Shaping Health Care Research Articles

Assessing Readmission Databases: How Reliable Is the Information?

Databases are being used to shape health care policy. However, the reliability of coding information entered into the databases may be difficult to validate. In this study, we assess readmission data from an institutional database that identified 1515 readmissions (708 patients) after total hip or total knee arthroplasty during a 5-year interval. After exclusions, 223 readmissions (190 patients) underwent medical record review. Bleeding, wound-related, and arthroplasty-related complications constituted most (62.8%) of readmissions. Bleeding and wound complications were nearly 6 times more frequently associated with readmission than venous thromboembolism events. On secondary review, there was discordance between the diagnosis obtained by a surgeon reviewer and coding for diagnoses consistent with periprosthetic infection (996.66, 77, 78, and 998.59) in 70% of cases. The findings of our study raise questions regarding the validity of accepting information obtained from larger databases without closer scrutiny.

Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation.

To develop a conceptual framework for investigating the role of racial/ethnic residential segregation on health care disparities. Review of the MEDLINE and the Web of Science databases for articles published from 1998 to 2011. The extant research was evaluated to describe mechanisms that shape health care access, utilization, and quality of preventive, diagnostic, therapeutic, and end-of-life services across the life course. The framework describes the influence of racial/ethnic segregation operating through neighborhood-, health care system-, provider-, and individual-level factors. Conceptual and methodological issues arising from limitations of the research and complex relationships between various levels were identified. Increasing evidence indicates that racial/ethnic residential segregation is a key factor driving place-based health care inequalities. Closer attention to address research gaps has implications for advancing and strengthening the literature to better inform effective interventions and policy-based solutions.

Life on the edge: immigrants confront the American health system

On the basis of a study of forty health care delivery institutions in Florida, California, and New Jersey, this paper examines the interaction between the immigration and health systems in the USA. We investigate barriers to care encountered by the foreign born, especially unauthorized immigrants, and the systemic contradictions between demand for their labour and the absence of an effective immigration policy. Lack of access and high costs have forced the uninsured poor into a series of coping strategies, which we describe in relation to commercial medicine. We highlight regional differences and the importance of local politics and history in shaping health care alternatives for the foreign born.

Moral Agency as Enacted Justice: A Clinical and Ethical Decision-Making Framework for Responding to Health Inequities and Social Injustice

This is the second of 2 companion articles in this issue. The first article explored the clinical and ethical implications of new emphases in physical therapy codes of conduct reflecting the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. The first article was theoretically oriented and proposed that a re-thinking of ethical frameworks expressed in codes of ethics could both inform and underpin practical strategies for working in primary health care. A review of the ethical principle of "justice," which, arguably, remains the least consensually understood and developed principle in the ethics literature of physical therapy, was provided, and a more recent perspective-the capability approach to justice-was discussed. The current article proposes a clinical and ethical decision-making framework, the ethical reasoning bridge (ER bridge), which can be used to assist physical therapy practitioners to: (1) understand and implement the capability approach to justice at a clinical level; (2) reflect on and evaluate both the fairness and influence of beliefs, perspectives, and context affecting health and disability through a process of "wide reflective equilibrium" and assist patients to do this as well; and (3) nurture the development of moral agency, in partnership with patients, through a transformative learning process manifest in a mutual "crossing" and "re-crossing" of the ER bridge. It is proposed that the development and exercise of moral agency represent an enacted justice that is the result of a shared reasoning and learning experience on the part of both therapists and patients.

New Perspectives on the Theory of Justice: Implications for Physical Therapy Ethics and Clinical Practice

Recent revisions of physical therapy codes of ethics have included a new emphasis concerning health inequities and social injustice. This emphasis reflects the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. This perspective article suggests that there is a "disconnect" between the societal obligations and aspirations expressed in the revised codes and the individualist ethical frameworks that predominantly underpin them. Primary health care is an approach to health care arising from an understanding of the nexus between health and social disadvantage that considers the health needs of patients as expressive of the health needs of the communities of which they are members. It is proposed that re-thinking ethical frameworks expressed in codes of ethics can both inform and underpin practical strategies for working in primary health care. This perspective article provides a new focus on the ethical principle of justice: the ethical principle that arguably remains the least consensually understood and developed in the ethics literature of physical therapy. A relatively recent theory of justice known as the "capability approach to justice" is discussed, along with its potential to assist physical therapy practitioners to further develop moral agency in order to address situations of health inequity and social injustice in clinical practice.

Modeling Security in Acceptance of Electronic Health Record Systems

Transactional systems are ubiquitous in most industries; however, healthcare organizations continue to slowly diffuse Electronic Health Record (EHR) systems. This research integrates security features such as biometrics for authentication purposes, multiple access connections, and single sign-on systems into the Technology Acceptance Model to explore whether these features might improve user acceptance of EHR. Security potentially affects user perceptions of ease of use and usefulness, improving acceptance of EHR systems. This work contributes to the literature by exploring whether security features are important in shaping health care worker attitudes towards EHR systems.

