CPA Management Consultant, Spring 1996

https://egrove.olemiss.edu/aicpa_news/5220/thumbnail.jp

Understanding the causes of missingness in primary care: a realist review

Background: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single ‘situational’ missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more ‘enduring’ multiple missed appointments in primary care and the role this has in producing health inequalities. Methods: We conducted a realist review of the literature on multiple missed appointments to identify the causes of ‘missingness.’ We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation. Results: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is ‘for them’; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place. Conclusions: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care

Actions for mitigating the negative effects of patient participation in patient safety:a qualitative study

Background: Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department. Methods: This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach. Results: Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: ‘structure’, ‘culture’, ‘education’, ‘emotional’, and ‘physical and technology’. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients. Conclusions: Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, ‘politics’. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations’ structure, culture and practices.</p

Actions for mitigating the negative effects of patient participation in patient safety:a qualitative study

Background: Recent research within the context of Obstetrics shows the added value of patient participation in in-hospital patient safety. Notwithstanding these benefits, recent research within an Obstetrics department shows that four different negative effects of patient participation in patient safety have emerged. However, the approach to addressing these negative effects within the perspective of patient participation in patient safety is currently lacking. For this reason, the aim of this study is to generate an overview of actions that could be taken to mitigate the negative effects of patient participation in patient safety within an Obstetrics department. Methods: This study was conducted in the Obstetrics Department of a tertiary academic center. An explorative qualitative interview study included sixteen interviews with professionals (N = 8) and patients (N = 8). The actions to mitigate the negative effects of patient participation in patient safety, were analyzed and classified using a deductive approach. Results: Eighteen actions were identified that mitigated the negative effects of patient participation in patient safety within an Obstetrics department. These actions were categorized into five themes: ‘structure’, ‘culture’, ‘education’, ‘emotional’, and ‘physical and technology’. These five categories reflect the current approach to improving patient safety which is primarily viewed from the perspective of professionals rather than of patients. Conclusions: Most of the identified actions are linked to changing the culture to generate more patient-centered care and change the current reality, which looks predominantly from the perspective of the professionals and too little from that of the patients. Furthermore, none of the suggested actions fit within a sixth anticipated category, namely, ‘politics’. Future research should explore ways to implement a patient-centered care approach based on these actions. By doing so, space, money and time have to be created to elaborate on these actions and integrate them into the organizations’ structure, culture and practices.</p

Transitions at the end of life for older adults - patient, carer and professional perspectives

BackgroundThe end of life may be a time of high service utilisation for older adults. Transitions between care settings occur frequently, but may produce little improvement in symptom control or quality of life for patients. Ensuring that patients experience co-ordinated care, and moves occur because of individual needs rather than system imperatives, is crucial to patients’ well-being and to containing health-care costs.ObjectiveThe aim of this study was to understand the experiences, influences and consequences of transitions between settings for older adults at the end of life. Three conditions were the focus of study, chosen to represent differing disease trajectories.SettingEngland.ParticipantsThirty patients aged over 75 years, in their last year of life, diagnosed with heart failure, lung cancer and stroke; 118 caregivers of decedents aged 66–98 years, who had died with heart failure, lung cancer, stroke, chronic obstructive pulmonary disease or selected other cancers; and 43 providers and commissioners of services in primary care, hospital, hospice, social care and ambulance services.Design and methodsThis was a mixed-methods study, composed of four parts: (1) in-depth interviews with older adults; (2) qualitative interviews and structured questionnaire with bereaved carers of older adult decedents; (3) telephone interviews with care commissioners and providers using case scenarios derived from the interviews with carers; and (4) analysis of linked Hospital Episode Statistics (HES) and mortality data relating to hospital admissions for heart failure and lung cancer in England 2001–10.ResultsTransitions between care settings in the last year of life were a common component of end-of-life care across all the data sets that made up this study, and many moves were made shortly before death. Patients’ and carers’ experiences of transitions were of a disjointed system in which organisational processes were prioritised over individual needs. In many cases, the family carer was the co-ordinator and provider of care at home, excluded from participation in institutional care but lacking the information and support to extend their role with confidence. The general practitioner (GP) was a valued, central figure in end-of-life care across settings, though other disciplines were critical of GPs’ expertise and adherence to guidelines. Out-of-hours services and care homes were identified by many as contributors to unnecessary transitions. Good relationships and communication between professionals in different settings and sectors was recognised by families as one of the most important influences on transitions but this was rarely acknowledged by staff.ConclusionsDevelopment of a shared understanding of professional and carer roles in end-of-life transitions may be one of the most effective ways of improving patients’ experiences. Patients and carers manage many aspects of end-of-life care for themselves. Identifying ways to extend their skills and strengthen their voices, particularly in hospital settings, would be welcomed and may reduce unnecessary end-of-life transitions. Why the experiences of carers appear to have changed little, despite the implementation of a range of relevant policies, is an important question that has not been answered. Recommendations for future research include the relationship between policy interventions and the experiences of end-of-life carers; identification of ways to harmonise understanding of the carers’ role and strengthen their voice, particularly in hospital settings; identification of ways to reduce the influence of interprofessional tensions in end-of-life care; and development of interventions to enhance patients’ experiences across transitions.FundingThe National Institute for Health Research Health Services and Delivery Research programme

