Managed care. Origins,principles, and evolution.

Managed care has entered the lexicon of healthcare reform, but confusion and ignorance surround its meaning and purpose. It seeks to cut the costs of health care while maintaining its quality, but the evidence that it is able to achieve these aims is mixed. As well as raising awareness and understanding of the issues surrounding managed care, this series considers whether managed care is desirable for the NHS. Developed in the United States as a response to spiralling healthcare costs and dysfunctional fragmented services, managed care is not a discrete activity but a spectrum of activities carried out in a range of organisational settings. Due to its constantly changing nature, managed care is a slippery concept--but all its permutations have in common an attempt to influence and modify the behaviour and practice of doctors and other health professionals towards cost effective care. Whatever potential managed care may hold in this regard, careful appraisal of its implications is essential.     

Old age takes its toll: Long-run projections of health-related public expenditure in Luxembourg

This paper simulates long-term trends in Luxembourg’s public expenditure on healthcare and on long-term care. We combine population projections with micro-simulations of individuals’ health status that account for their demographic, socio-economic characteristics and their childhood circumstances. Model equations estimated on data from the SHARE survey and from several branches of Social Security provide a rich framework to study policy-relevant applications. We simulate public expenditure on healthcare and long-term care under different scenarios to evaluate the separate contributions of population ageing, costs of producing health-related services, and the distribution of health status across age cohorts. Results suggest that rising per capita expenditure on healthcare will mostly result from production costs, while rising expenditure on long-term care will mostly reflect population ageing.     

Role of Endocrinologists In Eliminating Health Care Disparities

ObjectiveTo review some of the persistent disparities in health and health care in the United States related to race, ethnicity, and socioeconomic status, with a focus on diabetes mellitus and obesity, and to discuss the role of endocrinologists in preventing these disparities.MethodsSome of the efforts made by the US government, such as public health strategies, to address health disparities are outlined, and statistics about diabetes and obesity are presented.ResultsThe elimination of health disparities, recognized as a national challenge for decades, is a national priority as defined in the national goals for Healthy People 2010. Health disparities refer to the differences in the quality of health and health care access and outcomes across racial, ethnic, and socioeconomic groups. Such disparities may be related to the patient (education, socioeconomic status, environment, language), the health care system (location, structural barriers, financial resources), or the provider, including a lack of diversity in the health care workforce. Endocrinologists are responsible for the care of many patients with chronic diseases, including obesity and diabetes mellitus. Both of these chronic diseases are diagnosed with increased frequency in minority populations and are preventable, difficult to manage, and associated with many complications and high health care costs.ConclusionThe role of endocrinologists is to provide equitable, affordable, accessible, high-quality, timely, cost-effective, and culturally sensitive health care. They must be involved in population health decisions and development of optimal health care policy so that endocrine disorders can ultimately be prevented. In addition, they must educate themselves, their patients, and the community regarding maintenance of healthy lifestyles to prevent complications. (Endocr Pract. 2009;15:612-623)     

Communication Tools for End-of-Life Decision-Making in Ambulatory Care Settings: A Systematic Review and Meta-Analysis

