Co-production in healthcare services: What we know, how we can evaluate it

Background In times of increasing population aging, higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while keeping quality. In this context, debates on the importance of promoting systems of co-produced health between stakeholders have gained considerable traction both in the literature and in policy debates of the public sector (Dunston et al., 2009, Voorberg et al. 2015; European Commission 2010). Co-production occurs \u201cwhen public service organizations partner with external entities, including other public organizations, third sector, or service user, to jointly produce services that they previously produced on their own\u201d (Thomas, 2013, p. 788). In this perspective, co-production is not only a patient involvement tool, but mainly a managerial tool, where partner in the production process could influence the methods used to organise and manage the service delivery (Sorrentino et al., 2015; Brandsen and Honingh, 2015; Gilardi et al., 2016). Despite this widespread acceptance, minimal consensus exists on the mechanisms for evaluating the actual impacts of the co-production in healthcare sector. More specifically, little has been produced on how the results of these changing structures, practices and goals in healthcare management and provision can be monitored and evaluated (Hardyman et al., 2015; Gilardi et al., 2016; Palumbo, 2016). Objectives The study aims at filling this gap by developing a conceptual framework for assessing co-production in healthcare. Specifically, drawing on existing literature on co-production in healthcare, we develop an original analytical evaluation framework with respect to: i) the multidimensional perspectives to be taken into consideration; ii) the dimensions to be analysed; iii) the methods that allow implementing our framework in practice. Methodolody First of all, a quantitative bibliometric analysis, using Bibliometrix software (Aria and Cuccurullo, 2017), is carried out. The reference database chosen is WoS and the inclusion criterion is \u201cco-production AND heath* OR coproduction AND health*\u201d in topic. Moreover, the search is refined by language, i.e. English, and type of publication, i.e. journal academic article. No time limitation is selected. After deleting non-inherent papers, our final sample was made up of 213 papers. As second stage, a qualitative content analysis based on PRISMA protocol is developed, focusing on those papers targeting evaluation issues. Finally, a preliminary co-production evaluation model proposal is proposed and discussed. Main results The study shows an increasing attention on the co-production topic, as highlighted by an annual percentage growth rate of about 26% and the big increase in the last 5 years in number of publications. The countries with a highest number of publications and collaborations are UK (mainly England), Netherlands, Australia and USA. As expected, the most repeated keyword is co-production, however, it is interesting to underline the presence of \u201cmental health\u201d and \u201cpublic health\u201d, that can be assumed as the main topic of studies analyzed. Nonetheless, only few studies focus on the evaluation of outcomes. Among them, the content analysis has revealed a predominantly mono-dimensional and mono-stakeholder approach. Specifically, clinical, economic or psychological-social - mainly in terms of patient satisfaction \u2013 impacts (i.e. Lwembe et al., 2016; Harvey et al., 2017) are assessed. The analysis reveals that one of the main challenges of assessing co-production lies in its multi-dimensional nature; thus a multiple perspectives framework has to be adopted. To contribute filling this gap, we developed a preliminary multidimensional (i.e. performance indicators) and multi-stakeholder (i.e. different actors involved) evaluation model (Figure 1). Specifically, the framework takes into account the three main outcome domains \u2013 i) economic, ii) managerial/organisational and iii) clinical \u2013 and three main stakeholders involved \u2013 i) hospital, ii) healthcare professionals, iii) patients and their families. The economic and efficiency measures concerning direct and indirect cost for hospital and patients/family, should be integrated with clinical and managerial measures for each stakeholder: 1. Hospital: administrative efficiency, activating capacity, inclusiveness of decision making, stability/flexibility of rules, conflict resolution and collaboration climate, frequency of interaction. 2 Patient (and caregiver or family): objective (i.e. compliance) and subjective (i.e. quality of life, quality of care perception, patient satisfaction) indicators. 3. Healthcare professional and staff: objective (e.g. turnover rate, absences, injuries and work-related ill health) and subjective (e.g. burnout, satisfaction, healthcare professional engagement, occupational health, risk perception) indicators

A Computational Method for Combustion in High Speed Flows

A two-dimensional time-accurate numerical model to simulate complex reacting flowfields in chemical non-equilibrium is presented. The aim of this studyis to develop a computational tool which permits the analysis and the easy implementation of combustion phenomena for high speed flows. To construct an efficient numerical tool, while maintaining a reasonable accuracy, a semi-implicit numerical method was selected and verified for a hydrogen-air mixture. The numerical approach is based on a time-dependent, finite-volume integration of the governing equations suitably modified for chemical non-equilibrium. The evaluation of the reacting constants based on Gibbs free energy and the Van't Hoff equation allows a very easy implementation of the chemical model used, regardless of its complexity. Calculations were performed with adeguate temporal and spatial resolution for modeling the physical process for pratical calculation. Comparisons with numerical results are used for a verification of the numerical procedur