Private Health Insurance

A collection of comparative case studies analysing the history, politics and performance of private health insurance globally and its implications for universal health coverage. This is essential reading for graduate students, scholars and policy makers working on health systems financing worldwide

Partnering with carers in the management of delirium in general acute care settings:An integrative review

Objectives: Delirium is a common, preventable condition. However, delirium is poorly recognised and often missed because symptoms are misinterpreted, and risk factors overlooked by health-care professionals. Carers usually have intimate knowledge about the person they care for. Therefore, they are well placed within care teams to implement delirium prevention strategies, identify symptoms and support the early diagnosis of delirium. The aim of this integrative review was to synthesise findings from the published research reporting on partnering with carers in the management of delirium in general acute care settings. Methods: Five databases (Medline-EBSCO, PubMed, PsycINFO, ProQuest, CINAHL and SCOPUS) were searched to identify primary research regarding partnering with carers in the management of delirium in acute care settings, and results were synthesised. PRISMA guidelines were adhered to, and quality appraisal was conducted using the Mixed Methods Appraisal Tool. Results: All seven studies reported that partnering with carers was a viable strategy in the management of delirium to maximise outcomes for people at risk of or experiencing delirium and that increasing carers' knowledge of delirium was key. The synthesis of findings also identified two themes: Increasing knowledge and Effective partnerships. Conclusions: A collaborative approach to increasing carers' and nurses' knowledge about the management of delirium, coupled with education on how to develop therapeutic nurse–carer relationships, is important for ongoing effective partnerships in the management of delirium. Good communication supported effective partnerships, which enabled both nurses and carers the opportunity to express their needs and concerns and negotiate collaborative involvement in the management of delirium.</p

Exploring social and health care representations about home birth: an integrative literature review

Aims: exploring social and health care representations of home birth by conducting an integrative review of the literature. Design: Integrative Literature Review. Data sources: the search was based on the following keywords: 'birth, home,' 'home birth,' 'childbirth, home.' And the terms: 'planned home birth,' and 'empowerment women homebirth' (in English). 'partos en casa,' and 'partos domiciliarios' (in Spanish) in the following databases: Biomedical Central, Cochrane Library, Dialnet, DOAJ, Lilacs, PubMed, Scopus, Scielo, and Web of Science. Review methods: a total of 156 publications dated between 2004 and 2017 were initially obtained and a total of 41 articles were finally selected according to the criteria of inclusion, methodological rigor, and researchers' triangulation. Results: four dimensions of the issue emerged out of the 41 articles analyzed: (a) the Dimension of 'Empowerment in Childbirth;' (b) the Dimension of 'Comparative Socio-Medical Childbirth Studies;' (c) the 'Institutional Dimension of Childbirth;' (d) the 'Cultural Dimension of Childbirth.' Conclusion: from the health management perspective, home birth is not widely accepted today as a valid and safe alternative. However, women's social representations indicate an interest in returning to birth at home as a response to the excessive medicalization and institutionalization of childbirth, and value highly its autonomy and comfort