BackgroundPatients with serious illness, and their families, state that better communication and decision-making with healthcare providers is a high priority to improve the quality of end-of-life care. Numerous communication tools to assist patients, family members, and clinicians in end-of-life decision-making have been published, but their effectiveness remains unclear.ObjectivesTo determine, amongst adults in ambulatory care settings, the effect of structured communication tools for end-of-life decision-making on completion of advance care planning.MethodsWe searched for relevant randomized controlled trials (RCTs) or non-randomized intervention studies in MEDLINE, EMBASE, CINAHL, ERIC, and the Cochrane Database of Randomized Controlled Trials from database inception until July 2014. Two reviewers independently screened articles for eligibility, extracted data, and assessed risk of bias. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to evaluate the quality of evidence for each of the primary and secondary outcomes.ResultsSixty-seven studies, including 46 RCTs, were found. The majority evaluated communication tools in older patients (age >50) with no specific medical condition, but many specifically evaluated populations with cancer, lung, heart, neurologic, or renal disease. Most studies compared the use of communication tools against usual care, but several compared the tools to less-intensive advance care planning tools. The use of structured communication tools increased: the frequency of advance care planning discussions/discussions about advance directives (RR 2.31, 95% CI 1.25–4.26, p = 0.007, low quality evidence) and the completion of advance directives (ADs) (RR 1.92, 95% CI 1.43–2.59, p<0.001, low quality evidence); concordance between AD preferences and subsequent medical orders for use or non-use of life supporting treatment (RR 1.19, 95% CI 1.01–1.39, p = 0.028, very low quality evidence, 1 observational study); and concordance between the care desired and care received by patients (RR 1.17, 95% CI 1.05–1.30, p = 0.004, low quality evidence, 2 RCTs).ConclusionsThe use of structured communication tools may increase the frequency of discussions about and completion of advance directives, and concordance between the care desired and the care received by patients. The use of structured communication tools rather than an ad-hoc approach to end-of-life decision-making should be considered, and the selection and implementation of such tools should be tailored to address local needs and context.RegistrationPROSPERO CRD42014012913     

Quality of oral health services in residential care: towards an evaluation framework

Background: There is widespread neglect of oral healthcare, and uncertainty about how best to organise and evaluate the impact of oral health services in long‐term care (LTC) facilities. Consequently, there is need for an evaluation framework to improve and account for the quality of oral healthcare in the facilities. Objectives: This paper: (i) identifies basic concepts of quality of care and evaluation in healthcare; (ii) reviews the methods used to evaluate the operation and effectiveness of oral healthcare in LTC facilities and (iii) recommends change to assure oral health‐related quality and accountability for frail elders. Method: A literature review provided insights to the theoretical basis and practical applications for assessing the quality of healthcare relevant to oral healthcare for frail elders. Results: Oral health‐related programmes in LTC facilities could be improved by using a combination of quality assurance and health programme evaluation that: (i) engages everyone involved; (ii) seeks multiple attributes of quality; (iii) evaluates the structure, process or activities, and outcome of the oral health programme; (iv) uses formative and summative methods to provide both quantitative and qualitative evidence of care and (v) transfers new knowledge for appropriate consideration and action. Conclusions: This theoretical framework can be applied in dentistry in LTC to provide an assessment model specific to oral healthcare for frail elders in residential care.     

The quality of health care in prison: results of a year's programme of semistructured inspections.

OBJECTIVES: To assess, as part of wider inspections by HM Inspectorate of Prisons, the extent and quality of health care in prisons in England and Wales. DESIGN: Inspections based on a set of "expectations" derived mainly from existing healthcare quality standards published by the prison service and existing ethical guidelines; questionnaire survey of prisoners. SUBJECTS: 19 prisons in England and Wales, 1996-7. MAIN OUTCOME MEASURES: Appraisals of needs assessment and the commissioning and delivery of health care against the inspectorate''s expectations. RESULTS: The quality of health care varied greatly. A few prisons provided health care broadly equivalent to NHS care, but in many the health care was of low quality, some doctors were not adequately trained to do the work they faced, and some care failed to meet proper ethical standards. Little professional support was available to healthcare staff. CONCLUSIONS: The current policy for improving health care in prisons is not likely to achieve its objectives and is potentially wasteful. The prison service needs to recognise that expertise in the commissioning and delivery of health care is overwhelming based in the NHS. The current review of the provision of health care in prisons offers an opportunity to ensure that prisoners are not excluded from high quality health care.     

