Journal of Health Services Research & Policy最新文献

ObjectivesDouble-checking medication administrations is one of the most frequently used strategies to prevent errors and associated harm. This practice is time-consuming, introduces repeated interruptions into the care process and lacks evidence of effectiveness. Double-checking is widespread in hospitals worldwide. In England, double-checking happens despite there being no regulatory requirement except for intravenous drugs and medicines that require complex calculations. Many hospital Trusts have assimilated double-checking over the past 25-30 years in response to recommendations from the investigation of medication administration errors. There is currently no national picture in England of the extent to which organisational policies stipulate double-checking, the variation in double-checking policy or how closely double-checking is perceived to be conducted in accordance with policies. This study set out to address these gaps in our understanding.MethodsAn online survey was distributed to a network of Medication Safety Officers (MSOs) and Freedom of Information requests were sent to 118 English NHS acute hospital Trusts for policies underpinning medicines administration. Data were analysed to address the research questions.ResultsPolicies were received from 94 acute NHS Trusts (80% response rate) and 48 MSOs submitted a survey response (39% response rate). Double-checking policies vary considerably between Trusts. MSOs perceived that it is common in practice for double-checking not to be conducted in accordance with policy. All reviewed Trust policies required double-checking for controlled drugs. Further to this, many required double-checking for specific medicines or in particular circumstances. Most commonly, these were intravenous medicines, medicines administered to children, medicines requiring complex calculations and cytotoxic or chemotherapeutic medicines. However, policies varied considerably around administration of injectable medicines and insulin to adults. A minority of policies specified that 'intravenous fluids' needed to be double-checked. Most policies neither emphasised nor explained the importance of the independent nature of double-checking. There was also a great deal of variation between Trust policies in the medicines exempt from double-checking requirements.ConclusionsThe variation between policies identified by the present study might reflect a lack of robust evidence underpinning the practice of double-checking. Research is needed to understand if double-checking is effective at preventing medication errors and, if it is, the exact circumstances in which it is effective, to facilitate the standardisation of double-checking policies. Identifying circumstances in which double-checking is ineffective may justify the removal of some existing policies and could reduce nurse workload to free up time for patient-focused care.

ObjectivesThe NHS in England has introduced various innovations to keep up with the growing demand for elective care, one of which is patient-initiated follow-up (PIFU). This evaluation sought to understand staff experiences of implementing PIFU.MethodsWe conducted a rapid qualitative service evaluation between June 2022 and July 2023, based on semi-structured interviews (n = 36) with operational/managerial and clinical NHS staff from five English NHS Trusts, and an online workshop with 21 additional members of staff from the English NHS. We drew on the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to structure qualitative data collection and analysis and to generate new insights into the adoption of the innovation of PIFU.ResultsWe found that implementation of PIFU affected staff roles, workload, and job satisfaction. Levels of PIFU uptake, and experience with similar models, affected the extent to which participants experienced the impact of PIFU. How PIFU was implemented varied. Some staff saw changes in their role because of new administrative demands, safety-netting procedures (such as proactive measures by specialty teams to mitigate the risk of patients not initiating appointments when necessary), and selection of suitable patients. PIFU was felt by some staff to increase, and by others to decrease, workload. PIFU affected intensity of work, interrelated with other factors such as the size of waiting lists, and conditions experienced by patients. Whether staff were satisfied with PIFU related to its impact on their role and workload. Satisfaction was also affected by whether staff believed PIFU delivered benefits for patients, and by the aims they felt were driving rollout.ConclusionPIFU can significantly affect the experiences of staff and change staff roles and workload. However, the impact of PIFU is not uniform. Staff perspectives on PIFU from all parts of the health system should be better understood and considered during pathway design.

BackgroundWhen critical illness survivors are discharged home, they encounter a myriad of physical, emotional, cognitive, and socioeconomic challenges which can endure for an extended period of recovery. Given the extent of patient need, family members often assume the role of informal caregivers. The work inherent in this role can significantly compromise their own health, which can, in turn, influence the nature and trajectory of recovery for the survivor.PurposeThis study aimed to describe the role of informal family caregivers in patient recovery from critical illness following hospitalisation, in the context of publicly-funded healthcare and where there were no critical care follow-up or aftercare programmes.MethodsGuided by a qualitative, interpretive description approach, in-depth semi-structured interviews were conducted with 25 family caregivers of patients recovering from critical illness at home. In total, 29 interviews were conducted: 21 caregivers were interviewed once, and 4 caregivers were interviewed twice. Interview data were analyzed thematically using inductive, constant comparative methods.ResultsThe nature of family caregiving was grounded in the patient's condition, whether it involved slow recovery vs stagnation or decline, and the caregiver's capacity to engage in care. Caregivers influenced patient recovery by (1) assuming daily living and physical care responsibilities; (2) providing motivational and emotional support; (3) searching for and gathering information; (4) monitoring and supervising health and treatment; and (5) managing medical appointments and advocating for resources.ConclusionsFamily caregivers fulfilled a central role in managing a wide range of needs of survivors, found to be pivotal for their recovery. Policy and practical support are needed to help caregivers fulfil this role alongside meeting their own personal challenges and responsibilities.

