Implications For Health Care Quality Research Articles

Trends in Integration Between Physician Organizations and Pharmacies for Self-Administered Drugs

Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies. To describe trends in the use of in-house pharmacies, associated physician organization characteristics, and associated drug prices. A cross-sectional study was conducted from calendar years 2011 to 2019. Participants included 20% of beneficiaries enrolled in fee-for-service Medicare Parts A, B, and D. Data analysis was performed from September 15, 2020, to December 20, 2023. Prescriptions filled by in-house pharmacies. The share of Medicare Part D spending filled by in-house pharmacies by drug class, costliness, and specialty was evaluated. Growth in the number of physician organizations and physicians in organizations with in-house pharmacies was measured in 5 specialties: medical oncology, urology, infectious disease, gastroenterology, and rheumatology. Characteristics of physician organizations with in-house pharmacies and drug prices at in-house vs other pharmacies are described. Among 8 020 652 patients (median age, 72 [IQR, 66-81] years; 4 570 114 [57.0%] women), there was substantial growth in the share of Medicare Part D spending on high-cost drugs filled at in-house pharmacies from 2011 to 2019, including oral anticancer treatments (from 10% to 34%), antivirals (from 12% to 20%), and immunosuppressants (from 2% to 9%). By 2019, 63% of medical oncologists, 20% of urologists, 29% of infectious disease specialists, 21% of gastroenterologists, and 22% of rheumatologists were in organizations with specialty-relevant in-house pharmacies. Larger organizations had a greater likelihood of having an in-house pharmacy (0.75 percentage point increase [95% CI, 0.56-0.94] per each additional physician), as did organizations owning hospitals enrolled in the 340B Drug Discount Program (10.91 percentage point increased likelihood [95% CI, 6.33-15.48]). Point-of-sale prices for high-cost drugs were 1.76% [95% CI, 1.66%-1.87%] lower at in-house vs other pharmacies. In this cross-sectional study of physician organization-operated pharmacies, in-house pharmacies were increasingly used from 2011 to 2019, especially for high-cost drugs, potentially associated with organizations' financial incentives. In-house pharmacies offered high-cost drugs at lower prices, in contrast to findings of integration in other contexts, but their growth highlights a need to understand implications for patient care.

Escalating competition in NHS: implications for healthcare quality and workforce sustainability.

The UK's National Health Service (NHS) faces escalating competition ratios for specialty training positions, with application rates dramatically outpacing the growth in available posts. This trend contributes to systemic bottlenecks and challenges traditional career progression pathways within medicine. In this evolving landscape, the once-certain career progression within medicine is now increasingly uncertain. This commentary explores the complex dynamics of increased medical school admissions against stagnant specialty training placements and the broader strategic implications for workforce planning within the NHS. It critically evaluates the implications of current funding policies, which seem to prioritise an expansion of nondoctor healthcare roles over the development of specialist training, raising concerns about the long-term patient care quality and safety. Key recommendations include a reassessment of medical education expansion, a review of funding allocation, increased support for specialty training, and government accountability for healthcare workforce planning. The urgent need for strategic policy reform is underscored to ensure that NHS can sustain a high-quality, specialist-led healthcare provision in the face of rising competition and workforce pressures.

How do healthcare professionals experience communication with people with aphasia and what content should communication partner training entail?