Perspectives on Efficiency and Quality in an Ever Changing System: Healthcare 2010

The Healthcare 2010 conference at the Omni New Haven Hotel at Yale in April focused on how different stakeholders in the healthcare industry can excel in light of the recent landmark health-reform bill. A session titled “Maintaining Efficiency and Quality in an Ever Changing System” provided valuable insights into several perceptions of these two tenets, with respect to both the current state of U.S. healthcare and the recent reform. The engaging dialog that ensued concerning payer, provider, public, and patient perspectives yielded a unique view of the dynamic interplay between efficiency and quality in the context of the current healthcare system. While the discussion highlighted differences in the definitions of efficiency and quality upheld by the various players, a unifying theme emerged: In order to excel in this ever changing system, incentive structures will have to evolve to take full advantage of the potential synergies between the two.The recent passage of a landmark health-reform bill has tremendous implications for the future of U.S. medicine and healthcare. The Healthcare 2010 conference, which took place in April at the Omni New Haven Hotel at Yale, focused on how different stakeholders in the healthcare industry should proceed in light of this legislation. While a hallmark of the reform bill is expanded access to healthcare for millions of Americans, analysts generally couple the need for access with the tenets of efficiency and quality, forming the “iron triangle” of health policy. A session titled “Maintaining Efficiency and Quality in an Ever Changing System” provided valuable insight into perceptions of efficiency and quality from several perspectives, with respect to both the current state of healthcare and the recent reform.The session began with the perspective of a private-sector payer. Dr. Ricardo Guggenheim, vice president of Care Management Strategy at McKesson Health Solutions, emphasized that a large fraction of non-sustainable increases in healthcare costs are derived from non-medical expenses. Studies have found that administrative costs are one of the fastest-growing components of hospital budgets [1]. Dr. Guggenheim also revealed that hospitals are not nimble in their operations due to a heavy reliance on bonds and many fixed costs. Along these lines, one study conducted in a large urban hospital determined that 84 percent of the hospital’s budget stemmed from expenses that were fixed [2]. Likening it to the banking industry two decades ago, Dr. Guggenheim suggested that the healthcare industry has been lagging behind every other industry in leveraging technology for improvement. In his view, this represents large-scale inefficiency that can only be surmounted by enhanced quality. However, while Dr. Guggenheim acknowledged that the objective of various stakeholders in the healthcare sector is high quality of care, he asserted that cost-effective means should be developed to reach this eventual destination. The potential synergy between efficiency and quality was further elucidated from the provider perspective, represented by Dr. Leora Horwitz, an assistant professor at the Yale School of Medicine and a past Robert Wood Johnson Clinical Scholar. Dr. Horwitz highlighted how providers conceptualize fiscal efficiency in terms of maintaining revenues and minimizing costs, while also considering throughput efficiency in terms of patient flow as well as personnel efficiency, improved by reducing turnover and ensuring that work is done by the most qualified employee. Shifting to the issue of quality, she explained that while stakeholders in the health sector largely agree on the objective of high quality, varying — and sometimes conflicting — ideas of what constitutes high quality complicates policy decisions. Providers rely primarily on process measures and some outcome measures to assess quality in response to external mandates, including publicly reported CMS measures and malpractice drivers, and internal mandates, such as a hospital’s yearly quality plan or board of trustees’ reports. Dr. Horwitz then noted some points of divergence between efficiency and quality from the provider’s perspective. For instance, decreased lengths of stay may result in increased readmissions and using less expensive equipment can be more conducive to failed procedures. Yet she also outlined examples of how better quality may improve efficiency, such as when better discharge care results in fewer readmissions. Greater efficiency also can improve quality in her opinion, as exemplified by fewer medical errors with the advent of electronic medical records. Finally, Dr. Horwitz concluded that incentives are the primary determinant of whether quality and efficiency operate in conflict or synergy. A proper payment structure should incentivize efficiency, while internal and external mandates should work to incentivize quality.Dr. Elizabeth Drye, director of Quality Measurement Programs at Yale-New Haven Hospital Health Services Corp., followed with the public perspective, based on her extensive public health policy work in senior government positions in Washington, D.C. According to Dr. Drye, quality was not an issue given much emphasis in the United States before the Institute of Medicine (IOM) issued a report in 2001, entitled Crossing the Quality Chasm. This report established six aims in order to improve healthcare quality: safety, efficiency, effectiveness, timeliness, patient-centeredness, and equity [3]. Dr. Drye emphasized that existing methods of ensuring quality, such as accreditation and threats of malpractice, are not sufficient to improve quality. Building upon Dr. Horwitz’s call for a change in incentive structures, she advocated pay-for-performance using tools such as Healthcare Effectiveness Data and Information Set (HEDIS) scores to influence physician decision making. She added that the major problem in determining a measurable way to achieve high-quality care is that determining what constitutes the “right” care is a very polarizing issue. A solution sometimes employed by both the government and private health plans is to leave the decision of determining the “right” amount of care to providers. Dr. Drye specifically supported a semi-capitated system that gives providers a certain amount of money and allows them to determine how best to use it. She then detailed an array of new potential policy levers that the government could implement to enhance existing incentive structures, such as increasing public reporting of outcome measures, incorporating more quality measures, building broad coalitions in the private sector, instituting pay-for-performance, and using Medicare to test novel approaches.The conversation later shifted to the patient perspective, and the group questioned how the drive toward efficiency and quality could maintain respect for the views of the patient. Dr. Horwitz responded that providers could rely on results from publicly reported patient-satisfaction surveys. The Consumer Assessment of Health Plans (CAHPS) project and the Picker Institute, for instance, have developed valid and reliable patient survey instruments that provide useful qualitative data that have been increasingly publicly distributed [4]. Responding to the apparent shift toward considering the patient’s experience, Dr. Drye cautioned that patients may not always be in a position to make accurate assessments of quality. On a broader scale, she also worried that improved access, as laid out in the health-reform bill, may not necessarily lead to improved quality on its own.In sum, the engaging dialog concerning the payer, provider, public, and patient perspectives yielded unique insight into the dynamic interplay between efficiency and quality in the context of the current healthcare system. The recent healthcare reform has taken some steps toward achieving greater efficiency and quality, but the discussion at the conference highlighted the urgent need for additional progress. Looking ahead, different stakeholders in the healthcare space can borrow from other industries for innovative solutions. While the session highlighted differences in the definitions of efficiency and quality among the different players, a unifying theme emerged: To excel in this ever-changing healthcare system, incentive structures must evolve to foster potential synergies between the two.     

