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1.  The view of severely burned patients and healthcare professionals on the blind spots in the aftercare process: a qualitative study 
Background
In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person’s life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium.
Methods
By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups.
Results
Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process.
Conclusions
The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.
doi:10.1186/s12913-015-0973-2
PMCID: PMC4521491  PMID: 26231290
Burns; Burn units; Organisational policy; Aftercare
2.  Making patient centered care a reality: a survey of patient educational programs in Italian Cancer Research and Care Institutes 
Background
Educational intervention represents an essential element of care for cancer patients; while several single institutions develop their own patient education (PE) programs on cancer, little information is available on the effective existence of PE programs at the level of research and care institutes. In Italy such institutes - Istituti di Ricovero e Cura a Carattere Scientifico - are appointed by the Ministry of Health, and 11 (Cancer Research & Care Istitute-CRCI) of the 48 are specific for cancer on the basis of specific requirements regarding cancer care, research and education. Therefore, they represent an ideal and homogeneous model through which to investigate PE policies and activities throughout the country. The objective of this study was to assess PE activities in Italian CRCI.
Methods
We carried out a survey on PE strategies and services through a questionnaire. Four key points were investigated: a) PE as a cancer care priority, b) activities that are routinely part of PE, c) real involvement of the patients, and d) involvement of healthcare workers in PE activities.
Results
Most CRCI (85 %) completed the survey. All reported having ongoing PE activities, and 4 of the 11 considered PE an institutional activity. More than 90 % of CRCI organize classes and prepare PE handouts, while other PE activities (e.g., Cancer Information Services, mutual support groups) are less frequently part of institutional PE programs. Patients are frequently involved in the organization and preparation of educational activities on the basis of their own needs. Various PE activities are carried out for caregivers in 8 (73 %) out of 11 institutes. Finally, health care workers have an active role in the organization of PE programs, although nurses take part in these activities in only half of CRCI and pharmacists are seldom included.
Conclusions
The information arising from our research constitutes a necessary framework to identify areas of development and to design new strategies and standards to disseminate the culture of PE. This may ultimately help and stimulate the establishment of institutional integrated PE programs, including policies and interventions that can benefit a significant proportion of cancer patients.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0962-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0962-5
PMCID: PMC4518580
Patient education; Neoplasms; Comprehensive cancer centers; Patient participation; Data collection; Surveys; Educational policies; Educational activities; Healthcare workers
3.  A qualitative study of patient (dis)trust in public and private hospitals: the importance of choice and pragmatic acceptance for trust considerations in South Australia 
Background
This paper explores the nature and reasoning for (dis)trust in Australian public and private hospitals. Patient trust increases uptake of, engagement with and optimal outcomes from healthcare services and is therefore central to health practice, policy and planning.
Methods
A qualitative study in South Australia, including 36 in-depth interviews (18 from public and 18 from private hospitals).
Results
‘Private patients’ made active choices about both their hospital and doctor, playing the role of the ‘consumer’, where trust and choice went hand in hand. The reputation of the doctor and hospital were key drivers of trust, under the assumption that a better reputation equates with higher quality care. However, making a choice to trust a doctor led to personal responsibility and the additional requirement for self-trust. ‘Public patients’ described having no choice in their hospital or doctor. They recognised ‘problems’ in the public healthcare system but accepted and even excused these as ‘part of the system’. In order to justify their trust, they argued that doctors in public hospitals tried to do their best in difficult circumstances, thereby deserving of trust. This ‘resigned trust’ may stem from a lack of alternatives for free health care and thus a dependence on the system.
Conclusion
These two contrasting models of trust within the same locality point to the way different configurations of healthcare systems, hospital experiences, insurance coverage and related forms of ‘choice’ combine to shape different formats of trust, as patients act to manage their vulnerability within these contexts.
doi:10.1186/s12913-015-0967-0
PMCID: PMC4518638
Trust; Choice; Public hospitals; Private hospitals; Qualitative; Australia
4.  Non-use of health care service among empty-nest elderly in Shandong, China: a cross-sectional study 
Background
Empty-nest elderly refers to those elderly with no children or whose children have already left home. Few studies have focused on healthcare service use among empty-nest seniors, and no studies have identified the prevalence and profiles of non-use of healthcare services among empty-nest elderly. The purpose of this study is to compare the prevalence of non-use of healthcare services between empty-nest and non-empty-nest elderly and identify risk factors for the non-use of healthcare services among empty-nest seniors.
Methods
Four thousand four hundred sixty nine seniors (60 years and above) were draw from a cross-sectional study conducted in three urban districts and three rural counties of Shandong Province in China. Non-visiting within the past 2 weeks and non-hospitalization in previous year are used to measure non-use of healthcare services. Chi-square test is used to compare the prevalence of non-use between empty-nesters and non-empty-nesters. Multivariate logistic regression analysis is employed to identify the risk factors of non-use among empty-nest seniors.
