Showing papers in "Journal of Health Services Research & Policy in 2005"
TL;DR: A model of research synthesis designed to work with complex social interventions or programmes, and which is based on the emerging ‘realist’ approach to evaluation is offered, to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively.
Abstract: Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems--things like league tables, performance measures, regulation and inspection, or funding reforms. These are not 'magic bullets' which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging 'realist' approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories)--the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level.
2,297 citations
TL;DR: An overview and critique of a selection of strategies for synthesising qualitative and quantitative evidence, ranging from techniques that are largely qualitative and interpretive through to techniques that is largely quantitative and integrative.
Abstract: BackgroundThe limitations of traditional forms of systematic review in making optimal use of all forms of evidence are increasingly evident, especially for policy-makers and practitioners. There is...
1,655 citations
TL;DR: The key stages in reviewing and synthesizing qualitative and quantitative evidence for decision-making are described and various strategies that could offer a way forward are looked at.
Abstract: Policy-makers and managers have always used a wide range of sources of evidence in making decisions about policy and the organization of services. However, they are under increasing pressure to adopt a more systematic approach to the utilization of the complex evidence base. Decision-makers must address complicated questions about the nature and significance of the problem to be addressed; the nature of proposed interventions; their differential impact; cost-effectiveness; acceptability and so on. This means that Cochrane-style reviews alone are not sufficient. Rather, they require access to syntheses of high-quality evidence that include research and non-research sources, and both qualitative and quantitative research findings. There is no single, agreed framework for synthesizing such diverse forms of evidence and many of the approaches potentially applicable to such an endeavour were devised for either qualitative or quantitative synthesis and/or for analysing primary data. This paper describes the key stages in reviewing and synthesizing qualitative and quantitative evidence for decision-making and looks at various strategies that could offer a way forward. We identify four basic approaches: narrative (including traditional 'literature reviews' and more methodologically explicit approaches such as 'thematic analysis', 'narrative synthesis', 'realist synthesis' and 'meta-narrative mapping'), qualitative (which convert all available evidence into qualitative form using techniques such as 'meta-ethnography' and 'qualitative cross-case analysis'), quantitative (which convert all evidence into quantitative form using techniques such as 'quantitative case survey' or 'content analysis') and Bayesian meta-analysis and decision analysis (which can convert qualitative evidence such as preferences about different outcomes into quantitative form or 'weights' to use in quantitative synthesis). The choice of approach will be contingent on the aim of the review and nature of the available evidence, and often more than one approach will be required.
1,238 citations
TL;DR: A systematic review of studies of decision-making by health care managers and policy-makers and the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used.
Abstract: Objectives: To identify ways to improve the usefulness of systematic reviews for health care managers and policy-makers that could then be evaluated prospectively. Methods: We systematically reviewed studies of decision-making by health care managers and policy-makers, conducted interviews with a purposive sample of them in Canada and the United Kingdom (n ¼ 29), and reviewed the websites of research funders, producers/purveyors of research, and journals that include them among their target audiences (n ¼ 45). Results: Our systematic review identi¢ed that factors such as interactions between researchers and health care policy-makers and timing/timeliness appear to increase the prospects for research use among policymakers. Our interviews with health care managers and policy-makers suggest that they would bene¢t from having information that is relevant for decisions highlighted for them (e.g. contextual factors that aiect a review’s local applicability and information about the bene¢ts, harms/risks and costs of interventions) and having reviews presented in a way that allows for rapid scanning for relevance and then graded entry (such as one page of take-home messages, a three-page executive summary and a 25-page report). Managers and policy-makers have mixed views about the helpfulness of recommendations. Our analysis of websites found that contextual factors were rarely highlighted, recommendations were often provided and graded entry formats were rarely used. Conclusions: Researchers could help to ensure that the future £ow of systematic reviews will better inform health care management and policy-making by involving health care managers and policy-makers in their production and better highlighting information that is relevant for decisions. Research funders could help to ensure that the global stock of systematic reviews will better inform health care management and policymaking by supporting and evaluating local adaptation processes such as developing and making available online more user-friendly ‘front ends’ for potentially relevant systematic reviews.
594 citations
TL;DR: This research suggests that there has been insufficient emphasis on personal factors in knowledge translation, and has identified limitations to the common interpretations of knowledge translation principles and highlighted the characteristics of collaborative research initiatives that are of greatest importance to community partners.
