Health Services Insights最新文献

Introduction: Clinical pathways (CPWs) are evidence-based, standardised, clinical management plans that are designed to deliver a sequence of clinical interventions to improve the efficiency and effectiveness of healthcare. The aim of this study was to identify and summarise the current available evidence on the use of CPWs in emergency departments (EDs).

Study design: A literature search was conducted in Scopus, Embase, Emcare, and PubMed academic databases. The search strategy was guided by Arksey and O'Malley's framework and results reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews Checklist. Studies were included if they reported empirical data either qualitatively or quantitatively, studied the use of CPW practices, and reported on the use of at least one CPW activity.

Results: Sixty-four articles were eligible for the scoping review. Variation and quality of treatment, resource utilisation and time to treatment were identified as the three main patient and organisational outcomes from the use of CPWs. Three main categories of barriers to use were identified: Organisational environment factors, Healthcare professional-related factors, and CPW operational issues.

Conclusions: CPW implementation has wide positive patient and organisational outcomes in the ED. Whilst no single strategy would result in implementing CPWs in the ED settings successfully, broad engagement with clinicians of all disciplines who use the pathways and involvement of multidisciplinary teams in implementation is vital to increase visibility of the CPW.

Background: Integrated primary care teams remain a debatable policy in family medicine that could be a convenient response to French shortages in medical density.

Objectives: To analyse how general practitioners (GPs) respond to insufficient GP supply in their practice area in terms of quantity and quality of care, and how this response is mediated by enrolment in integrated primary care teams - multi-professional group practices (MGPs).

Methods: We used structural equation modelling on 3 representative cross-sectional surveys (2019-2020) of 1209 French GPs. Quantity and quality of care were approximated by latent variables comprising respectively GPs' demand absorption capacity and frequencies of vaccine recommendations.

Results: In the absence of potential mediators, low GP density was negatively associated with quantity (-0.221, unstandardized direct effects), but not with the quality of care. In the presence of mediators, low GP density was associated with higher work-related stress (0.120), which was consecutively associated with deteriorated demand absorption capacity (-0.202). Higher use of e-health tools was associated with greater involvement in vaccine recommendations (0.357). GPs in MGPs tended to use more e-health tools than those practicing outside MGPs (0.032), with a favourable effect on vaccine recommendations.

Conclusion: Lower level of work-related stress is the key mediator in handling patients' requests. When correcting for self-selection into MGPs, we found no significant mediation effect of enrolment in MGPs on the quantity of care but rather an effect on the quality of care. Our results pinpoint an added value of an enrolment in an MGPs to care quality that advocates for its further development.

Jel classification: I14, I18.

Background: Countries are implementing interventions to reduce avoidable hospital readmissions. However, evaluating such interventions are potentially complex. These interventions can cause unintended consequences, and they are among the most common causes of the intervention's failure. The objective of this study was to identify the unintended consequences from implementing a pilot case management team to reduce avoidable hospital readmissions at a tertiary hospital in Singapore.

Methods: We conducted five in-depth semi-structured interviews with stakeholders who were involved in the planning, development, and implementation of the intervention in addition to analysing 12 intervention documents. Deductive thematic analysis using Rogers' diffusion of innovation theory was conducted.

Results: Data analysis generated seven subthemes: ineffective targeting of patient population, fund constraints, lack of patient ownership, limited post discharge follow up, comprehensive care approaches, role overlap and patient confusion. The absence of a readmission risk assessment tool resulted in care plan needs assessments being conducted for all admitted patients, rather than targeting those who would benefit most. This broad approach overwhelmed care coordination efforts. The initial plan to form a specialised intervention team responsible for care plan needs assessments could not be fully established due to funding constraints. As a result, the intervention team functioned more as a consulting service, providing recommendations to the primary team, which retained decision-making authority. Overlapping roles with existing case managers caused patient confusion, prompting the intervention team to step back and support care plan needs assessment remotely.