Unit Cost of Medical Services at Different Hospitals in India

Institutional care is a growing component of health care costs in low- and middle-income countries, but local health planners in these countries have inadequate knowledge of the costs of different medical services. In India, greater utilisation of hospital services is driven both by rising incomes and by government insurance programmes that cover the cost of inpatient services; however, there is still a paucity of unit cost information from Indian hospitals. In this study, we estimated operating costs and cost per outpatient visit, cost per inpatient stay, cost per emergency room visit, and cost per surgery for five hospitals of different types across India: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed government district hospital, a 655-bed private teaching hospital, and a 778-bed government tertiary care hospital for the financial year 2010–11. The major cost component varied among human resources, capital costs, and material costs, by hospital type. The outpatient visit cost ranged from Rs. 94 (district hospital) to Rs. 2,213 (private hospital) (USD 1 = INR 52). The inpatient stay cost was Rs. 345 in the private teaching hospital, Rs. 394 in the district hospital, Rs. 614 in the tertiary care hospital, Rs. 1,959 in the charitable hospital, and Rs. 6,996 in the private hospital. Our study results can help hospital administrators understand their cost structures and run their facilities more efficiently, and we identify areas where improvements in efficiency might significantly lower unit costs. The study also demonstrates that detailed costing of Indian hospital operations is both feasible and essential, given the significant variation in the country’s hospital types. Because of the size and diversity of the country and variations across hospitals, a large-scale study should be undertaken to refine hospital costing for different types of hospitals so that the results can be used for policy purposes, such as revising payment rates under government-sponsored insurance schemes.     