Participation and the Right to Health: Lessons from Indonesia

The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.

Voting begins for paper of the year 2010

2010 has been an interesting year for elections: a republican-controlled House of Representatives in the USA resulted in a split between party control of the House and the Senate; a coalition government in the UK; and the first female President in Brazil. What surprises will voting bring to The Lancet's poll of the paper published in 2010 that is most likely to shape future research or health care?

The American Recovery and Reinvestment Act

The recently passed American Recovery and Reinvestment Act (the Act) is a landmark piece of legislation that will shape health care informatics in the United States for the foreseeable future. The Act provides financial incentives to hospitals and physicians who upgrade their medical record systems by implementing electronic versions. This article defines health care informatics, outlines the provisions of the Act and associated incentives that are available to hospitals and physicians, discusses the advantages and barriers related to upgrading to an electronic medical records system that have been identified in the literature, and details several case studies where small physician group practices put electronic medical records systems into operation. The analysis of these cases shows that the challenges faced by the physicians and practice administrators reinforce the key challenges identified in the literature. Given these seemingly common impediments, suggestions for overcoming such challenges are summarized. These key lessons should be of interest to any practice looking to upgrade their medical records system.

"Our reach is wide by any corporate standard": how the tobacco industry helped defeat the Clinton health plan and why it matters now.

Contemporary health care reformers, like those who promoted the failed Clinton era plan, face opposition from multiple corporate interests. However, scant literature has examined how relationships between corporations and other stakeholders, such as think tanks and advocacy groups, shape health care reform debate. We show how the 2 biggest US tobacco companies, Philip Morris and RJ Reynolds, and their trade association coordinated in mobilizing ideologically diverse constituencies to help defeat the Clinton plan. Unwittingly perhaps, some reform supporters advanced the tobacco industry's public relations blitz, contributing to perceptions of public opposition to the plan. As the current reform debate unfolds, this case highlights the importance of funding transparency for interpreting the activities of think tanks, advocacy groups, and "grassroots" movements.

National Health Insurance in the United States and Canada: Race, Territory, and the Roots of Difference

Reviewed by: National Health Insurance in the United States and Canada: Race, Territory, and the Roots of Difference Alecia Blake (bio), Latronda Davis (bio), Ayana Johnson (bio), Tonja Khabir (bio), Carlos Mahaffey (bio), Denise Smith (bio), Nythea Campbell, MPH (bio), and Patricia Rodney, PhD, MPH (bio) National Health Insurance in the United States and Canada: Race, Territory, and the Roots of Difference. Gerard W. Boychuk. Washington, DC: Georgetown University Press, 2008. 234 pp. National Health Insurance in the United States and Canada: Race, Territory, and the Roots of Difference compares the pathways of insurance reform in the United States (U.S.) and in Canada. The author, Gerard W. Boychuk, traces how the historical development of the U.S. contributed to the failure of health insurance reform, and contrasts this history with Canada's territorial politics and how it influenced health care policy there. The author identifies cultural distinctions related to health policy and reform in both countries. He argues that American individualism and distaste for big government contribute to the ongoing failure to develop a national U.S. health insurance plan, while Canadians' collective consciousness and preference for centralized government facilitates a national plan. The book is divided into four sections, which provide a chronology of health care reform in the U.S. and Canada. The author clearly delineates the specific political and social dynamics that initiated or impinged reform. First, he emphasizes the history of support and u8pposition for a national health insurance program in the U.S. along racial lines. Race is and has been an important social force shaping health care policy in the U.S., and has long been a salient characteristic of national politics that overall has defeated efforts at reform. Boychuk argues that opposition to a national health insurance from the American Medical Association (AMA) and segregation within the medical profession reinforced resistance to reform. The South, for most of its history, has rejected any policy changes that appeared to defy the racial status quo. Boyuchuk clearly elucidates challenges that faced public programs such as Medicare (for example, Title IV compliance, which integrated hospital care). Boychuk uses a similar case to describe Canada's medical insurance system, and how its history differed from the history of health policy in the U.S. Though innovations began at the provincial level, federal cost-sharing was a major problem with the Canadian process. Boychuk, an Associate Professor at the University of Waterloo in Ontario, emphasizes that Canadian reform was not simple or automatic. He also acknowledges that although the U.S. could learn from Canada, the difficulty of health reform in the U.S. was inevitable, given the differences in the two countries' histories. By identifying and explaining historical nuances and similarities—and how these affect reform—Boychuk offers a useful and intelligent comparison of public health reform in neighboring countries. The research is current, accurate, and comprehensive. The author notes that in both countries, polls conducted in 2005 ranked health care as the single most important domestic policy issue. Boychuk illustrates his discussion of health reform in the contemporary socio-political climate in both countries with a host of tables, charts, graphs, and notes. The research in this timely and relevant book is sometimes profound, and it should [End Page 750] certainly inform current debate on health care reform in the U.S. Despite the complexity of the racial history Boychuk analyzes, the author offers some hope for the future of reform in the U.S. His book is an invaluable addition to the literature on health systems reform. A limitation of the book for the general reader is the technical nature of much of the text, which is geared towards an audience including health care professionals, policy makers, and politicians. The author missed an opportunity to engage everyday citizens who will be the important beneficiaries of health care reform. Alecia Blake, Latronda Davis, Ayana Johnson, Tonja Khabir, Carlos Mahaffey, Denise Smith, Nythea Campbell, and Patricia Rodney The reviewers are affiliated with the Masters of Public Health Program at Morehouse School of Medicine in Atlanta. Please address correspondence to Dr. Rodney at prodney@msm.edu. Copyright © 2010 Meharry Medical College