Conclusion: Overall, results suggest that intervention team recognised a problem and participated in the intervention. This became the foundation for implementing change. However, the unintended consequences undermined the intervention from achieving its objectives and as a result the intervention was stopped. Decision-makers should pay attention to these unintended consequences to inform effective implementation and refine future interventions.

Background: With an increasing reliance on homecare and a scarcity of providers, there is potential to gain insight from existing administrative data to optimize planning and care delivery. To enable more accurate predictions of service use, it is important to understand the degree to which various factors influence clients' difficult decisions to temporarily pause their receipt of necessary homecare services.

Objectives: We utilized a large, longitudinal, administrative dataset to examine the relative effects of client-level factors on the outcomes of (1) placing a hold on homecare services and (2) the length of a homecare service hold, through stratified regression analyses separated by pre-, early-, and mid-pandemic periods.

Design: Descriptive summaries of the samples consisted of graphical representation and frequencies (proportions) or means. The relationship between client sociodemographic and homecare utilization factors on the service hold initiation and length were evaluated using mixed-effects logistic and linear regression, respectively, stratified by pre-, early-, and mid-pandemic periods. Odds ratios (OR) for hold initiation and exponentiated estimates for hold length were calculated with corresponding 95% confidence intervals.

Results: Findings provide a better understanding of the decisions made by a large sample of homecare clients to pause their homecare services in pre-, early-, and mid-pandemic scenarios. Frequency and length of service holds more than doubled in the early-pandemic period; although hold frequencies then returned to pre-pandemic rates, hold durations remained slightly longer. There were notable differences over time, but generally, clients with higher care needs had a reduced likelihood of placing a hold on homecare services. Shorter homecare tenure and previously cancelling individual homecare visits were also good indicators of future service decisions.

Conclusion: Findings are relevant for organizations providing homecare services, policymakers, and those interested in predicting homecare utilization for resource allocation planning with the goal of optimal care delivery.

Background: Access to healthcare is a critical determinant of individual and population health outcomes. However, few validated tools exist to evaluate healthcare access among Arabic-speaking populations.

Objectives: This study aimed to validate the Arabic version of the Perception of Access to Health Care Services Questionnaire (PAHSQ) and assess its psychometric properties, including reliability and construct validity, using factor and Rasch analyses.

Design: A cross-sectional study was conducted with 485 participants (53.4% female) recruited from hospitals and pharmacies in Jordan.

Methods: Confirmatory factor analysis (CFA) and Rasch analysis were employed to evaluate the construct validity and item performance of the 30-item, six-factor model. Internal consistency was assessed using Cronbach's alpha.

Results: The Arabic PAHSQ exhibited strong psychometric properties. CFA confirmed the suitability of the six-factor model (χ²/df = 3.2, RMSEA = 0.07, CFI = 0.93, TLI = 0.92). Cronbach's alpha values for the six dimensions ranged from 0.82 to 0.93. Rasch analysis demonstrated acceptable infit and outfit values for all items, with item thresholds correctly oriented. Key findings highlighted significant disparities in healthcare access, particularly among participants with low income and no insurance coverage.

Conclusions: The Arabic PAHSQ is a reliable and valid tool for assessing healthcare access among Arabic-speaking populations. Its use can inform targeted interventions, guide resource allocation, and support health equity initiatives. Further research should explore its applicability across diverse Arabic-speaking regions and incorporate qualitative methodologies to capture more subtle access barriers.

