Abstract
Background: Decisions affecting cost and quality are taken across health and care but investigation of the mediating role of context in these is in its infancy. This paper presents a synthesis of the evidence on the contextual factors that influence ‘decisions of value’ – defined as those characterised by having a significant and demonstrable impact on both quality and resources – in health and care. The review considers the full range of resource/quality decisions and synthesises knowledge on the contextual drivers of these. Methods: The method involved structured evidence review and narrative synthesis. Literature was identified through searches of electronic databases (HMIC, Medline, Embase, CINAHL, NHS Evidence, Cochrane, Web of Knowledge, ABI Inform/Proquest), journal and bibliography hand-searching and snowball searching using citation analysis. Structured data extraction was performed drawing out descriptive information and content against review aims and questions. Data synthesis followed a thematic approach in accordance with the varied nature of the retrieved literature. Results: Twenty-one literature items reporting 14 research studies and seven literature reviews met the inclusion criteria. The review shows that in health and care contexts, research into decisions of value in health and care is in its infancy and contains wide variation in approach and remit. The evidence is drawn from a range of service and country settings and this reduces generalisability or transferability of findings. An area of relative strength in the published evidence is inquiry into factors influencing coverage and commissioning decisions in health care systems. Allocative decisions have therefore been more consistently researched than technical decisions. We use Pettigrew’s (1985) distinction between inner and outer context to structure analysis of the range of factors reported as being influential. These include: evidence/information, organisational culture and governance regimes, and; economic and political conditions. Conclusion: Decisions of value in health and care are subject to range of intersecting influences that often lead to a departure from narrow notions of rational decision-making. Future research should pay greater attention to the relatively under-explored area of technical, as opposed to allocative, decision-making.
Highlights
Many governments find themselves faced with unprecedented constraints on their health and care spending capacity whilst demands and expectations continue to increase
This paper presents findings from an evidence synthesis carried out in order to understand the contextual factors that are influential in these decision-making domains, and which facilitate or attenuate the pursuit of quality and affordability
There are a number of observations that can reasonably be made with regard to the interplay of inner and outer context in shaping decisions of value in health and care
Summary
Many governments find themselves faced with unprecedented constraints on their health and care spending capacity whilst demands and expectations continue to increase This has led to the championing of investment and disinvestment decision-making that incorporates opportunity cost and budget impact, alongside quality and outcomes.[1] The development and spread of formal coverage decisionmaking bodies internationally has prompted inquiry into the drivers of resource allocation decisions of this kind. The paper begins with a definition of terms and an explanation of the scope and conceptual foundation of the review This is followed by a description of the study objectives, methods and a comparative thematic analysis of findings. Pettigrew’s2 distinction between inner and outer context is used to structure analysis of the factors identified, Full list of authors’ affiliations is available at the end of the article
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