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Kaempf JW, Wang L, Dunn M. The Triple Aim Quality Improvement Gold Standard Illustrated as Extremely Premature Infant Care. Am J Perinatol 2024; 41:e1172-e1182. [PMID: 36539206 DOI: 10.1055/a-2001-8844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress. STUDY DESIGN Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network calculated the Triple Aim in 230/7 to 276/7-week infants using three surrogate measures: (1) population health/x-axis-eight major morbidity rates as a composite, risk-adjusted metric; (2) cost/y-axis-total hospital length of stay; and (3) individual care/z-axis-mortality, then illustrated this relationship as a sphere within a three-dimensional cube. RESULTS Three thousand seven hundred six infants born between January 1, 2014 and December 31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth weight of 803 (208) grams were analyzed. Triple Aim three-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric), but moved backward in the y-axis length of stay and z-axis mortality measurements. CONCLUSION Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions. KEY POINTS · The Triple Aim gold standard is elusive. There is no demonstration of sustained, large-scale success in healthcare and our quality improvement network has previously published benchmark extreme prematuritymorbidity improvements.. · Extreme prematurity outcomes illustrated as the Triple Aim show uneven results in relevant surrogate parameters and Triple Aim achievement, if even possible, will necessitate evidence-based methodologies that are scalable.. · Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required for Triple Aim success..
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Affiliation(s)
- Joseph W Kaempf
- Providence St. Vincent Medical Center, Women and Children's Services, Medical Data and Research Center, Portland, Oregon
| | - Lian Wang
- Providence St. Vincent Medical Center, Women and Children's Services, Medical Data and Research Center, Portland, Oregon
| | - Michael Dunn
- Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Sharma KM, Jones PB, Cumming J, Middleton L. Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation. BMC Health Serv Res 2024; 24:54. [PMID: 38200522 PMCID: PMC10782523 DOI: 10.1186/s12913-023-10497-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. METHODS This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. RESULTS The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. DISCUSSION Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. CONCLUSIONS Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. OTHER This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).
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Affiliation(s)
- Kanchan M Sharma
- Te Tai Ōhanga- The Treasury, 1 The Terrace, 6011, Wellington, New Zealand.
| | - Peter B Jones
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, 34 Princes Street, Auckland CBD, 1010, Auckland, New Zealand
| | - Jacqueline Cumming
- Health Services Research Centre, Faculty of Health, Victoria University of Wellington, Kelburn Parade, 6012, Kelburn, Wellington, New Zealand
| | - Lesley Middleton
- Faculty of Health, Victoria University of Wellington, Kelburn Parade, 6012, Kelburn, Wellington, New Zealand
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Howe J, MacPhee M, Duddy C, Habib H, Wong G, Jacklin S, Oduola S, Upthegrove R, Carlish M, Allen K, Patterson E, Maidment I. A realist review of medication optimisation of community dwelling service users with serious mental illness. BMJ Qual Saf 2023:bmjqs-2023-016615. [PMID: 38071586 DOI: 10.1136/bmjqs-2023-016615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/14/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Severe mental illness (SMI) incorporates schizophrenia, bipolar disorder, non-organic psychosis, personality disorder or any other severe and enduring mental health illness. Medication, particularly antipsychotics and mood stabilisers are the main treatment options. Medication optimisation is a hallmark of medication safety, characterised by the use of collaborative, person-centred approaches. There is very little published research describing medication optimisation with people living with SMI. OBJECTIVE Published literature and two stakeholder groups were employed to answer: What works for whom and in what circumstances to optimise medication use with people living with SMI in the community? METHODS A five-stage realist review was co-conducted with a lived experience group of individuals living with SMI and a practitioner group caring for individuals with SMI. An initial programme theory was developed. A formal literature search was conducted across eight bibliographic databases, and literature were screened for relevance to programme theory refinement. In total 60 papers contributed to the review. 42 papers were from the original database search with 18 papers identified from additional database searches and citation searches conducted based on stakeholder recommendations. RESULTS Our programme theory represents a continuum from a service user's initial diagnosis of SMI to therapeutic alliance development with practitioners, followed by mutual exchange of information, shared decision-making and medication optimisation. Accompanying the programme theory are 11 context-mechanism-outcome configurations that propose evidence-informed contextual factors and mechanisms that either facilitate or impede medication optimisation. Two mid-range theories highlighted in this review are supported decision-making and trust formation. CONCLUSIONS Supported decision-making and trust are foundational to overcoming stigma and establishing 'safety' and comfort between service users and practitioners. Avenues for future research include the influence of stigma and equity across cultural and ethnic groups with individuals with SMI; and use of trained supports, such as peer support workers. PROSPERO REGISTRATION NUMBER CRD42021280980.
