RESUMEN
BACKGROUND: Many developed countries are reforming healthcare payment systems in order to limit costs and improve clinical outcomes. Knowledge on how different groups of professional stakeholders trade off the merits and downsides of healthcare payment systems is limited. METHODS: Using a discrete choice experiment we asked a sample of physicians, policy makers, healthcare executives and researchers from Canada, Europe, Oceania, and the United States to choose between profiles of hypothetical outcomes on eleven healthcare performance objectives which may arise from a healthcare payment system reform. We used a Bayesian D-optimal design with partial profiles, which enables studying a large number of attributes, i.e. the eleven performance objectives, in the experiment. RESULTS: Our findings suggest that (a) moving from current payment systems to a value-based system is supported by physicians, despite an income trade-off, if effectiveness and long term cost containment improve. (b) Physicians would gain in terms of overall objective fulfillment in Eastern Europe and the US, but not in Canada, Oceania and Western Europe. Finally, (c) such payment reform more closely aligns the overall fulfillment of objectives between stakeholders such as physicians versus healthcare executives. CONCLUSIONS: Although the findings should be interpreted with caution due to the potential selection effects of participants, it seems that the value driven nature of newly proposed and/or introduced care payment reforms is more closely aligned with what stakeholders favor in some health systems, but not in others. Future studies, including the use of random samples, should examine the contextual factors that explain such differences in values and buy-in. JEL CLASSIFICATION: C90, C99, E61, I11, I18, O57.
Asunto(s)
Personal Administrativo , Reforma de la Atención de Salud , Administradores de Instituciones de Salud/psicología , Médicos/psicología , Mecanismo de Reembolso , Investigadores/psicología , Adulto , Teorema de Bayes , Canadá , Control de Costos/economía , Atención a la Salud/economía , Europa (Continente) , Europa Oriental , Femenino , Reforma de la Atención de Salud/economía , Gastos en Salud , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Investigación Cualitativa , Estados UnidosRESUMEN
CONTEXT: Health care technological evolution through new drugs, implants and other interventions is a key driver of healthcare spending. Policy makers are currently challenged to strengthen the evidence for and cost-effectiveness of reimbursement decisions, while not reducing the capacity for real innovations. This article examines six cases of reimbursement decision making at the national health insurance authority in Belgium, with outcomes that were contested from an evidence-based perspective in scientific or public media. METHODS: In depth interviews with key stakeholders based on the adapted framework of Davies allowed us to identify the relative impact of clinical and health economic evidence; experience, expertise & judgment; financial impact & resources; values, ideology & political beliefs; habit & tradition; lobbyists & pressure groups; pragmatics & contingencies; media attention; and adoption from other payers & countries. FINDINGS: Evidence was not the sole criterion on which reimbursement decisions were based. Across six equivocal cases numerous other criteria were perceived to influence reimbursement policy. These included other considerations that stakeholders deemed crucial in this area, such as taking into account the cost to the patient, and managing crisis scenarios. However, negative impacts were also reported, in the form of bypassing regular procedures unnecessarily, dominance of an opinion leader, using information selectively, and influential conflicts of interest. CONCLUSIONS: 'Evidence' and 'negotiation' are both essential inputs of reimbursement policy. Yet, purposely selected equivocal cases in Belgium provide a rich source to learn from and to improve the interaction between both. We formulated policy recommendations to reconcile the impact of all factors identified. A more systematic approach to reimburse new care may be one of many instruments to resolve the budgetary crisis in health care in other countries as well, by separating what is truly innovative and value for money from additional 'waste'.
