Ambulatory healthcare information system: a conceptual framework

Transitional shared decision-making processes for patients with complex needs: A feasibility study

INTRODUCTION

Shared decision-making (SDM) processes, combining patients' and professionals' perspectives, are especially necessary for patients with complex needs (CNs) during their care transitions. In 2016, we started implementing interprofessional and interinstitutional SDM processes (IIPs) for patients admitted to a short-stay unit (SSU) for inpatient care and then followed-up by primary care providers. Two types of IIPs were identified: (a) iterative IIPs, and (b) meeting IIPs. These differed in terms of the timing of SDM processes: whereas the former were multilateral and iterative, meeting IIPs were simultaneous. However, the two processes had similar outcomes and participants had similar characteristics. The intervention included other components, such as CNs assessment and a care coordinator position. The present study aimed to assess the feasibility of the intervention's implementation.

METHODS

The intervention's feasibility was assessed using fidelity and coverage indicators. We collected data from the patients' records on (a) patients' and professionals' characteristics, (b) the fidelity (CNs evaluations and occurrences of IIPs), and (c) the intervention's coverage (types of IIPs, participants).

RESULTS

The study included 453 patients between September 2017 and February 2019: mean age of 82.3 years, 65.6% women and 61.1% considered to have CNs. For patients with CNs, iterative IIPs and meeting IIPs occurred in 78.3% and 23.8% of cases, respectively. 35.1% of iterative IIPs and 8.8% of meeting IIPs for patients with CNs involved patients or their informal caregivers, inpatient professionals, primary care physicians and homecare professionals.

DISCUSSION

These results showed that an intervention targeting the implementation of formalized IIPs for SDM in transitional care was feasible. However, to improve the evaluation of such interventions, other methods should be used to measure their appropriateness and acceptability. Additionally, assessing the effects of IIPs would legitimize their funding, supporting their sustainability and generalisability.

A Meta-summarization of Qualitative Findings About Health Systems Performance Evaluation Models: Conceptual Problems and Comparability Limitations

Due to the replacement of the issue of performance measurement in health policies worldwide this study identifies and analyzes the models for evaluating health systems performance. For this purpose, a systematic review of the literature on the topic "health systems performance evaluation" is done, making it compatible with a qualitative meta-synthesis of the type "meta-summarization." It works with all databases related to the theme (PubMed, Scopus, EMBASE, PubAdm and Lilacs/Scielo). Portuguese, English, and Spanish are elected as language limit. Of the total number of articles (n = 32), 23 articles (71.8%) do not have a definition on "performance." In those who have a definition, "performance" could be summed up in 6 central ideas. Among the most frequent subsidiary concepts that makes up the performance idea are the concepts of "efficiency" (11.9%), "quality" (9.5%) and "effectiveness" (7.1%). Six models were found in this review: "dashboard," "balanced scorecard," "open system model," "PCATool," "analyze dimension and performance indicators" and "standardized checklist and interview." The "dashboard" was the most frequent performance evaluation model, found in 35.7% of studies. Only 25% of the reviewed studies presented the performance evaluation model applied specifically to health systems. Far from being configured as management tools useful to comprehension of health systems, these performance evaluation models have shortcomings that compromise their systemic evaluative power. This reinforces the inversion of reality in the relationship between quality and performance. Also, the performance evaluation models used try to adapt to the object, however in most them with relevant analytical problems compromising the specificities in depth of the health system under analysis. This generates inaccuracies and replaces the question about its use and their limitations to compare health systems.

Patient safety issues in office-based surgery and anaesthesia in Switzerland: a qualitative study

OBJECTIVES

To identify the spectrum of patient safety issues in office-based surgery and anaesthesia in Switzerland.

METHODS

Purposive sample of 23 experts in surgery and anaesthesia and quality and regulation in Switzerland. Data were collected via individual qualitative interviews using a researcher-developed semi-structured interview guide between March 2016 and September 2016. Interviews were transcribed and analysed using conventional content analysis. Issues were categorised under the headings "structure", "process", and "outcome".

RESULTS

Experts identified two key overarching patient safety and regulatory issues in relation to office-based surgery and anaesthesia in Switzerland. First, experts repeatedly raised the current lack of data and transparency of the setting. It is unknown how many surgeons are operating in offices, how many and what types of operations are being done, and what the outcomes are. Secondly, experts also noted the limited oversight and regulation of the setting. While some standards exists, most experts felt that more minimal safety standards are needed regarding the requirements that must be met to do office-based surgery and what can and cannot be done in the office-based setting are needed, but they advocated a self-regulatory approach.

