Untangling the complexity of connected health evaluations

Societal changes are forcing us to reconsider how healthcare is delivered and ICT can support this reimagining of healthcare delivery. One of the emerging trends in this area is Connected Health. However, the evaluation of Connected Health technologies is crucial to assess whether their implementation has had a positive impact on healthcare delivery. To support this assessment process, we developed, an exploratory framework for the evaluation of Connected Health technologies in healthcare settings. This framework was developed after having critically appraised the existing findings of health information system evaluation studies. It also builds on previous models of Information Systems evaluation, in particular, the Information Systems Success Model. Our framework incorporates the concept of assessment from multiple perspectives. Furthermore, the framework identifies the primary stakeholders and extends the assessment based on their concerns. Finally, we elaborate on the framework, detailing its application to a Connected Health solution for primary care based dementia patients in Ireland

The nursing contribution to chronic disease management: a whole systems approach: Report for the National Institute for Health Research Service Delivery and Organisation programme

Background Transforming the delivery of care for people with Long Term Conditions (LTCs) requires understanding about how health care policies in England and historical patterns of service delivery have led to different models of chronic disease management (CDM). It is also essential in this transformation to analyse and critique the models that have emerged to provide a more detailed evidence base for future decision making and better patient care. Nurses have made, and continue to make, a particular contribution to the management of chronic diseases. In the context of this study, there is a particular focus on the origins of each CDM model examined, the processes by which nursing care is developed, sustained and mainstreamed, and the outcomes of each case study as experienced by service users and carers. Aims To explore, identify and characterise the origins, processes and outcomes of effective CDM models and the nursing contribution to such models using a whole systems approach Methods The study was divided into three phases: Phase 1: Systematic mapping of published and web-based literature. Phase 2: A consensus conference of nurses working within CDM. Sampling criteria were derived from the conference and selected nurses attended a follow up workshop where case study sites were identified. Phase 3: Multiple case study evaluation Sample: 7 case studies representing 4 CDM models. These were: i) public health nursing model; ii) primary care nursing model; iii) condition specific nurse specialist model; iv) community matron model. Methods: Evaluative case study design with the unit of analysis the CDM model (Yin, 2003): • semi-structured interviews with practitioners, patients, their carers, managers and commissioners • documentary analysis • psycho-social and clinical outcome data from specific conditions • children and young people: focus groups, age-specific survey tools. Benchmarking outcomes: Adults benchmarked against the Health Outcomes Data Repository (HODaR) dataset (Currie et al, 2005). Young people were benchmarked against the Health Behaviour of School aged Children Survey (Currie et al, 2008). Cost analysis: Due to limitations in the available data, a simple costing exercise was undertaken to ascertain the per patient cost of the nurse contribution to CDM in each of the models, and to explore patterns of health and social care utilisation. Analysis: A whole system methodology was used to establish the principles of CDM. i) The causal system is a “network of causal relationships” and focuses on long term trends and processes. ii) The data system recognises that for many important areas there is very little data. Where a particular explanatory factor is important but precise data are lacking, a range of methods should be employed to illuminate each factor as much as possible. iii) The organisational whole system emphasises how various parts of the health and social care system function together as a single system rather than as parallel systems. iv) The patient experience recognises that the whole system comes together and is embodied in the experience of each patient. Key findings While all the models strove to be patient centred in their implementation, all were linked at a causal level to disease centric principles of care which dominated the patient experience. Public Health Model • The users (both parents and children) experienced a well organised and coordinated service that is crossing health and education sectors. • The lead school nurse has provided a vision for asthma management in school-aged children. This has led to the implementation of the school asthma strategy, and the ensuing impacts including growing awareness, prevention of hospital admissions, confidence in schools about asthma management and healthier children. Primary Care Model • GP practices are providing planned and routine management of chronic disease, tending to focus on single diseases treated in isolation. Care is geared to the needs of the uncomplicated stable patient. • More complex cases tend to be escalated to secondary care where they may remain even after the patient has stabilised. • Patients with multiple diagnoses continue to experience difficulty in accessing services or practice that is designed to provide a coherent response to the idiosyncratic range of diseases with which they present. This is as true for secondary care as for primary care. • While the QOF system has