Healthcare Co-production and the Indirect Government Paradigm: addressing the managerial challenges

This qualitative study focuses on the relevant organizational challenges of co-production for the public healthcare system at the micro-level, that of the providers: the hospitals, trust, local health communities, etc. To build this complex picture the authors use a framework developed in the field of policy studies. An analysis and discussion of the scientific literature on the implications of the co-production options highlights the implementation gaps and the as-yet unsolved organizational puzzles and how they are managed in actual practice. The study considers co-production as an indirect tool of government and maps a research agenda of the knowledge gaps and open issues in extant literature

Co-production in healthcare: moving patient engagement towards a managerial approach

The pressure toward co-produced health services is increasing as an answer to quality improvement and system sustainability. However, the reflection and the empirical knowledge on the nature of co-production and on how healthcare practices change in order to manage effective partnerships between clients and professionals remain scant. The chapter addresses this gap by analysing how the concept of co-production is used and investigated in the healthcare literature. Specifically, it focuses on two key perspectives that vary significantly on the issues of who the co-producing health authors are; what the domains of co-production are; and how to stimulate and support patients in their role of co-producers. The first perspective frames co-production as focusing on individual patient engagement and on the bilateral clinical dimension of relations with the medical staff. The second recognises co-production as a complex system of multiple relations between a cast of both single (patients, informal caregivers, clinical staff) and collective actors (the healthcare providers such as hospitals, trusts, local health communities), that involves patients in different service delivery phases and focuses on the change in the production processes when value is co-produced

Healthcare Co-production and the indirect governance toolkit: demystifying the organizational puzzle

Background The economic meltdown, coupled with the public-sector legitimacy crisis, forced public services to reconcile increasing demand with decreasing resources and, at the same time, unleashed a wave of criticism on traditional service delivery patterns. One remedy to this challenge that is gaining an increasing attention is co-production - defined as engaging citizens and, more generally, voluntary and non-profit organizations in the production of public services (Alford, 2009; Pestoff, Osborne, & Brandsen, 2006; Thomas, 2013; van Eijk & Steen, 2013). Social and health services are the most elective co-production practices in the public sector, but set the healthcare providers two major challenges. The first is to engage the patient, an ongoing process that calls for this latter to actively participate in their healthcare plan (Coulter, Parsons, & Askham, 2008). The second is to ensure that the patient engages with both their therapy and the hospital organizational system by managing the interdependency within and between \u2018organizational production and client co-production\u2019 (Alford & O'Flynn, 2012, p. 182) in order to govern the healthcare organization\u2019s interactions (Alford, 2009; Brandsen & van Hout, 2008). Aim This qualitative study analyses and discusses the relevant organizational challenges of co-production for the public healthcare system at the micro-level, that of the providers \u2013 hospitals, trust, local health communities, etc. The paper highlights the implementation gaps and the as-yet unsolved organizational puzzles through an analysis and discussion of the scientific literature on the implications of co-production practices and on how they are managed in actual practice. Theoretical framework The co-production analysis is informed by the \u201cindirect government\u201d conceptual framework to gain access to the set of tools that \u2018rely heavily on a wide assortment of \u201cthird parties\u201d to deliver publicly financed services and pursue publicly authorized purposes\u2019 (Salamon, 2002, p. 2). Unlike traditional direct-government methods, this approach to public problem-solving sets fresh, sometimes unprecedented challenges and brings into play new capabilities and tools. It is not, therefore, something that \u2018self-implements\u2019. On the whole, co-production is a form of indirect government requiring \u201cconcerted action across multiple sectors\u201d (Kettl, 2006, p. 14) and actors and the taking on of new responsibilities. Kettl (2002) calls for a management approach that encompasses three key components: process (managing programs by structuring contracts and by tracking money); people (addressing people problems and the indirect government skill set); and performance (reinventing government and the performance puzzle). Research method The study was conducted in two phases. Phase one entailed an systematic interdisciplinary review of the public administration, management, and public policy literatures, mostly by trawling the main electronic databases to find scholarly articles on co-production in healthcare services. This first step enabled us to identify the theoretical and empirical contributions that investigate co-production from the specific viewpoint of the service providers. Phase two inventoried the themes, approaches and key findings of this subset of articles to draw a fairly clear picture of the conditions and capabilities needed by the healthcare providers to manage the organizational implications of co-production. Kettl\u2019s conceptual framework is the basis on which the results are then discussed and compared. Contribution 1) Up-to-date overview of the research on co-production in healthcare services. 2) Analysis of the co-production organizational challenges and how these are addressed in the practice. 3) Insights and policy indications for public managers on how government can play a supportive role in the delivery of co-produced healthcare services. References Alford, J. (2009). Engaging Public Sector Clients. From Service-Delivery to Co-production. Basingstoke: Palgrave Macmillan. Alford, J., & O'Flynn, J. (2012). Rethinking Public Service Delivery. Basingstoke: Palgrave Macmillan. Brandsen, T., & van Hout, E. (2008). Co-Management in Public Service Networks. The organizational effects. In V. Pestoff & T. Brandsen (Eds.), Co-Production. The Third Sector and the Delivery of Public Services (pp. 45-58). London: Routledge Taylor & Francis Group. Coulter, A., Parsons, S., & Askham, J. (2008). Where are the patients in decision-making about their own care? Kettl, D. F. (2002). Managing indirect government. In L. M. Salamon (Ed.), The tools of government. A Guide to the New Governance (pp. 490-510). Oxford: Oxford University Press. Kettl, D. F. (2006). Managing Boundaries in American Administration: the Collaboration Imperative. Public Administration Review, 66(Special Issue), 10-19. Pestoff, V., Osborne, S. P., & Brandsen, T. (2006). Patterns of co-production in public services. Public Management Review, 8(4), 591-595. Salamon, L. M. (Ed.). (2002). The tools of government. A Guide to the New Governance. Oxford: Oxford University Press. Thomas, J. C. (2013). Citizen, Customer, Partner: Rethinking the Place of the Public in Public Management. Public Administration Review, 73(6), 786-796. van Eijk, C. J. A., & Steen, T. P. S. (2013). Why People Co-Produce: Analysing citizens\u2019 perceptions on co-planning engagement in health care services. Public Management Review, 16(3), 358-382

