Journal of Health Services Research & Policy最新文献

Objectives: Pharmaceutical incentivisation of physicians for profit maximisation is a well-documented health system challenge. This study examined general practitioners' (GPs) reactions to pharmaceutical incentivisation offers in one region in Pakistan.

Methods: We used the Standardised Pharmaceutical Sales Representative (SPSR) method and qualitative interviews with GPs. SPSRs were field researchers representing mock pharmaceutical companies who recorded their observations of 267 GPs' responses to pharmaceutical incentivisation offers. We triangulated SPSR data using qualitative interviews with a subset of the same GPs to gather information about how they interpreted different interaction outcomes.

Results: We found four major outcomes for GPs being offered incentives by pharmaceutical companies for prescribing medications. GPs might agree to make incentivisation deals, reject incentivisation offers, disallow PSRs to access them, or remain indeterminate with no clear indication of acceptance or rejection of incentivisation offers. GPs rejecting SPSRs' incentivisation offers indicated having active commitments to other pharmaceutical companies, not being able to work with unheard-of companies, and asking SPSRs to return later.

Conclusions: The GP-pharmaceutical sales representative interaction that centres on profit-maximisation is complex as offers to engage in prescribing for mutual financial benefit are not taken up immediately. The SPSR method helps understand the extent of distortion of practices impacted by incentivisation. Such an understanding can support the development of strategies to control unethical behaviours.

Objective: To examine the projects of professionalisation and institutionalisation forming health care professions' engagement in quality improvement collaborative (QIC) implementation in Denmark, and to analyse the synergies and tensions between the two projects given the opportunities afforded by the QICs.

Methods: This was a cross-sectional interview study with professionals involved in the implementation of two national QICs in Denmark involving 23 individual interviews and focus group discussions with 75 people representing different professional groups. We conducted a reflexive thematic analysis of the data, drawing on institutional contributions to organisational studies of professions.

Results: Study participants engaged widely in QIC implementation. This engagement was formed by a constructive interplay between the professions' projects of professionalisation and institutionalisation, with only few tensions identified. The project of professionalisation relates to a self-oriented agenda of contributing professional expertise and promoting professional recognition and development, while the project of institutionalisation focuses on improving health care processes and outcomes and advancing quality improvement. Both projects were largely similar across professional groups. The interplay between the two projects was enabled by the bottom-up approach to implementation, participation of QI specialists, and a clear focus on developing and delivering high-quality patient care.

Conclusions: Future strategies for QIC implementation should position QICs as a framework that promotes the integration of professions' projects of professionalisation and institutionalisation to successfully engage professionals in the implementation process, and thereby optimise the effectiveness of QICs in health care.

Objectives: In the wake of national and global personnel shortages, it is becoming increasingly common for students to undertake casual and temporary agency work in the health care and social sectors. This phenomenon can have both advantages and disadvantages for these workers. The objective of this study was to describe health care and social sector students' experiences of such work.

Methods: Students currently undertaking casual work in the health care and social sector in Finland were recruited (n = 28). Qualitative semi-structured interviews of these students were conducted in March to May 2021. The data were analysed using inductive content analysis.

Results: Respondents reported some positive aspects of casual work. In particular, they liked the freedom to choose the workplace and working times that suited them. However, respondents' experiences were mostly negative. They perceived the induction into work as being insufficient, felt they had too few opportunities to give and receive feedback and believed they were not accepted into the working community.

Conclusions: Students who have bad experiences while undertaking causal work in the health care and social sectors may develop an aversion towards working in those sectors after graduating. In order to ensure the sectors are attractive to graduates, casual student workers' induction and experience of the workplace must be improved.

Objectives: In 2018, NHS England mandated that all patients in England should be able to access general practice services outside of ordinary hours. While some patients would access additional hours at their own practice, others would need supra-practice level provision - that is, they would be seen in a different location and by a different care team. The policy aim was to enhance patient access to care, with a particular focus on those who work during the day. This study examines (a) how supra-practice level provision of extended access appointments for general medical problems are operationalised and (b) whether the aims of the policy are being met.

Methods: This study presents qualitative comparative case studies of two contrasting service providers offering extended access. The data collected included 30 hours of clinician-patient observations, 25 interviews with staff, managers, and commissioners, 20 interviews with patients, organisational protocols/documentation, and routinely collected appointment data. Thematic analysis ran concurrently with data gathering and facilitated the iterative adaptation of data collection.

Results: Three cross-cutting themes were identified: extended access is being used to bolster a struggling primary care system, extended access provides a different service to in-hours general practice, and it is difficult for extended access to provide seamless care.

