Abstract

This chapter will deal with the actual and efficient functioning of health insurance in settings where risk (expected value) of medical spending or insurance benefits varies across individuals at a given point in time or over time for a given individual. It will deal with equilibrium in insurance markets with risk variation and will also deal with various configurations of information, the impacts on such markets of regulation motivated by risk variation, and the actual and optimal impact of governmental policies to deal with risk variation in national insurance systems. © 2012 Elsevier B.V.

Abstract

BACKGROUND:

The Reach Out and Read (ROR) program promotes early literacy as part of pediatric primary care through the distribution of children's books and anticipatory guidance duringearly childhood.

OBJECTIVES:

To improve the rates of age-appropriate book-giving during well-child care and the delivery of ROR-recommended anticipatory guidance in 6 pediatric clinics.

METHODS:

Three quality-improvement cycles were completed at each site. Practice-level data were shared with participants in iterative sessions to identify methods for improving care. A provider-training DVD was used to promote these ROR activities.

RESULTS:

Over the course of the project, the median rate of book-giving increased from 97% to 99% and for anticipatory guidance remained at 89%. Providers reported significantly improved ROR-related skills, particularly self-efficacy for modeling reading aloud and for using children's books to assess development.

CONCLUSIONS:

Baseline adherence to the ROR program is high, possibly because of the ease of implementation. Quality improvement for ROR is feasible and may be easier to implement for book distribution than anticipatory guidance, although providers reported improved anticipatory-guidance skills. Future quality-improvement efforts should continue to address giving books and anticipatory guidance, both of which are integral to the ROR model.

Abstract

Theories provide a way of understanding and predicting the effects of patient safety practices (PSPs), interventions intended to prevent or mitigate harm caused by healthcare or risks of such harm. Yet most published evaluations make little or no explicit reference to theory, thereby hindering efforts to generalise findings from one context to another. Theories from a wide range of disciplines are potentially relevant to research on PSPs. Theory can be used in research to explain clinical and organisational behaviour, to guide the development and selection of PSPs, and in evaluating their implementation and mechanisms of action. One key recommendation from an expert consensus process is that researchers should describe the theoretical basis for chosen intervention components or provide an explicit logic model for 'why this PSP should work.' Future theory-driven evaluations would enhance generalisability and help build a cumulative understanding of the nature of change.

Abstract

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

Abstract

OBJECTIVE:

Development of a coherent literature evaluating patient safety practices has been hampered by the lack of an underlying conceptual framework. The authors describe issues and choices in describing and classifying diverse patient safety practices (PSPs).

METHODS:

The authors developed a framework to classify PSPs by identifying and synthesising existing conceptual frameworks, evaluating the draft framework by asking a group of experts to use it to classify a diverse set of PSPs and revising the framework through an expert-panel consensus process.

RESULTS:

The 11 classification dimensions in the framework include: regulatory versus voluntary; setting; feasibility; individual activity versus organisational change; temporal (one-time vs repeated/long-term); pervasive versus targeted; common versus rare events; PSP maturity; degree of controversy/conflicting evidence; degree of behavioural change required for implementation; and sensitivity to context.

CONCLUSION:

This framework offers a way to classify and compare PSPs, and thereby to interpret the patient-safety literature. Further research is needed to develop understanding of these dimensions, how they evolve as the patient safety field matures, and their relative utilities in describing, evaluating and implementing PSPs.

Abstract

BACKGROUND:

Differences in contexts (eg, policies, healthcare organisation characteristics) may explain variations in the effects of patient safety practice (PSP) implementations. However, knowledge of which contextual features are important determinants of PSP effectiveness is limited and consensus is lacking on a taxonomy of which contexts matter.

METHODS:

Iterative, formal discussions were held with a 22-member technical expert panel composed of experts or leaders in patient safety, healthcare systems, and methods. First, potentially important contextual features were identified, focusing on five PSPs. Then, two surveys were conducted to determine the context likely to influence PSP implementations.

RESULTS:

The panel reached a consensus on a taxonomy of four broad domains of contextual features important for PSP implementations: safety culture, teamwork and leadership involvement; structural organisational characteristics (eg, size, organisational complexity or financial status); external factors (eg, financial or performance incentives or PSP regulations); and availability of implementation and management tools (eg, training organisational incentives). Panelists also tended to rate specific patient safety culture, teamwork and leadership contexts as high priority for assessing their effects on PSP implementations, but tended to rate specific organisational characteristic contexts as high priority only for use in PSP evaluations. Panelists appeared split on whether specific external factors and implementation/management tools were important for assessment or only description.