Results
Of 4469 respondents, 2667(59.7 %) are empty-nesters. Overall, 35.5 % of the participants had non-visiting and 34.5 % had non-hospitalization. Non-visiting rate among empty-nest elderly (37.7 %) is significantly higher than that among non-empty-nest ones (32.7 %) (P = 0.008). Non-hospitalization rate among empty-nesters (36.1 %) is slightly higher than that among non-empty-nesters (31.6 %) (P = 0.166). Financial difficulty is the leading cause for both non-visiting and non-hospitalization of the participants, and it exerts a larger negative effect on access to healthcare for empty-nest elderly than non-empty-nest ones. Both non-visiting and non-hospitalization among empty-nest seniors are independently associated with low-income households, health insurance status and non-communicable chronic diseases. The non-visiting rate is also found to be higher among the empty-nesters with lower education and those from rural areas.
Conclusions
Our findings indicate that empty-nest seniors have higher non-use rate of healthcare services than non-empty-nest ones. Financial difficulty is the leading cause of non-use of health services. Healthcare policies should be developed or modified to make them more pro-poor and also pro-empty-nested.
doi:10.1186/s12913-015-0974-1
PMCID: PMC4517420  PMID: 26219288
Elderly; Empty-nest; Non-visiting; Non-hospitalization; China
5.  Compliance with Australian stroke guideline recommendations for outdoor mobility and transport training by post-inpatient rehabilitation services: An observational cohort study 
Background
Community participation is often restricted after stroke, due to reduced confidence and outdoor mobility. Australian clinical guidelines recommend that specific evidence-based interventions be delivered to target these restrictions, such as multiple escorted outdoor journeys. The aim of this study was to describe post-inpatient outdoor mobility and transport training delivered to stroke survivors in New South Wales, Australia and whether therapy differed according to type, sector or location of service provider.
Methods
Using an observational retrospective cohort study design, 24 rehabilitation service providers were audited. Provider types included outpatient (n = 8), day therapy (n = 9), home-based rehabilitation (n = 5) and transitional aged care services (TAC, n = 2). Records of 15 stroke survivors who had received post-hospital rehabilitation were audited per service, for wait time, duration, amount of therapy and outdoor-related therapy.
Results
A total of 311 records were audited. Median wait time for post-hospital therapy was 13 days (IQR, 5–35). Median duration of therapy was 68 days (IQR, 35–109), consisting of 11 sessions (IQR 4–19). Overall, a median of one session (IQR 0–3) was conducted outdoors per person. Outdoor-related therapy was similar across service providers, except that TAC delivered an average of 5.4 more outdoor-related sessions (95 % CI 4.4 to 6.4), and 3.5 more outings into public streets (95 % CI 2.8 to 4.3) per person, compared to outpatient services.
Conclusion
The majority of service providers in the sample delivered little evidence-based outdoor mobility and travel training per stroke participant, as recommended in national stroke guidelines.
Trial registration
Australian and New Zealand Clinical Trials Registry ACTRN12611000554965.
doi:10.1186/s12913-015-0952-7
PMCID: PMC4518528  PMID: 26220778
Physical therapy; Occupational therapy; Physiotherapy; Knowledge translation; Walking
6.  Use of appropriate healthcare technologies: a cross-sectional study in rural Zhejiang of China 
Background
Appropriate healthcare technologies (AHTs) are an important strategy for improving the availability and accessibility of healthcare services. It is not clear what impact AHTs have on health workers and consumers; and whether those AHTs can continue in place without special or ongoing financial support. This study investigated the attitudes of health workers and consumers towards AHTs.
Methods
Health facilities from five counties in Zhejiang were surveyed. Participants of the study included all health workers who were involved in the delivery of AHTs in the selected organizations and a group of randomly selected patients who sought services from the participating organizations. A total of 822 questionnaires from health workers and 693 questionnaires from patients were collected for data analyses. The questionnaires measured perceptions and attitudes of respondents towards AHTs using a Likert scale.
Results
The respondents delivering public health services rated the highest scores to AHTs (4.42 ± 0.7), followed by those engaged in management of chronic conditions (4.41 ± 0.57) and Traditional Chinese Medicine (TCM) (4.29 ± 0.55). Around 90 % of health workers believed that AHTs were meaningful for rural patients; however, only 69 % of health workers believed that the technologies encouraged by the government were sufficiently developed or “mature”, and more than 24 % acknowledged difficulties in using those technologies. Overall, patients were satisfied with AHTs, with 71.6 % feeling “very satisfied” or “satisfied”, 24.2 % feeling “acceptable” and 1.6 % feeling “dissatisfied”. Most (83 %) patients were satisfied or very satisfied with Traditional Chinese Medicine, compared with management of chronic conditions (80 %), family planning (67 %), public health services (64 %), and finally with maternal and child health care (59 %).
Conclusions
Local acceptability should be taken into consideration in determination of AHTs; consumer health literacy needs improvement, particularly in relation to public health and preventive services.
doi:10.1186/s12913-015-0947-4
PMCID: PMC4518885  PMID: 26220653
Appropriate healthcare technology; Primary care; China
7.  Cost-effectiveness analysis of dabigatran and anticoagulation monitoring strategies of vitamin K antagonist 
Background
Vitamin K antagonists are commonly used for the prevention of thromboembolic events. Patient self-monitoring of vitamin K antagonists has proved superior to usual care. Dabigatran has been shown, relative to warfarin, to reduce thromboembolic events without increasing bleeding.