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Affiliation(s)
- Jo Howe
- Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, UK
| | - Maura MacPhee
- School of Nursing, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Claire Duddy
- Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hafsah Habib
- Pharmacy School, Aston University College of Health and Life Sciences, Birmingham, UK
| | - Geoff Wong
- Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon Jacklin
- School of Pharmacy and Bioengineering, Keele University, Keele, UK
| | - Sheri Oduola
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, Birmingham, UK
- Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Max Carlish
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Katherine Allen
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Emma Patterson
- Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Ian Maidment
- Pharmacy School, College of Health and Life Sciences, Aston University, Birmingham, UK
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Mora N, Arvanitakis Z, Thomas M, Kramer H, Morrato EH, Markossian TW. Applying Customer Discovery Method to a Chronic Disease Self-Management Mobile App: Qualitative Study. JMIR Form Res 2023; 7:e50334. [PMID: 37955947 PMCID: PMC10682919 DOI: 10.2196/50334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/22/2023] [Accepted: 10/05/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND A significant health challenge is evident in the United States, with 6 in 10 adults having a chronic disease and 4 in 10 adults having 2 or more. Chronic disease self-management aims to prevent or delay disease progression and disability and reduce mortality risk. The evidence to support the use of information technology tools, including mobile apps, web-based portals, and web-based educational interventions, that support disease self-management and improve clinical outcomes is growing. Customer discovery and value proposition design methodology is a form of stakeholder engagement and is based on marketing and lean start-up business methods. As applied in health care, customer discovery and value proposition methodology can be used to understand the clinical problem and articulate the product's hypothesized unique value proposition relative to alternative options that are available to end users. OBJECTIVE This study aims to describe the experience and findings of academic researchers applying the customer discovery and value proposition methodology to identify stakeholders, needs, adaptability, and sustainability of a chronic disease self-management mobile app (CDapp). The motivation of the work is to make mobile health app interventions accessible and acceptable for all segments of patients' chronic diseases. METHODS Data were obtained through key informant interviews and analyzed using rapid qualitative analysis techniques. The value proposition framework was used to build the interview guide. The aim was to identify the needs, challenges (pains), and potential benefits (gains) of the CDapp for our stakeholders. RESULTS Our results showed that the primary consumers (end users) of a CDapp were the patients. The app adopters (decision makers) can be medical center leaders including population health department managers or insurance providers, while the consumer adoption influencers (influencers or saboteurs) are clinicians and patient caregivers. We developed an ecosystem map to visualize the clinical practice workflow and how an app for chronic disease management might integrate within an academic health care center or system. A value proposition for the identified customer segments was generated. Each stakeholder segment was working within a different framework to improve patient self-management. Patients needed help to adhere to self-care activities and they needed tailored health education. Health care leaders aim to improve the quality of care while reducing costs and workload. Clinicians wanted to improve patient education and care while reducing the time burden. Our results also showed that within academic medical centers, there were variations regarding patients' self-reported abilities to manage their diseases. CONCLUSIONS Customer discovery is a useful form of stakeholder engagement when designing studies that seek to implement, adapt, and sustain an intervention. The customer discovery and value proposition methodology can be used as an alternative or complementary approach to formative research to generate valuable information in a brief period.
