The doctor patient relationship and adherence to medication: Empirical investigations in Greece and a game theory approach.

Non-adherence to medication is a problem of great magnitude as it leads to reduced health outcomes and increased health care costs. The impact of the doctor-patient relationship on non-adherence has attracted the interest of researchers yet relevant evidence is limited. The aim of this thesis is twofold. It empirically investigates the relationship between the doctor-patient interaction and non-adherence to medication in Greece, on a population and a patient level. It also develops a theoretical model of the doctor-patient relationship using non-cooperative game theory to explain how supply of information under conflict conditions affects non-adherence. Two empirical studies and a game theoretical model are used. The first study draws on data from the European Social Survey to examine beliefs about doctors and attitudes towards medication in the general population. The second study analyses a questionnaire survey of hypertensive patients in Greece, conducted for this thesis. The game theoretical approach investigates how conflicts between patients' preferences for information and doctors' effort to supply it may lead to non-adherence. It employs concepts from Behavioural Economics, which combines elements of both Economics and Psychology. The findings demonstrate a strong association between what individuals think of doctors and their attitudes towards medication. Beliefs about doctors are the strongest predictors of non-adherence in both studies. At a population and patient level, Greeks attach a lot of weight to their doctors' opinions and adhere to their recommendations. Finally, the game-theoretical framework shows that doctors' failure to understand patients' need for information may result in patients not adhering. The findings suggest that interventions to improve adherence rates should be built on the basis of a good doctor-patient relationship, where the doctors understand patients' needs, discuss about the treatment and pass on adequate information. The thesis is part of the cumulative knowledge in the area and could lead to further empirical and theoretical investigations

Retirement and household expenditure in turbulent times

We examine the impact of own and spousal retirement on household expenditure during a period of financial deterioration. We use detailed household data covering the period 2009- 2016 in Greece, during which the country experienced a severe financial crisis that affected retirees in ways that were not anticipated. Similar to Moreau and Stancanelli (2015) our empirical strategy allows for the household expenditure to depend on both own and spousal retirement status. We employ an instrumental variable identification strategy by exploiting variation coming from the early retirement age threshold. Our Two-Stage Least Squares estimates show that, even after controlling for income, total expenditure drops significantly when the husband retires and as he becomes older. The reduction is stronger in 2010, when the first wave of austerity plans, including measures affecting pensioners were announced, and after 2014 when horizontal pension cuts were implemented. Expenditure does not change significantly when the wife retires neither the older she gets. A drop-in expenditure for clothing, transport, housing and communication drives the overall reduction in expenditure. Overall, our results can have significant policy implications in the design of structural pension reforms in a period of financial hardship

Mapping the role of patient and public involvement during the different stages of healthcare innovation: A scoping review

Background Patient and public involvement (PPI) has become increasingly important in the development, delivery and improvement of healthcare. PPI is used in healthcare innovation; yet, how it is used has been under-reported. The aim of this scoping review is to identify and map the current available empirical evidence on the role of PPI during different stages of healthcare innovation. Methods The scoping review was conducted in accordance with PRISMAScR and included any study published in a peer-reviewed journal between 2004 and 2021 that reported on PPI in healthcare innovation within any healthcare setting or context in any country. The following databases were searched: Medline, EMBASE, CINAHL, PsycInfo, HMIC and Google Scholar. We included any study type, including quantitative, qualitative and mixed-method studies. We excluded theoretical frameworks, conceptual, scientific or grey literature as well as discussion and opinion papers. Results Of the 87 included studies, 81 (93%) focused on or were conducted by authors in developed countries. A wide range of conditions were considered, with more studies focusing on mental health (n = 18, 21%) and cancer care (n = 8, 9%). The vast majority of the studies focused on process and service innovations (n = 62, 71%). Seven studies focused on technological and clinical innovations (8%), while 12 looked at both technological and service innovations (14%). Only five studies examined systems innovation (5%) and one study looked across all types of innovations (1%). PPI is more common in the earlier stages of innovation, particularly problem identification and invention, in comparison to adoption and diffusion. Conclusion Healthcare innovation tends to be a lengthy process. Yet, our study highlights that PPI is more common across earlier stages of innovation and focuses mostly on service innovation. Stronger PPI in later stages could support the adoption and diffusion of innovation

The consent process: enabling or disabling patients’ active participation?

Standards expected by doctors’ regulatory bodies in respect of the process of consent to treatment have arguably sought to restructure the nature of the doctor-patient relationship from one of paternalism to that of shared decision-making. Yet, few studies have explored empirically, from patients’ perspectives, the extent to which the process of consent to treatment enables or disables patients’ participation in medical decision-making. Our paper examines patients’ attitudes towards the consent process, exploring how and why these attitudes influence patients’ active participation in decision-making and considering possible consequent medico-legal issues. Data were collected longitudinally using semi-structured interviews and field observations involving 35 patients and 19 of their caregivers, in an English hospital between February and November 2014. These indicate that generally patients defer to the doctor in respect of treatment decision-making. Although most patients and their caregivers wanted detailed information and discussion, they did not necessarily expect that this would be provided. Further, patients perceived that signing the consent form was an obligatory routine principally to protect doctors from legal action should something go wrong. Our study suggests that patients’ predominantly paternalistic perceptions of the consent process can not only undermine attempts by doctors to involve them in decision-making but, as patients are now considered in law as informed actors, their perceptions of the consent form as not being in their interests could be a self-fulfilling prophecy if signing is undertaken without due consideration to the content