clearly been instrumental in developing and sustaining a primary care nursing model of CDM, it has also limited the scope of the model to single diseases recordable on a register, rather than focus on patient centred care needs. Nurse Specialist Model • The model works under a disease focused system underpinned by evidence based medicine exemplified by NICE guidelines and NSF’s. • The model follows a template drawn from medicine and sustainability is significantly dependent on the championship and protectionism offered by senior medical clinicians. • A focus on self-management in LTCs gives particular impetus to nurse-led enablement of self-management. • The shift of LTC services from secondary care to primary care has often not been accompanied by a shift in expertise. Community Matron Model • The community matron model was distinctive in that it had been implemented as a top down initiative. • The model has been championed by the community matrons themselves, and the pressure to deliver observable results such as hospital admission reductions has been significant. • This model was the only one that consistently resulted in open access (albeit not 24 hours) and first point of contact for patients for the management of their ongoing condition. Survey Findings Compared to patients from our case studies those within HODaR visited the GP, practice nurse or NHS walk-in centres more, but had less home visits from nurses or social services within the six weeks prior to survey. HODaR patients also took significantly more time off work and away from normal activities, and needed more care from friends/ relatives than patients from our study within the last six weeks. The differences between the HODaR and case study patients in service use cannot easily be explained but it could be speculated when referring to the qualitative data that the case study patients are benefiting from nurse-led care. Cost analysis – The nurse costs per patient are at least ten times higher for community matrons conducting CDM than for nurses working in other CDM models. The pattern of service utilisation is consistent with the focus of the community matron role to provide intensive input to vulnerable patients. Conclusions Nurses are spearheading the kind of approaches at the heart of current health policies (Department of Health, 2008a). However, tensions in health policy and inherent contradictions in the context of health care delivery are hampering the implementation of CDM models and limiting the contribution nurses are able to make to CDM. These include: ? data systems that were incompatible and recorded patients as a disease entity ? QOF reinforced a disease centric approach ? practice based commissioning was resulting in increasing difficulties in cross health sector working in some sites ? the value of the public health model may not be captured in evaluation tools which focus on the individual patient experience. Recommendations Commissioners and providers 1. Disseminate new roles and innovations and articulate how the role or service fits and enhances existing provision. 2. Promote the role of the nurses in LTC management to patients and the wider community. 3. Actively engage with service users in shaping LTC services to meet patients’ needs. 4. Improve the support and supervision for nurses working within new roles. 5. Develop training and skills of nurses working in the community to enable them to take a more central role in LTC management. 6. Develop organisations that are enabling of innovation and actively seek funding for initiatives that provide an environment where nurses can reach their potential in improving LTC services. 7. Work towards data systems that are compatible between sectors and groups of professionals. Explore ways of enabling patients to access data and information systems for test results and latest information. 8. Promote horizontal as well as vertical integration of LTC services. Practitioners 1. Increase awareness of patient identified needs through active engagement with the service user. 2. Work to develop appropriate measures of nursing outcomes in LTC management including not only bureaucratic and physiological outcomes, but patient-identified outcomes. Implications of research findings 1. Investment should be made into changing patient perceptions about the traditional division of labour, the nurses’ role and skills, and the expertise available in primary care for CDM. 2. Development and evaluation of patient accessible websites where patients can access a range of information, their latest test results and ways of interpreting these. 3. Long-term funding of prospective evaluations to enable identification of CDM outcomes. 4. Mapping of patient experience and patient satisfaction so that the conceptual differences between these two related ideas can be demonstrated. 5. Development of appropriate measures of patient experience that can be used as part of the quality outcome measures. 6. Cost evaluation/effectiveness studies carried out over time that includes national quality outcome indicators and valid measures of patient experience. 7. The importance of whole system working needs to be identified in the planning of services. 8. Research into the role of the health visitor in chronic disease management within a public health model

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

Background: Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered. Methods: Process evaluation of an action research project (2003-2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process. Results: The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding. Conclusion: Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care

Process evaluation of a National Primary Eye Care Programme in Rwanda.