The implementation of sociosanitary pathways in the Quebec healthcare system aims to better meet the needs of communities and strengthen their participation at all levels of governance. This initiative will form the basis of our article, which will look at the challenges of adaptation both inside and outside organizations. Drawing on the complex adaptive systems approach, we have developed an analytical framework to highlight the processes that can lead to the adaptation of governance to facilitate community participation in the management of this pathways. The aim of this article is to propose a better understanding of coevolution in the process(es) of adaption of the governance of a complex healthcare organization to its environment, by mobilizing the complex adaptive systems approach. We conducted a qualitative case study, based on 4 sources: documents (n = 70) produced or used during implementation, participatory observations on various tactical and operational committees of the management structure, collaborative workshops with members of the management committee, and semi-structured interviews (n = 18) with managers, department heads, partners, and users of health and social services. To understand the co-evolutionary processes involved in the implementation of management by social and health pathways, we present our results in response to 3 research proposals on the theme of internal and external coherence in a healthcare organization, in terms of vision (cultural), structures (organizational and clinical), and relationships with external partners (environment). Our findings show that to implement and manage an innovation in a healthcare organization, it is fundamental to foster coevolution at operational, tactical and strategic levels, as well as with the external environment. To achieve this, it is necessary to maintain a balance and internal coherence between the structure being implemented and the existing structure, to establish formal and informal communication channels to ensure seamless interactions, while recognizing and reinforcing mutual interdependence in a systemic perspective.

Background: The introduction of the International Classification of Diseases 10th Revision (ICD-10) code Z71.81 in 2015 enabled the systematic documentation of spiritual and religious counseling (SRC) in hospital settings, opening avenues for research into its effect on patient outcomes and healthcare resource utilization. Religion and spirituality are integral to many patients' lives, influencing their well-being, recovery and health outcomes. Despite its potential to improve outcomes, limited data exist on SRC's application and effect in the hospital setting.

Objectives: This study evaluated the frequency and characteristics of SRC documentation and explored its associations with patient outcome in the inpatient hospital setting.

Design: A retrospective observational study.

Methods: Data were drawn from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2016 to 2021, encompassing all United States hospitalizations excluding military and specialty facilities. This dataset provided a nationally representative sample of all hospitalizations. Inpatient visits coded for SRC were identified using ICD-10 Z71.81. Statistical analyses assessed descriptive trends and associations with outcomes such as mortality, length of stay (LOS), and healthcare charges.

Results: The analysis included 5910 SRC-documented inpatient visits from 89 hospitals. SRC was frequently documented for patients with severe or terminal conditions, as evidenced by a significantly higher mortality rate (10.9% vs 2.3% overall). Temporal trends demonstrated a steady, albeit modest, increase in SRC documentation over the study period. While SRC utilization varied across demographic groups, differences in access and outcomes were evident.

Conclusion: SRC is primarily utilized in complex, high-mortality cases, underscoring its role in holistic care for severely ill patients. The disparities observed highlight the need for standardized SRC documentation and equitable access to SRC. Future research should investigate the clinical and economic impacts of SRC to enhance patient-centered care in alignment with value-based care practices.

Objectives: This research aims to enhance the quality of hospital services by utilizing Quality Function Deployment (QFD) with a novel Multi-Dimensional House of Quality (MD-HOQ) approach. This method integrates Service Quality (SERVQUAL) analysis and considers resource constraints, such as financial and workforce limitations, to select and prioritize technical requirements effectively.

Methods: The proposed MD-HOQ approach was applied to a private hospital in Tehran, Iran. Data were gathered from a sample of 8 experts and a sample of 386 patients, using 2 in-depth interviews and 4 questionnaires. The process included identifying hospital sections and determining their importance using the Analytic Hierarchy Process. Patients' needs in each section were then identified and weighted through SERVQUAL analysis. Subsequently, technical requirements to meet these needs were listed and weighted using MD-HOQ. A mathematical model was employed to determine the optimal set of technical requirements under resource constraints.

Results: Application of the MD-HOQ approach resulted in the identification of 50 patient needs across 5 hospital sections. Additionally, 40 technical requirements were identified. The highest implementation priorities were assigned to "training practitioners and nurses," "improving the staff's sense of responsibility," and "using experienced specialists, physicians, and surgeons."