Non-adherence to medication and doctor-patient relationship: Evidence from a European survey

Objective: Studies on the determinants of non-adherence to medication have put emphasis in understanding the role of the doctor-patient relationship in individuals’ decision to follow recommendations. Yet, evidence on general perceptions that individuals hold about doctors and their impact on their decision to non-adhere is lacking. This paper aims to explore the issue using data from the European Social Survey (ESS). Methods: The ESS was conducted in 2004/2005 and included 45,700 participants from 24 countries in Europe. A Heckman probit model with sample selection was used for the analysis. Results: The results show that perceptions about doctors constitute the model that better explains non-adherence to prescribed medication. Conclusion and Practice Implications: Our findings confirm that general beliefs individuals have about the doctor-patient relationship impact significantly on their decision to non-adhere to prescribed medication. Key points were shown to be involvement in the decision making process, treating patients as equals and avoiding leaving unresolved issues when prescribing

The impact generated by public and charity-funded research in the UK: A systematic literature review

Objective: To identify, synthesize and critically assess the empirical evidence of the impact generated by public and charity funded health research in the United Kingdom. Methods: We conducted a systematic literature review of the empirical evidence published in English in peer-reviewed journals between 2006 and 2017. Studies meeting the inclusion criteria were selected and their findings were analysed using the Payback Framework into five main categories: knowledge, benefits to future research and research use, benefits from informing policy and product development, health and health sector benefits and broader economic benefits. We assessed the studies for risk of selection, reporting and funding bias. Results: Thirteen studies met the inclusion criteria. The majority of the studies (10 out of 13) assessed impact at multiple domains including the main 5 key themes of the Payback Framework. All of them showed a positive impact of funded research on outcomes. Of those studies, one presented low risk of bias (8%), 6 studies were classified as presenting moderate risk of bias (46%) and 6 studies presented high risk of bias (46%). Conclusions: Empirical evidence on the impact of public and charity funded research is still limited and subject to funding and selection bias. More work is needed to establish the causal effects of funded research on academic outcomes, policy, practice and the broader economy

Compulsory licensing and access to drugs

Compulsory licensing allows the use of a patented invention without the owner's consent, with the aim of improving access to essential drugs. The pharmaceutical sector argues that, if broadly used, it can be detrimental to innovation. We model the interaction between a company in the North that holds the patent for a certain drug and a government in the South that needs to purchase it. We show that both access to drugs and pharmaceutical innovation depend largely on the Southern country's ability to manufacture a generic version. If the manufacturing cost is too high, compulsory licensing is not exercised. As the cost decreases, it becomes a credible threat forcing prices down, but reducing both access and innovation. When the cost is low enough, the South produces its own generic version and access reaches its highest value, despite a reduction in innovation. The global welfare analysis shows that the overall impact of compulsory licensing can be positive, even when accounting for its impact on innovation. We also consider the interaction between compulsory licensing and the strength of intellectual property rights, which can have global repercussions in other markets beyond the South

Patients' willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review

This systematic review identifies the factors that both support and deter patients from being willing and able to participate actively in reducing clinical errors. Specifically, we add to our understanding of the safety culture in healthcare by engaging with the call for more focus on the relational and subjective factors which enable patients' participation (Iedema, Jorm, & Lum, 2009; Ovretveit, 2009). A systematic search of six databases, ten journals and seven healthcare organisations' web sites resulted in the identification of 2714 studies of which 68 were included in the review. These studies investigated initiatives involving patients in safety or studies of patients' perspectives of being actively involved in the safety of their care. The factors explored varied considerably depending on the scope, setting and context of the study. Using thematic analysis we synthesized the data to build an explanation of why, when and how patients are likely to engage actively in helping to reduce clinical errors. The findings show that the main factors for engaging patients in their own safety can be summarised in four categories: illness; individual cognitive characteristics; the clinician-patient relationship; and organisational factors. We conclude that illness and patients' perceptions of their role and status as subordinate to that of clinicians are the most important barriers to their involvement in error reduction. In sum, patients' fear of being labelled "difficult" and a consequent desire for clinicians' approbation may cause them to assume a passive role as a means of actively protecting their personal safety

Conflict in the doctor-patient relation and non-adherence: a game theory approach

Abstract Non-adherence to medication leads to reduced health outcomes and increased health care costs. More evidence and analysis is needed to understand the determinants of non-adherence, particularly the impact of the doctor-patient interaction. This relationship is often characterised by conflict during consultations. The aim of this paper is to investigate whether a game theoretic approach can explain the conflict during consultations that lead patients to non-adhere to medical recommendations. The game theoretic models constructed employ the Psychological Expected Utility theory. There is a distinction between information-loving and information-averse patients. Doctors do not always know the type of patient they have and on the basis of limited knowledge, they need to decide how much information to pass on. We relax the assumption of perfect agency and introduce the concept of the doctor’s effort. Uncertainty is resolved under various hypotheses of bounded rationality. A complete resolution of the games is offered, and comparative statics results and economic interpretations are given. When a doctor knows with certainty the type of patient she has, she will transfer adequate information and the patient will adhere. If the doctor cannot recognize the patient’s need the outcome may be non-adherence to recommendations. Doctors who understand patients’ needs improve adherence rates. To enhance adherence, a number of policy recommendations are made. Financial incentives to the doctor do not benefit all types of patients