Practice variation in the Dutch long‐term care and the role of supply‐sensitive care: Is access to the Dutch long‐term care equitable?

Universal access and generous coverage are important goals of the Dutch long‐term care (LTC) system. It is a legal requirement that everyone eligible for LTC should be able to receive it. Institutional care (IC) made up for 90% of Dutch LTC spending. To investigate whether access to IC is as equitable as the Dutch government aspires, we explored practice variation in entitlements to IC across Dutch regions. We used a unique dataset that included all individual applications for Dutch LTC in January 2010–December 2013 (N = 3,373,358). This dataset enabled an accurate identification of the need for care. We examined the local variation in the probability of being granted long‐term IC and in the intensity of the care granted given that individuals have applied for LTC. We also investigated whether the variation observed was related to differences in the local availability of care facilities. Although our analyses indicated the presence of some practice variation, its magnitude was very small by national and international standards (up to 3%). Only a minor part of the practice variation could be accounted for by local supply differences in care facilities. Overall, we conclude that, unlike many other developed countries, the Dutch system ensured equitable access to long‐term IC.     

How does cost matter in health‐care discrete‐choice experiments?

Willingness‐to‐pay (WTP) estimates derived from discrete‐choice experiments (DCEs) generally assume that the marginal utility of income is constant. This assumption is consistent with theoretical expectations when costs are a small fraction of total income. We analyze the results of five DCEs that allow direct tests of this assumption. Tests indicate that marginal utility often violates theoretical expectations. We suggest that this result is an artifact of a cognitive heuristic that recodes cost levels from a numerical scale to qualitative categories. Instead of evaluating nominal costs in the context of a budget constraint, subjects may recode costs into categories such as ‘low’, ‘medium’, and ‘high’ and choose as if the differences between categories were equal. This simplifies the choice task, but undermines the validity of WTP estimates as welfare measures. Recoding may be a common heuristic in health‐care applications when insurance coverage distorts subjects' perception of the nominal costs presented in the DCE instrument. Recoding may also distort estimates of marginal rates of substitution for other attributes with numeric levels. Incorporating ‘cheap talk’ or graphic representation of attribute levels may encourage subjects to be more attentive to absolute attribute levels. Copyright © 2010 John Wiley & Sons, Ltd.     

Have out‐of‐pocket health care payments risen under free health care policy? The case of Sri Lanka

Compared to its neighbors, Sri Lanka performs well in terms of health. Health care is provided for free in the public sector, yet households' out‐of‐pocket health expenditures are steadily increasing. We explore whether this increase can be explained by supply shortages and insufficient public health care financing or whether it is rather the result of an income‐induced demand for supplementary and higher quality services from the private sector. We focus on total health care expenditures and health care expenditures for specific services such as expenses on private outpatient treatments and expenses on laboratory and other diagnostic services. Overall, we find little indication that limited supply of public health care per se pushes patients into the private sector. Yet income is identified as one key driver of rising health care expenditures, ie, as households get richer, they spend an increasing amount on private services suggesting a dissatisfaction with the quality offered by the public sector. Hence, quality improvements in the public sector seem to be necessary to ensure sustainability of the public health care sector. If the rich and the middle class increasingly opt out of public health care, the willingness to pay taxes to finance the free health care policy will certainly shrink.     

Does informal care impact utilisation of home‐based formal care services among end‐of‐life patients? A decade of evidence from Ontario,Canada

Understanding how informal care impacts formal care utilisation for home‐based end‐of‐life patients is an important policy‐ and practice‐relevant question. This paper aims to assess the relationship between informal and formal home care among home‐based end‐of‐life patients and how this relationship has changed over the last decade and over the end‐of‐life trajectory. We focus on informal care provided by family members or friends, and three types of home‐based formal care services: care by personal support workers, physician visits, and nurse visits. Using survey data collected in a home‐based end‐of‐life care programme in Ontario, Canada from 2005 to 2016, we build a two‐part utilisation model analysing both the propensity to use each type of formal care and the amount of formal care received by patients. The results suggest that informal care is a substitute for care by personal support workers, but a complement to physician visits and nurse visits. In the case of nurse visits, an increased complementary effect is observed in more recent years. For home‐based physician and nurse visits, the complementary effect grows with patient's proximity to death. These results highlight the complexity of the relationship between informal and formal care among home‐based end‐of‐life patients. Decision‐makers need to take into account the relationship between informal care and different types of formal services when introducing future policies.     