BACKGROUND: Visual impairment is a global public health problem, with an estimated 285 million affected globally, of which 43% are due to refractive error. A lack of specialist eye care in low and middle-income countries indicates a new model of care would support a task-shifting model and address this urgent need. We describe the features and results of the process evaluation of a national primary eye care (PEC) programme in Rwanda. METHODS: We used the Medical Research Council process evaluation framework to examine the implementation of the PEC programme, and to determine enablers and challenges to implementation. The process evaluation uses a mixed methods approach, drawing on results from several sources including a survey of 574 attendees at 50 PEC clinics, structured clinical observations of 30 PEC nurses, in-depth interviews with 19 key stakeholders, documentary review and a participatory process evaluation workshop with key stakeholders to review collated evidence and contextualize the results. RESULTS: Structured clinical assessment indicated that the PEC provided is consistent with the PEC curriculum, with over 90% of the clinical examination processes conducted correctly. In 4 years, programme monitoring data showed that nearly a million PEC eye examinations had been conducted in every health centre in Rwanda, with 2707 nurses trained. The development of the eye health system was an important enabler in the implementation of PEC, where political support allowed key developments such as inclusion of eye-drops on the essential medicines list, the inclusion of PEC on insurance benefits, the integration of PEC indicators on the health management information systems and integration of the PEC curriculum into the general nursing school curriculum. Challenges included high turnover of primary care nurses, lack of clarity and communication on the future funding of the programme, competing priorities for the health sector and sustained supervision to assure quality of care. CONCLUSIONS: A model of a national primary eye care programme is presented, with service delivery to all areas in Rwanda. Key learning from this evaluation is the importance of strengthening the eye health care system, together with a strong focus on training primary care nurses using a PEC curriculum

Healthcare Integrated Approach as a Dynamic Process leading Innovation and Inclusive growth: Conceptual Framework based on Care Puglia (Italy)

Background Societal challenges introduced by Horizon 2020 and global challenges around health and environment expressed by seventeen sustainable development goals seek a mission-oriented agenda. Healthcare evaluation require a portfolio of projects with bottom-up experimentation. Current economic evaluations do not include a social component within the analysis. This study describes an integrated care model involving several stakeholders across healthcare sectors primary, secondary, tertiary, private and community sectors. The new integrated care framework has the aim encompass social welfare. Methods The existing evidence about the economic impact of integrated care available in the thin scientific literature is inconclusive. A European programme called Strategic Intelligence Monitor on Personal Health Systems Phase 3 presented 24 projects of integrated care service. Those studies were set in fourteen different European countries at exception of Israel and USA. Those projects included telehealth, telecare and independent solutions for older patients with chronic conditions. Those studies mainly identified drivers and barriers of the organizational models to integrate healthcare and social care, they stress the role of Information and Communication technology in facilitating the integration of healthcare and social care. Results Care Puglia based on Assisted Diagnostic & Therapeutic Pathway (PDTA) developed a chronic care clinical network in the southern region of Italy. This study is going to implement a Situational Awareness Team (SAT) with the ability to fuse different types of information generating a real-time sense-check and understanding barriers to change while unfolding the properties of the model. The new framework is going to focus on the Socio-Economic aspect of the Integrated Care system fostering Management Performance, Cost-Effectiveness Analysis and Sustainability Plan. A well-informed local health authority system counts of better transparency upon local governance. The mainstay of this new integrated approach to healthcare is engaging the process of building organisations to becoming learning organisations. Integrated care results being a dynamic approach to the assessment of health policies to replace the more static cost-benefit approach. This pillar is about a smart thinking allowing innovation and inclusive growth