Methods
We constructed a Markov model to compare vitamin K self-monitoring strategies to dabigatran including effectiveness and costs of monitoring and complications (thromboembolism and major bleeding). The model was used to project the incidence of these complications, life years, quality-adjusted life years, and health system costs with anticoagulant treatment throughout life. The analysis was conducted from the health system perspective and from the societal perspective.
Results
Low quality evidence suggests that self-monitoring is at least as effective as dabigatran for the outcomes of thrombosis, bleeding and death. Moderate quality evidence that patient self-monitoring is more effective than other forms of monitoring degree of anticoagulation with vitamin K antagonists, reducing the relative risk of thromboembolism by 41 % and death by 34 %. The cost per quality adjusted year gained relative to other warfarin monitoring strategies is well below 30,000 € in the short term, and is a dominant alternative from the fourth year. In comparison with dabigatran, the lower annual cost and its equivalence in terms of effectiveness made self-monitoring the dominant option. These results were confirmed in the probabilistic sensitivity analysis.
Conclusions
We have moderate quality evidence that self-monitoring of vitamin K antagonists is a cost-effective alternative compared with hospital and primary care monitoring, and low quality evidence, compared with dabigatran. Our analyses contrast with the available cost analysis of dabigatran and usual care of anticoagulated patients.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0934-9) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0934-9
PMCID: PMC4515878  PMID: 26215871
Atrial fibrillation; Anticoagulant agents; Self-care; Cost an cost-analysis; Drug monitoring
8.  A qualitative study of the current state of heart failure community care in Canada: what can we learn for the future? 
Background
In North America and other industrialized countries, heart failure (HF) has become a national public health priority. Studies indicate there is significant heterogeneity in approaches to treat and manage HF and suggest targeted changes in health care delivery are needed to reduce unnecessary health care utilization and to optimize patient outcomes. Most recent published studies have reported on the care of HF patients in tertiary care hospitals and the perspective of non-specialist stakeholders on HF management, such as general practitioners and clinics or hospital administrators is rarely considered. This study explores the current state of community-based HF care in Canada as experienced by various healthcare stakeholders providing or coordinating care to HF patients.
Methods
This study employed a qualitative exploratory research design consisting of semi-structured telephone interviews conducted with health care providers and health care administrators working outside of tertiary care in the four most populous Canadian provinces. A modified thematic analysis process was used and the different data sources were triangulated. Findings were collectively interpreted by the authors.
Results
Twenty-eight participants were recruited in the study: eight cardiologists, five general practitioners/family physicians, eight nurse practitioners/registered nurses, four hospital pharmacists and three health care administrators/directors. Participants reported a lack of stakeholder engagement throughout the continuum of care, which hinders the implementation of a coordinated approach to quality HF care. Four substantive themes emerged that indicated challenges and gaps in the optimal treatment and management of HF in community settings: 1) challenges in the risk assessment and early diagnosis of HF, 2) challenges in ensuring efficient and consistent transition from acute care setting to the community, 3) challenges of primary care providers to optimally treat and manage HF patients, and 4) challenges in promoting a holistic approach in HF management.
Conclusions
As health systems evolve from tertiary-based care to community-based outpatient services for the management of chronic diseases, this study’s findings pinpoint challenges that have been observed in the Canadian context and can stimulate and orient dialogue toward solutions for a more coordinated approach to improve the care of HF patients and reduce pressure on the healthcare system.
doi:10.1186/s12913-015-0955-4
PMCID: PMC4515922  PMID: 26216103
Heart failure; Heart failure management; Chronic disease management; Health services; Qualitative study; Canada
9.  The integrated disease surveillance and response system in northern Ghana: challenges to the core and support functions 
Background
The integrated disease surveillance and response (IDSR) strategy was adopted in Ghana over a decade ago, yet gaps still remain in its proper functioning. The objective of this study was to assess the core and support functions of the IDSR system at the periphery level of the health system in northern Ghana.
Methods
A qualitative study has been conducted among 18 key informants in two districts of Upper East Region. The respondents were from 9 health facilities considered representative of the health system (public, private and mission). A semi-structured questionnaire with focus on core and support functions (e.g. case detection, confirmation, reporting, analysis, investigation, response, training, supervision and resources) of the IDSR system was administered to the respondents. The responses were recorded according to specific themes.
Results
The majority (7/9) of health facilities had designated disease surveillance officers. Some informants were of the opinion that the core and support functions of the IDSR system had improved over time. In particular, mobile phone reporting was mentioned to have made IDSR report submission easier. However, none of the health facilities had copies of the IDSR Technical Guidelines for standard case definitions, laboratories were ill-equipped, supervision was largely absent and feedback occurred rather irregular. Informants also reported, that the community perceived diagnostic testing at the health facilities to be unreliable (e.g. tuberculosis, Human Immunodeficiency Virus). In addition, disease surveillance activities were of low priority for nurses, doctors, administrators and laboratory workers.
