Interface flow process audit: using the patient's career as a tracer of quality of care and of system organisation

OBJECTIVES: This case study aims to demonstrate the method's feasibility and capacity to improve quality of care. Several drawbacks attached to tracer condition and selected procedure audits oblige clinicians to rely on external evaluators. Interface flow process audit is an alternative method, which also favours integration of health care across institutions divide. METHODS: An action research study was carried out to test the feasibility of interface flow process audit and its impact on quality improvement. An anonymous questionnaire was carried out to assess the participants' perception of the process. RESULTS: In this study, interface flow process audit brought together general practitioners and hospital doctors to analyse the co-ordination of their activities across the primary-secondary interface. Human factors and organisational characteristics had a clear influence on implementation of the solutions. In general, the participants confirmed that the interface flow process audit helped them to analyse the quality of case management both at primary and secondary care level. CONCLUSIONS: The interface flow process audit appears a useful method for regular in-service self-evaluation. Its practice enabled to address a wide scope of clinical, managerial and economical problems. Bridging the primary-secondary care gap, interface flow process audit's focus on the patient's career combined with the broad scope of problems that can be analysed are particularly powerful features. The methodology would benefit from an evaluation of its practice on larger scale

Integrated care: a fresh perspective for international health policies in low and middle-income countries

PURPOSE: To propose a social-and-democrat health policy alternative to the current neoliberal one. CONTEXT OF CASE: The general failure of neoliberal health policies in low and middle-income countries justifies the design of an alternative to bring disease control and health care back in step with ethical principles and desired outcomes. DATA SOURCES: National policies, international programmes and pilot experiments—including those led by the authors—are examined in both scientific and grey literature. CASE DESCRIPTION: We call for the promotion of a publicly-oriented health sector as a cornerstone of such alternative policy. We define ‘publicly-oriented’ as opposed to ‘private-for-profit’ in terms of objectives and commitment, not of ownership. We classify development strategies for such a sector according to an organisation-based typology of health systems defined by Mintzberg. As such, strategies are adapted to three types of health systems: machine bureaucracies, professional bureaucracies and divisionalized forms. We describe avenues for family and community health and for hospital care. We stress social control at the peripheral level to increase accountability and responsiveness. Community-based, national and international sources are required to provide viable financing. CONCLUSIONS AND DISCUSSION: Our proposed social-and-democrat health policy calls for networking, lobbying and training as a joint effort in which committed health professionals can lead the way

The production of critical theories in Health Systems Research and Education. An epistemological approach to emancipating public research and education from private interests

This paper aims at offering alternative methodological perspectives in health systems research, to produce critical, theoretical knowledge in domains such as health policy and management of health care, organization of disease control, political economy of health and medical practice.We first examined the reasons to believe that worldwide economic agents have driven publicly funded schools of public health to adopt their preferred policies and to orient their priority research topics. We then studied whether this hidden leadership has also contributed to shape research methodologies, which we contrasted with the epistemological consequences of a quest for intellectual independence, that is, the researcher’s quest to critically understand the state of health systems and generalize results of related action-research. To do so, we applied concepts of what could be named the ‘French School of Critical Sociology’ to qualitative research methodologies in descriptive health systems research. To do so, we applied concepts of what could be named the ‘French School of Critical Sociology’ to qualitative research methodologies in descriptive health systems research

Chile's Neoliberal Health Reform: An Assessment and a Critique

In spite of serious under-financing during the Pinochet years, Chile's public health system remains the backbone of health provision, responsible for the impressive public health status

Disintegrated care: the Achilles heel of international health policies in low and middle-income countries

PURPOSE: To review the evidence basis of international aid and health policy. CONTEXT OF CASE: Current international aid policy is largely neoliberal in its promotion of commoditization and privatisation. We review this policy's responsibility for the lack of effectiveness in disease control and poor access to care in low and middle-income countries. DATA SOURCES: National policies, international programmes and pilot experiments are examined in both scientific and grey literature. CONCLUSIONS AND DISCUSSION: We document how health care privatisation has led to the pool of patients being cut off from public disease control interventions—causing health care disintegration—which in turn resulted in substandard performance of disease control. Privatisation of health care also resulted in poor access. Our analysis consists of three steps. Pilot local contracting-out experiments are scrutinized; national health care records of Colombia and Chile, two countries having adopted contracting-out as a basis for health care delivery, are critically examined against Costa Rica; and specific failure mechanisms of the policy in low and middle-income countries are explored. We conclude by arguing that the negative impact of neoliberal health policy on disease control and health care in low and middle-income countries justifies an alternative aid policy to improve both disease control and health care

