Inquiry-The Journal of Health Care Organization Provision and Financing最新文献

Health care price transparency aims to empower patients to make better-informed purchasing decisions. However, the prospective availability of patients' out-of-pocket costs may lead to an increased rate of forgone care. The objective of this study was to examine whether obtaining a prospective out-of-pocket cost estimate is associated with the likelihood of canceling or not arriving at a scheduled outpatient health care appointment. We surveyed adult individuals with scheduled outpatient imaging appointments at a large health care system in Georgia. In this case-control pilot study, we estimated the adjusted association between obtaining an out-of-pocket cost estimate for a scheduled imaging appointment (did not obtain an estimate, did not seek an estimate but received it via an unsolicited phone call from the health care system, and actively sought and obtained an estimate) and not attending the appointment using multivariable logistic regression that controlled for the type of primary health insurance and patient demographics. Actively seeking an out-of-pocket cost estimate was not associated with appointment cancelation or no-show (adjusted odds ratio [aOR] = 0.81, P = .75). Passively receiving an out-of-pocket cost estimate via an unsolicited phone call from the health care system was marginally associated with lower odds of appointment cancelation or no-show (aOR = 0.24; P = .076). This study did not find evidence of an association between prospective exposure of patients to out-of-pocket cost information and the likelihood of health care appointment cancelation or no-show.

The economic contribution of family and friend carers of people with dementia is substantial. Pre-death grief experienced by carers of people living with a rare dementia is complex as carers are faced with unique challenges due to geographical isolation and a lack of access to shared experiences. There is an urgent need for specialised interventions to support carers lacking local support. A micro-costing analysis of a novel online group-based pre-death grief and loss programme ('The Road Less Travelled') tailored for the carers of people with rare dementias was conducted from a provider perspective. Sensitivity analysis was conducted to explore the potential costs of face-to-face delivery of the programme. A budget impact analysis was also conducted to explore the potential costs of roll-out of the programme to carers of people living with a rare dementia across the UK. The total cost of delivering three waves of the grief and loss programme to a total of 20 participant carers was £9848, which equates to a cost of £492 per carer participant. Sensitivity analysis indicated a total cost of £14 673 for face-to-face delivery, equating to £734 per carer participant. Sensitivity analysis indicated a total cost of £14 673 for face-to-face delivery, equating to £734 per carer participant. We estimate from our budget impact analysis that the total costs of a UK wide roll-out to people living with a rare dementia (based on 5% of all people with a dementia) would be £21.77 million. To our knowledge, this is first costing analysis of a pre-death grief and loss programme for carers of people living with a rare dementia. These initial assessments of costs provide a base case for future costing analyses and full economic evaluations which can assess both the cost and benefits to society from supporting people with rare dementias and their carers.

Emergency department (ED) overcrowding and prolonged length of stay (LOS) remain critical issues in healthcare systems. This study compared 4 bed allocation strategies to optimize patient flow and resource utilization in a regional teaching hospital in Taiwan. A discrete-event simulation model was developed using 1 year hospital data from January 2022, including 29 718 ED visits. The following strategies were evaluated: (1) intra-departmental bed sharing, (2) optimized bed allocation, (3) cross-departmental bed lending with 5% capacity, and (4) combined optimization with bed borrowing. The model was validated by t-tests comparing the simulation outputs with actual hospital data. Results: All strategies demonstrated improvement compared to current operations. Of these, Strategy 4, combined optimization with bed borrowing, was the most promising: it maintained stable ED nursing utilization at 45.65% with a 95% confidence interval (CI) of 45.60% to 45.71% while reducing the cases of extended LOS. The rates of ED LOS exceeding 6, 12, and 24 h were 2.48%, 0.38%, and 0.12%, respectively, which is a significant improvement compared with the baseline. Optimization alone contributed to a 20% improvement in extended LOS under Strategy 2, while additional bed-sharing policies further improved performance by 10%. Conclusions: Strategic bed allocation combined with controlled bed-sharing policies achieved a 30% reduction in extended ED LOS without increasing nursing workload. The optimal strategy (Strategy 4) reduced cases of ED LOS exceeding 6 h to 2.48% while maintaining stable nursing utilization at 45.65%, demonstrating the effectiveness of combining optimization with resource sharing in ED patient flow management.

Quality improvement is essential in long-term care for older adults. Reporting medical quality indicators (MQI) is commonplace, but the impact on care quality improvement remains uncertain. This paper presents the Swiss National Implementation Programme - Strengthening Quality of Care in Partnership with Residential Long-Term Care Facilities (LTCF) for Older People (NIP-Q-UPGRADE), that aims to develop quality in Swiss long-term care facilities (LTCFs) by (1) strengthening robustness of MQI data, (2) supporting LTCFs in data-driven quality improvement, (3) introducing further quality indicators. The protocol for implementing the programme is outlined by work package and specific sub-aims. NIP-Q-UPGRADE is grounded in implementation science principles, using EPIS (exploration, preparation, implementation, sustainment) as a process framework and the Consolidated Framework for Implementation Research (CFIR) for its contextual analyses, and it has a strong participatory approach. Sub-studies focus on understanding current context, leveraging expertise, developing and piloting actionable intervention bundles with corresponding strategies, and preparing a national scale-up. Methodologies include literature reviews, ethnographic research, international case studies, intervention mapping, online-surveys, participatory workshops as well as pragmatic trials. At the end of NIP-Q-UPGRADE, we expect to have intervention bundles ready to improve data quality and foster data-driven quality improvement in LTCFs and to have the field prepared with corresponding implementation strategies so that national and regional LTC organizations can plan and monitor the scale-up. NIP-Q-UPGRADE will implement strategies and inform policies for sustainable, data-driven quality development. Results will inform national quality improvement implementation applicable to global LTC policies and practices.

