Competition,gatekeeping, and health care access

We study gatekeeping physicians’ referrals of patients to specialty care. We derive theoretical results when competition in the physician market intensifies. First, due to competitive pressure, physicians refer patients to specialty care more often. Second, physicians earn more by treating patients themselves, so refer patients to specialty care less often. We assess empirically the overall effect of competition with data from a 2008–2009 Norwegian survey, National Health Insurance Administration, and Statistics Norway. From the data we construct three measures of competition: the number of open primary physician practices with and without population adjustment, and the Herfindahl–Hirschman index. The empirical results suggest that competition has negligible or small positive effects on referrals overall. Our results do not support the policy claim that increasing the number of primary care physicians reduces secondary care.     

Emergency and urgent care systems in Australia,Denmark, England,France, Germany and the Netherlands – Analyzing organization,payment and reforms

Introduction

Increasing numbers of hospital emergency department (ED) visits pose a challenge to health systems in many countries. This paper aims to examine emergency and urgent care systems, in six countries and to identify reform trends in response to current challenges.

Improving communication among attending physicians, long-term care facilities, residents, and residents' families

Effective bidirectional communication between attending physicians and long-term care facilities is of critical importance to ensure timely, appropriate, and high-quality care that is responsive to residents' needs, values, and preferences. Ongoing communication with residents and residents' families is essential to the establishment of mutual trust and respect. This earned trust and respect in turn promotes frank discussions among long-term care practitioners and the facility staff who can then better guide residents and families through difficult care decisions.     

Effects of an Integrated Palliative Care Pathway: More Proactive GPs,Well Timed,and Less Acute Care: A Clustered,Partially Controlled Before-After Study

ObjectivesThis study presents the design of an integrated, proactive palliative care pathway covering the full care cycle and evaluates its effects using 3 types of outcomes: (1) physician-reported outcomes, (2) outcomes reported by family, and (3) (utilization of) health care outcomes.DesignA clustered, partially controlled before-after study with a multidisciplinary integrated palliative care pathway as its main intervention.Setting and Participantsafter assessment in hospital departments of oncology, and geriatrics, and in 13 primary care facilities, terminally ill patients were proactively included into the pathway. Patients' relatives and patients’ general practitioners (GPs) participated in a before/after survey and in interviews and focus groups.InterventionA multidisciplinary, integrated palliative care pathway encompassing (among others) early identification of the palliative phase, multidisciplinary consultation and coordination, and continuous monitoring of outcomes.MeasuresMeasures included GP questionnaire: perceived quality of palliative care; questionnaires by family members: FAMCARE, QOD-LTC, EDIZ; and 3 types of health care outcomes: (1) utilization of primary care: consultations, intensive care, communication, palliative home visits, consultations and home visits during weekends and out-of-office-hours, ambulance, admission to hospital; (2) utilization of hospital care: outpatient ward consultations, day care, emergency room visits, inpatient care, (radio) diagnostics, surgical procedures, other therapeutic activities, intensive care unit activities; (3) pharmaceutical care utilization.ResultsGPs reported that palliative patients die more often at their preferred place of death, and that they now act more proactively toward palliative patients. Relatives of included, deceased patients reported clinically relevant improved quality of dying, and more timely palliative care. Patients in the pathway received more (intensive) primary care, less unexpected care during out-of-office hours, and more often received hospital care in the form of day care.Conclusions and ImplicationsAn integrated palliative care pathway improves a variety of clinical outcomes important to patients, their families, physicians, and the health care system. The integration of palliative care into multidisciplinary, proactive palliative care pathways, is therefore a desirable future development.     

Information, Education, and Communication Services in MCH Care Provided at an Urban Health Center

Background:

Regular IEC programs during antenatal and intranatal period, through individual or group approach, brings desirable changes in health practices of people, resulting in a healthy mother and a healthy baby.

Materials and Methods:

This study was conducted to assess the level of IEC services regarding pregnancy and child care, received by the women at an MCH clinic of an urban health center, where the study subjects comprised 400 antenatal (AN) and postnatal (PN) women and mothers of children under five years.