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Affiliation(s)
- Nallely Mora
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Zoe Arvanitakis
- Rush Medical College, Rush University Medical Center, Chicago, IL, United States
| | - Merly Thomas
- Center for Health Innovation and Entrepreneurship, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Holly Kramer
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
- Department of Medicine, Loyola University of Chicago, Maywood, IL, United States
| | - Elaine H Morrato
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
| | - Talar W Markossian
- Department of Public Health Sciences, Parkinson School of Health Sciences and Public Health, Loyola University of Chicago, Maywood, IL, United States
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Colectomy Complicated by High-Output Ileostomy Managed in a Virtual Hybrid Hospital-at-Home Program. Case Rep Surg 2022; 2022:3177934. [PMID: 36213589 PMCID: PMC9537035 DOI: 10.1155/2022/3177934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/21/2022] [Indexed: 11/30/2022] Open
Abstract
Chronically ill patients with superimposed acute illness requiring hospitalization are more likely to develop an extended length of stay, hospital-acquired infections, and adverse events throughout their hospitalization. An excellent alternative to managing this population of patients in the traditional bricks-and-mortal (BAM) hospital is the hospital-at-home (HaH) model. The Advanced Care at Home (ACH) program is Mayo Clinic's HaH model that provides acute and postacute care to high-acuity patients in their homes rather than in the traditional hospital and skilled nursing facility. We report a case of postoperative care through the ACH program of a patient suffering from short gut syndrome, high-output ileostomy, and severe protein-calorie malnutrition in the setting of previously diagnosed triple-negative invasive ductal carcinoma (IDC) of the right breast complicated by lung and brain metastasis. The patient had multiple complications that required repeated scare escalations directed by a multidisciplinary virtual care. Despite these complications, the ACH model of care was able to keep the patient in the home setting the majority of the time, limiting BAM hospital days, and eliminating the need to use the emergency department for acute escalation for 3 months. The patient was able to recover during this time period and proceed to successful take-down of the ileostomy. This case highlights the benefits of the ACH program by offering high-acuity hospital-level care to severely ill patients in the comfort of their homes. Highly qualified providers paired with curated technology in the home allowed for prompt identification of patient decompensation and timely initiation of treatment while avoiding institutionalization.
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Minderhout RN, Numans ME, Vos HMM, Bruijnzeels MA. A methodological framework for evaluating transitions in acute care services in the Netherlands to achieve Triple Aim. BMC Res Notes 2022; 15:296. [PMID: 36085241 PMCID: PMC9463780 DOI: 10.1186/s13104-022-06187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/27/2022] [Indexed: 11/16/2022] Open
Abstract
Objective The accessibility of acute care services is currently under pressure, and one way to improve services is better integration. Adequate methodology will be required to provide for a clear and accessible evaluation of the various intervention initiatives. The aim of this paper is to develop and propose a Population Health Management(PHM) methodology framework for evaluation of transitions in acute care services. Results Our methodological framework is developed from several concepts found in literature, including Triple Aim, integrated care and PHM, and includes continuous monitoring of results at both project and population levels. It is based on a broad view of health rather than focusing on a specific illness and facilitates the evaluation of various intervention initiatives in acute care services in the Netherlands and distinctly explains every step of the evaluation process and can be applied to a heterogeneous group of patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13104-022-06187-w.
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Affiliation(s)
- Rosa Naomi Minderhout
- Department of Public Health and Primary Care/HealthCampus The Hague, Leiden University Medical Centre, Turfmarkt 99, 5thflourflour, 2511 DP, The Hague, the Netherlands.