Several pharmacy standards exist within high-income countries for measuring standards of practice in clinical and hospital settings. Following the implementation of diverse hospital pharmacy standards in low- and middle-income countries (LMICs) like Nepal such as the hospital pharmacy service guideline 2015, minimum service standards, this study aims to assess compliance with Good Pharmacy Practice (GPP) standards as per the codes for sales and distribution of drugs (CSDD) 2024 guideline in one of the provincial hospital of Nepal, as a quality improvement project. A cross-sectional study design was conducted within the Hetauda Hospital pharmacy section to check the compliance nature of hospital pharmacy practice standards using the 16 components and 121 indicators mentioned in the CSDD, implemented by the National Drug Regulatory Authority of Nepal, Department of Drug Administration. CSDD is a publicly available guideline consisting of 5 chapters and 20 sections, where the codes specifically focus on structural, human resources, storage and documentation, pharmacovigilance, GPP, good storage and distribution practice license-related provisions. Following the checklist provided in the CSDD, data were collected and entered into the MS Excel and analyzed in terms of frequency and percentage compliance. If the indicators were found to be 100% compliant, it was categorized as fully compliant, if the indicators were scored from (>50%-99.9%), it was categorized as partially compliant whereas if it was in between (0.0%-≤50%), it was categorized as poorly compliant. Out of a total of 121 indicators mentioned in the CSDD, only 74 (61.2%) were compliant. Only 6 domains were fully compliant (100%), whereas 7 domains were partially compliant (≥50%-99.9%) and 10 domains were poorly compliant (<50%-0.0%). Following the CSDD guidelines, it was found that the hospital pharmacy lacked in domains such as quality policy, service strategy, training, client complaints, product recalls, counseling services, medication records, client follow-up and referral, and self-inspection process, underscoring the need for prompt attention and an action plan from the Drug and Therapeutic Committee and the executives.

Non-suicidal self-injury (NSSI) and suicidal ideation (SI) represent significant mental health challenges among university students. In low- and middle-income contexts like Bangladesh, there is limited understanding of how these behaviors differentially affect students with and without mental illness. This study addresses these gaps by investigating the prevalence and risk factors of NSSI and SI, with stratified analyses by mental illness status, to predict these behaviors. This cross-sectional study recruited 1401 university students between December 2024 and January 2025. Data was collected via a self-administered questionnaire assessing socio-demographics, and psychological factors. Traditional statistical analyses, including chi-square tests and logistic regression, were conducted in SPSS 27. The prevalence of NSSI and SI was 21.4% and 17.2%, respectively. Both NSSI and SI were more common among students with symptoms of depression or anxiety (mental illness) than those without. Multivariable analyses identified smoking, cyberbullying, and probable eating disorder as significant predictors of both NSSI and SI, with these associations persisting after stratification by mental illness status. Subgroup analyses showed that among students without mental illness, female gender, older age, smoking, cyberbullying, and eating disorder symptoms significantly predicted NSSI, while smoking, cyberbullying, eating disorder, and older age predicted SI. In students with mental illness, smoking and cyberbullying remained robust predictors of both NSSI and SI, while eating disorder was significantly associated with NSSI but not SI. The regression models explained 12.9% of the variance in NSSI and 16.6% in SI. The findings highlight the necessity to adopt interventions that address modifiable risk factors, with a strong emphasis on behavioral and mental health variables, to effectively reduce self-harming and suicidal behaviors in young adults.

Fifteen to thirty percent of Canadians have access to palliative care, with even fewer access opportunities for people with experiences of homelessness. Existing research identifies barriers to access but rarely shows how health and social institutions actively organize exclusion. Part of a larger study, this paper examines how health and social systems shape the need for community-based palliative and end-of-life care, using 3 stories from clients of the Community Allied Mobile Palliative Partnership (CAMPP). Using institutional ethnography, data were collected between Fall 2019 and Summer 2020. Sources included approximately 100 h of observation of the CAMPP team's work, 3 in-depth client interviews, and supplementary provider interviews. Data were analyzed to trace institutional processes that shape everyday experiences of illness and care. Findings reveal systemic demands like renewing insurance for medical equipment, restrictive housing rules, and standardized hospital protocols that overwhelm capacities of many people with experiences of homelessness. Rowan's story illustrates how bureaucratic requirements jeopardized his oxygen supply. Harriet's story shows the harm of being separated from her caregiver in housing and hospital contexts compounding distress and reluctance to receive care. Chapa's story demonstrates how fear and stigma delayed critical cardiology care. Overall, the clients valued CAMPP's persistent, relational, non-judgmental, and flexible approach. The team's independence from the mainstream health system mandates enabled responsive care but relies on precarious funding, constraining sustainability. Community-based palliative teams like CAMPP fill critical gaps in mainstream services by tailoring care to complex social realities. Their model shows the value of equity-informed, relational approaches, yet structural exclusion and precarious funding threaten long-term viability. Policy integration must sustain such programs without eroding the autonomy that enables them to deliver meaningful palliative and end-of-life care for people with experiences of homelessness.