Abstract: Objectives: While there is increasing interest in research related to so-called Knowledge Translation, much of this research is undertaken from the perspective of researchers. The objective of this paper is to explore, through the participatory evaluation of Manitoba's The Need to Know Project, the characteristics of effective knowledge translation initiatives from the perspective of community partners.Methods: The multi-method evaluation adopted a utilization-focused approach, where stakeholders participated in identifying evaluation questions, and methods were made transparent to participants. Over 100 open-ended, semi-structured interviews were conducted with project stakeholders over the first three years of the project. These interviews explored the perspectives of participants on all aspects of project development. Formal feedback processes allowed further refinement of emerging theory.Results: This research suggests that there has been insufficient emphasis on personal factors in knowledge translat...
197 citations
TL;DR: In an effort to advance thinking and encourage debate by those who commission or those who synthesize evidence, the Canadian Health Services Research Foundation and the NHS Service Delivery and Organisation R&D Programme commissioned three papers and four commentaries on them by policy-makers, advisors and health services managers, along with a workshop for them to refine their thinking.
Abstract: Evidence-based medicine (EBM), though still relatively new, is successful in challenging unjustified variations in clinical practice and helps to protect the public by shifting the centre of gravity of clinical decision-making to ensure a more explicit consideration of high-quality (usually evaluative) research evidence. EBM has spawned an international industry producing and synthesizing evidence and developing guidelines along with mechanisms to promote implementation. This has prompted calls for an analogous transformation in policy-making and health care management. There is growing international interest in encouraging public policy and management to be better informed by the results of relevant and reliable research (see the statement from the Ministerial Summit on Health Research in November 2004). This is fuelled by research showing that some health and social interventions which have been commonly applied in the belief that they were doing good are actually harmful, that others are largely ineffective and thus wasteful of public resources and, furthermore, that some effective interventions have been only slowly adopted or largely ignored. However, there has been disappointment at the lack of progress in promoting evidence-based policy and management compared with the relative success of evidence-based medicine. Methods of evidence synthesis – the process of bringing together the results of individual research studies in order to better map the knowledge base –have developed over the last couple of decades. However, the consumers of policy and management research have not found the outputs sufficiently relevant and useful, and researchers have become frustrated by the lack of uptake of the results of such systematic reviews by policy-makers and managers. In an effort to advance thinking and encourage debate by those who commission or those who synthesize evidence, the Canadian Health Services Research Foundation (CHSRF) and the NHS Service Delivery and Organisation R&D Programme commissioned three papers and four commentaries on them by policy-makers, advisors and health services managers, along with a workshop for them to refine their thinking. The papers and the commentaries appear in this supplement.
159 citations
TL;DR: There are important gaps in the knowledge base on access to health care for people with learning disabilities and while these need to be addressed, developing strategies to overcome identified barriers should be a priority, along with fuller evaluation of existing innovations.
Abstract: Objectives: People with learning disabilities are more prone to a wide range of additional physical and mental health problems than the general population. Our aim was to map the issues and review ...
149 citations
TL;DR: The health status of recent immigrant arrivals is observed to decline towards that of the native-born population, while health care utilization increases, meaning that need for health care within the immigrant population may be unmet.
Abstract: Objectives: This paper focuses upon health status, need for care, and use of health care from 1994/95 to 2000/01 in the Canadian foreign-born population.Methods: Using Statistics Canada's longitudinal National Population Health Survey, descriptive and survival analyses are used to explore immigrant health status and health care.Results: The health status of immigrants quickly declines after arrival, with a concomitant increase in use of health care services. However, survival analysis of the risk of a change to poor health indicates no difference between immigrants and the native-born. Similarly, there is no difference in the risk of hospital use between the two populations.Conclusions: The health status of recent immigrant arrivals is observed to decline towards that of the native-born population, while health care utilization increases. However, increased use may not be sufficient to offset declines in health, meaning that need for health care within the immigrant population may be unmet.
146 citations
TL;DR: A more formal and replicable approach to identification and assessment of quality of model inputs is required to reduce the 'black box' nature of decision models, and lead to less scepticism regarding model outputs.
Abstract: Objectives: To review the sources and quality of evidence used in the development of economic decision models in health technology assessments (HTAs)Methods: All economic decision models developed
142 citations
TL;DR: Current evidence indicates that social and environmental attributes of hospital nursing practice have an effect on the outcomes of care, and further research of greater rigour is needed to provide a better understanding of the mechanisms that link the nursing environment to patient outcomes.
