http://www.biomedcentral.com/bmchealthservres/ The latest research articles published by BMC Health Services Research 2010-01-05T00:00:00Z This is an RSS newsfeed from BioMed Central It is intended to be used with an RSS reader. For more information about RSS newsfeeds from BioMed Central, visit http://www.biomedcentral.com/info/about/rss/ Background: Despite universal health care, there continues to be regional access disparities to coronary angiography in Canada. Our objective was to evaluate the extent to which demand-side factors such as clinical urgency/need, and supply-side factors, as reflected by differences in physician and procedural supply account for these inequalities. Methods: Our cohort consisted of 74,254 consecutive patients referred for coronary angiography in Ontario, Canada between April 1st 2005 and March 31st 2006, divided into three urgency strata based on a clinical urgency scale. Cox-proportional hazard models were developed, adjusting for age, gender, and socioeconomic status (SES), region, and urgency score, with greater hazard ratios (HR) indicating shorter wait times. To evaluate mediators of any residual wait-time differences, we examined the influence of the regional supply of cath lab facilities, invasive cardiologists and general practitioners (GP). Results: We found that the urgency score was a significant predictor of wait time in all three strata (urgent patients: HR 1.61 for each unit increase in patient urgency (95% Confidence interval (CI) 1.55-1.67); semi-urgent patients: HR 1.55 (95% CI 1.44-1.68); elective patients: HR 1.13 (95% CI 1.08-1.18)). After accounting for clinical need/urgency, regional wait time differences persisted; these were most consistently associated with variation in cath lab supply. The impact of invasive cardiologist supply was restricted to urgent patients while that of GP supply was confined to semi-urgent and elective patients. Conclusion: We found that there remained significant regional disparities in access to coronary angiography after accounting for clinical need. These disparities are partially explained by variations in supply of both procedural capacity and physician services, most notably in elective and semi-urgent patients. http://www.biomedcentral.com/1472-6963/10/5 Harindra Wijeysundera Therese Stukel Alice Chong Madhu Natarajan David Alter BMC Health Services Research 2010, 10:5 2010-01-05T00:00:00Z doi:10.1186/1472-6963-10-5 BMC Health Services Research 1472-6963 10 5 2010-01-05T00:00:00Z PDF Background: Supplementary prescribing for mental health nurses was first introduced in the UK in 2003. Since then, a number of studies have reported stakeholders' perceptions of the success of the initiative. However, there has been little experimental research conducted into its effectiveness. This paper reports findings from the first known study to compare the cost and clinical impact of mental health nurse supplementary prescribing with independent medical prescribing. Methods: A post-test control group experimental design was used to compare the treatment costs, clinical outcomes and satisfaction of patients in receipt of mental health nurse supplementary prescribing with a matched group of patients in receipt of independent prescribing from consultant psychiatrists. The sample comprised 45 patients in receipt of mental health nurse supplementary prescribing for a minimum of six months and a matched group (by age, gender, diagnosis, and chronicity) of patients prescribed for by psychiatrists. Results: There were no significant differences between patients in the nurse supplementary prescribers' group and the independent prescribers' group in terms of medication adherence, health status, side effects, and satisfaction with overall care. Total costs per patient for service use were GBP803 higher for the nurse prescribers' group but this difference was not significant (95% confidence interval -GBP1341 to GBP3020). Conclusions: No significant differences were found between the health and social outcomes of patients in the mental health nurse supplementary prescribers' group, and those prescribed for by the independent medical prescribers. The cost appraisal also showed that there was no significant difference in the costs of the two types of prescribing, although the pattern of resources used differed between patients in the two prescriber groups. The results suggest that mental health nurse supplementary prescribers can deliver similar health benefits to patients as consultant psychiatrists without any significant difference in patients' service utilisation costs. http://www.biomedcentral.com/1472-6963/10/4 Ian Norman Samantha Coster Paul McCrone Andrew Sibley Cate Whittlesea BMC Health Services Research 2010, 10:4 2010-01-05T00:00:00Z doi:10.1186/1472-6963-10-4 BMC Health Services Research 1472-6963 10 4 2010-01-05T00:00:00Z PDF Background: Cancer program delivery, like the rest of health care in Canada, faces two ongoing challenges: to coordinate a pan-Canadian approach