Through the Eye of the Beholder: Multiple Perspectives on Quality in Women\u27s Health Care

Quality is an illusive concept with different meanings to different people. Providers often define quality in terms of patient outcomes, professional standards of practice, predetermined criteria used to measure quality, and even subjective opinion. Patients describe quality in terms of the interpersonal aspects of care, how well they were treated, and the responsiveness of the provider to their needs. This qualitative study using a semi-structured interview defined quality from the perspectives of patients, physicians, nurses, and payers associated with a hospital-based women\u27s service line, and how the attributes of quality varied among the multiple groups. The study also described how stakeholders become aware of quality and how they determined a hospital\u27s quality. From the findings of the study, a conceptual framework of quality in women\u27s health was developed

Appraisal of patient-reported outcome measures in analogous diseases and recommendations for use in phase II and III clinical trials of pyruvate kinase deficiency

Purpose: Pyruvate kinase deficiency (PKD) is a rare disease and understanding of its epidemiology and associated burden remains limited. With no current curative therapy, clinical manifestations can be life threatening, clinically managed by maintaining adequate hemoglobin levels through transfusion and subsequent support, but with frequent complications. Treatment goals are to maintain/improve the patient’s quality of life. With new therapies, reliable, valid, and relevant patient-reported outcome (PRO) tools are required for use in clinical trials. Methods: Systematic literature search identified no current PRO tools for capturing/measuring the impact of PKD and treatments in clinical trials. Therefore, the search strategy was revised to consider conditions analogous to PKD in terms of symptoms and impacts that might serve as parallels to the experience in PKD; this included sickle cell anemia, thalassemia, and hemolytic anemia. Psychometric properties, strengths, and weakness of selected appropriate PRO instruments were compared, and recommendations made for choice of PRO tools. Results: In adult populations, EORTC QLQ C30 and SF-36v2 are recommended, the former being a basic minimum, covering generic HRQoL, and core symptoms such as fatigue. In pediatric populations, PedsQL Generic Core Scale to measure HRQoL and PedsQL MFS scale to measure fatigue are recommended. Conclusions: Some symptoms/life impacts may be unique to PKD and not observable in analogous conditions. A ‘Physico-Psychosocial Model’ derived from the ‘Medical Model’ is proposed to form the basis for a hypothesized conceptual framework to address the development of PKD-specific PRO instruments.Peer reviewedFinal Published versio

Experiences with HPTN 067/ADAPT Study-Provided Open-Label PrEP Among Women in Cape Town: Facilitators and Barriers Within a Mutuality Framework.

Placebo-controlled trials of pre-exposure prophylaxis (PrEP) have reported challenges with study-product uptake and use, with the greatest challenges reported in studies with young women in sub-Saharan Africa. We conducted a qualitative sub-study to explore experiences with open-label PrEP among young women in Cape Town, South Africa participating in HTPN 067/Alternative Dosing to Augment Pre-Exposure Prophylaxis Pill Taking (ADAPT). HPTN 067/ADAPT provided open label oral FTC/TDF PrEP to young women in Cape Town, South Africa who were randomized to daily and non-daily PrEP regimens. Following completion of study participation, women were invited into a qualitative sub-study including focus groups and in-depth interviews. Interviews and groups followed a semi-structured guide, were recorded, transcribed, and translated to English from isiXhosa, and coded using framework analysis. Sixty of the 179 women enrolled in HPTN 067/ADAPT participated in either a focus group (six groups for a total of 42 participants) or an in-depth interview (n = 18). This sample of mostly young, unmarried women identified facilitators of and barriers to PrEP use, as well as factors influencing study participation. Cross-cutting themes characterizing discourse suggested that women placed high value on contributing to the well-being of one's community (Ubuntu), experienced a degree of skepticism towards PrEP and the study more generally, and reported a wide range of approaches towards PrEP (ranging from active avoidance to high levels of persistence and adherence). A Mutuality Framework is proposed that identifies four dynamics (distrust, uncertainty, alignment, and mutuality) that represent distinct interactions between self, community and study and serve to contextualize women's experiences. Implications for better understanding PrEP use, and non-use, and intervention opportunities are discussed. In this sample of women, PrEP use in the context of an open-label research trial was heavily influenced by underlying beliefs about safety, reciprocity of contributions to community, and trust in transparency and integrity of the research. Greater attention to factors positioning women in the different dynamics of the proposed Mutuality Framework could direct intervention approaches in clinical trials, as well as open-label PrEP scale-up

Learning: Does Organization Ownership Matter? Structure and Performance in For-profit, Nonprofit and Local Government Nursing Homes*