BackgroundThere is a growing debate on whether avoidable emergency department (ED) visits, those involving health issues that could have been managed in community settings, represent a significant workload for the department. Until recently an ED physician-validated measure of avoidable visits has not been available, hindering our understanding of these patients, services rendered in the ED and the nature of their conditions. We examined patient characteristics of ED visits retrospectively classified as avoidable and potentially avoidable at a Canadian academic hospital.MethodsWe conducted a retrospective cohort study using administrative ED data from an academic hospital in Hamilton, Canada from April 1, 2018 to August 31, 2023. We categorized all ED visits as avoidable, potentially avoidable, and not avoidable using the Emergency Department Avoidability Classification (EDAC). For each class, we analyzed patient characteristics and the top five physician interventions and diagnoses. We applied linear regression, locally weighted scatterplot smoothing (LOWESS) regression, and statistical process methods to examine monthly trends in avoidable and potentially avoidable visits. Additionally, we reported annual totals and length of stay for patients transported to the ED by paramedics.ResultsOverall, 58,528 (29.0%) of 201,741 ED visits were classified as either avoidable (11,302; 5.6%) or potentially avoidable (47,226; 23.4%). These patients were predominantly young-to-middle aged, with average visit durations of 3 hours 33 minutes (avoidable) and 4 hours 26 minutes (potentially avoidable). Their primary interventions were predominantly diagnostic imaging, skin repairs and mental health assessments. The proportion of ED visits in the study period that were avoidable increased from 2.1% to 7.7% and potentially avoidable from 18.2% to 21.2%. Approximately one-in-five paramedic transported patients were classified as having either an avoidable or potentially avoidable ED visit. Transported patients had an average length of stay of 4 hours 22 minutes for avoidable visits and 4 hours 35 minutes for potentially avoidable visits.ConclusionsA notable rise in the proportion of ED visits that could have been managed in non-ED settings was observed. Providing community clinicians with resources and capacity to manage and refer patients for diagnostic imaging, skin repairs and mental health assessments may reduce avoidable ED attendance. Further exploration of avoidable ED visits transported by paramedics could support refining ED diversion care models. Hospitals and health service policymakers could benefit from similar analyses using validated measures to identify care gaps that inform the development of new health services and models tailored to the specific needs of their communities.

ObjectivesTo (1) understand the challenges and benefits of providing pregnancy care to people with disabilities and (2) identify strategies to address challenges, from the perspectives of health care and social service providers and decision-makers.MethodsWe undertook a qualitative descriptive study in Ontario, Canada, of 31 health care and social service providers and decision-makers. Participants completed semi-structured interviews about their education, training, and clinical or administrative experience working with pregnant and/or parenting people with physical, sensory, and intellectual or developmental disabilities, including challenges and benefits in pregnancy care provision, programming, and policies, as well as their recommendations to improve care. We took a directed content analysis approach.ResultsParticipants identified challenges in providing pregnancy care to people with disabilities, including a lack of data to inform care, the influence of social determinants of health on disabled people's lives, inadequate infrastructure, poor coordination and communication across services, minimal disability-related training, and ableist attitudes among providers. Benefits to providing pregnancy care for people with disabilities included becoming advocates for system-level change, personal fulfillment, opportunities to confront one's own biases, and development of humility related to the expertise of people with disabilities. Reflecting on these challenges and benefits, participants identified strategies for improving care, through creative resource-sharing solutions, accessibility measures, interprofessional and coordinated care, enhanced provider training, and respectful care approaches.ConclusionsFindings show the need for changes at system, institutional, and service provider levels to improve pregnancy care for people with disabilities.