across complex provincial jurisdictions, and to facilitate the rapid translation of knowledge into clinical practice. Communities of practice, or CoPs, which have been described by Etienne Wenger as collaborative learning platforms, represent a promising solution to these challenges because they rely on bottom-up rather than top-down social structures for integrating knowledge and practice across regions and agencies. The communities of practice model has been realized in the corporate (e.g., Royal Dutch Shell, Xerox, IBM, etc) and development (e.g., World Bank) sectors, but its application to health care is relatively new. The Canadian Partnership Against Cancer (CPAC) is exploring the potential of Wenger's concept in the Canadian health care context. This paper provides an in-depth analysis of Wenger's concept with a focus on its applicability to the health care sector.DiscussionEmpirical studies and social science theory are used to examine the utility of Wenger's concept. Its value lies in emphasizing learning from peers and through practice in settings where innovation is valued. Yet the communities of practice concept lacks conceptual clarity because Wenger defines it so broadly and sidelines issues of decision making within CoPs. We consider the implications of his broad definition to establishing an informed nomenclature around this specific type of collaborative group. The CoP Project under CPAC and communities of practice in Canadian health care are discussed.SummaryThe use of communities of practice in Canadian health care has been shown in some instances to facilitate quality improvements, encourage buy in among participants, and generate high levels of satisfaction with clinical leadership and knowledge translation among participating physicians. Despite these individual success stories, more information is required on how group decisions are made and applied to the practice world in order to leverage the potential of Wenger's concept more fully, and advance the science of knowledge translation within an accountability framework. http://www.biomedcentral.com/1472-6963/10/3 Colene Bentley George Browman Barbara Poole BMC Health Services Research 2010, 10:3 2010-01-05T00:00:00Z doi:10.1186/1472-6963-10-3 BMC Health Services Research 1472-6963 10 3 2010-01-05T00:00:00Z PDF Background: Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines. Methods: Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG features with positive effect on the process of care. Results: Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR= 6.7; 95%CI: 1.3-34.3) were statistically significant predictors. Conclusions: From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system. http://www.biomedcentral.com/1472-6963/10/2 Gianfranco Damiani Luigi Pinnarelli Simona Colosimo Roberta Almiento Lorella Sicuro Rocco Galasso Lorenzo Sommella Walter Ricciardi BMC Health Services Research 2010, 10:2 2010-01-04T00:00:00Z doi:10.1186/1472-6963-10-2 BMC Health Services Research 1472-6963 10 2 2010-01-04T00:00:00Z PDF Background: Geriatric patients recently discharged from hospital experience increased chance of unplanned readmissions and admission to nursing homes. Several studies have shown that medication-related discrepancies are common. Few studies report unwanted incidents by other factors than medications. In 2002 an ambulatory team (AT) was established within the Department of Geriatrics, St. Olavs University Hospital HF, Trondheim, Norway. The AT monitored the transition of the patients from hospital to home and four weeks after discharge in order to reveal unwanted incidents.The aim of the present study was to describe unwanted incidents registered by the AT among patients discharged from a geriatric evaluation and management unit (GEMU) by character, frequency and stage in the transitional process. Only unwanted incidents with a severity making contact with the primary health care (PHC)necessary were registered. Methods: A prospective observational study with patients treated in the GEMU and followed by the AT was performed. Current practice included comprehensive geriatric assessment and management including discharge planning in the GEMU and collaboration with the primary health care on appointments on assistance to be provided after discharge from hospital. Unwanted incidents severe enough to induce contact with the primary health care were registered during the transitional phase and after discharge. Results: 118 patients (65 % female), with mean age 83.2 +/- 6.4 years participated. Median Barthel Index at discharge was 18 (interquartile range 16-19) and median Mini Mental Status Examination 24 (interquartile range 21-26). A total of 146 unwanted incidents were registered in 70 (59 %) of the patients. Most frequent were unwanted incidents related to drug prescription regime (32%), exchange of information in and between the GEMU and the primary health care (PHC) (25%) and service or help provided from the PHC (17%). Conclusions: Despite a seemingly well-organised