Conclusions
Although the IDSR system was associated with some benefits to the system such as reporting and accessibility of surveillance reports, there remain major challenges to the functioning and the quality of IDSR in Ghana. Disease surveillance needs to be much strengthened in West Africa to cope with outbreaks such as the recent Ebola epidemic.
doi:10.1186/s12913-015-0960-7
PMCID: PMC4515924  PMID: 26216356
Disease surveillance; Core and support functions; Health information system; Ghana
10.  Inbound medical tourism to Barbados: a qualitative examination of local lawyers’ prospective legal and regulatory concerns 
Background
Enabled by globalizing processes such as trade liberalization, medical tourism is a practice that involves patients’ intentional travel to privately obtain medical care in another country. Empirical legal research on this issue is limited and seldom based on the perspectives of destination countries receiving medical tourists. We consulted with diverse lawyers from across Barbados to explore their views on the prospective legal and regulatory implications of the developing medical tourism industry in the country.
Methods
We held a focus group in February 2014 in Barbados with lawyers from across the country. Nine lawyers with diverse legal backgrounds participated. Focus group moderators summarized the study objective and engaged participants in identifying the local implications of medical tourism and the anticipated legal and regulatory concerns. The focus group was transcribed verbatim and analyzed thematically.
Results
Five dominant legal and regulatory themes were identified through analysis: (1) liability; (2) immigration law; (3) physician licensing; (4) corporate ownership; and (5) reputational protection.
Conclusions
Two predominant legal and ethical concerns associated with medical tourism in Barbados were raised by participants and are reflected in the literature: the ability of medical tourists to recover medical malpractice for adverse events; and the effects of medical tourism on access to health care in the destination country. However, the participants also identified several topics that have received much less attention in the legal and ethical literature. Overall this analysis reveals that lawyers, at least in Barbados, have an important role to play in the medical tourism sector beyond litigation – particularly in transactional and gatekeeper capacities. It remains to be seen whether these findings are specific to the ecology of Barbados or can be extrapolated to the legal climate of other medical tourism destination countries.
doi:10.1186/s12913-015-0948-3
PMCID: PMC4517313  PMID: 26215979
Medical tourism; Legal; Barbados; Qualitative; Regulation
11.  Quality of life in patients treated with first-line antiretroviral therapy containing nevirapine or efavirenz in Uganda: a prospective non-randomized study 
Background
The goal of antiretroviral therapy (ART) is to suppress viral replication, reduce morbidity and mortality, and improve quality of life (QoL). For resource-limited settings, the World Health Organization recommends a first-line regimen of two-nucleoside reverse-transcriptase inhibitors and one non-nucleoside transcriptase inhibitor (nevirapine (NVP) or efavirenz (EFV)). There are few data comparing the QoL impact of NVP versus EFV. This study assessed the change in QoL and factors associated with QoL among HIV patients receiving ART regimens based on EFV or NVP.
Methods
We enrolled 640 people with HIV eligible for ART who received regimens including either NVP or EFV. QoL was assessed at baseline, three months and six months using Physical Health Summary (PHS) and Mental Health Summary (MHS) scores and the Global Person Generated Index (GPGI). Data were analyzed using generalized estimating equations, with ART regimen as the primary exposure, to identify associations between patient and disease factors and QoL.
Results
QoL increased on ART. The mean QoL scores did not differ significantly for regimens based on NVP versus EFV during follow-up for MHS and GPGI regardless of CD4 stratum and for PHS among patients with a CD4 count >250 cells/μL. The PHS-adjusted β coefficients for ART regimens based on EFV versus NVP by CD4 count strata were as follows: −1.61 (95 % CI −2.74, −0.49) for CD4 count <100 cells/μL; 0.82 (0.22, 1.43) for CD4 count 101–250 cells/μL; and −1.33 (−5.66, 3.00) for CD4 count >250 cells/μL. The corresponding MHS-adjusted β coefficients were as follows: −0.39 (−1.40, 0.62) for CD4 < 100 cells/μL; 0.16 (−0.66, 0.98) for CD4 count 101–250 cells/μL; and −0.75 (−2.01, 0.51) for CD4 count >250 cells/μL. The GPGI-adjusted odds ratios for EFV versus NVP were 0.51 (0.25, 1.04) for CD4 count <100 cells/μL, 0.98 (0.60, 1.58) for CD4 count 101–250 cells/μL, 1.39 (0.66, 2.90) for CD4 > 250 cells/μL. QoL improved among patients on EFV over the 6-month follow-up period (MHS p < 0.001; PHS p = 0.04, p = 0.028). Overall, patients with depression (PHS p < 0.001; GPGI p < 0.001) had lower scores and women had lower MHS (on NVP, p = 0.001). Other factors associated with lower QoL included alcohol use, low education level and advanced HIV disease.
Conclusions
ART improves QoL. The results support use of either NVP or EFV. Patients initiating ART should be assessed for depression and managed appropriately. Women may require extra support to improve their QoL.
doi:10.1186/s12913-015-0959-0
PMCID: PMC4517416  PMID: 26216221
Quality of life; HIV/AIDS; Efavirenz; Nevirapine
12.  What is the perceived impact of Alexander technique lessons on health status, costs and pain management in the real life setting of an English hospital? The results of a mixed methods evaluation of an Alexander technique service for those with chronic back pain 
Background
Randomised controlled trial evidence indicates that Alexander Technique is clinically and cost effective for chronic back pain. The aim of this mixed methods evaluation was to explore the role and perceived impact of Alexander Technique lessons in the naturalistic setting of an acute hospital Pain Management Clinic in England.