Abstract: Objective: Research has examined the effect of the structure of health systems on health outcomes, but not how outcomes are affected by the nursing environments in hospitals. Our objective was to gather, critically appraise and synthesize all relevant primary research on the effect of the nursing environment on patient mortality.Methods: Five electronic bibliographic databases were searched from their beginning through to May/June 2001, and Medline and CINAHL were updated to March 2004, using pre-determined search strategies and inclusion criteria. Studies were included if they met pre-determined criteria, reporting primary data both on a hospital environment and patient mortality. Methodological rigour was appraised using accepted criteria for the evaluation of research protocols, including case-mix adjustment.Results: This paper focuses on 27 identified studies that investigated the impact of one or more attributes of the nursing environment on patient mortality. Nineteen studies found an association be...
118 citations
TL;DR: The many dysfunctional consequences of publishing star ratings indicate a need for a re-examination of performance management policies, particularly in acute hospital trusts in England.
Abstract: ObjectiveTo explore some of the impacts of star performance ratings in acute hospital trusts in England.MethodsA multiple case study design was used which incorporated purposeful sampling of ‘low’ ...
TL;DR: Clinical directorates were designed to promote team approaches and to improve patient care delivery, but the results call for a rethink of what can be expected from structural reforms in organisations.
Abstract: ObjectivesTo examine assumptions made by proponents and critics of clinical directorate (CD) structures in hospitals. Proponents argue that CDs are supported by the health professionals who constit...
TL;DR: A measure of population-based chronic disease status was developed using Italian automated pharmacy data and, applying the model to pharmaceutical claims from Emilia Romagna 2001, a large proportion of the population was identified as having chronic conditions.
Abstract: Background and objectives: Automated pharmacy data have been used to develop a measure of chronic disease status in the general population. The objectives of this project were to refine and apply a model of chronic disease identification using Italian automated pharmacy data; to describe how this model may identify patterns of morbidity in Emilia Romagna, a large Italian region; and to compare estimated prevalence rates using pharmacy data with those available from a 2000 Emilia Romagna disease surveillance study.Methods: Using the Chronic Disease Score, a list of chronic conditions related to the consumption of drugs under the Italian pharmaceutical dispensing system was created. Clinical review identified medication classes within the Italian National Therapeutic Formulary that were linked to the management of each chronic condition. Algorithms were then tested on pharmaceutical claims data from Emilia Romagna for 2001 to verify the applicability of the classification scheme.Results: Thirty-one chronic ...
TL;DR: This paper aims to re-establish the meaning and importance of the concept of 'evidence-based policy making' (EBP) in health care by using examples based on large-scale policies of health care reform in England.
Abstract: In this paper, I aim to re-establish the meaning and importance of the concept of 'evidence-based policy making' (EBP) in health care. The term EBP is often misunderstood as being either vacuous (who thinks that public policy should not be based on evidence?), unrealistic (the naive product of ivory tower thinking) or conservative (an excuse permanently to delay reform). It need be none of these things. EBP should be thought of as a set of rules and institutional arrangements designed to encourage transparent and balanced use of evidence in public policy making. As well as controlled trials and observational studies, a broad range of theoretical and empirical evidence about human behaviour may be relevant to predicting policy outcomes - including stakeholder opinions and other sources of intelligence that might not qualify as scientific research. Gradual progress towards EBP, properly understood, has the potential to facilitate open democracy and to improve policy outcomes. The argument is illustrated using examples based on large-scale policies of health care reform in England, where progress towards EBP over the last decade has been real but modest.
TL;DR: Investigating the factors associated with qualified nurses in Britain moving to different employment statuses, including jobs outside nursing, unemployment, maternity leave and family care over time suggests that strategies to improve nurse retention must attend to nurses' status, authority and position in the hierarchy.
Abstract: Objectives: The current shortage of nurses is a major problem for health care systems around the world and has revitalized interest in the dynamics of nurses' careers. This paper investigates the factors associated with qualified nurses in Britain moving to different employment statuses, including jobs outside nursing, unemployment, maternity leave and family care over time.
Methods: British Household Panel Survey (BHPS) data collected between 1991 and 2001 were used to estimate the effects of covariates on transition rates between different employment statuses.
