Paying for Quality: Understanding and Assessing Physician Pay-for-Performance Initiatives

Reviews the structure, prevalence, measurement issues, perception, and impact of current quality incentive programs, and discusses how much and under what circumstances they will improve quality of care. Includes descriptions of select programs

Shared Decision-making in breast cancer screening programmes: Contributions to its implementations

A mesura que els pacients prenen consciència de ser usuaris del Sistema Nacional de Salut, demanen una prestació no relacionada només en resoldre el seu problema de salut de manera oportuna, sinó que també inclogui un bon acompanyament per part dels professionals, de manera que aconsegueixin un millor benestar. És a dir, sentir-se escoltat, rebre informació comprensible, ser tractat amb empatia i poder-se involucrar en les decisions que afecten la seva salut, sembla que són elements importants a considerar. Així ho han entès els diferents sistemes de salut, que han declarat com a centre del model els pacients, encara que de vegades sigui un desafiament portar-lo a la pràctica diària. La Presa de Decisions Compartides (TDC) pot ser una alternativa per concretar una atenció més participativa i centrada en el pacient, i models com "The Three-talk" faciliten la seva aplicació en situacions específiques de salut o malaltia. En aquest context, en el cribratge de càncer de mama, les dones tenen una baixa implicació a l'hora de decidir la seva participació, ja que no tenen ni un espai ni un temps específic on poder expressar els seus temors, dubtes o preferències a un professional de la salut, i moltes vegades manca informació sobre els beneficis i efectes adversos de participar en el cribratge. Més encara, elles no visualitzen aquestes mancances com una necessitat, perquè està molt interioritzat el benefici d'una detecció precoç com l'únic resultat possible i desconeixen o minimitzen els efectes adversos que coexisteixen amb el cribratge: falsos positius, falsos negatius o sobrediagnòstic. Aquesta tesi té per finalitat contribuir al desenvolupament d'una salut més participativa en l'àmbit del cribratge de càncer de mama, en un context de Sistema Nacional de Salut, utilitzant el model de TDC. Així, els resultats de tres estudis han permès: 1) conèixer les barreres i facilitadors per a l'aplicació de la TDC des de la perspectiva dels professionals de la salut, 2) crear dos documents –manual i guia– que ofereixen suport empíric als professionals de la salut per involucrar les dones en la presa de decisions del cribratge; 3) entendre les preferències de les dones comparant la significació dels atributs que defineixen el model de salut convencional i un amb incorporació d'una TDC.A medida que los pacientes toman conciencia como usuarios del Sistema Nacional de Salud, demandan prestaciones relacionadas no sólo con la resolución óptima de su problema de salud, sino una atención que también incluya un buen acompañamiento por parte de los profesionales, de forma que consigan un mejor bienestar. Es decir, sentirse escuchado, recibir información comprensible, ser tratado con empatía y poder involucrarse en las decisiones que afectan a su salud parecen ser elementos importantes que considerar. Así lo han entendido los diferentes sistemas de salud, que han declarado, como centro del modelo, a los pacientes, aunque en ocasiones sea un desafío llevarlo a la práctica diaria. La Toma de Decisiones Compartidas (TDC) puede ser una alternativa para concretar una atención más participativa y centrada en el paciente, y modelos como “The Three-talk model” facilitan su aplicación en situaciones específicas de salud o enfermedad. En este contexto, en el cribado de cáncer de mama, las mujeres tienen una baja implicación a la hora de decidir su participación, puesto que no tienen ni un espacio ni un tiempo específico donde poder expresar sus temores, dudas o preferencias a un profesional sanitario, y muchas veces carece de información sobre los beneficios y efectos adversos de participar en el cribado. Más aún, ellas no visualizan estas carencias como una necesidad, porque está muy interiorizado el beneficio de una detección precoz como el único resultado posible y desconocen o minimizan los efectos adversos que coexisten con el cribado: falsos positivos, falsos negativos o sobrediagnóstico. Esta tesis tiene por finalidad contribuir al desarrollo de una salud más participativa en el ámbito del cribado de cáncer de mama, en un contexto de Sistema Nacional de Salud, utilizando el modelo de TDC. Se realizaron tres estudios que han permitido: 1) conocer las barreras y facilitadores para la aplicación de la TDC desde la perspectiva de los profesionales de la salud, 2) crear dos documentos –manual y guía– que ofrecen soporte empírico a los profesionales sanitarios para involucrar a las mujeres en la toma de decisiones del cribado; 3) entender las preferencias de las mujeres comparando la significación de los atributos que definen el modelo de salud convencional y uno con incorporación de una TDC.As the awareness of patients as users of the national health system increases, they demand more well-being, which is not only related to solving their problem, but also a good accompaniment by health professionals. That is, feeling heard, receiving understandable information, being treated with empathy, and getting involved in decisions that affect your health seem to be important elements to consider. This has been understood by the different health systems, which have declared patients as the center of the model, although it is sometimes a challenge to put it into routine practice. Shared Decision-making (SDM) could be an alternative for more participatory and patient-centered care, as well as “The Three-talk” model would simplify its application in specific health or disease situations. In this context, women in breast cancer screening have a low involvement in the decision to participate, since they do not have a space in which to express their fears, doubts, or preferences to a health professional, and do not have sufficient information on the benefits and adverse effects of participating in screening. Even worse, they do not see these deficiencies as a necessity, since the benefit of early detection is very much internalized as the only possible result and they do not know or minimize the adverse effects they may suffer due to screening: false positives, false negatives or overdiagnosis. This thesis aims to contribute to the development of a more participatory health in the context of breast cancer screening in a context of the National Health System, using the SDM model. Three studies were carried out: 1) to know the barriers and facilitators for the application of the SDM from the perspective of health professionals, 2) create two documents, manual and guide, to give practical support to health professionals to involve women in the screening decision, 3) to know the preferences of women by comparing the attributes of the conventional health model and one with the incorporation of an SDM