Methods
To capture changes in health status and resource use amongst service users, 43 service users were administered three widely used questionnaires (Brief Pain Inventory, MYMOP and Client Service Resource Inventory) at three time points: baseline, six weeks and three months after baseline. We also carried out 27 telephone interviews with service users and seven face-to-face interviews with pain clinic staff and Alexander Technique teachers. Quantitative data were analysed using descriptive statistics and qualitative data were analysed thematically.
Results
Those taking Alexander Technique lessons reported small improvements in health outcomes, and condition-related costs fell. However, due to the non-randomised, uncontrolled nature of the study design, changes cannot be attributed to the Alexander Technique lessons. Service users stated that their relationship to pain and pain management had changed, especially those who were more committed to practising the techniques regularly. These changes may explain the reported reduction in pain-related service use and the corresponding lower associated costs.
Conclusions
Alexander Technique lessons may be used as another approach to pain management. The findings suggests that Alexander Technique lessons can help improve self-efficacy for those who are sufficiently motivated, which in turn may have an impact on service utilisation levels.
doi:10.1186/s12913-015-0966-1
PMCID: PMC4517566  PMID: 26215122
Pain management; Chronic back pain; Alexander technique; Complementary and alternative medicine; Service evaluation; Mixed methods
13.  Impact of socio-economic status on hospital length of stay following injury: a multicenter cohort study 
Background
Injury is second only to cardiovascular disease in terms of acute care costs in North America. One key to improving injury care efficiency is to generate knowledge on the determinants of resource use. Socio-economic status (SES) is a documented risk factor for injury severity and mortality but its impact on length of stay (LOS) for injury admissions is unknown. This study aimed to examine the relationship between SES and LOS following injury.
This multicenter retrospective cohort study was based on adults discharged alive from any trauma center (2007–2012; 57 hospitals; 65,486 patients) in a Canadian integrated provincial trauma system. SES was determined using ecological indices of material and social deprivation. Mean differences in LOS adjusted for age, gender, comorbidities, and injury severity were generated using multivariate linear regression.
Results
Mean LOS was 13.5 days. Patients in the highest quintile of material/social deprivation had a mean LOS 0.5 days (95 % CI 0.1-0.9)/1.4 days (1.1-1.8) longer than those in the lowest quintile. Patients in the highest quintiles of both social and material deprivation had a mean LOS 2.6 days (1.8-3.5) longer than those in the lowest quintiles.
Conclusions
Results suggest that patients admitted for traumatic injury who suffer from high social and/or material deprivation have longer acute care LOS in a universal-access health care system. The reasons behind observed differences need to be further explored but may indicate that discharge planning should take patient SES into consideration.
doi:10.1186/s12913-015-0949-2
PMCID: PMC4513757  PMID: 26204932
Injury; Hospital length of stay; Socioeconomic status; Material deprivation; Social deprivation
14.  Discrepancies in assessing home care workers’ working conditions in a Norwegian home care service: differing views of stakeholders at three organizational levels 
Background
The present study is a follow-up study of factors contributing to an undesirable quality of work environment and sick leave rate in the home care services in a Norwegian municipality. The underlying assumption is that organizational discrepancies in the perceptions and appraisals of significant factors and processes in an organization have detrimental effects on the management of the organization and on work environment conditions. Thus, the study aim is to explore potential organizational discrepancies in the appraisals of factors relating to home care workers’ working conditions.
Methods
The study, using a mixed-methods design, comprised six home care units. It included survey responses of home care workers (80 respondents, response rate 54 %) and qualitative descriptions of stakeholders’ appraisals of organizational issues gathered through semi-structured interviews (33 interviews with stakeholders at three organizational levels).
Results
Employees at different organizational levels in the home care services expressed divergent appraisals of factors related to the working conditions of home care workers, including impact of organizational measures (i.e. time pressure, work tasks, a new work program, organizational changes, budget model, budget allocation and coping strategies). Survey responses supported interview descriptions by home care workers. Results suggest that organizational discrepancy serve as an important barrier to a sustainable, well-functioning organization in general and to quality-enhancing changes to work procedures in particular.
Conclusions
It is recommended to improve communication channels and facilitate the exchange of information across levels to ensure a common understanding of matters significant to the organization of the home care services and to the work environment of home care workers. The prevalence and impact of organizational discrepancy should be included in organization research, particularly when exploring explanatory factors of an unhealthy organization.
doi:10.1186/s12913-015-0945-6
PMCID: PMC4514951  PMID: 26209514
Organizational discrepancy; Health care services; Home care services; Work environment; Organizational change; Interventions; Rationalization
15.  Measuring costs of data collection at village clinics by village doctors for a syndromic surveillance system-a cross sectional survey from China 
Background
Studies into the costs of syndromic surveillance systems are rare, especially for estimating the direct costs involved in implementing and maintaining these systems. An Integrated Surveillance System in rural China (ISSC project), with the aim of providing an early warning system for outbreaks, was implemented; village clinics were the main surveillance units. Village doctors expressed their willingness to join in the surveillance if a proper subsidy was provided. This study aims to measure the costs of data collection by village clinics to provide a reference regarding the subsidy level required for village clinics to participate in data collection.