system for transition of patients from the GEMU to their homes, one or more unwanted incidents occurred in most patients during discharge or four weeks post discharge. The study has revealed areas of importance for improving transitional care of geriatric patients. http://www.biomedcentral.com/1472-6963/10/1 Marianne Mesteig Jorunn Helbostad Olav Sletvold Tove Rosstad Ingvild Saltvedt BMC Health Services Research 2010, 10:1 2010-01-04T00:00:00Z doi:10.1186/1472-6963-10-1 BMC Health Services Research 1472-6963 10 1 2010-01-04T00:00:00Z PDF Background: Emergency departments (EDs) are high pressure health care settings involving complex interactions between staff members in providing and organising patient care. Without good communication and cooperation amongst members of the ED team, quality of care is at risk. This study examined the problem-solving, medication advice-seeking and socialising networks of staff working in an Australian hospital ED. Methods: A social network survey (Response Rate=94%) was administered to all ED staff (n=109) including doctors, nurses, allied health professionals, administrative staff and ward assistants. Analysis of the network characteristics was carried out by applying measures of density (the extent participants are concentrated), connectedness (how related they are), isolates (how segregated), degree centrality (who has most connections measured in two ways, in-degree, the number of ties directed to an individual and out-degree, the number of ties directed from an individual), betweenness centrality (who is important or powerful), degree of separation (how many ties lie between people) and reciprocity (how bi-directional are interactions). Results: In all three networks, individuals were more closely connected to colleagues from within their respective professional groups. The problem-solving network was the most densely connected network, followed by the medication advice network, and the loosely connected socialising network. ED staff relied on each other for help to solve work-related problems, but some senior doctors, some junior doctors and a senior nurse were important sources of medication advice for their ED colleagues. Conclusions: Network analyses provide useful ways to assess social structures in clinical settings by allowing us to understand how ED staff relate within their social and professional structures. This can provide insights of potential benefit to ED staff, their leaders, policymakers and researchers. http://www.biomedcentral.com/1472-6963/9/247 Nerida Creswick Johanna Westbrook Jeffrey Braithwaite BMC Health Services Research 2009, 9:247 2009-12-31T00:00:00Z doi:10.1186/1472-6963-9-247 BMC Health Services Research 1472-6963 9 247 2009-12-31T00:00:00Z PDF Background: Public drug insurance plans provide limited reimbursement for Alzheimer's disease (AD) medications in many jurisdictions, including Canada and the United Kingdom. This study was conducted to assess Canadians' level of support for an increase in annual personal income taxes to fund a public program of unrestricted access to AD medications. Methods: A telephone survey was administered to a national sample of 500 adult Canadians. The survey contained four scenarios describing a hypothetical, new AD medication. Descriptions varied across scenarios: the medication was alternatively described as being capable of treating the symptoms of cognitive decline or of halting the progression of cognitive decline, with either no probability of adverse effects or a 30% probability of primarily gastrointestinal adverse effects. After each scenario, participants were asked whether they would support a tax increase to provide unrestricted access to the drug. Participants who responded affirmatively were asked whether they would pay an additional $75, $150, or $225 per annum in taxes. Multivariable logistic regression analysis was conducted to examine the determinants of support for a tax increase. Results: Eighty percent of participants supported a tax increase for at least one scenario. Support was highest (67%) for the most favourable scenario (halt progression - no adverse effects) and lowest (49%) for the least favourable scenario (symptom treatment - 30% chance of adverse effects). The odds of supporting a tax increase under at least one scenario were approximately 55% less for participants who attached higher ratings to their health state under the assumption that they had moderate AD and almost five times greater if participants thought family members or friends would somewhat or strongly approve of their decision to support a tax increase. A majority of participants would pay an additional $150 per annum in taxes, regardless of scenario. Less than 50% would pay $225. Conclusions: Four out of five persons in a sample of adult Canadians reported they would support a tax increase to fund unrestricted access to a hypothetical, new AD medication. These results signal a willingness to pay for at least some relaxation of reimbursement