Performance‐based contracting in home‐care work in The Netherlands: professionalism under pressure?

Our aim was to improve the understanding of the relationships between performance‐based contracting, management supportiveness and professionalism in home care. Using path analysis, this article explores the relationships between home‐care workers' perceptions of management support, implementation of performance‐based contracting (i.e. use of strict time registration rules and cost‐efficiency measures) and autonomy and intrinsic job satisfaction. We hypothesised that: use of strict time registration rules and cost‐efficiency measures relates to lower levels of autonomy and intrinsic job satisfaction (H1); there is an indirect relationship between use of strict time registration rules and use of cost‐efficiency measures and intrinsic job satisfaction via autonomy (H2); higher levels of management support relate to the use of looser time registration rules and less use of cost‐efficiency measures (H3); and higher levels of management support relate to higher levels of autonomy and intrinsic job satisfaction (H4). We used data from a cross‐sectional survey conducted in 2010 of a sample of Dutch home‐care workers (N = 156, response rate = 34%). Overall, our study suggests that the consequences of performance‐based contracting for professionalism are ambiguous. More specifically, using strict time registration rules is related to lower levels of autonomy, whereas using cost‐efficiency measures does not seem to affect autonomy (H1). Performance‐based contracting has no consequences for the level of fulfilment home‐care workers find in their job, as neither of the two contracting dimensions measured was directly or indirectly related to intrinsic job satisfaction (H1, H2). The role of managers must be taken into account when studying performance‐based contracting, because perceived higher management support is related to managers' less frequent use of both strict time registration rules and of cost‐efficiency measures (H3). The insight we gained into the importance of supportive managers for both autonomy and job satisfaction (H4) can help home‐care organisations improve the attractiveness of home‐care work.     

What role do Death Doulas play in end‐of‐life care? A systematic review

Current health and social care systems do not always meet the needs of the dying in our communities. As a result, patients and families are choosing to place their trust in those who can advocate for them or fill the gaps in care. Birth Doulas have been working with women during pregnancy and after birth for many years, and we are now seeing a new role, that of a Death Doula emerging in the end‐of‐life care space. How Death Doulas work within health and social care systems is not understood and we conducted a systematic review to explore the published literature to explore the role and potential implications for models of care delivery. Following the PRISMA recommendations, we searched the literature in January 2018 via bibliographic databases and the grey literature without search date parameters to capture all published literature. We looked for articles that describe the role/work of a death doula or a death midwife in the context of end‐of‐life care, or death and dying. Our search retrieved 162 unique records of which five papers were included. We analysed the papers in relation to relationship to health service, funding source, number and demand for services, training, licensing and ongoing support, and tasks undertaken. Death Doulas are working with people at the end of life in varied roles that are still little understood, and can be described as similar to that of “an eldest daughter” or to a role that has similarities to specialist palliative care nurses. Death doulas may represent a new direction for personalised care directly controlled by the dying person, an adjunct to existing services, or an unregulated form of care provision without governing oversight.     

Is inequity undermining Australia's ‘universal’ health care system? Socio‐economic inequalities in the use of specialist medical and non‐medical ambulatory health care

Objectives: To quantify need-adjusted socio-economic inequalities in medical and non-medical ambulatory health care in Australia and to examine the effects of specific interventions, namely concession cards and private health insurance (PHI), on equity.
Methods: We used data from a 2004 survey of 10,905 Australian women aged 53 to 58 years. We modelled the association between socio-economic status and health service use — GPs, specialists, hospital doctors, allied and alternative health practitioners, and dentists — adjusting for health status and other confounding variables. We quantified inequalities using the relative index of inequality (RII) using Poisson regression. The contribution of concession cards and PHI in promoting equity/inequity was examined using mediating models.
Results: There was equality in the use of GP services, but socio-economically advantaged women were more likely than disadvantaged women to use specialist (RII=1.41, 95% CI:1.26–1.58), allied health (RII=1.21,1.12–1.30), alternative health (RII=1.29,1.13–1.47) and dental services (RII=1.61,1.48–1.75) after adjusting for need, and they were less likely to visit hospital doctors (RII=0.74,0.57–0.96). Concession cards reduced socio-economic inequality in GP but not specialist care. Inequality in dental and allied health services was partly explained by inequalities in PHI.
Conclusions and implications: Substantial socio-economic inequity exists in use of specialist and non-medical ambulatory care in Australia. This is likely to exacerbate existing health inequalities, but is potentially amenable to change.     