Results:

Warning signs of danger was explained to only 10% of the AN and PN women. Advice regarding family planning appeared to be the most frequently covered, though that too was explained to less than half of the subjects. About one third of the women were advised on breast feeding. Only 8% of the mothers had been told about all issues regarding pregnancy and child care. Breast feeding and weaning was properly explained to 85.7 and 81.1% of the total mothers of U5 children. Advice regarding subsequent nutrition was given to 60.9% of mothers. About only a quarter of the total mothers were advised on home management of diarrhea and acute respiratory infections. Very few mothers were counseled about the growth pattern of the children and none were shown the growth chart. Only 12.9% of the mothers were informed about all issues.

Conclusion:

IEC regarding maternal and child care other than feeding practices is a neglected service in the health facility where the study was conducted.     

Medical care in Australian residential aged care: Perspectives of residents,family, nurses and general practitioners

The importance of residential aged care facility (RACF)’s medical care is growing, driven by world-wide demographic trends in ageing populations. Despite this, there is a paucity of research into this care delivery from the perspective of those most involved. This study aimed to identify the enablers of and barriers to satisfactory RACF medical care by focusing on the general practitioner (GP) visit in the experience of residents, their family, registered nurses (RNs) and GPs. A multi-site case study was conducted at four purposively chosen RACFs in rural and regional New South Wales, Australia. Data derived from semi-structured interviews with 35 randomly selected aforementioned stakeholders and conducted in 2017 were evaluated using thematic, specifically framework analysis. The study's first key finding was related to the care team and to care recipients. It was evident that the quality of the RN–GP interprofessional collaboration was important for satisfactory care delivery. However, the care team was observed to additionally include RACF care staff and family members. Families were also in need of care. The study's second key finding was related to continuity of care. The interpersonal continuity of care provided by the existing GP continuing a new resident's care was beneficial. Informational continuity of care was found to be important but often disrupted by patient's information being initially unavailable, then fragmented and stored in different places. Medication management systems when accessed were poorly organised, time consuming and complex. This research suggests two useful new paradigms for residential aged care. The first is a re-envisaging of the resident care team to include the RN, GP, family and care staff, and those needing care to include residents and family. Secondly, care teams informed by interpersonal and informational continuity of care, and satisfactory resident care appears inextricably and positively linked.     

Alcohol,drug abuse,and mental health care for uninsured and insured adults

OBJECTIVE: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems. DATA SOURCES/STUDY SETTING: From a national telephone survey of 9,585 respondents. DESIGN: Follow-up of adult participants in the Community Tracking Study. DATA COLLECTION: Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use. PRINCIPAL FINDINGS: The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured. CONCLUSIONS: The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.     

Health care reform and equity: promise, pitfalls, and prescriptions

The United States has made little progress during the past decade in addressing health care disparities. Recent health care reforms offer an historic opportunity to create a more equitable health care system. Key elements of health care reform relevant to promoting equity include access, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity monitoring. With effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could measurably improve equity.     

Health Care Reform: Opportunities for Professional Chaplains to Build Intentional Communities of Learners by Integrating Faith,Science, Quality,and Systems Thinking

SUMMARY

Albert Einstein once said, “The significant problems we face cannot be solved at the same level of thinking we were at when we created them” (www.brainyquote.com). Health care reform has brought professional chaplains to a place of chaos–a place that raises many questions about the past, present and future. This chaos presents tremendous opportunities for professional chaplains to increase their capacities in building intentional communities of learners by integrating faith, science, quality and systems thinking. Pastoral care givers must truly understand the pressures from all sides and the new emerging paradigm of integrated health care delivery. Without this understanding, we will not see the opportunities and challenges of integrating pastoral and spiritual care in the emerging structures and systems. The future of chaplaincy largely will depend on the quality of the data, quality of our conversations and our ability to thinking together through dialogue.     

Chaplaincy Research: Its Value,Its Quality,and Its Future

The article is divided into four major sections, the first of which presents and discusses various reasons given by major researchers in the field why chaplains should do research. The second section summarizes findings on the sophistication of research on religion and health published in (a) medical and other healthcare journals, and (b) specialty journals on religion and health, chaplaincy, and pastoral care and counseling. The third section revisits suggestions that have been made by prominent chaplain researchers to increase and improve research by chaplains. The last section offers some suggestions for expanding several lines of current research in the future, including research: (1) to elucidate the nature of spiritual care chaplains provide to different populations, including patients, families and staff; (2) to assess the prevalence and intensity of patients' spiritual needs and the degree to which they are being met; (3) to identify that subset of patients who are spiritually at risk in terms of having high needs and slow religious resources; (4) to identify the biological causal mechanisms by which religion influences health; and (5) to measure the effectiveness of chaplain interventions.     