Purpose Aphasia after stroke has been shown to lead to communication difficulties between healthcare professionals (HCP) and people with aphasia. Clinical guidelines emphasize the importance of teaching HCP to use supportive conversative techniques through communication partner training (CPT). The aim of this study is to explore and describe the experiences of HCP in communicating with people with aphasia and their needs and wishes for the content in CPT. Materials and methods The data were collected through qualitative semi-structured interviews with 17 HCP. HCP were recruited from two geriatric rehabilitation centres in the Netherlands and one academic hospital in Belgium. The interviews drew upon the qualitative research methodologies ethnography and phenomenology and were thematically analysed using the six steps of Braun & Clarke. Results Three themes were derived from the interviews. HCP experienced that communication difficulties impede healthcare activities (theme 1) and reported the need to improve communication through organizational changes (theme 2), changing the roles of SLTs (theme 3) and increasing knowledge and skills of HCP (theme 4). Conclusions According to HCP, communication difficulties challenge the provision of healthcare activities and lead to negative feelings in HCP. HCP suggest that communication can be improved by providing more time in the healthcare pathway of people with aphasia, adapting healthcare information to the needs of people with aphasia, commitment of physicians and managers, changing the roles of SLTs and improving knowledge and skills of HCP. Implications for rehabilitation Communication between healthcare professionals (HCP) and people with aphasia can be improved by training HCP to use supportive conversation techniques and tools. An important condition for successful implementation of communication partner trainings in healthcare centres is to identify the experiences of HCP with communication with people with aphasia and their needs and wishes for training content. This study shows that communication problems between HCP and people with aphasia impede diagnosis and therapy with considerable implications for healthcare quality. The suggestions that HCP have concerning the content of communication partner trainings can be placed under “education” and “implementation and post-training support.” HCP describe specific roles for speech-and language therapists to fulfil after the training and suggest two main changes that should be made at an organizational level.

Development of a Scale Measuring Nurses’ Physical Activity Counseling in a Primary Care Facility: Implications for Healthcare Quality

This study constructed a scale for measuring nurses’ physical activity (PA) counseling in healthcare from the points of view of regular patients. Confirmatory factor analysis produced a two-factor solution with 7 items. The first factor extracted was “follow-up”, which accounted for a variance of 44.5% out of a total variance of 64.8% and comprises 4 items. The second factor, “PA recommendation”, accounted for a variance of 20.3% and comprises 3 items. The final scale had a good internal consistency (Cronbach's α = 0.75; factor loading ≥0.50) as well as satisfactory validity indicators.

Towards a multilevel governance framework on the implementation of patient rights in health facilities: a protocol for a systematic scoping review

IntroductionPatient rights are “those rights that are attributed to a person seeking healthcare”. Patient rights have implications for quality of healthcare and acts as a key accountability tool. It can...

What patients' complaints and praise tell the health practitioner: implications for health care quality. A qualitative research study.

In order to identify which health care aspects play a role in patient satisfaction and quality of health care, the present study analyses a large number of instances of complaint and praise. One thousand two hundred and thirty-five instances of complaint and one thousand five hundred thirty-six of praise submitted from patients or other souces (i.e. a patient's family member or a legal representative) to a northern-Italian hospital were analysed. We adopted Reader and colleagues' (2014) patients' complaint taxonomy, in conjunction with a detailed content analysis of relationship and communication of information aspects. The most frequent causes of complaint concerned care system management (68.1%), particularly the time taken to access treatment, and relationship aspects (52.8%). The importance of relationship aspects was confirmed by the expression of gratitude through praise (89%). The most critical factor of the relationship domain was effective communication of information to the patient (39.3%). Frequently patients complained of: (i) having received information that was inconsistent with the truth, (ii) having had difficulty in obtaining information, and (iii) untimely communication of information. Clinical aspects did not seem to be the main factors that triggered a complaint (36,8%), and, when indicated, they were almost always associated with relationship issues. This study indicates that not only complaints, but also instances of praise, are a potentially important source of information regarding health care aspects that play a role in patient satisfaction and quality of care. Our findings underline the relevance of relationship aspects in determining patients' satisfaction with the care received. In particular, health practitioners should focus their attention on how information is understood, translated and applied by patients.

Is It Time to Rethink Postgraduate Training Requirements for Licensure?