Asunto(s)
Toma de Decisiones , Práctica Clínica Basada en la Evidencia/economía , Política de Salud/economía , Reembolso de Seguro de Salud/economía , Anticuerpos Monoclonales Humanizados/economía , Anticuerpos Monoclonales Humanizados/uso terapéutico , Aorta/cirugía , Neoplasias de la Mama/diagnóstico , Procedimientos Endovasculares/economía , Hábitos , Humanos , Maniobras Políticas , Medios de Comunicación de Masas , Neutrones/uso terapéutico , Oseltamivir/economía , Oseltamivir/uso terapéutico , Terapia de Protones/economía , TrastuzumabRESUMEN
UNLABELLED: To test the hypothesis that care typology-being complex and highly unpredictable versus being clear-cut and highly predictable-guides healthcare payment preferences of physicians, policy makers, healthcare executives, and researchers. We collected survey data from 942 stakeholders across Canada, Europe, Oceania, and the United States. A total of 48 international societies invited their members to participate in our study. STUDY DESIGN: Cross-sectional analysis of stakeholder survey data linked to four scenarios of care typology: primary prevention, trial-and-error care, standard care and network care. PRINCIPAL FINDINGS: We identified two "extremes": (1) dominant preferences of physicians, who embraced fee for service (FFS), even when this precludes the advantages of other payment systems associated with a minimal risk of harm (OR 1.85 for primary prevention; OR 1.89 for standard care, compared to non-physicians); and (2) the dominant preferences of healthcare executives and researchers, who supported quality bonus or adjustment (OR 1.92) and capitation (OR 2.05), respectively, even when these could cause harm. CONCLUSIONS: Based on exploratory findings, we can cautiously state that payment reform will prove to be difficult as long as physicians, healthcare executives, and researchers misalign payment systems with the nature of care. Replication studies are needed to (dis)confirm our findings within representative subsamples per area and stakeholder group.
Asunto(s)
Atención a la Salud , Reforma de la Atención de Salud , Mecanismo de Reembolso , Actitud del Personal de Salud , Australia , Canadá , Estudios Transversales , Atención a la Salud/economía , Atención a la Salud/organización & administración , Europa (Continente) , Planes de Aranceles por Servicios/economía , Planes de Aranceles por Servicios/organización & administración , Femenino , Reforma de la Atención de Salud/economía , Reforma de la Atención de Salud/organización & administración , Administradores de Instituciones de Salud , Política de Salud , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Médicos , Prevención Primaria/economía , Prevención Primaria/organización & administración , Sistema de Pago Prospectivo/economía , Sistema de Pago Prospectivo/organización & administración , Estados UnidosRESUMEN
Care pathways are often said to promote interprofessional teamwork. As no systematic review on pathway effectiveness has ever focused on how care pathways promote teamwork, the objective of this review was to study this relationship. We performed an extensive search of electronic databases and identified 26 relevant studies. In our analysis of these studies we identified 20 team indicators and found that care pathways positively affected 17 of these indicators. Most frequently positive effects were found on staff knowledge, interprofessional documentation, team communication and team relations. However, the level of evidence was rather low. We found Level II evidence for improved interprofessional documentation. We also found Level II evidence for increased workload; improved actual versus planned team size; and improved continuity of care. The studies most frequently mentioned the need for a multidisciplinary approach and educational training sessions in order for pathways to be successful. The systematic review revealed that care pathways have the potential to support interprofessional teams in enhancing teamwork. Necessary conditions are a context that supports teamwork and including appropriate active pathway components that can mediate an effect on team processes. To achieve this, each care pathway requires a clearly defined team approach customized to the individual teams' needs.
