Hospital‐based health systems 20 years later: A taxonomy for policy research and analysis

ObjectiveBuilding on the original taxonomy of hospital‐based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments.Data SourcesThe 2016 American Hospital Association''s (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017‐2018 National Survey of Healthcare Organizations and Systems (NSHOS).Study DesignCluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital‐based health systems.Data CollectionPrincipal components factor analysis with varimax rotation generating the factors used in the cluster algorithms.Principal FindingsAmong the four cluster types, 54% (N = 202) of systems are decentralized (−0.35) and relatively less differentiated (−0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (−0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (−1.35) and most decentralized (−0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system.ConclusionsThe new taxonomy of hospital‐based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value‐based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.     

What attracts and sustain urban poor to informal healthcare practitioners? A study on practitioners' perspectives and patients' experiences in an Indian city

The practice of allopathic medicine by informal healthcare practitioners (IHPs) is ubiquitous in India. However, a little is known about the patients' experiences and IHPs' perspectives. The core questions guided the present study were (1) why do urban poor approach IHPs for healthcare? (2) what are their experiences of availing services from IHPs? and (3) what are the perspectives of IHPs about their practice with the population they serve? A qualitative research design guided the study. The study was conducted in the Gurugram city of Haryana, India. Nine IHPs and twenty‐seven patients who fit into the pre‐established inclusion criteria were interviewed. The findings of the study underline the structural constrains of healthcare access to the poor in India and the mutual dependencies between IHPs and the urban poor. Three themes were emerged corresponding to the perspectives of IHPs, and five themes were generated, which describes patients' experiences and perspectives of availing treatment. The factors that attract and sustain patients to IHPs are a mixture of socio‐economic aspects, which include poverty, inaccessibility, unaffordability, inefficient public healthcare facilities, and the positive behavioural and treatment attributes of the practitioners. The study implies urgent policy interventions to ensure quality healthcare to urban poor.     

Cancer patients who refuse treatment

The value of cancer treatment was assessed using a natural experiment where patients who refused treatment served as no-treatment controls in a situation where withholding treatment to form a control group is unethical. Each cancer patient who refused treatment in Alberta, Canada between 1975 and 1988 was compared with five subjects who accepted treatment, matched on cancer site, age, number of cancers, and time period. Variables associated with treatment-refusal were included in Cox's proportional hazards model of survival, with death from cancer as the endpoint and deaths from other causes as censored observations. Treatment was refused at a rate of 7.5 per 1,000. One-third of patients who refused treatment had lung cancer and most had unstaged disease. Treatment refusal was associated with a difference in median survival of approximately nine months. Site-specific analyses showed a range of effects. Case fatality among the treated patients fell by approximately 10 percent during the 14-year study period. Even in advanced disease, treatment can result in improved survival. However, the results of this study must be interpreted with caution and cannot be generalized to all cancer patients.Dr Huchcroft and Mr Snodgrass are with the Alberta Cancer Board, Calgary, Alberta, Canada. Address correspondence to Dr Shirley Huchcroft, Senior Scientist, Division of Epidemiology and Preventive Oncology, Alberta Cancer Board, Calgary, Alberta, Canada T2N 4N2.     

Symptoms in children of British and of Bangladeshi parents measured by the Rutter B2 questionnaire

Objectives. Bangladeshi children are less frequently referred to a child psychiatric clinic than their British peers. This study aimed to ascertain if teachers observed less psychological symptoms in Bangladeshi than British children.

Method. Teachers completed a Rutter B2 Scale on samples of 113 ‘Bangladeshi’ and 61 British children aged between 5 and 11 years.

Results. Teachers recognised less symptomatology in the Asian children than their British peers. This trend was significant in children under the age of 8, but there was no significant difference in those aged 8–11 years. Only 13% of Bangladeshi children were fully fluent in English.

Conclusions. Two alternate hypotheses are put forward to explain these findings: (a) because more of the younger children could not speak English and communicate freely with their teachers, their symptoms were not noted by teachers; (b) the symptoms of the older children were a response to the pressures both the children and families faced as new immigrants. This study clearly needs to be replicated with a larger sample and also with interviews with both children and parents in order to validate the Rutter B2 questionnaires as an appropriate measure of disturbance in Bangladeshi children. It should be replicated with validated assessments of the children's fluency in English. It is also important to discuss with Bangladeshi parents what support they would like from both the school and from child psychiatric services, to promote their children's psychological health.     

A STUDY OF POSTDIAGNOSIS BREAST CANCER CONCERNS FOR WOMEN LIVING IN RURAL AND REMOTE QUEENSLAND. PART I: PERSONAL CONCERNS

The findings presented in this paper are part of a research project designed to provide a preliminary indication of the support needs of postdiagnosis women with breast cancer in remote and isolated areas in Queensland. This discussion will present data that focuses on the women's expressed personal concerns. For participants in this research a diagnosis of breast cancer involves a confrontation with their own mortality and the possibility of a reduced life span. This is a definite life crisis, creating shock and needing considerable adjustment. Along with these generic issues the participants also articulated significant issues in relation to their experience as women in a rural setting. These concerns centred around worries about how their partner and families cope during their absences for treatment, the additional burden on the family of having to cope with running the property or farm during the participant's absence or illness, added financial strain brought about by the cost of travel for treatment, maintenance of properties during absences, and problems created by time off from properties or self-employment. These findings accord with other reports of health and welfare services for rural Australian and the generic literature on psycho-oncology studies of breast cancer.