What do women feel about community‐based antenatal care?

OBJECTIVE: This study evaluated women's perceptions of a new community-based model of continuity of antenatal care, the St George Outreach Maternity Project (STOMP). The model was established in an attempt to address some of the ongoing concerns and criticisms regarding antenatal care in Australia: lack of continuity of care and caregiver; prolonged waiting times; and inaccessible clinics. METHODS: A randomised controlled trial was conducted with 1,089 women (550 in the experimental group and 539 in the control group). The experimental group (the STOMP group) received antenatal care from small teams of midwives and an obstetrician in community-based settings. Data were collected using a questionnaire administered at 36 weeks' gestation, with a response rate of 75%. RESULTS: Women in the STOMP group reported waiting significantly less time for antenatal visits with easier access to care. STOMP group women also reported a higher perceived 'quality' of antenatal care compared with the control group. STOMP group women saw slightly more midwives and fewer doctors than control group women did. CONCLUSION AND IMPLICATIONS: This model of care has implications for the planning and provision of antenatal services within the Australian public health system, which is increasingly moving towards a community-based emphasis. Antenatal care is a service that can be successfully transferred into community-based settings with benefits for women.     

Home care or long‐term care? Setting the balance of care in urban and rural Northwestern Ontario,Canada

The objective of the study was to determine the extent to which community care packages could be provided at a lower cost than facility-based long-term care (LTC) for 864 individuals on the LTC waiting list in urban and rural parts of Northwestern Ontario, Canada. A sequential mixed methods design was used entailing a retrospective chart review, the formation of case vignettes, the creation of community care packages with an 'expert panel' of care managers, the costing of care packages and the calculation of potential diversion rates from LTC. Data collection took place in Northwestern Ontario between the months of March and June 2008. Eight per cent of individuals in the urban area and 50% of individuals from the rural areas could potentially be safely diverted to the community and provided with a community care package at a cost lower than facility-based LTC. There is potential for home and community care to substitute for more costly long-term care, but doing so requires building capacity in this sector, particularly in rural areas, which are currently underserviced. Reconfiguring the 'balance of care' may lead to long-term cost efficiencies for an ageing population.     

Is Managed Care Leading to Consolidation in Health‐care Markets?

OBJECTIVE: To determine the extent to which managed care has led to consolidation among hospitals and physicians. DATA SOURCES: We use data from the American Hospital Association, American Medical Association, and government censuses. STUDY DESIGN: Two stage least squares regression analysis examines how cross-section variation in managed care penetration affects provider consolidation, while controlling for the endogeneity of managed-care penetration. Specifically, we examine inpatient hospital markets and physician practice size in large metropolitan areas. DATA COLLECTION METHODS: All data are from secondary sources, merged at the level of the Primary Metropolitan Statistical Area. PRINCIPAL FINDINGS: We find that higher levels of local managed-care penetration are associated with substantial increases in consolidation in hospital and physician markets. In the average market (managed-care penetration equaled 34 percent in 1994), managed care was associated with an increase in the Herfindahl of .054 between 1981 and 1994, moving from .096 in 1981 to .154. This is equivalent to moving from 10.4 equal-size hospitals to 6.5 equal-sized hospitals. In the physician market place, we estimate that at the mean, managed care resulted in a 14 percentage point decrease of physicians in solo practice between 1986 and 1995. This implies a decrease in the percentage of doctors in solo practice from 38 percent in 1986 to 24 percent by 1995.     

Whither trial‐based economic evaluation for health care decision making?

The randomised controlled trial (RCT) has developed a central role in applied cost-effectiveness studies in health care as the vehicle for analysis. This paper considers the role of trial-based economic evaluation in this era of explicit decision making. It is argued that any framework for economic analysis can only be judged insofar as it can inform two key decisions and be consistent with the objectives of a health care system subject to its resource constraints. The two decisions are, firstly, whether to adopt a health technology given existing evidence and, secondly, an assessment of whether more evidence is required to support this decision in the future. It is argued that a framework of economic analysis is needed which can estimate costs and effects, based on all the available evidence, relating to the full range of possible alternative interventions and clinical strategies, over an appropriate time horizon and for specific patient groups. It must also enable the accumulated evidence to be synthesised in an explicit and transparent way in order to fully represent the decision uncertainty. These requirements suggest that, in most circumstances, the use of a single RCT as a vehicle for economic analysis will be an inadequate and partial basis for decision making. It is argued that RCT evidence, with or without economic content, should be viewed as simply one of the sources of evidence, which must be placed in a broader framework of evidence synthesis and decision analysis.     