A randomized controlled trial of interventions to enhance patient-physician partnership, patient adherence and high blood pressure control among ethnic minorities and poor persons: study protocol NCT00123045

Background

Disparities in health and healthcare are extensively documented across clinical conditions, settings, and dimensions of healthcare quality. In particular, studies show that ethnic minorities and persons with low socioeconomic status receive poorer quality of interpersonal or patient-centered care than whites and persons with higher socioeconomic status. Strong evidence links patient-centered care to improvements in patient adherence and health outcomes; therefore, interventions that enhance this dimension of care are promising strategies to improve adherence and overcome disparities in outcomes for ethnic minorities and poor persons.

Objective

This paper describes the design of the Patient-Physician Partnership (Triple P) Study. The goal of the study is to compare the relative effectiveness of the patient and physician intensive interventions, separately, and in combination with one another, with the effectiveness of minimal interventions. The main hypothesis is that patients in the intensive intervention groups will have better adherence to appointments, medication, and lifestyle recommendations at three and twelve months than patients in minimal intervention groups. The study also examines other process and outcome measures, including patient-physician communication behaviors, patient ratings of care, health service utilization, and blood pressure control.

Methods

A total of 50 primary care physicians and 279 of their ethnic minority or poor patients with hypertension were recruited into a randomized controlled trial with a two by two factorial design. The study used a patient-centered, culturally tailored, education and activation intervention for patients with active follow-up delivered by a community health worker in the clinic. It also included a computerized, self-study communication skills training program for physicians, delivered via an interactive CD-ROM, with tailored feedback to address their individual communication skills needs.

Conclusion

The Triple P study will provide new knowledge about how to improve patient adherence, quality of care, and cardiovascular outcomes, as well as how to reduce disparities in care and outcomes of ethnic minority and poor persons with hypertension.     

ADVANCE DIRECTIVES IN TURKEY'S CULTURAL CONTEXT: EXAMINING THE POTENTIAL BENEFITS FOR THE IMPLEMENTATION OF PATIENT RIGHTS

Advance directives are not a part of the healthcare service in Turkey. This may be related with the fact that paternalism is common among the healthcare professionals in the country, and patients are not yet integrated in the decision‐making process adequately. However, starting from the enactment of the Regulation of Patient Rights in 1998, this situation started to change. While the paternalist tradition still appears to be strong in Turkey, the Ministry of Health has been taking concrete measures in the recent years to ensure that patient rights are implemented in healthcare practice. Therefore, Turkey now seems to be in a transitional period where a move towards a more patient‐autonomy centred approach is being supported by the regulatory authorities, as well as the academic circles and the public at large. In the light of this background, this paper aims to examine the potential benefits of advance directives, particularly with regard to their possible effect in the clinical decision‐making process of Turkey's context. It will be argued that advance directives, if correctly understood and implemented in the right settings, may be beneficial, particularly for improving communication between patients and healthcare professionals and for implementing of the right to refuse treatment.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients'' instructions, the absence of legal status for directives, the possible interference with a practitioner''s clinical judgement, the adequacy and appropriateness of patients'' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Canadian Medicare: prognosis guarded.

Beset by unprecedented fiscal pressures, Canadian medicare has reached a crossroads. The authors review the impact of recent cuts in federal transfer payments on provincial health care programs and offer seven suggestions to policymakers trying to accommodate these reductions. (1) Go slowly: public health care spending is no longer rising and few provinces have the necessary systems in place to manage major reductions. (2) Target reductions, rewarding quality and efficiency instead of making across-the-board cuts. (3) Replace blame with praise:give health care professionals and institutions credit for their contributions. (4) Learn from the successful programs and policies already in place across the country. (5) Foster horizontal and vertical integration of services. (6) Promote physician leadership by rewarding efforts to promote the efficient use of resources. (7) Monitor the effects of cutbacks: physician groups should cooperate with government in maintaining a national "report card" on services, costs and the health status of Canadians.     

Diagnostic imaging at its centennial: the past,the present and the future.

