BMC Health Services Research - Latest Articles

An overiew of non medical prescribing across one strategic health authority: a questionnaire survey

Molly Courtenay — 2012-06-01T00:00:00Z

Background: Over 50,000 non-medical healthcare professionals across the United Kingdom now haveprescribing capabilities. However, there is no evidence available with regards to the extent towhich non-medical prescribing (NMP) has been implemented within organisations across astrategic health authority (SHA). The aim of the study was to provide an overview of NMPacross one SHA. Methods: NMP leads across one SHA were asked to supply the email addresses of NMPs within theirorganisation. One thousand five hundred and eighty five NMPs were contacted and invited tocomplete an on-line descriptive questionnaire survey, 883 (55.7%) participants responded.Data was collected between November 2010 and February 2011. Results: The majority of NMPs were based in primary care and worked in a team of 2 or more. Nurseindependent supplementary prescribers were the largest group (590 or 68.6%) compared tocommunity practitioner prescribers (198 or 22.4%), pharmacist independent supplementaryprescribers (35 or 4%), and allied health professionals and optometrist independent and/orsupplementary prescribers (8 or 0.9%). Nearly all (over 90%) of nurse independentsupplementary prescribers prescribed medicines. Approximately a third of pharmacistindependent supplementary prescribers, allied health professionals, and communitypractitioner prescribers did not prescribe. Clinical governance procedures were largely inplace, although fewer procedures were reported by community practitioner prescribers.General practice nurses prescribed the most items. Factors affecting prescribing practice were: employer, the level of experience prior to becoming a non-medical prescriber,existence of governance procedures and support for the prescribing role (p < 0.001). Conclusion: NMP in this strategic health authority reflects national development of this relatively newrole in that the majority of non-medical prescribers were nurses based in primary care, withfewer pharmacist and allied health professional prescribers. This workforce is contributing tomedicines management activities in a range of care settings. If non-medical prescibers are tomaximise their contribution, robust governance and support from healthcare organisations isessential. The continued use of supplementary prescribing is questionable if maximumefficiency is sought. These are important points that need to be considered by thoseresponsible for developing non-medical prescribing in the United Kingdom and othercountries around the world.

The diagnostic yield of the first episode of a periodic health evaluation: a descriptive epidemiology study

Cindy Kermott — 2012-05-30T00:00:00Z

Background: The benefits of a periodic health evaluation remain debatable. The incremental value addedby such evaluations beyond the delivery of age appropriate screening and preventivemedicine recommendations is unclear. Methods: We retrospectively collected data on a cohort of consecutive patients presenting for their firstepisode of a comprehensive periodic health evaluation. We abstracted data on new diagnosesthat were identified during this single episode of care and that were not trivial (i.e., requiredadditional testing or intervention). Results: The cohort consisted of 491 patients. The rate of new diagnoses per this single episode ofcare was 0.9 diagnoses per patient. The majority of these diagnoses was not prompted bypatients' complaints (71%) and would not have been identified by screening guidelines(51%). Men (odds ratio 2.67; 95% CI, 1.76, 4.03) and those with multiple complaints atpresentation (odds ratio 1.12; 95% CI, 1.05, 1.19) were more likely to receive a clinicallyrelevant diagnosis at the conclusion of the visit. Age was not a predictor of receiving adiagnosis in this cohort. Conclusion: The first episode of a comprehensive periodic health evaluation may reveal numerousimportant diagnoses or risk factors that are not always identified through routine screening.

