Purchasing better, innovative and integrated health services

Medical Graduates, Truthful and Useful Analytics With Big Data, and the Art of Persuasion

The authors propose that the provision of state-of-the-art, effective, safe, and affordable health care requires medical school graduates not only to be competent practitioners and scientists but also to be policy makers and professional leaders. To meet this challenge in the era of big data and cloud computing, these graduates must be able to understand and critically interpret analyses of large, observational datasets from electronic health records, third-party claims files, surveys, and epidemiologic health datasets.The authors contend that medical students need to be exposed to three components. First, students should be familiar with outcome metrics that not only are scientifically valid but also are robust, useful for the medical community, understandable to patients and relevant to their preferences and health goals, and persuasive to health administrators and policy decision makers. Next, students must interact with an inclusive set of analysts including biostatisticians, mathematical and computational statisticians, econometrists, psychometricians, epidemiologists, informaticians, and qualitative researchers. Last, students should learn in environments in which data analyses are not static with a "one-size-fits-all" solution but, rather, where mathematical and computer scientists provide new, innovative, and effective ways of solving predictable and commonplace data limitations such as missing data; make causal inferences from nonrandomized studies and/or those with selection biases; and estimate effect size when patient outcomes are heterogeneous and surveys have low response rates.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Matching the production of doctors with national needs

CONTEXT

Matching the supply of health workers to need is necessary if a health system is to be sustainable, affordable and fit for purpose. On the 30th anniversary of the 1988 Edinburgh Declaration of the World Federation for Medical Education, levels of compliance with the 10th recommendation, 'Ensure admission policies that match the numbers of students trained with national needs for doctors', warrant review. There are two domains to such a review, concerning, respectively, how well these health needs are known, and whether workforce supply is well matched.

METHODS

This is a literature review-based analysis of extant health system planning, which underpins current understanding of national health needs and of the consequent alignment of student selection processes.

RESULTS

The core finding is that national need for doctors, and any other health workers, is not confidently known for any jurisdiction. Consequently, validation of student selection processes is impossible against this endpoint and data to validate these processes against the alternative endpoint of a positive impact on health outcomes do not exist. Data do exist to suggest some student selection processes result in desirable career and career location uptakes.