Stroke is a leading cause of morbidity and disability, with limited data on in-hospital mortality from low-resource settings. This study aimed to identify predictors of in-hospital mortality among stroke patients at a tertiary care hospital in Nepal. A prospective cohort study was conducted among 120 stroke patients aged ≥ 18 years, enrolled between November 2023 and April 2024. The primary outcome was in-hospital mortality following admission. Data was analysed using SAS version 9.4. Kaplan-Meier survival analysis and Cox proportional hazards regression were employed to identify predictors of in-hospital mortality. A p-value < .05 was considered statistically significant. The cohort comprised 68.3% ischemic and 31.7% haemorrhagic strokes, with an overall in-hospital mortality rate of 9.0%. Multivariate analysis revealed that a Glasgow Coma (GCS) score < 8 (AHR: 12.36; 95% CI: 2.73-56.00), National Institutes of Health Stroke Scale (NIHSS) ≥12 (AHR: 14.75; 95% CI: 3.01-72.28), moderate to severe disability (mRS ≥ 3; AHR: 9.92; 95% CI: 1.10-89.24), hemiplegia (AHR: 6.70; 95% CI: 1.835-53.748), territorial infarcts (AHR: 26.33; 95% CI: 2.093-331.203), capsuloganglionic infarcts (AHR: 14.6; 95% CI: 1.819-160.877), presence of chronic obstructive pulmonary disease (COPD) (AHR: 2.48; 95% CI: 1.317-45.091), and alcohol use (AHR: 3.87; 95% CI: 1.014-18.478) were significant predictors of in-hospital mortality. Neurological impairment at admission, specific infarct locations, hemiplegia, COPD, and alcohol use are significant predictors of in-hospital mortality among stroke patients. These findings underscore the importance of early neurological assessment, systematic risk stratification, and targeted interventions to improve stroke outcomes in resource-constrained settings.

This study explores how undergraduate health care students in Taiwan observe others' needs and what factors influence their prosocial behavior in the context of priority seating. Using a qualitative descriptive design with thematic content analysis, structured open-ended questionnaires were distributed to 146 students from 3 health-related departments at a college in Taiwan. Thematic content analysis was conducted based on a pre-defined coding framework. Participants' reasoning reflected both normative categories (eg, older adults, pregnant women) and situational judgments based on observed needs (eg, signs of fatigue or injury). Voluntary seat-offering was the most common behavior and was strongly associated with internalized personal values. Decisions were also shaped by the perceived demeanor of the person in need. Visual cross-theme analyses highlighted how these factors interacted in cases involving older adults and people with mobility impairments. Health care students' decisions to offer their seat were influenced by a mix of internal moral orientations, interpersonal cues, and context sensitivity. While cultural norms may inform reasoning, students actively negotiated social expectations with personal judgment. These findings suggest a need for further educational attention to everyday moral decision-making in the development of professional identity.

Site-neutral payment reforms seek to align Medicare reimbursement rates for common outpatient services across care sites. Recent reports have assessed the composite impact of site-neutral payment policies on beneficiaries, federal savings, and the commercial market. This analysis builds on such work, focusing on the potential patient-level savings of site-neutral reform for high-utilizing Medicare beneficiaries facing common chronic cancers. We compiled the outpatient services of standard treatment regimens for a typical lung, ovarian, prostate, and colon cancer patient over their first year of treatment. By simulating scenarios for these patients in which hospital outpatient rates were and were not aligned with those of independent physician offices for the 57 service classifications recommended by the Medicare Payment Advisory Commission (MedPAC), we were able to estimate the effect of site-neutral payments on patient out-of-pocket cancer costs. We found that expanding site-neutral payments for MedPAC's recommended services would greatly reduce Medicare cancer patients' outpatient out-of-pocket share, with certain beneficiaries saving over $1000 in out-of-pocket spending in their first year of cancer treatment. Along with patient savings, site-neutral payment expansion would produce larger Medicare fee-for-service savings that average over $5500 per cancer patient for the 4 standard cancer treatments analyzed. The largest portions of Medicare and patient savings with site-neutral payments for these 4 cancers came in the form of drug administration costs, particularly when chemotherapy was included as a part of treatment. The findings of this analysis suggest that existing regulatory and legislative site-neutral proposals have the ability to save Medicare and its higher-need beneficiaries thousands of dollars per patient when treating typical lung, ovarian, prostate, and colon cancer cases.