Results: Individual characteristics associated with shorter tenure in the profession include being male, being younger, having a degree, and having been born in the UK. Many nurses leave to care for their families, which suggests the possibility of returning to the profession at a later date. A number of job characteristics are also related to leaving, including low pay, managerial responsibility, full-time work and lack of opportunities to use initiative. Nurses seem to be particularly vulnerable to leaving early in their careers, but those who survive the first few years are likely to remain in the profession for the rest of their working lives.
Conclusions: It is particularly important in policy terms that ability to use initiative is related to leaving nursing for another form of full-time employment and, in particular, to leaving for a better job. This finding is consistent with results from studies of the Magnet hospitals in the US. Taken together, these results suggest that strategies to improve nurse retention must attend to nurses' status, authority and position in the hierarchy if they are to be successful. The results also provide strong support for those who argue that better rates of pay are necessary in order to improve nurse retention.
TL;DR: It is concluded that nurse:patient ratios are a blunt instrument for achieving employer compliance, where reliance on alternative, voluntary (and often more sophisticated) methods of determining nurse staffing have not been effective.
Abstract: The debate about how best to determine nurse staffing levels continues. The conventional wisdom is that determining staffing levels is something best left to local management, taking account of local workload and resources. This 'bottom up' philosophy has now been challenged by the use of a different approach--the use of 'top down'standardized, and mandatory, nurse:patient or nurse:bed ratios. This paper examines the characteristics and early results of the use of staffing ratios in the two health systems where nurse staffing ratios are now mandatory--the states of Victoria (Australia) and California (USA). It then discusses the policy implications of using ratios. The paper identifies the main weaknesses of the use of nurse:patient ratios as being their relative inflexibility and their potential inefficiency, if they are wrongly calibrated. Their strength is their simplicity and their transparency. Their impact will be most pronounced when ratios are mandatory and where they offer a mechanism to improve and then to maintain staffing levels at some pre-determined level. The biggest challenges in their use are calibration (what is 'safe'? or 'minimum'?) and achieving the support of all stake-holders. The paper concludes that nurse:patient ratios are a blunt instrument for achieving employer compliance, where reliance on alternative, voluntary (and often more sophisticated) methods of determining nurse staffing have not been effective.
TL;DR: The effectiveness of the proposed intervention appears very small due to its inability to reach those at risk of falling, and it is most likely not to be cost-effective.
Abstract: Objectives: To develop a cost-effectiveness model of a complex intervention from pilot study data in order to inform the viability and design of a subsequent falls prevention trial.
Methods: We used two models; the first estimated the probability of falling over a 12-month period based on a probability tree; the second used Markov simulation to assess the impact of the programme over time.
Results: The first model indicated that our intervention would reduce the proportion falling by only 2.8% over a 12-month period. The major reason for this small effect was that less than a quarter of older people at risk of falling were assessed using our screening tool. Even if policy-makers were willing to spend £30,000 per quality-adjusted life-year gained, there is only a 40% chance that the intervention would be cost-effective. Sensitivity analyses showed that the only scenarios that produced a substantial increase in the effect of the intervention were those in which all older people are assessed.
Conclusions: The model-building approach described in this paper is vital when designing complex trials and where a trial is not possible. Information from the modelling can be used to re-design the intervention. The effectiveness of our proposed intervention appears very small due to its inability to reach those at risk of falling. It is most likely not to be cost-effective. If inability to reach the target group is a weakness common to other similar interventions, this suggests an area for further research.
TL;DR: This hospital-at-home programme was found to be more acceptable and as effective and safe as inpatient care, and while caring for patients at home was significantly more costly than standard in patient care, this was largely due to the hospital- at- home programme not operating at full capacity.
Abstract: Objective: To compare the safety, effectiveness, acceptability and costs of a hospital-at-home programme with usual acute hospital inpatient care.Method: Patients aged 55 years or over being treated for an acute medical problem were randomized to receive either standard inpatient hospital care or hospital-at-home care. Follow-up was for 90 days after randomization. Health outcome measures included physical and mental function, self-rated recovery, health status as assessed by the SF-36, adverse events and readmissions to hospital. Acceptability was assessed using satisfaction surveys and the Carer Strain Index. Costs comprised hospital care, care in the home, community services, general practitioner services and personal health care expenses.Results: In all, 285 people were randomized with a mean age of 80 years. There were no significant differences in health outcome measures between the two randomized groups. Significantly more patients receiving care at home reported high levels of satisfaction, as did...