Changes to the financial responsibility for juvenile court ordered psychiatric evaluations reduce inpatient services utilization: an interrupted time series study

Richard Epstein — 2012-05-30T00:00:00Z

Background: The purpose of the current study was to evaluate the impact of a July 2008 Tennessee Courtof Appeals opinion that shifted financial responsibility for juvenile court ordered psychiatricevaluations from the State to the County. Methods: We used de-identified administrative data from the Tennessee Department of Mental Healthand mid-year population estimates from the U.S. Census Bureau from July 1, 2006 to June30, 2010, and an interrupted time series design with segmented regression analysis toquantify the impact of the implementation of the Court opinion. Results: In the study period, there were 2,176 referrals for juvenile court ordered psychiatricevaluations in Tennessee; of these, 74.1% were inpatient evaluations. The Court opinion wasassociated with a decrease of 9.4 (95% C.I. = 7.9-10.8) inpatient and increase of 1.2 (95%C.I. = 0.4-2.1) outpatient evaluations per 100,000 Tennessee youth aged 12 to 19 years permonth. Conclusions: The Court opinion that shifted financial responsibility for juvenile court ordered psychiatricevaluations from the State to the County was associated with a sudden and significantdecrease in inpatient psychiatric evaluations, and more modest increase in outpatientevaluations.

An emigration versus a globalization perspective of the Lebanese physician workforce: a qualitative study

Elie Akl — 2012-05-30T00:00:00Z

Background: Lebanon is witnessing an increased emigration of physicians. The objective of this study wasto understand the perceptions of Lebanese policymakers of this emigration, and elicit theirproposals for future policies and strategies to deal with this emigration. Methods: We conducted semi-structured individual interviews with the deans of Lebanon's sevenmedical schools, the presidents of the two physicians professional associations, andgovernmental officials. We analyzed the results qualitatively. Results: Participants differed in the assessment of the extent and gravity of emigration. Lebanon has asurplus of physicians, driven largely by the over-production of graduates by a growingnumber of medical schools. Participants cited advantages and disadvantages of the emigrationon the personal, financial, medical education system, healthcare system, and national levels.Proposed strategies included limiting the number of students entering medical schools,creating job opportunities for graduating students, and implementing quality standards. Mostparticipants acknowledged the globalization of the Lebanese physician workforce, includingexchanges with the Gulf region, exchanges with developed countries, and the involvement ofNorth American medical education institutions in the region. Conclusion: Many Lebanese policy makers, particularly deans of medical schools, perceive the emigrationof the physician workforce as an opportunity in the context of the globalization of theprofession.

Brain Gains: a literature review of medical missions to low and middle-income countries

Alexandra Martiniuk — 2012-05-29T00:00:00Z

Background: Healthcare professionals' participation in short-term medical missions to low and middle income countries (LMIC) to provide healthcare has become common over the past 50 years yet little is known about the quantity and quality of these missions. The aim of this study was to review medical mission publications over 25 years to better understand missions and their potential impact on health systems in LMICs. Methods: A literature review was conducted by searching Medline for articles published from 1985-2009 about medical missions to LMICs, revealing 2512 publications. Exclusion criteria such as receiving country and mission length were applied, leaving 230 relevant articles. A data extraction sheet was used to collect information, including sending/receiving countries and funding source. Results: The majority of articles were descriptive and lacked contextual or theoretical analysis. Most missions were short-term (1 day - 1 month). The most common sending countries were the U.S. and Canada. The top destination country was Honduras, while regionally Africa received the highest number of missions. Health care professionals typically responded to presenting health needs, ranging from primary care to surgical relief. Cleft lip/palate surgeries were the next most common type of care provided. Conclusions: Based on the articles reviewed, there is significant scope for improvement in mission planning, monitoring and evaluation as well as global and/or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training in such areas as cross-cultural communication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy, harmonisation with existing government programming and transparency are needed.

Attractiveness of employment sectors for physical therapists in Ontario, Canada (1999-2007): implication for the long term care sector