Methods
We conducted a cross-sectional survey with a village clinic questionnaire and a staff questionnaire using a purposive sampling strategy. We tracked reported events using the ISSC internal database. Cost data included staff time, and the annual depreciation and opportunity costs of computers. We measured the village doctors’ time costs for data collection by multiplying the number of full time employment equivalents devoted to the surveillance by the village doctors’ annual salaries and benefits, which equaled their net incomes. We estimated the depreciation and opportunity costs of computers by calculating the equivalent annual computer cost and then allocating this to the surveillance based on the percentage usage.
Results
The estimated total annual cost of collecting data was 1,423 Chinese Renminbi (RMB) in 2012 (P25 = 857, P75 = 3284), including 1,250 RMB (P25 = 656, P75 = 3000) staff time costs and 134 RMB (P25 = 101, P75 = 335) depreciation and opportunity costs of computers.
Conclusions
The total costs of collecting data from the village clinics for the syndromic surveillance system was calculated to be low compared with the individual net income in County A.
doi:10.1186/s12913-015-0965-2
PMCID: PMC4515002  PMID: 26208506
Rural China; Village clinics; Infectious diseases; Syndromic surveillance system; Data collection; Staff time costs; Depreciation and opportunity costs
16.  Preventing mental illness: closing the evidence-practice gap through workforce and services planning 
Background
Mental illness is prevalent across the globe and affects multiple aspects of life. Despite advances in treatment, there is little evidence that prevalence rates of mental illness are falling. While the prevention of cardiovascular disease and cancers are common in the policy dialogue and in service delivery, the prevention of mental illness remains a neglected area. There is accumulating evidence that mental illness is at least partially preventable, with increasing recognition that its antecedents are often found in infancy, childhood, adolescence and youth, creating multiple opportunities into young adulthood for prevention. Developing valid and reproducible methods for translating the evidence base in mental illness prevention into actionable policy recommendations is a crucial step in taking the prevention agenda forward.
Method
Building on an aetiological model of adult mental illness that emphasizes the importance of intervening during infancy, childhood, adolescence and youth, we adapted a workforce and service planning framework, originally applied to diabetes care, to the analysis of the workforce and service structures required for best-practice prevention of mental illness.
Results
The resulting framework consists of 6 steps that include identifying priority risk factors, profiling the population in terms of these risk factors to identify at-risk groups, matching these at-risk groups to best-practice interventions, translation of these interventions to competencies, translation of competencies to workforce and service estimates, and finally, exploring the policy implications of these workforce and services estimates. The framework outlines the specific tasks involved in translating the evidence-base in prevention, to clearly actionable workforce, service delivery and funding recommendations.
Conclusions
The framework describes the means to deliver mental illness prevention that the literature indicates is achievable, and is the basis of an ongoing project to model the workforce and service structures required for mental illness prevention.
doi:10.1186/s12913-015-0954-5
PMCID: PMC4511973  PMID: 26205006
Mental illness; Prevention; Workforce planning; Health services planning; Health policy
17.  Validation of the safety attitudes questionnaire (short form 2006) in Italian in hospitals in the northeast of Italy 
Background
Studying safety attitudes of front-line workers can help hospital managers take initiatives to improve patient safety. The Safety Attitudes Questionnaire, a psychometric tool that measures safety attitudes in health facilities, has been used and validated in several languages worldwide but there is no Italian version available. Hence, the study is aimed at cross-culturally validating the questionnaire (short form 2006) in Italian at two hospitals in the Veneto region (northeastern Italy).
Methods
The translation and linguistic adaptation process of the questionnaire followed the World Health Organization guidelines. The questionnaire was delivered to staff working in four departments in two hospitals. Confirmatory factor analysis was used to assess the content validity of a pre-specified factor model that recognizes seven safety factors of the SAQ. Retest was performed to assess reliability. Internal consistency of items and safety factors was evaluated via Cronbach’s alpha.
Results
Response rate was 60 % (n = 261/433). Test-retest correlation between items and factors showed a high degree of agreement. Goodness-of-fit indices demonstrated an acceptable hypothesis model with seven safety factors. Cronbach’s alpha of a whole questionnaire was 0.85, demonstrating a good internal consistency. Polychoric correlations showed that the factors are well correlated with each other. Stress recognition was found to have negative correlation with other safety factors.
Conclusions
The Safety Attitudes Questionnaire in Italian language has satisfactory psychometric characteristics and is a valid instrument to measure safety culture in Italian hospitals.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0951-8) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0951-8
PMCID: PMC4512154  PMID: 26204957
Patient safety; Safety attitudes questionnaire; Italy; Questionnaire validation
18.  Relationship between cardiovascular risk and lipid testing in one health care system: a retrospective cohort study 
Background
The US Preventive Services Taskforce (USPSTF) recommends routine lipid screening beginning age 35 for men [1]. For women age 20 and older, as well as men age 20–34, screening is recommended if cardiovascular risk factors are present. Prior research has focused on underutilization but not overuse of lipid testing. The objective is to document over- and under-use of lipid testing in an insured population of persons at low, moderate and high cardiovascular disease (CVD) risk for persons not already on statins.