Front-Line Physicians' Satisfaction with Information Systems in Hospitals

Day-to-day operations management in hospital units is difficult due to continuously varying situations, several actors involved and a vast number of information systems in use. The aim of this study was to describe front-line physicians' satisfaction with existing information systems needed to support the day-to-day operations management in hospitals. A cross-sectional survey was used and data chosen with stratified random sampling were collected in nine hospitals. Data were analyzed with descriptive and inferential statistical methods. The response rate was 65 % (n = 111). The physicians reported that information systems support their decision making to some extent, but they do not improve access to information nor are they tailored for physicians. The respondents also reported that they need to use several information systems to support decision making and that they would prefer one information system to access important information. Improved information access would better support physicians' decision making and has the potential to improve the quality of decisions and speed up the decision making process.Peer reviewe

Independent therapeutic advice: How achievable is it?

This supplement is likely to be of interest to anyone involved in the development of clinical guidelines and clinical research, including: • health professionals, trainees and students who use guidelines as a basis for their decision making • policy makers and others working to improve the quality of health care • people involved in university, college and hospital education. The supplement outlines the issues discussed at an Independence Forum hosted by Therapeutic Guidelines Limited in Melbourne, Australia, on 29 October 2012. It puts forward recommendations to overcome limitations of the evidence base and improve the trustworthiness of guidelines. Therapeutic Guidelines is an independent, not-forprofit organisation that was established to promote the quality use of medicines through the publication of clear, concise and ready to use guidelines. Therapeutic Guidelines convened the Independence Forum to discuss issues of independence and conflicts of interest in the context of the development of therapeutic guidelines for health professionals. Two eminent overseas speakers, Professor Silvio Garattini from the Mario Negri Institute, Italy, and Assistant Professor Barbara Mintzes from the University of British Columbia, Canada, gave keynote presentations on the complexity of the therapeutic environment and clinical evidence base. Key Australian commentators and health ethicists – Professor Paul Komesaroff from the Centre for the Study of Ethics in Medicine and Society at Monash University, and Associate Professor Ian Kerridge from the Centre for Values, Ethics and the Law in Medicine at the University of Sydney – focused on the influence of vested interests in clinical research trials and guideline development, citing high profile examples such as the case of hormone therapy after menopause. Panel discussions provided insights on these issues from a range of perspectives, including government, evidence-based medicine, clinical research, health professionals and community. During the last session, speakers and participants worked in small groups to formulate recommendations and strategies to improve the suitability of the evidence base and trustworthiness of therapeutic recommendations and guidelines.NP

Independent therapeutic advice: How achievable is it?

This supplement is likely to be of interest to anyone involved in the development of clinical guidelines and clinical research, including: • health professionals, trainees and students who use guidelines as a basis for their decision making • policy makers and others working to improve the quality of health care • people involved in university, college and hospital education. The supplement outlines the issues discussed at an Independence Forum hosted by Therapeutic Guidelines Limited in Melbourne, Australia, on 29 October 2012. It puts forward recommendations to overcome limitations of the evidence base and improve the trustworthiness of guidelines. Therapeutic Guidelines is an independent, not-forprofit organisation that was established to promote the quality use of medicines through the publication of clear, concise and ready to use guidelines. Therapeutic Guidelines convened the Independence Forum to discuss issues of independence and conflicts of interest in the context of the development of therapeutic guidelines for health professionals. Two eminent overseas speakers, Professor Silvio Garattini from the Mario Negri Institute, Italy, and Assistant Professor Barbara Mintzes from the University of British Columbia, Canada, gave keynote presentations on the complexity of the therapeutic environment and clinical evidence base. Key Australian commentators and health ethicists – Professor Paul Komesaroff from the Centre for the Study of Ethics in Medicine and Society at Monash University, and Associate Professor Ian Kerridge from the Centre for Values, Ethics and the Law in Medicine at the University of Sydney – focused on the influence of vested interests in clinical research trials and guideline development, citing high profile examples such as the case of hormone therapy after menopause. Panel discussions provided insights on these issues from a range of perspectives, including government, evidence-based medicine, clinical research, health professionals and community. During the last session, speakers and participants worked in small groups to formulate recommendations and strategies to improve the suitability of the evidence base and trustworthiness of therapeutic recommendations and guidelines.NP