Factors influencing the collection of information by community health workers for tuberculosis contact tracing in Ekurhuleni, Johannesburg

A research report submitted to the Faculty of Health Sciences, University of The Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Science Epidemiology in the Field of Implementation Sciences. May 2018 Johannesburg, South Africa.Background: Surveillance structures for tuberculosis (TB) contact tracing are not well integrated into routine national reporting structures. The implementation of reingineering of primary health care through ward based outreach teams (WBOTs) is a step towards equitable primary health care. Data and information collected by WBOTs for household TB contact tracing is an integral part of the implementation model of primary health care reengineering. The quality of patient record documentation becomes even more vital in light of the increased focus on process and outcome measures in health programmes and as a result, careful consideration be given to the WBOT data collection system used by community health workers (CHWs). In order to contribute to efforts of developing an optimised model for household contact tracing, the acceptability of the current paper-based data collection system needs to be assessed in order to develop a comprehensive monitoring & evaluaiton (M&E) framework for an optimsed model for household tuberculosis contact tracing. Methods: The current cross sectional research project is nested within a project that aims to develop an optimised model for household TB contact tracing. In this nested mixed methods study; the exploratory sequential design was used to explore the facilitators and barriers to completing the current data collection tools used by CHWs. The study had two components, firstly three focus group discussions (FGDs) were conducted in the three Ekurhuleni health sub-districts (Northern, Eastern and Southern) in three purposively selected primary health clinics and secondary data analysis of the main study`s FGDs was also conducted. Manual coding and QDA Miner software was used for coding and all qualitative analysis. Emerging themes were identified through inductive thematic analysis using the constant comparison analysis framework. The results informed the quantitative data collection and analysis. Following qualitative analysis; a close ended questionnaire was refined and informed by the results of the qualitative inquiry. CHWs were recruited using targetted sampling techniques from 6 primary health care facilities located in the different sub-districts in order to administer the questionnaire. The four point Likert Scale questionnaire was developed using theoritical framework for acceptability (TFA) constructs to asses the level of acceptability of the current data collection tools used to document tuberculosis contact tracing activities. Univariate and multivariate linear regression models were fitted to examine significant relationships between the composite acceptability scores and several predictors. All quantitative analysis was perforned on STATA version 14 (StataCorp College Station, Texas 77845 USA). Results: A total of five FGDs were conducted; two that were conducted as part of the main study supplemented the data from the three that were conducted (one in each Ekurhuleni health Sub-district). The total of 54 CHWs participated in all the five FGDs with 89% being female. Average age of all CHWs was 34.41 years [mean (sd): 34.41(8.16)]. Five broad themes emerged including inadequate CHW training, WBOT programme integration with other health and social care service providers, challenges with the WBOT data collection system, community access issues and preference for a digital based data collection system. Data related barriers identified included limitations with the current paper based data collection system such as insufficient competency assessments about the different data collection tools, lack of a specific tool to capture TB contact tracing activities, incomplete referral forms due to clinic staff not completing them, patients providing wrong information, too many papers to complete. Those that were related to the WBOT actvities included lack of community acceptance, resource constraints, violent patients and community members, community members that are not welcoming . Facilitators included motivated CHWs. 94 CHWs were enrolled for the quantitative survey with 90 (95.74%) females. From the total, 35% of the CHWs were from the Ekurhuleni health southern subdistrict, 34% and 31% were from the eastern and northern sub-districts respectively. The overall median (IQR) composite acceptability scores from all sub-districts was 48 (45 51), with the highest scores observed in the Eastern sub-district 49 (45 46) . In the overall study population, the acceptability of the current WBOT data collection tools was low. Conclusions: Main findings pertaining to CHW training indicate that the different phases of the Primary Health Care (PHC) reingeering WBOT trainings were inconsistent. There is also a lack of acknowledgement of attendance as CHW expressed their dissatisfaction in not receiving certifications which resulted in low morale for conducting outreach activities. The sub-optimal integration of the WBOT programme into the primary health care system results in a patchy referral system characterised by incomplete back referrals resulted as referral forms remain incomplete. Communication between the primary health care facility staff and WBOT CHWs needs to be strengthened in order to strengthen the referral linkages with other health and social care service providers. Funding models for WBOT programme need to be reviewed to ensure that resources needed for optimal WBOT functioning are secured. Restricted access to some communities, patients providing wrong addresses, violent and unwelcoming household members and lack of WBOT safety were barriers to accessing TB patients during outreach activities; thus leading to incomplete and innacurate data. The limitations posed by the current paper-based data collection system have been acknowledged and the CHWs preference for a digital based system highlights the need for the evaluation of the current mobile data collection technologies in other regions in order to inform nationwide scale-up. Recommendations: The implementation of the WBOT programme is still in its infancy and in order to improve the data collection processes of the programme, more research on CHW post-training competence is needed to determine the effectiveness of the wide array of training programs. Moreover, the implementation of CHW program should be coordinated among the different training providers including government, civil society organizations and NGOs. To improve the quality of the CHW training delivery and content, CHW feedback should be sought through pre-and post-assessments. There is a need to focus efforts on coordinating and strengthening the different PHC reengineering streams and integrate them into the primary health care system. This will likely strengthen the referral system between the WBOT programme and PHC facilities. The current M&E policy needs to be reviewed and special consideration should be given to TB contact tracing related indicators. This should also be accompanied by an adjustment of the current WBOT data collection tools to better reflect the agreed upon TB contact tracing indicators. The study further recommends further research in the form of economic evaluations to determine the cost effectiveness of scaling up current digital based data collection methods to inform nationwide scale up. Key words: Ward Based Outreach Teams, data collection system, data collection tools, community health workers, TB contact tracing, Community Based Information System, acceptabiltity, mHealthLG201