Medical dominance and neoliberalisation in maternal care provision: The evidence from Canada and Australia

Since the 1970s, governments in many high-income countries have implemented a series of reforms in their health care systems to improve efficiency and effectiveness. Many of these reforms have been of a market-oriented character, involving the deregulation of key services, the creation of competitive markets, and the privatization of health and social care. Some scholars have argued that these "neoliberal" reforms have unseated the historical structural embeddedness of medicine, and in some cases even resulted in the proletarianisation of physicians. Other scholars have challenged this view, maintaining that medical hegemony continues to shape health care provision in most high-income countries. In this paper we examine how policy reforms may have altered medical dominance over maternity care in two comparatively similar countries - Canada and Australia. Our findings indicate that neoliberal reforms in these two countries have not substantially changed the historically hegemonic role medicine has played in maternity care provision. We discuss the implications of this outcome for the increased medicalisation of human reproduction.

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety

According to the human factors paradigm for patient safety, health care work systems and innovations such as electronic medical records do not have direct effects on patient safety. Instead, their effects are contingent on how the clinical work system, whether computerized or not, shapes health care providers' performance of cognitive work processes. An application of the human factors paradigm to interview data from two hospitals in the Midwest United States yielded numerous examples of the performance-altering effects of electronic medical records, electronic clinical documentation, and computerized provider order entry. Findings describe both improvements and decrements in the ease and quality of cognitive performance, both for interviewed clinicians and for their colleagues and patients. Changes in cognitive performance appear to have desirable and undesirable implications for patient safety as well as for quality of care and other important outcomes. Cognitive performance can also be traced to interactions between work system elements, including new technology, allowing for the discovery of problems with "fit" to be addressed through design interventions.

How Improving Practice Relationships Among Clinicians and Nonclinicians Can Improve Quality in Primary Care

Understanding the role of relationships health care organizations (HCOs) offers opportunities for shaping health care delivery. When quality is treated as a property arising from the relationships within HCOs, then different contributors of quality can be investigated and more effective strategies for improvement can be developed. Data were drawn from four large National Institutes of Health (NIH)-funded studies, and an iterative analytic strategy and a grounded theory approach were used to understand the characteristics of relationships within primary care practices. This multimethod approach amassed rich and comparable data sets in all four studies, which were all aimed at primary care practice improvement. The broad range of data included direct observation of practices during work activities and of patient-clinician interactions, in-depth interviews with physicians and other key staff members, surveys, structured checklists of office environments, and chart reviews. Analyses focused on characteristics of relationships in practices that exhibited a range of success in achieving practice improvement. Complex adaptive systems theory informed these analyses. Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes. Although this model of practice relationships was developed from data collected in primary care practices, which differ from other HCOs in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties.

Nursing shaping and influencing health and social care policy

This paper seeks to consider how nursing as a profession in the United Kingdom is developing its role in shaping and influencing policy using lessons learnt from a policy study tour undertaken in the United States of America and extensive experience as a senior nurse within the government, the health service and more recently within a Professional Organization. The nursing profession faces major changes in health and health care and nurses need to be visible in the public debate about future models of health and health care. This paper critically reviews recent UK and USA literature and policy with relevance to nursing. Strategies that support nurses and nursing to influence policy are in place but more needs to be done to address all levels of nursing in order to find creative solutions that promote and increase the participation of nurses in the political process and health policy. There are lessons to be learnt in the UK from the US nursing experience. These need to be considered in the context of the UK and devolution. Although much has been achieved in positioning nurses and nursing as an influencer in the arena of policy and political decision-making, there is a need for greater co-ordination of action to ensure that nursing is actively supported in influencing and shaping health and health care policy. All leaders and other stakeholders require to play their part in considering how the actions set out in this article can be taken forward and how gaps such as education, fellowship experience and media engagement can be addressed in the future.