We compare the structure and performance of for-profit (FP), nonprofit (NP) and local government (LG) organizations. These organizations differ in their ownership structure, objectives and agency relations. We conjecture that, compared to NP and LG, FP firms (a) delegate less decision-making power to employees, (b) provide more incentives and fewer fringe benefits, (c) monitor less, and (d) rely less on social networks to recruit employees. We also hypothesize that, relative to NP and LG, FP firms (i) are more efficient, (ii) provide similar levels of service elements that observable to their customers, (iii) provide lower levels of less-well observable elements, and (iv) provide less of the relational elements. Differences in structure and performance are likely to be tempered by regulation, market competition and institutional pressures for similarity. We study detailed performance outcomes for all the 369 Minnesota nursing homes included in federal and state datasets, and organization structure for a subsample of 105 homes that responded to our survey. Our empirical investigation generally supports our hypotheses. In particular, we find that FP homes serve more residents than NP and LG, after controlling for quality differences. However, FP homes provide lower quality services on a large array of attributes, especially those that are less observable by nursing home residents and their families. The differences among different types of organization are small, but significant.

A Checkup On Health Care Markets

Looks at key attributes of the healthcare markets in fourteen communities in order to gain a better understanding of how to help communities drive and sustain high-quality health care for patients with chronic illnesses

Restorative servicescapes in health care: examining the influence of hotel-like attributes on patient well-being

This study examines how 527 patients across different health states assessed the influence of hotel-like attributes on their well-being. Using theoretical mechanisms of attention restoration underlying restorative servicescapes, we postulated that hotel-like products and services will enhance patients’ perceived well-being, which, in turn, will favorably affect their behavioral intentions. We also tested an alternative model that included additional direct relationships between hotel-like products and services and behavioral intentions, based on the tenets of cue utilization theory. After conducting a series of nested model comparison procedures, we confirmed that the alternative model provided a theoretically and empirically stronger explanation for the dynamics of hotel-like restorative servicescapes. Although the differences between less healthy and more healthy patients were not statistically significant, the less healthy group demonstrated the same pattern of relationships as in the overall model, indicating that such patients may be more likely to derive greater restorative benefits from hotel-like hospital rooms, which may also make them more likely to pay higher out-of-pocket expenses for such rooms. The study furthers the empirical research agenda on evidence-based design (EBD) and the role of hospitality in health care.Accepted manuscrip

Consumer preferences for teledermoscopy screening to detect melanoma early

Introduction: ‘Store and forward’ teledermoscopy is a technology with potential advantages for melanoma screening. Any large-scale implementation of this technology is dependent on consumer acceptance. Aim: To investigate preferences for melanoma screening options compared with skin self-examination in adults considered to be at increased risk of developing skin cancer. Methods: A discrete choice experiment was completed by 35 consumers, all of whom had prior experience with the use of teledermoscopy, in Queensland, Australia. Participants made 12 choices between screening alternatives described by seven attributes including monetary cost. A mixed logit model was used to estimate the relative weights that consumers place on different aspects of screening, along with the marginal willingness to pay for teledermoscopy as opposed to screening at a clinic. Results: Overall, participants preferred screening/diagnosis by a health professional rather than skin self-examination. Key drivers of screening choice were for results to be reviewed by a dermatologist; a higher detection rate; fewer non-cancerous moles being removed in relation to every skin cancer detected; and less time spent away from usual activities. On average, participants were willing to pay AUD110 to have teledermoscopy with dermatologist review available to them as a screening option. Discussion and conclusions: Consumers preferentially value aspects of care that are more feasible with a teledermoscopy screening model, as compared with other skin cancer screening and diagnosis options. This study adds to previous literature in the area which has relied on the use of consumer satisfaction scales to assess the acceptability of teledermoscopy

The Question of Competence: Reconsidering Medical Education in the Twenty-First Century

[Excerpt] The real challenge for those involved in designing competency-based educational programs is to recognize the complexity of competence as a concept. Only then can they effectively delineate the knowledge, skills, and attitudes that learners must acquire to be able to perform within each domain at a predetermined level and to recognize that the expected level of performance within each domain will vary depending on the learner\u27s stage of education and the specialty he or she is learning. The authors of this book help us do just that. They examine the challenges facing medical education and introduce the concept of discourse as a mechanism both for examining the idea of competence and considering how to implement competency-based education. In so doing, they provide us with a new way to ask the questions that are at the heart of every report advocating change, every criticism of medical education, and every conversation that questions why health care is the way it is today