A successful chronic care program in Al Ain-United Arab Emirates

<p>Abstract</p> <p>Background</p> <p>The cost effective provision of quality care for chronic diseases is a major challenge for health care systems. We describe a project to improve the care of patients with the highly prevalent disorders of diabetes and hypertension, conducted in one of the major cities of the United Arab Emirates.</p> <p>Settings and Methods</p> <p>The project, using the principles of quality assurance cycles, was conducted in 4 stages.</p> <p>The assessment stage consisted of a community survey and an audit of the health care system, with particular emphasis on chronic disease care. The information gleaned from this stage provided feedback to the staff of participating health centers. In the second stage, deficiencies in health care were identified and interventions were developed for improvements, including topics for continuing professional development.</p> <p>In the third stage, these strategies were piloted in a single health centre for one year and the outcomes evaluated. In the still ongoing fourth stage, the project was rolled out to all the health centers in the area, with continuing evaluation. The intervention consisted of changes to establish a structured care model based on the predicted needs of this group of patients utilizing dedicated chronic disease clinics inside the existing primary health care system. These clinics incorporated decision-making tools, including evidence-based guidelines, patient education and ongoing professional education.</p> <p>Results</p> <p>The intervention was successfully implemented in all the health centers. The health care quality indicators that showed the greatest improvement were the documentation of patient history (e.g. smoking status and physical activity); improvement in recording physical signs (e.g. body mass index (BMI)); and an improvement in the requesting of appropriate investigations, such as HbA1c and microalbuminurea. There was also improvement in those parameters reflecting outcomes of care, which included HbA1c, blood pressure and lipid profiles. Indicators related to lifestyle changes, such as smoking cessation and BMI, failed to improve.</p> <p>Conclusion</p> <p>Chronic disease care is a joint commitment by health care providers and patients. This combined approach proved successful in most areas of the project, but the area of patient self management requires further improvement.</p

The effect of incongruity on quality of health information systems : Bama, Nigeria PHC case study