Since the discovery of x-rays by Wilhelm Conrad Röntgen 100 years ago, diagnostic imaging has profoundly influenced the practice of medicine. As a result of discoveries during this period, ultrasonography, nuclear imaging, computed tomography and magnetic resonance imaging, as well as conventional radiography, have assumed a major role in diagnostic medicine. In addition to their traditional role in diagnosis, imaging techniques are becoming an increasingly important factor in innovative treatment methods, and this role is likely to expand. In the current climate of rising health care costs, radiologists and other health care providers who use imaging must increasingly account to health care funders for the cost-effectiveness of imaging in relation to other diagnostic and interventional techniques. They must also assure minimum standards of quality and training, and determine the appropriate role for diagnostic imaging in health care systems of the future.     

Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

Background

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.

Methods

We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.

Result

There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.

Conclusions

Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.     

The problematization of medical tourism: a critique of neoliberalism

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that have, to date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term 'medical tourism' and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces.     

The cost of universal health care in India: a model based estimate

Introduction

As high out-of-pocket healthcare expenses pose heavy financial burden on the families, Government of India is considering a variety of financing and delivery options to universalize health care services. Hence, an estimate of the cost of delivering universal health care services is needed.

Methods

We developed a model to estimate recurrent and annual costs for providing health services through a mix of public and private providers in Chandigarh located in northern India. Necessary health services required to deliver good quality care were defined by the Indian Public Health Standards. National Sample Survey data was utilized to estimate disease burden. In addition, morbidity and treatment data was collected from two secondary and two tertiary care hospitals. The unit cost of treatment was estimated from the published literature. For diseases where data on treatment cost was not available, we collected data on standard treatment protocols and cost of care from local health providers.

Results

We estimate that the cost of universal health care delivery through the existing mix of public and private health institutions would be INR 1713 (USD 38, 95%CI USD 18–73) per person per annum in India. This cost would be 24% higher, if branded drugs are used. Extrapolation of these costs to entire country indicates that Indian government needs to spend 3.8% (2.1%–6.8%) of the GDP for universalizing health care services.

Conclusion

The cost of universal health care delivered through a combination of public and private providers is estimated to be INR 1713 per capita per year in India. Important issues such as delivery strategy for ensuring quality, reducing inequities in access, and managing the growth of health care demand need be explored.     

Decision-making for long-term tube-feeding in cognitively impaired elderly people

BACKGROUND: The decision to start long-term tube-feeding in elderly people is complex. The process by which such decisions are made is not well understood. The authors examined the factors involved in the decision to start long-term tube-feeding in cognitively impaired older people from the perspective of the substitute decision-maker. METHODS: A telephone survey was administered to the substitute decision-makers of tube-fed patients over 65 years old in chronic care facilities in Ottawa. Subjects were recruited from September 1997 to March 1998. Patients were incapable of making their own decisions about tube-feeding. Data were collected on sociodemographic factors, patients'' health status, advance directives, communication between the substitute decision-maker and the health care team, and the decision-maker''s perceived goals of tube-feeding and satisfaction with the decision regarding tube-feeding. RESULTS: Among the 57 cases in which the patient was eligible for inclusion in the study, 46 substitute decision-makers agreed to participate. Most of the patients had not given advance directives, and only 26 substitute decision-makers (56.5%) were confident that the patient would want to be tube-fed. A physician spoke with the substitute decision-maker about tube-feeding for 15 minutes or less in 17 cases (37.0%) and not at all in 13 cases (28.3%). Most of the substitute decision-makers (39 [84.8%]) felt that they understood the benefits of tube-feeding, but less than half (21 [45.7%]) felt that they understood the risks. The prevention of aspiration and the prolongation of life were the medical benefits most often cited as reasons for tube-feeding. Just over half (24 [52.2%]) of the substitute decision-makers felt that they had received adequate support from the health care team in making the decision. Substitute decision-makers of patients less than 75 years old were more likely than those of older patients to feel supported (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.0-17.9). Compared with the physician''s making the decision independently, substitute decision-makers felt more supported if they primarily made the decision (OR 16.5, 95% CI 2.7-101.4) or if they made the decision together with the physician (OR 5.3, 95% CI 1.0-27.9). Most (20 [43.5%]) of the substitute decision-makers did not feel that tube-feeding improved the patient''s quality of life, and less than half (21 [45.7%]) indicated that they would choose the intervention for themselves. INTERPRETATION: The substitute decision-making process for tube-feeding in cognitively impaired elderly people is limited by a need for advance directives, lack of confidence in substituted judgement and poor communication of information to the substitute decision-maker by the health care team.     