| | - Mattijs E Numans
- Department of Public Health and Primary Care/HealthCampus The Hague, Leiden University Medical Centre, Turfmarkt 99, 5thflourflour, 2511 DP, The Hague, the Netherlands
| | - Hedwig M M Vos
- Department of Public Health and Primary Care/HealthCampus The Hague, Leiden University Medical Centre, Turfmarkt 99, 5thflourflour, 2511 DP, The Hague, the Netherlands
| | - Marc A Bruijnzeels
- Department of Public Health and Primary Care/HealthCampus The Hague, Leiden University Medical Centre, Turfmarkt 99, 5thflourflour, 2511 DP, The Hague, the Netherlands
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Ludlow NC, de Grood J, Yang C, Murphy S, Berg S, Leischner R, McBrien KA, Santana MJ, Leslie M, Clement F, Cepoiu-Martin M, Ghali WA, McCaughey D. A multi-step approach to developing a health system evaluation framework for community-based health care. BMC Health Serv Res 2022; 22:889. [PMID: 35804388 PMCID: PMC9270820 DOI: 10.1186/s12913-022-08241-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/23/2022] [Indexed: 11/30/2022] Open
Abstract
Background Community-based health care (CBHC) is a shift towards healthcare integration and community services closer to home. Variation in system approaches harkens the need for a conceptual framework to evaluate outcomes and impacts. We set out to develop a CBHC-specific evaluation framework in the context of a provincial ministry of health planning process in Canada. Methods A multi-step approach was used to develop the CBHC evaluation framework. Modified Delphi informed conceptualization and prioritization of indicators. Formative research identified evaluation framework elements (triple aim, global measures, and impact), health system levels (tiers), and potential CBHC indicators (n = 461). Two Delphi rounds were held. Round 1, panelists independently ranked indicators on CBHC relevance and health system tiering. Results were analyzed by coding agreement/disagreement frequency and central tendency measures. Round 2, a consensus meeting was used to discuss disagreement, identify Tier 1 indicators and concepts, and define indicators not relevant to CBHC (Tier 4). Post-Delphi, indicators and concepts were refined, Tier 1 concepts mapped to the evaluation framework, and indicator narratives developed. Three stakeholder consultations (scientific, government, and public/patient communities) were held for endorsement and recommendation. Results Round 1 Delphi results showed agreement for 300 and disagreement for 161 indicators. Round 2 consensus resulted in 103 top tier indicators (Tier 1 = 19, Tier 2 = 84), 358 bottom Tier 3 and 4 indicators, non-CBHC measure definitions, and eight Tier 1 indicator concepts—Mortality/Suicide; Quality of Life, and Patient Reported Outcome Measures; Global Patient Reported Experience Measures; Cost of Care, Access to Integrated Primary Care; Avoidable Emergency Department Use; Avoidable Hospitalization; and E-health Penetration. Post Delphi results refined Tier 3 (n = 289) and 4 (n = 69) indicators, and identified 18 Tier 2 and 3 concepts. When mapped to the evaluation framework, Tier 1 concepts showed full coverage across the elements. ‘Indicator narratives’ depicted systemness and integration for evaluating CBHC. Stakeholder consultations affirmed endorsement of the approach and evaluation framework; refined concepts; and provided key considerations to further operationalize and contextualize indicators, and evaluate CBHC as a health system approach. Conclusions This research produced a novel evaluation framework to conceptualize and evaluate CBHC initiatives. The evaluation framework revealed the importance of a health system approach for evaluating CBHC.
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Affiliation(s)
- Natalie C Ludlow
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Jill de Grood
- W21C Research and Innovation Centre, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Connie Yang
- Department of Human Centered Design & Engineering, University of Washington, Seattle, USA
| | - Sydney Murphy
- Faculty of Law, University of Calgary, Calgary, AB, Canada
| | - Shannon Berg
- Department of Health, Government of Alberta, Edmonton, AB, Canada
| | - Rick Leischner
- Department of Health, Government of Alberta, Edmonton, AB, Canada
| | - Kerry A McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Maria J Santana
- Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Myles Leslie
- School of Public Policy and Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Fiona Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Monica Cepoiu-Martin
- Cumming School of Medicine, McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - William A Ghali
- Office of the Vice-President (Research), University of Calgary, Calgary, AB, Canada
| | - Deirdre McCaughey
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Kitzman H, Tecson K, Mamun A, da Graca B, Yeramaneni S, Halloran K, Wesson D. Integrating Population Health Strategies into Primary Care: Impact on Outcomes and Hospital Use for Low-Income Adults. Ethn Dis 2022; 32:91-100. [PMID: 35497399 DOI: 10.18865/ed.32.2.91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective Our objectives were two-fold: 1) To evaluate the benefits of population health strategies focused on social determinants of health and integrated into the primary care medical home (PCMH) and 2) to determine how these strategies impact diabetes and cardiovascular disease outcomes among a low-income, primarily minority community. We also investigated associations between these outcomes and emergency department (ED) and inpatient (IP) use and costs. Design Retrospective cohort. Setting Community-based PCMH: Baylor Scott & White Health and Wellness Center (BSW HWC). Patients/Participants All patients who attended at least two primary care visits at BSW HWC within a 12-month time span from 2011-2015. Methods Outcomes for patients participating in PCMH only (PCMH) as compared to PCMH plus population health services (PCMH+PoPH) were compared using electronic health record data. Main Outcomes Diastolic and systolic blood pressure, hemoglobin A1c, ED visits and costs, and IP hospitalizations and costs were examined. Results From 2011-2015, 445 patients (age=46±12 years, 63% African American, 61% female, 69.5% uninsured) were included. Adjusted regression analyses indicated PCMH+PoPH had greater improvement in diabetes outcomes (prediabetes HbA1c= -.65[SE=.32], P=.04; diabetes HbA1c= -.74 [SE=.37], P<.05) and 37% lower ED costs than the PCMH group (P=.01). Worsening chronic disease risk factors was associated with 39% higher expected ED visits (P<.01), whereas improved chronic disease risk was associated with 32% fewer ED visits (P=.04). Conclusions Integrating population health services into the PCMH can improve chronic disease outcomes, and impact hospital utilization and cost in un- or under-insured populations.