Regional-based Integrated Healthcare Network policy in Brazil: from formulation to practice

Background Regional-based Integrated Healthcare Networks (IHNs) have been promoted in Brazil to overcome the fragmentation due to the health system decentralization to the municipal level; however, evaluations are scarce. The aim of this article is to analyse the content of IHN policies in force in Brazil, and the factors that influence policy implementation from the policymakers’ perspective. Methods A two-fold, exploratory and descriptive qualitative study was carried out based on (1) content analysis of policy documents selected to meet the following criteria: legislative documents dealing with regional-based IHNs; enacted by federal government; and in force, (2) semi-structured individual interviews were conducted to a theoretical sample of policymakers at federal (eight), state (five) and municipal levels (four). Final sample size was reached by saturation of information. An inductive thematic analysis was conducted. Results The results show difficulties in the implementation of IHN policies due to weaknesses that arise from the policy design and the performance of the three levels of government. There is a lack of specificity as to the criteria and tools for configuring and financing IHNs that need to be agreed upon between involved governments. For their part, policymakers emphasize the difficulty of establishing agreements in a health system with disincentives for collaboration between municipalities. The allocation of responsibilities that are too complex for the capacity and size of the municipalities, the abandonment of essential functions such as network planning by states and the strategic role by the Ministry, the ‘invasion’ of competences among levels of government and high political turnover are also highlighted. Conclusions The implementation of regional-based IHN policy in Brazil is hampered by the decentralized organization of the health system to the municipal level, suggesting the need to centralize certain functions to regional structures or states and to define better the role of the government levels involved

Predictors of inappropriate hospital days in a department of internal medicine

Background This study aimed to identify predictors of inappropriate hospital days in a deparUnent of internal medicine, as a basis for quality improvement interventions. Methods The appropriateness of 5665 hospital days contributed by 500 patients admitted to the Department of Internal Medicine, Geneva University Hospitals, Switzerland, was assessed by means of the Appropriateness Evaluation Protocol. Predictor variables included patient's age and sex, manner of admission and discharge, and characteristics of hospital days (weekend, holiday, sequence). Results Overall, 15% of hospital admissions and 28% of hospital days were rated as inappropriate. In multivariate models, inappropriate hospital days were more frequent among patients whose admission was inappropriate (odds ratio [OR] = 5.3, 95% CI: 3.1-8.4) and among older patients (80-95 years: OR = 3.6. 95% CI: 1.7-7.0, versus <50 years). The likelihood of inappropriateness also increased with each subsequent hospital day, culminating on the day of discharge, regardless of the total length of stay. Conclusions This study identified both the admission and the discharge processes as important sources of inappropriate hospital use in a department of internal medicine. The oldest patients were also at high risk of remaining in the hospital inappropriately. Surprisingly, long hospital stays did not generate a higher proportion of inappropriate days than short hospital stays. This information proved useful in developing interventions to improve the hospitalization proces

Inequities in access to health care in different health systems: A study in municipalities of central Colombia and north-eastern Brazil

Introduction. Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia. Methods. A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need. Results: There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization. Conclusions: Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component. © 2014 Garcia-Subirats et al.; licensee BioMed Central Ltd

Apoptotic HPV Positive Cancer Cells Exhibit Transforming Properties

Previous studies have shown that DNA can be transferred from dying engineered cells to neighboring cells through the phagocytosis of apoptotic bodies, which leads to cellular transformation. Here, we provide evidence of an uptake of apoptotic-derived cervical cancer cells by human mesenchymal cells. Interestingly, HeLa (HPV 18+) or Ca Ski (HPV16+) cells, harboring integrated high-risk HPV DNA but not C-33 A cells (HPV-), were able to transform the recipient cells. Human primary fibroblasts engulfed the apoptotic bodies effectively within 30 minutes after co-cultivation. This mechanism is active and involves the actin cytoskeleton. In situ hybridization of transformed fibroblasts revealed the presence of HPV DNA in the nucleus of a subset of phagocytosing cells. These cells expressed the HPV16/18 E6 gene, which contributes to the disruption of the p53/p21 pathway, and the cells exhibited a tumorigenic phenotype, including an increased proliferation rate, polyploidy and anchorage independence growth. Such horizontal transfer of viral oncogenes to surrounding cells that lack receptors for HPV could facilitate the persistence of the virus, the main risk factor for cervical cancer development. This process might contribute to HPV-associated disease progression in vivo