Conclusions: The integrated QFD approach, utilizing MD-HOQ and SERVQUAL analysis, provides a comprehensive framework for hospital managers to prioritize technical requirements effectively. By considering resource constraints and the gap between patient expectations and perceptions, this method ensures that resources are allocated to the most impactful technical requirements, leading to improved patient satisfaction and better overall hospital service quality. This approach not only enhances the quality of hospital services but also ensures efficient utilization of resources, ultimately benefiting patient satisfaction.

Background: Many individuals in low- and middle-income countries with healthcare needs do not access the necessary, often lifesaving healthcare services. Existing universal health coverage (UHC) indicators do not account for a portion of the population with unmet healthcare needs.

Objective: To estimate the prevalence, wealth-related inequality, and determinants of unmet healthcare needs in Nigeria using data from the nationally-representative Nigeria Living Standards Survey, 2018-2019.

Methods: We analyzed data from a cross-sectional sample of 116 320 Nigerians from 22 110 households selected using multi-stage probability sampling. The outcome variable was self-reported unmet healthcare needs. We conducted concentration index (CIX) analyzes to assess wealth-related inequalities and performed multilevel logistic regression analysis to identify the determinants of unmet healthcare needs at the individual, household, and community levels.

Results: The prevalence of unmet healthcare needs was 5.2% (95% CI: 5.0-5.5), representing about 11 million Nigerians (95% CI: 10.5-11.5 million). The most common reasons were high costs (unaffordability) and the perception that the illness or injury was not serious. Wagstaff-normalized CIX for unmet healthcare needs was pro-poor: -0.09730 for the general population and -0.10878 for those with chronic illnesses. Significant determinants of unmet healthcare needs include age (AOR: 0.99, 95% CI: 0.99-1.00), chronic illness (AOR: 8.73, 95% CI: 7.99-9.55), single-person households (AOR: 1.55, 95% CI: 1.20-2.02), poorest quintile households (AOR: 1.45, 95% CI: 1.19-1.78), and mildly (AOR: 1.17, 95% CI: 1.01-1.36) or moderately food-insecure households (AOR: 1.30, 95% CI: 1.11-1.51).

Conclusion: A significant proportion of Nigerians, particularly the very poor, chronically ill, those living alone, or food insecure, have unmet healthcare needs. This highlights the necessity for targeted interventions to ensure vulnerable populations can access essential healthcare services. To progress toward UHC, the Nigerian health system must address critical issues related to healthcare accessibility.

Introduction: Online self-scheduling of medical appointments is increasingly common. An automated waitlist can be used for patients who desire an earlier appointment time if one becomes available after they are scheduled. Our study examines outcomes of an automated waitlist and self-rescheduling process.

Methods: We studied outcomes of an automated waitlist self-rescheduling process in which patients with existing appointments elected to be placed on an automated waitlist for an earlier appointment offer. When software found earlier dates for the same visit type, patients were then notified through an automated process and could self-reschedule. We reviewed appointments for which patients were sent new offers when earlier appointment slots were found. We compared the accepted appointment offers with the original scheduled appointments and determined the number of days that the appointment had been moved up.

Results: Spanning the calendar year 2023 there were 1 019 698 appointment offers generated by an automated waitlist process for 229 998 appointments and sent to 164 248 patients. The waitlist process automatically found open appointments as they became available and sent the first new appointment offer within 2 days after being placed on the waitlist for 74 736 (32.5%) of the 229 998 waitlisted appointments. Patients sent back at least 1 response for 104 554 (45.4%) of the waitlisted appointments. Of the responses, 56 636 accepted one of the sent offers for an accept rate of 24.6% (56 636/229 998). For accepted, moved-up visits, appointments were self-rescheduled earlier by a mean of 22.6 days (95%CI; 22.2, 22.9, P < .0001).

Conclusion: New appointments can be successfully self-rescheduled using an automated waitlist process that allows patients to accept or decline new appointment offers. This process can increase the efficiency of scheduling and decrease appointment wait time for patients desiring more timely access to healthcare. In addition, this process can be successfully applied across several different appointment type categories.