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Affiliation(s)
- Heather Kitzman
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | - Kristen Tecson
- Baylor Scott & White Heart and Vascular Institute, Baylor Scott & White Health, Dallas, TX
| | - Abdullah Mamun
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | | | | | - Kenneth Halloran
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
| | - Donald Wesson
- Baylor Scott & White Health and Wellness Center, Baylor Scott & White Health, Dallas, TX; Robbins Institute for Health Policy & Leadership, Baylor University, Waco, TX
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9
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Kokko P. Improving the value of healthcare systems using the Triple Aim framework: A systematic literature review. Health Policy 2022; 126:302-309. [DOI: 10.1016/j.healthpol.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 12/30/2022]
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Richesson RL, Marsolo KS, Douthit BJ, Staman K, Ho PM, Dailey D, Boyd AD, McTigue KM, Ezenwa MO, Schlaeger JM, Patil CL, Faurot KR, Tuzzio L, Larson EB, O'Brien EC, Zigler CK, Lakin JR, Pressman AR, Braciszewski JM, Grudzen C, Fiol GD. Enhancing the use of EHR systems for pragmatic embedded research: lessons from the NIH Health Care Systems Research Collaboratory. J Am Med Inform Assoc 2021; 28:2626-2640. [PMID: 34597383 PMCID: PMC8633608 DOI: 10.1093/jamia/ocab202] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/05/2021] [Accepted: 09/02/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE We identified challenges and solutions to using electronic health record (EHR) systems for the design and conduct of pragmatic research. MATERIALS AND METHODS Since 2012, the Health Care Systems Research Collaboratory has served as the resource coordinating center for 21 pragmatic clinical trial demonstration projects. The EHR Core working group invited these demonstration projects to complete a written semistructured survey and used an inductive approach to review responses and identify EHR-related challenges and suggested EHR enhancements. RESULTS We received survey responses from 20 projects and identified 21 challenges that fell into 6 broad themes: (1) inadequate collection of patient-reported outcome data, (2) lack of structured data collection, (3) data standardization, (4) resources to support customization of EHRs, (5) difficulties aggregating data across sites, and (6) accessing EHR data. DISCUSSION Based on these findings, we formulated 6 prerequisites for PCTs that would enable the conduct of pragmatic research: (1) integrate the collection of patient-centered data into EHR systems, (2) facilitate structured research data collection by leveraging standard EHR functions, usable interfaces, and standard workflows, (3) support the creation of high-quality research data by using standards, (4) ensure adequate IT staff to support embedded research, (5) create aggregate, multidata type resources for multisite trials, and (6) create re-usable and automated queries. CONCLUSION We are hopeful our collection of specific EHR challenges and research needs will drive health system leaders, policymakers, and EHR designers to support these suggestions to improve our national capacity for generating real-world evidence.
