Inequalities in access to health care in urban south India

Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal

Effect of Family Medicine Groups on Visits to the Emergency Department among Diabetics in Quebec between 2000 and 2011: A Population-Based Segmented Regression Analysis of an Interrupted Time Series

Poster Presentation Background: Family Medicine Groups (FMG) were introduced in Quebec in 2002 to reorganize primary care practices and encourage team-based and inter-professional approaches to service delivery. We measured the effect of this reform on the rate of emergency department (ED) visits among patients diagnosed with diabetes. Methods: Administrative databases were used to derive the weekly rate of ED visits between April 1, 2000 and March 31, 2012. We performed an interrupted segmented regression analysis to derive the estimated and extrapolated rates of visits in the years following the initial reform implementation. We employed an outcome control series of diabetics visiting the ED to treat appendicitis to strengthen the study’s internal validity. Results: A gradual decline in the rate of visits was observed for short term diabetes related complications and total ED visits. After 9 years of reform implementation, we observed a reduction of 1.42 and 1.70 ED visits per 10,000 diabetics to treat short term complications in urban and rural areas, respectively. A steady decrease was also observed in the total rate of ED visits in urban areas where we observed a reduction of 6.72 visits per 10,000 diabetics 9 years following the reform. Visits coded for appendicitis showed no clinically relevant changes over the study period. Interpretation: Our results suggest that the decreases in the rate of ED visits are attributed to the implementation of the FMG model across the province. The steady decline in the rate of total ED visits in urban areas is of particular relevance where overutilization of the ED is a problem. Evidence of these decreases despite the low-intensity nature of the FMG reform suggests the potential for this model to act as a future platform for implementing comprehensive care models for chronic disease management

The use of linked data to develop and validate measures of variation in mortality and readmissions for public reporting purposes in New South Wales, Australia

ABSTRACT Objectives To investigate variation across 78 New South Wales public hospitals, in mortality in the 30 days following admission and in returns to acute care (readmissions) in the 30 days following discharge for acute myocardial infarction, ischaemic stroke, heart failure, pneumonia, hip fracture surgery. Approach Linked data were used to (1) construct an analytic unit – an index period of care that comprised concatenated acute, contiguous hospitalisations with the principal diagnosis of interest; (2) to capture outcomes both within the index hospital and following discharge, wherever they occurred; (3) to enhance risk adjustment with one year look back for relevant comorbidities; (4) to assess fair attribution of outcomes. A risk-standardised mortality ratio (RSMR) and a risk standardised readmission ratio (RSRR) were calculated as the ratio of the observed to the expected number events at a given hospital, by developing and validating condition specific system-level prediction models. Funnel plots identified outliers. For the RSRR, the competing risk of death was considered. Results For both outcome indicators, sensitivity was enhanced by the use of linked data (33%-100% more deaths; 23%–32% more returns to acute care or readmissions). For mortality, RSMRs that only capture deaths in hospital, as opposed to deaths within 30 days of admission, were shown to be biased and change the outlier status of about 20% of hospitals. Including socioeconomic status in risk adjustment models altered the outlier status of about 10% of hospitals on the cusp of statistical significance but did not significantly alter the RSMRs. For returns to acute care, sensitivity analyses that included socioeconomic status in the models found there was no significant improvement in discriminatory power. For example, in the case of ischaemic stroke, the c-statistic for the model without inclusion of SES was 0.593 (0.578-0.610); inclusion of SES resulted in a c-statistic of 0.600 (0.583-0.616). There were some changes in hospital-level results but there was no clear evidence of a systematic effect on results. Conclusion The risk-standardised ratio method, based on linked data, compares a hospital’s results given its case mix with an average New South Wales hospital with the same case mix. Ratio-based indicators have been reported publicly and have proven to be a valuable screening tool to identify hospitals where further investigation may be required locally

Patients’ and Members of the Public’s Wishes Regarding Transparency in the Context of Secondary Use of Health Data: Scoping Review