TL;DR: This paper presents issues which arose in the conduct of qualitative evaluation research within a cluster-randomized, community-level, preventive intervention trial and argues that, in addition to the usual practice of having an outcome data-monitoring committee, community intervention trials also require a process data- monitoring committee as a forum for debate and decision-making.
Abstract: This paper presents issues which arose in the conduct of qualitative evaluation research within a cluster-randomized, community-level, preventive intervention trial. The research involved the collection of narratives of practice regarding the intervention by community development officers working in eight communities over a two-year period. The community development officers were largely responsible for implementing the intervention. We discuss the challenges associated with the collection of data as the intervention unfolded, in particular, the disputes over cues to revise and adjust the intervention (i.e. to use the early data formatively). We explore the ethical uncertainties that arise when multiple parties have different views on the legitimacy of types of knowledge and the appropriate role of research and theory in various trial stages. These issues are discussed drawing on the fields of ethnography, community psychology, epidemiology, qualitative methodology and notions of research reflexivity. We conclude by arguing that, in addition to the usual practice of having an outcome data-monitoring committee, community intervention trials also require a process data-monitoring committee as a forum for debate and decision-making. Without such a forum, the relevance, ethics and position of qualitative evaluation research within randomized controlled trials are destined to be a point of contention rather than a source of insight.
TL;DR: Appreciating the wider consequences of shifting the balance of care is essential if services are to be improved overall, and changing the goals that drive activity by seeking a waiting list goal rather than a waiting time goal is demonstrated.
Abstract: Objectives: The shift in the balance of health care, bringing services 'closer to home', is a well-established trend. This study sought to provide insight into the consequences of this trend, in particular the stimulation of demand, by exploring the underlying feedback structure.
Methods: We constructed a simulation model using the system dynamics method, which is specifically designed for the analysis of feedback structure. The model was calibrated to two cases of the shift in cardiac catheterization services in the UK. Data sources included archival data, observations and interviews with senior health care professionals. Key model outputs were the basic trends displayed by waiting lists, average waiting times, cumulative patient referrals, cumulative patient activity and cumulative overall costs.
Results: Demand was stimulated in both cases via several different mechanisms. We revealed the roles for clinical guidelines and capacity changes, and the typical responses to imbalances between supply and demand. Our analysis also demonstrated the potential benefits of changing the goals that drive activity by seeking a waiting list goal rather than a waiting time goal.
Conclusions: Appreciating the wider consequences of shifting the balance of care is essential if services are to be improved overall. The underlying feedback mechanisms of both intended and unintended effects need to be understood. Using a systemic approach, more effective policies may be designed through coordinated programmes rather than isolated initiatives, which may have only a limited impact.
TL;DR: While the 2001/2 waiting times target demonstrably changed admission patterns, the extent to which this represented significant and clinically relevant distortions is questionable and as targets become progressively tougher, there is a need to monitor consultants' concerns more closely.
Abstract: Objectives: To assess and quantify the impact of guarantees on maximum waiting times on clinical decisions to admit patients from waiting lists for orthopaedic surgery.Methods: Before and after com...
TL;DR: A pre-randomization design that would overcome ethical and methodological problems associated with the conventional Zelen design, and permit the rigorous evaluation of a complex package of care, involving physical therapy and behavioural changes, for patients with painful patello-femoral osteoarthritis of the knee joint is developed.
Abstract: Objectives: Standard randomized controlled trials of interventions for chronic conditions that involve behavioural change, or that are highly desired by participants, are difficult to undertake bec...
TL;DR: In this article, the authors assess the determinants of patient and surgeon-rated MAWT, and test whether the anticipated waiting time has an independent in£uence after adjusting for age, sex and patient urgency.