Michel Landry — 2012-05-29T00:00:00Z

Background: Recruiting and retaining health professions remains a high priority for health systemplanners. Different employment sectors may vary in their appeal to providers. We used theconcepts of inflow and stickiness to assess the relative attractiveness of sectors for physicaltherapists (PTs) in Ontario, Canada. Inflow was defined as the percentage of PTs working ina sector who were not there the previous year. Stickiness was defined as the transitionprobability that a physical therapist will remain in a given employment sector year-to-year. Methods: A longitudinal dataset of registered PTs in Ontario (1999-2007) was created, and primaryemployment sector was categorized as 'hospital', 'community', 'long term care' (LTC) or'other.' Inflow and stickiness values were then calculated for each sector, and trends wereanalyzed. Results: There were 5003 PTs in 1999, which grew to 6064 by 2007, representing a 21.2% absolutegrowth. Inflow grew across all sectors, but the LTC sector had the highest inflow of 32.0%.PTs practicing in hospitals had the highest stickiness, with 87.4% of those who worked in thissector remaining year-to-year. The community and other employment sectors had stickinessvalues of 78.2% and 86.8% respectively, while the LTC sector had the lowest stickiness of73.4%. Conclusion: Among all employment sectors, LTC had highest inflow but lowest stickiness. Givenexpected increases in demand for services, understanding provider transitional probabilitiesand employment preferences may provide a useful policy and planning tool in developing asustainable health human resource base across all employment sectors.

Comparing Dutch Case management care models for people with dementia and their caregivers: The design of the COMPAS study

Janet MacNeil Vroomen — 2012-05-28T00:00:00Z

Background: Dementia care in the Netherlands is shifting from fragmented, ad hoc care to more coordinated and personalised care. Case management contributes to this shift. The linkage model and a combination of intensive case management and joint agency care models were selected based on their emerging prominence in the Netherlands. It is unclear if these different forms of case management are more effective than usual care in improving or preserving the functioning and well-being at the patient and caregiver level and at the societal cost. The objective of this article is to describe the design of a study comparing these two case management care models against usual care. Clinical and cost outcomes are investigated while care processes and the facilitators and barriers for implementation of these models are considered.DesignMixed methods include a prospective, observational, controlled, cohort study among persons with dementia and their primary informal caregiver in regions of the Netherlands with and without case management including a qualitative process evaluation. Inclusion criteria for the cohort study are: community-dwelling individuals with a dementia diagnosis who are not terminally-ill or anticipate admission to a nursing home within 6 months and with an informal caregiver who speaks fluent Dutch. Person with dementia-informal caregiver dyads are followed for two years. The primary outcome measure is the Neuropsychiatric Inventory for the people with dementia and the General Health Questionnaire for their caregivers. Secondary outcomes include: quality of life and needs assessment in both persons with dementia and caregivers, activity of daily living, competence of care, and number of crises. Costs are measured from a societal perspective using cost diaries. Process indicators measure the quality of care from the participant's perspective. The qualitative study uses purposive sampling methods to ensure a wide variation of respondents. Semi-structured interviews with stakeholders based on the theoretical model of adaptive implementation are planned.DiscussionThis study provides relevant insights into care processes, description of two case management models along with clinical and economic data from persons with dementia andcaregivers to clarify important differences in two case management care models compared to usual care.

An assessment of the Zimbabwe ministry of health and child welfare provider initiated HIV testing and counselling programme

Euphemia Sibanda — 2012-05-28T00:00:00Z

Background: Provider-initiated HIV testing and counselling (PITC) is widely recommended to ensuretimely treatment of HIV. The Zimbabwe Ministry of Health introduced PITC in 2007. Weaimed to evaluate institutional capacity to implement PITC and investigate patient and healthcare worker (HCW) perceptions of the PITC programme. Methods: Purposive selection of health care institutions was conducted among those providing PITC.Study procedures included 1) assessment of implementation procedures and institutionalcapacity using a semi-structured questionnaire; 2) in-depth interviews with patients who hadbeen offered HIV testing to explore perceptions of PITC, 3) Focus group discussions withHCW to explore views on PITC. Qualitative data was analysed according to FrameworkAnalysis. Results: Sixteen health care institutions were selected (two central, two provincial, six districthospitals; and six primary care clinics. All institutions at least offered PITC in part. The mainchallenges which prevented optimum implementation were shortages of staff trained in PITC,HIV rapid testing and counselling; shortages of appropriate counselling space, and, at thetime of assessment, shortages of HIV test kits. Both health care workers and patientsembraced PITC because they had noticed that it had saved lives through early detection andtreatment of HIV. Although health care workers reported an increase in workload as a resultof PITC, they felt this was offset by the reduced number of HIV-related admissions andsatisfaction of working with healthier clients. Conclusion: PITC has been embraced by patients and health care workers as a life-saving intervention.There is need to address shortages in material, human and structural resources to ensureoptimum implementation.