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Affiliation(s)
- Rachel L Richesson
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Keith S Marsolo
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Brian J Douthit
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,US Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Karen Staman
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - P Michael Ho
- Department of Medicine, University of Colorado Medicine, Denver, Colorado, USA
| | - Dana Dailey
- Center for Health Sciences, St. Ambrose University, Davenport, Iowa and Department of Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, Iowa, USA
| | - Andrew D Boyd
- Department of Biomedical and Health Information Sciences University of Illinois Chicago, Chicago, Illinois, USA
| | - Kathleen M McTigue
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Miriam O Ezenwa
- Department of Biobehavioral Nursing Science, University of Florida, College of Nursing, Gainesville, Florida, USA
| | - Judith M Schlaeger
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Crystal L Patil
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois, USA
| | - Keturah R Faurot
- Department of Physical Medicine and Rehabilitation, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Leah Tuzzio
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Eric B Larson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christina K Zigler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joshua R Lakin
- Palliative Medicine, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alice R Pressman
- Center for Health Systems Research, Sutter Health Center for Health Systems Research, Walnut Creek, California, USA
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
| | - Corita Grudzen
- Department of Emergency Medicine, New York University School of Medicine, New York, New York, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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11
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Minderhout RN, Vos HMM, van Grunsven PM, de la Torre y Rivas I, Alkir-Yurt S, Numans ME, Bruijnzeels MA. The Value of Merging Medical Data from Ambulance Services and General Practice Cooperatives Using Triple Aim Outcomes. Int J Integr Care 2021; 21:4. [PMID: 34754280 PMCID: PMC8555478 DOI: 10.5334/ijic.5711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/15/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Acute care services are currently overstretched in many high income countries. Overcrowding also plays a major role in acute care in the Netherlands. In a region of the Netherlands, the general practice cooperative (GPC) and ambulance service have begun to integrate their care, and the rapid and complete transfer of information between these two care organisations is now the basis for delivering appropriate care. The primary aim of this mixed-methods study is to evaluate the Netherlands Triage System (NTS) merger project and answering the question: What is the added value of implementing a digital NTS merger in terms of healthcare use and healthcare costs? A secondary question is: What are the experiences of patients and care professionals in different acute healthcare organisations following implementation of the digital NTS merger? METHODS Patients who made an acute care request during the 12 months before the NTS merge intervention (control period) were compared with matched patients in the 12 months following the start of the NTS merge. Outcomes included difference in healthcare use 30 days after an acute event and patient' and care professional' experiences during the intervention period. To assess healthcare costs, we used reference prices updated to 2021. RESULTS Compared to patients in the control period, patients in the intervention period were hospitalized less often (52.9% vs 64.4%, p = 0.061) and had fewer emergency department (ED) visits (58.7% vs 69.3%, p = 0.074) in the 30 days following the acute care request. The ED costs were significantly lower during the intervention period compared to the control period (p = 0.042). Furthermore, patients in the intervention period were very satisfied overall with the acute care network (4.63 of 5) and care professionals were fairly satisfied with the cooperation to date (2.73 of 4). CONCLUSION The Triple Aim for acute care can be met using relatively simple interventions, but medical data merging is a prerequisite for achieving more robust results covering on the various aspects of the Triple Aim. These successes should be communicated so that a common language can be developed that will support the successful further implementation of larger scale initiatives.
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Affiliation(s)
- Rosa Naomi Minderhout
- Department of Public Health and Primary Care/LUMC-Campus The Hague, Leiden University Medical Centre, The Hague, NL
| | - Hedwig M. M. Vos
- Department of Public Health and Primary Care/LUMC-Campus The Hague, Leiden University Medical Centre, The Hague, NL
| | | | | | | | - Mattijs E. Numans
- Department of Public Health and Primary Care/LUMC-Campus The Hague, Leiden University Medical Centre, The Hague, NL
| | - Marc A. Bruijnzeels
- Department of Public Health and Primary Care/LUMC-Campus The Hague, Leiden University Medical Centre, The Hague, NL
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12
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Fuentes-Merlos Á, Orozco-Beltrán D, Quesada Rico JA, Reina R. Quality-of-Life Determinants in People with Diabetes Mellitus in Europe. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18136929. [PMID: 34203455 PMCID: PMC8297329 DOI: 10.3390/ijerph18136929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/18/2021] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
This study aims to analyze self-perceived health and lifestyles in the European Union Member States Iceland, Norway, and the United Kingdom, examining associations with diabetes prevalence; and to identify the demographic, economic and health variables associated with diabetes in this population. We performed a cross-sectional study of 312,172 people aged 15 years and over (150,656 men and 161,516 women), using data collected from the European Health Interview Survey (EHIS). The EHIS includes questions on the health status and health determinants of the adult population, as well as health care use and accessibility. To estimate the magnitudes of the associations with diabetes prevalence, we fitted multivariate logistic models. The EHIS data revealed a prevalence of diabetes in Europe of 6.5% (n = 17,029). Diabetes was associated with being physically inactive (OR 1.14; 95% CI 1.02–1.28), obese (OR 2.75; 95% CI 2.60–2.90), male (OR 1.46; 95% CI 1.40–1.53) and 65–74 years old (OR 3.47; 95% CI 3.09–3.89); and having long-standing health problems (OR 7.39; 95% CI, 6.85–7.97). These results were consistent in the bivariate and multivariate analyses, with an area under the receiver operating characteristic curve of 0.87 (95% CI 0.87–0.88). In a large European health survey, diabetes was clearly associated with a poorer perceived quality of life, physical inactivity, obesity, and other comorbidities, as well as non-modifiable factors such as older age and male sex.