Abstract: Objectives: Lengthy waiting times for hip and knee arthroplasty have raised concerns about equitable and timely access to care. The Western Canada Waiting List project has developed priority criteria scores linked to maximum acceptable waiting times (MAWT) for diierent levels of priority. Our study purpose was to assess the determinants of patient- and surgeon-rated MAWT, and to test whether the anticipated waiting time has an independent in£uence after adjusting for age, sex and patient urgency. A second aim was to compare MAWT, waiting time and anticipated waiting time for diierent levels of urgency assessed using the priority criteria score. Methods: Orthopaedic surgeons assessed 233 consecutive patients waiting for arthroplasty in terms of their urgency (assessed using the priority criteria score and a visual analogue scale), MAWT and anticipated waiting time. Patient data included urgency (assessed by a visual analogue scale), MAWT and the Western Ontario McMaster Osteoarthritis index. We used hierarchical linear regression to test the models. Results: After adjusting for age and sex, urgency (assessed by priority criteria score and visual analogue scale) and anticipated waiting time accounted for 40% of the variance in surgeon MAWT. The patient model accounted for 30% of the variance in patient MAWT. Older patients preferred signi¢cantly shorter MAWTs (Po0.05). Anticipated waiting time added signi¢cantly to both the surgeon and patient MAWT models (R 2 change 0.11 and 0.07, respectively). Actual waiting time was weakly correlated with urgency assessed using the priority criteria score (r ¼� 0.25, Po0.0001). Conclusions: Patients’ and surgeons’ views are critical to a fair process of establishing MAWT for elective procedures. Anticipated waiting time may in£uence the perspectives on MAWT and must be considered in their interpretation.
TL;DR: In this paper, the authors examined the impact of nurses' perceived barrierence on nurse retention and employment conditions on nurse recruitment and retention, and found that nurse retention was positively associated with employment conditions.
Abstract: ObjectivesPrevious research on nurse retention has focused mainly on its relationship with employment conditions. This study aimed to include an examination of the impact of nurses’ perceived barri...
TL;DR: Most Scots want rural health care to continue to be good, but the new UK National Health Service (NHS) general practitioner contract and service redesign will impact on provision, which should be monitored at intervals in future.
Abstract: Objectives: To compare satisfaction with, and expectations of, health care of people in rural and urban areas of Scotland.Methods: Questions were included in the 2002 Scottish Social Attitudes Survey (SSAS). The Scottish House-hold Survey urban-rural classification was used to categorize locations. A random sample of 2707 people was contacted to participate in a face-to-face interview and a self-completion questionnaire survey. SPSS (v.10) was used to analyse the data. Relationships between location category and responses were explored using logistic regression analysis.Results: In all, 1665 (61.5%) interviews were conducted and 1507 (56.0%) respondents returned self-completion questionnaires. Satisfaction with local doctors and hospital services was higher in rural locations. While around 40% of those living in remote areas thought A&E services too distant, this did not rank as a top priority for health service improvement. This could be due to expectations that general practitioners would assist in out-...
TL;DR: In the turbulent 1970s, the iconoclastic writer Ivan Illich published Limits to Medicine, a polemic underpinned by Illich's desire to incite action against what he saw as scientific medicine’s successful but harmful attempts to dominate not only health care but also other aspects of people's lives.
Abstract: In the turbulent 1970s, the iconoclastic writer Ivan Illich published Limits to Medicine. In line with a time of protest and social unrest, the book was a polemic, underpinned by Illich’s desire to incite action against what he saw as scientific medicine’s successful but harmful attempts to dominate not only health care but also other aspects of people’s lives. He argued that people had given up their autonomy to the medical profession, and become unhealthily dependent. When Illich was writing, the dominant critique of medicine within the sociology of health and illness was informed by Marxism. He and other critics of the time presented a counter argument to the structural functionalist approach represented in the 1950s and 1960s by Parsons and his followers. Structural functionalism had emphasized the necessary role played by doctors in maintaining social order. In stark contrast, proponents of the political economy approach saw the medical profession as conforming, either intentionally or unwittingly, to the dominant capitalist ideology that oppressed the underprivileged. Far from being benevolent, value-free and politically neutral, therefore, medicine was seen as a social institution that reproduced and reinforced social inequities, and whose power was bolstered by the state. Patients and doctors were viewed as having competing interests, involving struggles for power. Other influential writers of this time included Friedson with his theory of ‘professional dominance’, Zola with his examination of medicine as an institution of social control and Navarro’s account of medicine in support of capitalism. Like these authors, Illich took a view which was unrelentingly negative. He wrote from a classic Marxist standpoint in identifying the capitalist economic system as the cause of medical dominance and the subsequent reinforcing of disadvantage for the working class and the poor. Illich’s thesis is based on his theory of ‘iatrogenesis’: in traditional terms, the creating of illness as an unintended side-effect of medical treatment. According to Illich, iatrogenesis ‘is but one aspect of the destructive dominance of industry over society’ and ‘the result of industrial overproduction that paralyses autonomous action’. His major assertions include the following:
TL;DR: Regionalization in Newfoundland and Labrador facilitated aggregation of hospitals, but did not control the number of front-line workers and, consequently, total acute care expenditure, which increased significantly between 1995 and 2002.
