An Analysis of the interventions to improve the geographic distribution of physicians in OECD countries

Un déséquilibre dans la répartition géographique des médecins a été observé dans la plupart des pays membres de l'OCDE. Le nombre de médecins praticiens, par rapport à la densité de population générale, est nettement plus faible dans les régions rurales et éloignées que dans les zones urbaines. Plusieurs interventions ont été mises en œuvre pour tenter de corriger le déséquilibre, mais les rapports indiquent que les solutions durables n'ont pas été identifiées. L'objectif de cette étude est de comprendre la persistance d'une pénurie de médecins dans les régions rurales, malgré la mise en œuvre des interventions. Deux approches évaluatives fondées sur la théorie sont utilisées pour évaluer la pertinence et la plausibilité des interventions. Une analyse stratégique permet de hiérarchiser les causes des pénuries de médecins et de classer les interventions en fonction de leur capacité à cibler ces causes. Une analyse logique permet d'évaluer le fondement théorique des interventions afin de déterminer si les interventions peuvent atteindre leurs résultats escomptés. Les résultats de cette recherche démontrent que les interventions mises en œuvre dans les pays de l'OCDE pour réduire la pénurie de médecins sont conçues pour cibler les causes du problème et sont donc pertinentes pour la répartition géographique des médecins. Les résultats démontrent également qu’à l'exception des stratégies réglementaires, selon les théories de la motivation au travail, les interventions peuvent inciter les médecins à choisir une pratique médicale rurale. La persistance d'une pénurie de médecins dans les régions rurales n'est pas due à la faiblesse théorique des interventions. D'autres recherches sont nécessaires pour évaluer le processus de production et la mise en œuvre des interventions.An imbalance in the geographic distribution of physicians has been observed in most member countries of the OECD. The number of practicing physicians, in relation to the general population density, is significantly lower in rural and remote regions, than in urban areas. Several interventions have been implemented to rectify the geographic maldistribution of physicians, however, reports indicate that sustainable solutions have not been identified. The purpose of this study is to understand the persistence of physician shortages in rural regions of OECD countries, despite the implementation of interventions. Two, theory-based evaluative approaches are used to evaluate the relevance and the plausibility of interventions. A strategic analysis allows for the prioritization of the causes of physician shortages, and the ranking of the interventions, based on their ability to target these causes. A logic analysis allows for the evaluation of the theoretical foundation of the interventions, to determine whether the interventions can achieve their intended outcome. The results of this research demonstrate that the interventions implemented in OECD countries to reduce physician shortages, are designed to target the causes of the problem, and are therefore relevant to the geographic maldistribution of physicians. Results also demonstrate that, with the exception of regulatory strategies, according to the theories of work motivation, the interventions can plausibly encourage physicians to choose rural medical practice. The persistence of physician shortages in rural regions is not due to the theoretical weakness of the interventions. Further research is required to evaluate the production process, and the implementation of the interventions

Evaluating complex interventions in real context: Logic analysis of a case management program for frequent users of healthcare services

Case management programs for frequent users of healthcare services are complex interventions which implementation and application are challenging to evaluate. The aim of this article was to conduct a logic analysis to evaluate a case management program for frequent users of healthcare services. The study proceeded in three phases: 1) establishing causal links between the program’s components by the construction of a logic model, 2) developing an integrated framework from a realistic synthesis, and 3) making a new reading of the case management program in regard of the integrated framework. The study demonstrated, on one hand, strengths and weaknesses of the actual case management program, and, on the other hand, how logic analysis can create a constructive dialogue between theory and practice. The evaluative process with decision-makers, clinicians and patients has helped to make connexions between theory, practice, experience and services organization

Characteristics of self-management among patients with complex health needs: a thematic analysis review

Objective: There is a gap of knowledge among healthcare providers on characteristics of self-management among patients with chronic diseases and complex healthcare needs. Consequently, the objective of this paper was to identify characteristics of self-management among patients with chronic diseases and complex healthcare needs. Design: Thematic analysis review of the literature. Methods: We developed search strategies for the MEDLINE and CINAHL databases, covering the January 2000–October 2018 period. All articles in English or French addressing self-management among an adult clientele (18 years and older) with complex healthcare needs (multimorbidity, vulnerability, complexity and frequent use of health services) were included. Studies that addressed self-management of a single disease or that did not have any notion of complexity or vulnerability were excluded. A mixed thematic analysis, deductive and inductive, was performed by three evaluators as described by Mileset al. Results: Twenty-one articles were included. Patients with complex healthcare needs present specific features related to self-management that can be exacerbated by deprived socioeconomic conditions. These patients must often prioritise care based on one dominant condition. They are at risk for depression, psychological distress and low self-efficacy, as well as for receiving contradictory information from healthcare providers. However, the knowledge and experiences acquired in the past in relation to their condition may help them improve their self-management skills. Conclusions: This review identifies challenges to self-management for patients with complex healthcare needs, which are exacerbated in contexts of socioeconomic insecurity and proposes strategies to help healthcare providers better adapt their self-management support interventions to meet the specific needs of this vulnerable clientele

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population