Methods
The study is a retrospective cohort study that included all adults without prior CVD who were continuously enrolled in a large integrated healthcare system from 2005 to 2010.
Measures included lipid test frequency extracted from administrative data and Framingham cardiovascular risk equations applied using electronic medical record data. Five year lipid testing patterns were examined by age, sex and CVD risk. Generalized linear models were used to estimate the relative risk for over testing associated with patient characteristics.
Results
Among males and females for whom testing is not recommended, 35.8 % and 61.5 % received at least one lipid test in the prior 5 years and 8.4 % and 24.4 % had two or more.
Over-testing was associated with age, race, comorbidity, primary care use and neighborhood income. Among individuals at moderate and high-risk (not already treated with statins) and for whom screening is recommended, between 21.4 % and 25.1 % of individuals received no screening in the prior 5 years.
Conclusions
Based on USPSTF lipid screening recommendations, this study documents substantial over-testing among individuals with low CVD risk and under-testing among individuals with moderate to high-risk not already on statins. Opportunity exists to better focus lipid screening efforts appropriate to CVD risk.
doi:10.1186/s12913-015-0884-2
PMCID: PMC4511977  PMID: 26201968
Cholesterol testing; Quality of care; Cardiovascular disease risk
19.  A systematic review of hospital accreditation: the challenges of measuring complex intervention effects 
Background
The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness.
Methods
We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies.
Results
The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized.
Conclusion
Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0933-x) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0933-x
PMCID: PMC4511980  PMID: 26202068
Accreditation; Certification; Hospital; Patient Safety; Evaluation
20.  The number of discharge medications predicts thirty-day hospital readmission: a cohort study 
Background
Hospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined.
Methods
To determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications.
Results
The final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17–1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643–0.679]).
Conclusions
The number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.
doi:10.1186/s12913-015-0950-9
PMCID: PMC4512093  PMID: 26202163
Readmission; Discharge medications; Polypharmacy; Outcomes
21.  The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews 
Background
It is now widely accepted that the mixed effect and success rates of strategies to improve quality and safety in health care are in part due to the different contexts in which the interventions are planned and implemented. The objectives of this study were to (i) describe the reporting of contextual factors in the literature on the effectiveness of quality improvement strategies, (ii) assess the relationship between effectiveness and contextual factors, and (iii) analyse the importance of contextual factors.
Methods
We conducted an umbrella review of systematic reviews searching the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase and CINAHL. The search focused on quality improvement strategies included in the Cochrane Effective Practice and Organisation of Care Group taxonomy. We extracted data on quality improvement effectiveness and context factors. The latter were categorized according to the Model for Understanding Success in Quality tool.
Results
We included 56 systematic reviews in this study of which only 35 described contextual factors related with the effectiveness of quality improvement interventions. The most frequently reported contextual factors were: quality improvement team (n = 12), quality improvement support and capacity (n = 11), organization (n = 9), micro-system (n = 8), and external environment (n = 4). Overall, context factors were poorly reported. Where they were reported, they seem to explain differences in quality improvement effectiveness; however, publication bias may contribute to the observed differences.
Conclusions
Contextual factors may influence the effectiveness of quality improvement interventions, in particular at the level of the clinical micro-system. Future research on the implementation and effectiveness of quality improvement interventions should emphasize formative evaluation to elicit information on context factors and report on them in a more systematic way in order to better appreciate their relative importance.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0906-0) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0906-0
PMCID: PMC4508989  PMID: 26199147
22.  Evaluation of the HIV lay counselling and testing profession in South Africa 
Background
With the launch of the national HIV Counselling and Testing (HCT) campaign in South Africa (SA), lay HIV counsellors, who had been trained in blood withdrawal, have taken up the role of HIV testing. This study evaluated the experiences, training, motivation, support, supervision, and workload of HIV lay counsellors and testers in South Africa. The aim was to identify gaps in their resources, training, supervision, motivation, and workload related to HCT services. In addition it explored their experiences with providing HIV testing under the task shifting context.
Methods
The study was conducted in eight of South Africa’s nine provinces. 32 lay counsellors were recruited from 67 HCT sites, and were interviewed using two questionnaires that included structured and semi-structured questions. One questionnaire focused on their role as HIV counsellors and the other on their role as HIV testers.
Results
Ninety-seven percent of counsellors reported that they have received training in counselling and testing. Many rated their training as more than adequate or adequate, with 15.6 % rating it as not adequate. Respondents reported a lack of standardised counselling and testing training, and revealed gaps in counselling skills for specific groups such as discordant couples, homosexuals, older clients and children. They indicated health system barriers, including inadequate designated space for counselling, which compromises privacy and confidentiality. Lay counsellors carry the burden of counselling and testing nationally, and have other tasks such as administration and auxiliary duties due to staff shortages.