The impact of decision aids to enhance shared decision making for diabetes (the DAD study): protocol of a cluster randomized trial

Annie LeBlanc — 2012-05-28T00:00:00Z

Background: Shared decision making contributes to high quality healthcare by promoting a patientcenteredapproach. Patient involvement in selecting the components of a diabetes medicationprogram that best match the patient's values and preferences may also enhance medicationadherence and improve outcomes. Decision aids are tools designed to involve patients inshared decision making, but their adoption in practice has been limited. In this study, wepropose to obtain a preliminary estimate of the impact of patient decision aids vs. usual careon measures of patient involvement in decision making, diabetes care processes, medicationadherence, glycemic and cardiovascular risk factor control, and resource utilization. Inaddition, we propose to identify, describe, and explain factors that promote or inhibit theroutine embedding of decision aids in practice. Methods: We will be conducting a mixed-methods study comprised of a cluster-randomized, practical,multicentered trial enrolling clinicians and their patients (n = 240) with type 2 diabetes fromrural and suburban primary care practices (n = 8), with an embedded qualitative study toexamine factors that influence the incorporation of decision aids into routine practice. Theintervention will consist of the use of a decision aid (Statin Choice and Aspirin Choice, orDiabetes Medication Choice) during the clinical encounter. The qualitative study will includeanalysis of video recordings of clinical encounters and in-depth, semi-structured interviewswith participating patients, clinicians, and clinic support staff, in both trial arms.DiscussionUpon completion of this trial, we will have new knowledge about the effectiveness ofdiabetes decision aids in these practices. We will also better understand the factors thatpromote or inhibit the successful implementation and normalization of medication choicedecision aids in the care of chronic patients in primary care practices.Trial registrationNCT00388050

Variation in cancer surgical outcomes associated with physician and nurse staffing: a retrospective observational study using the Japanese Diagnosis Procedure Combination Database

Hideo Yasunaga — 2012-05-28T00:00:00Z

Background: Little is known about the effects of professional staffing on cancer surgical outcomes. Thepresent study aimed to investigate the association between cancer surgical outcomes andphysician/nurse staffing in relation to hospital volume. Methods: We analyzed 131,394 patients undergoing lung lobectomy, esophagectomy, gastrectomy,colorectal surgery, hepatectomy or pancreatectomy for cancer between July and December,2007-2008, using the Japanese Diagnosis Procedure Combination database linked to theSurvey of Medical Institutions data. Physician-to-bed ratio (PBR) and nurse-to-bed ratio(NBR) were determined for each hospital. Hospital volume was categorized into low,medium and high for each of six cancer surgeries. Failure to rescue (FTR) was defined as aproportion of inhospital deaths among those with postoperative complications. Multi-levellogistic regression analysis was performed to examine the association betweenphysician/nurse staffing and FTR, adjusting for patient characteristics and hospital volume. Results: Overall inhospital mortality was 1.8%, postoperative complication rate was 15.2%, and FTRrate was 11.9%. After adjustment for hospital volume, FTR rate in the group with high PBR([greater than or equal to]19.7 physicians per 100 beds) and high NBR ([greater than or equal to]77.0 nurses per 100 beds) was significantlylower than that in the group with low PBR (<19.7) and low NBR (<77.0) (9.2% vs. 14.5%;odds ratio, 0.76; 95% confidence interval, 0.68-0.86; p < 0.001). Conclusions: Well-staffed hospitals confer a benefit for cancer surgical patients regarding reduced FTR,irrespective of hospital volume. These results suggest that consolidation of surgical centerslinked with migration of medical professionals may improve the quality of cancer surgicalmanagement.