Abstract: Objectives Since the 1990s restructuring, including regionalization and downsizing, has largely been driven by a desire for cost containment. Regionalization, hospital closure and changes in management processes occurred in Newfoundland and Labrador (NL), Canada between 1995 and 2000. The objectives of the current study were: to describe trends in the utilization of acute care hospital services by residents of NL during and shortly after restructuring; to examine trends in the efficiency of utilization of acute care beds in the province during the same time frame; and to compare the trends in St John's with the rest of the province, taking account of confounding events, in an attempt to understand the impact of aggregation of hospitals in this region. Methods Hospital discharge and day surgical data were analysed for all facilities in NL from 1995/96 to 2000/01. Analyses were by facility of service and also by region of residence directly standardized to the provincial population for 1996. Efficiency of bed utilization was examined on three occasions by concurrent utilization review using a modified version of the Appropriateness Evaluation Protocol. Trends in the St John's region (where most tertiary services are located and greater aggregation of hospitals occurred) were compared with the rest of the province. Results Admissions declined by 14% in St John's facilities and by 17% elsewhere. Inpatient days fell by 9% in St John's and by 12% elsewhere. Average length of stay and Resource Intensity Weight changed little, apart from a rise in the final study year, with the largest change in St John's. Standardized hospital admission rates declined by 10% and inpatient days by 5.6% for residents of St John's region, and by 16% and 14% respectively for residents of other regions. There was no change over time in the use of day surgery. Efficiency of acute care bed use improved in 2002 in St John's, but was unchanged in other regions. Use of acute care beds by elderly patients for extended stay, or when an alternate level of care would have been appropriate, was greater in St John's with the disparity persisting over time. Waiting time for continuing care in the St John's region was unchanged comparing 1995/96 and 1999/00. Conclusions The degree to which acute care restructuring or financial pressures and constraints imposed at the provincial level contributed to observed utilization trends is unclear. Aggregation of hospitals in the St John's region may have contributed to more efficient use of acute care beds. Restructuring as carried out did not integrate health care sectors, and problems at the acute care/continuing care boundary were not resolved in St John's, where access to continuing care remained difficult.
TL;DR: It is argued in this paper that it may, on occasion, be acceptable for confidentiality to be breached according to all three of the major ethical justifications for respecting patient confidentiality.
Abstract: Current regulations do not allow most low-risk research using patient records without patient consent. One of the main reasons adduced for this is that such research constitutes an unacceptable breach of confidentiality. By contrast, it is argued in this paper that it may, on occasion, be acceptable for confidentiality to be breached according to all three of the major ethical justifications for respecting patient confidentiality. In practice, the arguments against allowing research using patient records are usually grounded in claims about the link between confidentiality and respect for patient autonomy rather than legitimate patient expectations. Patients may have good reason to expect, or come to expect, that their records will be used without their consent for low-risk research, under certain conditions. Where this is the case, such expectations provide reasonable grounds for considering such research to be ethical.
TL;DR: 1 Bloor K, Maynard A. Planning Human Resources in Healthcare: Towards an Economic Approach, and Scotton R. The doctor business.
Abstract: 1 Bloor K, Maynard A. Planning Human Resources in Healthcare: Towards an Economic Approach. An International Review. Ottawa: Canadian Health Services Research Foundation, 2003 2 Scotton R. The doctor business In: Mooney G, Scotton R, eds. Economics and Australian Health Policy. Sydney: Allen and Unwin, 1999 3 Australian Medical Workforce Advisory Committee. The General Practice Workforce in Australia: Supply and Requirements 1999–2010. Sydney: Australian Medical Workforce Advisory Committee, 2000 4 Australian Government. Strengthening Medicare. www.health. gov.au(accessed 24 June 2002) 5 Black N. Health care workforce: how research can help. J Health Serv Res Policy 2004;9(Suppl 1):1–2 6 Haas MR, Hall JP, Chinchen LA. The moving of St Vincent’s: a tale in two cities. Med J Aust 2001;174:93–6 7 Borland J. Report to the Australian Competition and Consumer Commission. Recommendations on AMWAC Process for Provision of Advice on Medical Workforce Matters. Sydney: Australian Competition and Consumer Commission, 2001; http://www.accc.gov.au/content/index.phtml/itemId/ 308640 8 Sax S. A Strife of Interests: Politics and Policies in Australian Health Services. Sydney: Allen and Unwin, 1984
TL;DR: The history and implementation of regionalization in Newfoundland and Labrador is described, which included the containment of escalating hospital costs; increased efficiency and effectiveness; integrated care; and the provision of a system that was more responsive to the needs of the local population.