Augmented Reality Ultrasound Guidance in Anesthesiology

Real-time ultrasound has become a mainstay in many image-guided interventions and increasingly popular in several percutaneous procedures in anesthesiology. One of the main constraints of ultrasound-guided needle interventions is identifying and distinguishing the needle tip from needle shaft in the image. Augmented reality (AR) environments have been employed to address challenges surrounding surgical tool visualization, navigation, and positioning in many image-guided interventions. The motivation behind this work was to explore the feasibility and utility of such visualization techniques in anesthesiology to address some of the specific limitations of ultrasound-guided needle interventions. This thesis brings together the goals, guidelines, and best development practices of functional AR ultrasound image guidance (AR-UIG) systems, examines the general structure of such systems suitable for applications in anesthesiology, and provides a series of recommendations for their development. The main components of such systems, including ultrasound calibration and system interface design, as well as applications of AR-UIG systems for quantitative skill assessment, were also examined in this thesis. The effects of ultrasound image reconstruction techniques, as well as phantom material and geometry on ultrasound calibration, were investigated. Ultrasound calibration error was reduced by 10% with synthetic transmit aperture imaging compared with B-mode ultrasound. Phantom properties were shown to have a significant effect on calibration error, which is a variable based on ultrasound beamforming techniques. This finding has the potential to alter how calibration phantoms are designed cognizant of the ultrasound imaging technique. Performance of an AR-UIG guidance system tailored to central line insertions was evaluated in novice and expert user studies. While the system outperformed ultrasound-only guidance with novice users, it did not significantly affect the performance of experienced operators. Although the extensive experience of the users with ultrasound may have affected the results, certain aspects of the AR-UIG system contributed to the lackluster outcomes, which were analyzed via a thorough critique of the design decisions. The application of an AR-UIG system in quantitative skill assessment was investigated, and the first quantitative analysis of needle tip localization error in ultrasound in a simulated central line procedure, performed by experienced operators, is presented. Most participants did not closely follow the needle tip in ultrasound, resulting in 42% unsuccessful needle placements and a 33% complication rate. Compared to successful trials, unsuccessful procedures featured a significantly greater (p=0.04) needle-tip to image-plane distance. Professional experience with ultrasound does not necessarily lead to expert level performance. Along with deliberate practice, quantitative skill assessment may reinforce clinical best practices in ultrasound-guided needle insertions. Based on the development guidelines, an AR-UIG system was developed to address the challenges in ultrasound-guided epidural injections. For improved needle positioning, this system integrated A-mode ultrasound signal obtained from a transducer housed at the tip of the needle. Improved needle navigation was achieved via enhanced visualization of the needle in an AR environment, in which B-mode and A-mode ultrasound data were incorporated. The technical feasibility of the AR-UIG system was evaluated in a preliminary user study. The results suggested that the AR-UIG system has the potential to outperform ultrasound-only guidance

Exploring the role of the general practitioner in obesity management in Australian primary care

As obesity prevalence continues to rise, approximately one third of patients seen by Australian general practitioners (GPs) are living with obesity. General practice is the cornerstone of primary care in Australia with 85% of the population seeing a GP at least annually. The current role of the GP in obesity management focuses on care co-ordination with guidelines encouraging the referral of patients to allied health services, including dietitians and exercise physiologists. But multidisciplinary team care is not always available due to factors such as location and cost, or patients may have a preference for working more closely with their GP. Currently there are no weight management programs where care is delivered by a GP. This doctoral work explores the current role of the GP in obesity management in Australia, outlines an intervention development study for a GPdelivered weight management program, and presents the findings of a feasibility trial of the program. Following the UK Medical Research Council’s Guidelines for the Development of a Complex Intervention, a GP-delivered weight management program was developed. The draft program was based on Australian evidence-based guidelines for obesity management and used a qualitative approach to engage stakeholders to refine the program materials. Following this intervention development, a six-month feasibility trial was undertaken in five general practices involving 11 GPs and 23 patients. Guided by Normalisation Process Theory, both quantitative and qualitative data were collected. Both GPs and patients reported high rates of acceptability and feasibility, and there was a low dropout rate with only three patients withdrawing. Based on the theoretical framework of Bordin, patients and GPs with a strong therapeutic alliance had better program retention and there was a trend to improvement in some health outcomes. Social cognitive theory suggests that “performance mastery” is the most effective way to develop self-efficacy. This was demonstrated in the feasibility trial with both qualitative and quantitative data showing the GPs improved self-efficacy for obesity management. Based on the findings in the feasibility trial, a modified approach to obesity management in primary care is suggested with a greater emphasis on therapeutic relationship, person-centredness, and the explicit recognition that care occurs over time and not within one consultation. A GP-delivered weight management program in Australia was demonstrated to be feasible and acceptable to both patients and their GPs. Future research will focus on a pseudo-cluster randomised controlled trial for effectiveness, alongside further development of a measure for therapeutic alliance in general practice for research, teaching, and clinical purposes