CONCLUSION:

This work can guide research commissioners and evaluators on the contextual features of PSP implementations that are important to report or evaluate. It represents a first step towards developing guidelines on contexts in PSP implementation evaluations. However, the science of context measurement needs maturing.

Abstract

Many models of infectious disease ignore the underlying contact structure through which the disease spreads. However, in order to evaluate the efficacy of certain disease control interventions, it may be important to include this network structure. We present a network modeling framework of the spread of disease and a methodology for inferring important model parameters, such as those governing network structure and network dynamics, from readily available data sources. This is a general and flexible framework with wide applicability to modeling the spread of disease through sexual or close contact networks. To illustrate, we apply this modeling framework to evaluate HIV control programs in sub-Saharan Africa, including programs aimed at concurrent partnership reduction, reductions in risky sexual behavior, and scale up of HIV treatment.

OBJECTIVES:

The objective of this study was to determine whether a 5-module self-paced computerized educational program improves residents' skills in assessing and managing youth presenting to the emergency department in acute psychiatric distress.

METHODS:

The evaluation used a quasi-experimental posttest-only design assessing both knowledge of the educational context of the program and self-rated pretest knowledge of program content with 32 residents recruited from 1 medical center in Cleveland, Ohio.

RESULTS:

About half of the respondents were female (48%); almost two thirds were white (65%), and few were trained in psychiatric assessment of children/adolescents. On average, residents had significantly higher scores on the posttest compared with the self-rated pretest (6.4 ± 1.1 vs 3.8 ± 2.3; P < 0.001), an effect size of 1.32. Residents responded positively to the modules and rated them highly on educational content (4.2 ± 0.5 on a 5-point scale) and satisfaction with clinical applicability (8.2 ± 1.2 on a 10-point scale) and found the program easy to navigate (8.5 ± 1.9 on a 10-point scale).

CONCLUSIONS:

A brief, self-administered, Web-based training program shows promise for improving residents' knowledge about suicidal behaviors in youth.

OBJECTIVE:

To examine trends in the specialty care hospitalization of pediatric rheumatology patients and determine how nonclinical factors influence access.

METHODS:

This study used California's Office of Statewide Health Planning and Development discharge database to perform a retrospective population analysis of pediatric rheumatology hospitalizations in California between 1999 and 2007. We used logistic regression to examine the relationship between hospitalization in specialty care centers with a pediatric rheumatologist and nonclinical patient characteristics.

RESULTS:

A total of 18,641 pediatric discharges revealed that 57% were discharged from a specialty care center with a pediatric rheumatologist. Multivariate analysis showed that the factors associated with increased utilization of specialty care centers with a pediatric rheumatologist were public insurance (odds ratio [OR] 1.62, 95% confidence interval [95% CI] 1.51-1.74; P < 0.0001), being Hispanic (OR 1.29, 95% CI 1.19-1.40; P < 0.0001) or Asian non-Hispanic (OR 1.39, 95% CI 1.26-1.54; P < 0.0001), and high pediatric rheumatology specialty care bed supply (OR 2.79, 95% CI 2.49-3.14; P < 0.0001). A decreased utilization of specialty care centers with a pediatric rheumatologist was seen for patients ages <1 year (OR 0.45, 95% CI 0.40-0.52; P < 0.0001), ages 1-4 years (OR 0.50, 95% CI 0.46-0.55; P < 0.0001), ages 5-9 years (OR 0.68, 95% CI 0.62-0.75; P < 0.0001), ages 15-18 years (OR 0.51, 95% CI 0.47-0.56; P < 0.0001), males (OR 0.75, 95% CI 0.70-0.80; P < 0.0001), and patients residing farther away from a specialty care center with a pediatric rheumatologist (OR 0.57, 95% CI 0.51-0.63; P < 0.0001).

CONCLUSION:

Nonclinical factors play an increasingly important role in the hospitalization patterns of pediatric rheumatology patients in California. Understanding these factors is crucial if we are to ensure that the variation in access to care reflects clinical need.