Health Policy RSS feed: Current Issue. Health Policy is intended to be a vehicle for the exploration and discussion of health policy and health system issues and is aimed in particular at enhancing communication between health policy and system researchers, legislators, decision-makers and professionals concerned with developing, implementing, and analysing health policy, health systems and health care reforms, primarily in high-income countries outside the U.S.A. Health care policies and reforms are made at an ever-increasing pace in countries around the world - and policy-makers are increasingly looking to other countries for solutions to their own problems. Health Policy is committed to support this international dialogue to ensure that policies are not just copied but used and adapted based on the specific problems and objectives as well as the respective context. The journal encourages the submission of short, full-length, comparative and review articles (as well as groups of articles in "special sections") which address 1. what is happening in terms of policies, reforms, regulation etc. of health systems; 2. where the ideas are coming from, i.e. whether they are "imported" from another country or developed within the country, and how innovative they are they in comparison to other countries; 3. why it is happening, e.g. as a consequence of a change in government, popular dissatisfaction or (perceived) unsustainable cost increases, and what are the objectives; 4. the actors involved (both governmental as well as non-governmental), incl. their roles, their opinions and their strength in the decision and implementation process; 5. intended and, especially, unintended effects of these policies or reforms on the health system in terms of access, appropriateness, costs, effectiveness, quality, patient experience and equity etc.; and 6. their final consequences in terms of health outcomes, financial protection and responsiveness to the population's legitimate expectations, i.e. a performance assessment of reforms and health systems. To achieve the journal's objectives, authors are encouraged to write in a non-technical style, which is understandable to health policy practitioners and specialists from other disciplines and in other countries. Electronic usage: An increasing number of readers access the journal online via ScienceDirect, one of the world's most advanced web delivery systems for scientific, technical and medical information. Average monthly article downloads for this journal: 35,538 * Figure is an average based on full text articles downloaded monthly via ScienceDirect between July 2010 and July 2011 http://www.healthpolicyjrnl.com/?rss=yesElsevier Inc.en © 2011 Elsevier Ireland Ltd. All rights reserved. Health Policy0168-85101042February 2012 © 2011 Elsevier Ireland Ltd. All rights reserved. healthpermissions@elsevier.comhttp://www.healthpolicyjrnl.com/article/PIIS0168851011002429/abstract?rss=yesAbstract: Objectives: The aim of this literature review is to identify whether differences between welfare regimes can manifest diverse consequences for the health effects of insecure and precarious employment, as well as to address challenging issues and implications for future research.Methods: By searching PubMed, PsychINFO, Stork Social Science Citation Index, and Index Lilac, from 1988 to June 2010, a total of 104 original articles were selected (65 on job insecurity; 39 on precarious employment).Results: After classifying selected empirical studies according to a six-regime welfare state typology (Scandinavian, Bismarckian, Southern European, Anglo-Saxon, Eastern European, and East Asian), this systematic review reveals that welfare regimes may be an important determinant of employment-related health. Precarious workers in Scandinavian welfare states report better or equal health status when compared to their permanent counterparts. By contrast, precarious work in the remaining welfare state regimes is found to be associated with adverse health outcomes, including poor self-rated health, musculoskeletal disorders, injuries, and mental health problems.Conclusions: Future research should be conducted by employing conceptual models that specify how macro-economic processes, country-level welfare factors, and individual employment histories and environments relate to employment-related health inequalities.Welfare states, flexible employment, and health: A critical reviewIl-Ho Kim, Carles Muntaner, Faraz Vahid Shahidi, Alejandra Vives, Christophe Vanroelen, Joan Benach10.1016/j.healthpol.2011.11.002Health Policy 104, 2 (2012)2011-12-05Health Policy2011-12-051042S0168-8510(11)X0014-3Review99127http://www.healthpolicyjrnl.com/article/PIIS0168851011001096/abstract?rss=yesAbstract: Objectives: Acute hospital reconfiguration is often presented as a problem to be solved by calculations of optimal design, a rational process amenable to influence by open and responsive consultation. We aimed to analyse factors in the process and ‘results’ of hospital reconfiguration in three case study sites in the English NHS.Methods: In-depth semi-structured interviews were conducted with internal and external stakeholders at each site. Analysis within each case was complemented by cross-case analysis focusing on the relationships between the features of the origins and process of reconfiguration and progress in the implementation of plans.Findings: We identified a number of inter-related factors operating in the process of implementation which influenced the ‘results’: the drivers for change, the reconfiguration, its content (particularly the extent to which services are withdrawn or made less accessible), the influence of stakeholders, such as local politicians, financial pressures, and the role of the management team.Conclusions: We argue that the differences in reconfiguration implementation between the three cases reflected the nature of the proposed changes and local politics, rather than the strength of the ‘evidence’ for change. National policy has tended to over-emphasise the importance of consultation using ‘evidence’ and underplays these influencing factors.Implementing changes to hospital services: Factors influencing the process and ‘results’ of reconfigurationNaomi Fulop, Rhiannon Walters, Perri 6, Peter Spurgeon10.1016/j.healthpol.2011.05.015Health Policy 104, 2 (2012)2011-06-30Health Policy2011-06-301042S0168-8510(11)X0014-3Focus on Hospitals128135http://www.healthpolicyjrnl.com/article/PIIS0168851011001552/abstract?rss=yesAbstract: This study investigates whether inclusion of patient profiles impacts on the inferences drawn from measuring performance using patient level data. Performance is in this setting defined by resources used in treating patients in a given diagnose related group where use of resources is approximated by length of stay (LOS). The analysis is based on Danish registry data from 2006. Patient data include registry data on income, employment status and information on whether the patient receives benefits or lives alone. Considerable variation in the socio-demographic characteristics of patients across Danish hospitals was observed, and some patient characteristics were shown to drive the need for longer hospital stays beyond what is captured in DRG scores. Ranking of hospitals based on observed versus expected LOS remained largely unaffected when controlling for patient characteristics, suggesting that variation in LOS across hospitals is mainly driven by other factors than patients’ socio-demographic characteristics. Nevertheless, the results of this study indicate that the current Danish remuneration system discriminates hospitals that more often serve older patients and patients with a less developed social network. These hospitals tend to have a reduced turnover of patients and their ability to generate revenue is therefore constrained.Socio-demographic patient profiles and hospital efficiency: Does patient mix affect a hospital's ability to perform?Dorte Gyrd-Hansen, Kim R. Olsen, Torben H. Sørensen10.1016/j.healthpol.2011.07.010Health Policy 104, 2 (2012)2011-08-18Health Policy2011-08-181042S0168-8510(11)X0014-3Focus on Hospitals136145http://www.healthpolicyjrnl.com/article/PIIS0168851011001205/abstract?rss=yesAbstract: Objectives: Adverse event or complication rates are increasingly advocated as measures of hospital quality and performance. Objective of this study is to analyse patient-complexity adjusted adverse events rates to compare the performance of hospitals in Victoria, Australia. We use a unique hospital dataset that routinely records adverse events which arise during the admission. We identify hospitals with below or above average performance in comparison to their peers, and show for which types of hospitals risk adjusting makes biggest difference.Methods: We estimate adverse event rates for 87,790 elective and 43,771 emergency episodes in 34 public hospitals over the financial year 2005/06 with a complementary log–log model, using patient level administrative hospital data and controlling for patient complexity with a range of covariates.Results: Teaching hospitals have average risk-adjusted adverse event rates of 24.3% for elective and 19.7% for emergency surgical patients. Suburban and rural hospitals have lower rates of 17.4% and 17%, and 16.1% and 15.7%, respectively. Selected non-teaching hospitals have relatively high rates, in particular hospitals in rural and socially disadvantaged areas. Risk adjustment makes a significant difference to most hospitals.Conclusion: We find comparably high adverse events rates for surgical patients in Australian hospitals, possibly because our data allow identification of a larger number of adverse events than data used in previous studies. There are marked variations in adverse event rates across hospitals in Victoria, even after risk adjusting. We discuss how policy makers could improve quality of care in Australian hospitals.Adverse event rates as measures of hospital performanceKatharina Hauck, Xueyan Zhao, Terri Jackson10.1016/j.healthpol.2011.06.010Health Policy 104, 2 (2012)2011-07-22Health Policy2011-07-221042S0168-8510(11)X0014-3Focus on Hospitals146154http://www.healthpolicyjrnl.com/article/PIIS0168851011001837/abstract?rss=yesAbstract: Objectives: To examine the association between patient injury claims and well-known quality indicators and to assess whether claims can be utilised in performance measurement.Methods: Data were derived from administrative registers and comprised hip and knee replacement patients (n=34181) in Finland from 1998 to 2003. Hospital-level correlations were calculated between claims and quality indicators (5-year revision rate, 1-year deep infection rate, and 14-day readmission rate), while logistic regression analysis was used to analyze patient-level data for an association between claims and quality indicators.Results: Correlations between claims and revisions as well as claims and infections were statistically significant, with correlation coefficients ranging from 0.21 