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Affiliation(s)
- Álvaro Fuentes-Merlos
- Department of Primary Health Care, San Juan de Alicante University Hospital, 03550 San Juan de Alicante, Spain;
| | - Domingo Orozco-Beltrán
- Department of Clinical Medicine, Miguel Hernández University, 03550 San Juan de Alicante, Spain;
| | - Jose A. Quesada Rico
- Department of Clinical Medicine, Miguel Hernández University, 03550 San Juan de Alicante, Spain;
- Correspondence: ; Tel.: +34-965-919-449
| | - Raul Reina
- Department of Sport Sciences, Sport Research Centre, Miguel Hernández University, 03202 Elche, Spain;
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13
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Taylor YJ, Kowalkowski M, Spencer MD, Evans SM, Hall MN, Rissmiller S, Shrestha R, McWilliams A. Realizing a learning health system through process, rigor and culture change. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100478. [PMID: 34175095 DOI: 10.1016/j.hjdsi.2020.100478] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 07/28/2020] [Accepted: 09/18/2020] [Indexed: 12/19/2022]
Abstract
While many healthcare organizations strive to achieve the patient care benefits of being a learning health system (LHS), myriad challenges stand in the way of successful implementation. The reality of creating a true LHS requires top-to-bottom commitment to culture change with the necessary vision, leadership, and investment. The Center for Outcomes Research and Evaluation (CORE) is a multidisciplinary research unit embedded within a large, vertically integrated healthcare system in the southeastern United States. We used a two-pronged approach to: a) methodically recruit a team of experts, while generating early wins that demonstrated real success; and b) build relationships and buy-in across organizational leadership. Building out a team with diverse expertise created the ability to deploy pragmatic, data-driven research designs that fit seamlessly into real-world care delivery, resulting in agile study execution that aligns with health system timelines. Case study examples from hospital readmissions and antibiotic stewardship illustrate how our LHS operationalizes practice-informed research and research-informed practice. Lessons from this experience can serve as a blueprint for other healthcare systems or networks seeking to expand the promise of the LHS framework to improve health for patients and communities.
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Affiliation(s)
| | - Marc Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | | | - Susan M Evans
- Center for Outcomes Research and Evaluation, Atrium Health, USA.
| | - Mary N Hall
- Division of Medical Education and Research, Atrium Health, USA; Medical Group Division, Atrium Health, USA.
| | | | | | - Andrew McWilliams
- Center for Outcomes Research and Evaluation, Atrium Health, USA; Medical Group Division, Atrium Health, USA; Department of Internal Medicine, Hospital Medicine, Atrium Health, USA.
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14
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Baynouna Al Ketbi LM. Meta-Decision in Healthcare. Front Public Health 2021; 9:694689. [PMID: 34211958 PMCID: PMC8239282 DOI: 10.3389/fpubh.2021.694689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/24/2021] [Indexed: 11/13/2022] Open
Abstract
Meta-decision as a junction between evidence and its rightful implementation is suggested in this review as a structured framework applied in healthcare, valuable to clinicians and healthcare decision-makers. The process of meta-decision requires optimum measurements to provide data necessary for identifying and developing decision alternatives and explicitly reflect on its value and choose the optimum decision. The location of value in the meta-decision framework is core component. Of equal importance are prerequisites for decision-makers' abilities to make meta-decisions and focus on optimum team environments. As well as improving their decision-making process through reflection and learning.