Asunto(s)
Vías Clínicas , Grupo de Atención al Paciente/organización & administración , Actitud del Personal de Salud , Comunicación , Documentación/métodos , Procesos de Grupo , Conocimientos, Actitudes y Práctica en Salud , Humanos , Relaciones InterprofesionalesRESUMEN
OBJECTIVES: Pay-for-performance is increasingly used as a system intervention to support quality improvement. Programs are however developed, implemented and evaluated in a heterogeneous way. This is partly due to the broad and disparate theoretical and empirical foundation of P4P practice, which is rapidly evolving. This paper guides the reader through the essential steps which should be taken into consideration when setting up a P4P program. To this end a model called 'Model for Implementing and Monitoring Incentives for Quality' (MIMIQ) is presented. METHODS: Literature review was performed with a search of multiple databases, reference screening and expert consultation. RESULTS: Central to the step-by-step approach is a Plan-Do-Check-Act cycle which incorporates communication, implementation and evaluation as key phases next to program development. In addition, the model explains how the decision making and results of each phase is modified by contextual factors. The model puts emphasis on quality and quality measurement as first items to develop. Only after these are in place, the development of the incentive component can be addressed. CONCLUSIONS: The model presents guidance for designing and implementing P4P programs in a practically structured way. According to future findings the MIMIQ model will continuously evolve as an up to date P4P policy and practice tool.
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Modelos Organizacionales , Reembolso de Incentivo/organización & administración , Comunicación , Atención a la Salud/economía , Atención a la Salud/organización & administración , Humanos , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Indicadores de Calidad de la Atención de Salud , Calidad de la Atención de Salud , Reembolso de Incentivo/economíaRESUMEN
BACKGROUND: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness. METHODS: The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers. RESULTS: One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level. CONCLUSIONS: P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.
Asunto(s)
Garantía de la Calidad de Atención de Salud/economía , Reembolso de Incentivo/organización & administración , Femenino , Humanos , MasculinoRESUMEN
UNLABELLED: SUMMARY RATIONALE, AIMS AND OBJECTIVES: Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway? METHOD: Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included. RESULTS: Joint arthroplasty clinical pathways address pre-admission education, pre-admission exercises, pre-admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home-based physiotherapy and continuous follow-up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking. CONCLUSIONS: A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta-analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.
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Artroplastia de Reemplazo/métodos , Vías Clínicas , Evaluación de Procesos y Resultados en Atención de Salud , Artroplastia de Reemplazo/economía , Artroplastia de Reemplazo/rehabilitación , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Humanos , Atención PerioperativaRESUMEN
RATIONALE, AIMS AND OBJECTIVES: Issues of overuse, underuse and misuse are paramount and lead to avoidable morbidity and mortality. Although evidence-based practice is advocated, the widespread implementation of this kind of practice remains a challenge. This is also the case for evidence-based practice related to the prevention of pressure ulcers, which varies widely in process and outcome in Belgian hospital care. One major obstacle to bridging this knowledge-to-action gap is data availability. We propose using large-scale hospital administrative data combined with the latest evidence-based methods as part of the solution to this problem. METHOD: To test our proposal, we applied this approach to pressure ulcer prevention, using an administrative dataset with regard to 6030 patients in 22 Belgian hospitals as a sample of nationally available data. Methods include a systematic review approach, evidence grading, recommendations formulation, algorithm construction, programming of the rule set and application on the database. RESULTS: We found that Belgian hospitals frequently failed to provide appropriate prevention care. Significant levels of underuse, up to 28.4% in pressure ulcer prevention education and 17.5% in the use of dynamic systems mattresses, were detected. Figures for overuse were mostly not significant. Misuse couldn't be assessed. CONCLUSIONS: These results demonstrate that this approach can indeed be successfully used to bridge the knowledge-to-action gap in medical practice, by implementing an innovative method to assess underuse and overuse in hospital care. The integrative use of administrative data and clinical applications should be replicated in other patient groups, other datasets and other countries.