Generally, organisations mobilise information from varying sources on which policies, plans, objectives and organisational management are predicated. indeed, everyone within organisation needs information to perform tasks, it is thus indispensable and its use so pervasive that a methodical approach for collection and processing is imperative. In health care organisations, involved with people and life, this is even of greater significance, in many instances allowable margin of error is narrow and can be devastating.Accurate and reliable information in clinical care for example cannot be compromised.On the other hand, adequate assessment of health services quality,effectiveness and efficiency depends on quality of information generated by the system, that is, accurate, relevant, timely, understandable and complete information. To achieve this, appropriate system design and operation is essential. Adoption of primary health care (PHC), in many developing countries in response to the Global 2000, necessitated establishment of chanisms for monitoring and evaluating effectiveness of services and programmes.Accordingly, in 1986 PHC was adopted in Nigeria, concomitantly, system monitoring and evaluation or the PHC Management Information System was effexted.The information system was envisaged to ameliorate the lack of reliable health information that has persisted since nception of modern health services in Nigeria. Findings in this and other studies indicate that existing health information systems have failed to provide accurate and reliable information, systems of data generation and processing are ineffective.The aim of this was to identify and understand factors that have contributed to the seemingly intractable and insalubrious information problem within the Nigerian health care system. It would be a herculean task for a lone researcher to undertake study of the entire health system, within resource and time limitations, data collection was therefore narrowed to the PHC level. Quality of the PHC management information system was assessed, with Bama Local Government as a case study. Focus was on understanding the information system's structure from a broad perspective to include, policies, objectives,established procedures; physical, material and human resources, in terms of their quality and quantity.Data collection was carried out using both qualitative and quantitative techniques. The structure, process and outcome models provided a framework for in-depth data collection, through observation, interview, review of records and administration of questionnaire, as well as for organisation and analysis of research data. The PHC MIS was followed through, from the village, health facility, local government, state and national levels.Study results suggest general ineffectiveness due to pervasive incongruity in the information system. In the first instance design of the MIS did not reflect information needs of community health workers and the community in general,who to the most part limited appreciation of the MIS structure, objectives to be achieved. Local and regional information need was not delineated, data collected had little relevance to local information needs, resource for systems operation was abysmal, skilled personnel and training provided severely inadequate.Consequently, data collection and processing was hampered, information produced often inaccurate, untimely, immense, irrelevant and unreliable. Data collected were neither analysed nor utilised. The information system was short of being integrated since 60% of functional units within the PHC department as well as related health organisations in the community ran parallel information systems.Research data point to serious incongruity in the organisation and management of the information system. Incongruity that resulted from factors within the organisation as well derived from events within the wider social environment, which however culminated in an effective and dysfunctional information system.Chapters one to three of the thesis deal with conceptual issues related to management information systems, organisational design and quality respectively. In chapter four methodological issues surrounding data collection were discussed. Empirical data and analysis are presented are presented in chapters five to seven. In chapter eight, an attempt was made to develop a model of organisational incongruity, applied to explicate research findings.Chapter nine focuses on measures toward establishment of an effective PHC information system in Nigeria, contributions of this study and suggestions for future research

Access and utilisation of primary health care services in Riyadh Province, Kingdom of Saudi Arabia

