datalink, using deprivation quintile (IMD2010) at individual postcode level. Incidence and mortality from diabetes mellitus, coronary heart disease, stroke and colorectal cancer, and prevalence of depression, were used to define multidisease states. Costs of health care use were estimated for each state from a two-part model.
Data were analysed for 141,535 men and 141,352 women aged ≥30 years, with 33,862 disease incidence events, and 13,933 deaths. Among incidences of single conditions, 22% were in the most deprived quintile and 19% in the least deprived; dual conditions, most deprived 26%, least deprived 16% and triple conditions, most deprived 29%, least deprived 14%. Deaths in participants without disease were distributed most deprived 22%, least deprived 19%; in participants with single conditions, most deprived 24%, least deprived 18%; dual conditions, most deprived 27%, least deprived 15%, and triple conditions, most deprived 33%, least deprived 17%. The relative rate of depression in most deprived participants with triple conditions, compared with least deprived and no disease, was 2.48 (1.74 to 3.54). Costs of health care use were associated with increasing deprivation and level of morbidity.
The higher incidence of disease, associated with deprivation, channels deprived populations into categories of multiple morbidity with a greater prevalence of depression, higher mortality and higher costs. This has implications for the way that resources are allocated in England’s National Health Service.
In several countries, patients are encouraged to choose health care providers. Simultaneously, there is a tendency towards the concentration of health care, which might lessen the choice. Our aim was to assess the impact of patients’ distances from their providers on their information-seeking, which is one element of choice.
Two thousand members of the Dutch Health Care Consumer Panel were sent a questionnaire that included a question on whether they would search for information about hospitals to inform their choice. Distances from providers were obtained from a database that includes the distances between all postcodes in the Netherlands. To assess the influence of distance on information-seeking, logistic regression analyses were conducted.
There was a good response (75%). Older, less educated respondents were less inclined to seek information when their nearest alternative was located further away (OR 0.85; 95% CI: 0.79–0.92), and younger, more educated respondents were more inclined to search in this situation (OR 1.11; 95% CI: 1.01–1.22).
As fewer older, less educated patients would search for information to guide their choice, they might not opt for the best hospital. Additionally, the need for providers to compete for the patronage of these patients might be lessened.
To establish current guidance and practice in UK on presentation of indirect comparison and mixed treatment comparison analyses; to provide recommendations to improve indirect comparison/mixed treatment comparison reporting and to identify research priorities for improved presentation.
Existing institutional guidance for conducting indirect comparison/mixed treatment comparison alongside current practice in health technology assessment was reviewed. Reports published in UK by the Health Technology Assessment programme since 1997, which utilized indirect comparison/mixed treatment comparison methods, were reviewed with respect to the presentation of study data, statistical models and results. Recommendations for presentation were developed.
Guidance exists that provide the details necessary to conduct a successful indirect comparison/mixed treatment comparison analysis but recommendations on presentation are limited. Of 205 health technology assessment reports that contained evidence synthesis for effectiveness, 19 used indirect comparison/mixed treatment comparison methods. These reports utilized numerous presentational formats from which the following key components were identified: network table/diagram for presenting data; model description to allow reproducibility; and tables, forest plots, matrix tables and summary forest plots for presenting a range of results. Recommendations were developed to ensure that reporting is explicit, transparent and reproducible. Approaches most understandable by non-technical decision makers, and areas where future research is required, are outlined.
There is no standard presentational style used in UK for reporting indirect comparison/mixed treatment comparison, and the use of graphical tools is limited. Standardization of reporting and innovation in graphical representation of indirect comparison/mixed treatment comparison results is required.
To examine the types of choices available to patients in the English NHS when being referred for acute hospital care in the light of the divergence of patient choice policy in the four countries of the UK.
Case studies of eight local health economies in England, Scotland, Northern Ireland and Wales (two in each country); 125 semi-structured interviews with staff in acute services providers, purchasers and general practitioners (GPs).