Co-production in healthcare services: What we know, how we can evaluate it

Purpose The implementation of co-production in healthcare provision is not only spreading rapidly but also being increasingly appraised as a more sustainable model for the future. Despite this widespread acceptance, minimal consensus exists, however, on the co-production\u2019s definition and on the mechanisms for evaluating the actual impacts of the implementation of co-production in healthcare. This study aims to define the current state of art of the healthcare service co-production research field with a specific focus on evaluation issues. Methodolody First of all, a quantitative bibliometric analysis, using Bibliometrix software (Aria and Cuccurullo, 2017), was carried. The reference database chosen is WoS and the inclusion criterion was \u201cco-production AND heath* OR coproduction AND health*\u201d in topic. As second stage, a qualitative content analysis based on PRISMA protocol is developed, focusing on those papers targeting evaluation issues. Results The bibliometric analysis shows an annual percentage growth rate of about 26% with the biggest increase in the last 5 years in number of publications. The co-citation analysis highlights two main intellectual areas: a public administration and management cluster and a service management cluster. Nonetheless, only few studies focus on the evaluation of outcomes. Among them, the content analysis has revealed a predominantly mono-dimensional and mono-stakeholder approach. Specifically, clinical, economic or psychological-social - mainly in terms of patient satisfaction \u2013 impacts are assessed. Practical implications The study offers the base to develop a systematic analytical framework for the evaluation of co-production of healthcare. Originality The study represents the first bibliometric analysis on co-production in healthcare

Resistance Patterns, mcr-4 and OXA-48 Genes, and Virulence Factors of Escherichia coli from Apennine Chamois Living in Sympatry with Domestic Species, Italy

The aim of this study was to determine and characterize potential resistance mechanisms against selected Critically Important Antibiotics in Escherichia coli isolates collected from wild and domestic ruminants living in the Maiella National Park, in Central Italy. A total of 38 isolates were obtained from red deer, Apennine chamois, cattle, sheep, and goats grazing in lands with different levels of anthropic pressure. Antimicrobial susceptibility was determined by Minimal Inhibitory Concentration testing, showing phenotypic resistance to colistin, meropenem, or ceftazidime in 9 isolates along with one bacterial strain being resistant to three of the tested antibiotics. In addition, the biomolecular assays allowed the amplification of the genes conferring the colistin (mcr-4), the carbapenems (OXA-48), penicillins and cephalosporins (TEM, SHV, CMY-1, CMY-2) resistance. In order to describe the potential pathogenicity of isolates under study, virulence genes related to Shiga toxin-producing (STEC) and enteropathogenic (EPEC) pathovars were identified. This study is the first report of mcr-4 and OXA-48 genes in resistant E. coli harboring virulence genes in Italian wildlife, with special regard to Apennine chamois and red deer species. The multidisciplinary approach used in this study can improve the early detection of emerging antibiotic resistance determinants in human-animal-environment interfaces by means of wildlife monitoring

Aetiology of canine infectious respiratory disease complex and prevalence of its pathogens in Europe