Income‐rich and wealth‐poor? The impact of measures of socio‐economic status in the analysis of the distribution of long‐term care use among older people

This article aims to investigate the impact of using 2 measures of socio‐economic status on the analysis of how informal care and home care use are distributed among older people living in the community. Using data from the Survey of Health, Ageing and Retirement in Europe for 14 European countries, we estimate differences in corrected concentration indices for use of informal care and home care, using equivalised household net income and equivalised net worth (as a proxy for wealth). We also calculate horizontal inequity indices using both measures of socio‐economic status and accounting for differences in need. The findings show that using wealth as a ranking variable results, as a rule, in a less pro‐poor inequality of use for both informal and home care. Once differences in need are controlled for (horizontal inequity), wealth still results in a less pro‐poor distribution for informal care, in comparison with income, whereas the opposite is observed for home care. Possible explanations for these differences and research and policy implications are discussed.     

Nutrition support in the critical care setting: current practice in canadian ICUs‐‐opportunities for improvement?

BACKGROUND: The purpose of this project was to describe current nutrition support practice in the critical care setting and to identify interventions to target for quality improvement initiatives. METHODS: We conducted a cross-sectional national survey of dietitians working in intensive care units (ICUs) across Canada to document various aspects of nutrition support practice. RESULTS: Of the 79 dietitians sent study materials, 66 responded (83%). Sixteen of 66 sites (24.2%) reported the presence of a nutrition support team, and 35 of 66 (53%) used a standard enteral feeding protocol. Dietitians retrospectively abstracted data from charts of all patients in the ICU on April 18, 2001. Of 702 patients, 313 (44.6%) received enteral nutrition only, 50 (7.1%) received parenteral nutrition only, 60 (8.5%) received both, and 279 (39.7%) received no form of nutrition support. Enteral nutrition was initiated on 1.6 days (median) after admission to ICU; 10.7% of patients were initiated on day 1. Of those receiving any form of nutrition support, on average, patients received 58% of their prescribed amounts of calories and protein over the first 12 days in the ICU. Of all days on enteral feeds, patients received feeds into the small bowel on 381 of 2321 (16.4%) days. The mean head of the bed elevation for all patients was 30 degrees. Controlling for differences in patient characteristics, site factors contributing the most successful application of nutrition support included the amount of funded dietitians per ICU bed, size of ICU, and the fact that the ICU was located in an academic setting. CONCLUSIONS: A significant number of critically ill patients did not receive any form of nutrition support for the study period. Those that did receive nutrition support did not meet their prescribed energy or protein needs, especially earlier in the course of their illness. Significant opportunities to improve provision of nutrition support to critically ill patients exist.     

How do hospital‐specialty characteristics influence health system responsiveness? An empirical evaluation of in‐patient care in the Italian region of Emilia‐Romagna

Studies of health system responsiveness mostly focus on the demand side by investigating the association between sociodemographic characteristics of patients and their reported level of responsiveness. However, little is known about the influence of supply‐side factors. This paper addresses that research gap by analysing the role of hospital‐specialty characteristics in explaining variations in patients' evaluation of responsiveness from a sample of about 38,700 in‐patients treated in public hospitals within the Italian Region of Emilia‐Romagna. The analysis is carried out by adopting a 2‐step procedure. First, we use patients' self‐reported data to derive 5 measures of responsiveness at the hospital‐specialty level. By estimating a generalised ordered probit model, we are able to correct for variations in individual reporting behaviour due to the health status of patients and their experience of being in pain. Second, we run cross‐sectional regressions to investigate the association between patients' responsiveness and potential supply‐side drivers, including waiting times, staff workload, the level of spending on non‐clinical facilities, the level of spending on staff education and training, and the proportion of staff expenditure between nursing and administrative staff. Results suggest that responsiveness is to some extent influenced by the supply‐side drivers considered.