to 0.62. In the regression analysis, both the revision and the infection indicator had a positive and statistically significant association with filing a claim (OR 1.002; 95% CI 1.001–1.003 and 1.001; 1.00005–1.001, respectively) and obtaining compensation (1.003; 1.001–1.005 and 1.001; 1.0003–1.002, respectively).Conclusions: A claims indicator has the potential to be applied as a quality indicator. It should be complemented, however, with other indicators or actions to improve its acceptability by health professionals and to mitigate its possible undesirable effects.Can patient injury claims be utilised as a quality indicator?Jutta Järvelin, Unto Häkkinen10.1016/j.healthpol.2011.08.012Health Policy 104, 2 (2012)2011-09-28Health Policy2011-09-281042S0168-8510(11)X0014-3Focus on Hospitals155162http://www.healthpolicyjrnl.com/article/PIIS0168851011002508/abstract?rss=yesAbstract: The German hospital market has been subject over the past two decades to a variety of healthcare reforms. Particularly the introduction of diagnosis-related groups (DRGs) in 2004 aimed to increase efficiency of hospitals. The objective of the paper is to review recent studies comparing the efficiency of German public, private non-profit and private for-profit hospitals. The results of the studies are quite mixed. However, in line with the evidence found in studies from other countries, especially the US, the evidence from Germany suggests that private ownership (i.e., private non-profit and private for-profit) is not necessarily associated with higher efficiency compared to public ownership. This may be a surprising result to many policy makers as private for-profit hospitals are often perceived the most efficient ownership type by the public.Hospital ownership and efficiency: A review of studies with particular focus on GermanyOliver Tiemann, Jonas Schreyögg, Reinhard Busse10.1016/j.healthpol.2011.11.010Health Policy 104, 2 (2012)2011-12-19Health Policy2011-12-191042S0168-8510(11)X0014-3Focus on Hospitals163171http://www.healthpolicyjrnl.com/article/PIIS0168851011001515/abstract?rss=yesAbstract: Objectives: With increased possibility that public healthcare services in the UK will be out-sourced to the private sector, this study investigates how clinicians working in Independent Sector Treatment Centres perceive the differences between public and private sectors.Methods: Qualitative interviews with 35 clinicians recruited from two ISTCs. All participants were transferred to the independent sector from the public National Health Service. Interview data were analysed to identify shared experience about the variable organisation and delivery of services.Results: Clinicians perceived differences between public and independent sectors in the areas of ‘environment and facilities’, ‘management’, ‘work organisation and care delivery’, and ‘patient experience’. The independent sector was described as offering a positive alternative to public services in regard to service environment and patient experience, but there were concerns about management priorities and the reconfiguration of work.Conclusions: Clinicians’ experience of moving between sectors reveals mixed experiences. Although some improvements might legitimise the growing role of the independent sector, there remain doubts about the commercialisation of services, the motives of managers and the impact of clinical roles and capabilities. With policies looking to expand the mixed economy of public healthcare services, the study suggests clinicians will not automatically embrace a move between sectors.Going private: Clinicians’ experience of working in UK Independent Sector Treatment CentresJustin Waring, Simon Bishop10.1016/j.healthpol.2011.07.006Health Policy 104, 2 (2012)2011-08-12Health Policy2011-08-121042S0168-8510(11)X0014-3Focus on Hospitals172178http://www.healthpolicyjrnl.com/article/PIIS0168851010003386/abstract?rss=yesAbstract: Background: Variations in the rate of use of common medical procedures/therapies are widely documented. Previous studies tend to focus on variations between either hospitals or geographic areas. Few studies examine within centre practice variations.Objective: To examine if variation in treatment recommendations exist among highly trained interventional cardiologists (n=9) working in a single, highly collaborative tertiary care centre.Study design and setting: Data was collected from a local registry. A logistic regression model was used to estimate each physician's odds of recommending revascularization therapy over medical therapy for patients with significant CAD. The analysis was repeated to estimate each physician's odds of recommending percutaneous coronary intervention (PCI) over coronary artery bypass graft surgery (CABG) when the physician indicated the need for revascularization. Each physician's odds were compared to those for a reference physician to yield odds ratios. The odds ratios were adjusted for multiple patient characteristics.Results: The adjusted odds ratios of four physicians differed significantly from the reference physician (range: 0.8–2.9). Variation was also seen among physicians in the decision to recommend CABG rather than PCI once revascularization therapy was selected. The odds ratios ranged from 1.5 to 4.2.Conclusion: Practice variations were seen despite case mix adjustment, similar resource and environmental constraints. The existence of within centre variations may have implications on service delivery and planning. Research is needed to both identify