Patients Are Paying Too Much for Tuberculosis: A Direct Cost-Burden Evaluation in Burkina Faso

Background

Paying for health care may exclude poor people. Burkina Faso adopted the DOTS strategy implementing “free care” for Tuberculosis (TB) diagnosis and treatment. This should increase universal health coverage and help to overcome social and economic barriers to health access.

Methods

Straddling 2007 and 2008, in-depth interviews were conducted over a year among smear-positive pulmonary tuberculosis patients in six rural districts of Burkina Faso. Out-of-pocket expenses (direct costs) associated with TB were collected according to the different stages of their healthcare pathway.

Results

Median direct cost associated with TB was US$101 (n = 229) (i.e. 2.8 months of household income). Respectively 72% of patients incurred direct costs during the pre-diagnosis stage (i.e. self-medication, travel, traditional healers'' services), 95% during the diagnosis process (i.e. user fees, travel costs to various providers, extra sputum smears microscopy and chest radiology), 68% during the intensive treatment (i.e. medical and travel costs) and 50% during the continuation treatment (i.e. medical and travel costs). For the diagnosis stage, median direct costs already amounted to 35% of overall direct costs.

Conclusions

The patient care pathway analysis in rural Burkina Faso showed substantial direct costs and healthcare system delay within a “free care” policy for TB diagnosis and treatment. Whether in terms of redefining the free TB package or rationalizing the care pathway, serious efforts must be undertaken to make “free” health care more affordable for the patients. Locally relevant for TB, this case-study in Burkina Faso has a real potential to document how health programs'' weaknesses can be identified and solved.     

Comparison of Perceived and Technical Healthcare Quality in Primary Health Facilities: Implications for a Sustainable National Health Insurance Scheme in Ghana

Background

Quality care in health facilities is critical for a sustainable health insurance system because of its influence on clients’ decisions to participate in health insurance and utilize health services. Exploration of the different dimensions of healthcare quality and their associations will help determine more effective quality improvement interventions and health insurance sustainability strategies, especially in resource constrained countries in Africa where universal access to good quality care remains a challenge.

Purpose

To examine the differences in perceptions of clients and health staff on quality healthcare and determine if these perceptions are associated with technical quality proxies in health facilities. Implications of the findings for a sustainable National Health Insurance Scheme (NHIS) in Ghana are also discussed.

Methods

This is a cross-sectional study in two southern regions in Ghana involving 64 primary health facilities: 1,903 households and 324 health staff. Data collection lasted from March to June, 2012. A Wilcoxon-Mann-Whitney test was performed to determine differences in client and health staff perceptions of quality healthcare. Spearman’s rank correlation test was used to ascertain associations between perceived and technical quality care proxies in health facilities, and ordered logistic regression employed to predict the determinants of client and staff-perceived quality healthcare.

Results

Negative association was found between technical quality and client-perceived quality care (coef. = -0.0991, p<0.0001). Significant staff-client perception differences were found in all healthcare quality proxies, suggesting some level of unbalanced commitment to quality improvement and potential information asymmetry between clients and service providers. Overall, the findings suggest that increased efforts towards technical quality care alone will not necessarily translate into better client-perceived quality care and willingness to utilize health services in NHIS-accredited health facilities.

Conclusion

There is the need to intensify client education and balanced commitment to technical and perceived quality improvement efforts. This will help enhance client confidence in Ghana’s healthcare system, stimulate active participation in the national health insurance, increase healthcare utilization and ultimately improve public health outcomes.