Approaches to postgraduate medical training have evolved substantially in recent years, reflecting the complexity of the educational mission. Residency programs seek to produce clinicians who achieve board certification as an attestation of their competency. Certification criteria are established by the American Board of Medical Specialties, are consistent from state to state, and include periods of supervised instruction ranging from as few as three years (for primary care specialties) to much longer for selected disciplines. In contrast, minimum postgraduate training criteria necessary for licensure as an independent practitioner are established by state medical boards and vary significantly among and within jurisdictions. In most states, licenses can be granted to individuals who have completed as little as one year of postgraduate training. The discrepancy between the minimum time commitment necessary to become a competent physician and that to be licensed as an independent practitioner has implications for health care quality and safety. Data are lacking as to the number of licenses issued nationally to individuals who have only partially completed residency training and the nature of practices they pursue. Extrapolating from available evidence, these individuals may very well provide care inferior to those who have satisfied training requirements for certification eligibility and be more prone to problematic behavior resulting in disciplinary action. Efforts to establish more rigorous licensure criteria will require dialog between members of the academic community, professional organizations, state medical boards, and legislatures. The recently proposed Interstate Medical Licensure Compact may serve as a prototype for achieving this goal.

Addressing implementation challenges during guideline development - a case study of Swedish national guidelines for methods of preventing disease.

BackgroundMany of the world’s life threatening diseases (e.g. cancer, heart disease, stroke) could be prevented by eliminating life-style habits such as tobacco use, unhealthy diet, physical inactivity and excessive alcohol use. Incorporating evidence-based research on methods to change unhealthy lifestyle habits in clinical practice would be equally valuable. However gaps between guideline development and implementation are well documented, with implications for health care quality, safety and effectiveness. The development phase of guidelines has been shown to be important both for the quality in guideline content and for the success of implementation. There are, however, indications that guidelines related to general disease prevention methods encounter specific barriers compared to guidelines that are diagnosis-specific. In 2011 the Swedish National board for Health and Welfare launched guidelines with a preventive scope. The aim of this study was to investigate how implementation challenges were addressed during the development process of these disease preventive guidelines.MethodsSeven semi-structured interviews were conducted with members of the guideline development management group. Archival data detailing the guideline development process were also collected and used in the analysis. Qualitative data were analysed using content analysis as the analytical framework.ResultsThe study identified several strategies and approaches that were used to address implementation challenges during guideline development. Four themes emerged from the analysis: broad agreements and consensus about scope and purpose; a formalized and structured development procedure; systematic and active involvement of stakeholders; and openness and transparency in the specific guideline development procedure. Additional factors concerning the scope of prevention and the work environment of guideline developers were perceived to influence the possibilities to address implementation issues.ConclusionsThis case study provides examples of how guideline developers perceive and approach the issue of implementation during the development and early launch of prevention guidelines. Models for guideline development could benefit from an initial assessment of how the guideline topic, its target context and stakeholders will affect the upcoming implementation.

The economic consequences of non–evidence-based clopidogrel use

Clinical trials have helped clarify the efficacy of clopidogrel for the treatment and prevention of vascular disease. Costs for its use exceeded $5.9 billion in 2005, making it the second greatest source of drug expenditure in the world. However, little is known about the appropriateness of that use. Overuse of clopidogrel could have important implications for health care quality and drug expenditures. We conducted a retrospective cohort study linking all filled prescriptions to all clinical encounter data for Medicare beneficiaries enrolled in a large state-wide pharmacy assistance program. We identified all patients newly prescribed clopidogrel during a recent 2-year period and determined the proportion who had indications for clopidogrel, the mean number of tablets filled by patients with and without apparent indications in the year after starting therapy, and the costs associated with the observed patterns of clopidogrel use. We identified 4977 patients who were newly prescribed clopidogrel. Of these patients, only 47% had > or = 1 documented indications for clopidogrel according to clinical trial findings. Using looser criteria, the number of patients with appropriate indications was 56%. During the first year of therapy, 43% ($2.05 million) of total clopidogrel expenditures for the patients studied was spent on patients without an indication that this agent was required, using the extended criteria for evidence-based use. More than 40% of the clopidogrel used in this population appears to have been prescribed to patients for whom the drug had no documented advantage over aspirin or no antiplatelet therapy. If the same proportion applies nationally, in 2005, it would represent almost $1.5 billion of potentially unnecessary health care expenditure.

The assessment of criterion audit cycles by external peer review – when is an audit not an audit?