Identity,Role, and Task

No abstract available for this article.     

Posthospital care transitions: patterns, complications, and risk identification

OBJECTIVES: To (1) describe patterns of posthospital care transitions; (2) characterize these patterns as uncomplicated or complicated; (3) identify those at greatest risk for complicated transitions. DATA SOURCES/STUDY SETTING: The Medicare Current Beneficiary Survey was used to identify beneficiaries aged 65 and older who were discharged from an acute care hospital in 1997-1998. STUDY DESIGN: Patterns of posthospital transfers were described over a 30-day time period following initial hospital discharge. Uncomplicated posthospital care patterns were defined as a sequence of transfers from higher-to lower-intensity care environments without recidivism, while complicated posthospital care patterns were defined as the opposite sequence of events. Indices were developed to identify patients at risk for complicated transitions. PRINCIPAL FINDINGS: Forty-six distinct types of care patterns were observed during the 30 days following hospital discharge. Among these patterns, 444 episodes (61.2 percent) were limited to a single transfer, 130 episodes (17.9 percent) included two transfers, 62 episodes (8.5 percent) involved three transfers, and 31 episodes (4.3 percent) involved four or more transfers. Fifty-nine episodes (8.1 percent) resulted in death. Between 13.4 percent and 25.0 percent of posthospital care patterns in the 1998 sample were classified as complicated. The area under the receiver operating curve was 0.771 for a predictive index that utilized administrative data and 0.833 for an index that used a combination of administrative and self-reported data. CONCLUSIONS: Posthospital care transitions are common among Medicare beneficiaries and patterns of care vary greatly. A significant number of beneficiaries experienced complicated care transitions-a finding that has important implications for both patient safety and cost-containment efforts. Patients at risk for complicated care patterns can be identified using data available at the time of hospital discharge.     

Physician group,physician and patient characteristics associated with joining interprofessional team-based primary care in Ontario,Canada

PurposeCountries throughout the world have been experimenting with new models to deliver primary care. We investigated physician group, physician and patient characteristics associated with voluntarily joining team-based primary care in Ontario.MethodsThis cross-sectional study linked provincial administrative datasets to form data extractions of interest over time with the earliest in 2005 and the latest in 2013. We generated mixed, generalized chi-square and multivariate models to compare the characteristics of teams and non-teams, both with blended capitation reimbursement, and to examine characteristics associated with joining a team.ResultsHaving more physicians per group, being a female physician, having more years under the blended capitation model, having more patients in the lowest income quintile and more patients residing in rural areas were positively associated with joining a team. Being a female physician and having more patients who are males, recent immigrants and living in rural areas were positively associated with the outcome of joining teams in the late phase.ConclusionsOur study findings indicate that there are differences in physician group, physician and patient characteristics when comparing teams to non-teams. Other jurisdictions aiming to expand physician participation in interprofessional care should note those factors. Researchers looking to understand the impact of team-based care should be aware of pre-existing differences and the need to address selection bias associated with participation in team-based care.     

Family day care and day care centres: Carer, family and child differences and their implications

The present study investigated child, maternal and caregiver characteristics in two day care settings, the independent contributions of these characteristics to children's adjustment to day care, and the utility of a goodness-of-fit framework as a means of assessing the impact of parent-caregiver differences on children's adjustment. Eight measures were used to assess child behavioural problems, maternal satisfaction with care, child temperament, maternal and caregiver child rearing practices, developmental timetables, day care goals, and demographic background. The study found strong support for the existence of differences between mothers choosing different types of care, between caregivers in these two settings, and between mothers and caregivers; and for the linkage between child, maternal and caregiver characteristics and child adjustment. However, the impact of goodness-of-fit between mothers and caregivers on children's adjustment to day care was not supported.     