the existence, and explain the determinants of “an even smaller area variation”.An even smaller area variation: Differing practice patterns among interventional cardiologists within a single high volume tertiary cardiac centreMathew Mercuri, Madhu K. Natarajan, Geoff Norman, Amiram Gafni10.1016/j.healthpol.2010.11.006Health Policy 104, 2 (2012)2010-12-06Health Policy2010-12-061042S0168-8510(11)X0014-3Focus on Hospitals179185http://www.healthpolicyjrnl.com/article/PIIS0168851011002211/abstract?rss=yesAbstract: Objective: Several innovative primary care models have recently been introduced in Ontario, Canada. Two of these models are funded primarily through age–sex based capitation. There is concern that adjusting capitation rates for age and sex alone does not take into account the increased morbidity burden and health care needs that are associated with lower socioeconomic status. This study assesses the extent to which the current age–sex capitation rates in Ontario reflect health care needs of patients across socioeconomic status by comparing Ontario's age–sex adjusted capitation remuneration rate index with relative expected health care resource use by socioeconomic status (SES).Methods: This study used administrative data collected by the Ontario Ministry of Health and Long-Term Care. The study sample was those patients who were enrolled to a FHN continuously from September 1, 2005 to August 31, 2006. Standardized expected health care utilization was calculated based on morbidity burden using The Johns Hopkins Adjusted Clinical Groups (ACG) Case-mix System and compared with standardized capitation rates across and within neighbourhood income quintiles.Results: Among those in the lowest income group expected utilization was much higher than the age–sex capitation rates, while the opposite was true for those in the highest income group.Conclusions: The findings suggests that under the physician reimbursement system used in Family Health Networks in Ontario, physicians are under-compensated for the health care needs of low income patients and over-compensated for the needs of high income patients. Adjusting capitation rates for morbidity burden in addition to age and sex may reduce incentives to preferentially enrol patients with higher socioeconomic status.Evaluation of the equity of age–sex adjusted primary care capitation payments in Ontario, CanadaLyn M. Sibley, Richard H. Glazier10.1016/j.healthpol.2011.10.008Health Policy 104, 2 (2012)2011-11-14Health Policy2011-11-141042S0168-8510(11)X0014-3Other Topics186192http://www.healthpolicyjrnl.com/article/PIIS016885101100220X/abstract?rss=yesAbstract: Objectives: To present new evidence both on the horizontal inequity in the delivery of primary health care and on the factors driving inequalities in the use of GP services for Spanish population aged 50 years and over.Methods: Cross-sectional study based on the Spanish sample of the Survey of Health, Aging and Retirement in Europe (SHARE) for 2006–07. We use the index proposed by Wagstaff and van Doorslaer (HIWV) to compute health care inequity. The concentration index measuring income related inequality in health care use is decomposed into the contribution of each determinant.Results: Our results show the presence of pro-poor inequality in both the access and the frequency of use for GP services, which is mainly explained by unequal distribution of need factors. The contribution of non-need factors to income related inequality is quite higher for the conditional number of GP visits (48.13%) than for the probability of positive use (17.55%). We have also found significant pro-poor inequity in the probability of access to a GP and in the conditional number of visits for elderly people.Conclusions: The relevance of social determinants of health is confirmed, and hence the need for wide-scoped public policies to reduce health inequalities. At equal levels of need, rich and poor elderly people are not treated equally. As much as appropriateness of care provided is unknown, we cannot conclude that inequity in GP services really favours the lower income individuals in terms of health gains.Equity and equality in the use of GP services for elderly people: The Spanish caseEva Crespo-Cebada, Rosa M. Urbanos-Garrido10.1016/j.healthpol.2011.10.007Health Policy 104, 2 (2012)2011-11-09Health Policy2011-11-091042S0168-8510(11)X0014-3Other Topics193199http://www.healthpolicyjrnl.com/article/PIIS0168851011002405/abstract?rss=yesAbstract: Nudging, or libertarian paternalism, is presented as a new and ethically justified way of improving people's health. It has proved influential and is currently taken up by the governments in the US, the UK and France. One may question the claim that the approach is new, in any case it has many similarities with the idea of “making healthy choices easier”. Whether the approach is better from an ethical perspective depends on the ethical principles one holds. From a paternalistic perspective there could be no objections, but from a libertarian, there are several. Contrary to what the authors state, libertarian paternalism is an oxymoron.Nudge—A new and better way to improve health?Signild Vallgårda10.1016/j.healthpol.2011.10.013Health Policy 104, 2 (2012)2011-11-23Health Policy2011-11-231042S0168-8510(11)X0014-3Other Topics200203http://www.healthpolicyjrnl.com/article/PIIS0168851011002867/abstract?rss=yesContents10.1016/S0168-8510(11)00286-7Health Policy 104, 2 (2012)2012-02-01Health Policy2012-02-011042S0168-8510(11)X0014-3CO4CO4