Clinical audit has failed to fully deliver the rewards initially envisaged. Contributory factors include: an ill-defined approach to audit; the assumption that health care professionals can intuitively apply audit methods; and the lack of a system to 'quality assure' the process. A method of criterion audit was defined and developed in conjunction with an instrument to facilitate trained General Practitioner (GP) assessors in the review of colleagues' audit projects. Given the potential for improving audit practice, this study aimed to define the methodological factors that contributed to 'unsatisfactory' audits as judged by peer assessors. West of Scotland GPs voluntarily submitted a criterion audit in a standard format for review by two trained colleagues using an assessment instrument. Audits judged unsatisfactory and associated educational feedback were subjected to content analysis. Between 1999 and 2004, 336 audits were submitted, of which 132 (39%) were judged to be unsatisfactory. Of these, 118 audits (89%) had a methodological issue identified in the initial project design (e.g. defining criteria) that effectively invalidated the audit. 119 projects (90%) were also judged to have at least one deficiency in the data analysis or change management stages of the audit (e.g. implementing inadequate change). A range of audit method issues was found. The proportion of unsatisfactory audits may point to a larger problem beyond this sample, which may have implications for health care quality. If audit practise is to be consistent and rigorous, consideration should be given to assessing the standard of this activity.

Technology's implications for health care quality. A clinical engineering perspective.

Bill Gates states in Business @ The Speed of Thought that "the 2000s will be about velocity." This "decade of velocity" is driven by the flow of digital information. Health care organizations should develop a "digital nervous system" that is distinguished from a network of computers by the accuracy, immediacy, and richness of the information it brings to health care workers and by the insight and collaboration made possible by this information. This article provides a clinical engineering perspective on technology in health care in an era of rapid change. It discusses how clinical engineers work with health care professionals to manage and adapt to technological, economic, social, and regulatory forces that are redefining our approach to health care delivery.

Sovereign Immunity And Health Care: Can Government Be Trusted?

When government provides or arranges for health care, it is held to lower legal standards than private parties are, especially when liability is barred by "sovereign immunity". This paper examines sovereign immunity and its implications for health care quality by comparing private-sector and government accountability in several legal contexts. It then considers whether the law should be changed; the possible relationship between limited government accountability and public mistrust of a larger government role in health care; and the potential role of disparate legal standards if a lower tier of care evolves in government programs.

Not-so-strange bedfellows: models of interaction between managed care plans and public health agencies.

Alliances between managed care plans and public health agencies are a growing phenomenon in local health care markets, with profound implications for health care quality, cost, and accessibility. A typology of interorganizational relations between managed care plans and local public health agencies is drawn from observations of over 60 public health jurisdictions. Relations are described along three dimensions corresponding to the strategic intent, functional operation, and structural design of each alliance type. The identified models of interaction reveal the motivations for forming alliances, the mechanics of their operation, and the possible outcomes. These alliances suggest that a wide range of interorganizational strategies is possible in order to pursue the shared interests of local public health agencies and managed care plans. Nonetheless, public health agencies may face challenges in forging managed care alliances that benefit community-wide populations and that are open to participation by the full spectrum of health care providers in the community.

Health System Reform: Still Twitching-Reply

In Reply. —The US health system is witnessing an alarming and rapid corporate transformation with profound implications for health care quality. Rather than addressing this disturbing reality, or engaging the 10 quality principles we outlined for US health system reform, Dr Noel echoes a series of inaccurate assertions about Canada, and instead offers the administratively unwieldy and inequitable remedy of individual retirement accounts. He misrepresents Canada as plagued by medical cost inflation, shortage, long queuing, and rationing. Recent Canadian data show that average real per capita health expenditures increased only 1.4% annually from 1987 through 1993, and have actually decreased for the latter 2 years. 1 While effectively containing costs, Canada provides more care— more physician visits, more hospital days, more procedures, and even more bone marrow transplantations (and at a more appropriate stage)—than the United States, while achieving the highest level of satisfaction in the world and winning