Conclusions
This study demonstrates that HCT counselling and testing services in South Africa are mainly performed by lay counsellors and testers. They are challenged by inadequate work space, limited counselling skills for specific groups, a lack of standardised training policies and considerable administrative and auxiliary duties. To improve HCT services, there needs to be training needs with a standardised curriculum and refresher courses, for HIV counselling and testing, specifically for specific elderly clients, discordant couples, homosexuals and children. The Department of Health should formally integrate lay counsellors into the health care system with proper allocation of tasks under the task shifting policy.
doi:10.1186/s12913-015-0940-y
PMCID: PMC4509846  PMID: 26197722
Lay counsellors; HIV Counselling and Training (HCT); Training; HIV testing; Workspace
23.  Minimum volume standards in German hospitals: do they get along with procedure centralization? A retrospective longitudinal data analysis 
Background
Compliance with minimum volume standards for specific procedures serves as a criterion for high-quality patient care. International experiences report a centralization of the respective procedures. In Germany, minimum volume standards for hospitals were introduced in 2004 for 5 procedures (complex esophageal and pancreatic interventions; liver, kidney and stem cell transplantations), in 2006 total knee replacement was added. This study explores whether any centralization is discernible for these procedures in Germany.
Methods
A retrospective longitudinal analysis of secondary data serves to determine a possible centralization of procedures from the system perspective. Centralization means that over time, fewer hospitals perform the respective procedure, the case volume in high-volume hospitals increases together with their percentage of the annual total case volume, and the case volume in low-volume hospitals decreases together with their percentage of the annual total case volume. Using data from the mandatory hospital quality reports for the years 2006, 2008 and 2010 we performed Kruskal Wallis and chi-square tests to evaluate potential centralization effects.
Results
No centralization was found for any of the six types of interventions over the period from 2006 to 2010. The annual case volume and the number of hospitals performing interventions rose at differing rates over the 5-year period depending on the type of intervention. Seven percent of esophagectomies and 14 % of pancreatectomies are still performed in hospitals with less than 10 interventions per year.
Conclusions
For the purpose of further centralization of interventions it will be necessary to first analyze and then appropriately address the reasons for non-compliance from the hospital and patient perspective.
doi:10.1186/s12913-015-0944-7
PMCID: PMC4511553  PMID: 26197817
Volume-outcome; Minimum volume standards; Centralization; Hospital; Germany; Pancreatectomy; Esophagectomy; Transplantation; Arthroplasty; Replacement; Knee
24.  The adoption of a new diagnostic technology for tuberculosis in two Brazilian cities from the perspective of patients and healthcare workers: a qualitative study 
Background
This article presents the qualitative component linked to a larger study of implementation of the Xpert™ MTB/Rif technology in two Brazilian cities. Despite intrinsic advantages of new health technologies, its introduction can be disruptive to existing routines, and it is thus important to understand how these innovations are perceived by the different groups involved in its regular use.
Methods
This study was based on semi-structured interviews with patients, lab technicians, health care workers and managers involved with diagnosis and care of Tuberculosis (TB). The interviews had their content analyzed in order to abstract the different perspectives for the various actors.
Results
For patients the changes were not perceived as significant, since their greatest concerns were related to treatment and the stigma associated with TB. The professionals in general welcomed the new technique, which dramatically decreases the workload, time and reliability of diagnosis, in their view. However, we noted difficulties with the concomitant implementation of new IT technology for recording and reporting test results, which negatively impacted the time necessary to get lab diagnosis to physicians.
Conclusions
Through this analysis we detected some bottlenecks in the surrounding environment, not necessarily linked to the technology itself but which could hamper considerably its advantages.
doi:10.1186/s12913-015-0941-x
PMCID: PMC4507311  PMID: 26195000
Tuberculosis; Diagnosis; Qualitative research
25.  Predictors of health worker performance after Integrated Management of Childhood Illness training in Benin: a cohort study 
Background
Correct treatment of potentially life-threatening illnesses (PLTIs) in children under 5 years, such as malaria, pneumonia, and diarrhea, can substantially reduce mortality. The Integrated Management of Childhood Illness (IMCI) strategy has been shown to improve treatment of child illnesses, but multiple studies have shown that gaps in health worker performance remain after training. To better understand factors related to health worker performance, we analyzed 9,330 patient consultations in Benin from 2001–2002, after training one of the first cohorts of 32 health workers in IMCI.
Methods
With data abstracted from patient registers specially designed for IMCI-trained health workers, we examined associations between health facility-, health worker-, and patient-level factors and 10 case-management outcomes for PLTIs.
Results
Altogether, 63.6 % of children received treatment for all their PLTIs in accordance with IMCI guidelines, and 77.8 % received life-saving treatment (i.e., clinically effective treatment, even if not exactly in accordance with IMCI guidelines). Performance of individual health workers varied greatly, from 15–88 % of patients treated correctly, on average. Multivariate regression analyses identified several factors that might have influenced case-management quality, many outside a manager’s direct control. Younger health workers significantly outperformed older ones, and infants received better care than older children. Children with danger signs, those with more complex illnesses, and those with anemia received worse care. Health worker supervision was associated with improved performance for some outcomes.
Conclusions
A variety of factors, some outside the direct control of program managers, can influence health worker practices. An understanding of these influences can help inform the development of strategies to improve performance.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-015-0910-4) contains supplementary material, which is available to authorized users.
doi:10.1186/s12913-015-0910-4
PMCID: PMC4509845  PMID: 26194895
Health worker performance; Case management; IMCI; Benin; Quality of care; Child health

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