Abstract: In Canada, the use of hospital services has changed over time, with inpatient days declining steadily, other than for the elderly, from 1969 to 1995/6. Similar trends have been noted in other countries, including the United States, the Netherlands and England. As Canadian provincial tax revenues fell in the early 1990s, the proportion spent on health care rose rapidly, an economic problem for which governments sought a solution. Although steadily declining, expenditure on hospitals was still the single largest component of health care spending under direct government control in Canada in 1990. By then, a series of provincial commissions and inquiries had also suggested that hospital capacity could be further reduced. In response, many provinces sharply cut per capita spending on hospitals from 1992 to 1997, which was followed by about a 30% reduction in the number of Canadian hospitals and hospital beds in the five years from 1995/ 6. At the same time, with growth in the use of day surgery, at least in some jurisdictions, surgical activity remained constant, despite a reduction in inpatient capacity. A variety of methods of cost containment have been applied to hospital services in Canada. These include the provision of global budgets through the longestablished single-payer financing system. In more recent years, regionalization and, to a lesser extent, use of information systems (such as the Canadian Institute for Health Information) to inform decisionmakers have been applied in an effort to control hospital costs. Since the late 1980s, there has been a focus on hospital restructuring (or hospital redesign) aimed at enhancing efficiency (possible within one organization), strategic alliances, whereby organizations work together aiming at enhanced efficiency, and rationing of care, under which services may be made less available. Following the introduction of Medicare in the 1960s, regionalization of the health care system has been an important mechanism for reform in Canada. Quebec led the country in establishing regional health authorities in 1989. Without much supporting data, proponents of regionalization have suggested that it might lead to improved efficiency, coordination and integration of services and, partly through economies of scale, assist in cost containment. By 2002, all provinces and territories, with the exception of Ontario, had regionalized the governance of their health care systems. Throughout the early 1990s, the health care system in Newfoundland and Labrador (NL) experienced substantial reform. Regionalization, as a process for change, is meant to ‘transfer the present level of power and authority from one level of government (i.e. the provincial ministry) to another level of government (i.e. the regional health board)’, in essence, a devolution of responsibility and accountability. The primary goals of regionalization were similar across provinces and included: the containment of escalating hospital costs; increased efficiency and effectiveness; integrated care; and the provision of a system that was more responsive to the needs of the local population. However, health care systems across the country varied with regard to their terms of governance (appointed or elected boards), type of board (community, institutional, integrated, district) and the type of services provided under the board (long-term care, acute care, social services). In order to understand the challenges facing health services providers in NL, the reader needs to appreciate the vast geography of the province. NL has an area of 405,720 km, more than three times the total area of the Maritime Provinces (Nova Scotia, New Brunswick and Prince Edward Island). NL ranks fourth in size behind Alaska, Texas and California. It is almost oneand-three-quarter times the size of Great Britain. The total population of the province was reported as 512,930 in 2003, with approximately half of the population living on the Avalon Peninsula in Newfoundland. The proportion of health spending on institutions in NL was 60% in 1995, considerably above the Canadian average of 44.1%. Heavy dependence on institutional services reached a critical level in the late 1980s and early 1990s. In 1994, almost 60 institutional community boards were responsible for health care delivery. Commissions and task forces were formed to identify solutions, and in 1995 regionalization of health boards was initiated to reform the health care system. The history of the evolution and implementation of regionalization in NL is described in detail in the paper by Twells et al. Six health care regions and 14 health boards were established in 1995/96. Integrated boards responsible for acute care, long-term care and community care services were initiated in two regions, Labrador and Northern. In three regions (Western, Central East and Central West), acute care and long-term care were combined and responsible to institutional boards, and separate community health boards were created. In the St John’s region, three boards governing acute care institutions, long-term care institutions and community care, as well as one provincially focused board addressing the cancer treatment and research needs of the province were established. In 1998, social services (child welfare, rehabilitation and corrections) were