A thesis submitted to the University of Bedfordshire, in fulfillment of the requirements for the degree of Doctor of PhilosophyThe Kingdom of Saudi Arabia (KSA) faces an increasing chronic disease burden. Despite the increase in numbers of primary health care centres (PHCCs) current evidence from the KSA, which is limited overall, suggests that access and utilisation of PHCCs, which are key to providing early intervention services, remain unequal with its rural populations having the poorest access and utilisation of PHCCs and health outcomes. There is a dearth (lack) of information from the KSA on the barriers and facilitators affecting access and utilisation of primary health care services (PHCS) and therefore this study aimed to examine the factors influencing the access and utilisation of primary health care centre (PHCC) in urban and rural areas of Riyadh province of the KSA. The behavioural model of health services use (Andersen’s model) provided the contextual and individual characteristics and predisposing, enabling and need factors which assist with an understanding of the barriers and facilitators to access and utilisation of PHCCs in Riyadh province. A mixed methods approach was used to answer the research questions and meet the objectives of the study. The converged qualitative and quantitative findings show that there are a number of predisposing (socio-demographic characteristics; language and communication and cultural competency) enabling barriers such as; distance from PHCCs to the rural residence, lack of services, new services, staff shortages, lack of training, PHC infrastructure, and poor equipment. Facilitators: service provider behaviour/communication, free PHCS, service provision and improvements, primary health care (PHC) infrastructure, manpower, opening hours, waiting time, and segregated spaces and need (increasing prevalence of chronic diseases, PHC developments in the KSA) factors influencing access and utilisation of PHCS. This study highlights important new knowledge on the barriers and facilitators to access and utilisation of PHCS in Riyadh province in the KSA. The findings have some important policy and planning implications for the MOH in the KSA. Specifically, the findings suggest: the need for clear documentation/guidance on minimum standards against which the PHCS can be measured; an audit of service availability at the PHCCs, regular patient satisfaction evaluations of PHCS, that the MOH take a parallel approach and continue to resource and improve buildings and equipment in existing PHCCs, the recruiting of more GPs, nurses, pharmacists, nutritionists and physiotherapists to meet patient demand and more Saudi health care staff, more targeted health education and interventions for the prevention of chronic diseases in the KSA and the need for an appointment system for attending the PHCCs. There is a need for further research into the barriers and enablers to accessing and utilising health care in Riyadh and the KSA overall. This research would be made easier with a clearer definition of rural and urban in the KSA context which would allow a greater comparability between urban and rural PHCS for future research, audit and evaluation as well as comparison with PHCS in other parts of the world. The Andersen model provided a useful conceptual model to frame this research and provided a structure for contrasting and comparing the findings with other studies that have used the Andersen model to understand the barriers and enablers to accessing and utilising health care services

Economic Evaluation of Potential Applications of Gene Expression Profiling in Clinical Oncology

Histopathological analysis of tumor is currently the main tool used to guide cancer management. Gene expression profiling may provide additional valuable information for both classification and prognostication of individual tumors. A number of gene expression profiling assays have been developed recently to inform therapy decisions in women with early stage breast cancer and help identify the primary tumor site in patients with metastatic cancer of unknown primary. The impact of these assays on health and economic outcomes, if introduced into general practice, has not been determined. I aimed to conduct an economic evaluation of regulatory-approved gene expression profiling assays for breast cancer and cancer of unknown primary for the purpose of determining whether these technologies represent value for money from the perspective of the Canadian health care system. I developed decision-analytic models to project the lifetime clinical and economic consequences of early stage breast cancer and metastatic cancer of unknown primary. I used Manitoba Cancer Registry and Manitoba administrative health databases to model current “real-world” Canadian clinical practices. I applied available data about gene expression profiling assays from secondary sources on these models to predict the impact of these assays on current clinical and economic outcomes. In the base case, gene expression profiling assays in early stage breast cancer and cancer of unknown primary resulted in incremental cost effectiveness ratios of less than $100,000 per quality-adjusted life-year gained. These results were most sensitive to the uncertainty associated with the accuracy of the assay, patient-physician response to gene expression profiling information and patient survival. The potential application of these gene expression profiling assays in clinical oncology appears to be cost-effective in the Canadian healthcare system. Field evaluation of these assays to establish their impact on cancer management and patient survival may have a large societal impact and should be initiated in Canada to ensure their clinical utility and cost-effectiveness. The use of Canadian provincial administrative population data in decision modeling is useful to quantify uncertainty about gene expression profiling assays and guide the use of novel funding models such as conditional funding alongside a field evaluation