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Conocimientos, Actitudes y Práctica en Salud , Hospitalización , Úlcera por Presión/prevención & control , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Algoritmos , Bélgica , Niño , Preescolar , Medicina Basada en la Evidencia , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Unidades de Cuidados Intensivos , Masculino , Aplicaciones de la Informática Médica , Persona de Mediana Edad , Calidad de la Atención de Salud , Adulto JovenRESUMEN
BACKGROUND: Internationally, nursing is not well represented in hospital financing systems. In Belgium a nursing weight system exists to adjust budget allocation for differences in nurse staffing requirements, but there is a need for revision. Arguments include the availability of a nursing minimum dataset and the adverse consequences of the current historically based nursing weight system. OBJECTIVES: The development and validation of nursing resource weights for the revised Belgium nursing minimum dataset (NMDS). DESIGN: Two independent cross sectional Delphi-surveys. SETTING AND PARTICIPANTS: A convenience sample of 222 head nurses from 69 Belgian hospitals participated in the cross sectional survey methods. To assess validity 112 patient case records from 61 nursing wards of 35 Belgian general hospitals representing general, surgical, pediatric, geriatric and intensive care were selected. METHODS: Nursing resource weights were constructed based on Delphi survey results by NMDSII intervention. The patient case Delphi survey results were used as the primary source for validation. A series of additional validation measures were calculated, based on the different patient classification systems. Finally, three validated nursing resource weighting systems were compared to the constructed NMDSII weighting system: the use of 'Closon', 'Ghent' and WIN weights. RESULTS: A coherent set of nursing resource weights was developed. The comparison of nurse resource weights, based on the survey per NMDS intervention versus the survey on patient cases, yielded high correlations: r=0.74 to r=0.97 (p<0.01) between three case rating questions, as an indication of reliability in terms of internal consistency, and r=0.90 (p<0.01) between summed intervention weights and patient case weights, as an indication of criterion validity in terms of concurrent validity. Other concurrent validity measures based on summed intervention weights versus patient classification dependency weights showed a correlation ranging from r=0.14 to r=0.74. The correlation of summed intervention weights with the Closon, Ghent and WIN weights ranged from r=0.93 to r=0.96 (p<0.01), as a third indication of concurrent validity. CONCLUSIONS: A system of valid nursing resource weights has been developed. The system should be further validated within an international context.
Asunto(s)
Hospitales Generales/organización & administración , Personal de Enfermería en Hospital , Bélgica , Técnica Delphi , Encuestas y CuestionariosRESUMEN
The purpose of this study was to examine and review the different ways in which nursing care can be accounted for in a general hospital reimbursement system. The study is based on a literature review and a survey of international experts. It provides a typology of nursing care adjustment methods, using current and past practices of 14 Western countries as key examples. The results of our review indicate that it is necessary to take the variability of nursing care within DRGs into account, not from a cost-accounting perspective, but from a management perspective in terms of correct resource allocation. However, further investigation of these complex relationships is urgently needed.
Asunto(s)
Grupos Diagnósticos Relacionados/economía , Costos de Hospital/estadística & datos numéricos , Personal de Enfermería en Hospital/economía , Mecanismo de Reembolso/economía , Ajuste de Riesgo/economía , Australia , Europa (Continente) , Administración Financiera de Hospitales/economía , Necesidades y Demandas de Servicios de Salud , Hospitales Generales/economía , Humanos , Tiempo de Internación/economía , Nueva Zelanda , América del Norte , Investigación en Administración de Enfermería , Asignación de Recursos/economía , Índice de Severidad de la Enfermedad , Carga de Trabajo/economíaRESUMEN
The Ministry of Public Health commissioned a research project to the Catholic University of Leuven and the University Hospital of Liège to revise the Belgian Nursing Minimum Dataset (B-NMDS). The study started in 2000 and will end with the implementation of the revised B-NMDS in January 2007. The study entailed four major phases. The first phase involved the development of a conceptual framework based on a literature review and secondary data analysis. The second phase focused on language development and development of a data collection tool. The third phase focused on data collection and validation of the new tool. In the fourth phase the validity and reliability of the dataset was tested. The new dataset is without avail if it is not leading to new information. Four applications of the dataset has been defined from the beginning: evaluation of the appropriateness of stay (AEP) in the hospital, nurse staffing, hospital financing and quality management. The aim of this paper is to describe how the B-NMDS can contribute to each of these applications.