The magnitude,share and determinants of unpaid care costs for home‐based palliative care service provision in Toronto,Canada

With increasing emphasis on the provision of home‐based palliative care in Canada, economic evaluation is warranted, given its tremendous demands on family caregivers. Despite this, very little is known about the economic outcomes associated with home‐based unpaid care‐giving at the end of life. The aims of this study were to (i) assess the magnitude and share of unpaid care costs in total healthcare costs for home‐based palliative care patients, from a societal perspective and (ii) examine the sociodemographic and clinical factors that account for variations in this share. One hundred and sixty‐nine caregivers of patients with a malignant neoplasm were interviewed from time of referral to a home‐based palliative care programme provided by the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital, Toronto, Canada, until death. Information regarding palliative care resource utilisation and costs, time devoted to care‐giving and sociodemographic and clinical characteristics was collected between July 2005 and September 2007. Over the last 12 months of life, the average monthly cost was $14 924 (2011 CDN$) per patient. Unpaid care‐giving costs were the largest component – $11 334, accounting for 77% of total palliative care expenses, followed by public costs ($3211; 21%) and out‐of‐pocket expenditures ($379; 2%). In all cost categories, monthly costs increased exponentially with proximity to death. Seemingly unrelated regression estimation suggested that the share of unpaid care costs of total costs was driven by patients' and caregivers' sociodemographic characteristics. Results suggest that overwhelming the proportion of palliative care costs is unpaid care‐giving. This share of costs requires urgent attention to identify interventions aimed at alleviating the heavy financial burden and to ultimately ensure the viability of home‐based palliative care in future.     

Hospital competition, managed care, and mortality after hospitalization for medical conditions in California

OBJECTIVE: To assess the effect of hospital competition and health maintenance organization (HMO) penetration on mortality after hospitalization for six medical conditions in California. DATA SOURCE: Linked hospital discharge and vital statistics data for short-term general hospitals in California in the period 1994-1999. The study sample included adult patients hospitalized for one of the following conditions: acute myocardial infarction (N=227,446), hip fracture (N=129,944), stroke (N=237,248), gastrointestinal hemorrhage (GIH, N=216,443), congestive heart failure (CHF, N=355,613), and diabetes (N=154,837). STUDY DESIGN: The outcome variable was 30-day mortality. We estimated multivariate logistic regression models for each study condition with hospital competition, HMO penetration, hospital characteristics, and patient severity measures as explanatory variables. PRINCIPAL FINDINGS: Higher hospital competition was associated with lower 30-day mortality for three to five of the six study conditions, depending on the choice of competition measure, and this finding was robust to a variety of sensitivity analyses. Higher HMO penetration was associated with lower mortality for GIH and CHF. CONCLUSIONS: Hospitals that faced more competition and hospitals in market areas with higher HMO penetration provided higher quality of care for adult patients with medical conditions in California. Studies using linked hospital discharge and vital statistics data from other states should be conducted to determine whether these findings are generalizable.     

Medicaid expansions,preconception insurance,and unintended pregnancy among new parents

ObjectiveTo assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first‐time parents.Data SourceThis study used individual‐level data from the national Pregnancy Risk Assessment Monitoring System (2006‐2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.Study DesignOutcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female‐identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.Data Collection/Extraction MethodsThe sample included all individuals aged 20‐44 with a first live birth in 2009‐2017.Principal FindingsAmong all first‐time parents, a 10‐percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high‐school degree or less.ConclusionsIncreasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first‐time parents.     

Making guidelines,research and scientific papers as simple as possible

Background: Most patients with cancer want to die at home and will spend most of the final year of life there. Primary care staff will, therefore, provide the bulk of palliative care at home. Yet, palliative care training for staff is fragmented and ad hoc. Some feel inadequately trained for the tasks they are expected to perform.

Aim: The aim of this study was to carry out an educational needs assessment in palliative care of general practitioners and community nurses in Northern Ireland.

Method: A semi-structured postal questionnaire was sent to 1018 GPs and 750 community nurses with a reminder approximately one month later.

Results: 611 GPs and 497 nurses replied giving a response rate of 60% for the doctors and 66% for nurses. 52% of doctors and 94% of nurses expressed a special interest in palliative care. Though the majority of both groups felt confident in their palliative care skills, 83% of doctors and 95% of nurses said they would be likely to undertake further training in palliative care. Preferences for the topics and type of further training were similar for the two groups. The most popular topics for further training for both groups were pain and symptom control, bereavement care and research and audit methods. Preferred methods of further training included specialist lectures, discussion with specialists, hands-on experience in a hospice and multidisciplinary team meetings. Perceived barriers to further training were lack of time, lack of locally available courses, expense of providing locums or of self-funding courses and lack of recognition from management.

Conclusion: Primary care staff have expressed a keenness to provide community palliative care and provide it well. It now rests with managers and educationalists in the field to recognise and support staff in their needs.