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15
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Kerman N, Kidd SA. The Healthcare Triple Aim in the Recovery Era. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2021; 47:492-496. [PMID: 31754880 DOI: 10.1007/s10488-019-00997-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Recovery is the guiding vision of mental health systems and policy. However, skepticism has emerged about whether the paradigm can achieve its sought goals. We argue that embedding recovery within a quality improvement framework, such as the Triple Aim, would increase leverage for systems change and advance recovery practice. The Triple Aim's goals of improving healthcare outcomes, quality, and costs are pertinent to mental health systems, although action is also needed to address the social determinants of health. Accordingly, we propose the recovery-oriented Triple Aim, which could be used to guide policy development and evaluation of mental health services.
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Affiliation(s)
- Nick Kerman
- School of Psychology, University of Ottawa, Ottawa, ON, K1N 6N5, Canada.
| | - Sean A Kidd
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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16
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Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review. J Clin Med 2021; 10:jcm10092041. [PMID: 34068727 PMCID: PMC8126257 DOI: 10.3390/jcm10092041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/25/2022] Open
Abstract
This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.
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17
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Reitz SM, Scaffa ME, Dorsey J. Occupational Therapy in the Promotion of Health and Well-Being. Am J Occup Ther 2020; 74:7403420010p1-7403420010p14. [PMID: 32365325 DOI: 10.5014/ajot.2020.743003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A balanced pattern of occupations enhances the health and fulfills the needs of individuals, families, communities, and populations (American Occupational Therapy Association [AOTA], 2014b; Hocking, 2019; Meyer, 1922). Occupations are personalized "everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life" (World Federation of Occupational Therapists, 2012, para. 2). The purpose of this statement is to describe occupational therapy's role and contribution in the areas of health promotion and prevention for internal and external audiences. AOTA supports and promotes the involvement of occupational therapy practitioners¹ in the development and delivery of programs and services that promote health, well-being, and social participation of all people.
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18
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Batool R, Zaman K, Khurshid MA, Sheikh SM, Aamir A, Shoukry AM, Sharkawy MA, Aldeek F, Khader J, Gani S. Economics of death and dying: a critical evaluation of environmental damages and healthcare reforms across the globe. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2019; 26:29799-29809. [PMID: 31407261 DOI: 10.1007/s11356-019-06159-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
The economics of death and dying highlighted that environmental factors negatively influence healthcare sustainability. Therefore, this study conducted a system-based literature review to identify the negative externality of environmental damages on global healthcare reforms. Based on 42 peer-reviewed papers in the field of healthcare reforms and 12 papers in the field of environmental hazards, we identified 25 factors associated with death and dying and 15 factors associated with health-related damages across the world respectively. We noted that environmental factors are largely responsible to affect healthcare sustainability reforms by associating with the number of healthcare diseases pertaining to air pollutants. The study suggests healthcare practitioners and environmentalists to devise long-term sustainable healthcare policies by limiting highly toxic air pollutants through technology-embodied green healthcare infrastructure to attained efficient global healthcare recovery.
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Affiliation(s)
- Rubeena Batool
- Gender and Development Studies Department, University of Balochistan, Quetta, Pakistan
| | - Khalid Zaman
- Department of Economics, University of Wah, Quaid Avenue, Wah Cantt, Pakistan.
| | - Muhammad Adnan Khurshid
- Department of Business Administration, Sindh Madressatul Islam University, Karachi, Pakistan
| | - Salman Masood Sheikh
- Department of Business and Management Sciences, The Superior College, Lahore, Pakistan
| | - Alamzeb Aamir
- Department of Management Sciences, FATA University, F.R, Kohat, Pakistan
| | - Alaa Mohamd Shoukry
- Arriyadh Community College, King Saud University, Riyadh, Saudi Arabia
- Department of Administrative Science, KSA Workers University, El Mansoura, Egypt
| | | | - Fares Aldeek
- Arriyadh Community College, King Saud University, Riyadh, Saudi Arabia
| | - Jameel Khader
- Arriyadh Community College, King Saud University, Riyadh, Saudi Arabia
| | - Showkat Gani
- College of Business Administration, King Saud University, Muzahimiyah, Saudi Arabia
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