GPs and providers in England both had a clear understanding of the choice of provider policy and the right of patients to choose a provider. Other referral choices potentially available to patients in all four countries were date and time of appointment, site and specialist. In practice, the availability of these choices differed between and within countries and was shaped by factors beyond choice policy, such as the number of providers in an area. There were similarities between the four countries in the way choices were offered to patients, namely lack of clarity about the options available, limited discussion of choices between referrers and patients, and tension between offering choice and managing waiting lists.
There are challenges in implementing pro-choice policy in health care systems where it has not traditionally existed. Differences between England and the other countries of the UK were limited in the way choice was offered to patients. A cultural shift is needed to ensure that patients are fully informed by GPs of the choices available to them.
Physician gender may be a source of differences in communication between physicians and their patients, which may in turn contribute to patient satisfaction and other outcomes. Our aim was to review systematically research on gender differences in the length, style and content of communication with patients.
Seven electronic databases were searched from inception to September 2010 with no language restrictions (included MEDLINE; PsychINFO; EMBASE; CINAHL; Health Management Information Consortium; Web of Science; and ASSIA). ‘Grey’ literature was also searched. Data extraction and quality assessment was carried out in accordance with Cochrane Collaboration guidelines by at least two reviewers. The review uses mainly narrative synthesis due to the heterogeneous nature of the studies, with only data on consultation length being pooled in a random effects generic inverse variance meta-analysis.
Searches yielded 6412 articles, of which 33 studies fulfilled the inclusion criteria. Studies were heterogenous and of mixed quality. Conflicting results are reported for many communication variables. There is some evidence that female physicians adopt a more partnership building style and spend on average 2.24 min longer with patients per consultation (95% CI 0.62–3.86) than their male colleagues.
Greater patient engagement by female doctors may reflect a more patient-centred approach, but their longer consultation times will limit the number of consultations they can provide. This has implications for planning and managing services.
Pregnant women who receive a high screening risk result for Down, Edwards or Patau syndrome are offered diagnostic tests that carry a procedure-related risk of miscarriage. This study quantifies the improvement in the screening tests by calculating the number of women who had such tests per syndrome diagnosis from 1991 to 2010.
Routinely stored data on prenatal chorionic villus sampling (CVS) and amniocentesis samples performed from 1991 to 2010 from the Wessex Regional Genetics Laboratory in England were extracted from the laboratory database. The numbers of diagnostic tests performed per Down, Edwards or Patau syndrome diagnosis were calculated according to the type of diagnostic test, and were adjusted for maternal age and gestational age at diagnosis.
A total of 32,345 CVSs and amniocenteses identified 872 diagnoses of Down syndrome and 328 of Edwards and Patau syndrome. In 1991, there were 46 (95%CI: 16–111) CVSs per syndrome diagnosis compared with five (95%CI: 4–7) in 2010. For amniocenteses, the number fell from 53 (37–78) to 15 (11–22).
This analysis demonstrates the improvements in antenatal screening for Down syndrome that have been made over the past 20 years, resulting in a reduction in the number of women tested and thus in the number of foetal deaths attributable to the testing procedure.
Health care reforms often include provider diversification, including privatization, to increase competition and thereby health care quality and efficiency. Donabedian's organizational theory implies that the consequences will vary according to the providers' ownership. The aim was to examine how far that theory applies to changes in English NHS primary medical care (general practice) since 1998, and the consequences for patterns of service provision.
Framework analysis whose categories and structure reflected Donabedian's theory and its implications, populated with data from a systematic review, administrative sources and press rapportage.
Two patterns of provider diversification occurred: 'native' diversification among existing providers and plural provision as providers with different types of ownership were introduced. Native diversification occurred through: extensive recruitment of salaried GPs; extending the range of services provided by general practices; introducing limited liability partnerships; establishing GPs with special clinical interests; and introducing a wider range of services for GPs to refer to. All of these had little apparent effect on competition between general practices. Plural provision involved: increased primary care provision by corporations; introducing GP-owned firms; establishing social enterprises (initially mostly out-of-hours cooperatives); and Primary Care Trusts taking over general practices. Plural provision was on a smaller scale than native diversification and appeared to go into reverse in 2011.
Although the available data confirm the implications of Donabedian's theory, there are exceptions. Native diversification and plural provision policies differ in their implications for service development.