ObjectivesSeveral meta-analyses have shown the effectiveness of specialized trauma care, but evidence on cost and cost-effectiveness remains unestablished. We aimed to systematically review evidence on the cost or cost-effectiveness of hospitals specialized in advanced trauma care compared to non or less-specialized hospitals.MethodsWe conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We searched PubMed, EMBASE, Cochrane Library, Web-of-Science, EconLit, and grey literature up until June 2024. Two reviewers independently assessed eligibility and extracted relevant data. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist. Per Cochrane recommendations, findings were synthesized qualitatively.ResultsWe identified 4 cost-effectiveness, 3 cost-consequence, and 3 cost-analysis studies, mostly US-based retrospective cohorts. Reporting quality was rated high for 4 studies. All cost-effectiveness studies found specialized trauma centres to be more costly but more effective than non-specialized centres, with incremental cost-effectiveness ratios ranging from 655 to 46,175 Int.$2022 (2022 international dollars) per quality-adjusted life-year (QALY) gained, 43,208 to 999,912 Int.$2022 per life-saved, and 48,567 Int.$2022 per life-year gained. Among cost-consequence studies, two found specialized trauma centres to be costlier and less effective, while one found the opposite. All cost analyses indicated higher costs at specialized trauma centres.ConclusionsFull economic evaluations identified in this review suggest that specialized trauma care may be cost-effective according to a threshold of $50,000 per QALY. However, our ability to draw conclusions is hampered by the low number of studies, high heterogeneity in study populations and settings, and lack of consideration of trauma systems and of costs beyond the acute phase. Results highlight a critical gap in evidence to guide policymakers in the development of cost-efficient trauma systems.

BackgroundCritical illness is a life-threatening condition impacting millions of patients globally each year. Critically ill patients often need to be transported within the hospital during their care and the safety and efficiency of transportation are key for good health outcomes. There is a lack of knowledge about the processes and safety of intra-hospital patient transport in low-resourced health care settings.ObjectiveThis study aimed to understand health workers' experiences of the process and the safety of intra-hospital transportation of critically ill patients in Tanzania.MethodsQualitative in-depth interviews were conducted with 15 health workers involved in the care and transportation of critically ill patients in five Tanzanian hospitals. Purposive sampling identified participants. Data were analysed using thematic analysis, guided by the Donabedian quality of care framework.ResultsThree themes of health workers' experiences of patient transportation were identified, the first two related to structures and the third to processes: (i) the design and organisation of hospitals did not facilitate the initiation and conduct of quick, short and safe transport for critically ill patients; (ii) hospitals lacked resources for safe, effective transportation of critically ill patients; (iii) there were weaknesses in the preparation for, conduct of, and handover of information concerning the transportation of critically ill patients. Health workers in Tanzania faced substantial challenges in ensuring safe transportation due to hospital infrastructure limitations, resource shortages, and inadequate processes.ConclusionWe conclude that the transport of critically ill patients is overlooked in hospital services in Tanzania, despite the importance of safe intra-hospital transportation in preventing deaths. Feasible solutions to these challenges are necessary for reducing high mortality and morbidity among critically ill patients.

ObjectiveIn Nepal, various health insurance schemes including community-based and national health insurance programmes have been implemented to reduce financial burdens on the population and improve access to health care, towards the goal of Universal Health Coverage. Despite these efforts, there are limited studies on health insurance ownership in Nepal. This study aimed to determine factors influencing insurance ownership at individual and household level in Nepal.Study designThis study utilized cross-sectional data from the Nepal Multiple Indicator Cluster Survey 2019, a nationally representative survey. This paper reports on analysis of data from 14,769 women and 5491 men aged 15-49 years and 4113 households, using logistic regression and the Cragg hurdle model.ResultsThe study found that less than 6% of respondents had health insurance: 5.8% of women (95% CI 4.82 - 6.88) and 5.1% of men (95%CI: 4.5 - 5.8), with higher rates among older women with higher education, belonging to the Newar ethnic group, and living in urban areas. Age and education were significant predictors of individual insurance ownership. Higher socio-economic status of the household and higher education of the individual were associated with greater likelihood of insurance ownership, while belonging to disadvantaged ethnicities and living in the Sudurpaschim and Madhesh provinces were associated with lower likelihood of insurance ownership.ConclusionHealth insurance ownership is low in Nepal, particularly among disadvantaged ethnicities and low socio-economic status households. Efforts to increase health insurance coverage need to focus on addressing the inequities related to socio-economic status, ethnicity, and regions. Further research is necessary to identify reasons for lower coverage among the specific population groups.