BackgroundSecondary use of health data has reached unequaled potential to improve health systems governance, knowledge, and clinical care. Transparency regarding this secondary use is frequently cited as necessary to address deficits in trust and conditional support and to increase patient awareness. ObjectiveWe aimed to review the current published literature to identify different stakeholders’ perspectives and recommendations on what information patients and members of the public want to learn about the secondary use of health data for research purposes and how and in which situations. MethodsUsing PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines, we conducted a scoping review using Medline, CINAHL, PsycINFO, Scopus, Cochrane Library, and PubMed databases to locate a broad range of studies published in English or French until November 2022. We included articles reporting a stakeholder’s perspective or recommendations of what information patients and members of the public want to learn about the secondary use of health data for research purposes and how or in which situations. Data were collected and analyzed with an iterative thematic approach using NVivo. ResultsOverall, 178 articles were included in this scoping review. The type of information can be divided into generic and specific content. Generic content includes information on governance and regulatory frameworks, technical aspects, and scientific aims. Specific content includes updates on the use of one’s data, return of results from individual tests, information on global results, information on data sharing, and how to access one’s data. Recommendations on how to communicate the information focused on frequency, use of various supports, formats, and wording. Methods for communication generally favored broad approaches such as nationwide publicity campaigns, mainstream and social media for generic content, and mixed approaches for specific content including websites, patient portals, and face-to-face encounters. Content should be tailored to the individual as much as possible with regard to length, avoidance of technical terms, cultural competence, and level of detail. Finally, the review outlined 4 major situations where communication was deemed necessary: before a new use of data, when new test results became available, when global research results were released, and in the advent of a breach in confidentiality. ConclusionsThis review highlights how different types of information and approaches to communication efforts may serve as the basis for achieving greater transparency. Governing bodies could use the results: to elaborate or evaluate strategies to educate on the potential benefits; to provide some knowledge and control over data use as a form of reciprocity; and as a condition to engage citizens and build and maintain trust. Future work is needed to assess which strategies achieve the greatest outreach while striking a balance between meeting information needs and use of resources

Effect of family medicine groups on visits to the emergency department among diabetic patients in Quebec between 2000 and 2011: a population-based segmented regression analysis

BackgroundFamily Medicine Groups (FMG) were introduced in Quebec in 2002 to re-organize primary care practices and encourage inter-professional service delivery. We measured visits to the emergency department (ED) for acute complications related to diabetes as a proxy for access to and quality of primary care, before and after the reform using an open cohort of individuals diagnosed with type 1 and type 2 diabetes.MethodsThe weekly rate of ED visits between April 1, 2000 and March 31, 2012 were derived from administrative databases. We performed an interrupted segmented regression analysis to obtain the estimated and predicted rates of visits in the years following the introduction of the reform. An outcome control series of diabetic patients visiting the ED to treat appendicitis was incorporated to strengthen the study’s internal validity. [...

Realising the potential of linked data in healthcare performance assessment efforts in New South Wales, Australia

ABSTRACT Objectives To describe: (1) a stepwise guide to the use of linked data in the development of individual healthcare performance metrics; and (2) the application of these metrics in comprehensive performance assessment efforts at a system, regional and hospital level of analysis. Approach A stepwise guide to the definition and validation of linked-data based indicators was developed following a rapid review of peer reviewed and grey literature and a series of semi-structured interviews with international subject experts. The review and interviews adopted a snowball approach to collect information on the ways in which linked data are currently used in performance measurement efforts. Data collection continued until indicator type saturation was reached. Details about existing applications of linked data in performance reporting were mapped, and used to inform the development of the guide. Indicators were aligned within a conceptual framework that is used to assess healthcare performance in New South Wales, on the basis of accessibility, appropriateness, effectiveness, efficiency, equity and sustainability. Results The guide to indicator development considers the use and contribution of linked data in four stages: defining a cohort; capturing outcomes of interest; risk adjustment; and attribution. A series of vignettes illustrate the various contributions that linked data can make to performance measurement efforts – highlighting the ways in which those data can enhance understanding of complexity and dynamic relationships, and help build a comprehensive picture of performance. Conclusion In performance measurement efforts internationally, linked data are used to strengthen the reliability, accuracy and precision of individual metrics and to inform efforts to assess various dimensions of healthcare performance. In New South Wales, linked data underpin publicly reported performance measures and have the potential to provide in the future whole-of-government and whole-of-system perspectives on health