CONCLUSION

There is a lack of empirical data regarding the quantity and quality office-based surgery and anaesthesia in Switzerland. Further research is needed to address these research gaps and inform health policy in relation to patient safety in office-based surgery and anaesthesia in Switzerland.

Comparing potentially avoidable hospitalization rates related to ambulatory care sensitive conditions in Switzerland: the need to refine the definition of health conditions and to adjust for population health status

Background

Regional rates of hospitalization for ambulatory care sensitive conditions (ACSC) are used to compare the availability and quality of ambulatory care but the risk adjustment for population health status is often minimal. The objectives of the study was to examine the impact of more extensive risk adjustment on regional comparisons and to investigate the relationship between various area-level factors and the properly adjusted rates.

Methods

Our study is an observational study based on routine data of 2 million anonymous insured in 26 Swiss cantons followed over one or two years. A binomial negative regression was modeled with increasingly detailed information on health status (age and gender only, inpatient diagnoses, outpatient conditions inferred from dispensed drugs and frequency of physician visits). Hospitalizations for ACSC were identified from principal diagnoses detecting 19 conditions, with an updated list of ICD-10 diagnostic codes. Co-morbidities and surgical procedures were used as exclusion criteria to improve the specificity of the detection of potentially avoidable hospitalizations. The impact of the adjustment approaches was measured by changes in the standardized ratios calculated with and without other data besides age and gender.

Results

25% of cases identified by inpatient main diagnoses were removed by applying exclusion criteria. Cantonal ACSC hospitalizations rates varied from to 1.4 to 8.9 per 1,000 insured, per year. Morbidity inferred from diagnoses and drugs dramatically increased the predictive performance, the greatest effect found for conditions linked to an ACSC. More visits were associated with fewer PAH although very high users were at greater risk and subjects who had not consulted at negligible risk. By maximizing health status adjustment, two thirds of the cantons changed their adjusted ratio by more than 10 percent. Cantonal variations remained substantial but unexplained by supply or demand.

Conclusion

Additional adjustment for health status is required when using ACSC to monitor ambulatory care. Drug-inferred morbidities are a promising approach.

Disease identification based on ambulatory drugs dispensation and in-hospital ICD-10 diagnoses: a comparison

BACKGROUND

Pharmacy-based case mix measures are an alternative source of information to the relatively scarce outpatient diagnoses data. But most published tools use national drug nomenclatures and offer no head-to-head comparisons between drugs-related and diagnoses-based categories. The objective of the study was to test the accuracy of drugs-based morbidity groups derived from the World Health Organization Anatomical Therapeutic Chemical Classification of drugs by checking them against diagnoses-based groups.

METHODS

We compared drugs-based categories with their diagnoses-based analogues using anonymous data on 108,915 individuals insured with one of four companies. They were followed throughout 2005 and 2006 and hospitalized at least once during this period. The agreement between the two approaches was measured by weighted kappa coefficients. The reproducibility of the drugs-based morbidity measure over the 2 years was assessed for all enrollees.

RESULTS

Eighty percent used a drug associated with at least one of the 60 morbidity categories derived from drugs dispensation. After accounting for inpatient under-coding, fifteen conditions agreed sufficiently with their diagnoses-based counterparts to be considered alternative strategies to diagnoses. In addition, they exhibited good reproducibility and allowed prevalence estimates in accordance with national estimates. For 22 conditions, drugs-based information identified accurately a subset of the population defined by diagnoses.

CONCLUSIONS

Most categories provide insurers with health status information that could be exploited for healthcare expenditure prediction or ambulatory cost control, especially when ambulatory diagnoses are not available. However, due to insufficient concordance with their diagnoses-based analogues, their use for morbidity indicators is limited.

The breadth of primary care: a systematic literature review of its core dimensions

Background

Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.

Methods

A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.

Results

Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.

Conclusions

A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.

Assessing health system performance in developing countries: a review of the literature

With the setting of ambitious international health goals and an influx of additional development assistance for health, there is growing interest in assessing the performance of health systems in developing countries. This paper proposes a framework for the assessment of health system performance and reviews the literature on indicators currently in use to measure performance using online medical and public health databases. This was complemented by a review of relevant books and reports in the grey literature. The indicators were organized into three categories: effectiveness, equity, and efficiency. Measures of health system effectiveness were improvement in health status, access to and quality of care and, increasingly, patient satisfaction. Measures of equity included access and quality of care for disadvantaged groups together with fair financing, risk protection and accountability. Measures of efficiency were appropriate levels of funding, the cost-effectiveness of interventions, and effective administration. This framework and review of indicators may be helpful to health policy makers interested in assessing the effects of different policies, expenditures, and organizational structures on health outputs and outcomes in developing countries.