From strategy to implementation - clinical and academic perspectives

From strategy to implementation - clinical and academic perspectives

Public Views Of Health System Issues In Four Asian Countries

To elicit the public's views on health system issues, we conducted an opinion poll survey in Bangladesh, Mongolia, Nepal, and Sri Lanka. We focused on health inequalities. The results show high levels of dissatisfaction with government health services in all four of the countries. Access to government health services was an important concern. A sizable number of respondents reported that their governments did not consider their views at all in shaping health care services. The policy implications of the study findings are discussed.

The social construction of chronicity – a key to understanding chronic care transformations

The purpose of this paper is to argue the importance of contemporary analysis of the modern social construction of chronicity--encapsulating the world views of the chronically ill, and the medical and health system constructions of chronic disease, through the nature of care for chronic conditions. It is argued that chronic diseases are themselves, socially constructed, despite widely accepted disease classification systems. Thus, there is a need to examine how different ideas have permeated our clinical and health system developments and their social context and vice versa. We examine historical ideas, theory and evidence about the tensions in social construction of chronic illness by those afflicted and the responses of society, the medical and health professions and increasingly the public and private institutions that shape health care. This is with the background of major differences in the two cultures that create knowledge: those based upon argument and intellectual logic--hermeneutic, and those based upon 'objectivist' empirical science, often called heuristic. Evidence-based medicine (EBM) is the flagship of disease management, increasingly narrative-based medicine and other similar genres are becoming the pragmatic face of social constructions, yet sit in juxtaposition without synthesis. A third culture has emerged of scientific intellectuals who straddle these cultures and in health care their public face is 'mixed methods'. Recent cases of modern ideas about improving chronic care were reviewed. We found that despite developments of social theory, the world view of the chronically ill exerts small influence in health system redesign, apparently dominated by chronic disease models. Confusion remains within health system reforms as to the social construction of chronicity--chronic disease, chronic condition or chronic illness and chronic care transformations. The role of Primary Care remains ambiguous straddling disease and illness. Radical redesign of health systems is taking place without an understanding and discourse about the nature of their construction. Ad hoc eclectism with unquestioning adoption of the dominant EBM paradigm is driving a new health culture based on disease-based performance incentives, which is intrusive beyond the medical model and pays little attention to narratives of illness and even less to the whole social reconstruction of illness and wellness. Health care systems cannot afford to avoid, and should actively embrace the critiques of social theory and analyses in the transformations of health systems to improve chronic care. Creative tensions between empirical and intellectual critique, and a synthetic middle ground are likely to lead to more realistic and innovative approaches spanning the nature of chronicity and the transformation of Primary Care.

Participation and the Right to Health: Lessons from Indonesia

The right to participation is the "the right of rights"--the basic right of people to have a say in how decisions that affect their lives are made. All legally binding international human rights treaties explicitly recognize the essential role of participation in realizing fundamental human rights. While the substance of the human right to health has been extensively developed, the right to participation as one of its components has remained largely unexplored. Should rights-based health advocacy focus on participation because there is a relationship between an individual's or a community's active involvement in health care decision-making and the highest attainable standard of health? In the context of the human right to health, does participation mean primarily political participation, or should we take the right to participation to mean more specifically the right of persons, individually and as a group, to shape health care policy for society and for themselves as patients? Decentralization of health care decision-making promises greater participation through citizen involvement in setting priorities, monitoring service provision, and finding new and creative ways to finance public health programs. Between 1999 and 2008, Indonesia decentralized health care funding and delivery to regional governments, resulting in substantial exclusion of its poor and uneducated citizens from the health care system while simultaneously expanding the opportunities for political participation for educated elites. This article explores the tension between the right to participation as an underlying determinant of health and as a political right by reviewing the experience of Indonesia ten years after its decision to decentralize health care provision. It is ultimately argued that rights-based advocates must be vigilant in retaining a unified perspective on human rights, resisting the persistent tendency to separate and prioritize the civil and political aspects of participation over its social component.

Public policy, caring practices and gender in health care work

Our final paper draws on the evidence presented in this supplement to discuss how policy trends in health care delivery are shaping health care work and health outcomes. As several contributors note, these policy trends have had heterogeneous effects across Canada and in other countries. Nevertheless, all of the cases discussed reveal a pressing need for a gendered understanding of health care policy, as well as of the diverse locations in which the effects of health care policy are experienced. Three central themes in this supplement illustrate the gendered dimensions of health care policies and health care work: the downloading of work from more highly paid workers to less well-paid or unpaid care workers; the link between deteriorating conditions of health care work and shortages of health care workers; and the increased presence of responsibilization and familialism as practices central to health care policy. We consider the Canadian case, where such trends have been more prominent, alongside experiences in Iceland and Finland, where they have been less fully developed, and draw some comparative lessons.