Conclusions: Supra-practice access models can provide effective care for most patients with straightforward issues. When ongoing management of complex problems is required, this model of patient care can be problematic.

Objectives: As general practice increasingly moves towards large group practices, there is debate about the relative benefits, safety and sustainability of different care delivery models. This study investigates the performance of single-handed practices compared to practices with multiple doctors in England, UK.

Methods: Practices in England with more than 1000 patients were included. Workforce data and a quality control process classified practices as single-handed or multiple-handed. Outcomes were (i) GP patient survey scores measuring access, continuity, confidence in health professional and overall satisfaction; (ii) reported diabetes and hypertension outcomes; and (iii) emergency department presentation rates and cancer detection (percentage of cancers diagnosed by a 2-week wait). Generalised linear models, controlling for patient and practice characteristics, compared outcomes in single and multiple-handed practices and assessed the effect of GP age in single-handed practices.

Results: Single-handed practices were more commonly found in areas of high deprivation (41% compared to 20% of multiple-handed practices). Single-handed practices had higher patient-reported access, continuity and overall satisfaction but slightly lower diabetes management and cancer detection rates. Emergency department presentations were higher when controlling for patient characteristics in single-handed practices but not when also controlling for practice rurality and size. Increased deprivation was associated with lower performance in seven out of eight outcomes.

Conclusions: We found single-handed practices to be associated with high patient satisfaction while performing slightly less well on selected clinical outcomes. Further research is required to better understand the association between practice size, including increasing multidisciplinary working, on patient experience and outcomes.

Objective: Routine health data has the potential to identify changes in patient-related outcomes, in close to real time. This pilot project used routine data to explore and compare the impact of changes to cultural responsiveness on service use by Aboriginal and Torres Strait Islander (hereafter, Aboriginal) clients in Australia.Methods: The New South Wales Minimum Data Set (MDS) for alcohol and other drug use treatment services was provided for 11 services for a period of 30 months from March 2019 to September 2021 (four months prior to two years after the intervention; data were analysed between March 2022 to February 2023). Change in cultural responsiveness was assessed via practice audits of services at baseline and two years. The average change in audit rating was analysed using a linear mixed regression model. Generalised Linear Mixed Models were used to identify changes in service use by Aboriginal clients. Results: All 11 services showed increased audit scores at two years, with a statistically significant mean increase of 18.6 (out of 63 points; b = 18.32, 95% CI 12.42-24.22). No statistically significant pre-to post-changes were identified in: (1) the proportion of episodes delivered to Aboriginal versus non-Aboriginal clients (OR = 1.15, 95% CI = 0.94-1.40), (2) the number of episodes of care provided to Aboriginal clients per month (IRR = 1.01, 95% CI = 0.84-1.23), or (3) the proportion of episodes completed by Aboriginal clients (OR = 0.96, 95% CI = 0.82-1.13). Conclusions: The lack of statistically significant impact on service use outcomes using MDS contrasts to the improvements in cultural responsiveness, suggesting further work is needed to identify appropriate outcome measures. This may include patient-reported experience measures. This project showed that routine data has potential as an efficient method for measuring changes in patient-related outcomes in response to health services improvements.

Objective: To explore the technology-based tools available for supporting the identification of victims of domestic abuse and modern slavery in remote services and consider the benefits and challenges posed by the existing tools.

Methods: We searched six academic databases. Studies were considered for inclusion if they were published in English between 2000 and 2023. The QuADS quality appraisal tool was used to assess the methodological quality of included studies. A narrative synthesis was conducted using the convergent integrated approach.

Results: Twenty-four studies were included, of which two were professional guidelines; each reported on a distinct technology-based tool for remote services. All tools related to domestic abuse and 21 focused on screening for intimate partner violence among young and mid-life women (18-65) in high-income countries. The review did not identify tools that support the identification of victims of modern slavery. We identified eight common themes of tool strengths, highlighting that the remote approach to screening was practical, acceptable to victims, and, in some circumstances, elicited better outcomes than face-to-face approaches. Five themes pointed to tool challenges, such as concerns around privacy and safety, and the inability of computerised tools to provide empathy and emotional support.

Conclusions: Available technology-based tools may support the identification of victims of domestic abuse by health and social care practitioners in remote services. However, it is important to be mindful of the limitations of such tools and the effects individuals' screening preferences can have on outcomes. Future research should focus on developing tools to support the identification of victims of modern slavery, as well as empirically validating tools for screening during remote consultations.