The canine infectious respiratory disease complex (CIRDC) is an endemic worldwide syndrome involving multiple viral and bacterial pathogens. Traditionally, Bordetella bronchiseptica (Bb), canine adenovirus type 2 (CAV-2), canine distemper virus (CDV), canine herpesvirus (CHV) and canine parainfluenza virus (CPiV) were considered the major causative agents. Lately, new pathogens have been implicated in the development of CIRDC, namely canine influenza virus (CIV), canine respiratory coronavirus (CRCoV), canine pneumovirus (CnPnV), Mycoplasma cynos and Streptococcus equi subspecies zooepidemicus. To better understand the role of the different pathogens in the development of CIRDC and their epidemiological relevance in Europe, prevalence data were collected from peer-reviewed publications and summarized. Evidence of exposure to Bb is frequently found in healthy and diseased dogs and client-owned dogs are as likely to be infected as kennelled dogs. Co-infections with viral pathogens are common. The findings confirm that Bb is an important cause of CIRDC in Europe. CAV-2 and CDV recovery rates from healthy and diseased dogs are low and the most likely explanation for this is control through vaccination. Seroconversion to CHV can be demonstrated following CIRDC outbreaks and CHV has been detected in the lower respiratory tract of diseased dogs. There is some evidence that CHV is not a primary cause of CIRDC, but opportunistically re-activates at the time of infection and exacerbates the disease. The currently available data suggest that CIV is, at present, neither a prevalent nor a significant pathogen in Europe. CPiV remains an important pathogen in CIRDC and facilitates co-infection with other viral and bacterial pathogens. CnPnV and CRCoV are important new elements in the aetiology of CIRDC and spread particularly well in multi-dog establishments. M. cynos is common in Europe and is more likely to occur in younger and kennelled dogs. This organism is frequently found together with other CIRDC pathogens and is significantly associated with more severe respiratory signs. S. zooepidemicus infection is not common and appears to be a particular problem in kennels. Protective immunity against respiratory diseases is rarely complete, and generally only a reduction in clinical signs and excretion of pathogen can be achieved through vaccination. However, even vaccines that only reduce and do not prevent infection carry epidemiological advantages. They reduce spread, increase herd immunity and decrease usage of antimicrobials. Recommending vaccination of dogs against pathogens of CIRDC will directly provide epidemiological advantages to the population and the individual dog

Co-production in healthcare services: the evaluation of economic and organizational impacts

In times of increasing population aging, higher incidence of chronic diseases and higher expectations regarding public service provision, healthcare services are under increasing strain to cut costs while keeping quality. In this context, debates on the importance of promoting systems of co-produced health between stakeholders have gained considerable traction both in the literature and in policy debates of the public sector. (Gilardi et al. 2016; European Commission 2010; UK Department of Health 2006) The implementation of co-production in healthcare provision is not only spreading rapidly but also being increasingly appraised as a more sustainable model for the future. Despite this widespread acceptance, minimal consensus exists, however, on the mechanisms for evaluating the actual impacts of the implementation of co-production in healthcare provision. More specifically, little has been produced on how the results of these changing structures, practices and goals in healthcare management and provision can be monitored and evaluated. Aiming at the reduction of this gap, this article proposes a discussion on the challenges and limitations of assessing co-production\u2019s impacts going beyond more traditionally used clinical criteria (that currently dominate evaluation activities in the field) towards analyses that take into consideration broader organizational and economic aspects of co-production activities. Finally, the article sketches the initial contours of an original and alternative evaluation model which highlights the importance of organizational and economic aspects for the effective implementation of co-production in healthcare

Molecular identification and characterization of a genotype 3 hepatitis e virus (HEV) strain detected in a wolf faecal sample, Italy

Hepatitis E virus (HEV) infection is a major health problem worldwide. In developed countries, zoonotic transmission of HEV genotypes (Gt) 3 and 4 is caused by the ingestion of raw or undercooked meat of infected pigs and wild boars, the main reservoirs of HEV. However, additional animals may harbour HEV or HEV-related strains, including carnivores. In this study, we investigated the molecular epidemiology of orthohepeviruses in wild canids by screening a total of 136 archival faecal samples, collected from wolves (42) and red foxes (94) in Northwestern Italy. Orthohepevirus RNA was identified in a faecal specimen, collected from a wolf carcass in the province of La Spezia (Liguria Region, Italy). The nearly full-length (7212 nucleotides) genome of the strain HEV/81236/Wolf/2019/ITA (GenBank accession no. MZ463196) was determined by combining a sequence-independent single-primer amplification (SISPA) approach with the Oxford Nanopore Technologies sequencing platform. Upon phylogenetic analysis, the HEV detected in wolf was segregated into clade HEV-3.1, displaying the highest nucleotide (nt) identity (89.0–93.3%) to Gt3 strains belonging to subtype c. Interestingly, the wolf faecal sample also contained porcine astrovirus sequences, endorsing the hypothesis of a dietary origin of the HEV strain due to preying habits