restrictions on AD medications. http://www.biomedcentral.com/1472-6963/9/246 Mark Oremus Jean-Eric Tarride Natasha Clayton Parminder Raina BMC Health Services Research 2009, 9:246 2009-12-29T00:00:00Z doi:10.1186/1472-6963-9-246 BMC Health Services Research 1472-6963 9 246 2009-12-29T00:00:00Z PDF Background: Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. Methods: Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. Results: Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. Conclusions: A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex. http://www.biomedcentral.com/1472-6963/9/245 Richard Della Penna Helene Martel Esther Neuwirth Jennifer Rice Marta Filipski Jennifer Green Jim Bellows BMC Health Services Research 2009, 9:245 2009-12-29T00:00:00Z doi:10.1186/1472-6963-9-245 BMC Health Services Research 1472-6963 9 245 2009-12-29T00:00:00Z PDF Background: Consumer directed health care proposes that patients will engage as informed consumers of health care services by sharing in more of their medical costs, often through deductibles. We examined knowledge of deductible plan details among new enrollees, and examined anticipated care-seeking changes in response to the deductible. Methods: In a large integrated delivery system with a range of deductible-based health plans which varied in services included or exempted from deductible, we conducted a mixed-method, cross-sectional telephone interview study. Results: Among 458 adults newly enrolled in a deductible plan (71% response rate), 51% knew they had a deductible, 26% knew the deductible amount, and 6% knew which medical services were included or exempted from their deductible. After adjusting for respondent characteristics, those with more deductible-applicable services and those with lower self-reported health status were significantly more likely to know they had a deductible. Among those who knew of their deductible, half anticipated that it would cause them to delay or avoid medical care, including avoiding doctor's office visits and medical tests, even services that they believed were medically necessary. Many expressed concern about their costs, anticipating the inability to afford care and expressing the desire to change plans. Conclusion: Early in their experience with a deductible, patients had limited awareness of the deductible and little knowledge of the details. Many who knew of the deductible reported that it would cause them to delay or avoid seeking care and were concerned about their healthcare costs. http://www.biomedcentral.com/1472-6963/9/244 Mary Reed Nancy Benedetti Richard Brand Joseph Newhouse John Hsu BMC Health Services Research 2009, 9:244 2009-12-29T00:00:00Z doi:10.1186/1472-6963-9-244 BMC Health Services Research 1472-6963 9 244 2009-12-29T00:00:00Z PDF Background: Health, fair financing and responsiveness to the user's needs and expectations are seen as the essential objectives of health systems. Efforts have been made to conceptualise and measure responsiveness as a basis for evaluating the non-health aspects of health systems performance. This study assesses the applicability of the responsiveness tool developed by WHO when applied in the context of voluntary HIV counselling and testing services (VCT) at a district level in Kenya. Methods: A mixed method study was conducted employing a combination of quantitative and qualitative research methods concurrently. The questionnaire proposed by WHO was administered to 328 VCT users and 36 VCT counsellors (health providers). In addition to the questionnaire, qualitative interviews were carried out among a total of 300 participants. Observational field notes were also written. Results: A majority of the health providers and users indicated that the responsiveness elements were very important, e.g. confidentiality and autonomy were regarded by most users and health providers as very important and were also reported as being highly observed in the VCT room. However, the qualitative findings revealed other important aspects related to confidentiality, autonomy and other responsiveness elements that were not captured by the WHO tool. Striking examples were inappropriate location of the VCT centre, limited information provided, language problems, and concern about the quality of counselling. Conclusion: The results indicate that the WHO developed responsiveness elements are relevant and important in measuring the performance of voluntary HIV counselling and testing. However, the tool needs substantial revision in order to capture other important dimensions or perspectives. The findings also confirm the importance of careful assessment and recognition of locally specific aspects when conducting comparative studies on responsiveness of HIV testing services. http://www.biomedcentral.com/1472-6963/9/243 Mercy Njeru Astrid Blystad Isaac Nyamongo Knut Fylkesnes BMC Health Services Research 2009, 9:243 2009-12-22T00:00:00Z doi:10.1186/1472-6963-9-243 BMC Health Services Research 1472-6963 9 243 2009-12-22T00:00:00Z PDF