Patient-centred ambulatory healthcare for people aged 80 and over

People aged 80 and over are the fastest-growing age group in most industrialised countries. On average, this life phase is characterised by a significantly higher burden of morbidity, limitations in daily activities, medical and dental treatment needs and phenomena such as multimorbidity and frailty. However, individual ageing and health trajectories are highly heterogenous. This challenges current healthcare systems that are still primarily organised around acute care occasions. Ambulatory healthcare is in particular demand as the sector closest to people’s lives and the guarantor to enable ageing in place. By now, ambulatory healthcare providers already face considerable work burdens and are the first to encounter the challenges of this demographic change, especially due to lacking adaptations on the health system level. So far, care models for the improvement of ambulatory healthcare for older people have mainly been developed without their participation. These models primarily focused on structural elements such as coordination to manage the complexity of conditions, with mixed results. A more recent approach to redesigning healthcare is the concept of patient-centred care, which puts the patients with their individual goals, expectations and living realities at the centre of healthcare design. Patient-centred care has gained widespread recognition and can now be considered an overall goal for healthcare. However, few studies have systematically incorporated older people’s views to design patient-centred care. In particular, the group of the oldest old, aged 80 and over, were seldom of interest, despite their rapid growth and special healthcare needs. Moreover, the topic of their oral health and healthcare was rarely included in researching health services. Additionally, the investigation of the perspectives of their healthcare providers is needed to understand the practical reality and to advance the support of an appropriate health workforce for an ageing population. Consequently, this dissertation aimed at investigating what matters in developing patientcentred ambulatory healthcare for people aged 80 and over. Three dissertation projects (DPs) were conducted to examine the views of community-dwelling people aged 80 and over and their healthcare providers regarding ambulatory healthcare comprehensively as well as indepth. In DP1, a systematic review of qualitative studies on the views and experiences of people aged 80 and over regarding ambulatory healthcare was conducted. A meta-synthesis of the 22 included primary studies resulted in the development of three core motives that older people have regarding healthcare: feeling safe, feeling like a meaningful human being, and maintaining control and independence. Parallel to that, a meta-summary of the same set of studies was conducted, resulting in 23 specific desirable features of ambulatory healthcare that were systematically appraised on their confidence in the evidence using the tool GRADE CERQual. In DP2, the findings from DP1 were used to further investigate desirable features of ambulatory healthcare from the perspective of community-dwelling people aged 80 and over in Cologne, Germany. In qualitative interviews using a semi-structured interview guide, 22 participants were asked about their perspectives on general ambulatory healthcare and oral healthcare. The interview transcripts were analysed thematically and resulted in a framework of 16 characteristics of good healthcare for the very old, incorporating oral healthcare equally. The study also revealed that older people particularly value and wish for trustful care relationships, that they are rarely aware of their oral health matters, and that they frequently encounter negative stereotypes of older age in the context of healthcare. In DP3, physicians and dentists providing ambulatory healthcare in the state of North-Rhine Westphalia, Germany, were researched. Using a qualitative survey design in the mode of online data collection, they were asked about their perceptions and views on their routine work and interactions with patients aged 80 and over. The results from 77 cases analysed with the approach of structuring qualitative content analysis showed that the healthcare providers found working with the very old particularly challenging due to their medical complexity and nonmedical demands, such as psychosocial matters. The results from all three DPs were taken together to describe and explain what is relevant in the design of patient-centred ambulatory healthcare for the very old. Apart from features of such healthcare, the dissertation discusses the broader implications in referring to the understanding of health, ageing and the role of healthcare, the further development of patientcentred care and the building of a healthcare workforce for the ageing population